Prosthetic rehabilitation

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

Top Contributors - Ewa Jaraczewska, Jess Bell, 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 lower-limb prosthetic rehabilitation is to help people walk safely and efficiently and manage everyday activities as independently as possible with a prosthesis. The rehabilitation programme is guided by the assessment, taking into account the person's physical capabilities, level of amputation, pre-amputation function, existing medical conditions, psychological status, social circumstances, and expectations. Prosthetic rehabilitation should begin quickly (BACPAR recommends starting within five working days of the person receiving their prosthesis). This page focuses on key exercises to improve prosthetic balance, gait and function in people with transtibial or transfemoral amputations. There are videos throughout that show variations on the exercises discussed. The exercises should be adapted as necessary, depending on the patient and their prosthesis.

Pre-prosthetic Exercises

Exercises in the pre-prosthetic phase focus on maintaining range of motion, preventing contractures, and building strength in both the residual and intact limbs. Abdominal and back exercises should also be considered to help with trunk control and reduce back pain. This pre-prosthetic work can help optimise prosthetic gait and avoid gait deviations.

Weight-bearing and Weight-shifting Exercises

The loss of a limb alters the body's centre of gravity. Prior to being fitted for a prosthesis, people with lower-limb amputations have to balance over their remaining limb to stand, use an assistive device, or hop. The more secure they become with this single-limb support, the harder it can be to relearn how to share weight across both limbs and eventually fully weight bear over a prosthesis. Helping the person reorient their centre of gravity in this way is an early aim of prosthetic rehabilitation. There are a number of exercises to address this and to improve proprioception and weight-bearing on the prosthetic side.

Lateral Weight Shifting

To practise shifting weight from the non-prosthetic leg to the prosthesis, the patient stands between parallel bars with two-hand support. First, they move their pelvis from side to side. As their confidence grows, they progress to shifting their whole body weight across. It is essential that they actively contract their gluteus medius rather than leaning into the socket (a Trendelenburg stance). A set of scales can be used to provide objective feedback on how much weight is distributed across each leg. Progressions include reducing the level of support (i.e. one-hand to no support).

Forward and Back Weight Shifting

The patient stands between parallel bars with two-hand support. They should stand tall with their feet hip-width apart, ensuring their weight is evenly distributed across both feet. The exercise begins with isolated anterior and posterior pelvic tilts, then progresses to full-body weight transfers. To progress, gradually reduce hand support.

Step-Up Activities

This exercise aims to improve single-leg stability on the prosthetic side. With two-handed support, the patient steps onto a stool with their non-prosthetic leg. Progressions include increasing the step height, reducing hand support, slowing the movement down, and adding arm swings.

The patient should focus on actively contracting the gluteal muscles of the standing (prosthetic) leg and avoiding trunk side flexion. As weight-bearing capacity and confidence increase, the movement of the non-prosthetic limb will become more controlled and deliberate.

Balance Board

A balance board can also be used to facilitate lateral and sagittal (forward and backward) shifts of body weight between the prosthetic and non-prosthetic limbs. Initially, this exercise is performed within parallel bars using two-handed support. It can be progressed by reducing hand support, adding arm movements, having the patient look in different directions, or throwing and catching a ball.

Throwing and Catching

Standing within parallel bars, the patient throws and catches a ball. This activity encourages the person to shift their weight as they reach beyond their base of support, over both the prosthetic and non-prosthetic limbs. To progress this exercise, the patient can stand with their non-prosthetic limb on a balance cushion or a step. Ensuring patient safety is paramount; a spotter should stand behind the patient if there is any risk of a fall.

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Ball Rolling

Rolling a ball under the non-prosthetic foot can improve standing posture and balance and encourage weight bearing on the prosthetic side. Starting within parallel bars, the patient moves the ball in circles and in forward, backward, and lateral directions. Progress this exercise by using a larger ball, speeding the movement up, or removing hand support.

Single Leg Standing

Balancing on the prosthetic leg helps to enhance unilateral stability. Adjust the amount of hand support provided to suit the patient.

Kicking a Ball

To encourage weight shift onto the prosthesis, the patient stands on the prosthetic leg and kicks a ball with the non-prosthetic limb, with or without hand support.

Gait Re-education

Gait Analysis

Gait analysis in prosthetic rehabilitation is primarily observational. Gait should be observed from multiple angles to identify specific deviations.

The gait assessment should include the following six areas:

• Width of walking base
• Stride length, remembering that patients will usually take a shorter, quicker step on the non-prosthetic limb
• Dynamic weight bearing over the prosthetic toe
• Transverse pelvic rotation on the prosthetic side
• Prosthetic knee flexion
• Trunk rotation and arm swing

These points are covered in more detail at the beginning of this video from Professor Gailey. For more information on common deviations, see: Gait Deviations in Individuals with Lower Limb Amputations.

Basic Principles of Gait Re-education

Gait training progresses from initial pre-gait tasks and supervised training in a clinical setting to mobility in home and outdoor environments. It should build gradually, increasing in duration as exercise capacity and skin tolerance allow. Training typically begins in a controlled environment, such as parallel bars, unless alternative approaches are clinically indicated. The use of walking aids is encouraged to help patients achieve full weight-bearing through the prosthesis. 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.

