O&P Library > Orthotics and Prosthetics > 1955, Vol 9, Num 3 > pp. 59 - 70

The Role Of Physical Therapy In The Use Of The Above Knee Prosthesis

Winifred Belfrage, R.P.T. 
Angelia Keifer, R.P.T. 
Verne T. Inman, M.D. 
Chester C. Haddan, C.P. & O. 

The successful above knee prosthesis wearer is the total achievement of teamwork carried out by the orthopedist in charge, the prosthetist (limbmaker), the physical therapist and the patient, each in his role of cooperative effort to that end. This article is thus concerned with the role of the physical therapist in the use of the prosthesis. This role is carried out cooperatively and co-ordinately with the orthopedist and prosthetist as the treatment progresses, hence special note of them is not readily suggested but such members are always at hand when occasion arises, especially noted upon boundary limits or the tendency to overlapping boundaries, when decisions are essential.

The management of the amputee before, during, and after the fitting of the prosthesis is a program of systematic continuity of procedure and interest, to the end of achieving the utmost comfort, best possible gait, and satisfaction on the part of the patient. It takes cognizance of the thoroughness of educating and undertaking with the patient, the interesting, varying, and trying procedure through which he must go in order to get the utmost benefit as intended by the maker, the user, and the supervisor of the prosthesis.

The patient must be so carefully instructed from the first meeting with the physical therapist and with the earliest simple exercise, in the reasons for and importance of muscle location and action singly, coordinated, and combined, that he will be able to understand and analyze with as little difficulty as possible his own particular gait when he is left on his own. Much of the treatment bears repetition and slowness of time involved so that the patient can comprehend as well as enjoy his progress.

The physical therapist thinks and treats the patient in total. There is only one goal to achieve-a patient walking with the best possible gait, (good posture or body alignment, freedom from contractures and deformities, good balance, and relaxed and rhythmic gait.) It is known that energy expenditure is higher in above knee amputees than in the normal individual doing the same job. (Walking the same cadence and the same distance.) Why?

1. From an engineerning analysis, the energy requirements should not be as great as actually measured in amputees (by C°2 liberation and 02 utilization).
2. The high energy expenditure is believed to be due, therefore, to increased muscular activity, either:-
   1. More muscles are used by amputee than in normal individuals at any instant (tenseness, balance, etc.).
   2. Muscles are used for longer periods of time than normal (not relaxed).

Training, therefore, (physical therapy and gait training) may be the most important item in rehabilitation of the amputee.

Prior to the fitting of the prosthesis, the stump must be shaped and muscle contractures of the stump and trunk reduced or corrected, postural faults corrected or avoided. All muscles of the trunk, stump, and normal leg are very important. There must be a balance of power for good gait, Prepare the patient for relaxation and rhythmic gait by helping him learn what muscle or group of muscles perform a particular motion as applied to locomotion and select exercises (with sequence and continuity in mind) according to contractures, deformities, weaknesses, hypertrophy, postural and gait achievements. The exercises are passive, active assistive, active, and active resistive according to need and dependent upon the condition of the patient as directed by the orthopedist in charge. The patient is taught in the beginning to consciously contract definite muscles, to definitely understand their function or action at a particular time in the swing and stance phase of the walking step, with no undue fatigue resulting. He is taught to achieve conscious contraction of muscles in an easy, relaxed manner.

The patient is so instructed in knowledge of muscle importance that he usually achieves knee control of the suction socket limb quite quickly. This comes easily during the fitting of the limb by the prosthetist, the physical therapist being at hand to guide the patient in his first steps and to administer balance and weight-bearing exercises, never losing sight of muscle action taking place during each phase of stepping, balancing and weight-bearing. In other words, the patient learns to control his prosthesis by using his stump muscles and yet maintaining good body posture.

The physical therapist finds the limb maker and orthopedist valuable at all times. Features of mechanical construction bear thought when giving gait direction, and consideration for the medical aspects bear attention, both of which are not discussed with the patient by the physical therapist. Mechanical construction and medical advice are understood, not spoken.

