Effects of prosthetic mass distribution on metabolic costs and walking symmetry

A scoping review and evaluation of open-source transtibial amputation musculoskeletal models for female populations

Musculoskeletal modeling is often used to study people with transtibial amputations. Females in this population are of particular interest as they are underrepresented in research, experience unique challenges, and demonstrate gait biomechanics distinct from males. Because generic models often neglect innate variations between populations, it is important to determine whether data used to develop a model are representative of the population studied. The objective of this study was to review and analyze existing transtibial amputation musculoskeletal models, establish a database from the information compiled, and use the database to select the model most relevant for studying female populations. A scoping search was performed and a database was created based on data detailing the eligible models. Models were evaluated through a weighted decision process based on criteria of their representation of females with transtibial amputations, prosthetic functionality, development transparency, overall functionality, and experimental validation methods. The scoping review identified 3 studies, Willson et al., LaPrè et al., and Miller and Esposito. A database detailing these models was established. The Willson model scored highest on all criteria except overall functionality, where the LaPrè model outscored it. Based on the established weightings, the Willson model was classed most appropriate for the stated goals. The created database can be used by other researchers to guide their own modeling studies, irrespective of the population of focus. Of the 3, the Willson model was found most relevant for studying females with transtibial amputations. This model will be used in future work investigating and addressing challenges of females with transtibial amputations.

Enhancing Walking Performance With a Bilateral Hip Exoskeleton Assistance in Individuals With Above-Knee Amputation

Transfemoral amputation is a debilitating condition that leads to long-term mobility restriction and secondary disorders that negatively affect the quality of life of millions of individuals worldwide. Currently available prostheses are not able to restore energetically efficient and functional gait, thus, recently, the alternative strategy to inject energy at the residual hip has been proposed to compensate for the lack of energy of the missing leg. Here, we show that a portable and powered hip exoskeleton assisting both the residual and intact limb induced a reduction of walking energy expenditure in four individuals with above-knee amputation. The reduction of the energy expenditure, quantified using the Physiological Cost Index, was in the range [-10, -17]% for all study participants compared to walking without assistance, and between [-2, -24]% in three out of four study participants compared to walking without the device. Additionally, all study participants were able to walk comfortably and confidently with the hip exoskeleton overground at both their self-selected comfortable and fast speed without any observable alterations in gait stability. The study findings confirm that injecting energy at the hip level is a promising approach for individuals with above-knee amputation. By reducing the energy expenditure of walking and facilitating gait, a hip exoskeleton may extend mobility and improve locomotor training of individuals with above-knee amputation, with several positive implications for their quality of life.

Intelligent ankle-foot prosthesis based on human structure and motion bionics

The ankle-foot prosthesis aims to compensate for the missing motor functions by fitting the motion characteristics of the human ankle, which contributes to enabling the lower-limb amputees to take care of themselves and improve mobility in daily life. To address the problems of poor bionic motion of the ankle-foot prosthesis and the lack of natural interaction among the patient, prosthesis, and the environment, we developed a complex reverse-rolling conjugate joint based on the human ankle-foot structure and motion characteristics, the rolling joint was used to simulate the rolling-sliding characteristics of the knee joint. Meanwhile, we established a segmental dynamics model of the prosthesis in the stance phase, and the prosthetic structure parameters were obtained with the optimal prosthetic structure dimensions and driving force. In addition, a carbon fiber energy-storage foot was designed based on the human foot profile, and the dynamic response of its elastic strain energy at different thicknesses was simulated and analyzed. Finally, we integrated a bionic ankle-foot prosthesis and experiments were conducted to verify the bionic nature of the prosthetic joint motion and the energy-storage characteristics of the carbon fiber prosthetic foot. The proposed ankle-foot prosthesis provides ambulation support to assist amputees in returning to social life normally and has the potential to help improve clinical viability to reduce medical rehabilitation costs.

Effect of transtibial prosthesis weight on the contralateral knee joint in relation to the risk of osteoarthritis

BACKGROUND

Individuals with transtibial amputation place more load on the contralateral lower extremity. A higher adduction moment at the knee joint has been shown to have an effect on the risk of osteoarthritis.

OBJECTIVE

The aim of this study was to investigate the effect of weight-bearing of lower-limb prosthesis on the biomechanical parameters associated with the risk of contralateral knee osteoarthritis.

STUDY DESIGN

Cross-sectional.

METHODS

The experimental group of 14 subjects with unilateral transtibial amputation (13 males). The mean age was 52.7 ± 14.2 years, height 175.6 ± 6.3 cm, weight 82.3 ± 12.5 kg, and duration of prosthesis use 16.5 ± 9.1 years. The control group consisted of 14 healthy subjects with identical anthropometric parameters. Dual emission X-ray absorptiometry was used to determine the weight of the amputated limb. For gait analysis, 10 Qualisys infrared cameras and a motion sensing system on 3 Kistler force platforms were used. Gait was analyzed with the original, lighter, commonly used prosthesis, as well as the prosthesis loaded to the original limb weight.

RESULTS

The gait cycle and kinetic parameters of the amputated and healthy limbs were more similar to those of the control group when using the weighted prosthesis.

CONCLUSIONS

We recommend further research to more accurately specify the weight of the lower-limb prosthesis with respect to the prosthesis design and duration of use of the heavier prosthesis during the day.

