Below-knee cast design and the energy cost of ambulation

The influence of various aspects of the design of below-knee walking casts on the energy required for ambulation has been examined using a technique based on heart rate measurements. It was found that the effects of the weight of the cast and the shape of the sole applied were small compared with the effects of changing ankle angle or of increasing the overall thickness of the cast sole.     

Crutch length: effect on energy cost and activity intensity in non-weight-bearing ambulation

OBJECTIVE: To investigate the effect of forearm crutch length on energy cost in three-point, non-weight-bearing (NWB) ambulation. DESIGN: Double-blind repeated measures design using crutch length as the independent variable. SETTING: Overland walking circuit at a university campus. PARTICIPANTS: Volunteer, convenience sample of 20 subjects consisting of university students and staff without cardiovascular, respiratory, or orthopedic conditions. INTERVENTION: Subjects used a three-point, NWB gait with forearm crutches set to length using conventional guidelines, and at 2.5 cm above and below this value. MAIN OUTCOME MEASURES: Oxygen consumption, carbon dioxide production, heart rate, speed of ambulation, and perceived exertion under steady-state conditions. RESULTS: In terms of oxygen cost, ambulation with crutches set to the length recommended in conventional guidelines was not significantly more energy efficient than ambulation with either the longer or shorter crutches. Using crutches set 2.5 cm longer than conventional guidelines produced the lowest respiratory exchange ratio (Vco2/Vo2) and the lowest ratings of perceived exertion. However, none of these differences reached statistical significance. CONCLUSION: Since exact crutch length was not critical in terms of oxygen cost, walking speed, or perceived exertion during NWB ambulation, the importance of rigidly adhering to specific guidelines for setting crutch length was not substantiated in this study. Clinically, consideration of patient preference regarding crutch length (within 2.5 cm) can be advocated.     

Energy cost of ambulation in health and disability: a literature review.

The literature concerning ambulation of normal and disabled persons--amputees, hemiplegics, and paraplegics--is reviewed. Also reviewed are studies of the energy cost of ambulating with assistive devices and of wheelchair locomotion. According to an average of the results available from the literature, a normal expenditure (Ee) of 0.063 kcal/min/kg and 0.00764 kcal/meter/kg. The disabled person walks more slowly, to avoid incurring an increase in Ec/minute. The more disabled the person, the more determinants of gait lost; thus, the more slowly he walks and the less efficient he becomes in terms of Ee/kcal/unit distance. The importance of a common terminology when measuring the energy cost of ambulation and the need to allow subjects to walk at their own most comfortable walking speed are stressed.     

Energy cost of ambulation in paraplegic patients using Craig-Scott braces

Energy metabolism data were collected in a series of 8 male paraplegic patients with neurologically complete spinal cord lesions between T4 and T12 (1 patient had complete motor paralysis with incomplete sensory function). Energy costs were measured at the subject's seated basal rate (mean = 17.12cal/min/kg) and during 2 separate trials at ambulation using Craig-Scott braces. The rates of ambulation reflected the patient's perceived comfortable rate and ranged from 2.2 to 44.8m/min. (mean = 14m/min). The subjects ambulated in a straight line, with the data collection instrumentation (the Mobile Automatic Metabolic Analyzer) moving alongside. Mean O2 consumption was 0.1867ml/sec/kg and mean energy cost was 52.96 cal/min/kg, which when compared to a mean of 17.12 cal/min/kg at their resting state, represents a 3-fold increase in their energy cost. Three cases were further measured for O2 debt, which ranged from 1483 to 3112 ml and was repaid completely within 10 minutes post-walk.     

Amputation: two views.

It has been over one year now since his surgery, and Allen has returned to school and work, ambulating on his prosthesis most of the time. As his phantom limb pain decreased and his proficiency in walking increased, his acceptance of his amputation has been demonstrated in his comments and references to himself and his relations with others. As he states, the more comfortable he is about his amputation, the easier it is for others to accept and relate to him. This, I think, is the key to approaching that final stage of acceptance mentioned earlier. The more we can help our patients accept their amputation initially by supporting them through this crisis period, the easier it will be for them to relate to others and grow emotionally from these relationships.     

Amputation of the lower extremity: an overview.

Amputation of the lower extremity may be traumatic or a necessary procedure to prevent further morbidity and possibly death in a patient. Advances have been made in the area of lower extremity amputation surgery and subsequent management. Prosthetic design has resulted in more lightweight, better fitting prostheses that more closely resemble the workings of a normal leg and foot. This results in a decrease in energy expenditure with walking and allows an increased activity level for amputees. This article addresses factors concerning phantom limb sensations and pain, prosthesis use and nursing considerations in rehabilitation.     

Postoperative ambulation in thoracic surgery patients: standard versus modern ambulation methods

Aim: A single‐subject study of two methods of postoperative ambulation of patients recovering from thoracic surgery. Background: During the postoperative setting, patients are often burdened by their condition that reduces their ability to ambulate. This problem is compounded by the addition of devices that make walking more cumbersome. To simplify the process of ambulation during the postoperative period, an intravenous pole/walker (IVPW) was specifically designed to allow all patient devices and attachments to accompany the patient during ambulation, without the need for supplemental caregiver assistance. Methods: The IVPW method of ambulation was compared with standard method of ambulation (SMA) in a single‐subject clinical trial. Thirty‐nine consecutive thoracic surgery patients with at least an IV and chest tube were ambulated using alternatively either the IVPW or the SMA. Immediately following the ambulation periods, the patient and patient's health care worker assessed both methods using satisfaction surveys consisting of several questions about the episodes of ambulation and the number of health care workers needed to assist during ambulation. Results: Patient satisfaction was significantly higher in the ability of the IVPW to provide support and assist in ambulation in comparison with the SMA (p < 0·001). Nurses felt the IVPW both facilitated and provided a safer method for ambulation compared with the SMA (p < 0·001). On average, one less employee was required during ambulation with the IVPW (p < 0·001). Conclusion: The IVPW provided better support and was perceived as a safer method for ambulation compared with the SMA. The IVPW also required one less person to assist with ambulation. Relevance to clinical practice: Facilitation of ambulation in the postoperative setting can impact nursing care and patient satisfaction.     

