Gait symmetry and walking speed analysis following lower-extremity trauma

Reconstruction of proximal hamstring ruptures restores joint biomechanics during various walking conditions

PURPOSE

We aimed to examine the functional outcome in different walking conditions in elderly adults who underwent surgical repair after a non-contact hamstring injury. Our objective was to compare lower limb kinematics and kinetics over the entire gait cycle between the injured and contralateral leg in overground and level and uphill treadmill walking.

METHODS

12 patients (mean ± SD, age: 65 ± 9 years; body mass index: 30 ± 6 kg/m2) walked at self-selected speed in overground (0% slope) and treadmill conditions (0% and 10% slope). We measured spatiotemporal parameters, joint angles (normalised to gait cycle) and joint moments (normalised to stance phase) of the hip, knee and ankle. Data between sides were compared using paired sample t-tests (p < 0.05) and continuous 95% confidence intervals of the paired difference between trajectories.

RESULTS

Patients walked at an average speed of 1.31 ± 0.26 m/second overground and 0.92 ± 0.31 m/second on the treadmill. Spatiotemporal parameters were comparable between the injured and contralateral leg (p > 0.05). Joint kinematic and joint kinetic trajectories were comparable between sides for all walking conditions.

CONCLUSIONS

Refixation of the proximal hamstring tendons resulted in comparable ambulatory mechanics at least 1 year after surgery in the injured leg and the contralateral leg, which were all within the range of normative values reported in the literature. These results complement our previous findings on hamstring repair in terms of clinical outcomes and muscle strength and support that surgical repair achieves good functional outcomes in terms of ambulation in an elderly population.

TRIAL REGISTRATION

clinicaltrials.gov (NCT04867746).

Gait recovery is not associated with meniscus and/or knee ligament injuries following lateral tibial plateau fractures. A prospective 3-year cohort study of 56 patients

INTRODUCTION

Though associated meniscus and/or knee ligament injuries following lateral tibial plateau fractures (TPF) are common, the importance of development in gait recovery is unknown. This study aim to report the 12- and 36-month gait recovery in patients with lateral TPF divided into two groups presenting with and without associated meniscus and/or knee ligament injuries. (Associated meniscus and/or knee ligament injuries were grouped as: 1) missing, 2) lateral or medial menisci, 2) posterior and anterior cruciate ligament (PCL/ACL), and 4) lateral or medial collateral ligament.) HYPOTHESIS: Comparable results at the 12- and 36-month follow-up between groups presenting with and without soft tissue injuries.

PATIENTS AND METHODS

Study design: cohort study. Included were patients admitted following a lateral TPF (AO-type 41 B) between December 1, 2013 and November 30, 2016. The primary outcome score was gait sample.

RESULTS

Fifty-six patients were included. The mean age of the patients at the time of fracture was 56 years (range from 22 to 86). Female gender represents 75%. MRI-verified associated meniscus and/or knee ligament injuries were observed in 28 patients (50%). The average gait speed at the 12- and 36-month follow-up were 125.7 (SD31.3) and 127.7 (SD16.6) cm/sec. for patients with associated meniscus and/or knee ligament injuries and 125.2 (SD31.1) and 130.1 (SD15.6) cm/sec. for patients without associated meniscus and/or knee ligament injuries (p=0.96, p=0.17). Regardless of soft tissue injuries, the development in percent of gait asymmetry for step-length and single-support decrease significantly between the 12- and the 36-month follow-up. (p>0.002) DISCUSSION: This study indicates that gait recovery following lateral TPFs were not associated with associated meniscus and/or knee ligament injuries at the 12- and 36-month follow-up. Between the 12- and 36-month follow-up asymmetry of the gait function decline significantly indicating a prolonged recovery period of gait function following TPFs.

LEVEL OF EVIDENCE

II; prospective cohort study.

Early Pain Catastrophizing Exacerbates Impaired Limb Loading and 6-Minute Walk Test Distance 12 Months After Lower Extremity Fracture

OBJECTIVE

Disability is common after lower extremity fracture (LEF). Although psychosocial factors have been associated with patient-reported outcomes after LEF, they have not been associated with objective measures of function. Aberrant gait patterns are important markers of function, but are poorly defined after LEF. The primary purpose of this study was to explore whether pain catastrophizing and fear of movement 6 weeks after surgery were associated with injured limb loading outcomes and 6-minute walk test (6MWT) distance 12 months after femur or tibia fracture. The secondary purpose was to determine if limb loading characteristics differed between injured and uninjured limbs.

METHODS

At 6 weeks after LEF, patients completed validated measures of pain catastrophizing, fear of movement, and depression. At 12 months, patients completed a 6MWT while wearing instrumented insoles that recorded the limb loading outcomes of stance time, impulse, and loading rate. Bivariate correlations assessed how patient and psychosocial characteristics at 6 weeks were associated with injured limb loading outcomes and 6MWT distance. Multivariable regression analyses were performed to determine if psychosocial variables were associated with each outcome after controlling for depression and patient demographic and clinical characteristics. Finally, paired t tests compared limb loading outcomes between limbs.

RESULTS

Forty-seven participants completed the 6MWT at 12 months (65%), and 38 completed the 6MWT with the instrumented insoles. Fear of movement carried a poor relationship (r = 0.11-0.32) and pain catastrophizing a moderate relationship (r = 0.46-0.54) with 12-month outcomes. The regression results indicated that pain catastrophizing continued to be associated with all outcomes. Finally, the injured limb had significantly lower limb loading outcomes than the uninjured limb at 12 months (Cohen d = 0.54-0.69).

CONCLUSION

Pain catastrophizing early after LEF was associated with impaired limb loading and 6MWT distance at 12 months.

