Prosthetic Rehabilitation: Re-establishing Normal gait & Maximizing function

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Prosthetic
Rehabilitation:

Re
-
establishing Normal gait &
Maximizing function



Frank
Austin, PT

Patient Presentation


34 year old male


Rx:


Dx: Right BKA


Evaluate and treat


3x/wk x 4wks



What Else Do You Want To
Know About
Your Patient?

Subjective History


Cause of amputation


How long ago did the amputation occur?


Pain?


Medications


Premorbid level of function


Current level of function


Functional limitations


Prior therapy received




Subjective History


PMHx


Social Hx


Occupation


Can the patient perform his duties


Obtain description of work duties


Extracurricular activities


Goals


Occupational vs. personal


Subjective History


Date of amputation? 1/26/2009



Occupation? general laborer in warehouse



Cause of amputation? crush injury @ work in warehouse



Pain?


Residual limb 3/10 (phantom pain)


Also reports back pain and intermittent left knee pain; not rated



Medications? Neurontin for phantom pain




Subjective History


Current level of function/limitations


Desk job 4 hours/day


Difficulty with lifting objects overhead without loss of balance


Difficulty with squatting and kneeling


Unable to play basketball


Afraid of carrying 1 year old daughter up/down steps


Premorbid level of function


Worked 8 hours per day as a general labor


Squatting to pick up and carry up to 30# containers


Lifting and stacking objects on shelves overhead up to 15#


Independent with squatting and kneeling to floor to get under
vehicles to change the oil


Able to carry daughter up/down steps independently without
upper extremity support of rail


Played basketball 1
-
2 days per week



Subjective History


Prior therapy received


Several weeks as an outpatient concentrating mostly on
exercise, not function or balance


PMH
-

asthma


Social
-

lives with wife and 2 daughters in 2 story home
with 12 steps to second floor


Goals (subjective)


Carry daughter up/down stairs safely


Return to work full time without limitation


Play basketball with friends


The Starting Line


What do you want to assess on

Initial Evaluation?

Objective Section of Evaluation


ROM


Strength


Sensation


Vision


Joint stability assessment


Residual Limb/Intact limb appearance


Balance


Prosthetic Componentry



ROM


Hip


Greater than neutral hip extension bilaterally


Hip flexion and abduction WNL


Hip IR:
L=30
°

R=35
°


Knee
-

WNL bilaterally


Ankle
-

WNL on left, all motions


Trunk


Sidebending (distance fingertip to floor):


L= 55cm

R= 51cm


Rotation



L=75
°

R= 83
°







Ankle
-

WNL on left, all motions


Trunk


Sidebending (distance fingertip to floor):


L= 55cm

R= 51cm


Rotation



L=75
°

R= 83
°


Strength




L


R



Hip flex




5/5



4/5


Hip ext.



3+/5


3/5


Hip abd.



5/5



4/5


Quads




5/5



5/5


HS






5/5



5/5


Ankle


PF/DF



5/5



N/A


Inv/Ev



5/5



N/A




Abdominals =
3/5

Sensation & Vision


Sensation


Intact to light touch and proprioception


Occasional periods of phantom sensation (right foot)


Vision


Not formally assessed based on age and cause of amputation


No limitations observed (reading of fine print with intake
information)


No subjective report of visual limitations (blurred vision or blind
spots)





#1 Which of the following is
not

an indication
that you need to formally assess vision?

A.
Vascular cause of amputation

B.
History of diabetes

C.
History of visual disorder

D.
Under the age of 40


College or Department name here

13

Joint Stability



Knee/hip/ankle joint stability
-

No signs of instability
bilaterally


Hip Joint: assessed by positioning femur in flexed and adducted
position with over pressure in supine; maximally extended
position in sidelying with over pressure


Knee joint: assessed via varus/valgus stress tests for MCL an
LCL; ACL/PCL testing (anterior and posterior drawer testing)


Ankle joint: assessed with over pressure at end ranges in all
planes

Balance


Tested wearing prosthetic limb



Tinetti score of 20/28
(moderate fall risk)