Gait Exercises

The following exercises are commonly included in a gait training programme.

Heel Strike

With two-handed support, the patient begins with a heel strike of the non-prosthetic limb while bearing weight through the prosthetic side, focusing on accurate foot positioning. This is then practised with the prosthetic limb.

Weight Shift

After a successful heel strike, the patient practises transferring their weight forward onto the prosthesis to achieve full foot contact and weight acceptance, while keeping the non-prosthetic limb grounded. This sequence is then repeated on the other side.

Swing Through

While the lead foot or prosthesis is in stance, the patient works on swinging the opposite leg through. The physiotherapist provides verbal cues and proprioceptive guidance to assist with weight transfer and ensure proper movement of the trunk and pelvis.

This video shows the progression of pre-gait activities: heel strike, then weight shift onto the prosthetic leg, and finally swing through.

Walking Inside and Outside the Parallel Bars

Patients start their walking practice within parallel bars under the guidance of a physiotherapist. They then progress to overground walking to refine their technique. Using crutches helps to maintain a symmetrical base of support and encourages a more natural rotation of the trunk.

Sidestepping

Sidestepping is a versatile exercise that promotes lateral weight shifting and increases abductor strength. Patients typically begin this activity within parallel bars using two-handed support. They then progress to navigating furniture and obstacles to mimic real-world environmental challenges.

Backward Walking

Backward walking is more difficult for people with a transfemoral amputation, but most can become proficient with practice. The most comfortable approach is to vault upward on the non-prosthetic foot, plantarflexing to gain enough height for the prosthetic limb to clear the ground as it moves back. The prosthetic foot should be positioned well behind, with most of the weight taken through the prosthetic toe. The non-prosthetic limb is then brought back, with the trunk held in slight flexion to keep the weight forward over the prosthetic toe.

Multidirectional Changes

Changing direction is difficult with a lower-limb prosthesis and can be awkward in confined or crowded spaces. A controlled turn is made in two steps rather than pivoting in one movement, keeping the pelvis rotating and the prosthetic knee stable throughout. Turning toward the prosthetic side needs particular care: keeping weight forward over the prosthetic toe holds the weight line in front of the knee and stops it from buckling. Practising turns in both directions, at varying speeds, helps people manage busier, more demanding environments.

Tandem Walking

Tandem walking helps improve coordination, foot placement and weight bearing. Using a line of tape on the floor, the person practises placing the feet on either side of the line, then heel-to-toe along the line, and finally crossing each foot over to the opposite side of the line.

Braiding

With both hands supported, the patient swings one leg across the front of their body and then behind. They then repeat this action with the other leg. Moving faster increases the difficulty of this exercise.

Stepping Over Obstacles

Starting in parallel bars and progressing to an open space, the patient practises stepping over obstacles, leading with the non-prosthetic limb. This can help encourage weight bearing on the prosthesis.

Functional Tasks

“Where possible, the physiotherapist should instruct the patient in a range of functional tasks which are both: i) relevant to the goals set with that individual, seeking to improve their community participation, ii) deemed by the physiotherapist as being within the patient’s physical capabilities to safely undertake a trial of the task.”

Alongside specific weight-bearing and gait training, prosthetic rehabilitation should include the practice of functional activities of daily living. These should be centred around the patient’s goals.

Floor to Stand Transition

Getting up from the floor is an important skill for independence and confidence. The technique depends on the person's level of amputation and ability. The videos below demonstrate different approaches.

Stairs

When navigating stairs, people with unilateral lower-limb amputations should ascend by leading with the non-prosthetic leg and descend by leading with the prosthetic limb. The amount of support is reduced as the person progresses, from two hands on the rails towards managing with one or none. A walking aid can be used where it helps. Some microprocessor and hydraulic knees also support step-over-step descent by providing resistance during flexion.

The following videos provide more information on ascending and descending stairs.

Slopes and Hills

People with lower-limb amputations often find slopes challenging. Going uphill, the body weight is kept slightly forward; going downhill tends to happen at a quicker pace. While many people choose short, equal strides to navigate slopes, sidestepping is the most efficient method. Handrails and walking aids can help, and the techniques used for stairs generally apply to slopes too. Certain hydraulic and microprocessor-controlled knees allow a fluid, step-over-step descent by giving controlled resistance during flexion.

Kerbs

Negotiating a kerb uses the same limb sequence as stair climbing. Walking aids can help with stability, but more proficient users can manage kerbs independently if they have sufficient balance and strong single-limb support.

Carrying Weights

To build functional capacity, patients should practise walking while carrying objects or a weight on their prosthetic side.

Uneven Surfaces

Practising walking on a variety of terrains improves proprioception and spatial awareness. It also encourages people to use visual cues to offset the diminished sensory feedback on the prosthetic side.

Running

For people with advanced walking skills, adding running can support greater involvement in leisure and recreational activities.

Playlists of Training Videos

• Genium/Genium X3 gait training | Ottobock
• C-Leg gait training | Ottobock
• Kenevo gait training (K2 prosthetic) | Ottobock

Additional Resources

Exercises for Prosthetic Rehabilitation (ICRC)