23 physical therapy management of adult lower limb amputees

Normal VersionChapter 23 - Atlas of Limb Prosthetics: Surgical, Prosthetic, and Rehabilitation Principles

Physical Therapy Management of Adult Lower-LimbAmputees

Robert S. Gailey, Jr., M.S.Ed., P.T. Curtis R. Clark, P.T.

The prosthetist and the physical therapist, as members of the rehabilitation team, often develop a very closerelationship when working together with lower-limb amputees. The prosthetist is responsible for fabricating andmodifying the specific socket design and providing prosthetic components that will best suit the life-style of a particularindividual. The physical therapist's role is threefold. First, the amputee must be physically prepared for prosthetic gaittraining and educated about residual-limb care prior to being fitted with the prosthesis. Second, the amputee must learnhow to use and care for the prosthesis. Prosthetic gait training can be the most frustrating, yet rewarding phase ofrehabilitation for all involved. The amputee must be patiently educated in the biomechanics of prosthetic gait. Oncesuccess is achieved, the amputee may look forward to resuming a productive life. Third, the therapist should introducethe amputee to higher levels of activities beyond just learning to walk. Although the amputee may not be ready toparticipate in recreational activities immediately, providing the names of support groups and disabled recreationalorganizations can furnish the necessary information for the individual to seek involvement when ready.

PRESURGICAL MANAGEMENT

Initial Patient Contact

This time provides an opportunity for the therapist to introduce himself to the patient and, in conjunction with otherqualified members of the rehabilitation team, to prepare the patient for the events to come. Specifically, the therapist willattempt to develop a professional rapport with the patient and earn his trust and confidence. This period also offers thetherapist an excellent opportunity to explain the time frame of the rehabilitation process. Fear of the unknown can beextremely frightening to many patients; therefore, having the comfort of knowing what the future holds as well as whatwill be expected of them can ease the process. A visit from another amputee who has been successfully rehabilitatedcan assist in this process. The visiting amputee should be carefully screened by appropriate personnel and should havea suitable personality for this task. Additional considerations should be given to similarities between level of amputation,age, gender, and outside interests. If available, any information on various prostheses or videos showing recreationalactivities may benefit the patient. The therapist must also keep in mind how much information the patient ispsychologically prepared to hear. Many hospitals have affiliations with local support groups, where amputees visit otheramputees to help them throughout the healing process.

The pragmatic aspect of the therapist's responsibilities presurgically will include discussing the possibilities of phantomlimb sensation and discomfort, joint contracture prevention, as well as overall functional assessment. If the patient sodesires, a prosthesis may be introduced at this point to satisfy curiosity.

POSTSURGICAL MANAGEMENT

Evaluation

Past Medical History

A complete medical history should be taken from the patient or obtained from the medical records to provide thetherapist with information that may be pertinent to the rehabilitation program.

Mental Status

An accurate assessment of the patient's mental status can lend insight into the likely comprehension level for futureprosthetic care. The therapist should be concerned with assessing the patient's potential to cognitively perform activitiessuch as donning and doffing the prosthesis, residual-limb sock regulation, bed positioning, skin care, safe ambulation,and other functional activities of the amputee. If the patient does not possess the necessary level of cognition, familymembers and/or friends should become involved in the rehabilitation process to help ensure a successful outcome.

Range of Motion

23: Physical Therapy Management of Adult Lower-Limb Amputees |... http://www.oandplibrary.org/alp/chap23-01.asp?mode=print

1 of 29 1/20/2014 6:02 PM

A functional assessment of gross upper-limb and sound lower-limb motions should be made. A measurement of theresidual limb's range of motion (ROM) should be recorded for future reference. Joint contractures are complications thatcan greatly hinder the amputee's ability to ambulate efficiently with a prosthesis; thus extra care should be taken toavoid them. The most common contracture for the transfemoral amputee is hip flexion, external rotation, and abduction,while knee flexion is the most frequently seen contracture for the transtibial amputee. During the ROM assessment thetherapist should determine whether the patient has a fixed contracture or just soft-tissue tightness from immobility thatcan be corrected within a short period of time. This may affect the manner in which the prosthesis is fabricated.

Strength

Functional strength of the major muscle groups should be assessed by manual muscle testing of all limbs including theresidual limb and the trunk. This will help determine the patient's potential skill level to perform activities such astransfers, wheelchair management, and ambulation with and without the prosthesis.

Sensation

Evaluation of the amputee's sensation is useful to both the patient and therapist alike. The therapist can gain insightinto the possible insensitivity of the residual limb and/or sound limb. This may affect proprioceptive feedback forbalance and single-limb stance, which in turn can lead to gait difficulties. The patient must be made aware thatdecreased pain, temperature, and light touch sensation can increase the potential for injury and tissue breakdown.

Bed Mobility

The importance of good bed mobility extends beyond simple positional adjustments for comfort or to get in and out ofbed. The patient must acquire bed mobility skills to maintain correct bed positioning in order to prevent contractures orexcessive friction of the sheets against the suture line or frail skin. If the patient is unable to perform the skills necessaryto maintain proper positioning, assistance must be provided. As with most patients, adequate bed mobility is a basicrequirement for higher-level skills such as bed-to-wheelchair transfers.

Balance/Coordination

Sitting and standing balance are of major concern when assessing the amputee's ability to maintain the center ofgravity over the base of support. Coordination assists with ease of movement and the refinement of motor skills. Bothbalance and coordination are required for weight shifting from one limb to another, thus improving the potential for anoptimal gait. After evaluating mental status, ROM, strength, sensation, balance, and coordination, the therapist will havea good indication of what would be the most appropriate choice of assistive device to use initially with the individualamputee.

Transfers

Transfer skills are essential for early mobility. Additional functional transfers such as toilet, shower, and car transfersmust also be assessed before discharge to more completely determine the patient's level of independence. Fortranstibial amputees who are not ambulatory candidates, a very basic prosthesis may be indicated for transfers only.

Wheelchair Propulsion

The primary means of mobility for a large majority of amputees, either temporarily or permanently, will be thewheelchair. The energy conservation of the wheelchair over prosthetic ambulation is considerable with some levels ofamputation. Therefore, wheelchair skills should be taught to all amputees during their rehabilitation program.

Ambulation With Assistive Devices Without a Prosthesis

A traditional evaluation of the amputee's potential for ambulation is performed, including strength of the sound lowerlimb and both upper limbs, single-limb balance, coordination, and mental status. The selection of an assistive deviceshould meet with the amputee's level of skill, while keeping in mind that with time the assistive device may change. Forexample, initially an individual may require a walker, but with proper training, forearm crutches may prove morebeneficial as a long-term assistive device.

Some patients who have difficulty in ambulating on one limb secondary to obesity, blindness, or generalized weaknesscan still be successful prosthetic ambulators when the additional support of a prosthesis is provided (Fig 23-1a. and Fig23-1b.).


2 of 29 1/20/2014 6:02 PM

Fig 23-1a. Page 1 of initial evaluation form.


3 of 29 1/20/2014 6:02 PM

Fig 23-1b. Page 2 of initial evaluation form.

