LE Prosthetic Gait Flashcards
(77 cards)
1
Q
Energy expenditure for LE amputees
A
Easiest: TT < crutches with no prosthesis = TF with prosthesis < bilateral TT < bilateral TF: hardest
2
Q
VO2 levels are…
A
Maintained with advancing amputee level
3
Q
Walking speed is…
A
Slowed with advancing amputee level
4
Q
Almost everyone is fitted even with contractures, scars or poorly shaped residual limbs
A
Transtibial amputees
5
Q
Hip flexion contractures, weakness, poor balance or coordination or unstable medical status limit prosthetic success for…
A
Transfemoral amputees
6
Q
Young agile individual = good candidates, most amputees can become functional
A
Bilateral amputees esp TT
7
Q
The amputee mobility predictor
A
An instrument to assess determinants of the lower limb amputees ability to ambulate (predicts functional outcome post-amputation
8
Q
Transtibial prosthetic evaluation in sitting
A
- Comfortable sole of shoe flat on floor
- Tissue rolls in popliteal area (prevent adequate knee flexion)
- Residual limb forced out of socket
- Level knee height
9
Q
Transtibial prosthetic evaluation in standing
A
- Pain or discomfort (sharp)
-Knee forced into flexion or extension - Level pelvis equal iliac crest height may indicate errors in height of prosthetic or position of limb in socket
- Sole of foot flat on floor
- Residual limb in contact with distal end of socket
- Is suspension adequate to hold limb when foot off floor (keep it in the socket)
10
Q
Transfemoral prosthetic evaluation in sitting
A
- Socket secure to residual limb
- Knees level in height
- Note any burning or pinching
- Pt able to lean forward to touch shoes comfortably (trunk flexion needed for sit to stand)
11
Q
Transfemoral prosthetic evaluation in standing
A
- Pain or discomfort
- Proper weight bearing for type of socket
- Knee stable with weight on prosthesis (extension)
- Level pelvis
- Adductor roll
- Pressure on pubic ramus
- Is suspension adequate to hold limb when foot off floor
12
Q
Normal gait requires
A
- Stability in stance
- Foot clearance in swing
- Pre-positioning of foot for heel strike
- Adequate step length & even between limbs
- Energy conservation - want efficient gait
13
Q
Normal ROM requirements for gait
A
- Foot: 5 deg inversion and eversion
- Ankle: 5 deg DF & 20 deg PF at push-off
- Knee: 0 deg extension & 60 deg flexion
- Hip: 20 deg flexion & 10 deg extension
14
Q
Stance phase of gait cycle
A
0-60% of gait cycle
- Heel strike -> foot flat (loading response)
- Midstance
- Terminal stance (heel off)
- Preswing (toe off)
15
Q
Swing phase of gait cycle
A
60-100% of gait cycle
- Initial swing (acceleration)
- Midswing
- Terminal swing (deceleration) preparing for heel strike
16
Q
% of stance phase (60%) that is spent in double vs single limb support
A
40% single limb support
20% double limb support
17
Q
Normal step width
A
2-4 inches or 5-10 cm
18
Q
External forces contributing to movement
A
- Joint and ground reaction
- Ground reaction forces include 1. Direction 2. Magnitude (amount of force)
19
Q
Internal forces contributing to movement
A
Produced by muscles and soft tissue
20
Q
Normal ground reaction force vector during loading response in Sagittal plane
A
- Posterior to the ankle joint
- Posterior to the knee joint
- Anterior to hip joint
- not a stable position
21
Q
During loading response, GRF produces…
A
- plantar flexion moment at the ankle joint
- flexion moment at the knee joint 15 deg
- flexion moment at the hip
22
Q
Body controls GRF moments during loading response with…
A
- eccentric activity in ankle DFs
- eccentric activity in knee extensors
- eccentric or isometric activity in hip extensors
23
Q
Normal ground reaction force vector during Midstance
A
- anterior to the ankle joint
- anterior to the knee joint
- posterior to hip joint
- stable position
24
Q
During Midstance, GRF produces…
A
- dorsiflexion moment at the ankle joint
- extension moment at the knee
- extension moment at the hip
25
Body controls GRF moments during Midstance with…
- eccentric activity in ankle PFs
- passive force which develops in posterior knee structures as they elongate during knee extension
26
Normal ground reaction force vector during terminal stance in Sagittal plane
- anterior to ankle joint
- anterior to knee joint
- posterior to hip joint
- stable position
27
During terminal stance, ground reaction force produces…
