O&P
Psychosocial Assessment
Roles -current and prior • Engagement or avoidance • Stages of grief
pressure intolerant/sensitive areas
_______ around the knee are small surface areas. bony prominences. patella lateral tibial condyle tibial tub tibial crest anterior-distal end of tibia fibular head distal fibula distal end of stump with surgical suture medial and lateral femoral condyles
support services for amputee patients
Vocational concerns Mental health (huge with trauma pts) Financial services Nutritional education (huge for optimal wound healing)
single stance
Walking faster proportionally lengthens _________ and shortens the 2 double stance intervals, while walking slower proportionally shortens single limb stance and lengthens the 2 double stance intervals
hip flexion contractures
_______ cause decreased ROM in terminal stance (lack of extension), early heel off, early toe rocker, reduced step length on the contralateral side, foot flat weight acceptance on the contralateral side.
Contracture
______ usually occur due to limited activity or injury. If it takes more than 2 fingers strength to move the joint through the full ROM = probably ________. Rigid and Elastic
weak quads
______ would show up with hyperextension of the knee during LR
Dysvascular disease
_______ (PVD, T2DM, etc) contribute the most to toe and partial foot amputations.
K levels
_______ are only for feet and knees. sockets are not included in the _____ groupings.
soft dressings
_______ do not do as good as a job preventing edema.
weight
_______ does not seem to impact energy expenditure during gait, but energy expenditure will decrease if the COG of the prosthesis becomes more proximal
shoulder amputation
_______ is 100% of the arm This converts to 60% of impairment to the whole person
mirror therapy
_______ is be best way to control pain in UE amputation pts. for bilateral amputees, watching someone else completing the task is also helpful. VR is helpful. strategy for before getting prosthetic.
total surface bearing
_______ is good for large bodies to spread forces through the tissues.
single leg stance
_______ is harder to do than stool stepping. _____ is not integrated into the prosthetic training progression bc controlling _____ with TFA is really hard for all pts.
limb advancement
_______ is pre-swing to terminal swing
open pack position
_______ is where the joint has the least amount of intra-articular pressure. ankle: 15deg PF knee: 30deg flexion
TPR
_______ should occur in terminal stance to create a pre-swing knee flexion. unlocks the prosthetic knee.
weak PFs, spasticity of PFs, or ROM deficit into DF
_______ would show up with hyperextension of the knee during midstance and terminal stance
3D printer/ Computer Aided Design
________ also known as additive manufacturing, refers to various processes used to synthesize a three-dimensional object. _______ is used for mass production. not always great for individual productions.
During transtibial gait excessive toe-in of the prosthetic foot would lead to which gait deviation?
excessive knee extension explanation: toe in creates a long lever which creates an extension moment at the knee
postural control
for _______, assess sitting balance, standing balance (static & dynamic) Interventions 1. Sitting balance, standing balance (static & dynamic) 2. Quadruped, tall kneeling, half kneeling, core strengthening
Trans-tibial amputations
for pts with ________, the same progression is used but a soft knee is required. (not pushing back into the socket) a ______ pt will not need TPR facilitation.
Controlled "Roll-Off" theory
force is stored in eccentric contractions during mid-stance and terminal stance. a forceful push by the PF is created during pre-swing to move into toe-walker.
lacking 15deg of DF will possibly present with:
forefoot or foot flat contact knee hyperextension early heel off lack of tibial advancement = knee hyperextension circumduction/hip hiking/vaulting to clear limb
53%
knee disarticulation of traumatic etiology has what % increase in oxygen consumption?
important positioning with Trans-tibial (B/K)
knee extension/prone hip extension
most common contracture with transtibial amputations
knee flexion (supine 90/90) hip flexion (thomas test)
causes of poor trailing limb stance in terminal stance
knee flexion contracture hip flexion contracture prosthetic misalignment (toe out) prosthetic componentry (keel to soft or too firm)
initial contact in TFA
knee instability rotation of heel rapid knee extension before initial contact early heel roll over
LR with TFA
lack of knee flexion: often no knee flexion is present by design, unless they have a certain componentry. often we accept the deviation of no knee flexion. main goal is that they maintain stability of the prosthetic knee. we want more knee extension during _______. we want more knee flexion during LR with TTA
swing limb advancement common problems
lack of toe extension and lack of passive knee flexion pistoning relatively longer limb
gravity
largest force that acts upon a body in motion is _____ constantly exerting a downward force on the different segments of the body, essentially trying to "pull" the body towards the ground. This external force creates a torque (or moment) about an axis of rotation (joints). In the case of external forces (i.e., _____), we are referring to a demand torque or an external moment.
Suspension test
long axis distract their limb. should feel a tiny amount of give. prosthetic should not come off (inadequate suspension).
transtibial residual limb pressure intolerant areas
patella lateral tibial condyle tib tub tibial crest anterior distal tibia fibular head distal fibula distal residual limb with surgical site medial and lateral femoral condyles
rigid contracture
resists all stretching efforts. the joint will not move.
2 MAS knee extensors will possibly present as:
terminal stance (quad stretch) will cause spasticity = decreased knee flexion during pre-swing and through swing limb advancement.
0 deg hip extension will possibly present with:
terminal stance will be the most effected. does not have enough ROM to achieve normal terminal stance
donning/doffing test
tests if the pt can perform ____ in the correct order with the correct alignment. good short term goal.
major deviations
the RLA gait analysis form should only notate ________. dont get hung up on little things.
Swing Phase
the entire period that begins as the foot lifts from the floor (toe off) ~40%
Stance Phase
the entire period the foot is on the ground _______can be subdivided into 3 intervals: Initial double limb stance (double limb support) Single limb stance Terminal double limb stance (double limb support) ~60%
expensive
the higher the K level, the more ______ the equipment.
direct relationship
the more the knee is contracted (flexion) the more the quads have to work harder to maintain stability = ______.
shank to vertical angle (SVA)
the relationship of the tibia to "true vertical" (gravity)
no prosthesis
the route of ______ is usually the most frequently pursued option. pts figure out how to complete ADLs without a prosthetic. no loss of sensory input, not expensive.
cone
transfemoral amputations should be _______ shaped. 1/3 to 1/2 of remaining limb is optimal. longer is better for muscular moment arms. circumference should be decreasing towards the distal part of the limb. measure from greater troch or IT
68%
transfemoral amputation of traumatic etiology has what % increase in oxygen consumption?
100%
transfemoral amputation of vascular etiology has what % increase in oxygen consumption?
K2
Has the ability or potential for ambulation with the ability to traverse low level environmental barriers such as curbs, stairs, or uneven surfaces limited community ambulation. Foot: • SACH • Flexible (elastic keel) • Single axis • Multiaxial
K3
Has the ability or potential for ambulation with variable cadence. Typical of the community ambulator who has the ability to traverse most environmental barriers. unlimited community ambulation. walking is primary form of locomotion. Foot: • SACH • Flexible (elastic keel) • Single axis • Multiaxial • Energy storage and return (ESAR/dynamic) • Microprocessor
what is the order of CATCAM exercise contractions?
2 sec concentric 6 sec isometric 2 sec eccentric
weak knee extensors
______ could lead to excessive knee flexion or extension, depending on how it is compensated for.
toe off
______ occurs between pre-swing and initial swing
5deg PF
at loading response, the ankle should be in _______.
5deg DF
at mid-stance, the ankle should be at ______.
10deg DF
at terminal stance, the ankle should be at _______.
Overall, the quality of a person's prosthetic gait will depend on:
(1) the quality of the prosthetic components and fit, (2) the condition of the residual limb, and (3) the interface between the body and prosthesis.
Targeted muscle reinnervation (TMR)
- can create new myoelectric control sites - Multiple joints can be simultaneously controlled with myoelectric signals - developed to reduce neuromas and pain. - surgical procedure ____ is becoming more routine. Changes where myosites will be -Gives an indication of dual site or pattern recognition functionality -Possible increase or decrease in myosites in an area -Operative report Helps understand what happened after the trauma operative report helps the prosthetist: -Provides details about viability of tissues otherwise not known -Helps plan the prosthetic course -Helps troubleshoot problems that arise when prosthesis is fit
Upper Limb Amputation Levels
- interscapulothoracic (shoulder girdle amputation) - shoulder disarticulation - transhumeral - elbow disarticulation - transradial - wrist disarticulation - transcarpal - finger amputations
important positioning with AK
-hip extension/internal rot/adduction
Shuttle locking/ pin lock
-uses a roll on liner with pin at end. -Same advantages/disadvantages as TT amputees,
infection severity
0 = no infection 1 = low grade soft tissue infection 2 = high grade soft tissue infection 3 = deep bone infection 4 = septic implant failure
initial contact
0%-2% GC Heel first contact initiates heel rocker. Hip flexed, knee extended, ankle dorsiflexed to neutral. Opposite limb is at beginning of pre-swing. Objectives: Start stance with heel rocker Impact deceleration ROM: hip: 20deg flexion knee: 5deg flexion ankle: neutral EMG: Glute max: 20% Glute med: 20% Vastus lat: 20% Lateral gastroc: 5% Anterior tib: 38% Semi ten: 20%
ambulation assessment without prosthesis
1. Ability to perform single leg stance (with or without AD) 2. Ability to ambulate short distances with AD 3. hopping 4. weight shift 5. single leg heel rise
balance recovery tips
1. If shifted too far back (over heels) and falling, bring trunk forwards 2. If shifted too far forward (over toes) and falling, head back and trunk back.
how to perform MMT on amputated limb
1. get normal MMT for good limb 2. get MMT score for good limb at the same point you would test the amputated limb 3. test the amputated limb.
running training
1. hop skip long step with prosthetic with pushing back into socket, hop skip. 2. circumduction with locked knee. must extend leg hard for stability and have a long step on the sound limb so there is time for the circumduction. no TPR in running (keeps knee straight) teach prosthetic trust. 3. running knees are available to get rid of circumduction. more natural swing phase.
Floor to Stand Strategy
1. push up position, walk backwards, stand up (like in SCI) 2. use chair, knee abducted or weight bear through prosthetic socket, push up through arms and sound side
chair to floor strategy
1. straighten out prosthetic knee, tricep dip down to floor. 2. tuck prosthetic under chair, twist and turn into a kneeling position, weight bearing through socket.
Stand to floor strategy
1. tricep dip on a chair or something onto sound limb. 2. wide base of support, forward flex, crawl forward. (bilateral)
midstance (2nd walker)
10 deg recline - 10deg incline SVA
terminal stance (3rd rocker)
10deg incline - 25deg incline SVA
mid-stance
12%-31% GC First half of SLS. Limb advances over stationary foot by ankle DF while knee and hip extend.. Opposite limb is advancing through mid swing. Objectives Progression over stationary foot. Limb and trunk stability. ROM: hip: 0deg knee: 5deg flexion ankle: 5deg DF EMG: Glute max, med, and vastus lat: 5% Lateral gastroc: 60% Tib anterior and semi ten: 5%
loading response
2%/12% GC Lead limb accepts body weight. Using heel rocker, knee is flexed for shock absorption. Brief arc of ankle PF interrups heel impact, but heel rocker is preserved until end of phase. Objectives Shock absorption Weight-bearing stability Preservation of progression ROM: hip: 20deg flexion knee: 15deg flexion ankle: 5deg PF EMG: Glute max and Glute med: 25% Vastus lat: 20% lateral gastroc: 18% tib anterior: 20% Semi ten: 20%
Outcome measures performance-based tools
2MWT* 6MWT* AMP* L test* TUG* 4 square step test (FSST)* ABC 10MWT Berg Functional Ambulation Profile Functional Reach POMA (Tinetti) * means accurate with amputee pts.
loading response (1st rocker)
25deg - 10deg recline SVA
terminal stance
31%-50% GC Completes SLS. Begins wtih heel rise until other foot strikes ground. Body weight advances over forefoot rocker. Knee completes extension and begins new arc of flexion. Increased hip extension and heel rise put limb in more trailing position. Opposite limb completing terminal stance. Objectives Progression of body beyond support foot. Limb and trunk stability. ROM: hip: 20deg extension knee: 5deg flexion ankle: 10deg DF EMG: Glute max, med, vastus lat, tib anterior, and semi ten: 5% lateral gastroc: 100%
males
70% of amputees are _________.
mid-swing
75%-87% GC Middle third of swing and begins as swinging foot is opposite the stance limb. Phase ends with swinging limb is forward and tibia is vertical (hip and knee flexion equal). Opposite limb is in late mid stance. Objectives Limb advancement. Foot clearance. ROM: hip: 25deg flexion knee: 25deg flexion ankle: 0 EMG: Glute max, med, vastus lat, lateral gastroc, and semi ten: 5% Tib anterior: 20%
terminal swing
87%-100% GC Final phase of swing. Begins with vertical tibia, ends with foot strike to floor. Limb advancement is complete as the leg moves ahead of thigh. Hip drops slightly and ankle remains DF to neutral. Opposite limb is in terminal stance. Objectives Complete limb advancement. Prepare limb for stance. ROM: hip: 20deg flexion knee: 5deg flexion ankle: 0deg EMG: Glute med, max, vastus lateralis, semi ten: 20% lateral gastroc: 5% tib anterior: 38%
diabetes
>50% of LL amputations are_________ related.
foot ulcers
>80% of nontraumatic amputations in diabetic patients are the result of ________
6 months
50% of Amputees over 60 years old discard their prosthesis in the first _______ due to lack of transportation to their therapy and prosthesis visits.
Patella Tendon Bearing (PTB)
50% patella tendon 20% tibial flare 30% tissue _______ is good for small individuals with well defined knee. ________ tries to place more weight through the patellar tendon
pre-swing
50%-62% GC Final phase of stance is the second (terminal) double stance interval. Begins with IC of the opposite limb. Weight release and transfer rapidly unloads limb contributing to progression with a forward "push". Increased PF, knee flexion, and reduced hip extension. Opposite limb is in LR. Objectives Position limb for swing. Accelerate progression. ROM: hip: 10deg extension knee: 40deg flexion dorsiflexion: 15deg PF EMG: Glute max, med, vastus lat, lateral gastroc, and semi ten: 5% Tib anterior: 25%
initial swing
62%-75% GC First phase of swing and 1/3 of the swing period. Begins when foot is lifted from floor and ends when swinging foot is opposite stance foot. Ankle DF is incomplete. Opposite limb is in early mid stance. Objectives Foot clearance. Advancement of limb from trailing position. ROM: hip: 15deg flexion knee: 60deg flexion ankle: 5deg PF EMG: Glute max, med, vastus lat, lateral gastroc, and semi ten: 5% Tib anterior: 25%
gait cycle (GC)
A single sequence by one limb from heel strike to the next ipsilateral heel strike is termed a _________.
