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NPTE > Gait, prosthetics/orthotics, AD Rx > Flashcards

Gait, prosthetics/orthotics, AD Rx Flashcards

1
Q

What is the first period of the gait cycle with double limb support?

A

Heel strike/initial contact

Lasts until end of heel off/terminal stance phase

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2
Q

What is the first period of single limb support during the gait cycle?

A

Midstance

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3
Q

What muscles are activated during Heel strike?

A

Quadriceps (Knee extension) - shock absorption

Ankle DF - control lowering of the foot from heel strike to foot flat

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4
Q

What muscles are activated during foot flat phase?

A

Triceps surae - eccentrically control tibial advancement

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5
Q

What muscles are activated during midstance?

A

Hip extensors - control FWD motion of the trunk

Hip Abductors - stabilize pelvis suring single limb support

Knee Extensors (quads)

Triceps Surae - control FWD tibial advancement

Ankle DF

Achilles tendon elongates and stores energy

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6
Q

What muscles are activated during heel off?

A

Ankle PF - Generates propulsion of the body and swing limb

The energy stored in the Achilles tendon releases

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7
Q

In what phase is the peak activity of the ankle PF mm?

A

heel off

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8
Q

What muscles are activated during the toe-off phase?

A

Hip extensors (Hamstrings)

Knee Extensors (Quads)

FWD propulsion

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9
Q

What muscles are activated during acceleration gait phase?

swing phase

A

Hip Flexors

Knee extensors (Quads)

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10
Q

The quadriceps become silent during what phase of the swing phase? Why?

A

a. Midswing

b. Pendular motion is in effect

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11
Q

What phase of the gait cycle has the most knee flexion?

A

Midswing

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12
Q

What muscles are activated during midswing?

A

Hip and knee flexors

Ankle DF (elevate the toe for clearance)

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13
Q

What muscles are active during terminal swing/Deceleration?

A

Early phase - Hip extensors (Hamstrings)

Late swing phase - Quads and ankle DF for preparation of heel strike

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14
Q

How much does the pelvis rotate during the gait cycle?

A

8 degrees in total

4 degrees for each limb

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15
Q

How much lateral pelvic tilt is there during gait cycle?

A

5 degrees

Controlled by hip ABD - swinging limb drops during loading response

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16
Q

To what degree is the pelvis naturally anteriorly tilted?

A

10-15 degrees

hip Flexors pull FWD until end of terminal stance

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17
Q

The pelvis moves side-side by ___ cm, towards the stance limb, in loading response.

A

4 cm

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18
Q

What is the avg cadence?

A

110 steps/min

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19
Q

What is the avg step width range?

A

1-5 inches

Steps width increases as a person grows

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20
Q

What is the avg. walking speed?

A

1.3 m/s

3 mi/hr

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21
Q

What is the avg metabolic cost of walking while on a even surface?

A

5.5 kcal/min

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22
Q

What is/are the possible cause(s) of the following Gait deviation?

Lateral Trunk bending during stance phase

A
  1. Weak gluteus medius
  2. Hip pain
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23
Q

What is/are the possible cause(s) of the following Gait deviation?

Backward trunk lean during stance phase

A

Weak gluteus maximus

Will also see difficulty with stairs and/or ramps

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24
Q

What is/are the possible cause(s) of the following Gait deviation?

FWD trunk lean during stance phase

A
  1. Weak quads
  2. hip/knee contractures
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25
Q

What is/are the possible cause(s) of the following Gait deviation?

Excessive hip FLX during stance phase

A
  1. weak hip EXT
  2. tight knee FLX
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26
Q

What is/are the possible cause(s) of the following Gait deviation?

Limited hip EXT during stance phase

A

Tight hip flexors

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27
Q

What is/are the possible cause(s) of the following Gait deviation?

Limited hip FLX during stance phase

A
  1. Weak hip flexors
  2. tight extensors
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28
Q

What is/are the possible cause(s) of the following Gait deviation?

Antalgic gait (painful gait)

A

UNINVOLVED limb as a shorter step length as WB occurs sooner than normal

asymmetrical gait pattern

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29
Q
A
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30
Q

What is/are the possible cause(s) of the following Gait deviation?

Excessive knee FLX during stance phase

A
  1. weaks quadriceps
  2. knee FLX contracture

Can observe difficulty going down ramps and/or steps

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31
Q

What can be a compensation for weak quads?

