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Management of Special Populations > Gait > Flashcards

Gait Flashcards

1
Q

Define a step

A
  • Initial contact to contralateral initial contact
  • Normal step length = 72 cm or ~28.4 in
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2
Q

Define stride

A
  • Initial contact to subsequent ipsilateral initial contact
  • Normal stride length = 144 cm or ~56.7 in
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3
Q

Define step width

A
  • The lateral distance b/w the heel centers of two consecutive foot contacts
  • Normal step width = 7-9 cm or ~2.8-3.5 in
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4
Q

Define foot angle

A
  • The degree of “toe out” or the line of progression b/w the body & the long axis of the foot
  • Normal foot angle = 10-14 degrees
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5
Q

Define cadence

A
  • The number of steps taken per minute (step rate)
  • Average adult cadence = 110 steps/min
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6
Q

Define stride time

A
  • The time for a full gait cycle to complete
  • Average adult stride time = 1 sec
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7
Q

Define step time

A
  • The time for a right or left step to complete
  • Average adult step time = 0.5 sec
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8
Q

Define stance time

A
  • Time reference foot is on the ground
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9
Q

Define swing time

A
  • Time reference foot is off the ground
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10
Q

Define double limb support time

A
  • Time both feet are on the ground that occurs twice during the gait cycle
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11
Q

Define single limb support time

A
  • Time non reference foot is swinging forward & reference foot is on the ground
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12
Q

What is normal gait speed

A
  • 1.37 m/s
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13
Q

Ways to calculate gait

A
  • Measuring the time it takes to cover a given distance
  • Measuring the distance covered in a given amount of time
  • Multiplying the step rate by the step length
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14
Q

What phases of gait are a part of weight acceptance

A
  • Initial contact
  • Loading response
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15
Q

What phases of gait are a part of single limb support

A
  • Mid-stance
  • Terminal stance
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16
Q

What phases of gait are a part of swing limb advancement

A
  • Pre-swing
  • Initial swing
  • Mid-swing
  • Terminal swing
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17
Q

What are the 4 basic functions of normal gait

A
  • Weight bearing stability: think ground reaction forces at different phases of gait & what effect these have on the hip & knee & ankle joint
  • Stance limb progression: heel rocker maintains fwd progression from heel strike to foot flat; forefoot rocker does fwd progression to metatarsal heads with heel rise
  • Shock absorption: ankle plantar flexion followed by knee flexion
  • Energy conservation
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18
Q

Difference b/w a hard and soft prosthetic heel during tibial advancement/heel strike

A
  • Too hard of a heel will cause the limb to progress forward too fast and result in knee buckling
  • Too soft of a heel will squish and lead to the foot going flat to the ground too early results in a knee extension force/thrust
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19
Q

Describe weight bearing stability in gait

A
  • Muscles around the hip, knee, & ankle sequentially stabilize these joints as the body weight is transferred to the stance limb
  • Pattern of muscle activation is dictated by the alignment of the body weight line to the joint
  • As the vector moves away from the joint center, a rotational force or moment develops that must be controlled by the opposing muscles to preserve postural stability
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20
Q

What are the 3 demands of weight acceptance

A
  • Shock absorption
  • Initial limb stability
  • Preservation of progression
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21
Q

What is the most challenging task in the gait cycle

A
  • Weight acceptance
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22
Q

What are the 2 demands of single limb support

A
  • One limb has total responsibility for supporting body weight in both the sagittal & coronal planes
  • Progression continues
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23
Q

What are the 3 demands of swing limb advancement

A
  • Lifting of foot
  • Completion of stride length
  • Preparation for next stance interval
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24
Q

Describe the cost of walking

A
  • O2 Cost = Rate of O2 Consumption ÷ Gait Speed
  • Minimized at preferred walking speeds
  • Higher cost with slow or fast walking
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25
Q

What are the weight bearing regions (pressure tolerant) for transtibial prosthesis

A
  • Anterior: Patella tendon and Pretibial musculature
  • Posterior: Gastric-soleus muscle belly and Popliteal fossa
  • Medial: Medial tibial flare
  • Lateral: Shaft of fibula
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26
Q

