In this presentation, we have included transtibial amputation & its management, goals of prosthetic gait training, stages of rehabilitation for transtibial amputees, pre prosthetic rehabilitation, various gait & activity training like applying the prosthesis correctly, balancing on the definitive prosthesis ,specific gait training exercises, functional exercises/activities, advance exercises, & advice and patient education & follow up.

1. Ms Priyasmita Naik
MPO 1st year
SVNIRTAR

2. CONTENTS
 INTRODUCTION
 GOALS OF PROSTHETIC GAIT TRAINING
 STAGES OF REHABILITATION FOR TRANSTIBIALAMPUTEES
 PRE PROSTHETIC REHABILITATION
 VARIOUS GAIT & ACTIVITY TRAINING
 ADVICE & PATIENT EDUCATION
 FOLLOW UP
 REFERENCES

3. INTRODUCTION
 Attaining functional independence is the ultimate aim of rehabilitation for lower-limb amputees.
 Gait training for the prosthesis user has maximum significance in the rehabilitation process.
 The clinic team makes a substantial investment of time & effort in the pre prescription, fabrication ,
& checkout of the prosthesis. This investment will become worthy if the amputee receive adequate
training with the prosthesis.
 The fitting of the prosthesis needs to be followed by functional training; in the case of transtibial
amputation, this is essentially gait training.
 Users also need to be taught about prosthesis maintenance and care and made aware of the need to
report back to the physical rehabilitation centre for follow-up.

4. GOALS OF PROSTHETIC GAIT TRAINING
 To help trans tibial amputees to adapt to their new condition.
 To achieve optimal weight bearing on the prosthesis.
 To improve balance and reaction to disturbance.
 To restore the optimal gait pattern.
 To reduce the amount of energy needed to walk .
 To teach amputees how to perform daily operations like sitting
down and walking up and down stairs.
 To help amputees attain the largest possible degree of mobility and
independence, so that they do not require a great deal of help in their
everyday lives.
 To regain their self confidence and play an active role in society.

5. FIVE MAIN STAGES OF REHABILITATION FOR
TRANSTIBIAL AMPUTEES :-
1. Immediate post-surgical management
2. Pre-prosthetic training
3. Post- fitting prosthetic training
4. Advice and patient education
5. Follow up

6. PRE- PROSTHETIC REHABILITATION
AIM:-
 To help the patient to recover from the surgical intervention physically and psychologically and to prepare
his/her body and mind for the prosthesis.
 The rehabilitation process is designed to provide assistance in the transition period immediately following
surgery.
1.ROM & Stretching exercise
2.Strengthening exercise
3.Balance
4.Positioning
5.Skin care
6.Bandaging
7.Upper extremity strengthening
8.Wheelchair propulsion & ambulation with assistive devices
9.Independence & self care

7. FLEXIBILITY / ROM & STRETCHING EXERCISES
Hamstring stretch in
long – sitting position
Quadriceps stretch:- A. Supine position
B. Prone position

8. STRENGTHENING EXERCISES
Isometric gluteus
maximus contraction
Knee extension exercise in prone
Short –arc quad exercise
Straight – leg exercise
Knee flexion exercise:- A. Supine
B. Prone

9. Weight bearing exercise
Dip exercise
Wheelchair barbell exercise
Stand - pivot transfer

10. Massage Mirror box therapy
Bandaging
Care of pathological scar
Ambulation using assistive devices
Care of stump / wound

11. chart showing the different stages of amputee rehabilitation following
surgery.