Full body musculoskeletal model for simulations of gait in persons with transtibial amputation

This paper describes the development, properties, and evaluation of a musculoskeletal model that reflects the anatomical and prosthetic properties of a transtibial amputee using OpenSim. Average passive prosthesis properties were used to develop CAD models of a socket, pylon, and foot to replace the lower leg. Additional degrees of freedom (DOF) were included in each joint of the prosthesis for potential use in a range of research areas, such as socket torque and socket pistoning. The ankle has three DOFs to provide further generality to the model. Seven transtibial amputee subjects were recruited for this study. 3 D motion capture, ground reaction force, and electromyographic (EMG) data were collected while participants wore their prescribed prosthesis, and then a passive prototype prosthesis instrumented with a 6-DOF load cell in series with the pylon. The model's estimates of the ankle, knee, and hip kinematics comparable to previous studies. The load cell provided an independent experimental measure of ankle joint torque, which was compared to inverse dynamics results from the model and showed a 7.7% mean absolute error. EMG data and muscle outputs from OpenSim's Static Optimization tool were qualitatively compared and showed reasonable agreement. Further improvements to the muscle characteristics or prosthesis-specific foot models may be necessary to better characterize individual amputee gait. The model is open-source and available at (https://simtk.org/projects/biartprosthesis) for other researchers to use to advance our understanding and amputee gait and assist with the development of new lower limb prostheses.

Effects of powered versus passive-elastic ankle foot prostheses on leg muscle activity during level, uphill and downhill walking

People with transtibial amputation (TTA) using passive-elastic prostheses have greater leg muscle activity and metabolic cost during level-ground and sloped walking than non-amputees. Use of a stance-phase powered (BiOM) versus passive-elastic prosthesis reduces metabolic cost for people with TTA during level-ground, +3° and +6° walking. Metabolic cost is associated with muscle activity, which may provide insight into differences between prostheses. We measured affected leg (AL) and unaffected leg (UL) muscle activity from ten people with TTA (6 males, 4 females) walking at 1.25 m s^-1 on a dual-belt force-measuring treadmill at 0°, ±3°, ±6° and ±9° using their own passive-elastic and the BiOM prosthesis. We compared stride average integrated EMG (iEMG), peak EMG and muscle activity burst duration. Use of the BiOM increased UL lateral gastrocnemius iEMG on downhill slopes and AL biceps femoris on +6° and +9° slopes, and decreased UL rectus femoris on uphill slopes, UL vastus lateralis on +6° and +9°, and soleus and tibialis anterior on a +9° slope compared to a passive-elastic prosthesis. Differences in leg muscle activity for people with TTA using a passive-elastic versus stance-phase powered prosthesis do not clearly explain differences in metabolic cost during walking on level ground and slopes.

A lightweight robotic leg prosthesis replicating the biomechanics of the knee, ankle, and toe joint

Robotic leg prostheses promise to improve the mobility and quality of life of millions of individuals with lower-limb amputations by imitating the biomechanics of the missing biological leg. Unfortunately, existing powered prostheses are much heavier and bigger and have shorter battery life than conventional passive prostheses, severely limiting their clinical viability and utility in the daily life of amputees. Here, we present a robotic leg prosthesis that replicates the key biomechanical functions of the biological knee, ankle, and toe in the sagittal plane while matching the weight, size, and battery life of conventional microprocessor-controlled prostheses. The powered knee joint uses a unique torque-sensitive mechanism combining the benefits of elastic actuators with that of variable transmissions. A single actuator powers the ankle and toe joints through a compliant, underactuated mechanism. Because the biological toe dissipates energy while the biological ankle injects energy into the gait cycle, this underactuated system regenerates substantial mechanical energy and replicates the key biomechanical functions of the ankle/foot complex during walking. A compact prosthesis frame encloses all mechanical and electrical components for increased robustness and efficiency. Preclinical tests with three individuals with above-knee amputation show that the proposed robotic leg prosthesis allows for common ambulation activities with close to normative kinematics and kinetics. Using an optional passive mode, users can walk on level ground indefinitely without charging the battery, which has not been shown with any other powered or microprocessor-controlled prostheses. A prosthesis with these characteristics has the potential to improve real-world mobility in individuals with above-knee amputation.

Gait asymmetry is associated with performance-based physical function among adults with lower-limb amputation

BACKGROUND

Adults with lower-limb amputation walk with an asymmetrical gait and exhibit poor functional outcomes, which may negatively impact quality-of-life.

OBJECTIVE

To evaluate associations between gait asymmetry and performance-based physical function among adults with lower-limb amputation.

METHODS

A cross-sectional study involving 38 adults with a unilateral transtibial (N = 24; 62.5 ± 10.5 years) or transfemoral amputation (N = 14; 59.9 ± 9.5 years) was conducted. Following gait analysis (capturing step length and stance time asymmetry at self-selected (SSWS) and fast walking speeds (FWS)), participants completed performance-based measures (i.e. Timed Up and Go (TUG), the 10-Meter Walk Test (10mwt), and the 6-Minute Walk Test (6MWT)).

