Physical activity and osseointegration: "step forward" to improve the quality of life of a trans-femoral amputee person

Lower limb amputation is an event that inevitably changes the lifestyle of the person with a significant impact on quality of life. The socket-type prosthesis entails that the residual limb is in direct contact with the socket which often implies numerous disadvantages. Osseointegrated prosthesis is a solution that avoids skin problems because not include the presence of the socket. In this type of prosthesis, a stem is surgically inserted inside the medullary canal and connected with the external prosthetic limb. Therefore, this thesis aims to highlight and explore the main strengths and problems of osseointegrated prostheses and to examine the role of physical activity, with attention to functional capacity and bone quality. The objectives of the thesis will be developed through 5 studies: (I) A gait analysis of a 44 years-old male patient who underwent surgery for the implantation of an osseointegrated prosthesis; (II) A systematic review to investigate the state of stump bone quality in patients with limb amputations; (III) A systematic review of the technologies involved in such devices has been carried out to identify the most fruitful ones in improving bone quality; (IV) A systematic review investigating the topic of physical activity and bone turnover biomarkers; (V) A systematic review to investigate the effects of physical activity interventions combined with drug treatments on bone biomarkers in people with osteopenia and osteoporosis. The integrated prosthesis is a good solution for people with lower limb amputation who cannot use their traditional socket-type prosthesis. Although many objectives have already been achieved, there are still many aspects that we can improve. These include the creation of a multidisciplinary path that support patients along their path, with particular attention to the pre-surgery and the post-rehabilitation phase that is still lacking even if of fundamental impact in determining the quality of life.

Valutazione cinematica complessiva, in vivo e sotto carico, di un modello protesico di caviglia a 3 componenti.

Nonostante le importanti ricadute che gli impianti protesici di caviglia hanno nella qualità della vita dei pazienti che si sottopongono ad intervento di sostituzione articolare, le reali proprietà biomeccaniche e cinematiche in-vivo e sotto carico degli impianti protesici sono state scarsamente studiate e descritte in letteratura. Lo scopo di questa trattazione è quella di valutare la cinematica protesica complessiva, in vivo, attraverso l’utilizzo dell’Analisi Radiostereometrica model-based (MB-RSA) e di ulteriori metodiche clinico-strumentali. La valutazione cinematica è stata permessa dall’analisi della posizione degli impianti attraverso la MB-RSA. Tra gli obiettivi secondari, i pazienti sono stati valutati clinicamente mediante AOFAS Ankle-Hindfoot score e SF-36, mediante full-body gait analysis con sensori inerziali e valutazione posturale-stabilometrica mediante Y Balance Test e workstation dedicata Delos DPPS. I pazienti sottoposti ad iter completo con valutazione clinica e strumentale a fine follow-up sono risultati 18 (2 drop-out). Il ROM complessivo a catena cinetica chiusa ha evidenziato una dorsi-plantarflessione complessiva media di 19.84°. Gli score clinici hanno mostrato tutti un netto miglioramento nel post-operatorio. La gait analysis ha evidenziato uno schema del passo composto dai tre principali spike e compatibile con schemi fisiologici. Dal punto di vista cinematico, i risultati angolari MB-RSA ricavati durante questo lavoro di tesi evidenziano tutti e 6 i gradi di libertà, dato coerente con la mobilità di una caviglia nativa. Valori di articolarità differenti sono stati registrati mediante sensori inerziali. Infine, in una valutazione cinematica complessiva, le possibili implicazioni sul bilanciamento posturale e propriocettivo presente nelle caviglie artrosiche e successivamente sottoposte a sostituzione protesica totale sono ampiamente descritte e discusse. I dati raccolti in questo lavoro di tesi rappresentano il risultato di una valutazione cinematica complessiva, e potranno aiutare a definire una tipologia di soggetto artrosico in cui i risultati siano verosimilmente migliori ed eventualmente a migliorare design e strumentari futuri.

