Rehabilitation Manual For Persons with Above-Knee Amputation by Natacha Poggio

Rehabilitation Manual

For Persons with Above-Knee Amputation

LIMBS INTERNATIONAL

This document was created by the â&#x20AC;&#x153;Prosthetics Across Bordersâ&#x20AC;? research group under the direction of Diana Veneri, EdD, PT, NCS, RYT within the Physical Therapy Department at the University of Hartford, West Hartford, Connecticut in collaboration with Jennifer Lucarevic, PT. Graphic Design Natacha Poggio (Design Global Change)

Exclusively for use by LIMBS International 2012

TABLE OF CONTENTS

INTRODUCTION Phase One PRE-PROSTHETIC REHABILITATION › Skin care for the amputated leg › Shaping of the amputated leg › Patient positioning › Strengthening exercises

- Lower Body - Upper Body

› Stretching exercises

Phase Two BALANCE / WEIGHT BEARING WITH THE PROSTHETIC DEVICE

5 6 7 8 9 10 11 27 30

› Proper alignment of prosthetic device › Standing Activities › Pre-gait activities including weight shifting

41 42 44

Phase Three GAIT TRAINING IN THE PARALLEL BARS › Stepping › Walking › Typical problems during walking

Phase Four GAIT TRAINING WITH AN ASSISTIVE DEVICE › Measuring walking devices › Walking with assistive devices on level surfaces - Walkers - Walker with wheels - Crutches - Canes › Negotiating stairs › Negotiating large steps or curbs › Negotiating hills › Getting up from the floor › Getting on a high surface

PATIENT EVALUATION › Mobility, Balance and Strength Assessment › Walking Assessment

58 59 60 62 63 66 68 76 78 84 89

92 93 94

GLOSSARY OF TERMS

REFERENCES

50 51 55

CLINICIAN RESOURCES › Sample Patient Evaluation Chart completed › Lower Extremity Medical Questionnaire › Above Knee Amputee Physical Therapy Evaluation

100 100 102 103

INTRODUCTION

The mission of LIMBS INTERNATIONAL is to transform the lives of people with lower limb amputation throughout the world by restoring their ability to walk. Achieving this goal is usually near impossible without physical therapy and specific exercises. Physical therapy, however, is not available throughout the world. This comprehensive manual is a resource for clinics that do not have physical therapists. Included is information about gait training and rehabilitation for persons with lower limb amputation. Every patient is different. Some patients will need many exercises; others will learn quickly and need very few. There are several goals of rehabilitation: to help persons with amputation feel safe using their new prosthetic device, to improve balance, to maximize walking technique, and to teach people to move within their home, workplace, and community with confidence.

The rehabilitation manual is divided into four phases: PHASE ONE includes pre-prosthetic rehabilitation. PHASE TWO incorporates balance and weight bearing exercises. PHASE THREE teaches gait training in the parallel bars. PHASE FOUR instructs gait training using an assistive device and on unlevel surfaces. Pictures and text are provided for each of the exercises/ activities included in each phase of the manual as a reference guide for clinicians. The assessment chart is a way to check patient progress during the different phases of gait training. It is based on the performance of functional tasks. This is the most important tool for clinicians. It is organized into three areas: the task, how the patient should perform the task, and which exercise will improve performance. The chart should be used for each patient, the goal of which is for the patient to perform each task to the best of his/her ability.

Phase 1

PRE-PROSTHETIC REHABILITATION

Phase 1

PRE-PROSTHETIC REHABILITATION Skin Care for the Amputated Leg

• The patient should inspect his/her leg every day by feeling the leg with his/her hands for excessive warmth (indicates an infection) or pain. The patient should look for openings in the skin, redness, cracking or dryness, and/or blisters. The leg should be viewed from the front, back and sides. A mirror can be useful. A family member can help or perform the inspection.

• The leg should always be clean. This will prevent skin breakdown and infection. • The patient should wash the leg with warm water and mild (scent free) soap each night. The leg should not be soaked as this might soften the skin and cause swelling. All of the soap should be removed with clean water. Carefully dry the leg with a clean, dry towel. Be careful not to rub the leg too hard as it might cause skin irritation. • The leg can be massaged several times a day. This will help decrease the sensitivity of the leg. • The patient should not shave the amputated leg. • Do not use lotions, creams or moisturizers unless prescribed by a physician.

• Patients with impaired sensation or medical conditions that impair circulation need to be especially careful with skin inspection. • Development of a wound may indicate a poor fitting prosthetic device.

PHASE 1 • PRE-PROSTHETIC REHABILITATION / Skin Care for the Amputated Leg

Phase 1

PRE-PROSTHETIC REHABILITATION Shaping of the amputated leg

• After surgery, the amputated leg will decrease greatly in size. • To prevent excessive swelling and to shape the amputated leg, instruct the patient on how to wear an ace wrap. • The patient should use dry, clean ace wraps, and the leg should be completely dry. • The patient may need to use more than one ace wrap, depending on the length of the amputated leg. Two bandages can be sewn together. • It is important to not make the ace wrap too tight. If the ace wrap is too tight, blood flow will be restricted and cause pain. • The pressure of the ace wrap should be adjusted from firm at the far end of the leg to moderate at the top of the leg. • Ace wrapping should be done in a diagonal manner. This will prevent the restriction of blood flow. • The ace wrap should cover all of the skin of the leg wrapped. • The ace wrap should be checked every four hours. Reapply the bandaging if it becomes too loose/tight, or causes pain. • The leg should be ace wrapped only during waking hours and removed for bathing and sleep.

PHASE 1 • PRE-PROSTHETIC REHABILITATION / Shaping of the amputated leg

Phase 1

PRE-PROSTHETIC REHABILITATION Patient Positioning

• The patient must be shown which positions are good for the amputated leg, and which should be avoided. • The most common problem with above knee amputations is muscle tightness from too much sitting.

BAD - Putting pillows under the amputated leg (stump) - Sitting all day - Sitting with the amputated leg (stump) angled out or in

• A patient can lose the motion for the leg to be positioned under the trunk making it very difficult to walk.

GOOD - Lying with the amputated leg (stump) flat on the bed - Changing positions every hour - Sitting with the thighs parallel DO:

PHASE 1 • PRE-PROSTHETIC REHABILITATION / Patient Positioning

Phase 1

PRE-PROSTHETIC REHABILITATION Exercises for Persons with an Above-Knee Amputation General Exercise Guidelines:

• For the best outcomes, patients should begin exercises before they receive a prosthetic device. During this time, the amputated leg must be prepared for walking with specific exercises that stretch and strengthen. • Exercise should not be performed if the patient is feeling sick (experiencing a fever, nausea, vomiting, dizziness, body aches, and chills). • The patient should wear loose fitting clothes. • The following exercises should not cause pain. At no time, should movement be forces. • Movements should be slow and steady (avoid bouncing movements). • The exercises should be performed with the patient lying on a firm surface. • The patient should breathe in prior to the exercise and breathe out when performing the exercise. The patient should avoid holding his/her breath while performing an exercise. • It is recommended that each exercise be performed 10 times, 2-3 times per day or as tolerated. • If the patient feels that an exercise is easy, a sock can be filled with rocks to provide resistance to the movements. For example, if the patient is performing a lift of the lower body (bridge), the sock is placed across the front of the pelvis/hips.

Note: More than one version of each exercise is provided below. The first version is the most challenging one.

PHASE 1 • PRE-PROSTHETIC REHABILITATION / Exercises for Persons with an Above-Knee Amputation

Phase 1

PRE-PROSTHETIC REHABILITATION LOWER BODY STRENGTHENING 1. Lifting the lower body (Bridging) • The patient lies on his/her back with the nonamputated knee bent to 90 degrees with the foot flat, arms at the sides, palms facing down.

• The patient pushes down through the foot and simultaneously raises the hips. • The hip on the amputated side should be turned in an upward direction until both hips are at the same height. • Hold this position for 5 seconds and then slowly lower. • As strength increases, have the patient move the foot further away from the body.

PHASE 1 • PRE-PROSTHETIC REHABILITATION / LOWER BODY STRENGTHENING EXERCISES / Lifting the lower body (Bridging)

Phase 1

PRE-PROSTHETIC REHABILITATION LOWER BODY STRENGTHENING 2. Lifting the upper body (Sit-Ups) a. The patient is lying down • The patient lies on his/her back, arms crossed over the chest with the knee of non-amputated leg bent to 90 degrees and foot flat. • The patient brings the chin towards the chest and continues to raise the upper body until the shoulder blades lift up. • Hold this position for 5 seconds and then slowly lower. • As strength increases, the patient can bring the legs in towards the chest as the upper body lifts. Another option is to have the patient position the hands behind the head.

PHASE 1 • PRE-PROSTHETIC REHABILITATION / LOWER BODY STRENGTHENING EXERCISES / Lifting the upper body (Sit-ups)

Phase 1

PRE-PROSTHETIC REHABILITATION LOWER BODY STRENGTHENING 2. Lifting the upper body (Sit-Ups) b. The patient is sitting • The patient begins in a seated position with nothing behind his/her back. • The arms are crossed over the chest and the patient slowly leans back. • Hold this position for 5 seconds and return to sitting upright. • As strength increases, the patient can clasp his/her hands behind the head.

PHASE 1 • PRE-PROSTHETIC REHABILITATION / LOWER BODY STRENGTHENING EXERCISES / Lifting the upper body (Sit-ups)

Phase 1

PRE-PROSTHETIC REHABILITATION LOWER BODY STRENGTHENING 3. Twisting the upper body a. The patient is lying down

• The patient lies on his/her back, arms crossed over the chest with the knee of non-amputated leg bent to 90 degrees and foot flat.

• The patient lifts the upper body towards one knee until the opposite shoulder blade lifts up. Hold this position for 5 seconds and then slowly lower.

• As strength increases, the patient can clasp his/her hands behind the head.

PHASE 1 • PRE-PROSTHETIC REHABILITATION / LOWER BODY STRENGTHENING EXERCISES / Twisting the upper body

Phase 1

PRE-PROSTHETIC REHABILITATION LOWER BODY STRENGTHENING 3. Twisting the upper body b. The patient is sitting • The patient begins in a seated position with nothing behind his/her back. • The arms are crossed over the chest and the patient slowly leans back and turns to one side, then the other. Hold for 3 seconds each side. • As strength increases, the patient can clasp his/her hands behind the head.

