Prosthetic Gait Evaluation & Deviations

what does examination look like before any gait elements?

edema control or areas of skin breakdown

quality/shape or residual limb

quality of intact limb

pt management of prosthesis 

gait specific to prosthesis 

what do areas of skin breakdown indicate?

indicate poor socket fit

indicate poor alignment of components

contribute to gait deviations due to pain

what should gait look like for a unilateral TT and a unilateral TF?

unilateral TT: should look like normal gait or very close

unilateral TF: may see lateral trunk lean, especially if residual limb is short

what will gait look like if they have a bilateral TT or TF?

TT variable gait but will compensate with a wide BOS likely device

how should gait assessments be done?

should occur in all planes

may need to have someone else gaurd the pt in walking

gait assessment is always ongoing

what are the phases of gait that we are looking at? 

initial contact 

loading response 

midstance 

pre-swing

swing 

what is the TKA line?

the throchanter, knee, ankle line and if the hip is behind that line the knee will be locked into extension, if it is front of that line the knee will flex

what are some things that qualify as gait training?

simple walking with a pt for endurance or strengthening is not always gait training

tell (verbal cues)

show (demonstrate)

cue manually

what is included in the gait training code? 

training patients whose walking abilites have been imparied by neurological, muscular, or skeletal abnormalities or trauma 

determine if issue is impairment based for motor planning/motor learning based 

what is included in neuro-re ed activites?

could be mat exercises but more typically WB exercises

use when working on WB activites related to purposes noted

think part practice vs. whole practice

what are some things apart of gentiles taxonomy of skills?

body stable vs. body transport

with or without manipulation

with or without intertrial variability

closed vs. open environment

what are the 3 different prosthetic alignment principles? 

bench: is the alignment set-up recommended by the manufactuere before the leg is donned by the patient 

static: the alignment when the leg is first put on the patient, and they stand still

dynamic: alignment is what the prosthetist does when the prosthesis is on the patient during gait, making changes relative to activity or position 

what is alignment the balance of?

between providing inherent stability within the prosthesis and allowing for mobility

what are some examples of a prosthetic problem vs. an amputee problem?

prosthetic: alignment, socket fit, charactersitcs of selected components

amputee: contracture, weakness, fear, insecurity

what is the TT bench alignment? 

sockets typically set in 5 degrees of flexion which improves suspension 

frontal- center of post falls ½ inch lateral ot the center of heel 

sagittal: center of lateral wall to just anterior of the heel 

why does a TF need to be in slight hip flexion

increases weight bearing on posterior surfaces

helps hip extensors generate more force

decreases range of hip extension needed for normal gait

PT take home: if pt is having difficulty w/ knee instability, could be strength or ROM issue; more flexion in the socket could help

why are TF sockets put into adduciton?

positions femur in more of an anatomical position for gait

helps hip adductors generate more force

compensates for loss of adductor force

socket must maintain the femur in this position during stance for approrpitae glut med function

what are 3 ways the patient can control the TKA line? 

A. prosthetic alignment compensation 

B. static compensation by patient 

C. Dynamic compensation by patient (firing hip extensors BEST)

what are some accomodatiosn that can be made for a hip contracure?

done at the knee, patients often feel Iike they are falling backwards

if a TT is having too much knee flexion what are some things that could be related to the patient vs. prosthesis? 

patient: weak knee extensors

heel on shoe too high

prosthesis: foot too postieror on socket 

heel cushion too firm 

foot too dorsiflexed 

reasons for early knee flexion in a TF? 

patient: timing/sequencing of hip extension

poor weight transfer onto prosthetic leg

prosthesis: too long 

knee joint resistance too light 

knee joint set into too much flexion

foot allows too much dorislfexion 

what are interventiosn for TT and TF early knee flexion?

