Abstract
ObjectiveThe energy cost of walking with a lower limb prosthesis is higher than able-bodied walking and depends on both cause and level of amputation. This increase might partly be related to problems with balance control. In this study we investigated to what extent energy cost can be reduced by providing support through a handrail or cane and how this depends on level and cause of amputation. DesignQuasi-experimental study. SettingRehabilitation gait laboratory. ParticipantsTwenty-six people with a lower limb amputation were included: 9 with vascular and 17 with nonvascular causes, 16 at transtibial, and 10 at transfemoral or knee disarticulation level (N=26). InterventionsParticipants walked on a treadmill with and without handrail support and overground with and without a cane. Main Outcome MeasuresEnergy cost was assessed using respirometry. ResultsOn the treadmill, handrail support resulted in a 6% reduction in energy cost on average. This effect was attributed to an 11% reduction in those with an amputation attributable to vascular causes, whereas the nonvascular group did not show a significant difference. No interaction with level of amputation was found. Overground, no main effect of cane support was found, although an interaction effect with cause of amputation demonstrated a small nonsignificant decrease in energy cost (3%) in the vascular group and a significant increase (6%) in the nonvascular group when walking with a cane. The effect of support was positively correlated with self-selected walking speed. ConclusionsThis study demonstrates that providing external support can contribute to a reduction in energy cost in people with an amputation due to vascular causes with reduced walking ability while walking in the more challenging condition of the treadmill. Although it is speculated that this effect might be related to problems with balance control, this will need further investigation.
Highlights
Regaining walking ability is a challenging rehabilitation goal for people with a lower limb amputation
Significant differences existed between subgroups stratified by cause of amputation: people with a vascular cause of amputation had significantly shorter time since amputation, significantly higher body mass index and body mass, and significantly slower preferred walking speed overground than those with an amputation due to nonvascular causes
Inspection of the energy cost data showed 1 outlier, with vascular cause of amputation at TF level in the energy cost data on the treadmill (>3 SD from the group mean), which affected the normal distribution of the data (Shapiro-Wilk test: P=.066, P=.027, P=.133, P=.273 for treadmill without and with support and overground without and with support, respectively)
Summary
A convenience sample of 26 people with a unilateral lower limb amputation was included in this study. This sample size was calculated based on the main effect size previously found by Ijmker et al[17] for a comparable study on patients after stroke (Gpower, 3.1; effect size, 0.3; a, 0.05; b, 0.8; correlation among repeated measures, 0.5). Participants were excluded in cases of (1) contraindications for moderate exercise; (2) comorbidity or medication use that could affect walking performance, energy cost, or balance control; (3) improper fitting of the prosthesis and residual limb problems; or (4) problems with understanding and following instructions and study protocol. All participants were fully informed about the aim and content of the study and signed a written informed consent before participation
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