Cardiac Precautions for Amputees

During the initial chart review, the therapist should make note of any history of coronary artery disease, congestiveheart failure, peripheral vascular disease, arteriosclerosis, hypertension, angina, arrhythmias, dyspnea, angioplasty,myocardial infarction, arterial bypass surgery, as well as prescribed cardiovascular medications that may affect theblood pressure and heart rate.

The heart rate and blood pressure of every patient should be closely monitored during initial training and thereafter asthe intensity of training increases. If the amputee experiences persistent symptoms such as shortness of breath, pallor,diaphoresis, chest pain, headache, or peripheral edema, further medical evaluation is strongly recommended.

Patient Education: Limb Management


4 of 29 1/20/2014 6:02 PM

Limb Care

It is important that the patient understand the care of the residual limb and sound limb. For example, the dysvascularpatient's prosthetic gait training could be delayed 3 to 4 weeks if an abrasion should occur. The patient must be taughtthe difference between weight-bearing areas and pressure-sensitive areas and also be oriented to the design of thesocket and the functions of the prosthetic componentry.

Problem Detection/Skin Care

Every patient should be instructed to visually inspect the residual limb on a daily basis or after any strenuous activity.More frequent inspection of the residual limb should be routine in the initial months of prosthetic training. A hand mirrormay be used to view the posterior aspect of the residual limb. Reddened areas should be monitored very closely aspotential sites for abrasions. If a skin abrasion occurs, the patient must understand that in most cases the prosthesisshould not be worn until healing occurs.

Prosthetic Management

The socket should be cleaned daily to promote good hygiene and prevent deterioration of prosthetic materials. As arule, solid plastic materials are cleaned with a damp cloth and foam materials with rubbing alcohol. The patient shouldalso be reminded that routine maintenance of the prosthesis should be performed by the prosthetist to ensuremaximum life and safety of the prosthesis.

Sock Regulation

Sock regulation is of extreme importance to prevent pistoning from occurring. The patient should carry extra socks at alltimes in case of pistoning or extreme perspiration. A thin nylon sock (sheath) should cover the residual limb to assist inreducing friction at the residual-limb/socket interface. Stump socks are available in assorted plies or thickness thatpermit the patient to obtain the desired fit within the socket. Socks should be applied wrinkle free, with the seamshorizontal and on the outside to prevent additional pressure on the skin.

Donning and Doffing of the Prosthesis

Today, there is a wide variety of suspension systems for all levels of amputation. To list just a few possibilities, thetranstibial amputee has the option of a hard socket with or without a soft insert, which could include auxiliarysuspension, a medial wedge, and suction or suction silicone sockets, while the transfemoral amputee has the choice ofa nonsuction external suspension or a suction suspension socket that can be donned with an elastic bandage, pullsock, wet fit, or a silicone sleeve. The methods of donning each of these combinations are too numerous for the scopeof this chapter; however, what is important is that the amputee become proficient in the method of donning and doffing

his particular prosthesis.

Residual-Limb Wrapping

Early wrapping of the residual limb can have a number of positive effects: (1) decrease edema and prevent venousstasis by ensuring a proper distal-to-proximal pressure gradient, (2) assist in shaping, (3) help counteract contracturesin the transfemoral amputee, (4) provide skin protection, (5) reduce redundant-tissue problems, (6) reduce phantomlimb discomfort/sensation, and (7) desensitize the residual limb with local pain. Controversy does exist concerning theuse of traditional elastic bandaging vs. the use of residual-limb shrinkers. Currently, many institutions prefer commercialshrinkers for their ease and reproducibility of donning. Advocates of elastic bandaging state that more control overpressure gradients and tissue shaping is provided. Regardless of individual preference, application must be performedcorrectly to prevent (1) circulation constriction, (2) poor residual-limb shaping, and (3) edema (Fig 23-2. and Fig 23-3.).


5 of 29 1/20/2014 6:02 PM

Fig 23-2. Transtibial residual limb wrapping. 1, begin by placing a double-length 4-in. elastic

bandage above the kneecap. 2, wrap around once to secure the bandage comfortably, but not

too tightly. 3, continue the bandage around the back, and cross to corner D. 4, bring thebandage around corner D, and cross upward in a direction toward B. 5, continue around the

back toward A. 6, wrap the bandage across and down to corner C. 7, continue to wrap around

the end and cover corner D. 8, move upward and across the front toward B. 9, continue to

move across the back and down toward corner D. 10, move upward and across the fronttoward B. 11, continue to move across the back toward A. 12, move down and across the

front toward corner C. 13,continue to wrap across the end and cover corner D. 14, move up

and across the front toward B. 15, continue across the back, and move down and across the


6 of 29 1/20/2014 6:02 PM

front toward corner C. 16, move around corner C toward corner D and continue up and across

the front toward B. This is the figure-of-8 pattern guide. 17, continue with the figure-of-8pattern, and move the bandage higher on the residual limb until completely covered in a

figure-8-pattern. Remember to apply less pressure as you move up. Complete the wrap by

anchoring it with tape.

Fig 23-3. Transfemoral residual limb wrapping. 1, begin by placing a double-length 6-in.

elastic bandage at letter D, and cross down to corner B. Note that the pressure should beuniform throughout part 1 (Nos. 1 to 8) of the wrapping procedure. 2, continue the bandage


7 of 29 1/20/2014 6:02 PM

around corner C, and cross the front up toward A 3, wrap around the waist, with the thigh

extended, and then back toward A 4, continue around the back of the thigh toward D. 5, crossto A, and wrap the uppermost part of the inner aspect of the thigh. 6, again, wrap the bandage

around the waist to A and then around the back of the thigh to D, and cover the upper inner

part of the thigh again. 7, return toward A, wrap the bandage down and across the back to

corner C, and then again return toward A. 8, wrap around the back, and anchor with tape. Thiscompletes part 1 with the 6-in. bandage. 9, part II: begin by placing a double-length 4-in.

elastic bandage on the residual limb between the corners A and B. Wrap diagonally around

corners B and C. 10, cross upward toward A, and anchor the wrap. 11, continue around the

back and down to corner C. 12, wrap upward and across to A and then around the backtoward D. 13, continue down and across to cover corners B and C. 14, continue upward and

across to A This is the figure-of-8 pattern guide. 15, wrap around the back toward D. 16,

continue down, and wrap corners b and C, but wrap slightly higher than the previous time

around. Continue wrapping higher on the residual limb until the figure-of-8 bandage iscompleted. 17, remember to apply less pressure as you move up. Complete the wrap by

anchoring it with tape. Note that the angle between the figure 8s should be 80 to 90 degrees

at the crossover point to avoid a tourniquet effect.

Preprosthetic Exercise

Strengthening

Eisert and Tester first described dynamic residual-limb exercises in 1954.2 Since then, their antigravity exercises have

been the most favored method of strengthening the residual limb. These dynamic exercises require little in the way ofequipment. A towel roll and step stool are all that is required. They also offer benefits aside from strengthening, such asdesensiti-zation, bed mobility, and joint ROM. The exercises are relatively easy to learn and can be performedindependently, thus permitting the therapist to spend patient contact time on other more advanced skills.

