PROSTHETIC GAIT ANALYSIS FOR PHYSIOTHERAPISTS ICRC PHYSIOTHERAPY REFERENCE MANUAL International Committee of the Red Cross 19, avenue de la Paix 1202 Geneva, Switzerland T +41 22 734 6001 F +41 22 733 2057 Email: [email protected] www.icrc.org © ICRC, January 2014 PROSTHETIC GAIT ANALYSIS FOR PHYSIOTHERAPISTS ICRC PHYSIOTHERAPY REFERENCE MANUAL TABLE OF CONTENTS Acknowledgements 4 Foreword 5 Lower-limb amputations and general prosthetic knowledge 7 Introduction 7 Terminology and definitions 8 What is a lower-limb prosthesis? 8 General points about lower-limb amputations 11 Surgery 11 Causes of amputation 15 The various types of prostheses for lower-limb amputations 16 Transtibial prostheses 16 Transfemoral prostheses 18 Knee disarticulation prostheses 20 Hip disarticulation prostheses 20 Hemipelvectomy prostheses 20 Symes prostheses 21 Partial foot prostheses 21 Polypropylene technology 23 Introduction 23 Raw materials and orthopaedic components 24 Raw materials 24 Orthopaedic components 25 Basic principles of alignment 27 Initial transtibial alignment 27 Initial transfemoral alignment 32 Clinical decisions and prescriptions 39 Introduction 39 General considerations 40 Specific considerations 40 Stump conditions 40 Ideal stump conditions 40 Problematic stump conditions 42 Amputee conditions 43 Multiple amputations 44 In brief 45 2 PROSTHETIC GAIT ANALYSIS FOR PHYSIOTHERAPISTS Materials and equipment 47 Introduction 47 Materials and equipment 48 Essential equipment 48 Advanced equipment 49 Optional equipment 49 Pre-prosthetic rehabilitation 51 Introduction 51 Aim of pre-prosthetic rehabilitation 52 Immediate post-surgical management 53 Advice and patient education 56 Pre-prosthetic training 59 Fitting a prosthesis 61 Introduction 61 First fitting principles 62 Fitting a prosthesis 63 TT prostheses 63 TF prostheses (quad socket) 66 Normal gait and prosthetic gait 71 Introduction 71 Normal gait 72 Gait terminology 72 Brief physiological recapitulation 73 Prosthetic gait 75 Quality of the prosthetic components 75 Condition of the stump – energy expenditure 77 Interface between the body and the prosthesis 78 Characteristics of prosthetic gait 80 Gait analysis and gait deviations 83 Introduction 83 General matters 84 Weakness 84 Deformity 85 Impaired control and sensory loss 86 Fear and anxiety 86 Pain 86 TT gait deviations 87 Lateral trunk bending 87 Rotation of the foot at heel strike 87 Knee hyperextension 88 Drop off/early knee flexion 88 Delayed knee flexion 89 Excessive knee flexion 89 Lateral shift of the prosthesis 89 TABLE OF CONTENTS 3 Knee instability 90 Wide-based gait 90 Pistoning 90 Uneven step length 91 Other deviations 91 TF gait deviations (free knee gait only)37 92 Lateral trunk bending (towards the prosthetic side) 92 Rotation of the foot at heel strike 92 Terminal swing impact 93 Drop off 93 Medial whip/Lateral whip 93 Pelvic rise (hip hiking) 94 Excessive heel rise 95 Knee instability 95 Vaulting 95 Abducted gait 96 Lumbar lordosis 96 Forward trunk 97 Uneven step length 97 Circumduction 98 Other deviations 99 Post-fitting rehabilitation 101 Introduction 101 Aim of post-fitting rehabilitation 102 Weight-bearing and balance 102 Gait training 103 Coordination and endurance 105 Functional activities and ADL 105 Advice and follow-up 105 References 109 Introduction 109 References 110 Bibliography 110 Articles in journals 111 Videos 112 ICRC/SFD internal documents 112 Training courses 112 Annexes 113 4 PROSTHETIC GAIT ANALYSIS FOR PHYSIOTHERAPISTS ACKNOWLEDGEMENTS Authors Catherine Morvan Venkatakannan Packirisamy Michael Rechsteiner François Friedel The authors would like to thank all those who edited the text and who provided illustrations and photographs. FOREWORD 5 FOREWORD The ICRC’s Physical Rehabilitation Department has designed a course for physiotherapists on prosthetic gait analysis. Physiotherapists who work in ICRC physical rehabilitation programmes are involved in the rehabilitation of lower- limb amputees on a daily basis. In conjunction with the patients and the ortho-prosthetists, physiotherapists usually define the objectives of the rehabilitation process and participate in the fitting of prostheses. After ortho-prosthetists have manufactured and adjusted the required orthopaedic devices, physiotherapists are in charge of making sure that the amputees are able to use them properly, can manage them easily and are ready to participate fully in society again. To achieve that, ICRC physiotherapists need to be familiar with the work of the ortho-prosthetists among their colleagues and to understand the specificities of prosthetic gait and prosthetic gait deviations. All these duties and responsibilities are only referred to briefly in standard international training courses for physiotherapists, and