A

FWD trunk bending

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32
Q

What is/are the possible cause(s) of the following Gait deviation?

Knee hyperextension during stance phase

A
  1. weak quads
  2. PF contracture
  3. extensor spasticity
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33
Q

What is/are the possible cause(s) of the following Gait deviation?

Forefoot initial contact

A
  1. weak DF
  2. tight/spastic PF
  3. LLD- shortened limb
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34
Q

What is/are the possible cause(s) of the following Gait deviation?

Foot slap

A
  1. weak DF
  2. hypotonia
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35
Q

What is/are the possible cause(s) of the following Gait deviation?

Foot flat

A
  1. weak DF
  2. decreased ROM
  3. neonatal/immature gait pattern
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36
Q

What is/are the possible cause(s) of the following Gait deviation?

calcaneal gait

Loading predominately on heel with excessive DF and uncontrolled FWD motion of the tibia

A

Weak PF

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37
Q

What is/are the possible cause(s) of the following Gait deviation?

Equinus gait

Heel does not touch the ground

A

spasticity/contracture of PF mm

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38
Q

What is/are the possible cause(s) of the following Gait deviation?

Supination

Varus calcaneus with excessive loading on lateral foot

A
  1. spastic inverters
  2. weak everters
  3. pes varus
  4. genu varum
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39
Q

What is/are the possible cause(s) of the following Gait deviation?

Hyperpronation

Valgus calcaneus and excessive medial contact of foot during stance

A
  1. weak invertors
  2. spasticity
  3. pes valgus
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40
Q

What is/are the possible cause(s) of the following Gait deviation?

Clawed toes

A
  1. spastic toe flexors
  2. hyperactive plantar grasp reflex
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41
Q

What is/are the possible cause(s) of the following Gait deviation?

Inadequate push-off

A
  1. weak PF
  2. decreased ROM into PF
  3. forefoot pain
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42
Q

What is/are the possible cause(s) of the following Gait deviation?

insufficient FWD pelvic motion during swing phase

A
  1. weak abdominal muscles
  2. weak flexor muscles
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43
Q

What is/are the possible cause(s) of the following Gait deviation?

Insufficient hip and knee FLX during swing phase

A
  1. weak hip and knee flexors
  2. inability to lift the leg and move it FWD
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44
Q

What is/are the possible cause(s) of the following Gait deviation?

Circumduction

A

weak hip and knee flexors

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45
Q

What is/are the possible cause(s) of the following Gait deviation?

hip hiking

QL action

A
  1. Weak hip and knee flexors
  2. extensor spasticity
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46
Q

What is/are the possible cause(s) of the following Gait deviation?

Excessive hip and knee FLX during swing phase (Steppage gait)

compensation for shortening the leg

A

weak DF

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47
Q

What is/are the possible cause(s) of the following Gait deviation?

insufficient knee FLX during swing phase

A
  1. extensor tightness
  2. pain
  3. decreased ROM
  4. weak hamstrings
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48
Q

What is/are the possible cause(s) of the following Gait deviation?

Excessive knee FLX during swing phase

A
  1. flexor spasticity
  2. flexor withdrawal reflex
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49
Q

What is/are the possible cause(s) of the following Gait deviation?

Foot drop

A
  1. weak or delayed DF
  2. spastic PF
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50
Q

What is/are the possible cause(s) of the following Gait deviation?

Varus or inverted foot during swing phase

A
  1. spastic inverters
  2. weak evertors
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51
Q

What is/are the possible cause(s) of the following Gait deviation?

equinovarus during swing phase

A
  1. spastic posterior tibialis and/or triceps surae
  2. developmental abnormality
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52
Q

Describe two point gait pattern

Cane or crutches

A

AD and opposite LE are moved together

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53
Q

Describe delayed two-point gait pattern with a cane

A
  1. cane advancement
  2. involved LE advanced
  3. uninvolved LE advanced
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54
Q

Describe three-point gait pattern

Crutches

A
  1. Both crutches and involved LE are advanced together
  2. uninvolved limb advancement
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55
Q

When is a delayed three-point gait pattern indicated?

