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L5: TFA_TTA Gait Training Part 1 Flashcards

1
Q

Functional capacity of amputees

TTA

A
  • Can resume prev activities
  • amb on lvl surfs, inclines, stairs
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2
Q

Functional capacity of amputees

TTA

Rely on ________ to push or lift heavy load

A

intact limb/balance

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3
Q

Functional capacity of amputees

TTA

Bilateral kneeling uncomfortable….what should you do?

A

Teach them to WB thru patellar tendons

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4
Q

Functional capacity of amputees

TTA

Amb _______ SLOWER why?

A

15-40% slower to conserve energy

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5
Q

Functional capacity of amputees

TFA

A
  • Can amb and maint prolonged standing w/ occ. breaks
  • Can lift/push light to med loads
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6
Q

Functional capacity of amputees

TFA

Stairs: Step TO pattern…..why?

A

No Ecc. quad control, but depends on the knee prescribed

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7
Q

Functional capacity of amputees

TFA

Walking speed is _________ SLOWER

A

40-55%

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8
Q

Functional capacity of amputees

TFA

Shorter the limb===________==_________

A

Shorter the limb==shorter lever arm==inc’d fatigue

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9
Q

Functional capacity of amputees

In General…..

Energy Req’s

A
  • INCd energy req’s and cardiac output to walk WITH prosth.
  • TTA→ O2 costs 16-28% more than controls
  • TFA→ 60-110% inc

GET THEM ON UBE IMMEDIATELY!!!!

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10
Q

TTA: Static WB Eval

2 tips

A
  1. Look @ prosth. separate
  2. Look @ pt as a whole

*best in standing

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11
Q

TTA: Static WB Eval

General…

A
  • Part of initial eval assess ROM, suture healing, strength, functional abilities
  • Provide pt w/ info on how skin tension may feel and have them distinguish bw skin tension and pain
    • **manual stretch to simulate !!!
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12
Q

TTA: Static WB Eval

Educate on what ?

A

*Wearing schedule

*Amt of socks

*Cleaning socket + interface

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13
Q

TTA: Static WB Eval

Assessing pt w/out prosth donned and why??

A
  • Assess whether pt can stand indep. w/out prosth donned
    • Gives info on type of interface and suspension most approp.
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14
Q

TTA: Static WB Eval

Wearing Schedule Flow Chart

A

PRINT!!!

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15
Q

TTA: Static WB Eval

Don/Doff should be done in ______

A

SITTING!!!

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16
Q

TTA: Static WB Eval

Should be done in sitting…..but if in standing these are the guidelines:

A
  • Pt wt shifts onto prosth and pulls wrinkles from socks
  • Tighten suspension system→ should be snug
  • ***Ensure prosth has NOT rotated during STS or tightening process
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17
Q

TTA: Static WB Eval

HOW SHOULD IT FIT????

KNOW THIS!!!!!!!!!!!!!!!!!

A

KEY INFO!

  • Pt may need to shift wt or take a few steps to accurately assess comfort and alignment
    • Remember→ check redness
  • Pts will often NOT put full wt onto newly fitted prosth device
    • *TIP: use Biodex to educate
  • Look for obv compensations @ trunk, prox LE and contralat limb
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18
Q

TTA: Static WB Eval

COM shifts which way?

A

COM shifts contralat & Sup. to prosth

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19
Q

TTA: Static WB Eval

Manual assessment by PT includes:

A
  • Good proximal fit
  • If PTB-SC
    • Approx ⅓ to ½ of patella should be w/in socket*****
  • Med and Lat flares should be superior to condyles and snug
    • **Test in sitting
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20
Q

TTA: Static WB Eval

In the case of PTB-SC

how much of patella should be w/in socket??

A

⅓ to ½ of patella should be within socket

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21
Q

TTA: Static WB Eval

Medial and lateral flares

A

Superior to condyles and snug

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22
Q

TTA: Static WB Eval

More on manual assessment by PT:

A
  • Include:
    • Total contact fit distally
      • *should be able to see and touch tissue in valve
    • Re-assess alignment including:
      • foot
      • pylon and socket relationship
      • ALL from anterior, lateral, and posterior views*****
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23
Q

TTA: Static WB Eval

How should they LOOK?

Once prosth fit is correct…. begin what?

A

Postural assessment

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24
Q

TTA: Static WB Eval

How should they LOOK?