In walking with the suction socket prosthesis, squares, lines, circles, and such gadgets are unnecessary. Stationary adjustable (from raised arm level to dropped arm level) bars, crutches, canes, ramp, stairs, rubber matting on floor, and large full-length mirror are necessary. If a patient has understood muscle location and action throughout his treatments, and applies them during swing and stance phase of walking, he can easily and consciously correct his gait faults and develop a pride in his " stride ." When he can bear weight correctly and balance, he can walk relaxed and rhythmically, ascend and descend a stair, fall down and rise, sit and rise from a chair, turn around, side step, back step, ascend and descend an incline, pick up objects from the floor with confidence and ease.

In walking with the suction socket prosthesis, normal leg and stump muscle action is of first importance, necessitated by the fact that a dual purpose exists. Muscle action in the trunk and stump and normal leg during the swing and stance phase of walking is of utmost importance, not only in carrying the prosthesis through but also in providing the adherence of the socket to the stump and thus achieving good gait.

I. Physical Therapy before fitting the above knee Prosthesis

1. Preface:
   1. In order to more carefully present the problem and to serve as a review, it is hoped that one might have access to the figure in the manual, "The Suction Socket Above-Knee Artificial Leg," Fig. 5 -Anatomy of cross section of thigh in suction socket 1/2 inch below ischial tuberosity. It pictures the muscles which act to maintain the suction and action of the stump in the wearing of the suction socket limb.
   2. Note that all the muscles of the trunk, stump and the hip of the stump are very important. There must be a balance of power for good gait. The body must be kept in good alignment during all exercises and often emphasized.
   3. Sequence is important except that if one is working directly with the limbmaker it is necessary to get knee control very early.
   4. Stump exercises bear such repetition and care that slowness is important.
2. Aims:
   1. Shrinking and shaping of the stump.
   2. Correction of contractures (thigh flexor, erector spinea, quadratus lumborum, hamstrings, abductors: gastrocnemius and soleus of normal side ).
   3. Develop muscle strength (all muscles of the stump; quadratus lumborum, gluteals, erector spinea, abdominals, laissimus dorsi, ilio psoas).
   4. Develop a balance of power in the trunk and stump muscles.
   5. General exercises fur good body alignment and balance, and prevention of postural faults. (Kyphosis, extreme lordosis, pronated foot, scoliosis and forward-head.)
   6. Prepare patient for relaxed and rhythmic gait. Help him to learn what muscle or group of muscles perform a particular motion. Enable him to analyze his own faults because he feels and is concerned of what is going on in the performance of good locomotion.
3. Procedure:
   1. Bandaging instruction. (Thomas-Haddan, "Amputation Prosthesis," page 36-49.)
   2. Use judgment in selecting exercises according to contractures, deformities, weaknesses and hypertrophy, and explain muscle action, location, importance and reasons for exercises to the patient.
   3. Exercises should be given in sequence (holds interest, effort, and continuity for the patient).
   4. Exercises are passive, active, active assistive, and resistive according to need and dependent upon the condition of the patient as directed by the orthopedist in charge.
   5. Patient must concentrate on each exercise and each detail of gait and feel what he is doing and why.
4. Exercises:
   Supine:
   1. Deep breathing-inhale and increase chest expansion as much as possible. (Chest breathers have better posture and increased tolerance.)
   2. Sialic contraction of abdominals. (Keep abdominals in ready state of contraction. Prevents visceroptosis and gives stability to trunk. Helps body incline and improves posture.)
   3. Combine deep breathing and static contraction of abdominals. (To develop normal chest breathing.)
   4. Pelvic tilt-with arms in T position-pull abdominals up and in, tilt pelvis and flatten back to table. Hold and relax.
      1. Repeat, combining with deep breathing. (Prevents extreme lordosis, relaxes low back muscles, strengthens abdominals, prepares patient for correct body alignment and posture.)
   5. Active stretching of thigh flexors and strengthening of thigh extensors. Bend normal leg up on chest and hold this position with hands. ( Fig. 1 ) Keep lower portion of back flat. From flexed position, extend stump to table. (All motion is true hip motion, to correct contracture of hip flexors. Patient learns location, action, and importance of Gluteus Maximum and Abductor Magnus.)