IMPACT

Impaired limb loading persists 12 months after LEF. Further research is needed to determine whether rehabilitative efforts focused on pain catastrophizing can restore limb loading after LEF.

A Quantitative Evaluation of Functional Recovery after Traumatic Lower Extremity Salvage

INTRODUCTION

Soft tissue reconstruction is a routine component of lower extremity trauma care and focus is increasingly being directed towards understanding functional outcomes. This study aims to quantify functional recovery and identify variables associated with functional outcomes of patients who undergo traumatic limb salvage.

METHODS

A retrospective review was performed of patients with lower extremity traumatic injuries requiring vascularized soft tissue reconstruction at a Level 1 trauma center between July 2007-December 2015. Postoperatively, patients were administered the 36-Item Short Form Health Survey Version 2 (SF-36v2) and the Lower Extremity Functional Scale (LEFS) questionnaires by telephone. Demographics, perioperative variables, and postoperative outcomes were analyzed by univariate and bivariate analysis.

RESULTS

Forty-two patients with 42 flaps and a mean of 12.7 months follow up were included in the study. Limb salvage was successful in 38 patients (90.5%). Patients ≥ 40 years old had significantly worse SF-36v2 scores in physical functioning (P ≤0.01) and mental health (P ≤0.05) than their younger counterparts. Patients who had pre-existing hypertension demonstrated significantly lower physical functioning (P ≤0.01). Role limitation due to emotional health was significantly lower in patients who were female (P ≤0.01) or required revision surgery (P ≤0.01). The mean LEFS score was 37.7 ± 18.5.

CONCLUSIONS

Patients exhibited poor functional outcomes following major limb trauma with attempted limb salvage based on two validated patient reported outcomes measures (PROMs). Patient characteristics should be considered in evaluating candidates for reconstruction to optimize outcomes and to effectively counsel patients on their functional prognosis.

Movement asymmetry during low and high demand mobility tasks after dysvascular transtibial amputation

BACKGROUND

Movement asymmetries between lower limbs are commonly exhibited by adults after transtibial amputation. However, the degree of movement asymmetry between low- and high-demand functional tasks remains unknown.

METHODS

Kinematic and kinetic data were collected during overground walking (low-demand) and step ascent (high-demand) tasks for two groups: 1) persons with transtibial amputation and 2) healthy matched peers. Analysis of covariance was used to compare sagittal-plane peak knee moment and joint angle (primary) and hip and ankle moments and joint angles, vertical ground reaction force and impulse (secondary).

FINDINGS

Within transtibial amputation group comparisons showed significantly greater between-limb asymmetry in peak knee moment (p < .01), vertical impulse (p < .01), peak vertical ground reaction force (p = .05), peak ankle angle (p < .01) and peak ankle moment (p < .01) with the step ascent task compared to overground walking. The transtibial amputation group had greater between-limb asymmetry during step ascent in peak knee moment (p < .01), vertical impulse (p < .01), peak vertical ground reaction force (p = .04) and peak ankle angle (p < .01) than healthy matched peers. During overground walking, the transtibial amputation group had greater between-limb asymmetry in peak vertical impulse (p = .05) and peak ankle moment (p < .01) than healthy matched peers.

INTERPRETATION

Movement asymmetry is increased during step ascent compared to overground walking for adults with transtibial amputation. While the restoration of overground walking is the focus of post-amputation rehabilitation and prosthetic design, higher demand tasks should also be considered to maximize mobility for adults with transtibial amputation.

Wearable Sensors Quantify Mobility in People With Lower Limb Amputation During Daily Life

It is necessary to effectively assess functional mobility for appropriate prosthetic prescription and post-amputation rehabilitation. As part of this process, patients' ability for variable cadence and community ambulation are assessed in-clinic, often through visual assessments and without objective standards. The purpose of this study was to explore the clinical viability of using wearable sensors to characterize the functional mobility of people with lower limb amputation. We collected inertial measurement unit (IMU) and global positioning system (GPS) data over two weeks, from 17 individuals with lower limb amputation and 14 healthy non-amputee controls. We calculated stride-by-stride cadence, walking speed and stride lengths, along with whether they occurred in or out of the home. Self-selected walking speed was also assessed in the lab. Compared to the lab, both groups walked slower and with a lower cadence during their daily lives. There were no differences in cadence variability between groups or between strides taken in and out of the home. Both groups walked faster and with greater stride lengths away from the homes. The results suggest that functional capacity measured in the lab was not necessarily reflected in routine walking during daily life. The walking measures derived in this approach can be used to aid in the prosthetic prescription process or in the assessment of different interventions.

Dynamic characterisation of Össur Flex-Run prosthetic feet for a more informed prescription

BACKGROUND:

The current method of prescribing composite running-specific energy-storing-and-returning feet is subjective and is based only on the amputee's static body weight/mass.

OBJECTIVES:

The aim was to investigate their dynamic characteristics and create a relationship between these dynamic data and the prescription of foot.

STUDY DESIGN:

Experimental Assessment.

METHODS:

This article presents the modal analysis results of the full range of Össur Flex-Run^™ running feet that are commercially available (1LO-9LO) using experimental modal analysis technique under a constant mass at 53 kg and boundary condition.

RESULTS:

It was shown that both the undamped natural frequency and stiffness increase linearly from the lowest to the highest stiffness category of foot which allows for a more informed prescription of foot when tuning to a matched natural frequency. The low damping characteristics determined experimentally that ranged between 1.5% and 2.0% indicates that the feet require less input energy to maintain the steady-state cyclic motion before take-off from the ground. An analysis of the mode shapes also showed a unique design feature of these feet that is hypothesised to enhance their performance.

