Prosthetics and Orthotics - Comprehensive Notes
Post Fitting Phase - Chapter 9
Part 1: First Fitting
First Fitting:
Part 1: First fitting
Part 2: Gait training phase
Is the client ready to start post fitting training?
Responsibility:
The Prosthetist & Orthotist (P&O) with the help of the Physical Therapist (PT) checks the fitting of the prosthesis.
Aims:
To ensure that:
The prosthesis fits appropriately.
The client has adequate stability.
The client is satisfied with the device.
Why?
The prosthesis is easily adjustable at this stage.
Trans-Tibial (TT) Prosthesis - First Fitting
Steps:
Inspection of the stump
Check the prosthesis
Check stump sock
Donning and Doffing the prosthesis
Check prosthesis fitting
Socket fitting
Suspension
Comfort
Height of the prosthesis
Static alignment
1. Inspection of the Stump
Factors affecting prosthetic wear:
Skin/scar problems
Vascular disease
Sensibility
Pain
2. Check of the TT Prosthesis
A: Is the prosthesis as prescribed?
PTB
PTB SC
PTB SC SP
B: Soft socket
Edges should be smooth and rounded.
Shape of the soft socket.
Soft socket sticks out of the socket.
Made of two layers of EVA with a piece of stockinet in between.
C: Suspension / Socket
Smooth and well-rounded edges
Shape
Pressure tolerant areas
Pressure sensitive areas
Suspension: In case of PTB, ensure screws are tight and without protrusion inside the socket.
Shape, height, and direction of the walls: posterior border is perpendicular to the direction of the patella.
The shape of the post border leaves some space for the hamstring tendons.
D: Bench Alignment / Shoe
The prosthesis can stand on its own.
The tube is vertical in both planes.
The socket is sufficiently flexed (commensurate with the stump's length).
Position of the foot / tube
Rotation of the foot
Size of the foot
3. Stump Sock
The sock should be:
Clean
Dry
Of proper size and length
Thick or thin enough
Sufficient in number (ideally, the prosthesis must be worn with one sock only)
4. Donning TT (Trans-Tibial Prosthesis)
In sitting position:
Put the sock / stockinet on.
Hold the sock when entering into the liner; sock end is pulled through the end of the liner, knee flexed; sock end is tucked into the liner.
The client dons his prosthesis (socket), keeping the knee flexed.
For prostheses with a belt, do not fasten too tightly.
4. Doffing TT (Trans-Tibial Prosthesis)
In sitting position:
Hold both sides of the liner.
The patient places their sound foot on top of the prosthetic foot while pulling out the liner.
5. Fit of the TT Prosthesis
In sitting or standing position:
Weight-bearing areas
Suspension
Length
Comfort
Static alignment
Sitting - Weight Bearing Areas
When the socket is on:
Check that it is not too loose, too small, or gapping.
If the socket is too small, donning is difficult or impossible.
Is the patient's stump well supported by the proper weight bearing areas?
Can the patient sit comfortably with the knee flexed at 90^\circ or more?
Does the posterior border of the socket leave space for the hamstring tendons?
Sitting - Suspension
In the case of PTB SC or PTB SC SP kind of socket, this one is tighter above the condyles.
To check that it is tight enough, the technician will pull slightly on the prosthesis.
If it is tight enough it will remain in place.
Sitting - Length
Size of the feet
Level of the knees
Sitting - Comfort
Is the client feeling comfortable with the prosthesis?
Sitting to Standing
The steps from sitting to standing are the following:
Move forward on the chair
Feet aligned under the knees
Back is straight, bent forward at the hips
Arms help to push the body up
More weight is put on the sound leg
Extension of both hips and knees
The Physiotherapist can help the patient with:
Manual grip on the pelvis or the shoulders
Stabilization of the prosthetic knee
Giving the patient enough space in front of him
Clear verbal commands
Standing - Weight Bearing Areas
Check the edge of the stump at the socket line for excessive roll
The end of the stump is not touching
Standing - Suspension
No pistoning ( عليقالت – في وضع الوقوف • عدم أنزلاق الطرف.)
Standing - Length
Level of the shoulders, iliac spines, iliac crests
Knees
Standing - Static Alignment
Checking the level of the pelvis:
Hands on the iliac crest
Thumbs on the anterior-superior iliac spine
Check also alignment of the spine
Tube is vertical
Flexion of the socket
The sole of the shoe is flat on the floor (antero-posteriorly and medio-laterally).
