Prosthetic training

Prosthetic training with amputees, this means to practice the handling of the prosthesis and other devices. The patient needs to learn how to correctly use the prosthesis in everyday life to increase confidence in the prosthesis and their own capabilities.

The focus is on walking ‒ based on balance, strength and coordination. Especially for older individuals with limited mobility ‒ training poses special challenges.

Donning and doffing of a prosthesis

To put on and take off the prosthesis correctly is a basic ability for amputees: it is the basis for walking with a prosthesis, which must be practised first.

The family may have to help at first. So it is important also to include them in the rehabilitation process. However, the goal for the patient is to learn the donning and doffing process with some practice of his/her independently. There are various ways to put on a prosthesis, depending on the type of prosthesis and the characteristics of the residual limb.

In the following video you can see how a transtibial amputee can put on his/her below knee prosthesis with a "one way valve" system and a knee sleeve. As another example, the second video shows how an above knee amputee with a "pin liner shuttle lock" system puts his/her prosthesis on:


Different components and their effects on gait training

The shoe
Footwear is an often forgotten, but very important component in the care of the amputee. There are basic factors that should be considered.
Care should be taken that the sole of the shoe is not slippery. All shoes used should have the same heel height, although there are prosthetic feet that can adjust the heel hight - like Triton Smart Ankle. If you are uncertain, please consult the prosthetist. The heel of the shoe should also be not too hard, so that the patient can softly roll over the heel during walking, but still does not loose its control over the prosthesis.

Feet
The correct choice of the foot depends on the requirements of the amputee and the challenges the amputee faces in his daily life. Some prosthetic feet have a movable ankle, whereas others have no movement, but are characterized by different material properties and thus facilitate walking especially in initial contact, mid stance and terminal stance.

Feet with Energy Return
The base element of the foot is the heel, which is often simulated by spring molded carbon fiber plates. By building such a "spring", the energy, which is taken up at the initial contact, is released again in the toe-off phase. Furthermore, the heel stiffness is an important factor to have a safe initial contact in the gait cycle.

Prosthetic Knee Joint
In recent years, a lot has been invested in the further development of prostheses for knee joints. For transfemoral amputees, there is a large variety of different knee joints - in general, a distinction can be made between monoaxial/singleaxial and multi-axial knee joints. Depending on the degree of mobility and the activities of daily life, the amputee has different requirements. Due to the different demands of amputees, there are important factors during walking that are influenced by the type of prosthesis.

A monoaxial knee joint can be divided into mechanical, pneumatic, hydraulic or microprocessor controlled knee joints. The multi-axial knee joint is also called polycentric knee joint. They are usually only mechanically, hydraulically or pneumatically controlled and do not have a microprocessor-controlled unit. Whether it is a monocentric or polycentric knee joint, there are different advantages and disadvantages of the joints. At this point we will only mention some details and advantages of the most popular knee joints (for more and deeper information please sign up for a special seminar for therapists about Ottobock Trainings or have a look at the technical informations of the Ottobock prosthesis).

Advantage microprocessor prosthetic knee joints (MPK) e.g. Kenevo, C-Leg, Genium:

  • Dynamic stance phase stabilization
  • Support in descending stairs, slopes, sitting down
  • Swing Phase Control
  • The knee joint is always secure - high safety for the user

General advantage monoaxial knee joints (3R41,3R93) :

  • easy to understand the mechanism for the therapist and patient to initiate the stance and swing phase

Advantage of the polycentric prosthetic knee joint (3R60, 3R80, 3R106)

  • High safety, if alignment of the prosthesis is correct
  • Leg length reduction during swing phase
  • Plus of toe clearance for the user

The socket
The prosthetic socket is fulfilling a key element in a good prosthetic fitting and has to perform a variety of tasks. There are three important criteria that a good socket must fulfil: Support, stabilization and adhesion. When walking, it is important that the socket can be loaded by the amputee and that the axial forces are evenly distributed during load transfer. Another important point is to absorb the horizontal forces well so that the residual limb in the socket does not tilt back and forth, but is securely and firmly connected to the prosthesis. It is equally important to have a firm connection between the residual limb and the socket during the swing phase so that the amputee does not have the feeling of losing the prosthesis. This ensures safety and comfort when walking.


