WAR DEPARTMENT TECHNICAL MANUAL 
PHYSICAL 
THERAPY 
FOR 
LOWER-EXTREMITY 
AMPUTEES 
WAR DEPARTMENT 
JZ/iVE 1946 WAR DEPARTMENT TECHNICAL MANUAL 
T M 8 - 293 
This manual supersedes TB MED 122, December 1944. 
PHYSICAL 
THERAPY 
FOR 
LOWER-EXTREMITY 
AMPUTEES 
VAR DEPARTMENT 
JUNE 1946 
United States Government Printing Office 
Washington: 1946 This manual contains copyrighted material. 
WAR DEPARTMENT 
Washington 25, D. C., 14 June 1946 
TM 8-293, Physical Therapy for Lower-Extremity Amputees, is 
published for the information and guidance of all concerned. 
[AG 300.7 (18 Jan 46)] 
order of the Secretary of War: 
Official : 
DWIGHT D. EISENHOWER 
Chief of Staff 
EDWARD F. WITSELL 
Major General 
The Adjutant General 
Distribution : 
AGF (5); Dept (1); Arm & Sv Bd (1); Tech Sv (2) except SGO 
(24); Tech Sv (Tng Div) (2); SvC (1); SvC (Surg) (1); SvC 
(Tng Div) (1); Named GH (8); RH (1); SH (1); ROTC (1); 
SvC Lab 8 (1); AAF Sta (Cont) (1); A (5); A (Surg) (1); CHQ 
(Surg) (1); D (Surg) (1); AF (Surg) (1) O & E 8-580 (2); 
8-581 (2). 
For explanation of distribution formula see FM 21-6. 
Acknowledgment is made to the American Physiotherapy Association for the use 
of Table 11, Comparative Muscle Grading Table. CONTENTS 
CHAPTER I. INTRODUCTION. 
Paragraph Page 
Section I. General. 
Purpose 1 1 
Scope 2 1 
II. Administration. 
Personnel 3 2 
General procedures 4 2 
CHAPTER 2. BANDAGING. 
Section I. General instructions. 
Bandaging technique 5 4 
Care of bandagqs ; 6 4 
//. Special instructions. 
Thigh stump 7 5 
Leg stump , 8 11 
Self-bandaging 9 11 
CHAPTER 3. MUSCLE AND POSTURAL EXAMINATION. 
Section I. General. 
Body mechanics examination chart 10 14 
11. Flexibility and contracture tests. 
Forward flexibility test 11 14 
Extensibility test 12 15 
Contracture test 13 18 
111. Muscle strength tests. 
Comparative muscle-grading table - 14 19 
Gluteus medius muscle, posterior portion, 15 19 
“Upper” and “lower” anterior abdominal muscles 16 19 
IV. Posture tests. 
Plumb-line tests 17 22 
Plumb-line test for anteroposterior alignment IS 22 
Plumb-line test for lateral alignment 19 24 
CHAPTER 4. PREPROSTHETIC EXERCISE PROGRAM. 
Section I. General. 
Purpose of exercises 20 26 
Selection of exercises 21 27 
11. Stump exercises. 
Strengthening weak muscles 22 28 
Stretching existing contractures 23 28 
111. Posture exercises. 
Typical posture faults 24 31 Section IV. Exercises for unilateral amputees. 
Purpose 25 37 
Bed stage 26 37 
Ambulatory stage 27 39 
V. General exercises. 
Purpose 28 40 
Exercise for oblique abdominal muscles 29 40 
Exercise for lateral abdominal muscles 30 40 
Exercise for upper anterior abdominal muscles 31 41 
Exercise for lower back muscles 32 42 
Breathing exercise 33 42 
Exercises contraindicated 34 42 
Paragraph Page 
CHAPTER 5. INDIVIDUAL WALKING INSTRUCTION. 
Section I. General. 
Administration 35 43 
Apparatus 36 43 
Teaching technique 37 43 
Classification 38 45 
11. Unilateral amputees. 
Beginners class 30 46 
Intermediate class 40 48 
Advanced class.. 41 52 
111. Tilting-table amputees. 
Exercise program 42 53 
Walking 43 53 
Sitting 44 53 
Rising.. 45 53 
IV. Bilateral amputees. 
General 1 46 54 
Beginners class 47 54 
Intermediate class 48 55 
Advanced class 49 57 
CHAPTER 6. CAUSES AND CORRECTION OF LIMPS. 
Recognition of limps 50 58 
Analysis of limps (A/K unilateral amputees) 51 58 This manual supersedes TB MED 122, December 1944. 
CHAPTER 1 
INTRODUCTION 
Section I. GENERAL 
1. Purpose 
This manual is concerned with the role of physical therapy in “manage- 
ment” of amputees. Management encompasses more then surgery, 
healing processes, restoration of function, and fitting of artificial limbs. 
It also takes cognizance of the number of persons who have lost limbs, 
the dramatic circumstances surrounding the injuries, the psychic trauma 
of amputation, and the necessity for physical and social adjustment. 
For this reason treatment for amputation is not considered as specific, 
but rather as a continuous process which begins on the battlefield or 
scene of injury and concludes with discharge of the patient from an 
Army hospital after he has been properly fitted with an artificial limb 
and educated in its use. 
The purpose of this manual is to present a standardized program for 
physical therapy management of lower extremity amputations. 
2. Scope 
a. The objectives of physical therapy in the treatment of amputa- 
tions are: 
(1) To shrink and toughen the stump. 
(2) To give muscle and postural examinations to determine existing 
defects in regard to muscle weakness, contractures, and faulty segmental 
alignment of the body as a whole. 
(3) To maintain or restore normal range of motion and muscle 
strength of the affected extremity. 
(4) To correct the existing defects before the amputee is fitted with 
his prosthesis. 
(5) To instruct the lower-extremity amputee in correct technique of 
walking, making turns, climbing stairs, picking up objects, etc. 
b. Bandaging and therapeutic exercise have been invaluable in 
accomplishing these objectives. Other forms of physical therapy such 
as massage, hydrotherapy, thermotherapy, ultra-violet irradiation, and 
common ion transfer have been employed extensively at times, but they 
must be individually prescribed and administered. Bandaging and 
therapeutic exercise, on the other hand, are applicable in the case of 
nearly every lower-extremity amputee; therefore they will be dealt with 
in detail in this manual. 
1 Section 11. ADMINISTRATION 
3. Personnel 
For the very reason that treatment for amputation is a continuous proc- 
ess, the utmost cooperation must exist among the several persons and 
departments interested in management of a patient. The medical 
officers, ward personnel, physical therapists, occupational therapists, 
various members of the reconditioning service, and the technicians 
from the artificial limb shop must work together closely if the program 
is to succeed. 
4. General Procedures 
To further cooperation in the course of treatment certain procedures 
must be agreed upon and adhered to: 
a. Except in emergencies, furloughs will not be granted a patient 
until it can be certified that he can satisfactorily manage his prosthesis 
(graduation from Intermediate Walking Class). This will insure that 
no important treatment is interrupted. 
b. No amputee should begin walking with his prosthesis until 
approval has been given by the chief of the amputation section and the 
physical therapy section. 
c. When a prosthesis has been finished it should be delivered to the 
physical therapy section and kept there until the patient has com- 
pleted the beginning phase of walking instructions and has been checked 
by the chief of the amputation section, or some person he may designate. 
Only then is the patient allowed to keep his prosthesis on the ward. 
d. All walking instruction will be under the supervision of the physi- 
cal therapy section. 
(1) A record system showing the current status of every amputa- 
tion case in relation to the walking program will be maintained in the 
physical therapy section. 
(2) Cases will be divided into four groups for instructions; unilateral 
below-knee amputee (B/K), unilateral above-knee amputee (A/K), 
amputees fitted with tilting-table prostheses (tilting tables; this cate- 
gory includes patients with disarticulation of the hip joint or thigh 
amputation too short for fitting with an ischial bearing thigh bucket, 
that is, stumps less than 3 inches long), and bilateral amputees. 
The instruction groups will be as small as possible so that instruction 
may be given on an individual basis. Classes 30 minutes in length will 
be conducted by physical therapists especially trained for the program. 
Each patient will receive a proportionate share of instruction. 
e. Arrangements should be made for a designated time every 2 days 
when a qualified orthopedic mechanic SSN 366 (limb fitter) can meet 
with the physical therapist in charge of walking instructions and patients 
whose prostheses need readjustment. 
2 /. A 16-millimeter movie camera with projector, screen, and other 
necessary photographic equipment should be assigned to the physical 
therapy section. Sufficient technical personnel from the local Signal 
Corps or other photographic unit should be placed at the disposal of 
the physical therapy section so that moving picture shots can be taken 
showing each emputee at the beginning of his walking program and 
recording his progress thereafter. 
About 100 feet of film should be exposed at each photographic record- 
ing to demonstrate: 
(1) Full figure walking toward the camera, executing a turn, and 
walking away from camera. 
(2) Lateral full figure with each side toward the camera in turn. 
(3) Close-up of lower extremities during walking. 
(4) Standing for lateral and posterior plumb line tests. 
The physical therapist will analyze these pictures, then show them 
to the amputee, at the same time pointing out defects in posture, co- 
ordination, or walking; noting improvement; and insuring that the 
pictures are utilized as much as possible from the instructional viewpoint. 
g. No amputee will be discharged from the service until he has com- 
pleted the walking program outlined for him. 
3 CHAPTER 2 
BANDAGING 
Section I. GENERAL INSTRUCTIONS 
5. Bandaging Technique 
a. Correct bandaging of a stump is an important part of the physical 
therapy treatment in insuring proper healing and shrinkage. 
After exercise, the stump must be bandaged firmly with as many 
bandages as necessary to give even pressure throughout. Bandaging 
must he repeated several times daily for the patient to derive maximum 
benefit. The bandage is worn continuously until the patient is fitted 
with his prosthesis; and for 5 or 6 months after fitting, whenever the 
prosthesis is removed. 
Incorrect bandaging will harm the stump. Common errors to be 
avoided are: 
(1) Exerting a constricting effect. This may produce edema distal 
to the site of the compression. 
(2) Undue general tightness, especially at the edges of the bandage 
where there is less elasticity than in the center. This error rfmst be 
especially guarded against by beginners who in striving for neat appear- 
ance of the bandage cause constriction. 
(3) Bandaging unhealed stumps too snugly. Bandaging should be 
less snug than for healed stumps. Persistence of this error will delay 
healing. 
b. The bandage stump should have a smooth, even contour without 
bulges. 
Four safety pins placed or spaced in diamond shape to secure the cross- 
wrappings of the hip spica (par. 7) at the lateral side of the hip should 
prevent a certain amount of shifting or crawling of that part of the 
bandage. 
6. Care of Bandages 
Because of their elastic qualities, ace type bandages are most suitable 
for bandaging stumps. These bandages contain no rubber, but are made 
of a soft, porous-weave cotton which must be laundered carefully to 
retain the elasticity necessary for proper application. 
The bandage should be washed with mild white soap and water. All 
soap particles should be removed by through rinsing. Since the bandages 
will lose their elasticity if hung, they should be spread on a clean, flat 
surface until dry, than rolled evenly and firmly without stretching. 
4 Section 11. SPECIAL INSTRUCTIONS 
7. Thigh Stump 
Application of bandages in thigh amputations is especially difficult and 
requires patience and practice in technique. 
a. Two 4-inch ace bandages sewed together end to end make a satis- 
factory bandage for the average thigh stump. The 6-inch bandage is 
recommended for larger stumps. 
h. A firm, even pressure must be maintained throughout the whole 
bandaging procedure. The bandages should be applied as firmly as the 
patient can tolerate without pain or circulatory interference. Appli- 
cation is slightly tighter at the distal end of the stump than at the proxi- 
mal end. 
c. The bandage is applied as follows (see FS 8-85): 
Figure 1. 