- dorsiflexion moment at the ankle joint
- extension moment at the knee
- extension moment at the hip
28
Body control GRF moments during terminal stance with…
- isometric plantar flexors
- passive force which develops in the posterior knee structures at they elongate during knee extension
29
Normal ground reaction force vector during preswing
- anterior to ankle joint
- posterior to knee joint
- posterior to hip joint
- not a stable position
30
During preswing the ground reaction force produces…
- dorsiflexion moment at the ankle joint
- flexion moment at the knee
- extension moment at the hip
31
Body controls GRF moments during preswing with…
- concentric plantar flexors for push-off/propulsion
- little or no muscle activity at the knee with normal walking speed. Rec fem at faster speeds & hamstrings at slower speeds
- hip flexors chases to isometric then concentric activity during pre and initial swing
32
Normal ground reaction force vector during loading response in frontal plane
- lateral to subtalar axis -> pronation moment at subtalar joint
- medial to knee joint -> varus moment at the knee (think this should be valgus moment)
- medial to hip joint -> adduction moment at the hip
33
Body responds to GRF moments during loading response in the frontal plane by…
- eccentric activity in the intrinsic foot muscles & other supinator muscles to control subtalar pronation
- passive tension in lateral knee structures, active force in tensor fascia lata may contribute to knee stability
- activity in hip abductor muscles
34
Normal ground reaction force vector during terminal stance in the frontal plane
- medial to axis of subtalar joint -> small supination moment at subtalar joint
- medial to knee joint -> varus moment at the knee (or valgus??)
- medial to hip joint -> adduction moment at the hip
35
Body responds to GRF moments during terminal stance in the frontal plane by…
- activity in intrinsic foot muscles, soleus & other supinator muscles. They augment supination moment in subtalar joint to produce increasingly rigid foot
- passive tension in lateral knee structures. Active force in tensor fascia lata may contribute to knee stability
- activity in hip abductor muscles
36
Muscle activity during heel strike -> heel off
- Eccentric: DR & quads (loading)
- Isometric: hip abductors (mainly), hip adductors (IR & ext of hip), erector spinae, PF
- Concentric: PF (terminal stance)
37
Muscle activity during swing phase of gait
- Eccentric: rec fem (slows knee flexion during preswing) hamstrings (terminal swing)
- Isometric: erector spinae
- Concentric: PF (push-off), iliopsoas (swing), DF to clear foot
38
What is happening in the transverse plane during gait
- Pelvis is maximally anteriorly rotated at heel-strike to Midstance
- Pelvis is maximally posteriorly rotated at toe off
- total pelvic motion is 8-10 degrees
- arm swing occurs in response to counter-act pelvic motion
39
What is happening in the frontal plane during gait
- On stance side the pelvis tilts upward 5 deg and downward 5 deg on swing side
- Pelvic tilt resisted eccentrically or isometrically by glut med
- Pelvis is raised to neutral at end of swing phase
Note: hip is highest during Midstance and lowest at heel-strike and push-off
40
Excessive knee extension at heel strike to mid stance (TT)
Amputee complains of walking uphill may appear as though prosthesis is too long
Prosthetic causes:
- heel cushion too soft; rapid PF -> knee extension
- toe lever arm too long -> forces knee into hyperextension
- socket placed too far posterior on foot
Amputee causes:
- weakness of quadriceps -> compensation
- habit pattern
41
42
Excessive knee instability at heel strike to mid stance (TT)
Amputee complains of walking downhill
Prosthetic causes:
- heel cushion too hard; limited PF -> knee flexion
- toe lever arm too short -> forces knee into flexion
- socket placed too far anterior on the foot
Amputee causes:
- quadriceps weakness
- habit pattern
- knee flexion contractures
43
Lateral bending (typically towards prosthetic side) aka trendelenburg lurch
Amputee may describe feeling like they’re stepping into a hole
Prosthetic causes:
- prosthetic too short
- lateral wall fails to adequately support femur
- high medial wall causes discomfort
- prosthesis aligned in abduction -> wide base gait
Amputee causes:
- inadequate abduction strength