A

When the patient requires increased stability and slower movements

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56
Q

Describe a delayed three-point gait pattern

A
  1. both crutches are advanced
  2. involved LE advancement
  3. uninvolved LE advancement
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57
Q

Describe the Three Point Pressure Principle use for orthotics

A

Single force is placed at the deformity/angulation; two additional counterforces are applied in opposing direction

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58
Q

What are metatarsal pads used for?

A

Moves pressure from the metatarsal heads to the shafts –> allows for more push-off in weak or inflexible feet

Located posterior to metatarsal heads

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59
Q

What is a cushion heel used for?

A

Used of relieve strain on plantar fascia –> Absorbs forces at heel contact

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60
Q

What is a longitudinal arch support used for?

A

Decompression of the subtalar joint and corrects pes planus/flat foot

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61
Q

What is a UBCL (university of California Biomechanics Lab) Insert used for?

A

Plastic molded insert to correct flexible pes planus

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62
Q

What is a scaphoid pad used for?

A

supports longitudinal arch

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63
Q

What is rearfoot posting used for?

A

Alters position of subtalar joint/rearfoot from heel strike to foot flat

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64
Q

What is a varus post/medial wedge used for?

A

Limits/controls eversion of the calcaneus and internal rotation of the tibial after heelstrike

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65
Q

What is a valgus post/lateral wedge used for?

A

Controls calcaneus and subtalar joints that are excessively inverted and supinated at heel strike

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66
Q

What orthotic modifications should you avoid when a patient has insensitive feet?

A
  1. heel lifts
  2. rocker bars

can inrcease localized forefoot pressure

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67
Q

What are heel lifts used for?

A

Correction of LLD and accommodates for ankle DF limitation

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68
Q

What heel wedge size can be inserted into the shoe?

A

Up to 3/8 of an inch – If a thicker wedge is warranted, it will be applied to the outer sole of the shoe

69
Q

What is a rocker bar used for?

A

Improves weight shifting onto the metatarsals

Proximal to metatarsal heads

70
Q

What is a rocker bottom used for?

A

Builds up the sole of a shoe over the metatarsal heads to improve push-off

71
Q

What does a hinged/articulating AFO do?

A

Allows motion in the sagittal plane while controlling motion in other planes

72
Q

What does a free motion AFO do?

A

Helps maintain alignment and medial/lateral stability

Little to no DF/PF resistance

73
Q

When does a PF-stop AFO block further PF?

A

at 90 degrees of PF

74
Q

What is a static/solid AFO used for?

A
  • provides maximal ankle stability and ankle control
  • assists in swing clearance and prepositioning
75
Q

What does a Ground reaction AFO do?

A

Controls FWD progression of the tibia
- primarily for weak PF
- resists ankle DF
- can control knee extension during stance

76
Q

What does a patellar tendon bearing AFO do?

A
  • unloads the distal limb
  • primarily for PF weakness
  • anterior shell transfers force to the medial tibial flare
77
Q

What does a hinge joint knee provide?

A

Mediolateral and hyperextension control of the knee

Allows FLX and EXT

78
Q

What does a Oregon Othotic system provide?

Specialized KAFO

A

Triplanar control in all planes of motion

combination of plastic and metal components

79
Q

What does a postsurgery Knee orthosis provide?

A

Protects repaired ligaments from overloading

80
Q

When is a functional knee orthosis used?

A

Long term use - sports, activity, etc.

81
Q

What does a swedish knee cage provide?

A

Mild control for excessive hyperextension of the knee

82
Q

What does a neoprene sleeve provide?

A
  • Compression, protection, and proprioceptive feedack
  • retains body heat promoting local circulation

Provides little stabilization unless it has hinges

83
Q

What motions does a HKAFO control at the hip?

A

ABD/ADD and ROT

84
Q

What motions does a HKAFO control at the hip when locked?

A

FLX

85
Q

What is a flexible LSO (corset) used for?

A
  • increases intrathoracic pressure
  • provides tactile cues for posture

Uses: Pregnancy, posture control, respiratory assistance, compression of abdominal incisions, low back pain, postoperative protection

86
Q

What is a Denis-Browne Splint used for?

A

Connecting two shoes on a swivel to correction of pes equinovarus or developmental hip dysplasia

87
Q

What is a Frejka pillow used for?

A

Preventing hip ADD – Used for conditions with tight ADD and/or hip dysplasia

88
Q

What is a Toronto Hip ABD orthosis used for?

A

ABD the hip

used for Legg-calve perthes disease

89
Q

What is a rigid LSO (shell) used for?

