Dụng Cụ Chỉnh Hình Và Chân Tay Giả Trong Phục Hồi Chức Năng (Ấn Bản Thứ 3)

692
Section III  Prostheses in Rehabilitation
muscle control and postural responses at the hip, bilateral
single-axis knees are often difficult to use safely in older adults
with dysvascular amputation. Bilateral single-axis knees may
be appropriate for small children because their short stature
reduces the balance required to manage such components.
Ankle-foot components that emphasize stability and
standing balances are typical for this group with bilateral loss.
­Solid-ankle designs predominate. Articulating designs are
used less often; only those with very long transfemoral residual
limbs and good muscle strength are typically able to control
the added mobility provided by articulating ankle compo­
nents. Many patients with bilateral transfemoral amputation
use crutches or canes to assist with balance and postural con­
trol. Single-axis or multiaxial feet become easier to control if
the patient leans forward slightly, shifting the center of gravity
forward, so that the weight line falls anterior to the ankle axis
at all times, eliminating the risk of falling backward.
Ancillary components, such as torque absorbers, often
make walking easier and more comfortable for patients with
bilateral transfemoral amputation. Some evidence exists that
including components that permit controlled transverse rota­
tion improves the gait kinematics of patients who wear two
lower limb prostheses.51 Locking rotation devices make many
activities of daily living easier to accomplish.52 Because the
weight of such ancillary components must be considered, the
perception of the artificial limb feeling heavy is minimized if
the devices are positioned as far proximally within the pros­
thesis as possible.
Transfemoral–Transtibial Amputation
For patients with one transfemoral and one transtibial ampu­
tation, the preservation of one biological knee makes pros­
thetic use much easier and successful ambulation more
likely.53 For most patients, the transtibial side is the propul­
sive and balance limb and the transfemoral side supplements
these functions. On the basis of these functional differences,
the prosthetist may choose to use different prosthetic feet.
When the transfemoral amputation is relatively short, for
example, a single-axis foot and stance control knee might
be recommended for the transfemoral prosthesis, whereas
a dynamic response foot might be used in the transtibial
prosthesis.
Socket Designs and Suspension
The person with bilateral lower-limb loss is constantly bear­
ing full weight on artificial limbs while walking or standing.
All options to increase skin protection and comfort should
be actively considered, and suspension must be as secure as
possible. A soft insert and flexible sockets may be used to
enhance comfort during wear and reduce the likelihood that
shear forces will be problematic for the skin. Suction suspen­
sion, with silicone sleeves or inserts as necessary, minimizes
pistoning during swing and should be considered for the
majority of patients with bilateral amputation.
Cotton or wool prosthetic socks are often used as an inter­
face between the residual limbs and the sockets when suction
suspension is not feasible. In that event, supracondylar wedge
or cuff suspensions are typically used in transtibial pros­
theses; Silesian belts are often used in transfemoral designs.
Because most patients with bilateral amputation use a pair of
prostheses, suspension belts are usually integrated into a sin­
gle assembly. Because thigh corsets with metal side joints, hip
joints and pelvic bands, and waist belts can be cumbersome
for donning and doffing, they are typically avoided unless
absolutely necessary.
Ischial containment sockets are as effective for patients
with bilateral amputation at the transfemoral level (of one or
both limbs) as they are for patients with a single transfemoral
amputation. Patients who have previously worn a quadrilat­
eral transfemoral socket, and those who are limited ambula­
tors, may be satisfied with a traditional quadrilateral design.
Total contact of the residual limb in the socket is important
for both ischial containment and quadrilateral socket skin
integrity.
The loss of both feet and both knees makes the use of
bilateral transfemoral prostheses quite challenging. For many
adults with acquired limb losses, an initial fitting with sock­
ets attached to special rocker platforms may be advocated to
facilitate initial gait training (Figure  25-7). Such “stubbies”
require less energy and balance than full-length prosthetic
limbs and give the patient new to bilateral prostheses the best
chance for successful ambulation.54 Once the patient is able to
balance effectively on the stubbies, the prostheses can be con­
verted to use artificial feet with solid pylons, which are gradu­
ally lengthened to increase the height of the prostheses. If the
patient is able to manage full-length prostheses, prosthetic
knees can be incorporated and definitive prostheses with full
components provided.
FIGURE  25-7  A pair of shortened prostheses, sometimes called
stubbies, for early gait training for patients with bilateral traumatic
transfemoral amputation. In these prostheses, patients can develop
postural control without having to worry about the stability of pros­
thetic knee units. (From May BJ. Assessment and treatment of indi­
viduals following lower extremity amputation. In O'Sullivan SB,
Schmitz TJ [eds], Physical Rehabilitation: Assessment and Treatment,
3 rd ed. Philadelphia: Davis, 1994. p. 392.)

Chapter 25  Prosthetic Options for Persons with High-Level and Bilateral Lower-Limb Amputation
693
Not all patients with bilateral transfemoral amputation
choose to pursue ambulation with prostheses. Some are unable
to build the necessary muscular strength or postural control
for a safe gait. Others find the energy cost of ambulation with
prostheses excessive. In these cases, patients choose wheelchair
mobility as a much less strenuous means of mobility and will­
ingly adopt wheelchair use for the independence it provides.
Many patients with bilateral transfemoral amputation find
a wheelchair most practical for long-distance mobility and
use their limbs for walking short to moderate distances at
home and work. Some patients accept the stubbies for long-
term use, particularly if these devices allow them to remain
independent in their home setting. Others choose to use their
stubbies at home because they take less effort but wear full
prostheses in public.
SUMMARY
Individuals with high-level or bilateral lower limb ampu­
tations are rare in the developed world. In North America,
they are believed to represent fewer than 5% of all persons
with amputation. Given these statistics, most prosthetists and
therapists have limited opportunity to work with patients
with such significant levels of limb loss. Although success­
ful prosthetic training and rehabilitation for these patients are
challenging, a large body of clinical information about man­
aging such cases is available in the literature. This chapter
highlights the key principles involved in rehabilitation of the
person with high-level or bilateral lower-limb amputations.
Surgical technique during the amputation largely deter­
mines the potential for long-term ambulation. Gentle han­
dling of soft tissues and careful preservation of all functional
joints and bony length are essential. Anchoring functioning
muscles to bone (myodesis) at their normal resting length is
strongly encouraged whenever possible.
The socket design and suspension methods chosen for
patients with high-level or bilateral amputation should incor­
porate strategies to protect the skin and maximize patient
comfort, especially for individuals with bilateral amputa­
tion. Components reflect each individual's need for stability
and responsiveness at the ankle-foot, knee, or hip joint level.
Ancillary components to make the prosthesis more comfort­
able and easier to manage are advocated.
Although patients with bilateral transfemoral amputation
caused by vascular disease often have difficulty mastering dual
prosthetic devices, long-term use of functional prostheses is
a realistic goal for patients with traumatic or tumor-related
amputation who are otherwise healthy. With appropriate fit­
ting and rehabilitation, many patients with hip disarticulation
and transpelvic amputations continue to use their prostheses
definitively. Even patients with translumbar amputation are
able to return to productive education or work activities with
an appropriate prosthesis for sitting or limited ambulation.
Despite the obvious physical and psychological chal­
lenges faced by patients with high-level or bilateral lower
limb amputation, prosthetic rehabilitation must always be
­considered and is often successful, especially when offered
by an ­experienced multidisciplinary team in a supportive set­
ting. Although the sequelae from amputations of this mag­
nitude present significant challenges, advances in surgical
technique, prosthetic design and components, and rehabili­
tation contribute to successful outcomes for patients with
­high-level and bilateral amputation.
CASE EXAMPLE 1
A Patient with Traumatic Hip Disarticulation
J. S. is a 20-year-old man with a traumatic hip disarticula­
tion amputation caused by a motorcycle accident 2 weeks
ago. His residual limb is healed but complicated by multi­
ple skin grafts and insensate areas in the abdominal region
from the amount of trauma. He is eager to return to col­
lege as quickly as possible to avoid having to repeat this
semester's courses but must walk several blocks to various
buildings on the small, hilly campus. He has a lean, athletic
build and demonstrates excellent balance and strength
when ambulating on his remaining limb with bilateral
forearm crutches.
Questions to Consider
• What additional information might be gathered to help
determine J. S.'s potential to use a hip disarticulation
prosthesis? How does his medical history and reason
for amputation affect his rehabilitation prognosis?
• How should J. S.'s readiness to be fit with a prosthesis be
determined? What tests and measures should be used?
• What major concerns or challenges will J. S., his pros­
thetist, and rehabilitation team face in fitting his hip
disarticulation prosthesis?
• What options for socket and suspension will the team
likely consider for J. S. given his functional needs and
prognosis?
• What factors will influence the choice of knee units for
J. S.'s prosthesis? What type of knee should be recom­
mended? Why?
• What factors will influence the choice of a prosthetic
foot for J. S.'s prosthesis? What type of foot should be
recommended? Why?
• How should rehabilitation goals be prioritized as J. S.
begins his prosthetic training? How should his rehabili­
tation progress? How should the efficacy of interven­
tion be assessed to determine how well the goals have
been met?
Recommendations
On the basis of findings during the evaluation and discus­
sion with J. S. about his current functional needs and ulti­
mate prosthetic goals, the team recommends an initial
endoskeletal prosthesis with a foam-lined ­thermoplastic
socket that includes additional gel padding in the region of
the tender grafted skin, a ­microprocessor-controlled stance
and swing-control hydraulic knee, ­dynamic-response foot,
Continued

694
Section III  Prostheses in Rehabilitation
and torque absorber. The clinical team considered first pro­
viding a less complex knee but decided against that option
because it would require training to use a less-responsive
prosthesis, then subsequent retraining with the micropro­
cessor knee more appropriate for his projected functional
abilities, thereby increasing the duration of his rehabilita­
tion program.
Intensive inpatient therapy focuses on ambulation first
within the parallel bars and then with his forearm crutches
to facilitate J. S.'s return to campus. He will continue with
outpatient therapy until his gait has matured and will likely
learn to ambulate with no balance aids. When his socket
no longer fits because of normal postoperative atrophy, he
will receive a new custom socket and protective covering
for the prosthesis but will continue to use the same func­
tional components originally provided for as long as they
are functionally appropriate for his needs.
• How should rehabilitation goals be prioritized as R. W.
begins her prosthetic training? How should rehabilita­
tion be assessed? Should the wearing schedules for her
new transtibial limb be similar to or different from her
transfemoral limb? Why or why not? How should the
efficacy of intervention be assessed to determine how
well the goals have been met?
Recommendations
Although her age and comorbidities make the use of two
artificial limbs challenging, R. W. is a good candidate for
bilateral fitting because of her motivation and proven suc­
cess with a prior prosthesis. Her existing transfemoral
prosthesis is well worn and no longer fitting optimally, so
the prosthetic rehabilitation team recommends that two
new prostheses be prescribed.
The transtibial prosthesis will provide primary balance
and propulsion and enable her to rise from a seated position,
applying significant forces to her residual limb. Her initial
transtibial prosthesis will include a roll-on locking liner for
suspension and a soft insert to protect the residual limb and
provide added mediolateral stability at the knee through its
supracondylar contours. She will use lightweight, solid-ankle
dynamic response prosthetic feet on both artificial limbs
because she prefers these components and has found them
both stable and functional with her unilateral prosthesis.
Her new transfemoral prosthesis will be similar to what
she has successfully worn, with a roll-on locking liner for
suspension and a flexible ischial containment socket within
a rigid frame for weight bearing and rotational stability. The
roll-on suspension permits donning from a seated position,
which is particularly advantageous for people with bilateral
amputations. Initially, R. W. will wear an auxiliary elastic
suspension belt for added security and rotational control.
Her unilateral prosthesis incorporated a single-axis
knee with pneumatic swing control, but she will require
a more mechanically stable design for bilateral stability.
Because of cardiopulmonary restrictions and the loss of
her second leg, the clinical team does not believe she will
vary her walking pace as widely now, so the weight of a
pneumatic swing-control unit is no longer necessary. R. W.
will receive a stable polycentric knee in her new prosthesis
and undergo gait training for several weeks.
Although she is eager to have her endoskeletal prostheses
finished with protective covers that make them appear more
lifelike, this fabrication step will be deferred until after she
has completed gait training and mastered the use of bilateral
artificial limbs. R. W.'s prosthetist will see her periodically to
reevaluate the alignment of both prostheses as her gait pat­
tern matures, making small alignment changes in response
to her changing needs and balance. Once her gait pattern
has stabilized, the final fabrication will be completed.
R. W. will also be prescribed a wheelchair with a poste­
riorly offset axle, which she will use for traversing long dis­
tances. Training in wheelchair transfers and mobility will
also be an important part of her rehabilitation.
CASE EXAMPLE 2
A Patient with Bilateral Lower-Extremity Amputations
Caused by Chronic Dysvascular/Neuropathic Disease
R. W. is a 72-year-old woman who recently underwent an
elective right transtibial amputation because of infection
associated with diabetic neuropathy. Her residual limb is
well healed and not unduly edematous, and she is eager to
return to the condominium she shares with her daughter.
Five years previously, R. W. underwent left transfemoral
amputation after failed femoral-popliteal bypass surgery
and has been a successful full-time prosthesis wearer until
hospitalization for the recent amputation.
Questions to Consider
• What additional information might be gathered to
help determine R. W.'s potential to use prostheses for
her new right transtibial and existing left transfemoral
residual limbs? How does her medical history and rea­
son for amputation affect her rehabilitation prognosis?
• How should R. W.'s readiness to be fit with a transtib­
ial prosthesis be determined? What tests and measures
should be used to make this determination?
• What major concerns or challenges will R. W., her pros­
thetist, and rehabilitation team face in fitting the new
transtibial prosthesis?
• What options for socket and suspension will the team
likely consider for R. W.'s new transtibial and transfemo­
ral prostheses, given her functional needs and prognosis?
• What factors influence the choice of knee units for R. W.'s
transfemoral prosthesis? What type of knee should be
recommended? Why?
• What factors influence the choice of a prosthetic foot
for R. W.'s transtibial and transfemoral prostheses?
What type of foot should be recommended for each
prosthesis? Why?

Chapter 25  Prosthetic Options for Persons with High-Level and Bilateral Lower-Limb Amputation
695
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697
Early Rehabilitation in Lower-Extremity Dysvascular
Amputation
Julie D. Ries and Victor Vaughan
Persons who have undergone transtibial or ­transfemoral
amputation may approach rehabilitation with a sense of
expectancy, excitement, and, often, apprehension. They may
be relieved to have healed and curious about the prosthesis
that they are about to receive. They may be anxious to com­
mence their prosthetic rehabilitation and may have realistic
or not so realistic expectations. To facilitate optimal reha­
bilitation outcome, the physical therapist must consider the
patient's goals, physical abilities, and mobility needs, along
with their previous functional level. This chapter explores the
key components of successful rehabilitation for persons with
transtibial and transfemoral amputation. It presents a model
consistent with the Guide to Physical Therapist Practice,1 with
emphasis on the components of a thorough examination. It
discusses the evaluation process, which is the synthesis of data
to establish a diagnosis and prognosis. The chapter also pro­
vides a range of interventions for persons with a new transtib­
ial or transfemoral amputation, from early physical therapy
interventions that focus on preparing the limb for use of a
prosthesis and building tolerance to prosthetic wear to more
functionally oriented activities aimed at ensuring safety and
efficiency in gait and functional mobility skills. As prosthetic
skills are mastered, interventions progress to more complex,
higher-level bipedal activities. With many individuals, voca­
tional, leisure, and sporting activities can be addressed to
facilitate the return to a productive and enjoyable lifestyle.
This chapter focuses primarily on strategies for initial and
intermediate-level rehabilitation, with a short discussion on
more advanced prosthetic training. Anticipated functional
outcomes for the transtibial or transfemoral prosthetic user
are also addressed.
Evidence-based practice requires the integration of best
research evidence, clinical expertise, and patient values.2
Although more research is needed to help to inform reha­
bilitation decisions for individuals with lower-extremity
amputation,3 limited research does support that individuals
who participate in postamputation rehabilitation programs
benefit from these programs.4–6 The goal of this chapter is
to provide a foundation for evidence-based practice in the
management of individuals with either transtibial or trans­
femoral amputation.
COMPONENTS OF THE PHYSICAL THERAPY
EXAMINATION
Effective physical therapy (PT) management for individuals
with amputation begins with a thorough and comprehen­
sive initial examination. In the PT examination, the physical
therapist must obtain a patient history, conduct a systems
review, and administer tests and measures to obtain base­
line data. Ideally, data collected represents all levels of the
World Health Organization's International Classification
of Functioning, Disability, and Health (ICF)7 including
impairments, activity limitations, and participation restric­
tions, with attention toward contextual factors for the
individual (environmental and personal modifiers).8 This
information allows the therapist to establish a diagnostic
classification that provides the basis for accurately identi­
fying the appropriate treatment interventions that will lead
to optimum outcomes. The PT examination may occur pre-­
amputation, immediately following amputation, at the time
26
LEARNING OBJECTIVES
Upon completion of this chapter, the reader will be able to:
1. Organize and justify each component of a comprehen­
sive physical therapy examination for the individual with
transtibial and transfemoral amputation.
2. Utilize and synthesize data collected during the examina­
tion to establish diagnosis and prognosis for rehabilitation.
3. Create a well-defined and focused treatment plan that
addresses the needs of the individual with transtibial and
transfemoral amputation.
4. Identify, justify, and prioritize rehabilitation issues about
which individuals with transtibial and transfemoral ampu­
tation must be educated.
5. Anticipate functional outcomes of an individual with
transtibial or transfemoral amputation, based upon data
collected and available evidence.
6. Identify and justify appropriate outcome measures for
use with individuals with transtibial and transfemoral
amputations.

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Section III  Prostheses in Rehabilitation
of the ­prosthetic fitting, or after the individual has already
obtained their prosthesis, depending upon the practice
setting.
Patient History
The patient history is the collection of health-related data
from the past and present. It helps to establish what brought
the person to seek PT services and to highlight the individu­
al's desires and expectations. The person's perspective of his
or her illness, functional limitations, and possible disability
has a powerful influence on the rehabilitation process. In fact,
a positive outlook is associated with constructive coping and
positive adjustment to amputation.9,10
A number of important areas must be explored while tak­
ing the patient history (Table 26-1). Although all the areas
provide important information, several are very integral to
the establishment of the diagnosis and the treatment plan.
The person's general health status may impact the individu­
al's overall health perception, physical functions, psychologi­
cal functions, and role and social functions. Discussion of the
current condition/chief complaint gives the therapist a sense
of the individual's concerns, previous interventions, mecha­
nism of injury or disease, and course of events. It also helps
to understand what the goals and aspirations are for a person
with a transtibial or transfemoral amputation. If the individ­
ual's initial goals appear to be over- or underambitious, the
therapist can address these issues with education and interac­
tion with peers as possible interventions.
The interview process provides valuable insights about
the person's communication ability, emotional status, cog­
nitive abilities, preferred coping strategies, insight into the
rehabilitation process, and usual learning style, as well as the
availability of emotional and instrumental support systems
(assistance with activities of daily living). Information about
the person's pre-amputation level of activity and mobility are
helpful in establishing a realistic prognosis. Patients who are
ambulatory prior to the amputation surgery are more likely
to recover at least a modest degree of ambulation ability with
their prosthesis.11 Specific and probing interview questions
are often helpful in obtaining clear and accurate information.
Although many individuals are accurate historians, others
may have an incomplete understanding or imprecise memory
TABLE 26-1  Important Patient-Client History Component of Physical Therapy Examination
Component
Issues to Consider
Social History
Cultural beliefs and behaviors
Family and caregiver resources
Social interactions, activities and support systems
Employment/work/leisure
Current and prior work
Community and leisure activities
Family/work roles
Living environment
Assistive devices and adaptive equipment
Home environment (e.g., stairs? railings? shower vs. tub?)
Projected discharge destination
General health status
General health perception
Physical and psychological functions
Social health habits
Health risks (e.g. smoking, alcohol, or drug abuse)
Level of physical fitness and exercise habits
Family history
Family medical history and health risks
Medical/surgical history
Prior hospitalizations, surgeries
Preexisting medical and other health-related conditions
Chief complaint/current
condition
Concerns that led patient or caregiver to seek PT services
Any current medical or therapeutic interventions
Mechanism of injury/disease including date of onset and course of events
Patient/caregiver/family expectations and goals
Patient/family/caregiver's perceptions of the person's emotional response to current situation
Any previous occurrences of this problem and therapeutic interventions
Functional status and
activity level
Current and prior functional status in self-care, home management activities and activities of daily living
Current and previous functional status in work and community/leisure activities
Medications
Medications for chief complaint or other conditions
Other clinical tests
Laboratory and diagnostic tests
Review of available records
Format and terminology consistent with The Guide to Physical Therapist Practice.1