Once prosth fit is correct begin Postural Assessment including:

A
  • Observation all three planes (@ least two)
  • Assess alignment of bony landmarks: Symmetry
    • Iliac crests
    • PSIS, ASIS
    • Greater trochs
    • Superior patella border
  • Overall leg length should be no more than ½ inch diff
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25
Q

TTA: Static WB Eval

How should they LOOK?

Bony landmarks for checking symmetry

A

Iliac crests

PSIS, ASIS

Greater trochs

Sup patella border

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26
Q

TTA: Static WB Eval

How should they LOOK?

Overall leg length should be NO MORE than _______ diff

A

½ inch

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27
Q

TTA: Static WB Eval

Checking EQUAL WB

MUST HAVE

A
  • Biodex
  • sheet of paper under toe, heel and med/lateral aspect
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28
Q

TTA: Static WB Eval

Checking PAINFUL WB

AVOID!!!

A
  • Clay, lipstick, marker in socket
    • determines where they are WB
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29
Q

TTA: Static WB Eval

IF more than ½ inch leg length diff, must determine what?

A

Whether oirigin is intrinsic (anatomical) OR extrinsic (prosthesis)

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30
Q

TTA: Static WB Eval

Intrinsic vs. Extrinsic cause for leg length difference (greater than ½ inch)

A
  • Intrinsic
    • Correct w/ approp interventions
  • Extrinsic
    • Consult CPO
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31
Q

TFA: IRC Socket Static Eval

Manual assessment by PT includes:

A
  • Good proximal fit→ sitting AND standing
  • Sitting:
    • should have LESS anterior hip discomfort when sitting
  • Standing:
    • In IRC: ischial tube and pelvic ramus should be resting WITHIN socket
      • Min. adductor roll present→ due to design
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32
Q

TFA: IRC Socket Static Eval

Sitting:

A

Should have LESS anterior hip discomfort

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33
Q

TFA: IRC Socket Static Eval

Standing:

A

In IRC socket→ Isch tube and pelvic ramus should be resting WITHIN socket

*MIN adductor roll present due to design

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34
Q

TFA: Quadrilateral (Quad) Socket Static Evaluation

what is KEY?

A

EDUCATION!

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35
Q

TFA: Quadrilateral (Quad) Socket Static Evaluation

Manual assess by PT includes:

A
  • Good proximal fit in BOTH sitting and standing
    • tell them this!
  • Sitting:
    • Discomfort common in groin/anterior hip due to higher ant. wall
  • Standing:
    • Palpate isch tubes by having them flex forward
    • When they return to standing→ should be pressure bw IT and post. shelf
  • *INFORM pt→ may feel “intense pressure @ ITs and in Ant hip== normal and needed
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36
Q

TFA: Quadrilateral (Quad) Socket Static Evaluation

Sitting:

A

Discomfort common in groin/anterior hip due to higher ant. wall

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37
Q

TFA: Quadrilateral (Quad) Socket Static Evaluation

Standing:

A

Palpate isch tubes by having them flex forward→ when they return to standing there should be pressure bw IT and post. shelf

*Pt may feel intense pressure @ ITs and anterior hip== Normal and Needed!!!

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38
Q

TFA: Static Eval

Talk about the fit distally

A
  • TOTAL CONTACT fit distally
    • Should be able to see/touch tissue in valve
    • Unable to easily fit fingers in socket proximally
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39
Q

TFA: Static Eval

Re-assess alignment what/where?

A
  • Re-assess alignment:
    • foot
    • pylon and socket relationships
    • ALL from ant, lateral, posterior views
    • *NOTE: Ensure 50/50 WB!!!
      • inset vs outset ****
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40
Q

TFA: Static Evaluation

A
  • If they have pain in WB they will inherently want to add cotton plys to increase comfort….
    • Sometimes this is NOT approp!!!
    • Need to assess origin of pain and alignment BEFORE adding socks
      • *REMEMBER: Intrinsic vs. Extrinsic origin
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41
Q

TFA:

If pain in WB….why is it NOT approp to add cotton plys right away?

A

must assess origin of pain and alignment and determine intrinsic vs extrinsic origin

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42
Q

TFA: Static Eval

How should they LOOK?

A
  • Once prosth fit is correct→ Postural assessment:
    • Observe all three planes
    • Alignment bony landmarks
      • Iliac crests
      • PSIS, ASIS
      • Greater trochs
    • Overall leg length should be NO MORE than ½ in. difference******
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43
Q

Overall leg length diff no more than _______

A

½ inch difference

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44
Q

At the end of evaluation…..

A

TAKE EVERYTHING OFF!!!!

