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OJHAS Vol. 9, Issue 3:
(Jul - Sep, 2010) |
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| Energy
Cost and Gait Efficiency of Below-Knee Amputee and Normal Subject
with Similar Physical Parameters & Quality of Life: A Comparative
Case Study |
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Durbadal
Biswas,
National
Institute for the Orthopaedically Handicapped, Under Ministry
of Social Justice & Empowerment, Govt. of India, B-T Road, Bon
Hooghly, Kolkata-700090,
Sukumar
Roy,
HOD of Biomedical Engineering Dept., NSEC, Garia,
PK Lenka,
National
Institute for the Orthopaedically Handicapped, Under Ministry
of Social Justice & Empowerment, Govt. of India, B-T Road, Bon
Hooghly, Kolkata-700090
Ratnesh
Kumar,
National
Institute for the Orthopaedically Handicapped, Under Ministry
of Social Justice & Empowerment, Govt. of India, B-T Road, Bon
Hooghly, Kolkata-700090. |
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Address For Correspondence |
Department of Research &
Development,
National Institute for the
Orthopaedically Handicapped,
Under Ministry of Social Justice
& Empowerment, Govt. of India,
B.T. Road, Bon Hooghly,
Kolkata-90,
India
E-mail:
durbadal.bme@gmail.com |
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Biswas D, Roy S, Lenka PK, Kumar R. Energy
Cost and Gait Efficiency of Below-Knee Amputee and Normal Subject
with Similar Physical Parameters & Quality of Life: A Comparative
Case Study. Online J Health Allied Scs.
2010;9(3):14 |
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Submitted: Jul 16, 2010;
Suggested revision: Sep 20, 2010; Resubmitted: Sep 25, 2010; Accepted:
Sep29, 2010; Published: Oct 15, 2010 |
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| Abstract: |
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The
study focused on the comparative analysis of energy cost and gait efficiency
between a below knee (BK) amputee and a reference subject (without amputation).
It also attempted to indicate the specific feature responsible for a
controlled gait with optimum energy cost for BK amputees. Selection
criteria of the subjects were similar physical parameters and quality
of life studied with WHOQOL-100
quality of life assessment. A Cosmed® k4 b2 Respiratory
Analyzer system was used for the measurement of Oxygen Uptake (VO2),
Energy Expenditure per minute (EE) and Heart Rate (HR). Gait efficiency
(p < 0.0002) was found higher for BK amputee than normal subject.
The therapeutic activities and mainly walking rhythm contributed to
improve the mobility & balance. This ensures the optimum time &
co-ordination of movements and hence improves the gait efficiency for
the BK amputee. Comparison
with control group was performed to validate the data.
Key Words:
Energy Cost; Gait Efficiency; Below knee amputee |
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The lower
extremity amputees have to spend huge effort & time to achieve their
lost gait efficiency. Achieving the efficient locomotion plays a major
role in the individual development. (1) Ambulation is practically difficult
in trans-tibial amputees. Excessive energy cost may be the cause behind
that. Earlier studies have shown elevated relation of energy expenditure
& decreased gait efficiency in the transtibial amputees in comparison
to the normal subjects with non-pathological gait. (2-9) Gait efficiency
is defined as energy cost per distance traveled in previous research
papers. (15) The lowest value is considered the Optimum efficiency at
the self selected speed. (2, 7) Previous research indicates the higher
energy cost in amputees with leg prosthesis than normal at comparable
walking velocities. (10-12) Ganguly et al discussed transtibial amputees
consume 33% more energy than the normal subjects at 50 m/min walking
speed. (3) In spite of this, most of those amputees achieved their normal
gait within their limitation of disabilities. The physical parameters
& Quality of life are the factors affecting the performance of the
subjects. In this study, the subjects have been selected with similar
physical parameters & similar Quality of life.
The purpose
of this study was to compare the energy cost, gait efficiency of a physically
active person with conventional BK Prosthesis versus a normal person
with similar physical parameters (sex, age, height, and weight) &
quality of life during their normal locomotion. The similar comparison
was also done with reference to a control group for the data validation.
One right
trans-tibial
amputee with conventional prosthesis with patella-tendon-bearing (PTB)
socket & a solid-ankle-cushion-heel (SACH) foot for more than five
years was selected in this study with his consent to the National Institute
for the Orthopaedically Handicapped, Bon-hooghly, Kolkata-90, India.