Chapter 26  Early Rehabilitation in Lower-Extremity Dysvascular Amputation
699
of what has happened. It is always advisable to confirm infor­
mation by interview with family members and review of the
medical record.
The interview is a means to gather important information
that is used to guide treatment interventions and to begin the
process of education about amputation, treatment, and pros­
thetic training. Many individuals with transtibial or trans­
femoral amputation do not have a clear understanding of
what to expect during rehabilitation or how their disease pro­
cess might progress. Amputation is not selective to patients
of a specific age group, cultural background, educational
experience, or socioeconomic level. Every individual ben­
efits by being well-educated about his or her condition and
treatment. For many, the events that brought them to reha­
bilitation may be a blur of disjointed experiences and medical
jargon, or a laundry list of conditions that seem unrelated or
independent. The physical therapist can help individuals to
place their history and experience in a meaningful context,
which, in turn, assists them in forming realistic expectations,
and may decrease the likelihood of a second amputation.
Systems Review
The systems review provides a gross and limited review of the
anatomical and physiological status of the person's cardio­
pulmonary, musculoskeletal, integumentary, neuromuscular,
endocrine, gastrointestinal, and urogenital systems. Cognitive
screening is also an important part of the review of systems.
This gross screening process aids in focusing and prioritiz­
ing the tests and measures portion of the examination. For
instance, a gross screen of range of motion and strength of
all uninvolved extremities may reveal findings to be within
normal limits, eliminating the need for further assessment.
An integumentary screen may reveal an intact and healing
surgical site, but a stage II sacral pressure ulcer, requiring fur­
ther assessment and inclusion in the plan of care. The systems
review helps to focus the rest of the examination in the most
constructive and productive way.
Tests and Measures
The third component of the examination is the employment
of appropriate tests and measures to gather objective data
about the individual with amputation's various impairments
and activity limitations. Combining this data with the history
and systems review, the physical therapist is able to estab­
lish a working diagnostic hypothesis. The physical therapist
chooses from among an array of possible tests and measures
those that will best confirm or deny the developing diagnos­
tic hypothesis. The information gathered in the interview,
systems review, and examination allows the physical thera­
pist to establish a suitable plan of care and develop the most
appropriate interventions.1 It is important to note that some
assessments, such as strength testing or joint play motions,
might require modification of technique because loss of limb
length necessarily changes where the therapist is able to hold
or resist the limb. Table 26-2 provides categories of tests and
measures that might be appropriate for the patient with trans­
tibial or transfemoral amputation and some detail of how the
therapist might assess each area.
THE EVALUATION PROCESS
The process of evaluation requires the physical therapist to
interpret and integrate the information obtained from the
history, systems review and the tests and measures to identify
TABLE 26-2  Tests and Measures Used in the Physical Therapy Examination
Component
Issues to Examine
Aerobic capacity
During functional activities
During standardized exercise testing
Signs and symptoms of cardiovascular and/or pulmonary systems in response to increased oxygen
demand during increased activity
Anthropometric characteristics
Body composition
Body dimensions
Edema
Arousal, attention, cognition
Motivation
Ability to comprehend instructions
Ability to problem solve
Safety awareness and judgment
Assistive/adaptive devices
Equipment or devices used during functional activities
Ability to care for devices or equipment
Effectiveness of devices or equipment in correcting impairments, activity limitations or participation
restrictions
Safety during use of equipment or devices
Circulation
Cardiovascular signs
Physiological responses to position changes
(Continued)

700
Section III  Prostheses in Rehabilitation
Component
Issues to Examine
Cranial/peripheral nerve
integrity
Motor distribution and integrity
Sensory distribution and integrity
Environmental barriers
Physical space and environment
Ergonomics/body mechanics
Functional and physical performance during work tasks
Safety in work environment
Specific work conditions/activities
Tools, equipment, and workstation design used during job activities
Body mechanics during home and work activities
Gait and balance
Static and dynamic balance with and without prosthesis
Balance during functional activities with and without prosthesis
Ambulation with and without prosthesis
Integumentary integrity
Activities and positioning that produce or relieve trauma to the skin
Equipment, devices or prosthesis that may produce trauma to the skin
Current skin characteristics and conditions
Activities or positioning that may aggravate the wound or scar
Presence of signs of infection
Wound/scar characteristics (e.g., appearance, mobility, sensitivity)
Joint integrity and mobility
Joint play, including accessory movements
Motor function
Timing, coordination, and agility
Hand function and dexterity
Muscle performance
Strength, power, and endurance
Strength, power, and endurance during functional activities
Orthotic, protective, and
supportive devices
Components, alignment, and fit of any orthotic or supportive devices
Use during functional activities
Effectiveness of devices in addressing activity limitations and participation restrictions
Safety during use of devices
Pain
Location and description of pain with intensity ratings
Current regime for management of pain and effectiveness
Posture
Postural alignment and positioning, static and dynamic
Alignment of specific body parts
Prosthetic requirements
Components, alignment, fit and ability to care for prosthesis
Use of prosthesis during functional activities
Effectiveness of prosthesis at correcting activity limitations and participation restrictions
Residual limb edema, strength, range of motion, and skin integrity
Safety during use of prosthesis
Range of motion
Functional range of motion
Active and passive joint movement
Muscle length and flexibility, soft-tissue extensibility
Self-care and home management Ability to access home
Ability to perform self-care and home management activities
Safety in home and self-care management
Sensory integrity
Superficial sensation
Deep sensation
Combined/cortical sensation
Work/community/leisure
integration
Ability to return to work, community, and leisure activities
Ability to access work site, community, and leisure activities
Safety in work, community, and leisure activities
Format and terminology consistent with The Guide to Physical Therapist Practice.1
TABLE 26-2  Tests and Measures Used in the Physical Therapy Examination—cont'd

Chapter 26  Early Rehabilitation in Lower-Extremity Dysvascular Amputation
701
the primary areas of impairment, activity limitation, and par­
ticipation restriction. The physical therapist uses professional
judgment to predict or make a prognosis as to the likely func­
tional outcome and time required for effective preprosthetic
and prosthetic rehabilitation. The evaluation must include
a summary of the individual's major problems and the pre­
sumed underlying cause(s). Problems are prioritized, with
those that have the most significant functional implications
receiving top priority. This is done within the personal and
environmental context of the individual, as the same prob­
lem may affect different individuals in different ways. For
instance, poor sensation of the residual limb in an individual
who is cognitively intact may be easily resolved with educa­
tion about compensating for the sensory deficit with visual
inspection, effectively reducing the risk of compromise of
skin integrity. Another individual with the same sensory defi­
cit who also has cognitive impairment may require a more
extensive educational intervention that is focused on resid­
ual limb care. This individual has a much higher risk of skin
problems, and is likely to require the assistance of a caregiver
to monitor skin integrity.
Physical therapists must also be skilled in determining the
functional implications of specific problems. For instance, a
slight knee flexion contracture can be accommodated for in
transtibial socket alignment, whereas a significant knee flex­
ion contracture prohibits prosthetic fitting with a conven­
tional prosthesis. Prosthetic prescription and PT intervention
may be quite different for two individuals who both present
with knee flexion contractures.
ESTABLISHING A PHYSICAL THERAPY
DIAGNOSIS
The establishment of the diagnosis for a person with lower
extremity amputation is relatively straightforward. The diag­
nosis is determined by a collection of signs and symptoms
that delineate the primary dysfunction of the individual. The
physical therapist then directs interventions toward resolv­
ing that dysfunction. According to the Guide to Physical
Therapist Practice, Part 2, the preferred practice pattern for
a person with an amputation is “Impaired Motor Function,
Muscle Performance, Range of Motion, Gait, Locomotion,
and Balance Associated with Amputation.”1
FORMULATING A PROGNOSIS
The physical therapist uses patient history information and
specific test findings in the context of knowledge of previous
outcomes for individuals with transtibial and transfemoral
amputation, to predict each person's rehabilitation poten­
tial and probable functional outcome. Based on the individ­
ual's prognosis, measurable short-term and long-term goals
are defined to guide planning for interventions. These goals
are also used to inform assessment of outcomes as rehabili­
tation progresses. An important component of the progno­
sis is delineation of the likely time frame for achievement of
the optimal final outcome. A young, active, healthy person
with traumatic transtibial amputation who has few postop­
erative complications is likely to progress through rehabili­
tation more quickly, achieving a high level of function in a
short period of time. In contrast, a medically frail and decon­
ditioned individual who has had a transfemoral amputation
as a result of vascular compromise or nonhealing neuropathic
ulcer will likely have a longer rehabilitation course, likely
resulting in a less ambitious final functional outcome.
Research findings indicate several prognostic indica­
tors of functional prosthetic use following rehabilitation.
All of the following have been found to negatively affect
functional prosthetic use, despite rehabilitation efforts:
advanced age,11–16 presence of comorbidities,11–13 level of
amputation (transfemoral vs. transtibial),11–14,16 and cogni­
tive and/or memory ­impairment.11,12,17,18 This information is
not intended to suggest the exclusion of individuals with any
of these predictors from prosthetic rehabilitation efforts; in
fact, there is evidence of successful prosthetic rehabilitation
in even the oldest old,19 but therapists need to be realistic
in assessing the challenges facing each individual prosthetic
user. It is generally accepted that the best predictor of post­
amputation mobility is the level of pre-amputation mobility.
Patients who were ambulating prior to their amputation are
much more likely to be able to use a prosthesis for ambu­
lation postsurgery.11,12 Consideration of all of these factors
should be reflected in the plan of care, as well as the specific
goals set and the anticipated rate at which goals will be met.
Plan of Care
The PT plan of care includes information about the frequency,
duration, location, and specific PT interventions that are to be
used. The plan of care is directly related to the goals delineated
by the evaluation/prognostic process. The prioritized prob­
lem list provides a foundation for determination of functional
short-term and long-term goals that, in turn, direct rehabilita­
tion activities. If independent donning and doffing of a pros­
thesis are primary short-term goals, the associated treatment
plan must include education strategies, opportunities to prac­
tice this skill, and remediation or adaptation of any movement
components that, if missing, would compromise the indivi­
dual's ability to perform this necessary task (e.g., the person
may need to improve grip strength or intrinsic hand strength
to manipulate prosthetic suspension). The plan includes infor­
mation about equipment to be ordered, referrals to be made,
and the ultimate PT discharge plan.
PREPROSTHETIC INTERVENTIONS
A variety of skills and physical/functional characteristics
create the foundation for successful prosthetic use. These
key areas include functional range of motion (ROM) of the
hip and (if applicable) knee; functional strength of muscles
at the hip and (if applicable) knee; adequacy of motor con­
trol and balance; aerobic capacity and endurance; effec­
tive edema control and maturation of the residual limb;

702
Section III  Prostheses in Rehabilitation
­integrity of the skin and soft tissue; and sensory integrity
of the residual limb. It is crucial to address these areas early
in the rehabilitation process. Inability to achieve a certain
status or level of performance in one area does not prohibit
a good prosthetic outcome; however, difficulties in multi­
ple areas have an impact on prosthetic candidacy and use.
Each of these areas should be carefully evaluated and appro­
priate interventions undertaken to achieve at least minimal
requirements for functional prosthetic use, if not optimal
level of performance.
Range of Motion
Early and aggressive achievement of functional ROM of the
involved lower extremity is of paramount importance. The
flexor withdrawal pattern of hip flexion, abduction, and
external rotation, and knee flexion, is a position associated
with lower-extremity pain and is often a position of choice
in individuals postsurgically. The elevation of the residual
limb on pillows serves to reinforce this undesirable posture
and puts these individuals at risk for contracture formation.
The development of contractures or tightness of muscles con­
sistent with this position of the residual limb, especially hip
and knee flexors, can have a significant negative impact on
ultimate prosthetic use.11,20 Maintaining or increasing avail­
able ROM at the hip for persons with a transfemoral residual
limb and at the hip and knee of the transtibial residual limb
continues to be a primary treatment goal as the patient moves
from preprosthetic into prosthetic rehabilitation. The preven­
tion of loss of ROM is much easier than efforts to regain lost
motion.21 Prone positioning is an excellent strategy to com­
bat contracture formation of the hip flexors and should be
prescribed (60 minutes daily) as early as possible for all indi­
viduals who are able to tolerate this position. Low load, long
duration stretch is safe and can yield significant elastic and
plastic changes in soft tissues.21 Active and passive stretching
in the side-lying position may be used for those unable to lie
prone. Full functional hip ROM into flexion, extension, and
adduction is critical to achieving efficient ambulation and
functional mobility with a prosthesis. Typical gait on level
surfaces requires the hip to move from 30 degrees flexion to
10 degrees extension and requires adduction slightly beyond
neutral.22 More extreme ranges of hip flexion are required for
transitioning sit to/from stand or reaching forward from a
seated position.
To avoid knee flexion contracture in the individual with
a transtibial amputation, a postoperative rigid dressing or
knee extension splint or board (extending from under seat­
ing cushion) can be an effective technique early in the pro­
cess to position the knee resting in an extended position while
seated. Full knee extension ROM is required in typical ambu­
lation on level surfaces22 and for exploiting passive stability
at the knee joint in static standing. Individuals with recent
transtibial amputation should be encouraged to use the knee
extension splint as long as tolerable throughout the day, supple­
mented with frequent active quadriceps exercises (“quad set”).
The person must also be taught to regularly check the ­integrity
of skin of the residual limb while using the splint or board,
to minimize risk of pressure-related skin damage that would
delay use of the prosthesis.
For individuals with transtibial amputations, achieving
knee flexion ROM is sometimes overlooked early in reha­
bilitation. Typical gait on level surfaces generally requires
approximately 60 degrees of knee flexion,22 and 90 degrees or
more is required for efficient step-over-step stair ambulation,
rising from a seated position, and high-level mobility activi­
ties such as kneeling or rising from the floor.
Assessment of ROM of the intact limb is also important,
as loss of ROM of either limb has an impact on quality and
energy efficiency of gait.23 The importance of functional
ROM is also emphasized in individual education and home
exercise routines. Table 26-3 summarizes the potential pros­
thetic problems that are associated with loss of functional
ROM. Utilization of a wide variety of active and passive ROM
therapeutic exercise techniques is appropriate as early as pos­
sible. All exercises that are started during the preprosthetic
phase are generally appropriate to continue as prescribed,
or to be progressed as tolerated during the prosthetic train­
ing phase. Once full functional ROM is achieved, the person
must be educated to maintain this level.
Strength
In a systematic review, van Velzen et al.24 found several studies
that demonstrated significant strength differences between
muscles of the amputated limb as compared to the sound
limb in subjects with transtibial and transfemoral amputa­
tions. Deficits in muscular endurance of the amputated limb
as compared to the sound limb25 and weakness of both the
amputated and the sound limb in comparison to age-matched
norms26 have also been demonstrated. Although we cannot
draw direct relationships between strength impairment and
specific activity limitations, there has been some evidence to
support the impact of weakness on activity level performance.
For instance, hip extensor strength in persons with lower-
extremity amputation has been identified as a useful predic­
tor of performance on the 6-minute walk test,27 and increased
abductor strength in individuals with transtibial amputation
is correlated with improved weight bearing on the prosthetic
limb in quiet stance.28
Accurate strength assessment can help to elucidate the
potential causes of gait deviations, as deviations are often
related to strength deficits. Knowing which muscles are
weak will serve to guide therapeutic exercise interventions.
Gathering muscle strength measures in the initial stages of
prosthetic training will also establish baseline strength levels
against which progress can be demonstrated.
Early in the prosthetic training process, it is important
to evaluate baseline strength in several ways. Assessing hip
and, in persons with transtibial amputation, knee strength of
the residual limb becomes somewhat more subjective, as the
standard lever arm for providing resistance has been altered
by the amputation. Isokinetic instrumentation or hand held
dynamometers may be used to evaluate muscle strength,
although the validity and reliability of these tests has not been
well-established for this population.26,29 Functional strength

Chapter 26  Early Rehabilitation in Lower-Extremity Dysvascular Amputation
703
of the hip and knee during closed chain activities and eccen­
tric control are equally important, as they reflect muscle
activity during normal gait.
Although strengthening programs should address all mus­
cles of the residual limb and sound limb, prioritizing exercises
that address hip extensor strength in the amputated side is
appropriate, as hip extension strength has been identified as a
strong predictor of gait outcome in persons with ­amputation.27,30
Hip abductor strength is a priority for frontal plane stability and
knee extensor strength is key for knee stability in the sagittal
plane in individuals with transtibial amputation, so these mus­
cle groups must also be emphasized in a preprosthetic exercise
program. Stability of the hip and pelvis, especially in stance on
the prosthetic side, is one of the key ingredients in achieving
effective forward progression over the prosthesis during gait.
In persons with amputations appropriate hip extensor and
abductor strength is critical to achieving stability of the pelvis
over the prosthetic limb during single limb stance in gait.27,30
Strengthening exercises targeting hip extensors and abductors
should be initiated early and progressed appropriately.
Although pre-amputation weakness of proximal muscles
is often subtle with little to no observable abnormalities in
pre-amputation gait patterns, these impairments of strength
and muscle endurance may be magnified in prosthetic gait.
Periods of disuse prior to and following amputation typically
produce further weakness in much of the involved limb's
musculature. Without adequate proximal muscle strength
and with the loss of distal musculature because of the ampu­
tation, problems with gait are likely.
Attention to strengthening of the hip extensors, abductors,
adductors, and, in the person with transtibial amputation, the
quadriceps and hamstrings are paramount to achieving opti­
mal ambulation abilities. This is best addressed in the early
phases of rehabilitation but should continue throughout the
rehab process. Core strengthening of the abdominal and para­
spinal muscles is important to develop as a strong core is
essential for trunk stabilization during mobility training for
transfers and gait. The degree of strengthening for the extrem­
ities and the positioning of the individual's limb in gravity
resistance or gravity neutral position will depend upon exist­
ing strength levels. Utilization of closed chain (e.g., residual
limb on bolster or gymnastic ball, or individual in kneeling
position if tolerated) and open-chain exercise techniques, with
both concentric and eccentric muscle contractions, are appro­
priate and effective. Progressive resistance protocols are often
used to improve strength and muscle endurance. Resistance
may be applied manually or with equipment, such as cuff
weights, elastic bands, or pulley weights. Using body weight
is an effective way to introduce resistance training. Resistance
is generally not applied at or near the suture line until the sur­
gical wound is well healed. Basic physiological principles of
strengthening (e.g., overload principle, ­specificity of training)
TABLE 26-3  Prosthetic Consequences of Limitations in Range of Motion
Range of Motion Limitation
Potential Functional Limitation
Implication
↓ Hip extension
Inability to achieve upright posture in stance and
inability to take advantage of extensor moment at
hip; hip and low back extensors firing continually
to maintain upright
Compensatory anterior pelvic tilt
Compensatory knee flexion in transtibial prosthetic
Body cannot progress beyond prosthetic leg
during gait
Fatigue of hip and low back extensors
Chronic low back pain
Instability during stance phase of gait
Decreased step and stride length of contralateral
limb in gait
↓ Hip adduction
Abducted stance in gait (wide base of support)
Abductor lurch/lateral lean on ipsilateral side
during stance decreasing gait efficiency
↓ Internal rotation
Toe-out stance and gait
Pelvic progression over stance limb in gait may be
limited (contralateral pelvis rotates anteriorly from
fulcrum of weight bearing hip; if limited internal
rotation, this will impede pelvic rotation on fixed
femur)
Knee joint pain and/or pathology in transtibial
prosthetic user because of lack of anterior/
posterior orientation of knee joint
Decreased step and stride length of contralateral
limb in gait
↓ Knee extension in
transtibial prosthetic user
Limb functionally shorter
Inability to take advantage of extensor moment at
knee; knee extensors firing continually to maintain
knee extension
Gait deviations associated with leg length
discrepancy
Quadriceps fatigue, decreased midstance stability
in gait
↓ Knee flexion in transtibial
prosthetic user

Inability to place foot flat on the floor when sitting
Inability to climb or descend stairs step over step
Inability to weight bear through prosthesis during
sit-to-stand transfers
Limited to step-to-step method, which may be
less efficient and slower

704
Section III  Prostheses in Rehabilitation
are employed in the design of an appropriate resistance train­
ing program. Resistance exercises should specifically target
muscles identified as weak in the examination and muscles
that are functionally required in gait, transfer, and mobil­
ity activities. Strengthening within the context of functional
activities is desirable. Correct exercise technique is critical to
achieving the desired strength gains with the ultimate goal of
minimizing an individual's activity limitations.
As an individual's strength improves, exercises become
more functionally oriented as well as more intense. Closed-
chain exercises can take on greater emphasis during the lat­
ter stages of rehabilitation as the intervention focus may be
exclusively on upright functional activities. Table 26-4 high­
lights some exercises that may be helpful in strengthening an
individual with transtibial or transfemoral amputation.
The strength requirements for ambulation with a prosthe­
sis are similar but not identical to those of normal gait. Both
the involved and intact lower extremities display increased
muscle activity during their respective stance phases.
Specifically, activity of the ipsilateral hip extensors and, in
the case of transtibial amputation, knee extensors is increased
and prolonged during stance as compared to persons without
amputation.30,31 The intact limb is subject to increased ground
reaction forces, presumably a result of the absence of the nor­
mal foot and ankle mechanism of the involved side.32,33 Hip
abductors and extensors and knee extensors of the intact limb
must respond to these increased forces. They demonstrate an
increase in power generation and muscle activity.34
It is clear that PT interventions must address the strength
not only of the residual limb, but of the uninvolved limb and
trunk as well. Persons with amputation often go through pro­
tracted periods of inactivity before and after amputation.
Because of this “disuse,” the patient often experiences general­
ized loss of strength. Adding exercises that address the trunk,
upper extremities, and uninvolved limb will generally be ben­
eficial to overall functional mobility as the demand on them
will be increased during preprosthetic and prosthetic training.
Balance and Postural Control
Effective postural control during functional tasks has two fun­
damental components: (a) controlling the body's position in
space for purposes of stability (maintaining center of mass over
base of support) and (b) orientation of the trunk and limbs in
space (appropriate relationship between body segments and
between body and environment).35 The normal balance mech­
anism relies on visual, vestibular, and somatosensory input.
Visual and vestibular information add awareness of position in
space with respect to objects in the environment and to gravity
and somatosensation provides information about the positions
of the joints of the lower extremity and the pressures through
those joints. With loss of the distal limb to amputation, somato­
sensation and proprioception can no longer provide direct infor­
mation about limb's interaction with support surfaces. Balance
deficits are well documented in persons with amputation,24,36
as are deficits in balance confidence.37,38 Balance performance
is associated with ambulation outcome following amputa­
tion15,24,27,39 and reduced balance confidence has been linked to
a loss of perceived ability with the prosthesis, a loss of perfor­
mance with the prosthesis, and a reduction in a sense of social
importance.40 Additionally, the incidence of falls in persons
with amputation is higher than in age-matched peers,36,40 and
many falls occur during the inpatient postoperative period,41
especially during transitional movements such as transfers
to/from wheelchairs.42
Before discussing standing balance, it is important to men­
tion that some individuals will have difficulty adjusting to
changes in sitting balance following transtibial or transfem­
oral amputation. Prior to receiving the prosthesis, lack of a
second foot on the floor, or in the case of transfemoral ampu­
tation, loss of the surface area of the thigh on the seating sur­
face, alters the base of support while sitting; and loss of the
mass of the lower extremity impacts the location of the body's
center of gravity in sitting. Most individuals adjust fairly
quickly in achieving static sitting stability, but the inability
to weight shift onto that foot can challenge dynamic sitting
balance, especially with reaching tasks requiring movement
anterior and ipsilateral to the amputated side. For this rea­
son, seated reaching ability is evaluated during the initial
TABLE 26-4  Examples of Therapeutic Exercises for
Strengthening Used in Preprosthetic Training
Muscle Group
Exercises
Hip extensors
Bridging with residual limb over ball, bolster,
or padded stool
Prone leg lifts with weights
Manual resistance in prone or side lying,
or even sitting (early in range)
Supported standing (parallel bars) hip
extension with pulley weights or elastic
bands
Hip abductors
Side-lying bridges with small ball or padded
stool under knee (TTA) or distal femur
(TFA) of residual limb
Hip abduction in side-lying with weights
or manual resistance
Supported standing hip abduction with
pulleys or elastic bands
Hip flexors
Supine hip flexion (with knee extension for
TTA) with manual resistance or weights
Supported standing hip flexion with pulleys
or elastic bands
Hip ER/IR
Seated or supine hip ER and IR with manual
resistance or elastic bands
Knee extensors
(TTA)
Seated knee extension, open chain with
manual resistance or weights (long arc quad)
Supine short arc quad over bolster
Knee flexors (TTA)


Seated knee flexion with manual resistance
or elastic bands
Prone knee flexion with manual resistance
or weights
ER, external rotation; IR, internal rotation; TFA, transfemoral
amputation; TTA, transtibial amputation.