  1. Re-inspect skin
  2. Re-take vitals
  3. Borg RPE???
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45
Q

Key factors that contribute to changes in gait in Transtibial amputees (TTAs):

4:

A
  1. Length of RL
  2. Suspension and socket→ alignment
  3. Fit of prosth.
  4. Foot componentry
    1. Stability vs. Mobility
      1. Maybe they are better w/ more stable foot
        1. REMEMBER: More mobility === LESS stability
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46
Q

Key factors that contribute to changes in gait in Transfemoral amputees (TFAs):

6:

A
  1. Length of RL
  2. Suspension + Socket→ alignment
  3. Wt. of prosth
  4. Fit of prosth
  5. Knee componentry→ *another jt to control
    1. stability vs mobility
  6. Foot componentry→ *another jt to control
    1. stability vs mobility
47
Q

Prosthetic Gait: TTA

A
  • MAIN GOAL of TTA gait progression:
    • Facilitate smooth progression of tibia over a fixed ankle-foot complex
  • A typical pattern in TTAs:
    • Hesitation of stance progression caused by the amp. shifting wt too far anterior over knee due to weakness or fear
  • This will increase shearing forces, dec gait velocity and inc energy expend.
48
Q

Prosthetic Gait: TTA

MAIN GOAL of TTA gait progression:

A

Facilitate smooth progression of tibia over fixed ankle-foot complex

49
Q

Prosthetic Gait: TTA

Typical pattern?

A

Hesitation of stance progression caused by the amp. shifting wt too far anterior over knee due to weakness or fear

50
Q

Prosthetic Gait: TFA

A
  • Hip Ext strength deficits (<3/5) typ catastrophic in those w/ TFA
  • Profound glute weakness may preclude functional amb in this pop.
    • Glutes + RL stabilize knee during entire stance phase
51
Q

Prosthetic Gait: TFA

Catastrophic in those w/ TFA?

A

Hip Ext strength deficits

<3/5

52
Q

Prosthetic Gait: TFA

May preclude functional amb in TFA pop?

A

Glute weakness

*Glutes + RL stabilize knee during entire stance phase

53
Q

Prosthetic Gait: TFA

More on this….

A
  • Knee jt stability is paramount when considering knee jt. componentry
  • Length of RL has drastic effects on knee control
    • Longer RL’s, Longer lever arms== improved control against socket wall
54
Q

Prosthetic Gait: TFA

Paramount when considering knee componentry

A

Knee Jt Stability

55
Q

Prosthetic Gait: TFA

Drastic effects on knee control

A

Length of RL

56
Q

Prosthetic Gait: TFA

Length of RL has drastic effects on knee control

Longer RLs==_______==______

A

Longer RLs==longer lever arms==improved control against socket wall

57
Q

Prosthetic Gait: TFA

2 things that will generally have gait profiles closer to normal profiles

A
  1. Traumatic amputees
  2. Microprocessor controlled knees
58
Q

Prosthetic Gait: TFA

Traumatic amps gen have gait profiles closer to normal profiles

Why?

A

Younger pop. typ.

Less pain

Improved strength/balance

59
Q

Prosthetic vs. Normal Gait

What aspects are DIFFERENT in prosthetic gait?

A
  • Decd selective mm control
  • Decd jt proprio and afferent info sent to brain
  • Change in COM location
  • Incd energy expenditure
60
Q

Sag. Plane biomechanics

TTA gait

Significant Findings:

A

Decd velocity

Decd stride length

Incd heel only time

61
Q

Sagittal Plane biomechanics

TTA

*BE ABLE TO EXPLAIN THIS PICTURE!!!

62
Q

Sagittal Plane biomechanics

TTA

Vastus Lateralis

A

BE ABLE TO EXPLAIN!!!

63
Q

Sagittal Plane Biomechanics:

TTA

*Co-contraction of HS’s

64
Q

Prosthetic Gait: Knee ROM profiles

A

EXPLAIN!!!

Involved limb

Thick= Gressinger PLUS foot

Thin= SACH foot (stable foot)

65
Q

Prosthetic Gait: Hip, Knee, Ankle profiles

ROM, Moment (Torque), Power

66
Q

Prosthetic Gait: TFA

Transfemoral knee flex/ext

What type of knee most likely?

A

Single Axis→ flex/ext only

67
Q

GRF Vector in normal gait

A

Kinetics + vectors video slide 42

WATCH IT!!!

