ependymal layer

mantle: gray matter

marginal: white matter

medulla: hypoglossa: innervates intrinsic and extrinsic muscles of the tongue

abducens: innervates lateral rectus muscle of the eye

Midbrain: trochlear: innervates superior oblique

oculomotoer: innervates extraocular muscles

Pons: facial & motor trigeminal (V3)

Medulla: spinal accessory

Nuscleus ambiguus (CN 9 & 10) muscles of larynx, pharynx, soft palate, and upper esophagus)

Midbrain: edinger-westphal nucleus: CNIII; pregang paraysymp to pupillar sphincter and ciliary muscle

Pons: superior salivatory nucleus: CN7; pregang parymp to submandibular, sublingual, lacrimal glands

Medulla: dorsal motor nucleus of vagus

nucleus ambiguus: 10

inferior salivatory nucleus: 9

• arteriosclerosis obliterans
• chronic venous insufficiency
• thromboanglitis obliterans *buerger's disease 

narrowing and occlusion of the arterial  lumen of the large arteries

-AKA arterial insufficency

• >50 years old
• tobacco use
• males>females
• obesity
• HTN
• sedentary lifestyle
• hyperlipids 

narrowing and occlusion of the arterial lumen of the medium and small arteries

-aka arterial insufficiency

• > 40 years old
• tobacco
• males > females
• obesity
• HTN
• sedentary lifestyle
• hyperlipids 

• intermittent claduication
• decreased pedal pulses
• dry skin/hair loss
• clubbing of toenails
• ischemia
• ulceration on shins
• pain relieved in standing or in dep. position 
• with diabetes:
• same as above plus:
• decreased/absent sensation
• renal complications
• impaired vision

• palpation of pulses
• dependent rubor test
• walking test
• sensation
• ABI index 

• femoral-popliteal bypass
• angioplasty: go in with balloon and inflate and take out plaque
• endarterectomy: tool that breaks up plaque and cleans out and suck dry 

• arterial ulcer treatment
• bed rest
• limb protection
• gentle indirect warming
• avoid topical agents
• avoid leg elevation
• arterial ulcer limb protection
• pad the limb, no compression
• cottom webbing between toes
• warm temp
• preserve joint mobility
• dietary management
• no tobacco
• ambulation to increase collateral circulation
• active exercises 

• compromised bf of superficial veins as result of perforating valves, increase systolic pressure, and decrease BF
• leads to proliferation of venous capillaries and increases the fibrins leaking in to the interstitial tissues
• causes: decrease BF, cell death, edema 

• 1% of general population
• superficial or deep veins
• incidence increases with age 

• edema
• dilated veins
• dermatitis with indurated skin
• ulcerations proximal to medial mallelus
• ulcers are weepy with ill-defined borders
• pain relieved with elevation 

• circumferential measurements
• pulses
• skin inspection 

• cleansing, avoid W/P
• intermittent compression
• elevation
• ambulation
• dress wound
• compression stockings, elastic bandages, unna boots 

• inflammation of small and medium arteries and veins involving both the LE & UE
• directly related to smoking 

• males 20-40
• tobacco users 

• bilateral ischemia
• ulcers
• phlebitis
• dysthesias
• pedal claudication
• pain with rest 

• loss of pain and temp sensation distal to the knee
• stockingdistrubition 

• loss of sympathetic control
• leads to tough, dry skin 

• neurogenic, sympathetic arthropathy that results from loss of proprioception, pain and temperature sensation
• demineralization of the bones, which weakens them and repetitive trauma leads to silent fractures and deformities 

• prominent dorsal veins
• edema
• increased skin temp
• visible deformity of the mid foot 

• clawing deformity of the foot
• HTN of the MTP, flexion of the PIP
• flexion contractures of IP joints
• foot drop 

• osteomyelitis (other sepsis)
• infection of bone often due to wound/infection
• destruction with infection
• infection spreads with repetitive forces 

• through history
• pt. knowledge of the disease and consequences
• vascular assessment
• pulses, cap refil, doppler studies
• sensation
• proprioception, light touch, pain/temp
• skin inspection
• met heads
• lateral great toe
• digits 2-5
• medial and lateral mid foot
• calcaneus 

• toe nails: broken, crack, sharp
• broken skin: between toes, sides of feet, top and ends of toes, soles
• callus: cracks
• drainage: from a sore
• odor 