CONCLUSION:

A better understanding of dynamic characteristics of the feet can help tune the feet to the user's requirements in promoting a better gait performance.

CLINICAL RELEVANCE

The dynamic data determined from this study are needed to better inform the amputees in predicting the natural frequency of the foot prescribed. The amputees can intuitively tune the cyclic body rhythm during walking or running to match with the natural frequency. This could eventually promote a better gait performance.

Gait Evaluation Using Procrustes and Euclidean Distance Matrix Analysis

Objective assessment of gait is important in the treatment and rehabilitation of patients with different diseases. In this paper, we propose a gait evaluation system using the Procrustes and Euclidean distance matrix analysis. We design and develop an android app to collect real time synchronous accelerometer and gyroscope data from two inertial measurement unit sensors through Bluetooth connectivity. The data is collected from 12 young (ten for modeling and two for validation) and 20 older subjects. We analyze the data collected from real world for stride, step, stance, and swing gait features. We validate our method with the measurements of gait features. The generalized Procrustes analysis is used to estimate a standard normal mean gait shape (NMGS) for ten young subjects. Each gait feature of both young and older subjects is then converted to find the best match with the NMGS using the ordinary Procrustes analysis. The shape distance between the NMGS and each gait shape is estimated using Riemannian shape distance, Riemannian size-and-shape distance, Procrustes size-and-shape distance, and root-mean-square deviation. A t-test is performed to provide statistical evidence of gait shape differences between young and older gaits. A mean form, which is considered as a standard normal mean gait form (NMGF), and inter-feature distances are estimated from the set of ten young subjects. The form difference is estimated between the NMGF and individual gaits of young and older. The degree of abnormality is then estimated for individual features and the result is plotted to visualize the feature in a gait. Experimental results demonstrate the performance of the proposed method.

Continuous Monitoring of Patient Mobility for 18 Months Using Inertial Sensors following Traumatic Knee Injury: A Case Study

Continuous patient activity monitoring during rehabilitation, enabled by digital technologies, will allow the objective capture of real-world mobility and aligning treatment to each individual's recovery trajectory in real time. To explore the feasibility and added value of such approaches, we present a case study of a 36-year-old male participant monitored continuously for activity levels and gait parameters using a waist-worn inertial sensor following a tibial plateau fracture on the right side, sustained as a result of a high-energy trauma during a sporting accident. During rehabilitation, data were collected for a period of 553 days, with > 80% daytime compliance, until the participant returned to near full mobility. The participant completed a daily diary with the annotation of major events (falls, near falls, cycling periods, or physiotherapy sessions) and key dates in the patient's recovery, including medical interventions, transitioning off crutches, and returning to work. We demonstrate the feasibility of collecting, storing, and mining of continuous digital mobility data and show that such data can detect changes in mobility and provide insights into long-term rehabilitation. We make both raw data and annotations available as a resource with the aspiration that further methods and insights will be built on this initial exploration of added value and continue to demonstrate that continuous monitoring can be deployed to aid rehabilitation.

Physical Performance Limitations After Severe Lower Extremity Trauma in Military Service Members

OBJECTIVES

To characterize the type and magnitude of lower extremity physical performance deficits in military service members who have undergone rehabilitation after limb salvage or transtibial amputation.

DESIGN

Cross-sectional prospective.

SETTING

Level I trauma military medical and rehabilitation center.

PATIENTS/PARTICIPANTS

Service members with lower extremity trauma resulting in limb salvage (n = 20) or unilateral transtibial amputation (n = 14) compared with uninjured actively training service members (n = 123).

INTERVENTION

Control participants and individuals with amputation were tested during a single session. Participants with limb salvage were tested with and without the use of a custom carbon fiber orthosis.

MAIN OUTCOME MEASUREMENTS

Physical performance as measured using four-square step, sit-to-stand 5 times, and timed stair ascent tests. Secondary outcomes included the associations between these lower extremity activity measures to determine the interrelationship of activity limitations.

RESULTS

The ability of service members to rapidly ascend stairs, a demanding lower limb mobility task, is limited after amputation and limb salvage. However, performance on an agility test similar to the four-square step test approximated normative levels. Differences between individuals with amputation or limb salvage were less than 1 second for all tests and were not statistically significant. Correlations were observed among the physical performance measures in the tested patient populations, particularly between the sit-to-stand and timed stair ascent tests.

CONCLUSIONS

Severe limb trauma significantly affects performance, particularly during tasks requiring lower extremity strength and power. Individuals with amputation or limb salvage who were provided a custom carbon fiber orthosis and intensive rehabilitation had similar performance.

LEVEL OF EVIDENCE

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

An Automatic Gait Feature Extraction Method for Identifying Gait Asymmetry Using Wearable Sensors

This paper aims to assess the use of Inertial Measurement Unit (IMU) sensors to identify gait asymmetry by extracting automatic gait features. We design and develop an android app to collect real time synchronous IMU data from legs. The results from our method are validated using a Qualisys Motion Capture System. The data are collected from 10 young and 10 older subjects. Each performed a trial in a straight corridor comprising 15 strides of normal walking, a turn around and another 15 strides. We analyse the data for total distance, total time, total velocity, stride, step, cadence, step ratio, stance, and swing. The accuracy of detecting the stride number using the proposed method is 100% for young and 92.67% for older subjects. The accuracy of estimating travelled distance using the proposed method for young subjects is 97.73% and 98.82% for right and left legs; and for the older, is 88.71% and 89.88% for right and left legs. The average travelled distance is 37.77 (95% CI ± 3.57) meters for young subjects and is 22.50 (95% CI ± 2.34) meters for older subjects. The average travelled time for young subjects is 51.85 (95% CI ± 3.08) seconds and for older subjects is 84.02 (95% CI ± 9.98) seconds. The results show that wearable sensors can be used for identifying gait asymmetry without the requirement and expense of an elaborate laboratory setup. This can serve as a tool in diagnosing gait abnormalities in individuals and opens the possibilities for home based self-gait asymmetry assessment.