Incorporating isometric contractions at the peak of the isotonic movement will help to maximize strength increases. Aperiod of a 10-second contraction followed by 10 seconds of relaxation for 10 repetitions gives the patient an easymnemonic to remember, the "rule of ten." The rationale behind a 10-second contraction is that a maximal isometriccontraction can be maintained for 6 seconds; however, there is a 2-second rise time and a 2-second fall time for a total

of 10 seconds.1

All amputees should consider performing abdominal and back extensor strengthening exercises to maintain trunkstrength, decrease the possible risk of back pain, and assist in the reduction of gait deviations associated with the trunk.

The following illustrations demonstrate the basic dynamic strength training program for transfemoral and transtibialamputees (Fig 23-4.).


8 of 29 1/20/2014 6:02 PM

Fig 23-4. Residual-limb strengthening exercises.

Amputees who have access to isotonic and isokinetic strengthening equipment can take advantage of the benefitsderived from these forms of strengthening with few modifications in their positioning on the machines.

Range of Motion

Prevention of decreased ROM and contractures is a major concern to all involved. Limited ROM can often result indifficulties with prosthetic fit, gait deviations, or the inability to ambulate with a prosthesis altogether. The best way toprevent loss of ROM is to remain active and ensure full ROM of affected joints. Unfortunately, not all amputees havethis option, and therefore, proper limb positioning becomes important. The transfemoral amputee should place a pillowlaterally along the residual limb to maintain neutral rotation with no abduction when in a supine position. If the proneposition is tolerable during the day or evening, a pillow is placed anteriorly under the residual limb for 20 to 30 minutes,two to three times daily, to maintain hip extension. Transtibial amputees should avoid knee flexion for prolonged periodsof time. A stump board will help maintain knee extension when using a wheelchair. All amputees must be made awarethat continual sitting in a wheelchair without any effort to promote hip extension may lead to limited motion duringprosthetic ambulation (Fig 23-5.).


9 of 29 1/20/2014 6:02 PM

Fig 23-5. Proper residual-limb positioning. A, neutral hip rotation with no abduction. B, knee

extension when in bed. C, hip and knee extension when prone. D, knee extension when sitting.

Amputees who have already developed a loss of ROM may benefit from many of the traditional therapy proceduressuch as passive ROM, contract-relax stretching, soft-tissue mobilization, myofascial techniques, joint mobilization, andother methods that promote increased ROM.

Functional Activities

Encouraging activity as soon as possible after amputation surgery helps speed recovery in several ways. First, it willoffset the negative affects of immobility by promoting movement through the joints, muscle activity, and increasedcirculation. Second, the patient will begin to re-establish personal independence, which may be perceived asthreatened due to limb loss. Finally, the psychological advantage derived from activity and independence will continueto motivate the patient throughout the rehabilitation process.

General Conditioning

A decrease in general conditioning and endurance are contributory factors leading to difficulties in learning functionalactivities and prosthetic gait training. Regardless of age or present physical condition, a progressive general exerciseprogram should be prescribed for every patient beginning immediately after surgery, continued throughout thepreprosthetic period, and finally incorporated as part of the daily routine.

The list of possible general strengthening/endurance exercise activities is long: cuff weights in bed, wheelchairpropulsion for a predetermined distance, dynamic residual-limb exercises, ambulation with an assistive device prior toprosthetic fitting, loweror upper-limb ergometer work, wheelchair aerobics, swimming, aquatic therapy, lowerandupper-body strengthening at the local fitness center, and any sport or recreational activity of interest. The amputeeshould select one or more of these, begin participation to tolerance, and progress to 1 hour or more a day.

The advantages of participation extend well beyond improving the chances of ambulating well with a prosthesis. Theindividual has the opportunity to experience and enjoy activities thought impossible for an amputee. If difficulties areexperienced, the amputee is still within an environment where assistance may be readily obtained either from thetherapist or from a fellow amputee who has mastered a particular activity.


10 of 29 1/20/2014 6:02 PM

Bed Mobility

The severely involved patient may be taught to utilize a trapeze, side rail, or human assistance when learning bedmobility. This practice, however, should not be employed for the general amputee population because, while easierinitially, continued use of these methods will only hamper the future rehabilitation process. Regardless of age, eachpatient should be taught a safe and efficient manner in which to roll, come to sitting, or adjust their position. Log rolling,followed by side lying to sitting or supine lying on elbows to long sitting, are two acceptable methods that incorporate allthe necessary skills for efficient bed mobility.

Transfers

Once bed mobility is mastered, the patient must learn to transfer from the bed to a chair or wheelchair and thenprogress to more advanced transfer skills such as to the toilet, tub, and car. Unilateral amputees initially are taughtsingle-limb transfers where the wheelchair is positioned on the sound-limb side and the patient pivots over the limbwhile maintaining contact with either the bed or chair. In most cases, it is advised that transfers to both the sound andinvolved side be taught since the patient will frequently be in situations where transferring to the sound side will not bepossible. As the patient's single-limb standing balance improves, more advanced transfers may be taught to improvethe patient's independence. In cases where an immediate postoperative or preparatory prosthesis is utilized, weightbearing through the prosthesis can assist the patient in the transfer and provide additional safety.

Bilateral amputees who are not fitted with an initial prosthesis transfer in a "head-on" manner. The wheelchairapproaches the mat or chair, with the front of the chair abutting the transferring surface. The patient then slides forwardonto the desired surface by lifting the body and pushing forward with both hands. Until adequate strength of thelatissimus dorsi and triceps is attained for this transfer, a lateral sliding-board transfer will be necessary to minimize

friction and to cross the gap between the chair and desired surface (Fig 23-6.).

Fig 23-6. Head-on wheelchair-to-mat transfer.

Wheelchair Propulsion

Wheelchair mobility is the first skill that will give the amputee independence in the world outside of the hospital room.The degree of skill and mastery of the wheelchair varies depending on age, strength, and agility. Basic skills such asforward propulsion, turns, and preparation for transfers, i.e., parking and braking, should be taught immediately. Later,advanced wheelchair skills should be taught: ascending and descending inclines, wheelies, floor-to-wheelchairtransfers, and curb jumping. The time dedicated to wheelchair skills is dependent on the degree to which the amputeemay potentially require the wheelchair. Bilateral and older amputees may require greater use of the wheelchair, whileunilateral and younger amputees will be more likely to utilize other assistive devices when not ambulating with theirprosthesis. Because of the loss of body weight anteriorly the amputee will be prone to tipping backward while in thestandard wheelchair. Amputee adapters set the wheels back approximately 5 cm, thus moving the amputee's center ofgravity forward to prevent tipping, especially when ascending ramps or curbs.

Unsupported Standing Balance

In preparation for ambulation without a prosthesis, all amputees must learn to compensate for the loss of weight of theamputated limb by balancing the center of gravity over the sound limb. Although this habit must be broken whenlearning prosthetic ambulation, single-limb balance must be learned initially to provide confidence during stand pivottransfers, ambulation with assistive devices, and eventually hopping, depending on the amputee's level of skill. Apatient should be able to balance for at least 0.5 seconds to allow for smooth and safe progression of an assistivedevice during ambulation.


11 of 29 1/20/2014 6:02 PM

One method of progressive ambulation starts with the amputee standing in the parallel bars while using both hands forsupport. Once confidence in standing with double arm support is attained, the hand on the same side as the amputatedlimb should be removed from the bars; subsequently both hands are removed as independent balance is achieved. Inorder to improve balance and righting skills, the patient should be challenged by gently tapping the shoulders in multipledirections or tossing a ball back and forth (Fig 23-7.). Allow enough time between taps or throws for the patient toregain a comfortable standing posture. Once confidence is gained within the parallel bars, the patient should practicethese skills outside the parallel bars, eventually progressing to hopping activities.

