Military Medicine International Journal of amsus raising the bar: extremity trauma care guest editors
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Hip Back 5.6 (2.8) 3.6 (3.0) 4.7 (2.8) Transverse ROM 10.9 (3.2) 8.4 (3.4) 8.6 (2.1) Temporal (s) Spatial (m) Stance Time 0.73 (0.04) 0.71 (0.06) 0.75 (0.04) Step Length 0.70 (0.05) 0.73 (0.16) 0.65 (0.10) Swing Time 0.44 (0.03) 0.44 (0.03) 0.41 (0.02) Step Width 0.12 (0.03) 0.13 (0.03) 0.12 (0.03) Step Time 0.58 (0.03) 0.61 (0.13) 0.54 (0.08) Stride Length 1.41 (0.09) 1.38 (0.11) 1.39 (0.09) BW, body weight; ROM, range of motion; IC, initial contact; LR, loading response; MSt, midstance; TSt, terminal stance, St, stance; PSw, preswing; ISw, initial swing; MSw, midswing; TSw, terminal swing; Sw, swing. N/A: Trunk motion is tracked as 1 segment; therefore, duplicate measures in the intact limb are not reported. Kinematic and kinetic measures in bold exhibit a signi ficant between group differences after Bonferroni–Holm correction with the smallest p-value cutoff of 0.0009. Temporal spatial measures in bold exhibit a significant between group differences after Bonferroni–Holm correction with the smallest
p-value cutoff of 0.0083. MILITARY MEDICINE, Vol. 181, November/December Supplement 2016 33 The Prevalence of Gait Deviations in Individuals With Transtibial Amputation the AB group ( p ≤ 0.001), but showed low deviation preva- lence in the TTA group. Hip
The greatest prevalence of deviations at the hip of the intact limb was with abduction (56.3%). All sagittal plane hip kinematic measures of the prosthetic limb had low deviation prevalence (12.5 –18.8%), but unlike the knee of the prosthetic limb, the measures are skewed in a single direction relative to the NRR. Moderate deviation prevalence was observed for intact limb hip extension during preswing and flexion during terminal swing, however, only the latter TABLE III. Prevalence (%) of Individuals within the TTA Group with Kinematic, Kinetic, or Temporal Spatial Deviations of the Prosthetic or Intact Limbs as Identi fied Using an AB NRR for Each Measure. “High” (>50%), Moderate (25–49%), and Low (<25%) Prevalence is Indicated for Each Measure. Arrows Represent a Signi ficant Increase (↑) or Decrease (↓) in the TTA Mean Group Measure Relative to the AB Group and Correspond to Differences Presented in Table II. For Each Peak Kinematic and Kinetic Measure, the Timing of the Peak in the Gait Cycle is identi fied Deviation Prevalence (%) Prosthetic Intact
Deviation Prevalence (%) Prosthetic Intact Ankle Angle Ankle Moment Plantar
flexion: LR 18.8%
6.3% Dorsiflexion: LR ↑ 12.5%
↑ 12.5%
Dorsi flexion: TSt 6.3% 0.0%
Plantarflexion: TSt 6.3%
0.0% Plantar
flexion: ISw ↓ 100.0% 12.5% Ankle Powers Sagittal ROM ↓ 81.3% 6.3% Absorption: LR 6.3% ↑
Absorption: TSt 12.5%
12.5% Generation: TSt ↓ 50.0%
12.5% Knee Angle Knee Moment Flexion: IC 18.8% 6.3%
Flexion: LR ↓ 6.3% ↑ 6.3%
Flexion: LR 25.0%
6.3% Extension: MSt ↓ 0.0%
0.0% Extension: TSt 18.8% 0.0%
Flexion: TSt 12.5%
0.0% Flexion: MSw 31.3% ↓
Extension: TSt 6.3%
0.0% Sagittal ROM ↓ 68.8%
↓ 18.8%
Varus: LR ↓ 18.8% 6.3% Valgus: LR 12.5% 12.5%
Knee Powers Generation: MSt ↓ 87.5%
12.5% Absorption: LR ↓ 0.0%
0.0% Generation: TSt ↓ 0.0%
0.0% Absorption: TSt 0.0% 6.3%
Hip Angle Hip Moment Flexion: LR 12.5%
18.8% Extension: LR ↓ 0.0%
↑ 6.3%
Extension: PSw 18.8%
31.3% Flexion: TSt 6.3% ↓
Flexion: TSw 12.5%
↓ 31.3%
Extension: Sw 31.3%
↑ 18.8%
Sagittal ROM 18.8%
0.0% Abductor
6.3% 31.3%
Adduction 12.5%
0.0% Adductor
↓ 12.5%
0.0% Abduction 31.3% ↓
Hip Powers Generation: MSt ↑ 0.0%
6.3% Absorption: TSt 12.5% 12.5%
Generation: TSt 6.3%
6.3% Pelvic Angle Trunk-Pelvic Angle Anterior Tilt ↓ 31.3%
↓ 31.3%
Sagittal ROM 37.5%
N/A Posterior Tilt 31.3% 31.3%
Frontal ROM ↓ 6.3% N/A Sagittal ROM ↑ 25.0%
↑ 25.0%
Transverse ROM 6.3%
N/A Contralateral Drop ↓ 37.5%