Chapter 26  Early Rehabilitation in Lower-Extremity Dysvascular Amputation
705
­examination and is addressed in treatment as necessary. Once
an individual is training with a prosthesis, practicing dynamic
sitting balance activities usually progresses quite quickly.
In the preprosthetic phase, standing balance assessment
and training might include single-limb standing in the par­
allel bars or at a support surface with decreasing reliance on
upper-extremity support. Ability to stand on the sound limb
without upper-extremity support has been associated with
better prosthetic gait outcomes in individuals with unilateral
lower-extremity amputation,15,24,27 making this an important
skill to assess and train as early as possible.
In patients with transtibial amputation, if the individ­
ual can tolerate a kneeling position over the healed surgical
site, or in individuals with either transtibial or transfemoral
amputations, if they can tolerate gentle pressure to the healed
distal end, the individual may stand with the intact limb on
the floor and the residual limb resting on an elevated surface
(low mat, gymnastic ball, or foam block) that allows minimal
weight bearing and balance support. Preprosthetic gait train­
ing with an appropriate assistive device is another useful and
functional approach to upright balance training.
Because sensory and proprioceptive input from the dis­
tal segment is absent after amputation, a new prosthetic user
must learn to compensate for this lack of important pos­
tural information. In individuals with nonvascular ampu­
tations (sensory status of remaining limb presumed intact),
quiet stance is characterized by asymmetrical weight bear­
ing (sound limb greater than prosthesis) and an alteration of
the location and trajectory of the center of pressure on both
the prosthetic limb and the sound limb.43 These sound limb
variations are strategies to compensate for the prosthetic
limb in maintaining upright balance. Because the vast major­
ity of lower-extremity amputations are the result of vascular
pathology, the underlying sensory mechanisms that help to
inform the balance compensation cannot be presumed to be
intact. Balance assessment and training is, therefore, a signifi­
cant and justifiable component of the prosthetic rehabilita­
tion process.
Prosthetic users may learn to deduce the position of the
prosthetic foot and contact with the support surface by the
angle of the hip or, in the case of the person with transtibial
amputation, the knee, and/or pressures felt within the pros­
thetic socket. Early in gait training, the person with a trans­
femoral amputation may make an exaggerated effort to dig
the prosthetic heel into the floor at initial contact, so as to
use the resulting pressure at the posterior residual limb as an
indicator of contact with the floor and to assure prosthetic
knee extension. The individual may learn to interpret this
sensory experience as the secure position for proceeding with
loading response and progressing into midstance.
In addition to the loss of direct sensory knowledge of
contact with the floor, the loss of muscles at the ankle often
compromises postural responses. Nashner44 describes three
stereotypical motor responses that are used to ensure that the
center of mass stays within the base of support in response
to unexpected anteroposterior perturbations: ankle, hip, and
stepping strategies. These postural strategies are also evident
during functional activities, such as ambulation.35 The ankle
strategy movement pattern, evident in normal postural sway,
requires intact ROM and strength of muscles at the ankle.
After amputation, this strategy is no longer available to the
involved limb, so that the person may not be able to resolve
the balance perturbation using intact limb response only,
and instead may need to rely on a hip strategy (movement
of the trunk over the base of support) or a stepping strategy
(­moving the base of support under the center of mass) when
a postural response is necessary.
Individuals with transtibial and transfemoral amputations
must be able to respond to environmental demands during
ambulation and other functional tasks in anticipatory (feed
forward) and reactive (feedback) modes. Therapists can
design activities to assess and encourage postural control in
varying tasks and environments.45 For example, successfully
catching and throwing a ball requires the person to anticipate
postural demands (in an effort to throw) and react to pos­
tural disruptions (in an effort to catch). Reaching activities
in standing help individuals develop skill and confidence in
their anticipatory postural responses and, should the reach
distance be excessive, their reactive postural responses as
well. Individuals with higher functional demands will require
more advanced training. Therapists must consider the per­
son's ultimate likely functional requirements and design a
variety of balance tasks to help the individual achieve those
levels.
Cardiovascular Endurance
A thorough assessment of a person's cardiovascular status fol­
lowed by appropriate cardiovascular endurance training is an
integral part of pre-prosthetic and prosthetic management.
The energy requirements for an individual who is using a
prosthesis for ambulation are higher than those of an individ­
ual who ambulates on two intact lower limbs. Aerobic capac­
ity of persons with amputations has been demonstrated to be
lower than age-matched peers, even in younger individuals
with traumatic amputations.46 An extensive literature review
by Waters47 identifies some of the key physiological consider­
ations for gait in persons with prostheses:
• The energy cost of walking is greater in individuals
with amputations than those without.
• Higher level amputations are associated with higher
energy costs of walking than lower level amputations.
• Persons with amputations as a consequence of vascular
pathology demonstrate greater energy cost of walking
than those with traumatic amputations; this may likely
be associated with overall fitness level.
• Customary walking speed decreases with higher level
of amputation.
• Average rate of oxygen consumption during self-
selected walking may not be significantly greater than
normal, as users of prosthetics often adjust (decrease)
their speed.
• It is generally more efficient for an individual with a
prosthesis to ambulate with the prosthesis (with or
without assistive device), than it is to ambulate with the

706
Section III  Prostheses in Rehabilitation
assistive device without the prosthesis. The one excep­
tion to this may be the person with a vascular trans­
femoral amputation, where the energy expenditure is
similar with and without prosthesis, likely a result of
the substantial dependency on the assistive device, even
when using the prosthesis.
The energy expenditure for overground walking in peo­
ple with unilateral transtibial amputation may be 10% to 36%
higher than that of individuals without amputation,48–52 with
the lower end of the range representing those with non–
vascular-related amputations, and subjects who were more
physically active. Individuals with transfemoral amputations
demonstrate even higher energy requirements, 27% to 65%
higher than people without an amputation.50,53–55 Physical con­
ditioning is an essential component of rehabilitation for indi­
viduals with lower-extremity amputation, especially those
with cardiopulmonary or vascular compromise. Individuals
with vascular amputations are significantly less active than
their peers.56 Improving metabolic efficiency (aerobic capac­
ity) has a direct impact on the potential for functional ambula­
tion even for the frailest and most deconditioned individuals.57
The ability to gain an exercise intensity of greater than or equal to
50% VO2 has been associated with “successful” prosthetic out­
come (i.e., ability to walk 100 m with or without cane) in older
adults with high-level amputations (transfemoral and hip dis­
articulation).58,59 Endurance activities during the preprosthetic
rehabilitation phase (e.g., wheelchair propulsion, single-limb
ambulation with an appropriate assistive device, bilateral upper
or unilateral lower-extremity ergometry) can help improve car­
diovascular status before prosthetic training. Individuals often
continue these activities as they enter into the prosthetic phase
of rehabilitation. As the condition of the person's residual limb
and wearing tolerance permit, ambulation with the prosthesis
can be used as an additional cardiovascular endurance activity.
The 2-­minute walk test with prosthesis may be a useful tool to
document changes in functional exercise capacity for an indi­
vidual with amputation.60,61 For those whose endurance may be
a limiting factor for prosthetic ambulation, the PT plan of care
must include a cardiovascular exercise component as a priority.
Individuals who are taught to monitor their own pulse, respi­
ratory rate, and/or perceived rate of exertion are able to par­
ticipate more fully in prosthetic rehabilitation and prosthetic
training. To develop an effective cardiovascular conditioning
program, the therapist uses knowledge of the person's past
medical history and cardiovascular pathophysiology, adapting
the program to provide an appropriate challenge without sur­
passing their physiologic capabilities. The therapist must rec­
ognize the influence of cardiopulmonary pathologies, such as
unstable angina or advanced chronic obstructive pulmonary
disease, on the individual's ability to improve his or her endur­
ance and adjust goals and intervention strategies as appropri­
ate. For individuals with few cardiovascular restrictions, more
advanced cardiovascular exercises can be utilized as rehabili­
tation progresses. Brisk walking and/or use of exercise equip­
ment (e.g., treadmill, stationary bicycle, stair climber, or
elliptical machine) are excellent endurance training activities
for the appropriate person. An amputation need not prevent
individuals from participating in health and wellness exercise
programs during and following their rehabilitation.
Edema Control of Residual Limb
Reduction of postsurgical edema is critical in the early post­
operative rehabilitation phase. Use of rigid postoperative
dressings (e.g., cast) after transtibial amputation appear to be
superior to soft dressings (including ace wrapping) in con­
trolling volume of the residual limb62,63 and are associated
with a shorter time frame from amputation to initial pros­
thetic ­fitting64,65; however, this type of postoperative care is not
routinely used throughout the United States, perhaps because
of physicians' hesitancy to be blinded to the surgical site for
5 to 7 days postsurgery. When the more common soft dress­
ings are used, ace wrapping for compression is applied over
the transtibial residual limb dressing. Ace wraps should be
applied in oblique angles (not circumferentially, so as to avoid
a tourniquet effect), with gradual increase in pressure from
distal to proximal, and always extending above the knee (as
the transtibial prosthetic socket engulfs the medial and lateral
aspects of the knee). Patients and family members should be
instructed in wrapping technique, as the Ace wrap typically
needs to be reapplied several times per day.
The transfemoral residual limb does not lend itself to rigid
postoperative dressings and is more challenging to Ace wrap,
as it requires anchoring over the pelvis and it may be difficult
for a patient to elevate the pelvis for wrapping. Nevertheless,
efforts at compression wrapping postsurgically should be a
part of the treatment plan.
After the staples or sutures are removed, use of a commer­
cial pressure garment (“shrinker”) is suggested for persons
with either transtibial or transfemoral amputation. Residual
limb edema plays a big role in determining when initial pros­
thetic fitting will take place—if the prosthesis is fitted too
early and the residual limb is still substantially shrinking, this
will affect the intimacy of prosthetic socket fit, making train­
ing more difficult and increasing the risk of complications
caused by a poorly fitting socket.
Prerequisites for initial prosthetic fitting include sutures
removed, surgical wound healed or healing, and edema con­
trolled, with distal measurements less than or equal to proxi­
mal measurements. The importance of continued shrinking
efforts, even after prosthetic training has begun, should be
emphasized. Individuals usually must continue to wear a
shrinker sock when they are not wearing their prosthesis, at
least during early training efforts. If patients allow the edema
to return to the limb the socket may no longer fit and aggres­
sive efforts to reduce limb volume will need to precede any
further prosthetic training.
Initiation of weight-bearing activities in the prosthetic
socket significantly decreases limb edema and accelerates
maturation of the residual limb as a result of total contact
within the socket and the pumping of muscle contractions
during weight-bearing activities and movement. Shrinking of
the residual limb in early prosthetic training is accommodated
for with the addition of layers of appropriate ply thickness of
prosthetic socks to maintain a snug residual limb-prosthesis

Chapter 26  Early Rehabilitation in Lower-Extremity Dysvascular Amputation
707
interface. Given fluctuations in residual limb size during early
training and the need for an intimate socket fit, new pros­
thetic users must carry extra socks with them whenever they
are going to be out for longer than 2 to 3 hours.
As mentioned, during early prosthetic rehabilitation,
individuals continue to use a shrinker when not wearing
the prosthesis to reduce the likelihood of insidious edema
when the prosthesis is not being worn. Individuals prone
to fluid volume fluctuations (e.g., those with kidney dys­
function or congestive heart failure) will likely need to use
a shrinker indefinitely. For others, whose residual limb ulti­
mately reaches a stable size and shape, a shrinker may not be
necessary once the prosthesis is consistently being used. The
decision to discontinue the use of a shrinker permanently is
based on two factors: (a) consistency in the number of sock
ply worn during the day and (b) the ability to don the pros­
thesis without decreasing the usual number of sock ply after a
night's sleep without the shrinker.
Significant changes in body weight can also dramatically
affect socket fit. Patients should be educated regarding the
importance of limiting weight gain or loss so as not to com­
promise socket fit.
Soft-Tissue Mobility of Residual Limb
Soft-tissue and bony adhesions that limit tissue mobil­
ity around the incision scar and the surrounding area may
have an impact on prosthetic tolerance, comfort, and use.
Surgical amputation can include muscle-to-muscle (myo­
plasty), muscle-to-fascia (myofascial), and/or muscle-to-
bone (myodesis) surgical fixations to stabilize the remaining
muscle.66,67 Scarring or adhesions can occur among any or
all of these tissues. The normal stresses and shearing forces
of cyclic loading and unloading during gait require that soft
tissue throughout the residual limb be mobile. If the soft tis­
sue is not able to move independently of the scar tissue or
skeletal structures, the stress can lead to tissue breakdown
and/or discomfort. Soft-tissue mobilization techniques
early in the rehabilitation process can help establish appro­
priate tissue mobility in the residual limb. Once the surgi­
cal incision is securely closed, soft-tissue massage can be
an effective tool in maintaining tissue mobility. Deep fric­
tion massage may be helpful in managing scar tissue that
is restrictively adhered. Individuals can be instructed in
the use of this modality with specific guidelines for proper
technique. Appropriate deep friction massage targets move­
ments between skin, subcutaneous soft tissue and fascia, and
muscle layers. Improper deep friction massage technique is
ineffective in managing scar tissue and potentially harmful
for the person with fragile skin and soft tissue. Friction gen­
erated between the fingers and skin results in skin irritation,
blistering, or breakdown and can delay prosthetic use until
adequate healing occurs.
Sensory Status of Residual and Remaining Limb
Residual limb and sound limb sensibility is formally assessed
during the initial PT examination. Standard sensation
­testing guidelines are used to assess all sensory modalities
(pain, ­temperature, light touch, deep pressure, ­proprioception,
vibration). Semmes-Weinstein monofilament testing may
be used to assess for protective sensation of the sound limb.
Several commonly occurring post-amputation sensory phe­
nomena can have implications for functional outcome in
patients with amputation. These include hyposensitivity,
hypersensitivity, phantom sensations, and phantom limb pain.
Hyposensitivity
Hyposensitivity is most often encountered among those with
a history of diabetes, neuropathy, traumatic nerve damage, or
vascular disease. Limited research suggests that deep pressure
remains intact, but superficial pain sensibility is impaired in
transtibial residual limbs.68 Individuals with amputation who
have impaired sensation are at high risk for skin breakdown
because they may not recognize discomfort associated with
skin irritation resulting from repetitive stresses and pressures.
Inclusion of education about the preventative need for visual
inspection, and practice time to perform visual inspection of
the residual limb for signs and symptoms of soft-tissue lesions
can reduce the risk of skin breakdown. Adaptive equipment,
such as mirrors, or the assistance of caregivers may be neces­
sary for people with concurrent limitations in flexibility and/
or visual impairment.
Hypersensitivity
Early in rehabilitation, it is not uncommon to encounter a
generalized hypersensitivity of the residual limb. This hyper­
sensitivity is thought to be a consequence of nerve dam­
age from amputation surgery itself.69 Hypersensitivity can
be effectively managed by bombarding the residual limb
with tactile stimuli using a variety of textures and pressures.
Strategies for reducing hypersensitivity include gently tap­
ping with the fingers, massaging with lotion, touching with a
soft fabric (e.g., flannel or towel), rolling a small ball over the
residual limb, and implementing a specific wearing schedule
for shrinker socks and removable rigid dressings. Intensity
of intervention is based on the individual's tolerance to the
sensory stimulation. The techniques can be progressed in
intensity, type of modality used, and duration of stimulus
(e.g., touching the limb with a rougher fabric and increasing
wearing time for the shrinker socks). Individuals with ampu­
tations are strongly encouraged to use these techniques inde­
pendently as part of their home program. Over time these
techniques should help reduce the hypersensitivity with the
ultimate goal of tolerance to normal sensory input without
discomfort. Physiologically, overloading the nervous system
with sensory stimuli is thought to encourage habituation via
downregulation of neural receptors.
Localized hypersensitivity may be an indication that a
troublesome neuroma has developed at the distal end of a
surgically severed peripheral nerve. A neuroma is suspected
when localized tapping sends a shock sensation up the leg.
If conservative clinical treatment is unsuccessful in reduc­
ing the hypersensitivity and pain caused by a neuroma, injec­
tion of a local anesthetic directly into the region or surgical
removal may be necessary.

708
Section III  Prostheses in Rehabilitation
Phantom Limb Sensations
Phantom limb sensations are quite common after ­amputation.70–72
Many individuals report experiencing feelings of itching, tin­
gling, numbness, or sensations of heat and cold in the toes or foot
of the limb that has been amputated. Although the sensation can
include the entire missing extremity, proximal sensation often
fades leaving only distal perceptions, a phenomenon known as
“telescoping,” presumably related to the large area of somatosen­
sory cortex dedicated to the distal extremity.72–74 Phantom limb
sensation is a relatively harmless condition that tends to resolve
in 2 to 3 years without treatment.72 It has potential functional
implications, as it may be useful in providing a semblance of pro­
prioceptive feedback from the prosthesis. Be alerted, however, as
to the importance of educating individuals of the potential dan­
ger of phantom limb sensations: nighttime falls are not uncom­
mon when, half asleep, an individual attempts to stand and walk
to the bathroom, expecting their phantom foot to make contact
with the floor.
Phantom Limb Pain
Phantom limb pain occurs in 60% to 80% of all persons with
amputation.70,72,74,75 Incidence of phantom limb pain has been
demonstrated to be higher with upper-extremity amputations
as compared to lower-extremity amputations,72,76,77 with prox­
imal as compared to distal amputations,72 and demonstrated
to decrease over time.70,72,74,76 When phantom pain occurs, it
is most often described as a cramping, squeezing, aching, or
burning sensation in the part of the limb that has been ampu­
tated. The spectrum of complaints may vary from occasional
mild pain to continuous severe pain. The absence of observ­
able abnormalities of the residual limb is common. Although
the etiology of phantom pain is not definitively understood,
changes in the peripheral nervous system, the spinal cord,
and reorganization at the level of the cerebral cortex may all
be involved in the perception of phantom limb pain.70–72,74
The association between the etiology of amputation (vascu­
lar versus traumatic) and the incidence of phantom pain is
unclear, but there does appear to be higher incidence of phan­
tom pain in individuals who experienced pain in the limb
prior to amputation.70,74,78 Whatever the etiology and predis­
posing factors, phantom limb pain is challenging to manage
and disabling if the pain is severe. Presently, there are no evi­
dence based practice recommendations for the management
of phantom limb pain. Clinically, strategies used to address
phantom limb pain include medications (antidepressants,
anticonvulsants, and analgesics), neural blockade, transcuta­
neous electrical nerve stimulators, heat and cold modalities,
acupuncture, biofeedback, firm pressure applied to the resid­
ual limb (e.g., massage, compression or prosthetic socket),
mirror box therapy, phantom exercises of the phantom limb,
psychological treatment, and patient education.70,72,73,79,80
Residual Limb Pain
Residual limb pain is another potential limiting factor in per­
sons after lower-extremity amputation. Common early after
surgery, this pain usually subsides over time.70,72,74 Ongoing
complaints of residual limb pain should prompt careful
inspection of the residual limb, as the therapist may pick
up on signs of infection or small cutaneous or subcutane­
ous problems that could be manifesting as pain. This careful
inspection and follow through is especially important in indi­
viduals with diabetes and vascular disease, as those who have
an initial distal amputation at any level are at substantial risk
of revision of amputation to a higher level. In a recent study
of 277 subjects with diabetic amputation, 27% of patients
required surgical revision by 1 year, and 61% by 5 years.81
Care of Sound Limb
Ongoing assessment of the intact lower extremity should be
made the responsibility of the individual with the amputation,
with support of the physical therapist. Individuals with diabe­
tes, peripheral neuropathy, or peripheral vascular disease who
have lost one leg as a result of the disease process have a sig­
nificant chance of losing the other leg, given the symmetri­
cal distribution of these disease processes and the increased
functional demand on the remaining limb after the amputa­
tion. The added burden to the remaining limb extends beyond
the preprosthetic period. Once ambulatory with a prosthesis,
individuals will preferentially initiate level surface walking
with the prosthetic limb, placing a larger burden on the sound
limb for stability and propulsion.82 And as an ambulatory indi­
vidual makes adjustments to increase walking speed, this, too,
will increased demands on the sound limb.83
Contralateral major limb amputation has long been
known to be a very real threat in those with diabetes and vas­
cular compromise,84 and this is continually being reaffirmed.
A 2006 study by Izumi demonstrated amputation of the con­
tralateral limb of 12% of subjects with diabetes within 1 year
of initial amputation, 44% within 3 years, and 53% within 5
years.81 To minimize the risk of loss of the remaining limb,
close monitoring of limb condition (especially for subtle
or insidious trophic, sensory, or motor changes) and opti­
mal foot care is essential. Ongoing, systematic, and frequent
assessment of pulses, edema, temperature, and skin is sug­
gested. Education about the importance of a daily routine of
cleansing, drying, and closely inspecting the foot (including
the plantar surface and between the toes) is crucial. Podiatric
care of nails, corns, and plantar callus, appropriately fitting
footwear or accommodative foot orthoses, and avoidance
of barefoot walking are three additional imperatives for the
longevity of the remaining foot. If unable to perform daily
foot inspection independently because of disease or visual
impairment or decreased agility, individuals must be able to
direct a caregiver in inspecting the foot. Even if individuals
are physically incapable of performing certain tasks for their
own health and safety, they are ultimately responsible for
their own care. Developing or improving on a person's skill at
directing assistance is a useful and realistic PT treatment goal.
INITIAL PROSTHETIC TRAINING
Prosthetic fitting with an initial prosthesis (also called a tem­
porary or training prosthesis) occurs when the surgical inci­
sion is healed (or healing without complications) and girth