Fig 23-7. Balancing activities.

Ambulation With Assistive Devices

All amputees will need an assistive device for times when they choose not to wear their prosthesis or for occasionswhen they are unable to wear their prosthesis secondary to edema, skin irritation, or poor prosthetic fit. Other amputeeswill require an assistive device while ambulating with the prosthesis. There are a variety of assistive devices to choose

from. While safety is a primary factor in selecting an appropriate assistive device, mobility is a secondary considerationthat cannot be overlooked. The criteria for selection should include (1) unsupported standing balance, (2) upper-limbstrength, (3) coordination and skill with the assistive device, and (4) cognition. A walker is chosen when a amputee hasfair to poor balance, strength, and coordination. If balance and strength are good to normal, forearm crutches may beused for ambulation with or without a prosthesis. A quad or straight cane may be selected to ensure safety whenbalance is questionable while ambulating with a prosthesis.

Pregait Training

Balance and Coordination

After the loss of a limb, the decrease in body weight will alter the body's center of gravity. In order to maintain thesingle-limb balance necessary during stance without a prosthesis, ambulating with an assistive device, or single-limbhopping, the amputee must shift the center of gravity over the base of support, which in this case is the foot of thesound limb. As amputees become more secure in their single-limb support, there is greater difficulty in reorienting themto maintaining the center of gravity over both the sound and prosthetic limbs. Ultimately, amputees must learn tomaintain the center of gravity and their entire body weight over the prosthesis. Once comfortable with weight bearingequally on both limbs, the amputee can begin to develop confidence with independent standing and eventually withambulation.

Orientation to the Center of Gravity and Base of Support

Orientation of the center of gravity over the base of support in order to maintain balance requires that the amputee


12 of 29 1/20/2014 6:02 PM

become familiar with these terms and aware of their relationship. The body's center of gravity is located just anterior tothe second sacral vertebra. Average persons stand with their feet 5 to 10 cm (2 to 4 in.) apart, varying according to

body height.3, 5

Various methods of proprioceptive and visual feedback may be employed to promote the amputee'sability to maximize the displacement of the center of gravity over the base of support. The amputee must learn todisplace the center of gravity forward and backward, as well as from side to side (Fig 23-8. and Fig 23-9.). Theseexercises vary little from traditional weight-shifting exercises, with the one exception that concentration is placed on themovement of the center of gravity over the base of support rather than weight bearing into the prosthesis. Increasedweight bearing will be a direct result of improved center of gravity displacement and will establish a firm foundation foractual weight shifting during ambulation.

Fig 23-8. Lateral weight-shifting and balance orientation.

Fig 23-9. Forward and backward weight-shifting and balance orientation.

Single-Limb Standing


13 of 29 1/20/2014 6:02 PM

Weight acceptance in the prosthesis is one of the most difficult challenges facing both therapist and amputee. Withoutthe ability to maintain full single-limb weight bearing and balance for an adequate amount of time (0.5 secondsminimum) the amputee will exhibit a number of gait deviations, including (1) decreased stance time on the prostheticside, (2) a shortened stride length on the sound side, or (3) lateral trunk bending over the prosthetic limb. Strength,balance, and coordination are the primary physical factors influencing single-limb stance on a prosthesis. Additionally,fear, pain, and lack of confidence in the prosthesis must be considered when an amputee is demonstrating extremedifficulty in overcoming weight bearing on the prosthesis. It is important to recognize the need to promote adequateweight bearing and balance on the prosthesis prior to and during ambulation.

Single-limb balance over the prosthetic limb while advancing the sound limb should be practiced in a controlled mannerso that when required to do so in a dynamic situation such as walking, this skill can be employed with relatively littledifficulty. The stool-stepping exercise is an excellent method by which this skill may be learned. Have the amputeestand in the parallel bars with the sound limb in front of a 10- to 20-cm (4- to 8-in.) stool (or block), its height dependingon the patients level of ability. Then ask the amputee to step slowly onto the stool with the sound limb while usingbilateral upper-limb support on the parallel bars. To further increase this weight-bearing skill ask the patient to removethe sound-side hand from the parallel bars and eventually the other hand. Initially, the speed of the sound leg willincrease when upper-limb support is removed, but with practice the speed will become slower and more controlled, thuspromoting increased weight bearing on the prosthesis (Fig 23-10.).

Fig 23-10. Stool-stepping exercise.

The amputee's ability to control sound-limb advancement is directly related to the ability to control prosthetic limbstance. The following are three contributing factors that may help the amputee achieve adequate balance over theprosthetic limb. First, control of the musculature of the residual limb is necessary to maintain balance over theprosthesis. Second, the patient must learn to utilize the available proprioceptive sensation at the residual-limb/socketinterface to control the prosthesis. Third, the amputee must visualize the prosthetic foot and its relationship to theground. New amputees will find it difficult to understand this concept at first but will gain a greater appreciation as timegoes on.

Gait-Training Skills

Sound Limb and Prosthetic Limb Training

Another component in adjusting to the amputation of a limb is restoration of the gait biomechanics that were unique to a

particular person prior to the amputation. That is to say, not everyone has the same gait pattern. Prostheticdevelopments in the last decade have provided limbs that more closely replicate the mechanics of the human leg.Therefore, the goal of gait training should be the restoration of function to the remaining joints of the amputated limb.Prosthetic gait training should not alter the amputee's gait mechanics for the prosthesis, but instead, the mechanics ofthe prosthesis should be designed around the amputee's individual gait.

Pelvic Motions

The pelvis, with the body's center of gravity, moves as a unit in four directions: it displaces vertically, shifts laterally, tilts


14 of 29 1/20/2014 6:02 PM

horizontally, and rotates transversely. Each of these motions can directly affect the amputee's gait and result in gaitdeviations or increased energy consumption during ambulation. If restoration of function to the remaining joints of theamputated limb is a goal of gait training, then the pelvic motions play a decisive role in determining the final outcome ofan individual's gait pattern.

Vertical displacement is simply the rhythmic upward and downward motion of the body's center of gravity. Theknee must flex 10 to 15 degrees during foot flat, and full extension must be obtained during midstance. Thetranstibial amputee has the ability to flex and extend the knee during the stance phase of gait. The transfemoralamputee is at a disadvantage because the knee must remain in extension throughout the entire stance phase toavoid buckling of the knee (Fig 23-11.).

1.

Lateral shift occurs when the pelvis shifts from side to side approximately 5 cm (2 in.). The amount of lateral shiftis determined by the width of the base of support, which is 5 to 10 cm (2 to 4 in.), depending on the height of theindividual. Amputees have to spend an inordinate amount of time in single-limb standing on the sound limb whenthey are on crutches and hopping without the prosthesis or during relaxed standing. Because of this, theybecome adept at maintaining their center of gravity over the sound limb and therefore have a habit of crossingmidline with the sound foot, which leaves inadequate space for the prosthetic limb to follow a natural line ofprogression. The result is an abducted or circumducted gait with greater-than-normal lateral displacement of thepelvis toward the prosthetic side. While more frequently observed in transfemoral amputees, this altered base ofsupport may also be seen with transtibial amputees (Fig 23-12.).