PHASE 1 • PRE-PROSTHETIC REHABILITATION / LOWER BODY STRENGTHENING EXERCISES / Twisting the upper body

Phase 1

PRE-PROSTHETIC REHABILITATION LOWER BODY STRENGTHENING

4. Lifting the amputated leg behind (Hip Extension) a. The patient is lying down • The patient lies on his/her back with a rolled towel under the lower end of the amputated leg. The arms are at the sides, palms facing down. The non-amputated leg is straight. 1

• The patient pushes down through the amputated leg into the towel and simultaneously raises the hips. Hold this position for 5 seconds and then slowly lower the hips. 2

• As strength increases, the patient can raise the non-amputated leg off the surface while performing the exercise.

PHASE 1 • PRE-PROSTHETIC REHABILITATION / LOWER BODY STRENGTHENING EXERCISES / Lifting the amputated leg behind (Hip Extension) 16

Phase 1

PRE-PROSTHETIC REHABILITATION LOWER BODY STRENGTHENING

4. Lifting the amputated leg behind (Hip Extension) b. The patient is standing • The patient stands holding on to a firm surface to help maintain balance. • The patient lifts the amputated leg back behind. • A family member can make the exercise more difficult by adding hands-on resistance by applying pressure in the forward direction. • It is important that the patient keep the body upright during the activity (and not lean forward).

17 PHASE 1 • PRE-PROSTHETIC REHABILITATION / LOWER BODY STRENGTHENING EXERCISES / Lifting the amputated leg behind (Hip Extension)

Phase 1

PRE-PROSTHETIC REHABILITATION LOWER BODY STRENGTHENING

5. Lifting the amputated leg forward (Hip Flexion) a. The patient is standing • The patient stands holding on to a firm surface to help maintain balance. • The patient lifts the amputated leg straight up. • The patient then holds the leg up for 5 seconds and then returns the leg to the starting position. • A family member can provide hands-on resistance by pushing in a downward direction to make the activity more challenging.

18 PHASE 1 • PRE-PROSTHETIC REHABILITATION / LOWER BODY STRENGTHENING EXERCISES / Lifting the amputated leg forward (Hip Flexion)

Phase 1

PRE-PROSTHETIC REHABILITATION LOWER BODY STRENGTHENING

5. Lifting the amputated leg forward (Hip Flexion) b. The patient is seated • The patient is sitting. • The patient lifts the amputated leg straight up. • The patient then holds the leg up for 5 seconds and then slowly lowers the leg. • A family member can provide hands-on resistance by pushing in a downward direction on the leg to make the activity more challenging.

PHASE 1 • PRE-PROSTHETIC REHABILITATION / LOWER BODY STRENGTHENING EXERCISES / Lifting the amputated leg forward (Hip Flexion)19

Phase 1

PRE-PROSTHETIC REHABILITATION LOWER BODY STRENGTHENING

5. Lifting the amputated leg forward (Hip Flexion) c. The patient is lying down • The patient lies on his/her back with the arms by the sides, palms facing up. • The amputated leg is brought towards the chest. • The patient then holds the leg for 5 seconds and then slowly lowers the leg.

PHASE 1 • PRE-PROSTHETIC REHABILITATION / LOWER BODY STRENGTHENING EXERCISES / Lifting the amputated leg forward (Hip Flexion) 20

Phase 1

PRE-PROSTHETIC REHABILITATION LOWER BODY STRENGTHENING

6. Lifting the amputated leg outward (Hip Abduction) a. The patient is lying down • The patient lies on the side of the non-amputated leg. • Have the patient lift the amputated leg up, without bringing the hip forward. • Hold this position for 5 seconds and then slowly lower the leg. • As strength increases, have the patient lie on the side of the amputated leg. Place a pillow between the patient’s thighs. Instruct the patient to push into the surface with the amputated leg to lift the lower body. The non-amputated leg rests on the pillow.

21 PHASE 1 • PRE-PROSTHETIC REHABILITATION / LOWER BODY STRENGTHENING EXERCISES / Lifting the amputated leg outward (Hip Abduction)

Phase 1

PRE-PROSTHETIC REHABILITATION LOWER BODY STRENGTHENING

6. Lifting the amputated leg outward (Hip Abduction) b. The patient is standing • The patient is standing holding on to a firm surface to help maintain balance. • The amputated leg is lifted out to side, without bringing it forward. • The patient holds this position for 5 seconds and then slowly lowers the leg.

• A family member can provide manual resistance by applying pressure towards the other leg to make the activity more challenging. 22 PHASE 1 • PRE-PROSTHETIC REHABILITATION / LOWER BODY STRENGTHENING EXERCISES / Lifting the amputated leg outward (Hip Abduction)

Phase 1

PRE-PROSTHETIC REHABILITATION LOWER BODY STRENGTHENING

7. Lifting the amputated leg inward (Hip Adduction) a. The patient is lying down • The patient lies on the side of the non-amputated leg. The bottom arm is placed under head for comfort; the top arm is placed in front of body for support.

• Place a pillow or rolled towel between the patient’s thighs.

• The patient squeezes the thighs together into the pillow.

• Hold this position for 5 seconds and then relax the legs.

• As strength increases, the patient can lie on side of the amputated leg. The arms are in same position. Bend the knee of the top leg and place the foot flat in front of the amputated leg. Lift the amputated leg up as high as possible.

23 PHASE 1 • PRE-PROSTHETIC REHABILITATION / LOWER BODY STRENGTHENING EXERCISES / Lifting the amputated leg inward (Hip Abduction)

Phase 1

PRE-PROSTHETIC REHABILITATION LOWER BODY STRENGTHENING

7. Lifting the amputated leg inward (Hip Adduction) b. The patient is standing • The patient is standing holding on to a firm surface to help maintain balance. • The amputated leg is brought in front of the non-amputated leg. • The patient holds this position for 5 seconds and then slowly lowers the leg.

• A family member can provide manual resistance by gently pulling the leg out to the side to make the activity more challenging.

24 PHASE 1 • PRE-PROSTHETIC REHABILITATION / LOWER BODY STRENGTHENING EXERCISES / Lifting the amputated leg inward (Hip Abduction)

Phase 1

PRE-PROSTHETIC REHABILITATION LOWER BODY STRENGTHENING 8. Bending Backwards (Back Extension) a. The patient is lying down

a. The patient is standing

• The patient lies on his/her stomach with a rolled towel placed between the thighs with the arms at the patient’s sides, palms facing up.

• The patient stands with equal weight on both legs. • The patient raises the arms overhead, and leans backward.

• The patient squeezes the towel while raising the arms and head up. • Hold the position for 5 seconds and then slowly lower.

• Hold the position for 5 seconds and then slowly return to starting position.

• As strength increases, have the patient lift the legs, arms and head up at the same time.

• As strength increases, the patient can progress to the next activity.

PHASE 1 • PRE-PROSTHETIC REHABILITATION / LOWER BODY STRENGTHENING EXERCISES / Bending Backwards (Back Extension)

Phase 1

PRE-PROSTHETIC REHABILITATION LOWER BODY STRENGTHENING 8. Bending Backwards (Back Extension) c. The patient is standing with weighted object. • The patient is standing with equal weight bearing through both legs, holding a weighted object in both hands in front of his/her thighs. • Have the patient hold a weighted object straight out in front of him/her. • The patient should maintain an upright posture during the activity. • Hold the position for 5 seconds and then slowly lower the object.

d. Nudging the patient • Have the patient stand upright with equal weight in both legs, with the arms at the sides. • The clinician or family member uses his/her hands to nudge (push) the patient’s upper body in different directions (front, back, side to side, diagonally) • As the patient’s strength and balance improves, the clinician or family member can use more force or nudge at a faster rate to make the exercise more challenging.

PHASE 1 • PRE-PROSTHETIC REHABILITATION / LOWER BODY STRENGTHENING EXERCISES / Bending Backwards (Back Extension)

Phase 1

PRE-PROSTHETIC REHABILITATION UPPER BODY STRENGTHENING 1. Elbow straightening The patient is sitting • The patient starts with the arms held overhead, elbows bent with the hands clasped together. A weighted object is held in the hands (sock filled with rocks). • The patient straightens the elbows raising the hands upward • A family member can place his/her hands on the clasped hands of the patient to provide downward resistance to make the exercise more challenging. 1

PHASE 1 • PRE-PROSTHETIC REHABILITATION / UPPER BODY STRENGTHENING EXERCISES / Elbow straightening

Phase 1

PRE-PROSTHETIC REHABILITATION UPPER BODY STRENGTHENING 2. Body lifts 1

a. The patient is sitting

• The patient is sitting with the legs out in front with the hands placed on either side of the hips. • The patient pushes down through the arms and lifts the body. • A family member can make this activity more challenging by holding the non-prosthetic foot off of the floor.

PHASE 1 • PRE-PROSTHETIC REHABILITATION / UPPER BODY STRENGTHENING EXERCISES / Body lifts

Phase 1

PRE-PROSTHETIC REHABILITATION UPPER BODY STRENGTHENING

2. Body lifts b. The patient is lying on his/her stomach. • The patient places both hands on either side of the chest with the non-prosthetic toes pressing in to the floor.

• The patient lifts the body, lowers partially by bending the elbows. • Now, the patient straightens the elbows. • If this is too difficult, the starting position can be with the patient kneeling on their non-prosthetic knee.

• This activity can also be modified for the patient by using a wall. The patient stands facing a wall with the hands at shoulder height. The patient bends and straightens the elbows.

PHASE 1 • PRE-PROSTHETIC REHABILITATION / UPPER BODY STRENGTHENING EXERCISES / Body lifts

Phase 1

PRE-PROSTHETIC REHABILITATION STRETCHING EXERCISES

It is very important that the patient relaxes and performs the stretches slowly. The patient should hold each stretch for 30 seconds and release for 5 seconds, reposition and repeat each stretch 2-3 times. Stretching activities should be repeated 2-3 times a day. The patient can use a belt to help with the stretches. Manual assistance can also be provided by a family member. None of the movements should be forced or painful. 1. Hip flexor stretch a. The patient is standing • Keep the body upright. • Place a belt around the lower part of the thigh and hold the belt in one hand. Use the belt to bring the leg back behind the body.

