DURING AMBULATION WITH PROSTHETICS AND IMPACT OF NEW TECHNOLOGY Jeffrey M Cohen MD Clinical Professor of Rehabilitation Medicine NYULangone Medical Center Energy consumption in normal gait Linear Relationship ID: 164026
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Slide1
ENERGY EXPENDITURE DURING AMBULATION WITH PROSTHETICS AND IMPACT OF NEW TECHNOLOGY
Jeffrey M. Cohen, MD
Clinical Professor of Rehabilitation Medicine
NYU-Langone Medical CenterSlide2
Energy consumption in normal gait
Linear Relationship
:
Gait speed and energy cost of walking
(O2 consumption)
(Perry, J (ed),
Gait Analysis: Normal and Pathological Gait
,1992)Slide3
Energy consumption in normal gaitSlide4
Energy Consumption in Amputees:Prosthetic ambulation Walking speed is slower (Chosen Walking Speed)
Minimizes the rate of energy used during walking
(Duff, Kerrigan, Corcoran et al,
Arch Phys Med Rehabil
, 1996)Slide5
Energy Consumption in Amputees:Chosen Walking Speed-Prosthetic ambulation70 patients with unilateral traumatic and vascular amputations 40 control subjects Compared selected gait parameters and the energy cost of prosthetic walking
(Waters, Perry, Antonelli et al,
JBJS
, 1976)Slide6
Energy Consumption in Amputees:Chosen Walking Speed-Prosthetic ambulationChosen Walking Speed declines at each higher amputation level for both traumatic and vascular amputee groups
Transtibial (TT) (71 m/min)
Knee disarticulation (61 m/min)
Transfemoral (TF) (52 m/min)
Hip Disarticulation (47 m/min)
In all groups of amputees performance was significantly better the lower the level of the amputation. Slide7
Energy Consumption in Amputees:Chosen Walking Speed-Prosthetic ambulationConclusion:When preservation of function is the chief concern, amputation should be performed at the lowest possible level.Slide8
Energy Consumption in Amputees:Gait Speed, Oxygen CostSlide9
Energy Consumption in Amputees:Traumatic amputees Level of amputation Increased energy
(Traumatic
)
above normal
TT 20-25% (Short-40%)
(Long-10%)
TT + TT 41% (Gonzalez-1974)
TF 60-70% (Traugh-1975)
TF + TT 118% (Traugh-1975)
TF + TF 260% (Huang 1979)
(Gonzalez, Corcoran, Reyes,
Arch Phys Med Rehabil
, 1974)
(Traugh, Corcoran, Reyes,
Arch Phys Med Rehabil
1975)
(Huang, Jackson, Moore et al,
Arch Phys Med Rehabil
1974)Slide10
Energy Consumption in Amputees:Bilateral (TT) vs Unilateral (TF)
-Bilateral TT exert less effort (41%) than a Unilateral TF
(60-70%)
-Important to retain biological knee whenever possible
(Gonzalez, Corcoran, Reyes,
Arch Phys Med Rehabil
, 1974)Slide11
Energy Consumption in Amputees:Hip Disarticulation Prosthesis> 200 % increase in energy compared with unimpaired walking
High rejection rate
(Huang, Jackson, Moore et al,
Arch Phys Med Rehabil
1979)Slide12
Energy Consumption in Amputees:Traumatic vs VascularTraumatic Amputees:
-Walk faster
-Exert less oxygen cost (ml/kg/m)
Vascular amputees:
-Older
-Cardiovascular disease
-Lower energy reserves
-Anaerobic energy
(Waters, Perry, Antonelli et al,
JBJS
, 1976)Slide13
Energy Consumption in Amputees: Traumatic vs VascularLevel of amputation Metabolic cost
above normal
Traumatic Transtibial 25%
Vascular Transtibial 40%
Traumatic Transfemoral 68%
Vascular Transfemoral 100%
(Huang, Jackson, Moore et al,
Arch Phys Med Rehabil
1974)Slide14
Energy Consumption in Amputees:Traumatic vs Vascular Relation between aerobic capacity and walking ability in older adults with a lower-limb amputation
Wezenberg D, van der Woude LH, Faber WX, de Haan A, Houdik H
Arch Phys Med Rehabil;
2013 Sep; 94 (9):1714-20Slide15
Energy Consumption in Amputees:Traumatic vs VascularOBJECTIVES: To determine the relative aerobic load, walking speed, and walking economy of older adults with a lower-limb prosthesisSETTING:
Human motion laboratory at a rehabilitation center.
PARTICIPANTS:
Sample of older adults (n=36) who underwent lower-limb amputation because of vascular deficiency or trauma and able-bodied controls (n=21).
MAIN OUTCOME MEASURES:
Peak aerobic capacity and oxygen consumption while walking were determined. The relative aerobic load and walking economy were assessed as a function of walking speedSlide16
Energy Consumption in Amputees:Traumatic vs VascularRESULTS: -People with a vascular amputation walked at a substantially higher (45.2%) relative aerobic load than people with an amputation because of trauma.
