Advanced Prosthetic Knee Rehabilitation

Carolyn A Hirons HCPC Registered & Chartered

Physiotherapist BACPAR Conference 2014

Objectives

l  Gain familiarity with different prosthetic knee components

l  Understand knee functions, including stance resistance (yield)

l  Consider ‘advanced rehab’ l  Demonstrate training

techniques

SIGAM E & F

EIndependent

Walks 50m or more without walking aids expect to improve confidence in adverse terrain or weather.

FNormal Normal or near normal walking

Disability Definition A Non-limb user Those who have abandoned the

use of an artificial limb or use only non-functioning prostheses

B Therapeutic Wear prostheses ONLY in the following circumstances; for transfer, to assist nursing, walking with the physical aid of another OR during therapy.

C Limited/restricted Walks up to 50m on even ground with or without walking aids; a=frame, b=2crutches/sticks, c=1crutch/stick, d=no walking aids.

D Impaired Walks 50m or more on level ground in good weather with walking aids; a= 2 sticks/crutches, b= 1stick/crutch.

E Independent Walks 50m or more without walking aids expect to improve confidence in adverse terrain or weather.

F Normal Normal or near normal walking

The purpose of a prosthesis is to replace a body part & its function

l  Bones & Joints l  Ligaments & tendons l  Muscles l  Sensation To support normal movement,

to allow function. Note – designed for this!!!

Muscles

l  Control movement with gravity (lengthening)

l  Hold a movement (static length)

l  Generate movement & power against gravity (shortening)

l  Respond to sensation l  Sensory motor loop

Eccentric quadriceps action

Control movement with gravity (lengthening) Stance resistance for sitting, stair and ramp descent. Referred to as ‘yield’

Upright posture is imperative Essential for: l  Central head position l  Muscle recruitment l  Balance reactions l  Comfort & ease l  Energy efficiency l  Confidence Prosthetic alignment is crucial

Co-ordination & practise perfect practise!

Knee characteristics – what to consider?

l  What controls stance (WB)? l  What controls swing? l  How does it switch between

the two? l  Does it have stance flexion? Other: l  Has it other functions? l  How do you initiate these? l  Can the user do it?

But…knees are like cars!

l  User learns how to drive but not how the car works!

l  Expensive sports car does not make you a good driver!

l  Efficiency of a car depends on how you drive it!

l  Poor tracking causes wear & tear!

l  Lazy driving habits!

Mechanical knees with yield

l  KX06 (Endolite) l  3R80 (Otto Bock) l  Mauch Knee (Ӧssur) l  VGK (Orthomobility) l  Sensor (OrthoEurope) *Separate swing &

stance controls

KX06 (Endolite)

l  Polycentric knee l  Hydraulic cyclinder swing

& stance control l  Swing only (hyperextend

knee, lift lever) l  Can lock l  Mode to cycling/run

3R80 (Otto Bock)

l  Rotary hydraulic system for stance & swing

l  Weight activated stance, responds to GRF, variable

l  Unload to swing, variable speeds

Mauch Knee (Ӧssur)

l  Single axis hydraulic cylinder

l  Swing & stance control l  Swing only (hyperextend

knee, lift lever) l  Hyperextension moment to

disengage stance l  Manual lock

VGK (Orthomobility)

l  Adaptive fluidic joint l  Third technology l  Variable swing l  Stumble recovery l  Stance resistance

(yield) l  Bike mode l  Water resistant

Sensor (OrthoEurope)

l  Weight activated hydraulic knee

l  Downstairs leg over leg yield

l  Stance lock l  Electronic device records

activity (steps taken, distance walked

Microprocessor Controlled (MPC) knees with yield

l  Orion (Endolite) l  Plié (Freedom

Innovations) l  Rheo knee III (Ӧssur) l  C leg (Otto Bock) l  Genium/X3 (Otto Bock) l  Power knee II (Ӧssur)