(1) Begin with the bandage at the groin where it is held by the pa- 
tient’s thumb. (See fig. 1.) 
5 Figure 2. 
(2) Proceed over the end of the stump to the upper thigh, posteriorly, 
where the bandage is held by the patient’s fingers. (See fig. 2.) 
Figure 3. 
(3) Return bandage over end of stump, laterally. (See fig. 3.) 
6 Figure J+. 
(4) Again over end of stump, medially. Each recurrent is held like 
the first. (See fig. 4.) 
(5) Having completed three recurrent turns, begin the anchoring 
turn by drawing the bandage laterally from the posterior aspect to the 
lateral side of the stump. (See fig. 5.) 
Figure 5. 
7 Figure 6. 
(6) Encircle, carrying the bandage high in the groin. (See fig. 6.) 
Figure 7. 
(7) Begin spiral to stump by carrying the bandage from the lateral 
thigh toward the medial side of the stump. Continue spiral, encircling 
stump twice. Then turn patient on his side. (See fig. 7.) 
8 Figure 8. 
(8) From the posterior thigh, carry the bandage over the lateral side 
of the hip, and continue over the crest of the ilium, across the abdomen. 
(See fig. 8.) 
Figure 9. 
(9) Continue around lower hip. (See fig. 9.) 
9 Figure 10. 
(10) Return to stump. (See fig. 10.) 
Figure 11. 
(11) Encircle stump, completing first spica. Begin second spica, 
following the course of the first. Return to stump and continue spirals 
to complete bandage. (See fig. 11.) 
10 Figure 12. 
(12) Bandage is completed. (See fig. 12.) 
8. Leg Stump 
Apply and anchor the three recurrents as demonstrated in figures 1 
through 6 for the thigh stump. 
Then secure the bandage by passing it to one side above the patella, 
encircling the lower thigh twice, and returning on the opposite side of the 
patella to the stump. The patella is left exposed. 
9. Self-Bandaging 
Each patient should be taught to bandage his own stump as soon as 
possible. All amputees who are ambulatory and who are going to the 
physical therapy section should be bandaged once a day under the guid- 
ance of the physical therapist and be instructed to reapply the bandage 
themselves as often as necessary. Group instruction may be given to 
save time. 
Someone must secure the bandage for the thigh amputee when he does 
recurrent turns over the end of his stump in applying his own bandage. 
He should be taught to elevate his pelvis with his good leg so that his 
stump is held in extension when he applies the spica to his waist. 
11 Table I. 
Name | Ward number 
Height j Weight | Age 
Site of amputation j Right, left, or bilateral 
Handedness | Date physical therapy started 
PART I. PRE-PROSTHETIC AND POST-PROSTHETIC TESTS 
Tests for Flexibility 
Pre-op. 
Date 
Post-op. 
Date 
Post-Pros. 
Date 
Forward Flexibility 
(Record in inch 
string or back 
Extensibility Test- 
(Normal, fair, or 
y Test: __ _ 
es) (If limited, note whether ham- 
muscles). 
poor) 
LEFT 
Tests for Contractures 
{Record in Degrees) 
Gastroc-soleus 
RIGHT 
Post-Pros. 
(Date) 
Post-op. 
(Date) 
Pre-op. 
(Date) 
Pre-op. 
(Date) 
Post-op. 
(Date) 
Post-Pros. 
(Date) 
Hamstrings 
Hip flexors. 
Hip abductors . 
Pectorals (si. mod. or 
mark.). 
Tests for Muscle Strength 
{Record by Percentage) 
“Upper” anterior Ab- 
dominals: (Trunk-rais- 
ing test). 
“Lower” anterior Ab- 
dominals: (Leg-rais- 
ing test)*. 
Hip flexors. 
LEFT 
RIGHT 
Post-Pros. 
(Date) 
Post-op. 
(Date) 
Pre-op. 
(Date) 
Pre-op. 
(Date) 
Post-op. 
(Date) 
Post-Pros. 
(Date) 
Hip ext. rotators 
Hip int. rotators 
Tibialis posticus 
Long toe flexors 
Gluteus, medius (post. 
part). 
Hip adductors 
Hip abductors . 
Lateral abdominals 
Hip extensors 
Hamstrings. _ 
Back extensors 
Quadriceps _ 
Signature of physical therapist 
Date 
* If test performed with prosthesis, record results with asterisk. 
BODY MECHANICS EXAMINATION CHART FOR LOWER EXTREMITY AMPUTEES 
12 Table I—Continued 
PART II. POST-PROSTHETIC TESTS 
Tests for Posture 
Segmental alignment: 
_ .Normal alignment _ _ Lordosis Pronated foot 
Forward head . _ Int. rotated femur 
Kvnhosis 
Other defects. _ _ 
Lateral pelvic alignment: 
Level 
High on.. side. 
Plumb Line Test for Anteroposterior Alignment (Hung in line with point anterior to 
lateral malleolus). 
Normal Body ant. to Plumb line 
Good except Lordosis Pelvis ant. to Plumb line 
Good except Forward Head _ Other deviations 
Plumb Line Test for Lateral Alignment (Hung from point midway between heels 
placed 3" apart). 
Normal _ Displacement of trunk to right 
_ _ .. Scoliosis _ . . Displacement of trunk to left 
Test for Causes of Improper Gait 
Limp 
Type 
Cause 
Recommendation for Correction: 
Special exercises 
Summary Note. For classification of 
amputees into special groups for Physical 
Therapy treatment 
1. Patient shows no defects in body 
mechanics and is ready for 
walking . 
2. Patient requires special exercise to 
correct: 
Muscle weakness 
. Special Walking Instruction 
. Prosthesis Correction 
..Shoe Correction / 
.. Contractures 
Fanltv nosture 
Limp 
Signature of physical therapist 
Date 
13 CHAPTER 3 
MUSCLE AND POSTURAL EXAMINATION 
Section I. GENERAL 
10. Body Mechanics Examination Chart 
This chart is used to record findings in preprosthetic and postprosthetic 
tests of muscle strength and contractures, and postprosthetic test of 
posture. It is largely self-explanatory (table I), but detailed directions 
are given in paragraphs 11 through 19 and in paragraphs 50 and 51 in 
order to explain the standardization of some of the tests, as well as meth- 
ods of recording test results. 
Section 11. FLEXIBILITY AND CONTRACTURE TESTS 
11. Forward Flexibility Test 
This is a means of checking forward mobility of the lower back. In 
the test position, the patient sits on a plinth with legs extended forward 
and tries to reach his toes. (See fig. 13.) Extent of limitation is re- 
corded as the number of inches by which he fails to touch his toes. If 
the patient shows much limitation, this test should be followed by the 
straight-leg raising test to determine whether any hamstring tightness 
exists. (See fig. 14.) 
Figure 13. Normal forward flexibility test. The ■patient is able to touch fingertips to 
toes with knees straight and with well-rounded contour of entire spine. 
14 Figure 14• Straight-leg raising test for hamstring tightness. This patient shows marked 
restriction due to tightness in hamstring muscles. Normal length of hamstrings 
would permit flexion of the hip to about 85° with the leg in full extension, as required 
in this test. 
a. When the patient reaches forward, the contour of his lower back 
should be noted. The hamstring muscles may be relaxed and allow 
more than normal hip-joint motion; the upper back may be more than 
normally flexible or it may be in a definitely kyphotic position so that 
the patient is able to touch his toes even though his lower back is con- 
siderably limited in flexibility. 
h. Low back flexibility cannot be determined accurately when the 
test is given with the patient in a standing position. Any rotation of 
the pelvis (clockwise—forward on the left; or counterclockwise—forward 
on the right) will necessarily be accompanied by rotation of the lumbar 
spines. This, in turn, will limit trunk flexion from a standing position. 
When the patient is sitting on a plinth with his legs extended forward, 
the pelvic rotation usually disappears (except in cases of structural 
rotation); thus, trunk flexion becomes a more accurate index of the limi- 
tation of low back flexibility. 
12. Extensibility Test 
This is a means of checking general ability to extend hips and knees, 
flatten lumbar spine, and raise arms overhead. (See fig. 15.) The 
patient should be able to lie supine on a plinth with knees and hips ex- 
tended,’ lumbar spine flat on the plinth, and arms raised directly over- 
head. Findings are recorded as N (normal), F (fair), or P (poor). 
15 Test 
Percentages 
Letters 
Numerals 
Neurological 
ratings 
Combination ratings 
Full range of motion against gravity with 
normal resistance, repeated several times 
without signs of fatigue. 
Contracted 
or hy per- 
trophied. 
100 
95 
Normal-}- (N-b) 
Normal (N) 
Normal — (N —) 
5 
13 
12 
11 
0 
+ + + + 
Normal (N) 9 
Normal— (NM) 8 
Normal. 
Increase against re- 
sistance but quite 
normal. 
Beginning power 
against added re- 
sistance. 
Full range of motion against gravity with 
medium amount of resistance, repeated 
several times without sign of fatigue, but 
tires quickly or is unable to complete 
range of motion with normal resistance. 
90 
80 
70 
Good + (G-f-) 
Good (G) 
Good- (G —) 
4 
10 
9 
8 
1 
+ + + 
Good-}- (GP) 
7 
Full range of motion against gravity, mini- 
mum resistance. 
Full range of motion against gravity, no 
resistance. May tire after 3 to 6 move- 
ments. 
60 
50 
Fair-}- (F+) 
Fair (F) 
3 
7 
6 
2 
+ + 
Good (G) 
6 
Well-defined 
control over 
gravity or 
friction. 
Almost full range of motion against gravity. _ 
40 
Fair— (F —) 
5 
Beginning motion against gravity or com- 
pletion of arc of motion with gravity 
eliminated, either against friction of table 
or with minimum resistance. 
30 
Poor-}- (P+) 
4 
Good- (GM) 
5 
Beginning action 
against gravity 
or friction. 
Table 11. Comparative Muscle Grading 
16 No motion against gravity but completes 
20 
Poor (P) 
2 
3 
3 
+ 
Fair 4- (FP) 
4 
Beginning action 
range of motion with gravity eliminated 
of joints but not 
(no friction). 
against gravity 
or enough to 
overcome friction 
of table. 
Partial range of motion with gravity 
10 
Poor- (P-) 
2 
Fair— (FM) 
2 
Definite muscle ac- 
eliminated. 
t i o n without 
much influence 
+ 
on the joint. 
Palpable or visible contraction of muscle, 
5 
Trace (Tr) 
1 
1 
4 
Action weak 
1 
Definite muscle 
but no apparent movement of part. 
(AW) 
contraction. Be- 
tween IA and 
AW is fibrella- 
tion or question- 
able contraction. 
No contraction felt in muscle ._ 
0 
0 
0 
0 
5 
0 
Inactive (IA) 
0 
N o appreciable 
motion. 
17 Figure 15. Normal extensibility test. Above patient would be rated normal. 
13. Contracture Test 
a. Limitation of motion due to contractures in gastrocnemius, soleus, 
hamstrings, hip flexors, and hip abductors is tested and recorded in 
degrees. In testing limitation of motion due to contractures in the hip 
flexors, the patient lies on a plinth as illustrated in figure 16. The 
patient tries to extend his right thigh while holding his pelvis flat on the 
table; all motion is, therefore, true hip joint motion alone. 
