Prosthetic Rehabilitation: Re-establishing Normal gait

1
Prosthetic Rehabilitation Re-establishing
Normal gait Maximizing function

• Frank Austin, PT

2
Patient Presentation

• 34 year old male
• Rx
• Dx Right BKA
• Evaluate and treat
• 3x/wk x 4wks

3
What Else Do You Want To Know About Your Patient?
4
Subjective History

• Cause of amputation
• How long ago did the amputation occur?
• Pain?
• Medications
• Premorbid level of function
• Current level of function
• Functional limitations
• Prior therapy received

5
Subjective History

• PMHx
• Social Hx
• Occupation
• Can the patient perform his duties
• Obtain description of work duties
• Extracurricular activities
• Goals
• Occupational vs. personal

6
Subjective History

• Date of amputation? 1/26/2009
• Occupation? general laborer in warehouse
• Cause of amputation? crush injury _at_ work in
  warehouse
• Pain?
• Residual limb 3/10 (phantom pain)
• Also reports back pain and intermittent left knee
  pain not rated
• Medications? Neurontin for phantom pain

7
Subjective History

• Current level of function/limitations
• Desk job 4 hours/day
• Difficulty with lifting objects overhead without
  loss of balance
• Difficulty with squatting and kneeling
• Unable to play basketball
• Afraid of carrying 1 year old daughter up/down
  steps
• Premorbid level of function
• Worked 8 hours per day as a general labor
• Squatting to pick up and carry up to 30
  containers
• Lifting and stacking objects on shelves overhead
  up to 15
• Independent with squatting and kneeling to floor
  to get under vehicles to change the oil
• Able to carry daughter up/down steps
  independently without upper extremity support of
  rail
• Played basketball 1-2 days per week

8
Subjective History

• Prior therapy received
• Several weeks as an outpatient concentrating
  mostly on exercise, not function or balance
• PMH- asthma
• Social- lives with wife and 2 daughters in 2
  story home with 12 steps to second floor
• Goals (subjective)
• Carry daughter up/down stairs safely
• Return to work full time without limitation
• Play basketball with friends

9
The Starting Line

• What do you want to assess on
• Initial Evaluation?

10
Objective Section of Evaluation

• ROM
• Strength
• Sensation
• Vision
• Joint stability assessment
• Residual Limb/Intact limb appearance
• Balance
• Prosthetic Componentry

11
ROM

• Hip
• Greater than neutral hip extension bilaterally
• Hip flexion and abduction WNL
• Hip IR L30 R35
• Knee- WNL bilaterally
• Ankle- WNL on left, all motions
• Trunk
• Sidebending (distance fingertip to floor)
• L 55cm R 51cm
• Rotation
• L75 R 83
• Ankle- WNL on left, all motions
• Trunk
• Sidebending (distance fingertip to floor)

12
Strength

• L R
• Hip flex 5/5 4/5
• Hip ext. 3/5 3/5
• Hip abd. 5/5 4/5
• Quads 5/5 5/5
• HS 5/5 5/5
• Ankle
• PF/DF 5/5 N/A
• Inv/Ev 5/5 N/A
• Abdominals 3/5

13
Sensation Vision

• Sensation
• Intact to light touch and proprioception
• Occasional periods of phantom sensation (right
  foot)
• Vision
• Not formally assessed based on age and cause of
  amputation
• No limitations observed (reading of fine print
  with intake information)
• No subjective report of visual limitations
  (blurred vision or blind spots)

14
1 Which of the following is not an indication
that you need to formally assess vision?

• Vascular cause of amputation
• History of diabetes
• History of visual disorder
• Under the age of 40

15
Joint Stability

• Knee/hip/ankle joint stability- No signs of
  instability bilaterally
• Hip Joint assessed by positioning femur in
  flexed and adducted position with over pressure
  in supine maximally extended position in
  sidelying with over pressure
• Knee joint assessed via varus/valgus stress
  tests for MCL an LCL ACL/PCL testing (anterior
  and posterior drawer testing)
• Ankle joint assessed with over pressure at end
  ranges in all planes

16
Balance

• Tested wearing prosthetic limb
• Tinetti score of 20/28 (moderate fall risk)
• Eyes closed/non-compliant surface- no LOB
• Eyes closed/compliant foam pad- LOB
• Unilateral stance time
• Left gt 20 seconds
• Right avg. of 1.85 seconds