Chapter 26  Early Rehabilitation in Lower-Extremity Dysvascular Amputation
709
measurements at the distal residual limb are equal to or less
than proximal girth measurements. The timeline from sur­
gery to initial prosthetic fitting generally takes 6 to 12 weeks,
although younger individuals with traumatic amputation and
no other complications may be fitted as early as 2 to 3 weeks,
and older dysvascular individuals may require substantially
longer than 12 weeks, often because of delayed wound heal­
ing issues.
As a new residual limb matures and shrinks in size, the
person will add additional ply (layers) of prosthetic sock to
ensure adequate fit in the prosthesis. Typically, when the inti­
macy of fit within the socket is compromised by 15 or more
ply of sock, a new prosthetic socket is indicated. How quickly
the initial socket needs to be replaced varies depending on
the pattern of shrinkage of the residual limb. For some, the
first replacement socket may be necessary in 2 to 3 months,
whereas others may use their initial socket for 6 months or
more. The socket may be replaced several additional times
as the residual limb continues to shrink in the first postop­
erative year. A definitive prosthetic socket is prescribed when
the residual limb size is stable for an 8- to 12-week period, as
indicated by girth measurements and by a consistent num­
ber of sock ply for prosthetic fit. Although some people are
ready for their definitive prosthesis within 6 months after sur­
gery, others do not achieve stable residual limb size for 12 to
18 months or longer. With each new socket, close monitor­
ing of the residual limb throughout the adjustment period is
necessary.
Several important components of rehabilitation involving
prevention of skin breakdown and safe use of equipment can
be effectively addressed in group classes or through printed
materials. These components include care of the sound limb,
donning and doffing the prosthesis, establishing a prosthetic
wearing schedule, management and prevention of skin break­
down, positioning with the prosthesis, and care of equipment.
Prosthetic Prescription
The members of the interdisciplinary team involved in the
care and rehabilitation of persons with amputation include
the surgeon, a physiatrist, a prosthetist, a physical therapist, an
occupational therapist, a social worker, a rehabilitation nurse,
and a vocational rehabilitation counselor. Many hospitals
and rehabilitation centers have established prosthetic clinics
that bring together the appropriate professionals to address
the needs and problems of prosthetic users. Determining
prosthetic candidacy is the first major clinical decision to be
made. Although the research literature has identified predic­
tors of outcome of prosthetic use,11,14,15,27 the team considers
the individual's needs, motivation, and functional capacity
in deciding about prosthetic candidacy. Factors that are most
often considered in determining whether to fit an individual
with a prosthesis include:
1. Medical history: Disabling medical conditions may pro­
hibit successful prosthetic use. An earlier referenced
systematic review by Sansam11 suggests some studies
relate increased number of comorbidities with poorer
prosthetic outcome. Advanced cardiac or pulmonary
disease that significantly impairs functional status
before amputation has an impact on a person's pros­
thetic candidacy. A history of cerebrovascular accident
with hemiplegia of the side opposite the amputation
may limit functional prosthetic use, although some evi­
dence suggests that degree of motor impairment is more
predictive of outcome than the side of involvement.11
2. Premorbid and present level of function: An individ­
ual who required substantial assistance for functional
mobility before amputation may have limited prosthetic
training goals. Pre-amputation ambulation ability is
predictive of prosthetic walking ability.11,12 Additionally,
individuals who are independent with functional activ­
ities, activities of daily living, and ambulation with an
assistive device postamputation, will do well with a
prosthesis.
3. Body build: Morbid obesity may pose significant chal­
lenges to prosthetic fitting. Individuals should not,
however, be excluded from prosthetic fitting and train­
ing on the basis of their weight alone, as Kalbaugh and
associates demonstrated that prosthetic outcome in
overweight and obese individuals was comparable to
that of a cohort of typical weight.85 Interestingly, the
study demonstrated that prosthetic outcome in the
overweight and obese individuals was superior to indi­
viduals classified as underweight, although these find­
ings were confounded by the increased numbers of
comorbidities in the underweight group.
4. ROM: Significant hip and knee flexion contractures
are best addressed prior to prosthetic fitting if an indi­
vidual is to achieve efficiency and functional inde­
pendence with a prosthesis, as contractures have been
shown to have a negative impact on functional pros­
thetic outcome.11,20
5. Support at home: People who are likely to require assis­
tance must depend on family members, significant
others, or formal caregivers to help with one or more
prosthetic tasks. The potential to be a limited house­
hold ambulator with a prosthesis may be important
in reducing the burden of care for caregivers and may
allow a person to remain at home with a caregiver as
opposed to living in an institutional setting.
Because there is no definitive criteria for determining
who is and is not a strong prosthetic candidate, careful con­
sideration of the individuals' characteristics and situation are
imperative. Some authors believe that even individuals who
show limited/moderate potential for prosthetic success based
upon our existing “criteria” should be fitted with a prosthesis
and afforded the opportunity to try.86,87 Should an individual
be deemed a reasonable prosthetic candidate, these same con­
siderations and others, are used in determining the specific
prosthetic prescription for that individual.
The physical therapist must have a basic understanding of
prosthetic components and design to be able to contribute to
the prescription process. Because therapists spend a great deal
of time working with people in one-on-one circumstances,
they often have a better perspective about the individual's

710
Section III  Prostheses in Rehabilitation
goals or needs than do other members of the team. The thera­
pist may gain insight or information that is important in the
decision-making process. If the therapist is familiar with pros­
thetic components, the therapist may be forming an opinion
about the best prosthetic prescription for a person during the
early rehabilitation phase. Physical therapists stay current with
developments in prosthetic design and technology through
professional interactions with prosthetists and by being crit­
ical consumers of the professional literature. For example,
an understanding of the different characteristics of various
prosthetic feet will help the therapist to work with the pros­
thetist in identifying the type of foot that is most suitable and
economical to meet a specific patient's functional needs.
Therapists must also be familiar with the special needs of
certain clinical populations so that they can assist in the opti­
mal prosthetic prescription to meet any individual's needs.
People with diabetes who are at great risk for additional skin
breakdown and poor healing may benefit from a socket with a
soft insert or from a silicone sleeve that is designed to reduce
friction during prosthetic use. Frail or deconditioned individ­
uals may reach higher levels of function if lightweight com­
ponents are chosen and stability in prosthetic prescription is
emphasized. Active children need durable components, but
replacement costs must also be considered, as components
will likely need to be replaced frequently to accommodate
growth. Athletes with amputation desire durable, lightweight,
high-technology components for a competitive edge in their
sport performance.
Decisions to change socket design or suspension for long-
term prosthetic users must be carefully considered. A person
who has worn a particular type of prosthesis for a long period
of time may have difficulty acclimating to a new type of device.
If a person has no complaints about a prosthesis other than
“it's worn out,” it is advisable to use similar components for
a replacement prosthesis. If a person is expressing interest in
new goals or activities (e.g., a prosthetic user who has never
run would like to try jogging), prosthetic prescription changes
may be warranted. Hafner and Smith demonstrated that per­
sons with transfemoral amputations originally classified as
Medicare Functional Classification Levels (K Levels) 2 and 3
improved function and reduced the frequency of falls and
transitioned to a higher Medicare Functional Classification
Level when using an active microprocessor-controlled knee
prosthesis,88 and this advancement in Medicare Functional
Classification Level with microprocessor-controlled knee joint
has been identified as an incidental finding in another study as
well.89 This finding reminds therapists to suspend their biases
that higher tech equipment should be reserved for younger
individuals.
Medicare K levels are used to determine which prosthetic
components are appropriate based on the persons with ampu­
tation's level of function. Components that are designed for
higher activity levels would not be covered for payment under
the Medicare policy. The physician determines the patient's
functional ability level. If the patient's functional ability
increases over time, the rating can be changed to a higher level.
Functional level 0: Patient does not have the ability or
potential to ambulate or transfer safely with or without
assistance and a prosthesis does not enhance his or her
quality of life or mobility.
Functional level 1: Patient has the ability or potential to
use a prosthesis for transfers or ambulation on level
surfaces at fixed cadence—household ambulator.
Functional level 2: The patient has the ability or poten­
tial for ambulation with the ability to traverse low-level
environmental barriers such as curbs, stairs, or uneven
surfaces—limited community ambulator.
Functional level 3: The patient has the ability or potential
for ambulation with variable cadence—advanced com­
munity ambulator who has the ability to traverse most
environmental barriers and may have vocational, ther­
apeutic, or exercise activity that demands prosthetic
­utilization beyond simple locomotion.
Functional level 4: The patient has the ability or poten­
tial for prosthetic ambulation that exceeds basic ambu­
lation skills, exhibiting high-impact, stress, or energy
levels—active children, young adults, and older adults
engaged in recreational activities and sports.
The Preparatory Prosthesis
The initial socket is most often fabricated from high-­
temperature thermoplastic, but can be made of plaster of
Paris, fiberglass, laminate, or other materials. The socket
is connected to the prosthetic foot using an alignment sys­
tem at either end of a metal or plastic pylon (pipe), and
in the case of the transfemoral prosthetic, a knee joint.
Endoskeletal modular prostheses are preferred to exoskele­
tal prostheses because alignment modification is likely early
in the rehabilitation process. Some people are fitted with a
permanent pylon and prosthetic foot at this early stage and
progress through a series of sockets until their residual limb
reaches its mature contours. Most often, a foam and stock­
ing cosmetic prosthetic cover is not provided until the final
socket fitting. Because of significant changes in residual
limb size and shape, individuals may progress through two
or three sockets before being fitted for the definitive socket
or prosthesis.
Donning and Doffing the Prosthesis
Donning the prosthesis (Figure  26-1) should be taught
through a series of steps including dressing the prosthesis;
donning socks; donning a silicone liner, pull sock, or Dry-
Lite lubricant; prepositioning the prosthesis while sitting;
and then standing to weight bear through the prosthesis and
adjust the suspension system. The steps for a given individual
are dictated to a large extent by the prosthetic components.
For instance, a roll-on liner with a pin-lock suspension sys­
tem requires the individual to attend to the orientation of
the distal pin when rolling the liner onto the residual limb,
to adjust alignment and initiate the pin into the ring lock
in a seated position, and stand for the final engagement of
the suspension mechanism. A transfemoral prosthesis with
a classic suction socket may require the individual to use a
donning sleeve or pull sock to help ease the residual limb into
the socket though a coordinated series of weighting and pull­
ing maneuvers on the sleeve, which is threaded through the

Chapter 26  Early Rehabilitation in Lower-Extremity Dysvascular Amputation
711
A
B
C
D
FIGURE 26-1  This patient with a recent transtibial amputation demonstrates the correct sequence for
donning his prosthesis. A, First, he applies a nylon sheath, adjusting its fit to prevent formation of wrinkles
or folds as additional layers of sock are added. Wrinkles result in uneven distribution of pressure and can
increase the likelihood of residual limb discomfort and skin breakdown. B, Once the sheath is positioned,
prosthetic socks are added, one at a time, and carefully adjusted for smooth fit until the desired number of
ply is reached. The least possible number of socks is used to create a snug, comfortable prosthetic fit. C, This
patient's prosthetic design includes a soft Pelite insert. The anterior trim line of the liner is cup shaped to
accommodate the patella and is used to guide the position of the liner on the limb during donning. Patients
are cautioned against using a twisting motion when applying the insert/liner, to avoid causing wrinkles in
the underlying sheath or socks. D, The final step is to insert the residual limb with properly positioned
socks and liner into the prosthesis. This patient dons the prosthesis in a sitting position, gradually increasing
weight bearing to achieve the desired total contact fit. Note that a patellar tendon-bearing orthosis is used to
support and protect his remaining limb, which is vulnerable as a result of Charcot arthropathy.

712
Section III  Prostheses in Rehabilitation
valve hole in the socket. Performed while standing, this don­
ning procedure requires good balance and dexterity. Once the
residual limb is deep into the socket and the air is expelled,
the socket valve must be screwed into place. The chapters on
prosthetic components elucidate further the donning require­
ments for specific types of prostheses.
One universal theme in donning of the prosthesis is to
educate individuals to pay close attention to the orienta­
tion of socket in the horizontal plane. The contours of the
socket are intimately designed to accommodate the patient's
anatomical structures of the residual limb. In a person with
a sensate residual limb, this may be constructive in assuring
proper prosthetic alignment, as the socket will not “feel right”
unless it is oriented appropriately; however, in the insensate
limb, the patient must compensate with vision and palpation
to assure proper alignment. Often, individuals use the pros­
thetic foot as a reference for horizontal plane alignment; static
prosthetic alignment often places the foot in slight out-toeing
in standing and the individual can use this visual cue as an
affirmation of proper prosthetic alignment.
Teaching appropriate donning and fit of the transfemo­
ral socket often requires the therapist to palpate the ischial
tuberosity and potentially other structures (e.g., pubic rami,
adductor tendons) for optimal positioning within the socket.
This requires clear and professional patient and family edu­
cation to clarify the purpose and process of a palpation that
might be considered a serious invasion of personal space.
Prosthetic Sock Use
In early prosthetic rehabilitation, prosthetic socks are used to
modify the fit between the socket and the shrinking residual
limb. Proper use of prosthetic socks enhances residual limb
weight bearing in pressure-tolerant areas, decreases the like­
lihood of skin breakdown in pressure-intolerant areas, and
increases patient comfort during ambulation. Wool or cot­
ton prosthetic socks are available in three different ply (thick­
nesses): 1 (thinnest), 3, and 5 (thickest). Many individuals
with amputation who use a rigid or flexible socket will first
apply a thin nylon sheath directly over the skin (under the
socks) to minimize friction forces and wick moisture away
from the skin. Cotton or wool socks of various ply (thickness)
are then applied before the limb is placed in the socket. If a
nylon sheath is not used, socks are applied smoothly directly
onto the residual limb. When silicone suction suspension or a
friction reducing liner that require skin contact is used, socks
are applied after the sleeve or liner has been donned. For lin­
ers with a pin-lock mechanism, a small hole in the bottom of
the socks will accommodate for engagement of the pin into its
receptacle. Socks of various thicknesses are combined to cre­
ate a snug and comfortable fit. Individuals are encouraged to
don the fewest number of socks to achieve the same amount
of thickness (e.g., one 3-ply sock is preferable to three 1-ply
socks). Prosthetic socks can also be used creatively to solve
problems with socket fit. If, for example, the person's distal
residual limb girth has decreased more quickly than proximal
girth, creating a pendulum effect within the socket during
ambulation, one of the prosthetic socks can be cut to cover
just the lower half of the residual limb. When layered between
two full-sized socks, the shorter sock helps to fill the extra
space within the socket, ensuring total contact between the
limb and socket.
Fluctuations in limb volume associated with edema in
the first weeks and months after amputation often mean that
the appropriate number of sock ply varies from day to day
and perhaps within a given day. Because of this variability in
limb size, choosing the correct number of prosthetic socks
may be challenging for those new to prosthetic use. Limb size
can change rapidly. Even a few minutes in a dependent posi­
tion without a shrinker or Ace wrap in place can substantially
increase residual limb size. For this reason, individuals must
wear their compression device until the moment that they are
ready to don the prosthesis. Therapists and prosthetists work
with new prosthetic users to assist in the development of
problem-solving skills and strategies to determine the appro­
priate number of socks to don.
Good prosthetic socket fit and satisfaction with the prosthe­
sis is extremely important to individuals with amputations.90,91
New prosthetic users must be educated on the principles of
prosthetic fit and weight bearing. The optimal prosthetic fit is
quite snug, like that of a custom-fit glove on the hand. Total
contact between the residual limb and socket is very important
and significant skin problems can occur when total contact
is not achieved. Individuals must understand where weight-­
bearing pressures are best tolerated on the limb and where pres­
sure sensitivity is likely to occur. Although they might initially
expect to bear weight through the distal end of the limb, they
must understand that sockets are designed to be total contact
and to distribute weight-bearing forces across several areas. For
the transtibial socket, these areas include the patellar tendon,
anteromedial and anterolateral surfaces of the residual limb,
medial tibial flare, and distal posterior aspect of the residual
limb. For the ischial-ramal containment transfemoral socket,
they include the posterior aspect of the residual limb with the
pubic ramus (medially), ischial tuberosity (posteriorly), and
greater trochanter (laterally) contained in the prosthetic socket.
The ischial-ramal containment socket also distributes pressure
through the lateral femur to increase the efficiency of the hip
abductors in weight bearing. The quadrilateral socket utilizes
pressure anteriorly on the Scarpa triangle, forcing the ischial
tuberosity to rest on a posterior shelf of the socket.
A number of indicators are used to assess the adequacy
of sock ply during prosthetic ambulation. If too few socks
are used, the residual limb descends too far down within
the socket. The individual may complain of pistoning dur­
ing ambulation—that is, the prosthesis slips downward when
unweighted during the swing phase and is pushed upward on
the residual limb during weight bearing in stance. If piston­
ing is suspected, a pen or marker is used to mark the pros­
thetic sock at the anterior or posterior trim line of the socket.
If the line becomes more visible when the individual lifts the
limb (using a hip-hiking motion), it is likely that slippage is
occurring, and additional sock layers are indicated. When the
transtibial prosthesis and socks are taken off for inspection of
the skin, reactive hyperemia (redness) is seen at the proximal

Chapter 26  Early Rehabilitation in Lower-Extremity Dysvascular Amputation
713
patellar tendon and at the inferior border of the patella, as
well as at the distal anterior residual limb. Redness may also
be present on the fibular head, which contacted the socket
below its intended relief area. These are all signs that thick­
ness of the socks is inadequate and additional sock layers
should be added. Too few ply socks in a transfemoral socket
may result in increased weight bearing and hyperemia on the
distal residual limb and complaints of pressure in the groin as
the socket rides up higher than intended.
A different set of signs indicates that too many ply of sock
have been donned. The person may feel that the prosthetic
limb is difficult to don, fits too tightly, and is just slightly lon­
ger during forward progression at midstance and during foot
clearance in swing. In the transtibial prosthetic user, when the
skin is inspected after ambulation, reactive hyperemia is seen
at the distal patellar tendon and the tibial tubercle. Redness
may also be present at the head of the fibula, which contacted
the socket above its intended relief within the socket. In the
ischial containment transfemoral socket, too many socks will
prohibit the residual limb from gaining good purchase within
the socket and the patient will not feel “locked-in” to the
socket; in the quadrilateral socket the ischial tuberosity will
be elevated off of the posterior shelf. These are indications
that one or more ply of socks should be removed to enhance
socket fit. Although pistoning is usually an indication of too-
few-ply socks, paradoxically, it might also be seen in a patient
wearing too many ply, because the residual limb is never fully
into the socket and therefore never gains good purchase and
moves up and down with ambulation.
Most individuals become adept at judging the adequacy
of sock ply when given the opportunity to practice and prob­
lem solve early in their rehabilitation. For the functional pros­
thetic user, donning and doffing the prosthesis becomes as
second nature as donning and doffing one's pants or shoes.
The initial instruction period in this skill, however, requires
attention to detail. Individuals should be encouraged to estab­
lish a careful routine of donning the appropriate number of
prosthetic socks, one layer at a time. The socks should be
smoothed free of wrinkles, with any seams facing down and
out so as to minimize pressure on the surgical scar.
Checking Adequacy of Suspension
Once the individual is comfortably in the socket, adjust­
ment of the suspension device is necessary. Suspension
options for transtibial prostheses include suspension sleeves,
supra­condylar straps with or without waist belt and auxil­
iary fork strap, supracondylar socket design, supracondylar/­
suprapatellar socket design, thigh corset with joint uprights,
and suction liner with ridges or with pin in ring suspension.
To complete the donning process, the person stands and
weight bears through the socket to ensure proper positioning
of the residual limb while adjusting the suspension system.
Roll-on silicone sleeves with pin-locking or shuttle-lock
mechanisms are becoming one of the most commonly pre­
scribed suspension systems. When rolling on the suspen­
sion sleeve, care must be taken that the pin is centered on the
inferior surface of the distal residual limb. The ­appropriate
­number of socks is applied over the silicon sleeve by slid­
ing the pin through the hole in each sock. The hard socket
is donned as the individual aligns the pin with the socket
receptacle and pushes into the socket; the pin should click
into place. Once the residual limb is seated in the hard socket,
the individual stands and weight bears through the prosthe­
sis; the pin should further depress into the ring mechanism,
confirmed with three to five audible clicks. If more clicks are
audible upon initial weight bearing than anticipated, this is an
indication that more ply of sock may be required.
Prevention and Management of Residual
Limb Skin Problems
Because prolonged wound healing and development of new
skin irritation can delay prosthetic training, the prevention
and management of skin breakdown on the residual limb
represent important goals. The prevalence of skin problems
on the residual limb in prosthetic users has been reported to
be between 36% and 64%.92–94 Especially vulnerable to skin
issues are very active prosthetic users92 and individuals with
impaired hand function.95 Residual limb skin issues have
been demonstrated to have an impact on functioning in daily
life for the prosthetic user.96
In the new prosthetic user, skin issues can preclude
weight-bearing and gait-training activities. Pressure, fric­
tion, or shearing forces are the primary etiologies of skin
breakdown related to prosthetic wear. If, during weight
bearing, external pressure exceeds capillary refill pressure
(25 to 32 mm Hg) for an extended period of time, the deliv­
ery of oxygen and nutrients and the removal of waste prod­
ucts from active tissues are interrupted. If relief of pressure is
provided, this local ischemia is followed by a reactive vaso­
dilation or hyperemia. This is the mechanism that produces
the redness over weight-bearing areas, such as the patellar
tendon and medial tibial flare and shaft, that is observed in
new transtibial prosthetic users. A blanchable area of redness
over weight-bearing areas, which returns to normal skin col­
oration within 10 minutes, is to be expected in early pros­
thetic training and indicates normal reactive hyperemia.97
If redness persists or does not blanch on firm palpation,
­tissue damage has likely occurred, and the risk of skin break­
down increases significantly.
It is important that therapists and individuals with ampu­
tation recognize the different implications of redness over
pressure-tolerant versus pressure-sensitive areas of the resid­
ual limb. If a pressure-tolerant area shows evidence of exces­
sive pressure, socket fit and alignment may be appropriate,
but the amount of weight bearing or duration of wearing
time may need to be decreased. If pressure-sensitive areas
are showing signs of too much pressure, it is more likely that
socket fit or alignment needs to be adjusted. When exces­
sive redness is observed, successful problem solving dictates
changing a single variable at a time and assessing the impact
of this one change on the prosthetic problem. If multiple
changes are made at the same time (e.g., wearing time, align­
ment, and socket fit are all altered), it is not clear which change
actually solved the problem, if indeed the problem is solved.

