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EmpoweringAmputees.org
Improving Transfemoral Amputee Gait: A Step in the
Right Direction
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Continuing Education Series
Improving Transfemoral Amputee Gait:A Step in the Right Direction
Continuing Education Series
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)
Continuing Education Series
Hanger ClinicContinuing Education Program
Spinal Orthotics
Lower Limb Orthotics
Upper Limb Orthotics
Lower Limb Prosthetics
Upper Limb Prosthetics
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Continuing Education Series
Improving Transfemoral Amputee GaitA Step in the Right Direction
What gait deviation do you see here?
Continuing Education Series
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
Continuing Education Series
Agenda
• Bench, Static, and DynamicAlignment
• Gait Deviations Definitionso Stance Phase Deviationso Swing Phase Deviations
• Therapy Goals
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Continuing Education Series
Improving Transfemoral Amputee Gait: A Step in the Right Direction
Four Factors of Gait• Patient• Socket Fit
• Prosthetic alignment• Physical Therapy
Continuing Education Series
• 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?
Continuing Education Series
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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Continuing Education Series
Alignment Definitions
Socket flexion
Toe lever arm
Heel lever arm
Continuing Education Series
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
Continuing Education Series
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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Continuing Education Series
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
Continuing Education Series
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
Continuing Education Series
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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Continuing Education Series
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.
Continuing Education Series
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
Continuing Education Series
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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Continuing Education Series
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
Continuing Education Series
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
Continuing Education Series
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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Continuing Education Series
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
Continuing Education Series
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
Continuing Education Series
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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Continuing Education Series
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
Continuing Education Series
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
Continuing Education Series
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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Continuing Education Series
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
Continuing Education Series
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
Continuing Education Series
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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Continuing Education Series
Improving Transfemoral Amputee GaitA Step in the Right Direction
Four Factors of Gait
• Patient• Socket Fit
• Prostheticalignment
• PhysicalTherapy
Continuing Education Series
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.
Continuing Education Series
Improving Transfemoral Amputee Gait: A Step in the Right Direction
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Continuing Education Series
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
Continuing Education Series
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