Eyes closed/non
-
compliant surface
-

no LOB



Eyes closed/compliant foam pad
-

+ LOB



Unilateral stance time


Left > 20 seconds


Right avg. of 1.85 seconds


Limb Appearance & Management


Residual limb/Intact limb appearance


Shape
-

cylindrical


Incision
-

well healed and smooth; mobile


Skin
-

good condition (well hydrated) with good signs of vascularity (no
discoloration and good hair growth)


Bone: tibia longer than fibula (normal); tibia properly beveled


No signs of vascular compromise with good skin hydration of intact limb


Volume management


Was using shrinker; no longer using


Girth: not tested secondary to time post amputation and no history of
dialysis


Prosthetic management

Independent donn/doff


Wearing time


All day



Prosthetic Checkout


Prosthetic alignment (static and dynamic
)


Socket in approximately 5 degrees of flexion


Less than 5 degrees of toe out


Varus thrust at knee at midstance indicating good foot alignment in
relation to socket


Prosthetic fit


Good suction of sleeve on limb; no sign of excessive stretch of sleeve
on socket at sleeve socket interface connection


Initially socket too loose on limb leading to excessive socket rotation


Corrected by prosthetist with padding along inner shell of socket


Prosthetic height


Iliac crest heights were even with static standing assessment

Prosthetic Prescription


Multiple factors are
considered:


General health


Projected activity level


Height and weight


Length and shape


Level of amputation


Insurance/financial means


Type of componentry
chosen for patient:


Patella tendon bearing socket


Silicone sleeve suction


Vertical shock foot


Foot/Ankle


For more active amputees


Carbon vertical compression strut


Allows up to one inch of vertical
compression


Reduces forces applied to the
residual limb and proximal joints


Flexfoot VSP

Suspension


Suction suspension


Reduced liner distal pull


Allows more uniform distribution of
pressure along residual limb


Decreased bunching behind knee;
easier to flex the knee


Straight forward with donning


Roll on leg


Step into socket to create
suction


Suction release button on side of
socket



Iceross Seal
-
In X5 liner

Is there anything else you need to
assess?


What about function?

Functional Assessment


ADLs


Driving


Transfers


Lifting


Gait


Multiple surfaces


Stairs



Functional Assessment


ADLs
-

independent with dressing and bathing without
prosthesis


Driving
-

independent


Transfers


Sit to stand independently but asymmetrical;
decreased wt. through prosthesis


Unable to kneel to floor and stand without upper
extremities


Lifting task


Squat lifts: 7.5 pounds x 5 reps before fatigue


Overhead lifts: 15# x 12 reps before fatigue

Functional Assessment


Gait
-

walks on level surfaces independently without assistive
device; difficulty with walking on compliant surfaces (ie grass)


Demonstrated a right lateral trunk lean


No arm swing


Decreased pelvic rotation bilaterally; right < left


Decreased stance time on right


Decreased rollover on right


Decreased step length on left



Stairs


Independent with use of hand rail


Without rails


Up
-

with supervision


Down
-

decreased eccentric control with several LOB. Minimal assistance
required for balance control




#2 Other than pain, what else could cause
the demonstrated gait deviations (in this
particular patient)
?

A.
ROM and strength deficits

B.
Prosthetic alignment

C.
Prosthetic fit

D.
Prosthetic height

Causes of Gait Deviations


Patient must adjust Center of Gravity (COG) out of necessity to
maintain balance after amputation and before receiving prosthetic


Pt’s COG shifted to the left.



Due to the shift in the COG and moving through space in a uni pedal
way, the following occur:


ROM limitations


Strength limitations



While healing after amputation and waiting to receive the prosthesis,
it is important for the client to perform a basic exercise program to
minimize strength and ROM losses caused by being uni pedal.


Center of Gravity

Why is it so important?

#3 What could happen if the COG is not
controlled during gait?

A.
Nothing

B.
Loss of balance

C.
Increased energy expenditure

D.
B & C


Importance of COG


Energy is conserved during gait by muscles of the pelvis,
hips and limbs offsetting the forces of gravity and
preventing excessive movement of the COG



Without muscle forces offsetting each other, the COG
would move excessively outside of the base of support
and require greater muscular effort to control the COG
and expend more energy.



If the COG is not adequately controlled, balance loss
occurs

#4 What motions at the knee and ankle
lower Center of Gravity (COG)?