• A family member can also perform the stretch. The family member is behind the patient and places one hand on the patient’s low back area and the other hand is placed on the front of the thigh to bring the leg behind the body.

PHASE 1 • PRE-PROSTHETIC REHABILITATION / STRETCHING EXERCISES / Hip flexor stretch

Phase 1

PRE-PROSTHETIC REHABILITATION STRETCHING EXERCISES 1. Hip flexor stretch b. The patient is lying on his/her stomach • Have a family member place his/her hands around the front of the thigh and lift the leg up behind. • The patient can also place a towel roll under the lower end of his/her thigh.

PHASE 1 • PRE-PROSTHETIC REHABILITATION / STRETCHING EXERCISES / Hip flexor stretch

Phase 1

PRE-PROSTHETIC REHABILITATION STRETCHING EXERCISES 2. Hamstring stretch a. The patient is lying on his/her back or side

b. The patient is standing

• Bring the leg towards the chest, grasp the thigh and pull the thigh closer to the chest.

• Keep the body straight.

• Using a belt placed around the lower part of the thigh, bring the amputated leg towards the chest.

• Bring the leg towards the chest, grasp the thigh and pull the thigh closer to the chest.

PHASE 1 • PRE-PROSTHETIC REHABILITATION / STRETCHING EXERCISES / Hamstring stretch

Phase 1

PRE-PROSTHETIC REHABILITATION STRETCHING EXERCISES 3. Inner thigh (Hip adductors) a. The patient is lying on his/her back • Using a belt placed around the lower part of the thigh, bring the amputated leg out to the side. • A family member can be used in place of the belt. The family member places one hand on the opposite pelvis and the other on inner aspect of the lower thigh and moves it outward away from the non-amputated leg.

PHASE 1 • PRE-PROSTHETIC REHABILITATION / STRETCHING EXERCISES / Inner thigh (Hip adductors)

Phase 1

PRE-PROSTHETIC REHABILITATION STRETCHING EXERCISES 3. Inner thigh (Hip adductors) b. The patient is standing • Keep the body straight. • Using a belt placed around the lower part of the thigh, bring the amputated leg out to the side. • A family member can be used in place of the belt. The family member places one hand on the opposite pelvis and the other on the inner aspect of the lower thigh and moves it outward away from the non-amputated leg.

PHASE 1 • PRE-PROSTHETIC REHABILITATION / STRETCHING EXERCISES / Inner thigh (Hip adductors)

Phase 1

PRE-PROSTHETIC REHABILITATION STRETCHING EXERCISES 4. Outer thigh (Hip abductors) a. The patient is lying on his/her back • Bring the non-amputated leg out to the side. • Using the belt placed around the lower part of the thigh, bring the amputated leg towards the non-amputated leg. • A family member can be used in place of the belt. The family member places one hand on the opposite pelvis and the other on the outer aspect of the lower thigh and moves it in front of the non-amputated leg.

PHASE 1 • PRE-PROSTHETIC REHABILITATION / STRETCHING EXERCISES / Outer thigh (Hip abductors)

Phase 1

PRE-PROSTHETIC REHABILITATION STRETCHING EXERCISES 4. Outer thigh (Hip abductors) b. The patient is standing • Keep the body straight. • Using a belt placed around the thigh, bring the amputated leg in front of the non-amputated leg. • A family member can be used in place of the belt. The family member places one hand on the pelvis on the non-amputated side, the other on the lower thigh of the amputated leg and moves it in front of the non-amputated leg.

PHASE 1 • PRE-PROSTHETIC REHABILITATION / STRETCHING EXERCISES / Outer thigh (Hip abductors)

Phase 1

PRE-PROSTHETIC REHABILITATION STRETCHING OF THE UPPER BODY 1. Belly (Abdominals) a. The patient is lying on his/her stomach • Prop up on the elbows

b. The patient is sitting • Clasp hands behind the neck or reach overhead and lean backwards.

PHASE 1 • PRE-PROSTHETIC REHABILITATION / STRETCHING OF THE UPPER BODY / Belly (Abdominals)

Phase 1

PRE-PROSTHETIC REHABILITATION STRETCHING OF THE UPPER BODY 2. Chest (Pectorals) a. The patient is sitting • The patient holds the ends of a belt behind his/her back with each hand, palms facing forward. • The patient lifts the arms away from the body. • The patient grasps the belt and moves each hand closer to the other. • A family member can be used instead of the belt. The family member stands behind the patient. The patient raises the arms and the family member presses the patient’s palms backwards behind the patient. The family member can stand with his/her hip against the patient’s back to stabilize the body.

b. The patient is standing in the corner of a room • The patient places both hands on either wall at shoulder height.

• The patient leans forward towards the wall to stretch the chest.

PHASE 1 • PRE-PROSTHETIC REHABILITATION / STRETCHING OF THE UPPER BODY / Chest (Pectorals)

Phase 2

BALANCE/WEIGHT BEARING WITH PROSTHETIC DEVICE

Phase 2

BALANCE/WEIGHT BEARING WITH PROSTHETIC DEVICE After the patient has received a prosthetic device, it is important to begin standing balance and weight shifting exercises. These movements are very important to teach the patient to trust the prosthetic device. The patient must also learn when the knee component will remain straight and when it will bend.

Donning • The first lesson for each patient is how to put the prosthetic leg on correctly. • The patient should be taught the names of the parts of the prosthetic device. • Patients should be instructed that only liners and socks go inside the socket. • Patients should be instructed not to modify the prosthetic limb in any way. • Tight clothing may prevent the knee from working properly.

Proper Alignment of the Prosthetic Device • For a patient to be independent and successful, he/she must be taught how to assess the alignment of the prosthetic device. • The patient should be shown how to find the prominent bones of the pelvis: the iliac crest. These two areas can help the patient check if the prosthetic device is too tall or too short. • The patient should also be shown which areas of the socket should be fitting tightly around the upper leg. When the leg is put on correctly the patient should be able to stand with the feet apart, pelvis should be level, and the feet should be pointed out equally on each side.

Patients should return to the clinic if any of the following occur: 1. The pelvis is not level. 2. The prosthetic device is damaged or broken. Patients should be instructed to stop wearing the prosthetic device immediately if it is damaged or broken. 3. The prosthetic device shifts or slides off of the amputated leg (stump) when standing or walking. The patient should first try to tighten the suspension strap or add more socks. If this does not correct the problem, the patient should return to the clinic. 4. The prosthetic device causes pain. 5. Skin damage occurs. 6. Redness, blisters, odd smells, or bruising that lasts more than an hour after removing the prosthetic device. If any of the listed warning signs occur, the patient should stop wearing the prosthetic device until clinic evaluation.

PHASE 2 • BALANCE & WEIGHT BEARING / DONNING + PROPER ALIGNMENT OF PROSTHETIC DEVICE

Phase 2

BALANCE/WEIGHT BEARING WITH PROSTHETIC DEVICE Standing Activities

Preparation of the Parallel Bars The parallel bars should be set to the height of the patient’s wrists when the arms are resting at the side. The hands should have an open grasp of the parallel bars; the fingers are open and not gripping the bars. The patient’s weight is placed through the palms onto the bars. Practicing with this open hand position will make it easier for the patient to transition to walking outside of the parallel bars with an assistive device.

PHASE 2 • BALANCE / WEIGHT BEARING / STANDING ACTIVITIES / Preparation of the Parallel Bars

Phase 2

BALANCE/WEIGHT BEARING WITH PROSTHETIC DEVICE Standing Activities Initial Stance When beginning training with a prosthetic limb, the patient should start by holding onto the parallel bars with an open grasp. The feet should be hip-width apart. Bearing equal weight through the legs is essential. The patient should be given time to get used to the socket. The clinician can provide hands-on corrections at the hips to encourage equal weight bearing. As the patient becomes more comfortable and stable, he/she can hold on to the parallel bar with the hand on the non-prosthetic side only. Eventually, the patient can stand without holding onto the bars at all.

PHASE 2 â&#x20AC;˘ BALANCE / WEIGHT BEARING / STANDING ACTIVITIES / Initial Stance

Phase 2

BALANCE/WEIGHT BEARING WITH PROSTHETIC DEVICE Standing Activities Weight Shift Side to Side The patient is standing in the parallel bars with the feet parallel to one another, hip-width apart. The patient can practice shifting weight side to side through the hips. The clinician can provide hands-on corrections at the hips to encourage weight shift towards each side. The patient should become familiar with weight acceptance on each leg, as well as how the prosthetic limb functions with this type of side to side motion. The patient should be progressed from holding with two hands, to one hand, and then to no hands.

PHASE 2 â&#x20AC;˘ BALANCE / WEIGHT BEARING / STANDING ACTIVITIES / Weight Shift Side to Side

Phase 2

BALANCE/WEIGHT BEARING WITH PROSTHETIC DEVICE Standing Activities

Weight Shift Front to Back The patient is standing in the parallel bars with the feet parallel to one another, hip-width apart. The patient shifts his/her weight forwards and backwards through the hips and feet. The patient should focus on leaning back through the heels and then shifting forward through the toes. The clinician can provide hands-on corrections at the hips to encourage equal weight shift in both directions. The patient can be progressed from holding with two hands, to one hand, and then to no hands. Another way to progress the activity would be to have the patient shift the hips further in each direction.

PHASE 2 â&#x20AC;˘ BALANCE / WEIGHT BEARING / STANDING ACTIVITIES / Weight Shift Front to Back

Phase 2

BALANCE/WEIGHT BEARING WITH PROSTHETIC DEVICE Standing Activities

Diagonal Weight Shifting The patient is standing in the parallel bars with feet parallel to one another, hip-width apart. The patient takes a step forward with the prosthetic limb. The patient should then press the leg back in the socket to straighten and stabilize the knee. Next, the patient shifts that hips forward and over the prosthetic foot, heel to toe. If the patient is having difficulty performing this activity, the clinician can place his/her palm on the front of the patient’s pelvis/hip and ask the patient to press the pelvis/hip forward into the clinician’s hand. The patient should then shift the hips backwards and diagonally over the non-prosthetic limb, toe to heel and step back with the prosthetic foot past the non-prosthetic foot. The clinician can also provide hands-on corrections at the hips to encourage equal weight shift. The patient should practice this activity several times. As the patient becomes comfortable with this activity, he/she should switch the position of the legs and repeat the activity. Progress the patient from holding with two hands, to one hand and then to no hands.