Gait training

In gait training for transfemoral amputees, the basic functioning of the knee joint also plays a major role - for transtibial amputees the foot is an important component for walking. Ideally, the training and education programme is therefore tailored to the prosthesis components being used. The programme should be aimed at relearning everyday motion sequences and explaining the functionality of the prosthesis to the patient.

First the patient has to learn how to shift the body weight on the prosthesis and stand on both legs equally between the parallel bars, like shown in the picture above. The patient should not carry all the weight with the arms and sound leg; he/she has to use the prosthesis too. As soon as he/she can walk between parallel bars, the patient can start the first exercises without support. The first objective is to gradually reduce the use of any walking aids he/she may require initially. This is achieved through a combination of correct walking technique, activities of daily living and strengthening the torso musculature.

Basic recommendation for the first steps in the parallel bars:

  • Stand close to the patient (e.g. directly behind)
  • Make sure the patient stands with upright posture
  • Give support at the hip if needed
  • Perform some manual resistance to increase the level of difficulty.

Here you can find gait training tutorials for different kinds of prosthetic knee joints on YouTube:

Stance phase training

The largest part of the gait cycle is made up by the stance phase with 60%. For many users, this phase is significantly shortened compared to the healthy side, so a therapeutic focus for gait training should be based primarily on stance phase training. It requires the user to have increased confidence in the prosthesis and adequate good stability in the trunk as well as in the affected leg.

Swing phase training

The first steps on the prosthesis require good coordination skills, and especially when users receive a new prosthesis and take the first steps, they must first reintegrate the prosthesis into their body scheme. This also means that the user knows how the swing phase is triggered and how the prosthesis swings forward. The user has to learn which muscles have to be activated. An example exercise: the therapist and the user stand between the walking bars. The therapist has a ball in front of her/him, the user should now take a step with the prosthesis and then kick the ball lightly. The hip should not be raised during the exercise.

Ways to practise:

Balance, coordination and trunk stability

Balance, coordination and stability training should be a further part of prosthesis training. Especially in everyday situations unexpected movements can arise in which physical reactivity is required. This skill can be improved and built up through exercises during training.

An example excercise for the patient is her/him holding a large ball ahead or over her/his head. The ball should be held, thrown and stabilized in different positions. You should instruct the patient and observe the correct execution.

Sitting down and standing up with a prosthesis

Appropriate weight distribution while sitting down and standing up is dependend on the prosthetic knee joint. Users with a transfemoral amputation fitted with a knee joint with sit down support can put weight on both legs while sitting down. The Prosedo, Kenevo, C.Leg 4, Genium or Genium X3 have this function, for example. This results in significant relief of the sound side, which helps prevent premature problems from excessive strain.

Users with a transtibial amputation should also put the same amount of weight on both legs when sitting down and standing up for the same reason.

Activities of daily life - ADL

Training exercises need to be individually chosen, based on the social background history. The training must be realistic and related to everyday life.

Examples for ADL training

  • Standing up from the ground
  • Managing stairs
  • Managing slopes
  • Managing obstacles
  • Walking on different surfaces/uneven ground
  • Training for specific free-time and work activities
  • Getting up from the ground

The following pictures show you an example of "how to get up from the ground".

Ottobock apps for therapy

A man and a woman with prosthesis are working out using the Fitness for Amputees App by Ottobock.

Ottobock Fitness for Amputees app

Further ideas and more exercises you can find in the Ottobock Fitness for Amputees App.

Click here to get the App for free.

Ottobock therapist helping a prosthesis user.

New for therapists: The Kenevo A-B-C app

The Kenevo A-B-C app now lets therapists respond to the patient's needs in an even more individual way and provide users with perfect support as they work towards their therapy goals. During each training session, the physiotherapist can adjust the prosthetic joint in response to the user’s actual needs and abilities.

iOS: Download it from the App Store for free.
Android: Download it from the Google Play Store for free.


