Pregait Training

Balance and Coordination

After the loss of a limb, the decrease in body weight will alter the body's center of gravity. In
order to maintain the single-limb balance necessary during stance without a prosthesis,
ambulating with an assistive device, or single-limb hopping, the amputee must shift the center of
gravity over the base of support, which in this case is the foot of the sound limb. As amputees
become more secure in their single-limb support, there is greater difficulty in reorien ting them to
maintaining the center of gravity over both the sound and prosthetic limbs. Ultimately, amputees
must learn to maintain the center of gravity and their entire body weight over the prosthesis. Once
comfortable with weight bearing equally on both limbs, the amputee can begin to develop
confidence with independent standing and eventually with ambulation.

Orientation to the Center of Gravity and Base of Support

Orientation of the center of gravity over the base of support in order to mainta in balance requires
that the amputee become
familiar with these terms and aware of their relationship. The body's center of gravity is located
just anterior to the second sacral vertebra. Average persons stand with their feet 5 to 10 cm (2 to 4
in.) apart, varying according to body height.3, 5 Various methods of proprioceptive and visual
feedback may be employed to promote the amputee's a bility to maximize the displacement of the
center of gravity over the base of support. The amputee must learn to displace t he center of
gravity forward and backward, as well as from side to side (Fig 23-8. and Fig 23-9.). These
exercises vary little from traditional weight-shifting exercises, with the one exception that
concentration is placed on the movement of the center of gravity over the base of support rather
than weight bearing into the prosthesis. Increased weight bearing will be a direct result of
improved center of gravity displacement and will establish a firm foundation for actual weight
shifting during ambulation.

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Fig 23-8. Lateral weight-shifting and balance orientation.

Fig 23-9. Forward and backward weight-shifting and balance orientation

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Single-Limb Standing

Weight acceptance in the prosthesis is one of the most difficult challenges facing both therapist
and amputee. Without the ability to maintain full single-limb weight bearing and balance for an
adequate amount o f time (0.5 seconds minimum) the amputee will exhibit a number of gait
deviations, including (1) decreased stance time on the prosthetic side, (2) a shortened stride
length on the sound side, or (3) lateral trunk bending over the prosthetic limb. Strength, bal ance,
and coordination are the primary physical factors influencing single-limb stance on a prosthesis.
Additionally, fear, pain, and lack of confidence in the prosthesis must be considered when an
amputee is demonstrating extreme difficulty in overcoming wei ght bearing on the prosthesis. It
is important to recognize the need to promote adequate weight bearing and balance on the prosthe
sis prior to and during ambulation.
Single-limb balance over the prosthetic limb while advancing the sound limb should be practiced
in a controlled manner so that when required to do so in a dynamic situation such as walking, this
skill can be employed with relatively little difficulty. The stool-stepping exercise is an excellent
method by which this skill may be learned. Have the amputee stand in the parallel bars with
the sound limb in front of a 10- to 20-cm (4- to 8-in.) stool (or block), its height depending on the
patients level of ability. Then ask the amputee to step slowly onto the stool with the sound limb
while using bilateral upper-limb support on the parallel bars. To further increase this weight-
bearing skill ask the patient to remove the sound-s ide hand from the parallel bars and eventually
the other hand. Initially, the speed of the sound leg will increase when upper-limb support is
removed, but with practice the speed will become slower and more controlled, thus promoting
increased weight bearing on th e prosthesis (Fig 23-10.).

Fig 23-10. Stool-stepping exercise.

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The amputee's ability to control sound-limb advancement is directly related to the ability to
control prosthetic limb stance. The following are three contributing factors that may help the
amputee achieve adequate balance over the prosthetic limb. First, control of the musculature of
the residual limb is necessary to maintain balance over the prosthesis. Second, the patient must
learn to utilize the available proprioceptive sensation at the residual-limb/soc ket interface to
control the prosthesis. Third, the amputee must visualize the prosthetic foot and its relationship to
the ground. New amputees will find it difficult to understand this concept at first but will gain a
greater appreciation as time goes on.

Gait-Training Skills

Sound Limb and Prosthetic Limb Training

Another component in adjusting to the amputation of a limb is restoration of the gait

biomechanics that were unique to a particular person prior to the amputation. That is to say, not
everyone has the same gait pattern. Prosthetic developments in the last decade have provided
limbs that more closely replicate the mechanics of the human leg. Therefore, the goal of gait
training should be the restoration of function to the remaining joints of the amputated limb.
Prosthetic gait training should not alter the amputee's gait mechanics for the prosthesis, but
instead, the mechanics of the prosthesis should be designed around the amputee's individual gait.