   6. Stump adduction - With position of the pelvic tilt, adduct stump to normal leg. (Patient learns location, importance and action of the Adductors: Adductor Magnus, Adductor Brevis, Adductor Longus. Important at beginning and during swing phase and end of stance phase in gait.)
   7. Repeat No. 5, combining it with No. 6. Deep breathing, etc. Extend and adduct stump.
   8. Internal rotation of the stump. With patient in position of pelvic tilt, internally rotate stump. (Patient learns location, action, and importance of internal rotators.)
   9. External rotation of stump. With patient in position of pelvic tilt, externally rotate stump. (Patient learns importance of external rotators, action and location.) Important at weight bearing of stance phase in gait.
   10. Hip shrugging. ( Fig. 2 ) Shrug one hip tben the other. (Patient learns location, action and importance of Quadratus Lumborum. To avoid flexing chest laterally and forward and hiking of hip. Especially in gait training.)
   11. Abdominals:
       1. UPPER With arms at sides and slightly off table, raise head and shoulders off table, until thorax is flexed on pelvis. (Patient learns location, action, and importance of upper abdominals.)
       2. LOWER With arms in T position and normal knee bent and foot on table, patient in pelvic tilt position, straighten leg by sliding heel down and return. Keep stump flat on table during exercises. (To eliminate thigh flexion as much as possible by distinguishing it from abdominal contraction.)
       3. Combined upper and lower abdominals-also active back and hamstring stretching. Patient comes to sitting position with well rounded back and arms reaching to toes and slightly beyond. ( Fig. 3 ) Patient learns action of the entire abdominals and stretches back muscles. Abdominals very important to pelvis motions.)
          Note: Legs are supported as pelvis begins flexing on thigh. Abdominals aid in body incline to 45° when hip flexors take over.
       4. Lateral abdominals. With leg and stump abducted and right arm across chest with hand clasping left shoulder, reach left hand to right toe, and vice versa. (Abducted legs prevent anterior abdominal action and patient learns location, action, and importance of lateral abdominals.)
          Note: Abdominals and quadratus lumborum aid in lateral stability to trunk to 45° when hip flexors take over. Strengthens them for trunk stability and improvement of gait. 12.
   12. Body in pelvic tilt position, alternately flex one thigh then the other rhythmically as in walking. Watch that one leg flexes while the other extends. (Patient learns combined and coordinated action of adductors, flexors, quadriceps, gluteals back, abdominals, and quadratus lumborum.)
   13. Normal foot. Bring foot in and up. (Patient learns action, location, and importance of Anterior Tibial, Posterior Tibial, and Peroneus Longus.) Aids in prevention of foot eversion and pronation.
   14. With arms straight at sides and legs and body straight and in good postural position. Keep upper body and arms flat to table and roll lower body and legs, slightly from side to side, lifting one buttock then the other to rotate the pelvis on the lower spine. (To demonstrate the alternate forward and backward rotation of the pelvis which might be too extreme in gait patterns.)
   Side Lying: Lying on stump side.
   1. Side bends:
      Bring head and shoulders off table and reach hand toward toes. (To stretch and strengthen erector spinea, lateral abdominals, quadratus lumborum. Lateral flexibility and strength are important to gait.)
   2. Adduction of stump:
      Abduct normal leg. with knee extended. Adduct stump to abducted normal leg. Abduct stump, adduct normal leg to starting position, (To stretch abductors and strengthen adductors. Emphasize action and location of adductors.)
   3. Gluteus Medius.
      Abduct, externally rotate and hyperextend normal straight leg. (Strengthen gluteus medius and prevent limp in gait.) (Patient learns location, action, and important of gluteus medius.)
   Side Lying: Lying on normal leg side.
   1. Tensor Fasciae Latae.
      From neutral position, abduct, internally rotate, and slightly flex stump. (Patient learns location, action, and importance of tensor fasciae latae.)
   2. Gluteus Medius.
      Abduct, externally rotate and hyperextend stump. (Strengthens gluteus medius.) (Patient learns location, action and importance of gluteus medius.) (Important at weight-bearing of stance phase in gait.)
   3. Combined abduction, adduction, internal rotation and flexion from neutral position.