PHASE 2 • BALANCE / WEIGHT BEARING / STANDING ACTIVITIES / Diagonal Weight Shifting

Phase 2

BALANCE/WEIGHT BEARING WITH PROSTHETIC DEVICE Standing Activities

Dynamic Standing Activities To increase weight bearing through the prosthetic limb, have the patient turn to that side. Next, the patient can perform reaching activities towards the prosthetic side first with the hand on the prosthetic side, then with the other hand. The patient can then stand on the prosthetic limb and lift the other (single limb stance). The patient can stand on the prosthetic limb and tap the toes of the other leg to various targets on the floor. The patient can also practice repetitive standing and sitting from and to a chair to help the patient learn the knee mechanism.

PHASE 2 â&#x20AC;˘ BALANCE / WEIGHT BEARING / STANDING ACTIVITIES / Dynamic Standing Activities

Phase 2

BALANCE/WEIGHT BEARING WITH PROSTHETIC DEVICE Standing Activities

Dynamic Standing Activities The patient can practice hiking the hip on the prosthetic side to help strengthen it. The patient can roll a ball with the sound leg to increase weight bearing on the prosthetic leg.

PHASE 2 â&#x20AC;˘ BALANCE / WEIGHT BEARING / STANDING ACTIVITIES / Dynamic Standing Activities

Phase 3

GAIT TRAINING IN THE PARALLEL BARS

Phase 3

GAIT TRAINING IN THE PARALLEL BARS When patients are learning to take the first steps it is important to create a safe atmosphere. The parallel bars provide support for the patient and allow the clinician to have hands free.

Initial Stepping The patient is standing in the parallel bars with feet parallel to one another, hip-width apart. The patient takes a step forward with the prosthetic limb. The patient should then press the leg back in the socket to straighten and stabilize the knee. The patient should be given time to learn at exactly what point of knee straightening (extension) the limb will lock. Next the patient shifts the pelvis/hip forward and over the prosthetic foot, heel to toe. If the patient is having difficulty performing this activity, the clinician can place his/her palm on the front of the patientâ&#x20AC;&#x2122;s pelvis/hip and ask the patient to press the pelvis/hip forward in to the clinicianâ&#x20AC;&#x2122;s hand. The patient should then shift the pelvis/hip backwards and diagonally over the non-prosthetic limb, toe to heel. The clinician can provide hands-on corrections at the hips to encourage equal weight shift. The patient then steps back with prosthetic limb. The patient should practice this activity several times. Once the patient is comfortable with this activity, switch the position of the legs and repeat the activity. Progress the patient from holding with two hands, to one hand and then to no hands. The clinician should be looking for similar movements when comparing the two legs to each other. There should be equal bending at the hips and knees, step length and similar foot placement. Repeat the exercise with the non-prosthetic limb in stance with the prosthetic limb stepping forward and back. The patient should bend his/her hip on the prosthetic side high enough to ensure that the foot does not contact the ground too early. Progress the patient from holding with two hands, to one and then to no hands. Provide the patient with hands-on contact at the hips to assist and/or encourage the desired movement, if necessary. Note: Once the patient gets comfortable taking steps, encourage the patient to increase his/her step length to what feels most natural.

PHASE 3 â&#x20AC;˘ GAIT TRAINING IN THE PARALLEL BARS / Initial Stepping

Phase 3

GAIT TRAINING IN THE PARALLEL BARS

When patients are learning to take the first steps it is important to create a safe atmosphere. The parallel bars provide support for the patient and allow the clinician to have hands free.

Initial Stepping

The Clinician’s Assessment of Walking

Walking with proper technique will help minimize energy costs, decrease the risk of falling, and prevent future injuries. The patient may need to work on pre-gait activities more to increase patient’s confidence before attempting walking training. It is better to progress slowly and allow patients to form good habits as bad habits are difficult to break. The clinician should encourage the patient to maintain upright posture and keep eyes ahead. The use of a mirror or reflective surface can help the patient become aware of his/her posture. Allow the patient to walk up and down the parallel bars a few times without commenting. It is best to use a few, specific words of criticism. Once the patient gets comfortable taking steps, encourage the patient to increase step length to what feels most natural.

The clinician should assess the patient from the front, the back and the sides to evaluate the quality of walking and identify any walking problems that may be present. Working from the bottom up, assess movement at each body segment (ankle, knee, hip/pelvis, trunk, shoulders, head).When viewing the patient from the front and the back, compare movement between the left and right sides. The goal is for the movement to be the same (symmetrical). A lateral trunk lean and the patient’s base of support can be evaluated from this view. When looking at a patient from the side, the various phases of gait can be observed (heel strike, foot flat, heel off, toe off, early swing, midswing, and late swing). Step length symmetry, stride length symmetry and forward or backward trunk lean can also be observed from this view. If the patient is walking without a device or with a cane, you should observe the opposite shoulder moving forward with each step.

The patient must be taught that to move the prosthetic limb, the amputated leg must be in contact with the sides of the prosthetic socket. The pressure into the walls of the socket should be emphasized with all walking activities.

Walking Training The patient should stand in the parallel bars. The bars should be set to the level of the patient’s wrists, with the arms at the sides. During the entire walking phase, the clinician should take note of the rotation of the hips, the amount of hip and knee bend, base of support, movement of the trunk (lean), stance time, and step length. The clinician should observe the patient’s arm position prior to initial walking. If the shoulders are shrugged and elevated, it indicates that the patient is bearing too much weight through the arms. If this is not corrected, the patient will tire too quickly. The patient may need to work on pre-gait activities more to increase his/her confidence before attempting walking training. It is also very important that the patient maintain an upright posture during walking. Good posture will also help to minimize wasted energy. Cue the patient to keep his/her eyes looking ahead. It is very tempting to look down at the feet, but this will make stepping more difficult. It is better to progress slowly and allow patients to form good habits as bad habits are difficult to break.

PHASE 3 • GAIT TRAINING IN THE PARALLEL BARS / Initial Stepping + The Clinician’s Assessment of Walking + Walking Training

Phase 3

GAIT TRAINING IN THE PARALLEL BARS

Walking Training (continued) the prosthetic limb initiates a step, observe the trunk. Make sure that there is no leaning of the trunk in any direction; the patient should maintain an upright position of the trunk. There should be an even step length when comparing the two sides. The patient will continue to move forward, working to bear weight equally through both legs. These steps should be repeated until the patient is comfortable to advance to one hand support on the nonprosthetic side. When no problems with walking are observed, the patient can walk without holding with the hands while walking between the parallel bars. As the patient becomes more confident, progress to walking with an assistive gait device outside of the parallel bars. The sooner the patient progresses to gait with an assistive device outside of the parallel bars, the better. The goal of walking for some patients is to walk without an assistive device at all. Walking without an assistive device results in significantly lower energy expenditure that walking with an assistive device.

The patient will begin by stepping with the prosthetic limb. The clinician should observe the bending of the hip as the patient is swinging the prosthetic limb forward to heel strike. Ensure that the patient does not step too far. Keep the feet hip-width apart; the foot should not land with the heel out to the side or too close to the non-prosthetic limb. As the patient pushes the leg back in the socket, he/she will now be ready to accept full weight onto the prosthetic limb. If the patient is having difficulty with this activity, the clinician can tap the gluteus maximus muscle with his/her fingertips to encourage contraction of the hip extensors. As the same time, the pelvis on the side of the prosthetic limb continues to move forward. This is an essential component of the gait cycle and will minimize gait deviations/problems. The patient then takes a step forward with the non-prosthetic limb making sure that the heel contacts the ground with the toes point upwards. As the patient moves forward over his/her non-prosthetic limb and 1

PHASE 3 â&#x20AC;˘ GAIT TRAINING IN THE PARALLEL BARS / Walking Training

Phase 3

GAIT TRAINING IN THE PARALLEL BARS

Side Stepping The patient is standing in the parallel bars facing one of the bars with both hands on the bar, feet hip-width apart. The patient begins by stepping to the side of the prosthetic limb. Next, the patient will bring the non-prosthetic limb towards the prosthetic limb, keeping the feet hip-width apart. Have the patient side step to the end of the bar, and repeat in the opposite direction. During the activity, the clinician will observe the level of the hips as the patient steps with his/her limbs. The clinician will also look for any trunk leaning, especially towards the prosthetic limb when taking a step with the non-prosthetic limb. If the patient is unable to correct this trunk bending, it may indicate weakness of the gluteus medius muscle and require strengthening. Progress the patient from holding with two hands, to one hand and then to no hands.

PHASE 3 â&#x20AC;˘ GAIT TRAINING IN THE PARALLEL BARS / Side Stepping

Phase 3

GAIT TRAINING IN THE PARALLEL BARS

Backwards The patient is standing between the parallel bars using both hands for support; fingers open bearing weight through the palms. The patient steps back with his/her prosthetic limb using a slight hip hike. Starting with smaller steps will ensure that the knee remains extended (straight) and locked when weight bearing on the prosthetic side. Next the patient takes a step back with the non-prosthetic limb. The clinician can provide hands-on corrections at the hips to encourage equal weight shift. The patient should avoid leaning the trunk forward as the limbs move backwards. The patient should progress from holding with two hands, to one hand and then to no hands.

PHASE 3 â&#x20AC;˘ GAIT TRAINING IN THE PARALLEL BARS / Backwards

Phase 3

GAIT TRAINING IN THE PARALLEL BARS

Typical Problems during Walking (Compensation) There are various reasons why a patient may walk different than the ideal gait pattern. Deviation from the normal gait mechanics can waste energy, lead to injury, and limit a patientâ&#x20AC;&#x2122;s mobility. Many of these abnormalities can be corrected once the deviation and cause is identified.

Abducted Walking

The patient walks with a wider than normal base of support to increase his/her stability. This can be due to tightness of the outer hip muscles, and necessitate stretching. This walking pattern can also be seen if the patient is lacking confidence, feels unstable or is fearful of falling.

Circumduction

The patient utilizes the entire hip and pelvis to initiate a step with the prosthetic limb. The pelvis and hip moves forward as a unit swinging the leg out to the side. If the patient does not bend the hip or knee enough due to lack of confidence or weakness, or there is tightness of the outer hip muscles, circumduction may occur. Other circumstances that can lead to circumduction include problems with the prosthetic device itself: the prosthetic device is too long, the knee is locked, the suspension is not working properly, and the socket is too small or if the foot is positioned in too much of a toe down position.