-The preferred walking speed in both groups of amputees was slower than that
of able-bodied controls and below their most economical walking speed.
CONCLUSIONS:
F
indings corroborate the notion that, especially in people with a vascular amputation, the peak aerobic capacity is an important determinant for walking ability. Slide17
Energy Consumption in Amputees:Prosthesis vs Walker/Crutches -The increased energy cost over baseline of walking with a
comfortably fitting prosthesis without an assistive device
is
less than that expended when walking w/out prosthesis
using walker or crutches
(Waters, Perry, Antonelli et al,
JBJS
, 1976)Slide18
Energy Consumption in Amputees:Prosthesis vs Walker/Crutches Comparison of energy cost
in transtibial
amputees
using "prosthesis" and "crutches without prosthesis" for
walking
activities.
Mohanty RK, Lenka P, Fouehal, A, Kumar, R
Ann Phys Med Rehabil
2012 May;55(4):252-62.Slide19
Energy Consumption in Amputees:Prosthesis vs Walker/CrutchesMETHODS:
Thirty adults who had a unilateral transtibial amputation
Oxygen consumption was measured as the participants walked over level ground for 30 meters at a self-selected speed
.
RESULTS:
Ambulation “with prosthesis”:
21% more efficiency in terms of VO(2) uptake rate
92% more efficiency in terms of energy expenditure/min
(compared to “crutches without prosthesis”)
Slide20
Energy Consumption in Amputees:Prosthesis vs Walker/Crutches CONCLUSIONS:
Significant difference between “prosthesis walking” and “crutches without prosthesis” walking in terms of VO(2) uptake rate (P<0.005) and EE/min (P<0.00001)
All below knee amputee groups walk with less effort by using prosthesis.
Slide21
Energy Consumption in AmputeesEffect of New TechnologyReduce energy cost of prosthetic gait by developing: -Dynamic Responsive (energy storing) feet
-Cadence Responsive Microprocessor Controlled Knee
Units
-Suspension System ModificationsSlide22
Energy Consumption in Amputees: Effect of Prosthetic Foot Design The effects of prosthetic foot design on physiologic measurements, self-selected walking velocity, and physical activity in people with transtibial amputation
Hsu MJ, Nielsen DH, Lin-Chan SJ, Shurr D.
Arch Phys Med Rehabil
. 2006 Jan;87(1):123-9.Slide23
Energy Consumption in Amputees: Effect of Prosthetic Foot DesignOBJECTIVE: Investigate the physiologic differences during multispeed treadmill walking and physical activity profiles for the Otto Bock C-Walk foot (C-Walk), Flex-Foot, and solid ankle cushion heel (SACH) foot in people with transtibial amputation.SETTING:
Research laboratory
PARTICIPANTS:
Eight men with unilateral transtibial amputation.
MAIN OUTCOME MEASURES:
Physiologic responses (energy expenditure, gait efficiency, exercise intensity, rating of perceived exertion [RPE]) during multispeed treadmill walking (53.64, 67.05, 80.46, 93.87, 107.28 m/min)Slide24
Energy Consumption in Amputees: Effect of Prosthetic Foot DesignRESULTS: The C-Walk had a trend of improved physiologic responses compared with the SACH; however, no foot-type differences were statistically significant
The Flex-Foot showed a significantly lower percentage of age-predicted maximum heart rate and RPE values (compared with the C-Walk and SACH)
CONCLUSIONS:
The energy storing-releasing feet appeared to have certain trends of improved gait performance compared with the SACH; however, not many objective foot-type differences were significantly noted. Further studies with a larger sample size are suggested.Slide25
Energy Consumption in Amputees:Carbon Fiber vs Bionic foot Assessment of the effects of carbon fiber and bionic foot (Proprio) during over ground and treadmill walking in transtibial amputees
Delussu AS, Brunelli S, Paradisi F, Iosa M, Pellegrini R, Zenardi D, Traballesi
Gait Posture
2013 Sep;38(4):876-82Slide26
Energy Consumption in Amputees:Carbon Fiber vs Bionic footMETHOD: -Ten transtibial amputees
-Assess energy cost of walking and perceived mobility wearing prosthesis using a bionic foot (Proprio-Foot®) vs a dynamic carbon fiber foot.
-Testing done on a regular floor surface and on treadmill with -5%, 0% and 12%
slopes.
-Amputees walked at their own self-selected speed. Metabolic and cardiac data
were collected using a portable gas analyzer. Slide27
Energy Consumption in Amputees:Carbon Fiber vs Bionic footPROPRIO FOOT -for low to moderately active below-knee amputees -mimics natural foot motion -
Motor-powered ankle motion
increases ground clearance and reduces the risk of
tripping and falling. Allows users to traverse different kinds of terrain.Slide28
Energy Consumption in Amputees:Carbon Fiber vs Bionic footRESULTS: -
Energy cost of walking with the Proprio-Foot® was significantly lower than with
a dynamic carbon fiber foot (p=0.002).
-No significant improvements were observed for perceived mobility or walking
ability.
