removal of part or all of a limb or some other outgrowth of the body enclosed by
performed to prevent the spread of gangrene as a complication of frostbite, injury,
DM, arteriosclerosis or any other illness that impairs blood circulation & also
performed to prevent the spread of bone cancer, to terminate loss of blood & to
prevent infection in a person who has suffered severe & irreparable damage to a
o GANGRENE – decay of tse
o FROSTBITE – death of tse d/t exposure to cold
o ARTERIOSCLEROSIS – hardening of arteries
o AMPUTEE- a person who has undergone an amputation
When bld supply of a limb has been lost & cannot be restored,
amputation is always necessary.
Irreparable loss of nerve supply, amputation is occasionally indicated to remove a
limb or part of a limb that may be useless, unsightly, and subj to chronic ulceration.
1. Vascular Dse or Accident
• bld supply on LE may be destroyed suddenly by
thrombosis or embolism or gradually PVD such as
arteriosclerosis or thromboangiitis oblitereans.
• PVD is the MC reason for LE amputation about 75%
particularly associated c smoking & DM.
When an adequate bld supply cannot be maintained or restored by
Tx, gangrene unsues & ampu becomes necessary.
The level of ampu is determined by the adequacy of the remaining
Peripheral Vascular Dse
• Refers to any dse or dso of the circulatory sys
outside of the brain & heart
• Other name for this cond’n is arteriosclerosis.
• Caused by build-up of fatty material w/n the
vessels called atherosclerosis
• MC dse of the arteries
• Almost all such amputations involve the LE.
• aka Buerger's disease
• is a recurring progressive inflammation and
thrombosis (clotting) of small and medium
arteries and veins of the hands and feet.
• It is strongly associated with use of tobacco
products,primarily from smoking, but also
from smokeless tobacco.
• 2nd leading cause of ampu usually from MVA
• Common on young adults♂
• Traumatic ampu may be performed at any
level, the surgeon tries to maintain the
greatest bone length and save all possible jts.
Mx: wound care shld be done 1st then
3. Tumor (Malignant)
• e.g. Osteogenic sarcoma - aggressive cancerous neoplasm
Neoplasm - an abnormal mass of tissue as a result of neoplasia
Neoplasia - abnormal proliferationof cells
• Biopsy used to checked if tumore is malignant
• Tx: resection, irridation or (B) & Limb salvage surgery(possible in certain
• Feasibility is considered 1st a advising ampu
• Metastasis not occured, ampu may be curative
If tumor is already metastasized:
Tx: ampu to relieve pain, improve systemic status & prevent ulceration,
infection, hemorrhage & pathologic fx (tumor weakens the bone that leads to
o Mestastasis spread of a disease from one organ or part to another non-
adjacent organ or part
Benign tumors: ampu may be indicated when excision of the tumor
would cause severe loss of fxn of limb
• Gas gangrene – MC infection
• Osteomyelitis (long-standing draining)
– a chronic infection simply means an infection of the bone or bone marrow
- Ampu is indicated bec of either local or systemic abnormalities
• Systemic complications such as amyloidosis, glomerular nephritis & bacterial endocarditis may prove
fatal unless ampu is done
o Amyloidosis- refers to a variety of conditions in which amyloid proteins are abnormally deposited
in organs and/or tissues
Amyloid- insoluble fibrous protein aggregates sharing specific structural traits. Abnormal accumulation of
amyloid in organs may lead to amyloidosis, and may play a role in various neurodegenerative diseases
o Glomerular nephritis- characterized by inflammation of the glomeruli, or small blood vessels in the kidneys
o Bacterial endocarditis-inflammation of the inner tissue of the heart
• Local ab(N)ities of chronic infection that may make ampu & use prosthesis: mutilating loss of ms/bone,
deforming contractures & ankylosis. Chronic ulceration, painful scars, ischemic changes, persistent
sinuses nad dev’t of carcinoma about the sinuses.
Tx: Povidine Iodine (betadine) – best used to counter infection.
Extensive tuberculous or mycotic infection of the foot or ankle c multiple sinuses is often best treated by
Mycotic infection - fungal infection
Ampu for infection & its ab(N)ities are uncommon today as improved methods for the ctrl of acute
5. Thermal, chemical or electrical injury
• Extensive, severe tse damage from excessive heat
or cold or foam chemical or electrical burns may
• Electrical burn (3o
) when necrosis occurs
6. Congenital Anomaly
• Supernumerary fingers/toes- ampu is indicated if
• Phocomelia – congenital deformity involving loss
– aka Seal Limb
TYPES OF AMPUTATION
- Amputation performed through a jt
2. Open Amputation
- Amputation in which the surface of the wound is
not covered c skin but left unclosed
- Shld have 2o
operation/surgery to ctrl infection
3. Closed Amputation
- final/definitive amputation performed to create a
stump that can be used effectively by prosthesis
4. Minor Amputation
- Ampu through or distal to the metacarpus or the
- No artificial limb used & stump shld be planned so
that its fxn is retained or recreated.