A.
Knee extension and ankle plantarflexion

B.
Ankle dorsiflexion and knee extension

C.
Eccentric knee flexion and ankle dorsiflexion during
loading

D.
Ankle supination and knee extension during loading




College or Department name here

30

#5 What motion at hip on stance side helps
to control lateral displacement of COG?


A.
Hip adduction to prevent excessive pelvic drop

B.
Hip abduction to prevent excessive pelvic drop

C.
Hip extension

D.
Hip internal rotation


College or Department name here

31

Toward the middle of the program, even though ROM
and strength deficits were addressed and eliminated,
gait deviations sometimes reappeared



#6 What do you think was the cause of
the reappearance of this patient’s gait
deviations?


A.
Fatigue/decreased endurance

B.
Faulty prosthetic
componentry

C.
Loss of control of the COG

D.
Decreased attention to proper gait


The effect of level of amputation and
cause of amputation on energy
expenditure

Why do amputees fatigue faster ?

Energy Expenditure and Velocity


Level/Cause



VO2


Velocity


TTA trauma



15%


10%


TTA vascular


30%


30%


TFA trauma



40%


20%


TFA vascular


65%


40%







Esquinazi 1994


Ertl 2005

Gailey 1994

#7 The Amputee expends greater
energy secondary to:

A.
Missing joints and muscles on the side of amputation

B.
Decreased joint motion of remaining joints on non
-
amputated
and amputated sides

C.
Decreased strength of limbs, pelvis/hip and trunk

D.
Excessive displacement of the COG

E.
All of the above


Problem list

What problems can you identify based on
the objective information collected?

Problem List


Decreased ROM


Decreased strength


Decreased balance


Gait dysfunction


Decreased safety


Decreased activity tolerance/muscle endurance


What piece of subjective information
is most important in driving your
treatment program?

GOALS!!!!!

What goals can be generated


from your problem list?

Objective Goals


Improve Tinetti to > 23/28 for low risk of falls with level
surface ambulation around the home


Equalize left and right sidebending ROM to decrease
stress on lumbar spine


Equalize left and right trunk rotation ROM to decrease
stress on lumbar spine


Increase bilateral hip internal rotation ROM to increase
balance with gait and promote independent and safe
level surface ambulation without an assistive device


Decrease trunk lean with gait to decrease stress on
lumbar spine and decrease pain


Objective Goals



Improve pelvic rotation with gait to increase dynamic
balance and promote safe and independent level surface
ambulation without an assistive device


Equalize stance time bilaterally/improve rollover on the
right to decrease joint reaction forces on the non
amputated limb


Improve abdominal strength to > 4/5 to decrease strain
on lumbar spine and assist with balance control during
functional activities


Improve right unilateral stance time > 5 seconds to
facilitate proper right stance, proper rollover on the right
and normalize step length on the left with level surface
gait

What special considerations do you need to
make when goal setting and designing a
POC for this particular patient/the acute
amputee population?

Things To Keep In Mind


Sometimes your client will come in with unrealistic ideas
of how they will be able to function after receiving the
prosthesis



A prosthesis will help a client to
maximize their post
amputation level of function.



Help the client to understand that a prosthesis requires
increased energy expenditure to manipulate



If the client has significant cardiac or renal history,
demands will be greater than for someone without this
history.




What Would You Suggest as a

Treatment Plan?

ROM


Lateral trunk flexion stretches


Seated, standing



start at 10
-
15 and progress to 30 seconds


5 second rest in between each repetition


5 reps of each


Trunk rotation stretches


Seated and standing


Same guidelines as above


Can progress to weighted activity


Trunk/pelvis disassociation exercises


Sidelying, standing


Focus on upper extremity and pelvis on same side moving in opposite
directions

Strength


Squats


Progress to weighted activity


Wall squats


Bilateral and unilateral


Start without weight and progress to weighted


Lunges


Progress to weighted activity


Eccentric step downs


Progress from smaller to larger stools with focus on speed


Should be done as slowly as possible


Step ups


Forward and lateral with cueing to push down through the forefoot of
prosthesis when placing foot of sound limb on stool


progress from smaller to larger stools; done slowly as possible


Abdominal crunches


Weighted trunk rotation


Seated, standing


Push ups


Balance and Agility


Weight shifts


Anteriorly through the forefoot of the prosthetic



Standing ball rolls


Progress from bilateral to one arm and then no arms


Progress from small ball ( tennis) to large ball (physio ball)