Difference b/w terminal stance and pre-swing

A
  • In pre-swing the limb is unloaded
  • In terminal stance the limb is still under load
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27
Q

What is the concern for putting pressure of the fibula shaft

A
  • Compression of the fibular nerve
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28
Q

What happens to pressure areas that are over muscle bellies overtime

A
  • Atrophy which will lead to socket adjustments later on which is normal
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29
Q

What is a good landmark to make sure that the socket fits properly

A
  • The patella tendon bar area
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30
Q

Pressure on tibia through the gait cycle

A
  • Loading response: anterior distal/posterior proximal
  • Mid-stance: all pressure tolerant weight bearing surfaces
  • Terminal stance: anterior proximal/posterior distal
  • Pre-swing: anterior distal/posterior proximal
  • Initial swing: anterior proximal/posterior distal
  • Mid-swing: foot clearance dependent on appropriate suspension & pelvic control on contralateral side
  • Terminal swing: anterior distal/posterior proximal
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31
Q

A lot of impairments in swing phases are due to inadequate terminal stance True/False

A
  • True
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32
Q

Define suspension

A
  • The interface between the prosthetic and the residual limb
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33
Q

What is inadequate suspension

A
  • When off loaded the prosthetic is being pulled by gravity causing the leg to be long leads to a compensatory hip hike
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34
Q

During mid-stance what force couples are occurring

A
  • Medial proximal/lateral distal
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35
Q

Describe unleveled bones

A
  • Jagged bones from surgery
  • Appear more prominent as atrophy occurs
  • May lead to skin breakdown during weight bearing
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36
Q

What do you due before putting on the prosthesis

A
  • Evaluate weight bearing regions
37
Q

What are the goals of prosthetic training

A
  • # 1: don’t compromise your PT session with poor fitting limbs that cause you more problems#2: solve issues within your scope without the prosthetist
38
Q

Describe the initial check of the prosthesis

A
  • Check height (pub-floor)
  • Foot is level in the shoe
  • 5-7 degrees socket flexion (means knee flexion or moved anteriorly)
  • Weight line is near posterior third of foot
  • Pin suspension engages/disengages easily
39
Q

What happens if too much flexion or weight line too far forward?

A
  • Rapid knee flexion
  • Increased distal tibia pressure
40
Q

Before calling the prosthetist ask what

A
  • Take the leg off & put on again
  • When in gait does it hurt?: on heel, mid foot, or toe
  • Can you duplicate the pain with the leg off?
  • Are there pressure areas on the limb you can relate to gait?
41
Q

Describe residual limb pain

A
  • Pain in the limb between the end of the residual limb & the next most proximal joint
42
Q

Describe MSK pain for amputees

A
  • Amputation has been associated with increased prevalence of secondary MSK pain in the lumbar spine & in the contralateral knee/hip
43
Q

Describe phantom limb pain

A
  • Pain distal to the end of the residual limb
  • Onset in early post amputation period
  • Often nocturnal
  • Gradually reduced in intensity & frequency over time
  • Can be exacerbated by residual limb pain
44
Q

Describe phantom limb sensation

A
  • Non-painful sensations distal to the residual limb
  • Wide spectrum of sensory experiences that vary in intensity, frequency, & severity
45
Q

Describe residual limb management through the different stages

A
  • Preoperative: desensitization exercises, skin hygiene, & description of types of pain; explain & differentiate b/w residual limb pain, phantom pain, & phantom sensation
  • Postoperative: Donning/doffing of ACE wrap or shrinker if appropriate; desensitization exercises, skin hygiene, & description of types of pain
  • Pre-prosthetic: care of residual limb
  • Prosthetic training: donning/doffing of prosthetic system, use of shrinker when out of the prosthesis, skin checks & skin hygiene, management of sock ply if appropriate, observe pressure points & protect contralateral foot
  • Long term follow up: foot care & skin checks
46
Q

