Temporal spatial and metabolic measures of walking in highly functional individuals with lower limb amputations

OBJECTIVE: The aim of this descriptive exploratory study is to record the temporal spatial parameters and metabolic energy expenditure during walking of individuals with amputation, walking with advanced prostheses and following completion of comprehensive rehabilitation, to able-bodied controls. DESIGN: Cross-sectional SETTING: Multi-disciplinary comprehensive rehabilitation centre PARTICIPANTS: Thirty severely injured United Kingdom military personnel with amputation and subsequent completion of their rehabilitation programme (10 unilateral trans-tibial, 10 unilateral trans-femoral, and 10 bilateral trans-femoral) were compared to (and of similar age, height and mass (p < 0.537) as) 10 able-bodied controls. INTERVENTIONS: Not applicable Main Outcomes and Measures: Temporal spatial and metabolic energy expenditure data were captured during walking on level ground at self-selected speed. RESULTS: The individuals with amputation were all male, with a mean age 29 years (SD = 4) and mean New Injury Severity Score of 31 (SD = 16). Walking speed, stride length, step length and cadence of individuals with a unilateral trans-tibial or trans-femoral amputation was comparable to controls, and only for individuals with a bilateral trans-femoral amputation was walking speed significantly slower (1·12m/s, p = 0.025) and cadence reduced (96 steps/min, p = 0.026). Oxygen cost for individuals with a unilateral trans-tibial amputation (0·15 ml/kg/m) was the same as for controls (0·15 ml/kg/m), and significantly increased by 20% (0·18ml/kg/m, p = 0.023) for unilateral trans-femoral and by 60% (0·24 ml/kg/m, p < 0.001) for bilateral trans-femoral individuals with amputation. CONCLUSION: The scientific literature reports a wide range of gait and metabolic energy expenditure across individuals with amputation. The results of this study indicate that the individuals with amputation have a gait pattern which is highly functional and efficient. This is comparable to a small number of studies reporting similar outcomes for individuals with a unilateral trans-tibial amputation, but the results from this study are better than those on individuals with trans-femoral amputations reported elsewhere, despite comparison with populations wearing similar prosthetic componentry. Those studies that do report similar outcomes have included individuals who have been provided with a comprehensive rehabilitation programme. This suggests that such a programme may be as important as, or even more important than, prosthetic component selection in improving metabolic energy expenditure. The data are made available as a benchmark for what is achievable in the rehabilitation of some individuals with amputations, but agreeably may not be possible for all amputees to achieve

Kinematic differences exist between transtibial amputee fallers and non-fallers during downwards step transitioning.

Stair negotiation is biomechanically more challenging than level gait. There are few biomechanical assessments of transtibial amputees descending stairs and none specifically related to falls. Stair descent may elicit more differences than level gait in amputees with and without a previous falls history

Energy cost of ambulation in trans-tibial amputees using a dynamic-response foot with hydraulic versus rigid 'ankle': insights from body centre of mass dynamics.

BACKGROUND:Previous research has shown that use of a dynamic-response prosthetic foot (DRF) that incorporates a small passive hydraulic ankle device (hyA-F), provides certain biomechanical benefits over using a DRF that has no ankle mechanism (rigA-F). This study investigated whether use of a hyA-F in unilateral trans-tibial amputees (UTA) additionally provides metabolic energy expenditure savings and increases the symmetry in walking kinematics, compared to rigA-F. METHODS:Nine active UTA completed treadmill walking trials at zero gradient (at 0.8, 1.0, 1.2, 1.4, and 1.6 of customary walking speed) and for customary walking speed only, at two angles of decline (5° and 10°). The metabolic cost of locomotion was determined using respirometry. To gain insights into the source of any metabolic savings, 3D motion capture was used to determine segment kinematics, allowing body centre of mass dynamics (BCoM), differences in inter-limb symmetry and potential for energy recovery through pendulum-like motion to be quantified for each foot type. RESULTS:During both level and decline walking, use of a hyA-F compared to rigA-F significantly reduced the total mechanical work and increased the interchange between the mechanical energies of the BCoM (recovery index), leading to a significant reduction in the metabolic energy cost of locomotion, and hence an associated increase in locomotor efficiency (p < 0.001). It also increased inter-limb symmetry (medio-lateral and progression axes, particularly when walking on a 10° decline), highlighting the improvements in gait were related to a lessening of the kinematic compensations evident when using the rigA-F. CONCLUSIONS:Findings suggest that use of a DRF that incorporates a small passive hydraulic ankle device will deliver improvements in metabolic energy expenditure and kinematics and thus should provide clinically meaningful benefits to UTAs' everyday locomotion, particularly for those who are able to walk at a range of speeds and over different terrains

A comparative study of oxygen consumption for conventional and energy-storing prosthetic feet in transfemoral amputees

Objective: To compare oxygen consumption for traumatic high-functioning transfemoral amputees wearing initially a conventional prosthetic foot (Multiflex) and then an energy-storing prosthetic foot (Vari-Flex). Setting: A regional prosthetic and amputee rehabilitation tertiary referral centre in a teaching hospital. Study design: Experimental crossover trial. Subjects: Six established unilateral transfemoral prosthetic users. Interventions: Oxygen consumption breath-by-breath analysis at multiple speeds on a treadmill for each amputee wearing initially the Multiflex foot and then repeated wearing the Vari-Flex foot. Results: Mean oxygen consumption across all subjects was lower for the Vari-Flex foot than for the Multiflex foot at all speeds, although the differences were only significant at speeds of 0.83 and 1.1 m/s (P &lt; 0.05). ANCOVA analysis across all speeds showed that oxygen consumption with the Vari-Flex foot was significantly lower (P &lt; 0.001). The estimated difference across all speeds was 3.54 mL/kg.min. Conclusion: A high functioning transfemoral amputee who wears an energy-storing prosthetic foot may have significantly reduced oxygen consumption at normal walking speeds