Compliant pad work (foam pad, pillow, grass)


Bipedal and uni pedal



Agility ladder


Forward, lateral, backwards if able


Increase speed as able



Forward step overs/lateral step overs


Progress from smaller to larger diameter rolls




Balance and Agility


Forward and retro gait through serpentine course


Increase speed as able



Unilateral and bilateral jumping


Jump up on step stool or over objects ie foam roll



Dribbling basketball around objects



Simulated one on one basketball games



Walking up steps without upper extremity support


Progress from no weight to weighted task


Gait Training


Emphasis on the following


Increased stance time on right by encouraging proper rollover
from initial contact to terminal stance


Increased step length on the left through emphasis on the above


Increased pelvic rotation on the bilaterally (mostly on the right by
emphasizing increased trunk rotation and arm swing



T
-
mill


Start at speed where patient can focus on and maintain normal
aspects of gait. Progress speed as able, keeping normal gait in
mind


Start with upper extremity support and progress to no arm
support as balance and control improve


Finish Line!!!

Discharge at 12 weeks



Discharge Summary


ROM


Equalized/improved lateral trunk flexion: 45 cm bilaterally


Increased left trunk rotation by 5 degrees




Pain


Decreased frequency of phantom limb pain


Decreased intensity of phantom limb pain 1
-
2 out of pain


Elimination of lumbar pain



Discharge Summary


Balance


Right unilateral stance time of 9.0 secs


20 repetitions of vertical jumps


Tinetti 26/28
(low fall risk)


TUG
-

6.79 seconds
(low fall risk)



Gait


Disassociated trunk and pelvic motion to improve pelvic
rotation


Improved arm swing/trunk rotation


Decreased lateral trunk flexion with right stance


Symmetrical stance times bilaterally


Symmetrical step length bilaterally


Improved pelvic rotation




Discharge Summary


Functional tasks



Improved weighted squats from 7.5# x 5 reps to 30# x
20 reps



Improved overhead reach from 15# x 12 reps to 15# x
30 reps



20 repetitions of squat lifts with 30#



Stairs
-

able to carry 20# of weight without support of
rails independently



Discharge Summary


Current Level of Function (ADLs, Recreation, Work)



Reported walking on beach without difficulty (compliant surface
walking)



Playing basketball with friends on limited basis; Building
tolerance on the court



Working 6 hours per day with split between office work and in the
warehouse



Able to squat and kneel to floor without upper extremity support



Able to carry daughter up/down the stairs without use of a railing


Problems During Program


Decreased patient compliance with Home Exercise
program


<80% compliant with stretches and balance exercises



Excessive movement of prosthesis on limb secondary to
inadequate suspension


Several adjustments made by prosthetist; adjustments helped
with level surface walking


Created problems during running and balance/agility drills


Eventually re
-
casted for new socket after treatment program.
Client reports improved control with mobility

References


Chao, EY, Laughman, RK, Schneider, E, Staufer, RN. Normative Data of
Knee Joint Motion and Ground Reaction Forces in Adult Walking. J
Biomech 1983: 16: 219
-
33


Ensberg JR, Lee AG, Patterson JL, Harder JA. External Loading
Comparisons Between Able Bodied and Below Knee Amputee Children
During Walking. Arch Phys Med Rehabil 1991: 72: 657
-
661


Esquenazi, A: Analysis of Prosthetic Gait. Phys Med and Rehab, Vol. 8,
February 1994


Ertyl, J, Janos, P: Amputations of Lower Extremity. E
-

Medicine, January 30
2005, section 1
-
11


Gailey, R: Comparison of Metabolic Cost During Ambulation Between the
Contained Trochanteric
-
Controlled Alignment Method and the Quadrilateral
Socket. Prosthetic
-
orthotic int. 17:2, 99
-
106, 1993


Perry, J. Gait Analysis: Normal and Pathological Function. Thorofare, NJ,
Slack Inc. 1992


Powers CM, Torburn L, Perry J, Ayappa E. Influence of Prosthetic Foot
Design on Sound Limb Loading in Adults With Unilateral Below Knee
Amputations. Arch Phy Med Rehabil 1994: 75: 825
-
9