Prosthetic rehabilitation

Original Editor - Abby Cain as part of the WCPT Network for Amputee Rehabilitation Project

Top Contributors - Tarina van der Stockt, Kim Jackson, Sheik Abdul Khadir, Admin, Tony Lowe, Osama Faisal, Rucha Gadgil, Naomi O'Reilly, Simisola Ajeyalemi and Amrita Patro  

Introduction

The aim of the rehabilitation is to aid the amputee to gain independence at the highest level they can, with the most efficient gait possible. The assessment must take into account the physical capabilities, level of amputation, psychological status, pre-amputation function, existing medical conditions and the patient’s expectations. Rehabilitation should begin 5 days post-surgery .  A crucial element of constructing a rehabilitation programme is sound gait analysis. This will largely be observational. Validated outcome measures are available to aid goal setting and measure function. Gait analysis consists of observation of the gait, which should occur from all angles. Knowledge of normal gait patterns for the prosthetic and non-prosthetic user is required to help analysis of movement. On observation of the gait, the assessor compares the function of the amputee to expected patterns of gait and look for deviations. Analysis of the gait pattern will help determine why these deviations are occurring. This will then help to formulate the rehabilitation programme, which includes the correction of the deviations. Outcomes measures can be used to monitor progress.

Amputees should perform pre-prosthetic exercises to help maintain ROM and improve muscle strength in the lower limb and residual limb in preparation for using the prosthetic limb. Abdominal and back exercises should also be considered to help trunk control and reduce back pain. Pre-prosthetic limb exercises can help prevent the occurrence of prosthetic gait deviations

Due to the loss of the limb, the amputee will automatically shift their centre of gravity over the foot of the non-prosthetic side. After an amputation, there will be a period of time where the amputee is without a prosthesis. This is due to the timeframe of the assessments required to decide if the provision of a limb is appropriate. During this period the amputee will become familiar with the shifted centre which will increase the difficulty of reorientation of the centre of gravity once they receive a prosthetic limb.

The authors of a systematic review study reviewed 18 manuscripts to evaluate the evidence on gait training interventions in patients with lower limb amputations, in order to guide both research and practice. They found that gait training is needed due to asymmetry, change in biomechanics, and related secondary consequences after an amputation. Both overground and treadmill-based rehabilitation was included for review. Their results showed that the following interventions are effective in improving gait: overground training (with verbal, manual, or psychological awareness interventions), treadmill-based training both as a supplement to overground, as a home exercise, or on its own with visual feedback or with body weight support.

Orientation of Centre of Gravity and Weight Bearing on the Prosthesis

Prosthetic training should include orientation of centre of gravity and improve weight bearing on the prosthetic side. There are a number of technique/exercises which can be employed to facilitate the rehabilitation of this, such as 

Standing Stability Exercises

Lateral weight shifting

Stand between parallel bars with two-handed support. The amputee practices shifting the weight from the non-prosthetic limb to the prosthetic side. This can be performed with pelvis only initially and progress to full body movement when the amputee becomes more confident. This exercise will help the patient to contract his/her gluteal muscles and contract the muscles of their residual limb to stabilize. Make sure that the patient is actively engaging the muscles especially when the amputation is above the knee where the patient might lean into the socket (Trendelenburg stance) instead of using gluteus medius. A pair of scales under the feet can help to determine the weight transference. Two handed support can be reduced to one handed (alternating hands to the contralateral side of the weight shift) and fingertip support, for progression.

All the exercises below can be done with a gait belt and it is important that the therapist focuses on the patient's safety and that all exercises are tailored to the patient's ability and fall risk.

Forward and back weight shifting

Weight transference can be practiced forwards and backwards to help balance and orientation. The exercise is performed as for lateral weight shifting but the body weight is moved forwards and back. This can begin with pelvic movements only to build confidence and progress to entire body weight. Reduced hand support will be a progression of this exercise. The patient should stand upright, with the feet hip-width apart and start by distributing their weight evenly between the two feet.

High stepping

Single leg stance on the prosthetic side can be improved by high stepping with the non-prosthetic side. With 2 handed support, the amputee steps the non-prosthetic limb onto a stool of approx. 4-8 inches. This exercise can be progressed by increasing the height of the step and/or reducing the hand support required, doing the movement slower, giving a bigger step on the sound side, and swinging the arms. The patient needs to actively engage the gluteals on the standing leg and avoid trunk side flexion. As the amputee becomes more confident and weight bearing improves the step of the non-prosthetic limb will be slower and more controlled.