A
  • tactile posture reminder
  • controls FLX/EXT, and SB of sacral and lumbar regions

Three-point pressure system

90
Q

What is the correct trimline/fitting of a rigid LSO (shell)?

A

Anterior portion: Below the xiphoid process to the pubic symphysis

Posterior portion: Below inferior angle of scapula to the sacrococcygeal junction

91
Q

What is a TLSO Shell used to control?

A

FLX/EXT, SB, ROT of thoracic, lumbar, and sacral regions

92
Q

What is the correct trimline/fitting of a TLSO?

A

Anterior portion: distal to sternal notch to pubic symphysis

Posterior portion: distal to scapular spine down to the sacrococcygeal junction

Uses: postoperative protection, stable vertebral Fx, scoliosis, SCI

93
Q

What does an Anterior control TLSO Jewett Orthosis used for?

Also called Cruciform Anterior Spinal Hyperextension orthosis (CASH)

A

controls FLX of thoracic and lumbar segments

Use: Thoracolumbar anterior vertebral compression Fx

94
Q

What is a Cx soft collar used for?

A
  • Controls cervical motion and provides cues for posture

Minimal control

Uses: Whiplash injury, cervical pain, weakness

95
Q

What is a Cx semirigid collar used for?

Miami J Collar / Philadelphia collar

A
  • ## controls FLX/EXT, SB, and ROT of Cx spine

Uses: Postoperative protection, stable cx injury, whiplash

96
Q

What is the correct trimline/fitting of a Semirigid Cx collar?

A

Anterior portion: Mandible to sternal notch

Posterior portion: Occiput to T1

97
Q

What is a Rigid-halo collar/orthosis used for?

A

maximal control of all Cx motion with a halo attachment to the skull and a thoracic jacket

“Regina George Halo”

Uses: Unstable Cx Fx, SCI

98
Q

What is a minerva orthosis / Cervical thoracic orthosis (CTO) used for?

A

Control of all Cx motions via cervical collar attached to a thoracic jacket

uses: stable cervical and upper thoracic Fx and fushions

99
Q

What is a wrist cock-up splint used for?

A
  1. weak/absent hand strength
  2. wrist pathologies

Palmar splint that contains forearm, metacarpals and/or phalanges

Ex: RA, carpal Fx, Colles’ Fx, Carpal tunnel, stroke paralysis

100
Q

What is a thumb spica splint used for?

A

Immobilize the first CMC joint

Ex: CMC arthritis, scaphoid Fx, scaphoid-lunate instability, De Quervain’s

101
Q

What is the correct fitting for a wrist cock-up splint when used for weak/absent hand strength?

A
  • Support full hand with phalanges slightly flexed
  • Slight thumb ABD and OPP
102
Q

What is the correct fitting for a wrist cock-up splint when used for wrist pathologies?

A

distal palmar crease to thenar crease

103
Q

What is a dorsal wrist splint used for?

A

Flexor tendon repairs

104
Q

What is an airplane splint used for?

A

To immoilize the shoulder following Fx or burn injury to prevent axillary region contracture(s)

105
Q

What is the correct fitting for an airplane splint?

A

90 degreees ABD
90 degrees elbow FLX

  • connected to a padded lateral trunk bar and iliac crest band
106
Q

What does a tendonesis splint do?

A
  • Assists with wrist extension to approximate grip in the absence of active finger flexion
  • Facilitates tendonesis grasp in those with quadriplegia
107
Q

Definition: Amputation through ankle joint; preserves the heel pad and is then connected to distal tibia for WB

A

Symes amputation/Ankle disarticulation

108
Q

definition: Amputation of entire LE along with the pelvis below L4/L5

A

hemicorporectomy

109
Q

definition: Amputation of entire LE and lower 1/2 of pelvis

A

hemipelvectomy

110
Q

definition: below elbow amputation

A

transradial amputation

111
Q

definition: above elbow amputation

A

transhumeral amputation

112
Q

definition: amputation through elbow joint

A

elbow disarticulation

113
Q

What two components are included in all prosthetics?

A
  1. socket
  2. terminal device
114
Q

Describe selective loading sockets

A

Sockets that allow increased loading at pressure-tolerant areas

Decreases load on pressure-sensitive areas

115
Q

What is the most commonly prescribed foot for a BKA prosthesis?