PHASE 3 â&#x20AC;˘ GAIT TRAINING IN THE PARALLEL BARS / Typical Problems during Walking / Abducted walking + Circumduction

Phase 3

GAIT TRAINING IN THE PARALLEL BARS

Typical Problems during Walking (Compensation) Decreased weight shift onto the prosthetic limb (vaulting): The patient pushes down through the toes

of the non-prosthetic limb to raise the body during swing of the prosthetic limb. This is typically seen in patients who have a fear of contacting the ground with their foot prematurely or when they do not bend the prosthetic limb enough during swing.

Vaulting: The patient raises the heel up bearing weight

Hip hiking: The patient elevates the hip and pelvis of the prosthetic limb to swing the leg through. This will occur if the patient has weakness of the muscles that bend the hip and/or knee. Other circumstances that can lead to hip hiking include problems with the prosthetic device itself: the prosthetic device is too long, the knee is locked, the suspension is not working properly, and the socket is too small or the foot is positioned in too much of a toe down position.

through the non-prosthetic limb. This is done to help the prosthetic limb swing through. Patients who lack sufficient knee bend during swing will vault.

Whip: Rotation of the Prosthetic foot when lifting off the ground. The rotation can be to the outside or inside. The whip is named for which direction the heel travels. Toe in/toe out: If the foot of the prosthetic limb is either in a toe in or toe out position, the prosthetic device should be removed and re-aligned.

Patients should return to the clinic if any of the following occur: 1. If use of the prosthetic device causes pain. 2. If skin breakdown develops, particularly if the patient has compromised circulation or healing. If breakdown occurs, use of the prosthetic device should be discontinued immediately. 3. If the prosthetic limb is damaged or broken, the patient should discontinue use immediately. 4. If there is pistoning within the socket (the socket slides downward when the prosthetic limb is unweighted), the patient can tighten the suspension strap or add more socks. If this does not correct the problem, the patient should return to the clinic. 5. If the heights of the two pelvises are not level (it may indicate that the prosthetic limb is too long).

PHASE 3 â&#x20AC;˘ GAIT TRAINING IN THE PARALLEL BARS / Typical Problems during Walking / Vaulting + Whip + Toe in/out + Hip Hiking

Phase 4

WALKING WITH ASSISTIVE DEVICE

Phase 4

WALKING WITH ASSISTIVE DEVICE Assistive Devices to aid Walking

Initially, assistive walking devices may be necessary to help patients learn safe, normal (without problems) walking patterns. Such devices include walkers, crutches, or canes. It is ideal for patients to use assistive devices during initial prosthetic gait training outside of the parallel bars and progress to walking without them. Walkers are the most stable but consume the most energy and walking speed is relatively slow compared to crutches and canes. Crutches are the next most stable device, followed by canes. Walking forwards, backwards and side to side should also be practiced with assistive walking devices. . If the patient is walking on difficult terrain or is fearful, a family member can be used in addition to the assistive device. The family member stands on the side of the prosthetic device. If assistive devices are not available, a family member can be used in place of the device. The family member stands on the side opposite the prosthetic device. If the patient is walking on difficult terrain or is fearful, a second family member can be used.

SELECTING AN ASSISTIVE DEVICE

Measuring walking devices

Most Supportive Parallel Bars Pick Up Walker Wheeled Walker Forearm crutches Armpit (Auxiliary) Crutches Walking Stick Cane Least Supportive None

Walker and canes: The hand grip of the device should be at the level of the patient’s wrist when the patient stands with the arms at his/her sides. Crutches: The clinician places his/her index, middle and ring fingers together and puts that hand between the patient’s axilla (armpit) and top of the crutch. The clinician’s fingers should touch the axilla and top of the crutch at the same time. The hand grip should be at the level of the patient’s wrist when the patient stands with the arms at his/her sides.

PHASE 4 • WALKING WITH ASSISTIVE DEVICE / Assistive Devices to aid Walking / Introduction

Phase 4

WALKING WITH ASSISTIVE DEVICE Assistive Devices to aid Walking Use of a walker without wheels Three-step pattern: The first step is to move the walker forward so that the back legs of the walker are even with the patientâ&#x20AC;&#x2122;s toes. The patient then takes a step with the prosthetic limb into the center of the walker, followed by a step with the non-prosthetic limb even with the other. Cue the patient to keep good upright posture and keep their eyes looking ahead. It is very tempting to look down at the feet, but this will make stepping more difficult.

PHASE 4 â&#x20AC;˘ WALKING WITH ASSISTIVE DEVICE / Assistive Devices to aid Walking / Use of a walker without wheels: three-step pattern

Phase 4

WALKING WITH ASSISTIVE DEVICE Assistive Devices to aid Walking Use of a walker without wheels Two-step pattern: Eventually, the patient may be able to advance the walker and prosthetic limb at the same time, followed by the non-prosthetic limb.

PHASE 4 â&#x20AC;˘ WALKING WITH ASSISTIVE DEVICE / Assistive Devices to aid Walking / Use of a walker without wheels: two-step pattern

Phase 4

WALKING WITH ASSISTIVE DEVICE Assistive Devices to aid Walking Use of a walker with wheels Two-step pattern: The patient moves the walker forward. He/she then steps with the prosthetic limb, followed by the non-prosthetic limb. The goal of this gait pattern is for the patient to walk continuously, without any hesitation or stopping.

PHASE 4 â&#x20AC;˘ WALKING WITH ASSISTIVE DEVICE / Assistive Devices to aid Walking / Use of a walker with wheels: two-step pattern

Phase 4

WALKING WITH ASSISTIVE DEVICE Assistive Devices to aid Walking Use of crutches Four-step pattern: The patient stands with the crutches. To more easily describe the pattern, the patient has a prosthetic device on his/her right limb. The patient advances the left crutch, and then steps with the right prosthetic limb. Body weight is shifted to the forward crutch and right limb. The right crutch is then advanced, followed by the left limb. If the prosthetic device is on the left limb, switch the gait pattern. As the patient becomes proficient with this activity, the crutch and opposite limb can advance at the same time. The four-step pattern is the most stable.

PHASE 4 â&#x20AC;˘ WALKING WITH ASSISTIVE DEVICE / Assistive Devices to aid Walking / Use of crutches: four-step pattern

Phase 4

WALKING WITH ASSISTIVE DEVICE Assistive Devices to aid Walking Use of crutches Three-step pattern: The crutches can also be used like a walker. The patient advances the crutches, the prosthetic limb and finally the non-prosthetic limb.

PHASE 4 â&#x20AC;˘ WALKING WITH ASSISTIVE DEVICE / Assistive Devices to aid Walking / Use of crutches: three-step pattern

Phase 4

WALKING WITH ASSISTIVE DEVICE Assistive Devices to aid Walking Use of crutches two-step pattern: Eventually, the crutches and prosthetic limb can be advanced at the same time, followed by the non-prosthetic limb. This is the least stable pattern.

PHASE 4 â&#x20AC;˘ WALKING WITH ASSISTIVE DEVICE / Assistive Devices to aid Walking / Use of crutches: two-step pattern

Phase 4

WALKING WITH ASSISTIVE DEVICE Assistive Devices to aid Walking Use of a cane *

* This includes single point canes, footed canes and use of one crutch. Three-point gait pattern: The cane is held in the hand opposite of the prosthetic limb. Place the cane forward, step with the prosthetic limb, followed by the non-prosthetic limb.

PHASE 4 â&#x20AC;˘ WALKING WITH ASSISTIVE DEVICE / Assistive Devices to aid Walking / Use of a cane: three-point gait pattern

Phase 4

WALKING WITH ASSISTIVE DEVICE Assistive Devices to aid Walking Use of a cane *

* This includes single point canes, footed canes and use of one crutch. Two-point gait pattern: Advance the cane and prosthetic limb at the same time. Step through with the non-prosthetic limb.

PHASE 4 â&#x20AC;˘ WALKING WITH ASSISTIVE DEVICE / Assistive Devices to aid Walking / Use of a cane: two-point gait pattern

Phase 4

WALKING WITH ASSISTIVE DEVICE Assistive Devices to aid Walking Negotiating Stairs The patient should use support whenever possible; a wall, an assistive device or another person can all serve as support. It is more stable and safer to climb the stairs with two feet on each step, this is called a step-to pattern. However, this pattern wastes a lot of energy. When the patient ascends, he/she must be certain that the toes don’t catch on the stair, especially if there is an overhang. The patient steps up with the non-prosthetic limb first, followed by the prosthetic limb to the same step. For a patient using the LIMBS M1 knee, going up the stairs should be performed in a step-to pattern. It is possible to go down the stairs with only one foot on each step, this pattern is called a step-over-step pattern. This pattern is difficult and very fast, and should only be taught to patients with advanced skills. All other patients, including those who are less stable, should be taught to go down the stairs in a step-to pattern. When descending, the patient should stand with the feet close to the edge of the step. This will shorten the length of the step that the patient has to take. The patient must be sure that the heels clear the edge of each stair when stepping down. The patient steps down with the prosthetic limb first, followed by the non-prosthetic limb. A simple way to remember which leg to advance is “Up with the strong, down with the weak.”

PHASE 4 • WALKING WITH ASSISTIVE DEVICE / Assistive Devices to aid Walking / Negotiating Stairs

Phase 4

WALKING WITH ASSISTIVE DEVICE Assistive Devices to aid Walking Use of a walker on stairs (ascending) It is difficult to use a walker on stairs and it is not generally recommended. It is best to progress a patient to the use of two crutches to improve their mobility within the community. If there is a railing, sometimes a walker can be used if it is turned sideways. If the rail in on the left side when the patient ascends the stairs, the walker is placed on the right side of the patient and turned so that the right side of the walker is on the step that the patient to moving to. The left side of the walker is on the step that the patient is standing on. The patient ascends stepping with the non-prosthetic limb first, followed by stepping with the prosthetic limb to the same step (step-to pattern).