12. GAIT & ACTIVITIES TRAINING
WEIGHT BEARING
AND BALANCE
SPECIFIC GAIT
TRAINING
EXERCISES
ADVANCE
EXERCISES
FUNCTIONAL
EXERCISES &
ACTIVITIES

13. 1. APPLYING THE PROSTHESIS CORRECTLY
Prior to initiating dynamic alignment and interdisciplinary prosthetic gait
analysis,
 The amputee is need to be comfortable & obtain good prosthetic function .
 The amputated limb must be placed in the socket so that all the tissue are in the position
planned for them by the prosthetist.
Following equipments are needed to apply a below knee prosthesis:-
 Stump sock(s)
 PTB prosthesis with cuff, SC wedge ,or corset suspension
 Talcum powder
 Parallel bars or other sturdy support
 chair

14. 2. BALANCING ON THE DEFINITIVE PROSTHESIS

15. 2.1 WEIGHT BEARING AND BALANCE
Aim:-
1) To be able to perform full single-leg weight-bearing on the prosthetic side.
2) To enhance stability by controlling the residual limb.
 Balancing exercises must be gradual and progressive.
Steps:-
1. amputee stands in or alongside parallel bars facing a posture mirror.
2. Medial borders of the feet are (4-6 in.) apart.
3. Equal weight distribution on both the feet.
4. Erect posture.

16. 2.2 WEIGHT SHIFTING – SIDE TO SIDE
Steps:-
1. Same as in preceding exercise.
2. Shift weight to the prosthesis, keeping feet flat & knees straight.
3. Weight shift is done by pelvic movement; the shoulders & pelvis remain
horizontal.
4. Shift weight to the sound leg.
5. Repeat the sequence, shifting from side to side smoothly.

17. 2.3 WEIGHT SHIFTING – FORWARD AND BACK
Steps:-
1. Same as in preceding exercise.
2. Shift weight forward to the forefeet , do not
bend the knees or hips.
3. Shift weight back to the heels.

18. 2.4 FORWARD & BACKWARD SWING
Steps:-
1. same as in preceding exercise.
2. Shift weight & balance on the sound leg.
3. Swing the prosthesis backward & forward.
4. Resume the starting position.
5. Shift weight to the prosthesis, & swing the sound
leg forward & backward.
6. Alternate weight shifting & leg swinging.

19. 2.5 ABDUCTION & ADDUCTION
Steps:-
1. same as in preceding exercise.
2. Shift weight to the sound leg.
3. Swing the prosthesis out to the side, cross it in front of the sound leg &
to the amputated side.
4. Resume the starting position.
5. Continue the exercise, swing the prosthesis in a circular motion.
6. Alternate swinging the prosthesis & sound leg.
Note:-
A ½ in. (1.3 cm) thick board under the sound foot facilitates clearance of
the floor as the prosthesis swings.

20. 2.6 PIVOTING ON HEELS , TOE –IN & TOE- OUT
Steps:-
1. same as in preceding exercise.
2. Shift weight to the heels.
3. Pivot on heels to turn the toes out.
4. Return to the starting position.
5. Pivot on the heels to turn the toes in .
6. Return to the starting position.

21. 2.7 PIVOTING ON TOES , HEEL –IN & HEEL -OUT
Steps:-
1. same as in preceding exercise.
2. Shift weight to the toes.
3. Pivot on the toes to turn the heels out.
4. Return to the starting position.
5. Pivot on the toes to turn the heels in
6. Return to the starting position.

22. 2.8 MARKING TIME & WALKING IN PLACE
Steps:-
1. same as in preceding exercise.
2. Shift the weight to the sound leg & bend the knee on the
amputated side until the prosthetic heel rises from the floor.
3. Keep the toe of the prosthetic foot in contact with the floor.
4. Straighten the knee on the amputated side.
5. Place the prosthetic heel to its original position.
6. Extend the hip to keep knee extended.
7. Shift the weight to the prosthesis.
8. Repeat the same( in sound side).

23. 2.9 WEIGHT SHIFTING – IN –STEP POSITION
Steps:-
1. Stand with the heel of the prosthesis 5-10 cm ahead of the toe of the
sound foot.
2. Move the pelvis forward to shift the weight over the prosthesis.
3. Extend the hip to keep the knee extended.
4. Allow the sound knee to bend.
5. Shift the weight rearward & return to the starting position.
6. Repeat the steps from 1 to 5 with sound foot advanced.
7. Allow the prosthetic knee to bend, keeping the toe in contact with
the floor.