K2 cut off scores on AMP
AMPnoPRO 21-28 AMPPRO 27-36
K3 cut off scores on AMP
AMPnoPRO 29-36 AMPPRO 37-42
K4 cut off scores on AMP
AMPnoPRO 37-43 AMPPRO 43-47
K1 cut off scores on AMP
AMPnoPRO 9-20 AMPPRO 15-26
K0 cut off scores on AMP
AMPnoPRO: 0-8 AMPPRO: NA
slight varus
Adding a ________ moment helps to stress the more taught and stronger LCL and not the MCL to accommodate for the following issues: muscular disadvantage and nonexistence of a foot structure or the musculature to anchor the tibia on the foot. This alignment is well tolerated over pressure-tolerant areas and helps to increase energy efficiency.
reconstructive surgery
Amputation is NOT Ablation! Amputation should be thought of as _________. Don't be afraid to suggest a revision limb optimization, especially early on in their recovery process.
vascular
Amputations due to ________ disease tend to be more costly in terms of energy demands than traumatic causes
less energy
Amputees with non-vascular TTAs expend _______when walking with a prosthesis than when when walking on crutches without a prosthesis. Do people with TFA amputations expend ________ when walking with a prosthesis than when walking on crutches without a prosthesis? = unclear
forefoot rocker
As the GRFV reaches the metatarsal heads, the heel start to rise and the ankle is stabilized by the eccentric action of the gastroc-soleus complex. The metatarsal heads serve as the ________ and progression is accelerated as the body weight falls beyond the area of foot support. This is the strongest propelling force during the GC. The body mass is a passive weight at the end of a long lever and this rate of fall is restrained by vigorous action of the gastrosoleus. occurs during terminal stance.
flexion, adduction, anterior
As you can see from the figures above, the general alignment of the transfermoral prosthesis is with the socket in slight ______, the socket in slight As you can see from the figures above, the general alignment of the transfermoral prosthesis is with the socket in slight flexion, the socket in slight ______, the pylon (tube) is vertical, and the TKA line is _______ to the knee joint. This initial static alignment provides the patient with the most stability. Based on componentry, patient-related factors, and goals for prosthetic use, these alignments can and will be changed.
Sickness Impact Profile (SIP)
Assesses physical, psychological, and social domains of health and disability. Lengthy with 68 questions.
Amputee Activity Survey (AAS)
Assessment of daily activity level and step rate. Amputees with higher AAS score walked more. Reliability and validity never statistically addressed
shank incline
At the end of LR through PSw, the SVA is in ______
higher
BP and HR will be _______ than without an amputation. interventions: UE ergometer, LE bicycle, Functional tasks: sit/stand, WC propulsion
list the types of myoelectric prosthetics
Basic Myoelectric Hand Basic Myoelectric Hand and Greifer Myo Hand with Wrist Flexion Unit Electric Terminal Device (ETD) Hero arm Michelangelo Axon Hook Interchange with Michelangelo Hand Bebionic i-limb Hand and i-Digits Taska hand Activity specific
torques on pre-swing
Demand torques for the hip, knee, and ankle: Hip: GRFV is posterior to the hip creating extension moment. Knee: GRFV is posterior to the knee creating flexion moment. Ankle: GRFV is anterior to the ankle creating DF moment. Response torques for the hip, knee, and ankle: Hip: flexors counterbalance Knee: extensors counterbalance Ankle: PF counterbalance
Ergonomic Considerations
Compare body mechanics when you: Can move your wrist versus having no wrist motion.... What happens with buttoning pants? Have supination versus no FA rotation... What happens with pouring? Are able to externally rotate your shoulder v. very limited ER... What happens to jacket donning?
Ideal presentation of mid to late stance with TFA
Continue with primary goal of knee stability Smooth forward progression of body over prosthetic foot Efficient preparation for upcoming swing phase
PF response torque
During a squat: Ankle: The GRFV is causing a dorsiflexion demand torque at the ankle. The body's muscles (i.e., plantar flexors) are exerting an equal muscular response in the opposite direction: _________ or internal plantar flexion moment. This prevents further flexion at the knee joint.
musculoskeletal pain
Excessive tissue tension can cause ________ which results in gait compensations
torques during loading response
Demand torques for the hip, knee, and ankle: Hip: GRFV is anterior to the hip creating a flexion moment. Knee: GRFV is posterior to the knee creating an flexion moment Ankle: GRFV is posterior to the ankle creating a PF moment. Response torques for the hip, knee, and ankle: Hip: extensors work to counterbalance the flexion moment. Knee: extensors work to counterbalance the flexion moment. Ankle: DF's eccentrically control PF moment.
torques on initial contact
Demand torques for the hip, knee, and ankle: Hip: GRFV is anterior to the hip creating flexion moment. Knee: GRFV is anterior to the knee creating extension moment. Ankle: GRFV is posterior to the ankle creating a PF moment. Response torques for the hip, knee, and ankle: Hip: extensors work to counterbalance the flexion moment. Knee: flexors work to counterbalance the extension moment. Ankle: DFs work to counterbalance the PF moment.
torques on midstance
Demand torques for the hip, knee, and ankle: Hip: GRFV is posterior to the hip creating extension moment. Knee: GRFV is anterior to the knee creating extension moment Ankle: GRFV is anterior to the ankle creating DF moment. Response torques for the hip, knee, and ankle: Hip: flexors counterbalance Knee: flexors counterbalance Ankle: PFs counterbalance
torques on terminal stance
Demand torques for the hip, knee, and ankle: Hip: GRFV is posterior to the hip creating extension moment. Knee: GRFV is anterior to the knee creating extension moment. Ankle: GRFV is anterior to the ankle creating DF moment. Response torques for the hip, knee, and ankle: Hip: flexors counterbalance. Knee: flexors counterbalance Ankle: PF counterbalance
What will the patient be able to do?
Determined by •Patient-related factors •Scientific evidence •Outcome measures •Clinical research •Your clinical expertise and judgment
common tissue damage locations with transmetatarsal amputations
Distal end 1st and 5th metatarsal heads Navicular Malleoli
K0
Does not have the ability or potential to ambulate or transfer safely with or without assistance and a prosthesis does not enhance their quality of life. pt could not walk or transfer safely even with a prosthetic
extension response torque
During a squat: Hip: Because gravity (GRFV) is exerting a flexion demand torque at the hip, the body's muscles (i.e., hip extensors) are exerting an equal muscular response in the opposite direction that we refer to as an _______ or internal extension moment. This prevents further flexion from occurring at the hip joint. Knee: The GRFV is causing a flexion demand torque at the knee. The body's muscles (i.e., knee extensors) are exerting an equal muscular response in the opposite direction: ________ or internal extension moment. This prevents further flexion at the knee joint.
non-disabled
Energy expenditure: 100% Cadence: 70-90 Distance/min: 70-80m
unilateral Transtibial amputation
Energy expenditure: 110-125% Cadence: 60-80 Distance/min: 60-70m
unilateral transfemoral amputation
Energy expenditure: 150-170% Cadence: 40-50 Distance/min: 30-40m
bilateral transtibial amputation
Energy expenditure: 180-200% Cadence: 35-45 Distance/min: 25-35m
PPS with unilateral KAFO
Energy expenditure: 190-210% Cadence: 35-45 Distance/min: 20-30m
bilateral transfemoral amputation
Energy expenditure: 300-400% Cadence: 15-25 Distance/min: 15-25m
weight acceptance
First task of stance Most challenging task in GC, as person must accomplish the following: Shock absorption Initial limb stability Preservation of progress Phases: Initial Contact (IC) Loading Response (LR)
quality
For prosthetic management, the ______ of the residual limb is more important than the residual limb's length.
c
For the hip extensors, a 5/5 MMT equates to what percentage of non-paralytic normal? a)26% b)42% c)65% 78%
b
For the knee extensors, a 5/5 MMT equates to what percentage of non-paralytic normal? a)33% b)53% c)68% 82%
a
For the plantar flexors, a 5/5 MMT equates to what percentage of non-paralytic normal? a)18% b)27% c)34% d)51%
shank recline
From IC to LR, the SVA is in _____ In true LR the SVA is vertical.
age
Gait becomes less efficient with older______ Distinction between two groups of individuals with TFA: Older users: Can walk without too much effort and faster with a locked prosthetic knee Younger users: Can walk faster when the knee is unlocked
SF-36
General health, physical functioning, physical role, bodily pain, mental health, emotional functioning, vitality, social functioning. Floor effect for lower functioning amputees.
ideal presentation of mid to late swing with TFA
Goal is to advance the unweighted limb Initiate swing period with enough hip flexor momentum to obtain knee flexion of the prosthesis for toe clearance Position the knee in extension in preparation for IC
K4
Has the ability or potential for prosthetic ambulation that exceeds basic ambulation skills, exhibiting high impact, stress, or energy levels. specialty level. sports and rec involvement. Foot: • SACH • Flexible (elastic keel) • Single axis • Multiaxial • Energy storage and return (ESAR/dynamic) • Microprocessor • Specialized Feet
K1
Has the ability or potential to use a prosthesis for transfers or ambulation on level surfaces a fixed cadence. transfers and home ambulation Foot: • Solid ankle, cushion -heel foot (SACH) • Single axis
common contractures with trans-femoral amputations
Hip flex, hip ext rot., hip abd
the most typical questions
How long will it be before I can walk? Can I return to work and do the same job? Will I be able to drive a car? How much will a prosthesis cost?
These prosthetic knees allow an individual to comfortably vary cadence through an oil filled cylinder attached to the knee axis:
Hydraulic knee
osseointegration
Implanting man-made, load bearing devices directly into the bone, whereby the fixture bonds with the surrounding tissue. Approximately 3300 amputees have been treated with __________ techniques to date, most with excellent results. Benefits: direct prosthesis control with improved stability and fixation improved ROM around hip joint not limited by the brim of a socket. increased functional capacity with prosthetic use. improved walking ability increased sitting comfort quick donning/doffing reduced socket related soft tissue problems improved overall QOL Adverse Events: infection peri-prosthetic fracture implant failure due to septic and aseptic loosening granulation tissue formation implant fatigue soft tissue redundancy causes discomfort. not the strongest available (marathoner would not benefit) have to avoid public waters + infection risk environments _______ is indicated for the difficult-to-fit amputee. _______ is approved experimentally trans-femoral by the FDA, trans-tibial is not approved. _______ is not approved in the US for diabetic or other co-morbid pts. _______ is a more simple surgery than joint replacements. Depending on the leg attachment, pts can stand in the shower.
toe break
In addition to the weakness of the quadriceps in those with dysvascular disease, the shorter lever arm in those with partial foot amputation due to dysvascular disease contributes to further increases in COG displacement, increasing energy expenditure. Additionally, the shortened lever arm of the foot results in premature ________ and forefoot collapse. The contralateral step length is thus reduced.
toe rocker
In pre-swing, the most anterior margin of the medial forefoot and great toe serve as the base for accelerated limb advancement. Elastic recoil of the plantar flexors thrusts the tibia forward.
pattern recognition
Instead of one or two electrode sites, an array of electrodes is used to capture a pattern of movement that is more intuitive for the end user creates more ROM
muscle weakness
Insufficient muscle strength to meet the demands of walking: •Disuse atrophy •Neurological impairment - Upper Motor Neuron Pathologies - Lower Motor Neuron Pathologies •Post-Polio Syndrome •Guillain-Barré Syndrome •Muscular Dystrophy Primary Muscular Atrophy ex: a common compensation for ______ in older adults is shortening their steps bc they do not have the strength to overcome the normal level arms.
large surface area
It is important to distribute the pressure from the prosthetic devices over a ________ to reduce the load at any one location, improving comfort. Remember that Pressure = Force/Area. In other words, the smaller the area, the greater the pressure, and the greater the discomfort.
Single Axis Foot
K1: Allows PF and DF for knee stability, allows for transfemoral amputees to control the knee better. The quicker the whole plantar aspect of the foot, the more stable the prosthetic knee is. Advantages: - contains an ankle joint that allows the foot to move up and down, enhancing knee stability - less force is transmitted to the user's residual limb and to their knee - more stable that SACH foot - Allows PF and DF for knee stability - Patients with high TF amputations will benefit from this because it reduces the effort to control the prosthetic knee during the heel contact to standing phase. - Fast transition from IC = LR takes advantage of the passive extension moment we get at the knee during this phase Disadvantages: - Heavier, more servicing needed - It will make the prosthesis heavier compared to a SACH - Appropriate mostly for prosthetic users that need stability around the prosthetic knee
Solid ankle cushion heel (SACH) feet
K1: Rigid, does not bend, traditionally for low activity individuals. the most basic prosthetic foot available Advantages: Waterproof, low cost, durable. very stable. allows for stability in stance period. Disadvantages: - Rigid keel cannot bend. - Heel height is fixed and cannot be readily customized. - Minimal shock absorption. - Almost no option to tune the foot to a users requirements. - Fixed with a single bolt which can fail without warning. - Active users will quickly overpower a passive ________ - Cannot be made strong enough to support an extremely heavy-weight person (250+ ibs) - Minimal energy return and anterior support - Shorter keel, about 3/4 of the length higher activity carbon feet à leads to a poor toe-off with quicker transition to the sound foot. - The keel cannot be customized — stuck with the amount of shock absorption we have for a particular foot. Can be quickly worn out by active users
List the feet in each K level
K1: SACH; Single axis K2: SACH; Flexible (elastic keel); Single axis; Multiaxial K3: SACH; Flexible (elastic keel); Single axis; Multiaxial; Energy storage and return (ESAR/dynamic); Microprocessor K4: ANY foot; Specialized foot
Stationary Attachment Flexible Endoskeletal (SAFE) Foot
K2: Has an elastic or flexible keel to allow for triplanar movement. good for unlevel surfaces. Advantages: - Adapts to multiple surfaces, gives semi-rigid toe lever for rollover - Has semi-rigid toe lever for rollover which assists with preservation of momentum during gait - Light weight Disadvantages: -motion still limited -no energy storage capacity -more servicing needed -Still relatively stiff compared to a multiaxial foot due to the stationary attachment. Kind of a hybrid K1/K2
Multiaxial Foot
K2: one step above single axis foot. can move in multiple directions. Multiple axis, allows motion in multiple plane, either flexible keep or true mechanical joint options (PF, DF, inversion, eversion) Advantages: - Absorbs some of stresses of walking, pressures in socket thus protecting the skin and the prosthesis from wear and tear. - Able to adjust to individual. — Can adjust stiffness of keel - Improved function when compared to the SACH or single axis. More adaptable to various surfaces. - For medium to high activity individuals. Disadvantages: - Heavier, more expensive, poor shock absorption, energy return, not for those with poor balance/proprioception. lower stability - Poor shock absorption and energy return
pneumatic and hydraulic knees
K3 knees that allow for the user to change cadence when walking.