TT: quad timing and control via weight shifts

TF: glutes timing and control, plus effective latearl weight shift

reasons for too much ER at heel strike for TT/TF?

patient: donning incorrectly

excessive hip ER

poor weight transfer

prosthesis: socket fit problem

DF/PF adjustment issue

if TF, knee tracking can be off

problems with lateral trunk lean in TT? 

patient: hip weakness, socket fit/sock management 

prosthesis: too short or too long 

poor socket fit 

foot set too far medial 

reasons for a lateral trunk lean in TF? 

patient: weak abductors, inadequate weight shift, socket fit/sock management 

prosthesis: prosthetsis too short or long 

inadequate adduction of femur within socket 

medial wall too high or too low 

what are some interventoisn to help lateral trunk lean?

power in glute med, rotations

what are some reasons for a wide bOS in midstance for a TT?

patient: poor weight shifting onto prosthesis, sock management/socket fit

prosthesis: too long, foot set too laterally

reasons for wide BOS in TF?

patient: abduiton contracutre, poor weight shift, weak abductors

prosthesis: too long, high medial wall,inadequate adduction of femur

what are some interventions for TT/TF and wide BOS? 

focus on proper foot placement then weight shifting through pelvis to prosthetic side 

what are some reasons for delyaed knee flexion in TT?

patient: fear/habit related to wanting decreased stance time on prostheis

timing/sequening or weakness of quads

prosthesis: foot set too anteriorly, foot set in too much PF, prosthesis too short

what are some reasons for delayed knee flexion in TF?

patient: timing/sequencing of hip flexion,

inadequate weight shift

prosthesis: too short

too much resistance set in knee

what are some interventions to do for delyaed knee flexion?

hip flexion to encourage knee flexion, plus TKA line

what are some reasons for hip hiking in TT/TF? 

weak hip flexion

timing/sequening of hip flexion/extension

decreased hip ROM

poor sock management 

habit/fear

prosthesis: too long, or excessive knee friction 

what are some reasons for circumduction in TT/TF?

patient: weak hip flexion, timing/sequencing of hip felxion, decreased hip ROM, poor sock management, habit/fear

prosthesis: too long, excessive knee friction/resistance

what are some reasons for vaulting in TF? 

patient: weak hip felxion, timing/sequencing of hip flexion, decreased hip ROM, poor sock management, habit/fear

prosthesis: too long, excessive knee frcition 

what are some interventiosn for vaulting in TT and TF?

TT: less seen, more common to see toe drag, focus on kicking out

TF: focus on hip flexion and foot placement

what are some reasons for a lateral whip TF?

patient: socked donned in IR, poor sock management

prosthesis: possible foot or knee angle alignment

what are some reasons for a medial whip TF? 

patient: socket donned in ER, poor sock management 

prosthesis: possible foot or knee angle adjustment? 

what are some reasons for uneven step length and cadence?

patient: fear of putting weight equally on the prosthesis, extended use of walker, decreased ROM/strength

prosthesis: socket not set in enough flexion, poor overall socket fit

what are some reasons for uneven arm swing in TT and TF?

frequetly accompnaies uneven step length

reflection of lack of normal trunk/pelvic rotation or fear of falling

you can’t get arm swing without pelvic rotation and you can’t get pelvic rotaiton without proper weight shift

what are some interventions to work on rotation?

hold pelvis and make them push through your hand

what are Gaileys FLAG for training? 

step width

step length

toe load

knee flexion

pelvic rotation

trunk rotaiton 

what is the role of the PT in all of htis?

identify deviations and possible causes

address any patient-related causes first to see if deviation improves

consult with prosthesis

reconigze one problem can cause multiple

best-case scenario: ask prosthesit to attend PT session

what are some goals for TT?

WB tolerance, endurance, balance, functionla activites

what are some intervetnions focused for TF?

forceful hip extension

leg swings

heel strikes

targeting

step-ups

step-overs

what are some gait training ideas for TF? 

baby steps- small steps to increase need for finger control

resisted walked with Theraband

step-ups or step-overs can work on flexion and extnsion concurrenlty