Interdipendenza regionale: un nuovo modello valutativo-interpretativo. Le relazioni tra anca e cingolo pelvico--revisione sistematica della letteratura

Obiettivo: valutare l’effetto del tilt pelvico rispetto all’antiversione del collo femorale, all’antiversione dell’acetabolo e all’adattamento dell’anca nei tre piani dello spazio secondo il concetto dell’interdipendenza regionale. Metodi: si sono scelti gli studi conformi con il P.E.O di ricerca: Popolazione = tutti, Esposizione = modificazioni del tilt pelvico, Outcome = aumento/diminuzione dell’antiversione dell’acetabolo, del collo femorale e del rom dell’anca nei tre piani dello spazio. Risultati: otto studi sono stati suddivisi in tre gruppi: Il primo gruppo permette di osservare l’effetto del tilt pelvico rispetto all’antiversione dell’acetabolo e alla mobilità dell’anca, facendo emergere che la retroversione del bacino aumenta l’antiversione acetabolare e l’estensione dell’anca. Nel secondo gruppo è stato evidenziato che l’aumento dell’antiversione femorale porta ad una rotazione interna dell’anca più pronunciata durante il cammino, ad una diminuzione dei bracci di leva abduttivi e ad un aumento delle forze di contatto. Il terzo gruppo di studio non ha riportato nessuna relazione tra antiversione femorale e acetabolare nei soggetti affetti da coxartrosi. D’altro canto, è possibile che la correlazione ricercata non sia stata trovata proprio perché il campione esaminato in questo studio presentava coxartrosi, elemento che potrebbe essere espressione di un non corretto adattamento tra anca e bacino. Conclusioni: la retroversione del bacino aumenta l’antiversione acetabolare e l’estensione dell’anca; l'aumento dell'antiversione del collo femorale è comunemente associato ad una maggiore rotazione interna dell'anca sia in stazione eretta che durante l'andatura, agendo come strategia compensativa per la diminuzione dei bracci di leva dei muscoli abduttori dell'anca. Non ci sono elementi per trarre conclusioni sulla relazione tra il grado di versione del bacino, l’antiversione del collo femorale e la mobilità dell’anca nel piano orizzontale e frontale.

Force and pressure analysis during occasional loaded gait

O documento em anexo encontra-se na versão pre-print (versão inicial enviada para o editor).

Interlimb relation during the double support phase of gait: an electromyographic, mechanical and energy based analysis

The purpose of this study is to analyse the interlimb relation and the influence of mechanical energy on metabolic energy expenditure during gait. In total, 22 subjects were monitored as to electromyographic activity, ground reaction forces and VO2 consumption (metabolic power) during gait. The results demonstrate a moderate negative correlation between the activity of tibialis anterior, biceps femoris and vastus medialis of the trailing limb during the transition between midstance and double support and that of the leading limb during double support for the same muscles, and between these and gastrocnemius medialis and soleus of the trailing limb during double support. Trailing limb soleus during the transition between mid-stance and double support was positively correlated to leading limb tibialis anterior, vastus medialis and biceps femoris during double support. Also, the trailing limb centre of mass mechanical work was strongly influenced by the leading limbs, although only the mechanical power related to forward progression of both limbs was correlated to metabolic power. These findings demonstrate a consistent interlimb relation in terms of electromyographic activity and centre of mass mechanical work, being the relations occurred in the plane of forward progression the more important to gait energy expenditure.

Objective analysis of gait coordination for total knee arthroplasty outcome

Introduction: Coordination is a strategy chosen by the central nervous system to control the movements and maintain stability during gait. Coordinated multi-joint movements require a complex interaction between nervous outputs, biomechanical constraints, and pro-prioception. Quantitatively understanding and modeling gait coordination still remain a challenge. Surgeons lack a way to model and appreciate the coordination of patients before and after surgery of the lower limbs. Patients alter their gait patterns and their kinematic synergies when they walk faster or slower than normal speed to maintain their stability and minimize the energy cost of locomotion. The goal of this study was to provide a dynamical system approach to quantitatively describe human gait coordination and apply it to patients before and after total knee arthroplasty. Methods: A new method of quantitative analysis of interjoint coordination during gait was designed, providing a general model to capture the whole dynamics and showing the kinematic synergies at various walking speeds. The proposed model imposed a relationship among lower limb joint angles (hips and knees) to parameterize the dynamics of locomotion of each individual. An integration of different analysis tools such as Harmonic analysis, Principal Component Analysis, and Artificial Neural Network helped overcome high-dimensionality, temporal dependence, and non-linear relationships of the gait patterns. Ten patients were studied using an ambulatory gait device (Physilog®). Each participant was asked to perform two walking trials of 30m long at 3 different speeds and to complete an EQ-5D questionnaire, a WOMAC and Knee Society Score. Lower limbs rotations were measured by four miniature angular rate sensors mounted respectively, on each shank and thigh. The outcomes of the eight patients undergoing total knee arthroplasty, recorded pre-operatively and post-operatively at 6 weeks, 3 months, 6 months and 1 year were compared to 2 age-matched healthy subjects. Results: The new method provided coordination scores at various walking speeds, ranged between 0 and 10. It determined the overall coordination of the lower limbs as well as the contribution of each joint to the total coordination. The difference between the pre-operative and post-operative coordination values were correlated with the improvements of the subjective outcome scores. Although the study group was small, the results showed a new way to objectively quantify gait coordination of patients undergoing total knee arthroplasty, using only portable body-fixed sensors. Conclusion: A new method for objective gait coordination analysis has been developed with very encouraging results regarding the objective outcome of lower limb surgery.