Locomotor-respiratory coupling during axillary crutch ambulation.

OBJECTIVE: To test the hypotheses that locomotor-respiratory coupling occurs in humans using axillary crutches in a swing-through ambulation pattern and that expiration occurs during crutch-stance phase during locomotor-respiratory coupling. DESIGN: Eighteen able-bodied persons were trained in one-footed swing-through gait with axillary crutches. Then, as subjects walked at "somewhat hard" speeds (Borg) on a motorized treadmill for 5 min, we recorded signals from a crutch pressure switch and a mouthpiece-mounted thermocouple. Coupling was defined as being present when the onset of inspiration varied by < or = 5% with respect to the onset of the crutch gait cycle for a minimum of 10 consecutive gait cycles and when there was no drift on a raster plot of the respiratory phases relative to the onset of the gait cycle. RESULTS: Ten (56%) of the 18 subjects exhibited locomotor-respiratory coupling on 1-4 occasions each, with episodes lasting 11.3-148 sec. In 17 (89%) of the 19 episodes of 1:1 locomotor-respiratory coupling, expiration occurred during the crutch-stance phase of the gait cycle and inspiration occurred during crutch swing. CONCLUSIONS: Transient 1:1 locomotor-respiratory coupling occurs in many able-bodied subjects ambulating with axillary crutches and a swing-through gait. Expiration is most often associated with the crutch-stance phase of the gait cycle. This study may have implications for training axillary crutch users.     

Immediate ambulation of patients with lower-extremity grafts.

Immediate ambulation of patients who have had lower-extremity skin grafting has been practiced in our burn center since 1987. A retrospective review of patients who had lower-extremity skin grafting only and a survey of burn centers in which 109 centers responded were conducted. Average skin graft take in our burn center was 96.4%. Patients in our burn center walked 30 feet independently by postoperative day 1.7, whereas the survey response average was 7.2 days (p less than 0.001). Average length of stay was 12.6 days (p less than 0.012). This review demonstrated that although immediate ambulation after lower-extremity grafting is not a widely adopted procedure, it does not impair graft take and may decrease the average length of stay.     

Influence of floor surface on the energy cost of wheelchair propulsion.

Carpeting of the type commonly used in hospitals imposed a burden upon normal and patient wheelchair users propelling a wheelchair as reflected in increased energy cost per unit of distance traveled. Wheelchair propulsion also tended to produce high heart rates compared to values reported for normal walking. Pneumatic tires offered no advantage over hard rubber tires on the type of carpet used in this study. Wheelchair propulsion required more energy expenditure per minute than values reported for normal ambulation at the same velocity.     

Amputation and phantom limb pain: a pain-prevention model.

Within the figure of more than 200,000 surgical amputations performed in the United States each year lies another--70% of patients experience phantom limb pain after the procedure, and 50% still experience phantom pain 5 years after surgery. Patients describe burning, stabbing, twisting, cramping, or throbbing pains in the missing part. Adding to the patient's and the anesthesia professional's conundrum has been the lack of a simple model that tissue injury produces pain. The patient with a surgical amputation who experiences phantom limb pain can have several sources for discomfort including problems from the original tissue injury or from pathology, e.g., scarring or continued cellular dysfunction resulting from diabetes, ischemia, or infection. Suboptimal prosthesis fit and tissues and joints connected to the affected part can continue to generate pain long after surgical wound healing. In addition, nonaffected tissues and joints now made to carry extra loads as a result of altered gait and balance can sustain collateral stress and damage and produce nociception. In addition to this series of problems, amputee patients remain susceptible to the pain problems experienced by the general population. There is a positive correlation between a painful limb before amputation and experiencing chronic phantom limb pain. Authors have described patients with preamputation pain who benefited from effective preemptive analgesia and experienced less phantom limb pain. CRNAs can have a significant role in providing anesthesia and analgesia services to these patients and can begin to think in terms of preventing lifelong pain.     

The impact of calculated ambulation on health promotion.

A study to assess the impact of calculated ambulation on health promotion was conducted over a five-month period at a southern university. The study, which initially included approximately forty-three healthcare management students, was based on a similar study conducted at a larger university in South Carolina. The study at the larger university showed a connection between the number of steps one took and one's health/fitness status. With a 10,000 steps a day intervention /walking plan, pre- and post-tests on weight, blood pressure and cholesterol levels were conducted with the assistance of the local County Health Department. Individualized longitudinal case profiles were then presented, with an overview of program benefits; the role of support persons and the examination of the individual responsibility for health concept.     

Paraplegic ambulation: a systems point of view

Neurophysiological systems preserved distal to a complete spinal lesion, and relevant to walking, are reviewed in the manner of an engineering control systems analysis. On that basis, an outline is given of theoretical concepts, current developments and future possibilities for neuromuscular electrical stimulation to provide paraplegic ambulation.