68
Q

Frontal Plane Biomechanics

All info…

A
  • Inset foot will induce counterclockwise force (when viewed from front)→ Creates pressure on proximal medial limb and distal lateral limb
  • **BOTH pressure tolerant areas
  • *Bench alignment typ slightly medially inset to axis of rotation
69
Q

Frontal Plane Biomechanics

Inset foot induces a ________ force

A

Counterclockwise

70
Q

Frontal plane biomechanics

Inset foot induces counterclockwise force

Creates pressure on _________ limb and ___________ limb

A

Pressure on prox medial and distal lateral limb

71
Q

Frontal plane biomechanics

Bench alignment typ ___________ to axis of rotation

A

slightly medially inset

72
Q

Clinical Pearl:

When training pts, particularly during gait…

Keep these points in mind:

A
  • Efficiency of doing any activity is the ratio bw work accomplished and the energy expended
    • Work/Energy
  • This must be balanced w/ conscious effort to maintain safety of all pts***
  • May not look like normal gait** but may be **optimal for that pt***
  • Develop realistic and measurable goals that match lvl of activity and potential
73
Q

Develop realistic and measurable goals that match lvl of activity and potential

Accurate goals dictate what?

A

Accurate goals dictate type of prosth/orthotic you prescribe

74
Q

Early Gait Training:

TTA gait and rehab vs TFA outcome wise? Who has better outcomes?

A

TTA gait/rehab typ BETTER OUTCOMES vs TFA or high amps

75
Q

Early gait training:

TTA gait/rehab typ better outcomes vs TFA or high amps

Due to:

A
  • Incd knee control
  • LESS prosth weight
  • LESS energy cost
  • *More anatomical jts→ more jt awareness→ incd proprio and balance
  • Less prosth parts, less alterations
76
Q

TTA gait/rehab typ better outcomes vs TFA or high amps

More anatomical jts==______==________

A

More anatomical jts→ more jt awareness→ Incd proprio and balance

77
Q

Early Gait Training:

Usually more advanced and IND pts and goals should match:

Examples?

A
  • Gait w/out AD
  • Reciprocal stair pattern
  • Return to sports
  • Uneven terrain IND
  • Single (prosth.) limb balance
78
Q

Early Gait Training:

REGARDLESS of lvl of amputation….

EARLY goals for gait SHOULD include:

A
  • Progressive WB time
  • Wt shifting
  • Foot placement
  • Pelvic and trunk rotation
  • Upright reciprocal and symmetrical gait pattern
79
Q

Early Gait Training

Progression Ideas******

IMPORTANT!!!!!!

A
  • One UE assist
  • Full gait cycle in //bars
  • NO UEs
  • Outside //bars w/ approp AD

*Match real life scenarios→ stairs, incline/declines, dual-tasking, etc…..

80
Q

Gait Training: TFA

These two things are CRUCIAL!

2:

A
  1. Alignment
  2. Fit
81
Q

Gait Training: TFA

Make sure pt is educated in:

A

How it should feel

Approp areas of redness

Wear time

***DEVELOP CONFIDENCE!!!

82
Q

Gait Training: TFA

Active process where pt is _______

A

In control of his/her own progress!!!

83
Q

Gait Training: TFA

Pt needs to develop _________

A

TRUST in prosthesis!!!

84
Q

Gait Training: TFA

Important to gain control of Hip Ext for….

A

Knee stability

85
Q

Gait Training: TFA

Gaining control of hip EXT (knee stability) @ ________ in loading phase of stance is top priority**

86
Q

Gait Training: TFA

Gaining control of ______ (_____) @ IC &MSt in loading phase of stance is top priority

A

Hip Ext

(Knee stability)

87
Q

Gait Training: TFA

Gaining control of hip EXT (knee stability) @ IC&MSt in loading phase of stance is TOP PRIORITY**

Exercise should simulate this how?

A
  • Exercise should simulate this control in WB
    • ex. bridging w/ distal limb on towel roll
  • Or manually facilitate
88
Q

Early Gait Training

Intervention Idea….

A

Stance and Swing activities in ½ cycles

aka “Pre-gait activities”

Break it down into “Stance Goals” and “Swing Goals”

89
Q

Early Gait Training:

Stance and Swing activities in ½ cycles:

Stance goals:

A
  • Stance Goals:
    • Controlled heel strike
    • Hip EXT from IC to MSt
    • Controlled knee flex from MSt→ PSw
90
Q

Early Gait Training:

Stance and Swing activities in ½ cycles:

Swing Goals:

A
  • Swing goals:
    • Initiate w/ hip flexion
    • Prepare for IC
91
Q

Early Gait Training

Other intervention ideas outside of St vs Sw activities

A

Foot tapping in various stages

**Proprioception

**YOU tap the foot

92
Q

Gait Training: TFA

Understanding when to facilitate or inhibit a motion

vs.