Combat-related foot injuries: impact on gait and functional outcome

Introduction

Prior to deployment of the Netherlands Army Task Force Urozgan in Afghanistan, the Dutch Military and civilian healthcare systems had limited experience in treating blast injuries and their long-term consequences. This meant that guidelines for treatment and rehabilitation were lacking. The aim of this cohort study was to quantify kinematic and kinetic abnormalities in service members with foot injuries in relation to functional outcome using gait analysis.

Method

In nine service members with combat-related talus, calcaneus and/or navicular bone (TCN) fractures and nine controls, gait parameters were measured using Gait Real-Time Analysis Interactive Lab system. High-level mobility was evaluated by the Comprehensive High-Level Activity Mobility Predictor (CHAMP), and functional ability was assessed by Lower Extremity Functional Scale (LEFS) questionnaire.

Results

Significant differences were found for LEFS and CHAMP scores (P<0.01), comfortable walking speed and ankle joint range of motion (ROM) (P<0.05), all lower in the group with TCN fractures. For this group, a trend (0.1>P>0.05) for higher step width and lower stride duration and peak power was found. A strong correlation (0.6>r>0.79) is shown between LEFS and comfortable walking speed and CHAMP and ankle joint ROM. The correlations between LEFS and stride duration, step width, ankle joint ROM and peak power, and between CHAMP and comfortable walking speed and stride duration, were moderate (0.4>r>0.59).

Conclusions

This study demonstrated that service members with TCN fractures, compared with healthy controls, have altered gait characteristics, specifically lower walking speed and ankle joint ROM, both related to lower physical functioning. Patients with bilateral depressed Böhler’s angle had the worse functional performance, and further research is recommended to evaluate the relationship between Böhler’s angle and physical performance.

Clinical Trial

The Dutch Ministry of Defence (MOD) and the Institutional Review Board and Medical Ethics Review Committee Brabant, The Netherlands, approved this study (P1550).

Asymmetry in gait pattern following bicondylar tibial plateau fractures-A prospective one-year cohort study

INTRODUCTION

Despite the high number of studies evaluating outcomes following tibial plateau fractures, the literature lacks studies including the objective assessment of gait pattern. The purpose of the present study was to evaluate asymmetry in gait patterns at 12 months after frame removal following ring fixation of a tibial plateau fracture.

PATIENTS AND METHODS

The study design was a prospective cohort study. The primary outcome measurement was the gait patterns 12 months after frame removal measured with a pressure-sensitive mat. The mat registers footprints and present gait speed, cadence, as well as temporal and spatial parameters of the gait cycle. Gait patterns were compared to a healthy reference population.

RESULTS

Twenty-three patients were included with a mean age of 54.4 years (32-78 years). Patients presented with a shorter step-length of the injured leg compared to the non-injured leg (asymmetry of 11.3%). Analysis of single-support showed shorter support time of the injured leg compared to the non-injured leg (asymmetry of 8.7%). Moreover, analysis of swing-time showed increased swing-time of the injured leg (asymmetry of 8.9%). Compared to a healthy reference population, increased asymmetry in all gait patterns was observed. The association between asymmetry and health-related quality of life (HRQOL) showed moderate associations (single-support: R=0.50, P=0.03; step-length: R=0.43, P=0.07; swing-time: R=0.46, P=0.05).

CONCLUSION

Compared to a healthy reference population, gait asymmetry is common 12 months after frame removal in patients treated with external ring fixation following a tibial plateau fracture of the tibia.

[Limb salvage or amputation after severe trauma to the lower extremities : Evidence from the LEAP Study]

Deciding between reconstruction and primary amputation after severe high-energy trauma to the lower extremities is difficult and consequential. The Lower Extremity Assessment Project (LEAP) prospectively included and investigated patients with severe, limb-threatening injuries below the femur, with third-grade open fractures, defined soft-tissue damage and amputation wounds. This paper aims to review the key results of the LEAP study, which were published in several parts, in due consideration of the newer relevant literature, and to deduce the consequences for clinical practice. The main results are as follows: No score is sufficiently reliable to predict the success of reconstruction. Loss of muscle seems to be more momentous than loss of bone. Any accompanying injuries that should be taken into account in the individual treatment concepts are crucial to the results, in addition to comorbidities and other individual patient-related factors, such as alcoholism, smoking, insurance, and social background. Psychological impairment is frequent after these injuries and should therefore be addressed regularly with regard to rehabilitation.

Single-Camera-Based Method for Step Length Symmetry Measurement in Unconstrained Elderly Home Monitoring

OBJECTIVE

single-camera-based gait monitoring is unobtrusive, inexpensive, and easy-to-use to monitor daily gait of seniors in their homes. However, most studies require subjects to walk perpendicularly to camera's optical axis or along some specified routes, which limits its application in elderly home monitoring. To build unconstrained monitoring environments, we propose a method to measure step length symmetry ratio (a useful gait parameter representing gait symmetry without significant relationship with age) from unconstrained straight walking using a single camera, without strict restrictions on walking directions or routes.

METHODS

according to projective geometry theory, we first develop a calculation formula of step length ratio for the case of unconstrained straight-line walking. Then, to adapt to general cases, we propose to modify noncollinear footprints, and accordingly provide general procedure for step length ratio extraction from unconstrained straight walking.