2.

Horizontal dip of the pelvis is normal up to 5 degrees; anything greater is considered a gluteus me-dius gait.Usually, this is directly related to weak hip abductor musculature, more specifically, the gluteus medius.Maintenance of the residual femur in adduction via the socket theoretically places the gluteus medius at theoptimal length-tension ratio. However, if the limb is abducted, the muscle is placed in a compromised positionand is unable to function properly. The result is a gluteus medius gait where the trunk leans laterally over the

side of the weak limb in an attempt to maintain the pelvis in a horizontal position (Fig 23-12.).

3.

Transverse rotation of the pelvis occurs around the longitudinal axis approximately 5 to 10 degrees to eitherside. This transverse rotation assists in shifting the body's center of gravity from one side to the other. Inaddition, it also helps to initiate the 30 degrees of knee flexion during toe-off that is necessary to achieve 60degrees of knee flexion during the acceleration phase of swing. Knee flexion during toe-off is created by otherinfluences as well, including plantar flexion of the foot, horizontal dip of the pelvis, and gravity. No prosthetic footpermits active plantar flexion, and horizontal dip greater than 5 degrees is abnormal; therefore restoration oftransverse rotation of the pelvis becomes of great importance in order to obtain sufficient knee flexion (Fig23-13.).

4.

Normalization of trunk, pelvic, and limb biomechanics can be taught to the amputee in a systematic way. First,independent movements of the various joint and muscle groups are developed. Second, the independent movementsare incorporated into functional movement patterns of the gait cycle. Finally, all component movement patterns areintegrated to produce a smooth normalized gait.

One suggested method of training is as follows:

Strengthening of all available musculature by dynamic residual-limb exercises (see "Preprosthetic Exercise").1.Proprioceptive neuromuscular facilitation (PNF), Feldenkrais, or any other movement awareness techniquesmay be performed for trunk, pelvic, and limb re-education patterns. These exercises encourage rotationalmotions and promote independent movements of the trunk, pelvic girdle, and limbs.

2.

Pregait training exercises (see "Pregait Training").3.Sound-limb stepping within the parallel bars is performed with the amputee stepping forward and backward, heelrise to heel strike, with both hands on the bars. The purpose of this activity is for the amputee and therapist tobecome familiar with the gait mechanics of the sound limb without having to be concerned about weight bearingand balance on the prosthetic limb. This also affords the therapist an opportunity to palpate the anterior superioriliac spines (ASIS) in order to gain a feeling for the patient's pelvic motion, which in most cases is close tonormal for that individual (Fig 23-14.).

4.

Prosthetic-limb stepping in the parallel bars is similar to the activity described above except that the amputeeuses the prosthetic limb. As the therapist palpates the ASIS, in many cases a posterior rotation of the pelvis willbe observed. This is often the result of the amputee's attempt to kick the prosthesis forward with the residuallimb. The pelvis rotates posteriorly, just as it would if someone were kicking a football.It is important that theamputee feel the difference between the pelvic motion on the prosthetic side and the sound side.

5.

To restore the correct pelvic motion, the amputee places the prosthetic limb behind the sound limb while holdingon to the parallel bars with both hands. The therapist blocks the prosthetic foot to prevent forward movement ofthe prosthesis. Rhythmic initiation is employed to give the amputee the feeling of rotating the pelvis forward aspassive flexion of the prosthetic knee occurs. As the amputee becomes comfortable with the motion, he canbegin to move the pelvis actively, eventually progressing to resistive movements when the therapist deems themappropriate (Fig 23-15.).

6.

Once the amputee and therapist are satisfied with the pelvic motions, the swing phase of gait can be taught. The7.


15 of 29 1/20/2014 6:02 PM

amputee is now ready to step forward and backward with the prosthetic limb. Attention must be given to thepelvic motions, that the line of progression of the prosthesis remains constant without circumducting, and thatheel contact occurs within boundaries of the base of support (Fig 23-16.). As the amputee improves, release thesound-side hand from the parallel bars and eventually both hands. There should be little if any loss of efficiencywith the motion, but if there is, revert to the previous splinter skill.Return to sound-limb stepping with both hands on the parallel bars. Observe that the mechanics are correct andthat the sound foot is not crossing midline as heel strike occurs. When ready, have the amputee remove thesound-side hand from the bars. At this time, there may be an increase in the speed of the step, a decrease instep length, and/or lateral leaning of the trunk. This is a direct result of the inability to bear weight or balanceover the prosthesis. Cue the amputee in remembering the skills learned while performing the stool-steppingexercise (see "Pregait Training"). After adequate skill is perfected, sound-limb stepping without any hand supportmay be practiced until sufficient mastery of single-limb balance over the prosthetic leg is acquired (Fig 23-17.).

8.

When each of the skills described above is developed to an acceptable level, the amputee is ready to combinethe individual skills and actually begin walking with the prosthesis. Initially, begin in the parallel bars with thetherapist and amputee facing each other, the therapist's hands on the amputee's ASISs, and the amputeeholding onto the bars. As the amputee ambulates within the bars, the therapist applies slight resistance throughthe hips to provide proprioceptive feedback for the pelvis and musculature of the involved lower limb.

9.

When both the therapist and the amputee are comfortable with the gait demonstrated in the parallel bars, thesame procedure as described above is practiced out of the bars, with the amputee initially using the therapist'sshoulders as support and progressing to both hands free when appropriate. The therapist may or may notcontinue to provide proprioceptive input to the pelvis (Fig 23-18.). As the amputee begins to ambulateindependently, verbal cueing may be necessary as a reminder to keep the sound foot away from midline in orderthat the proper base of support can be maintained. Maintenance of equal stride length may not be immediatelyforthcoming because many amputees have a tendency to take a longer step with the prosthetic limb than the

sound limb. When adequate weight bearing through the prosthetic limb has been achieved, have the amputeebegin to take longer steps with the sound limb and slightly shorter steps with the prosthetic limb. This principlealso applies when increasing the cadence. When an amputee increases his speed of ambulation, the prostheticlimb often compensates by taking a longer step, thus increasing the asymmetry. By simply having the amputeetake a longer step with the sound limb and a moderate step with the prosthetic limb, increased speed of gait isaccomplished without increased asymmetry.

10.

