Exercises For Lower-limb Amputees

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exercises forlower-limb amputeesGait training

International Committee of the Red Cross19, avenue de la Paix1202 Geneva, SwitzerlandT 41 22 734 60 01 F 41 22 733 20 57E-mail: shop@icrc.orgwww.icrc.org ICRC, September 2008

Table of .101.111.121.131.141.151.161.171.181.191.20Weight bearing and balancePartial weight bearing (two-hand support)Partial weight bearing (one-hand support)Partial weight bearing (fingertip support)Partial weight bearing (without support)Partial weight shift (two-hand support)Partial weight shift (one-hand support)Partial weight shift (without support)Partial weight shift (two-hand support)Partial weight shift (one-hand support)Partial weight shift (without support)Pelvic rotationSideward walking (two-hand support)Full weight shift (two-hand support)Full weight shift (without support)Heel strike (with or without support)Handball (with or without support)Balance boardObstacle stepping (with or without support)Football (with or without 22324252627281

22.2.12.22.32.42.52.62.72.82.92.102.112.12Specific gait trainingSound-leg step forward (two-hand support)Sound-leg step backward (two-hand support)Sound-leg step through (two-hand support)Sound-leg step through (one-hand support)Sound-leg step through (without support)Prosthetic-leg step forward (two-hand support)Prosthetic-leg step backward (two-hand support)Prosthetic-leg step through (two-hand support)Prosthetic-leg step forward (one-hand support)Prosthetic-leg step through (without support)Walking between the parallel bars (one-hand support)Walking between the parallel bars (without .33.43.53.63.73.8Advanced exercisesBouncing a ball (stationary position)Bouncing a ball (walking)Balancing a stickBalancing on the prosthesisWalking on an uneven surfaceGoing up and down a slopeJumping (for below-knee amputees only)RunningNotes47484950515253545556

4.4.14.24.3.14.3.24.4.14.4.24.54.64.74.8Functional exercisesRising from a chairClimbing a staircaseDescending a staircase: sound leg step to (for above-knee amputees)Descending a staircase: sound leg step through (for below-knee amputees)Sitting down and getting up from the floor (method 1: forward)Sitting down and getting up from the floor (method 2: backward)Sitting down on a chair (for bilateral amputees)Lying down (for bilateral amputees)Getting up from the floor (for bilateral amputees)Weight carryingNotesCreditsThe teamBibliography5960616263646566676869707272723

Introduction4Physiotherapy plays a crucial role in the post-prostheticmanagement of lower-limb amputees. However,experience shows that it is neglected or not even availablein many physical-rehabilitation centres that receiveassistance from the ICRC and other aid organizations.This CD-ROM/booklet seeks to address the problem byproviding examples of basic post-prosthetic exercisesfor use by physiotherapists, physiotherapy assistants,orthoprosthetists and others involved in the gait trainingof lower-limb amputees.non-amputees) and to teach amputees how to performdaily operations like sitting down and walking up anddown stairs. All this will help amputees regain their selfconfidence and play an active role in society.Prosthetic gait training has several goals: to help amputeesadapt to their new condition, to achieve optimal weightbearing on the prosthesis, to improve balance and reactionto disturbance, to restore the optimal gait pattern, toreduce the amount of energy needed to walk (transfemoral amputees use up to 50% more energy thanIn administering the exercises, daily hands-on, individualsessions are recommended in addition to group sessions.It is also advisable to work closely with technicalprosthetics personnel with a view to jointly assessing thepatient’s progress and analysing the causes of observedgait defects, preferably on a daily basis.It is important that the exercises be built up graduallyto reduce the risk of skin abrasions and consequentdelays in the fitting process. A progressive, step-by-stepapproach will also minimize gait defects, which hampercosmetic and functional restoration.

The exercises are described in four chapters:1.2.3.4.Weight-bearing and balance exercisesSpecific gait-training exercisesAdvanced exercisesFunctional exercisesIn view of the above, patients should be discouragedfrom walking by themselves as soon as they have beenfitted with prostheses, however eager they may be to doso. Instead, they should follow an exercise programmeallowing them to improve their abilities gradually.This booklet presents the basic aspects of gaittraining, taking into account the constraintsoften posed by lack of qualified personnelin situations where aid organizations work.Your comments and/or suggestions are mostwelcome and can be addressed to:ICRC Physical Rehabilitation Programmes19, avenue de la Paix1202 GenevaSwitzerlandTel: 41 22 734 6001E-mail: icrc.gva@icrc.org5

Weight bearingand balance

1Weight bearing and balanceIt is important to ensurethat the patient performsthe exercises accurately,always maintaining thecorrect posture.