• daily and after activities
• avoid HOT water
• mild cleansing agent, AVOID perfume soaps
• dry completely (between toes)
• minimize force/friction of skin
• use of moisture
• toenails trimmed straight 

• NEVER:
• walk barefoot
• use adhesive tape
• put feet in hot water
• soak feet
• use OCP on corns, calluses or to treat nails 

• dry, white cottom or whool socks, loose fitting
• leather upper, tight enough in hind foot to prevent slipage
• custom modled inserts
• extra depth in toe box
• inspect shoes for foreign objects
• wearing schedule for new shoes 

• decreases plantar pressures
• careful application and close follow-up
• redistributes walking pressures
• prevents direct trauma
• reduces edema
• immobilization of joint and soft tissues
• average healing time=6wks
• never cut window in case
• reduce activity by 2/3
• change case 7-10 days
• contraindications: infection, hypotrophic skin 

• combo of AGO & custom boot
• same advantages as total contact casting
• indicated for Charcot joint or chronic ulcers
• easily adjusted to alter wt bearing surface
• sock adjustment for volume control
• rocker sole for ambulation
• contralateral shoe height adjustment
• permits daily inspection & cleansing 

• reduce edema and promote healing
• prevent loss of ROM
• increase UE and LE strength
• mobility and self care
• sound limb care
• assist with limb loss adjustment 

• denial
• bargaining
• anger
• depression
• acceptance 

• 3 types of dressings
• soft dressing
• rigid dressing
• semi-rigid dressing
• level of amputation
• surgical technique
• healing requirements
• pt. compliance
• MD PREFERENCE 

• objective:
• provide protection, support and graded pressure to residual limb
• materials:
• sterile dressings, gauze, cottom padding, elastic bandages (ACE), shirinkers 
• advantages:
• ease of application, able to inspect wound
• disadvantage:
• difficult to control moisture, temp and streility of wound, potential tourniquet effect, slippage and mov't of dressing

• objective
• provide sterile dry environment, distal end pressure and avoid edema
• materials:
• semi: unna paste, felt cotton, polyurethane pads
• rigid: plaster, fibgerglass, plastics with padding
• advantages
• good support for surgical site
• greater confidence with movement
• limb protection
• reduction of unncessary wound inspections
• disadvantages
• if applied improper, can promote poor cirulation
• inability to quickly and rountinely access wound

describe the objective, material advantages, and disadvantages of a immediate post operative prosthesis (IPOP)

• objective: promote early bipedal ambulation
• materials: plaster, fiberglass, plastic, pylon, inexpensive foot
• advantages: provides a socket and temporary prosthesis for psychological and physiological benefits of ambulation, maybe decreases severity of phantom pain?
• disadvantages: potential risk for falls,
• limited wt bearing could impair healing
• if not removable, difficult to access wound
• hard to equally distribute pressure over the dressing 

• use lotions to moistureize skin
• deep friction massage perpendicular to, parallel to and once healed over the incision/scar to mobilize scar tissue to prevent adhesions 

• residual limb often hypersensitive to stimuli
• involves introducing various stimuli to the limb to re-educate the NS
• ex: massage, cotton swabs/balls, tapping, reflex hammers etc 

• paster case is suspended with stockineete
• prosthetic socks can be used inside as shrinking occurs
• eliminates rewrapping and reduces likelihood of distal edema
• protects limb and can allow early wt. bearing 

• easy to do with fair hand strength
• provides for uniform compression
• tends to be more expensive than other options 

• patient and caregiver training
• pressure gradient must decrease from distal to proximal
• turns of the bandage must be made on the diagonal to prevent constriction
• must be rewrapped frequently (up to ever 4-6 horus) 

• BKA
• abrasions over cut end of tibia
• reverse pressure gradient creating a bulbous distal end to residual limb
• above knee amp
• creating an adductor roll
• reverse pressure gradient creating a turnip shaped limb 

• vascular disease & infection
• trauma
• tumor
• congenital
• other 

• osteogenic sarcoma 

• k0: has no potntion, non prosthetic user
• K1: limited potential for ambulation, limited pros
• K2: ability to traverse low level barriers, unlimited pros household
• K3: ambulation veriable cadences-unlimted community
• K4: ability beyond basic amb, active adult, athlete or child