0.0% Trunk-Lab Angle Contralateral Elevation 0.0%
↓ 12.5%
Sagittal ROM 0.0%
N/A Frontal ROM ↓ 0.0%
↓ 0.0%
Frontal ROM 25.0%
N/A Hip Forward 6.3% 0.0%
Transverse ROM 12.5%
N/A Hip Back
0.0% 12.5%
Transverse ROM 6.3%
0.0% Temporal
Spatial Stance Time 18.8% 6.3%
Step Length 31.3%
43.8% Swing Time 6.3% ↓
Step Width 0.0%
0.0% Step Time 31.3% 37.5%
Stride Length 18.8%
12.5% Signi
ficant between group differences of kinematic and kinetic measures are after Bonferroni–Holm correction with the smallest p-value cutoff of 0.0009. Signi
ficant between group differences of temporal spatial measures are after Bonferroni–Holm correction with the smallest p-value cutoff of 0.0083. MILITARY MEDICINE, Vol. 181, November/December Supplement 2016 34 The Prevalence of Gait Deviations in Individuals With Transtibial Amputation was found to be signi ficantly different from the AB group ( p ≤ 0.001). Pelvis/Trunk Deviation prevalence was low to moderate for all pelvic and trunk measures of the TTA group. Five individuals (31.3%) with TTA accounted for all deviations of anterior and poste- rior tilt. Overall, the TTA group ambulated with less anterior pelvic tilt and had a signi ficantly larger sagittal ROM than the AB group ( p ≤ 0.001). In the AB group, the frontal plane motion was symmetrical, with 3.1 (SD 1.5) degrees of contralateral drop and 3.7(SD 2.1) degrees of contralat- eral elevation relative to the stance limb. However, the TTA group demonstrated asymmetric pelvic motion with signi
ficantly reduced contralateral pelvic drop on the pros- thetic limb and intact limb elevation ( p ≤ 0.001). The frontal pelvic ROM of the TTA group was signi ficantly decreased ( p ≤ 0.001), although there were no values out- side the NRR. DISCUSSION The current study is the first, to our knowledge, to identify and characterize deviations in individuals with a TTA using both group mean comparisons and NRRs. The use of NRR and prevalence is presented as an additional method for identifying and quantifying deviations in individuals with a TTA likely to be encountered in a treatment environment. This approach allows direct comparisons of each individual to the NRR. This is in contrast to the group mean approach which, as evident in (Fig. 1), requires a high proportion of values be consistently greater or less than the AB group mean, or a few individuals with a TTA with large devia- tions in the same direction. When using the NRR approach, a relatively large sample of AB individuals is needed to provide an accurate estimate of NRRs. In this study, data from 40 AB males were the largest sample available at the time of analysis and presented in Table II for use by others. Prosthetic Limb Similar to previous reports, individuals with a TTA in this study exhibited signi ficant kinematic 16 and kinetic 10,19 devi-
ations at the prosthetic ankle. Kinematic deviations such as decreased peak plantar flexion during initial swing and decreased sagittal ROM were highly prevalent. The decrease in peak plantar flexion was due to an inability of the pros- thetic devices to actively plantar flex. When unloaded, these passive devices return to their aligned position of approxi- mately 5 degrees of dorsi flexion. The use of passive pros- thetic devices and associated decrease in plantar flexion contributed to the signi ficant decrease in prosthetic ankle power generation at terminal stance. Similar to earlier works, 10,19