RESULTS

Step length and stance time asymmetry (at SSWS and FWS) were significantly correlated with each performance-based measure (p < .001 to p = .035). Overall, models with gait measures obtained at SSWS explained 40.1%, 46.8% and 40.1% of the variance in TUG-time (p = .022), 10mwt-speed (p = .003) and 6MWT-distance (p = .010), respectively. Models with gait measures obtained at FWS explained 70.0%, 59.8% and 51.8% of the variance in TUG-time (p < .001), 10mwt-speed (p < .001), and 6MWT-distance (p < .001), respectively.

CONCLUSIONS

Increases in step length or stance time asymmetry are associated with increased TUG-time, slower 10mwt-speed, and reduced 6MWT-distance. Findings suggest gait asymmetry may be a factor in poor functional outcomes following lower-limb amputation.

The impact of added mass placement on metabolic and temporal-spatial characteristics of transfemoral prosthetic gait

BACKGROUND

Despite prosthetic technology advancements, individuals with transfemoral amputation have compromised temporal-spatial gait parameters and high metabolic requirements for ambulation. It is unclear how adding mass at different locations on a transfemoral prosthesis might affect these outcomes. Research question Does walking with mass added at different locations on a transfemoral prosthesis affect temporal-spatial gait parameters and metabolic requirements compared to walking with no additional mass?

METHODS

Fourteen participants with unilateral transfemoral amputations took part. A 1.8 kg mass was added to their prostheses in three locations: Knee, just proximal to the prosthetic knee; Shank, mid-shank on the prosthesis; or Ankle, just proximal to the prosthetic foot. Temporal-spatial gait parameters were collected as participants walked over a GAITRite® walkway and metabolic data were collected during treadmill walking for each of these conditions and with no mass added, the None condition. Separate linear mixed effects models were created and post-hoc tests to compare with the control condition of None were performed with a significance level of 0.05.

RESULTS

Overground self-selected walking speed for Ankle was significantly slower than for None (p < 0.05) (None: 1.16 ± 0.24; Knee: 1.15 ± 0.19; Shank: 1.14 ± 0.24; Ankle 0.99 ± 0.20 m/s). Compared to None, Ankle showed significantly increased oxygen consumption during treadmill walking (p < 0.05) (None: 13.82 ± 2.98; Knee: 13.83 ± 2.82; Shank: 14.30 ± 2.89; Ankle 14.56 ± 2.99 ml O₂/kg/min). Other metabolic outcomes (power, cost of transport, oxygen cost) showed similar trends. Knee and Shank did not have significant negative effects on any metabolic or temporal-spatial parameters, as compared to None (p > 0.05). Significance Results suggest that additional mass located mid-shank or further proximal on a transfemoral prosthesis may not have negative temporal-spatial or metabolic consequences. Clinicians, researchers, and designers may be able to utilize heavier components, as long as the center of mass is not further distal than mid-shank, without adversely affecting gait parameters or metabolic requirements.

General estimates of the energy cost of walking in people with different levels and causes of lower-limb amputation: a systematic review and meta-analysis

BACKGROUND

Energy cost of walking (ECw) is an important determinant of walking ability in people with a lower-limb amputation. Large variety in estimates of ECw has been reported, likely because of the heterogeneity of this population in terms of level and cause of amputation and walking speed.

OBJECTIVES

To assess (1) differences in ECw between people with and without a lower-limb amputation, and between people with different levels and causes of amputation, and (2) the association between ECw and walking speed.

STUDY DESIGN

Systematic review and meta-analysis.

METHODS

We included studies that compared ECw in people with and without a lower-limb amputation. A meta-analysis was done to compare ECw between both groups, and between different levels and causes of amputation. A second analysis investigated the association between self-selected walking speed and ECw in people with an amputation.

RESULTS

Out of 526 identified articles, 25 were included in the meta-analysis and an additional 30 in the walking speed analysis. Overall, people with a lower-limb amputation have significantly higher ECw compared to people without an amputation. People with vascular transfemoral amputations showed the greatest difference (+102%) in ECw. The smallest difference (+12%) was found for people with nonvascular transtibial amputations. Slower self-selected walking speed was associated with substantial increases in ECw.

CONCLUSION

This study provides general estimates on the ECw in people with a lower-limb amputation, quantifying the differences as a function of level and cause of amputation, as well as the relationship with walking speed.

Transtibial limb loss does not increase metabolic cost in three-dimensional computer simulations of human walking

Loss of a lower limb below the knee, i.e., transtibial limb loss, and subsequently walking with a prosthesis, is generally thought to increase the metabolic cost of walking vs. able-bodied controls. However, high-functioning individuals with limb loss such as military service members often walk with the same metabolic cost as controls. Here we used a 3-D computer model and optimal control simulation approach to test the hypothesis that transtibial limb loss in and of itself causes an increase in metabolic cost of walking. We first generated N = 36 simulations of walking at 1.45 m/s using a “pre-limb loss” model, with two intact biological legs, that minimized deviations from able-bodied experimental walking mechanics with minimum muscular effort. We then repeated these simulations using a “post-limb loss” model, with the right leg’s ankle muscles and joints replaced with a simple model of a passive transtibial prosthesis. No other changes were made to the post-limb loss model’s remaining muscles or musculoskeletal parameters compared to the pre-limb loss case. Post-limb loss, the gait deviations on average increased by only 0.17 standard deviations from the experimental means, and metabolic cost did not increase (3.58 ± 0.10 J/m/kg pre-limb loss vs. 3.59 ± 0.12 J/m/kg post-limb loss, p = 0.65). The results suggest that transtibial limb loss does not directly lead to an increase in metabolic cost, even when deviations from able-bodied gait mechanics are minimized. High metabolic costs observed in individuals with transtibial limb loss may be due to secondary changes in strength or general fitness after limb loss, modifiable prosthesis issues, or to prioritization of factors that affect locomotor control other than gait deviations and muscular effort.