Microprocessor Foot
K3: Ankle/foot components controlled by microprocessor and multiple sensors to make decisions on how to position the ankle, dampening resistance, and drive an ankle motor in stance. •These ankle/foot components are controlled by a small computer and sensors. The "computer" processes information from the prosthesis, prosthetic user's limb and the environment and then adjusts the speed and range of motion of the ankle depending on the action required. "Current __________ ankles use a variety of sensors, including ankle angle sensors, accelerometers, gyroscopes and torque sensors. The microprocessors in these systems then take the input signals and make decisions as to how to position the ankle, how to set the damping resistance in the ankle, and how to drive an ankle motor during stance phase" Advantages: good ankle movement and control on uneven terrain. good for stairs (DF), helps with decreased socket pressures, decreased tripping. •Responds to the environment or different situations by changing the speed or ROM. •Ankle alignment can also adjust for different situations, like a shoe with a heel, or when the individual carries a back pack or walks up an incline, this will improve the individual's mobility and balance in that situation. •It also provides an active push-off or propulsion as well as active dorsiflexion. Depending on the manufacture these feet can be connected to a mobile device or computer to change settings to individualize certain actions of the foot in different scenarios Disadvantages: Does not communicate with patient, battery powered, electronic failure, expensive, heavier. •It does not communicate directly with the person, but rather adapts through sensing movement or the environment. •It is powered by a battery, that needs to be charged. •Electronic parts that may fail/break. •Additional weight. •More expensive than other prosthetic feet and the current models are not waterproof.
Always consider postural alignment
Level of pelvis Leg lengths ROM MMT Joint mobility
Energy Storing And Return (ESAR) Foot
K3: Dynamic response foot, usually made of carbon-fiber, releases energy during rollover for propulsion. carbon fiber or nylon material. -The basic element of these feet is the design of the keel that simulates a spring molded carbon fiber plates. This design has better energy response during the toe-off phase (imitating the natural impulse of the foot) by means of the shape and the material of the keel. -The foot stores and releases energy when the individual is walking by absorbing the energy from the keel in the "roll-over" phase of walking. This creates a push off action. Advantages: Good for those with intermediate activity level, allows for propulsion during rollover, decreases impact and stress of sound leg during gait. •Can be used for regular prosthetic treatment of the majority of amputees. In particular for those with intermediate activity level, meaning they vary their walking speed, walk longer distances, and change direction quickly. •Very durable and lightweight •"Push off" gait is possible leading to a more symmetric gait. Because of the dynamic response of the foot, it usually encourages individuals to progress from moderate to higher activity levels Disadvantages: check every 6mo for wear and tear. sacrifice stability for increased propulsion. more difficult to use to take advantage of the energy storage. pt must be able to load the foot properly. •Cost. •Stiff keel for individuals with low activity levels (cant use the energy storage function).
common problems in mid to late stance with TFA
Lateral trunk bending Lumbar lordosis Forward trunk
ground reaction force vector (GRFV)
Let's take the squat as an example. The center of gravity of the person in the figure to the left is directly below the bar and this exerts a downward force that is directly perpendicular to the floor (dotted line). We know that with any force, there is an equal and opposite force, i.e., the floor exerting an upward force (also, dotted line) called the ________. Hip: The ______ is anterior to the hip joint, creating a flexion demand torque or an external flexion moment. This will cause the hip joint to flex. Knee: The ______ is posterior to the knee joint, creating a flexion demand torque or an external flexion moment. This will cause the knee joint to flex. Ankle: The ______ is anterior to the ankle joint, creating a dorsiflexion demand torque or an external doriflexion moment. This will cause the ankle joint to dorsiflex. the floor exerts an opposite and equal force (_______) to our COG (body weight)
three phases of training
Literature has _______ a patient with a prosthesis -Phase one: Basic control of the components -Phase two: Gaining and refining control of the components -Phase three: Bimanual training • Each phase builds on the previous one - To be done in order to prevent frustration build up on time so the pt can increase endurance to wear the prosthetic most of the day.
Name four different types of suspension commonly used in transtibial prostheses. What are the advantages and disadvantages of each? Which patients are best for which?
Locking Liners Sleeve Suspension Liner Suction (no liner) Cuff
Orthotic & Prosthetic User's Survey (OPUS)
Lower limb functional measure, health-related quality of life scale, follow-up evaluation of satisfaction with device AND services. Reliability and MDCs have been studied.
Prosthetic Limb Users Survey of Mobility (PLUS-M)
Measures perceived mobility in those with limb loss. Correlates with other standard measures and demonstrates good construct validity.
Prosthesis Evaluation Questionnaire (PEQ-17)
Measures prosthesis function, mobility, psychosocial experiences, and well-being. Evaluates the prosthesis and life with prosthesis. Moderate correlations with standard tests. 41 questions.
common problems with the swing period with TFA
Medial or Lateral Whip Hip hiking Contralateral vaulting Abducted gait/circumduction of the prosthetic limb
goals of prosthesises
Minimum effort (energy expenditure) Adequate stability Acceptable appearance
Prosthetic Profile of the Amputee - Locomotor Capabilities Index (PPA-LCI)
Moderate-good reliability and validity in determining factors potentially related to prosthetic use after discharge from rehabilitation. Prone to high ceiling effects. Lengthy.
vacuum
More socket materials are gaining momentum that take advantage of _______ suspension to lower trimlines and have more total surface bearing properties
gluteus medius
Most patients with a transfemoral prosthesis demonstrate compensated _______ gait pattern, where the contralateral shoulder and pelvis elevate, resulting in trunk and pelvic retraction and sidebending toward the stance limb.
Myo Hand with Electric Terminal Device (ETD)
Motion Control High pinch force Slender tips and high pinch force Water-Resistant Good visibility Wide opening looks like 2 hooks.
Myo Hand with Wrist Flexion Unit
Multi-flex or flexion wrist Improves Ability to Reach Midline Hand is in better position for reading Hand is in better position. Minimizes compensatory motions at shoulder and trunk Easier to get to midline for dressing, zipper
ankle rocker
Once the forefoot strikes the ground at the end of IC and at the start of LR, the ______ now becomes the fulcrum for continued progression. The foot is stationary as it is in full contact with the ground, which allows the tibia to continue the body's advancement through further inclination of the tibia through passive ankle DF in response to the ongoing momentum. The body vector (ground reaction force vector or GRFV) advances to the metatarsal heads. The critical point of the ______ is the yielding quality of the soleus musculotendinous complex. As it contacts eccentrically assisted by the gastrocnemius, it provides the tibia a stable base for knee extension locking the ankle joint in preparation for heel rise.
most common contracture with transmetarsal amputations
PF
Name the two types of transtibial socket designs. Compare and contrast them both.
Patellar-Tendon Bearing Socket Total Surface-Bearing Socket
Patient Specific Function Scale (PSFS)
Patient lists up to 5 main activities that they find difficulty to perform, then rate their current ability: 0 is "can't perform the activity at all" and 10 is "can perform the activity full." Reliability and MDCs have been studied in those with LL.
transfemoral amputations
People with ________ are more likely to have more pronounced gait deviations and will always have differences from normal gait. For example, the prosthetic knee will always be in full extension during stance period whereas the knee in normal gait never normally reaches full extension deviations at the knee and the hip are more pronounced. a consistent hip extension internal torque is necessary throughout stance phase in this population
pathologic gait
Persons with LE LL will adopt many kinds of abnormal movements to minimize their energy expenditure, notably decreasing their gait speed to compensate for the increase in energy demands. These maladaptive behaviors contribute to ________, an inefficient mode of locomotion requiring considerably more energy than normal gait.
Deformity; weakness
Physiological reactions to pain = 2 obstacles to effective walking ________ •body changes its Natural resting postures due to post-pain/trauma _______ associated with pain •Secondary to pain •Reduced activity •Protective response
Swing phase deviation can include
Pistoning/rotation/slipping of the socket Catching of the toe Medial and lateral whips Causes may include: Prosthesis being too short or long Problems with suspension Insufficient knee flexion Foot position.
body powered prosthesis
Powered and controlled by gross body movements captured by a harness system. good for active outdoor pts. devices can take the most wear and tear. Uses a cable (rubber band) system to open and close the hand based on shoulder movements. Benefits: • Can be less expensive than myoelectric (external power) • Can be heavy duty construction and function • Environmentally resistant • Increase in sensory feedback through shoulders Limitations: • Grip strength or pinch force limited compared to myoelectric prosthetic • Restrictive and uncomfortable harness - functional envelope limited • Poor static and dynamic cosmesis • Axilla anchor (possible sound side nerve problems) • not able to move multiple joints at the same time. • Common to develop shoulder injuries
prosthetic process
Pre-Operatively, it is important to Ease Emotional Stress by Educating the Amputee on the ________. it is best to have the pt see the prosthetist before surgery to understand the whole ______.
post-operative visits
Pre-Prosthetic Rehabilitation (optimization) Crutch Train, Exercises, Healing Stump Wrapping + Shrinkers Pain Management Address problems that will prolong rehab (contractures, etc.) 1-14 days
4 Square Step Test (FSST)
Predictive of increased fall risk: >24 sec
14-28 days post-op
Prepare Amputee for First Prosthesis Shrink + Shape Strengthen + Maintain ROM Prescribe great HEP.
valgus moment at the knee with transtibial amputation (midstance)
Problems: excessive pressure at lateral proximal and medial distal areas gap at medial supracondylar area medial instability Prosthetic related causes: foot too outset or socket too inset foot too abducted or socket too adducted (short lever) prosthesis too long = creates wide BOS on the involved side, weight added = valgus moment. socket is uncomfortable User related causes: tends to walk with wide BOS hip abduction contracture = wide BOS structural deformity = wide BOS
excessive varus with transtibial amputation (midstance)
Problems: excessive pressure at medial proximal and lateral distal areas gap at lateral supracondylar area lateral instability Prosthetic related causes: foot too inset or socket too outset foot too adducted or socket too abducted prosthesis too short = lateral trunk lean to involved side socket is uncomfortable mediolateral socket dimension is too large (leaning into side of socket) User related causes: tends to walk with narrow BOS adductor tightness (leads to narrow BOS which when they put weight through it the knee enters varus) other habit-type deviations (ex: circumduction) pain shoes wearing on lateral side of sole
excessive extension at the knee in transtibial amputation (IC)
Problems: hyperextension at knee pain at patella excessive pressure at patellar tendon and posterior distal areas Prosthetic-Related Causes: heel too soft = want a firm heel to promote knee flexion socket too extended = long lever foot too PF = long lever socket too posterior foot too anterior User related causes: excessive quad activation weak quads pt changed to a lower heeled shoe residuum discomfort
excessive flexion at the knee in transtibial amputation (LR)
Problems: raped and premature knee flexion premature forefoot contact (slap foot) excessive pressure at posterior proximal and anterior distal areas Prosthetic related causes: foot too far posterior socket too far anterior = short lever foot too DF = short lever socket too flexed heel too firm heel too tall keel is too short or too soft = weak lever User related causes: weak hip or knee extensors resolving flexion contracture causes excess socket flexion pt changed to a higher heel shoe pain
Pneumatic Post-Amputation Mobility Aide (PPAM)
Pros: Early walking, weight bearing, reduction in edema, patient morale Cons: No knee flexion, bulky, unstable Components: Rigid frame, pneumatic bag(s), crucible strap, rocker foot
ideal initial contact in TFA
Prosthetic knee should be fully extended to position foot appropriately for smooth loading As loading occurs, prosthetic foot rolls smoothly into LR (foot flat)
goal of UE prosthetics
Provide appropriate appearance and function to increase independence with ADLs and improve quality of life
Differentiate between the quadrilateral and ischial containment transfemoral sockets
Quadrilateral Ischial Containment
common problems with initial contact with TFA
Risk of instability as weight is transferred onto prosthesis: Rotation of foot at heel strike Excessively rapid knee extension just prior to IC (extension thrust) Ealy heel rollover Decreased swing time and step length
Rheo knee
Sensors constantly monitor the weight of the user and the angle between knee and thigh, providing real-time information about the speed and movement of the prosthesis, as well as ground reaction forces and any bending movements.