A normal subject participated as a reference with similarity in age,
sex, height and weight data to the trans-tibial amputee.(Table-1) A
control group was also selected with 30 normal subjects with non pathological
gait.(Table 2) All the participants were physically active & well
balanced to complete the protocol in full. The amputee was accustomed
to wear the prosthesis and did not suffer from residual limb pain, swelling,
or pressure sores. The fitting & alignment of the prosthesis was
carried out by the resident Department of Prosthetics & Orthotics
of the institute. The amputee was trained by therapeutic activities
to improve the mobility with balance & to ensure the optimum time
& co-ordination of movements.
All the normal subjects were also examined
& their fitness was certified. Subjects were asked not to ingest
alcohol or caffeine for 24 hours prior to testing. A record of the subjects’
diet was kept & a similar diet was maintained through out the study.
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Table 1:
Physical Parameters of the amputee and reference subject |
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Criteria |
Bk(R) Amputee |
Reference subject |
| Sex |
Male |
Male |
| Age
(yrs.) |
45 |
46 |
| Height
(cm.) |
162 |
163 |
| Weight
(kgs.) |
61.5 |
62 |
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Table 2: Physical
Parameters of control group
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Criteria |
Average value |
| Age (yrs.) |
43±6 |
| Height (cm.) |
16.2±14.5 |
| Weight (kgs.) |
59.6±7.3 |
The subjects’
Quality Of Life was studied with WHOQOL-100 quality of life assessment.
The assessment would be applicable cross-culturally.(13) In this study
the assessment indicates the similar Quality of life for both subjects.
(Table 3)
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Table 3: Quality
of Life Assessment
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Domain |
Average
Scores |
| Subjects
with BK Prosthesis |
Reference Subject |
| Physical
health |
24.66 |
25 |
| Psychological |
19.18 |
18 |
| Social
relationship |
10 |
11 |
| Environment |
27.7 |
27.5 |
The subjects
were allowed to practice their usual gait prior to the testing until
the normal gait pattern was observed. The subjects were instructed to
walk at self selected speed. Through out this period, breath by breath
analysis of the subjects was carried out. A Cosmed® K4 B2
Respiratory Analyzer system (COSMED Srl – Italy) at National Institute
for the Orthopaedically Handicapped, Bon-hooghly, Kolkata-90, India
was used for the measurement of Oxygen Uptake (VO2), Energy
Expenditure per minute (EE), Heart Rate (HR) for both subjects. (Figure
1)
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Figure 1: Cosmed® K4 B2 Respiratory Analyzer system |
The print out giving the subjects average VO2 (ml/Min) over
consecutive 60 seconds interval was processed by calculating the mean
and standard deviation. A plane surface of 30 m was fixed for subjects’
walking. The subjects were given sufficient time to become accustomed
to the analyzer system before the experiments. Total test time was approximately
25 minutes consisting of a 3-minute warm-up period to ensure that the
muscles did not utilize anaerobic sources of energy, 1 minute to prime
the airways, and 1 minute of exhaled gas collection. The order of test
configurations was maintained, and the consecutive information of the
test was recorded at each condition. Fatigue was minimized by allowing
subjects to rest during the intervals. Difference in VO2 was
determined for walking period of the subjects as follows:
| Difference
in VO2 = |
VO2 BK
amputee-VO2 normal |
x 100 |
(Equation-1) |
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VO2 normal |
Thus a negative
percentage would indicate energy saving and positive percentage would
indicate higher energy cost for the subject with BK amputee.(14)
A more easily
determined alternative criterion measure of gait efficiency is the term
we refer to as "distance efficiency". Gait (distance) efficiency
was calculated simply from the ratio of the oxygen uptake to the walking
velocity and may be expressed in milliliters of oxygen consumed per
kilogram of body weight per meter traveled.(15)
| Gait
Efficiency= |
mlO2
/kg.min |
=mlO2
/kg.min |
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m/min |
Statistics
Two-way analysis
of variance (ANOVA) was used separately to test the level of significance
of VO2, HR, EE, velocity and gait efficiency & a level
of p < 0.05 was adopted for the determination of statistical
significance.