5. Major Amputation
- All ampu prox to the metacarpal/metatarsal bones
- Designed 1o
to produce stumps suitable for artificial
Limb Salvage of LE vs Amputation Surgery
- It requires more surgeries, involves longer hosp stays,
delays wt bearing & slows the return to preinjury activities
- Poor prognosis: extensive soft-tse loss, prox arterial
injuries, multiple arterial injuries, & sciatic/tibial nerve
• Reconstructive procedure
• Bones are beveled to minimize sharp edges that can cause
• 5x common than UE amputation
• LE amputation is MC than UE d/t better bld
• LE amputation is better than UE amputation
because it can compensate the fxn of LE by
Levels of Amputation
• Principle in choosing level of ampu is to
preserve as much limb length as possible that
is consistent w/ wound healing, an acceptable
soft-tse envelope, & fxnal prosthethic fitting.
LEVELS OF AMPUTATION
Partial toe Excision(Surgical removal of a body part) of
any part of 1 or more toe
Toe disarticulation Disarticulation at the metatarsal phalangeal
Partial foot/ray resection Resection of 3rd to 5th metatarsals & digits
Transmetatarsal Amputation through the midsection of all
Syme’s Ankle disarticulation c attachment of heel
pad to distal end of tibia. May include
removal of malleoli & distal tibial/fibular
Long Transtibial (BK) More than 50% tibial length
Transtibial(BK) Bet 20-50% of tibial length
Short transtibial (BK) Less than 20% tibial length
Knee disarticulation Amputation through the knee jt; femur
Long transfemoral (AK) More than 60% femoral length
Tranfemoral (AK) Between 35-60% femoral length
Short Transfemoral (AK) Less than 35% femoral length
Hip disarticulation Amputation through the hip jt; pelvis intact
Hemipelvectomy Resection of lower half of the pelvis
Hemicorporectomy Amputation of (B) lower limbs & pelvis
below L4-L5 level
AKA causes HIP
sensitive & tolerant areas for LE AMPU:
-tibial crest (below patellar tendon)
-distal ant tibia
-Medial tibial flare
-Ant compartment (T.A)
Characteristic of an ideal stump:
BK – cylindrical shaped; no phantom pain
AK- conical shaped; no open wound
Sensitive – all bones + 1 ms (hamstring)
Tolerant – all ms + 1bone(medial tibial flare); can bear wt upon prosthesis
• Amputation of the great toe doesn’t
significantly impair standing or unhurried
• Disarticulation of the 2nd toe leads to HALLUX
• Loss of 3 smaller toes doesn’t cause
b. TRANSMETATARSAL AMPU
- aka Lisfranc’s ampu
• Require no prosthesis
• End of shoe is filled c sponge rubber on a
Toe filler – most fxnal prosthetic device
• For better wt. distribution, a metatarsal bar may
be added to the shoe
c. TARSAL BONE
• usually unsatisfactory
• Lisfranc’s disarticulation(tarsometatarsal
level) and Chopart’s ampu (talonavicular
& calcaneocuboid jts) become obsolete
bec by distorting the muscular bal of the
foot they frequently produce intractable
d. Boyd Ampu
e. Pirogoff Ampu
f. Syme’s ampu – above the transmetatarsal level &
below the middle 3rd of the leg
- aka transmalleolar amputation
- only one generally accepted and widely used
- an end-bearing ampu in w/c the tough plantar skin of
the heel is used to cover the end of the tibia p it has
beed severed 0.5cm above the ankle jt.
- for cosmetics reasons, it is better procedure for
♂ than for .♀
- uses syme prosthesis w/c includes only a BK molded
knee plastic socket & a modified solid-ankle, cushion-
heel (SACH) foot.
Which inlcude tibiocalcaneal fusion, are rarely done.
A. Rigid dressing
- aka immediate postoperative fitting
- best to use in edema and swelling mx.
-an attachment incorporated @ the distal end of the dressing allows later
add’n of a foot & pylon allowing limited wtbearing ambu w/n a few days or
a week of surgery (immediate postoperative prosthesis or IPOP)
- may be handmade from plaster of Paris by the surgeon or prosthetist & are
-In rigid postsurgical dressing, orthopedic surgeons use this TQ bec it is found
to be successful in reducing postoperative edema, pain & enhancing healing
even in cases of delayed healing.
Plaster of Paris (POP)
- grp of gypsum cements, essentially hemihydrated calcium sulfate, a white powder that
forms a paste when is mixed c water and then hardens into a solid, used in making
casts, molds and sculpture.