Orion (Endolite) l  Hydraulic stance,

drops off in swing l  One speed yield l  No stance flexion l  Toe load stance

release l  High stance

resistance if no battery but adjusts

Orion (Endolite)

l  Pneumatic, variable swing

l  Weather proof l  2 modes l  Can run/cycle

Plié (Freedom Innovations) l  Stance flexion l  Variable swing phase l  Water resistant l  Stumble control l  Can ‘run’ l  Plié 3 – submersible &

robust

Rheo knee III (Ӧssur) l  Default is free in NWB l  Stance - weight activated l  Magneto-rheological fluid l  Release into swing: toe

load & pelvic rotation creates extension moment at knee

l  Manual lock

Rheo Knee III (Össur)

l  Stance resistance adjusts to weight

l  More load, more resistance*

l  Unload for swing on slopes & stairs (no extension moment required)

C leg (Otto Bock) l  Default straight; unload or

with no battery or in sitting l  Initiate swing via toe load l  Not for sport but will ‘run’ l  Care backwards as may

trigger swing phase!

C leg (Otto Bock)

l  Constant hydraulic stance flexion resistance, initiate through heel load (sit, slope, stairs)

l  Resistance does not adapt to different weight shoes or carrying luggage

Genium/X3 (Otto Bock)

l  Stance resistance down stairs, initiate foot over step

l  Weight activated stance l  Position and weight

deactivated swing l  Adjusts to weight changes

(shoes, bags) l  X3 – water proof, run mode

Genium/X3 (Otto Bock)

l  Intuitive stance – allows more normal posture (stand on flexed knee)

l  Stance flexion pre set 4º l  No concentric power but step

up or over on ‘locked’ flexed knee

l  Safe backwards, no toe trigger l  5 extra modes, splash proof,

will ‘run’ l  Straight when no power, can

alter

Power knee II (Ӧssur) l  Position and weight activated l  Concentric power in stance

•  Climb a stair & slope •  Rise/lower in sitting •  Push through objects •  Rest in knee flexion

l  Uneven ground l  ‘Off road’, unload sound leg l  Will not ‘run’ l  Two batteries a day required

Why are MPC knees the bees knees?

l  Stable, responsive and forgiving

l  Allow more normal posture l  Allow more normal

movement pattern l  Less compensations l  Fewer falls l  Increased confidence

So, what does the knee do -functions & features?

l  Stance flexion resistance variability

l  Stumble recovery l  Stairs ascent l  Water proof l  Hobbies (run, bike) l  Battery life l  Noise l  Size, build height

l  Appearance l  Battery empty l  Additional modes l  Weight of unit l  Weight of user l  Car charger l  Power l  Socket fit l  Foot function

What can the user do? What does the user need?

Motor skills – co-ordination, flexibility, body control, endurance, stamina, fitness, athletic prowess and agility, proprioceptivity

Co-morbidities - contralateral limb, OA, other amputations and injury, pain, socket stability, suspension and comfort, residual limb condition

Lifestyle, goals, attitude, intelligence, technical interest, compliance, diligence, motivation, support network,

Confidence & fear of falling, commitment, time & ability to learn, personality, cosmetic requirements, previous prosthetic history and bad habits, expectations

Access to specialist physiotherapy?

‘Advanced’ Rehabilitation

l  Lifting & carrying l  Head turning l  360º turning l  Eyes shut *Use Tinetti &

AmpPro as guide

‘Advanced’ rehabilitation? l  Shopping centres

• Escalators • Stairs & slopes • Crowds

l  Park - grass good for running & yield

l  Chill factor e *Use ABC scale as guide

Fitness, exercise & running l  Core stability:

mat, gym ball, Theraband

l  Step box routine, with weights

l  Trampet l  Running drills l  Boxing

Fitness, exercise & running

l  Nordic walking l  Fitness Initiative (gym) l  Personal trainers &

buddies l  AlterG treadmill &

balance plate l  Cycling l  Sports groups

Training commitment

Thank You & Demonstration

‘Yield’ training: l Stand to sit – weight thru’ heel, flex hip l Down steps – load stance flexion, foot over step l Down slopes – load stance flexion, not a walking action