1.1 Partial weight bearing (two-hand support)Step 1Stand between the parallelbars using both hands tosupport yourself.8Step 2Shift the body weight from the soundleg to the prosthesis (a pair of scalesmay be useful to measure the weightshifted).

CHAPTER1.2 Partial weight bearing (one-hand support)Step 1Stand between the parallelbars using one hand tosupport yourself.Step 21Shift the body weight from thesound leg to the prosthesis.Always use the contralateral hand.9

1.3 Partial weight bearing (fingertip support)Step 1Stand between theparallel bars using onlyyour fingertips to supportyourself.10Step 2Shift the body weight from thesound leg to the prosthesis (apair of scales may be useful tomeasure the weight shifted).

CHAPTER1.4 Partial weight bearing (without support)Step 1Stand between the parallelbars without support.Step 21Shift the body weightfrom the sound leg to theprosthesis.11

1.5 Partial weight shift (two-hand support)Step 1Stand between the parallelbars using both hands tosupport yourself.12Step 2Shift the pelvis from rightto left and vice versa,without moving yourshoulders.

CHAPTER1.6 Partial weight shift (one-hand support)Step 1Stand between the parallelbars using one hand tosupport yourself.Step 21Shift the pelvis from right toleft and vice versa. Alwaysuse the contralateral hand.13

1.7 Partial weight shift (without support)Step 1Stand between theparallel bars withoutsupport.14Step 2Shift the pelvis from rightto left and vice versa,without moving yourshoulders.

CHAPTER1.8 Partial weight shift (two-hand support)Step 1Stand between the parallel barson both legs using both hands tosupport yourself.Step 21Shift the pelvis forward andbackward, without moving yourshoulders.15

1.9 Partial weight shift (one-hand support)Step 1Stand between the parallel barson both legs using one hand tosupport yourself.16Step 2Shift the pelvis forwardand backward. Always usecontralateral hand.

CHAPTER1.10 Partial weight shift (without support)Step 1Stand between the parallel barson both legs without support.Step 21Shift the pelvis forward andbackward.17

1.11 Pelvic rotation18Step 1Step 2Stand between the parallelbars with or without support.Rotate the pelvis.

CHAPTER1.12 Sideward walking (two-hand support)Step 1Stand between the parallel barsusing both hands to supportyourself.Step 21Walk sideways towards theprosthetic side and back.19

1.13 Full weight shift (two-hand support)Step 1Stand between the parallelbars with one leg in frontof the other using bothhands to support yourself.20Step 2Shift the body weight fromone leg to the other by movingthe pelvis and trunk from frontto back, with or without thesupport of your arms.Step 3Repeat the exercise,changing the initialposition of your legs.

CHAPTER1.14 Full weight shift (without support)Step 1Stand between the parallelbars without support andwith one leg in front of theother.Step 2Shift the body weightfrom one leg to the otherby moving the pelvis andtrunk from front to back,with or without the supportof your arms.1Step 3Repeat the exercise,changing the initialposition of your legs.21

1.15 Heel strike (with or without support)Step 1Stand between theparallel bars with orwithout the support ofyour hands.22Step 2Step forward with theprosthesis.Step 3Keep the knee jointstraight and push theheel downwards.

CHAPTER1.16 Handball (with or without support)Step 1Step 2Stand between the parallel barswith or without support; placethe sound leg on a raised object.Play catch with the instructor.123

1.17 Balance boardStep 1Stand between theparallel bars on abalance board usingboth hands to supportyourself.24Step 2Shift the body weightfrom one leg to the other.Step 3Repeat the exercise, shiftingthe body weight from front toback.

Step 1Step 2Stand between the parallel barswith or without support.Step over an object with thesound leg.CHAPTER1.18 Obstacle stepping (with or without support)125

1.19 Football (with or without support)26Step 1Step 2Stand between the parallel barswith or without support.Kick a ball with the sound leg.

