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