List 4 types of knee components and differentiate between them by function
Single Axis Stance Phase Control Polycentric Manual Lock
In order to facilitate a flexion moment at the knee in TSt:
Socket can be pre-sized into 5-10 degrees of flexion Foot can be dorsiflexed Foot can be moved posteriorly
7 degrees
Socket fit is key for proper transverse plane alignment and stability. If the prosthesis is not donned properly, it can lead to a rotated socket and, consequently, a rotated foot. Prosthetically, the foot is matched to the sound limb. In anatomic normal, humans have around ________ of toe out.
quads
Some people with dysvascular disease will demonstrate weakness of the ________. This functional weakness during gait is compensated for by the person through locking out of their knee during IC through LR. By doing so, the person shifts the GRFV anterior to the knee, creating an extension demand torque as opposed to a flexion demand torque during IC and LR. This effectively reduces the eccentric demand on the _______ for knee stability, though it sacrifices shock absorption
Prosthetic limb stepping, partial weight bearing
Start with prosthetic backwards i. Same activity as (a) but with prosthetic limb stepping ii. Therapist observes 1. Transverse pelvic rotation** of prosthetic side 2. Knee flexion 3. Ankle movement 4. Step length 5. Foot placement Pt often takes a longer step with prosthetic limb, use tape as an equal step que. iii. Therapist places hands on ASIS feeling for transverse pelvic rotation Facilitating forward pelvic rotation (protraction): at the terminal stance phase, pt pushes hips down and in to facilitate TPR. practice hip rotation then practice hip rotation with prosthetic swing. can we do TPR
Sound limb stepping, partial weight bearing
Start with prosthetic forwards. i. Repetitive steps forward and backward with sound limb (heel rise to heel strike - full swing phase of sound side) ii. Therapist observes 1. Transverse pelvic rotation 2. Knee flexion 3. Ankle movement 4. Step length 5. Foot placement iii. Patient continues stepping, therapist places hands on ASIS feeling for transverse rotation of pelvis in preparation for advancing LE. TPR is starting PT is behind the pt to tap on posterior socket. focus on stability. progress through UE progression can we achieve stance stability on the prosthetic limb?
the TKA line
Stationary alignment line to identify the relative alignment between the center of socket weight line, rotation point of knee, and functional rotation point of ankle/foot. If the TKA line is posterior to the knee, the knee will: flex If the TKA line is anterior to the knee, the knee will: extend This concept is not as important with the emergence of more advanced componentry.
Power knee
Stimuli realized. Sensors measure position and movement, plus applied forces and loading. AI evaluates gait patterns and calculates the optimum response to any situation. Advanced actuator technology generates power according to user needs. pushes the pt forward with each step.
Does the length of time before the fit matter?
Success is over 90% if fit in first month (golden window of time) Drops to 42% if fitted over a month from amputation. the sooner the pt can get in a prosthesis, the better chances of their outcomes (less risk of abandonment)
T
T/F: A BILATERAL TRANSTIBIAL MORE LIKELY TO BE A FUNCTIONAL PROSTHETIC USER THAN A UNILATERAL TRANS FEMORAL. having a intact knee is the key factor.
T
T/F: MMT is unable to identify the upper levels of normal strength
T
T/F: No single prosthetic system meets all needs
F: The shank is NOT vertical during MSt.
T/F: the SVA is vertical during mid-stance
swing limb advancement
Task of swing Preparatory posturing begins in stance in preparation for limb advancement to complete the following: Foot clearance Limb advancement Prepare for next stance interval Phases: Pre-Swing Initial Swing Mid Swing Terminal Swing
tibial collapse
Terminal stance is actually when the plantar flexors peak in their activity to resist _______ and allow for a rigid foot lever for toe rocker.
foot rockers
The ______ are an important concept to understand within the context of gait efficiency and the ability for the body to transition from one gait phase to the next. The advancement of the body over the supporting foot is dependent on stance limb mobility. Take for example when the heel is about to contact the floor during IC. The challenge the body has to overcome at this point is to somehow tackle the issue of the body's weight rapidly dropping onto that forward limb. Since the thigh is only flexed to 20 degrees, most of the force is directed toward the floor. This force needs to be redirected and transferred in some way that allows the body to continue moving forward in gait and not down into the floor. This is where we get into the concepts of the __________ acting as a pivot system to allow the body to progress and advance smoothly in the horizontal plane. Heel rocker Ankle rocker Forefoot rocker Toe rocker
higher
The ________ the amputation level, the higher the energy demands.
shank-to-vertical angle (SVA)
The __________ is an important concept when we get into orthotics and prosthetics. The ______ is the angle of the shank (tibia) in relation to vertical and can be described in degrees of incline or recline from vertical. The _______ is NOT the dorsiflexion angle of the ankle. It is good practice now to differentiate between the _____ and ankle DF angle, as they are not synonymous.
postoperative pain
The individual with new amputation is likely to be coping with significant acute __________ and may be distressed by the sense that the limb is still in place (phantom sensation) after amputation
heel rocker
The momentum generated by the forward fall of the body weight is preserved by the ________. Floor contact is made by the rounded surface of the calcaneus, providing the body an unstable lever that rolls toward the ground as the body weight is dropped onto the foot. The pretibials slow down the rate at which the foot/forefoot drop to the ground, which also draws the tibia to incline forward during this phase. Important to consider as well is the action of the quadricepts which ties the tibia to the femur, which is also drawn forward by the quadriceps' action. In this way the heel rocker facilitates progression of the entire stance limb, transferring a lot of that energy and force toward the floor into forward momentum.
patient
The most important part of any prosthesis is the ________ aka the motor/engine
inverse
The precise duration of these GC intervals varies with the person's gait velocity The duration of both gait periods show an _______ relationship to walking velocity, i.e., both stance and swing times decrease as gait velocity increases
knee
The preservation of the_______joint is fundamental in terms of energy expenditure, shock absorption, and minimizing variations in the displacement of the COM that are very costly. For example, contractions of the gluteus and psoas muscles increase on the amputated side and are very costly in terms of energy expenditure
In order to produce a desired varus/slight varus moment:
The prosthesis' socket can be slightly ADDUcted on the pylon Too much adduction of the socket will change the forces from a varus moment to a valgus moment Small changes to alignments can significantly impact the patient's function A foot insert can be added
excessive toe out
This deviation is most noticeable in the frontal plane from LR to PSw and is noted in the sagittal plane and creates both a valgus moment and a knee flexion moment. Again, the problem is in the transverse plane. An ________ shortens the foot, leading to a greater flexion moment
excessive toe in
This deviation is most noticeable in the frontal plane from LR to PSw and is noted in the sagittal plane during extension movement at TSt. However, the biggest problem arises in the transverse plane. An _______ effectively lengthens the foot. This in turn, creates a greater extension moment, which will affect which phases of the GC the most? = terminal stance. extension moment causes extra knee extension
transmetatarsal amputations
Those with ________ demonstrate gait velocities 61% of normal controls. These individuals display delayed peak dorsiflexion angles leading to delays in forward progression over the shortened stance limb and the transition into double limb support. There is an increased energy cost. Plantar flexion contractures are common due to muscle imbalance.
abnormal joint ROM
Tissues do not allow for sufficient passive mobility for normal postures and ranges usually limited ROM. can be excessive ROM.
total surface bearing (TSB) socket
Transtibial amputations: Active individuals, pressures and forces are distributed over whole residual limb. good for 6mo-years post amputation so there isnt as much volume changes. Want all of limb to be loaded, less pressure in areas prone to skin breakdown. Reduce shear forces c gel lining. Reduce normal forces c as much contact surface as possible taking into account tissue type (compress soft tissue structures more, allow more space for bony prominences). advantages: Reduces pistoning, improved proprioception, better suspension, comfort. •Active amputees benefit from the lower trim lines possible with the TSB style design •TSB sockets reduce pistoning of the socket on the residual limb by providing total contact •Suspension of the TSB socket is also noted to be better •Proprioception is increased •more comfortable because overall socket pressure is reduced Disadvantages: Needs more relief; high pressure due to the stance phase; extra room for the bony prominences any volume changes in the limb then the pressure changes and it will not fit. Needs exact volume determination. •Amputees with bony spurs are not suitable for TSB sockets •TSB sockets are not suitable for primary amputees due to volume changes in the first 12-18 months post-amputation •For the same reason TSB sockets are also not suitable for amputees undergoing treatments such as dialysis due to volume fluctuation •Unsuitable for patients with short residual limbs, less then 10cm long, which require higher trim lines for stability around the knee •Some amputees may experience pain at the distal end of their residual limb due to the way a TSB socket weight bears over the entire limb •Patients with excessive soft tissue on their residual limb may drop down into a TSB socket too much which will cause pain at the distal end
cuff suspension
Transtibial amputations: Also called auxiliary suspension, was original way of keeping socket on, especially in swing phase. -Even though this and "old" way of suspension it is still used today as it is an inexpensive, simple, reliable and durable way of suspension. -This can vary from a simple soft strap/cuff to a very rigid band around the pelvis. •Transtibial: With PTB sockets there can be a strap over the patella. advantages: Better sitting comfort, adjustable, good for pts with short residual limbs (3in or shorter). •Simple, durable, reliable, inexpensive disadvantages: Cosmesis, interface not as intimate. •Can cause chafing/bruising •May not be reliable for all body shapes •Cosmesis •Interface not as intimate
Sleeve Suspension
Transtibial amputations: Flexible sleeve that goes over the socket and proximal limb advantages: Pistoning is reduced with airtight seal, flexible, more cosmetic, inexpensive. •Sleeves are flexible and usually allows the knee to bend (if the sleeve has a ribbed or wave design over the knee joint) and it is cosmetic as it covers the top edge of the socket. •It is a reliable form of suspension and relatively inexpensive. disadvantages: Can cause skin issues, needs UE hand dexterity/strength, wear and tear reduces effectiveness •Sleeves without a ribbed or wave design can cause abrasion over the patella. •If applied incorrectly the person can get a skin irritation where the sleeve touches the skin. •Needs hand dexterity and strength. The sleeve's effectiveness is reduced with wear and tear, a hole in the sleeve can lead to a loss of suction
suction suspension (no liner)
Transtibial amputations: Not as widely used, socket-direct skin interface. vacuum like, when limb is placed inside, uses negative pressure to keep the limb inside the socket. relies on skin contact with the inner wall of the socket. -Valve removes air from distal end of socket as limb is inserted. -due to closeness of socket fit, the amputee uses a pull in device (cord, webbing, or special sock to pull into the socket. This device is expelled through valve at distal end of prosthesis that will have cap to eliminate air exchange -Doff by taking off cap and letting air in socket advantages: Intimate interface between socket and limb. Same suspension advantages as sleeve disadvantages: Highly susceptible to failure because of leaks in the airtight seal; not very durable -Direct skin contact -Complex donning procedure requiring significant dexterity -Fluctuations in limb volume can lead to loss of suction
locking liner suspension
Transtibial amputations: Uses a pin lock with auditory feedback when pin engages advantages: •Provide a positive mechanical lock with auditory feedback for the user when the pin engages. •Relatively easy donning and doffing and can be done in a sitting position. •More forgiving with volume fluctuations. disadvantages: Has lots of un-controlled pull that causes a "milking" phenomenon during SWING phase. This milking phenomenon, causes skin breakdown, pain, and edema at distal limb. Not good for new amputations. skin irritation at the distal limb. •Due to the pulling down action of the pin on the liner an elongation effect can happen at the bottom of the residuum and cause skin breakdown, but newer liners may include a custom molded flexible socket between the interface material and the hard socket to avoid this from happening. •Some pistoning will still be present which can create distal limb pain and increase edema/skin breakdown •Wear and tear on liners. •When the pin is misaligned or the liner is donned incorrectly the locking mechanism will not be engaged, this might be difficult for someone not having the ability to bend down or with poor eyesight.
Patellar Tendon Bearing (PTB) socket
Transtibial amputations: At least 50% of weight bearing on patellar tendon; most common load limb in patellar tendon and medial tibial flare. Set in 5o of flexion to allow the patellar bar to bear weight. Advantages: increase surface area for weight bearing. good for pts with volume changes in their limb (especially early in their recovery). Tried and true- has been done for 80 years Disadvantages: Pressure on bony structures like fibular head -May have pain on patellar surface -TSB is more globally appropriate. Non-traumatic injury with no integ issues could do _______
fatigue the patient
Transtibial gait can be difficult, may need to ________ for deviations to present, or may need to see number of socks, the shoe wear, or presence of any redness
3"
Transtibial residual limbs of less than ___ may be insufficient for proper prosthetic control and insufficient in contact surface area for skin tolerance for weight-bearing pressures.
10 min
redness that lasts more than _____ in pressure intolerant areas warrants a referral to the prosthetist.
trauma
Upper extremities are most often due to _____ (up to 92%). other reason is congenital.
how to fix lateral leaning in midstance with TFA
User changes: hip abductor strengthening adjust wearing schedule pain modulation techniques motor control/learning techniques to fix bad habit Prosthetic changes: ensure correct length adduct prosthesis add sock socket adjustment
strategies to control pain
Usually managed by physician • Modalities: E-stim, Heat/ice, Ultrasound • Mirror therapy: 12-15 minutes/day, Daily • Graded Motor Imagery. Three stages, App to guide patient strategy for before getting prosthetic.
rapid knee extension with TFA during terminal swing
Visible shock in the knee. can hear the knee of the prosthetic click Prosthetic related causes: Insufficient knee friction Excessively strong extension aid User related causes: Residuum forcibly flexed to produce extension of knee to ensure safety Excessive acceleration force Lack of confidence Bad habit
knee flexion
We typically see poor knee flexor torques, exhibiting poor ________ in transfemoral amputations
Main causes of amputee gait deviations
Weakness Deformity Impaired motor control Sensory loss Pain Fear/anxiety
The 8 gait phases contribute to accomplish 3 basic tasks:
Weight Acceptance (WA) Single Limb Support (SLS) Swing Limb Advancement (SLA)
proprioception
When _______ is primarily impaired... •Inconsistent gait pattern •Inability to substitute for weaker muscles •Slower gait speed results in exaggerated or excessive motion. pt will use other sensory systems (vision) to compensate.
efficient speed
When a person without an injury or pathological condition walks at their self-selected walking speed, they are walking at their own most_______. This means walking speeds at higher or lower levels that that of a person's self-selected walking speed leads to increases in metabolic costs.
hip hiking
With a relatively "longer limb" vaulting and ________may also occur. excessive elevation of pelvis and shoulder on the prosthetic side. Prosthetic related causes: Prosthesis too long Excessive plantar flexion Toe lever too long Incorrect socket fit Insufficient suspension Excessive friction in knee Excessive strength of knee extension mechanism of prosthetic User related causes: Weak hip flexors Weak hip IRs Fear of scuffing the ground Bad habit Amputee may have donned the prosthesis in ER
internal moments
____ occur from initial contact to mid-stance.
Neuropathic pain
_____ occurs from neuromas or agitated nerves after amputation. _____ occurs due to vasomotor changes in the amputated area.
pistoning
______ can create wearing down of parts
How do we restore the 2nd and 3rd rocker for gait in those with partial foot amputation?