CHAPTER1.20 HandballStep 1Step 2Stand on both legs between theparallel bars.Play catch with the instructor.127

Notes28

CHAPTERNotes129

Specificgait training

2Specific gait trainingIt is important to ensurethat the patient performsthe exercises accurately,always maintaining thecorrect posture.

2.1 Sound-leg step forward (two-hand support)Step 1Stand between the parallel barsusing both hands to supportyourself.32Step 2Step forward with the sound leg,keeping hands parallel to theprosthesis.

Step 1Stand between the parallel barsusing both hands to supportyourself.Step 2CHAPTER2.2 Sound-leg step backward (two-hand support)2Step backward with the soundleg, keeping hands parallel tothe prosthesis.33

2.3 Sound-leg step through (two-hand support)Step 1Stand between the parallel barsusing both hands to supportyourself.34Step 2Step forward and backward with thesound leg, keeping hands parallel to theprosthesis. Hold the prosthesis slightly inadduction. Maintain an upright position,allowing the trunk and shoulders tomove backward and forward, but withoutlateroflexion.

Step 1Stand between the parallel barswith support of one hand.Step 2CHAPTER2.4 Sound-leg step through (one-hand support)2Step forward and backward withthe sound leg. Always use thecontralateral hand.35

2.5 Sound-leg step through (without support)Step 1Stand between the parallel barswithout support.36Step 2Step forward and backward with thesound leg, holding the prosthesisslightly in adduction. Maintain anupright position, allowing the trunkand shoulders to move backward andforward, but without lateroflexion.

Step 1Stand between the parallel barsusing both hands to supportyourself.Step 2CHAPTER2.6 Prosthetic-leg step forward (two-hand support)2Step forward with the prosthesis,keeping hands parallel to thesound leg.37

2.7 Prosthetic-leg step backward (two-hand support)Step 1Stand between the parallel barsusing both hands to supportyourself.38Step 2Step backward with the prosthesis,keeping hands parallel to thesound leg.

Step 1Stand between the parallel barsusing both hands to supportyourself.Step 2Step forward and backward with theprosthesis, keeping hands parallel to thesound leg and holding the prosthesisslightly in adduction. Maintain an uprightposition, allowing the trunk and shouldersto move backward and forward, butwithout lateroflexion.CHAPTER2.8 Prosthetic-leg step through (two-hand support)239

2.9 Prosthetic-leg step forward (one-hand support)Step 1Stand between the parallelbars using one hand to supportyourself.40Step 2Step forward and backward withthe prosthesis. Always use thecontralateral hand.

Step 1Stand between the parallel barswithout support.Step 2CHAPTER2.10 Prosthetic-leg step through (without support)2Step forward and backward withthe prosthesis.41

2.11 Walking between the parallel bars (one-hand support)Step 1Stand between the parallel bars.42Step 2Walk between them usingone hand to support yourself.Always use contralateral hand.No lateroflexion of the trunk oruneven step length.

Step 1Stand between the parallel bars.Step 2CHAPTER2.12 Walking between the parallel bars (without support)2Walk between them withoutsupport. No lateroflexion of thetrunk or uneven step length.43

Notes44

CHAPTERNotes245

Advancedexercises

3Advanced exercisesIt is important to ensurethat the patient performsthe exercises accurately,always maintaining thecorrect posture.

3.1 Bouncing a ball (stationary position)Step 1Stand in balance on both legs.48Step 2Bounce a ball on the ground.

CHAPTER3.2 Bouncing a ball (walking)Step 1Step 23Walk while bouncing a ball on the ground.49

3.3 Balancing a stickStep 1Stand a stick upright on yourhand.50Step 2Try to balance it.

CHAPTER3.4 Balancing on the prosthesisStep 1Step 23Stand in balance on the prosthesis; flex the sound leg, trying to keep your balance.51

3.5 Walking on an uneven surfaceStep 1Step 2Walk on an uneven surface, keeping to a narrow path.52

CHAPTER3.6 Going up and down a slopeStep 1Go up or down a slope.Step 23Place the body weight on theprosthesis while doing this.53

3.7 Jumping (for below-knee amputees only)Step 1Step 2Jump from a spread-leg position to a closed-leg position and back again.54

CHAPTER3.8 RunningStep 1Step 23Place the forefoot of the prosthesis on the ground and stretch the knee, keeping the trunk slightly flexed.55

Notes56

CHAPTERNotes357

functionalexercises

4Functional exercisesIt is important to ensurethat the patient performsthe exercises accurately,always maintaining thecorrect posture.