Trunk rotation and arm swing are the final missing components in restoring the biomechanics of gait. Duringhuman locomotion, the trunk and upper limbs rotate opposite the pelvic girdle and lower limbs. Trunk rotation isnecessary for balance, momentum, and symmetry of gait. Many amputees have a decreased trunk rotation andarm swing, especially on the prosthetic side. This may be the result of fear of displacing their center of gravitytoo far forward or backward over the prosthesis (Fig 23-19.). Normal cadence is considered to be 90 to 120

steps per minute, or 2.5 mph.5 Arm swing provides balance, momentum, and symmetry of gait and is directly

influenced by the speed of ambulation.4 With acceleration of gait, arm swing excursion becomes greater, thuspermitting a more efficient gait due to increased forward momentum. Similarly, amputees who walk at slowerspeeds will demonstrate a diminished swing excursion and hence less gait efficiency. Restoring trunk rotationand arm swing is easily accomplished by utilizing rhythmic initiation or passively cueing the trunk as the amputeewalks. The therapist stands behind the amputee with one hand on either shoulder. As the amputee walks, thetherapist gently rotates the trunk. When the left leg steps forward, the right shoulder is rotated forward and viceversa. Once the amputee feels comfortable with the motion, he can actively take over the motion. Amputees whowill be independent ambulators as well as those who will require an assistive device can benefit to varyingdegrees from the above systematic rehabilitation program. Most patients can be progressed to the point ofambulating out of the parallel bars. At that time, the amputee must practice ambulating with the chosen assistivedevice and maintaining pelvic rotation, an adequate base of support, equal stance time, and equal stride length,all of which can have a direct influence on the energy cost of walking. Trunk rotation will be absent in amputeesutilizing a walker, but those ambulating with crutches or a cane should be able to incorporate trunk rotation intotheir gait.

11.

Variations

Naturally, the time and degree of prosthetic training required is individual to each amputee, depending on many factorssuch as age and motivation, as well as the cause and level of amputation.

Syme ankle disarticulates have a major advantage over transtibial amputees due to the ability to bear weight distally.This allows them to have better kinesthetic feedback for placement of the prosthetic foot. Because of this kinestheticcapability and the increased length of the lever arm, minimal prosthetic gait training is required. Although Syme ankledisarticulates are able to progress rapidly with weight shifting and other basic gait skills, they may require practice toattain equal stride length and stance time.

Knee disarticulates have several advantages over transfemoral amputees, including a longer lever arm, enhanced


16 of 29 1/20/2014 6:02 PM

muscular control, improved kinesthetic feedback, and greater distal-end weight bearing. Although these advantages doprovide an opportunity for decreased rehabilitation time, the knee disarticulate must learn all the same skills as atransfemoral amputee.

Hip disarticulates and transpelvic (hemipelvectomy) amputees have the additional responsibility of learning to masterthe skills of a mechanical hip joint as well as the knee joint and foot/ankle assembly. The gait-training procedures areessentially the same as for transfemoral amputees. In some cases the mechanical hip joint may dictate that a slightvaulting action is necessary in order to clear the ground.

Amputees of all levels should be educated in residual-limb sock regulation, knowledge of pressure and relief areas,care of the prosthesis, and residual-limb donning and doffing techniques.

Advanced Gait-Training Activities

Stairs

Ascending and descending stairs is most safely and comfortably performed one step at a time (step by step). A fewexceptional transfemoral amputees can descend stairs step over step, with or without a railing, or by the "jackknifing"method. Even fewer, very strong transfemoral amputees can ascend stairs step over step. Most transtibial amputeeshave the option of either method, while hip disarticulates and transpelvic amputees are limited to the step-by-stepmethod.

Step By Step

This method is essentially the same for all levels of amputees. When ascending stairs, the body weight is shifted to theprosthetic limb as the sound limb firmly places the foot on the stair. The trunk is slightly flexed over the sound limb asthe knee extends and raises the prosthetic limb to the same step. The same process is repeated for each step. Whendescending stairs, the body weight is shifted to the sound limb, which lowers the prosthetic limb to the step belowprimarily by eccentric contraction of the quadriceps muscle. Once the prosthetic limb is securely in place, body weight istransferred to the prosthetic limb, and the sound limb is lowered to the same step.

Transfemoral Amputees: Step Over Step

Timing and coordination become critical factors in executing stair climbing step over step. As the transfemoral amputeeapproaches the stairs, the prosthetic limb is the first to ascend the stairs by rapid acceleration of hip flexion with slightabduction in order to achieve sufficient knee flexion to clear the step. Some transfemoral amputees will actually hit theapproaching step with the toe of the prosthetic foot to achieve adequate knee flexion. With the prosthetic foot firmly onthe step, usually with the toe against the step riser, the residual limb must exert a great enough force to fully extend the

hip so that the sound foot may advance to the step above. As the sound-side hip extends, the prosthetic-side hip mustflex at an accelerated speed to achieve sufficient knee flexion to place the prosthetic foot on the next step above.

Descending stairs is achieved by placing only the heel of the prosthetic foot on the stair below and then shifting thebody weight over the prosthetic limb, thus passively flexing the knee. The sound limb must quickly reach the step belowin time to catch the body's weight. The process is repeated at a rapid rate until a rhythm is achieved. Most transfemoralamputees who have mastered this skill descend stairs at an extremely fast pace, much faster than would be consideredsafe for the average amputee. In fact, both ascending and descending stairs step over step for transfemoral amputeesis so difficult and energy demanding that the majority who master these skills still prefer the step-by-step method.

Transtibial Amputees: Step Over Step

When ascending stairs, the transtibial amputee who does not have the ability to dorsiflex his foot/ankle assembly mustgenerate a stronger concentric contraction of the knee and hip extensors in order to successfully transfer body weightover the prosthetic limb.

Descending stairs is very similar to normal descent with one exception: only the prosthetic heel is placed on the stair.This compensates for the lack of dorsiflex-ion within the foot/ankle assembly.

Crutches

When using crutches with stairs, hold both crutches in the hand opposite the handrail, or use both crutches in thetraditional manner.


17 of 29 1/20/2014 6:02 PM

Curbs

The methods described for stairs are identical for curbs. Depending on the level of skill, the amputee can step up ordown curbs with either leg.

Uneven Surfaces

A good practice with gait training is to have the amputee ambulate over a variety of surfaces, including concrete, grass,gravel, uneven terrain, and varied carpet heights. Initially, the new amputee will have difficulty in recognizing thedifferent surfaces secondary to the loss of proprioception. To promote an increased awareness, spending time ondifferent surfaces and becoming visually aware of the changes help to initiate this learning process. Additionally, theamputee must realize that it is important to observe the terrain ahead to avoid any slippery surfaces or potholes thatmight result in a fall.

Ramps and Hills

Ascending inclines presents a problem for all amputees because of the lack of dorsiflexion present within mostprosthetic foot/ankle assemblies. For most amputees, descending inclines is even more difficult than ascending,primarily because of the lack of plantar flexion in the foot/ankle assembly. Prosthesis wearers with knee joints have theadded dilemma of the weight line falling posterior to the knee joint, resulting in a flexion moment.

When ascending an incline, the body weight should be slightly more forward than normal to obtain maximal dosiflexionwith articulating foot/ankle assemblies or to keep the knee in extension. Depending on the grade of the incline, pelvicrotation with additional acceleration may be required in order to achieve maximal knee flexion during swing.

Descent of an incline usually occurs at a more rapid pace than normal because of the lack of plantar flexion resulting indecreased stance time on the prosthetic limb. Amputees with prosthetic knees must exert a greater-than-normal forceon the posterior wall of the socket to maintain knee extension.

Most amputees find it easier to ascend and descend inclines with short but equal strides. They prefer this method sinceit simulates a more normal appearance as opposed to the sidestepping or zigzag method.

When ascending and descending hills, the amputee will find sidestepping to be the most efficient means. The soundlimb should lead and provide the power to lift the body to the next level, while the prosthetic limb remains slightlyposterior to keep the weight line anterior to the knee and act as a firm base.