PHASE 4 â&#x20AC;˘ WALKING WITH ASSISTIVE DEVICE / Assistive Devices to aid Walking / Use of a walker on stairs: ascending

Phase 4

WALKING WITH ASSISTIVE DEVICE Assistive Devices to aid Walking Use of a walker on stairs (descending) To descend, the walker is placed on the left side of the patient and turned so that the right side of the walker is on the step that the patient is standing on and the left side of the walker is on the step that the patient is moving to. The patient descends by stepping with the prosthetic limb first, followed by the non-prosthetic limb to the same step (step-to pattern). If the rail is on the right side of the patient when the patient is facing the stairs to ascend, reverse the placement of the walker.

PHASE 4 â&#x20AC;˘ WALKING WITH ASSISTIVE DEVICE / Assistive Devices to aid Walking / Use of a walker on stairs: descending

Phase 4

WALKING WITH ASSISTIVE DEVICE Assistive Devices to aid Walking Use of crutches on stairs (ascending) The patient steps up with the non-prosthetic limb, followed by the assistive device and prosthetic limb. The patient descends by moving the assistive device forward first, then the prosthetic limb, and the non-prosthetic limb. Eventually, the assistive device and the prosthetic limb can move together at the same time.

PHASE 4 â&#x20AC;˘ WALKING WITH ASSISTIVE DEVICE / Assistive Devices to aid Walking / Use of crutches on stairs: ascending

Phase 4

WALKING WITH ASSISTIVE DEVICE Assistive Devices to aid Walking Use of crutches on stairs (descending) The patient steps up with the non-prosthetic limb, followed by the assistive device and prosthetic limb. The patient descends by moving the assistive device forward first, then the prosthetic limb, and the non-prosthetic limb. Eventually, the assistive device and the prosthetic limb can move together at the same time.

PHASE 4 â&#x20AC;˘ WALKING WITH ASSISTIVE DEVICE / Assistive Devices to aid Walking / Use of crutches on stairs: descending

Phase 4

WALKING WITH ASSISTIVE DEVICE Assistive Devices to aid Walking Use of canes on stairs (ascending) The patient steps up with the non-prosthetic limb, followed by the assistive device and prosthetic limb. The patient descends by moving the assistive device forward first, then the prosthetic limb, and the non-prosthetic limb. Eventually, the assistive device and the prosthetic limb can move together at the same time.

PHASE 4 â&#x20AC;˘ WALKING WITH ASSISTIVE DEVICE / Assistive Devices to aid Walking / Use of canes on stairs: ascending

Phase 4

WALKING WITH ASSISTIVE DEVICE Assistive Devices to aid Walking Use of canes on stairs (descending) The patient steps up with the non-prosthetic limb, followed by the assistive device and prosthetic limb. The patient descends by moving the assistive device forward first, then the prosthetic limb, and the non-prosthetic limb. Eventually, the assistive device and the prosthetic limb can move together at the same time.

PHASE 4 â&#x20AC;˘ WALKING WITH ASSISTIVE DEVICE / Assistive Devices to aid Walking / Use of a walker on stairs: descending

Phase 4

WALKING WITH ASSISTIVE DEVICE Assistive Devices to aid Walking Negotiating large steps or curbs

The patient should get as close to the curb as possible. This will shorten the step that he/she needs to take. The patient steps up with the non-prosthetic limb first, followed by the prosthetic limb. When descending a curb, the patient gets as close to the curb as possible. The patient steps down with the prosthetic limb, followed by the non-prosthetic limb.

Use of a walker on a large step or curb (ascending)

The patient should position the feet as close to the curb as possible. This will shorten the step that he/she needs to take. Place the walker on the curb and step up with the non-prosthetic limb, followed by the prosthetic limb. Eventually, the walker and prosthetic limb can move forward together at the same time. 4

PHASE 4 â&#x20AC;˘ WALKING WITH ASSISTIVE DEVICE / Assistive Devices to aid Walking / Use of a walker on a large step or curb: ascending

Phase 4

WALKING WITH ASSISTIVE DEVICE Assistive Devices to aid Walking Use of a walker on a large step or curb (descending)

When descending a curb, the patient positions the toes over the edge of the curb. The patient moves the walker first, then the prosthetic limb, followed by the non-prosthetic limb. Eventually, the walker and prosthetic limb can move forward together at the same time.

PHASE 4 â&#x20AC;˘ WALKING WITH ASSISTIVE DEVICE / Assistive Devices to aid Walking / Use of a walker on a large step or curb: descending

Phase 4

WALKING WITH ASSISTIVE DEVICE Assistive Devices to aid Walking Use of a cane on a large step or curb

The patient steps up with the non-prosthetic limb first, followed by the assistive device and prosthetic limb. The patient descends with the assistive device first, followed by the prosthetic limb, then non-prosthetic limb. Eventually, the assistive device and prosthetic limb can move forward together at the same time.

down 1

PHASE 4 â&#x20AC;˘ WALKING WITH ASSISTIVE DEVICE / Assistive Devices to aid Walking / Use of a cane on a large step or curb

Phase 4

WALKING WITH ASSISTIVE DEVICE Assistive Devices to aid Walking Negotiating Hills

If the hill is steep or the patient is fearful, the patient should begin by sidestepping (walking sideways) or walking in a zig-zag pattern up the hill leading with the non-prosthetic limb. When the patient descends a hill, he/she should be sure to press the limb back in the socket to straighten the knee in anticipation of weight acceptance. Another method of ascending a hill is for that patient to face the hill and takes a small step forward with the non-prosthetic, then prosthetic limb. To descend, the patient can sidestep leading with the prosthetic limb. Another way to descend a hill is for the patient to face the hill and takes a small step forward with the prosthetic limb, pressing the limb back in the socket in anticipation of weight acceptance. The non-prosthetic limb follows.

Use of a walker on hills (ascending)

The patient can negotiate hills either forward-facing or sideways (as above). When ascending, the walker is moved first, followed by the non-prosthetic limb. To descend, the walker is moved first, followed by the prosthetic limb, then non-prosthetic limb. Eventually, the walker and the prosthetic limb can move together at the same time.

PHASE 4 â&#x20AC;˘ WALKING WITH ASSISTIVE DEVICE / Assistive Devices to aid Walking / Use of a walker on hills: ascending

Phase 4

WALKING WITH ASSISTIVE DEVICE Assistive Devices to aid Walking Use of a walker on hills (descending)

PHASE 4 â&#x20AC;˘ WALKING WITH ASSISTIVE DEVICE / Assistive Devices to aid Walking / Use of a walker on hills: descending

Phase 4

WALKING WITH ASSISTIVE DEVICE Assistive Devices to aid Walking Use of crutches on hills (ascending)

The patient can negotiate hills either forward-facing or sideways (as above). When ascending, the patient steps forward with the nonprosthetic limb first, followed by the assistive device and prosthetic limb. To descend, the assistive device is moved first, followed by the prosthetic limb, then non-prosthetic limb. Eventually, the assistive device and prosthetic limb can move together as the same time

PHASE 4 â&#x20AC;˘ WALKING WITH ASSISTIVE DEVICE / Assistive Devices to aid Walking / Use of crutches on hills: ascending

Phase 4

WALKING WITH ASSISTIVE DEVICE Assistive Devices to aid Walking Use of crutches on hills (descending)

PHASE 4 â&#x20AC;˘ WALKING WITH ASSISTIVE DEVICE / Assistive Devices to aid Walking / Use of crutches on hills: descending

Phase 4

WALKING WITH ASSISTIVE DEVICE Assistive Devices to aid Walking Use of canes on hills (ascending)

PHASE 4 â&#x20AC;˘ WALKING WITH ASSISTIVE DEVICE / Assistive Devices to aid Walking / Use of canes on hills: ascending

Phase 4

WALKING WITH ASSISTIVE DEVICE Assistive Devices to aid Walking Use of canes on hills (descending)

PHASE 4 â&#x20AC;˘ WALKING WITH ASSISTIVE DEVICE / Assistive Devices to aid Walking / Use of canes on hills: descending

Phase 4

WALKING WITH ASSISTIVE DEVICE Assistive Devices to aid Walking Getting up from the Floor

There is no correct or incorrect way to get on and off the floor. There are ways that are safer, and ways that require less strength. It is best to demonstrate the floor transfer for the patient, and then have him/her try it. The clinician should remain close for safety. Falling is a common problem for patients with above knee amputations. Therefore, this is an important skill for people to have.

Getting up from the Floor without help

The patient moves to a hands and knees position. The patient bends the hip and knee of the non-prosthetic limb and places the foot flat onto the floor with the other leg in the kneeling position. Next, the patient places his/her hands on the thigh of the non-prosthetic limb and applies pressure in a downward direction to help straighten the knee as the patient stands.

Note: If the patient needs assistance refer to assistance with family member and/or chair. The patient may also use a wall if available to assist with returning to standing.

PHASE 4 â&#x20AC;˘ WALKING WITH ASSISTIVE DEVICE / Assistive Devices to aid Walking / Getting up from the Floor

Phase 4

WALKING WITH ASSISTIVE DEVICE Assistive Devices to aid Walking Using a family member to get up from the floor

The patient moves to a hands and knees position. The family member stands in front of the patient more towards the prosthetic limb. The patient bends the hip and knee of the nonprosthetic limb and places the foot flat onto the floor with the other leg in the kneeling position. The patient place one hand on the non-prosthetic thigh and applies downward pressure on the non-amputated thigh to help straighten the knee as the patient stands. The patientâ&#x20AC;&#x2122;s other hand is placed onto the family memberâ&#x20AC;&#x2122;s shoulder to push down on. The family member should not lift the patient but rather assist the patient using as little assistance as necessary. The family member provides stability and helps the patient maintain his/her balance.

PHASE 4 â&#x20AC;˘ WALKING WITH ASSISTIVE DEVICE / Assistive Devices to aid Walking / Using a family member to get up from the floor

Phase 4

WALKING WITH ASSISTIVE DEVICE Assistive Devices to aid Walking

Using a sturdy chair to get up from the floor and sit

Have the patient support themselves on their hands and knees and crawl to the nearest chair or sofa. If necessary, push the chair against a wall to make it more stable. The patient kneels in front of the chair. The patient puts his/her hands on either side of the chair or hip-width apart on the sofa, and leans forward. The patient bends the hip and knee of the non-prosthetic limb and places the foot flat onto the floor while the other knee is in the kneeling position. Pressing down on the chair, the patient straightens the non-prosthetic limb and brings the prosthetic limb forward and comes to a standing position. The patient may also push himself/herself up partially, turning towards the non-prosthetic limb 1 2 3 and sit on the chair.