Figure 16. Position of patient for measuring degree of hip flexion contracture. Op- 
posite thigh is flexed on chest to help keep lumbar spine flat on table. The above 
patient shows a hip flexion contracture of approximately 30°. 
h. The normal state of extensibility of the pectoral muscles is illus- 
trated by the position of the arms in figure 15; the amount of tightness 
18 in pectoral muscles should be recorded as si. (slight), mod. (moderate), 
or mark, (marked). 
Section 111. MUSCLE STRENGTH TESTS 
14. Comparative Muscle-Grading Table 
Muscle strength tests of the lower extremity and abdominal muscles 
are to be recorded in percentages accorded to table 11. Detailed in- 
structions for testing particular muscles are given in paragraphs 15 and 16. 
15. Gluteus Medius Muscle, Posterior Portion 
In this test the patient lies on his side with his trunk and pelvis in straight 
alignment. (See fig. 17.) His upper leg is placed in position with leg 
extended and thigh in abduction, slight extension, and slight external 
rotation. The patient holds against resistance which is applied to his 
ankle in a downward and slightly forward direction. 
Figure 17. Testing strength of posterior portion of gluteus medius 
16. “Upper” and “Lower” Anterior Abdominal Muscles 
Percentage 
Test 
100 
(1) With hands clasped behind head, roll pelvis backward and “fold” to 
sitting position. Legs are not supported until trunk flexion is 
complete, but may be supported as soon as the pelvis should nor- 
mally begin flexing on the thighs. (See fig. 18® and @.) 
(2) With hands clasped behind head, roll pelvis backward and hold 
lumbar spine flat on table as legs are raised and lowered. (Leg 
raising tests are modified for unilateral amputees with prosthesis 
by resting prosthesis on normal leg.) (See fig. 19.) 
These muscles are tested and graded as follows 
19 Percentage 
Test 
80 
(1) With arms folded on chest, roll pelvis backward and “fold” to sitting 
position. 
(2) With hands clasped behind head, roll pelvis backward to flatten 
lumbar spine. Your legs are then raised at a 40° angle to the 
table by the examiner; try to keep back flat on table and at same 
time retain legs in raised position. 
60 
(1) With arms down at side (but with no assistance from hands or elbows), 
roll pelvis and “fold” to sitting position. 
(2) With hands clasped behind head, roll pelvis backward to flatten 
lumbar spine. Your legs are then raised at a 60° angle to the 
table by the examiner; try to keep back flat on table and at same 
time retain legs in raised position. 
50 
(1) With arms down at side, roll pelvis and lift head and shoulders about 
4 or 5 inches from the table. 
(2) With hands clasped behind head, roll pelvis backward to flatten 
lumbar spine. Your legs are then raised at a 75° angle to the 
table by the examiner; try to keep back flat on table and at same 
time retain legs in raised position. 
20 ® Legs are not supported during movement of flexion of thorax on pelvis. 
® J.s trunk-raising continues by flexion of pelvis on thigh, legs are held down on table 
by examiner. 
Figure 18. Testing strength of “upper” anterior abdominal muscles. Above figures 
show position of arms for 100% (normal) trunk-raising test. See paragraph 16 
for positions in 80 percent and 60 percent trunk-raising tests. 
21 Figure 19. Testing strength of “lower” anterior abdominal muscles. Strong action of 
anterior abdominal muscles keeps lumbar region fiat on table as weight of legs is 
raised and lowered. Test may be modified for unilateral amputees who have been 
fitted with prostheses, as above, by placing prosthesis on normal leg to keep knee 
of prosthesis extended. Above patient shows 100 percent {normal) strength for 
these muscles. 
Section IV. POSTURE TESTS 
17. Plumb-Line Tests 
There is one standard reference point in all postures, the base, where the 
feet touch the floor. To determine variations in posture, a plumb line 
is suspended from a stationary point above the patient’s head to the 
fixed reference point at his feet. 
When a patient has correctly balanced posture, his body will coincide 
with the plumb line at several points above the normal base; when he 
has faulty posture, there will be a lack of normal alignment. In the test 
for anteroposterior alignment, the plumb line will coincide with the 
frontal plane of the body in normal posture; in the test for lateral align- 
ment, it will coincide with the sagittal plane. 
18. Plumb-Line Test for Anteroposterior Alignment 
To assume the test position, the patient steps up to the plumb line and 
places his feet so that the plumb-bob hangs in line with a point just 
anterior to his lateral malleolus. (See fig. 20.) 
If his posture is correctly balanced, the patient’s body will coincide 
with the plumb line at the following points above the normal base: 
a. Posterior to the patella. 
h. Through the hip joint (anterior to the greater trochanter). 
c. Midway between abdomen and back. 
d. Through the shoulder joint. 
e. Through the lobe of the ear. 
22 ® A bove patient shows good postural alignment except that his head and shoulders are slightly 
forward. 
® A bove patient shows faulty postural alignment with pelvis slightly displaced marked lor- 
dosis and head forward. {Note clockwise rotation of pelvis and trunk; compare with 
figure 21®.) 
Figure 20. Plumb line test for anteroposterior alignment. 
23 19. Plumb-Line Test for Lateral Alignment 
To assume the test position, the patient stands with the inner border of 
his heels 3 inches apart and equidistant from a line which coincides with 
® Above patient shoivs good (but not perfect) postural alignment, and good weight distri- 
bution over both legs. 
@ Above patient shows faulty postural alignment. Displacement of pelvis, trunk, and 
head toward right shows that more weight is being borne on the normal leg than on 
the prosthesis. 
Figure 21. Plumb line test for lateral alignment. 
24 the tip of the plumb-bob. (See fig. 21.) (Bilateral amputees should 
stand with heels as nearly 3 inches apart as possible.) Weight should 
be distributed evenly on both feet. 
If his posture is correctly balanced, the midline of the patient’s body 
will coincide with the plumb line. 
25 CHAPTER 4 
PREPROSTHETIC EXERCISE PROGRAM 
Section I. GENERAL 
20. Purpose of Exercises 
The purpose of this program is to correct defects in body alignment and 
to establish muscle balance and normal range of motion before fitting 
with prosthesis. This will insure that the body and prosthesis function 
together with maximum efficiency. 
a. Before the patient is ready for the postprosthetic program of 
walking, stair-climbing, turns, etc., he must accomplish the following 
objectives of the preprosthetic program: 
Figure 22. Anterior pelvic tilt due to hip flexion contracture. 
26 (1) Increasing muscle strength of extremity involved, including 
correction of existing contractures when condition of patient permits. 
(2) Correcting defects in muscle balance and body alignment. 
(3) In cases of unilateral amputation, improving weight-bearing 
strength and balance of normal leg. 
(4) Maintaining general muscle tone. 
h. When an amputee is measured for his prosthesis before correction 
of defects in body mechanics, the limb-fitter will necessarily fit the 
prosthesis to the deformity. As a result, the patient tends to be held 
in the position of deformity despite subsequent efforts to correct his 
postural defects. For example, if an abd'uction contracture exists in 
the thigh stump at the time of the fitting, the patient will stand in a 
position of lateral pelvic tilt; if a hip flexion contracture of the stump is 
present, the patient will stand in a position of anterior pelvic tilt (lor- 
dosis), and his prosthesis will fit and tend to hold him in this position. 
(See fig. 22.) 
If defects are corrected by exercise before measuring and fitting takes 
place, the need for constant alterations in the fit of the prosthesis will be 
obviated. 
21. Selection of Exercises 
The preprosthetic exercise program may be divided into two stages: the 
preoperative (before final surgical revision), and the postoperative (after 
final surgical revision). This division into stages does not necessarily 
influence the over-all selection of exercises, since the need for a particular 
exercise continues until the defect of the given muscle group is corrected. 
Some exercises may have to be discontinued temporarily during the early 
postoperative stage, but their essentiality will undoubtedly be increased 
by the interruption. 
The stages through which a patient progresses, however, will influence 
the administration of the exercise program in several ways: 
a. Preoperative Stage. Exercises of involved part are not usually 
given during the healing phase following the initial guillotine ampu- 
tation. As soon as the stump is healed, exercises may be given upon 
the approval of the ward officer. However, since the surgical revision 
is usually accomplished shortly after the stump has healed, this period 
is not very long. 
h. Early Postoperative Stage. The intensity of some exercises 
given in the preoperative stage may have to be decreased from an active 
or resistive movement to a movement of static contraction; other ex- 
ercises may have to be omitted temporarily. 
c. Preoperative and Postoperative Ambulatory Phases. Nor- 
mal leg balance exercises in standing can be added. 
27 Section 11. STUMP EXERCISES 
22. Strengthening Weak Muscles 
a. After the initial postoperative period, hip extension, hip adduction, 
and quadriceps exercises (for B /K’s) are usually best performed with 
pulley weights. Care must be taken to insure pelvic fixation in the 
first two of these exercises. Exercises for the remaining muscles of the 
involved extremity are usually best performed against resistance pro- 
vided by another person. 
The governing principle in all of these exercises is to increase resistance 
progressively as muscle strength improves. 
b. Occasionally, tests reveal weakness of the muscles involved in 
contracture. The contracture may be due to changes in joint capsules, 
ligaments, or soft tissues. Therefore, it is advisable to reduce the de- 
formity before instituting exercises to strengthen these muscles. 
23. Stretching Existing Contractures 
a. Hip Flexion. The choice of the exercise position may depend 
upon the condition of the patient, available apparatus, or other factors. 
Figure 23. Stretching contracted hip flexors with patient in supine position. Note 
that the normal thigh is in a comfortably flexed position, the lumbar region is flat- 
tened, and the pelvis is fixed firmly by the strap. The stretching of the contracted 
• hip flexors is a passive procedure accomplished by the physical therapist's steady 
pressure on the anterior iliac crest and the distal half of the thigh stump. (In prac- 
tice, the physical therapist stands on the side of the amputation.) The patient 
assumes the above position only when he cannot assume the preferred position in 
figure 25. 
28 Regardless of what position is employed, however, the technique must 
include firm fixation of the pelvis to prevent anterior pelvic tilt while 
pressure is being exerted to stretch the hip flexors. 
(1) The standing position is not recommended because of the diffi- 
culties encountered in fixing the pelvis. (See par. 116.) 
(2) In the supine position (with or without the extension table), a 
strap is used in addition to the force exerted by flexion of the normal 
thigh in order to fix the pelvis. When the pelvis is fixed by a strap, the 
normal extremity need not remain in such extreme flexion while the hip 
flexors of the opposite thigh are being stretched; it can rest on the table 
in knee-bent position. (See figs. 23 and 26.) 
(3) See figure 24 for the prone position. 
Figure 24- Stretching contracted hip flexors with the patient prone and with his legs 
over the end of the plinth. Note that the patient leans as far forward as possible 
with comfort. He grasps the sides of the plinth for support. The physical ther- 
apist maintains stabilization of the thigh of the patient’s normal extremity by coun- 
ter pressure of her left knee. This stretching is a passive procedure accomplished 
by the physical therapist’s applying traction on the distal half of the stump and, 
simultaneously, pressure over the gluteal region. The above position is ordinarily 
employed only when the position shown in figure 25 cannot be used. 
(4) See figure 25 for the sitting position. 
b. Hip Abduction. (1) Side-lying position. The extension table 
may be used as in hip-flexor stretching. (See fig. 26.) The patient lies 
on the side of his normal leg with his knee and thigh flexed about 45 ° to 
29 60°. The pelvis is fixed to the table by a strap. The weight pulls 
downward to stretch the stump abductors. 
