Prosthetic Rehabilitation: Re-establishing Normal gait & Maximizing function

1. Prosthetic Rehabilitation: Re-establishing Normal gait & Maximizing function Frank Austin, PT

2. Patient Presentation • 34 year old male • Rx: • Dx: Right BKA • Evaluate and treat • 3x/wk x 4wks

3. What Else Do You Want To Know About Your Patient?

4. Subjective History • Cause of amputation • How long ago did the amputation occur? • Pain? • Medications • Premorbid level of function • Current level of function • Functional limitations • Prior therapy received

5. Subjective History • PMHx • Social Hx • Occupation • Can the patient perform his duties • Obtain description of work duties • Extracurricular activities • Goals • Occupational vs. personal

6. Subjective History • Date of amputation? 1/26/2009 • Occupation? general laborer in warehouse • Cause of amputation? crush injury @ work in warehouse • Pain? • Residual limb 3/10 (phantom pain) • Also reports back pain and intermittent left knee pain; not rated • Medications? Neurontin for phantom pain

7. Subjective History • Current level of function/limitations • Desk job 4 hours/day • Difficulty with lifting objects overhead without loss of balance • Difficulty with squatting and kneeling • Unable to play basketball • Afraid of carrying 1 year old daughter up/down steps • Premorbid level of function • Worked 8 hours per day as a general labor • Squatting to pick up and carry up to 30# containers • Lifting and stacking objects on shelves overhead up to 15# • Independent with squatting and kneeling to floor to get under vehicles to change the oil • Able to carry daughter up/down steps independently without upper extremity support of rail • Played basketball 1-2 days per week

8. Subjective History • Prior therapy received • Several weeks as an outpatient concentrating mostly on exercise, not function or balance • PMH- asthma • Social- lives with wife and 2 daughters in 2 story home with 12 steps to second floor • Goals (subjective) • Carry daughter up/down stairs safely • Return to work full time without limitation • Play basketball with friends

9. The Starting Line What do you want to assess on Initial Evaluation?

10. Objective Section of Evaluation • ROM • Strength • Sensation • Vision • Joint stability assessment • Residual Limb/Intact limb appearance • Balance • Prosthetic Componentry

11. ROM • Hip • Greater than neutral hip extension bilaterally • Hip flexion and abduction WNL • Hip IR: L=30°R=35° • Knee- WNL bilaterally • Ankle- WNL on left, all motions • Trunk • Sidebending (distance fingertip to floor): • L= 55cm R= 51cm • Rotation • L=75° R= 83° • Ankle- WNL on left, all motions • Trunk • Sidebending (distance fingertip to floor): • L= 55cm R= 51cm • Rotation • L=75° R= 83°

12. Strength LR • Hip flex 5/5 4/5 • Hip ext. 3+/5 3/5 • Hip abd. 5/5 4/5 • Quads 5/5 5/5 • HS 5/5 5/5 • Ankle • PF/DF 5/5 N/A • Inv/Ev 5/5 N/A • Abdominals = 3/5

13. Sensation & Vision • Sensation • Intact to light touch and proprioception • Occasional periods of phantom sensation (right foot) • Vision • Not formally assessed based on age and cause of amputation • No limitations observed (reading of fine print with intake information) • No subjective report of visual limitations (blurred vision or blind spots)

14. #1 Which of the following is not an indication that you need to formally assess vision? • Vascular cause of amputation • History of diabetes • History of visual disorder • Under the age of 40 College or Department name here

15. Joint Stability • Knee/hip/ankle joint stability- No signs of instability bilaterally • Hip Joint: assessed by positioning femur in flexed and adducted position with over pressure in supine; maximally extended position in sidelying with over pressure • Knee joint: assessed via varus/valgus stress tests for MCL an LCL; ACL/PCL testing (anterior and posterior drawer testing) • Ankle joint: assessed with over pressure at end ranges in all planes

16. Balance • Tested wearing prosthetic limb • Tinetti score of 20/28 (moderate fall risk) • Eyes closed/non-compliant surface- no LOB • Eyes closed/compliant foam pad- + LOB • Unilateral stance time • Left > 20 seconds • Right avg. of 1.85 seconds