      In sequence as named, abduct, internally rotate, flex and adduct Stump. Extend to neutral position, (Important sequence in swing phase in gait training to suction socket wearers. ) 1. Combined abduction, external rotation, extension and adduction. Abduct, externally rotate, extend and adduct stump. Flex to neutral position. Important sequence in stance phase in gait training to suction socket wearers.)
   Prone:
   1. Gluteal pinch.
      Pinch buttocks as if holding a coin between them. (Patient learns more fully the location, action, and importance of the gluteus maximus.)
      Note: Gluteus Maximus is an extensor of the leg onto the pelvis. It is important at the end of the stance phase, aided by the Gluteus Medius and the Adductor Magnus.
   2. Gluteus Maximus.
      Patient lying with stump side of body over the edge of the table. With stump flexed, extend stump to neutral position. (Resistance essential.)
      1. Repeat adducting during extension phase. (Patient learns importance and action of adductor magnus during the latter part of stance phase.) (Adductor Magnus very important to wearing the suction socket.)
   3. Extension of stump.
      Lying prone on table. Body in neutral position, extend and adduct stump from neutral position. (Patient learns location, action, and importance of back muscles, adductor magnus, and hamstrings.) (Important at end of stance phase and beginning of swing phase. Low back muscle, latissimus dorsi, and gluteus maximus stabilize trunk in hyperextended position.)
   4. Alternate extending of normal leg and the stump in slow rhythm as in walking. ( Fig. 4 ) Patient learns combined and coordinated action of gluteus maximus, quadratus lumborum, latissimus dorsi, erector spinea, hamstrings, and adductor magnus.)
   5. Extension of neck and back.
      With arms at sides, adduct scapulae, and raise head and shoulders. Hold and relax. (Strengthening of erector spinea,, shoulder adductors, and depressors and is important in good posture.)
      Repeat, taking side bends.
      Note: Lateral abdominals, quadratus lumborum.
   Sitting:
   1. Pectoralis stretching. (03 the edge of the table with normal knee bent.)
      Arms abducted to shoulder level at T position. Physical Therapist: places knee between shoulders of patient and helps him slightly abduct, externally rotate, then extend arms. (Aids in prevention of kyphosis. Develops shoulder adductors and elevators, and stretches shoulder flexors.)
   2. Erector Spinea and Quadratus Lumborum.
      Sit Indian fashion (if possible) and bend forward, curling back and keeping buttocks to floor; bring forehead to floor between bent knee of normal leg and stump.
      Note: (The three pelvic motions should be well understood and their function depends upon a back which is not taut.)
   Standing: On normal leg.
   Note: Begin to stress importance of pelvis motions, especially the pelvic tilt or find the "tail under."
   1. Check total body alignment. Begin exercise with both arms supported at bars. Repeat with one arm supported at bars. Repeat with no support. Repeat with arms abducted to shoulder level. Repeat with arms flexed at 90° with body at proper incline.
   2. Knee bend on normal leg with good body alignment. Repeat with two arms supported at bars. Repeat with one arm supported at bars. Repeat with no support. Repeat with arms abducted. Repeat with arms flexed at 90°. (Test for balance on normal leg. Essential to sitting, rising, picking up objects, stair climbing, walking, etc.)
   3. Hop on normal leg. (Develops coordination, balance, and proper body alignment.)
   4. Muscle Education and Coordination for the suction socket wearers.
      At very slow rhythm when in motion:
      1. In neutral position statically contract all stump muscles and hip muscles active in holding body in good alignment.
      2. Stump in (flexed ) swing phase.
         Flex stump from neutral position, bring into coordinated action ilio psoas, adductors, tensor fasciae latae, quadriceps, quadratus lumborum, then extend to neutral position.
      3. Stump hyperextended in stance phase.
         Hyperextend stump from neutral position, bringing into coordinated action, gluteus medius. adductor magnus. gluteus maximus, erector spinea, latissimus dorsi, and hamstrings. Flex to neutral position.
      4. Gluteus medius.
         Extend slightly, externally rotate, and contract gluteus medius. Importance of muscle realized in weight-bearing of stance phase.
      5. Gluteus maximus
         With stump in flexed position, extend and hyperextend stump. (Important in end of stance phase and beginning of swing phase and stabilizes pelvis.