Figure 25. Stretching contracted hip flexors and hip abductors in the sitting position. 
Note that the patient is sitting flat against the railing of the frame with his normal 
leg extended as fully as possible. The strap fixes his pelvis still further; and the 
weights (not shown) are exerting traction in the direction in which his thigh is ex- 
tended. The patient is making no active effort at movement of the right hip joint. 
The use of the radiant heat infra-red lamp, as illustrated, facilitates relaxation of 
muscle spasm. Since the single application of traction, as above, usually pulls the 
thigh in abduction as well as extension, the abduction component is negated by 
secondary traction. This, in turn, pulls the thigh in adduction-extension. This 
appears to be the most satisfactory arrangement for simultaneously stretching con- 
tracted hip flexors and contracted hip abductors. 
(2) - Supine position, or prone position with pillow under abdomen. 
Fixation of the pelvis is essential in order to localize stretching to the 
stump abductor muscles. Without pelvic fixation, the pelvis tends to 
ride upward on the side of the normal leg. A wide belt should be fastened 
around the pelvis and attached to the table by a strap which will pull 
the pelvis down on the side of the normal leg. 
(3) Standing position. This position is not recommended unless the 
patient can stand with his pelvis fixed by a pelyic-grip apparatus. 
(4) Sitting position. See figure 25. 
c. Using Weights to Stretch Hip Flexors or Abductors. It 
must be strongly emphasized that a weight must be kept on long enough 
and be heavy enough to overcome the ability of the muscle to pull against 
30 it. Otherwise, the weight will act like a resistance stimulus and will 
increase the strength of the muscle instead of stretching it. 
(1) The amount of time will usually be a 15- to 30-minute period. 
(2) The amount of weight will vary with the individual patient—the 
length of his stump, the degree of contracture, and his tolerance. The 
maximum amount of weight should be used immediately (without gradual 
increase); it should be sufficient to produce a definite feeling of relaxation 
in the muscle within several minutes. Immediately after this exercise, 
the patient usually complains of temporary pain in the “hip joint” 
(actually the hip flexors) and of difficulty in flexing his thigh. He should 
be told to expect such reaction and reassured that the symptoms are not 
serious. 
Figure 26. Use of the extension table in stretching contracted hip flexors. 
Section 111. POSTURE EXERCISES 
24. Typical Posture Faults 
Individual examination of patients will determine individual variations 
in exercise. However, since postural defects tend to assume the same 
pattern in most patients, it is possible to establish a general corrective 
exercise program which will apply in most cases. 
The following chart outlines conditions of muscle imbalance which 
usually accompany (as a cause of, or result of) typical faults in adult 
posture. It also prescribes exercises to correct muscle imbalance and 
posture defects: 
31 Posture fault 
Muscle weakness 
Muscle tightness 
Exercises and other corrective procedures for muscle imbalance 
a. Lordosis. 
“Lower” anterior 
abdominals. 
Low back erector spinae. 
Strengthening “lower" anterior abdominal muscles: 
(External oblique and 
Ilio psoas. 
Supine position: 
rectus abdominis.) 
Other hip flexors. 
(1) Roll pelvis until back is flat on table by pulling up and 
in with lower abdominal muscles. Hold low back 
Hamstring muscles and 
flat on table and breathe in and out to relax upper 
gluteus maximus, less 
abdominal muscles. 
frequently than ab- 
(2) With hands up beside the head, knee bent, and foot 
dominal muscles. 
flat on table, roll pelvis until back is flat on table by 
pulling up and in with the lower abdominal muscles. 
Hold back flat on table and straighten leg by sliding 
heel down along table. Keep pelvis rolled and 
return knee to bent position. Stump remains ex- 
tended on table. (See fig. 27.) 
Stretching tight low back muscles: 
Sitting position: 
With knees slightly bent and arms extended forward, pull 
up and in with lower abdominal muscles to roll the pelvis 
back. Then bend upper trunk forward to round lower 
back, and reach toward toes. 
Strengthening abdominal muscles and stretching low back muscles 
(combined exercise); 
Supine position: 
With arms at sides, palms up, and knees flexed on chest, 
lift hips a few inches from table to flex pelvis on thorax 
(but not to point of dorsal flexion). 
32 h. Kyphosis. 
Stretching hip flexors (see par. 23); 
Supine position: 
Keep low back flat on table by flexing normal leg (Knee 
to chest) with aid of hands around thigh. As assistant 
presses stump down toward table, help with active hip 
extension. (See fig. 23.) 
Prone position: 
With legs over end of table and trunk resting on table, fix 
pelvis by pressure against normal leg. At the same time, 
extend hip joint on stump side to stretch hip flexors. (See 
fig. 24.) 
Sitting position: 
See figure 25. 
Supine position (with extension table): 
See figure 26. 
Dorsal erector spinae. 
Pectorals and “upper” 
anterior abdominal 
Strengthening dorsal erector spinae and middle and lower 
trapezius: 
Middle and lower trapezi- 
muscles (internal ob- 
Sitting position; 
us. 
lique and rectus ab- 
On stool with lower back against wall (or on floor with legs 
dominis). 
extended forward, and with back to wall), hands up beside 
head—keeping low back against wall, straighten upper back, 
trying to touch entire back to wall. Then press elbows 
and head back toward wall, keeping chin down and in. 
(See fig. 28.) 
Stretching tight pectorals: 
Sitting position: 
Starting with arms in an abducted and externally rotated 
position, move arms backward and slightly upward. Physi- 
cal therapist aids arm movement and stabilizes upper back 
by pressure of her knee. (See fig. 29.) 
33 Posture fault 
Muscle weakness 
Muscle tightness 
Exercises and other corrective procedures for muscle imbalance 
c. Forward Head. 
Anterior neck flexors (an- 
Cervical spine extensors, 
Strengthening and stretching (combined exercise): 
(This position is usually 
terior-vertebral cervi- 
including upper 
Supine position: 
compensatory for a de- 
pressed chest; its cor- 
cal spine flexors). 
trapezius. 
Knee is bent and foot is flat on table, arms are in “inverse 
T” position, | | (arms elevated to shoulder level, hands 
rection will greatly de- 
pend on correction of 
faulty chest and upper 
back positions.) 
Sternocleidomastoid, 
up beside head). Raise chest (without arching back) and 
depress chin in direction of flattening cervical spine. (This 
exercise is somewhat comparable to flattening of lumbar 
spine in cases of lumbar lordosis, except that patient is not 
expected to touch entire cervical spine to table.) 
Sitting position: 
On stool with lower back against wall (or on floor with legs 
extended forward and with back to wall), hands up beside 
head—keeping low back against wall, straighten upper 
back, trying to touch entire back to wall. 1’hen press 
elbows and head back toward wall, keeping chin down and 
in. (See fig. 28.) 
d. Pronated Foot. 
Tibialis posterior and 
long toe flexors. 
Peroneals 
In preweight hearing stage—foot exercises for tibialis posterior 
and for toe flexors: 
Supine positions: 
With toes gripped, turn foot in a position of inversion in 
plantar flexion. 
In weight-bearing stage: 
Postural strain on weak tibialis posterior and toe flexor should 
be relieved by placing an inner border wedge on the heel, 
or a Thomas heel on the shoe (of normal leg in case of uni- 
lateral amputees), if the ward officer so recommends. 
34 e. Internally 
Hip external rotators, 
Tensor fascia femoris 
In preweight-bearing stage—exercises for external rotators (if 
Rotated 
particularly posterior 
examination shows them to be weak): 
Femur. 
portion gluteus medius. 
Supine position: 
With lower extremities in normal alignment, perform an 
outward axial turn. 
Side-lying position (fig. 17): 
As in test for strength of posterior portion of gluteus medius 
(par. 15), keep trunk and pelvis in straight alignment. 
Place upper leg in position with leg extended and thigh in 
abduction, slight extension, and slight external rotation. 
Hold against resistance which physical therapist applies to 
ankle in a downward and slightly forward direction. 
In weight-bearing stage: 
Strain on external rotators should be relieved by placing an 
inner border wedge on heel, or Thomas heel on shoe (of 
normal leg in case of unilateral amputees), as for pronation, 
if the ward officer so recommends. 
With the knee in extension, the hip joint and astragalo- 
navicular joint act together as a universal joint; the pro- 
nation of the foot results in internal rotation of the femur, 
and vice versa. 
35 Figure 27. Exercise to strengthen ‘'lower” anterior abdominal muscles. 
Figure 28. Exercise to correct faulty positions of upper hack and head. (Directions 
in paragraph 2Jfb must be followed exactly.) 
36 Figure 29. Position for stretching contracted 'pectoral muscles. 
Section IV. EXERCISES FOR UNILATERAL AMPUTEES 
25. Purpose 
This section prescribes exercises for strengthening and improving balance 
on the normal leg. 
The number of repetitions or amount of resistance offered a patient in 
particular exercises increases in direct proportion to the return of muscle 
strength. 
26. Bed Stage 
Exercises 
Purpose 
Position and movements 
a. Foot Exercises. 
Dorsiflexion 
Maintaining tone and 
strength of dorsiflexors 
and offsetting tendency 
toward gastrocnemius 
soleus contracture. 
Supine position: 
Pull foot upward (toward 
body). 
Inversion __ . 
Maintaining tone and 
Supine position: 
(Exercise is done in 
strength of tibialis an- 
Pull foot upward and 
both dorsiflexion and 
terior and tibialis pos- 
slightly inward. 
plantar flexion, where 
latter is not contra- 
indicated by a con- 
tracture in that po- 
sition.) 
terior muscles. 
Push foot downward and 
slightly inward. 
37 Exercises 
Purpose 
Position and movements 
Toe flexion .. 
Strengthening both long 
Supine position: 
and short flexors of 
toes, and preventing 
contracture of toe 
extensors. 
Grip toes, strongly flex- 
ing all toe joints. 
Foot circling .. . 
Maintaining general 
Supine position; 
(Not to be performed 
strength of leg and 
Beginning with foot 
where contraindi- 
cation in the form of 
contractures of gas- 
trocnemius, 
soleus, peroneals, or 
or other muscles 
foot muscles. 
turned inward, describe 
a complete circle. 
With toes gripped, de- 
scribe a complete circle, 
beginning with foot 
turned inward. 
exists.) 
b. Knee Exercises. 
Quadriceps “setting” 
Preventing atrophy and 
maintaining tone and 
strength of quadriceps 
muscle group. 
Supine position: 
Contract quadriceps mus- 
cle without moving 
knee joint, by tensing 
. muscle and exerting up- 
ward pull on patella. 
Knee extension _ 
Preventing atrophy and 
maintaining tone and 
strength of quadriceps 
muscle group. 
Supine position (pillow under 
knee); 
Raise lower leg to straight- 
en knee. 
Emphasize complete ex- 
tension of leg. 
c. Hip Exercises. 
Hip extension.. 
Preventing atrophy and 
maintaining tone and 
strength of hip 
extensors. 
Prone position: 
Keeping knee straight, 
extend hip fully. (Back 
must not arch during 
movement.) 
Hip abduction _ 
Preventing atrophy and 
maintaining tone and 
strength of hip abduc- 
tors, with particular 
attention given to 
gluteus medius muscle. 
Side-lying on stump side: 
Place leg with knee 
straight in abduction, 
slight extension, and 
outward rotation; hold 
against resistance. 
(Same movement as test 
for gluteus medius, pos- 
terior portion.) (See fig. 
17.) 
