Improving Transfemoral Amputee Gait: A Step in the Right ... Gait... · Rabuffetti, M., Recalcati,...

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Improving Transfemoral Amputee Gait: A Step in the

Right Direction

1

Continuing Education Series

Improving Transfemoral Amputee Gait:A Step in the Right Direction


Disclosure Statements

I have the following relevant relationships in the products or services described, reviewed, evaluated or compared in this

presentation.

Hanger Clinic• Our speaker is a paid employee of Hanger Clinic and

receives a salary.

Other Disclosures (if any):

• Financial

• Nonfinancial relationships (i.e. board member, association committees outside of Hanger Clinic)


Hanger ClinicContinuing Education Program

Spinal Orthotics

Lower Limb Orthotics

Upper Limb Orthotics

Lower Limb Prosthetics

Upper Limb Prosthetics

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Improving Transfemoral Amputee GaitA Step in the Right Direction

What gait deviation do you see here?


Learning Outcomes

Upon completion of this presentation, the participant will be able to:

• Describe processes oftransfemoral prosthetic alignment

• Identify common transfemoralgait deviations

• Explain the cause(s) ofcommon transfemoral gait deviations

• Discuss how therapy canimprove patient outcomes


Agenda

• Bench, Static, and DynamicAlignment

• Gait Deviations Definitionso Stance Phase Deviationso Swing Phase Deviations

• Therapy Goals

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Improving Transfemoral Amputee Gait: A Step in the Right Direction

Four Factors of Gait• Patient• Socket Fit

• Prosthetic alignment• Physical Therapy


• Walking is defined as “the translation of the centerof mass through space in a manner requiring theleast energy expenditure.” (Saunders, Inman, & Eberhart, 1953)

• The six determinants or variables that affectenergy expenditure of gait:

o pelvic rotationo pelvic tilto knee flexion at mid-stanceo foot and ankle motiono knee motiono lateral pelvic displacement

What is normal gait?


Alignment

• Bench – Completed prior to placing the prosthesison the patient

• Static – Performed with the patient standing• Dynamic – Observed during ambulation

Alignment is adjustable in all three planes of motion

• Sagittal – flexion/extension, A-P slide• Coronal – abduction/adduction, M-L slide• Transverse – internal/external rotation

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Alignment Definitions

Socket flexion

Toe lever arm

Heel lever arm


Alignment Definitions

TKA(Trochanter/Knee/Ankle)

• Stationary alignment line toidentify the relative alignment between the center of socket weight line, the rotation point of the knee and the functional rotation point of the ankle/foot

• Knee center typically slightlyposterior to TKA line

Trochanter

Knee

Ankle


Bench AlignmentSagittal Plane

A-P alignment: TKA from trochanter to anterior of front of heel

• Can vary slightly for some feet, goal is to be inthe correct rotational alignment point for foot

A-P socket tilt: Initial 5 to 10 degrees of socket flexion*

• Must be 5 degrees greater than the flexioncontracture.

• 10° flexion contracture = socket set in 15° socket flexion

• 0° flexion contracture = 5-10° socket flexion

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Bench AlignmentCoronal Plane

• Socket alignment with approx. 5 to 7degrees of adduction

• The knee unit alignment is typically 5degrees externally rotated from theline of progression

• Center of the heel to fall just under thepoint of contact of the ischial tuberosityin the socket


Bench AlignmentTransverse Plane

Line

Of P

rogr

essi

on

Knee Axis

3 - 5 degrees externally Rotated

Foot Axis

5 – 7 degrees externally Rotated

• Socket rotation• Knee Rotation• Foot rotation


Static Alignment

• Check the overall height of theprosthesis and verify the knee centermatches the sound side

• Check that the pylon is vertical

• Check the trim lines and overallcomfort of the socket

• Make sure that the knee is stable, thefoot is flat on the ground, and theback has a normal lordotic curve

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Gait Deviations

Prosthetic Cause

• Identify alignment or design aspectsof the prosthesis that can cause orcontribute to the deviation.

• Determine what adjustments ormodifications to the prosthesis canbe made to correct the deviation.

Amputee Cause• Identify habits or conditions that the patient is doing that can

cause or contribute to the deviation.

Therapy Goals• Determine what therapy or gait training intervention can be

provided to assist the patient to correct or address the deviation.