PHASE 4 â&#x20AC;˘ WALKING WITH ASSISTIVE DEVICE / Assistive Devices to aid Walking / Using a sturdy chair to get up from the floor and sit

Phase 4

WALKING WITH ASSISTIVE DEVICE Assistive Devices to aid Walking

Using a sturdy chair to get up from the floor and stand

PHASE 4 â&#x20AC;˘ WALKING WITH ASSISTIVE DEVICE / Assistive Devices to aid Walking / Using a sturdy chair to get up from the floor and stand87

Phase 4

WALKING WITH ASSISTIVE DEVICE Assistive Devices to aid Walking

Using a tree to get up from the ground and stand

PHASE 4 â&#x20AC;˘ WALKING WITH ASSISTIVE DEVICE / Assistive Devices to aid Walking / Using a tree to get up from the ground and stand

Phase 4

WALKING WITH ASSISTIVE DEVICE Assistive Devices to aid Walking

Getting on a high surface (bed of a pick-up truck)

It is important for patients to know how to get up and down from a vehicle that is used for public transportation. In some locations this could be the back of a truck. The patient approaches the high surface and turns facing away from the surface. Standing as close to the surface as possible, the patient reaches back for the surface with both hands. Pushing on the hands the patient lifts the hips and sits on the surface. To get off of the high surface, the patient should move his/her body to the very edge and slowly lower the nonprosthetic limb to the floor first, then the prosthetic limb.

PHASE 4 â&#x20AC;˘ WALKING WITH ASSISTIVE DEVICE / Assistive Devices to aid Walking / Getting on a high surface (bed of a pick-up truck)

Phase 4

WALKING WITH ASSISTIVE DEVICE Assistive Devices to aid Walking

Getting off a high surface (bed of a pick-up truck)

PHASE 4 â&#x20AC;˘ WALKING WITH ASSISTIVE DEVICE / Assistive Devices to aid Walking / Getting off a high surface (bed of a pick-up truck)

PATIENT EVALUATION

Mobility, Balance and Strength Assessment It is important to assess the patient’s strength and performance, since weakness, decreased confidence and poor technique can all contribute to poor outcomes. The assessment chart is a tool that can be used with each patient to help identify areas of poor performance. The tool also helps the clinician decide how to improve a patient’s performance with targeted exercises. The items on the assessment tool are based on several research studies which have found these tests to be important, identifying the patient’s potential to walk well. Each item on the chart will be explained in detail below. All items are easy to perform and can be learned quickly. The complete assessment can be completed in 10-15 minutes.

1. Amputated leg range of motion Hip Extension (most important motion) Position: patient lying down or standing

Hip Abduction Position: patient lying down or standing

Ideal performance: A minimum of 10 degrees of extension is needed for walking with a prosthetic device. A minimum of 0 degrees of hip abduction/adduction is needed for walking with a prosthetic device.

PATIENT EVALUATION / Mobility, Balance and Strength Assessment

PATIENT EVALUATION

Mobility, Balance and Strength Assessment 2. Don/doff the prosthetic device

Clinician: Watch the patient put on the prosthetic device. Ideal performance: The patient is able to put on the prosthetic device independently, with proper alignment.

3. Stand up from a chair

Instructions to patient: “Fold your arms across chest and try to stand up, use your hands only if you need to.” Ideal performance: The patient is able to stand up and sit down safely without use of hands on first attempt.

4. Repeated sit to stand

Instructions to patient: “Stand up and sit down 5 times as quickly as possible.” Clinician: Measure the time to repeat 5 sit to stands. Start when patient begins to move, stop when the patient’s bottom touches the chair. Ideal performance: The patient completes the task in less than 10 seconds, without use of the hands.

7. Single leg balance

Instructions to patient: “Stand with your arms at your sides, stand on one leg and balance yourself. You can use the parallel bars. Do not let your legs touch together. Repeat this activity standing on the other leg.” Clinician: Stand near the patient for safety. Time how long the patient can balance (up to 30 seconds). Ideal performance: The patient is able to balance on each leg for 30 seconds without support or loss of balance.

8. Standing reach

Instructions to patient: “Reach forward and grasp my hand. Do not move your feet.” Clinician: Hold hand 12 inches in front of the patient’s outstretched hand. Ideal performance: The patient is able to reach 12 inches beyond the outstretched arm without loss of balance or use of support.

5. Balance with eyes open

Instructions to patient: “Stand with your feet together, arms folded across your chest.” Clinician: Time how long the patient can balance (up to 30 seconds). Ideal performance: The patient is able to stand for 30 seconds without needing assistance or loss of balance.

6. Balance with eyes closed

Instructions to patient: “Stand with your feet together, arms across your chest, now close your eyes.” Clinician: Stand near the patient for safety. Time how long the patient can balance (up to 30 seconds). Ideal performance: The patient is able to stand for 30 seconds without opening eyes, needing assistance or loss of balance.

PATIENT EVALUATION / Mobility, Balance and Strength Assessment

PATIENT EVALUATION

Mobility, Balance and Strength Assessment 9. Push test

Instructions to patient: “Stand with you feet close together. Keep your balance as I try to push you three times.” Clinician: Stand close to the patient for safety. Push the patient three times lightly in the sternum. Push enough so the patient’s toes rise up from the floor. Ideal performance: The patient is able to maintain upright posture without grabbing for help.

10. Picking object from the floor

Instructions to patient: “Pick up the object from the floor.” Clinician: Stand close to the patient for safety. Place an item on the floor one step away from the patient. Ideal performance: The patient is able to grab the item and return to standing without loss of balance.

11. Standing with weights in extended arms

Instructions to patient: “Hold these weights as long as you can, standing with your arms out held in front of you with your wrists as high as your shoulders.” Clinician: Time how long (up to 2 minutes) the patient is able to hold the position. If the patient stops the activity, ask why and if it is because of back fatigue. Ideal performance: The patient is able to maintain the position for 2 minutes.

12. Getting down and up from the floor

Instructions to patient: “As best you can sit on the ground and then stand back up. You may use the chair/wall for support if needed.” Clinician: Have patient near a chair or wall for support, stand close to the patient for safety. Ideal performance: The patient is able to perform the transfer safely and with no assistance.

11. Image taken from research study Shipp et al, 2000.

13. Stepping up and down from a medium step

Instructions to patient: “Step up and down this step. You may use support if you need to.” Clinician: Stand by the patient for safety Ideal performance: The patient is able to step down no assistance or with the assistance of a single cane or crutch.

14. Stepping up and down from a large step

Instructions to patient: “Step up and down this step. You may use support if you need to.” Clinician: Stand by the patient for safety Ideal performance: The patient is able to step down with only the assistance of a single cane or crutch.

PATIENT EVALUATION / Mobility, Balance and Strength Assessment

PATIENT EVALUATION WALKING Assessment

To observe how well a patient is walking, the clinician should watch from different positions. To begin stand behind the patient and have them walk away from you to a target and then turn around and walk back to the starting position. Your eyes should move from the feet upward, looking at one joint at a time. You may need to have the patient walk several times. This process should be repeated when standing at the side of the patient. Abnormal movements during walking should be easy to notice.

ASSESSMENT FROM THE FRONT OR THE BACK VIEW

15. Start walking after “Go”

Instructions to patient: “When I say “go,” walk forward.” Ideal performance: no hesitation

16. Feet

Ideal performance: The patient’s first contact with the floor is through the heel. The foot remains in a straight line under the body as weight comes off of the prosthetic device.

17. Leg swing

Ideal performance: The prosthetic limb moves forward in a straight line.

PATIENT EVALUATION / WALKING Assessment

18. Trunk posture

Ideal performance: The patient is able to maintain upright posture, with the eyes looking ahead. The shoulder rotates opposite of the pelvis (when the right shoulder is forward the left pelvis is forward).

19. Pelvis

Ideal performance: The pelvis remains level (ASIS in a line) throughout walking, and rotates opposite of the shoulders.

20. Shoulders and arms

Ideal performance: The shoulders are relaxed. Forward arm swing occurs when the opposite leg steps forward (right step with left arm swing). The arm swing equal in size, comparing the left and right sides.

PATIENT EVALUATION WALKING Assessment

ASSESSMENT FROM THE SIDE VIEW 21. Step length

25. Walking fast and slow

22. Step height

Ideal performance: Both feet clear the floor without dragging.

Ideal performance: The patient is able to turn 180 degrees to each side in less than 3 steps, with no significant loss of balance or loss of upright posture.

23. Step continuity

27. Knees

Clinician: Watch the distance between the two heel strikes for a few steps. Ideal performance: The leg advances a minimum of 12 inches/30.5 centimeters forward. The step size of the prosthetic leg is equal to the step size of the non prosthetic leg.

Ideal performance: Steps are continuous.

24. Walking speed

Clinician: Measure the distance of 7 meters (m) on the floor. Mark the floor at the start, 1m, 6m and 7m (1m_5m__1m). The meter at the beginning and the end of the path is for acceleration and deceleration. Time how long it takes the patient to walk the 5m. Start timing when the patient’s foot crosses the 1 meter mark, and stop when the first foot crosses the 6 meter mark. To calculate the walking speed divide the distance walked over the time to complete. Instructions to patient: “Walk from here (0m) to here (7m) as fast as you can safely.” Ideal performance: For unlimited walking in the community, the patient walks with a speed faster than 0.8 meters/second or 2.625 feet/second. For limited walking in the community, the patient must walk at a speed of at least 0.4 meters/second or 1.31 feet/second.

PATIENT EVALUATION / WALKING Assessment

Instructions to patient: “Walk at your normal speed. When I say “fast,” speed up; and when say “slow,” slow down.” Ideal performance: The patient is able to noticeably change speeds with smooth transitions, without hesitation.

26. Turning 180 degrees

Ideal performance: The knee on the prosthetic device bends before the foot comes off the ground. The knee is mostly straight when the foot first contacts the ground. Both legs should have an equal amount of knee bending and straightening.

28. Back posture

Clinician: You may need to lift the patient’s shirt to examine the back posture Ideal performance: The patient is able to walk while maintaining the slight curvature in the low back. The size of curvature in standing should be the same when the patient is walking.