17
Limb Appearance Management

• Residual limb/Intact limb appearance
• Shape - cylindrical
• Incision- well healed and smooth mobile
• Skin- good condition (well hydrated) with good
  signs of vascularity (no discoloration and good
  hair growth)
• Bone tibia longer than fibula (normal) tibia
  properly beveled
• No signs of vascular compromise with good skin
  hydration of intact limb
• Volume management
• Was using shrinker no longer using
• Girth not tested secondary to time post
  amputation and no history of dialysis
• Prosthetic management
• Independent donn/doff
• Wearing time
• All day

18
Prosthetic Checkout

• Prosthetic alignment (static and dynamic)
• Socket in approximately 5 degrees of flexion
• Less than 5 degrees of toe out
• Varus thrust at knee at midstance indicating good
  foot alignment in relation to socket
• Prosthetic fit
• Good suction of sleeve on limb no sign of
  excessive stretch of sleeve on socket at sleeve
  socket interface connection
• Initially socket too loose on limb leading to
  excessive socket rotation
• Corrected by prosthetist with padding along inner
  shell of socket
• Prosthetic height
• Iliac crest heights were even with static
  standing assessment

19
Prosthetic Prescription

• Multiple factors are considered
• General health
• Projected activity level
• Height and weight
• Length and shape
• Level of amputation
• Insurance/financial means

• Type of componentry chosen for patient
• Patella tendon bearing socket
• Silicone sleeve suction
• Vertical shock foot

20
Foot/Ankle

• For more active amputees
• Carbon vertical compression strut
• Allows up to one inch of vertical compression
• Reduces forces applied to the residual limb and
  proximal joints

• Flexfoot VSP

21
Suspension

• Suction suspension
• Reduced liner distal pull
• Allows more uniform distribution of pressure
  along residual limb
• Decreased bunching behind knee easier to flex
  the knee
• Straight forward with donning
• Roll on leg
• Step into socket to create suction
• Suction release button on side of socket

• Iceross Seal-In X5 liner

22
Is there anything else you need to assess?
What about function?
23
Functional Assessment

• ADLs
• Driving
• Transfers
• Lifting
• Gait
• Multiple surfaces
• Stairs

24
Functional Assessment

• ADLs- independent with dressing and bathing
  without prosthesis
• Driving- independent
• Transfers
• Sit to stand independently but asymmetrical
  decreased wt. through prosthesis
• Unable to kneel to floor and stand without upper
  extremities
• Lifting task
• Squat lifts 7.5 pounds x 5 reps before fatigue
• Overhead lifts 15 x 12 reps before fatigue

25
Functional Assessment

• Gait- walks on level surfaces independently
  without assistive device difficulty with walking
  on compliant surfaces (ie grass)
• Demonstrated a right lateral trunk lean
• No arm swing
• Decreased pelvic rotation bilaterally right lt
  left
• Decreased stance time on right
• Decreased rollover on right
• Decreased step length on left
• Stairs
• Independent with use of hand rail
• Without rails
• Up- with supervision
• Down- decreased eccentric control with several
  LOB. Minimal assistance required for balance
  control

26
2 Other than pain, what else could cause the
demonstrated gait deviations (in this particular
patient)?

1. ROM and strength deficits
2. Prosthetic alignment
3. Prosthetic fit
4. Prosthetic height

27
Causes of Gait Deviations

• Patient must adjust Center of Gravity (COG) out
  of necessity to maintain balance after amputation
  and before receiving prosthetic
• Pts COG shifted to the left.
• Due to the shift in the COG and moving through
  space in a uni pedal way, the following occur
• ROM limitations
• Strength limitations
• While healing after amputation and waiting to
  receive the prosthesis, it is important for the
  client to perform a basic exercise program to
  minimize strength and ROM losses caused by being
  uni pedal.

28
Center of Gravity

• Why is it so important?

29
3 What could happen if the COG is not controlled
during gait?

1. Nothing
2. Loss of balance
3. Increased energy expenditure
4. B C

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Importance of COG

• Energy is conserved during gait by muscles of the
  pelvis, hips and limbs offsetting the forces of
  gravity and preventing excessive movement of the
  COG
• Without muscle forces offsetting each other, the
  COG would move excessively outside of the base of
  support and require greater muscular effort to
  control the COG and expend more energy.
• If the COG is not adequately controlled, balance
  loss occurs

31
4 What motions at the knee and ankle lower
Center of Gravity (COG)?