- must be cut like a cast for removal & a new one applied as the residual limb heals,
sutures are removed, & the limb changes shape.
Removable Rigid Dressings (RRD)
-may be handmade from plaster or
prefabricated from plastic materials & come in
- adjustable as the limb changes & may be
removed as needed for wound inspection.
ex: AirLimb® - is a plastic socket c inflatable
bladders that help maintain proper fit as the
residual limb shrinks
-removable for wound inspection & care but it
is easier to fit & use.
Figure 4. A, A patient with an elastic compression sock and an AirLimb
IPOP system by AirCast B, Schematic of a cut away view of the AirLimb
modular system with inflatable bladders to accommodate for residual
limb volume loss. Distal end pads help with tissue contact and
Images courtesy of John Rheinstein, CP, FAAOP & Lew Schon, MD
limits dev’t of postoperative edema in residual limb.
allows earlier ambu c attachment of pylon & foot
allows earlier fitting of permanent prosthesis
pylon- artificial LL
requires special training
needs close supervision during early stage of healing
B. Semirigid dressing
- all provide better ctrl of edema than soft
dressing but each has same disadvantage that
limits its use.
Unna’s dressing –gauze impregnated c a compound
of zinc oxide, gelatin, glycerin & calamine
applied in OR.
> Major disadvantage is that it may loosen easily &
is not rigid as POP dressing
C. Soft dressing
- oldest method of postsurgical Mx of the residual limb.
- indicated in cases of local infection but is not the Tx of choice
for the majority of indi.
A. Elastic wrap- applied over postsurgical dressing if care is
taken to ensure proper compression.
- one of the major drawbacks is that it needs frequent
B. Elastic Shrinkers- are socks-like garments knitted of heavy,
rubber-reinforced cotton; conical in shape & come in a
variety of sizes.
-not economical to purchase while the residual limb
is still covered c gauze dressing.
used p surgery; not a long-term used
light wt & readily avail
provide relatively poor ctrl of edema
can slip & form a tourniquet
elastic wrap requires skill in proper appl’n
elastic wrap needs frequent reappl’n
new shrinkers must be purchased as the residual limb gets markedly smaller
shrinkers cannot be used until sutures have been removed & 1o
Tourniquet - Bandage that stops the flow of blood from an artery by applying
-sensation of the limb is no longer there.
-often described as tingling, burning, itching or po
-felt at the distal part of extremity & the sensation is also
responsive to external stimuli such as bandaging/rigid
-impt for the px to understand that the feeling is quite (N)
Phantom limb pain – free nerve endings left over
- trigger pain sensation
- follows ampu about 80% of amputee
- characterized by cramping/squeezing sensation, or
shooting or burning pain.
-observe s fold, super firm on the part
-shouldn’t have dog ears or shrinks that leads to
- Develops when there is a simultaneous impairment of
venous return from a prosthetic socket that is too tight
proximally & a lack of total contact bet the residual
limb and the socket
- Edema develops
- Prone to developing cellulitis & tender to palpation
*BKA – Post flap
*AKA – Fish Mouth Flap
Residual Limb Care
Indi not fitted c a rigid dressing or a temporary
prosthesis use elastic wrap or shrinkers to reduce the
size of residual limb
Removable rigid dressings for use c transtibial ampu are
avail & may be an impt alternative to the elastic wrap.
There are fewer alternatives for transfemoral amput;
rigid dressings & inexpensive temporary prosthesis are
more difficult to fabricate & elastic wraps /shrinkers are
only minimally effective.
It is advisable to fit the indi ff transfemoral ampu c a
definitive prosthesis early & then adjust it for shrinkage
by using additional socks or a liner.
• Edema in the residual limb is often difficult to ctrl owing to
complications of diabetes, cardiovascular dse or HTN.
• An intermittent compression unit can be used to reduce edema
on a temporary basis.
• Proper hygiene & skin care are impt. The residual limb is
treated as any other part of the body; kept clean & dry. The px
is taught to inspect the residual limb c mirror each night to
make sure there are no sores or impending probs.
• Residual limb tends to become edematous p bathing as a rxn to
the warm H2O, nightly bathing is recommended particularly
once prosthesis has been fitted.
• p bathing, elastic bandage, shrinker or removable rigid dressing
• If person has been fitted c a temporary prosthesis, residual limb
is wrapped @ night & any time prosthesis is not worn.
• Learning proper bandaging is part of the therapy prog
• The skin of the residual limb may be affected by a
variety of dermatological probs such as eczema,
psoriasis or radiation burns.
• Eczema- a form of dermatitis or inflammation of the epidermis
• Psoriasis- chronic immune-mediated disease that appears on the skin. It occurs
when the immune system sends out faulty signals that speed up the growth
cycle of skin cells
Tx may include: UV irradiation, whirlpool, reflex heating,
hyperbaric O2 or medication.
o Care must be taken in using UV or heat int he presence of
o Whirlpool- may not be the Tx of choice bec it ↑ circualtion &
edema in the part under Tx.