24. 2.10 SWING THROUGH ALTERNATE LIMBS
Steps:-
1. Stand with the heel of the prosthetic foot 5-10 cm ahead of the toe of the sound side.
2. Shift weight to the prosthesis, then swing the sound leg forward & take a step.
3. Shift weight to the sound foot.
4. Return to the starting position.
5. Repeat the steps from 1 to 4 with the sound foot advanced.
6. Swing the prosthesis forward so that the prosthetic foot is a step ahead of the sound
one.

25. 2.11 COMBINED SHIFT & SWING
Steps:-
1. Keep heel of the prosthesis 5-10 cm ahead of the toe of the sound foot.
2. Shift weight forward on to the prosthesis, then back to the sound leg.
3. Shift weight forward to the prosthesis again, & swing the sound leg through to place the
sound foot a step ahead of the prosthetic foot.
4. Repeat the steps from 1 to 3 (swing the prosthetic leg).

26. 2.12 BALANCE RECOVERY
Steps:-
1. Same as in preceding exercise.
2. Shift weight forward until the prosthetic heel starts to rise from floor& balance is about to
be lost.
3. Shift weight back to regain balance.
4. Resume the exercise, shifting weight forward until balance is nearly lost in the forward
direction.
5. Recover by taking a quick step forward with the sound foot.

27. 2.13 BALANCE CHALLENGING
 It promotes trunk stability.
Steps:-
The patient is asked to maintain proper standing stability
while the therapist’s hands are placed on either side of the
shoulders / pelvis & the patient is gently pushed.

28. 3. SPECIFIC GAIT TRAINING EXERCISES

29. 3.1 FORWARD WALKING
Steps:-
1. Stand with the feet about 10 cm apart with weight evenly distributed.
2. Shift weight forward; as balance is about to be lost, step forward with Sound foot.
3. Shift weight to the sound leg, allow the prosthetic knee to bend, and swing the
prosthesis forward until the prosthetic foot is a step ahead of the sound foot.
4. Move rhythmically to advance the, body smoothly.
5. Shift weight over the prosthesis and swing the sound leg ahead of the prosthesis.
6. After heel of sound foot strikes, shift weight to the sound leg and bring the prosthetic
foot in line with the sound foot.
7. Redistribute weight equally on both feet.

30. 3.2 BACKWARD WALKING
Steps:-
1. Keep both the feet 5-10 cm (2-4-in.) apart, with weight evenly distributed on both feet.
2. Take a short backward step with prosthesis.
3. Transfer weight to the prosthesis.
4. Step back with sound foot.

31. 3.3 WALKING WITH A NARRW BASE
Steps :-
1. Walk between lines that are 10 cm (4 in.) apart.
2. The purpose of this exercise is to develop the ability to walk without undue pelvic and trunk
movement.
3. This exercise is more challenging if the amputee walks on a board that is 10m (4 in.) wide.

32. 3.4 SIDE-STEPPING TOWARD POSTHETIC SIDE & SOUND SIDE
Steps:-
1. Stand with feet 10-15 cm (4-6 in.) apart, with weight evenly distributed.
2. Shift weight to the sound leg.
3. Slide the prosthetic foot toward the sound foot.
4. As soon as the prosthetic foot touches the sound foot, shift weight onto the prosthesis, and
slide the sound foot laterally.
5. Repeat steps 2 through 4.
6. follow the same steps for side-stepping toward the sound side.

33. 4. FUNCTIONAL EXERCISES/ ACTIVITIES

34. 4.1 SITTING IN A CHAIR
Steps:-
1. Select a heavy armchair placed against a wall.
2. Face the chair so that the prosthesis is to the side .
3. Pivot on the sound foot until the back of the sound leg touches the chair.
Inexperienced amputees may also wish to augment balance by placing the hand on the sound side on the armrest of
the seat of the chair.
 CAUTION:- Never lean against the back of the chair.
4. Bend forward at the waist, allowing the sound hip and knee to flex, in order to lower the trunk into the chair.