A

Solid ankle cushion heel (SACH) foot

116
Q

What does a SACH heel do?

A
  1. Limits DF/PF motion
  2. assists in hyperEXT of the knee during stance phase
117
Q

What population commonly uses a SACH foot?

A
  1. youth
  2. sedentary individuals
118
Q

What plane of motion does a single axis foot only allow movement in?

A

sagittal (PF/DF)

119
Q

What foot prosthetic is commonly used for medium-highly active individuals?

A

Multi-axis foot

BUT not used often due to weight of device

120
Q

What foot prosthetic is commonly used for active community ambulators?

A

Energy storing foot

leaf spring shank used with endoskeletal prosthesis- lightweight

Decreased energy consumption due to smoother gait pattern and energy return in terminal stance and preswing

121
Q

What does a prosthetic shank do?

A
  1. provide leg length and shape
  2. connect and transmit WB from socket to foot

endoskeletal vs. exoskeletal

122
Q

What are pressure sensitive areas of a typical BKA limb?

A
  1. anterior tibial condyle
  2. anterior tibial crest
  3. fibular head and neck
  4. distal cut end of tibia and fibula
123
Q

What are the pressure tolerant areas of a typical BKA residual limb?

A
  1. tibial plateau
  2. shafts of tibia and fibula
  3. gastrocnemius
124
Q

What type of BKA socket allows for a more natural fit?

A

Total surface bearing socket

weight is equal throughout soft tissue and bones - must use gel liner

125
Q

If a Total Elastic suspension for an AKA prosthesis is used, what can occur in the gait cycle if it is the only form of suspension within the prosthesis?

A

Pistoning

126
Q

Definition: Strap that wraps around the pelvis (below iliac crest) to anchor an AKA prosthesis

A

Silescian Belt

127
Q

A lower shank for a knee disarticulation prosthesis is (shortened/lengthened) to balance leg length while standing

A

shortened

128
Q

What movements of a body-powered above/below elbow prosthesis are used to put tension on the cable and open the hand?

A
  1. Bilateral scapular ABD
  2. Bilateral scapular depression
  3. ipsilateral FLX
129
Q

How does a myoelectric system work for UE prostheses?

A
  1. utilizes surface electrical activity of various muscles
  2. small electric motors operate the terminal device via signal intensity from the muscles - allowing graded power output from the terminal device
130
Q

When using KT tape, injured ligaments should be held in a (shortened/neutral, lengthened) position

A

shortened

Ex: lateral ankle injury should be taped into Eversion

131
Q

KT tape must be applied with even pressure and overlap the previous strip of tape by ___ inch(es)

A

1/2 inch

132
Q

What positions should a patient with a BKA avoid to prevent contracture?

A
  • prolonged Hip FLX and ER
  • prolonged Knee FLX
133
Q

What positions should a patient with an AKA avoid to prevent contracture?

A

Hip FLX, ABD, and ER

FABER- counteract with regularly scheduled prone time

134
Q

What is/are the possible cause(s) of the following Gait deviation with an AKA prosthesis?

Circumduction

Arc swinging

A
  1. long prosthesis
  2. locked knee
  3. small or loose socket
  4. inadequate suspension
  5. PF
  6. Hip ABD contracture
  7. poor knee control
135
Q

What is/are the possible cause(s) of the following Gait deviation with an AKA prosthesis?

ABD gait

Lateral displacement of prosthesis

A
  1. medial wall discomfort
  2. long prosthesis
  3. low lateral wall
  4. tight hip ABD
136
Q

What is/are the possible cause(s) of the following Gait deviation with an AKA prosthesis?

Vaulting

rising up on sound limb to advance prosthesis

A
  1. prosthesis too long
  2. inadequate suspension
  3. small socket
  4. increased PF
  5. decreased knee FLX
137
Q

What is/are the possible cause(s) of the following Gait deviation with an AKA prosthesis?

Lateral trunk bending during stance phase

Towards prosthetic side

A
  1. low lateral wall
  2. short prosthesis
  3. high medial wall
  4. weak ABD
  5. ABD contracture
  6. hip pain
  7. short limb
138
Q

What is/are the possible cause(s) of the following Gait deviation with an AKA prosthesis?

FWD FLX during stance phase

A
  1. unstable knee
  2. short AD
  3. hip FLX contracture
139
Q

What is/are the possible cause(s) of the following Gait deviation with an AKA prosthesis?