- Advantage: as a cleansing agent for skin prob, infected
wounds/incidence of delayed healing
Residual Limb Wrapping
Px tends tp wrap their own residual limb in a circular
manner, often creating a tourniquet, w/c may
compromise healing & foster the devt of a bulbous
EFFECTIVE BANDAGE: smooth & wrinkle free,
emphasizes angular turns, provides po
encourages prox jt ext.
ends of bandages are fastened c tape, safety pins
• A sys of wrapping that uses mostly angular Fig-of-8
turns was developed specifically to meet the needs of
the older px & has been successfully in use for the
a. Transtibial Bandage
Two 4-in. elastic bandages are usually enough to wrap most
transtibial residual limb.
Px is in sitting pos’n
VERY LARGE RESIDUAL LIMBS – require 3 bandages.
Must not be sewn together so that the weave of each
bandage can be brought in contrapos’n to the other to provide
A firm, even po
against all soft tses is desirable to prevent the
devt of edema.
Pattern is usually from prox to distal and back to prox, starting
@ the tibial condyles & covering (B) condyles as well as the
patellar tendon. Usually patella is left free to aid in knee
motion. Although c short residual limbs, it may be necessary
to cover for better suspension.
b. Transfemoral Bandage
• Two 6-in and one 4-in bandages will adequately
cover the limb
• Two 6-in bandages can be sewn together end-to-end
taking care not to create a heavy seam.
• Px is in sidelying pos’n w/c allows a family member
or therapist easy access tot he residual limb. / px c
good bal on the remaining llimb can bandage the
residual limb in standing pos’n, but difficult to self-
bandage correctly in sitting pos’n.
• Transtibial shrinker is rolled over the residual limb to
midthigh & is designed to be self-suspending.
Indi c heavy thighs may need add’l suspension c garters or a waist
• Transfemoral shrinkers incorporate a hip spica, which
provides good suspension except c obese indi.
• Shrinkers are easier to apply than elastic bandages and may
be a better alternative for transfemoral residual limb.
• May not be used until the incision has healed & sutures have
Sutures can be caught in the shrinker’s mesh & the distal distraction
forces that accompany donning may cause wound dehiscence
Any rolling of the edges/slipping of the shrinker can create a
tourniquet around the prox part of the residual limb
One of the greatest deterrents to fxnal prosthetic rehab is contracture of hip or
Contractures can develop as a result of ms imbalance or fascial tightness, from a
protective w/drawal reflex into hip and knee flexion, from loss of plantar
stimulation in extension or as a result of faulty positioning such as prolonged sitting
or placing residual limb on a pillow.
For all levels of ampu, full ROM in hip in ext. is critical in allowing the indi to assume
a balanced upright posture.
For transtibial ampu, full ROM in hips and knee particularly in ext is needed.
While sitting, px can keep the knee extended by using a post splint or a board
attached to the w/c.
For transfemoral ampu needs full ROM in hip particularly in ext & abd
Prolonged sitting is to be avoided
Some time each day shld be spent in the prone pos’n
Elevation of residual limb on apillow ff either transfemoral or
transtibial ampu can lead to devt of hip flex contractures & shld be
Mx of Contractures
• Mild contractures may respond to manual mobilization & active
exercises but it is almost impossible to reduce mod to severe
contractures by manual stretching, esp hip flex contractures.
• Facilitated stretching TQ (PNF) are more effective than passive
stretching; hold-relax & hold-relax active contraction that utilizes
restricted contraction of antagonist ms may ↑ ROM particularly of
• To reduce knee flexion contracture, px is to fit a patellar-tendon-
bearing (PTB) prosthesis that places the hamstrings on stretch c each
Hip flexion contractures are more frequently found c transfemoral
Prevention continues to be the best Tx for contractures.
Contributors in restoring ambulation ability: Hip extensors (g.max&hamstrings),
g.medius, hip flexors & contralat ankle plantar flexors
• Exer prog is individually designed & includes strengthening,
balance & coordination activities.
• Postsurgucal dressing, degree of postoperative pain & healing
of the incision will determine when resistive exer for the
involved extremity can be started.
• Hip extensors & abductors, & knee extensors & flexors are
impt for prosthetic ambulation.
• Gen strengthening prog includes the trunk & all extremities is
often indicated, particularly for older persons (sedentary prior
• Proprioceptive neuromuscular exer routines are beneficial
• Isometric exer CI for some indi c cardiac dse or HTN.
• (B) exers can be modified bt lfting buttocks off the Tx table in a
modified bridging movt.
• Ideally, exer prog shld be sequenced for progressive motor ctrl &
increasing coordination & fxn as well as increased strength.