38 Exercises 
Purpose 
Position and movements 
d. Combined 
Exercise. 
Strengthening muscle 
Supine position, with hands 
groups particularly 
up beside head, elbows 
subject to weakness 
resting on bed, and knee 
because of position and 
slightly flexed over pillow: 
lack of use in bed. 
Components of following 
exercise are performed 
simultaneously: 
(1) Pull foot upward and 
slightly inward. 
(2) Press knee and hip 
downward. 
(3) Pull up and in with 
lower abdominal mus- 
cles, flattening lower 
back. 
27. Ambulatory Stage 
Exercises 
Purpose 
Position and movements 
a. Balancing 
on Normal 
Leg. 
Developing coordination 
of standing balance. 
Standing on normal leg, 
near bed footrail or other 
support: 
(1) Stand with hand light- 
ly on support and main- 
tain good postural align- 
ment. (Use minimum 
support.) 
(2) Stand unsupported. 
(Progression may be 
marked by length 
of time (number of 
counts) for which po- 
sition can be held.) 
b. Hopping on 
Normal Leg. 
Developing coordination 
of standing balance. 
Standing on normal leg near 
object of support: 
Hop lightly on foot. 
(Shock of impact should 
be absorbed in foot, 
ankle, knee, and thigh.) 
c. Deep Knee Bend- 
ing. 
Developing coordination 
of standing balance. 
Standing position (fig. 30); 
Perform deep knee bend, 
raising arms forward. 
39 Figure 30. Deep knee bending exercise to strengthen normal leg. (Note value of exer 
cise in sitting and rising from a chair.) 
Section V. GENERAL EXERCISES 
28. Purpose 
This section describes exercises for muscles which have not previously 
received specific attention in this manual. 
29. Exercise for Oblique Abdominal Muscles 
Supine position: 
Raise trunk to half-sitting position, twisting to right and reaching 
with left hand toward right thigh, keeping legs flat on plinth. 
Repeat exercise on opposite side. 
30. Exercise for Lateral Abdominal Muscles 
a. Lateral Hip “Hiking.” 
Supine position: 
“Hike” hip up on right side (draw hip toward shoulder). 
b. Lateral Trunk Raising. This exercise should not be given to 
lateral abdominals on involved side where there is an abduction contracture 
of the thigh. 
Lying on right side with legs supported by operator: 
With body in straight alignment, raise trunk sideways up from plinth. 
40 (See fig. 31.) 
Repeat exercise on opposite side. 
Figure 31. Exercise to strengthen lateral abdominal muscles. 
31. Exercise for Upper Anterior Abdominal Muscles 
Supine position; 
Roll pelvis to flatten lower back on plinth. With arms extended, raise 
head and shoulders from plinth. Do not attempt to come to a sitting 
position, but raise upper trunk as high as back will bend—about 8 inches. 
(See fig. 32.) 
Figure 32. Head and shoulder exercise to strengthen upper anterior abdominal muscles 
41 32. Exercise for Lower Back Muscles 
Prone position, with legs supported by operator: 
With hands clasped behind back, raise trunk upward, arching back; 
draw shoulders back, keeping arms free from body. 
33. Breathing Exercise 
Supine position: 
Breathe fully and deeply in through nose and out through mouth. 
(Aim for intercostal expansion and diaphragmatic contraction. Guard 
against raising the shoulders and mere elevation of the chest by arching 
the back.) 
34. Exercises Contraindicated 
Exercises for sternocleidomastoid, pectoral, and hip flexor muscles have 
been‘omitted in this section because ordinary supine bed positions and 
movements of the head, arms, and legs in the forward plane of the body 
provide sufficient use to maintain their tone. Frequently, these muscles 
are over-used and even necessitate corrective measures such as stretch- 
ing and lengthening. 
42 CHAPTER 5 
INDIVIDUAL WALKING INSTRUCTION 
Section I. GENERAL 
35. Administration 
The general procedures in establishing and managing the instruction 
program are set forth in paragraph 4; a more detailed discussion of classi- 
fication, apparatus, and teaching technique is set forth below. 
36. Apparatus 
A well-equipped room for conducting walking and exercise classes 
should include: 
a. Parallel Bars (standard item P 010230, bars, parallel; two 
sections)—about 20 feet long, 3 feet high, and 2 feet 2 inches apart, with 
lines inches wide and 5 inches apart painted on the floor between 
bars (measurement taken from inner borders of lines). 
h. Mirror (standard item P 504550, mirror, postural training: 
triple, full length)—6 feet high and 10 feet wide, composed of portable 
posture mirrors. 
c. Lines on Floor at Right Angles to Mirror—20 feet long, V/2 
inches wide, and 5 inches apart (measurement taken from inner borders 
of lines). 
d. Stairs—each step 11 inches wide; six low steps 5 inches high on 
one side; four high steps 73i> inches high on other side. Rails on both 
sides of steps, about 2 feet 8 inches high. 
e. Walking Ramp—about 10 feet long, 1 foot 9 inches wide; height 
is 1 inch at low end and graded to 18 inches at the upper end. Rails on 
each side of ramp, 36 inches high. Three 6-inch steps leading from upper 
end of ramp to floor. 
/. Phonograph and Slow Fox-Trot and March Records. 
g. 16-mm Projector, Screen, Viewer, and Editing Equipment. 
37. Teaching Technique 
It is imperative for amputees to appreciate the goal of walking classes 
and the necessity for adhering to their established sequence. Patients 
must be made to realize that merely learning to get around on a pros- 
thesis is not enough—a patient does not achieve maximum utility from 
his prosthesis until he has learned to walk as normally as possible. 
Three components of excellent walking with a prosthesis are balance 
and muscular coordination in motion, smoothness of walking rhythm, 
and steps of equal length. These components should be taught to the 
patient as follows: 
43 a. Maintaining Walking Balance. Balance is achieved by equal 
distribution of weight above a center of support. Therefore, in order 
to obtain walking balance an amputee must walk with his feet under the 
weight-bearing axis of his body in such a way that he attains equal 
weight distribution during his walking stride. Helpful exercises are con- 
sidered in paragraphs 39, 40, and 47. 
h. Keeping Soles and Heels Close to Ground During Walking. 
In order to duplicate the normal stride with the prosthesis, as nearly as 
possible, it is imperative to adjust the travel pattern of the prosthetic 
foot so that it will duplicate that of the normal foot. Time and travel 
distance with the prosthetic foot must be synchronized with that of the 
normal foot. Before a patient can do this, he must understand the 
mechanics of both the normal and the prosthetic legs. 
Table 111. 
PHYSICAL THERAPY ACHIEVEMENT TEST FOR LOWER-EXTREMITY AMPUTEES 
Name 
Ward number 
Type of amputation 
Date of final surgical revision 
Handedness 
Date walking began 
Date walking completed 
Gradings , . r-, . 
(Check one) Poor! 1 Fair! 1 Good! 1 
Excellent! 1 
Achievement Beginners Intermediate 
General posture 
Advanced 
Balance.... .. . . . _. 
Forward walking. , .... 
Stair climbing 
Ramp walking . . . . 
Turns: 180° 
90° 
45° 
Walking on straight line 
Prosthetic foot close to floor. . . . _ . . 
Eoual length stens _ _ „ _ . 
Walking rhythm . _ . .... 
Backward walking _ 
Sideward walking _ _ . 
Sitting on chair _ . .... . . 
Rising from chair. . _ .. _ .... 
Sitting on floor: ... . . .... 
Rising from floor. . __ 
Picking up objects. . ... 
Balance on prosthesis. ... 
Curb, stepping on and off.. .. ... 
Walking on rough terrain 
Walking on grass, sand, etc 
Hill climbing . 
-Z. .. 
Signature of physical therapist 
Date 
44 In the normal gait, the sole and heel are carried as close to the ground 
as possible from the point at which the foot leaves the floor to the point 
at which it returns in forward position. With this kind of movement, 
the foot covers the shortest distance between these two points in the 
least amount of time, and with the least possible effort. 
The normal knee is slightly flexed when the leg is in its forward walk- 
ing position, whereas the prosthetic knee is completely extended in that 
position. Because of this variance in mechanics, the length of stride 
with the prosthesis tends to be slightly longer than the stride with the 
normal leg. This tendency can and must be minimized to avoid the 
typical “amputee gait.” 
Exercises developing the proper kinesthetic sense for carrying the sol 
and heel of the 'prosthetic foot as close to the floor as possible are considered 
in paragraphs 39 through 41. 
c. Achieving Uniform Stride. Among the common causes of 
longer stride with the prosthesis than with the normal leg are: (1) 
prosthesis longer than normal leg, (2) hyperextension of knee joint, 
(3) swinging prosthesis in abduction, (4) excessive hip flexion, and (5) 
elevation of pelvis on side of prosthesis. (The last two result when the 
prosthetic foot is carried too high above the floor.) 
Keeping in mind that the prosthetic leg and the normal leg differ in 
length of stride because of variance of mechanics, it is very important 
to check the above-knee prosthesis for hyperextension at the knee joint; 
each 5° of hyperextension will increase the length of stride by about 
inches. 
Exercises to promote uniform stride are set forth in paragraphs 40 
and 48. 
38. Classification 
Within each of the four groups described in paragraph 4 (unilateral 
A/K, unilateral B/K, tilting-table, and bilateral amputees), there are 
three distinct classes (or grades) in walking instruction through which 
patients progress according to their walking ability: Beginners, Inter- 
mediate, and Advanced. (As many of each of these classes are con- 
ducted as are necessary for individual instruction, each class period 
lasting 30 minutes.) 
With the exception of bilaterals, all amputees remain in the beginners 
class until they are able to walk comfortably at a normal walking speed 
without such aids as crutches or canes. Thereafter, as soon as they can 
accomplish all the activities prescribed for a class, they progress to the 
succeeding class. 
The Physical Therapy Achievement Test for Lower Extremity Am- 
putees (table III) will be used to record progress in walking and related 
activities. This record should represent average performance through- 
out the walking program. 
45 Paragraphs 39 through 41 include exercises for unilateral amputees. 
In general, these exercises apply to A/K, B/K, and tilting-table cases; 
however, certain modifications are necessary for the last group. For 
example, patients with disarticulation of the hip joint and loss of con- 
tiguous muscles obviously cannot have the same degree of balance and 
control over the prosthesis as persons without such defects. These 
patients should not be required to perform the check balance exercises. 
Special instructions or modifications of a particular exercise for one of 
the three groups are called to the attention of the instructor. 
Paragraphs 42 through 45 describe problems of sitting and walking 
which are peculiar to tilting-table amputees because of the mechanics 
of the prosthesis. 
Paragraphs 46 through 49 include exercises for bilateral amputees. 
In general, these exercises apply to A/K, B/K, and tilting-table cases. 
Where modifications or special instructions are necessary for a particular 
group, they are called to the attention of the instructor. 
Section 11. UNILATERAL AMPUTEES 
39. Beginners Class 
a. Objectives. In the beginning phase of walking instruction, 
emphasis is placed on acquiring balance and a normal walking speed of 
about 120 steps a minute. For example, the instructor requests the 
amputee to walk with his heels between lines 5 inches apart, but does 
not attempt to influence the patient’s walking stride by insisting that 
he synchronize the time of both feet. Such insistence upon form in the 
early stage will only hinder the patient’s progress. 