individuals with a TTA on average exhibited an approximate 50% reduction in prosthetic ankle power generation at terminal stance compared to the intact ankle and AB group. However, this deviation was only prevalent in 50% of our TTA group. This suggests that, although pros- thetic ankle ROM was limited, 50% of the TTA group were capable of achieving push-off powers within the NRR. This demonstrates that performance within normative ranges is possible, and interventions which allow individuals with a TTA to more effectively load and store energy in the foot are warranted. Individuals with a TTA in the present study walked with a signi ficant decrease in prosthetic limb sagittal knee ROM, which was highly prevalent and may be related to an extended knee posture observed in the prosthetic limb throughout gait. In agreement with previous reports, the effects of the extended knee posture were greatest at initial contact when individuals with a TTA displayed a signi fi- cantly decreased knee flexor moment 15,16
and a signi ficant
and highly prevalent reduction in knee power genera- tion.
15 Signi
ficant decreases in sagittal knee moments and powers measured later in stance were consistent with ear- lier works, 11,15,16,19,27 however, demonstrated 0% devia- tion prevalence meaning all values were within the NRR. These kinetic differences may be related to a compensatory extended knee posture, which prevents the knee from col- lapsing 16
Similar to previous literature, 12,16
individuals with a TTA demonstrated a trend toward greater hip extension during prosthetic limb stance. This was associated with a signi fi- cant increase in hip power generation during stance 10,12,19 and used to control knee flexion in the prosthetic limb and aid forward progression. 19 Despite signi ficant kinetic group mean differences, the TTA group exhibited little to no prev- alence of hip deviations. Longitudinal analysis of our partici- pants would provide insight into when and if compensations at the hip develop. Intact Limb Individuals with a TTA in the present study exhibited no signi
ficant differences in intact ankle kinematics compared to the AB group. However, a signi ficant increase in intact ankle power absorption at initial contact was observed with 43.8% prevalence. We speculate this was in response to an abrupt transition off the prosthetic ankle at terminal stance and onto the intact limb at initial contact. 28 Individuals with a TTA must transition off the prosthetic foot more quickly due to a shortened roll-over arc of the prosthetic foot 28 and
lack of active plantar flexion. This is consistent with the sig- ni ficant reduction in intact limb swing times observed in the TTA group. The increase in intact ankle power absorption during loading response may be associated with reports of increased intact limb loading 1,3,5,29
thought to contribute to secondary musculoskeletal disorders. The results from the intact limb knee are in contrast to previous works, which reported increases in swing knee flexion, 11
11,16 and stance knee MILITARY MEDICINE, Vol. 181, November/December Supplement 2016 35 The Prevalence of Gait Deviations in Individuals With Transtibial Amputation power generation. 11,14
The few signi ficant kinematic and kinetic differences observed demonstrated prevalence less than 18.8%. Thus, it appears that knee deviations of the intact limb noted in older populations with a TTA 11,14,16
may not frequently occur in our young population with a TTA this early following independent ambulation. In contrast to Bateni et al 10 who reported an increase in hip flexion of the intact limb during stance, we observed a trend toward increased extension throughout the gait cycle compared to the AB group. During swing, individuals with a TTA demonstrated signi ficant decreases in hip flexion and abduction of the intact limb not previously reported in the literature. These deviations were 31.3% and 56.3% preva- lent, respectively, and may be associated with the signi ficant