35. 4.2 RISING FROM A CHAIR
Steps:-
1. Place the sound foot under the chair. If necessary to assist in rising,
place one or both hands on the sound knee or thigh, or on the armrest
on the sound side, or both armrests .
2. Bend forward at the waist and rise to the standing position by
extending the sound hip and knee. If necessary, place one or both
hands on the knee, thigh, or armrest to assist in rising.
3. Shift weight to the prosthesis and step forward with the sound foot .
STEP 1
STEP 2

36. 4.3 SITTING DOWN ON A CHAIR& GETTING UP (FOR BILATERAL
AMPUTEES)
Face the chair and place one
hand on the seat of the chair and the
other on the back.
Turn your body and flex your
legs.
Sit down and do the reverse for
getting up.
STEP 1 STEP 2 STEP 3

37. 4.4 ASCENDING & DESCENDING STAIRS & CURBS
Steps:-
(for ascending):-
1. Place the sound foot on the first step, shift weight to the sound leg .
2. Extend the sound hip and knee to bring the prosthetic foot up to the sound foot.
NOTE:-Most below-knee amputees will be able to ascend stairs step-
over step, alternating sound and amputated sides.

38. (for descending):-
1. Keep the first step above the bottom of the stair.
2. Shift weight to the sound limb.
3. Lower the prosthesis while bending the sound hip and knee.
4. Shift weight to the prosthesis and lower the sound limb.
NOTE: -The inexperienced amputee may prefer to ascend and descend stairs facing
diagonally or sideward, holding the rail with both hands to facilitate rapid
recovery of balance.

39. 4.5 ASCENDING & DESCENDING STAIRS & CURBS(B/L AMPUTEE)
 The longer RL should ascend the stair first.
 The shorter RL should descend the stair first.
 Steps:- same as unilateral amputees.
NOTE: -The inexperienced amputee may prefer to ascend and descend stairs facing diagonally or
sideward, holding the rail with both hands to facilitate rapid recovery of balance.

40. 4.6 STEP– OVER- STEP
Steps:-
1. Place the prosthetic heel on the edge of the step, so the sole of the foot extends beyond the step .
2. Move the pelvis and trunk forward to shift weight to the prosthesis.
3. Advance the sound foot beyond the prosthesis .
4. Place the sound foot on the step below and shift weight onto the sound limb .
5. Swing the prosthesis to lower the prosthetic heel to the edge of the next step.
6. Alternate descending stairs so that the sound foot lowers to the 1st step, then the prosthetic foot
lowers to the second step, the sound foot lowers to the third step, until the bottom of the staircase
is reached.

41. 4.7 ASCENDING INCLINES & DESCENDING INCLINES
Steps:-
(for ascending):-
1. Lead with the sound foot.
2. Flex the knee on the amputated side while advancing the prosthesis.
3. Take a shorter prosthetic step, passing the sound foot slightly or just reaching the sound foot.
4. Extend the hip and knee on the amputated side.
( for descending inclines):-
1. Lead with the prosthetic foot (shorter step than usual).at heel strike extend the hip & knee on the amputated side.
2. Shift the weight to the prosthesis.
3. Swing the sound leg forward; relax the amputated side to allow the knee on the amputated side to flex as the sound limb passes it.
4. Recover on the sound leg.

42. 4.8 ASCENDING & DESCENDING INCLINES (B/LAMPUTEE)
 The longer RL should ascend the incline first.
 The shorter RL should descend the incline first.
 A sideways or lateral approach is also an option in ascending & descending inclines.
 Steps:- same as unilateral amputees.

43. 4.9 PICKING UP OBJECTS
Steps:-
1. Place the sound foot ahead of the prosthetic one .
2. Weight should be on the sound leg.
3. Bend at the waist, flexing the hips and knee.
4. Grasp the object and rise to the standing position by extending both hips and the knee .

44. 4.10 KNEELING
Steps:-
1. Place the sound foot well ahead of the prosthetic foot.
2. Keep the knee on the amputated side extended .
3. Shift most of the weight to the sound foot.
4. Bend both knees to place the knee on the amputated side gently on the ground.
5. As that knee is flexed, the toe of the prosthesis will slide backwards on the floor.
6. Maintain the knee on the amputated side in full flexion and keep the weight back to avoid falling forward.