High heel rise during early swing phase

A
  1. inadequate knee friction
  2. decreased tension in the extension aid
140
Q

What is/are the possible cause(s) of the following Gait deviation with an AKA prosthesis?

Terminal swing impact

peosthesis comes to sudden stop as the knee extends during late swing

A
  1. insufficient knee friction
  2. too much tension in the extension aid
  3. pt fear for knee buckling
  4. forceful hip FLX
141
Q

What is/are the possible cause(s) of the following Gait deviation with an AKA prosthesis?

Swing phase whips

heel moving medially or laterally during toe-off

A
  1. rotated socket
  2. rotated knee bolt
  3. malaligned foot
142
Q

What is/are the possible cause(s) of the following Gait deviation with an AKA prosthesis?

Foot rotation at heel strike

A
  1. malaligned foot
  2. stiff heel cushion
  3. PF bumper
143
Q

What is/are the possible cause(s) of the following Gait deviation with a BKA prosthesis?

excessive knee FLX during stance

A
  1. socket too far FWD or tilted anteriorly
  2. PF bumper is too stiff
  3. high heels
  4. knee FLX contracture
  5. weak quadriceps
144
Q

What is/are the possible cause(s) of the following Gait deviation with a BKA prosthesis?

Inadequate knee FLX during stance

A
  1. socket is aligned too far back or posteriorly tilted
  2. PF bumper or heel cushion is too soft
  3. low heel shoes
  4. anterodistal discomfort
  5. weak quadriceps
145
Q

What is/are the possible cause(s) of the following Gait deviation with a BKA prosthesis?

Drop off or premature knee FLX in late stance

A
  1. socket too far FWD
  2. DF bumper is soft resulting in excessive DF
  3. knee FLX contracture
  4. prosthetic keel to short
146
Q

What is/are the possible cause(s) of the following Gait deviation with a BKA prosthesis?

Delayed knee FLX during late stance phase

A
  1. socket set too far back
  2. DF bumper is too stiff causing excessive PF
  3. prosthetic keel too long
147
Q

Pressure relief activities are typically encouraged every —- minutes when using a WC

A

15-20 minutes

148
Q

Add __ inches to a patient’s hip width to prescribe correct WC seat width

A

2 inches

149
Q

WC footplates should be at least ___ inches from the floor

A

2 inches

150
Q

Add __ inches to a patient’s hanging elbow measurement to prescribe correct WC armrests

A

1 inch

151
Q

(true/false) patient’s with C6 injuries can be independent with transfer boards

A

true

152
Q

What is a standard door width for ADA when using a WC?

A

32 inches

ouside swing doors: 26 inches

153
Q

What is the optimal toilet seat height according to ADA?

A

17-19 inches

154
Q

What is the optimal height of horizontal grab bars from the floor?

A

33-36 inches

155
Q

What is the recommended ramp ratio?

A

1:12 – for every inch of vertical rise, 12 inches of ramp is required

156
Q

Handicapped parking spots require a ___ foot aisle for WC maneuverability

A

4 feet

157
Q

What is the rancho los amigos term for heel off?

A

terminal stance

158
Q

What is the ranchos los amigos term for toe off?

A

preswing

159
Q

What is the rancho los amigos term for acceleration?

A

initial swing

160
Q

What is the rancho los amigos term for deceleration?

A

terminal swing

161
Q

What is the rancho los amigos term for foot flat?

A

loading response

162
Q

What is the rancho los amigos term for heel strike?

A

initial contact

163
Q

(true/false) The abdominal muscles are active throughout the whole gait cycle

A

true

164
Q

The (ipsilateral/contralateral) erector spinae muscles are active during the toe off phase as the contralateral limb is being loaded

A

ipsilateral

165
Q

During terminal stance, which muscles are active at the knee?

A

none

166
Q

When are all hip extensors active during the gait cycle?

A

initial contact (heel strike) to prepare for loading response

167
Q

When are hip Flexors only activated during the gait cycle?

A

only activated during toe-off and part of midswing

168
Q

When are the knee flexors only active during the gait cycle?

A

Only activated for last 30 degrees of midswing and all of heel strike

169
Q

When are the hip ADD muscles active during the gait cycle?

A

heel off and toe off

NPTE (20 decks)

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