Pelvic Motions

The pelvis, with the body's center of gravity, moves as a unit in four directions: it displaces
vertically, shifts laterally, tilts horizontally, and rotates transversely. Each of these motions can
directly affect the amputee's gait and result in gait deviations or increased energy consumption
during ambulation. If restoration of function to th e remaining joints of the amputated limb is a
goal of gait training, then the pelvic motions play a decisive role in determining th e final
outcome of an individual's gait pattern.

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Fig 23-14. Sound-leg stepping is designed to orient the amputee to gait biomechanics.

Fig 23-15. Rhythmic initiation designed to promote transverse rotation of the pelvis.

5
Fig 23-16. Resistive gait techniques are proprioceptive neuromuscular facilitation
techniques to assist and establish a normalized gait pattern.

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Fig 23-17. Sound-side stepping to promote equal stride length of the sound limb and stance
time of the prosthetic limb.

Fig 23-18. Once correct biomechanics are established within the parallel bars, resistive gait
training may be performed in an open area to build confidence and independent gait skills.

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Fig 23-19. Passive trunk rotation will assist in restoring arm swing for improved balance,
symmetry of gait, and momentum.

Advanced Gait-Training Activities

Stairs

Ascending and descending stairs is most safely and comfortably performed one step at a time
(step by step). A few exceptional transfemoral amputees can descend stairs step over step, with or
without a railing, or by the "jackknifing" method. Even fewer, very strong transfemoral amputees
can ascend stairs step over step. Most transtibial amputees have the option of either method,
while hip disarticulates and transpelvic amputees are limited to the step-by-step method.

Step By Step

This method is essentially the same for all levels of amputees. When ascending stairs, the body
weight is shifted to the prosthetic limb as the sound limb firmly places the foot on the stair. The
trunk is slightly flexed over the sound limb as the knee extends and raises the prosthetic limb to

8
the same step. The same process is repeated for each step. When descending stairs, the body
weight is shifted to the sound limb, which lowers the prosthetic limb to the step below primarily
by eccentric contraction of the quadriceps muscle. Once the prosthetic limb is securely in place,
body weight is transferred to the prosthetic limb, and the sound limb is lowered to the same step.

Transfemoral Amputees: Step Over Step

Timing and coordination become critical factors in executing stair climbing step over step. As the
transfemoral amputee order to achieve sufficient knee flexion to clear the step. Some
transfemoral amputees will actually hit the approaching step with the toe of the prosthetic foot to
achieve adequate knee flexion. With the prosthetic foot firmly on the step, usually with the toe
against the step riser, the residual limb must exert a great enough force to fully extend the hip so
that the sound foot may advance to the step above. As the sound-side hip extends, the prosthetic-
side hip must flex at an accelerated speed to achieve sufficient knee flexion to place the prosthetic
foot on the next step above.
Descending stairs is achieved by placing only the heel of the prosthetic foot on the stair below
and then shifting the body weight over the prosthetic limb, thus passively flexing the knee. The
sound limb must quickly reach the step below in time to catch the body's weight. The process is
repeated at a rapid rate until a rhythm is achieved. Most transfemoral amputees who have
mastered this skill descend stairs at an extremely fast pace, much faster than would be considered
safe for the average amputee. In fact, both ascending and descending stairs step over step for
transfemoral amputees is so difficult and energy demanding that the majority who master these
skills still prefer the step-by-step method.

Transtibial Amputees: Step Over Step

When ascending stairs, the transtibial amputee who does not have the ability to dorsiflex his
foot/ankle assembly must generate a stronger concentric contraction of the knee and hip extensors
in order to successfully transfer body weight over the prosthetic limb.
Descending stairs is very similar to normal descent with one exception: only the prosthetic heel is
placed on the stair. This compensates for the lack of dorsiflex-ion within the foot/ankle assembly.

Crutches

When using crutches with stairs, hold both crutches in the hand opposite the handrail, or use both
crutches in the traditional manner.

Uneven Surfaces
A
good practice with gait training is to have the amputee ambulate over a variety of surfaces,
including concrete, grass, gravel, uneven terrain, and varied carpet heights. Initially, the new
amputee will have difficulty in recognizing the different surfaces secondary to the loss of
proprioception. To promote an increased awareness, spen ding time on different surfaces and
becoming visually aware of the changes help to initiate this learning process. Additional ly, the

9
amputee must realize that it is important to observe the terrain ahead to avoid any slippery
surfaces or potholes that might result in a fall.