A summary of result is given in Table
4. Average Heart rate for BK amputee & reference subject was
87.92 ± 14.06 beats/min (p < 0.002) & 103.71 ± 7.80
beats/min(p < 0.0003) respectively. The measurement of Heart Rate
showed 12% more stability in the BK amputee. The velocity of the BK
amputee & reference subject was 17.08 ± 1.48 m/min & 30.25
± 3.59 m/min. Gait efficiency (p < 0.0002) is higher for the BK
amputee (0.98± 0.10) than the reference subject (0.30± 0.26). The
difference in VO2 uptake for the amputee was -31.97%.
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Table 4: Summary of result |
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Parameter |
BK
Amputee |
Reference
Subject |
| VO2
(ml/mint) |
405.53± 264.99 |
596.096± 366.91 |
| HR
(beats/mint) |
87.92± 14.06 |
103.71± 7.80 |
| EE
(kcal/mint) |
1.87± 1.24 |
2.66± 1.72 |
| Velocity
(m/min) |
17.08± 1.48 |
30.25± 3.59 |
| Gait
Efficiency (mlO2 /
kg . m) |
0.98± 0.10 |
0.30± 0.26 |
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Graph 1: Comparison of Oxygen Uptake |
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Graph 2: Comparison of Energy Expenditure |
In comparison
to the control group, the VO2 uptake for BK were studied
-16.26% whereas gait efficiency for the control group was found 0.29
± 0.17 mlO2 / kg . m.
The focus of
the current study was to compare the Energy Cost & Gait Efficiency
of BK- amputee with reference subject having the similar physical parameters
& quality of life. Similar physical parameters allowed the subjects
to be considered for comparison analysis. Both the subjects were found
to lead similar Quality of Life. This indicates the nullification of
any effect of the subjects’ life style on their comparative performances.
Thus the only difference between the subjects is due to the trans-tibial
prosthesis of the BK amputee. The subjects were certified to be physically
fit. The fitment & alignment of the prosthesis was checked &
found perfect. The result obtained from Cosmed® K4b2 showed
consistency in heart rate monitoring for both the subjects. The subjects
performed their normal gait during the test in their self selected velocity.
The gait study advocated the normal gait pattern in both subjects through
out the test. The energy expenditure for BK amputee & normal subject
was 1.87 ±
1.24 Kcal/min & 2.66 ± 1.72 Kcal/min. The Energy expenditure of
BK amputee was found 29.5% less with respect to the normal subject (p
< 0.0008) & the difference in VO2 uptake was -31.97%
(p < 0.0004)(Equation-1).
The negative percentage indicates energy saving for the BK amputee,
which was not consistent with the previous paper.(10-12) The Gait efficiency
was found (p < 0.0002) higher for the BK amputee (0.98 ± 0.10) than
the normal subject (0.30 ± 0.26). In comparison to the control group
the BK amputee showed negative percentage of VO2 uptake &
higher gait efficiency. This advocated the similar trend of data &
validated the comparison between the amputee & the reference subject.
This indicates that the BK amputee achieves a normal gait pattern under
the limitation of disabilities. The result showed inconsistency with
the previous published papers that the BK amputee was more efficient
in Gait performance & less consumer of the energy in their usual
& normal gait pattern. As most of the physical parameters were normalized
by carefully selecting the test subjects after screening 50 numbers
of patients and normal subjects, the walking rhythm played an important
role to control the stability and increase the gait efficiency. This
rhythm also contributed the uniformity of step time, step duration,
cadence and stride length and helped the subject to achieve higher gait
efficiency. The amputee achieved the gait rhythm & balance appropriate
for his body mechanics by therapeutic practice. Improvement in time
& co-ordination of movements ensured the efficient gait performance
with reduced energy cost.(16) For this particular reason the BK amputee
patient in this study was able to diminish his energy consumption compare
to the normal subject for the identical performances. The study will
continue and additional research is recommended with more subjects to
corroborate the findings of the current study.
Appropriate
time & co-ordination of movement resulted in confident gait rhythm
& balance with less energy cost for the amputee in this study. Higher
Gait efficiency & less Energy Expenditure were found for the BK
amputee than the reference subjects with the similar physical parameters
& quality of life for identical performances. This advocated that
therapeutic practice & proper training for time & co-ordination
of movements can help the amputee with below knee prosthesis to perform
their ideal gait with less energy consumption.
This project
would not have been possible without the participation of the subjects.
Their cooperation, patience, and genuine interest in the progress of
research will be remembered. The research was supported by the Prosthetic
& Orthotic Department of National Institute for the Orthopaedically
Handicapped, Bon-hooghly, Kolkata-90.
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