When to have pt learn on their own

Talk about feedback…

A

Constant, repetitive feedback may NOT be best @ this stage***

93
Q

Gait Training: TFA

Equalizing WB in //bars

A
  • Equalize WB in standing w/ Wt shifting in all planes
  • **String and blue marble analogy→ imagine string w/ marble hanging down and they have to center it!!
94
Q

Gait Training: TFA

MSt must have balance bw hip _______ and _______

A

MSt must have balance bw hip ABDs and ADDs

95
Q

Gait Training: TFA

What would cause the pt to lurch TOWARDS prosth. side to INC stance control

2:

A
  1. Poor socket fit
    1. med. soft tissue/groin discomf.
  2. Weak hip ABDs
96
Q

Gait Training: TFA

Poor socket fit (med soft tissue/groin) or

Weak hip ABDs…..

What happens and what does it do?

A
  • Pt will lurch TOWARDS prosth. side to INC stance control
    • This compensation strategy will DEC forward momentum and waste energy
97
Q

Gait Training: TFA

Manual facil/inhibit during Stance Gait

Techniques to do this:

A
  • Behind pt on posterior lateral aspect of hips
  • Fingers flared out “feeling for” motion in the frontal plane and rotation in the transv. plane
  • IF pelvis drifts laterally, therapist provides a downward, medial and anterior force to limit.
98
Q

Gait Training: TFA

In PSw, IF pt can NOT actively shorten leg by flexing (transverse rotation)

What happens as a result?

A

Toe drag or catch

99
Q

Gait Training: TFA

In PSw, IF pt can NOT actively shorten leg by flexing (transverse rotation)

==> Toe Drag or catch

Compensatory strategies to clear foot include:

3:

A
  1. Hip hiking
  2. Circumduction
  3. Vaulting
100
Q

THIS has been shown to be the single, most important source of propulsive energy for effective prosthetic gait:

A

Rapid and brief contraction of the hip flexors -→ going into swing phase

101
Q

Gait Training: TFA

Cueing to imagine kicking a ball w/ front of thigh

Why?

A

Rapid and brief contraction of the hip flexors has been shown to be the single, most important source of propulsive energy for effective prosth. gait

102
Q

Gait Training: TFA

In TSt/PSw….how can therapist facilitate increased hip flexion initiation?

A

Provide quick stretch to POST downward facilitation @ hip flexor

103
Q

Gait Training: TFA

Talk about heel rise during stance

A

Timing and ability for proper heel rise during stance promotes efficient gait pattern

104
Q

Gait Training: TFA

Timing and ability for proper heel rise during stance

Almost entirely dependent on what?

A

Prosth. alignment that influences heel and toe levers

105
Q

Gait Training: TFA

Timing and ability for proper heel rise during stance

Distinguish bw different heel and toe levers

A
  • LONG toe levers== LATE heel rise (L and L***)
  • SHORT toe levers== PREMATURE heel rise and knee flex==drop off
106
Q

LONG toe levers====

A

LATE heel rise

107
Q

SHORT toe levers==

A

PREMATURE (EARLY) heel rise AND knee flexion causing “drop off”

108
Q

Pre Gait training vids

A

STOP AND WATCH!!!

SLIDE 59

109
Q

Pelvic facilitation/inhibition during gait (stance and swing)

Intervention to use @ IC:

A

Hip EXT facilitation

110
Q

Pelvic facilitation/inhibition during gait (stance and swing)

Intervention to use @ LR→MSt (remember frontal plane motion here)

A

Hip ABD facilitation

111
Q

Pelvic facilitation/inhibition during gait (stance and swing)

Intervention to use @ MSt→PSw (need that quick hip flex)

A

Quick stretch hip flexor facilitation

112
Q

Pelvic facilitation/inhibition during gait (stance and swing)

Interventions to use @ TSt→ISw

Need that rotation and hard hip flex

A

Resistance (@ hip flex) to facilitate transverse plane hip rotation (to flex knee)

***remember you did this in class!

113
Q

GAIT DEVIATIONS AND POSSIBLE CAUSES

A

TTA vs TFA

@ VARIOUS STAGES OF GAIT CYCLE

IN ANOTHER DECK!!! KNOW THEM ALL!!!

Prosthetics&Orthotics (19 decks)

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