RESULTS

Our method achieves a mean absolute percentage error (MAPE) of 1.9547% for 15 subjects' normal and abnormal side-view gaits, and also obtains satisfactory MAPEs for non-side-view gaits (2.4026% for 45°-view gaits and 3.9721% for 30°-view gaits). The performance is much better than a well-established monocular gait measurement system suitable only for side-view gaits with a MAPE of 3.5538%.

CONCLUSION

Independently of walking directions, our method can accurately estimate step length ratios from unconstrained straight walking.

SIGNIFICANCE

This demonstrates our method is applicable for elders' daily gait monitoring to provide valuable information for elderly health care, such as abnormal gait recognition, fall risk assessment, etc.

OBJECTIVE

single-camera-based gait monitoring is unobtrusive, inexpensive, and easy-to-use to monitor daily gait of seniors in their homes. However, most studies require subjects to walk perpendicularly to camera's optical axis or along some specified routes, which limits its application in elderly home monitoring. To build unconstrained monitoring environments, we propose a method to measure step length symmetry ratio (a useful gait parameter representing gait symmetry without significant relationship with age) from unconstrained straight walking using a single camera, without strict restrictions on walking directions or routes.

METHODS

according to projective geometry theory, we first develop a calculation formula of step length ratio for the case of unconstrained straight-line walking. Then, to adapt to general cases, we propose to modify noncollinear footprints, and accordingly provide general procedure for step length ratio extraction from unconstrained straight walking.

RESULTS

Our method achieves a mean absolute percentage error (MAPE) of 1.9547% for 15 subjects' normal and abnormal side-view gaits, and also obtains satisfactory MAPEs for non-side-view gaits (2.4026% for 45°-view gaits and 3.9721% for 30°-view gaits). The performance is much better than a well-established monocular gait measurement system suitable only for side-view gaits with a MAPE of 3.5538%.

CONCLUSION

Independently of walking directions, our method can accurately estimate step length ratios from unconstrained straight walking.

SIGNIFICANCE

This demonstrates our method is applicable for elders' daily gait monitoring to provide valuable information for elderly health care, such as abnormal gait recognition, fall risk assessment, etc.

Stair ascent and descent biomechanical adaptations while using a custom ankle-foot orthosis

The ability to navigate stairs step-over-step is an important functional outcome following severe lower leg injury and is difficult for many patients. Ankle-foot orthoses, such as the Intrepid Dynamic Exoskeletal Orthosis (IDEO), are often prescribed to improve function. This study compared stair climbing mechanics between IDEO users and able-bodied control participants. Thirteen IDEO users who sustained severe lower leg injury and 13 controls underwent biomechanical gait analysis. Participants ascended and descended a 16-step instrumented staircase without handrail use at a controlled cadence of 80 steps/min. Peak joint angles, moments, powers, and ground reaction forces, and integrated mechanical work were calculated. Independent t-tests with Bonferroni-Holm corrections were used to compare controls to IDEO and sound limbs. Reduced ankle range of motion on the IDEO limb resulted in compensatory strategies while ascending or descending stairs. During ascent, IDEO users had greater bilateral hip power during pull-up (p<0.007) to compensate for the IDEO limb׳s reduced ankle dorsiflexion (p<0.001) and knee extensor moment (p=0.001) while it was leading, and reduced ankle plantarflexor power while it was trailing (p<0.001). During stair descent, when the IDEO limb had was trailing, it had less ankle dorsiflexion during controlled lowering (p<0.001), resulting in greater vertical ground reaction force (p=0.005) and greater ankle and knee power absorption (p<0.001). Reduced IDEO limb ankle power absorption during weight acceptance (p<0.001) resulted in a large knee extensor moment (p<0.001) on the trailing sound limb to lower the body. Despite gait deviations, IDEO users were able to climb stairs step-over-step unassisted.

Quantifying prosthetic gait deviation using simple outcome measures

AIM: To develop a subset of simple outcome measures to quantify prosthetic gait deviation without needing three-dimensional gait analysis (3DGA).

METHODS: Eight unilateral, transfemoral amputees and 12 unilateral, transtibial amputees were recruited. Twenty-eight able-bodied controls were recruited. All participants underwent 3DGA, the timed-up-and-go test and the six-minute walk test (6MWT). The lower-limb amputees also completed the Prosthesis Evaluation Questionnaire. Results from 3DGA were summarised using the gait deviation index (GDI), which was subsequently regressed, using stepwise regression, against the other measures.

RESULTS: Step-length (SL), self-selected walking speed (SSWS) and the distance walked during the 6MWT (6MWD) were significantly correlated with GDI. The 6MWD was the strongest, single predictor of the GDI, followed by SL and SSWS. The predictive ability of the regression equations were improved following inclusion of self-report data related to mobility and prosthetic utility.

CONCLUSION: This study offers a practicable alternative to quantifying kinematic deviation without the need to conduct complete 3DGA.

An Argument for Salvage in Severe Lower Extremity Trauma with Posterior Tibial Nerve Injury: The Ganga Hospital Experience

BACKGROUND

Absence of plantar sensation is a critical factor considered in favor of amputation for patients with lower limb-threatening injuries. This study aims to assess outcomes of limb salvage in a group of patients with severe lower extremity injuries associated with posterior tibial nerve transection.

METHODS

The authors studied eight cases of limb salvage after traumatic injuries with documented tibial nerve laceration managed at Ganga Hospital, India. Functional and health-related quality-of-life outcomes were assessed. Outcomes from this case series were compared to outcomes of studies from a systematic literature review on salvage of the severely injured lower extremity.

