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
2
Q
Functional capacity of amputees
TTA
Rely on ________ to push or lift heavy load
A
intact limb/balance
3
Q
Functional capacity of amputees
TTA
Bilateral kneeling uncomfortable….what should you do?
A
Teach them to WB thru patellar tendons
4
Q
Functional capacity of amputees
TTA
Amb _______ SLOWER why?
A
15-40% slower to conserve energy
5
Q
Functional capacity of amputees
TFA
A
- Can amb and maint prolonged standing w/ occ. breaks
- Can lift/push light to med loads
6
Q
Functional capacity of amputees
TFA
Stairs: Step TO pattern…..why?
A
No Ecc. quad control, but depends on the knee prescribed
7
Q
Functional capacity of amputees
TFA
Walking speed is _________ SLOWER
A
40-55%
8
Q
Functional capacity of amputees
TFA
Shorter the limb===________==_________
A
Shorter the limb==shorter lever arm==inc’d fatigue
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!!!!
10
Q
TTA: Static WB Eval
2 tips
A
- Look @ prosth. separate
- Look @ pt as a whole
*best in standing
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 !!!
12
Q
TTA: Static WB Eval
Educate on what ?
A
*Wearing schedule
*Amt of socks
*Cleaning socket + interface
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.
14
Q
TTA: Static WB Eval
Wearing Schedule Flow Chart
A
PRINT!!!
15
Q
TTA: Static WB Eval
Don/Doff should be done in ______
A
SITTING!!!
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
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
18
Q
TTA: Static WB Eval
COM shifts which way?
A
COM shifts contralat & Sup. to prosth
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
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
21
Q
TTA: Static WB Eval
Medial and lateral flares
A
Superior to condyles and snug
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*****
-
Total contact fit distally
23
Q
TTA: Static WB Eval
How should they LOOK?
Once prosth fit is correct…. begin what?
A
Postural assessment
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
25
**TTA: Static WB Eval**
**How should they LOOK?**
**Bony landmarks for checking symmetry**
Iliac crests
PSIS, ASIS
Greater trochs
Sup patella border
26
**TTA: Static WB Eval**
**How should they LOOK?**
**Overall leg length should be NO MORE than _______ diff**
½ inch
27
**TTA: Static WB Eval**
**Checking EQUAL WB**
MUST HAVE
* Biodex
* sheet of paper under toe, heel and med/lateral aspect
28
**TTA: Static WB Eval**
**Checking PAINFUL WB**
**AVOID!!!**
* Clay, lipstick, marker in socket
* **determines where they are WB**
29
**TTA: Static WB Eval**
**IF more than ½ inch leg length diff, must determine what?**
Whether oirigin is **intrinsic (anatomical) OR extrinsic (prosthesis)**
30
**TTA: Static WB Eval**
Intrinsic vs. Extrinsic cause for leg length difference (**greater than ½ inch)**
* **Intrinsic**
* Correct w/ approp **interventions**
* **Extrinsic**
* Consult **CPO**
31
**TFA: IRC Socket Static Eval**
**Manual assessment by PT includes:**
* 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
32
**TFA: IRC Socket Static Eval**
**Sitting:**
Should have LESS **anterior hip discomfort**
33
**TFA: IRC Socket Static Eval**
**Standing:**
In IRC socket→ **Isch tube and pelvic ramus** should be **resting WITHIN socket**
**\***MIN adductor roll present due to design
34
**TFA: Quadrilateral (Quad) Socket Static Evaluation**
**what is KEY?**
EDUCATION!
35
**TFA: Quadrilateral (Quad) Socket Static Evaluation**
**Manual assess by PT includes:**
* 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**
36
**TFA: Quadrilateral (Quad) Socket Static Evaluation**
**Sitting:**
Discomfort common in **groin/anterior hip due to higher ant. wall**
37
**TFA: Quadrilateral (Quad) Socket Static Evaluation**
**Standing:**
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!!!**
38
**TFA**: Static Eval
## Footnote
**Talk about the _fit distally_**
* **TOTAL CONTACT fit distally**
* Should be able to **see/touch tissue in valve**
* Unable to easily fit fingers in socket **proximally**
39
**TFA**: Static Eval
## Footnote
**Re-assess alignment what/where?**
* Re-assess **alignment**:
* foot
* pylon and socket relationships
* ALL from **ant, lateral, posterior views**
* **\*NOTE: Ensure 50/50 WB!!!**
* inset vs outset \*\*\*\*
40
**TFA**: Static Evaluation
* 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
41
TFA:
## Footnote
**If pain in WB….why is it NOT approp to add cotton plys right away?**
must assess origin of pain and alignment and determine **intrinsic vs extrinsic origin**
42
**TFA:** Static Eval
## Footnote
**How should they LOOK?**
* 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\*\*\*\*\*\***
43
Overall leg length diff no more than \_\_\_\_\_\_\_
½ inch difference
44
At the end of evaluation…..