– Px slhd progress fr bed to mat activities using exers that emphasize
coordinated fxnal mobility.
• Early mobility is impt to total physiological recovery.
• Movt transtition (supine-to-sit, sit-to-supine) are preliminary to
• Care must be taken during early bed & transfer movts to protect the
residual limb from any trauma.
• Px must be advised not to push on or slide the residual limb against a
• Px also advised not to spend too much time in any 1 posn to prevent
jt contractures/skin breakdowns.
• UE strengthening exers c wts or elastic bands are impt in preparation
for crutch walking.
• Sh depression & elbow extension are necessary to improve the ability
to lift the body in ambu.
Ambulation & Gait Training
• Walking is an excellent exer & necessary for independence
in daily life.
• Gait training can start early in the postoperative phase &
the person c unilat LE ampu can become quire indep using
3-pt gait pattern on crutches.
• Crutch walking is a good preparation for prosthetic ambu &
the perosn who can learn to yse crutches generally will not
have diffivulty learning to use prosthesis
• Cardiovascular endurance is necessary for effective
prosthetic ambu particularly at the transfemoral level.
Walking with a walker is physiologically & psychologically
more beneficial than sitting in a w/c.
Walker is sturdier than crutches but cannot be used on
stairs or curbs.
Gait pattern used c a walker is not appropriate c a
A walker encourages a step-to-gait pattern whereas
efficient prosthetic use requires a step-through gait
Reciprocal walker is not safe during the postsurgical pd
when the indi is using a 3-pt gait pattern.
All individuals c an ampu need to learn some form of
mobility s a prosthesis for use @ night or when the
prosthesis is not worn for some reason.
• postsurgical prog is similar to the prog developed for someone c a unilat
ampu except possibly ambulation.
• needs a w/c on a permanent basis.
chair shld be as narrow as possible c removable desk arms & removable leg
easier to add anti-tipping devices to the rear of the w/c or attach small wts to
the front uprights for use when the foot rests are removed.
• spends considerable time sitting & more prone to develop flexion
contracture particularly around the jts.
• px shld sleep or spent more time in prone pos’n each day
• Bilat transfemoral amputations can be fitted c shortened prosthesis called
stubbies- have reg sockets, no articulated knee jts/shrank & modified
rocker bottoms turned backward to prevent the person from falling
-acquire erect bal & participate in ambulatory activities quickly & c only
mod expenditures of energy
-effective for indi c short residual limbs or who will not be able to
ambulate c reg prosthesis
Figure 2. Left, bilateral amputee using
tilting stubbies. Right, extension bias to
assist extension and control flexion.
- used most frequently to improve bal & to either relieve wt
bearing fully/partial on a LE
- typically used bilaterally, & fxn to ↑ the BOS, to improve
lat stability, & to allow the use to transfer body wt to the
2 basic designs of crutches
a. Axillary crutches
-aka regular or standard crutches
-made of lightwt wood or aluminum
-generally adjustable in adult sizes from ~48 to 60”(122 to
Parts of Axillary Crutches:
•single leg/upright (adjustable from 48-60”; avail in children & extra
--allows for ht variations:
a. wooden: altering placement of screws & wing bolts in predrilled holes
b. aluminum: push-button pin mechanism
•rubber suction tip (1.5-3” in diameter)
o Modification: Ortho Crutches
- Can be adjusted proximally to alter the degree of elbow
flexion & distally to alter the crutch ht
- Made of aluminum
- Parts: Single upright, Axillary piece/bar(covered c sponge-
rubber padding), Hand piece(covered c molded plastic),
Rubber suction tip
- The crutch adjusts (B) proximally (to alter elbow angle) &
distally (to alter ht of crutch)
- Adjustments are made using a push-buttom mechanism
•improves bal & lat stability
•provides for fxnal ambulation c restricted wt bearing
•adjustable (locking pin/notch mechanism or screw & wing bolt mechanism)
•use in stair climbing
•inexpensive if made from wood
• tendency to exert axillary po
• diff to use in stairs
• Safety of the user may be compromised when ambulating in crowded areas
–2” below ant axillary fold to 2” lateral & 6” an to 5th
–2” below ant axillary fold to 4-6” anterolat to 5th
–subtract 16” from px’s ht / 77% of px’s ht
–in all cases, adjust hand piece to allow 20-30o
elbow flexion c sh relaxed
–from ant axillary fold to a point 6-8” from the lat border of heel
–1 UE abducted to 90o
c elbow flexed 90o
, the other UE in 90o
sh abd c elbow ext
–measure from the tip of the olecranon process of the flexed elbow to the tip of the
middle finger of the extremity c the extended elbow
b. Platform Attachments
-aka FA rests or troughs
-also used c walkers
-Fxn: allows transfer of body wt through the FA to the assistive
device c the elbow held in 90o
-used by px who couldn’t bear wt on the wrists/hands (e.g arthritis,
BE amputee, Colles fx)
-px c elbow flexion contractures, FA or hand fx, weakness of triceps &
-FA piece is usually padded, has a dowel or handgrip & has Velcro
straps to maintain the pos’n of FA.