RESULTS

Patients in this case series reported mild pain (median score, 20 on a visual analogue scale ranging from 0 to 100), with some return of plantar sensation in patients with tibial nerve repairs (median score, 2 of 5). Patients demonstrated a decrease in ankle motion (27.5 degrees' plantar flexion and 10 degrees' extension) and muscle strength (median heel flexor score, 3 of 5). All patients could ambulate independently. Quality of life and function measured by validated instruments revealed minimal disability. The authors identified 1767 articles on lower extremity trauma, and 14 articles were reviewed systematically. Relative to the case series, published articles reported similarly diminished ankle motion and muscle strength, with reports of mild pain in select studies. Patient-reported outcomes instruments found variations in the degree of physical disability based on the time from injury.

CONCLUSION

Although limited in number, this case series demonstrates the value of limb salvage even for patients with posterior tibial nerve injury.

Gait characteristics and quality of life perception of patients following tibial plateau fracture

INTRODUCTION

The purpose of the current study was to evaluate the long-term functional outcome as measured by gait patterns and quality of life assessment of patients with high-energy tibial plateau fracture compared to matched controls.

MATERIALS AND METHODS

Thirty-eight patients were evaluated in a case-controlled comparison. Twenty-two patients with tibial plateau fracture were evaluated after 3.1 (1.63) years (sd) from injury. Patients underwent a computerized spatiotemporal gait test and completed the SF-12 health survey. 16 healthy subjects, matched for age and gender served as a control group. The main outcome measures for this study were spatiotemporal gait characteristics, physical quality of life and mental quality of life.

RESULTS

Significant differences were found in all gait parameters between patients with tibial plateau fracture and healthy controls. Patients with tibial plateau fracture walked slower by 18% compared to the control group (p < 0.001), had slower cadence by 8% compared (p = 0.002) to the control group and had shorter step length in the involved leg by 11% and in the uninvolved leg by 12% compared to the control group (p = 0.006 and p = 0.003, respectively). Patients with tibial plateau fracture also showed shorter single limb support (SLS) in the involved leg by 12% compared to the uninvolved leg and 5% in the uninvolved leg compared to the control group (p < 0.001 and p = 0.017, respectively). Significant differences were found in the Short Form (SF)-12 scores. Physical Health Score of patients with tibial plateau fracture was 65% lower compared to healthy controls (p < 0.001), and Mental Health Score of the patients was 40% lower compared to healthy controls (p < 0.001). Finally, significant correlations were found between SF-12 and gait patterns.

CONCLUSION

Long-term deviations in gait and quality of life exist in patients following tibial plateau fracture. Patients following tibial plateau fracture present altered spatiotemporal gait patterns compared to healthy controls, as well as self-reported quality of life.

Return of functional mobility after an open tibial fracture: a sensor-based longitudinal cohort study using the Hamlyn Mobility Score

In this study we quantified and characterised the return of functional mobility following open tibial fracture using the Hamlyn Mobility Score. A total of 20 patients who had undergone reconstruction following this fracture were reviewed at three-month intervals for one year. An ear-worn movement sensor was used to assess their mobility and gait. The Hamlyn Mobility Score and its constituent kinematic features were calculated longitudinally, allowing analysis of mobility during recovery and between patients with varying grades of fracture. The mean score improved throughout the study period. Patients with more severe fractures recovered at a slower rate; those with a grade I Gustilo-Anderson fracture completing most of their recovery within three months, those with a grade II fracture within six months and those with a grade III fracture within nine months. Analysis of gait showed that the quality of walking continued to improve up to 12 months post-operatively, whereas the capacity to walk, as measured by the six-minute walking test, plateaued after six months. Late complications occurred in two patients, in whom the trajectory of recovery deviated by > 0.5 standard deviations below that of the remaining patients. This is the first objective, longitudinal assessment of functional recovery in patients with an open tibial fracture, providing some clarification of the differences in prognosis and recovery associated with different grades of fracture.

Analysis of asymmetry of the forces applied on the lower limb in subjects with nonspecific chronic low back pain

Objective. Several studies have investigated asymmetry and loading patterns in different spine pathologies, motor disorders, and other conditions; there is a lack of knowledge on these aspects in chronic low back pain (CLBP). The aim of this study was to analyse asymmetry and loading patterns in patients with nonspecific chronic low back pain (NCLBP) compared to normal individuals, during walking. Method. Forty participants (20 healthy subjects and 20 patients with NCLBP) participated in the study. Asymmetry of the force was measured based on the Asymmetry Index (ASI). The difference in the mean values of all data between the two groups was examined using the independent t-test. Results. The mean value of the first peak of ground reaction force of normal subjects was 1.02 ± 0.0354 N/BW compared to 1.038 ± 0.099 N/BW in NCLBP patients (P = 0.25) and 0.1004 ± 0.036 N/BW mediolateral force applied on the leg in normal subjects compared to 0.089 ± 0.022 N/BW in NCLBP patients (P = 0.214). The Asymmetry Index (ASI) of the first peak of vertical force was 2.59% ± 1.89% and 3.88% ± 2.94% for NCLBP and normal subjects, respectively, P = 0.2. Conclusion. Therefore, it can be concluded that NCLBP subjects follow avoidance-endurance model without any limitation during walking.

Validation of a standardised gait score to predict the healing of tibial fractures

There is no absolute method of evaluating healing of a fracture of the tibial shaft. In this study we sought to validate a new clinical method based on the systematic observation of gait, first by assessing the degree of agreement between three independent observers regarding the gait score for a given patient, and secondly by determining how such a score might predict healing of a fracture.

