P - Prosthetic Gait Training Flashcards
what is the name of the typical guideline for amputee strengthening
“rule of ten”
what is the Rule of Ten
10 second exercise
- 2sec upward
- 6sec hold
- 2sec downward
10 second rest
10 reps
should still be individualized, modify prn to individualize to pt
hip extension strengthening
ms activated
exercise set up
phases of gait
gluts, HS
bridge (pressing into residual limb)
- glut sets, trying to get hips up
- BL bridge, towel under residual limb
- progress to single limb bridge on residual
phases of gait:
- terminal swing
- initial contact
- loading response
hip ABD strengthening
ms activated
exercise set up
phases of gait
glut med, glut min
side plank (on amp side)
- start isometric
- BL, push down w both limbs and hips go up
- progress to single limb on residual, keeping sound limb elevated, pressin hips up
phases of gait: SL support (for balance and stability)
- mid stance
- terminal stance
hip flexor strengthening
ms activated
exercise set up
phases of gait
iliopsoas, rectus fem
prone, reverse bridge
- pressing limbs down to lift hips up
phases of gait:
- mid stance
- entire swing phase
- loading response
what is a consideration of hip flexion strengthening in amputees
iliopsoas tightness is common in almost amps, spend more time stretching and not strengthening bc pts will need hip ext for gait
prone is a good place to start for stretching
back extension strengthening
ms activated
exercise set up
phases of gait
back ext, glut max, hip ADDs
prone, towel roll b/w legs
- lifting chest/head/legs up like a superman
phases of gait:
- initial contact
- loading response
- mid swing
- terminal swing
who should you take caution with for a back extension strengthening exercise? how can you modify for that pt pop?
LBP
avoid end range, use ab pillow, glut sets
he doesn’t do a lot of this, focuses more on bridges
common to have LBP in amps bc using different ms for stability
hip ADD strengthening
ms activated
exercise set up
phases of gait
hip ADD
side lying on sound side
- have residual limb propped on a step, they push down into it and lift hips up
phases of gait:
- mid swing
- terminal swing
- initial contact
bridging for sound limb strengthening
ms activated
exercise set up
phases of gait
glut max, back ext, sound side IRs
bridging (typical setup)
phases of gait:
- loading response
- mid stance
- terminal stance
will help dec LBP bc dec stress in bridging vs the prone back ext
sit-ups
ms activated
exercise set up
phases of gait (& why?)
abdominals
typical sit up
- can progress to lift legs at same time when you crunch up
phases of gait: mid stance
- for lumbo pelvic stabilization
he doesn’t do sit ups a lot
- he thinks you can get more stabilization from leg lowering
- more appropriate for advanced pts
what pt pop should you be cautious of doing sit ups with
LBP
knee extension strengthening
ms activated
exercise set up
phases of gait
quads
in prone, towel roll under tibial tub - leg presses down into it to straighten knee
- can incorporate different positions
phases of gait:
- initial contact
- loading response
- mid stance
in prone will work on iliopsoas flexibility
what is the significance of knee extension strengthening
need TKE for ambulation
knee flexion strengthening
ms activated
exercise set up
phases of gait
HS
supine, towel roll inferior to popliteal fossa & leg presses down to bend knee
- can progress to have leg off table and bending knee there
phases of gait:
- initial swing
- mid swing
what is a consideration of knee flexion strengthening
important to have full HS ms length
- will likely spend more time working on HS flexibility rather than strength
how can having the prosthesis on for exercises alter the activity
can inc activation and control of residual limb musculature
how can exercises be performed to inc activation and control of residual limb ms
pt places pressure on each part of socket to engage ms for stability
- pt needs to feel engaged ms bc affects pressure against various parts of socket –> engages different ms
- want to engage entire socket
start in sitting or standing pending fatigue and standing abilities
what are examples of general stabilization exercises
abdominal stabilization:
- supine: TrA, UE/LE mvmt
- seated: mat, ball, UE/LE mvmt
hip stabilization:
- half kneeling (w pro)
- tall kneeling (w pro)
- Q-ped (w pro)
- planks
what was the key to functional activities and their progression with amputee strengthening