Slide 75

A
47
Q

Describe cardiovascular endurance in amputees with prosthetics

A
  • Energy cost of walking is greater in amputees
  • Higher level amputations are associated with higher energy costs of gait
  • Dysvascular amputations demonstrate greater energy cost of gait than those with traumatic amputations
  • Self-selected gait speed decreases with higher levels of amputation
  • Generally more efficient for an individual with a prosthesis to ambulate with the prosthesis than it is to ambulate w/o the prosthesis using an AD
48
Q

Difference in energy expenditure for over ground walking between transtibial and transfemoral amputees

A
  • Energy expenditure for over-ground walking in people with unilateral dysvascular amputations is increased by up to 36% for transtibial and up to 65% for transfemoral amputations
49
Q

Describe the socket-residual limb interface

A
  • The static and dynamic pressure distribution of the residual limb within the socket are essential considerations in patient comfort, function, and well-being
  • You could have the best prosthetic foot on the market, but if your socket is uncomfortable you’re not going to walk very far
50
Q

Describe a joint and corset

A
  • May/may not have a waist belt depending on how prominent the femoral condyles are
  • May include posterior check strap to limit full knee extension
  • Load-bearing forces were split b/w the socket & a thigh corset
  • Primarily indicated for very short residual limb (transtibial)
51
Q

Describe a patella tendon bearing (PTB) socket

A
  • Localization of load-bearing pressures soon designated “pressure tolerant” regions, & targeted offloading of regions generally intolerant to pressure
  • Patellar tendon bar & medial tibial flare are major WBing areas for a PTB socket
  • Total contact socket design has been used for ≥60 years for a comfortable prosthetic fit
52
Q

Describe a total surface bearing (TSB) socket

A
  • Globally reduced socks volumes & relatively equal load bearing pressures throughout the entirety of the socket
  • Allows increased surface area for WBing
  • Shear forces run parallel to the limb surface & are best mitigated through the use of a socket interface
  • Normal forces are those that are applied perpendicular to the surface of the limb
53
Q

Viscoelastic interface liners provide reduction of shear at skin surface, these are fabricated from a range of elastic materials including:

A
  • Silicone
  • Urethane
  • Other Gel-like substances
54
Q

What is included in the socket interface

A
  • Elastic liners
  • Socks
  • Foam liners
55
Q

Describe elastic liners

A
  • Composed of silicone, urethane, & other thermoset elastomeric materials
  • Used with & w/o external fabric covers & imbedded matrices of reinforcing mesh material
  • Fabricated in custom & non-custom variants
56
Q

Describe socks

A
  • Compressible textiles, occasionally infused w/thermoplastic elastomer gels
  • Primarily used to accommodate changes in limb volume but occasionally used as a primary interface b/w the limb & socket
57
Q

Describe foam liners

A
  • Nonporous material of soft to moderate durometer, frequently heat contoured over a positive model of the limb to mimic the contours of the socket
  • Good option for individuals with fluctuating residual limb volume
58
Q

Compared with traditional PTB-designed interfaces, the use of gel liners reportedly:

A
  • Decreases walk aid dependence
  • Improves prosthetic suspension when used with a shuttle lock mechanisms compared with supracondylar, cuff, or corset alternatives
  • Improves load distribution
  • Decreases pain & increases comfort
59
Q

Describe an anatomic suspension

A
  • Proximal socket contours are shaped to secure purchase over the bony shape of the femoral condyles
60
Q

Describe a mechanical “locking” liner suspension

A
  • Combo of an elastic liner fitted with a distal locking pin which engages a locking mechanism fabricated into the socket
  • Suspension results from the suction of the liner & transfers through the locking mechanism attached to the socket
  • Reinforcing mesh is frequently impregnated into the liners distally to limit longitudinal dissension of the liner
61
Q

Describe suction suspension

A
  • Creation of an airtight socket environment
  • Frequently obtained through the use of a proximal sealing sleeve worn against the thigh & outer surface of the socket but alternatively obtained with sealing gaskets worn over the external surface of the interface liner
  • During gait when the prosthesis would separate from the limb it results in an increase negative pressure further resulting in an increasing force keeping the prosthesis on the limb
62
Q

Describe a vacuum assisted suction suspension

A
  • Similar to suction suspension with the addition of a vacuum element that actively draws air form the socket environment resulting in elevated negative pressure w/o need for initial prosthesis distraction from the residual limb to obtain negative pressure
63
Q