Quantifying Step Count and Oxygen Consumption with Portable Technology during the 2-Min Walk Test in People with Lower Limb Amputation

Step counts and oxygen consumption have yet to be reported during the 2-min walk test (2MWT) test in persons with lower-limb amputations (LLA). The purpose of this study was to determine step counts and oxygen consumption during the 2MWT in LLA. Thirty-five men and women walked for two minutes as quickly as possible while wearing activity monitors (ActiGraph Link on the wrist (LW) and ankle (LA), Garmin vivofit^®3 on the wrist (VW) and ankle (VA), and a modus StepWatch on the ankle (SA), and a portable oxygen analyzer. The StepWatch on the ankle (SA) and the vivofit3 on the wrist (VW) had the least error and best accuracy of the activity monitors studied. While there were no significant differences in distance walked, oxygen consumption (VO₂) or heart rate (HR) between sexes or level of amputation (p > 0.05), females took significantly more steps than males (p = 0.034), and those with unilateral transfemoral amputations took significantly fewer steps than those with unilateral transtibial amputations (p = 0.023). The VW and SA provided the most accurate step counts among the activity monitors and were not significantly different than hand counts. Oxygen consumption for all participants during the 2MWT was 8.9 ± 2.9 mL/kg/min, which is lower than moderate-intensity activity. While some may argue that steady-state activity has not yet been reached in the 2MWT, it may also be possible participants are not walking as fast as they can, thereby misclassifying their performance to a lower standard.

Effects of Handrail and Cane Support on Energy Cost of Walking in People With Different Levels and Causes of Lower Limb Amputation

OBJECTIVE

The energy cost of walking with a lower limb prosthesis is higher than able-bodied walking and depends on both cause and level of amputation. This increase might partly be related to problems with balance control. In this study we investigated to what extent energy cost can be reduced by providing support through a handrail or cane and how this depends on level and cause of amputation.

DESIGN

Quasi-experimental study.

SETTING

Rehabilitation gait laboratory.

PARTICIPANTS

Twenty-six people with a lower limb amputation were included: 9 with vascular and 17 with nonvascular causes, 16 at transtibial, and 10 at transfemoral or knee disarticulation level (N=26).

INTERVENTIONS

Participants walked on a treadmill with and without handrail support and overground with and without a cane.

MAIN OUTCOME MEASURES

Energy cost was assessed using respirometry.

RESULTS

On the treadmill, handrail support resulted in a 6% reduction in energy cost on average. This effect was attributed to an 11% reduction in those with an amputation attributable to vascular causes, whereas the nonvascular group did not show a significant difference. No interaction with level of amputation was found. Overground, no main effect of cane support was found, although an interaction effect with cause of amputation demonstrated a small nonsignificant decrease in energy cost (3%) in the vascular group and a significant increase (6%) in the nonvascular group when walking with a cane. The effect of support was positively correlated with self-selected walking speed.

CONCLUSIONS

This study demonstrates that providing external support can contribute to a reduction in energy cost in people with an amputation due to vascular causes with reduced walking ability while walking in the more challenging condition of the treadmill. Although it is speculated that this effect might be related to problems with balance control, this will need further investigation.

Automatic Control of Prosthetic Socket Size for People WithTranstibial Amputation: Implementation and Evaluation

OBJECTIVE

The purpose was to design, implement, and test a control system for a motor-actuated, cable-panel prosthetic socket that automatically maintains socket fit by continuous adjustment of the socket size.

METHODS

Sockets with motor-driven adjustable panels were fabricated for participants with transtibial amputation. A proportional-integral control system was implemented to adjust socket size based on Socket Fit Metric (SFM) data collected by an inductive sensor embedded within the socket wall. The sensed distance was representative of limb-to-socket distance. Testing was conducted with participants walking on a treadmill to characterize the system's capability to maintain a set point and to respond to a change in the set point.

RESULTS

Test results from 10 participants with transtibial amputation showed that the Integral of Absolute Error (IAE) to maintain a set point ranged from 0.001 to 0.046 mm with a median of 0.003 mm. When the set point was changed, IAE errors ranged from 0.001 to 0.005 mm, with a median of 0.003 mm. An IAE of 0.003 mm corresponded to approximately a 0.08% socket volume error, which was considered clinically acceptable.

CONCLUSION

The capability of the control system to maintain and respond to a change in set point indicates that it is ready for evaluation outside of the laboratory.

SIGNIFICANCE

Integration of the developed control system into everyday prostheses may improve quality of life of prosthesis users by relieving them of the burden of continually adjusting socket size to maintain fit.