GLOSSARY OF TERMS

Base of Support: The distance between the two feet when the feet are parallel with one another.

Mid-swing: Begins when the swinging foot is even with stance foot and ends when the swinging leg has moved passed the stance leg, but knee straightening has not yet occurred.

Early swing: Begins as the foot is lifted off the ground and ends when the swinging foot is even with stance leg.

Step length: The distance between the two heels when a step is taken.

Foot flat: When the entire foot is in contact with the ground and the limb begins to accept the weight of the body.

Stride length: The distance between the two heels of the same foot during walking. Stride length is two consecutive step lengths of the same foot.

Ambulation: Walking

Heel off: Begins with the rise of the heel and continues until the other leg strikes the ground.

Toe off: When the stance leg is pushing off to propel the body forward.

Heel strike: When the heel first contacts the ground. Late swing: Occurs when knee straightening begins. It ends when the foot strikes the ground with a straight knee.

GLOSSARY OF TERMS

Trunk Lean: The patientâ&#x20AC;&#x2122;s trunk (body) moves laterally (to one side or the other), posteriorly (backwards) or anteriorly (forwards) relative to the legs.

references

Gailey RS, McKenzie A. (1989) Advanced Gait Training Program for Lower Extremity Amputees. Monograph, Advanced Rehabilitation Therapy, Inc. Gailey RS, McKenzie A. (1994) Stretching and Strengthening for Lower Extremity Amputees. Monograph, Advanced Rehabilitation Therapy, Inc. Gailey RS, McKenzie A. (1994) Balance, Agility, Coordination and Endurance for Lower Extremity Amputees. Monograph, Advanced Rehabilitation Therapy, Inc. Gailey RS, McKenzie A. (1995) Home Exercise Guide for Lower Extremity Amputees. Monograph, Advanced Rehabilitation Therapy, Inc. Gailey RS. (2006) Predictive outcome measures versus functional outcome measures in the lower limb amputee. Journal of Orthotics and Prosthetics Online Library. 8(1S), 51-60. Shipp KM, Purse JL, Gold DT, Pieper CF, Sloane R, Schenkman M, Lyles KW. (2000) Timed loaded standing: a measure of combined trunk and arm endurance suitable for people with vertebral osteoporosis. Osteoporosis International 11: 914-922.

REFERENCES

CLINICIAN RESOURCES › Sample Patient Evaluation Chart completed › Lower Extremity Medical Questionnaire › Above Knee Amputee Physical Therapy Evaluation

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Birth Date (dd/mm/yyyy): ___ / ____ / _____

Nickname: ___________________________

Full Name: ___________________________

Lower Extremity Amputation Description □RIGHT: □ABOVE KNEE □THROUGH KNEE □BELOW KNEE □LEFT: □ABOVE KNEE □THROUGH KNEE □BELOW KNEE What was/were the date(s) of your amputation(s) (dd/mm/yyyy)? _________________________ What was the reason for the amputation(s)? □BIRTH DEFECT □CANCER □CIRCULATION □DIABETES □INFECTION □TRAUMA □UNKNOWN Other surgeries?_________________________________________________________________ Have you EVER been diagnosed as having any of the following conditions? (check all that apply) □Cancer □Heart Problems □High Blood Pressure □Diabetes □ Epilepsy □Circulation Problems □ Alcohol/Tobacco Use □Dizziness □Phantom Pain or Sensation □Joint pain: ___________________ □Other:______________________ Are you currently wearing a prosthesis? □Yes □No If yes, how many hours/day? _______ hours/day What percentage of the time are you up walking? ____% How many days/week are you up walking? ____ days/week Are you having any problems with your prosthesis? □Yes □No If yes, what problems: ____________________________________________________________ Do you need assistance to walk? □Yes □No Help of another person? □All of the Time □Some of the time □Rarely □Never Wheelchair use? □All of the Time □Some of the time □Rarely □Never Crutches, walker, or a cane? □All the time □Some of the time □Rarely □Never How far can you walk? _____________________________________________________________ What is the reason you stop? ________________________________________________________ Do you have any concerns regarding your skin? □Yes □No If yes, what are your concerns? ______________________________________________________

LOWER EXTREMITY MEDICAL QUESTIONAIRE

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Gender: M / F

6. Balance With Eyes Closed

5. Balance With Eyes Open

4. Repeated Sit to Stand (5x)

3. Stand Up From Chair

2. Don / Doff Prosthesis

FUNCTIONAL TASK

HIP EXTENSION HIP ABDUCTION HIP ADDUCTION

More than 10 degrees Able to get to 0 degrees Able to get to degrees PERFORMANCE (goal is bold) □Able □Needs verbal help □Needs physical help □Able (no hands) on first try □More than one attempt □ Uses hands □Needs physical help TIME: _______ □ Completes 5 in less than 10 seconds □Takes more than 10 seconds TIME: _______ □Can balance for 30 seconds □ 0-‐29 seconds □Needs physical help TIME: _______ □Can balance for 30 seconds □ 0-‐29 seconds □Needs physical help

STUMP: □Good Shape □Bad Shape □Skin Problems: Wound, scar or rash RIGHT Stump Length ______cm: □ABOVE KNEE □THROUGH KNEE LEFT Stump Length ______ cm: □ABOVE KNEE □THROUGH KNEE Prosthetic description: ________________________________________________________________________ Current Suspension: □ Direct suction □Pelvic band □ Other EXAMANATION RESULTS: Muscle strength testing: _______________________________________________________________________ RIGHT LEFT GOAL 1. RANGE OF MOTION

OBJECTIVE FINDINGS:

Equipment: □Wheelchair □Forearm Crutch □Armpit Crutch □Walker □Cane

________________________________________________________________________________________________

PATIENT HISTORY: ____________________________________________________________________________

ABOVE KNEE AMPUTEE PHYSICAL THERAPY EVALUATION

Birth Date (dd/mm/yyyy): ___ / ____ / _____

Nickname: ____________

Full Name: ___________________________

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(PROSTHESIS SIDE) TIME: _______ (NORMAL SIDE) TIME: _____ □Can balance for 30 seconds on each leg □ 0-‐29 seconds on prosthetic side REACH: _______ inches Standing Reach □Able to reach 12 inches without loss of balance □Able to reach 1-‐11 inches □Loses balance □Able to stay standing without loss of balance Push Test (3x) □ Loses balance □Able to grab without loss of balance Picking Object From the Floor □Unable to reach object □ Loses balance TIME: _______ Standing With Weight in Extended □Able t o h old f or 2 m inutes Arms □ Drops arms or stops before 2 minutes □Independent and safe Get Down and Up From The Floor □Needs verbal help □Needs physical help Step Up and Down From MEDIUM Step □Independent and safe with single crutch or cane □Needs walker or two crutches □Needs physical help Step Up and Down From a LARGE Step □Independent and safe with 1 crutch or 1 cane □Needs a walker or 2 crutches □Needs physical help

□Upright posture □Eyes looking ahead □Trunk and pelvis rotate opposite □The pelvis and hips remains level during walking

18. Trunk Posture

19. Pelvis

20. Shoulders and Arms □Shoulders are relaxed □Arm swings with the opposite leg □Arm swing is same size

straight line under the body

□Prosthesis moves forward in a

17. Leg Swing

ground

□The heel rotates in or out before moving forward (WHIP) □Bent forward □Bent to one side □Eyes looking down □Trunk and pelvis are stiff □The opposite hip drops when standing on the prosthesis □The same hip lifts up when swinging the prosthesis □Shoulders are lifted up to ears □No arm swing □Uneven arm swing

□Lifting the heel of the good foot (VAULTING) when standing on the good leg □Prosthesis swings to the side (CIRCUMDUCTION)

WALKING ASSESSMENT: VIEW PATIENT FROM THE FRONT OR BACK NORMAL NOT NORMAL □ □ 15. Starting walking No delay Delay in moving after “Go” □Heel touches floor first □Bottom of foot touches floor first 16. Feet □Foot is in line with the hip on the □Foot is inside or outside of hip

14.

13.

12.

11.

10.

7. Balance On One Leg

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___________________________________________________________________________________________ □Return to the clinic in _____ weeks GOALS FOR THERAPY: □ The patient is able to perform the exercises □The patient will improve performance on number _____ to listed goal/normal value □ The patient will improve performance on number _____ to listed goal/normal value □The patient will improve performance on number _____ to listed goal/normal value EXAMINATION COMPLETED BY: ____________________________ EXAM DATE: __________________

□Limited ROM □Skin problems on stump □Bad prosthetic fit □Bad Balance □Bad technique with stairs □Weakness □Abnormal walking □Slow walking speed □Bad technique with transfers Recommendations: □Practice Exercises at home: ___________________________________________________________________

PROBLEMS:

__________________________________________________________________________________________

PT ASSESSMENT: ___________________________________________________________________________

28. Back Posture

27. Knees

26. Turing 180 degrees

□Able to change speed □Smooth transition □No loss of balance □Able to turn to each side □Less than 3 steps to turn □No loss of balance □The prosthetic knee is mostly straight when the artificial heel/foot hits the ground □The prosthetic knee bends before the foot comes off the ground □Knee movement is the same size on both sides □The patient can keep a small curve in □The patient back curvature increases during the low back while walking walking □The curvature size is the same with □The low back curve changes during walking walking and standing

25. Walking Fast and Slow

□Only able to walk 0.4-‐0.8 meters/second for close distances only □Very slow speed (less than 0.4m/s) may need a wheelchair □Unable to change speed □Stop of walking during speed change □Loss of balance □Unable to turn to one side □Takes more than 3 steps □Loss of balance □The prosthetic knee is bent when the artificial foot touches the ground □The prosthetic knee does not bend each time □The prosthetic knee bends at the wrong time □Knee movement is not equal on both sides (bend and straight)

□Able to walk faster than 0.8 meters/ second or 2.625 feet per second to be able to walk around outdoors

24. Walking Speed

23. Step Continuity

22. Step Height

21. Step Length

WALKING ASSESSMENT: VIEW PATIENT FROM SIDE □Each foot moves forward at least 12 □Small steps inches / 30.5 cm □Uneven step size □The step size of each leg is equal □Feet do not drag on the floor □Foot drag □Both feet are the same distance from □One foot lifts higher during swinging the floor during swinging □No breaks or stopping during walking □Consistent breaks or hesitations

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