II. Physical Therapy after Fitting the Above Knee Prosthesis

1. Review the patient to see if he can relax and contract muscles performing definite motions. He will need to be sure as it enables him to analyze his own gait and solve gait problems as they occur.
2. Patient should be taught balance exercises in the above knee prosthesis, especially the suction socket. Essential before he does too much walking.
3. Balance or body alignment ( with prosthetic limb on. Stress repeatedly the importance of finding the "tail under".) Balance exercises done between bars with both arms supporting, then repeat with one arm supporting, then repeat with no support. ( Fig. 5 ) Also in front of mirror.
   1. With stump in neutral position, contract stump muscles against socket. (Patient to get feel of contraction of muscles against socket-Important.)
   2. With stump and prosthesis in flexed position, contract stump muscles against socket. (Patient gets feel of contraction of stump flexors and adductors against socket.)
   3. With stump and prosthesis in extended position, contract muscles against socket. (Important to get feel of contraction of muscles against socket.) These muscles provide the suction ability in controlling the management of such a limb, gluteus maximus and adductor magnus, mainly.
   4. With legs about 8" apart, shift weight from side to side without moving feet from floor. (Get feel of evenness and confidence in prosthesis. Be sure to check for lateral stability.)
   5. With normal leg forward and prosthetic leg back, shift weight forward and backward, rocking from one leg to the other without moving feet from the floor. Repeat with prosthetic leg forward and normal leg back. Check muscle action in beginning of swing phase and end of stance phase.
   6. With prosthetic leg in forward walking position, bring normal leg forward and backward as in walking, shifting weight rhythmically in line of balance.
   7. With normal leg in forward walking position, bring prosthetic leg forward and backward as in walking, shifting weight slowly and rhythmically in line of balance. ( Slowly to emphasize specific muscle action as patient places prosthetic leg in swing and stance phase of the walking step. Bears much repetition. )
   8. Full weight-bearing on the prosthetic leg. Bear full weight on prosthetic leg in neutral position. Knee of normal leg slightly bent and normal toe touching floor. Emphasize control of gluteus medius, (Bears repetition.) Quadratus lumborum for lateral trunk stabilization.
4. Walking. (Thomas and Haddan, "Amputation Prosthesis," p. p. 126-135)
   In walking with the suction socket prosthesis, leg muscle action is of first importance, necessitated by the fact that a dual purpose exists. Muscle action in the trunk and stump during the swing and stance phases of walking is of utmost importance not only in carrying the limb through but also in providing the adherence of the socket to the stump, and good gait.
   Three components of excellent walking with an above knee prosthesis are balance or body alignment, muscle coordination in motion, smoothness and relaxation in walking rhythm . Muscles fitting into the performance of good walking with the suction limb are:
   The Quadriceps come into action as the weight is coming over and directly after weight comes on the leg during the stance phase.
   The Hamstrings come into action in picking leg off the floor and they relax as the leg is brought forward.
   The Abductors contract strongest when the weight is heaviest on the leg and relax as the extensors take over.
   The Adductors come into play just after the leg is put down, helping to pull the body forward and then when the individual begins to raise the leg bringing the body forward.
   The Gluteus Maximus comes into action at the end of the stance phase and at the beginning of the swing phase.
   The Gluteus Medius comes into importance when bearing full weight on the prosthesis and begins to relax as hyperextensors take over.
   The Quadratus Lumborum aids in flexing chest laterally and forward during weight-bearing phase when normal leg is in flexion, and vice versa.
   The Erector Spinea maintains erect posture in early stance phase.
   The Ilio Psoas , a hip flexor, internally rotates when hip is in extension and externally rotates when hip is in 30° flexion.
   It is felt that with the attachment of Lattissimus Dorsi on spine, pelvis and ribs, that it aids in hyperextension of pelvis and gait. It hyperextends on normal side when stump side is in weight-bearing and vice versa.
   1. Walking with both arms supporting at bars, then with the arm opposite to the prosthesis, then with no support. Walk also in front of mirror.
   2. Check with limb-maker and surgeon on total fitting of prosthesis as related to alignment and gait.
   3. Beginners begin advancing normal leg first.
   Walking Training:
   