During descent the prosthetic limb leads but remains slightly posterior to the sound limb. The prosthetic knee remains inextension, again acting as a form of support so that the sound limb may lower the body.

For hip disarticulates or transpelvic amputees, sidestepping is the most common alternative regardless of the grade ofthe incline.

Sidestepping

Sidestepping, or walking sideways, can be introduced to the amputee at various times throughout the rehabilitationprogram. He can begin with simple weight shifting in the parallel bars and later perform higher-level activities such asunassisted sidestepping around tables or a small obstacle course that requires many small turns. During earlyrehabilitation this skill provides the amputee with a functional exercise for strengthening the hip abductors and, later inthe rehabilitation process, with an opportunity to progress into multidirectional movements.

Backward Walking

Walking backward is not difficult for transtibial amputees but poses a problem for amputees requiring a prosthetic kneesince there is no means of actively flexing the knee for adequate ground clearance. In addition, the weight line fallsposterior to the knee, and this causes a flexion moment with possible buckling of the knee.

The most comfortable method of backward walking is by the amputee vaulting upward (plantar-flexing) on the soundfoot to obtain sufficient height so that the prosthetic limb that is moving posteriorly can clear the ground. The prostheticfoot is placed well behind the sound limb, with the majority of the body's weight being born on the prosthetic toe, thuskeeping the weight line anterior to the knee. The sound limb is then brought back, usually at a slightly faster speed anda somewhat shorter distance. The trunk is also maintained in some flexion in order to maintain the weight forward onthe prosthetic toe. With a little practice most amputees become quite proficient in backward walking.


18 of 29 1/20/2014 6:02 PM

Multidirectional Turns

Changing direction during walking or maneuvering within confined areas often magnifies an amputee's difficulty incontrolling the prosthesis. Situations such as crowded restaurants, elevators, or just simply turning around are oftenovercome by "hip-hiking" the prosthesis and pivoting around the sound limb. This method is effective but hardly themost aesthetic means of maneuvering.

When turning to the sound side, two key factors for a smooth transition should be remembered: first, maintain pelvicrotation in the transverse plane, and second, perform the turn in two steps. Simply move the prosthetic limb over thesound limb 45 degrees, rotate the sound limb 180 degrees, and complete the turn by stepping in the desired directionwith the prosthetic limb and leading with the pelvis to ensure adequate knee flexion (Fig 23-20.).

Fig 23-20. Turning to the sound side: 1-3, maintain normal

gait biomechanics; 4, move the prosthetic limb over thesound limb 45 degrees; 5, rotate the sound limb 180 degrees;

6, complete the turn by stepping in the desired direction.

Turning to the prosthetic side is performed almost exactly the same way as turning to the sound side with oneexception: slightly more weight is maintained on the prosthetic toe in order to keep the weight line anterior to the knee,thus preventing knee flexion. For example, by crossing the sound limb 45 degrees over the prosthetic limb, the weightline is automatically thrown forward. The prosthetic limb is rotated as close to 180 degrees as possible without losingbalance (135 degrees is usually comfortable), and the turn is completed by stepping in the desired direction with thesound limb. If necessary, remind the amputee to maintain knee extension by applying a force with the residual limbagainst the posterior wall of the socket (Fig 23-21.).


19 of 29 1/20/2014 6:02 PM

Fig 23-21. Turning to the prosthetic side: 1-3, maintain normal

gait biomechanics; 4, move the sound limb over the

prosthetic limb 45 degrees; 5, rotate the prosthetic limbapproximately 135 degrees; 6,7, complete the turn by

stepping in the desired direction.

One exercise that will reinforce turning skills is follow the leader, where the amputee follows the therapist who is makinga series of turns in all directions and with various speeds and degrees of difficulty.

The level of skill in turning will vary among amputees. All functional ambulators should be taught to turn in bothdirections regardless of the prosthetic side. Those with poor balance may be limited to unidirectional turns and require aseries of small steps to complete the turn.

Tandem Walking

Walking with a normal base of support is of prime importance. However, tandem walking can assist with balance andcoordination and improve prosthetic awareness for the amputee. Place a 5- to 10-cm (2- to 4-in.)-wide strip on the floor.The amputee is asked to walk in three different ways: first, with one foot to either side of the line; second, heel to toewith one foot in front of the other; and third, with one foot crossing over in front of the other so that neither foot touchesthe line and yet the left foot is always on the right side and vice versa.

Braiding

Braiding (cariocas) may be taught either in the parallel bars or in an open area depending upon the person's ability.Simple braiding is one leg crossing in front of the other. As the amputee's skill improves, the prosthetic limb canalternate, first in front of and then behind the sound limb, and vice versa. As ability improves, the speed of movementshould increase. With increased speed the arms will be required to assist with balance, and likewise, trunk rotation willincrease, further emphasizing the need for independent movement between the trunk and pelvis (Fig 23-22.).


20 of 29 1/20/2014 6:02 PM

Fig 23-22. Braiding is an exercise designed to improve prosthetic control, balance, and coordination

by crossing one leg in front of or behind the other in a continuous manner.

Single-Limb Squatting

Single-limb balance is taught during the early stages of rehabilitation for crutch walking, hopping, and other skills.Single-limb squatting is considerably more difficult but can help improve balance and strength. When first attemptingthis skill, half squats with a chair underneath the individual are recommended in case balance is lost.

Falling

Falling or lowering oneself to the floor is an important skill to learn not only for safety reasons but also as a means toperform floor-level activities.

During falling, amputees must first discard any assistive device to avoid injury. They should land on their hands with the

elbows slightly flexed to dampen the force and decrease the possibility of injury. As the elbows flex, they should roll toone side, further decreasing the impact of the fall.

Lowering the body to the floor in a controlled manner is initiated by squatting with the sound limb followed by gentlyleaning forward onto the slightly flexed upper limbs. From this position the amputee has the choice of remainingquadruped or assuming a sitting posture.

Floor to Standing

Many techniques exist for teaching the amputee how to rise from the floor to a standing position. The fundamentalprinciple is to have the amputee use the assistive device for balance and the sound limb for power as the body beginsto rise. Depending on the type of amputation and the level of skill, the amputee and therapist must work closelytogether to determine the most efficient and safe manner to successfully master this task.

Running Skills

For most amputees, the inability to run is the single most common factor limiting participation in recreational activities,and yet it is the most desired skill. Many amputees who do not have a strong desire to run for sport or leisure do havean interest in learning how to run for the simple peace of mind of knowing that they could move quickly to avoid athreatening situation. Rarely, if ever, is running taught in the rehabilitation setting. Running, as with all gait-training andadvanced skills, takes time and practice to master. If the amputee is exposed to the basic skills of running duringrehabilitation, then the individual may make the decision to pursue running at a later date.