hip flexor and extensor/glut strength
what were differing characteristics in TTA fallers and non-fallers
fallers = walk faster
non-fallers = ext support, hip ABD and knee ext eccentric training, proper socket fit
how often should the amputee perform a skin inspection
every time doff prosthesis
managing a prosthesis: how do you work on increasing wearing tolerance
gradual inc thru duration and activities the prosthesis is worn
when and why do you need to adjust sock ply
as volume of residual limb will change throughout the day
at what point w the # of sock ply is a new socket indicated
if >10-15 sock ply, talk to prosthetist about a new socket bc this is a lot of sock
what is a concern with sweating in the residual limb w a prosthesis
sweating can lead to skin maceration –> once you get skin breakdown, it all slows down and you have to change gait training
how do you monitor the fit of the prosthesis
in sitting
standing
- look at pelvic landmarks to check alignment
when you do skin checks what do you look for
ID areas of skin concerns: redness, abrasions
- short term redness is fine bc there is a certain amt of compression w a prosthesis
- if longer than short term - there is too much compression or force on the residual limb
what environment do you often start gait training w a prosthesis
in parallel bars
what is the purpose of establishing a wearing schedule and how do you create one
gradually inc wearing time and wt bearing
30min 3x/day to start
inc by 30min each day if no issue
- concerned if redness lasts >15-20min
tolerant vs intolerant pressure areas
tolerant: load bearing areas
- designed for WBing and can accept weight from prosthesis
intolerant: not meant to bear weight
- these are the areas to assess
what are tolerant vs intolerant areas in a TTA
tolerant:
* patellar tendon
* medial tibia
* lateral fibula
* gastrocs
intolerant:
* tibial crest
* fibular head
* distal ends
* HS tendons
what are tolerant vs intolerant areas in the TFA
tolerant:
- ischial tub
- soft tissues (protective)
intolerant:
- distal femur
- pubic ramus (superior medial portion of socket)
what is a common complaint of pts w a TFA prosthesis
pain by pubic ramus if too high up in the groin
what are pre-gait activities to promote ambulation
- stretching - hip flexors, HS
- strengthening - sound, residual, lumbopelvic region
- WBing
- trunk rotation - dissociate trunk from pelvis
- balance activities - challenge systems and improve confidence
what is there a loss of in TFA which impacts ambulation
lose distal HS attachment & ability for post pelvic tilt
what is there a loss of in TTA which impacts ambulation
dec HS length d/t 5-10deg knee flexion w gait
what are benefits to pre-gait weight bearing
(5)
- dec phantom pain
- inc strength/stability
- dec edema
- inc joint compression
- dec forces on sound limb - more WBing in prosthesis promotes symmetrical WBing
how does BOS and COG change after an amputation
BOS is much smaller
- COG moves laterally and slightly superiorly
- have to work on balance w new BOS and moved COG
how big should their standing BOS be roughly after an amputation
2-4’’
what are strategies to improve proprioception pre-gait
(4)
- tapping & vibration
- reflex hammer vs prosthetic foot - (A/P) vibratory sensation and feedback
- sensation in socket - (A/P) feel limb in socket for more awareness and control
- EO -> EC
what is the goal of sit to stand transfers
equal body weight on both limbs
- pts have a tendency to shift wt to should side
how can a PT facilitate equal WBing during a STS transfer
apply lateral and anterior force on same side as amputation during the STS
- facilitates WBing on prosthetic limb
what is the goal of weight-shifting
equal body weight on both limbs
how do you facilitate a weight shift and what cues do you give
cue hip and shoulders to go together
- find balance point (marble) and feel for change in ms activation
what is the progression of weight shifting in pre-gait training
- lateral
- A/P
- diagonal
- no UE support on sound side
- no UE support at all
- stool stepping with sound limb
what is the importance of diagonal weight shifting practice
more functional for amb
- mimics gait and swing phase
how is diagonal weight shifting introduced and how do you progress it
shift from prosthetic side to sound side
- heel to toe
shift from sound side to prosthetic side
- toe load unlocks knee
how do you remove UE support progressively with weight shifting
remove UE support on sound side first
- inc WBing on prosthesis