• mid-calf
• need 7 1/4'' clearance for flex foot
• preserve all possible length 

• patellar tendon
• anterior compartment
• medial flare
• shaft of tibia
• popliteal fossa
• gastroc
• distal end 

• lateral tibial condyle
• peroneal nerve
• fibular head
• crest of tibia
• distal cut fibula
• HS
• anterior distal tibia 

• utilizes gel-type liner
• pin or sleeve suspension
• overall model reduction to load bone and soft tissue
• rounder socket shape vs. PTB
• contraindication: UE involvement 

• elongate tissue to create stiffness
• wt. bearing on fluid
• more cylindrical in shape
• OB Harmony "VASS"-vacuum suspension sockets
• positive pressure 

• have good subcutaneous tissue
• full function of UE
• best suspension & increased proprioception
• difficult to don
• must clean daily
• with or without lock 

• ossur seal-in liner
• no pin/lock
• expulsion valvle
• various lock and pin types
• serrated
• mooth clutch
• lanyard 

• longer residual limbs
• conceals trim lines
• excellent suspensions
• difficult to don 

• short ot very short limbs
• require increased ML stability
• less suspension straps
• increases wb surface
• difficult to achieve suspension with obese or muscular thighs 

• longer residual limbs
• good suspension over patella
• kinesthetic hyperextension stop
• can use with waist belt
• can be restrictive in sitting 

• increased WB surface
• maximum ML stability
• heavy
• uncosmetic
• inherent pistoning 

• used to accommodate to volume loss/gain
• ply means thickness
• proper placement within socket 

• amputation level
• activity level
• weight
• appearance
• cost
• SACH-solid ankle cushioned heal
• articulated
• energy storing 

• solid ankle cushioned heel
• majority LE individuals (K1-K3)
• juveniles
• little maintenance
• not recommended for active individuals
• get drop off effect on pros. side 

• use for individuals needing increased knee stability (k1-k3)
• no torque absorption
• not recommended for majority of LE amputeese 

• gressinger (k1-K3)
• allows in/eversion
• absorbs torque
• poor cosmesis
• conforms to uneven surfaces
• increased weight and maintence 

• active/community ambulators (low level K3)
• smoother gait
• light weight
• good cosmesis
• decreased energy consumption
• expensive 

• active individuals (k3-k4)
• multi-axial
• dynamic response
• decreased energy expenditure 

• ossur bionic technology
• advantages
• computerized foot
• DF/PF based on position
• easier to walk on in/declines
• easier to get out of chairs easier to walk up/down stairs
• disadvantages
• heavier
• expensive
• must charge regularly
• better for K2
• better unilateral than bilateral 

• hard plastic outer shell
• foam inside
•  heavy duty users
• difficult to change alignment
• less expensive
• heavier

• pylon system
• soft outer cover
• perimanent alignment adjustability
• lighter weight
• cover less durable
• patient weight limit 

• angle change
• one level
• loosen one, tighten opposite
• linear change
• 2 equal but opposite angle changes 

• flex socket (5-10 degrees)
• increase vertical load area for weight bearing
• encourages knee flexion at heel stirke
• discourages knee extension moment at heel off
• foot is inset from center of socket (0-12mm)
• varus moment moment at midstance
• stimulates NHL narrows base of support
• decreased energy expenditure
• creates ML stability
• ankle bolt 37mm (18-65mm) posterior to socket midpoint for SACH
• standard bench alignment
• encourages knee flexion

• observe
• knee flexes quickly or excessively at HS
• c/o increased anteriordistal tibial pressure
• possible causes
• heel to firm
• foot to posterior
• foot to DF
• socket too flexed
• shoe heel to high
• weak knee extensors 

• observe
• appear to walk into hole
• knee flexes excessively at heel-off
• possible causes:
• foot too posterior
• foot too DF
• foot keel to short or flexible
• socket too flexes 

• observe
• c/o knee hyperextension or patella discomfort
• c/o feel like climbing a hill
• possible causes
• foot too anterior
• foot too PF
• foot keel to long or stiff
• excessive use of knee extensors or weak quads
• show heel height to low
•  

• observe
• lateral bending of the trunk
• causes:
• proesthesis too short
• residual limb pain
• weak residual limb hip abductors 