17. Limb Appearance & Management • Residual limb/Intact limb appearance • Shape - cylindrical • Incision- well healed and smooth; mobile • Skin- good condition (well hydrated) with good signs of vascularity (no discoloration and good hair growth) • Bone: tibia longer than fibula (normal); tibia properly beveled • No signs of vascular compromise with good skin hydration of intact limb • Volume management • Was using shrinker; no longer using • Girth: not tested secondary to time post amputation and no history of dialysis • Prosthetic management Independent donn/doff • Wearing time • All day

18. Prosthetic Checkout • Prosthetic alignment (static and dynamic) • Socket in approximately 5 degrees of flexion • Less than 5 degrees of toe out • Varus thrust at knee at midstance indicating good foot alignment in relation to socket • Prosthetic fit • Good suction of sleeve on limb; no sign of excessive stretch of sleeve on socket at sleeve socket interface connection • Initially socket too loose on limb leading to excessive socket rotation • Corrected by prosthetist with padding along inner shell of socket • Prosthetic height • Iliac crest heights were even with static standing assessment

19. Prosthetic Prescription • Multiple factors are considered: • General health • Projected activity level • Height and weight • Length and shape • Level of amputation • Insurance/financial means • Type of componentry chosen for patient: • Patella tendon bearing socket • Silicone sleeve suction • Vertical shock foot

20. Foot/Ankle • For more active amputees • Carbon vertical compression strut • Allows up to one inch of vertical compression • Reduces forces applied to the residual limb and proximal joints • Flexfoot VSP

21. Suspension • Suction suspension • Reduced liner distal pull • Allows more uniform distribution of pressure along residual limb • Decreased bunching behind knee; easier to flex the knee • Straight forward with donning • Roll on leg • Step into socket to create suction • Suction release button on side of socket • Iceross Seal-In X5 liner

22. Is there anything else you need to assess? What about function?

23. Functional Assessment • ADLs • Driving • Transfers • Lifting • Gait • Multiple surfaces • Stairs

24. Functional Assessment • ADLs- independent with dressing and bathing without prosthesis • Driving- independent • Transfers • Sit to stand independently but asymmetrical; decreased wt. through prosthesis • Unable to kneel to floor and stand without upper extremities • Lifting task • Squat lifts: 7.5 pounds x 5 reps before fatigue • Overhead lifts: 15# x 12 reps before fatigue

25. Functional Assessment • Gait- walks on level surfaces independently without assistive device; difficulty with walking on compliant surfaces (ie grass) • Demonstrated a right lateral trunk lean • No arm swing • Decreased pelvic rotation bilaterally; right < left • Decreased stance time on right • Decreased rollover on right • Decreased step length on left • Stairs • Independent with use of hand rail • Without rails • Up- with supervision • Down- decreased eccentric control with several LOB. Minimal assistance required for balance control

26. #2 Other than pain, what else could cause the demonstrated gait deviations (in this particular patient)? • ROM and strength deficits • Prosthetic alignment • Prosthetic fit • Prosthetic height

27. Causes of Gait Deviations • Patient must adjust Center of Gravity (COG) out of necessity to maintain balance after amputation and before receiving prosthetic • Pt’s COG shifted to the left. • Due to the shift in the COG and moving through space in a uni pedal way, the following occur: • ROM limitations • Strength limitations • While healing after amputation and waiting to receive the prosthesis, it is important for the client to perform a basic exercise program to minimize strength and ROM losses caused by being uni pedal.

28. Center of Gravity Why is it so important?

29. #3 What could happen if the COG is not controlled during gait? • Nothing • Loss of balance • Increased energy expenditure • B & C

30. Importance of COG • Energy is conserved during gait by muscles of the pelvis, hips and limbs offsetting the forces of gravity and preventing excessive movement of the COG • Without muscle forces offsetting each other, the COG would move excessively outside of the base of support and require greater muscular effort to control the COG and expend more energy. • If the COG is not adequately controlled, balance loss occurs

31. #4 What motions at the knee and ankle lower Center of Gravity (COG)? • Knee extension and ankle plantarflexion • Ankle dorsiflexion and knee extension • Eccentric knee flexion and ankle dorsiflexion during loading • Ankle supination and knee extension during loading College or Department name here

32. #5 What motion at hip on stance side helps to control lateral displacement of COG? • Hip adduction to prevent excessive pelvic drop • Hip abduction to prevent excessive pelvic drop • Hip extension • Hip internal rotation College or Department name here