-flex elbow to 90o
, measure fromt he lower border of the FA in
neutral toa point 4-6” anterolat to 5th toe
c. Non-axillary or FA Crutches
-aka Loftstand or Canadian Crutches
• use c good to (N) UE strength
• for more athletic & younger indi
• requires more stability & bal
• adjusts prox to alter the pos’n of the FA cuff & distally to alter crutch
• used mostly by indi needing crutches on a long-term basis
• Constructed c aluminum
• Height: indicated from handgrip to floor & are generally adjustable
in adult sizes from 29 to 35” (74-89cm)
• Distal end is covered c a rubber suction tip
– FA cuff: avail c either a medial or ant opening
Made of metal
Obtained c a plastic coating
– Hand piece/hand grip
– Single upright
– may release the grip s dropping the crutch
– easily adjusted
– allows fxnal stair climbing activities esp for px c bilat KAFO
– more cosmetic
– more transportable d/t ↓ ht
– more expensive
– ↓ lat support d/t the absence of axillary bar
– cuff may be diff to remove esp during falls
– elbow in 20-30o
flexion, the crutch shld come to a point 4-6”
anterolat to the 5th
toe or 2” lat and 6” ant to the foot
– FA cuff: 1-1.5” below the olecranon process
Gait Patterns for Use of Crutches
• Are selected on the basis of the px’s bal, coordination, ms fxn, &wtbearing
• Differ significantly in their energy requirements, BOS & the speed c which
they can be executed
Several impt points shld be emphasized prior to initiating gait patterns:
1. During axillary crutch use, body wt shld always be borne on the hands & not
on the axillary bar. (prevent po
on (B) theVascular & nervous structures loc
in the axillary region)
2. Bal will be optimal by always maintaining a wide (tripod) BOS.
-Resting stance: px shld keep crutches at least 4”(10cm) to the front & to the side of
each foot. [foot shldn’t be allowed to achieve parallel alignment c the crutches
bec this will jeopardize ant-post stability by decreasing the BOS]
3. When using standard crutches, the axillary bars shld be held close to
the chest wall to provide improved lateral stability
4. Px shld also be cautioned about the importance of holding the head up
& maintaining good postural alignment during ambulation
5. Turning shld be accomplished by stepping in a small circle rather than
1. swing-to gait
– Used c bilat LE involvement
– Forward movt of the crutches simultaneously
– LE “swing to” the crutches (AD level only)
1. swing-through gait
– (B) crutches are advanced simultaneously
– LE swing beyond the crutches(exceeding the level of AD)
3. 3-point gait(fig14.22)
– May be from amputee
– Other part or extremity is not fxning
– 3 points of support contact the floor.
– Used when a non-wtbearing stat is required on 1 LE.
Body wt is borne on the crutches instead of on the affected LE
o Modification: Partial Wt.bearing Gait (fig14.23)
- during forward progression of involved extremity, wt is borne
partially on (B) crutches & on the affected extremity
-while instructing, emphasis shld be placed on use of a (N) heel-toe
progression on the affected extremity.
-interpreted by px as only the toes/ball of the foot shld contact the
-use of this positioning over a pd of days or weeks will lead to heel
The maj. Force to
propel the body is
provided by the
o Modification: Partial Wt.bearing Gait (fig14.23)
- during forward progression of involved extremity, wt is borne
partially on (B) crutches & on the affected extremity
-while instructing, emphasis shld be placed on use of a (N)
heel-toe progression on the affected extremity.
-interpreted by px as only the toes/ball of the foot shld contact
-use of this positioning over a pd of days or weeks will lead to
heel cord tightness
4. Alternate crutch / 4-point gait(fig 14.24)
- provides a slow, stable gait as 3points of floor contact are
- wt is borne on (B) Les & used c bilat involvement d/t poor
balance, incoordination/ms weakness.