**TAKE EVERYTHING _OFF_!!!!**
1. Re-inspect **skin**
2. Re-take **vitals**
3. Borg RPE???
45
**Key factors** that contribute to **changes in gait** in **_Transtibial amputees (TTAs)_:**
## Footnote
**4:**
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**
46
**Key factors** that contribute to **changes in gait** in **Transfemoral amputees (TFAs):**
## Footnote
**6:**
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
Prosthetic Gait: **TTA**
* **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
Prosthetic Gait: **TTA**
## Footnote
**MAIN GOAL of TTA gait progression:**
Facilitate **smooth progression** of **tibia over fixed ankle-foot complex**
49
Prosthetic Gait: **TTA**
## Footnote
**Typical pattern?**
Hesitation of **stance progression** caused by the amp. **shifting wt _too far anterior over knee_** due to weakness or fear
50
Prosthetic Gait: **TFA**
* **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
Prosthetic Gait: **TFA**
## Footnote
**Catastrophic in those w/ TFA?**
Hip Ext strength deficits
\<3/5
52
Prosthetic Gait: **TFA**
## Footnote
**May _preclude_ functional amb in TFA pop?**
Glute weakness
\***Glutes + RL stabilize knee during entire stance phase**
53
Prosthetic Gait: **TFA**
## Footnote
**More on this….**
* **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
Prosthetic Gait: **TFA**
## Footnote
**Paramount when considering knee componentry**
Knee Jt Stability
55
Prosthetic Gait: **TFA**
## Footnote
**Drastic effects on knee control**
Length of RL
56
Prosthetic Gait: **TFA**
## Footnote
**Length of RL has drastic effects on knee control**
**Longer RLs==\_\_\_\_\_\_\_==\_\_\_\_\_\_**
Longer RLs==longer lever arms==**improved control against socket wall**
57
Prosthetic Gait: **TFA**
## Footnote
**2 things that will generally have gait profiles _closer to normal profiles_**
1. Traumatic amputees
2. Microprocessor controlled knees
58
Prosthetic Gait: **TFA**
## Footnote
**Traumatic amps gen have gait profiles closer to normal profiles**
**Why?**
Younger pop. typ.
Less **pain**
Improved **strength/balance**
59
**Prosthetic vs. Normal Gait**
**What aspects are DIFFERENT in _prosthetic gait?_**
* Decd **selective mm control**
* Decd **jt proprio** and **afferent info** sent to brain
* Change in **COM location**
* Incd **energy expenditure**
60
Sag. Plane biomechanics
## Footnote
**TTA gait**
**Significant Findings:**
Decd velocity
Decd stride length
Incd heel only time
61
Sagittal Plane biomechanics
## Footnote
**TTA**
**\*BE ABLE TO EXPLAIN THIS PICTURE!!!**
SEE PICS
62
Sagittal Plane biomechanics
## Footnote
**TTA**
**Vastus Lateralis**
BE ABLE TO EXPLAIN!!!
63
Sagittal Plane Biomechanics:
## Footnote
**TTA**
**\*Co-contraction of HS's**
see pics
64
Prosthetic Gait: **Knee ROM profiles**
EXPLAIN!!!