714
Section III  Prostheses in Rehabilitation
If the problem is not solved, there is no way of knowing if the
interventions may have been more successful independent of
one another.
An individual's risk for skin breakdown on the residual
limb is determined by physiologic and mechanical factors.
The vascular, sensory, and musculoskeletal conditions of
the residual limb are the physiologic determinants, whereas
socket fit, socket alignment, amount of weight bearing,
and duration of weight bearing are the mechanical deter­
minants. Each of these risk factors may have clinical impli­
cations. A  conservative prosthetic wearing schedule and
frequent residual limb inspection may be indicated for those
with skin breakdown caused by any of the physiological risk
factors. If poor scar and soft tissue mobility of the resid­
ual limb leads to tissue breakdown, deep friction massage
over the involved area (after healing) and/or application of
a nylon sheath under prosthetic socks may be appropriate
interventions.
Improper socket fit or alignment can result in increased
weight bearing to pressure-sensitive areas of the residual
limb and may result in skin breakdown. If poor fit or align­
ment is suspected, the first step in problem solving is a thor­
ough reevaluation of donning technique and the number of
socks used. Prosthetic fit is then reassessed to determine if
total contact between the residual limb and socket has been
achieved. If all of these areas are sufficient, potential prob­
lems with prosthetic alignment are investigated. It is impor­
tant to note that increasing duration of prosthetic wearing too
quickly in a well-aligned and appropriately fitting prosthesis
can also result in skin breakdown to pressure-tolerant areas
of the residual limb. An individual who has been ambulat­
ing with partial weight bearing using axillary crutches with­
out any problems with skin integrity may, when progressed to
full-time unilateral crutch use, present with skin breakdown
over a pressure-tolerant area as a result of increased weight
bearing.
The presence of skin breakdown is not a direct contraindi­
cation to further use of the prosthetic device. The first prior­
ity should be to identify the cause of breakdown and eliminate
it by making the appropriate changes. Close observation and
ongoing assessment and treatment of any lesions using appro­
priate nonadherent dressings inside the socket should allow
prosthetic training to continue. Certainly, if a lesion becomes
progressively worse despite clinical management during
prosthetic training, a hiatus from prosthetic use may be indi­
cated. In the example presented previously, a return to bilat­
eral crutch use and diminished prosthetic wearing time may
be indicated until the lesion is healed. After healing, ambula­
tion time might be divided between bilateral and unilateral
crutch use, to build tolerance for increased weight bearing
before full-time unilateral crutch use is attempted once more.
If the area does not show signs of healing or becomes worse
with increasing lesion size or signs of inflammation or infec­
tion, prosthetic use may need to be discontinued altogether
for healing to occur.
As a person begins to ambulate over different terrains, the
magnitude and direction of weight-bearing pressures within
the socket may change as well, presenting additional mechan­
ical risk factors for skin breakdown. Descending stairs using
a step-to-step pattern protects the residual limb by leading
with the prosthetic leg; when advancing to a step-over-step
technique, the residual limb experiences a different pattern
of pressure distribution. Depth of stairs also has an impact
on pressure distribution within the socket: As step height
increases, so does the total excursion through ROM neces­
sary to descend the stairs. Ambulation on uneven terrain,
such as grass or gravel, produces different pressures within
the prosthetic socket than walking on a predictable, level sur­
face. When evaluating potential causes of skin breakdown, it
is important to consider the characteristics of the environ­
ments and the task demands of the activities in which the
individual has been engaging. Changing task technique by
adapting the movement strategy or the environment, or add­
ing an assistive device can provide just enough protection for
the residual limb to prevent skin irritation and breakdown.
If localized increased pressure is determined to be the
cause of tissue breakdown, pressure relief is the goal, and
socket modification by the prosthetist may be necessary.
Certain methods of pressure relief are inappropriate and
should be avoided. The use of “donut” padding around an
area of breakdown or potential breakdown is counterproduc­
tive for three reasons. A donut pad (a) increases pressure to
the area surrounding the lesion when the limb is placed in
the socket, (b) increases the ischemic effect of weight bearing,
and (c) potentially leads to edema or extrusion of the vul­
nerable tissue through the “hole” of the donut. Any adhesive
materials that are in contact with skin should be used with
extreme caution. A nylon sheath can be used to hold a dress­
ing in place under the prosthetic socks. Finally, the abrasive
quality of certain dressings, including standard gauze, must
be avoided inside the socket. Nonadherent dressings or non­
stick pads tend to be less textured and less abrasive to an area
of skin breakdown. Many new products are available that are
thin and self-adherent, but not noxious to the skin, effectively
providing another “tissue” layer to an area that is threatening
breakdown or in the process of healing.
Dressings should be used sparingly inside a prosthetic
socket, as the socket fit is designed to be snug, and any
padded dressing increases pressure over the affected area,
which is counterproductive to the goal of wound healing.
The therapist must reevaluate the prosthetic fit if a dressing
is used within the socket, recognizing that the application
of even a thin dressing may require the removal of one ply
layer of socks.
Prosthetic Wearing Schedule
After the evaluation of socket fit and alignment has been
completed and any adjustments have been made, it is time to
begin prosthetic training. Constant reassessment of socket fit
and alignment is necessary during the entire training phase
because of changes in residual limb shape and size. The dura­
tion of time for initial prosthetic wearing is usually conserva­
tive, especially for individuals with a history of skin integrity
problems. Often, the first prosthetic weight-bearing activities

Chapter 26  Early Rehabilitation in Lower-Extremity Dysvascular Amputation
715
are closely supervised, lasting no longer than 5 to 10 minutes
in between skin inspections. Once individuals are tolerating
30 to 60 minutes in the prosthesis without problems, total
time in the prosthesis is gradually increased, often in incre­
ments of 15 to 30 minutes, as skin condition permits. People
with no history of skin integrity problems (e.g., after trau­
matic amputation or revision of congenital limb anomaly)
often progress quickly with wearing activities, whereas those
with sensory impairment or peripheral vascular disease may
need to be progressed much more cautiously.
Inspection of the residual limb after the first few minutes
of weight bearing should reveal redness of the skin in pre­
dictable pressure-bearing regions. Because both the trans­
tibial and transfemoral sockets are intended to have total
contact with the residual limb, the entire limb may develop
a mild reactive hyperemia that is apparent when the socket
is first removed. Increasing wearing time requires contin­
ued, frequent skin inspection. It is vital that the individ­
ual understand the importance of gradual progression of
wearing time. If a person is allowed to initiate prosthetic
wearing unsupervised or does not take the wearing sched­
ule seriously, the potential for skin breakdown is greatly
increased.
It is optimal, but not always possible, for the prosthetist
and physical therapist to both be present for the delivery of
the prosthesis to the patient with amputation, so that both
may be involved in the final fitting and alignment check­
out. After delivery of the prosthesis, the physical therapist
and person with amputation may determine that it is safest
to use the prosthesis only when supervised by the therapist
during the first week or more of therapy. Once the patient
is cleared to use the prosthesis at home, an individualized
written wearing schedule (Figure  26-2) is used to guide
prosthetic wear and prevent misunderstandings about the
time permitted for prosthetic use.
Positioning
People will often need instruction about positioning of the
lower extremity in the prosthesis when seated. The trim
lines of the transtibial socket are designed for optimal pres­
sure distribution during upright weight-bearing activities.
The high posterior wall of the socket is necessary to pro­
vide counterpressure to the anterior weight-bearing surface
in stance, but can provide undue pressure to the hamstring
tendons in sitting. The patellar tendon indentation in the
prosthesis is designed to take weight in standing but can
provide pressure to the anterior aspect of the tibial tuber­
osity if the prosthesis slips down when the patient is seated.
Similarly, the transfemoral socket can shift or lose suction
in sitting which can result in undue pressure if maintained
over an extended period. It is optimal that when seated, the
individual's prosthetic foot should rest flat on the floor or
foot plate of the wheelchair so that the residual limb remains
in total contact with the socket. This helps avoid the risk
of undue pressure and decreases the chance of gapping
between the prosthesis and the residual limb that may allow
edema to collect. This becomes especially difficult when sit­
ting on low surfaces and for individuals with transfemoral
prosthesis since the socket is often moved because of the
posterior pressure in sitting.
Additionally, although some individuals may be anxious
to carry out exercise programs with the prosthesis in place,
they must understand that using the prosthesis for activities
other than walking (e.g., weighted long-arc quad exercise)
changes the magnitude and direction of forces on the residual
limb and may increase the possibility of skin breakdown.
PROSTHESIS WEARING SCHEDULE
Patient Name:
Your wearing schedule for your prosthesis is on and off.
Check your skin every time you take your prosthesis off. You are looking for areas of redness that
do not go away within 10 minutes, areas of blistering or abrasions, or pain in your residual limb.
If you have any of these problems, or any questions, call your therapist at the number below and
do not wear your prosthesis again until the problem is addressed with your therapist.
If you do not have any of the problems above, in two (2) days you can increase the "on time"
to and maintain the off time as above.
Next scheduled appointment:
Therapist name & phone number:
FIGURE 26-2  Example of a wearing schedule used to guide the patient's use of the new prosthesis at
home, early in rehabilitation.

716
Section III  Prostheses in Rehabilitation
Care of Prosthetic Equipment
People with amputations also require explicit instructions
about the proper care and maintenance of their prosthetic
equipment. The prosthetic socket and liner should be wiped
daily with a damp cloth. Prosthetic socks should be washed
daily and laid flat to dry (wool socks shrink when dried in an
electric clothes dryer). When not being worn, most prosthetic
devices (with the exception of those with hydraulic mecha­
nisms) should be stored in a flat position to minimize the risk
of damage should they fall over (hard sockets are particularly
vulnerable to traumatic cracks).
PROSTHETIC FIT AND ALIGNMENT
As new prosthetic users become comfortable and confident
with their prosthetic limb, changes in socket fit and align­
ment may be necessary to achieve the most energy-efficient
and cosmetic gait. Ideally, the prosthetist, the person with
amputation, and therapist work as an interdisciplinary team
to solve problems with socket fit and alignment as they arise.
The physical therapist ought to have a thorough foundational
knowledge of optimal socket fit and alignment in order to rec­
ognize and troubleshoot problems and be ready to refer the
patient to the prosthetist should alignment need adjustment.
The Prosthetic Socket
An intimate fit between the residual limb and the socket is
necessary for successful prosthetic training. The total contact
socket is designed to distribute the load of weight bearing over
the residual limb to assist in venous blood return from the
limb, provide some sensory feedback to the prosthetic user
through the residual limb, and provide an efficient ­transfer of
muscle function to the prosthetic device. Although the socket
is prepared over a positive model of the patient's limb, either
through casting or computerized technology, as a result of
early changes in the residual limb it is not uncommon for the
socket to be modified in the early days of prosthetic training.
Frequent and careful inspection of the residual limb and ver­
bal feedback from the user both help to assess socket fit and
patient tolerance to prosthetic wear.
Alignment
Prosthetic alignment is evaluated in quiet standing (stati­
cally) and during gait activities (dynamically). Static align­
ment refers to assessment of the relationships between the
socket, prosthetic knee joint (if applicable), pylon, prosthetic
foot, and floor; the length of the prosthesis; and the overall
fit of the socket on the residual limb. Dynamic alignment
includes those concepts as well as prosthetic considerations
as they relate to suspension, symmetry of gait, and energy
requirements of gait.98 Because static alignment assessment is
the first standing activity in which a patient engages, it is pru­
dent to carry this out in the parallel bars or with substantial
support if parallel bars are not readily available. Information
gleaned from alignment assessment can reveal clues about
pressure distribution on the tissues of the residual limb inside
the socket. Problems with alignment affect not only pressures
within the socket but also the biomechanics of gait and the
translation of forces from the prosthetic foot up the kinematic
chain. Both static and dynamic alignment must be evaluated
from an anterior, posterior, and lateral (prosthetic side) view.
For a thorough review of prosthetic alignment, see compo­
nentry chapters; Table 26-5 provides a basic rationale for stan­
dard transtibial and transfemoral static prosthetic alignment.
PROSTHETIC GAIT TRAINING
The ability to move within and over one's base of support with
efficient timing and sequencing of muscle activity and appro­
priate postural control is the key determinant of functional
TABLE 26-5  Static Prosthetic Alignment and Rationale
Alignment
Rationale for Alignment
POSTERIOR VIEW
Prosthetic height (symmetrical leg
length)
• Prevents gait deviations associated with leg length discrepancy
• Provides optimal weight bearing through the socket to prevent pain or skin issues
• Prevents sound limb orthopedic deformity associated with leg-length discrepancy
Plumb line: midsocket to slightly
lateral to midheel
• In the transtibial prosthesis, creates slight varus moment during stance, as in normal gait
• In the transtibial socket, directs compressive forces to pressure-tolerant areas at medial proximal
(medial tibial flare, medial femoral condyle) and lateral distal (fibular shaft) residual limb and
minimizes compressive forces on nontolerant areas at lateral proximal (fibular head) and medial
distal residual limb
• In the transfemoral socket, directs forces onto the residual lateral femoral shaft
Slight adduction of transfemoral
socket
• Adduction of the transfemoral socket serves to improve length tension relationship and efficiency
of the hip abductors in maintaining a level pelvis during unilateral stance
LATERAL VIEW
Transtibial socket in 5 to 10 degrees
of flexion (anterior tilt of socket,
encouraging slight knee flexion)
when in a midstance position
• Distributes weight bearing forces to anterior, pressure tolerant aspect of transtibial residual limb
• Limits vertical displacement of center of gravity at midstance to decrease energy cost of gait
• Allows for controlled knee flexion in loading response and late stance, as in normal gait
• Prevents abnormal hyperextension of the knee in midstance

Chapter 26  Early Rehabilitation in Lower-Extremity Dysvascular Amputation
717
ambulation across the wide variety of environments that are
encountered in daily life. Many prosthetic users have the poten­
tial to ambulate with a near-normal symmetrical gait pattern
that is free of significant gait deviations and independent of
assistive devices.23 To do this, however, the person must meet
a variety of challenges, including (a) building tolerance to pros­
thetic wear and weight bearing through the residual limb; (b)
controlling dynamic weight shifting through the prosthesis in
all planes of movement; and (c) reintegrating postural control
and balance with respect to the lack of ankle, and in the case of
transfemoral amputation, knee joint sensory and propriocep­
tive input, muscle control, and ROM.
An individual's fears and concerns influence determina­
tion and motivation. Fear and concern are powerful determi­
nants of the ability to ambulate and perform other important
functional activities.38,40 An individual with an amputation
who is otherwise functionally capable of safe ambulation in
the community may choose not to venture outside of their
home because they lack confidence in their physical ability
or are fearful of being identified as disabled or different. In
contrast, a person whose clinical picture is less promising for
functional prosthetic use but who is determined to return to
a busy and productive life “on two feet” may very well do so.
Initial Training
For the new prosthetic user, initiation of gait training typi­
cally starts with ambulation on level surfaces with few envi­
ronmental demands. Gait training often begins in the parallel
bars, as a protected environment, because it provides a stable
and secure setting with minimal environmental challenges.
Countertop or table support, raised mats, plinths or chairs,
even assistive devices can all be appropriate alternatives if
parallel bars are unavailable. When training does begin in
the parallel bars, individuals are encouraged to use a relaxed
and open handed grip on the bars, as the tendency to pull
and rely heavily on the secure bars is a difficult habit to “un-
train” when transitioning out of the bars. When an individual
receives the prosthesis and is excited to take the first steps, it is
useful to limit cues and simply allow the individual to walk in
the parallel bars. It is valuable to educate the person regarding
what to expect with their first attempts at ambulation with a
prosthesis: The socket may feel tight, almost as if it is squeez­
ing the residual limb because of the nature of the total contact
of the socket, and weight bearing through the prosthesis may
feel strange initially.
Ambulation in the parallel bars helps the therapist to iden­
tify gait deviations early in training before maladaptive habits
become problematic. Based on this preliminary gait assess­
ment, individual problem areas can be addressed with exer­
cise 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. A typical progression of early
prosthetic training activities might include:
1. Static weight bearing with decreasing dependency
on upper extremity (UE) support (e.g., progressing
from bilateral open-handed UE support, to contra­
lateral open-handed UE support, to ipsilateral open-
handed UE support, to static standing activities without
support).
2. 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 pro­
gressed by decreasing UE support and varying foot
positions (parallel stance, step-stance, tandem stance).
It may be 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. Another
important cue 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 stand­
ing in persons with transfemoral amputations than
TABLE 26-5  Static Prosthetic Alignment and Rationale—cont'd
Alignment
Rationale for Alignment
Transfemoral socket in 5 degrees
of flexion (posterior tilt of socket,
encouraging hip flexion) with
the knee in full extension at the
midstance position
• Serves to improve length tension relationship and efficiency of the hip extensors during stance
phase of gait
• Distributes weight bearing forces to posterior, pressure tolerant aspect of transfemoral residual
limb
Plumb line: midsocket to anterior
edge of heel
• In transtibial alignment, allows for knee flexion from mid to terminal stance
• In transtibial alignment, prevents hyperextension of the knee in stance
Assessment of trochanter-knee-
ankle line
• In transfemoral alignment, provides assessment of the location of the center of rotation of the knee
joint in the transfemoral prosthesis relative to hip and ankle, which dictates the stability of prosthetic
knee extension during stance and the ease of prosthetic knee flexion in preparation for swing

