the effect of prolonged effort on bilateral asymmetry in ... · traumatic trans tibial amputation...

The Effect of Prolonged Effort on Bilateral Asymmetry in Running in

Traumatic Trans Tibial Amputees using Running Specific Prosthesis

Dikla Goor Prihed, PT

Sheba Medical Center; Zinman College, Wingate

Prof. Yeshayahu Hutzler, Dr. Ayelet Dunsky

Zinman College, Wingate

Dr. Izhak Ziev-Ner

Sheba Medical Center

• Trans Tibial Amputation

• Trans Tibial Prosthesis

• Running Specific Prosthesis

• TTA Asymmetry - Biomechanics

• AB Fatigue - Biomechanics

• Study

Traumatic Trans Tibial Amputation (TTA)

• Combat, MVA, Work

• Soft Tissue, Blood Supply

• Full and Active Lifestyle

• Sport Activities

• Running

Trans Tibial Prosthesis

Socket

Suspension

Pylon

Ankle-Foot

The Evolution of Running Specific Prosthesis (RSP)

1984 – Flex Foot1992 – Flex Sprint

Basic Principles of RSP

• Energy Storing and Return

• “Running on Toes”

• Stiffness Category

• “C” Shape / “J” Shape

“C” Shaped Blades

• Distance Running / Jogging

• Stiffness

• Store and Release Energy over time

• Shock Absorbing

“J” Shaped Blades

• Sprints

Short Distance Running

• Stiffness

• Quick Response, Energy Return

• Higher Speeds

Active Foot with Heel

• Active Lifestyle

• High Energy Return, Dynamic Push-off

• Increased Balance and Stability

• Variety Sports and Activities

• Worn with Standard Athletic Shoes

The Effect of Prolonged Effort on Bilateral Asymmetry in Running in

Traumatic Trans Tibial Amputees using Running Specific Prosthesis

Asymmetry - TTA

Fatigue - AB

Prolonged Effort

Thesis

Lower Limb Symmetry

• AB - Desirable, Assumed in literature

• TTA - Inherent Structural and Functional Asymmetry

• TTA Running - Biomechanical Asymmetry

- Level of Disability

- Prosthesis Employed

TTA Running Asymmetry -Kinematics

• Step Length (RSP) - P>I

• Step Frequency (RSP) – I>P

• Contact Time (RSP) - P>I 2.7 m/s, I>P 3.5 m/s

• Hip & Knee joint angles - P more vertical

• Ankle joint angles (non RSP) – I>P

I = Intact LimbP = Prosthetic LimbRSP = Running Specific Prosthesis

AB long distance running fatigue -Kinematics

• Step Length - =

• Step Frequency - =

• Contact Time - =

• Hip & Knee joint angles - IC Flex, TO Ext,

Swing Flex

TTA Asymmetry and AB Fatigue -Kinetics

• Decreased on Prosthetic limb compared to

Intact limb

• Reduced following Fatigue

• Peak active V+AP GRF• Peak impact vGRF + impact Loading Rate• Torque Hip + Knee• V + Braking GR Impulse• Propulsion GR Impulse• Work

➢ Loading variables in the intact limb were greater than the prosthetic limb and the limbs of able-bodied subjects for a range of running speeds

➢ The intact limb may be exposed to a greater risk of running related injury than the prosthetic limb or able-bodied limbs

Amputee locomotion: Lower extremity loading using RSP

(Hobara et al., 2014)

Purpose

• Assess asymmetry in kinetics and kinematic variables in TTA running.

• Asses changes in bilateral asymmetry following prolonged effort.

Objectives

➢ Overuse Injuries

➢ Degenerative Changes

➢ Efficient Training Program

Participants characteristics

Running Exp (years)

Time from amp (years)

Mass(kg)

Height(cm)

Age(years)

No.

5.424.473.2177.648.49

Method

• Warm-Up - 6 Min.

• Run - 20-30 Min. in 90% Best 5k speed

• End - 17 in Borg Scale (RPE)

- Pain

12 camera real- time motion capture system

Dual belt treadmill with

force plates

Control panel

3 Video cameras

Gait Analysis Lab

(GRAIL, Motekforce, Amsterdam)

Center of Advanced Technology, Sheba Medical Center

Variables

• Peak Active vGRF (N/BW)

• V Impulse (NS/BW)

• Step Length (M)

• Contact / Flight Time (S)

• Hip & Knee Max Angles()

Beginning of Test and every 5 minutes

Results

0

5

10

15

20

25

0 20

vG

RF

(N

/B

W)

Time (Min.)

Mean Peak Active vGRF

Intact

Pros.

Intact

Pros.