We used a method of evaluating gait to assess 33 patients (29 men and four women, with a mean age of 29 years (15 to 62)) who had sustained an isolated fracture of the tibial shaft and had been treated with a locked intramedullary nail. There were 15 closed and 18 open fractures (three Gustilo and Anderson grade I, seven grade II, seven grade IIIA and one grade IIIB). Assessment was carried out three and six months post-operatively using videos taken with a digital camera. Gait was graded on a scale ranging from 1 (extreme difficulty) to 4 (normal gait). Bivariate analysis included analysis of variance to determine whether the gait score statistically correlated with previously validated and standardised scores of clinical status and radiological evidence of union.

An association was found between the pattern of gait and all the other variables. Improvement in gait was associated with the absence of pain on weight-bearing, reduced tenderness over the fracture, a higher Radiographic Union Scale in Tibial Fractures score, and improved functional status, measured using the Brazilian version of the Short Musculoskeletal Function Assessment questionnaire (all p < 0.001). Although further study is needed, the analysis of gait in this way may prove to be a useful clinical tool.

A CaRBS analysis of hip replacement approaches and non-pathology

This study investigates the differences in hip biomechanics for subjects following a total hip arthroplasty (THA), through the lateral approach (LA) and posterior approach (PA), to those with no pathology (NP). The principal component analysis was performed on two kinematic and two kinetic waveforms (subject-based characteristics) from level gait to identify salient portions of the waveforms for comparison between the subject cohorts. These were classified to identify the differences between post-THA and non-pathological cohorts. The primary technique exposited in the THA analysis is classification and ranking belief simplex (CaRBS). Within the analysis, from the configuration of a CaRBS model, there is discussion on the model fit and contribution of the subject-based characteristics. Where appropriate, comparisons to the CaRBS model are made with the results from a logistic regression (LR) analysis. In terms of model fit, using CaRBS, 24 out of 27 LA/PA subjects (88.89%) and 13 out of 16 NP subjects (81.25%) were correctly classified as exhibiting either post-THA or NP hip functional characteristics during level gait, combining to 86.05% classification accuracy, compared with 81.40% classification accuracy when using LR.

Physical performance assessment in military service members

Few established measures allow effective quantification of physical performance in severely injured service members. We sought to establish preliminary normative data in 180 healthy, active-duty service members for physical performance measures that can be readily implemented in a clinical setting. Interrater and test-retest reliability and minimal detectable change (MDC) values were also determined. Physical performance testing included self-selected walking velocity on level and uneven terrain, timed stair ascent, the sit-to-stand five times test, the four-square step test, and the 6-minute walk test. Data analysis included descriptive statistics, intraclass correlation coefficients, and MDC. Interrater and test-retest reliability were excellent for all measures (intraclass correlation coefficients >0.75). MDC values for timed measures were <0.3 seconds for interrater comparisons and <1.5 seconds for between-day comparisons. Physical performance measures had a narrow range of normal performance and were reliable and stable between days.

Return to running and sports participation after limb salvage

BACKGROUND

The ability to return to running and sports participation after lower extremity limb salvage has not been well documented previously. Although the ability to ambulate without pain or assistive devices is generally a criteria for a good limb salvage outcome, many patients at our institution have expressed a desire to return to a more athletic lifestyle to include running and sports participation. The purpose of this study was to investigate the types of athletic endeavors our high-energy lower extremity trauma patients were able to pursue after limb salvage.

METHODS

We retrospectively analyzed lower extremity limb salvage patients who were at least 12 weeks status after external fixation removal and participated in our limb salvage return-to-running clinical pathway. Patients were rehabilitated to their highest functional level through a sports medicine-based approach. A custom energy-storing ankle-foot orthosis was implemented to help augment plantarflexion strength in conjunction with running gait retraining.

RESULTS

The first 10 patients to complete the clinical pathway were identified. All patients were treated at the same institution by the same orthopedic surgeon and physical therapist. Eight patients have returned to running, and 10 patients have returned to weight-lifting. Seven patients have returned to cycling, three have returned to golf, three to basketball, and two to softball. Two patients have completed a mini-triathlon.

CONCLUSION

Aggressive rehabilitation, an energy-storing ankle-foot orthosis, and running gait retraining can restore an active recreational lifestyle to patients who have undergone lower extremity limb salvage.

Bionic ankle-foot prosthesis normalizes walking gait for persons with leg amputation

Over time, leg prostheses have improved in design, but have been incapable of actively adapting to different walking velocities in a manner comparable to a biological limb. People with a leg amputation using such commercially available passive-elastic prostheses require significantly more metabolic energy to walk at the same velocities, prefer to walk slower and have abnormal biomechanics compared with non-amputees. A bionic prosthesis has been developed that emulates the function of a biological ankle during level-ground walking, specifically providing the net positive work required for a range of walking velocities. We compared metabolic energy costs, preferred velocities and biomechanical patterns of seven people with a unilateral transtibial amputation using the bionic prosthesis and using their own passive-elastic prosthesis to those of seven non-amputees during level-ground walking. Compared with using a passive-elastic prosthesis, using the bionic prosthesis decreased metabolic cost by 8 per cent, increased trailing prosthetic leg mechanical work by 57 per cent and decreased the leading biological leg mechanical work by 10 per cent, on average, across walking velocities of 0.75-1.75 m s(-1) and increased preferred walking velocity by 23 per cent. Using the bionic prosthesis resulted in metabolic energy costs, preferred walking velocities and biomechanical patterns that were not significantly different from people without an amputation.