‒ e.g (L) crutch forward (R) leg (R) crutch (L) Leg
5. Leg gait/ 2-point gait (fig14.25)
‒Highest coordination required
‒One assistive device & the opp LE are lifted & moved forward
• Used in current clinical prac are constructed of lightwt aluminum
• Not intended for use w/ restricted wtbearing gaits (such as non or partial
– Only minimial support is needed
– Minimal bal/endurance probs are present
– FWB status
– For hip probs
– Widen the BOS
– Further improve bal
– Transmit 20-25% of the body wt away from the LE
• Types of cane:
– Standard/regular/conventional C-cane
– Standard adjustable aluminum cane
– Adjustable aluminum cane
– Quad cane
– Walk cane
-Made of wood/plastic
-Crook handle (half-circle)
+ can fit easily on stairs &
other limited spaces
+ not adjustable
+ pt of support is ant to hand &
not directly beaneath it
-Locking pins to match the proper
notches ont he can appropriate for
the px’s ht
+ can be easily adjusted
+can fit in limited spaces
+ more expensive
+ pt of support ant to the hand
Adjustable Aluminum Offset
-Prox component of the body of the
cane is offset ant-ly
+ allows po
to be borne over the
+ fits easily on stairs and other lim
Quad Cane -made of aluminum
-Provides a stable BOS
+Bases avail in diff sizes
+easily adjusted to proper ht
+not practical to use on stairs
+slower gait pattern
+pt of support may not be centered
Walk cane -broad BOS w/ legs farther from the px’s body
+very broad BOS;more stable
+folds flat for wasy transportability
+not practical for use on stairs
+slower gait pattern
+pt of support may not be cantered
• Cane Measurement:
– From the level of the greater troch to 6” from the lat border
of 5th toe
– Elbows shld be flexed abt 20-30o
(more impt indicator of
correct cane ht)
• Allows shortening & lengthening of the hand during the diff phases
• Provides a shock-absorbing mechanism
– Short canes may result in an inefficient gait
– Long canes ↑ triceps & sh ms activity
• Use of the cane:
– Held opp the involved extremity
• Reduces stress on the involved extremity by ↑-ing the lever arm of
• Less lat shifting of the COG
• Closely ~s a (N) reciprocal gait pattern w/ the opp arm & ipsilat leg
• Used to improve bal & relieve wtberaing either full/partial on a LE.
• Affords the greatest stability
• I: when more stability is required
– fair or poor bal & coordination
– any wt bearing stat
• Fxn: provides a wide BOS
– improves ant & lat stability
– allows body wt to be transferred to UE
– Are small, plastic attachments placed ont he post legs of wlakers typically
combi c wheels on the front legs.
– Promote smooth forward progression s having to lift & place the walker c each
– Made of high-density plastic in an inverted mushroom-shape
o Other common glides:
1” diameter “disk” c a central stem
Tennis ball within a fixed housing
Folding Mechanism –useful for pxs who travel
Handgrips(handles)-enlarged & molded; useful for px c arthritis.
-some offer 2nd set of handles to assist c sit-to-stand transitions
Platform Attachments- used when wtbearing is CI through the wrist
Wheel Attachments- adaptation to walkers
-often called rollators/rolling walkers includes add’n of wheels
either to the 2 front wheels onlt or to all 4 wheels(allows fxnl
ambu for pxs who are unable to lift & to move a conventional
a. Swivel wheels turn freely in a complete circle
b.Fixed wheels rotate around a central axis
*wheels are avail in 3 to 6” diameters; 8” diameter wheels are
also avail & can be used to add ht for tall users
Breaking Mechanism- post po
brakes are effective when wheels are
placed inly on front walker legs
Measuring Walkers- handgrip/handle of the walker shld come to ~
• Posn: supine (#1-3); prone (#4)
• Assume: (L) BKA –actively done
1. hip , knee / of residual limb
2. hip , knee of residual limb
3. hip in neutral, knee / place towel under distal
end of stump (quad setting)
4. residual limb /-ed (gluteal setting)
• Posn: supine
1. Place towel roll under stump(gluteal setting), pt’s hands
clasped behind the head
2. Trochanter roll bet legs than elastic band placed around
(duration 10reps) c band resistance Gr4-5
3. a) relaxed – prone pt’s hands supporting chin
b) tightened – prone, buttocks are squeezed
4. prone, hip / hands on chin
5. Sidelying, hip abd Gr.3
6. Sidelying, hip / Gr2 gravity eliminated
DEVELOP BAL & COORDINATION FOR
ALL UP(R) ACT’S
• Pos’n: kneeling c crutches
• Action: wt shifting, forward&sideward, arm &
crutch raising(forward, backward, sideward)
hip swayer; crutch place (forward, backward,
Locomotor Training Using AD
– wt bearing for 5-10 minutes
– stump lies on rolling stool
• Shadow Walking
– Aka ___________________
– Aims at the maintenance of the (N) pattern of gait in the
absence of actual wt bearing
– Helps in establishing the correct pattern of gait
– No 2pt gait, no hopping
Proc: crutch on the opp side of the non-wt-bearing limb is put
forward first to be followed by forward movt of the non-wt-
bearing leg. Next the other crutch is put forward to be followed
by the (N) limb
• PT is pos’ned post & lat on the affected side
• A wide BOS shld be maintained w/ each foot on a different stair
• A step shld be taken only when the px is not moving
• 1 hand is placed post-ly on the guarding belt & 1 is ant to, but not
touching, the sh on the weaker side
• PT is pos’ned ant & lat on the affected side
• A wide BOS shld be maintained w/ each foot on a diff stair
• A step shld be taken only when px is not moving
• 1 hand is placed ant-ly on the guarding belt & 1 is ant to, but not
touching, the sh on the weaker side
If railing is avail it shld always be used.