- abduction contracture -> difficult to adduct
- very short limb may fail to provide sufficient lever arm
- habit pattern
44
Prosthesis held away from midline at all times (abducted gait) seen in Midstance
Prosthetic causes:
- prosthesis too long
- too much abduction built into prosthesis
- high medial wall causing discomfort
- lateral wall failing to adequately support femur
Amputee causes:
- inadequate abduction strength
- abduction contracture
- habit pattern
45
Vaulting gait seen in terminal stance
Rises on toe of sound side to permit swing through with limited knee flexion
Prosthetic causes:
- prosthesis too long
- inadequate socket suspension
- difficulty flexion knee (adequate toe load needed)
Amputee causes:
- fear of stubbing toe
- limb discomfort
- not achieving adequate toe load
- not forcefully rotating hip enough to move prosthetic through swing phase
- habit pattern
46
Drop off gait seen in terminal stance
Premature knee flexion before toe off
Prosthetic causes:
- toe lever too short
- socket placed too anterior on foot
Amputee causes:
- none
47
Circumducted gait seen in swing
Prosthesis swung laterally in wide arc
Prosthetic causes:
- prosthesis too long (may also see vault on sound side)
- knee is too stiff to bend for swing through
Amputee causes:
- inadequate abduction/hip flexion strength
- abduction contracture
- lack confidence for flexing prosthetic knee
- habit pattern
48
Uneven heel rise seen in swing
Rapid rise of prosthetic heel during early swing phase
Prosthetic causes: (normally controlled by rectus femoris eccentric activity)
- insufficient knee joint friction
- inadequate extension aid
Amputee causes:
- excessive hip flexion forcing knee into flexion
49
Medial or lateral whips seen in swing
Present when heel moves medially or laterally at beginning of swing phase
Prosthetic causes:
- excessive IR/ER or prosthetic knee in socket
- socket may be too tight
- excessive valgus of prosthetic knee
Amputee causes:
- faulty walking habits
50
Terminal swing impact
Knee snaps into extension before heel strike
Prosthetic causes:
- insufficient knee friction
- knee extension aid too strong
Amputee causes:
- assuring knee is in full extension by deliberately and forcibly extending residual limb before heel strike
51
Foot rotation seen at heel strike
Medial or lateral (more common) rotation of prosthetic foot on heel strike
Prosthetic causes:
- too much resistance to PF
- too much toe-out built into prosthesis
- too loose socket
Amputee causes:
- vigorous extension at heel strike
- poor hip rotation control
52
Foot slap seen at heel strike
Too rapid descent of foot at heel strike
Prosthetic causes:
- PF resistance too soft ie. SACH foot
Amputee causes:
- driving prosthesis into the walking surface too hard to assure knee extension
53
Prosthetic knee instability at heel strike
Knee instability creates danger of falling
Prosthetic causes:
- knee joint too far ahead of TKA line
- insufficient flexion built into socket
- PF resistance too great -> knee to buckle at HS
- failure to limit DF -> poor knee control at toe off
Amputee causes:
- hip extensor weakness
- hip flexion contracture
54
Reduced arm swing seen in all phases of gait
Uneven swing on prosthetic side
Prosthetic causes:
- poorly fitted socket causes limb discomfort
Amputee causes:
- poor balance (hip control)
- uneven step length
- vaulting, circumducted, abducted gait
55
Uneven step length seen in all phases of gait
Very short stance phase on prosthetic side
Prosthetic causes:
- poorly fitted socket -> limb discomfort
- weak extension aid or insufficient friction in prosthetic knee -> excessive heel rise
- knee buckles too easily
Amputee causes:
- poor balance (hip control)
- extension weakness
- fear and insecurity
56
Excessive trunk extension
Active lumbar lordosis in stance of prosthetic
Prosthetic causes:
- improperly shaped posterior wall -> forward rotation of pelvis to avoid full WB on ischium
- insufficient initial flexion built into socket
Amputee causes:
- hip flexor tightness
- substitution of lumbar erector spinae for weak hip extensors
- weak abdominals
- moving shoulders backwards in effort to obtain better balance
57
Skin care
- Important for diabetic and PVD pts especially
- Soft tissue/scar management
58
Expected pressure patterns
TT: femoral condyles, patellar tendon, med tibial flare, tibial shaft, ant and pos compartments