Criteria of gait asymmetry in patients with hip osteoarthritis

Gait symmetry is often a goal for physiotherapy in patients with hip osteoarthritis and after total hip replacement. However, there is no agreement on criteria for pathological gait asymmetry. In this study we investigated discriminative abilities of trunk and footfall gait symmetry measures, and thereafter assessed whether a 10% cutoff value is valid as a general criterion of pathological gait asymmetry across measures. Anteroposterior, vertical, and mediolateral trunk symmetry, single support, and step length symmetry were obtained simultaneously by trunk accelerometry and an electronic walkway in 37 patients with end-stage hip osteoarthritis and 56 controls. Subjects walked six times along a 7-meter walkway at slow, preferred, and fast speed, before data were normalized for gait velocity. Anteroposterior, vertical, and single support symmetry measures showed best discriminating abilities. The general 10% criterion of gait asymmetry and optimal cutoff criteria calculated for each symmetry measure showed approximately equal total classification ability. However, the optimal cutoff criteria classified a high number of controls as having pathological gait asymmetry. The general criterion of 10% is valid with high total classification ability, does not classify asymmetry in able-bodied subjects as pathological, and is feasible for use on individual patients in the clinic as well as in research.

Physical therapy of the patient with foot and ankle injuries sustained in combat

The rehabilitation of soldiers returning from Operation Iraqi Freedom and Operation Enduring Freedom after combat-related trauma poses significant challenges. Polytrauma from high-energy blasts are common and frequently associated with mangled extremities, axial fractures, and traumatic brain injuries. Current evidence in the physical therapy literature is scant for this population and an empiric approach is often used. This article highlights the challenges encountered and techniques used in the rehabilitation of soldiers with foot and ankle injuries sustained in recent combat operations.

Orthopedic surgeons and physical therapists differ in assessment of need for physical therapy after traumatic lower-extremity injury

BACKGROUND

Lower-extremity injuries constitute the leading cause of trauma hospitalizations among people under the age of 65 years. Rehabilitation has the potential to favorably influence the outcomes associated with traumatic lower-extremity injuries.

OBJECTIVES

The objectives of this study were to explore variability in surgeon and physical therapist assessments of the need for physical therapy in patients with traumatic lower-extremity injuries and to determine the factors associated with assessments of need.

DESIGN

This study was a retrospective cohort investigation.

METHODS

Participants were 395 patients treated by reconstruction in the Lower-Extremity Assessment Project. They were evaluated at 8 level I trauma centers at 3, 6, and 12 months after hospitalization by an orthopedic surgeon and a physical therapist to determine the need for physical therapy. Analyses included multilevel logistic regression.

RESULTS

Chi-square analyses showed that surgeon and therapist assessments of need differed statistically across trauma centers. Surgeons were more likely to assess a need for therapy at 3 months when participants had low work self-efficacy, impaired knee flexion range of motion (ROM), and weight-bearing limitations and at 6 and 12 months when participants had impaired knee flexion ROM and weight-bearing and balance limitations. Therapists were more likely to assess a need for therapy at 3 months when participants had moderate to severe pain and at 6 and 12 months when participants had low work self-efficacy, pain, impaired knee flexion ROM, and balance limitations.

CONCLUSIONS

The results revealed variability in assessments of the need for physical therapy at the provider and trauma center levels. Differences in provider assessments highlight the need for communication and further investigation into the outcomes and timing of physical therapy for the treatment of traumatic lower-extremity injuries.

Prescription footwear for severe injuries of foot and ankle: effect on regularity and symmetry of the gait assessed by trunk accelerometry

After foot and/or ankle fracture, the restoration of optimal gait symmetry is one of the criteria of recovery. Orthotic insoles and orthopaedic shoes improve gait symmetry and regularity by controlling joint motion and improving alignment. The aim of the present study was to assess the effect of prescription footwear on gait quality by using accelerometers attached to the lower back. Sixteen adult patients with persistent disability after ankle and/or foot fractures performed two 30-s walking trials with and without prescription footwear (insoles and stabilizing shoes). Sixteen control subjects were also tested for comparison. The autocorrelation function was computed from the acceleration signal and the first two dominant periods were assessed (d1 and d2). Two parameters were used: (1) Stride Regularity (SR) which expresses the similarity between strides over time (d2), and (2) Stride Symmetry (SS) a ratio (d1/d2) which expresses the left/right similarity of gait independently of repeatability in the successive movements of each limb. In control subjects, SR and SS were 0.86+/-0.05 (correlation coefficient) and 81+/-10%, respectively. In the patient group, the effect of footwear was significant (SR: 0.88+/-0.06 vs. 0.90+/-0.05, SS: 38+/-23% vs. 46+/-27%). Pain was also significantly reduced (-34%). By using a rapid and low-cost method, we objectively quantified gait quality improvement after footwear intervention, concomitant to pain reduction. Substantial inter-patient variability in the footwear outcome was observed. In conclusion, we believe that trunk accelerometry can be a useful tool in the field of gait rehabilitation.

Investigation of clinical effects of high- and low-resistance training for patients with knee osteoarthritis: a randomized controlled trial

BACKGROUND AND PURPOSE

Muscle strength training is important for people with knee osteoarthritis (OA). High-resistance exercise has been demonstrated to be more beneficial than low-resistance exercise for young subjects. The purpose of this study was to compare the effects of high- and low-resistance strength training in elderly subjects with knee OA.

SUBJECTS AND METHODS

One hundred two subjects were randomly assigned to groups that received 8 weeks of high-resistance exercise (HR group), 8 weeks of low-resistance exercise (LR group), or no exercise (control group). Pain, function, walking time, and muscle torque were examined before and after intervention.

RESULTS

Significant improvement for all measures was observed in both exercise groups. There was no significant difference in any measures between HR and LR groups. However, based on effect size between exercise and control groups, the HR group improved more than the LR group.

DISCUSSION AND CONCLUSION

Both high- and low-resistance strength training significantly improved clinical effects in this study. The effects of high-resistance strength training appear to be larger than those of low-resistance strength training for people with mild to moderate knee OA, although the differences between the HR and LR groups were not statistically significant.