Syme ankle disarticulates and transtibial amputees do have the ability to achieve the same running biomechanics asable-bodied runners if emphasis is placed on the following principles. At ground contact, the hip on the amputated sideshould be flexed and moving toward extension with the knee flexed and the prosthetic foot passively dorsiflexing. Theknee flexion not only permits greater shock absorption but in addition creates a backward force between the groundand the foot to provide additional forward momentum. As the center of gravity passes over the prosthesis during the


21 of 29 1/20/2014 6:02 PM

stance phase, the ipsilateral arm should be fully forward (shoulder flexed to 60 to 90 degrees), while the contralateralarm is simultaneously extended. Extreme arm movement can initially be difficult for the amputee concerned withmaintaining balance. During late mid-stance to toe-off, the hip should be forcefully driven downward and backwardthrough the prosthesis as the knee extends. If the prosthetic foot is of the dynamic-response type, the force producedby hip extension should deflect the keel so that additional push-off will be provided by the prosthetic foot. Forwardswing and the float phase are periods when the hip should be rapidly flexing and elevating the thigh. The arms shouldagain be opposing the advancing lower limb, with the ipsilateral arm backward and the contralateral arm forward.During foot descent, the hip should be flexed and then begin to extend as the knee is rapidly extending and reachingforward for a full stride (Fig 23-23.).

Fig 23-23. Normal running gait cycle.

Transfemoral amputees and knee disarticulates traditionally run with a period of double support on the sound limbduring the running cycle, commonly referred to as the "hop-skip" running gait pattern. The typical running gait cyclebegins with a long stride by the prosthetic leg, followed by a shorter stride with the sound leg. In order to give theprosthetic leg sufficient time to advance, the sound leg takes a small hop as the prosthetic limb clears the ground andmoves forward to complete the stride. The speed that a transfemoral amputee runner may achieve will be hamperedbecause every time either foot makes contact with the ground, the foot's forces are traveling forward and the reactionforce of the ground must therefore be in a backward or opposite direction (Newton's third law). The result is that eachtime the foot contacts the ground, forward momentum is decelerated. In other words, with every stride the amputee isslowing down when running with the "hop-skip" gait.

The ability to run "leg over leg" has been achieved by a number of transfemoral amputees who have developed this

technique through training and working with knowledgeable coaches. The transfemoral amputee takes a full stride withthe prosthetic leg, followed by a typically shorter stride with the sound leg. With training, equal stride length and stancetime may be achieved. This running pattern is a more natural gait where the double-support phase of the sound limb iseliminated and forward momentum maintained by both legs. Initially, problems that may occur include excessivevaulting off the sound limb to ensure ground clearance of the prosthetic limb, decreased pelvic and trunk rotation,decreased and asymmetrical arm swing, and excessive trunk extension. Again with training, many of these deviationswill decrease and possibly be eliminated (Fig 23-24.).

Fig 23-24. Transfemoral amputee running gait cycle.

The transfemoral amputee has an additional consideration when learning to run. To date, no knee system permitsflexion during the prosthetic support phase, and this results in the residual limb having to absorb the ground reactionforce during initial ground contact. Another problem with present knee units that transfemoral amputees must contendwith is maintaining the appropriate cadence during swing. Hydraulic knee units offer the ability to adjust the hydraulicresistance during knee flexion and extension. During running, less resistance in extension permits faster knee


22 of 29 1/20/2014 6:02 PM

extension, while increased resistance in flexion decreases the amount of heel rise with beginning runners. Seasonedrunners often reduce knee flexion resistance to permit the prosthetic shank to bounce off the socket and thus return tothe extended position at an accelerated rate. Collectively, these adjustments decrease the amount of time required forthe prosthetic swing phase.

The "leg-over-leg" running style does permit the transfemoral amputee to run faster for short distances but at a greatermetabolic cost. While the "leg-overleg" style is preferred, the hop-skip method is often more easily taught and lessdemanding physically on the amputee. If the sole purpose of instructing running is to permit the individual to movequickly in a safe and sure manner, the hop-skip method is most frequently suggested.

Recreational Activities

By definition, recreation is any play or amusement used for the refreshment of the body or mind. That is to say, the termrecreational activities need not exclusively mean athletics such as running or team sports. In fact, many people enjoyrecreational activities such as gardening, shuffleboard, or playing cards as a means of socializing or relaxing. Acomprehensive rehabilitation program should include educating the amputee on how to return to those activities thatare found pleasurable. For example, the therapist can teach physical splinter skills such as weight shifting, necessary tohelp the amputee participate in shuffleboard, or various methods of kneeling for gardening. In addition, there are manynational and local recreational organizations and support groups that provide clinics, coaching, or another amputee whocan teach from experience how to perform various higher-level recreational skills. Providing the amputee withinformation on how to contact these groups is the first step to mainstreaming the patient back into a life-style completewith recreational skills as well as activities of daily living.

CONCLUSION

In summary, the physical therapist must work closely with the rehabilitation team to provide comprehensive care for theamputee. An individualized program must be constructed according to the level of ability and skill of each patient. Theprimary skills of preprosthetic training help build the foundation necessary for successful prosthetic ambulation. Thedegree of success the amputee experiences with ambulation may directly influence how much the prosthesis will beused and how active a life-style is chosen. Therefore, the primary goal of the rehabilitation team should be to make thistransitional period as smooth and successful as possible.

Acknowledgment

We would like to thank Mr. Frank Angulo for his time and talents in creating the illustrations in this chapter.


23 of 29 1/20/2014 6:02 PM

Fig 23-11. A, nonamputee vertical displacement of the center of gravity. B, transfemoral amputee

vertical displacement of the center of gravity.

Fig 23-12. Lateral displacement of the body's center of gravity is 5 cm, and horizontal dip of the

pelvis is approximately 5 degrees.


24 of 29 1/20/2014 6:02 PM

Fig 23-13. Transverse rotation of the pelvis is approximately 5 degrees anterior and posterior to the

neutral position.

Fig 23-14. Sound-leg stepping is designed to orient the amputee to gaitbiomechanics.


25 of 29 1/20/2014 6:02 PM

Fig 23-15. Rhythmic initiation designed to promote transverse rotation of the pelvis.

Fig 23-16. Resistive gait techniques are proprioceptive neuromuscular facilitation techniques to

assist and establish a normalized gait pattern.


26 of 29 1/20/2014 6:02 PM

Fig 23-17. Sound-side stepping to promote equal stride length of the

sound limb and stance time of the prosthetic limb.


27 of 29 1/20/2014 6:02 PM

Fig 23-18. Once correct biomechanics are established within

the parallel bars, resistive gait training may be performed in

an open area to build confidence and independent gaitskills.


28 of 29 1/20/2014 6:02 PM

Fig 23-19. Passive trunk rotation will assist in restoring arm swing for improved balance, symmetry

of gait, and momentum.

References:

Davis GJ: A Compendium of Isokinetics in Clinical Usages and Rehabilitation Techniques, ed 2. S & SPublishing, La Crosse, Wise, 1985.

1.

Eisert O, Tester OW: Dynamic exercises for lower extremity amputees. Arch Phys Med Rehabil 1954;35:695-704.

2.

Murray MP: Gait as a total pattern of movement. Am J Phy Med Rehabil 1967; 16:290-333.3.Murray MP, Drought AB, Kory RC: Walking patterns of normal men. J Bone Joint Surg [Am] 1964; 46: 335-360.4.

Peizer E, Wright DW, Mason C: Human locomotion. Bull Prosthet Res 1969; 10:48-105.5.

Chapter 23 - Atlas of Limb Prosthetics: Surgical, Prosthetic, and Rehabilitation Principles

Normal Version


29 of 29 1/20/2014 6:02 PM

Health & Medicine

23 physical therapy management of adult lower limb amputees