4.1 Rising from a chairStep 1Place the sound leg under thechair and flex the trunk.60Step 2Stand up.

CHAPTER4.2 Climbing a staircaseStep 1Climb a staircase, starting withthe sound leg.Step 24Follow with the prosthesis.61

4.3.1 Descending a staircase: sound leg step through(for above-knee amputees)Step 1Descend a staircase, startingwith the prosthesis.62Step 2Follow with the sound leg,which comes to rest next to theprosthesis.

Step 1Descend a staircase, placing theheel of the prosthesis on theedge of the first step down.Step 2CHAPTER4.3.2 Descending a staircase: sound leg step through(for below-knee amputees)4Step through onto the next stepwith the sound leg which comesto rest next to the prosthesis .63

4.4.1 Sitting down and getting up from the floor(method 1: forward)Step 1Place the prosthesis inretroflexion, abduction andexternal rotation.64Step 2Bend the trunk and supportyourself on both hands and oneknee; turn and sit down. Do thereverse for getting up.

CHAPTER4.4.2 Sitting down and getting up from the floor(method 2: backward)Step 1Move the prosthesis forward.Step 24Bend the knee and supportyourself on both hands; sitdown. Do the reverse for gettingup.65

4.5 Sitting down on a chair (for bilateral amputees)Step 1Face the chair and place onehand on the seat of the chair andthe other on the back.66Step 2Turn your body and flex yourlegs.Step 3Sit down and do the reverse forgetting up.

CHAPTER4.6 Lying down (for bilateral amputees)Step 14Place both hands on the floor.Step 2Increase the distance between handsand feet.Step 3Turn around, sit down and lie downusing the elbow.67

4.7 Getting up from the floor (for bilateral amputees)Step 1Come to a sitting position; turn aroundand support yourself on your handsand knees.68Step 2Stretch one prosthesis backward andoutward; shift the body weight to thestretched prosthesis and both arms;stretch the other prosthesis; decrease thedistance between hands and feet andstand up.

CHAPTER4.8 Weight carryingStep 1Step 24Walk carrying a weight on the prosthetic side.69

Notes70

CHAPTERNotes471

CreditsThis CD ROM/booklet is based on an internal ICRC document produced in 1990 by Theo Verhoeff.The team:International Committee of the Red Cross (ICRC)Theo Verhoeff, PT, MPHBarbara Rau, PT, MPTScFrançois Friedel, PTDeutsche Gesellschaft für Technische Zusammenarbeit (GTZ)Heinz Trebbin, Project ManagerUniversity Don Bosco, El SalvadorGilberto Meléndez, Designer and AnimatorHector Rodríguez, AnimatorBibliography: Engstrom B., Van de Ven C.Therapy for Amputees, Churchill Livingstone, London, 199972

MISSIONThe International Committee of the Red Cross (ICRC) is an impartial, neutral andindependent organization whose exclusively humanitarian mission is to protect thelives and dignity of victims of armed conflict and other situations of violence and toprovide them with assistance.The ICRC also endeavours to prevent suffering by promoting and strengtheninghumanitarian law and universal humanitarian principles.Established in 1863, the ICRC is at the origin of the Geneva Conventions and theInternational Red Cross and Red Crescent Movement. It directs and coordinates theinternational activities conducted by the Movement in armed conflicts and othersituations of violence.

For further information, visit09.20080936/002International Committee of the Red Cross19, avenue de la Paix1202 Geneva, SwitzerlandT 41 22 734 60 01 F 41 22 733 20 57E-mail: shop@icrc.orgwww.icrc.org ICRC, September 2008300www.icrc.org

The exercises are described in four chapters: 1. Weight-bearing and balance exercises 2. Specific gait-training exercises 3. Advanced exercises 4. Functional exercises In view of the above, patients should be discouraged from walking by themselves as soon as they have been fi

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