ICRC physiotherapists therefore usually start their first assignment with very little knowledge about amputees’ rehabilitation or prosthetic gait deviations. For that reason, the ICRC has set up a short training course that can be taken by physiotherapists before they are sent to join an ICRC physical rehabilitation programme. The purpose of the course is to give physiotherapists some initial insight into the prosthetic profession, general skills in rehabilitation for lower-limb amputees and preliminary knowledge of prosthetic gait in a way that will help prepare them for ICRC physical rehabilitation programmes. This manual presents the course content and adds a wealth of commentary and advice from ortho-prosthetists and physiotherapists with extensive experience in the rehabilitation of amputees. We trust that this manual will be of use to physiotherapists in carrying out their duties as part of the ICRC physical rehabilitation team. ICRC Physical Rehabilitation Department 6 PROSTHETIC GAIT ANALYSIS FOR PHYSIOTHERAPISTS LOwer-limb AMPUTATIONS AND GENERAL PROSTHETIC KNOWLEDGE 7 LOWER-LIMB AMPUTATIONS AND GENERAL PROSTHETIC KNOWLEDGE Introduction Content This chapter outlines the different causes of lower-limb amputations, especially in the context of the ICRC’s physical rehabilitation activities. It also discusses the different types of lower-limb prostheses manufactured in ICRC-supported programmes. Rationale It is logical to review the surgical aspects of amputations and to be familiar with the basics of prosthetics before exploring the issues of gait problems, their prosthetic or amputee-related causes and possible rectification. Hence, this chapter attempts to guide readers along the same path. 8 PROSTHETIC GAIT ANALYSIS FOR PHYSIOTHERAPISTS Terminology and definitions Physical rehabilitation refers to a process aimed at removing – or reducing as far as possible – restrictions to the activities of people with disabilities and at enabling them to become more independent and to enjoy the highest possible quality of life in physical, psychological, social and professional terms. Orthoses are externally applied devices used to modify the structural and functional characteristics of the neuromuscular and skeletal systems (ISO 9999 06 Orthoses and Prostheses). Prostheses are externally applied devices used to replace, wholly or in part, an absent or deficient body part (ISO 9999 06 Orthoses and Prostheses). The terms also cover, for example, body-powered and externally powered external orthoses, prostheses, cosmetic prostheses and orthopaedic footwear. Endoprostheses, which are not covered by this international standard, are excluded. What is a lower-limb prosthesis? 1 A lower-limb prosthesis is composed of: y a prosthetic socket; y a suspension system; y some prosthetic joints; y other components (interjoint segments); y a foot; y a cosmetic covering. The socket must provide: ICRC y comfort for the amputee; y provision of an interface between the residual limb and the prosthesis; y maintenance of suspension for the prosthesis. The suspension system: y holds the prosthesis in place on the residual limb; y enhances efficient energy transfer; y maximizes control; y allows movement; y minimizes discomfort and abrasions. The components and foot: y are used to build up the prosthesis; y are also used to align the prosthesis. ICRC 1 The specifications on this page are taken from B. Engstrom, C. Van de Ven, Therapy for Amputees, 3rd edition, Churchill Livingstone, 1999. LOwer-limb AMPUTATIONS AND GENERAL PROSTHETIC KNOWLEDGE 9 Classifications of prostheses Ì First classification An endoskeletal/modular prosthesis is a lower-limb support consisting of an internal pylon which can be adjusted at any time and which is covered with a lightweight material such as polyurethane foam (e.g. ICRC type of prosthesis). The structural and cosmetic elements are separate. web An exoskeletal/conventional prosthesis is a prosthetic device with a shell design, in which support is provided by an outer structure. The structural and cosmetic elements are the same. web 10 PROSTHETIC GAIT ANALYSIS FOR PHYSIOTHERAPISTS Ì Second classification Immediate/early prosthesis (post-operation): applied at the time of surgery or before the removal of the sutures. It is fitted at the hospital and allows early verticalization. The socket may be made of plaster of Paris. Temporary/interim prosthesis: applied after the sutures have been removed. It is not manufactured from expensive material because it does not last very long (approximately two months). It permits amputees to leave the hospital by walking even if the stump is not ready for a permanent fitting. It is worn for only a short period daily. The aim is to gradually enhance the resilience of the