## Footnote
**Involved limb**
**Thick= Gressinger PLUS foot**
**Thin= SACH foot (stable foot)**
65
Prosthetic Gait: **Hip, Knee, Ankle profiles**
## Footnote
**ROM, Moment (Torque), Power**
see pics
66
Prosthetic Gait: **TFA**
## Footnote
**Transfemoral knee flex/ext**
**What type of knee most likely?**
Single Axis→ **flex/ext only**
67
GRF Vector in **normal gait**
Kinetics + vectors video **slide 42**
## Footnote
**WATCH IT!!!**
68
**Frontal Plane** Biomechanics
All info…
* **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
**Frontal Plane** Biomechanics
## Footnote
**Inset foot induces a ________ force**
Counterclockwise
70
**Frontal plane** biomechanics
Inset foot induces counterclockwise force
**Creates pressure on _________ limb and ___________ limb**
Pressure on **prox medial** and **distal lateral limb**
71
Frontal plane biomechanics
## Footnote
**Bench alignment typ ___________ to axis of rotation**
slightly **medially inset**
72
Clinical Pearl:
When training pts, **particularly during gait…**
**Keep these points in mind:**
* **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
Develop **realistic and measurable goals** that **match lvl of activity and potential**
## Footnote
**Accurate goals dictate what?**
Accurate goals dictate **type** of prosth/orthotic you prescribe
74
Early Gait Training:
## Footnote
**TTA gait and rehab vs TFA outcome wise? Who has better outcomes?**
**TTA gait/rehab** typ BETTER OUTCOMES vs TFA or high amps
75
Early gait training:
## Footnote
**TTA gait/rehab typ better outcomes vs TFA or high amps**
**Due to:**
* 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
TTA gait/rehab typ better outcomes vs TFA or high amps
## Footnote
**More anatomical jts==\_\_\_\_\_\_==\_\_\_\_\_\_\_\_**
More anatomical jts→ more jt awareness→ Incd **proprio and balance**
77
Early Gait Training:
## Footnote
**Usually more advanced and IND pts and _goals_ should match:**
**Examples?**
* Gait w/out AD
* Reciprocal stair pattern
* Return to sports
* Uneven terrain IND
* Single (prosth.) limb balance
78
Early Gait Training:
## Footnote
**REGARDLESS of _lvl of amputation_….**
**EARLY goals for gait SHOULD include:**
* Progressive WB time
* Wt shifting
* Foot placement
* Pelvic and trunk rotation
* Upright reciprocal and symmetrical gait pattern
79
Early Gait Training
## Footnote
**_Progression_ Ideas\*\*\*\*\*\***
**IMPORTANT!!!!!!**
* **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
Gait Training: **TFA**
## Footnote
**These two things are _CRUCIAL_!**
**2:**
1. Alignment
2. Fit
81
Gait Training: **TFA**
## Footnote
**Make sure pt is _educated in_:**
How it should **feel**
## Footnote
**Approp areas of redness**
**Wear time**
**\*\*\*DEVELOP CONFIDENCE!!!**
82
Gait Training: **TFA**
## Footnote
**Active process where pt is \_\_\_\_\_\_\_**
In control of his/her own progress!!!
83
Gait Training: **TFA**
## Footnote
**Pt needs to develop \_\_\_\_\_\_\_\_\_**
**TRUST in prosthesis!!!**
84
Gait Training: **TFA**
Important to gain control of **Hip Ext for….**
Knee stability
85
Gait Training: **TFA**
**Gaining control of hip EXT (knee stability) @ ________ in _loading phase_ of _stance_ is _top priority_\*\***
IC & MSt
86
Gait Training: **TFA**
## Footnote
**Gaining control of ______ (\_\_\_\_\_) @ IC &MSt in loading phase of stance is top priority**
Hip Ext
| (Knee stability)
87
Gait Training: **TFA**
## Footnote
**Gaining control of hip EXT (knee stability) @ IC&MSt in loading phase of stance is TOP PRIORITY\*\***
**Exercise should _simulate_ this how?**
* Exercise should **simulate this control** in **WB**
* **ex. bridging w/ distal limb on towel roll**
* Or manually facilitate
88
**Early Gait Training**
**Intervention Idea….**
Stance and Swing activities in ½ cycles
aka **“Pre-gait activities”**
**Break it down into “Stance Goals” and “Swing Goals”**
89
Early Gait Training:
## Footnote
**Stance and Swing activities in ½ cycles:**
**_Stance_ goals:**
* **Stance Goals:**
* Controlled **heel strike**
* Hip EXT from **IC to MSt**
* Controlled **knee flex** from **MSt→ PSw**