Diminution of Weight and Heat Accumulation in Transfemoral Socket Using PE/MWCNT Composite

The socket plays an important role in prostheses by providing structural integrity and suspension to the distal thigh of an amputee. Heat accumulation and weight of the socket increase the energy consumption in the amputee. To overcome the same, widely used polyester-based sandwich-structured composite was reinforced with 0.2, 0.4, 0.6, 0.8, and 1 wt% multiwalled carbon nanotube (MWCNT) and analyzed for the thermal and mechanical properties. MWCNT added in a small weight proportion with polyester enhances the mechanical properties of the resulting nanocomposites as they have excellent mechanical and physical properties. The flexural and thermal property was evaluated as per ASTM D790 and ISO 22007-2 standard. It was noticed that the thermal property enhances with increase in wt% of MWCNT and mechanical properties decreased when more than 0.6 wt% MWCNT was reinforced. Hence, the sandwich-structured composite was prepared using polyester resin, 2 to 10 stockinette layers, fiberglass cloth, and 0.6 wt% of MWCNT. The thermal conductivity and flexural strength of 0.6 wt% MWCNT-reinforced sandwich-structured composite were enhanced upto 68.4% and 11.4% for 2-10 stockinette layers, respectively, while comparing to the unreinforced polyester sandwich-structured composite. The 0.6 wt% MWCNT-reinforced sandwich-structured composite may help in reducing the weight and heat build up in the socket. Hence, it is recommended to analyze further on their application in transfemoral socket preparation to bring down an amputee’s metabolic cost.

The efficacy of the Ankle Mimicking Prosthetic Foot prototype 4.0 during walking: Physiological determinants

BACKGROUND

Evaluating the effectiveness of a novel prosthetic device during walking is an important step in product development.

OBJECTIVE

To investigate the efficacy of a novel quasi-passive ankle prosthetic device, Ankle Mimicking Prosthetic Foot 4.0, during walking at different speeds, using physiological determinants in transtibial and transfemoral amputees.

STUDY DESIGN

Nonrandomized crossover design for amputees.

METHODS

Six able-bodied subjects, six unilateral transtibial amputees, and six unilateral transfemoral amputees underwent a 6-min walk test at normal speed, followed by series of 2-min walking at slow, normal, and fast speeds. The intensity of effort and subjective measures were determined. Amputees performed all walking tests on a treadmill with current and novel prostheses. Shapiro-Wilk normality tests and parametric and nonparametric tests were conducted (p < 0.05).

RESULTS

Compared to able-bodied individuals, the rating of perceived exertion levels were significantly elevated in transtibial and transfemoral amputees for both prostheses (p ≤ 0.016). Compared to able-bodied individuals transfemoral amputees also showed significantly elevated heart rate for both prostheses at normal speed (p ≤ 0.043). Within-group comparisons demonstrated that walking with Ankle Mimicking Prosthetic Foot significantly increased the heart rate in transfemoral amputees and transtibial compared to current prosthesis (p = 0.002). Furthermore, transfemoral amputees reached a significantly higher rating of perceived exertion levels.

CONCLUSION

Intensity of effort during walking with Ankle Mimicking Prosthetic Foot is higher compared to current prostheses. Clinical relevance Ankle Mimicking Prosthetic Foot 4.0 is a novel quasi-passive ankle prosthesis with state-of-the-art technological parts. Subjective measures show the importance of this technology, but the intensity of effort during walking still remains higher compared to current passive prostheses, especially in transfemoral amputees.

Design, development, and testing of a lightweight hybrid robotic knee prosthesis

We present a lightweight robotic knee prosthesis with a novel hybrid actuation system that enables passive and active operation modes. The proposed hybrid knee uses a spring-damper system in combination with an electric motor and transmission system, which can be engaged to provide a stair ambulation capability. In comparison to fully powered prostheses that power all ambulation activities, a hybrid knee prosthesis can achieve significant weight reduction by focusing the design of the actuator on a subset of activities without losing the ability to produce equivalent torque and mechanical power in the active mode. The hybrid knee prototype weighs 1.7 kg, including battery and control, and can provide up to 125 Nm of repetitive torque. Experiments with two transfemoral amputee subjects show that the proposed hybrid knee prosthesis can support walking on level ground in the passive mode, as well as stair ambulation with a reciprocal gait pattern in the active mode.

Maintenance of muscle strength retains a normal metabolic cost in simulated walking after transtibial limb loss

Recent studies on relatively young and fit individuals with limb loss suggest that maintaining muscle strength after limb loss may mitigate the high metabolic cost of walking typically seen in the larger general limb loss population. However, these data are cross-sectional and the muscle strength prior to limb loss is unknown, and it is therefore difficult to draw causal inferences on changes in strength and gait energetics. Here we used musculoskeletal modeling and optimal control simulations to perform a longitudinal study (25 virtual “subjects”) of the metabolic cost of walking pre- and post-limb loss (unilateral transtibial). Simulations of walking were first performed pre-limb loss on a model with two intact biological legs, then post-limb loss on a model with a unilateral transtibial prosthesis, with a cost function that minimized the weighted sum of gait deviations plus metabolic cost. Metabolic costs were compared pre- vs. post-limb loss, with systematic modifications to the muscle strength and prosthesis type (passive, powered) in the post-limb loss model. The metabolic cost prior to limb loss was 3.44±0.13 J/m/kg. After limb loss, with a passive prosthesis the metabolic cost did not increase above the pre-limb loss cost if pre-limb loss muscle strength was maintained (mean -0.6%, p = 0.17, d = 0.17). With 10% strength loss the metabolic cost with the passive prosthesis increased (mean +5.9%, p < 0.001, d = 1.61). With a powered prosthesis, the metabolic cost was at or below the pre-limb loss cost for all subjects with strength losses of 10% and 20%, but increased for all subjects with strength loss of 30% (mean +5.9%, p < 0.001, d = 1.59). The results suggest that maintaining muscle strength may prevent an increase in the metabolic cost of walking following unilateral transtibial limb loss, and that a gait with minimal deviations can be achieved when muscle strength is sufficiently high, even when using a passive prosthesis.