33. Toward the middle of the program, even though ROM and strength deficits were addressed and eliminated, gait deviations sometimes reappeared #6 What do you think was the cause of the reappearance of this patient’s gait deviations? Fatigue/decreased endurance Faulty prosthetic componentry Loss of control of the COG Decreased attention to proper gait

34. The effect of level of amputation and cause of amputation on energy expenditure Why do amputees fatigue faster ?

35. Energy Expenditure and Velocity • Level/CauseVO2Velocity • TTA trauma 15% 10% • TTA vascular 30% 30% • TFA trauma 40% 20% • TFA vascular 65% 40% Esquinazi 1994 Ertl 2005 Gailey 1994

36. #7 The Amputee expends greater energy secondary to: • Missing joints and muscles on the side of amputation • Decreased joint motion of remaining joints on non-amputated and amputated sides • Decreased strength of limbs, pelvis/hip and trunk • Excessive displacement of the COG • All of the above

37. Problem list What problems can you identify based on the objective information collected?

38. Problem List • Decreased ROM • Decreased strength • Decreased balance • Gait dysfunction • Decreased safety • Decreased activity tolerance/muscle endurance

39. What piece of subjective information is most important in driving your treatment program?

40. GOALS!!!!!

41. What goals can be generated from your problem list?

42. Objective Goals • Improve Tinetti to > 23/28 for low risk of falls with level surface ambulation around the home • Equalize left and right sidebending ROM to decrease stress on lumbar spine • Equalize left and right trunk rotation ROM to decrease stress on lumbar spine • Increase bilateral hip internal rotation ROM to increase balance with gait and promote independent and safe level surface ambulation without an assistive device • Decrease trunk lean with gait to decrease stress on lumbar spine and decrease pain

43. Objective Goals Improve pelvic rotation with gait to increase dynamic balance and promote safe and independent level surface ambulation without an assistive device Equalize stance time bilaterally/improve rollover on the right to decrease joint reaction forces on the non amputated limb Improve abdominal strength to > 4/5 to decrease strain on lumbar spine and assist with balance control during functional activities Improve right unilateral stance time > 5 seconds to facilitate proper right stance, proper rollover on the right and normalize step length on the left with level surface gait

44. What special considerations do you need to make when goal setting and designing a POC for this particular patient/the acute amputee population?

45. Things To Keep In Mind • Sometimes your client will come in with unrealistic ideas of how they will be able to function after receiving the prosthesis • A prosthesis will help a client to maximize their post amputation level of function. • Help the client to understand that a prosthesis requires increased energy expenditure to manipulate • If the client has significant cardiac or renal history, demands will be greater than for someone without this history.

46. What Would You Suggest as a Treatment Plan?

47. ROM • Lateral trunk flexion stretches • Seated, standing • start at 10-15 and progress to 30 seconds • 5 second rest in between each repetition • 5 reps of each • Trunk rotation stretches • Seated and standing • Same guidelines as above • Can progress to weighted activity • Trunk/pelvis disassociation exercises • Sidelying, standing • Focus on upper extremity and pelvis on same side moving in opposite directions

48. Strength • Squats • Progress to weighted activity • Wall squats • Bilateral and unilateral • Start without weight and progress to weighted • Lunges • Progress to weighted activity • Eccentric step downs • Progress from smaller to larger stools with focus on speed • Should be done as slowly as possible • Step ups • Forward and lateral with cueing to push down through the forefoot of prosthesis when placing foot of sound limb on stool • progress from smaller to larger stools; done slowly as possible • Abdominal crunches • Weighted trunk rotation • Seated, standing • Push ups

49. Balance and Agility • Weight shifts • Anteriorly through the forefoot of the prosthetic • Standing ball rolls • Progress from bilateral to one arm and then no arms • Progress from small ball ( tennis) to large ball (physio ball) • Compliant pad work (foam pad, pillow, grass) • Bipedal and uni pedal • Agility ladder • Forward, lateral, backwards if able • Increase speed as able • Forward step overs/lateral step overs • Progress from smaller to larger diameter rolls

50. Balance and Agility • Forward and retro gait through serpentine course • Increase speed as able • Unilateral and bilateral jumping • Jump up on step stool or over objects ie foam roll • Dribbling basketball around objects • Simulated one on one basketball games • Walking up steps without upper extremity support • Progress from no weight to weighted task