Medial Whip

Prosthetic Cause• External rotation of the knee• Tight socket• Incorrect foot rotation• Cylindrical socket shape vs anatomical• Heel too stiff

Amputee Cause• Gait habit• Socket not put on properly• External rotation of hip at toe off/hip

flexionTherapy goals• Encourage proper donning• Strengthen internal hip rotators

and hip extensors


Lateral Whip

Prosthetic Cause• Internal rotation of the knee• Loose socket• Incorrect foot rotation• Cylindrical socket shape vs anatomical• Heel too stiff

Amputee Cause• Gait habit• Socket not put on properly• Internal rotation of hip at toe off/hip

flexion• Tight adductors, int. rotators, flexors

Therapy goals• Encourage proper donning• Strengthen external hip rotators• Stretch hip flexors and adductors

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Abducted Gait

Prosthetic Cause• Prosthesis too long• Medial wall too high• Insufficient femoral stability in

socket- may cause distal-lateral femoral pressure

• Induces medial whip

Therapy goals• Stretch abductors• Strengthen core, residual limb

and sound leg

Amputee Cause• Abduction contracture• Poor gait habit, patient insecure and

desires wide basin in belief it will increase stability


Circumducted Gait

Prosthetic Cause• Long prosthesis• Excessive knee friction• Excessive knee stability

Therapy goals• Stretch abductors• Strengthen hip flexors• Gait training

Amputee Cause• Lack of confidence in flexing knee• Abduction contracture• Weak hip flexors• Habit, using entire hip and pelvis to

initiate gait


Vaulting

Prosthetic Cause• Long prosthesis• Poor suspension• Excessive plantar flexion of foot• Excessive knee resistance or stability• Inadequate knee extension assist

Therapy goals• Strengthen hip flexors• Work on timing and symmetrical

pelvic rotation

Amputee Cause• Gait habit, fear of catching toe• Weak hip flexors on residual limb• Improper initiation of hip flexors on

residual limb

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Heel Rise

Amputee Cause• Excessive use of hip flexors to

initiate swing phase, overpowering knee unit

Therapy goals• Work on coordination and encourage

symmetrical motion of the femurs• Work on timing of flexor firing

Prosthetic Cause• Inadequate extension aid• Insufficient knee friction• Improper knee selection


Knee Instability

Prosthetic Cause• Excessive dorsiflexion• Knee aligned in unstable

position…TKA• Insufficient socket flexion• Poor foot alignment• Incorrect knee settings

Therapy goals• Strengthen hip extensors• Stretch hip flexors

Amputee Cause• Weak hip extensors• Hip flexion contracture


Uneven Timing

Prosthetic Cause• Socket Pain• Weak extension aid• Unstable knee• Leg length discrepancy• Poor suspension

Therapy goals• Strengthen hip flexors and

extensors• Improve balance

Amputee Cause• Patient insecurity• Weak hip muscles• Poor balance

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Lateral Trunk Bend

Prosthetic Cause• Foot too far outset• High medial wall• Aligned in abduction

Therapy goals• Improve balance• Strengthen core

Amputee Cause• Inadequate balance• Short residual limb• Habit


Toe Drag

Prosthetic Cause• Long prosthesis• Excessive plantar flexion• Excessive knee friction

Therapy goals• Strengthen hip extensors and hip abductors• Encourage pelvic motion to initiate enough knee

flexion for swing phase

Amputee Cause• Weak hip extensors• Weak hip abductors on sound side• Poor posture• Poor gait habits


Wide Gait

Prosthetic Cause• Prosthesis too long• Medial wall too high• Insufficient femoral stability

Therapy goals• Stretch abductors• Strengthen core, residual limb and sound

leg

Amputee Cause• Abduction contracture• Poor gait habit, patient insecure and

desires wide base in belief it will increase stability

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Internal Foot Rotation

Prosthetic Cause• Internal knee rotation• Internal foot rotation• Socket design issues• Excessive quad pressure

Therapy goals• Work on donning correctly• More upright position during

ambulation

Amputee Cause• Improperly donning socket• Flexed at the hip during gait,

typically with walker orcrutches, looking down atground


External Foot Rotation

Prosthetic Cause• External knee rotation• External foot rotation• Socket design• Tight adductor channel in

socket

Therapy goals• Work on donning correctly

Amputee Cause• Improperly donning socket


Uneven Pelvic Rotation(Guarded Gait)

*In normal gait, the pelvismoves 5 degrees anterior and posterior from neutral position

Atlas of amputations and limb deficiencies

Prosthetic cause• Instability of prosthesis• Poor suspension• Proximal trim line is too high or tight

Therapy goals• Strengthen abductors• Stretch adductors• Gait training

Amputee Cause• Reduced pelvic rotation• Fear of falling• Weak abductors, excessive adductors• Habit

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Improving Transfemoral Amputee GaitA Step in the Right Direction

Four Factors of Gait

• Patient• Socket Fit

• Prostheticalignment

• PhysicalTherapy


Thank You and Feedback!Improving Transfemoral Amputee Gait:A Step in the Right Direction

Visit: HangerClinic.com/ContinuingEducation toprovide us with feedback on this presentation.