Aprovechamiento de energía, cinemática y estabilidad en la marcha de un paciente con amputación transfemoral sin abordaje de rehabilitación

Introducción. Los pacientes con amputación de miembros inferiores presentan marcadas asimetrías en la marcha, las cuales pueden aumentar cuando no se cumple con un adecuado proceso de rehabilitación, comprometiendo los objetivos fundamentales de la marcha e incrementando factores de riesgo.Objetivo. Analizar el grado de aprovechamiento de energía mecánica, la estabilidad dinámica y las variables cinemáticas de interés clínico en la marcha de un paciente con amputación transfemoral que no realizó el proceso de rehabilitación.Materiales y métodos. Con base en una reconstrucción 3D, se cuantificaron valores angulares para cadera, rodilla y tobillo y se estimó el intercambio de energía mecánica y la estabilidad dinámica en tres velocidades de marcha diferentes.Resultados. Se observaron variaciones en los parámetros espaciotemporales con el cambio de la velocidad que no son consistentes con los encontrados en otros estudios de amputados. Los valores angulares, principalmente a nivel de rodilla y tobillo, presentan asimetrías que se pueden asociar con una disminución en el aprovechamiento de energía mecánica mientras aumenta la estabilidad en diferentes velocidades.Conclusión. El uso de prótesis en las condiciones en las que fue realizada la evaluación compromete la recuperación de energía mecánica en la marcha del paciente.

The effect of segmental weight of prosthesis on hemodynamic responses and energy expenditure of lower extremity amputees

[Purpose] The aim of this study was to investigate the effect of segmental weight of the prosthesis on hemodynamic responses and energy expenditure in lower extremity amputees. [Subjects and Methods] Thirteen patients with a mean age of 44 ± 15.84 years and with unilateral transtibial, transfemoral and Syme’s amputation were included to the study. The difference between the lightest and the heaviest prosthesis, 250 g used as the weight. All the patients completed the measurements first without weight and then with 250 g weight on the ankle joint. The blood pressure and heart rate of the patients were recorded before and after Six Minute Walk Test (6MWT) and 10 stairs up & down stairs test. Physiological Cost Index was used to calculate the energy expenditure. [Results] Heart rate and energy expenditure increased significantly when without weight and with weight results compared. [Conclusion] We conclude that the segmental weight of the prosthetic limb has a significant effect on the heart rate and energy expenditure but has no effect on the systolic and diastolic blood pressure of lower limb amputees. In order to generalize our results to lower limb amputees, more patients need to be included in future studies.

Design and Characterization of a Quasi-Passive Pneumatic Foot-Ankle Prosthesis

The majority of commercially available passive prosthetic feet are not capable of providing joint mechanics that match that of the intact human ankle. Due to their cantilever design, their stiffness characteristics contrast with what has been observed in the biological ankle, namely, an increase in stiffness during the stance phase of walking. In this paper, we introduce the design and control of a pneumatic foot-ankle prosthesis that attempts to provide biomimetic mechanics. The prosthesis is comprised of a pneumatic cylinder in series with a fiberglass leaf spring, and a solenoid valve to control the flow of air between the two sides of the cylinder. The solenoid valve acts as a mechanical clutch, enabling resetting of the ankle's equilibrium position. By adjusting the pressure inside the cylinder, the prosthesis can be customized to provide a range of ankle mechanics. A mechanical testing machine is used to compare the torque-angle curve of the pneumatic prosthesis with a low-profile passive prosthetic foot. Finally, data are presented of one transtibial amputee walking with the prosthesis at 1.2 m/s. The testing shows that the pneumatic prosthesis is capable of providing an appropriate range of motion as well a maximum torque of 94 Nm, while returning approximately 11.5 J of energy.

Ertl and Non-Ertl amputees exhibit functional biomechanical differences during the sit-to-stand task

BACKGROUND

People with transtibial amputation stand ~50times/day. There are two general approaches to transtibial amputation: 1) distal tibia and fibula union using a "bone-bridge" (Ertl), 2) non-union of the tibia and fibula (Non-Ertl). The Ertl technique may improve functional outcomes by increasing the end-bearing ability of the residual limb. We hypothesized individuals with an Ertl would perform a five-time sit-to-stand task faster through greater involvement/end-bearing of the affected limb.

METHODS

Ertl (n=11) and Non-Ertl (n=7) participants sat on a chair with each foot on separate force plates and performed the five-time sit-to-stand task. A symmetry index (intact vs affected limbs) was calculated using peak ground reaction forces.

FINDINGS

The Ertl group performed the task significantly faster (9.33s (2.66) vs 13.27 (2.83)s). Symmetry index (23.33 (23.83)% Ertl, 36.53 (13.51)% Non-Ertl) indicated the intact limb for both groups produced more force than the affected limb. Ertl affected limb peak ground reaction forces were significantly larger than the Non-Ertl affected limb. Peak knee power and net work of the affected limb were smaller than their respective intact limb for both groups. The Ertl intact limb produced significantly greater peak knee power and net work than the Non-Ertl intact knee.