Compared with Total Surface Bearing-designed interfaces with pin locking suspension mechanism, VAS interfaces reportedly:

A
  • Reduce time to prosthetic fitting and improve mobility post-operative or post-ulceration
  • Decrease step activity
  • Decrease pistoning
  • Decrease positive pressure in stance phase of gait
  • Increase negative pressure in swing phase when walking
  • Could decrease daily limb volume changes, maintain a better socket fit
  • Improve mobility, comfort, stability, proprioception, functional outcome, overall satisfaction, prosthetic function, and quality of life.
  • Reduce skin irritation, cure residual limb wounds faster, and decrease pain.
  • More maintenance was required for VAS systems
64
Q

Indications for a vacuum assisted suspension (VAS)

A
  • Indicated to decrease daily limb volume changes while facilitating more favorable pressure distribution during gait-
65
Q

Precautions for VAS

A
  • VAS requires both awareness & compliance on the part of the end user & are not universally indicated
  • Possibility of creating skin blisters when worn improperly
  • Requires that the pt has sufficient cognitive ability to know what to watch for & how to fix problems
  • Requires more maintenance than other suspension systems
66
Q

Which type of suspension is best among modern suspension optiosn

A
  • Vacuum-assisted suspension (VAS) sockets permit the least amount of pistoning within the socket
  • Suction suspension
  • Pin lock suspension
  • Traditional suspension options of supracondylar, cuff, and sleeve suspension provide comparatively compromised suspension
67
Q

Why do we care about sockets & suspension

A
  • Socket has been the most important consideration in lower limb prosthesis user satisfaction
  • Dissatisfactionn is mainly caused by strains & injuries associated with socket fit
  • Pressure distribution (within the socket) directly/indirectly affects the effective indices of user satisfaction
68
Q

Describe heel position and its effects on socket & foot alignment

A
  • Heel too low creates excessive extensor moment at the knee in mid-stance, hampering forward progression
  • Heel too high creates a flexion moment at the knees in mid-stance leading to early “drop off” & compromise of stance phase stability
  • Goal is pylon vertical*
69
Q

Socket and foot alignment during gait

A
  • Initial contact: made at the heel, & compression of the prosthetic heel simulates controlled lowering of the foot during loading response
  • Mid-stance: WBing forces move anteriorly to the ball of the foot
  • Terminal stance: the anterior portion of the prosthetic foot simulates toe extension & the heel rises
  • Pre-swing: the individual rolls over the toe & moves into knee flexion for effective shortening of the limb for swing limb clearance
70
Q

Describe the K-levels that are based on the amputee mobility predictor

A
  • Level 0: 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 or mobility.
  • Level 1: Has the ability or potential to use a prosthesis for transfers or ambulation on level surfaces at fixed cadence.
  • Level 2: Has the ability or potential for ambulation with the ability to traverse low-level environmental barriers such as curbs, stairs or uneven surfaces.
  • Level 3: Has the ability or potential for ambulation with variable cadence.
  • Level 4: Has the ability or potential for prosthetic ambulation that exceeds basic ambulation skills, exhibiting high impact, stress, or energy levels.
71
Q

Describe the amputee mobility predictor

A
  • Ceiling effect with higher level mobility
  • Scores >37 indicate that the pt demos proficient balance, postural stability during sitting & standing, and the ability to vary walking cadence then they are ready to perform activities beyond basic ambulation
  • Scores 32-47: have adequate balance with both static & lower level dynamic activities, demo better than average lower limb power, & show competent use of prosthesis
72
Q

Potential functional ability is based on the reasonable expectations of the prosthetist, and treating physician, considering factors including, but not limited to the following:

A
  • Pt’s past Hx
  • Pt’s current condition including the status of the residual limb & the nature of other medical problems
  • Pt’s desire to ambulate
73
Q

Slide 112

A
74
Q

Recommendations or single axis foot

A
  • Pts ambulating at a single speed who require greater stability during weight acceptance bc of weak knee extensors or poor balance
75
Q