• observe
• heel travels in direction of whip during pre-swing phase
• causes
• suspension cuff not aligned evenly
• prosthesis rotated 

• observe
• localized red area
• blisters
• open wound
• possible causes
• excessive localized pressure in socket
• proximal edge of liner too snug 

• observe
• bruised distal end
• warty thickened skin with odor
• cause: lack of distal contact
• (put in distal pad to resolve this) 

describe bony overgrowth of TT problems 

• appositional growth due to through-bone cut in children
• most common sites: fibula & humerus
• disarticulate vs. through-bone
• save all length possible 

• hemipelvectomy (small %, cancer, high level of truama)
• hip disartic (5%)
• transfemoral
• short
• medium
• long
• knee disartic 

• four well defined walls
• rectangular shape
• ischial-gluteal weight bearing 

• femur held in adduction
• very intimate fit
• triangular shape
• higher lateral trim line than quad 

• suction
• liner (pin/lock & lanyard)
• suction liner
• silesian belt
• hip joint and pelv band 

• interface smaller than limb
• patient pulls in with sock
• one-way valve
• no pistoning
• beteer proprioception
• no straps/belts
• (don't use liner, skin on socket) 

• provides positive suspension
• doesn't limit ROM
• reduces shear
• difficult to don
• difficult to control rotation 

• total elastic suspension
• belt fits inferior to iliac crest
• easy to don
• may add coronal stbaility
• stops rotation aspects 

• auxiliary suspension
• rotation control
• aid in coronal control
• attached laterally and buckled interiorly
• fits inferior to iliac crest 

• single axis hip joint
• pelvic band between iliac crest and trochanter
• maximum ML stability
• hip abductors 3 or less 

• K1 & K2: non-fluid based
• K3: fluid/pneumatic systems 

• manual lock
• single axis (weight activated stance control)
• polycentric
• single axis (hydraulic SNS)
• single axis constant friction 

• pt. un/locks
• max stability
• unlocked for sitting
• shorten to clear floor
• use for:
• very weak patient
• blind
• bilateral 

• low to medium level K3
• moving center of rotation
• stable at stance
• use for:
•  KD
• short TF
• weak hip extensors
• stance control

• weight activated brakeing (10-15 degrees knee flexion)
• need extension assist
• use for: K3
• weak hip extensors
• poor balance
• short TF 

• single axis hinge joint
• indicated use
• long limbs
• good muscle control
• children
• less expensive
• lightweight
• durable 

• highly active (k3-k4)
• lock and free-swing modes
• yielding hydraulic brake
• ride knee down to sit 

• microporcessor
• electronically-swing and stance phase
• gather data 60X per gait cycle
• fails in lock mode
• various modes to switch between 

• microprocessor knee
• magneto-pheological technology
• fails in free swing mode
• various modes user can switch between
• automatically adapts swing resistances to match user movements 

• displaced fulcrum medially
• reduces magnitude of moment 

• 5 degrees socket flexion + amount of contracture
• permits normal sound side step
• places extensors on strentch
• allows to get foot behind them 

• plumb from IT to bisection of heel
• quad foot is 0-85mm outset
• IC: foot is 35-37mm outset
• causes varus moment at hip
• hip abudctors fire to balance 

• TKA alignment
• quad socket
• 1" anterior to posterior wall at IT level
• through knee and ankle bolt
• european alignment
• IC socket
• bisect socket AP at IT level
• pumb 10-15mm anterior to angle axis knee joint 

observe: excessive lateral bending of trunk to pros side

prost causes:

• pros too short
• high medial wall of socket
• improper lateral wall shape of socket
• pros aligned in abduction
• amputee causes
• poor balance
• hip abductino contracture
• residual limb sensitivity/painful
• very short limb/lever arm
• habit pattern 

• observe: WBOS with prosthesis held away from midline at all times
• pros causes:
• pros to long
• pros aligned in abudction
• high medial wall socket
• improper lateral wall shape of socket
• amputee causes
• hip abduction contracture
• patient habit 

• observe: swings prosthesis laterally in wide arc
• pros causes:
• pros too long
• excessive knee friction
• amp causes:
• hip abduction contracture
• muscle weakness
• fear of stubbing toe
• habit pattern
•  

• observe: rising on toe of normal foot to permit prosthesis to swing through with little knee flexion
• pro causes 
• prosthesis too long
• inadquate socket suspension
• amp causes
• frequently due to habit
• fear of stubbing toe
• limb discomfort