INTERPRETATION

Although loading asymmetries existed between the intact and affected limb of both groups, the Ertl group performed the task ~30% faster. This was driven by greater power and work production of the Ertl intact limb knee. Our results suggest that functional differences exist between the procedures.

Marker-based method to measure movement between the residual limb and a transtibial prosthetic socket

BACKGROUND

Limb movement between the residuum and socket continues to be an underlying factor in limb health, prosthetic comfort, and gait performance yet techniques to measure this have been underdeveloped.

OBJECTIVES

Develop a method to measure motion between the residual limb and a transtibial prosthetic socket.

STUDY DESIGN

Single subject, repeated measures with mathematical modeling.

METHODS

The gait of a participant with transtibial amputation was recorded using a motion capture system using a marker set that included arrays on the anterior distal tibia and the lateral epicondyle of the femur. The proximal or distal translation, anterior or posterior translation, and angular movements were quantified. A random Monte Carlo simulation based on the precision of the motion capture system and a model of the bone moving under the skin explored the technique's accuracy. Residual limb tissue stiffness was modeled as a linear spring based on data from Papaioannou et al.

RESULTS

Residuum movement relative to the socket went through ~30 mm, 18 mm, and 15° range of motion. Root mean squared errors were 5.47 mm, 1.86 mm, and 0.75° when considering the modeled bone-skin movement in the proximal or distal, anterior or posterior, and angular directions, respectively.

CONCLUSION

The measured movement was greater than the root mean squared error, indicating that this method can measure motion between the residuum and socket.

CLINICAL RELEVANCE

The ability to quantify movement between the residual limb and the prosthetic socket will improve prosthetic treatment through the evaluation of different prosthetic suspensions, socket designs, and motor control of the prosthetic interface.

A pilot study examining measures of balance and mobility in children with unilateral lower-limb amputation

BACKGROUND

Individuals with unilateral lower-limb amputation (LLA) have altered structure and physiology of their lower limbs which impairs their balance, mobility, physical function and participation in physical activities. As part of (re)habilitation, focus is given to improving gait and balance in order to enhance overall mobility, function, self-efficacy, and independence. However, the relationships amongst body impairments and physical activity limitations remain unclear, particularly in the pediatric population.

OBJECTIVE

To provide an examination of the relationships among balance and mobility measures in children with unilateral lower-limb amputation and able-bodied children.

STUDY DESIGN

Cross-sectional prospective comparative pilot study.

METHODS

Spatiotemporal gait parameters and standing postural control were evaluated in children with lower-limb amputation (n = 10) and age-matched able-bodied children (n = 10) in a laboratory-based setting. Clinical tests for mobility and balance consisted of the 10-m walk test, the 6-min walk test, and the Community Balance and Mobility scale. Energy expenditure was estimated during the 6-min walk test using the Physiological Cost Index. Analysis included comparing variables between able-bodied and lower-limb amputation groups, as well as examining the correlations among them.

RESULTS

Walking speed, distance, and functional balance (p < 0.05) were significantly diminished in children with lower-limb amputation compared to able-bodied children. For children with lower-limb amputation, reduced energy expenditure was associated with narrower step width and more symmetrical gait; better postural control and balance were associated with faster walking speeds (p < 0.05).

CONCLUSION

A greater clinical understanding of gait and balance deficits in this population may help to improve rehabilitation outcomes and overall functional mobility.

CLINICAL RELEVANCE

Improved understanding of deficits in children with lower-limb amputation (LLA) may lead to more targeted interventions and facilitate clinical decision-making in rehabilitation settings for this population. The findings contribute to the limited literature and provide a basis to further examine suitable clinical outcome measures to be used in children with LLA.

Symmetrical kinematics does not imply symmetrical kinetics in people with transtibial amputation using cycling model

People with amputation move asymmetrically with regard to kinematics (joint angles) and kinetics (joint forces and moments). Clinicians have traditionally sought to minimize kinematic asymmetries, assuming kinetic asymmetries would also be minimized. A cycling model evaluated locomotor asymmetries. Eight individuals with unilateral transtibial amputation pedaled with 172 mm-length crank arms on both sides (control condition) and with the crank arm length shortened to 162 mm on the amputated side (CRANK condition). Pedaling kinetics and limb kinematics were recorded. Joint kinetics, joint angles (mean and range of motion [ROM]), and pedaling asymmetries were calculated from force pedals and with a motion capture system. A one-way analysis of variance with tukey post hoc compared kinetics and kinematics across limbs. Statistical significance was set to p </= 0.05. The CRANK condition reduced hip and knee ROM in the amputated limb compared with the control condition. There were no differences in joint kinematics between the contralateral and amputated limbs during the CRANK condition. Pedaling asymmetries did not differ and were 23.0% +/= 9.8% and 23.2% +/= 12% for the control and CRANK conditions, respectively. Our results suggest that minimizing kinematic asymmetries does not relate to kinetic asymmetries as clinically assumed. We propose that future research should concentrate on defining acceptable asymmetry.

