Han Houdijk

Physical capacity and walking ability after lower limb amputation: a systematic review

Objective: To review the influence of physical capacity on regaining walking ability and the development of walking ability after lower limb amputation. Design: A systematic search of literature was performed. The quality of all relevant studies was evaluated according to a checklist for statistical review of general papers. Subjects: Lower limb amputees. Main measures: Physical capacity (expressed by aerobic capacity, anaerobic capacity, muscle force, flexibility and balance) and walking ability (expressed by the walking velocity and symmetry). Results: A total of 48 studies that complied with the inclusion criteria were selected. From these studies there is strong evidence for deterioration of two aspects of physical capacity (muscle strength and balance) and of two aspects of walking ability (walking velocity and symmetry) after lower limb amputation. Strong evidence was found for a relation between balance and walking ability. Conclusion: Strong evidence was only found for a relation between balance and walking ability. Evidence about a relation between other elements of physical capacity and walking ability was insufficient. Training of physical capacity as well as walking ability during rehabilitation following lower limb amputation should not be discouraged since several parameters have been shown to be reduced after amputation, although their relation to regaining walking ability and to the development of walking ability remains unclear.

Gait analysis after successful mobile bearing total ankle replacement.

Background: The effect of total ankle replacement on gait is not fully known in terms of joint kinematics, ground reaction force, and activity of the muscles of the lower leg. Methods: A comparative gait study was done in 10 patients after uneventful unilateral mobile-bearing total ankle replacement and 10 healthy controls. A rigid body model was used to describe the motion of the knee and the three-dimensional motion of the ankle-hindfoot complex during barefoot walking. An opto-electronic motion analysis system was used to analyze bilateral movement patterns, synchronized with recordings of the ipsilateral vertical ground reaction forces and the electromyographic activity of four lower leg muscles. Results: Velocity was 6% lower in the patient group. Dorsiflexion in the operated ankles was reduced (p < 0.001). No differences were found in the joint angular pattern of the knee joint and only minimal changes were found at the hindfoot-to-tibia and forefoot-to-hindfoot levels. The ground reaction force at midstance was somewhat increased (p = 0.005), while the magnitude of the vertical peak at terminal stance was decreased (p < 0.001). EMG activity patterns in the patient group were normal except for a higher activity of the gastrocnemius in early stance and the anterior tibial muscle in late stance. Conclusions: There is a near normal gait pattern in terms of joint kinematics of the knee, ankle, and foot after uneventful mobile-bearing total ankle replacement. The ground reaction forces and the EMG activity, however, do not fully normalize.

Speeding up or slowing down?: Gait adaptations to preserve gait stability in response to balance perturbations

It has frequently been proposed that lowering walking speed is a strategy to enhance gait stability and to decrease the probability of falling. However, previous studies have not been able to establish a clear relation between walking speed and gait stability. We investigated whether people do indeed lower walking speed when gait stability is challenged, and whether this reduces the probability of falling. Nine healthy subjects walked on the Computer Assisted Rehabilitation ENvironment (CAREN) system, while quasi-random medio-lateral translations of the walking surface were imposed at four different intensities. A self-paced treadmill setting allowed subjects to regulate their walking speed throughout the trials. Walking speed, step length, step frequency, step width, local dynamic stability (LDS), and margins of stability (MoS) were measured. Subjects did not change walking speed in response to the balance perturbations (p=0.118), but made shorter, faster, and wider steps (p<0.01) with increasing perturbation intensity. Subjects became locally less stable in response to the perturbations (p<0.01), but increased their MoS in medio-lateral (p<0.01) and backward (p<0.01) direction. In conclusion, not a lower walking speed, but a combination of decreased step length and increased step frequency and step width seems to be the strategy of choice to cope with medio-lateral balance perturbations, which increases MoS and thus decreases the risk of falling.