TF: soft tissue, ischial tuberosity
59
Pressure intolerant areas
TT: fibular head, tibial crest, distal end of tibia, hamstring insertions/tendons
TF: distal femur, pubic ramus, adductors rolls
60
Wear schedule of prosthesis
* 2, 2, 20 *
2 hours on, 2 hours off, < 20 min weight bearing PER HOUR
- increase by 1 hour every 2-3 days
61
Socks
Come in 1, 3, and 5 ply
- applied over a thin sheath with thickest layer against skin, must have no wrinkles
- increase by 1 ply at a time
- if pt is over 10-15 ply socks -> need new socket
- if used with gel liners -> sock goes over liner and not against skin
- should be washed in mild soap and rinsed well no washer or drying, rolled in towel for drying
62
Soft liners
- mostly used w/ TT where bone is prominent or there is an increased skin sensitivity
- made of perlite, nickelplast, PPT, silicone, gel, plastazote & leather
- meant to be an exact/tight fit into prosthesis
- don sheath/apply appropriate ply of sock and gently pull liner on from the top as its pushed up from bottom
Care: wipe with damp cloth
63
Gel liners
- worn directly against skin; decreases shearing on skin and can be used with more fragile skin
- Donn liner by turning it inside out, create a cup and roll it on pulling on the top of the liners rips them
- if pt sweats heavily, use and AI containing spray to control perspiration
- liners are porous, no powders
Care: several times a day take liners off and spray with alcohol and wipe them with linen towel, hand wash each evening in mild soap and rinse well, hang to dry inside out
64
Sockets
- wash out with damp cloth and make sure all detergent removed
- endoskeletal components: return to prosthetist to replace stockings/foam with tears, hand wash stockings with mild soap if removable
- return to prosthetist with any other problems with fit, the joints, or changes in function
65
Donning TF prosthetic in sitting
Need to have socket aligned in external rotation to match position of residual limb
- WB to fully seat residual limb in prosthesis and check to ensure proper alignment prior to ambulation
- Initiate step with sound leg to ensure knee lock
66
When GRF anterior to the knee
The prosthetic knee extends and locks
67
When GRF is posterior to the knee
The knee flexes
68
Sit to stand training
- begin in parallel bars
- progress outside of parallel bars
- start by handing the patient the assistive device and progress to independent
69
Standing in parallel bars with weight shifting and balance
- progress to no hands
- sway side to side first -> forwards and backwards
- starting gait training with non-prosthetic leg in swing to work on stance on prosthetic limb
70
Repetitive single stepping
- sound leg first to foster prosthetic weight acceptance and enforce knee lock with TF pts
- followed by prosthetic stepping
71
Gait training in parallel bars
- forward progression
- backwards
- side stepping
72
Assistive device progression
- walker
- 2 forearm crutches
- 1 forearm crutch
- wide base quad cane
- narrow base quad cane
- straight cane
- freedom under good weather conditions ?
73
More advanced gait training
- single leg stance on prosthesis
- unsupported standing
- kick ball, catching, throwing
- ascending and descending inclines, ambulating on uneven surfaces
- controlled lowering to floor
- floor to stand
- falling with protective methods
74
Curbs and stair training
Up with the good, down with the bad
-microprocessor legs; ride knee down after placing midfoot on tread edge
75
Bilateral TF amputees and gait training
- requires large energy capacity to functionally ambulate on level surfaces for short, in home distances (K1 and K2)
- most used wheelchairs as primary mode of transportation
- large number chose not to ambulate and conserve energy for ADLs
76
Stubbies
Sockets without any shanks or knees
Advantages:
- lower to ground
- easier for balance
- don’t have to control knees
- feet can go on backwards and increase hip flexor stretch on pts with large contractures and allow them to remain upright
Disadvantages:
- energy inefficient
- abnormal gait
- cosmesis
77
TF advanced exercise ideas
1. Lateral shifting -> anterior (unstable)/posterior (more stable) shifting
2. Side stepping -> step ups leading with sound
3. Grapevine stepping -> ball rolling w/ sound
4. Advance weight shifting with tubing on sound
5. Side hops -> cone pick ups