CONCLUSIONS:
-
Results suggest that use of the Proprio-Foot® can lower the energy cost of
walking for transtibial amputees in spite of its added weight Slide29
Energy Consumption in Amputees: Mechanical vs Microprocessor-controlled knee -21 unilateral, transfemoral amputees
-Transition from mechanical to microprocessor knee
(Otto Bock C leg)
(Hafner, Willingham, et al
Arch Phys Med Rehabil
2007)Slide30
Energy Consumption in Amputees:Mechanical vs Microprocessor-controlled kneeResults:Stair descent score, hill descent time improved significantly, significant decrease in frequency of stumbles and falls
Subject satisfaction significantly greater with microprocessor controlled knee
Slide31
Energy Consumption in Amputees: Mechanical vs Microprocessor-controlled knee Energy Expenditure and Activity of Transfemoral Amputees Using Mechanical and Microprocessor-Controlled Prosthetic Knees
Kaufman KR, Levine JA, Brey RH, McCrady SK, Padgett DJ, Joyner MJ.
Arch Phys Med Rehabil
. 2008 Jul;89(7):1380-5Slide32
Energy Consumption in Amputees: Mechanical vs Microprocessor-controlled kneeObjective To quantify the energy efficiency of locomotion and energy expenditure of transfemoral amputees using a mechanical and microprocessor-controlled prosthetic knee
Methods
Subjects (N=15; 12 men, 3 women; age, 42±9y; range, 26 –57y)
Transfemoral amputees; long-term users of a mechanical prosthesis (20±10y as an amputee; range, 3–36y). Subjects served as their own controls
Tested with a mechanical fluid-controlled knee prosthesis (11 Mauch SNS,
a
2 CaTach,
b
1 Black Max,
c
1 Century 2000
a
). Then given an acclimation period (18±8 weeks) before testing on the microprocessor-controlled knee (Otto Bock C-Leg
d
). Slide33
Energy Consumption in Amputees:Mechanical vs Microprocessor-controlled kneeResults -Increased physical activity–related energy expenditure levels (P=.04) after wearing
the microprocessor-controlled prosthetic knee joint.
-When using the microprocessor-controlled knee, the subjects expressed increased
satisfaction in their daily lives (
P
=.02
)
-
No significant difference in the energy efficiency of walking (
P
=.34)
Conclusions
People ambulating with a microprocessor-controlled knee significantly increased their physical activity during daily life, outside the laboratory setting, and expressed an increased quality of life
.Slide34
Energy Consumption in Amputees:Mechanical vs Microprocessor-controlled knee Safety, energy efficiency, and cost efficacy of the C-Leg for transfemoral amputees: A review of the literature.
Highsmith MJ, Kahle JT, Bongiorni DR, Sutton BS, Groer S, Kaufman KR
Prosthet Orthot Int
.
2010 34(4):362-377 Slide35
Energy Consumption in Amputees:Mechanical vs Microprocessor-controlled kneePurpose: -Performed a structured literature review and provided a grade of recommendation for patient safety, gait energy efficiency, and cost effectiveness of the C-Leg microprocessor-controlled prosthetic knee for transfemoral amputees
-Review of Medline (Ovid) and CINAHL (EBSCO) data bases from1995-2009.
-18 articles were determined to be pertinent:
Conclusions:
.
Methodologic quality was low with a moderate risk of bias in the safety and energy effectiveness categories.
Sufficient evidence to suggest increased efficacy of the C-Leg in the areas of safety, energy efficiency and cost when compared with other prosthetic knees for transfemoral amputees.Slide36
Energy Consumption in Amputees:Effect of suspension system A comparison between the suction suspension system and the hypobaric Iceross Seal-In® X5 in transtibial amputees.
Brunelli S, Delussu AS, Paradisi F, Pellegrini R, Traballesi M.
Prosthet Orthot Int.
2013 Dec;37(6):436-44.Slide37
Energy Consumption in Amputees:Effect of suspension systemOBJECTIVES: Compare the effect of the hypobaric Iceross Seal-In(®) liner with that of the suction suspension system for quality of life, pistoning, and prosthesis efficiency in unilateral transtibial amputees.
METHODS:
Ten amputees were enrolled
Testing:
wearing suction suspension system and after 2, 5,7 weeks of Seal-In® X5 use.
Pistoning test
to compare vertical movement of the stump within the socket
E
nergy cost of walking test
Prosthesis Evaluation Questionnaire
and
Houghton Scale Questionnaire
of perceived mobility and quality of life with the prosthesis
Timed Up &Go Test
Locomotor Capability Index
for functional mobilitySlide38
Energy Consumption in Amputees:Effect of suspension systemRESULTS: The hypobaric Iceross Seal-In® X5 led to significant pistoning reduction and improvement on the Houghton Scale Questionnaire and 3 of 9 domains of the Prosthesis Evaluation Questionnaire
.
No statistical changes were observed in functional mobility or the energy cost of walking tests.
CONCLUSION:
Replacing the suction suspension system with the hypobaric Iceross Seal-In® X5 improves quality of life in transtibial amputees
.Slide39
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