1. Knee extension and ankle plantarflexion
2. Ankle dorsiflexion and knee extension
3. Eccentric knee flexion and ankle dorsiflexion
   during loading
4. Ankle supination and knee extension during
   loading

32
5 What motion at hip on stance side helps to
control lateral displacement of COG?

1. Hip adduction to prevent excessive pelvic drop
2. Hip abduction to prevent excessive pelvic drop
3. Hip extension
4. Hip internal rotation

33
Toward the middle of the program, even though ROM
and strength deficits were addressed and
eliminated, gait deviations sometimes reappeared

• 6 What do you think was the cause of the
  reappearance of this patients gait deviations?
• Fatigue/decreased endurance
• Faulty prosthetic componentry
• Loss of control of the COG
• Decreased attention to proper gait

34
The effect of level of amputation and cause of
amputation on energy expenditure

• Why do amputees fatigue faster ?

35
Energy Expenditure and Velocity

• Level/Cause VO2 Velocity
• TTA trauma 15 10
• TTA vascular 30 30
• TFA trauma 40 20
• TFA vascular 65 40
• Esquinazi 1994 Ertl 2005 Gailey 1994

36
7 The Amputee expends greater energy secondary
to

• Missing joints and muscles on the side of
  amputation
• Decreased joint motion of remaining joints on
  non-amputated and amputated sides
• Decreased strength of limbs, pelvis/hip and trunk
• Excessive displacement of the COG
• All of the above

37
Problem list

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

38
Problem List

• Decreased ROM
• Decreased strength
• Decreased balance
• Gait dysfunction
• Decreased safety
• Decreased activity tolerance/muscle endurance

39
What piece of subjective information is most
important in driving your treatment program?
40
GOALS!!!!!
41
What goals can be generated from your problem
list?
42
Objective Goals

• Improve Tinetti to gt 23/28 for low risk of falls
  with level surface ambulation around the home
• Equalize left and right sidebending ROM to
  decrease stress on lumbar spine
• Equalize left and right trunk rotation ROM to
  decrease stress on lumbar spine
• Increase bilateral hip internal rotation ROM to
  increase balance with gait and promote
  independent and safe level surface ambulation
  without an assistive device
• Decrease trunk lean with gait to decrease stress
  on lumbar spine and decrease pain

43
Objective Goals

• Improve pelvic rotation with gait to increase
  dynamic balance and promote safe and independent
  level surface ambulation without an assistive
  device
• Equalize stance time bilaterally/improve rollover
  on the right to decrease joint reaction forces on
  the non amputated limb
• Improve abdominal strength to gt 4/5 to decrease
  strain on lumbar spine and assist with balance
  control during functional activities
• Improve right unilateral stance time gt 5 seconds
  to facilitate proper right stance, proper
  rollover on the right and normalize step length
  on the left with level surface gait

44
What special considerations do you need to make
when goal setting and designing a POC for this
particular patient/the acute amputee population?
45
Things To Keep In Mind

• Sometimes your client will come in with
  unrealistic ideas of how they will be able to
  function after receiving the prosthesis
• A prosthesis will help a client to maximize their
  post amputation level of function.
• Help the client to understand that a prosthesis
  requires increased energy expenditure to
  manipulate
• If the client has significant cardiac or renal
  history, demands will be greater than for someone
  without this history.

46
What Would You Suggest as a Treatment Plan?
47
ROM

• Lateral trunk flexion stretches
• Seated, standing
• start at 10-15 and progress to 30 seconds
• 5 second rest in between each repetition
• 5 reps of each
• Trunk rotation stretches
• Seated and standing
• Same guidelines as above
• Can progress to weighted activity
• Trunk/pelvis disassociation exercises
• Sidelying, standing
• Focus on upper extremity and pelvis on same side
  moving in opposite directions

48
Strength

• Squats
• Progress to weighted activity
• Wall squats
• Bilateral and unilateral
• Start without weight and progress to weighted
• Lunges
• Progress to weighted activity
• Eccentric step downs
• Progress from smaller to larger stools with focus
  on speed
• Should be done as slowly as possible
• Step ups
• Forward and lateral with cueing to push down
  through the forefoot of prosthesis when placing
  foot of sound limb on stool
• progress from smaller to larger stools done
  slowly as possible
• Abdominal crunches
• Weighted trunk rotation
• Seated, standing
• Push ups

