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

Normalized kinematic walking symmetry data for individuals who use lower-limb prostheses: considerations for clinical practice and future research

Introduction

Individuals who use unilateral transtibial or transfemoral prostheses have negative secondary health effects associated with decreased kinematic (e.g., spatiotemporal and joint angle) walking symmetry between prosthetic and intact limbs. Research studies have quantified kinematic walking symmetry, but studies can be difficult to compare owing to the inclusion of small sample sizes and differences in participant demographics, biomechanical parameters, and mathematical analysis of symmetry. This review aims to normalize kinematic walking symmetry research data across studies by level of limb loss and prosthetic factors to inform considerations in clinical practice and future research.

Methods

A search was performed on March 18, 2020, in PubMed, Scopus, and Google Scholar to encompass kinematic walking symmetry literature from the year 2000. First, the most common participant demographics, kinematic parameters, and mathematical analysis of symmetry were identified across studies. Then, the most common mathematical analysis of symmetry was used to recalculate symmetry data across studies for the five most common kinematic parameters.

Results

Forty-four studies were included in this review. The most common participant demographics were younger adults with traumatic etiology who used componentry intended for higher activity levels. The most common kinematic parameters were step length, stance time, and sagittal plane ankle, knee, and hip range of motion. The most common mathematical analysis was a particular symmetry index equation.

Conclusions

Normalization of data showed that symmetry tended to decrease as level of limb loss became more proximal and to increase with prosthetic componentry intended for higher activity levels. However, most studies included 10 or fewer individuals who were active younger adults with traumatic etiologies.

Clinical Relevance

Data summarized in this review could be used as reference values for rehabilitation and payer justification. Specifically, these data can help guide expectations for magnitudes of walking symmetry throughout rehabilitation or to justify advanced prosthetic componentry for active younger adults under 65 years of age with traumatic etiologies to payers.

Cycling in people with a lower limb amputation

Background

To evaluate cycling participation and identify barriers and facilitators related to cycling participation in people with a lower limb amputation (LLA) in the Netherlands.

Methods

A questionnaire was sent to adults with a LLA between March and August 2019 to obtain information regarding prosthesis, individual’s characteristics, amputation, cycling barriers and facilitators, and prosthetic satisfaction. The questionnaires were distributed via 8 orthopedic workshops, post and were given directly. To find cycling predictors, variables associated with cycling (p < 0.1) were entered into a logistic regression analysis. Non-significant variables were removed manually.

Results

Participants (n = 207, 71% males) had a mean age of 62.0 ± 13.0 years. The most frequent level of amputation was transtibial (42%), and trauma was the most frequent cause of amputation (43%). After the LLA, 141 participants (68%) cycled for recreation (80%), physical fitness (74%), and transport (50%). In the past six months, cyclists cycled for recreation (79%) and transport (66%). Most cycled less than once a day. Recreational cyclists cycled alone (75%) for a median duration of 45 min or 14 km per ride. Cyclists with a transportation purpose usually cycled to go shopping (80%) or to visit friends (68%), with a median duration of 20 min or five kilometers per ride. Cyclists reported more facilitators (median (IQR) = 5 (3, 7) than non-cyclists 0 (0, 3). The majority of cyclists reported a positive attitude toward cycling (89%) and cycled because of health benefits (81%). A dynamic foot (odds ratio: 5.2, 95% CI 2.0, 13.3) and a higher number of facilitators (odds ratio: 1.3, 95% CI 1.2, 1.5) positively predicted cycling, whereas the presence of other underlying diseases (odds ratio: 0.4, 95% CI 0.2, 0.9) negatively predicted cycling (R²: 40.2%).

Conclusion

In the Netherlands, the majority of adults cycled after a LLA, mainly for recreational purposes. A dynamic foot, a higher number of facilitators, and no other underlying diseases increases the likelihood of cycling after a LLA. The results suggest that personal motivation and a higher mobility level could be the key to increasing cycling participation. Future research should determine the association between motivation, mobility levels, and cycling with a LLA.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13102-021-00302-3.

Bicycling participation in people with a lower limb amputation: a scoping review

BACKGROUND

To review literature on bicycling participation, as well as facilitators and barriers for bicycling in people with a lower limb amputation (LLA).

METHODS

Peer-reviewed, primary, full text, studies about bicycling in people with a LLA from midfoot level to hemipelvectomy were searched in Pubmed, Embase, Cinahl, Cochrane library, and Sportdiscus. No language or publication date restrictions were applied. Included full-text studies were assessed for methodological quality using the Effective Public Health Practice Project tool. Data were extracted, synthesized and reported following Preferred Reporting Items for Systematic Review.

RESULTS

In total, 3144 papers were identified and 14 studies were included. The methodological quality of 13 studies was weak and 1 was moderate. Bicycling participation ranged from 4 to 48%. A shorter time span after LLA and a distal amputation were associated with a higher bicycling participation rate particularly for transportation. In people with a transtibial amputation, a correct prosthetic foot or crank length can reduce pedalling asymmetry during high-intensity bicycling. People with limitations in knee range of motion or skin abrasion can use a hinged crank arm or a low profile prosthetic socket respectively.

CONCLUSION

People with a LLA bicycled for transportation, recreation, sport and physical activity. Adaptation of prosthetic socket, pylon and foot as well as bicycle crank can affect pedalling work and force, range of motion, and aerodynamic drag. Because the suggestions from this review were drawn from evidences mostly associated to competition, prosthetists should carefully adapt the existing knowledge to clients who are recreational bicyclists.

Sport-Specific Limb Prostheses in Para Sport

Prostheses form an essential part of participation in sport and physical activity for athletes with lower or upper limb amputation. These prostheses come in the form of everyday nonsport-specific prostheses, as well as sport-specific prostheses designed to enable participation in specific sports. Sport-specific prostheses are designed to the requirements of the sport to facilitate the achievement of peak performance without causing significant risk of injury. This article addresses the various factors associated with participation in sport and physical activity for individuals with amputation, including the various prostheses for upper and lower limbs and prostheses for different sports.

Dual-task walking over a compliant foam surface: A comparison of people with transfemoral amputation and controls

People with lower limb amputation are unable to reliably sense ground characteristics due to compromised sensory inputs from the missing limb. As a result, they may rely on compensatory strategies, such as use of cognitive resources, when walking over complex surfaces. This study examined interactions between cognition and walking over a compliant surface in 14 people with transfemoral amputation (TFA) and 14 controls using a dual-task paradigm. Walking was assessed with quantitative motion analysis in both single-task (walking alone) and dual-task (walking while performing a cognitive task) conditions over a compliant foam surface. Outcomes were walking speed, step width, step time asymmetry, step time variability, and the speed and accuracy of cognitive task performance. For each outcome, effects of task (single-task, dual-task) and group (TFA, control) were examined with repeated-measures analysis of variance. No significant group-by-task interactions were observed for cognitive task performance. A significant group-by-task interaction for step time asymmetry indicated that participants with TFA increased temporal asymmetry in dual-task relative to single-task conditions, while control participants maintained symmetrical gait. The addition of a concurrent cognitive task did not differentially affect other aspects of gait between groups. Significant main effects of group for all walking outcomes indicated that participants with TFA walked slower, with wider, more asymmetric, and more variable steps than controls. Results suggest that gait quality degrades in challenging dual-task conditions for people with TFA, but not controls, consistent with the idea that people with TFA may use increased cognitive resources to control walking in complex environments.