Prosthetic gait training.pptx

Prosthetic gait training.pptx

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  Prosthetic gait training AbhishekTripathi Lecturer, address Reference: Orthoticis & Prosthetics in Rehabiilation -Lusardi
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  Preface • Alignment isdefined 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.
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  Preface contd.. • Staticalignment: 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
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  Preface contd.. Dynamic alignmentevaluation: • 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
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  Objectives • Purpose ofgait 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
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  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
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  Main challenges (Objectivesof 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
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  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
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  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.
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  Important tools andequipments 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
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  Importance of staticand 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.
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  Contd.. • Another importantcue 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;
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  Contd.. – (b) thepelvis 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.
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  Static Gait TrainingProcess 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)
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  Dynamic Gait trainingprocess • 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).
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  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)
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  Contd.. • Repeated steppingactivities (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.
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  Contd.. • Stepping withthe 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.
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  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.
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  Advantage • Advantage: – Decreasingdependency 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
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  Contd.. • Gait traininghelps 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.
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  Contd.. • Sit-to-stand andstand-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.
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  Challenges in Prostheticgait 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
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  Thank you