90
Early Gait Training:
## Footnote
**Stance and Swing activities in ½ cycles:**
**Swing Goals:**
* **Swing goals:**
* **Initiate** w/ **hip flexion**
* **Prepare** for **IC**
91
Early Gait Training
## Footnote
**Other intervention ideas outside of St vs Sw activities**
**Foot tapping** in **various** **stages**
**\*\*Proprioception**
**\*\*YOU tap the foot**
92
Gait Training: **TFA**
**Understanding when to _facilitate_ or _inhibit_ a motion**
**vs.**
**When to have pt learn _on their own_**
Talk about **feedback…**
Constant, repetitive feedback may NOT be best @ this stage\*\*\*
93
Gait Training: **TFA**
## Footnote
**Equalizing WB in //bars**
* 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
Gait Training: **TFA**
## Footnote
**MSt must have _balance_ bw hip _______ and \_\_\_\_\_\_\_**
MSt must have balance bw **hip ABDs and ADDs**
95
Gait Training: **TFA**
## Footnote
**What would cause the pt to _lurch_ TOWARDS prosth. side to INC stance control**
**2:**
1. Poor socket fit
1. **med. soft tissue/groin discomf.**
2. Weak hip ABDs
96
Gait Training: **TFA**
## Footnote
**Poor socket fit (med soft tissue/groin) or**
**Weak hip ABDs…..**
**What happens and what does it do?**
* Pt will **lurch TOWARDS prosth. side to INC _stance control_**
* This **compensation** **strategy** will DEC forward momentum and **waste energy**
97
Gait Training: **TFA**
## Footnote
**Manual facil/inhibit during _Stance Gait_**
**Techniques to do this:**
* **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
Gait Training: **TFA**
**In PSw,** IF pt can NOT actively **shorten leg by flexing (transverse rotation)**
**What happens as a result?**
Toe drag or catch
99
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:**
1. Hip hiking
2. Circumduction
3. Vaulting
100
**THIS** has been shown to be the **single, most important source of _propulsive energy_ for effective prosthetic gait:**
Rapid and brief contraction of the hip flexors -→ **going into swing phase**
101
Gait Training: **TFA**
## Footnote
**Cueing to imagine kicking a ball w/ front of thigh**
**Why?**
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
Gait Training: **TFA**
## Footnote
**In TSt/PSw….how can therapist facilitate increased hip flexion initiation?**
Provide **quick stretch to POST downward facilitation @ hip flexor**
103
Gait Training: **TFA**
## Footnote
**Talk about heel rise during stance**
**Timing and ability** for **proper heel rise** during stance promotes efficient gait pattern
104
Gait Training: **TFA**
## Footnote
**Timing and ability for proper heel rise during stance**
**Almost entirely dependent on what?**
**Prosth. alignment** that influences **heel and toe levers**
105
Gait Training: **TFA**
## Footnote
**Timing and ability for proper heel rise during stance**
**Distinguish bw different heel and toe levers**
* LONG toe levers== LATE heel rise (L and L\*\*\*)
* SHORT toe levers== PREMATURE heel rise and knee flex==**drop off**
106
LONG toe levers====
LATE heel rise
107
SHORT toe levers==
PREMATURE (EARLY) heel rise AND knee flexion causing “**drop off”**
108
Pre Gait training vids
STOP AND WATCH!!!
SLIDE 59
109
Pelvic facilitation/inhibition during gait (**stance and swing)**
## Footnote
**Intervention to use @ IC:**
Hip EXT facilitation
110
Pelvic facilitation/inhibition during gait (**stance and swing)**
**Intervention to use @ LR→MSt (**remember frontal plane motion here)
Hip ABD facilitation
111
Pelvic facilitation/inhibition during gait (**stance and swing)**
## Footnote
**Intervention to use @ MSt→PSw (need that quick hip flex)**
Quick stretch hip flexor facilitation
112
Pelvic facilitation/inhibition during gait (**stance and swing)**
## Footnote
**Interventions to use @ TSt→ISw**
**Need that rotation and hard hip flex**
Resistance (@ hip flex) to facilitate transverse plane hip rotation (**to flex knee)**
## Footnote
**\*\*\*remember you did this in class!**
113
GAIT DEVIATIONS AND POSSIBLE CAUSES
TTA vs TFA
@ VARIOUS STAGES OF GAIT CYCLE
IN ANOTHER DECK!!! KNOW THEM ALL!!!
