 A major contribution toward the rehabilitation of amputees is made by the physical therapy section. Let's follow some new patients in the early stages of treatment. One concern of the physical therapist is that of maintaining normal joint range of motion of the remaining lower extremity joints. This is accomplished by strict adherence to proper bed positioning and through the use of active range of motion exercises. A hip flexion, abduction, external rotation contracture is typical in the above knee amputee. With the pelvis level, the above knee stump should be positioned in abduction and extension. This can best be accomplished with the amputee lying prone. Active exercises to the hip extensors and hip adductors help to maintain muscle tone. Full excursion of hip abduction and flexion is delayed until the severed muscle groups have sufficiently reattached. The below knee stump should be maintained in extension. Quadriceps setting exercises aid in maintaining full knee extension. Avoidance of prolonged periods of sitting or the use of pillows is important in preventing the development of muscular imbalance and subsequent joint contractures. Proper stump bandaging is necessary for shaping and shrinking the stump before the artificial limb is fitted. Stump bandaging should be started early and be continued until the prosthesis is used throughout the day. For the above the knee amputee, the side lying position allows the stump to be wrapped in extension to aid in preventing a hip flexion contracture. A six-inch bandage is anchored about the waist, providing a base for additional bandages. Two four-inch bandages with recurrent and spiral turns are used to shape the stump. Firm pressure is applied throughout the process. With slightly more pressure exerted distally than proximally, an adductor roll causes improper fitting of the stump into the prosthesis, an effective method of preventing the development of an adductor roll is to wrap the hip spica high into the groin. This is the most critical aspect of wrapping the above the knee stump. The final bandage is crossed posteriorly to maintain hip extension and pinned to prevent slipping. In wrapping the below the knee stump, two four-inch bandages can be used. One bandage is started by making three recurrent turns. These are anchored by spiral rather than circular turns to avoid choking of the stump. The second bandage utilizes recurrence from the lateral to the medial aspects of the stump. The bandage is secured above the knee and should include the femoral condyles as these are contained within the patellar tendon bearing prosthesis. An automobile accident necessitated the amputation of this patient's left lower extremity above the knee and his right lower extremity below the knee. He now wears a quadrilateral total contact suction socket prosthesis on the left leg and a patellar tendon bearing prosthesis on the right. The program of mat exercises is used before the patient is to be fitted with his prosthesis. Such a program helps to improve strength, coordination, balance and endurance of the involved extremities and the body as a whole. The hip abductors may be shortened and weakened if there is a typical contracture of the above the knee stump. This strengthening exercise may prevent a gluteus medius limp. Strengthening of the hip abductors assists in preventing the abducted posture of the above the knee stump. The hip extensors are vital in prosthetic control. Such an exercise may also prevent a hip flexion contracture. Exercises for both trunk and hip extensors afford a general reconditioning activity which can be done independently. Ball balancing enhances body balance and coordination and helps to develop a kinesthetic awareness of an altered center of gravity. By placing the below the knee stump against the ball for resistance to the hamstrings, the patient finds another means of exercising independently. This is an important factor when designing a mat program for a group of amputees. The development of the upper extremities through weight lifting techniques is an important part of the amputee's pre-prostatic program. Pushups are initiated as a pre-crutch training activity. The ability to maintain balance can be improved by resisting attempts to shift the trunk beyond its base of support. Ball throwing and catching with deliberate efforts to throw the patient off balance also improve trunk stability. Functional activities which will help the patient to become independent are emphasized from the beginning of the mat program. Here the amputee learns to get from the mat to the wheelchair unassisted. As the condition of the stump improves, mechanical pulley resistance may be utilized to assist in developing muscle strength. The progressive resistance exercise method, as described by DeLorm, is utilized here in exercising the gluteus medius muscle. Resistance to the gluteus maximus is given within the range in which it is required to be used in the above the knee prosthesis. In addition to quadriceps resistive exercises, special emphasis is given to hamstring strengthening because of the importance of this muscle group in the use of the patellar tendon bearing prosthesis. Good care of the stump's skin is a vital part of rehabilitation and can prevent many complications which might delay continued use of the prosthesis by the patient. A daily routine of stump cleansing with a good white soap is important. The stump should be thoroughly rinsed. Proper drying will prevent irritation and maceration of the skin. Stump cleansing at night rather than in the morning will eliminate the possibility of damp skin sticking to the prosthesis which tends to cause skin irritation. Since the socket of the artificial limb may itself produce a skin disorder, cleansing of the socket is as important as care of the stump. Cleaning the valve's seat will help prevent air leakage. Dirt or powder in the valve will result in a poorly maintained vacuum. Depressing the spring allows for thorough cleansing of the valve and rubber gasket. This is the quadrilateral total contact suction socket prosthesis. It contains a constant friction knee joint which can readily be adjusted. The ischial seat provides the major weight bearing area. This is the medial brim. The anterior medial corner of which is the channel for the adductor longus and grassless muscles. The scarpus bulge and the high anterior and lateral walls provide the necessary stability to force the stump back onto the ischial seat. With the patellar tendon bearing prosthesis, the weight is born at the midpoint of the patellar tendon. The popliteal bulge forces the stump forward onto the weight bearing surface. The socket