Ramps and Hills

Ascending inclines presents a problem for all amputees because of the lack of dorsiflexion
present within most prosthetic foot/ankle assemblies. For most amputees, descending inclines is
even more difficult than ascending, primarily because of the lack of plantar flexion in the
foot/ankle assembly. Prosthesis wearers with knee joints have the added dilemma of the weight
line falling posterior to the knee joint, resulting in a flexion moment.
When ascending an incline, the body weight should be slightly more forward than normal to
obtain maximal dosiflexion with articulating foot/ankle assemblies or to keep the knee in
extension. Depending o n the grade of the incline, pelvic rotation with additional acceleration
may be required in order to achieve maximal knee flexion during swing.
Descent of an incline usually occurs at a more rapid pace than normal because of the lack of
plantar flexion resulting in decreased stance time on the prosthetic limb. Amputees with
prosthetic knees must exert a greater-than-normal force on the posterior wall of the socket to
maintain knee extension.
Most amputees find it easier to ascend and descend inclines with short but equal strides. They
prefer this method since it simulates a more normal appearance as opposed to the sidestepping or
zigzag meth od.
When ascending and descending hills, the amputee will find sidestepping to be th e most efficient
means. The sound limb should lead and provide the power to lift the body to the next level, while
the prosthetic limb remains slightly posterior to keep the weight line anterior to the knee and act
as a firm base.
During descent the prosthetic limb leads but remains slightly posterior to the sound limb. The
prosthetic knee remains in extension, again acting as a form of support so that the sound limb
may lower the body.
For hip disarticulates or transpelvic amputees, sidestepping is the most common alternative
regardless of the grade of the incline.

Sidestepping

Sidestepping, or walking sideways, can be introduced to the amputee at various times throughout
the rehabilitation program. He can begin with simple weight shifting in the parallel bars and later
perform hig her-level activities such as unassisted sidestepping around tables or a small obstacle
course that requires many small turns. During early rehabilitation this skill provides the amputee
with a functional exercise for strengthening the hip abductors and, later in the rehabilitation
process, with an opportunity to progress into multidirectional movements.
Backward Walking

Walking backward is not difficult for transtibial amputees but poses a problem for amputees
requiring a prosthetic knee since there is no means of actively flexing the knee for adequate
ground clearance. In addit ion, the weight line falls posterior to the knee, and this causes a flexion
moment with possible buckling of the knee.

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The most comfortable method of backward walking is by the amputee vaulting upward (plantar-
flexing) on the sound foot to obtain sufficient height so that the prosthetic limb that is moving
posteriorly can clear the ground. The prosthetic foot is placed well behind the sound limb, with
the majority of the body's weight being born on the prosthetic toe, thus keeping the weight line
anterior to the knee. The sound limb is then brought back, usually at a slightly faster speed and a
somewhat shorter distance. The trunk is also maintained in some flexion in order to maintain the
weight forward on the p rosthetic toe. With a little practice most amputees become quite
proficient in backward walking.

Multidirectional Turns

Changing direction during walking or maneuvering within confined areas often mag nifies an
amputee's difficulty in controlling the prosthesis. Situations such as crowded restaurants,
elevators, or just simply turning around are often overcome by "hip-hiking" the prosthesis and
pivoting around the sound limb. This method is effective but hard ly the most aesthetic means of
maneuvering.
When turning to the sound side, two key factors for a smooth transition should be remembered:
first, maintain pelvic rotation in the transverse plane, and second, perform the turn in two steps.
Simply move the prosthetic limb over the sound limb 45 degrees, rotate the sound limb 180
degrees, and complete the turn by stepping in the desi red direction with the prosthetic limb and
leading with the pelvis to ensure adequate knee flexion (Fig 23-20.).

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Fig 23-20. Turning to the sound side: 1-3, maintain normal gait biomechanics; 4, move the
prosthetic limb over the sound limb 45 degrees; 5, rotate the sound limb 180 degrees; 6,
complete the turn by stepping in the desired direction.