decrease in swing time and a rapid transition onto the intact limb. Consistent with these results, individuals with a TTA demonstrated a signi ficant increase in swing hip extension moments at the intact limb, likely in preparation for initial contact with a shortened step length. However, most intact limb hip kinetic values were within the NRR with less than 32% prevalence. Similar to the intact limb ankle and knee, individuals with a TTA in this study did not frequently exhibit hip deviations reported in populations with a longer history of prosthetic ambulation. 10,12,14
Pelvis/Trunk To the best of our knowledge, no study has reported pelvis and trunk biomechanical data for individuals with a TTA in all three planes of motion. Consistent with a previous report of asymmetry in pelvic obliquity, 13 our participants exhibited a signi ficant decrease in pelvic drop on the intact side with 37.5% prevalence. Although we found signi fi- cantly decreased frontal plane pelvic ROM using group comparisons, all individual values were within the NRR. The 0% deviation prevalence is consistent with the work of Rueda et al 30 suggesting no difference between TTA and AB groups. In addition to the frontal plane deviations, indi- viduals with a TTA exhibited a signi ficant decrease in ante- rior pelvic tilt compared to the AB group with 31.5% prevalence. The presence of pelvic and trunk deviations early following independent ambulation and their potential links to the development of low back pain 13,31
suggest lon- gitudinal study of pelvic and trunk deviations and their rela- tionship to low back pain may be warranted. CONCLUSION Prosthetic limb deviations identi fied and characterized using group mean and prevalence approaches are in general agree- ment with, and add to, those reported in the literature. Spe- ci fically, knee and hip deviations observed in the prosthetic limb are indicative of known compensations used to control the knee during stance. Decreased prosthetic ankle power generation during push off did not, however, appear to elicit compensations in the intact limb, knee, and hip. Further, individuals with a TTA in this study exhibited few of the intact limb deviations that have been previously reported. Inconsistencies between our data and previous literature may be associated with differences in age, activity level, or pros- thetic gait experience. Prior data demonstrating recovery of normative metabolic cost of walking and greater function in the injured service member as compared to civilian cohorts are consistent with the reduced deviations observed here. 32 Finally, pelvic and trunk deviations in all three planes of motion are reported here for the first time. The use the NRR method allows clinicians and researchers to identify gait deviations in a single individual matching clinical practice. Further study is needed to determine the exact etiology of these deviations, and their association with the development of secondary musculoskeletal conditions. ACKNOWLEDGMENTS We thank our colleague, Kelly M. Rodriguez, for her efforts in data collec- tion analysis and insight on this manuscript. We also thank Dr. Benjamin J. Darter, Linda Waetjen, and Melissa Brawner for contribution to data collection. REFERENCES 1. Gailey R, Allen K, Castles J, Kucharik J, Roeder M: Review of secondary physical conditions associated with lower-limb amputa- tion and long-term prosthesis use. J Rehabil Res Dev 2008; 45(1): 15 –29.
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20. O ’Sullivan R, Walsh M, Jenkinson A, O’Brien T: Factors associated with pelvic retraction during gait in cerebral palsy. Gait Posture 2007; 25(3): 425 –31. 21. Bennett DA, Beckett LA, Murray AM, et al: Prevalence of Parkinsonian signs and associated mortality in a community popula- tion of older people. N Engl J Med 1996; 334(2): 71 –6. 22. Verghese J, LeValley A, Hall CB, Katz MJ, Ambrose AF, Lipton RB: Epidemiology of gait disorders in community-residing older adults. J Am Geriatr Soc 2006; 54(2): 255 Yüklə 2,47 Mb. Dostları ilə paylaş:
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