• obsever: foot rotates at heel strike
• pros causes:
• too much PF resistance in foot
• too much toe out
• socket too loose
• amp causes
• poor muscle control of limb
• extends limb too vigorously at heel strike 

• observe
• pros heel rises markedly and rapidly when knee flexed at pre-swing
• pros causes
• insufficent friction of knee joint
• inadqueate knee extension aid
• amp causes
• uses excessive power to force knee into flexion 

• observe
• rapid forward movement of shank causing knee to maximally extend prior to heel strike
• may hear audible lcick
• pros causes:
• insufficent knee friction
• knee extension aid too strong
• amp causes
• done deliberately to insure knee fully extended 

• observe: heel travels in that direction at beginning of swing phase
• prosthetic causes:
• int/ext rotated knee
• socket too snuf
• amp causes
• habit 

• observe: too rapid descent of anterior aspect of foot at heel strike, may hear audible slap
• pros causes:
• too little PF resistance in foot
• amp causes:
• driving foot into floor to forcible assure extension of knee 

• observe
• actively increases lumbar lordosis
• pros causes
• improper shape of posterior wall
• insufficent socket flexion
• amp causes
• hip flexor tightness
• has weak hip extensors and subs ES muscles
• weak abs
• habit
• moves shoulders back for better balance 

• observe:
• knee unstable during weight bearing
• falling danger
• pros causes
• knee joint too interiorly located
• insufficient socket flexion
• PF resistance too great
• inability to limit DF in stance
• amp causes
• hip extensor weakness
• severe hip flexion contracture 

• not FDA approved
• direct skeletal attachment
• high infection rate
• secure suspension
• best proprioception 

• ambulation skills
• significant others
• residence
• attitude
• questions 

• ambulation
• transfers
• stump exercises
• stump care
• shoes (DM, MC)
• rigid dressing care 

• independent ambulation
• independent donning and doffing
• understanding of socket fit
• potential pressure areas
• who to call if problems arise
• use until volume stabilizes 

1. knee is almost in complete extension at heel stroke during normal gait. Immediately after, the knee should flex smoothly and quickly to about 20 degrees as the foot reaches foot flat. Kness flexion that is too forceful and rapid after heel stroke may be cause by:

1. heel cushion too stiff

2. foot too DF

3. foot too posterior

4. improper SACH foot/shoe fit

5. shoe heel height greater than prothesis originally designed for

6. weak quads

• supporting body weight with knee in a flexed attitude is possible only if knee extensors act with sufficient force to restrain the flexion moment. Pressure between the Anterodistal surface of the stump and the socket is increased considerably. Discomfort at heel strike may be caused by:
• foot too DF
• improper socket contour
• heel cushion too striff
• foot too posterior
• improper SACH foot/shoe fit
• shoe heel hight greater than pros originally designed for 

• transtibial: conical
• transfemoral: cylindrical 

• sequence of rehab and prosthetics
• expectations
• peer visits
• sound limb care
• residual limb care
• phantom sensation/pain
• orientation/awareness at night 

• positioning-avoid hip and knee flexion
• motion
• compression: shrinker vs. ACE (Ace more vigorous) 

• supine
• BkA: avoid knee flexino, hip flexion, hip abduction & ER
• AKA: avoid hip flexion, hip abduction, ER
• sitting
• BK: avoid knee flexion 

• goal is for independent stretching program
• hip flexors
• hip extensors
• abductors
• adductors
• for BK-want HS too 

• core strengthening
• sound limb
• dynamic strengthening
• manual resistive strengthening
• isometric/isotonic
• endurance work
• residual limb
• isometric best
• aggressive discouraged secondary to potential anterodistal tibial skin closure 

• disadv
• least effective type of exercise
• increases HTN-encourage breathing
• no joint ROM
• muscular endurance or coordination not promoted
• do it because:
• good intro exercises
• safe
• no equipment-can be done anywhere
• can be done during immobilization
• minimal irritation to joints
• held 10 seconds/rest 10 seconds 

• bed mobility
• encourage sound limb awareness
• cncourage to rely on head, arms and pelvis
• transfers
• teach to shift weight side to side to 'walk' hips forward to prevent pressure on stump
• gait training
• without prosthesis or with IPOP-limited weight
• sit to stands
• level surfaces
• turns/obstacles
• equipment
• walker/crutches
• wheelchair
• anti-tippers stump board
• amp adaptor (posterior set wheels) 