Max. Peak Active vertical GRF

0

5

10

15

20

25

30

1 2 3 4 5 6 7 8 9

vG

RF

(N

/B

W)

Subjects

INTStart

INTEnd

PROSStart

PROSEnd

Max. Impulse

0

0.5

1

1.5

2

2.5

3

3.5

4

4.5

5

1 2 3 4 5 6 7 8 9

Imp

uls

e N

s/B

W

Subjects

INTStart

INTEnd

PROSStart

PROSEnd

Conclusions

• Bilateral asymmetry exist

• No Significant Difference in asymmetry following prolonged effort of 20-25 minutes run

Limitations

• Treadmill vs. Overground (Contact Time, Swing max

Knee Angle, Ankle DF, Altered running pattern)

• Treadmill users, dual belt

• Small sample

• Variability in foot type, gender, experience, athletic level, age

• RPE – Borg scale

• Protocol

Participating in sports for a man who's missing a limb nullify his

limitation completely, especially when doing it within a team and as

a consequence there is no difference between him and others

, העיסוק בספורט לאדם החסר איבר מבטלת לחלוטין את חסרונווכפועל יוצא אין הבדל בינו , במיוחד כאשר עושה הוא יחד עם קבוצה

ואחרים

To all my friends in FIDF Strides program,

THANK YOU !You are truly an inspiration !

References• Bragaru, M., Dekker, R., Geertzen, J.H.B., Dijkstra, P.U.: “Amputees and

Sports - A Systematic Review.” Sports Medicine (2011); 41:721-740

• Chin T, Sawamura S, Fujita H, Nakajima S, Oyabu H, Nagakura Y, Ojima I, Otsuka H, Nakagawa A: “Physical fitness of lower limb amputees.” American Journal of Physical Medicine and Rehabilitation (2002);81:321–325.

• Dyer, B.T.J.: “An Insight into the Acceptable Use & Assessment of Lower-limb Running Prostheses in Disability Sport.” Thesis submitted to Bournemouth University (2013)

• Gailey, R. “The biomechanics of amputee running.” (2002) Available from:

www.oandp.co./edge/issues/articles/2002-10_02.asp [Accessed 29/2/8].

• Hreljac, A.: “Etiology, Prevention, and Early Intervention of Overuse Injuries in Runners: a Biomechanical Perspective.” Physical Medicine and Rehabilitation Clinics of North America (2005): 651–667

• Hobara, H., Baum, B.S., Kwon, H.J., Linberg, A., Wolf, E.J., Miller, R.H., Shim, J.K. "Amputee locomotion: Lower extremity loading using running-specificprostheses." Gait & Posture (2014): 386-390.

Thank you

EH-SE Comparison

EH SE

Marathon Hobby

Age 43 59

BMI 20 27.5

Years from amp 10 36

Years running 9 3

Foot type Cheetah Flex-Run

Volume (km/w) 65 16.5

5k run (min) 18 32

Running speed (m/s) 4.05 2.34

Max. Peak Active vertical GRF

0.00

1.00

2.00

3.00

4.00

5.00

6.00

7.00

8.00

9.00

10.00

11.00

12.00

13.00

14.00

15.00

16.00

17.00

18.00

19.00

20.00

21.00

22.00

23.00

24.00

EH Start EH End SE Start SE End

INT

PROS

Max. Impulse

0.00

0.20

0.40

0.60

0.80

1.00

1.20

1.40

1.60

1.80

2.00

2.20

2.40

2.60

2.80

3.00

3.20

3.40

3.60

3.80

4.00

EH Start EH End SE Start SE End

INT

PROS

Step Length

0.00

0.20

0.40

0.60

0.80

1.00

1.20

EH Start EH End SE Start SE End

INT

PROS

76.2% 72.4%

55.6% 53.8%

Hip Joint Angles

-20

-10

0

10

20

30

40

50

60

0 50 100 150 200 250

EH

Int Start Pros Start Int End Pros End

-20

-10

0

10

20

30

40

50

60

0 50 100 150 200 250

SE

Hip Extension

-20.00

-15.00

-10.00

-5.00

0.00

5.00

EH Pros EH Int SE Pros SE Int

Start

End

Contact Time

0.00

0.04

0.08

0.12

0.16

0.20

0.24

0.28

0.32

0.36

0.40

EH Start EH End SE Start SE End

INT

PROS

Flight Time

0.00

0.05

0.10

0.15

0.20

0.25

0.30

0.35

0.40

0.45

EH Start EH End SE Start SE End

INT

PROS

Hip ROM

0

10

20

30

40

50

60

70

80

Min 0 Min 25

EH

INT PROS

0

10

20

30

40

50

60

70

80

Min 0 Min 25

SE

INT PROS

Knee ROM

0

10

20

30

40

Min 0 Min 25

STANCE EH

INT

PROS

0

20

40

60

80

Min 0 Min 25

SWING EH

INT

PROS

0

10

20

30

40

Min 0 Min 25

STANCE SE

INT

PROS

0

20

40

60

80

Min 0 Min 25

SWING SE

INT

PROS

HR

130.0

135.0

140.0

145.0

150.0

155.0

160.0

165.0

170.0

175.0

EH Start EH End SE Start SE End

HR

RPE

0.0

2.0

4.0

6.0

8.0

10.0

12.0

14.0

16.0

18.0

EH Start EH End SE Start SE End

RPE