Standing - Comfort
Is the client feeling comfortable with the prosthesis?
Check Prosthesis
Is the skin free of any abrasions, blisters, excessive redness, or area of pressure?
Check the skin, the marks left by the socket.
Trans-Femoral (TF) Amputation - First Fitting
1. Inspection of the Stump
Factors affecting prosthetic wear:
Skin/scar problems
Vascular disease
Sensibility
Pain
2. Check of the TF Prosthesis
A: Is the prosthesis as prescribed?
Quadrilateral
Ischial containment / CAT CAM
B: Socket
Are the edges smooth and well rounded?
Does the shape of the socket correspond to international standards: pressure tolerant area, pressure sensitive area?
Are medial, lateral, anterior, and posterior contours of adequate height, shape, direction?
C: Suspension
Are the riveting well located?
Are the riveting strong and without protrusion inside the socket?
Is the belt long enough?
D: Bench Alignment / Shoe
The tube is vertical in both planes.
The socket is enough flexed and abducted.
Position of the foot / tube.
Rotation of the foot.
Size of the foot.
The knee moves freely and smoothly.
The knee joint axis is horizontal.
The knee is aligned just behind a line dropped from the trochanter to the knee axis.
The knee lock lever is on the external side / shoe.
3. Inspection of the Sock
The sock should be:
Clean
Dry
Of proper size and length
Thick or thin enough
Sufficient in number (ideally, must be worn with one sock only)
4. Donning TF (Trans-Femoral Prosthesis)
In standing position:
Put the sock / stockinet on the stump. Instead of a stockinet, you can also use a circularly wrapped bandage.
Put the stump into the socket.
Sock end is pulled through the end of the hole. Pull up the stockinet until the stump is well fitted.
Attach the Silesian belt fairly tight.
If the prosthesis is supplied with a suction valve, the rubber valve should be wet before inserting it into the ring.
To lock or unlock the knee: Place the prosthesis behind; put weight on the forefoot, then open or close the knee lock lever.
5. Fit of the TF Prosthesis
In sitting or standing position:
Weight bearing areas
Suspension
Length
Comfort
Static alignment
Standing - Weight Bearing Areas
Ischiatic plate
Anterior border
Check if the socket is not too tight or loose
Is there an adductor roll?
Standing - Suspension
Suspension should be maintained in all positions (no pistoning).
Standing - Length
Level of the shoulders, iliac spines, iliac crests
Knees
Does the length of the shin and thigh correspond to the shin and thigh of the sound leg?
Standing - Comfort
Does the socket fit comfortably?
Sitting - Weight Bearing Areas
Check the pressure of the posterior brim against the seat and the stump.
Is the client able to bend forward without discomfort?
Sitting - Suspension
Pull slightly on the prosthesis.
Sitting - Length
Does the length of the shin and thigh in the prosthesis correspond to the shin and thigh of the sound leg?
Sitting - Comfort
Is the client feeling comfortable with the prosthesis so far?
Donning - Doffing
Independent donning / doffing is essential if the client is to wear the prosthesis on a regular basis following discharge from the training program.
Proper prosthetic donning is one of the first things to be learned. Teaching proper donning involves:
Showing the client the appropriate reference points between the residual limb and the socket.
The client learning the correct feel of the prosthesis.
References
Palmer - Toms, 1992, Manual for functional training
May b. J.,1996 Amputations and prosthetics.
ICRC documents, P & O DB, Leaflet Trans Tibial, Leaflet Trans Femoral.
Engstrom B., van de Ven C., 1999, Therapy for amputees
Lusardi M, 2007, Orthotics and prosthetics in rehabilitation
Part 2: Gait Training Phase
Clients should be discouraged from walking by themselves as soon as they have been fitted with the prostheses.
They should follow an exercise program allowing them to improve their abilities gradually.
Goal Planning
A progressive, step-by-step approach will also minimize:
The risk of skin abrasions and consequent delays in the fitting process.
The gait defects.
Prosthetic Gait Training - Goals:
To help amputees adapt to their new condition.
To achieve optimal weight bearing on the prosthesis.
To improve balance and reaction to disturbance.
To restore the optimal gait pattern.
To reduce the amount of energy needed to walk.
To teach amputees how to perform daily operations like sitting down and walking up and down stairs.
Treatment should be given on a daily basis.
Client should attend for a whole morning or afternoon or both so that sufficient time is given to exercise walking rest and socialize with other amputees gaining advice from either them or the therapists.