45. 4.11 RISING FROM THE KNEELING POSITION
Steps:-
1. Place the sound foot flat on the floor.
2. Bend forward at the waist.
3. Extend the hip and knee of the sound limb. If necessary, place the hands on the sound thigh and
push to assist rising.
4. On arising, the prosthetic foot is brought forward so that it is only slightly behind the sound
foot.

46. 4. 12 SITTING ON THE FLOOR
Steps:-
Weight is borne progressively by the sound leg , the arm on the sound side, and the sound
buttock.
1. Place the prosthesis slightly forward.
2. Shift weight to the sound foot.
3. Turn the trunk toward the sound side.
4. Bending from the waist, the amputee flexes both knees and hips and reaches downward and backward to place the hand on the sound
side on the floor ; that elbow is extended firmly .
5. Gently lower the body to the floor and sit on the sound buttock.
6. Twist to sit squarely on the floor.
 For older patients the following procedure is safer:-
1. Place the sound foot slightly ahead of the prosthesis.
2. Lower the body , make a quarter turn toward the sound side , & sit on the sound buttock.
3. Continue to turn the body to sit on the buttock.

47. 4. 13 RISING FROM THE FLOOR
Steps:-
1. Bring the sound leg under the trunk.
2. Place the hand on the sound side behind the trunk .
3. Turn toward the sound side. Push with the hand while extending the sound leg.
4. As the sound leg extends, the amputee pivots on the sound foot until the opposite hand contacts the floor in front of the body.
5. The sound foot will be directly under the trunk .
6. Push strongly with both hands to extend the sound knee.
7. Advance the prosthetic foot until it is in line with the sound foot.
8. Complete the extension of both knees.
For older patients:-
1. Cross the sound leg over the prosthesis, flexing the hip and knee on the sound side as much as possible.
2. Roll onto the prosthesis.
3. Place the hand on the sound side in line with the other hand.
4. Press to a standing position, using the hands to assist the sound leg.

48. 4 .14 CLEARING OBSTACLES
Steps:-
(Direct approach):-
1. Face the obstacle squarely with the toes 7-8 cm (about 3 in.) away.
2. Transfer weight to the sound limb.
3. Circumduct the hip on the prosthetic side forcefully to fling the prosthesis over the obstacle .
4. When the prosthetic heel touches the ground, extend the hip and knee on the prosthetic side strongly to regain stability.
5. Step over obstacle with the sound leg and regain balance.
(side approach), used for traversing relatively high obstacles:-
1. Stand sideward with the prosthesis about 13 cm (5 in.) from the obstacle.
2. Use forceful hip flexion on the amputated side to whip that knee into extension while clearing the obstacle.
3. At heel strike, extend the hip on the amputated side strongly to regain stability.
4. Bring the sound leg over the obstacle and regain balance.
5. The above steps, 1 through 4, may be performed with the sound leg leading. Shift weight forward slightly, extend the hip on the amputated
side and swing the sound leg over the obstacle.

49. 4. 15 WEIGHT CARRYING
 Walk carrying a weight on the prosthetic side.

50. 4. 16 WHEELCHAIR USE ( B/L)
 Amputee wheel chair having a wheel axis posteriorly
to the centre support to allow better balance.
 This wheelchair should have removable armrests &
swing away leg rests.
 Two inserts are used to prevent knee flexion
contracture.
Wheelchair insert

51. 4. 17 DRESSING (B/LAMPUTEE)
 Individuals with B/L lower extremity amputations may require clothing adaptations such as
velcro closures or a reaching device.
 They should master rolling to pull trousers up over their hips.
 The prosthesis should be dressed first.
 The prostheses may be applied in bed or , if the patient uses a wheelchair, may be applied from
the wheelchair.
 Dressing activities may involve the need for occupational therapist.

52. 4 .18 DRIVING
 A patient with a right below knee amputation may need to have the brake & gas pedals switched to
move the gas pedals closer to the left sound leg.
 Hand controls are necessary for patients with bilateral lower – extremity amputations.
 Two door cars offer more front seat leg room than four – door cars.