718
Section III  Prostheses in Rehabilitation
in individuals without amputations99; (b) the pelvis is
key to stability in the upright position, so the patient is
cued in to this important locus of control; (c) by focus­
ing on the pelvis, the patient is being directed to con­
trol 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. In controlling the pel­
vis during weight-shifting activities, the patient might
envision the pelvis as a table top and a very tall vase
centrally located on the table, so if the pelvis tips in
any direction, the vase will fall and break; or they may
imagine a ball on that table and regardless of the direc­
tion of the weight shift, they must not let the ball roll
off of the table. These cues are intended to encourage
anterior, posterior, and lateral translational movements
of the pelvis, but without substantial anterior, posterior,
or lateral tilting of the pelvis.
3. 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 direc­
tions, 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.
4. Repeated stepping activities (e.g., breaking down gait
cycle into its component parts) in all directions with
decreasing UE support. The focus here may be in load­
ing and offloading the prosthetic limb with good proxi­
mal/pelvic control.
5. Stepping with the 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) forc­
ing increased weight bearing through the prosthetic
limb with progressively decreasing UE support.
6. Gait training to minimize gait deviations inside, or
progressing out of the parallel bars. Early in training,
individuals often benefit from cues to make firm con­
tact 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.
7. Sit-to-stand and stand-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 pros­
thesis; whereas a transfemoral prosthesis is much more
difficult to weight 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. Figure 26-3
depicts some of these early prosthetic training activities.
Although use of specific weight-bearing activities outside
of functional tasks may be contrary to fundamental motor
learning principles of encouraging action-directed perfor­
mance versus motor performance, activities that encourage
weight bearing can be successfully practiced and then inte­
grated into functional gait and mobility skills. Repetitive
loading of the prosthesis is an appropriate task, even with­
out translation of weight over the foot as in the intact gait
cycle. Once the individual becomes accustomed to accepting
the weight (as in initial contact through loading response of
the stance phase of gait), the individual may then progress to
practicing more full-weight-bearing activities in preparation
for the single-limb support phase of gait and finally integrate
the activity into the full gait cycle. Regardless of the focus of
the intervention (weight bearing, balance, postural control,
or coordination and sequencing), the activity can and should
be integrated into the gait cycle or the functional task within
the same treatment session. Interventions are most effective
if they are ultimately done within the context of functional
tasks.35 A typical and detrimental mistake often made in reha­
bilitation is implementing a treatment plan that is beneath the
capabilities of the patient. Therapists are reminded that phys­
ically and functionally challenging the person training with a
prosthesis is vital to reaching the person's full potential.
Progressing prosthetic training requires increasing chal­
lenges to postural control and balance. Dynamic activities
without UE support and activities that require both anticipa­
tory and reactive balance strategies (e.g., playing catch) can
be used to prepare the prosthetic user for more open, unpre­
dictable environments.45 Again, challenging the individual
is important to their long-term balance success. New pros­
thetic users must be allowed to find their limits of stability
in the upright position. If the individual is not challenged to
really test the limits of the individual's stability, because they
are always permitted the use of UE support and/or the thera­
pist is guarding very closely and intervening with even the
slightest loss of balance, the person will likely not learn their
own zone of stability and may never have the opportunity to
develop their own confidence in their ability to monitor and
maintain their own balance. Figure 26-4 depicts some bal­
ance activities. Coordination and sequencing of an appro­
priate assistive device and activities to promote timing and
fluidity of gait (e.g., use of cues, for instance a metronome, to
facilitate symmetrical timing of steps) as well as to encourage
appropriate weight bearing (e.g., use of audio biofeedback for
weight bearing) are other areas that can be included in this
phase of prosthetic training. During all activities with the new
prosthetic user, the therapist must remain cognizant of the
need for frequent skin checks for signs of pressure intolerance
and skin irritation.
Some individuals will have difficulty accepting weight
through the prosthetic limb even during static standing
activities. They may rely heavily on weight bearing through

Chapter 26  Early Rehabilitation in Lower-Extremity Dysvascular Amputation
719
A
B
C
D
FIGURE 26-3  Weight-bearing, weight-shifting, and balance activities in early prosthetic training. A,
A new prosthetic user practices loading weight onto the prosthesis by repeatedly practicing single steps
(forward and backward) with the intact limb. Note full weight bearing through the prosthesis, dem­
onstrating good prosthetic alignment and erect trunk and head posture, with a gentle open-handed
grip on the parallel bars. B, Stepping up onto a phone book or low stool can increase weight bearing
through the prosthesis. C, Reaching activities, using all planes of movement, encourage weight shifting
onto and off of the prosthesis and can challenge balance and postural control. Early on, the opposite
hand grip on the parallel bar compensates for decreased balance and postural control. This activity
can be progressed by decreasing, and ultimately eliminating, upper extremity support. D, Reaching
­activities in a functional context should be integrated early in the rehabilitation process.

720
Section III  Prostheses in Rehabilitation
the upper extremities in the parallel bars, and express hesi­
tancy or simply be unable to put all of their weight through
the prosthesis. Ironically, individuals who have been espe­
cially active and functional during the preprosthetic phase,
ambulating with crutches or a walker may find weight bear­
ing through a prosthesis difficult. During the preprosthetic
phase, the sound limb often gravitates to a more central
location under the individual so that their center of gravity
is directly over their base of support. This puts the remain­
ing limb in an adducted position and the amputated limb in
an abducted position. These individuals must reorient their
lower-extremity positioning when training with a prosthesis.
Individuals with hip and/or knee strength deficits may
also struggle with weight bearing through the prosthesis and/
or decreasing reliance on upper extremities during standing
activities. A long history of vascular disease that has progres­
sively limited physical activity may likely impact strength of
the lower extremities, which can affect stance stability of the
prosthetic limb. Ambulation without an assistive device will
not be possible unless functional levels of strength are recov­
ered. Individuals who are hesitant to weight bear through the
prosthesis, whether because of weakness or fear or habitual
patterns, may be tempted to use the prosthesis as an “assis­
tive device” for ambulation rather than a true replacement
limb. Having the individual step onto a bathroom scale to
provide objective feedback regarding weight bearing through
the prosthesis may be useful with these individuals who are
having difficulty loading the limb. The use of mental imagery
of successful mastery of all weight-bearing and ambulation
activities may be an appropriate adjunct to PT.100 It is impor­
tant for both therapist and new prosthetic wearer to recognize
that improved prosthetic weight bearing allows for decreased
mechanical stresses on the sound limb,34 which often has
­vascular compromise.
Other intervention strategies that might be useful in
early gait training include verbal cueing to progress the pel­
vis toward the parallel bars (laterally) and anteriorly during
stance on the prosthetic side over a stable foot, and tactile
cueing of the therapist's hand placed on the anterolateral
aspect of the involved hip to facilitate anterior progression.
In persons with transfemoral amputations, early gait train­
ing presents some additional challenges since prosthetic knee
stability and mobility are directly related to prosthetic align­
ment and strength and motor control of the hip musculature.
Although this focus on pelvic control is presented in the con­
text of helping to control the prosthetic knee in persons with
transfemoral amputations, those with transtibial amputations
will also benefit from improved pelvic control as facilitated by
verbal and tactile cues during gait training.
The transfemoral prosthesis is aligned to provide stance
stability through the knee joint during weight bearing. In
unilateral stance on the prosthetic limb, the person must
A
B
FIGURE  26-4  Progression of weight-shifting and balance activities in prosthetic training. A,
Stepping activities become more challenging without the use of the upper extremities for balance or
support. B, Throwing and catching activities encompass balance (feed-forward and feedback), coor­
dination, postural control, and weight bearing through the prosthesis.

Chapter 26  Early Rehabilitation in Lower-Extremity Dysvascular Amputation
721
be able to stabilize and control their trunk and pelvis over
the prosthesis, which requires adequate strength in the hip
abductors (to counteract the gravitational adduction torque
at the hip) and hip extensors (to maintain the hip and trunk
in an upright and extended position). Forward progres­
sion while weight bearing on the prosthetic limb is a chal­
lenge that requires a focus on pelvic position and movement.
Active hip abduction and extension and forward pelvic pro­
gression are vital to stance stability. There is often a tendency
for the prosthetic stance limb to display posterior pelvic rota­
tion or to let the pelvis “drift” posteriorly during stance—the
swing-side pelvis should be rotating forward at this time, but
the stance-side pelvis should not be rotating posteriorly. This
posterior pelvic position makes smooth transition over the
prosthetic limb impossible as it disrupts the normal forward
progression.
The therapist can facilitate forward pelvic progression
during stance using principles of proprioceptive neuromus­
cular facilitation (PNF) with deliberate application of hand
position and input to muscles (e.g. resistance, quick stretch).
Pelvic movement can be successfully encouraged from in
front of or behind the patient (Figure 26-5). Swing phase
likewise requires training to facilitate the correct motion. An
effective swing will allow for correct step length and facili­
tates a smooth transition into stance phase. Symmetrical
step lengths are conducive to a smooth and energy effi­
cient gait pattern. There are two specific cues that may help
individuals with transfemoral prostheses to achieve a good
swing of the prosthetic limb. Initially the person needs to be
encouraged to step forward with a normal step on the unin­
volved side. Prosthetic users are often hesitant to do this—
when they have an asymmetrical gait pattern, it is often
because the prosthetic step is very large (because they are
comfortable taking weight through the sound limb) and the
sound limb step is very small (because they are not com­
fortable taking weight through the prosthesis). A full-size
sound limb step creates more hip extension and posterior
pelvic transverse rotation on the involved side. Because of
the design of many prostheses, anterior pelvic rotation in
the transverse plane at preswing will facilitate “knee break.”
This effectively shortens the limb to allow clearance during
swing phase. Persons with transfemoral amputations should
be cued to rotate the pelvis forward, which will swing the
prosthetic limb forward and extend the knee, allowing for
full knee extension at initial contact. Early gait training with
a transfemoral prosthesis might involve practice and per­
haps facilitation of this forward pelvic translation to help the
person get the feeling of the knee break and initial swing.
The same types of PNF techniques that are used to facilitate
stability of the pelvis during weight bearing can be used to
facilitate active movement of the pelvis for swing. Forceful
hip flexion in the absence of pelvic rotation to advance the
prosthesis forward prohibits normal step length. Likewise
vaulting, hip hiking, and circumduction are not efficient
methods of forwarding the prosthesis during swing phase.
These are common gait deviations that should be eliminated
as quickly as possible.
Assistive Devices
Assistive devices can provide help with balance only (i.e.,
­single-point cane or quad cane) or with weight bearing and
balance (i.e., standard walker, rolling walker, axillary crutches,
or Lofstrand crutches). The goals of assistive device use are to
provide only the amount of support that is necessary to pro­
tect the healing residual limb and to reduce the risk of falling
without hampering the individual's willingness or ability to
load the prosthesis. It may be prudent to spend time on pros­
thetic weight-bearing and weight-shifting activities in the
parallel bars or at a stable surface to allow the person to prog­
ress directly to an assistive device that aids in balance only.
FIGURE 26-5  Facilitation of forward pelvic motion for efficient pros­
thetic gait. A, The therapist can use manual techniques to cue pelvic
position from behind. B, The therapist can also use proprioceptive
neuromuscular facilitation manual contacts and appropriate resistance,
asking the patient to move the pelvis upward and forward as he or she
steps with either limb.
A
B

722
Section III  Prostheses in Rehabilitation
Optimally, the prosthetic limb can tolerate 100% weight bear­
ing, so that UE weight bearing through an assistive device is
unnecessary. Individuals who demonstrate good weight bear­
ing, strength, and balance may progress directly from the
parallel bars to the use of a single-point cane or no assistive
device. Quad canes should be prescribed with caution, as they
are frequently misused as weight-bearing devices and the
wide base can create a fall hazard. For those who are unable
to achieve early full weight bearing through the prosthesis
and require a weight-bearing assistive device, the devices of
choice are a rolling walker or axillary or Lofstrand crutches.
Crutches allow individuals to progress to a two-point gait
using a step-through gait pattern, which closely approximates
a normal sequence and pattern of gait. Individuals may begin
with bilateral support and progress to unilateral support with
crutches as prosthetic weight bearing improves.
Standard walkers impede progression of an efficient recip­
rocal gait pattern because they limit forward progression to
a “step-to” rather than “step-through” movement ­strategy.
This interrupts fluid movement, hampers smooth forward
progression of the center of gravity over the base of sup­
port, and precludes an effective terminal stance and pre­
swing. Standard walkers are used only when individuals are
long-term users and/or are resistant to transitioning to a new
device. A wheeled walker can minimize interruptions to the
gait cycle if it is advanced between each step or if the person is
weight bearing only slightly through the walker (i.e., pushing
the walker like a grocery cart).
Although persons with amputation who also have physical
or medical frailty may require assistive devices for household
ambulation, many individuals with transtibial amputation
reach functional independence without any assistive device,
or choose to use just a straight cane for “balance assist” when
walking on unpredictable surfaces or in crowded environ­
mental conditions. Depending on age, balance abilities and
strength, and fear of falling, persons with transfemoral ampu­
tation may walk with or without an assistive device.
Prosthetic Gait
An understanding of the biomechanics of normal gait is cru­
cial for physical therapists, as it provides the standard by
which prosthetic gait is measured. The main objective of
static and dynamic prosthetic alignment and PT intervention
is to optimize the energy efficiency, biomechanics, and cos­
mesis of gait. The ultimate goal is a gait that is safe, energy
efficient, and symmetrical. When deviations from the norm
are observed, the therapist and prosthetist seek to discover
and resolve the underlying cause(s) of the problem.
It is well documented that gait speed of persons with ampu­
tations is slower than in persons without amputation24,30,101,102
and that symmetry of gait is affected by amputation.24,83
Biomechanically speaking, there are several well-documented
changes in comparing prosthetic gait to gait of able-bodied
individuals. In persons with transtibial amputation, the lack
of plantar flexors is thought to be the most influential compo­
nent driving gait changes,31,103,104 and this is compensated for
by increased activity and power of the muscles around the hip
of the prosthetic limb, most notably the hip extensors. In per­
sons with transfemoral amputation, the strength, endurance
and power demands on musculature of the hip are higher
still, as the hip also must compensate for the missing knee.
There is conflicting information about whether specific
prosthetic devices have a significant impact on efficiency
and quality of prosthetic gait. Some studies support the ben­
efit of microprocessor-controlled knees105–107 and dynamic
response feet33,108 in enhancing gait mechanics and/or effi­
ciency, whereas others have had more equivocal findings.52,107
A full discussion comparing and contrasting different pros­
thetic componentry is beyond the scope of this chapter, but
the therapist should work closely with the prosthetist in iden­
tifying the best prosthetic prescription for patients based
upon their ambulation and functional goals.
Commonly observed prosthetic gait deviations have
many different potential contributors. Gait deviations may
be a product of intrinsic factors (pertaining to the individ­
ual using the prosthesis), or extrinsic factors (pertaining to
the prosthesis and/or environmental factors). The observed
deviation may be a primary gait problem, caused directly by
an intrinsic or extrinsic factor, or a compensatory strategy, a
result of the individual's attempt to avoid a primary devia­
tion. If a new prosthetic user is observed to ambulate with a
forward-leaning trunk throughout the stance phase of gait,
the therapist must determine if this is a primary or a com­
pensatory problem. It may be a primary gait deviation result­
ing from a hip flexion contracture that limits the individual's
ability to achieve upright posture. Or it may be a compensa­
tory strategy of the person who is fearful of knee instability
during prosthetic stance; by using a forward-leaning trunk,
the individual's line of gravity is dropped anterior to the knee
joint, improving stability at the knee by creating an extensor
moment at that joint.
During initial gait training, prosthetic alignment issues
may not be immediately evident. Hesitancy to fully load the
prosthesis and UE weight bearing through the parallel bars
or assistive device will affect the resulting gait pattern. As the
individual becomes more willing to bear weight through the
residual limb, a “truer” gait pattern will emerge and the func­
tion of the prosthesis becomes more critical. The therapist,
along with the prosthetist, must be attentive to the potential
emerging need to correct prosthetic alignment as the indi­
vidual improves in prosthetic weight bearing and as impair­
ments improve (i.e., changes in strength, ROM, or balance
might warrant prosthetic alignment changes).
When problem solving, the clinician must think about
why certain gait deviations might occur and whether they are
primary or compensatory. Answering these questions allows
the therapist to focus treatment on the most salient issues.
Table 26-6 describes some of the more common prosthetic
gait deviations and their most likely potential causes.
Consider an individual who shows knee instability during
loading response and throughout midstance, as evidenced by
lack of knee extension or excessive knee flexion. The thera­
pist must use deductive reasoning to identify what the true
sources of the problem might be. If the instability is occurring

Chapter 26  Early Rehabilitation in Lower-Extremity Dysvascular Amputation
723
TABLE 26-6  Prosthetic Gait Deviations
Gait Deviation
Phase of Gait
Category*
Possible Causes
GAIT DEVIATIONS COMMON TO TRANSTIBIAL AND TRANSFEMORAL PROSTHETIC USERS
Lateral trunk lean toward
prosthetic side
Loading response through
terminal stance
Intrinsic
Lacking hip abductor strength and/or timing on prosthetic side (compensate with
lateral lean to avoid Trendelenburg)
Abductor contracture on prosthetic side
Hip joint pain on prosthetic side
Very short transfemoral residual limb (poor purchase in socket, poor leverage)
Prosthetic (extrinsic)
Prosthesis too short
Foot too outset
Transfemoral socket medial wall trim line too high
Transfemoral socket places femur in abduction
Transfemoral socket lateral wall fails to provide adequate femoral support/stabilization
Environmental (extrinsic)
Uneven terrain
Anterior trunk lean
Loading response through
terminal stance
Intrinsic
Hip flexion contracture
Lacking knee extensor strength and/or timing in individual with transtibial
amputation (compensate with forward lean to provide knee stability)
Fear of instability of physiological or prosthetic knee
Insufficient hip extensor strength or lumbar extensor strength making maintenance
of an upright trunk difficult
Prosthetic (extrinsic)
Transtibial socket set too posterior (forcing knee hyperextension)
Transtibial socket lacks anterior tilt
Transfemoral prosthetic knee positioned too anterior (trochanter-knee-ankle line
not providing stability)
Environmental (extrinsic)
Walking up incline
Insufficient weight bearing
through prosthesis






Loading response through
terminal stance






Intrinsic
Residual limb pain or hypersensitivity
Excessive upper-extremity weight bearing on assistive device
Instability of the physiological or prosthetic knee joint
Decreased muscle strength of residual limb
Fear of falling/lack of confidence in prosthesis
Prosthetic (extrinsic)
Prosthesis is too long
Poor socket fit
Environmental (extrinsic)
Walking uphill
Walking on rugged terrain
(Continued)

724
Section III  Prostheses in Rehabilitation
Gait Deviation
Phase of Gait
Category*
Possible Causes
Inadequate prosthetic foot
clearance†
Throughout swing phases
Intrinsic
Poor hip stabilization on sound limb (pelvic drop on prosthetic side during swing)
Lacking active anterior pelvic rotation strength and/or timing required to initiate
prosthetic swing
Lacking hip flexor strength and/or timing required to initiate prosthetic swing
Lacking knee flexor strength and/or timing to contribute to prosthetic swing in
transtibial amputation
Prosthetic (extrinsic)
Prosthesis too long
Transfemoral prosthetic knee with excessive friction
Prosthetic foot/ankle too plantar flexed
Environmental (extrinsic)
Uneven terrain with unexpected elevations
Pistoning (downward translation
of prosthesis on residual limb
when unloaded)
Throughout swing phases
Intrinsic
Error in sock application (too few or too many plies)
Prosthetic (extrinsic)
Inadequate suspension
Poor socket fit
Environmental (extrinsic)
Muddy or wet environment can create pull on prosthesis
GAIT DEVIATIONS COMMON TO TRANSTIBIAL PROSTHETIC USERS
Excessive knee flexion/knee
instability
Initial contact or loading
response to midstance
Intrinsic
Knee or hip flexion contracture
Lacking knee or hip extensor strength and/or timing
Anterior distal residual limb pain
Prosthetic (extrinsic)
Excessive dorsiflexion of the prosthetic foot
Excessive transtibial socket flexion (anterior tilt)
Transtibial socket positioned anterior to prosthetic foot
Excessive heel cushion stiffness (SACH foot)
Prosthesis too long
Environmental (extrinsic)
Walking down inclines
Excessive knee extension (no shock
absorption)/hyperextension
Initial contact or loading
response to midstance
Intrinsic
Lacking knee extensor strength and/or timing (hyperextend knee as compensation)
Cruciate ligament insufficiency
Lacking hip extensor strength and/or timing
Posterior distal residual limb pain
Prosthetic (extrinsic)
Excessive plantar flexion of prosthetic foot
Lacking appropriate socket flexion (posterior tilt)
Excessively soft heel cushion (SACH foot)
Socket positioned posterior to prosthetic foot
Prosthesis too short
Environmental (extrinsic)
Ascending inclines/walking uphill
TABLE 26-6  Prosthetic Gait Deviations—cont'd

Chapter 26  Early Rehabilitation in Lower-Extremity Dysvascular Amputation
725
Genu valgus moment at knee
Midstance
Intrinsic
Medial collateral ligament insufficiency
Coxa vara at hip
Medial distal residual limb pain
Prosthetic (extrinsic)
Excessive outset of prosthetic foot
Tilt of transtibial socket in frontal plane
Environmental (extrinsic)
Walking on uneven surfaces
Excessive genu varus moment
at knee
Midstance
Intrinsic
Lateral collateral ligament insufficiency
Coxa valga at hip
Lateral distal residual limb pain
Prosthetic (extrinsic)
Excessive inset of prosthetic foot
Tilt of transtibial socket in the frontal plane
Environmental (extrinsic)
Walking on uneven surfaces
Early heel rise/early knee flexion
or “drop off”
Midstance to preswing
Intrinsic
Hip and/or knee flexion contracture
Weakness of hip extensor muscles
Anterior/distal residual limb pain
Prosthetic (extrinsic)
Excessive dorsiflexion of prosthetic foot
Socket positioned anterior to prosthetic foot
Too much socket flexion (anterior tilt)
The opposite prosthetic problems (plantar flexed foot, socket positioned posteriorly,
not enough socket flexion) can all cause this same gait deviation if the person
is working to “overcome” being forced into hyperextended knee position by the
prosthesis.
Environmental (extrinsic)
Walking down inclines or hills
Delayed heel rise/delayed knee
flexion
Terminal stance to preswing
Intrinsic
Knee hyperextension as compensation for instability or weakness earlier in stance
makes transition to knee flexion difficult
Decreased anterior weight shift (weight through heel of prosthesis)
Posterior/distal residual limb pain
Prosthetic (extrinsic)
Excessive plantar flexion of prosthetic foot
Socket positioned posterior to prosthetic foot
Insufficient socket flexion
Excessively long keel of prosthetic foot
Environmental (extrinsic)
Walking up inclines/uphill
GAIT DEVIATIONS COMMON TO TRANSFEMORAL PROSTHETIC USERS
Excessive anterior pelvic
tilt/lumbar lordosis