• Axillary crutches: “up c the good & down c the bad”
-(B) crutches are placed together under 1 arm.
- px stronger LE always lead going up the stairs
- weaker/involved limb always lead coming down
- px pos’ned close to the foot of the stairs
(R)Crutch→ (L) good leg → (L) crutch→(R) bad leg
B. Descending Stairs
- px stands close to the edge of the stair
(L) crutch→(R) bad leg→(R) crutch→(L) good leg
• Cane Gait Patterns:
– Level Surface
• Cane → bad leg → good leg
• Cane + bad leg → good leg
– Ascending Stairs
• Good leg → cane + bad leg
*uninvoled leg away from the handle of stairs
*opp hand holding the handle of stairs
*AD hang at the other hand
– Descending Stairs
• Bad leg + cane → good leg
*PT in front
*PT&px shld be harmonious in going down
Cane shld remain relatively close to the body & shldn’t be
placed ahead of the toe of the involved extremity bec placing
the cane too far forward/to the side will cause lat/forward
bending w/ a resultant ↓in dynamic stability
A. AXILLARY CRUTCHES
o Pos’n in front of hinges
o Push door away
o Pos’n in front of knob
Affected side away from the knob
+ use hand to puch & hold the cane the other hand
Affected side near the knob
+ same process; no changing of hand in holding the cane
Assuming Standing & Seated Pos’ns w/ AD
•Pos’n: quadruped c each crutches at the
•Action:Grasp handpiece of 1 crutch, palms
forward; place crutch semivertical on the
floor by pronating FA (crutches cane style).
Brace crutch against arm & sh, bring other
crutch to same pos’n, push up erect & roll
pelvis forward, walk crutches back & place
Drug Mechanism of action
Sodium channel blocker
Sodium channel blocker
Sodium channel blocker
Sodium channel blocker
Ca channel blocker
Ca channel blocker
Na channel blocker
Na channel blocker
Ca channel blocker
Na channel blocker
Carbamazepine Na channel blocker
Phenytoin Na channel blocker
Using a Walker After Lower Limb Amputation
For safety, keep your
hands on the
handgrips at all times
while using a walker.
•Stand in the center of the walker frame with your
hands on both handgrips.
Balance your weight between your intact limb and
•Shift your weight slightly back, onto your intact limb.
Lift or roll the walker forward about 12 inches.
•Shift your weight onto your hands, pushing down on
Move your foot forward, to the center of the walker
Make sure your toe does not go past the front of the
•Repeat to take your next step.
Note: Don’t step too far inside the walker. Always aim for the center of the frame.
•Position yourself in front of the chair, keeping your
residual limb slightly forward.
•Be sure the chair is braced so it can’t slide out from
under you as you sit.
•Bend forward at the hip, reaching behind you with
•Grasp the armrest or side of the chair.
•Do the same with the other hand.
•Lower yourself onto the center of the chair, then slide
•To get up, reverse the steps above.
Note: This method can also be used to get into and
out of a car.
Moving Through Doorways
•To push open a closed door, stand facing the doorway with the
walker close to the door. Use one hand to turn the knob and push
the door so it swings open. Then move the walker into the
doorway to keep it from closing. Walk through the doorway, using
the walker to hold the door open as you pass through.
•To pull open a closed door, stand to the side opposite the
direction the door will open. Use one hand to turn the knob and
pull the door so it swings open. Move the walker into the doorway
and keep the walker firmly planted to keep the door from closing.
Walk through the doorway. The walker will keep it from closing
until you are through.
Note: For safety, never remove both hands from the walker at the
same time. Avoid revolving doors when using a walker.
Curbs and Steps
•Your walker may be used to climb a single step, such as a curb.
Before climbing a curb, look for “curb cuts.” These are places
where curbs are cut down to street level. Use curb cuts
whenever you can. To step onto a curb, position the walker as
close as possible to the curb. Step into the center of the frame.
Lift the walker onto the curb. Step up and into the frame with
your intact leg, pushing down onto the handgrips with your
hands. To descend a curb or step, position the walker as close to
the edge as you safely can. Place your foot close to the edge of
the curb. Lower the walker to the street. (Brace the frame against
the curb to keep the walker steady.) Holding the handgrips
securely, lower your foot down into the center of the frame.
Note: For a person with an amputation, walkers may not be safe
for use on stairs. If you can’t avoid taking stairs, ask your
physical therapist for special instructions.