2. Preface
• Alignment is defined as angular and linear
relationship of different components of the
prosthesis (intra-relation) and in relation to
patient (inter-relation), based on need of
patient.
• Bench alignment process: is the angular and
linear intra-relationship of different component
of the prosthesis with the customized socket as
per some standard of alignment.
3. Preface contd..
• Static alignment: Static alignment refers to assessment of
the inter-relation between the prosthesis and person’s body
and thereby improvisation in the intra-relation between the
socket and rest of the Prosthesis during static standing.
• Factors affecting standing static alignment
– Socket-stump relation, stump sensitivity to pressure
– Variability among Prosthetic components
– Patient overall health condition/balance
– Contracture/tightness/deformities
– Psychological factors
– Activity based factors such as Standing activity in which a
patient engages
– Participation based factors
4. Preface contd..
Dynamic alignment evaluation:
• Dynamic alignment refers to assessment of the inter-relation
between the prosthesis and person’s body and thereby
improvisation in the intra-relation between the socket and rest of
the Prosthesis during dynamic activity (walking/jogging etc).
• Factors affecting dynamic alignment are:
– Suspension
– Variability among Prosthetic components
– Prosthetic weight
– Length of the Prosthesis in relation to sound side
– Type of components (inherent control of the components)
– Voluntary control by the patient
– Activities (basic or advance)
– Participation related facotors
5. Objectives
• Purpose of gait training
• Challenges or limiting factors in gait training
• Initial training and principle of gait training
• Important tools and equipment of gait training
• Static and dynamic gait training principles
• Advantages and
6. Introduction: Gait Training
• Purpose of gait training
– Improve postural balance and control
– Improve the weight bearing capacity from the
prosthetic side
– Improve ROM, strength and coordination
– Sequencing and rhythm
– Improvising accessibility in the environment
– Improving patient understanding about
prosthesis usability
7. Main challenges (Objectives of Initial gait
training)
• Fear, pain and lack of confidence
• To make learn to bearing weight on the newer
areas of the lower limb as a result of
amputation
• Gait deviations: for example:
– Decreased stance time on the prosthetic side
– Shortened stride length on the sound side
– Lateral trunk bending over the prosthetic side
8. Initial training setting/principles
• Protected environment:
– Safety instructions (ask the patient to follow instructions and is to be
observed for comprehension).
• For example; Instruct not lift your hand from the parallel bar until asked for.
– Stable and secure setting
• Minimum environmental barrier
– Example: Parallel bar, Level surface,
• Proper instruction to the patient regarding goals and method
• Its necessary to observe and listen to the patient , Do watch for
verbal or non-verbal clues
9. Initial training setting/principles
• Ask to “keep your head straight, get practiced for”
• Ask to keep hands on the parallel bar until not asked to remove
• Height of the parallel bars should be adjusted to GT level or wrist
position with elbow flexed to 20 to 30 degrees.
• Watch/Observe overall body rather than the prosthesis, i.e.
Gross Symmetry of gait should be seen first
• Watch for the Posture in frontal and sagittal both… should be
vertical
• Minute symmetry of gait (normal gait characteristics)
• Most of the joint movement are in sagittal, first view from side
• Watch for motion synchronicity of hip and knee and foot
• Gradual decreasing dependency on upper limb during static
and dynamic activities.
10. Important tools and equipments for
Gait training
• Level measuring tool (
for ASIS Level
checking)
• Plumb line and Marker
• Stockinet and scissor
• Allen keys (most used is
4mm Allen key)
• Foot blocks (often PP
plastic slabs)
• Rubber compensation
for inside shoe
• Parallel bar
• Staircase/Low and high
portable steps
• Inclined surface of
different slopes
• Variable height
obstacles (up to
4inches)
• Round step
• Mirror
11. Importance of static and dynamic
weight bearing
• The static and dynamic weight bearing
activities helpful to cue the individual to
think about the weight going through the
“ball” or “heel,” or the medial or lateral
surface of the prosthetic foot as they shift
weight in different directions.
• This may help to correlate sensations within
the prosthetic socket with former
somatosensory experiences of the foot.
12. Contd..
• Another important cue during these activities
may be to have the individual focus on the
pelvic position versus the prosthesis during
weight shifting activities
• The focus on the pelvis is important for several
reasons:
– (a) the pelvis has been found to be less stable in
upright standing in persons with transfemoral
amputations than in individuals without
amputations;
13. Contd..
– (b) the pelvis is key to stability in the upright position,
so the patient is cued in to this important locus of
control;
– (c) by focusing on the pelvis, the patient is being directed
to control a part of the body that is intact and “whole,” and
although some individuals have not focused on pelvic
awareness prior to prosthetic rehabilitation, this takes the
focus off of the prosthesis and the “new” challenges that
the patient is facing; and
– (d) awareness of pelvic position in early weight-shifting
activities may make later gait demands, such as
emphasizing pelvic rotation, easier for the patient to grasp.