Initial contact through
preswing



Intrinsic
Hip flexion contracture
Weak hip extensors and/or abdominals
Effort to shift center of gravity anteriorly for stability at prosthetic knee
Prosthetic (extrinsic)
Insufficient flexion (posterior tilt) of socket
Trochanter-knee-ankle line does not provide adequate knee stability
Environmental (extrinsic)
Walking up inclines/uphill
(Continued)

726
Section III  Prostheses in Rehabilitation
Gait Deviation
Phase of Gait
Category*
Possible Causes
Abducted gait
Initial contact through
preswing
Intrinsic
Hip abduction contracture
Adductor tissue roll/redundant tissue
Impaired balance (compensatory widened base of support)
Distal femur pain
Prosthetic (extrinsic)
Prosthesis too long
Socket alignment places femur in abduction
Medial socket wall too high
Environmental (extrinsic)
Uneven terrain
Delayed prosthetic knee flexion
Terminal stance to preswing
Intrinsic
Lacking active anterior pelvic rotation strength and/or timing required to unload
prosthesis
Lacking hip flexor strength and/or timing required to initiate forwarding of prosthesis
Prosthetic (extrinsic)
Trochanter-knee-ankle line providing excessive knee stability
Excessive plantar flexion of prosthetic foot or excessively soft heel cushion
(SACH foot)
Environmental (extrinsic)
Walking up inclines
Medial heel whip
Preswing to early swing
Intrinsic
Loose residual limb tissue that rotates freely around femur
Patient improperly dons socket in internally rotated position
Prosthetic (extrinsic)
Prosthetic knee oriented in external/lateral direction
Prosthetic foot oriented laterally
Prosthetic foot toe break oriented laterally
Environmental (extrinsic)
Rugged terrain
Lateral heel whip
Preswing to early swing
Intrinsic
Loose residual limb tissue that rotates freely around femur
Patient improperly dons socket in externally rotated position
Prosthetic (extrinsic)
Prosthetic knee oriented in internal/medial direction
Prosthetic foot oriented medially
Prosthetic foot toe break oriented medially
Environmental (extrinsic)
Rugged terrain
Terminal swing impact





Intrinsic
Excessive anterior pelvic rotation and/or hip flexion to assure knee extension in swing
Prosthetic (extrinsic)
Insufficient knee friction
Extension aid too strong
Environmental (extrinsic)
Environment demands rapid movement
*Intrinsic problems are a result of patient-related factors. Extrinsic problems are associated with prosthetic issues (alignment or fit) or environmental issues (best understood by analyzing the
specific conditions or activity in which they are observed).
†Possible compensations for inadequate prosthetic swing-phase clearance include a lateral lean of the trunk toward the sound limb, vaulting on the sound limb, hip hiking or circumduction
of the prosthetic limb, and, in the case of transtibial amputation, a high steppage gait.
TABLE 26-6  Prosthetic Gait Deviations—cont'd

Chapter 26  Early Rehabilitation in Lower-Extremity Dysvascular Amputation
727
on level surfaces, environmental causes of the problem can be
ruled out. If evaluation of the static alignment of the prosthe­
sis reveals appropriate alignment of the foot and pylon but the
socket is set in excessive knee flexion, this could contribute
to the problem. Thorough evaluation of the problem requires
assessment of potential intrinsic causes as well. If examina­
tion reveals full, strong, active ROM at the knee and no com­
plaints of pain, the therapist must look to the joints proximal
to the problem. Assessment of the hip may reveal a hip ­flexion
contracture that leads the person to maintain knee flexion as
a compensatory strategy to maintain upright posture. When
these two (excessive socket flexion and hip flexion contrac­
ture) distinct potential causes of the problem are identified,
the therapist can then prioritize and address each cause.
Initiation of a stretching intervention to address the ROM lim­
itation can be started immediately, but likely will not have an
immediate effect, but perhaps an effect over time. Prosthetic
extrinsic causes can be modified immediately: if quality of
gait improves and deviations are eliminated after realignment
(typically the responsibility of the prosthetist), this suggests
that alignment was the factor underlying the gait deviation.
If a socket alignment adjustment does not have a significant
impact, magnifies the observed gait problem, or leads to a new
gait deviation, the underlying cause is likely to be an intrinsic
issue needing PT intervention.
Gait Training on Alternate Surfaces
To adapt to and meet environmental demands, the individ­
ual with a prosthesis must be able to adjust his or her step
length and cadence while ambulating in response to environ­
mental conditions or circumstances. The PT program might
begin with practice opportunities until the person is able to
achieve a normal cadence. It might then progress to activities
that demand an increased or decreased cadence, and tran­
sitional gait movements, such as sidestepping, turning, and
walking backward. These skills can initially be practiced in
the clinic with minimal environmental demands. They can
be progressed to situations in which the environment pres­
ents a challenge, such as crossing a street in a timely manner,
getting on and off an elevator or escalator, walking through
a crowded corridor in a busy store, or walking to a seat in
the middle of an aisle in an auditorium or theater. Successful
community ambulation also requires management of many
different ground surfaces, including steps, curbs, ramps, and
varied terrain. In providing therapeutic practice opportuni­
ties for a person who is new to prosthetic use, the therapist
considers the following important extrinsic variables:
1. Level of assistance required for safe performance;
2. The specific demands of the environment, such as
depth or height of steps and curbs, or degree of slope of
a ramp;
3. The need for an assistive device or railing;
4. The optimal technique for performing the task safely; and
5. The ability to superimpose an additional activity while
walking or moving in the environment.
An initial goal might be to decrease the level of assistance
on these alternative surfaces. This can be accomplished by
simplifying one or more of the other variables of the task,
such as decreasing the depth of the step/curb, allowing the
use of sturdy rail versus crutch or cane, and/or allowing the
sound limb to “lead” or dominate the task. As skill improves,
the task demands are increased. Early skills in stair climb­
ing are generally developed in a step-to gait pattern with the
sound limb leading in ascent and the prosthetic limb lead­
ing in descent. Advanced gait training activities may instead
require the patient to use the prosthetic limb first while
ascending and the sound limb first while descending; these
skills are necessary if the patient is to master a step-over-step
pattern for stair ascent/descent. Placement of the prosthetic
forefoot off of the step for step-over-step stair descent allows
the forward progression of the prosthetic shank, mimicking
ankle dorsiflexion required to lower the body onto the next
step. In persons with transfemoral amputation using a micro­
processor-controlled knee or some pneumatic/­hydraulic
knees step-over-step descent of stairs or curbs may be pos­
sible as the servomechanism in the knee mimics eccentrically
controlled knee flexion.
Managing slopes, inclines, and ramps are challenging for
persons with both transtibial and transfemoral amputation.
In both situations, the relative stiffness of the ankle that will
not allow for fully functional dorsiflexion or plantar flexion
creates a lack of adaptability to the incline or decline surface.
In the person with a transfemoral prosthesis the loss of the
knee joint and accompanying quadriceps control compounds
the challenge. Most people with transfemoral prosthesis nav­
igate inclines, declines, ramps, and slopes using one of two
methods (or some combination of the two). They will either
shorten the step length of the involved limb to help compen­
sate for the lack of quadriceps contraction and ankle mobil­
ity and continue with an asymmetrical step-to-step pattern
or they will turn partially sideways and employ a sidestep­
ping pattern leading with the uninvolved limb going up and
prosthetic limb going down. By reorienting the axis of rota­
tion for knee motion in this manner, there is less of a risk
of the slope directly impacting knee position or stability. The
method used is generally determined by patient preference
and the grade of the slope. As in stair descent, if the person
has a microprocessor-controlled knee, then angled surfaces
are more easily managed by the computer control of the knee,
especially descending.
Treadmill training has become a popular mechanism for
gait training in many PT clinics, both with and without partial
body-weight support. Although partial body-weight support
treadmill training has not been studied with this population,
treadmill training has been compared to overground gait
training. Self-selected comfortable gait speed on the tread­
mill has been demonstrated to be significantly slower than
overground walking at the same energy cost, which suggests
a higher energy cost of walking on the treadmill than over­
ground.109 A small case series suggests that movement strate­
gies may be altered in walking on a treadmill as compared to
overground.110 If a treadmill is to be used in training, these
considerations may be important, as is special consideration
to safety and guarding technique.

728
Section III  Prostheses in Rehabilitation
The ultimate goal is to provide a repertoire of strategies
for the individual to choose from to respond to environmen­
tal demands. For example, when crossing the street, it is ideal
if one can ascend the curb without disrupting gait cadence,
even if this means leading with the prosthetic foot. The unpre­
dictable surface of uneven terrain encountered in walking
across a lawn can challenge postural responses significantly
if no assistive device is used. Sidestepping is a skill needed
in environments such as theaters and can be practiced when
the theater is empty or when people are seated. A supervised
community outing is an excellent strategy for addressing and
achieving high-level ambulation goals.
Curtze demonstrated that when transtibial prosthetic
users were faced with the challenge of rough terrain ver­
sus smooth surfaces, arm swing speed increased (presum­
ably to assist with balance) and gait speed decreased slightly,
but other gait parameters were not significantly altered.111
Vrieling and colleagues concluded that specific training for
prosthetic gait initiation, termination, obstacle crossing, and
incline and decline management should be a purposeful com­
ponent of the rehabilitation regime, as movement strategies of
these functional tasks are different than those of able-bodied
individuals,82,112–115 and addressing these tasks in rehabilita­
tion has the potential to impact safety and confidence.
Superimposing functional activities on gait during thera­
peutic treatment prepares patients for the daily “real-world”
challenges that they are sure to encounter. The variety of
functional tasks practiced by the patient may be driven by
specific patient goals. Safe ambulation while carrying objects
of varying weights and sizes is an important functional skill
and an appropriate PT activity. The individual's specific goal
may be to carry a full laundry basket down the hall or a cup
of hot coffee from the kitchen to the living room. As indi­
viduals become functional prosthetic users, household tasks
and leisure or work activities may guide their therapeutic
needs. Safe ambulation while doing more dexterous skills,
such as using a mobile phone or texting is another very likely
patient goal.
High-level activities, such as running and athletic endeav­
ors, are appropriate and attainable goals for many prosthetic
users. Some individuals with amputation may wish to resume
certain sports or leisure activities that they participated in
prior to their amputation. With current advances in pros­
thetic components a person can enjoy a multitude of athletic
and recreational activities. Individuals with amputation are
returning to basketball, running, rock climbing, and cycling;
and some are taking up these sports for the first time as pros­
thetic users! With the technological advances in prosthetics
and the growth and exposure of the Paralympics, high-level
athletics are no longer limited to a small elite group of pros­
thetic users. Table 26-7 describes some more advanced reha­
bilitation activities that can help individuals prepare to take
part in their chosen activity.
Functional Activities
Prosthetic training is not just a matter of teaching an indi­
vidual to ambulate but includes a variety of other functional
activities, such as transfer training from a variety of surfaces,
picking up objects from different levels and surfaces, kneel­
ing, management of falls, and rising from the floor. Motor
learning theory supports that prescriptive instruction on
different functional tasks such as these may not be the most
effective way to assist individuals in developing these skills;
rather, encouraging individuals to solve their own motor
problems and figure out how to best perform a given func­
tional task allows them to “own” the task and to better gener­
alize to other related tasks.35 The skilled therapist will design
an environment for success when introducing new skills and
TABLE 26-7  Advanced Exercises and Activities for Individuals with Lower-Extremity Amputation*
Range of motion
Independent stretching of hip flexors, abductors, external rotators are top priority for all levels of
amputation; for transtibial amputation, add stretching of hamstrings and quadriceps
Stretching of hip extensors, adductors and internal rotators will also be part of a comprehensive stretching
program; however, these muscles pose a lower risk of developing contractures
Strengthening
Resistance training of hip musculature, and in the case of transtibial amputation, quads and hamstrings
Closed-chain exercises with prosthesis: step-ups, leg press, wall or ball squats, involved limb stance with
opposite limb resistance exercises, multiple plane stepping exercises with Thera-Band resistance, involved
limb lunges, advance to using handheld weights to increase resistance
Balance and coordination
Standing activities with balance challenges including compliant surface (foam) or mobile surface
(Biomechanical Ankle Platform System [BAPS] board, rocker board); catching and throwing balls
of different shapes and weights and throwing variable distances
Involved single-limb stance, with stool stepping with uninvolved limb, progress to stepping on less stable
surface (foam, ball); catching and throwing with staggered stance (involved limb on step/stool/ball)
Dynamic challenges to upright balance: functional multidirectional walking, avoiding obstacles, picking up
objects from floor, narrow base or support or beam walking, starts and stops and turns in rapid progression
Speed and agility
Figure-eight walking, progressing to running, shuttle walk to run, sprinting, obstacle course
Cardiovascular activities
Swimming, running, cycling, treadmill walking, stair climbing or stepper
*Some activities and exercises adapted from Gailey RS, Gailey AM. Prosthetic Gait Training Program for Lower Extremity Amputees. Miami FL:
Advanced Rehabilitation Therapy, 1989.122

Chapter 26  Early Rehabilitation in Lower-Extremity Dysvascular Amputation
729
should have suggestions and ideas to offer, if needed, to the
patient who is attempting new tasks. Additionally, the ther­
apist should creatively progress the demands of the task as
appropriate, always working to challenge the individual in
working toward realistic and functional goals. Specific func­
tional tasks should also be designed to address unique goals
as they relate to activities of daily living, job-related activities,
or recreational activities. Occupational therapists have excel­
lent knowledge of adaptive devices and skill in environmen­
tal adaptation, thus working with these team members may
prove to be very helpful.
For many people with amputation there is a strong desire
or need to return to work and leisure activities. The success­
ful return to employment of persons with amputation has
been studied18,116 and a review article by Burger and Marincek
puts the return to work rate at approximately 66% for per­
sons with lower-extremity amputation.117 Factors found to
be associated with success in returning people to work after
lower-­extremity amputation include younger age at the time
of amputation, lower level of amputation, higher educa­
tion level, good prosthetic comfort, and higher gross annual
income.18,116,117 Certainly, no individual who is motivated to
return to work should be discouraged based upon not meet­
ing these criteria. Functional tasks that simulate job or leisure
activities would be very appropriate to incorporate into the
PT plan of care. Couture and associates found that, while indi­
viduals with lower-extremity amputations may demonstrate
a decrease in participation of leisure activities, their satis­
faction with activities remains high.118 In progressing func­
tional, vocational, and leisure activities, the art of designing
interventions that are task oriented and that help to develop
the person's problem-solving skills is the goal. Challenging
individual's problem solving skills and assisting them in the
development of creative solutions when they are faced with
new challenges is a rewarding and important component of
prosthetic rehabilitation.
Outcome Assessment
Recognizing and measuring the effectiveness of PT inter­
ventions is an important component of the patient/client
management model in PT.1 The overriding goal of the reha­
bilitation plan of care is to return the person with amputa­
tion to the highest functional level attainable with the best
possible outcome. The ICF framework reminds us that it is
important to assess performance at different levels of the ICF
paradigm: the body function level (impairments), the activ­
ities level (activity limitations), and the participation level
(participation restrictions). Recent publications reviewing
outcome measures in amputation rehabilitation at both the
body function and activity levels of the ICF119,120 concluded
that there are few outcome measures in amputation rehabili­
tation that demonstrate strong validity within the body func­
tion domain, and while there may be more methodological
studies supporting use of outcome measures in the activities
domain, the responsiveness of these tools requires further
study. There are no definitive guidelines as to what outcome
measures should be used with persons with amputation who
are undergoing rehabilitation119–121; however, careful docu­
mentation of performance in each domain of the ICF can be
useful. Impairment level changes that may be measured in the
individual with transtibial or transfemoral amputation might
include increases in ROM, strength or balance. Activity lim­
itation level changes might include improvements in trans­
fer ability (less assistance or improvement in varied surfaces)
or ambulation (less assistance, change in assistive device or
increased distance and/or speed) or activities of daily liv­
ing (less assistance or improved endurance). Participation
restriction level changes might include improved satisfaction
with ability to carry out specific life's roles in the family or
with respect to social/work/leisure activities.
Some of the outcome measures that have been used in
amputation rehabilitation are amputation specific (e.g.,
Amputation Mobility Predictor or the Prosthetic Evaluation
Questionnaire [PEQ]) and others are broader rehabilitation
outcome measures that have been used with this population
(e.g., Activity-Specific Balance Confidence Scale, Functional
Independence Measure [FIM]). Standardized walking tests
that have been used in the amputation rehabilitation research
include 2-Minute Walk Test, 6-Minute Walk Test, Timed
Up and Go, 10-Meter Walk, and instrumented walkways.
Although normative values for individuals with amputations
have not been well established for these outcome measures,
there are norms available for the older adult that can be useful
in monitoring change over time and assessing performance
relative to age-matched peers. Gait speed has been routinely
linked to function in the rehabilitation of the older adult, and
gait speed has been studied repeatedly in persons with ampu­
tations. Table 26-8 demonstrates the consistent findings that
self-selected gait speed is slower in persons with vascular ver­
sus traumatic amputation, and slower in persons with trans­
femoral versus transtibial amputation.
Minimal detectable change (MDC) scores are becoming
an increasingly popular way to demonstrate change in per­
formance in physical therapy. MDC provides the amount of
change required to represent “true” change in performance,
more than what would be expected in measurement error and
patient variability of performance. Table 26-9 displays test-
retest reliability and MDC scores of outcome measures that
might be useful in monitoring progress of persons with lower
limb amputation.
SUMMARY
Prosthetic rehabilitation of individuals with lower-extremity
amputation is both challenging and rewarding. Early in the
rehabilitation process, concerns for the integrity of the suture
line and skin are a major determinant of progression of time
in the prosthesis and the types of activities that are appro­
priate. As the residual limb matures, emphasis is placed on
the quality of ambulation and on developing adaptive motor
skills that enable the patient to function safely during a vari­
ety of activities under many different environmental condi­
tions. The diversity of people with amputation requires that
the therapist carefully consider individual circumstances to

730
Section III  Prostheses in Rehabilitation
TABLE 26-8  Published Gait Speed Findings in Persons with Amputation
Author (year), Brief Description
of Participants

Vascular Amputation Etiology
Mean ± Standard Deviation
(if reported) (m/sec)
Nonvascular Amputation
Etiology Mean ± Standard
Deviation (if reported)
(m/sec)
Normals/controls
(if included in study)
Mean ± Standard Deviation
(if reported) (m/sec)
Waters (1976)123
13 participants with vascular TTA (mean age
63 with mean 1.4 years prosthetic use) and 13
with vascular TFA (mean age 60 with mean
1.2 years prosthetic use); 14 participants with
traumatic TTA (mean age 29 with mean 9.5
years prosthetic use) and 15 with traumatic
TFA (mean age 31 with mean 10 years
prosthetic use); gait speed calculated from
final 2 minutes of 5 minute walk
TFA 0.60 ± 0.25*
TTA 0.75 ± 0.15*
TFA 0.87 ± 0.23*
TTA 1.18 ± 0.17*
1.37*
Lemaire (1993)124
8 male participants with traumatic TTA; mean
age 65; long term prosthetic use (>40 years);
“walkway” length for data collection not
specified
N/A
TTA 1.20 ± 0.18
N/A
Boonstra (1993)125
16 participants with TFA (etiology of
amputation not specified; but mean age
40 suggests non-vascular etiology) and 15
controls (mean age 30); gait speed data
collected in 7m of 10m walkway
N/A
TFA 1.04 ± 0.214
1.45 ± 0.175
Hermodsson (1994)126
24 male participants with TTA (12 with
vascular amputation and 12 with traumatic
amputation; mean age 67) and 12 age
matched persons without amputation; gait
speed data collected on 8 m walkway
TTA 0.85 ± 0.2
TTA 0.99 ± 0.2
1.42 ± 0.2
Isakov (2000)127
14 male participants with traumatic TTA
(mean age 45, with mean prosthetic use 16.5
years); gait speed data collected on 3.6 m
walkway
N/A
TTA 1.25*
N/A
Hagberg (2007)128
41 participants with non-vascular TFA (mean
age 49) and 22 age-matched controls; gait
speed calculated from 5 minute walk
N/A
TFA 1.03 ± 0.21*
1.50 ± 0.21*
Su (2008)129
10 participants with bilateral traumatic TTA
(mean age 43) and 9 participants with
bilateral vascular TTA (mean age 64); lab
database of 14 control subjects (mean age
26); “walkway” length for data collection not
specified
Bilateral TTA 0.69
Bilateral TTA 1.11
1.20
Hoffman (1997)130
5 participants with bilateral TFA for trauma or
congenital malformation (mean age 22) and
5 matched controls; gait speed calculated from
6 minute walk (unclear if calculated from full
6 minutes or final 2-3 minutes)
N/A




Bilateral TF 0.82 ± 0.28
(mean speed 0.70 when
single outlier eliminated)


1.04 ± 0.07




TF, Transfemoral amputation; TT, transtibial amputation.
*Values published in m/min and converted to m/sec for this chart.

Chapter 26  Early Rehabilitation in Lower-Extremity Dysvascular Amputation
731
guide prosthetic prescription and progression of the rehabili­
tation program. Effective education strategies and opportuni­
ties for practice of a variety of skills in a variety of settings are
essential for mastery of mobility skills and optimal outcomes
for rehabilitation.
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TABLE 26-9  Outcome Measures for Persons with Lower-Extremity Amputations
Outcome Measure

Test-Retest Reliability Intraclass
Correlation Coefficient
(95% confidence interval)
Standard Error of
Measurement (SEM)
Minimal Detectable Change
(calculated at 90% confidence
interval)90
Two Minute Walk Test121
.83 (.71-.90)
14.8 m
34.3 m
Six Minute Walk Test121
.97 (.95-.99)
19.4 m
45.0 m
Timed Up and Go121
.88 (.80-.94)
1.6 sec
3.6 sec
L test131
.96 (.94-.97)§
3.0 sec
7.0 sec*
Amputee Mobility Predictor121
.88 (.79-.93)
1.5 U
3.4 U
Activities specific Balance
Confidence (ABC) Scale132
.91 (.84-.95)
6.0 U
14.0 U*
*Calculated from SEM data using: MDC90 = SEM*1.65*√2.
§Authors focused on intra- and inter-rater reliability; inter-rater reliability listed here as it was used by authors to determine SEM.