GPS analysis of human locomotion: further evidence for long-range correlations in stride-to-stride fluctuations of gait parameters.

During free walking, gait is automatically adjusted to provide optimal mechanical output and minimal energy expenditure; gait parameters, such as cadence, fluctuate from one stride to the next around average values. It was described that this fluctuation exhibited long-range correlations and fractal-like patterns. In addition, it was suggested that these long-range correlations disappeared if the participant followed the beep of metronome to regulate his or her pace. Until now, these fractal fluctuations were only observed for stride interval, because no technique existed to adequately analyze an extended time of free walking. The aim of the present study was to measure walking speed (WS), step frequency (SF) and step length (SL) with high accuracy (<1 cm) satellite positioning method (global positioning system or GPS) in order to detect long-range correlations in the stride-to-stride fluctuations. Eight participants walked 30 min under free and constrained (metronome) conditions. Under free walking conditions, DFA (detrended fluctuation analysis) and surrogate data tests showed that the fluctuation of WS, SL and SF exhibited a fractal pattern (i.e., scaling exponent alpha: 0.5 < alpha < 1) in a large majority of participants (7/8). Under constrained conditions (metronome), SF fluctuations became significantly anti-correlated (alpha < 0.5) in all participants. However, the scaling exponent of SL and WS was not modified. We conclude that, when the walking pace is controlled by an auditory signal, the feedback loop between the planned movement (at supraspinal level) and the sensory inputs induces a continual shifting of SF around the mean (persistent anti-correlation), but with no effect on the fluctuation dynamics of the other parameters (SL, WS).

Video analysis software increases the interrater reliability of video gait assessments in children with cerebral palsy.

The aim of this study was to determine the effect of using video analysis software on the interrater reliability of visual assessments of gait videos in children with cerebral palsy. Two clinicians viewed the same random selection of 20 sagittal and frontal video recordings of 12 children with cerebral palsy routinely acquired during outpatient rehabilitation clinics. Both observers rated these videos in a random sequence for each lower limb using the Observational Gait Scale, once with standard video software and another with video analysis software (Dartfish(®)) which can perform angle and timing measurements. The video analysis software improved interrater agreement, measured by weighted Cohen's kappas, for the total score (κ 0.778→0.809) and all of the items that required angle and/or timing measurements (knee position mid-stance κ 0.344→0.591; hindfoot position mid-stance κ 0.160→0.346; foot contact mid-stance κ 0.700→0.854; timing of heel rise κ 0.769→0.835). The use of video analysis software is an efficient approach to improve the reliability of visual video assessments.

Effects of Three Types of Exercise Interventions on Healthy Old Adults' Gait Speed : A Systematic Review and Meta-Analysis.