With the use of AFOs with toe or foot "fillers" to help promote smooth rollover during gait as well as protect the remaining tissue of the residual foot.
trans-femoral (A/K)
________ amputations take 40-65% extra energy expenditure. with _________ amputations, 50% of weight is on Ischial Tuberosity in standing. The rest is through Soft Tissues. the socket needs to be changed based on their physical changes. Pressure Sensitive Areas • Pubic Ramus • Symphysis Pubis • Adductor Tendon • Lateral Distal Femur
motor neuron diseases
________ are very variable in their gait patterns.
pressure tolerant areas
________ around the knee are broad areas. soft tissue structures. not bony prominences. supracondylar areas suprapatellar areas patellar tendon medial flare of tibia lateral flare of tibia lateral flare of fibula posterior area of stump popliteal area (gentle pressure) distal end of stump for total contact socket (no pressure, but contact is allowed).
positional rotators
________ can be added to most prostheses. allows for the joint to rotate out of normal ROM. does not sacrifice stability.
decreased arm swing
________ occurs due to Decreased gait speed, lack of trunk and pelvic rotation
UMN pathology
________ results in Emergence of primitive control mechanisms (CPGs) -Locomotor synergies (flexion an extension synergies) -Postural reflexes (increased tone leading to synergies) -Stretch reflexes (spasticity) extension synergies: bad swing phase flexion synergies: bad stance phase
cosmetic covering
________ should wait until all changes to the prosthetic are finished.
prosthetic fabrication
________ starts between 21 days - 6 weeks. goal is to start ________ within 1 month of amputation. starts about 4-6 visits to Prosthetist
CAT CAM exercises
_________ can be used to strengthen the amputated limb. also: PROM, AAROM, AROM, manual
dynamic alignment
_________ is very Important. Should be studied at midstance (Foot flat on the floor in all planes. Knee Flexed slightly) Toe out should match or be very straight for Dynamic Response feet. Check Length (use PSIS, ASIS, Gr Trochanter, Iliac Crests as markers) Must have equal weight on both sides. Often ________ issues are related to poor weight shifting
total suction sockets
_________ require less energy than conventional sockets.
ischial containment sockets
_________ require less energy than quadrilateral sockets.
rigid dressings
_________ surround the residual limb. does not allow for edema accumulation bc is not stretchy. prevent contractures bc casted in full knee extension.
Balance impairments
_________ that can be both motor control and/or sensory deficits related
gait
__________ is a sequential process of reciprocal foot contacts.
impaired motor control
__________ usually occurs in UMN and/or LMN pathology. •Loss of selective control (specificity), loss of ability to switch between contraction types, inability to vary speed and force of contractions •Disrupts muscle phasing
normal pelvic orientation
________which is 15 degrees of anterior pelvic tilt and 5 degrees of forward rotation. However, in those with transfemoral prostheses, these are increased, especially in late stance
locking liner
a ______ is the most common suspension. the sock locks into the base.
wearing schedule
a ______ is to build tolerance bearing weight into their residual limb. look for areas of skin/pressure irritation as more time is added to the ______. educate the pt on pressure areas. day 1: 30min 3x/day
foot slap
a _______ can only occur if there is a heel contact at initial contact. _______ cannot occur if there is a forefoot or flat foot initial contact
knee flexion contracture in gait
a _______ challenges the quads more to stabilize the knee. tight hamstrings causes knee to not reach adequate extension in terminal stance which causes a decreased step length on the ipsilateral side. this alters the initial contact position.
tibial tubercle height prosthesis (AFO)
a __________ Increases Toe Lever Arm and Spreads forces over larger area. great for active pts. ex: pt who wants to return to playing basketball.
lumbar lordosis
a mild hip flexion contracture can be compensated by increased ________.
Gait training strategies
a. Sound limb stepping, partial weight bearing a. Prosthetic limb stepping, partial weight bearing a. Prosthetic limb stepping, full weight bearing a. Sound limb stepping, full weight bearing a. Step length and prosthetic control a. Sidestepping a. Resisted gait training a. Trunk rotation and arm swing a. Unassisted ambulation
5 categories that can cause pathological gait
abnormal joint ROM muscle weakness sensory impairment pain impaired motor control
altered gait leads to:
additional MSK impairments increased energy expenditure falls activity and participation restrictions stigma and psychological impact
A patient describes no pain with gait, but demonstrates a lateral lean to the prosthetic side in midstance. One way the prosthetist might address this issue would be to:
adduct the socket
3-5 years
after the pts 2nd prosthesis, they will need a new LE prosthesis every ________ depending on physical changes.
foot function in midstance
allow tibia to advance from 8-10deg of recline to 5-8deg incline flexibility to accommodate to surfaces
stance phase
always fix the ______ issue first. often times it will also fix the swing phase issue.
dysvascular or trauma
amputations from _______ origins are more likely to experience phantom limb pain/sensations.
heel off
an extension moment in the knee occurs at _____.
Syme's amputation
ankle disarticulation, end bearing adequate. Good for physically fit pts bc blood flow in the ankle is not great.
transverse pelvic rotation (TPR)
anteromedial rotation generated at the pelvis when loading the prosthetic toe. _______ assists with rapid flexion of the prosthetic knee and begin advancement of the swing limb. rotational moment at the hip. creates knee flexion in swing limb advancement start the motion at terminal stance. strongly activates hip flexors to advance through limb advancement
10min
any redness from pressure in pressure intolerant areas should go away after _____ of doffing the prosthetic. continue to monitor the area if any redness occurs in pressure intolerant areas.
20min
any redness from pressure in pressure tolerant areas should go away after _____ of doffing the prosthetic.
decreases
as the articular pressure of a joint increases, the muscle strength around that joint __________. ex: knee articular pressure increases, quad strength ________. after injection = restored muscle strength. protective mechanism.
neutral
at initial contact, the ankle should be in ______.
PPAM Brackets
balloon leg to help pts regain balance and understand how to use a prosthesis before the pt has their real prosthesis. can be used for multiple pts in a clinic/inpt
hydraulic knee
bends in several areas. during the swing phase it shortens to allow for toe clearance.
3 months - 2 years
between ________, the pt Learns to Master their Prosthesis, Deals With Physical Changes (strength changes and atrophy in the limb), and May need new socket depending how much change takes place
3 weeks - 3 months
between _________, the pt Learns to Use Prosthesis with the PT and Refines the Prosthesis with the Prosthetist. communication between PT and Prosthetist is key.
UE support progression
bilateral support remove ipsilateral hand remove contralateral hand remove bilateral support
240%
bilateral trans-femoral amputations take _____ energy expenditure.
125%
bilateral trans-tibial amputations take ______ energy expenditure.
stiff knee in swing phase
cause: lack of heel off in terminal stance, impaired motor control, knee pain, knee extension contracture, PF/quad spasticity, weakness in hamstrings, hip flexor weakness (RF takes over) consequence: foot clearance, increased cost of energy
no heel rise at all
cause: weak calf = no eccentric storage, ankle and metatarsal pain, inadequate extension of toes consequence: impaired forefoot rocker = decreased efficiency, limited knee flexion during swing limb advancement
Time & Distance Qualities
cadence, distance of steps, swing phase, stance phase, double and single limb support times, etc.
if the pt has knee pain on the sound side
can enter kneeling from stance onto the prosthetic (so not landing on the sound side) can use a chair, abduct the prosthetic towards the chair side. weight bear through UE and lower themselves to their sound side knee.
turning 180deg
can turn to the sound or prosthetic side. step, arc, L step, step pivot! when pivoting on the prosthetic side, there will probably be more steps involved for the full pivot. proprioception is key.
lack of DF in mid and terminal stance
cause: PF contracture/spasticity, weak quads (if occurring with knee hyperextension), impaired proprioception, ankle pain consequence: poor position for heel rocker = decreases efficiency and momentum
lack of heel contact
cause: excessive knee flexion in terminal swing = flat foot contact, weak quads, excessive PF in terminal swing = flat foot contact, heel pain consequence: poor positioning for heel rocker = lose momentum and decrease efficiency, decreases shock absorption by limiting knee flexion
knee extension in loading response
cause: weak quads, forefoot/foot flat contact due to decreased DF, knee pain, quad hypertonicity Consequence: decreased shock absorption, impaired forward momentum = decreases efficiency, injury of posterior knee capsule
excessive PF during swing phase
cause: weakness in pre-tibials, PF contracture, PF spasticity, lack of DF control consequences: foot clearance, poor foot position for initial contact
too hard keel
causes an excessive knee extension
too soft keel
causes excessive knee flexion
aberrant heel rise (too early)
causes: hip flexion contracture, anterior hip pain consequences: decrease step length on contralateral side, increases demand on quads and hip extensors, decreased efficiency, lack of achieving passive stability.
K levels
classifying amputees by their potential functional levels • Medicare -driven • Considers - Past medical history - Current medical condition - Status of residual limb - Other medical comorbidities • Desire to ambulate, But more importantly, potential to ambulate
hybrid prosthesis
combination of body power and external power. can provide a balance when considering cost vs weight. can allow greater choice of components for a higher level amputation. Will need to consider expectations of both body powered and external powered devices
micro-processer knee
computer chip controls stance and swing phase. most stable on the market. can go up stairs reciprocally, walk backwards, and change velocity.
floor to chair strategy
cross prosthetic over, work into quadruped position, high kneeling, step up with sound limb to enter chair, or push through posterior socket to a stance position.
common deviations
decreased velocity asymmetrical step length altered swing/stance time increased BOS (wide) swing/stance asymmetries between legs unable to alter speed or pattern altered double/single limb support
5 stages of grief
denial and isolation, anger, depression, bargaining, acceptance
phantom limb pain
described as shooting pain, severe cramping, or a distressing burning sensation that may be localized in the amputated foot or present throughout the missing limb. A smaller percentage (46%-63%) of those with new amputation experience _________. most experience transient mild to moderate discomfort that does not interfere with usual activity. ________ is more likely in those with longstanding and severe preoperative dysvascular pain and for those requiring amputation after severe traumatic injury Pulse radiofrequency ablation and botulinum toxin type A injection are being investigated as possible interventions for severe longstanding _________ VR has shown promise in combatting _______. interventions: pain medications, beta blockers, muscle relaxers, injections, VR, mirror therapy, massage, TENS, PNE
short non-articulated prostheses (stubbies)
designed for bilateral AK amputees. hard to control 2 bilateral prostheses. often a first prosthesis, progress to longer legs. can use ______ and long legs for different ADLs.
Cerebral palsy gait pattern
diminished heel contact crouched gait hyperextension of trunk plantarflexed ankles scissoring due to spasticity excessive DF toe drag
5deg backwards
during terminal stance, pre-swing, and initial swing, the pelvis is rotated ______.
5deg forward
during terminal swing and weight acceptance, the pelvis is rotated ________.
John is a 65 year-old who underwent a unilateral transtibial amputation following a traumatic accident at work. He is concerned with his walking speed. You think he has the potential to navigate most environmental barriers. What foot is most appropriate?
energy storage and return (K3)
During transtibial gait at the knee, we want a slight _______ moment in the sagittal plane and a slight ________ moment in the frontal plane.
flexion, varus flexion is created by slight socket flexion varus is created by slight adduction
loading response TTA
goal = controlled knee flexion probs: excessive extension excessive flexion
transtibial initial contact
goal is a heel contact. problems: knee flexion contracture = flat foot contact prosthetic length too short = flat foot contact suspension problems = weight acceptance instability and swing limb advancement instability (prosthetic falling off)
midstance with TTA
goals = tibial progression with flexed knee, slight varus moment at the knee
transfemoral pressure intolerant areas
greater troch ramus ASIS adductor tendon distal end of femur inguinal fossa pubic tubercle surgical suture
early heel rollover with TFA
heel contact with ground is too short Prosthetic related causes: Anteriorly displaced socket Insufficient flexion of socket Excess dorsiflexion Soft heel cushion User related causes: Weak gluteal muscles
common contractures with trans-tibial amputations
hip flex, ext. rot., hip abd., knee flex
most common contracture with transfemoral amputations
hip flexion hip abduction hip ER
Prosthetic limb stepping, full weight bearing
i. Once satisfied with previous prosthetic limb stepping forward and backward biomechanics, progress patient to remove ipsilateral UE, the contralateral UE, then no UE support with stepping pattern ii. Therapist observes 1. Pelvic rotation through light manual contact on ASIS 2. Prosthetic knee flexing at TSt, increasing through MSw 3. Hip should not be flexing excessively at IC, movement should be controlled facilitate TPR at the hip and facilitate locking the knee for weight acceptance by having pt push back on the socket use tape cues to gauge hip strength requirements for different step lengths. chains together TPR with weight acceptance. iii. Provide facilitation progression if indicated UE progression. Can we time TPR and stance stability effectively in gait cycle
Trunk rotation and arm swing
i. Preferably performed once patient has mastered LE biomechanics ii. Most trunk rotation comes from spinal level T10, facilitate proximally at bilateral shoulders iii. Begin with forward/backward prosthetic limb stepping, facilitate contralateral arm swing with therapist manual placement on posterior/anterior opposite shoulders to facilitate trunk rotation iv. Repeat with sound limb stepping. Note: This is considerably more difficult wince the patient is required to move trunk over and behind the prosthetic knee. Patients have a fear of the prosthetic knee collapsing and have a tendency not to follow through completely with this motion. start at shoulders. PT facilitates opposite arm swing to the step. work on timing and fade your cueing. can also go back to pre-gait strategies and ask the pt to use arm swing during each phase.
weight shifting exercises
i. Side-to-side ii. Forward/backward (train hip strategy) iv. Diagonal 1. Shift body weight from prosthetic heel to intact toes in diagonal pattern (tandem stance). Start with prosthetic limb backwards, switch to prosthetic limb forward (creates knee flexion moment at the knee which is more challenging) 2. Amplitude: Starting small to big 3. Reverse patter, shifting weight from unaffected heel to prosthetic toe promote pt pushing posterior into the socket. in each step, progress through UE support progression
initial standing balance training in parallel bars
i. Standing in // bars with normal BOS ___ to ___ inches, with mirror placement ii. Ask patient to note how their residual limb feels in relation to the socket iii. Remove ipsilateral hand = contralateral hand = note change with each iv. Remove both hands = note change with each
Side Stepping
i. improves frontal plane stability and practice pushing into posterior socket. As patient abducts sound limb, apply resistance through sound hip to facilitation the contralateral hip ABDuctors. ii. Therapist observes 1. Maintenance of pelvic height while the sound limb is being ABDucted 2. Lateral trunk flexion over prosthetic limb 3. Repeat in other direction start stepping away from the prosthetic. Pt side steps towards the PT. PT puts resistance on pelvis in frontal plane. hip abductor workout switch sides. start with bilateral UE support, progress through UE progression.
crouched gait
if a pt has a hip flexion contracture and has limited lumbar ROM, they will most likely enter into a _______.
external substitution strategies
if a pt has weakness and proprioception issues, the PT needs to provide ______. ex: AD or orthotic.