53. 5. ADVANCE EXERCISES

54. 5.1 ADVANCE WALKING EXERCISES:-
 Walk in a circle with the prosthesis on the inside of the circle
 Walk in a circle with the prosthesis on the outside of the circle
 Walk in a figure-eight pattern
 90-deg. Turns
Steps( for 90̊ turn):-
1. Place the prosthetic foot forward.
2. Transfer weight to the prosthetic forefoot, maintaining knee stability.
3. Pivot on the prosthetic forefoot to make a 90-deg. turn toward the sound side; step forward with the sound foot.
4. Repeat steps 1 through 3, pivoting on the sound forefoot. At the same time take a short step forward with the
prosthesis.

55. 5. 2 JUMPING
Jump from a spread-leg position to a closed-leg position and back
again.

56. 5. 3 RUNNING (HOP- SKIP METHOD)
Place the forefoot of the prosthesis on the ground and stretch
the knee, keeping the trunk slightly flexed.
Steps:-
1. Step forward with the sound foot.
2. Shift weight to the sound foot.
3. Swing the prosthesis forward , transfer
weight to it momentarily, then swing the
sound leg through quickly.
4. Transfer weight to the sound foot.
5. Hop on the sound foot as the prosthesis
swings through.
6. Continue the pattern of progression,
taking one hop on the sound leg, then one
balancing step on the prosthesis.
Step 1 Step 2

57. 5.4 WALKING ON AN UNEVEN SURFACE
Walk on an uneven surface, keeping to a narrow path.

58. 5.5 RESISTED AMBULATION
 Resisted ambulation using a cable column machine may
also strengthen pelvic & hip motions.

59. SELF PROTECTION IN FALLING
1. Discard any AD to avoid injury.
2. Try to fall forward , landing on their hands with elbows slightly flexed.
3. Roll to one side, preferably the sound side.
4. Land on soft , cushioned surface, if possible.
How to get up from a fall:-
1. Roll to stomach.
2. Assume all – four position.
3. Crawl to nearest , safest supportive surfaces if on wheels, push hands on supportive surface.
4. Bring sound limb up first- be sure to place foot flat on floor in front & slightly out to side to increase BOS.
5. Use hands & sound foot to push up &straighten sound knee.
6. Bring prosthetic limb forward & foot flat.
7. Turn & sit on supportive surface to recover.
8. If no supporting surface, arise from tall – kneeling, bring sound limb up, place hands on thigh of sound limb & push down to
straighten sound knee & bring prosthesis forward.
9. If have an AD, place hands on AD, then bring sound limb up first.
10. Be sure to have someone stabilizing AD, if needed.

60. ADVICE AND PATIENT EDUCATION
 When the amputee is discharged from rehabilitation, they should be fully trained in care of the
prosthesis and the stump.
A. Stump care
 Amputees should know that using a prosthesis should be completely painless and donning should
always be carried out carefully with a clean sock correctly pulled up.
 If the skin breaks, blisters occur or other problems arise, amputees should be taught:-
 to report to the Prosthetist.
 to stop wearing the prosthesis.
 to seek medical advice.

61. B. Prosthesis care
 Amputees will be advised to wipe the prosthesis (socket, soft socket and EVA cosmetic) with a
damp cloth at night and then to dry it thoroughly.
 The prosthesis should also be kept away from any fire or naked flames, dampness or corrosive
materials.

62. FOLLOW UP
 Prostheses for adult amputees may last up to three years but this period could be shorter, depending on
the manner in which the prosthesis is used , e.g. daily long-distance walking , rural field work etc.
 The environment (rice fields, mountainous area) and the climate, which affects in particular, the
prosthetic feet, requiring their repeated replacement.
 Physical changes in the user’s condition (weight changes, stump volume changes) are also a common
justification for regular follow-ups.

63. REFERENCES
 NEW YORK UNIVERSITY MANUAL FOR LOWER LIMB PROSTHETICS, 1990 REVISION
 RON SHEYMOR PROSTHETICS AND ORTHOTICS
 ICRC PROSTHETIC GAIT ANALYSIS
 ICRC EXERCISES FOR LOWER-LIMB AMPUTEES

64. THANK YOU