49
Balance and Agility

• Weight shifts
• Anteriorly through the forefoot of the prosthetic
• Standing ball rolls
• Progress from bilateral to one arm and then no
  arms
• Progress from small ball ( tennis) to large ball
  (physio ball)
• Compliant pad work (foam pad, pillow, grass)
• Bipedal and uni pedal
• Agility ladder
• Forward, lateral, backwards if able
• Increase speed as able
• Forward step overs/lateral step overs
• Progress from smaller to larger diameter rolls

50
Balance and Agility

• Forward and retro gait through serpentine course
• Increase speed as able
• Unilateral and bilateral jumping
• Jump up on step stool or over objects ie foam
  roll
• Dribbling basketball around objects
• Simulated one on one basketball games
• Walking up steps without upper extremity support
• Progress from no weight to weighted task

51
Gait Training

• Emphasis on the following
• Increased stance time on right by encouraging
  proper rollover from initial contact to terminal
  stance
• Increased step length on the left through
  emphasis on the above
• Increased pelvic rotation on the bilaterally
  (mostly on the right by emphasizing increased
  trunk rotation and arm swing
• T-mill
• Start at speed where patient can focus on and
  maintain normal aspects of gait. Progress speed
  as able, keeping normal gait in mind
• Start with upper extremity support and progress
  to no arm support as balance and control improve

52
Finish Line!!!

• Discharge at 12 weeks

53
Discharge Summary

• ROM
• Equalized/improved lateral trunk flexion 45 cm
  bilaterally
• Increased left trunk rotation by 5 degrees
• Pain
• Decreased frequency of phantom limb pain
• Decreased intensity of phantom limb pain 1-2 out
  of pain
• Elimination of lumbar pain

54
Discharge Summary

• Balance
• Right unilateral stance time of 9.0 secs
• 20 repetitions of vertical jumps
• Tinetti 26/28 (low fall risk)
• TUG- 6.79 seconds (low fall risk)
• Gait
• Disassociated trunk and pelvic motion to improve
  pelvic rotation
• Improved arm swing/trunk rotation
• Decreased lateral trunk flexion with right stance
• Symmetrical stance times bilaterally
• Symmetrical step length bilaterally
• Improved pelvic rotation

55
Discharge Summary

• Functional tasks
• Improved weighted squats from 7.5 x 5 reps to
  30 x 20 reps
• Improved overhead reach from 15 x 12 reps to 15
  x 30 reps
• 20 repetitions of squat lifts with 30
• Stairs- able to carry 20 of weight without
  support of rails independently

56
Discharge Summary

• Current Level of Function (ADLs, Recreation,
  Work)
• Reported walking on beach without difficulty
  (compliant surface walking)
• Playing basketball with friends on limited basis
  Building tolerance on the court
• Working 6 hours per day with split between office
  work and in the warehouse
• Able to squat and kneel to floor without upper
  extremity support
• Able to carry daughter up/down the stairs without
  use of a railing

57
Problems During Program

• Decreased patient compliance with Home Exercise
  program
• lt80 compliant with stretches and balance
  exercises
• Excessive movement of prosthesis on limb
  secondary to inadequate suspension
• Several adjustments made by prosthetist
  adjustments helped with level surface walking
• Created problems during running and
  balance/agility drills
• Eventually re-casted for new socket after
  treatment program. Client reports improved
  control with mobility

58
References

• Chao, EY, Laughman, RK, Schneider, E, Staufer,
  RN. Normative Data of Knee Joint Motion and
  Ground Reaction Forces in Adult Walking. J
  Biomech 1983 16 219-33
• Ensberg JR, Lee AG, Patterson JL, Harder JA.
  External Loading Comparisons Between Able Bodied
  and Below Knee Amputee Children During Walking.
  Arch Phys Med Rehabil 1991 72 657-661
• Esquenazi, A Analysis of Prosthetic Gait. Phys
  Med and Rehab, Vol. 8, February 1994
• Ertyl, J, Janos, P Amputations of Lower
  Extremity. E- Medicine, January 30 2005, section
  1-11
• Gailey, R Comparison of Metabolic Cost During
  Ambulation Between the Contained
  Trochanteric-Controlled Alignment Method and the
  Quadrilateral Socket. Prosthetic-orthotic int.
  172, 99-106, 1993
• Perry, J. Gait Analysis Normal and Pathological
  Function. Thorofare, NJ, Slack Inc. 1992
• Powers CM, Torburn L, Perry J, Ayappa E.
  Influence of Prosthetic Foot Design on Sound Limb
  Loading in Adults With Unilateral Below Knee
  Amputations. Arch Phy Med Rehabil 1994 75 825-9