is set in approximately 15 degrees of knee flexion. Initially, the prosthesis contains an adjustable shank which allows periodic realignments to be made before fitting the patient with the final prosthesis. Both limbs are fitted with a solid ankle cushion heel foot or sash foot. Prior to evaluation of the fit of the artificial limb, the patient is assisted in putting the stump into the prosthesis with a silk stocking. The stump must make total contact with the wall of the prosthesis. The adductor longus muscles should fit into the adductor channel for proper rotation alignment. The pubic ramus is checked for proper length of the medial wall of the prosthesis. Firmness of the skin above the prosthesis implies adequate seating of the stump. Level hips indicate appropriate length of the prosthesis. The tuberosity of the ischium should ride on the ischial seat. The anterior brim of the above the knee prosthesis should not contact the anterior superior spine of the ilium in forward bending of the trunk. The upper brim of the pateller tendon bearing prosthesis bisects the patella, utilizing the cuff suspension to help maintain the knee inflection and to suspend the prosthesis itself. The cuff suspension should be taught in standing. When sitting, the cuff suspension should be relaxed. Choking of the below the knee stump occurs. If the posterior wall of the prosthesis is too high, the constant friction of this knee unit is inadequate because it permits excessive freedom of the knee. The mechanical friction of the knee unit is constant, but adjustable. The friction may be increased or decreased by adjustment with an allen wrench. Adequate friction is essential for knee stability in the stance phase and proper timing in the swing phase. Here the patient applies his own prosthesis. A stump sock is used for the pateller tendon bearing prosthesis. Talcum powder is needed in applying the suction socket prosthesis when the stump itself perspires freely or is unusually flat. The stocking should be placed high on the stump to prevent an excessive roll of flesh above the brim of the prosthesis after its application. Note the pumping action at the hip and the steady pull on the stocking to assist in getting the stump into the prosthesis. The valve should be well seated. Early gait training activities are concerned with learning to balance on the prosthetic legs. With the pelvis and shoulders level, the patient shifts his weight laterally first with and then without hands and progresses to balancing on one prosthetic leg. Forward and backward shifting of weight is practiced. The patient advances to shifting his entire body weight onto the forward leg, stepping through with the opposite leg. In using the above-the-knee prosthesis, the patient must learn two basic skills. First, he must learn to swing the prosthesis and time the swing so that complete knee extension comes just at heel strike. Second, he must learn to lock the knee joint by extending the hip. There are also two basic skills to be mastered with the pateller tendon bearing prosthesis. Controlled knee flexion from heel strike to foot flat must first be practiced. With the foot flat as a base of support, controlled knee extension as the body weight is shifted over, the extremity is then practiced. Ball throwing develops balance. Early recognition and correction of some of the more common gait deviations is necessary before a habit pattern is established. The causes can be many and complete evaluation requires the clinic team approach. One of the most frequently seen gait faults in the above-knee amputee is lateral trunk bending toward the amputated side. It is often caused by weakened or shortened hip abductors and may be anticipated when the patient has a very short stump. Another common gait fault is heel whip. The lateral heel whip in this instance is related to improper rotation alignment of the above-knee prosthesis as it was put on. The hip is often flexed excessively to clear the prosthetic foot. Circumduction of the prosthesis implies that the limb may be too long. Abduction of the prosthetic leg may represent an effort to avoid full weight bearing on the prosthetic side. This fault may be partially corrected by line walking to force weight bearing on the offending side. Unequal step length is a common problem which ordinarily can be corrected by training. One frequent mistake in using the patellar tendon bearing prosthesis is hyper extension of the knee at heel strike. It is more often seen in amputees who have previously worn a conventional below-the-knee prosthesis. Hyper extension of the knee can be related to failure to decelerate the lower leg by hamstring contraction. The correct relationship of the prosthesis to the femur at heel strike is approximately 10 degrees of flexion. Properly done, the knee should remain flexed from heel strike through mid-stance. The patient begins ambulation out of the parallel bars with the four-point crutch gate. The two-point gate is a natural progression as balance improves. Finally, the cane may be used for walking on level surfaces. When walking on inclines, the patient takes a shorter step with the above-the-knee prosthesis. In ascending ramps, this short step compensates for the limited dorsiflexion of the foot. In descending ramps, the shortened step prevents buckling of the knee as weight is born on the above-the-knee prosthesis. At first, the bilateral amputee can be taught to get into and out of a chair by pivoting, as might a paraplegic. The knee of the suction socket prosthesis is locked by contracting the hip extensors. The amputee soon sits in the more conventional manner with less hand assistance and less attention to his disability. As falls happen suddenly, the amputee should be prepared to discard the crutches, break the fall with his hands, and roll with the fall. In rising, the prosthetic left knee must be stable. One crutch is used for support. Stair activities begin with hand rail assistance. Control descent is affected one step at a time by the right knee joint. In ascending, again the right quadriceps provides the muscular power for elevation. In observing the patient and stair activities, one can readily note the advantages of having an intact knee joint. The patient demonstrates the progression in which he learned to negotiate stairs. These advanced functional skills require time and sustained effort on the amputee's part. And much depends upon the individual patient's motivation. Every service on the rehabilitation team played an important role in returning this man to duty. The officer conducting this briefing is continuing to fill an important role in the defense of our nation.