MMT eval strategy
if a pt is having gait deviations due to weakness, you can MMT the muscles that come on strongly during that specific phase of gait.
microprocessor
if the pt has a ____ knee, use it as much as possible going up stairs/curbs to save the sound limb from overuse
PF contracture/spasticity
if the pt has a _______, stance phase heel and forefoot rocker will be limited.
Goal of prosthetic gait training
improve ambulation efficiency by minimizing gait deviations.**
resisted gait training
improves prosthetic stability put belt around pts waist. pt walks against resistance. they will really have to push into the posterior socket. maintain upright posture. PT can improve TPR timing with the belt to provide a quick stretch to the prosthetic side hip
1/8-1/4
in clay test, the clay ball afterwards should measure _______ in. for and adequate fit.
pre-gait training strategies
in parallel bars, BOS 2-4in apart. Static standing weight shifting exercises Stool Stepping with sound limb
pre-op visit
in the _______, Share Information. Patient and family must understand the rehab process. Evaluate patients wholistic needs.
posterior
in transmetatarsal amputations: Because the passive stability provided by the foot and forefoot lever is lost in late stance, the GRFV shifts ______ to the knee joint in late stance, thus the quadriceps muscle must contract to a greater degree to maintain stance limb stability, contributing to increases in energy cost of walking
Since our goal is to create a slight flexion moment at the knee during transtibial gait, what adjustments to a prosthetic heel could assist in accomplishing this goal?
increase firmness of the heel or raise the height of the heel
name the sub-phases of the stance phase
initial contact loading response (10%) mid stance (10-30%) terminal stance (30-50%) pre-swing (50-60%)
initial double support (0-10%); weight acceptance
initial contact and loading response is part of ___________ and _________
name the sub-phases of the swing phase
initial swing (60-73%) mid-swing (73-87%) terminal swing (87-100%)
keel of prosthetic
inner flexible part of foot.
advanced prosthetic
insurance will not pay for an ______ if the pt cannot demonstrate advanced movements (ex: running)
step
interval from left (or right) heel contact to right (or left) heel contact 2 ______ = 1 stride
transfemoral pressure tolerant areas
ischial tub lateral and medial flare of residual limb anterior and posterior flare of residual limb distal end of limb (contact only)
where should the pt be weightbearing with a trans-femoral amputation?
ischial tuberosity. test by sticking your fingers into the socket and have the pt weight bear into their prosthetic.
2 fingers strength
it should take _______ to move a joint through the full ROM.
lateral trunk bending with TFA (midstance)
lateral inclination of the trunk to the prosthetic side. Prosthetic related causes: Insufficient femoral support of lateral socket wall = pt has insufficient adduction due to losing original attachment. femur drifts into abduction without lateral socket support. Prosthesis too short Excessive abduction of socket (wide BOS) Medial brim too high/uncomfortable Type of socket (quadrilateral) (wide frontal plane dimension causes them to fill the open space) User related causes: Contracture of abductor muscles of the residuum Very short residuum = less stable, more abductor force than adductors) Sensitive or painful residuum Weak hip abductor Bad gait habit
midstance with TFA
lateral lean towards prosthetic side is often present with __________
ascending ramp
lean trunk forwards if going straight on. side stepping. walk in zig zag pattern
foot functions terminal stance to pre-swing
lock foot into position to provide a rigid lever for heel rise and tibial advancement transitions from forefoot to toe rocker
weight activated Safety knee
locks with weight load
Oppositional/ Passive Functional Prosthetic
made of medical silicone. very realistic. don't call it a "non-functional" device because it does have some function. Benefits: • Provides opposition • Can be lightweight • Most are simple • Usually little maintenance Limitations: • No active prehension • Limited function • Patient can have unreal expectations for cosmesis • No movement in the prosthetic • Changes in skin-tone are not reflected in the prosthetic.
preswing (4th rocker)
max incline SVA
single support (10-50%)
mid-stance and terminal stance is part of _________.
single limb support
mid-stance, terminal stance, and pre-swing are part of __________ second task of stance Advancing body weight over single limb, person must accomplish the following: Stability Forward progression Phases: Mid Stance (MSt) Terminal Stance (TSt)
pediatric
most ____ pts do not use prosthetics bc they are adapting from day 1. Consider etiology, level of involvement, patient goals, level of development, family support and compliance More adjustments are needed due to growth Can assist with achieving early milestones
trans-tibial (B/K)
most amputations are ________. (65%) _____ amputations take 15-30% extra energy expenditure.
excessive PF
most common ROM deformity at the ankle
excessive flexion
most common ROM deformity at the knee and hip
instrumented gait analysis
motion analysis research lab electronic pressure sensitive walkway stopwatch w/ camera GAITRite/Zeno Walkway Shoe inserts/sensors Motion analysis Force plate analysis EMG analysis
outdoor walking at a fixed cadence would fit which foot?
multi-axial
fatigue
need to _______ a TTA pt to really start seeing their bad gait deviations
running blades
no heel component - can vary in stiffness depending on if goal is to sprint or run long distance
steps of gait analysis
observe determine deviations for each functional task (3) list major problems consider causes choose the most likely cause test
rigid deformity of the ankle in gait
obstructs progression of the limb or tibia over the supporting foot in stance; foot clearance obstructed, as well. Will require compensations at other joints during stance phase, e.g. greater hip flexion during initial contact/loading response disrupts stance and swing phase.
forward trunk lean
occurs due to knee instability, results in knee hyperextension. occurs in mid-stance and terminal stance. due to weak PF, decreased sensation, spasticity.
stride
one GC, from heel strike to the very same foot's next heel strike
UE amputations
only 10% of prosthetics are for ________.
management of infections
oral antibiotics parenteral antibiotics surgical intervention implant removal
why dont we collapse to the floor under the pressure of external forces?
our body exerts internal forces that resist these external forces (demand torques). These internal forces are created by both passive and dynamic structures. Passive structures include your joint capsules, ligaments, and bony structures. Your dynamic structures include your muscles and tendons. These forces together or separately, provide the internal torques needed to resist and counteract demand torques.
lack of toe extension with TFA in terminal stance or preswing
potential end result of other deviations in terminal stance (excessive lumbar lordosis or forward trunk)
terminal double support (50-60%)
pre-swing is part of ________.
what to consider with transtibial amputation gait
prognosis demographics problem foot function during gait biomechanics in all planes proper alignment in frontal and sagittal planes gait deviations (extension, flexion, varus, valgus moments, transverse plane probs)
circumduction
prosthesis curves laterally Prosthesis related causes: Prosthesis too long Socket too wide Insufficient suspension Excessive friction in knee axis Knee axis too far posteriorly offset Medial brim too high Excessive suspension Locked knee joint User related causes: Weak hip flexors and/or ADDuctors (train TPR) Lack of confidence flexing the knee Contracture of residual limb ABDuctors Muscle imbalance Weak ADDuctors Perineal pain Bad habit
Empower (Biom)
prosthetic foot that allows for active toe off (simulates gastroc activity)
normal
prosthetic gait will never truly return to "_______", but we can for sure try to get as close as we can
socket abduction
prosthetic limb appears to be abducted slightly
socket adduction
prosthetic limb appears to be adducted slightly
socket flexion
prosthetic limb appears to be extended slightly
socket extension
prosthetic limb appears to be flexed slightly
1/4
prosthetic limb is usually _____ in shorter than intact limb to improve clearance. Stand feet together, shoulder width apart, equal weight bearing can measure height with PSIS, ASIS, Iliac Crest, pubic ramus, etc.
alternate ways to test proprioception
pt looks in a mirror. PT taps prothetics big toe, pinky toe, and heel. pt closes eyes and identifies if the PT is tapping the big toe, pinky toe, or heel of the prosthetic foot. pt should feel vibrations up the leg into their residual limb. ask where they feel it on their residual limb. as long as the vibrations are consistent between the different areas tapped they are good. can identify problems in the prosthetic fit if they cannot ID tapping. heel = initial contact toes = push off, turning, rockers not a gentle tap.
buckeling
pushing in the posterior of the socket prevents the prosthetic knee ______ in a TFA.
Powder test
put baby powder on the pts leg and put their prosthetic on. determine the fit based on the powder distribution after doffing.
Medial or Lateral whip
seen at initial swing describes what the heel is doing. prosthetic related causes: Excessive IR (lateral)/ER (medial) of prosthetic knee axis Socket too narrow Excessive valgus (medial)/varus (lateral) set into prosthesis at knee level user related causes: Bad habit Prosthesis donned in ER (medial)/IR (lateral) Weak hip IRs/ERs fixes: reattempt donning retrain hip IR/ER fix varus/valgus stance phase issue to indirectly fix swing phase issue prosthetic adjustment
3 MAS PFs, 6-7 beats clonus will possibly present as:
setting off spasticity during terminal swing = foot flat or forefoot contact = knee hyperextension. forward trunk lean during stance phase due to lack of DF. loading response to midstance will set off the spasticity = knee hyperextension + early heel off.
foot function in initial contact to loading response
shock absorption achieves foot flat position
descending ramps
short steps and lean backwards to avoid knee buckling. TFA sill has to go though TFR. focus on pass-retract mechanism to get into posterior socket.
suspension belts
similar to cuffs for TT Advantages •Simple, durable, reliable, inexpensive Disadvantages •Can cause chafing/bruising •May not be reliable for all body shapes
Sound limb stepping, full weight bearing
sound limb step with a prosthetic limb step chained together. pt should be able to stabilize the knee with posterior pressure. i. Same as prior activity (c) but with sound limb ii. Therapist observes 1. Speed of advancing limb 2. Step length 3. facilitate TPR 4. lateral trunk flexion 5. BOS issues can we time TPR effectively?
STS strategy
start in parallel bars, assistive device, work to independent. use the prosthetic side as much as possible put prosthetic side slightly behind sound side. creates knee extension motion. pt will enter stance in a tandem stance posture. for sitting: if microprocessor knee, can ride the knee into sit. reach for arm rest on prosthetic side. no microprocessor knee: flex the knee by loading into the toe before they sit. turn and reach back for arm rest on sound side or bilaterally. for bilateral TFAs, may be a plopping motion like SCI, one microprocessor knee is helpful for STS.
stool stepping with sound limb
start with 1-2 inches, move up to 6in+. use UE progression fully before you progress to higher stools. step should be slow so they can control the prosthetic side. i. Step unaffected LE onto step/stool with bilateral UE support first... as slowly as possible! ii. Remove ipsilateral hand - contralateral hand - both hands, progressing only if patient demonstrates appropriate control Tips to concentrate on 1. Muscular control of hip 2. Controlling prosthesis by pushing backwards into socket. 3. Visualize controlling the movement of the prosthetic ankle/foot assembly
TFA without microprocessor descending stairs
step to: prosthetic down first. create stability in the posterior socket. can even lock out the knee by hitting heel on the step. step through: prosthetic first, place foot half way off step, roll foot off of step while brining sound leg down (quickly). micro-processor knees and stance flexion control knees can do this. if unstable, can face 45deg sideways to create more stability with a step-to pattern.
hip extension
strengthen _______ with transfemoral amputations
knee flexion
strengthen _______ with transtibial amputations
balance
strengthen _________ with geriatric amputation pts.
transtibial pressure tolerant areas
supracondylar areas suprapatellar area patellar tendon medial flare of tibia lateral flare of tibia lateral flare of fibula posterior limb popliteal fossa (gentle pressure) distal end of residual limb for total contact socket (contact only, no pressure)
basic management
teach the _______ of the prosthetic before moving to phase 1. -Independent donning and doffing -Changing terminal devices -Cleaning -Charging
In what direction does the center of mass shift following an amputation
towards sound side, upwards, and posterior
single axis knee
transfemoral amputations: •This is a simple hinge type knee. •During the flexion/extension these articulations execute a simple rotation around the knee axis. •Can have manual or automatic blocking of the flexion to be used in users with poor muscle power. •The knees without blocking can be used for regular prosthetic fitting of amputees with adequate muscle control and/or in situations of limited economic resources. advantages: Simple, durable, light, economical disadvantages: Requires use of own muscle power to keep knee stable. Due to the simplicity, the individual has to use their own muscle power in the limb to keep the knee stable with heel contact and standing.