Biomechanics of a single axis foot

A
  • Prosthetic comes into full contact with the floor more quickly during weight acceptance which decreases magnitude of the external knee flexion moment
  • This reduces the likelihood of a knee-buckling event, creating a more stable environment for users with weak knee extensors or transfemoral prostheses
76
Q

Recommendation for energy storage & return foot (ESAR)

A
  • Pts at elevated risks for overuse injury to the contralateral lower limb & lower back
  • Pts capable of variable speed and/or community ambulation
77
Q

Biomechanics of a ESAR

A
  • Reductions in the peak ground reaction force experienced by the sound-side limb during weight acceptance which Improved tibial progression into terminal stance
  • Shock-absorbing characteristics seem to be more apparent at speeds exceeding self-selected walking velocities
  • Reduced energy costs of ambulation are more pronounced at elevated walking speeds, during the negotiation of inclines/declines, and during stair ascent
78
Q

K1 level feet

A
  • Single axis feet are appropriate
  • Solid ankle cushioned heel (SACH) foot may not be appropriate for heavier pts
79
Q

K2 level feet

A
  • Lightweight, flexible heel, multi-axial ankle
  • Modest energy return
  • Flexible bumper cushions dampen PF from heel strike to foot flat (stiffness/softness can be changed)
80
Q

K3 level feet

A
  • Integrated pylon is the lightest design
  • ESAR
  • Typically carbon fiber or fiberglass
  • Reduce energy consumption
  • Offer increased ankle ROM
  • Reduce sound side loading
  • Variable degree of frontal plane motion (inversion/eversion)
  • Microprocessor feet: heavier than most ft, require nightly charging, currently limited to single axis, not appropriate for very high activity or running, responses to changes in incline/decline, walking speed, and shoes
81
Q

Line of gravity through the body in standing

A
  • anterior to ankle
  • anterior to knee
  • posterior to hip
  • anterior to 2nd sacral vertebra
  • straight through the ear hole
82
Q

Describe loading response 0-12% & muscles activated

A
  • weight is rapidly transferred onto the outstretched limb
  • hip stability, controlled knee flexion, & ankle PF
  • Hip 20º flexion
  • Knee 15º flexion
  • Ankle 5-10º PF
  • hip extensors & abductors, quads, pretibial muscles/DF
83
Q

Describe midstance 12-30% & muscles activated

A
  • body progresses over single limb
  • controlled tibial advancement
  • Hip 0º
  • Knee 5º flexion
  • Ankle 5º DF
  • hip abductors, quads initially, gastroc/soleus
84
Q

Describe terminal stance 30-50% & muscles activated

A
  • body moves ahead of the stance limb
  • controlled ankle DF with heel rise & trailing limb posture
  • Hip 20º ext
  • Knee 0-5º flexion
  • Ankle 10º DF
  • gastroc/soleus
85
Q

Describe pre-swing 50-62% & muscles activated

A
  • rapid unloading of trailing limb as weight is transferred to opposite foot
  • passive knee flexion to 40º & rapid ankle PF
  • Hip 10º ext
  • Knee 40º flexion
  • Ankle 15º PF
  • hip adductors
86
Q

Describe initial swing 62-75% & muscles activated

A
  • thigh begins advancement as the foot comes up off the floor
  • hip flexion 15º & knee flexion 60º
  • Hip 15º flexion
  • Knee 60º flexion
  • Ankle 5º PF
  • hip flexors, hamstrings, pretibial muscles/DF
87
Q

Describe mid swing 75-87% & muscles activated

A
  • continued thigh advancement with foot clearance & begin knee extension
  • hip flexion 25º, ankle DF 0º
  • Hip 25º flexion
  • Knee 25º flexion
  • Ankle 0º
  • hip flexors initially then hamstrings, pretibial muscles/DF
88
Q

Describe terminal swing 87-100% & muscles activated

A
  • final knee extension in preparation for contact with ground
  • knee extension to neutral
  • Hip 20º flexion
  • Knee 5º flexion
  • Ankle 0º
  • hamstrings & add/abductors, quads, pretibial muscles/DF

Management of Special Populations (13 decks)

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