732
Section III  Prostheses in Rehabilitation
through isokinetic evaluation in normal subjects and patients
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102. Su P-F, Gard SA, Lipschutz RD, et al. Differences in gait charac­
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2008;22(10–11):896–901.

734
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735
Advanced Rehabilitation for People with Microprocessor
Knee Prostheses
Christopher Kevin Wong and Joan E. Edelstein
HISTORICAL DEVELOPMENT
Since Ambroise Parè's sixteenth century articulated trans­
femoral prosthesis,1 surgeons, patients, and engineers have
attempted to imitate the function of the human leg. In the
United States, scientific prosthetics development began in
1945 with the establishment of the Prosthetic Appliance
Service of the Veterans Administration and the research and
development program of the National Academy of Sciences.2
Early versions of sophisticated knee units include the 1942
Filippi hydraulic stance control unit3 and the hydraulic
swing and stance control knee unit patented by engineer
Hans Mauch and radiologist Ulrich Henschke in 1949.4
The Veterans Administration approved the first hydraulic
swing-phase control mechanism in 1962; the component
linked a hydraulic knee unit to a single-axis ankle.5 This
chapter discusses the unique features of microprocessor knee
(MPK) prostheses that are increasingly used, and provides
prosthetic and training solutions for persons with common
gait deviations that can be reduced by using a MPK.
Research beginning in the 1970s led to the 1993 introduc­
tion by Blatchford (Basingstoke, England) of the first commer­
cially available microprocessor-controlled prosthetic knee:
the Endolite Intelligent Prosthesis. The Endolite Intelligent
Prosthesis required a wired connection to program the vari­
able swing-phase control. The Adaptive Prosthesis followed
in 1998, allowing wireless programming and featuring an
onboard processor that controlled adjustment of the hybrid
pneumatic/hydraulic MPK; Endolite Intelligent Prosthesis
(sixth generation) MPK is the Orion (Figure  27-1).6 Since
introduction of the Endolite Intelligent Prosthesis, at least
six other companies have joined the marketplace in offering
MPK prostheses. Otto Bock (Duderstadt, Germany) initiated
the hydraulic C-Leg MPK in 1997.2,7–10 Other manufactur­
ers presented comparable units. Össur (Reykjavik, Iceland)
launched the Rheo Knee in 2006 and the Power Knee in
2009.11 Freedom Innovations (Irvine, CA) recently intro­
duced the Plié MPK unit.12 The Nabtesco Corporation of
Japan also offers MPK units through the Swedish distributor,
Centri AB.13
OVERVIEW OF NONMICROPROCESSOR KNEE
PROSTHESES
After amputation that includes the knee joint, people face sig­
nificantly more difficulty in mobility tasks than those whose
knees remain intact. Without the knee and the muscles that
control it, the prosthesis user must control knee flexion in
new ways to avoid falling. The simplest way to remain stable
is to use a mechanically locked knee unit. Some older first-
time prosthesis users prefer the security of a locked knee to
one that is unlocked.14 If the knee is not locked, knee stabil­
ity can be maintained simply through alignment of the joint
27
LEARNING OBJECTIVES
On completion of this chapter, the reader will be able to do
the following:
1. Provide a chronology for the development of prosthetics
research leading to the microprocessor knee prostheses.
2. Compare knee control function for a variety of micropro­
cessor knee prostheses.
3. Explain functional ambulation skills and activities of
daily living that are challenging for users of transfemo­
ral prosthesis or higher that do not have microprocessor
knee.
4. Apply Medicare K-level requirements when considering
microprocessor knee prostheses for patients.
5. Explain the similarities and differences of microprocessor
knee prostheses.
6. Describe how a microprocessor knee unit can benefit the
user during gait, stair climbing and ramp negotiation,
transfers, and stumbling.
7. Discuss prosthetic and training solutions for common gait
deviations which microprocessor knee prostheses can sig­
nificantly benefit.
8. Evaluate a variety of physical therapy interventions that
can be applied when rehabilitating individuals with
transfemoral amputation who use microprocessor knee
prosthesis.
9. Describe the evidence to support use of microprocessor
knee prostheses.

736
Section III  Prostheses in Rehabilitation
axes combined with significant residual limb gluteal muscle
power. However, many prosthesis users who wish to walk in
the community with additional stability benefit from more
sophisticated non-MPK units.
Weight-activated friction brake knees are non-MPK units
that control knee flexion upon initial loading and through
most of stance phase. Weight bearing on the prosthesis acti­
vates strong braking resistance to knee flexion even when
the knee is slightly bent. If the knee is flexed more than
20 degrees, no flexion resistance is provided making stair
descent or stumble recovery difficult. Hydraulic non-MPK
units provide sufficient resistance to weight bearing knee
flexion beyond 20 degrees to allow step-over-step descent of
stairs or curbs (Figure 27-2).15 Hydraulic or pneumatic knees
also provide variable levels of resistance to knee flexion dur­
ing swing phase to minimize asymmetry between sound and
prosthetic knee flexion at different gait speeds.
The two different resistance modes in hydraulic knees
make these units ideal for those who are able to move at
different speeds and traverse a variety of surfaces such as
encountered in the community. However, these knees require
specific motions during gait to provide the mechanical cue,
such as a firm knee hyperextension force of at least 0.1 ­second
in terminal stance phase,11 to switch between the two different
levels of resistance required for weight-bearing stance phase
and non–weight-bearing swing phase. If a sufficient cue is not
achieved at the end of the swing phase, the appropriate resis­
tance to support the weight-bearing limb will not be applied
and a fall may occur. Alternatively, if the cue is not achieved at
the end of stance phase, the leg may remain stiff in the swing
phase, leading to an awkward gait pattern. As a result, the
user must be careful to move with adequate hip action to pre­
vent stumbles.
Users of non-MPK prostheses must use compensatory
techniques for other activities. For instance, to go from sit-
to-stand, the wearer generally places more weight on the
sound limb and depends on that leg, and arms as needed,
to raise themselves to standing. When sitting, unweight­
ing the prosthetic leg is required in order for the knee to
bend easily. Such basic activities place extra stress on the
sound limb, which can contribute to the frequent report­
ing of low back and sound limb pain among prosthesis
users.16 Another example is descending slopes, a notori­
ously difficult activity for users of transfemoral prostheses.
A step length matching that of the sound limb often results
in a prosthetic knee angle that exceeds the approximately
20-degree safety range of a hydraulic stance phase con­
trol or a weight-activated knee unit. Thus, most prosthesis
users learn to take very short steps. Finally, ascending stairs
step-over-step is very difficult for any transfemoral pros­
thesis user, generally requiring use of a banister if the step
is of standard height.
FIGURE  27-1  Orion: a pneumatic microprocessor knee unit
with stance and swing-phase control. (Courtesy Endolite, www.
endolite.com.)
FIGURE  27-2  Prosthetic and sound foot placement for stair
descent. (Courtesy Otto Bock Health Care, )

Chapter 27  Advanced Rehabilitation for People with Microprocessor Knee Prostheses
737
INTRODUCTION TO MICROPROCESSOR
KNEE PROSTHESES
Unlike non-MPK prostheses that use alignment, locked
knees, or weight-activated friction brakes, and hydraulic or
pneumatic mechanisms, MPK prostheses incorporate an
onboard microprocessor to compute data from various elec­
tronic sensors and provide real-time adjustments during
the user's activities. The computer's processor enables rapid
adjustments in knee resistance during both swing and stance
phases control, usually with pneumatic or hydraulic com­
ponents. The speed of current microprocessors allows data
sampling from sensors in the MPKs at speeds of up to 50
times per second17 to provide more responsiveness to indi­
vidual movements than can be offered by non-MPK pneu­
matic and hydraulic knee prostheses. Based on input from
various combinations of joint position and motion sensors,
pressure sensors, and gyroscopes, proprietary software algo­
rithms determine the phase of gait or function of the leg to
provide real-time adjustment of resistance within the MPK
unit to facilitate the optimal walking pattern.
The prosthetist performs the initial MPK calibration for
the wearer's typical use patterns with software specific to
the MPK manufacturer. Calibration requires that the wearer
walk at slow, normal, and fast speeds for approximately 12 m
(40 ft). Then the wearer negotiates stairs and ramps so that
the appropriate knee resistance levels can be set. Additional
adjustments may be necessary as the user bears more weight
on the prosthesis and participates in more activities.
MPKs offer a variety of swing and stance phase con­
trol functions, including resisted swing-phase knee exten­
sion and knee flexion, resisted stance-phase knee flexion,
powered stance-phase knee extension, locked or unlocked
(free) knee motions, and various combinations for ­specific
functional applications. MPKs offer stance-phase knee
resistance within a 0- to 35-degree range (Table 27-1).6
As with the non-MPK units that have both swing- and
stance-phase control functions, the MPK must switch between
different functions. MPK units receive data from various sen­
sors, such as plantar pressure on different foot regions, that
indicate the portion of stance phase, especially initial load­
ing. Some MPKs, like the C-Leg and the Rheo Knee, allow
controlled knee flexion upon initial loading to reduce verti­
cal shock impact. Angle and velocity of the knee indicate the
oncoming of terminal swing. A MPK like the Genium has
a gyroscope, which senses the direction of movement and
determines when the user lifts the leg to ascend stairs or to
step over an obstacle (Figure 27-3).
In general, manufacturers suggest that MPKs with stance-
phase control be prescribed for Medicare K2- and K3-level
users (Table  27-2) whereas MPKs with both stance- and
swing phase-control be prescribed for K3- and K4-level
users who will utilize different walking speeds.11,17 However,
all currently available MPKs are designed for low to moder­
ate impact activities (Table 27-3).11,17 Processor and actuator
TABLE 27-1  Microprocessor Knee Prostheses Offer a Variety of Knee Control Functions
Gait-Phase Controlled
Manufacturer
Endolite
Freedom Innovations
Nabtesco
Otto Bock
Össur
Swing only
Smart IP
Intelligent Hybrid
Stance only
Compact
Swing and stance
Smart Adapt, Orion
Plie 2.0
C-Leg, Genium
Rheo Knee, Power Knee
Stair ascent (powered assist)




Power Knee
FIGURE 27-3  Genium microprocessor knee with gyroscope, accel­
erometer, and angle sensors responds to movement in all directions.
(Courtesy Otto Bock Health Care, )

738
Section III  Prostheses in Rehabilitation
speeds are insufficient for high-speed activities and, as with
all electronic devices, MPKs are vulnerable to overheating.
Prosthesis users at the K4 level who engage in high impact
activities, such as running or jumping, are more suited to
hydraulic non-MPK designs like the Mauch Knee.
In addition to different combinations of swing- and
stance-phase control, the commercially available MPKs
have other options. For instance, the Plie 2.0 knee utilizes
a pneumatic mechanism that the user pumps regularly
to adjust resistance levels (Figure 27-4).12 The pneumatic
hybrid is available with both single and multiaxis knee
joints that allow up to 160 degrees of flexion.13 MPKs, how­
ever, generally provide a knee flexion range from 120 to
140 degrees, which exceeds that of most non-MPKs like
the Mauch Knee. MPKs generally dampen knee extension
to minimize terminal knee extension impact as well as to
adjust the arc of shank swing to the speed of walking, but
not early swing phase knee flexion. The C-Leg and Genium
have dampened swing phase knee flexion to approximate
the 60 degrees normal in level walking.17,18 The Power Knee
offers powered robotic assistance in sit-to-stand and stair
ascent functions (Figure 27-5).11
All MPKs have some common characteristics. Although
technical specifications of individual MPKs vary, all are
­powered by batteries that must be charged 4 to 14 hours for
use limited in general to 1 to 5 days. The Power Knee, the
only MPK to provide robotic assistance to movement, main­
tains its charge for only 12 hours.11 Depending on use inten­
sity, the Smart Adaptive MPK can maintain charge for up to
14 days.6 The battery and hydraulic mechanisms do not func­
tion in all environments and are limited to operating temper­
atures ranging from − 10 ° C (14 ° F) to 60 ° C (140 ° F) for the
C-Leg,17 sufficient for most people's requirements. As with
other electronic devices, such as laptop computers, MPKs
are also vulnerable to sand, debris, and water—especially
salt water. The most water-resistant MPK, the Plie knee, is
purported to be able to withstand occasional submersion in
water up to 0.5 m (1.64 ft) in depth (see Figure 27-4).
Electronic signals, such as repeated beeps or vibrations,
warn the user of impending shutdown because of computer or
hydraulic overload or other malfunction, as well as changes in
mode of function. The wearer must learn the meaning of the
different signals to assure proper use. Upon shutdown, MPK
will default to various states. Most default to swing phase con­
trol, which allows knee bending in swing phase but can also
permit collapse in stance phase. The C-Leg and Power Knee
default to stance-phase resistance, which causes the knee to
lock and protects against falls if the microprocessor receives
abnormal input such as can occur during a stumble or step
onto an obstacle or uneven surface. A stance-phase resistance
default setting, however, requires circumduction, hip hik­
ing, or vaulting in swing phase until normal MPK function
is restored.
The battery and other electronic components add weight,
causing MPKs to be heavier than hydraulic non-MPK units.
Weights for MPK units range from 1145 g (2.5 lb) for the
C-Leg to 3200 g (7.1 lb) for the more complicated Power Knee;
compared to the hydraulic non-MPK units such as the SR9517
at 360 g (12.6 oz) or the Mauch knee which weighs 1140 g
(2.5 lb).11 While the Mauch Knee Plus can accommodate high
impact use by users weighing to 166 kg (366 lb),11 MPKs are
generally designed for low to moderate impact use by individ­
uals who weigh less than 125 kg (275.6 lb). The newly available
Genium can support people up to 150 kg (330.7 lb).17 Typical
MPK units cost $16,000 to $18,000, with total cost of the
prosthesis as much as $50,000 in 2004,19 with 3-year warran­
ties standard; Otto Bock offers an extended 6-year ­warranty
for the Genium.17 Cost can be two to three times the cost of
a ­non-MPK unit. However, in a cost analysis of Dutch trans­
femoral prosthetic users, total intervention costs were only
23% more because associated rehabilitation expense was less.
When patient and family expenses, such as housekeeping and
decreased work productivity, were included, the cost to MPK
users was roughly half of non-MPK users although the two
groups both averaged 47 years of age and had similar work
profiles and amputation etiologies.20
Any MPK can be integrated with many other prosthetic
components. Endoskeletal construction is typically employed
to save weight and provide space for componentry. Each
company recommends integrating its MPK with an energy-­
storing foot selected from its catalog. The difference between
feet may not make a substantial difference21 and can be indi­
vidually determined based on the judgment of the prosthetist,
patient, physician, and therapist.
TABLE 27-2  Medicare Functional Levels for People with Unilateral Transtibial and Transfemoral Amputation
Level
Typical User Profile
Functional Abilities with Prosthesis
K1
Household ambulator
Has ability or potential to transfer and ambulate on level surfaces at slow speeds with fixed
cadence. Time and distance severely limited.
K2
Limited community ambulator
Has ability or potential to ambulate and traverse common environmental barriers such as
curbs, stairs, or uneven surfaces. Time and distance often limited.
K3
Community ambulator
Has ability or potential to ambulate at faster speeds with variable cadence and traverse
most environmental barriers. Can undertake vocational, therapeutic, or exercise activity
that demands use beyond ambulation. Time and distance still somewhat limited.
K4

Active user (child, active adult,
athlete)
Has the ability or potential for prosthetic use that exceeds ambulation, including high
impact, torsion, or energy levels common to sport. Time and distance essentially
unlimited.

Chapter 27  Advanced Rehabilitation for People with Microprocessor Knee Prostheses
739
When integrating a MPK into a hip disarticulation pros­
thesis, some shank, feet, or hip joint units may provide func­
tional benefits. Particularly useful are shank devices that
provide transverse plane rotation, such as the Delta Twist,
which can dampen over 20 degrees of rotation and can be
combined with the C-Leg. The Ceterus foot,11 for instance,
also may help provide transverse plane rotation accentu­
ated by the longer step lengths that sometimes result when
using a MPK.22 The Helix3D hip joint provides transverse
plane rotation unlike other prosthetic hip joints.
MICROPROCESSOR KNEE PROSTHESES
CONTROL MECHANISMS
The MPK works by sensors transmitting input to the micro­
processor, which converts the data so that the appropriate
output can be provided. In some cases, artificial intelligence
allows the MPK to adapt to the user's movements in differ­
ent activities. Two types of mechanisms provide input to the
MPK namely, computational and interactive.23
Computational control mechanisms use sensors to detect
movement and forces and send this information to a com­
puter that processes the information and adjusts the resis­
tance provided by the knee mechanism to accommodate for
variations determined by the data. For instance, 70% body
FIGURE  27-4  Plie 2.0, a water-resistant pneumatic microproces­
sor knee unit. (Courtesy Freedom Innovations LLC,
innovations.com.)
FIGURE  27-5  Power Knee provides assisted knee extension.
(Courtesy Össur Americas, )

740
Section III  Prostheses in Rehabilitation
weight borne through the weight-bearing foot will be inter­
preted as occurring during stance phase leading to full resis­
tance to knee flexion. This intrinsic mechanism is so-called
because the sensory information and decision-making pro­
cess is intrinsic to the knee unit sensors and microprocessor,
which prompts an automatic reaction. It is the most common
form of input mechanism.
Interactive control mechanisms, more common to upper-
limb myoelectric prostheses, integrate the user's conscious
initiation. Pattern recognition or electromyographic sig­
nal sensors detect the movement initiation. Upper-limb
prosthetic function is distinctly different from lower-limb
function. Arm movement is modulated primarily by the
­cognitively variable central nervous system to perform com­
plex acts like grasping a variety of foods. In the lower-limb,
most everyday function involves walking, which is modu­
lated by the spinal cord and central pattern generators with­
out many fine motor variations.
While the prosthesis user would not want to think about
each of the average 6000 steps taken each day,24 the future
may bring interactive control of the prosthesis through myo­
electric input. Preliminary experiments with people with
lower-limb amputations using myoelectric technology in a
virtual environment demonstrate that electrodes imbedded
in muscles of the residual lower limb can be used to facili­
tate specific movements, as is typically done in myoelectric
upper-limb prostheses. However, the time to complete simple
tasks in the experiments, like extending and relaxing the knee
in sitting, exceeded 1.5 seconds.25 Perhaps myoelectrically
driven intrinsic control mechanisms may eventually assist
slow and deliberate non–weight-bearing tasks for people with
leg amputation.
Currently, the Proprio foot, outfitted with an accelerom­
eter, joint sensor, and motorized actuator, can plantar and
dorsiflex the foot in non–weight-bearing positions upon
receiving the correct cues (by heel tap or wireless remote
control), enabling the user to sit or don trousers more easily
(Figure 27-6). Other functions for the transfemoral prosthe­
sis user, such as rotating the leg to place it on the knee to don
shoes and socks, would be the kind of action such an interac­
tive control system may perform in the future.11
Once the sensor data has been input and the micropro­
cessor has determined what function is occurring, the MPK
can provide two types of knee movement output: resistance
or powered assistance. Most commonly, MPKs resist move­
ment, which can be thought of as an eccentric force. Most
knee function in gait is eccentric, whether resisting knee flex­
ion in early stance or resisting knee extension in terminal
swing phase. By providing the appropriate amount of resis­
tance through the required range of motion, the MPK can
assist the wearer to walk at varied speeds and descend stairs
and ramps with less difficulty.
Powered MPKs can also assist movement, comparable to
a concentric force. Such a force can be helpful in ascending
stairs and rising from a chair, especially for those with bilat­
eral limb loss or a weak intact limb. Although powered assis­
tance provides the potential for the most complete replication
of normal leg function, this potential is limited by actuator
technology and electromechanical speed. For instance, the
human knee moves more than 300 degrees per second in
walking26 and can increase to over 600 degrees per second in
running.27 It would be difficult for actuators that have acti­
vation times only as fast as 10 milliseconds12 to create such
high velocities, without overheating when maximum speeds
are maintained.
Artificial intelligence is used in MPKs to varying degrees.
Standard setup includes initial programmed learning while
the wearer walks with the MPK at various speeds and negoti­
ates ramps and stairs. Setup programming prepares the pros­
thesis for normal function but may not provide sufficient
information for the knee to respond appropriately during
unexpected events, such as stepping into a divot. Although
technically possible, most MPKs do not use real-time accom­
modation, as it is unnecessary for ordinary use. For instance,
even unexpected situations such as stumbles cause predict­
able inputs that are anticipated by default settings.
COMMON MOBILITY PROBLEMS AND
POTENTIAL SOLUTIONS
Despite sophisticated technology, prosthesis users face a
variety of problems in moving around the community.
Some problems can be significantly improved by MPK use,
although users who are transitioning from non-MPK pros­
theses may have developed habits that must be unlearned.
To illustrate how a MPK unit can benefit the user, common
problems in gait, stair and ramp negotiation, transfers, and
stumbling are presented.
Despite rigorous training and dedicated practice, some
gait deviations persist.15,28 The most common deviations that
MPKs can significantly benefit are discussed here with pros­
thetic and training solutions.
FIGURE  27-6  Proprio foot. (Courtesy Össur Americas, www.
ossur.com.)