We continue our series on improving the professional relationship between the prosthetist and the physical therapist by discussing the last two steps in the therapist's evaluation of a prosthesis:
3. Evaluate the static alignment.
4. Evaluate the dynamic alignment.
Evaluate the static alignment: First, with the patient in the parallel bars, be sure that the prosthesis is the correct height. Often, with individuals that have a transfemoral amputation, the sacrum may be out of alignment when the prosthesis is fit. This becomes a HUGE problem as pelvic alignment is most definitely in the scope of practice for a physical therapist, but not for a prosthetist. Prosthetists fit the patient dependent upon the alignment of the pelvis on the day that they visit their office. If the pelvis is not stable, the alignment/height could change by the time that the patient is in the physical therapy clinic! Check the height in standing to assure that the PSIS and iliac crests are symmetrical. If they are not, utilize a cast shoe to double check the height and allow the gait training session to continue without interruption. I often allow the patient to wear the cast shoe for several days to continue to confirm the proper height and then assist the prosthetist with knowing the proper height for the limb when the patient is next are able to visit their office. Also, be sure to test the hip flexion contracture angle with the Thomas test and then be sure that the alignment is consistent with the flexion angle in the socket. If not, the knee alignment may not be correct and you may have to contact the prosthesist to assure that the patient is properly accommodated. Finally, be sure that you palpate the entire rim of the socket to confirm that the patient is fitting into the limb as it is designed and has not donned it improperly.
Evaluate the dynamic alignment: After assessing the first three steps, check the static alignment of the prosthesis while the patient is ambulating. First, assess that the step length is appropriate. If the patient trusts the prosthesis appropriately and has effective gait training, the step length should be even. Also, determine if the patient demonstrates any rotational movement such as a medial or lateral "whip" in the limb. Assess the patient's hip movement and educate the patient to complete proper hip flexion through the swing phase to avoid this "whip." If the whip persists despite appropriate gait training, it is important to contact the prosthetist to assist with alignment. Finally, assess lateral trunk lean. A lateral trunk lean is common as a patient learns to ambulate with a prosthesit but SHOULD NOT be present with proper gait training. If the patient continues to lean despite proper training, the patient may not be fitting into the socket correctly, or the socket may not be the correct height and consulting the prosthetist is imperative.
Check back next week for the final part in this series to tie it all together and promote the best interdisciplinary care for this patient population.