The ability to judge the position of the prosthetic foot with respect 
to the floor is a prerequisite to correction of walking technique. A/K 
amputees must learn to swing the lower portion of the prosthesis at a 
speed which will produce sufficient momentum to develop this kinesthetic 
sense of position in the stump. (The amputee must have this ability 
before he is ready for Intermediate Class exercises which require him to 
scrape the foot of his prosthesis on the floor or to carry it as close to the 
floor as possible.) A certain amount of momentum is also necessary 
before the amputee can move his prosthetic foot without lifting the 
pelvis on the side of the prosthesis. Therefore, speed and balance, 
rather than form, are the objectives in the Beginners Class. 
b. Exercises. (1) Pelvic Tilt. Roll pelvis by action of abdominal 
muscles pulling the pubic symphysis toward the sternum. 
Note. Instructor checks patient for good body mechanics in upright position, 
placing special emphasis on lateral and anteroposterior alignment. 
(2) Balance Exercise I. Stand with feet Bto 10 inches apart, balanc- 
ing with aid of crutches or canes. 
Stand erect and hold crutches or canes off floor. 
Balance—first on one leg, then on the other. Hold weight for same 
length of time on each leg, keeping both feet on the floor at all times. 
46 (3) Balance Exercise 11. Place prosthesis in forward walking posi- 
tion with weight on normal leg. 
Take full step forward with normal leg, placing inner border of normal 
foot in line with inner border of prosthetic foot. 
Take backward step with normal foot, passing it as close to prosthetic 
foot as possible. 
Repeat exercise about 10 times without interruption. (When exer- 
cise is properly executed, a feeling of proper walking balance over the 
prosthetic leg is experienced. No lateral motion of the body should 
exist during the exercise.) 
Note. Instructor should emphasize importance of exercise and explain to amputee 
the necessity of keeping feet together to maintain balance. Amputee should be 
requested to conduct the following experiment regarding improper walking balance; 
Stand in front of mirror with feet spread about 12 inches apart. 
Take step directly forward with normal foot. 
Take step directly backward. 
Repeat exercise, noting development of lateral motion and feeling of being off 
balance. Compare with feeling in balance exercise II above. 
(4) Forward Walking Exercise. Walk between parallel bars, or on 
crutches, with feet not more than 5 inches apart. Always advance normal 
leg first. 
In accomplishing a forward step with the prosthesis, be sure to obtain 
sufficient speed to break the knee so as to clear the foot from the floor. 
Check the forward swing of the prosthesis by quickly extending the hip 
in order to extend the knee. 
Note. Instructor should warn patient that unless there is sufficient speed, the 
prostethic foot will drag on the floor and the consequent buckling of the knee may 
cause him to fall. Patient may develop faulty walking habits when he tries to 
overcome fear of falling by raising pelvis on side of prosthesis, or by abducting the 
prosthesis to maintain knee in extension. 
(5) 180° Turns (Walking or Standing). Place normal foot forward, 
shifting body weight to ball of normal foot, and pivot toward prosthesis. 
This leaves prosthetic foot in forward position at completion of the 
turn and normal leg in position to take forward step. 
(6) Stairs (For A/K, B/K, and tilting-table amputees in beginning 
phase). 
Place normal foot on first step. 
Shift body weight over normal leg. 
Bring prosthetic foot to a position beside normal foot. 
Repeat. 
Note. Tilting-table amputees may be taught to ascend two steps at a time. 
To descend: 
Place a minimum of three-fourths of the prosthetic foot on 
lower step. 
Shift body weight to prosthesis. 
Bring normal foot to a position beside the prosthetic foot. 
Repeat. 
To ascend: 
47 c. Late Stage of Beginners Class. One of the required activities 
is walking the ramp. When walking up or down an inclined plane, the 
amputee shortens his stride in order to maintain maximum walking 
balance. The reduction in the length of his stride is proportionate to 
the angle of the incline. He uses the same technique in breaking the 
knee as A/K amputees use in descending steps alternately, as required 
by the Intermediate Class exercise, Steps. (See par. 406 (7).) 
d. Photography. Each amputee’s walking form will be recorded on 
on 100 feet of motion picture film as soon as he can walk without crutches, 
canes, or other aids. 
40. intermediate Class 
а. Objectives, In this class, the amputees develop uniform stride 
and rhythm and learn the more common walking procedures. 
Each amputee views motion pictures of his walking form along with 
his instructor. The instructor points out imperfections in form, and 
clearly explains reasons for the faults and means of correcting them. 
Posture is under constant supervision during this period. 
б. Exercises. (1) Balance Exercises I and 11. See paragraph 
396 (2) and (3). 
(2) Balance Exercise 111. Place prosthesis in forward walking 
position. 
Take a full step with normal leg, forward and backward. 
Take a full step forward with normal leg. 
Take a full step with prosthesis; then step forward with normal foot, 
stopping in that position. 
Rock back on prosthesis. 
Return normal foot to its backward position. 
Continue with remainder of exercise, as outlined above. 
(3) Corrective Walking I. Walk between lines 5 inches apart for 
at least 10 minutes of each class period, until principles of good walking 
technique described in paragraph 37 are mastered. 
(4) Standing Turns. 
45° or 90° Turns (right or left). Stand with feet about 6 inches 
apart. Without lifting feet from floor, execute turn as follows: 
Pivot to left by turning on heel of left foot and ball of right foot 
(pivot to right by turning on heel of right foot and ball of left). 
180° Turns. Place normal foot forward about 6 to 8 inches. 
Shift body weight to ball of normal foot, and pivot toward 
side of prosthesis. 
(5) Walking Turns. 
45° Turns. Pivot on either foot. 
90° Turns. When turning toward prosthesis, always pivot on 
prosthetic foot; when turning toward normal leg, pivot on 
either foot. 
180° Turns. Shift body weight over normal leg when it is in a 
forward walking position, and pivot toward prosthesis. 
48 (6) Stooping to Pick up Objects. 
B/K Amputees. Place prosthesis forward, lean forward from 
waist, and pick up object from floor. 
A/K Amputees: 
Placing feet slightly apart, weight on normal leg; flex both 
knees and bend from waist; or 
Placing prosthesis back, weight on normal leg; flex both 
knees and bend from waist. 
(7) Steps. 
B/K Amputees. Ascend and descend steps as in Beginners Class 
(par. 39) until discomfort is no longer experienced. Stairs 
may then be taken alternately, in the normal manner. There 
should be no difficulty in guiding the placement of the pros- 
thetic foot on alternate steps. 
A/K Amputees: 
To ascend steps, follow procedure outlined in paragraph 
396 (6), but take two steps at a time instead of one. 
To descend steps, place hand on rail. Place heel of pros- 
thesis on edge of step and transfer weight to prosthesis. 
Move normal foot to alternate step, at the same time 
breaking knee of prosthesis before the normal foot actually 
touches the step. Do not try to descend with any portion 
of the prosthesis other than the heel on the step. 
Note. Instructor should explain to the amputee that his prosthetic knee will 
break automatically as he shifts his weight forward to bring the normal foot to a 
lower level. (See Training Film “Sky is the Limit.”) 
(8) Balance Exercise IV. Start with feet Bto 10 inches apart. Face 
parallel bars, grasping rail for support. 
Shift body weight over prosthesis. 
Remove normal foot from floor. 
Hold normal leg and arms in abduction to help maintain balance. 
Balance away from rail. 
Shift weight to normal leg and balance. 
Continue exercise until it is possible to balance on either leg without 
any assistance. 
(9) Balance Exercise V. To develop a finer sense of the fundamental 
principles of walking, practice walking on a straight line as follows: 
Place prosthesis on line. 
Walk forward, placing normal foot on line in front of prosthesis. 
Walk length of line; abduct arms, if necessary, to maintain balance. 
(10) Sitting and Rising from Chair. 
Sitting: 
Approach chair from front. 
Step close to chair with normal foot about 4 inches in front 
of opposite corner of chair. 
Turn 180° toward prosthesis. 
49 With weight on normal foot, bring prosthetic foot back to 
same level. 
Lean slightly forward, place both hands on knees, and lower 
body into chair. 
Rising: 
Place normal foot near chair and prosthesis slightly forward. 
Lean forward, at the same time lifting body weight out of 
chair with normal leg and placing hands on knees to assist. 
Shift weight to prosthesis and step out on normal foot. 
(11) Sitting and Rising from Floor. (In the following exercise, the 
body is visualized as in the center of a clock face and facing a position 
of 12:00 o’clock.) 
Sitting (Directions below are for left prosthesis): 
Feet are 6 to 8 inches apart laterally, with prosthetic foot 6 
to 8 inches forward. 
Shift weight to normal leg. 
Flex both prosthetic and normal knees, stoop, and place 
right hand on floor at position 4:00 o’clock. 
Place left hand at 8:00 o’clock and lower body to floor. 
(An amputee with a right prosthesis places the left hand on 
the floor first, in above exercise.) 
Rising (Directions below are for left prosthesis): 
Place right hand on floor at position of 4:00 o’clock. 
Flex right leg with foot flat on floor. 
Swing left hand across body and place in position of 1:00 
o’clock. At the same time rotate body to right, bearing 
weight on right leg and hands. 
Stand, bearing weight on normal leg. 
Shift weight to prosthesis and step out on normal foot. 
(An amputee with a right prosthesis follows the same direc- 
tions as above, except that he pivots to the left, instead of 
the right.) 
(12) Bach Step. 
A/K and Tilting-table Amputees. If backward steps are neces- 
sary, be sure they are short; never lift the feet from the floor. 
Keep legs straight and slide feet over floor. 
B/K Amputees. Walk backward in the normal manner, lifting 
feet from floor. 
(13) Side Step. 
Right Step: 
Shift weight to left side. 
Abduct right leg and take side step, transferring weight to 
right leg. 
Slide left foot over floor to position of normal stance and 
repeat exercise. 
Left Step: Reverse procedure given above for right step. 
50 (14) Walking Up and Down Steep Incline. 
A/K and Tilting-Toble Amputees. Go up sideways, with the normal 
leg nearest the top of the incline; or walk up diagonally, with the 
normal leg on the uphill side. Descend with normal leg nearest 
top of incline. 
B/K Amputees. Walk up and down in the normal manner. 
(15) Curbs. 
Step-Up. Approach curb and place heel of prosthetic foot on it 
without looking down; keep knee completely extended. With 
a strong push-off, step on the curb with the normal foot. As 
skill develops, it is possible to learn to step up on curb with 
either foot. (Tilting-table amputees, however, of necessity 
place the normal leg on the curb first since there is no hip 
joint motion on the side of the amputation.) 
Step-Down. Place prosthesis down first in stepping off a curb. 
(16) Proper Carriage of Prosthetic Foot. A strongly recommended 
and practicable way of learning to carry the sole and heel of the foot as 
close to the floor as possible is the following “scraping-toe” exercise. 
Practice this exercise until the prosthesis can be controlled with the 
highest degree of proficiency. 
Walk at normal walking speed, lightly scraping the toe of both the 
prosthetic foot and the normal foot, in turn, on the surface of the floor. 
Immediately upon scraping the toe, place the heel upon the floor in 
such a position that both heels come in contact with an imaginary line 
2 inches in width. 
(17) Development of Uniform Stride. In performing the following 
exercise, keep the feet together and soles and heels as close to the floor 
as possible: 
Walk slowly. 
Look down and study the angles of both feet with relation to the 
floor as they are successively placed in forward position. If their stride 
is uniform, the angle of the prosthetic foot will be comparable to the 
angle of the normal foot. However, if the stride with the prosthesis 
is too long, the angle of that foot to the floor will exceed the angle of the 
normal foot. 
In order to walk slowly and keep the sole of the prosthetic foot close 
to the floor, the stride with the prosthesis must be shortened to a point 
where it will duplicate the stride of the normal foot. 