The Effects of Prosthesis Inertial Properties on Prosthetic Knee Moment and Hip Energetics Required to Achieve Able-Bodied Kinematics

There is a major need in the developing world for a low-cost prosthetic knee that enables users to walk with able-bodied kinematics and low energy expenditure. To efficiently design such a knee, the relationship between the inertial properties of a prosthetic leg and joint kinetics and energetics must be determined. In this paper, using inverse dynamics, the theoretical effects of varying the inertial properties of an above-knee prosthesis on the prosthetic knee moment, hip power, and absolute hip work required for walking with able-bodied kinematics were quantified. The effects of independently varying mass and moment of inertia of the prosthesis, as well as independently varying the masses of each prosthesis segment, were also compared. Decreasing prosthesis mass to 25% of physiological leg mass increased peak late-stance knee moment by 43% and decreased peak swing knee moment by 76%. In addition, it reduced peak stance hip power by 26%, average swing hip power by 76%, and absolute hip work by 22%. Decreasing upper leg mass to 25% of its physiological value reduced absolute hip work by just 2%, whereas decreasing lower leg and foot mass reduced work by up to 22%, with foot mass having the greater effect. Results are reported in the form of parametric illustrations that can be utilized by researchers, designers, and prosthetists. The methods and outcomes presented have the potential to improve prosthetic knee component selection, facilitate able-bodied kinematics, and reduce energy expenditure for users of low-cost, passive knees in developing countries, as well as for users of advanced active knees in developed countries.

Mechanical characterization and validation of poly (methyl methacrylate)/multi walled carbon nanotube composite for the polycentric knee joint

Trans femoral amputation is one of the most uncomfortable surgeries in patient׳s life, where the prosthesis consisting of a socket, knee joint, pylon and foot is used to do the walking activities. The artificial prosthetic knee joint imitates the functions of human knee to achieve the flexion-extension for the above knee amputee. The objective of present work is to develop a light weight composite material for the knee joint to reduce the metabolic cost of an amputee. Hence, an attempt was made to study the mechanical properties of multi walled carbon nanotubes (MWCNT) reinforced Poly (methyl methacrylate) (PMMA) prepared through melt mixing technique and optimize the concentration of reinforcement. The PMMA nanocomposites were prepared by reinforcing 0, 0.1, 0.2, 0.25, 0.3 and 0.4 wt% of MWCNT using injection moulding machine via twin screw extruder. It is observed that the tensile and flexural strength of PMMA, which were studied as per ASTM D638 and D790, respectively, were increased by 32.9% and 26.3% till 0.25 wt% reinforcement of MWCNT. The experimental results of strength and modulus were compared with theoretical prediction, where a good correlation was noted. It is concluded that the mechanical properties of PMMA were found to be increased to maximum at 0.25 wt% reinforcement of MWCNT, where the Pukanszky model and modified Halpin-Tsai model are suggested to predict the strength and modulus, respectively, of the PMMA/MWCNT composite, which can be opted as a suitable materiel for the development of polycentric knee joint.

Motor adaptation to prosthetic cycling in people with trans-tibial amputation

The neuromusculoskeletal system interacts with the external environment via end-segments, e.g. feet. A person with trans-tibial amputation (TTAmp) has lost a foot and ankle; hence the residuum with prosthesis becomes the new end-segment. We investigated changes in kinetics and muscle activity in TTAmps during cycling with this altered interface with the environment. Nine unilateral TTAmps and nine subjects without amputation (NoAmp) pedaled at a constant torque of 15 Nm and a constant cadence of 90 rpm (~150 watts). Pedal forces and limb kinematics were used to calculate resultant joint moments. Electromyographic activity was recorded to determine its magnitude and timing. Biomechanical and EMG variables of the amputated limb were compared to those of the TTAmp sound limb and to the dominant limb in the NoAmp group using a one-way ANOVA. Results showed maximum angular displacement between the residuum and prosthesis was 4.8±1.8 deg. The amputated limb compared to sound limb and NoAmp group produced lower extensor moments averaged over the cycle about the ankle (13±2.3, 20±5.7, and 19±5.3 Nm, respectfully) and knee (8.4±5.0, 15±4.5, and 12.7±5.9 Nm, respectfully) (p<0.05). Gastrocnemius and rectus femoris peak activity in the TTAmps shifted to later in the crank cycle (by 36° and 75°, respectfully; p<0.05). These data suggest gastrocnemius was utilized as a one-joint knee flexor in combination with rectus femoris for prosthetic socket control and highlight prosthetic control as an interaction between the residuum, prosthesis and external environment.

Oscillation and reaction board techniques for estimating inertial properties of a below-knee prosthesis

The purpose of this study was two-fold: (1) demonstrate a technique that can be used to directly estimate the inertial properties of a below-knee prosthesis, and (2) contrast the effects of the proposed technique and that of using intact limb inertial properties on joint kinetic estimates during walking in unilateral, transtibial amputees. An oscillation and reaction board system was validated and shown to be reliable when measuring inertial properties of known geometrical solids. When direct measurements of inertial properties of the prosthesis were used in inverse dynamics modeling of the lower extremity compared with inertial estimates based on an intact shank and foot, joint kinetics at the hip and knee were significantly lower during the swing phase of walking. Differences in joint kinetics during stance, however, were smaller than those observed during swing. Therefore, researchers focusing on the swing phase of walking should consider the impact of prosthesis inertia property estimates on study outcomes. For stance, either one of the two inertial models investigated in our study would likely lead to similar outcomes with an inverse dynamics assessment.