Balance board

A balance board can be used to help weight bearing and balance where they shift body weight forward and back and laterally bewteen the prosthetic and non-prosthetic side. This can be performed between parallel bars with 2 handed support and then progressed to 1 hand, no hands, movement of the arms, looking up and down, left and right, and catching and throwing a ball. .

Throwing and catching

Stood between parallel bars or with supervision, as required the amputee performs throwing and catching with the therapist. This encourages the amputee to adjust their weight bearing as they reach outside their base of support over the prosthetic and non-prosthetic limb. This exercise can be progressed by the non-prosthetic limb being placed on a step or balance cushion. Make sure that the patient is safe. If the patient has a risk of falling make sure that they have a gait belt on and that someone is standing behind them.

Ball Rolling

This exercise improves standing posture and balance. Start in the parallel bars and progress from there. The ball is placed under the sound limb, to work on muscle activitation and weight bearing on the prosthetic side. Move forwards, backwards, sideways, and make circles. Progress by not holding on, increase the size of the ball, move faster, and change direction.

Stepping

Side Stepping

Obstacle stepping

Between parallel bars or with supervision, the action of stepping over obstacles leading with the non-prosthetic limb can help encourage weight bearing on the prosthesis.

Football

With or without hand support, standing on the prosthetic side, the amputee kicks a ball with the non-prosthetic leg to promote weight shift onto the prosthesis.

Braiding

The amputee stands with 2 handed support and swings one leg across the front of the body and then behind. This is performed with both the prosthetic and non-prosthetic side. To advance this exercise the amputee performs this action with more speed meaning they must adjust their weight bearing and balance to compensate for the speed of the movement.

Single leg standing

Practice balancing on the prosthetic limb will help improve balance on that side. This can be performed with varying levels of hand support.

Gait Re-Education

Specific gait re-education and facilitation is important during rehabilitation in order to ensure the correct biomechanics of gait are achieved. Recommendations are that gait re-education commences between parallel bars.

Pneumatic post Amputation Mobility Aid (PPAM Aid)

This is an aid that can be used to encourage early mobilisation before the amputee has a prosthetic limb. It can be used from 5 days post op providing there are no complications with the wound. Trial inflations should occur until the patient is able to tolerate the sleeve. The sleeve should be applied and slowly inflated from 5 minutes to a maximum of 2 hours twice daily. The maximum pressure of inflation should not exceed 40 mm Hg. The sleeve can be placed over soft dressings, plaster cast or bandaging. The wound should be checked before and after using the PPAM aid. The PPAM aid is designed as a short term mobility aid, for partial weight bearing and is not a substitute for a long term prosthetic limb.

Specific Gait re-education

The gait cycle can be broken down and each segment practiced with the amputee. With 2 handed support begin with heel strike of the non-prosthetic limb while weight bearing on the prosthetic side, encouraging correct foot placement. This is then practiced with the opposite leg. Step by step progression of the gait should commence once heel strike is achieved. Forward weight transference onto and off the prosthetic limb to allow floor contact of the prosthetic foot and weight acceptance, without the swing through of the opposite leg, is the next step. This again is practised with both sides. Once this is satisfactory, swing through of the opposite leg can be practised when the leading foot/prosthesis is in stance. This process is followed with each step to help encourage a rhythmical, reciprocal gait pattern with appropriate weight shift. Regular proprioceptive facilitation to aid correct pelvic and trunk movements and help facilitate weight transference along with verbal feedback is used to reinforce correct movement.

Walking aids

Rehabilitation should begin between parallel bars. However once the amputee becomes confident and a good gait pattern is achieved walking aids should be introduced to aid progression of mobility and to encourage mobility in the amputee home environment. Aids should be provided to promote the maximum level of independence and encourage the amputee to be as full weight bearing as possible. The patient’s pre-amputation level of function, current abilities, level of progression, overall health and medical status should be considered when selecting and progressing walking aids.