Improving Transfemoral Amputee Gait: A Step in the Right Direction

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CitationsBae, T.S., Choi, K., Hong, D., & Mun, M. (2007). Dynamic analysis of above-knee amputee gait. Clinical

Biomechanics, 22, 557-566. doi:10.1016/j.clinbiomech.2006.12.009

Baum, B.S., Schnall, B.L., Tis, J.E., & Lipton, J.S. (July, 2008). Correlation of residual limb length and gait parameters in amputees. Injury ,7, 728-733. doi:10.1016/j.injury.2007.11.021

Carroll, K. & Edelstein, J.E. (2006). Prosthetics and patient management: A comprehensive clinical approach. Thorofare, NJ: Slack Inc.

Farahmand, F., Rezaeian, T., Narimani, R., & Hejazi Dinan, P. (2006). Kinematic and dynamic analysis of the gait cycle of above-knee amputees. Scientia Iranica, 13 (3), 261-271. Tehran, Iran: Sharif University of Technology.

Highsmith, M.J., Schulz, B.W., Hart-Hughes, S., Latlief, G. Al, & Phillips, S.L. (2010). Differences in the Spatiotemporal Parameters of Transtibial and Transfemoral Amputee Gait. Journal of Prosthetics & Orthotics. 22(1) 26-30. doi: 10.1097/JPO.0b013e3181cc0e34

Kishner, S. (updated 2015). Gait Analysis After Amputation. Medscape. Retrieved on January 11, 2016 from http://emedicine.medscape.com/article/1237638-overview#showall

Lusardi, M.M. & Nielsen, C.C. (2006). Orthotics and prosthetics in rehabilitation, 2nd edition. St. Louis, MO: Elsevier Health Sciences.

Moylan, B., Paner, R., Pauley, T., Dilkas, S., & Devlin, M. (2015) Impact of increased prosthetic mass on gait symmetry in dysvascular transfemoral amputees: A randomized prospective double-blinecrossover trial. Journal of Prosthetics & Orthotics. 27(2) 63-67. doi: 10.1097/JPO.0000000000000056

Pelvic rotation (n.d.) Clinical Gait Analysis. Retrieved on January 12, 2016 from http://www.clinicalgaitanalysis.com/teach-in/pelvic-rotation.gif


CitationsPelvic rotation and stride length image (n.d.) Body alignment, posture, and gait. Retrieved on January

12, 2016 from http://www.chiro.org/ACAPress/Body_Alignment

Perry J. (1992). Gait analysis: Normal and pathological function. Thorofare, NJ: Slack Inc.

Rabuffetti, M., Recalcati, M. & Ferrarin, M. (2005). Trans-femoral amputee gait: Socket-pelvis constraints and compensation strategies. Prosthetics and Orthotics International, 29(2). doi: 10.1080/03093640500217182

Saunders, J.B., Inman, V.T. & Eberhart, H.D. (1953). The major determinants in normal and pathological gait. The journal of bone & joint surgery. 35, 543-558. Retrieved from jbjs.org/content/35/3/543

Sjodahl, C., Jarnlo, G-B., Soderberg, B., & Persson, B.M. (2003). Pelvic motion in trans-femoral amputees in the frontal and transverse plane before and after special gait re-education. Prosthetics and Orthotics International, 27(3). doi: 10.1080/03093640308726686

Smith, D.G., Michael J.W., Bowker, J.H. (2004) Atlas of amputations and limb deficiencies: surgical, prosthetic, and rehabilitation principles, 3rd edition. St. Louis, MO: American Academy of Orthopedic Surgeons.

Taheri, A., Karimi, M.T. (2012). Evaluation of the gait performance of above-knee amputees while walking with 3R20 and 3R15 knee joints. Journal of Research in Medical Sciences, 17(3), 258-263. Retrieved from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3527044

Talaty, M., & Esquenazi, A. (2013). Determination of dynamic prosthetic alignment using forcelinevisualization. Journal of Prosthetics & Orthotics. 25(1) 15-21. doi:10.1097/JPO.0b013e31827afc29.

Tura, A., Raggi, M., Rocchi, L., Cutti, A.G., Chiari, L. (2010). Gait symmetry and regularity in transfemoral amputees assessed by trunk accelerations. Journal of Neuroengineering and Rehabilitation, 7(4). Retrieved from http://www.jneuroengrehab.com/content/7/1/4

Improving Transfemoral Amputee Gait: A Step in the Right ... Gait... · Rabuffetti, M., Recalcati,...

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