Turning to the prosthetic side is performed almost exactly the same way as turning to the sound
side with one exception: slightly more weight is maintained on the prosthetic toe in order to keep
the weight line anterior to the knee, thus preventing knee flexion. For example, by crossing the
sound limb 45 degrees over the prosthetic limb, the weight line is automatically thrown forward.
The prosthetic limb is rotated as close to 180 degrees as possible without losing balance (135
degrees is usually comfortable), and the turn is completed by stepping in the desired direction
with the sound limb. If necessary, remind the amputee to maintain knee extension by applying a
force with the residual limb against the posterior wall of the socket (Fig 23-21.).

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Fig 23-21. Turning to the prosthetic side: 1-3, maintain normal gait biomechanics; 4, move
the sound limb over the prosthetic limb 45 degrees; 5, rotate the prosthetic limb
approximately 135 degrees; 6,7, complete the turn by stepping in the desired direction.

One exercise that will reinforce turning skills is follow the leader, where the amputee follows the
therapist who is making a series of turns in all directions and with various speeds and degrees of
difficulty.
The level of skill in turning will vary among amputees. All functional ambulators should be
taught to turn in both directions regardless of the prosthetic side. Those with poor balance may be
limited to unidirectional turns and require a series of small steps to complete the turn.

Tandem Walking

Walking with a normal base of support is of prime importance. However, tandem walking can
assist with balance and coordination and improve prosthetic awareness for the amputee. Place a
5- to 10-cm (2- to 4-in.)-wide strip on the floor. The amputee is asked to walk in three different
ways: first, with one foot to either side of the line; second, heel to toe with one foot in front of the

13
other; and third, with one foot crossing over in front of the other so that neither foot touches the
line and yet the left foot is always on the right side and vice versa.

Braiding

Braiding (cariocas) may be taught either in the parallel bars or in an open area depending upon
the person's ability. Simple braiding is one leg crossing in front of the other. As the amputee's
skill improves, the prosthetic limb can alternate, first in front of and then behind the sound limb,
and vice versa. As ability improves, the speed o f movement should increase. With increased
speed the arms will be required to assist with balance, and likewise, trunk rotation will increase,
further emphasizing the need for independent movement between the trunk and pelvis (Fig 23-
22.).

Fig 23-22. Braiding is an exercise designed to improve prosthetic control, balance, and
coordination by crossing one leg in front of or behind the other in a continuous manner.

Falling

Falling or lowering oneself to the floor is an important skill to learn not only for safety reasons
but also as a means to perform floor-level activities.
During falling, amputees must first discard any assistive device to avoid injury . They should land
on their hands with the elbows slightly flexed to dampen the force and decrease the possibility of
injury. As the elbows flex, they should roll to one side, further decreasing the impact of the fall.
Lowering the body to the floor in a controlled manner is initiated by squatting with the sound
limb followed by gently leaning forward onto the slightly flexed upper limbs. From this position
the amputee has the choice of remaining quadruped or assuming a sitting posture.

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Floor to Standing

Many techniques exist for teaching the amputee how to rise from the floor to a standing position.
The fundamental principle is to have the amputee use the assistive device for balance and the
sound limb for pow er as the body begins to rise. Depending on the type of amputation and the
level of skill, the amputee and therapist must work closely together to determine the most
efficient and safe manner to successfully master this task.

CONCLUSION

In summary, the physical therapist must work closely with the rehabilitation team to provide
comprehensive care for the amputee. An individualized program must be constructed according
to the level of ability and skill of each patient. The primary skills of preprosthetic training help
build the foundation necessary for successful prosth etic ambulation. The degree of success the
amputee experiences with ambulation may directly influence how much the prosthesis will be
used and how active a life-style is chosen. Therefore, the primary goal of the rehabilitation team
should be to make this transitional period as smooth and successful as possible.

References:

1. Davis GJ: A Compendium of Isokinetics in Clinical Usages and Rehabilitation Techniques, ed 2. S & S Publishing,
La Crosse, Wise, 1985.

2. Eisert O, Tester OW: Dynamic exercises for lower extremity amputees. Arch Phys Med Rehabil 1954; 35:695-704.

3. Murray MP: Gait as a total pattern of movement. Am J Phy Med Rehabil 1967; 16:290-333.

4. Murray MP, Drought AB, Kory RC: Walking patterns of normal men. J Bone Joint Surg [Am] 1964; 46: 335-360.

5. Peizer E, Wright DW, Mason C: Human locomotion. Bull Prosthet Res 1969; 10:48-105.

Chapter 23 -Atlas of Limb Prosthetics: Surgical, Prosthetic, and Rehabilitation Principles

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