This exercise should be practiced 15 minutes a day until a uniform 
stride has been developed and all of the foregoing exercises can be per- 
formed with a fair degree of proficiency. Then the amputee can be 
graduated to the Advanced Class. 
c. Music. Music may prove beneficial in developing rhythm and 
relaxation in walking if records are carefully selected. 
d. Photography. At the completion of this class, motion pictures 
should be taken of each amputee’s walking form. 
51 41. Advanced Class 
a. Objectives. In this class, walking technique should be per- 
fected. With this as a goal, the instructor and amputee will view to- 
gether the motion pictures taken at the end of the Intermediate Class 
(and any other pictures which may have been taken). The instructor 
will point out errors and outline the amputee’s advanced training ac- 
cordingly. 
Faults to be corrected are: 
(1) Walking. 
Stepping off with prosthesis first. 
Limp of any type. 
Abduction of the stump. 
Lifting prosthetic foot too high from floor. 
Placing feet too far apart during walking stride. 
Lateral pelvic motion. 
Rigid walking posture. 
(2) Awkward Turns. 
(3) Stairs. 
Inability to descend steps without aid of railing. 
Improper placement of prosthetic foot on step. 
b. Exercises. The following check exercises should be given at 
the beginning of this class (these exercises should not be required of 
tilting table amputees): 
(1) Check I (to determine walking balance): 
Walk at normal speed. 
Stop at command of instructor and balance on the leg which is 
bearing the body weight at the time. 
Inability to perform this exercise is the result of improper place- 
ment of the feet during the walking stride and hence unequal 
distribution of body weight. 
(2) Check II (to determine efficiency of control over prosthesis): 
Walk at normal speed, conforming to the fundamentals of good 
walking technique set forth in paragraph 37. 
Scrape the toe of the prosthesis on command. 
Above exercise should be practiced until it can be accomplished 
successfully. 
c. Requirements for Discharge from Advanced Class. 
(1) Proper walking balance with no detectable fault in gait. 
(2) Walking with soles and heels as close to the floor as possible. 
(3) Uniform stride. 
(4) Walking with ease, arms swinging freely. 
(5) Passing achievement test. (See table III.) 
52 Section Ml. TILTINC-TABLE AMPUTEES 
42. Exercise Program 
As explained in paragraph 38, the exercises for tilting-table amputees 
are, in general, the same as those described for unilateral A/K amputees 
in paragraphs 39 through 41. Obviously, the tilting-table prosthesis 
presents special problems in control and balance which may require 
modification of the program for individual cases. 
Paragraphs 43 through 45 describe problems of walking, sitting, and 
rising which are peculiar to tilting-table amputees because of the me- 
chanics of the prosthesis. 
43. Walking 
The technique is the same employed by A/K amputees except for the 
following points: 
a. Since there is no movement of the prosthesis at the hip joint, 
forward flexion of the entire prosthetic leg is produced by a movement 
of quick flexion of the pelvis, rather than by ‘‘hiking” the hip and ex- 
tending the trunk on the pelvis. The last two movements are commonly 
seen, but result in an ungainly, awkward gait. 
h. The normal leg of tilting-table amputees tends to take a longer 
stride than the prosthetic leg, contrary to the case of A/K amputees. 
This is because of the anatomical and mechanical difficulties in bringing 
the prosthesis forward in a long step. 
c. After a patient acquires skill in controlling his prosthesis, he is 
permitted to unlock the knee, so that knee flexion is possible (assuming 
that the knee is mechanically arranged for flexion in walking). Walking 
with knee motion contributes materially toward a more normal appear- 
ing gait. 
44. Sitting 
Unlocking the hip and knee joints must be incorporated into the techni- 
que used by A/K amputees. The knee joint is unlocked first, when 
the patient has turned and is ready to sit. The weight is then shifted to 
the normal leg, the hip of the prosthesis is unlocked, and the patient sits 
down, still bearing his weight on the normal leg. The technique should 
be practiced until the patient unlocks the prosthesis automatically. 
45. Rising 
The weight is borne on the normal leg. As the patient assumes the 
erect position, the hip joint locks automatically. The knee is then 
locked normally, the weight is transferred to the prosthesis, and the 
patient steps forward with his normal leg. 
53 Section IV. BILATERAL AMPUTEES 
46. General 
The problem of learning to balance is more difficult for the bilateral 
amputee than for any other type of amputee because he has no normal 
leg upon which to support himself. 
In general, the B/K bilateral amputee is taught the same walking tech- 
niques used by unilateral A/K amputees; however, variations may be 
necessary to meet individual needs. 
47. Beginners Class 
a. Objectives. The exercises in b below are designed to develop a 
sense of balance and should be continued until the patient can walk with 
the support of canes. Then he is ready for the Intermediate Class. 
h. Exercises. Patients who take these exercises with pylons must 
repeat the routine upon acquiring full length prostheses. 
(1) Balance Exercise VI—Between Parallel Bars. 
Stand with feet as close together as possible. 
Tighten abdominal muscles to correct anterior pelvic tilt. 
Shift body weight laterally over one prosthesis, theji over the other. 
Keep the body in good postural alignment. 
Note. “Pelvic roll,” as such, is not desired because it is almost always accompanied 
by a marked feeling of instability of the knees. 
(2) Balance Exercise VII—Between Parallel Bars. 
A/K Amputees: 
Stand with feet no more than 6 inches apart, if possible. 
Hold pelvis in correct alignment. 
Bear weight on one prosthesis, flex opposite thigh, and bring 
second prosthesis forward. 
Shift weight to second prosthesis and hold briefly. 
Then assume original position by bringing first prosthesis 
forward. 
Repeat exercise, alternating prostheses. 
Tilting-Table Amputees (with disarticulation). Follow above 
directions, alternating prostheses, but walk forward. (This 
will provide the momentum necessary for walking with tilt- 
ing-table prostheses.) 
(3) Walking Exercise I—Between Parallel Bars. 
Stand with feet no more than 6 inches apart, if possible; and with 
hands on bars. 
Shift body weight to right prosthesis and left arm and hand. 
Advance left prosthesis and right hand. 
Shift weight to left prosthesis, advancing right prosthesis. 
Continue moving forward. 
54 48. Intermediate Class 
a. Objectives. Amputees should acquire the technique of walking 
with canes and of encountering ordinary obstacles. 
When a patient has developed a uniform stride, is walking with all 
of his weight on the prostheses, and can perform the exercises in 6 below 
with a fair degree of proficiency, he progresses to the Advanced Class. 
At the completion of this class, 100 feet of motion picture film is taken 
of each amputee’s walking form. 
h. Exercises. (1) Walking Exercise I. Follow directions in para- 
graph 476(3), using two canes. Do not support all of the body weight 
on the canes or walk with canes ahead of the body. Try to get into the 
habit of swinging the arms as the walking technique improves. 
(2) Sitting and Rising from Chair. The following directions are for 
the A/K amputee; however, a patient with disarticulation uses the same 
technique, making sure the hip is unlocked. 
Sitting: 
Approach chair from side. 
Turn trunk and face chair. 
Place one hand on back of chair and the other on the arm or 
seat of the chair. 
Shift body weight to arms; flex hips, and swing into chair. 
Rising: 
Place right hand on the back, arm, or seat of chair (using 
position which feels most stable). 
Place left hand on arm of chair (if cane is used, place well 
forward). 
Extend left leg and lock knee in extension; raise body out of 
chair, bearing weight on hands and on left prosthesis. 
Turning body toward right side, thrust weight over left 
prosthesis. 
Extend and lock right prosthesis. 
(It makes no difference whether the right or left prosthesis is 
extended first in rising, as long as the same sequence of 
events is followed.) 
(3) Turns. An A/K amputee or a patient with hip disarticulation can 
make no pivots. Instead, he must move one leg laterally pivoting on 
the heel slightly, and then bring the second leg toward it; or he must 
walk in a small circle. 
(4) Stairs. 
Ascending: 
(a) A/K Amputee (assuming left railing is used). 
Place left hand and forearm on rail, and right hand on 
cane. 
Place foot of left prosthesis on step. 
Pull weight over left prosthesis by pushing off with cane 
and pulling up on rail. 
Bring right foot to position beside left foot. 
55 An alternate method is to— 
Stand facing railing. 
Place hands on railing. 
Swing left (right) foot up on step and lock knee. 
Pull upon railing and swing (left) foot back and up 
on step behind the first foot, assuming stride position; 
and lock knee. 
Rock back on right (left) foot and swing the other foot 
to the next higher step. 
Continue up steps. 
(h) Bilateral Tilting-Table Amputee. 
Place one hand on railing and other hand on cane. 
Put weight on hands, extend elbows and, at the same 
time, swing prostheses through to step. 
Descending (the more advanced walkers may be taught to descend 
stairs facing in forward position): 
(a) A/K Amputee. 
Using one railing and one cane; or, if 
the steps are wide, using two canes: 
Place left (right) hand on railing and right (left) hand 
on cane. 
Lower cane to step and grasp rail. 
Place heel only of left (right) foot on edge- of step so 
that the knee will break. At the same time, lower 
the locked prosthesis to the next step, beside the cane. 
(The knee of the left (right) prosthesis should break 
simultaneously with the placing of the right (left) heel 
on the edge of the next lower step.) 
Using two canes: 
Lower left (right) cane to step below and place left 
(right) heel on edge of step from which descending. 
Lower right (left) foot to step below, carrying weight on 
left (right) cane. 
Lower left (right) foot and right (left) cane. 
Note. The two techniques which follow are less stable, but practicable: 
Lower left (right) cane and left (right) foot together; then right (left) cane and 
right (left) foot together. 
Lower both canes together and swing feet to lower step. 
(b) Amputee with Tilting Table Prostheses. 
Place both hands on railing. 
Extend elbows to lift body weight; at the same time 
swing prostheses to lower step. 
(c) Amputee with One A/K Prosthesis and One Tilting Table 
Prosthesis. Descend, as in (a) above, but lower tilting table 
prosthesis first. 
(d) Amputee with One B/K Prosthesis and One Tilting Table 
Prosthesis. Descend as in (a) above, but lower tilting table 
prosthesis first. 
56 (5) Walking the Ramp. In order to maintain balance, shorten the 
stride proportionately to the angle of the incline. 
Use the same technique for breaking the knee as unilateral A/K ampu- 
tees use in descending steps alternately, as required by the Intermediate 
Class exercise, Steps. (See par. 406(7).) 
(6) Sitting and Rising from Floor. 
Sitting: 
Stand with feet apart and bend at the waist until the fingers 
almost touch the floor. 
Walk forward on hands to a point where it is possible to 
pivot to a sitting position. 
* Rising: 
Lock knees. 
Using one heel as a pivot, cross other leg over and turn 180 °. 
Take weight on hands and side of pivot foot. 
Walk back on hands until hips are flexed to more than 90°. 
Come to standing position with aid of cane. 
Note. This technique is not recommended for patients with bilateral disarticulation. 
49. Advanced Class 
a. Objectives. Walking technique should be perfected to the point 
where the amputee no longer feels completely dependent upon his canes 
even though he continues to carry them for reasons of security. With 
this as a goal, the amputee and instructor view together the motion 
pictures taken at the end of the Intermediate Class. The instructor 
points out errors and outlines advanced training accordingly. 
Faults to be corrected are; 
(1) Abduction of stump. 
(2) Lifting feet too high from the floor. 
(3) Placing feet too far apart during walking stride, 
(4) Lateral pelvic motion. 