– (e) Gait deviations can be controlled with focus on pelvis.
14. Static Gait Training Process
Static weight bearing progresses from decreasing dependency on upper
extremity (UE) support to static standing activities without support
1. Position of the patient
a) Patient standing in parallel bar with prosthesis properly wore
b) Instruction to have equal weight bearing on both side and is observed
c) Hands on the bars
d) Upright posture
e) Front mirror watching
2. With bilateral weight bearing, keeping both hand on the bar to
contralateral hand on the bar to ipsilateral hand on the bar to no hand on
the bar
3. Single limb weight bearing (on prosthetic side) and repeat the step
number 2 (it will be necessary to ensure safety and necessary comfort in
mind)
15. Dynamic Gait training process
• Simple dynamic weight-shifting activities,
consisting of loading and unloading body
weight through the prosthesis in multiple
directions (anterior/posterior, medial/lateral,
and diagonal patterns) as is required in gait and
functional activities.
• These tasks are progressed by decreasing UE
support and varying foot positions (parallel
stance, step-stance, tandem stance).
16. Dynamic Gait training: step by step
process
1. Dynamic Weight shift training
a) Lateral weight shifting (side to side) with changing BOS, hands grip fix
b) Antero-posterior shifting with changing BOS, hand grip fix
c) Single hand on parallel bar (Opposite to the amputated side, then ipsilateral
and then without hand support) and repetition of above weight shift modules
2. Stepping forward-backward on one limb (repeated for both sides)
3. Side-stepping (turn 90 degree so that both hand on the same parallel bar)
then take side step once towards amputated and then non-amputated
4. Cross stepping (one limb across other stance limb)
5. Forward progression (specific gait-Short and equal steps)
6. Turning (towards stronger side)
7. For sitting (turn from the stronger side)
8. For standing (loading on the stronger side first)
17.
18. Contd..
• Repeated stepping activities (e.g., breaking
down gait cycle into its component parts) in all
directions with decreasing UE support so that
readying patient for sudden demand.
• The focus here may be in loading and
offloading the prosthetic limb with good
proximal/pelvic control.
19. Contd..
• Stepping with the uninvolved
limb onto an elevated surface
(begin with a low surface and
progress height and/or begin
with stable surface, such as
stepstool, and progress to less
stable surface, such as small
ball) forcing increased weight
bearing through the prosthetic
limb with progressively
decreasing UE support.
• This helps in improvising
control over the prosthesis.
20. Standing reaching activities
• that require the person to reach to
a variety of heights and directions
within a functional context.
• These activities are progressed by
increasingly challenging reaching
limits in all directions, varying
foot position and decreasing UE
support.
• These early reaching activities are
prerequisites to very functional
goals such as reaching to high
shelves and lifting something of
substantial weight or picking up
a heavy object from the floor.
21. Advantage
• Advantage:
– Decreasing dependency on upper limb
– Ambulation in the parallel bars helps to identify gait deviations
early in training before maladaptive habits become problematic
– Based on this preliminary gait assessment, individual problem
areas can be addressed with exercise activities and gait training.
– Early therapeutic activities will progress from initially
supporting and later challenging the individual's postural
stability.
– Progressing from weight bearing and gait activities with
significant bilateral upper extremity support to minimal or no
support is a common early goal in the rehabilitation process of
both transtibial and transfemoral prosthetic users
22. Contd..
• Gait training helps to minimize gait deviations
inside, or progressing out of the parallel bars.
• Early in training, individuals often benefit
from cues to make firm contact with the
prosthetic heel during initial contact to
enhance awareness of the location of the
prosthetic foot on the floor and assure stability
of the prosthetic knee of the transfemoral
prosthesis with active hip extension.
23. Contd..
• Sit-to-stand and stand-to-sit activities, to enhance the
ease and independence of transitional movements.
• Persons with transtibial amputations are encouraging to
integrate partial weight bearing through the prosthesis;
whereas a transfemoral prosthesis is much more
difficult to load partially during transitional
movements.
• Beginning training to/from high surfaces with arm rests
and progressing to lower surfaces without arm rests,
and varying training to include different types of
support surfaces will enhance the individual's ability to
generalize the skill to a variety of settings.
24. Challenges in Prosthetic gait
training
Factors affecting Prosthetic gait
Over all physical condition of the patient; non accommodated
contractures, spinal deformities etc
Tolerance to prosthetic socket and weight bearing through the residual limb;
Controlling dynamic weight shifting through the prosthesis in all planes of
movement; and
Reintegrating postural control and balance with respect to the lack of ankle,
and in the case of transfemoral amputation, knee joint, sensory and
proprioceptive input, muscle control, and ROM.
Ability to follow instructions
Fear and concern
Determination and motivation
Habits which are difficult to untrain
Language of instruction but is a minimal limitation if vision and understanding
is intact