Prosthetic Assessments

Below you can see three validated, standardized tests for different mobility grades, which can be implemented quickly without much material and can determine the current mobility level, the therapy improvement after a period of therapy among other things.

6 Minutes Walk Test (6MWT)

This test measures the distance the patient is able to walk over six minutes on a hard, flat surface. The goal is to walk as far as possible around the pylons but still feeling save. The patient can choose her/his own pace, use assistive devices and rest as needed.
Objective: Recording the level of the patient’s endurance
Equipment: Two cones
Number of runs: One
Starting position: Patient standing at defined spot
Instructions for the patient:

  • Try to complete the marked course as many times as possible in six minutes. Stick to the same walking speed as long as possible; you may slow down or stop and rest if you need to
  • Carry on as soon as you can
  • You may use devices if you need to

Recommendation: Demonstrate the test to the patient
Start measurement of each run: When the patient is ready say “Go!” and start stopwatch
End measurement of each run: After six minutes. Document the distance covered and the devices used


Timed Up and Go Test (TUG)

This test assesses mobility, balance, walking ability and the risk of falling. The time that the patient needs to rise from a chair, walk three meters, turn around, walk back to the chair and sit down again is measured. This test will be repeated three times and the user is allowed to use assistive devices if necessary.
Objective: Recording the level of the patient’s balance
Equipment: Chair with armrests
Number of runs: Three
Starting position:

  • Patient should be sitting on a chair
  • Arms are resting on the armrests
  • Back is leaning against the back of the chair
  • Devices are nearby (do not use for standing up, only for walking)

Instructions for the patient:

  • Stand up from the chair
  • Walk at a speed that is comfortable for you during the test
  • Turn around after three metres (after crossing the marker)
  • Return to the chair
  • Sit down and lean against the back of the chair
  • You may use devices to walk if you need to

Recommendation: Demonstrate the test to the patient
Start measurement of each run: When the patient is ready say “Go!” and start stopwatch
End measurement of each run: When the patient’s back is leaning against the back of the chair. Document for each run the time in seconds and the devices used


Four Square Step Test (FSST)

Test procedure may be demonstrated and one practice trial is allowed prior to administering the test. Two trials are then performed, and the better time (in seconds) is taken as the score. Timing starts when the right foot contacts the floor in square and ends when the patients stands with both feets back in the starting position.

Patient steps over four canes set-up like a cross on the floor with the tips of the canes facing together.
At the start of the test, the patient stands on the upper left square (in Square 1, facing Square 2).

The stepping sequence is (clockwise):

  • Square 1, Square 2, Square 3, Square 4, return to Square 1 with both feet

Then (counterclockwise):

  • Back to Square 4, Square 3, Square 2, and end in Square 1 with both feet.

Objective: Recording the level of the patient’s coordination
Equipment: Four canes, stopwatch
Number of runs: One trial run, two definitive
Starting position: Patient stands in square 1, facing towards square 2
Instruction for the patient:

  • Try to carry out the sequence as quickly as possible without touching the rods
  • Both feet must have contact with the floor in each field.
  • If possible, try to perform this test while looking straight ahead
  • You may use devices if you need to
  • Sequence: 1 > 2 > 3 > 4 > 1 > 4 > 3 > 2 > 1

Recommendation: Demonstrate the test to the patient
Start measurement of each run: When the patient is ready, say “Go!” and start the stopwatch as soon as the first foot touches square 2
End measurement of each run: When the second foot touches square 1 again. Document the time in seconds and the devices used


Glossary

There are many different, specific technical terms for prosthesis fitting. Here you will find an overview and explanation of the most important terms that you may need in your therapeutic treatment and in communication with doctors and orthopaedic technicians.

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Education

To support you in your daily work with amputees we offer targeted seminars. All seminar impart specific knowledge about our products and how to train with amputees, to make it easier and more effective.

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Download Area

Find information brochures for you and your patients here.

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