Polycentric Knee
transfemoral amputations: 2 or pairs of bars connecting the upper and lower portions of the unit. Bars cross proximally and posteriorly... changes center or rotation... increase stability during the STANCE phase. This knee has multiple axes of rotation. Polycentric knees can be four bar knees (4 axes of rotation) or seven bar knees (seven axes of rotation). Knees of the most frequent use are of 4 axes (or 4 bars). •Multiple axes of rotation allow knee to bend with a more anatomically correct gliding motion •Multiple axes reduce the length of the limb during SLA Standard polycentric knees have a single walking speed but when a manufacturer includes pneumatic or hydraulic features the patient will be able to vary their walking speed advantages: Stable in stance phase, shortens at PSw for foot clearance Great for ppl with short amputation, limbs... weak hip extensors •It is very versatile in terms of stability and can be adjusted to be extremely stable when the patient goes into stance phase, but also allows an easy swing and sitting down with a bent knee. •Due to the multiple axes and the center of rotation, the prosthetic length "shortens" at the start of toe-off and will allow for foot clearance. •It is suitable for patients with the potential to be independent with the prosthesis in their home and community as well as the more active person disadvantages: Heavier, more parts need services, no stance flexion resistance Less durable than single axis units •It is heavier than a single axis knee. •More parts that need servicing. •Most polycentric knees do not have stance flexion resistance and therefore cannot yield during sitting, ramps, or stairs. • A person with a knee that is not controlled by a microprocessor, needs to actively generate a knee extension moment in the stance phase to prevent the knee from buckling and cause the person to fall down.
Hydraulic or Pneumatic Knee
transfemoral amputations: A piston from the axis to the cylinder interior descends during early swing; this action forces oil to flow through narrow channels to provide frictional resistance. •This is when a pneumatic or hydraulic component (piston within cylinders containing air or fluid) is added to single-axis or poly-axial knee. •These components control the swinging action of the prosthetic knee and allows the individual to vary speeds. When speed is increased the valve in the cylinder closes and gradually limits the air flow/ fluid to limit flexion of the knee, when knee flexion is reduced the individual can walk at a faster pace. •The opposite will happen with slower walking, the fluid or air will be able to move more easily, allowing for more knee flexion and slower gait. •Pneumatic control will compress the air as the knee is flexed and then stores the energy and releases it with knee extension. •Spring coils can be added for more control during gait. •Pneumatics or hydraulics are also added to computerized prosthetic knees. Hydraulics are better for very active individuals. advantages: More comfortable walking speeds, more natural gait, less expensive than MCP knees, weight can be kept on prosthesis when sitting, can climb down steps, stairs, ramps due to friction SWING PHASE AFFECTED Some hydraulics have stance control(braking mechanism), increases resistance to knee motion at early stance. This allows gait over uneven surfaces using step-over-step pattern allows for more control and freedom in swing phase uses air via pressure to make swing phase slower or faster •The individual will be able to walk more comfortably at different walking speeds with a more natural gait. •Less expensive and lighter than computerized knees. •Weight can be kept on the prosthetic leg when sitting down and the knee will assist the individual to sit down. The resistance in the knee will allow the individual to climb down step over step when walking down stairs, when weight is kept on the leg before and during the motion disadvantages: Heavier, more maintenance, higher initial cost of hydraulic vs pneumatic •Hydraulic knees are heavier, need more maintenance, and have a higher initial cost when compared to pneumatics. •Overall cost is more than earlier mentioned knees.
manual locking knee
transfemoral amputations: Automatically locks knee in weight bearing for those who need extra security The manual locking knee is locked stiff at the knee when in use. The knee will not bend until a release mechanism is operated to free the knee lock (e.g. when sitting). This system makes the knee extremely safe. These types of knee are best suited to users with weak musculature or balance issues advantages: Indicated for K1 or those who cannot control prosthetic knee •Allows for automatic locking of the knee with weight bearing, but the patient can choose to manually lock the knee. This is especially important for people who need extra security to keep the knee from buckling in standing or with heel contact or when walking on uneven terrain. The indication for this type of knee is usually for K1 ambulators or debilitated individuals who cannot voluntarily control their prosthetic knee disadvantages: Circumduction, hip hiking, vaulting for swing phase •The patient will need circumduct or hip hitch to allow for foot clearance when the knee is locked during gait. •Will require stiff legged gait
stance control or safety knees
transfemoral amputations: Constant friction system in knee and applies braking force when weight is placed on prosthesis; good for first time users •There is a constant friction system in the knee, which means it will apply a braking force as the patient puts weight on the prosthesis, to prevent the knee from buckling. •The rest of the time the knee will swing freely, until the weight is applied to it. advantages: very stable •Prescribed for first time prosthetic users who need the stability especially in the older or less active population but are still able to exert some control over the knee. Or a person who fatigues quickly after just a few steps. •This is especially valuable for the patient who forgets that they should not put their weight on a partially bent knee, the friction in the knee will brake if this happens and prevent the knee from collapsing into flexion. disadvantages: Sitting is difficult, slower walking speed, small steps •When sitting down the patient will have to take the weight off the leg to allow it to bend, this means that they will not be able to use the prosthetic side in the sitting motion. The patient will also need to take the weight off the leg before the knee will bend, this means that the normal knee flexion at toe off will not happen. •Due to the friction in the knee the patient will also walk slower and take smaller steps.
lanyard suspension
transfemoral amputations: Incorporates a strap or cord in the liner that is routed through a slot or hole in the distal socket. Used to pull amputation limb into socket. Also uses a roll-on liner with a lanyard at the very end. advantages: Easy to don, secure suspension, decreases socket rotation. like a pin and lock system but you have a velcro to keep socket in place •Easy to don (put on) the prosthesis in a seated position, especially for someone with poor eyesight or balance. •It provides a secure suspension and decreases socket rotation. •Inexpensive, simple, and reliable. disadvantages: Needs hand dexterity and strength, liner is required for suspension
vacuum suspension
transfemoral amputations: Mechanical or electronic mechanism creates negative pressure for suspension advantages: •Less pistoning and rotation occur within the socket. •allows for better suspension when there is volume fluctuation. disadvantages: suction suspension is inappropriate for patients with a recent amputation whose limb volume will continue to reduce or for those with fluctuating edema or unstable weight. High shear force associated with donning may preclude its use for patients with fragile or sensitive skin, painful trigger points, significant scarring, adhesions, or upper limb weakness. •More expensive. •Mechanical components that can break. Adds weight to the prosthesis
Microprocessor Knees
transfemoral amputations: Uses microprocessor and multiple sensors to adjust knee flexion/extension resistance and range, "enhanced hydraulic system" when battery is dead, becomes manually locking knee •These knees have a microprocessor that receives feedback from sensors located inside the knee joint and/ or the foot. The data from the sensors are used to adjust the knee flexion and extension range and speed to match what the individual requires at that moment in time. •It can be explained as an "enhanced hydraulic system" where the computer is controlling the opening and closing of the valves to allow the flow of hydraulic fluid within the unit. A typical microprocessor knee has a hydraulic actuator and a powered knee has a motor actuator. •In a motor-powered knee, knee extension is 'powered' for standing up from sitting and controlled resistance is provided when sitting down. advantages: More natural gait, more stable, adapts to different walking speeds, stumble recovery, more obstacle negotiation, adjusts to different loads •Microprocessor knee lowers the amount and effort that an individual needs for walking. •More natural gait. •The knee is able to quickly adapt to accommodate different walking speeds, changing environment, or for specific situations. •Some knees also have a stumble recovery to prevent the individual from falling. •Can use a mobile device or computer to adjust settings. Can have different walking/ activity modes. •Once learned, it takes less cognitive effort. •Allows descending stairs step over step. •The individual will be able to use the prosthetic side when sitting down or standing up. •If the knee is able to adjust automatically according to the load the patient is carrying (like adding a hiking pack or carrying a child), then it will reduced the perceived exertion of the person disadvantages: More expensive!!! -"thats about it" -Can lose power bc its battery powered. if it does lose power, it becomes stiff. Does not become floppy so is still functional •Cost - very expensive. •The battery needs to charge. •Weight is more than other knees. •Cosmesis may be difficult. •Specific foot selection. •Can be damaged by environmental conditions (water, heat, cold, etc), kneeling etc. •Initial steep learning curve and commitment to gait re-education. •Regular servicing. Maybe not sufficient for... -obese patients or - activities involve heavy loads -hazardous environments (water, coal mines, commercial bakeries)
Air Expulsion Valve suspension
transfemoral amputations: Uses negative pressure using a suction liner put limb in, press button and allows air to come out the amputation limb is pushed into the socket, expelling air through the valve, creating negative pressure. can control air input/output Uses a roll-on gel liner with silicone ring for suction/negative pressure (white band in picture) advantages: secure hold, expelling air, somewhat adhesive, decrease risk of pressure sores valve that control the amount of air that can come out sweaty peeps can use this to let water to come out -Even pressure throughout the socket. -Secure fit. Good suspension even with small volume fluctuations. -Donning in a seated position is possible. -Used to stabilize excess residual tissue. -Liner and socket donning does not have to be as precise to secure suspension but may cause rotation in the socket. disadvantages: Expensive, liner wear and tear, UE hand strength/dexterity problems w durability -Relatively expensive. -Wear and tear on liners. -Poor suspension with significant volume fluctuations. -Good hand strength and dexterity needed. -Lubricant is needed for donning.
Ischial Containment socket
transfemoral amputations: Weight bearing takes place all over surface of residuum. Weight bearing takes place all over surface of residuum -Decreased medial/lateral width to try and promote natural adduction of femur. -More AP dimension to accommodate muscle contraction. Contain the ischial tuberosity and the ramus in the socket to control socket rotation. -Lateral wall highest so it can capture the greater trochanter to grasp femur better. -Without good myodesis of add magnus, femur will want to abduct- when we capture greater troch we keep alignment vertical and capture adductor moment. -Posterior shelf curved and lipped out to capture ischium -Need to palpate posterior/lateral walls c pain to make sure bone is in right place advantages: Better comfort, control, and proprioception Disadvantages: Needs exact volume determination
quadrilateral socket
transfemoral amputations: Weight bearing takes place on ischial tuberosity, suspension via negative pressure. -4 walls designed to contain the thigh -Primary weight bearing on the ischial tuberosity and glutes -Anterior/lateral dimension is higher than the posterior/medial dimension -It is narrower anterior/posterior than it is medial/lateral -May cause excessive pressure to inguinal structures because the socket can displace laterally during midstance -Extinct now essentially advantages: Good interface, pressure distribution on IT disadvantages: the scarpa bulge is convex which increases the area contacting the tender femoral triangle. bad if the pt has a too short residual limb (reduces stability)
7%
transtibial amputation of traumatic etiology has what % increase in oxygen consumption?
33%
transtibial amputation of vascular etiology has what % increase in oxygen consumption?
cylinder
transtibial amputations should be _______ shaped. 1/3 to 1/2 of remaining limb is optimal. circumference should be about the same all the way down the leg. measure from medial joint line or tibial tub.
phantom limb sensation
typically described as a sense of numbness, tingling, tickling, or pressure in the missing limb, and some complain of itchy toes or mild muscle cramps in the foot or calf. 54% to 99% of persons with new amputation have noticeable ________.
TFA without microprocessor ascending stairs
use a step to gait pattern with the railing on the opposite side. need to extend hip to clear the foot over the steps. microprocessor knees allow for step through gait pattern
falling and fall recovery
use floor-stand transition movements. train falling into push up position with bent elbows for shock absorption.
knee hyperextension
using _________ as a strategy to compensate for quad weakness is successful for jamming femur into the tibia to enhance passive stability through bony structures.
spasticity
velocity dependent stretch reflex. impacts ability of muscles to contract eccentrically during stance phase. can present similar to contracture. effects the gait cycle where there is a large ROM demand or an eccentric control demand.
excessive lumbar lordosis with TFA
visible anterior lumbar bend. Prosthetic related causes: Insufficient stability in knee mechanism Insufficient socket flexion Discomfort Prosthesis too long Heel of shoe too high User related causes: Hip flexion contracture Weak hip extensors Weak abdominals Attempt to move COG forward for stability
rotation of foot at IC with TFA
visible foot rotation on heel strike Prosthetic related causes: Too hard plantar flexion resistance Socket loose Too much toe out User related causes: Poor muscle control of residual limb in transverse plane
forward trunk with TFA
visible forward bend. Prosthetic related causes: Insufficient flexion in socket Discomfort Insufficient stability in knee mechanism User related causes: Weak hip extensors Hip flexion contracture Hyperkyphosis Compensation Looking at feet Habit from using AD poorly
knee instability with TFA (initial contact)
visible insecurity during gait prosthetic related causes: Gravity line/TKA posterior to knee = extension Socket too anterior = long lever arm = more force at IC Lack of socket flexion Heel support too hard = knee flexion Hip flexion contracture not accommodated User related causes: Weak hip extensors
tapered
want the residual UE to be a ______ shape
70%
we want at least ________ of BW on the prosthetic toe (terminal stance and pre-swing TFA) to help with breaking knee over the prosthetic foot want the foot to store energy to help with push off
All of these may create excessive knee flexion during early stance in transfemoral gait
weakness of glute max heel is too firm socket is insufficiently flexed
common gait impairments in stance phase
weakness: PF, Abd/Add, extensors, knee extensors, ankle E/I spasticity: extensors and PFs decreased ROM: DF decreased sensation
common gait impairments in swing phase
weakness: flexors, knee extensors spasticity: extensors decreased ROM: DF decreased sensation
functional phases of gait
weight acceptance single limb stance swing limb advancement
quadrilateral socket
with TFA: With a ________ (a very common type of socket used for people with transfemoral prostheses termed for its appearance when viewed in the transverse plane), the essential components of force transmission do not occur via the center of the femur head but via the ischial tuberosity. Hence, when standing on the prosthesis on one leg: the ischial tuberosity tends to move inward and there is nothing to stop it the femur goes into abduction and the gluteus medius is therefore not able to stabilize the pelvis amputees will therefore very often display lateral trunk bending on the side of the prosthesis
partial foot amputations
with ______, Shoe modifications, orthotics and/or prosthetics may be required. Patients' activity level helps determine intervention. High active user tends to have recurrent skin issues after ________. shoe fillers are common for ________.
glute
with a transfemoral or higher amputation: The hamstrings are no longer polyarticular and powerful. Therefore, increased contraction of the _____ occurs on the amputated side
psoas
with a transfemoral or higher amputation: The hip has to flex just before toe raise in order to flex the prosthetic knee. This is mainly effected by the _______, which is not as active during normal gait (as the movement is performed by the TFL, sartorius, add magnus and rectus femoris). In case of amputation, the hip flexion is increased (________) to compensate for the fact that there is no ankle movement and to bring the knee into extension.