(5) Rigid walking posture. 
b. Requirements for Discharge from Advanced Class. 
(1) Proper walking balance with no detectable limp or lateral 
motion. 
(2) Walking with soles and heels as close to the floor as possible. 
(3) Uniform stride. 
(4) Walking relaxed, with arms swinging freely. 
57 CHAPTER 6 
CAUSES AND CORRECTION OF LIMPS 
50. Recognition of Limps 
Certain factors influence the motion of a step, causing an awkward gait. 
Other factors influence the weight-hearing phases of the step, with re- 
sultant body “lists” and changes in the level of the pelvis laterally. 
Types of limps are best distinguished in relation to the component 
parts of a step. If a step were broken down by slow motion, four im- 
portant parts could be recognized: 
a. Weight bearing on the prosthesis. 
b. Motion of step with normal leg. 
c. Weight bearing on normal leg. 
d. Motion of step with prosthesis. 
(Actually a and b above occur simultaneously, as do c and d. However, 
for the purpose of determining the defect which is responsible for a 
patient’s walking difficulty, each component should be considered 
separately.) 
51. Analysis of Limps (A/K Unilateral Amputees) 
The following chart is used by instructor to determine causes of limps 
and means of correcting defects: 
58 Limp 
Probable causes 
Explanation of gait 
Tests to determine cause accurately 
Correction 
a. Abduction of 
(1) Contraction of hip 
Contraction of the abduc- 
Test for degree of hip abduc- 
Exercises for stretching out 
prosthesis 
abductors o n 
tors necessarily causes 
tion contracture. 
contracture in hip abduc- 
IN MOTION. 
stump side. 
abduction of leg during 
forward motion of step 
with prosthesis. 
tors on stump side. 
(2) Crotch pressure. 
Patient abducts prosthetic 
leg in motion to relieve 
(a) Observe areas of redness 
on the upper inner part 
Checking for fit of socket and 
alignment of prosthesis. 
crotch pressure. 
of the thigh following 
attempts at walking. 
Note presence of roll of 
flesh over inner flange 
of prosthesis and pres- 
ence of sebaceous 
adenites. 
(b) Have patient stand with 
weight on prosthesis. 
(c) Have patient stand with 
body weight inclined 
forward (to increase the 
pressure on anterior 
crotch), balancing by 
holding on to stall bars, 
bars, or chair. 
Patient will complain of pain 
due to pressure in tests (6) 
and (c) above. 
59 Limp 
Probable causes 
Explanation of gait 
Tests to determine cause accurately 
Correction 
(3) Weakness in glu- 
Weak gluteus medius on 
Test for strength of gluteus 
(a) Checking length of legs by 
tens medius on 
normal leg causes pelvis 
medius on normal leg (iso- 
height of anterior su- 
normal leg. 
to tilt down toward op- 
posite side during weight 
bearing on normal leg. 
This pelvic tilt creates an 
apparent lengthening of 
• the prosthetic leg; in 
order to raise leg from 
floor, patient must ab- 
duct it. 
lating the posterior 
portion). 
perior iliac spines to 
determine whether pros- 
thesis is shorter and, 
hence, causing a con- 
s t a n t weight-bearing 
strain on normal leg 
gluteus medius. 
(b) Checking for advisability 
of inner border wedge 
on heel or Thomas heel 
on shoe of normal foot. 
(c) Special exercises for nor- 
mal leg gluteus medius— 
indicated only if the 
muscle is not subjected 
to weight-bearing strain. 
(4) Weakness of lower 
Lack of anterior pelvic fix- 
(a) Test for strength of lower 
Special exercise to strengthen 
anterior ab- 
ation throws an excessive 
anterior abdominal 
the lower anterior abdomi- 
dominal muscles 
load on hip flexors in per- 
muscles. 
nals; and to stretch out the 
(particularly i f 
forming the forward mo- 
(6) Test for contractures in 
tight low back and hip 
i n association 
tion of step with prosthe- 
hip flexor and low back 
flexor muscles in order to 
with low back 
and hip flexor 
contracture). 
sis. If, in addition to 
the abdominal weakness, 
the hip flexor muscles 
are contracted to the 
extent that their range 
of action is very limited, 
muscles. 
reestablish free range of 
motion of pelvis in relation 
to femur and lumbar spine. 
60 (5) Fear of knee 
the patient cannot raise 
the leg forward sufficient- 
ly to lift the foot from the 
floor. Patients tend to 
substitute by using later- 
al abductor muscles to 
raise foot from floor. 
Patient may be afraid that 
Test to rule out other causes 
(a) Practicing correct balance 
buckling. 
he will not be able to ex- 
of abduction (as listed 
and fundamental walk- 
tend the knee after 
“breaking” it in the for- 
ward motion of a step. 
As a result he keeps the 
knee straight and ab- 
ducts the leg to bring it 
forward. He may also 
fear that the toe will 
catch and prevent ex- 
tension of the leg. 
above). 
ing techniques. 
(&) Developing reassurance. 
61 Limp 
Probable causes 
Explanation of gait 
Tests to determine cause accurately 
Correction 
h. W E I G H T 
0 N 
(1) Weakness of hip 
Stump adductor weakness 
Test for strength of stump 
Exercises for stump adductors. 
prosthesis; 
adductors 
is frequently mentioned 
adductors. 
PELVIC DROP 
DOWN ON SIDE 
OF PROSTHESIS. 
on stump. 
(2) Prosthesis 
too short. 
(3) Stump sinks into 
prosthesis 
in weight- 
ing. 
as a cause of abduction 
of prosthesis in motion. 
Actually adductor weak- 
ness does not cause such 
abduction, because the 
thigh can be carried in 
the forward plane by the 
hip flexors despite such 
weakness. However, the 
effect of adductor weak- 
ness becomes apparent in 
the phase of weightbear- 
ing on the prosthesis; 
the stabilizing ef f e c t 
which these muscles nor- 
mally give in fixing the 
pelvis to the thigh is lost 
and the pelvis shifts with 
a drop on the side of 
prosthesis. 
Pelvis drops on side of 
prosthesis as in cases of 
short leg. 
Prosthesis may be fitted 
for ischial weightbearing; 
but if pelvis tilts in walk- 
ing, the ischium sepa- 
Measure length of prosthesis 
while patient is standing 
with weight evenly distrib- 
uted on both feet. 
To detect an up and down 
motion, place hand between 
ischial tuberosity and sock- 
et while patient stands 
Lengthening of prosthesis at 
direction of responsible 
medical officer. 
(а) Checking with responsible 
medical officer regard- 
ing fit of prosthesis. 
(б) Checking for advisability 
62  
(4) Abduction contrac- 
rates from point of con- 
tact with prosthesis and 
allows a “piston action” 
of the stump in the pros- 
thesis. (Note. A slight 
“piston action” is nor- 
mal.) 
and transfers weight from 
one foot to the other. 
of additional stump 
socks. 
(c) If prosthesis cannot be 
corrected, patient should 
consciously tense mus- 
cles of stump just before 
taking weight on pros- 
thesis. This muscle 
“setting” tends to less- 
en tendency of stump to 
sink down into the 
prosthesis. 
Contracture of the abduc- 
Test for contracture of ab- 
Exercises for stretching thigh 
c. Weight on 
ture of stump. 
tors places a strain on 
the adductors with re- 
sultant lack of fixation 
of the thigh to the pelvis 
as in actual adductor 
weakness. Pelvis shifts 
with drop on side of the 
prosthesis. 
ductors on stump side. 
abductors. 
Stump abductor 
Lack of sufficient lateral fix- 
Test strength of abductors on 
Exercises to strengthen stump 
prosthesis: 
PELVIC DROP 
DOWN TOWARD 
SIDE OF NORMAL 
LEG. 
weakness. 
ation between pelvis and 
femur causes wider sepa- 
ration of attachment at 
this point, as demonstrat- 
ed by the tilt of pelvis 
down on the opposite side 
in a standing position. 
stump side. 
abductors. 
63 Limp 
Probable causes 
Explanation of gait 
Tests to determine cause accurately 
Correction 
d. Weight on 
Abductor (particularly 
See explanation of pelvic 
(a) Test strength of gluteus 
(a) See a(3) above. 
NORMAL LEG: 
PELVIC DROP 
DOWN ON SIDE 
OP PROSTHESIS. 
gluteus medius) 
weakness on normal 
leg. 
drop under a(3) above. 
medius on normal leg. 
(&) Test for balance with 
weight on normal leg, 
while patient is hold- 
ing pelvis level. 
(h) Practicing balance on nor- 
mal leg. 
e. Weight on 
prosthesis : 
UPPER TRUNK 
“sinking” DOWN 
TOWARD SIDE OP 
PROSTHESIS 
(fig. 21®). 
(1) Short stump. 
(2) Generalized weak- 
ness of stump 
muscles, particu- 
larly abductors 
or adductors. 
This trunk motion tends to 
“lock” the upper trunk 
on the pelvis, and the 
pelvis on the amputated 
extremity, in order to 
compensate for instabil- 
ity at the hip joint. 
Test strength of all stump 
muscles. 
(a) Exercises for strengthen- 
ing stump muscles. 
(b) If stump is too short to 
produce effective lever- 
age on the prosthesis, 
the limp will be difficult 
to correct. Work to 
correct faults of body 
mechanics generally so 
that best balance is 
achieved with least mus- 
cular effort. 
/■.Weight on 
Usually a substitute 
Rising on toes of normal 
Check to determine defects 
Correction of any muscle de- 
NORMAL LEG: 
gait to avoid leg ab- 
foot “suspends” the pros- 
in muscle action which 
fects and instruction in 
RISING ON TOES 
duction or to over- 
thesis and makes it easy 
make it difficult to raise 
correct walking, with em- 
OF NORMAL FOOT 
AT THE BEGIN- 
NING OF FOR- 
WARD MOTION OF 
PROSTHESIS. 
come difficulty in 
raising prosthesis 
forward in step. 
for prosthesis to swing 
through in the forward 
motion of a step. This 
creates an up and down 
motion of body. Such a 
gait is common for pa- 
tients with thigh stumps 
shorter than 6 inches. 
prosthesis from floor and 
bring it forward. 
phasis on pelvic flexion. 
64 g. Transfer of 
Pear of knee buckling 
The gait resembles that of 
(a) Test strength of hip 
General correction of body 
WEIGHT ONTO 
plus weakness o r 
a patient with residual 
extensors. 
and prosthesis mechanics. 
PROSTHESIS ; 
poor functional use 
quadriceps paralysis fol- 
(b) Check knee of prosthesis 
TRUNK IN- 
CLINED FORWARD 
AS KNEE EX- 
TENDS. 
of hip extensors. 
lowing anterior poliomye- 
litis. The body is in- 
clined forward to force 
the knee backward in 
extension. 
A prosthetic knee which 
must be forced into hy- 
perextension for stability 
of the artificial leg will 
produce the same gait. 
for hyperextension. 
h. Body “bobbing up 
Too long a step with 
If the stride is longer on 
(a) Have patient walk with 
This limp is purely functional 
AND DOWN.” 
prosthesis. 
one side, the body drops 
in height with each step 
on that side. There is a 
temptation to lengthen 
the forward stride with 
the prosthesis because 
this makes the normal 
leg maintain weight and 
balance for a longer time. 
Note distinction between 
this defect and that of / 
above. 
equal length stride for 
both legs. 
(b) Rule out drop due to 
stump sinking into 
prosthesis. 
—not due to defect in body 
mechanics. Patient should 
shorten stride. 
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