progress to remove UE support on prosthetic side when stable
what is the rational for tool taps w the sound limb
(3)
- promotes single leg balance on prosthetic side
- facilitates ms within socket
- assists w kinesthetic awareness of prosthetic foot in space
what are the pre-gait requirements to “graduate” to a gait training program
good ROM/ms length
strength
balance
lumbopelvic stabilization
what is the progression of gait training activities
- sound limb stepping
- prosthetic limb stepping
- sidestepping
- resisted gait training
- amb outside parallel bars
what is the pre-gait counterpart to sound limb stepping
diagonal weight shift
what are critical components to look for with sound limb stepping
normal 2-4’’ BOS
no crossover
where do you facilitate for both sound and prosthetic limb stepping
tactile cues at anterior pelvis
what is crossover or “scissoring” gait pattern often a compensatory habit from
following amb w crutches
what do you look for in prosthetic limb stepping
can they advance leg from pelvis forward and back w/ good anterior pelvic rotation in transverse plane
what compensations do you watch for to avoid with prosthetic limb stepping
- kicking leg forward
- posterior pelvic rotation
- leaning trunk back
how do you progress prosthetic limb stepping
start w rhythmic initiation at ant pelvis
- progress from PWB to FWB
sidestepping:
set up
facilitation
to sound side first
resistance at swing limb
- facilitates glut med
- activating ms inside the socket
how is resisted gait training facilitated and what is the rationale for this intervention
resist at ASIS
encourages anterior pelvic rotation in transverse plane
- help w pelvic dissociation from trunk
how is ambulation outside parallel bars introduced and progressed
- pt puts UE on PT’s shoulders, PT provides resistance at ASIS to facilitate transverse plane motion
- progress to facilitate trunk rotation & arm swing
- rhythmic initiation w PT behind pt and tactile cues at shoulders for facilitating trunk rotation
do we use an AD w the pt when they first start outside the parallel bars and why?
goal: no AD
- depends on pt and safe functional mobility
- if cane start w it on sound side (normal)
- discourage ASAP
why do we care about fine tuning ambulation outside of parallel bars w trunk rotation and arm swing
key for energy expenditure as ambulate
- normal arm swing helps w balance and ability to amb
stair training
ascent and descent pattern in TTA
ascent - step over step
descent - step over step
stair training
ascent and descent pattern in TFA and why
ascent - step to
* knee “locked” by pushing back into the socket
descent - step over step
- take advantage of resistance in knee to lower the body weight down
stair training
why is the prosthetic foot placement important in the descent for both TTA and TFA
foot forward on step d/t loss of DF/PF
- allows knee flex and PF
what is the “safe” technique to teach amps first when starting to use ramps
side step technique
ramp training
ascent and descent body mechanics
ascent
* lean forward
* lead with sound limb
descent
* lean backward
* lead with prosthetic limb
ramp training
what is part of the strategy with leading with the prosthetic limb on the descent
taking advantage of hammy strength in socket
what is the goal of advanced balance activities
get them stronger and more stable in the socket
what are examples of advanced balance activities
(8)
- balance on foam/balance board
- SLS
- multi-task/distraction/ EC
- tandem walking
- side stepping
- crossover stepping
- braiding/ grapevine / karaoke
- close-quarter turning
what does an advanced balance activity like tandem walking facilitate
narrow BOS
what does an advanced balance activity like side stepping facilitate
hip ABD and ADD
what does an advanced balance activity like braiding or karaoke/grapevine facilitate
inc pelvic and trunk rotation
trunk dissociation
what does an advanced balance activity like close-quarter turning facilitate
simulates grocery store, functional environment
- amps tend to make wide turns, we are fine tuning
what are 5 self-report outcome measures
- SF-36
- sickness impact profile
- amputee activity survey (AAS)
- locomotor capabilities index (LCI)
- prosthesis eval Q (PEQ-17)
what are 5 performance based outcome measures
- 6MWT
- 2MWT
- TUG
- L-test
- AMP
what is the significance of the AMP as a performance based outcome measure
predicts k-level
* justify to insurance what they will get for prosthesis