   1. Standing in neutral position shrug hips alternately and relax, bringing foot slightly off floor.
   2. Alternately pick up and set down the prosthetic leg and normal leg. (Develop rhythmic control and motion. Emphasize contraction of Ilio Psoas, Adductors, Abductors, Quads, Tensor Fasciae Latae, Erector Spinea, Quadratus Lumborum, and Latissimus Dorsi.)
   3. With normal leg in forward walking position, bring prosthetic limb forward and back as in balance exercise several times to get the feel of walking and developing momentum, then go directly into two full walking steps, (Keep emphasizing muscles used in swing phase and stance phase. Repeat, increasing number of steps each time until good walking develops.)
   4. Facing the patient, physical therapist places her hands on the shoulders of the patient, and walks backwards as the patient walks forward. Resistance is offered with the patient pushing against physical therapist's hands, thus tinning the trunk forward, (Help patient to gel the feel of the body position in space.)
      (Note difference in sides.)
      Note: Importance of abdominals, lateral trunk, stabilizer, erector spinet and gluteus maximus. Repeat, placing only one hand to the shoulder of the side opposite to the prosthetic side.
      Repeat, gradually lessening resistance as patient maintains inclination and good gait.
   5. With no aid from the physical therapist, patient bends elbows to bring back of hands toward shoulders and walks as if pushing. Repeat with hands in same position except pushing against hands of the physical therapist.
   6. With arms abducted and elbows flexed at shoulder level (as in putting arms around an object or dancing) walk forward maintaining incline of trunk.
   7. At a position behind the patient, physical therapist places hands just above anterior thigh joint (bilaterally) and offers resistance as the patient walks forward. (Note difference in stride and strength.) Repeat, placing one hand on the thigh opposite to the prosthetic side. (Note how offering of resistance aids the strength of the posterior muscle on the prosthetic side.) (Important in equalization and rhythm of stride.) Repeal gradually lessening resistance while the patient maintains good gait.
   8. Walk swinging arms at sides.
   9. Walk carrying objects.
   10. Walk with arms flexed at 20°.
   11. Walk with arms abducted to shoulder level.
   12. Walk with hands clasped behind body.
   13. Side stepping. side step from either side.
   14. Stepping backward. Shorten stride. Keen knee locked in extension. (Gluteus Maximus.)
   15. Pivoting: With normal leg forward and supporting all the body weight, pivot on the ball of the normal foot and turn in the direction of the prosthesis. This leaves the artificial foot in forward position and the normal leg in position to step forward.
   16. Picking up objects from the floor: With weight on normal leg and prosthetic leg slightly behind normal leg, flex both legs and bend forward from the waist.
   17. Sitting and rising from a chair:
       Approach from the front, pivot and bring prosthesis back beside normal leg. Weight on normal leg. hands on knees, bend slightly forward and sit into chair. On rising from chair, place normal foot close to chair and behind prosthetic foot, bend forward, place weight on normal leg and rise.
   18. Walking up and down inclines: Shorten stride or if steep walk sideward from normal side. Walking down inclines, shorten stride, incline trunk forward so as to keep center of gravity anterior to knee center of prosthesis. Keep gluteals contracted to hold artificial knee in extension. (Confidence is important.)
   19. Stair climbing: Normal foot placed on step first, body weight shifted over normal leg, bringing the artificial foot to a position beside the normal foot. In descending, artificial foot is placed forward over lower step so instep is over edge of tread. Body weight is shifted forward over prosthesis and normal foot brought to position on next step below, as prosthesis bends at knee. the foot rolls over the edge of the tread. (Fig. 206-7. Thomas and Haddan. "Amputation Prosthesis." Confidence is important, and comes with practice. Learning should be begun at lower step.)
   20. Sitting and rising from floor: Sitting on the floor with prosthetic leg slightly forward position, and trunk inclined forward, bend with weight on normal leg and lower body to floor as knee bends. Support with hands on floor. Hiding from the floor, supporting body with hands on floor, bend normal knee to set foot on floor. Push with arms and normal leg to raise body upward until the normal leg can take over the balance and complete the bringing of the body to an upright position.

O&P Library > Orthotics and Prosthetics > 1955, Vol 9, Num 3 > pp. 59 - 70