Sidestepping

This can be performed at any stage in the rehabilitation programme. The aim is to encourage lateral weight shifting and strengthen the abductors, The exercise can be performed with 2 hand support in the parallel bars and progress by the amputee moving around furniture/obstacles as a patient would in their own environment.

Backward walking

This activity is more difficult for transfemoral amputees than transtibial due to the lack of knee flexion of the prosthesis. However with practise the transfemoral amputee can perform this action with confidence. They will commonly need to plantarflex the ankle, come onto the toes, of on the non-prosthetic limb as they bring the prosthetic limb back.

Multidirectional changes

This will help improve prosthetic control and balance. Often changes in direction will prove difficult for amputees and practice will help improve mobility in more challenging environments such as crowded public places.

Tandem walking

This can help improve co-ordination, foot placement and weight bearing. A strip is placed on the floor. The exercise can be progressed through 3 stages

1. Foot placement on each side of the line
2. Foot placement heel toe along the line
3. Foot placement crossing over onto opposite sides of the line- for the more advanced amputee .

Functional tasks

In addition to specific weight bearing and gait training, prosthetic rehabilitation should also include practice of more functional tasks of daily living. These should be centred on the patient’s individual goals.

Stairs

The technique for performing stairs is the same for above and below knee amputees. Leading with the non-prosthetic limb ascending the stairs and descending with the prosthetic limb first. This can be progressed from 2 handed to non handed support, dependent on the ability of the amputee. Walking aids can also be used to help amputees manage stairs..

Slopes/hills

Walking up and down slopes can be difficult for amputee patients. Often forward trunk flexion is required and shorted stride lengths. Some amputees will find it easiest ascending and descending slopes through side stepping. Aids and rails can aid with slopes. The same techniques in terms of stepping are applied to slopes as it is for stairs.

Curb

The limb sequence applied to walking up and down stairs can be adopted for curbs. Walking aids are useful for assisting with curbs, however more advanced amputee will manage without. Balance and good single limb support is necessary for this. For the more advanced transtibial amputee the prosthetic limb can also be used to ascend curb and control descent.

Weight carrying

Practise walking with a weight on the prosthetic side or with objects in the hand. This may require a walking aid dependent on the patient’s ability.

Uneven surfaces

Walking over various terrains helps improve awareness and proprioception. It encourages the amputee to make use of their vision to compensate for the reduced proprioception on the prosthetic side.

Running

For advanced amputee running can be incorporated in to the rehabilitation programme and can help amputees to increase participation in recreational activities.

Rehablitation by artificial intelligence

This is the era of technology ,and artificial intelligence is the best invention of this century . So now we have to improve our rehablitation programme by using robitics limb and train the patient according to them . these are some machines we can use in rehablitaion programme

Resourcesmans adjust their grasp or gait based on many low-level, unconscious control decisions. If a glass is about to slip, people instinctively tighten their grasp; likewise, as water is poured into a cup, the hand reflexively tightens the grasp. When people start to walk faster, their muscles fire more strongly to prevent the leg from jerking to a stop. This same type of low-level control, termed “artificial intelligence,” is even more beneficial in the field of prosthetics, where there is a paucity of control channels. With so few ways to control a prosthesis, it would be ideal for the user to direct only the highest level of control, allowing the prosthesis to provide lower level decisions. Several implementations of this concept have been introduced into prostheses. Examples include the following: • the Otto Bock SensorHand Speed hand (Otto Bock Healthcare), which senses when an object is about to slip and tightens its grasp; • the Otto Bock C-Leg (Otto Bock Healthcare), which changes knee resistance depending on the activity required as determined by the prosthesis; and • the Ossur RHEO KNEE (Ossur, Aliso Viejo, California), which continuously adapts to provide better low-level control of the prosthetic knee throughout the entire life span of the prosthesis. Future artificial intelligence technology may play a crucial role in orchestrating the control of prosthetic hands with multiple actuated fingers, the interaction of powered lower limb prostheses with the environment to provide proper dynamics, the low-level coordination of prostheses for subjects with bilateral amputation, and many other areas of control

Exercises for Prosthetic Rehabilitation (ICRC)

Amputee Exercises (ICRC)

https://www.eurekalert.org/pub_releases/2015.../iop-abi081715.php

http://sci-hub.hk/http://ieeexplore.ieee.org/abstract/document/736154/?reload=true

References