• strengthening
• continue with isometrics as before
• add resistive strengthening
• add CKC activities
• multiple plane stepping 

• balance/coordination
• sitting-swiss ball, bolsters
• quadruped
• complex gait
• bilateral standing
• wt shifting
• rocker board
• single limb
• stepping with sound limb
• single limb stance on prosthesis
• ball rolling under sound limb
• gait training
• move from more restrictve to loss
• complex gait activities
• variable cadence
• obstacles
• variable surface
• rotation of pelvisrt34 

• donning/doffing
• maintenance of correct fit and alignment
• maintenance of skin integrity
• care/cleaning of residual limb and prosthesis
• progressing wearing schedules 

• intimate socket fit
• socks used to maintain fit as limb shrinks
• found in 1,3,5 ply thickness
• placed under pr-lite liner, over gell liner
• no wrinkles or seams over pressure sensitive area
• sock fit will vary a lot first few months
• shrinker use very important throughout this time
• ply greater than 15-20 means time for a new socket! 

• intimate fit in socket
• suction
• powder, liquid, powder, towel
• valve to bleed air
• PT ed on fit, sensations, ect. 

• BKs
• take slack out in skin and put thumb on red mark
• no other usual pressure marks
• AKS
• IT location
• no void at bottom of socket 

• not enough socks
• looseness of fit, pistoning, pressure marks in incorrect locations (PTB)-too proximal
• too many socks
• difficult to fit on prosthesis, leg feels too long, pressure sign to distal 

• wash socks, liners daily, and let air dry
• wash residual limb and wipe down socket daily with soap and water
• sweating may be reduced by using anti-persperant the night before-sweating in general will decrease over time 

• phantom sensation
• phantom pain
• residual limb pain 

• a non-painful sensation or awareness that gives form to body part with specific dimensions, weight, or ROM
• a normal part of recovery from an amputation
• described as: touch, pressure, numbness, coldness, wetness, itching, bugs crawling, fatigue, telescoping, limb, phantom movement  

• pain arising from within the residual limb related to a specific anatomical structure that can be identified 

• prosthetic
• neuroma
• sympathetic
• referred
• abnormal tissue
• incision
• joint pain
• bone pain
• soft tissue pain
• residual limb changes 

• painful sensation experienced within the residual limb
• NOT a normal part of recovery
• but, fairly common 

• dull aching
• burning
• stabiing/knife-like
• sticking
• squeezing
• electrical shocks
• feeling as though leg is being pulled off
• trauma related pain
• pre-op pain
• unnatural positioning
• OFTEN INTERMITTANT 

• independent age, gender, cause of amputation, race, health status or psychological profile
• first onset usally occurs about 1 week post-op
• usually lasts less than 6 months
• can start up several years later
• most recent studies report phantom limb pain at rates of 50-85%
• phantom pain may diminish with time
• prospective studies indicate that even 2 years after amp the incidence is almost the same as at onset
• duration, frequency, and intensity of pain attacks is reduced with time 

• increased emotional stress
• exposure to extreme temperatures
• local irritants
• change in weather
• fatigue 

• using a prosthesis: give nerve endings contact
• desensitization/stroking residual limb
• heat
• distraction (mental) 

• somatosensory and motor cortices undergo neuroplastic changes following limb amputation
• relationship between cortical regonization and intesnity of PLP-the greater the extent of reorganization, the more intense the PLP 

• brain pre-wired to think of the body in total
• so if arm amputated-brain still thinks arm is there
•  if brain believes arm is still there, it might tell limb to move by stimulating a certain neural pathway in neuromatrix. Since limb not there, and brain has no sensory feedback, it will increase the strength of its stimulus potentially causing pain

• sympathetically generated phantom limb dysthesia
• caused by muscle spasms causing direct pressure to neuroma 

• relationship sometimes seen between residual limb temperature and increase muscle tension, followed by decreased blood flow and increased pain
• most commonly seen in amputees complaining of burning throbbing and tingling pain 

• amputees with shock-like and shooting pains reported an increase of pain with activity and a decrease with relaxation 

