Learning to walk with a prosthesis is one of the main goals of lower extremity amputee rehabilitation. An amputation can occur at various levels of the lower extremity. With an above knee amputation, there are more factors to consider during gait training for these individuals.
In this article, we discuss the concept of an above knee amputation and discuss different types of training that an experienced physiotherapist will take you through to help you become more comfortable and independent when walking on your prosthesis.
Tables of Contents:
- What is an above knee amputation?
- Balance training after above knee amputation
- Overground prosthetic gait training
- Treadmill gait training after above knee amputation
- Stair training after above knee amputation
- Running training with prosthetic
- Learning to walk after above knee amputation: client story
- Conclusion
What is an Above Knee Amputation?
An above knee amputation (AKA), also known as a transfemoral amputation, refers to the removal of the lower limb anywhere above the knee. This procedure may be necessary for a wide variety of reasons, such as trauma, infection, tumor, and vascular compromise.[i]
There are increased challenges with gait training after an AKA due to loss of the knee joint. For example, learning to walk again with a prosthesis requires more coordination and energy compared to a lower-level amputation. However, walking and many other skills can still be accomplished with an AKA. A registered physiotherapist with experience in leg amputee rehabilitation can help you to accomplish these goals.
Balance Training After Above Knee Amputation
Balance is also affected with an AKA due to the loss of sensation and position awareness that comes with losing a large part of the body. Therefore, balance training and learning how to bear weight through the prosthesis in a safe manner is an important part of rehabilitation.
When first starting to stand on your prosthesis, exercises will often include static and dynamic weight shifting, tandem standing, and various stepping activities, among others. Dual-task training has also been found to improve balance and mobility in individuals with AKAs.[ii]
Dual-task balance training involves performing a balance or mobility exercise while also completing a cognitive (e.g., math problems) or motor task (e.g., holding a tray) at the same time. Learning how to perform other tasks while walking on your prosthesis will help to decrease your risk of falls and improve your efficiency of walking.
Overground Prosthetic Gait Training
Evidence suggests that breaking down the components of walking and practicing them individually helps to improve the process of walking as a whole.[iii] Throughout the gait training process, the physiotherapist may use verbal and/or hands-on cues to help support and guide you through correct mechanics with your prosthesis.
The way that you control your prosthetic knee joint will largely depend on the type of prosthetic that you have. Check out our blog “Prosthetic Leg Fit: Types of Knee Prosthesis for Leg Amputations” to learn more about the different types of knee prostheses.
Gait training will often begin in parallel bars and supports will be decreased as confidence and mobility improves. Initial exercises often include stepping forward and backwards with the sound leg, stepping forwards and backwards with the prosthesis, then practicing step-over-step.
Once this can be accomplished safely, different walking patterns can be practiced including side-stepping, backwards walking, tandem walking and crossover walking to help accommodate for everyday life.[iv]
Treadmill Training for Above Knee Amputation
Supervised walking is also an important part of gait training and treadmills are a great tool for this. Treadmill training can help to improve walking speed, step length and other gait-related factors to create a more normal and comfortable walking pattern with your prosthesis.[ii]
In addition to overground training, evidence suggests incorporating treadmill training with visual feedback, body weight support, or as a home exercise.[ii] Treadmill training has also been found to improve walking speed and promote more symmetrical overground gait pattern in individuals with a long-standing AKA and microprocessor knees.[iv]
Stairs Training with an Above Knee Amputation
Being able to walk up and down stairs allows for easier mobility within home and community environments. Stair training often starts with practicing stepping up and down onto one step with hand support. This can be progressed by decreasing hand support and increasing the step height to simulate typical stairs in the community.
As you become more confident and controlled using a single step, you can progress to using stairs. Most individuals with an AKA use a handrail or other assistive devices when using stairs. Additionally, most individuals with an AKA use a step-to-step method for stair climbing.[v] This involves leading with your sound leg when going upstairs and bringing your prosthesis to meet it on the same step. Then when going downstairs, leading with your prosthesis and bring your sound foot to meet it.
A more advanced method is a skipping pattern where you can ascend two steps at a time leading with your sound foot and bringing your prosthetic to meet it on the same step.[v] Step-over-step stair pattern is most easily achieved with a microprocessor knee.
Running Training with a Prosthetic
Running is a commonly sought after activity that allows individuals with lower extremity amputees to be able to move quickly in emergent situation as well as return to sport and other recreational activities.
There are different methods of running or quickly walking that can be taught to individuals with an AKA. One method is a “hop-skip” which allows you to move quickly for short distances on a fixed prosthetic knee.[vi] Another is leg-over-leg running on a fixed knee which can be beneficial to maintain stability during long distance running. And lastly, leg-over-leg running on a bendable prosthetic knee allows for sport-specific activities.[vi]
Learning to Walk After Above Knee Amputation Client Story
I have successfully implemented many of these training techniques with a Propel client with a left AKA. When first analyzing the client’s walking pattern, they were using a single point cane and there was a right hip drop noted when they were standing on their prosthesis. This suggested to me that there was weakness in the left glute/hips of the residual limb.
Therefore, treatment started by focusing on strength training of the hip and glute muscles. By ensuring that the residual limb could withstand the weight of their body when walking, we achieved a decrease in hip drop and improved normalization of the client’s walking pattern.
We also began more advanced overground gait training techniques including lateral walking, backwards walking, and crossover walking. This helped to reduce the risk of falls and allowed the client to become more comfortable when navigating different environments where these different techniques are required. This will help to achieve the client’s goals of returning to hiking as well as work, both of which will require walking over various terrains.
Additionally, we incorporated treadmill training during their sessions with verbal cues to help facilitate postural adjustments and a more normal walking pattern. This allowed the client to practice making real-time changes to their walking pattern in a safe environment with the goal of decreasing falls risk.
Most recently, we implemented single leg balance training on the prosthesis as well as stairs training by stepping onto one step with the prosthesis and decreasing hand support as this becomes easier. The client can now successfully descend stairs step-over-step and has the goal of being able to ascend stairs step-over-step as well.
All these interventions have helped the client to become more confident and independent with their prosthesis. They have since decreased their use of their single point cane and have been classified under the highest mobility level for an amputee (K-level 4). They have also recently acquired a new prosthetic with a microprocessor knee. This prosthetic has an entirely new joint mechanism compared to their previous model, in addition to many new features that can be explored to assist with normalizing their gait pattern. Thus, gait training will continue to be an imperative part of their rehabilitation journey.
Above Knee Amputation Rehabilitation Conclusion
Gait training with a prosthesis allows individuals to become more confident and independent in their every day lives. The physiotherapists at Propel Physiotherapy are trained to guide you through the gait training process to help you meet all your functional goals.
If you have any questions about above knee amputee rehabilitation, please email or call us at 866-210-6335 to schedule a complimentary consultation with one of our clinicians.