The energy cost for the step-to-step transition in amputee walking

The purpose of this study was to investigate whether the increased energy cost of amputee gait could be accounted for by an increase in the mechanical work dissipated during the step-to-step transition in walking. Eleven transtibial amputees (AMP) and 11 age-matched controls (CO) walked at both comfortable (CWS) and fixed (FWS, 1.3m/s) walking speed, while external mechanical work of each separate leg and metabolic energy consumption were measured. At FWS the metabolic energy consumption (E(met)) was significantly higher in AMP compared to CO (3.34 Jkg(-1)s(-1) vs. 2.73 Jkg(-1)s(-1)). At CWS, no difference in energy consumption was found (3.56 Jkg(-1)s(-1) vs. 3.58 Jkg(-1)s(-1)) but CWS was significantly lower in AMP compared to CO (1.35 ms(-1) vs. 1.52 ms(-1)). In conjunction with the higher E(met) at FWS, the negative work generated by the intact leading leg for the step-to-step transition in double support was significantly higher for AMP than CO at FWS. A moderate though significant correlation was found between negative mechanical power generated during the step-to-step transition and metabolic power (CWS: r=-0.56, p=0.007; FWS: r=-0.50, p=0.019). Despite the difference in negative work during the step-to-step transition, the total absolute mechanical work over a stride did not differ between groups. This could possibly be attributed to exchange of internal positive and negative work during single support, which remains unnoticed in the external work calculations. It was concluded that the increased mechanical work for the step-to-step transition from prosthetic to intact limb contributes to the increased metabolic energy cost of amputee walking.

Variability and stability analysis of walking of transfemoral amputees

Variability and stability of walking of eight transfemoral amputees and eight healthy controls was studied under four conditions: walking inside on a smooth terrain, walking while performing a dual-task and walking outside on (ir)regular surfaces. Trunk accelerations were recorded with a tri-axial accelerometer. Walking speed, mean and coefficient of variation of stride times (ST) and the root mean squares (RMS) of trunk accelerations was calculated. Gait variability and stability were quantified using measures derived from the theory of stochastic dynamics. Regularity was indexed using the sample entropy (SEn) and the scaling exponent α derived form Detrended Fluctuations Analysis. Local stability (LSE) quantified gait stability. Walking speed was lower, but ST variability was not different for amputees than controls. RMS of medio-lateral accelerations was higher for amputees; SEn was higher, implying less predictable accelerations, and LSE higher, indicating decreased stability. The largest condition effect was present for walking outside: trunk RMS increased and LSE decreased. Differences in walking between amputees and healthy controls and their responses to perturbations revealed themselves in the magnitude, variability and stability measures of trunk accelerations. These results imply that quantifying the dynamical structure of trunk accelerations can differentiate between groups with different walking abilities and between conditions of increasing difficulty and may therefore provide a useful diagnostic tool.

Steps to take to enhance gait stability: the effect of stride frequency, stride length, and walking speed on local dynamic stability and margins of stability

The purpose of the current study was to investigate whether adaptations of stride length, stride frequency, and walking speed, independently influence local dynamic stability and the size of the medio-lateral and backward margins of stability during walking. Nine healthy subjects walked 25 trials on a treadmill at different combinations of stride frequency, stride length, and consequently at different walking speeds. Visual feedback about the required and the actual combination of stride frequency and stride length was given during the trials. Generalized Estimating Equations were used to investigate the independent contribution of stride length, stride frequency, and walking speed on the measures of gait stability. Increasing stride frequency was found to enhance medio-lateral margins of stability. Backward margins of stability became larger as stride length decreased or walking speed increased. For local dynamic stability no significant effects of stride frequency, stride length or walking speed were found. We conclude that adaptations in stride frequency, stride length and/or walking speed can result in an increase of the medio-lateral and backward margins of stability, while these adaptations do not seem to affect local dynamic stability. Gait training focusing on the observed stepping strategies to enhance margins of stability might be a useful contribution to programs aimed at fall prevention.