The advantages of daily treatment
Continuity of treatment improves prosthetic re-education and acceptance of the prosthesis by the client.
The client adjusts more quickly to the new body image.
Functional activities other than walking are practiced.
Independent using the prosthesis is achieved more quickly.
Goal planning
Set realistic goals
Each rehabilitation program should be designed for the individual client.
Following points should be considered:
Age
Physical condition
State of psychological adjustment
Motivation
Social and housing situation
Client's expectations with the prosthesis supplied
Prior prosthetic experience
Walking Aids
Most desirable is training the client for functional ambulation without external devices.
A single point or quad cane is often needed by elderly people for use outside in the street.
Sometimes using the cane on the prosthetic side helps to learn the weight shift to that side.
On occasion, crutches may be needed if the client has other medical conditions that preclude ambulating with less support.
A four-point gait is usually taught unless the client needs to protect the sound leg from full weight bearing.
Walker
A walker is not indicated in most instances and should not be considered as an intermediate step between the parallel bars and a cane.
Does not allow a smooth step-over-step pattern.
Reinforces a slow gait pattern characterized by uneven steps.
Reinforces forward flexion.
Eliminates the normal use of the arm in the gait pattern.
Should only be used if it is obvious that the client will not be able to use the prosthesis with any other form of external support.
Initial Stage
The Physical Therapist (PT) must follow an organized sequence:
Examination of the client
Examination of the stump
Check of the prosthesis
Check the sock
Check the fitting of the prosthesis.
Weight-Bearing and Balance Exercises
The patient has to be able to perform these exercises before starting to walk!
Goals:
Teach the patient to progressively put weight on the prosthesis
Teach the patient to keep balance on two and one leg
Teach the patient to control the movement of his prosthesis during the different steps of the gait cycle
Progression: Weight-Bearing
Progression: Specific Gait Training
Specific gait training teaches the patient to progressively perform the different phases of the gait.
Gait Training Phases
Swing phase
Stance phase
Gait
Gait Training Progression
Movements of shoulders and arms
Side walking
Walking backward
Advanced Gait Training
Advanced balance and gait training are taught to the patient when he can walk without walking aids or with only one crutch.
Aims at improving the patient's confidence for walking in difficult conditions.
Functional Activities
Walking on uneven surfaces
Climbing stairs
Getting up from the floor
Carrying a bucket
Planting activities in the garden
Dressing
Getting Up from the Floor
TF (Trans-Femoral) amputee
Double amputee
References
ICRC pictures.
Verhoeff, T., 1990, STICKY, ICRC
Gailey R., 1989, Prosthetic gait training program for lower extremity amputees, an Advanced Rehab Therapy
May J. B., 1996, Amputations and prosthetics
Seymour R., 2002, Prosthetics and orthotics
Part 3: Gait Deviations
Common Gait Deviations of Non-Amputees
Antalgic Gait: If the patient has pain during the gait, he will adopt an antalgic gait, allowing him to avoid the pain. Antalgic gait will depend on the localization of the pain.
Weakness of Dorsiflexors (Tibialis Anterior)
During the stance phase, heel strike is impossible; the foot touches the ground flat.
During the swing phase, to avoid the toes scraping the floor, the patient will exaggerate the knee flexion.
Weakness of Plantar Flexors (Triceps Surae)
The foot will remain flat on the ground; the patient has no good propulsion of the leg.
Fixed Plantar Flexion
To put his foot flat on the ground, the patient will:
A. Push his pelvis backwards and bend his trunk forward.
B. Use maximum knee extension, which will result in the long term in a genu recurvatum.
Weakness of Quadriceps
Knee is unstable during the stance phase; the patient will push his knee manually into extension.
When standing, passive knee extension will be achieved with hyperextension of the knee.
In the long term, this will result in a genu recurvatum (and hyperlordosis).
Stiff Knee
During the swing phase, the patient will walk on the toes of the other leg and shorten his lateral trunk on the side of the stiff knee, allowing him to bring the leg forward.
Weakness of Hip Abductors (Gluteus Medius)
The pelvis on the opposite side of weakness dips downwards (= uncompensated Trendelenburg).
The trunk bends towards the weakness, and the pelvis shifts to the other side (= compensated Trendelenburg).
Weakness of the Hip Extensors (Gluteus Maximus)
After midstance, the patient bends his trunk backwards, which will push his pelvis forwards and allow the body to advance over the supporting foot.