1-2 years
with children, after the pts 2nd prosthesis, they will need a new LE prosthesis every ________ depending on physical changes to their amputation and growth spurts.
prosthetic
with osseointegration: _______ Use increased from 56 to 101 hrs/wk Walking Speed increased by 32 % Energy Cost decreased by 18% Quality of Life improved from 39 to 62 (100 point scale)
2nd and 3rd
with partial foot amputations, this long lever arm of the intact foot is lost, resulting in a short lever arm. This shorter lever arm contributes to changes in the biomechanics of gait, influencing GRFV, which in turn affects torque demands and muscular responses. In essence, we lose our __________ rockers of gait. The loss of this anterior lever arm functionally results in reduced time in single limb support on the limb with the amputation, and reduced time in swing phase on the intact limb
Elastic deformity of the ankle in gait
yields in stance with bodyweight and allows for normal to slightly delayed ankle motion Motion is limited in mid-swing as pretibials are not programmed to pull harder, inhibiting floor clearance. pt will have most problems with swing limb advancement.
Elastic contracture
yields to a forceful stretch. results in open-chain problems.
strategies for AROM, Strengthening, Symmetry
• Core exercises • Sitting on ball for tasks • Scapular stability: Prone "I,L,Y", ER, abduction • Exercises/activities in mirror so pt can observe posture
strategies to Edema Control/Limb Shaping
• Figure of 8 wrapping - Distal to proximal • Tubular compression. Ex: compressogrip or coban • Kinesiotape • Teach manual edema mobilization/retro massage • Elevation • Shrinkers/liner (provided by prosthetist) strategy for before getting prosthetic.
upper limb functions
• Fine motor • Communication • Power grasp • Pinch • Self image • Interaction with environment • Writing • Touch
Phase 1: Basic Control
• Focus is basic operation of each component on prosthesis with the least amount of cognitive load to start. • Start with most stabilized and basic positioning: sitting and at midline • Add more planes of motion and situations: Progress to right/left of midline, overhead, close to ground, Standing, Walking/ dynamic activities • Repetitive drills and tasks to build motor control patterns: Stacking cones, Flipping blocks, Repetitive ADL components • Progress to alternating components: Mirroring activities, Grasp cone then flip cone to stack goal is to have the pt fire the "close" signal, relax, then fire the "open" signal. the relax part is essential. Encourage normal movement patterns and watch for compensatory motions!
Myosite Testing and Training
• Guide patient in understanding what muscles they are contracting, Teach palpation, Use a myotester • Move both arms at the same time with eyes closed, Tap into the phantom limb to help pt find the correct muscle. • Practice Separating flexors from extensors, practice Co-contracting flexors and extensors electrodes provide real time feedback to movements. strategy for before getting prosthetic.
Physical Assessment
• Movement patterns • ROM • Wound • Edema • Shape • Pain • Hypersensitivity • Sensory impairment • Scar
Preprosthetic Management
• Patient Education • Psychological Support in the Grieving Process • ADLs and Change of Dominance • Edema Control and Limb Shaping • Desensitization / Scar Massage • Mirror Therapy • Functional AROM, Strengthening, Body Symmetry • Myosite testing / training tackles body, function, and psychosocial aspects of the pt.
externally powered prosthetic
• Powered by battery systems, switch, or myoelectric control • Controlled by various input devices such as switches or electrodes • Incorporates surface electrodes to control movements. Benefits: • Increased grip strength • Harness system reduced or eliminated = Improved comfort = Increased functional range of motion • Minimal energy expenditure Limitations: • Initial cost • Maintenance cost • Weight* due to battery • Requires battery power. most pts can last a full day between charges • Often not water or dust proof
Phase 2: Gaining Control
• Prepositioning of terminal device (TD): Placing the terminal device in the most optimal position before initiating grasp/release, Minimizes compensatory movements at the trunk, shoulder and elbow. • Proportional control of terminal device: How hard or soft an item is gripped practice picking up coffee cup without crushing it. practice picking up heavy glass mug without dropping it.
ADL/Function Assessment
• Self care • Feeding • Toileting • Sleep • Home care • Full meal prep • Recreation • Driving
strategies for Desensitization/Scar Massage
• Tapping • Massage/rubbing • Particle immersion • Texture wands • Weight bearing • Elastomer • Kinesiotape strategy for before getting prosthetic.
Phase 3: Bi-manual Skills Training
• The longest and most challenging phase of prosthetic training. • Patient directed. Use checklist to identify goals that are important and meaningful to the patient. • Allow patient to problem solve. Intervene only as needed. • As therapists, we may learn more from our patients than we may be able to teach them. • Repetition and practice. Takes time to learn a new way of doing things. goal oriented specific to the pt.
Osseointegration
• Titanium fixture implanted directly to bone • Fixture protrudes through skin • Prosthesis directly attaches to fixture - Solves many current socket fitting problems - Has problem with infection at fixture site • Recently, FDA awarded SLC/VA group permission for human subject testing infection is a risk. pt has more sensation at their distal extremity.
additional components to add to Energy Storing And Return (ESAR) Foot
•A shock absorber and torque adapter could be added to the prosthetic foot that will decrease the stress on the residual limb by absorbing the impact and any rotation due to environment. •It is also possible to get prosthetic feet with an adjustable ankle to allow the individual to wear different height shoes
self report measures
•Amputee Activity Survey (AAS) •Patient Specific Function Scale (PSFS) •Prosthesis Evaluation Questionnaire (PEQ-17) •Prosthetic Limb Users Survey of Mobility (PLUS-M) •Prosthetic Profile of the Amputee - Locomotor Capabilities Index (PPA-LCI) •Orthotic & Prosthetic User's Survey (OPUS) •Medical Outcomes Study 36-Item Short Form (SF-36) •Sickness Impact Profile (SIP) good for participation related goals.
lateral trunk lean
•Over-reliance on sound side •Lean away from weaker side for swing clearance
socks
•Can be all you need to fix fit issues •1-ply all the way to 5-ply thickness (1 5ply = 5 1ply socks) •Accommodates for limb volume fluctuations throughout day. •Carry with them ALL THE TIME ______ should not be in the double digits with sock ply. if they are using a lot of sock ply then they need a socket adjustment.
3 theories of the role of PFs in gait
•Controlled "Roll-Off"** •Active "Push-Off" •Acceleration of leg into swing Regardless, the plantar flexors are crucial in accomplishing normal forward progression, swing initiation, and power generation.
pelvic retraction (ER)compensations
•Decreases momentum that can be generated •Hip flexion activation difficult •Decreases step length
borderline strength deficits
•Demonstrate difficulty during phase of gait that places the highest demand on the weakened muscles •e.g., for weakened PFs, highest PF demand would come during what phase? terminal stance •Muscles normally function at a 3+/5 MMT level. this avoids fatigue. using only about 25% of normal strength. if a pt has a 3/5 MMT, one stride will most likely equate to their 1RM
SCI gait
•Dependent on the level and degree of incompleteness •Often asymmetrical presentation •Spasticity (presence and pattern) •Often more weakness in extensors than in flexors
Amputee Mobility Predictor (AMP)
•Determine functional level •Predict distance walked in 6 minutes •Determine contribution of functional ability •Determine physical systems that need to be addressed*** •Predict potential to ambulate with a prosthesis •Measure change over time Different versions: •With prosthesis AMPPRO (0-47) •Without prosthesis AMPnoPRO (0-43) •With bilateral amputation AMP-B •Comprehensive High-Level Activity Mobility Predictor CHAMP (power, jumping, plyo, etc) •Average time to administer: 15mins •21 Items •Items # 0-20: performance testing •Item # 21: assistive device score Scoring: •AMPPRO: 0-47 •AMPnoPRO: 0-43 (takes out SLS on the prosthetic side bc they do not have a prosthetic yet) •MDC: 3.4 points •AMP can be used as outcome measure for functional goal setting •AMP also used to predict necessary prosthetic care using standardized tests in combination with MFCL (K Levels) Testing equipment •stopwatch, 2 chairs,12 in ruler, pencil, a 4-in high obstacle "brick" (preferably 18-24in long), stairs with 3 steps, gait belt, pt's AD (if they use one). Initial instructions •Testee is seated in a hard chair 40-50cm height with arms. •All test items for AMPPRO are tested with prosthesis donned •All test items for AMPnoPRO are tested without the prosthesis. •Instruct the person of each task or group of tasks prior to performance. •Avoid unnecessary chatter throughout the test •No task should be performed if either the tester or testee is uncertain of a safe outcome. •One attempt only per item •Maximum of 2 days allowed to complete assessment
diabetic peripheral neuropathy gait
•Deviations consistent with sensory loss (wide BOS) •Impaired swing limb clearance •Potential instability in stance •Pain with gait •impaired proprioception
pathology
•Disrupts the precisions, coordination, speed, and versatility
AMP functional program
•Each subtest targets specific balance components related to everyday requirements of ADL for amputees •For each component of the test the therapist may customize an exercise program to target specific systems challenged to improve that specific subtest/activity ex: #4 - Arises from a chair •Ask patient to fold arms across chest and stand. If unable, use arms or assistive device (AD) - Scoring: •Unable without help = 0 •Able, uses arms/assist device = 1 •Able, without using arms = 2 - Systems Challenged: •Organizational skills •Momentum strategies •Dynamic balance •Concentric postural extensors - Functional program planning & treatment strategies for item #4 •Organizational planning •Seated forward weight shifts for momentum •Sit-to-stand progression •Concentric LE strengthening Partial wall squats to full wall squats ex: #7 Standing Balance •Standing balance 30 sec (stopwatch ready). •First attempt is without assistive device. If support is required, allow after first attempt. - Scoring: •Unsteady = 0 •Steady, but uses aid or other support = 1 •Steady without support = 2 - Systems Challenged: •Postural organization •Standing balance •Vision/vestibular/ proprioceptive systems •Postural extensors •Standing endurance •Weight-bearing - Functional program planning & treatment strategies for item 7 •Side-to-side weight shift •Forward-backward weight shifts •Diagonal weight shifts •Variations to the task: -Non-compliant surfaces -Compliant surfaces -2x4 board -Tilt board Balance board
Compensations for Knee Instability
•Forward trunk lean •Knee hyperextension = Weak quadriceps, but those with CVA/TBI, most likely weak plantar flexors
hip weakness compensations
•Forward trunk lean for knee stability •increases Energy cost and step length
MS gait pattern
•Highly variable •Knee instability •Impaired balance •Impaired or absent sensation •Decreased walking speed •Increased energy expenditure •Spasticity •Decreased selective motor control
walking
•Is a convenient means for traveling short distances •Appears coordinated, efficient, and effortless
CVA and TBI presentation
•Knee instability •Impaired balance •Impaired or absent sensation •Decreased walking speed •Increased energy expenditure •Spasticity •Decreased selective motor control Swing Phase •Poor swing limb clearance •Equinovarus posture •Poor prepositioning for initial contact Stance Phase •Foot flat/forefoot contact •Medial/lateral instability •Varus ankle •Lack of pronation •Lack of dorsiflexion •Absent 1st rocker •Absent or impaired 2nd, 3rd, 4th rocker Knee Instability •Poor tibial control and/or quadriceps weakness Hip weakness Pelvic retraction lateral trunk lean forward trunk lean decreased arm swing
TUG
•MDC: 3.6 sec •Predictive of fall risk: >19 sec
quality of life
•Many ______ measures include items related to gait function •________ improves with increases in gait speed •Relationships between ________ and various gait parameters •Determinants of community ambulation •Association to cost and caregiver burden (walking reduces risk of secondary complications)
why are OMs important
•Measures current and potential functional level using standardized, valid, and reliable tests •Third-party payors (e.g., Medicare) love standardized measures for reimbursement because it reduces bias and improves reliability of results •Able to determine patient's current level of function and keep track of measurable progress
parkinson's disease gait pattern
•Narrow BOS •Poor weight shift •Decreased step lengths •Increased cadence •Festination or retropulsion •Difficulty with transitions
Three Basic Approaches of Analyzing
•Reciprocal Floor Contact Patterns •Time & Distance Qualities •Functional Significance of Events Within the Gait Cycle (Functional Phases of Gait)
combination gait outcome measures
•Timed Up & Go •Dynamic Gait Index or Functional Gait Assessment •Tinetti-Test or Performance-Oriented Mobility Assessment (POMA)
functional status
•Use of outcome measures for LLA is crucial to measure current _________, predict potential functional status, and measure progress.
appropriate measures
•Use your clinical-decision making to determine most _______ to administer to the patient. •Psychometrics •Constructs being measured •Overall value of interpretation
6MWT
•Valid in measuring walking capacity for those with LL amputation •Distance ambulated in 6 minutes •Able to compare results with meaningful changes •MDC: 147.5 ft K0-K1: 50±30m, 4-96 range m K2: 190±111m, range 16-480 K3: 299±102m, range 48-475 K4: 419±86m, range 264-624
2MWT
•has been proven valid for persons with limb loss •No MCID studies done for persons with amputations •Brooks D et al. 2001 •Report the 2MWT as the "fastest and most efficient measure among the timed walk tests" among lower limb amputees •High intraclass correlation coefficient values for intra and interrater reliability •MDC: 112.5ft
L test
•modified version of the TUG •The L-Test incorporates 2 transfers and 4 turns, of which at least 1 must be to the opposite side. The total distance covered is a 20-m walk •Clinician measures the time (in seconds, to the nearest 10th of a second) that it takes for the subject to: •stand from an armless chair - analyze positional movements. •walk 10 m in the shape of an "L" at subject's usual walking speed (walk 3m-followed by a 90-degree turn-walk 7m, turning 180 degrees to reverse direction, and return the same path) •transition to a seated position designed for LL amputations to see at least 1 turn over the prosthetic side. longer distance than the TUG. shows more mobility than TUG.
biomechanical deficiencies in gait after partial foot amputations
▪Reduced plantar weight bearing surface ▪Impaired pronation/supination ▪Loss of active push-off
Goals of Pre-prosthetic Treatment
▪Regain strength + ROM ▪Promote healing + shrinking ▪Regain independent mobility ▪Help adjust physically + mentally to loss of limb ▪Maintain viability of other leg ▪Determine physical + emotional stability for a prosthesis