Effects of Hand Cycle Training on Physical Capacity in Individuals With Tetraplegia: A Clinical Trial

Background: Regular physical activity is important for people with tetraplegia to maintain fitness but may not always be easily integrated into daily life. In many countries, hand cycling has become a serious option for daily mobility in people with tetraplegia. However, little information exists regarding the suitability of this exercise mode for this population. Objective: The purpose of this study was to evaluate the effects of a structured hand cycle training program in individuals with chronic tetraplegia. Design: Pretraining and posttraining outcome measurements of physical capacity were compared. Setting: Structured hand cycle interval training was conducted at home or in a rehabilitation center in the Netherlands. Participants: Twenty-two patients with tetraplegia (American Spinal Injury Association Impairment Scale classification A-D) at least 2 years since injury participated. Intervention: The intervention was an 8- to 12-week hand cycle interval training program. Measures: Primary outcomes of physical capacity were: peak power output (POpeak) and peak oxygen uptake (V̇o2peak), as determined in hand cycle peak exercise tests on a motor-driven treadmill. Secondary outcome measures were: peak muscle strength (force-generating capacity) of the upper extremities (as assessed by handheld dynamometry), respiratory function (forced vital capacity and peak expiratory flow) and participant-reported shoulder pain. Results: Significant improvements following a mean of 19 (SD=3) sessions of hand cycle training were found in POpeak (from 42.5 W [SD=21.9] to 50.8 W [SD=25.4]), V̇o2peak (from 1.32 L·min−1 [SD=0.40] to 1.43 L·min−1 [SD=0.43]), and mechanical efficiency, as reflected by a decrease in submaximal oxygen uptake. Except for shoulder abduction strength, no significant effects were found on the secondary outcomes. Limitations: Common health complications, such as urinary tract infections, bowel problems, and pressure sores, led to dropout and nonadherence. Conclusion: Patients with tetraplegia were able to improve their physical capacity through regular hand cycle interval training, without participant-reported shoulder-arm pain or discomfort.

External attentional focus enhances movement automatization: A comprehensive test of the constrained action hypothesis

An external focus of attention has been shown to result in superior motor performance compared to an internal focus of attention. This study investigated whether this is due to enhanced levels of movement automatization, as predicted by the constrained action hypothesis (McNevin, Shea, & Wulf, 2003). Thirty healthy participants performed a cyclic one-leg extension-flexion task with both the dominant and non-dominant leg. Focus of attention was manipulated via instructions. The degree of automatization of movement was assessed by measuring dual task costs as well as movement execution parameters (i.e., EMG activity, movement fluency, and movement regularity). Results revealed that an external focus of attention led to significantly better motor performance (i.e., shorter movement duration) than an internal focus. Although dual task costs of the motor task did not differ as a function of attentional focus, cognitive dual task costs were significantly higher when attention was directed internally. An external focus of attention resulted in more fluent and more regular movement execution than an internal focus, whereas no differences were found concerning muscular activity. These results indicate that an external focus of attention results in more automatized movements than an internal focus and, therefore, provide support for the constrained action hypothesis.

Stepping strategies for regulating gait adaptability and stability

Besides a stable gait pattern, gait in daily life requires the capability to adapt this pattern in response to environmental conditions. The purpose of this study was to elucidate the anticipatory strategies used by able-bodied people to attain an adaptive gait pattern, and how these strategies interact with strategies used to maintain gait stability. Ten healthy subjects walked in a Computer Assisted Rehabilitation ENvironment (CAREN). To provoke an adaptive gait pattern, subjects had to hit virtual targets, with markers guided by their knees, while walking on a self-paced treadmill. The effects of walking with and without this task on walking speed, step length, step frequency, step width and the margins of stability (MoS) were assessed. Furthermore, these trials were performed with and without additional continuous ML platform translations. When an adaptive gait pattern was required, subjects decreased step length (p<0.01), tended to increase step width (p=0.074), and decreased walking speed while maintaining similar step frequency compared to unconstrained walking. These adaptations resulted in the preservation of equal MoS between trials, despite the disturbing influence of the gait adaptability task. When the gait adaptability task was combined with the balance perturbation subjects further decreased step length, as evidenced by a significant interaction between both manipulations (p=0.012). In conclusion, able-bodied people reduce step length and increase step width during walking conditions requiring a high level of both stability and adaptability. Although an increase in step frequency has previously been found to enhance stability, a faster movement, which would coincide with a higher step frequency, hampers accuracy and may consequently limit gait adaptability.

From biomechanical theory to application in top sports: the Klapskate story

The development of the new skate design specifically the klapskate in a historical and scientific perspective is described. Reasons why it took so long for top athletes to use the new skate design is explained. The klapskate demonstrated its advantage over conventional skates and proved its benefits.