This Case Study describes the gait of a patient who underwent bilateral lower limb amputations, a transtibial amputation on the Right and a transfemoral amputation on the Left
Mr. NL is a 34 year old male bilateral amputee with a Right Transtibial amputation and a Left transfemoral amputation due to traumatic injuries. At the time of gait assessment, he was fit with an ischial containment socket along with a mechanical knee with a SACH foot on the Left side. On the Right side, he was using a thigh lacer type of prosthesis with a SACH foot.
LEFT Hip: Patient has moderate weakness in the hip flexor and abductor muscles (Flexor strength grade 3-/5, Abductor strength grade 3+/5) as well as moderate weakness in the hip extensors and adductor muscles (Extensor strength 3-/5, Adductor strength 3+/5). Passive range of motion was within normal limits and active range of motion was limited to 90 degrees of hip flexion and 30 degrees of extension.
Right Hip: Muscle strength was grade 5/5 for all muscles tested and the range of motion was within normal limits.
Right Knee: Knee extensor muscle strength was grade 3+/5 while the knee flexor muscle strength was grade 5/5. Active and passive range of motion was within normal limits.
Upper Extremities: For both right and left arms, muscle strength was 5/5 for all muscles tested and the range of motion was within normal limits.
The initial gait assessment identified several deviations at the ankle, knee, hip and the pelvis. These deviations affected all the 5 gait functions of:
(i) Balance/stability (as the patient is walking with a cane);
(ii) Equality/symmetry (asymmetrical step length);
(iii) Energy Conservation (trunk lean);
(iv) Progression (forceful knee extension) and
(v) Shock Absorption (limited knee flexion).
Gait assessment also revealed that the majority of these deviations were due to prosthetic causes, i.e. due to the type prosthetic knee and foot used by the patient.
As a result, the patient was prescribed a microprocessor controlled knee joint along with a dynamic response prosthetic foot. Along with the prosthetic components, physical therapy and gait training were also recommended to address the deviations at the hip and pelvis. The following video shows the patient’s gait with the prescribed prosthetic components. Note: there was a significant time difference (10+ years) between the initial and follow-up gait assessment of this patient.
Following the interventions, there was a significant improvement in the patient’ gait. The most notable improvement is the absence of a cane post-intervention. The patient’s balance and stability improved with the intervention, and he was able to walk not only without a cane, but also with symmetrical step length and stance time. There was also a moderate improvement in progression and shock absorption with the microprocessor knee. The energy consumption didn’t change after the intervention, as the patient was still walking with a trunk lean and a wide base of support. Overall, the intervention was effective as 3 out of the 5 functions showed improvement. The long period of time between the initial and follow-up gait assessments (10+ years) may have also contributed to the improved gait pattern.
It is recommended that the patient should continue with the same prosthetic components and seek physical therapy as needed. The deviations observed post-intervention, such as a wide base of support and trunk lean, are typical of bilateral amputees. These deviations may not see a significant improvement with therapy.