• pain intensity increases with decreased barometric pressure
• increase in swelling may affect small blood vessels and decreased local blood flow
• possible arthritic pain 

• stress and fatigue may play of a role
• unlikely that personality disorders are a cause, but may exacerbate symptoms 

• people who had pain in limb before amputation are likely to report phantom pain afterward
• this connection may be strongest in the period of time immediately after amputation 

• surgery
• sympathectomy
• sc stimulation
• deep brain stim
• acupuntcture
• electric shock
• tens analgesics
• holistic or multi-disciplinary approach
• psych intervention
• education
• sensory overload
• medications
• mirror therapy 

• variety of sensory stimuli are presented at random to residual limb for 20-60 minutes at a time
• intended to provide an overload to sensory system
• ex: pin, cotton balls, reflex hammer, heat, cold, massage 

• foot hits the ground
• critical event: heel contact first 

• weight is transferred to outstretched limb for double limb support. "heel rocker"
• critical event: hip stability, controlled knee flexion 

• body progresses over a single stable limb "ankle rocker"
• critical event: controlled tibial advancement 

• the body moves ahead of the limb. Weight is transferred to the forefoot. "forefoot" rocker
• critical event: controlled ankle DF with heel rise 

• unloading of limb
• weight is transferred to contralateral limb
• double support phase 

• thigh advanced and foot comes off the floor
• critical event: limb must clear the floor with adequate DF, knee flexion, and hip flexion 

• thigh advances, knee extends, foot clear floor
• critical: ankle DF to neutral 

• knee extends to neutral to prepare for intial contact 

• have to have wt acceptance, limb must be stable and able to absorb the impact of body weight
• GRF are posterior to ankle joint axis=PF moment
• eccentric PF by pre-tib muscles
• eccentric quad=knee stability
• hip stability from extensors-body wt accpeted at hip in 25 degrees flexion 

• midstance and terminal stance
• control of tibia is critical-allows knee and hip to achieve alignment for stability
• GRF moves anterior to knee-stability without active quads
• hip abductors give frontal plane stability 

• pre swing, initial swing, mid swing, terminal swing
• forward movement from active hip flexors
• knee flexes to 60 degrees-critical to dynamic of normal gait 

• speed up/slow down
• rise/fall with each step
• lateral cycle with each step 

what are the ankle/foot functions in gait (5)

• surface adaption
• shock absorption
• effect on COG
• knee stability
• swing phase control 

• frontal plane function
• foot adapts to uneven surfafces
• usually sacrificed in P & O 

• decreases rate of rise of GRF as pre-tibial muscles (ant/tibialis) eccentrically places the foot on the floor 

• rocker changes from heel -> ankle -> forefoot which allows COG to undergo smooth and minimal vertical displacement 

• in sagittal plane, GRF may pass anterior, posterior or through axis of knee
• anterior: extension moment (passive) = stable knee 
• posterior-flexion moment=unstable knee, quads must be active to counteract flexion moment

• normal ROM: 20 pF at preswing/initial swing, 0 at midswing
• if can't occur-elongated limb results which leads to compensations somewhere else 

1. shock absorption

2. support body wt

3. limb shortening in swing phase

• up to 15 degrees of controlled knee flexion at weight acceptance (eccentric quads)
• smoothes path of COG which is lowest at double limb support 

• GRF anterior to knee: passive structures prevent motion
• GRF  posterior to knee: quads regulate stability
• methods to stabilize knee if quads unable
• change alignment
• locate COG more anterior
• produce increase hip extension moment

• normal gait: 60 degrees of knee flexion with 30 degrees before foot leaves the ground 

what are the 4 gait deviations with limb shortening

• vaulting
• hip hiking
• circumduction
• contralateral side bending 

• stance phase extension
• swing phase
• M/L stability 

• moves from 30 degrees flexion at initial contact to 10 degrees extension at terminal stance
• early GRF
• anterior to hip and extenors must be active
• at midstance GRF moves posterior to hip and flexors active to control hip extension then intiate hip flexion 

• backward lean/lumbar lordosis: during early stance phase keeps GRF closer to hip, less extensors needed
• forwardlean/posterior pelvic tilt: during late stance to assist in moving GRF anterior to hip to create hip flexion moment for swing 

• abductors (gluetus medius) active when weight is on limb
• weakness is often compensated by a lateral lean to the affected side during mid-stance