BACKGROUND: Habitual walking speed predicts many clinical conditions later in life, but it declines with age. However, which particular exercise intervention can minimize the age-related gait speed loss is unclear. PURPOSE: Our objective was to determine the effects of strength, power, coordination, and multimodal exercise training on healthy old adults' habitual and fast gait speed. METHODS: We performed a computerized systematic literature search in PubMed and Web of Knowledge from January 1984 up to December 2014. Search terms included 'Resistance training', 'power training', 'coordination training', 'multimodal training', and 'gait speed (outcome term). Inclusion criteria were articles available in full text, publication period over past 30 years, human species, journal articles, clinical trials, randomized controlled trials, English as publication language, and subject age ≥65 years. The methodological quality of all eligible intervention studies was assessed using the Physiotherapy Evidence Database (PEDro) scale. We computed weighted average standardized mean differences of the intervention-induced adaptations in gait speed using a random-effects model and tested for overall and individual intervention effects relative to no-exercise controls. RESULTS: A total of 42 studies (mean PEDro score of 5.0 ± 1.2) were included in the analyses (2495 healthy old adults; age 74.2 years [64.4-82.7]; body mass 69.9 ± 4.9 kg, height 1.64 ± 0.05 m, body mass index 26.4 ± 1.9 kg/m(2), and gait speed 1.22 ± 0.18 m/s). The search identified only one power training study, therefore the subsequent analyses focused only on the effects of resistance, coordination, and multimodal training on gait speed. The three types of intervention improved gait speed in the three experimental groups combined (n = 1297) by 0.10 m/s (±0.12) or 8.4 % (±9.7), with a large effect size (ES) of 0.84. Resistance (24 studies; n = 613; 0.11 m/s; 9.3 %; ES: 0.84), coordination (eight studies, n = 198; 0.09 m/s; 7.6 %; ES: 0.76), and multimodal training (19 studies; n = 486; 0.09 m/s; 8.4 %, ES: 0.86) increased gait speed statistically and similarly. CONCLUSIONS: Commonly used exercise interventions can functionally and clinically increase habitual and fast gait speed and help slow the loss of gait speed or delay its onset.

Motion Cues Analysis for Parkinson Gait Recognition

Background: Previous assessment methods for PG recognition used sensor mechanisms for PG that may cause discomfort. In order to avoid stress of applying wearable sensors, computer vision (CV) based diagnostic systems for PG recognition have been proposed. Main constraints in these methods are the laboratory setup procedures: Novel colored dresses for the patients were specifically designed to segment the test body from a specific colored background. Objective: To develop an image processing tool for home-assessment of Parkinson Gait(PG) by analyzing motion cues extracted during the gait cycles. Methods: The system is based on the idea that a normal body attains equilibrium during the gait by aligning the body posture with the axis of gravity. Due to the rigidity in muscular tone, persons with PD fail to align their bodies with the axis of gravity. The leaned posture of PD patients appears to fall forward. Whereas a normal posture exhibits a constant erect posture throughout the gait. Patients with PD walk with shortened stride angle (less than 15 degrees on average) with high variability in the stride frequency. Whereas a normal gait exhibits a constant stride frequency with an average stride angle of 45 degrees. In order to analyze PG, levodopa-responsive patients and normal controls were videotaped with several gait cycles. First, the test body is segmented in each frame of the gait video based on the pixel contrast from the background to form a silhouette. Next, the center of gravity of this silhouette is calculated. This silhouette is further skeletonized from the video frames to extract the motion cues. Two motion cues were stride frequency based on the cyclic leg motion and the lean frequency based on the angle between the leaned torso tangent and the axis of gravity. The differences in the peaks in stride and lean frequencies between PG and normal gait are calculated using Cosine Similarity measurements. Results: High cosine dissimilarity was observed in the stride and lean frequencies between PG and normal gait. High variations are found in the stride intervals of PG whereas constant stride intervals are found in the normal gait. Conclusions: We propose an algorithm as a source to eliminate laboratory constraints and discomfort during PG analysis. Installing this tool in a home computer with a webcam allows assessment of gait in the home environment.

Motion cue analysis for parkinsonian gait recognition

This paper presents a computer-vision based marker-free method for gait-impairment detection in Patients with Parkinson's disease (PWP). The system is based upon the idea that a normal human body attains equilibrium during the gait by aligning the body posture with Axis-of-Gravity (AOG) using feet as the base of support. In contrast, PWP appear to be falling forward as they are less-able to align their body with AOG due to rigid muscular tone. A normal gait exhibits periodic stride-cycles with stride-angle around 45o between the legs, whereas PWP walk with shortened stride-angle with high variability between the stride-cycles. In order to analyze Parkinsonian-gait (PG), subjects were videotaped with several gait-cycles. The subject's body was segmented using a color-segmentation method to form a silhouette. The silhouette was skeletonized for motion cues extraction. The motion cues analyzed were stride-cycles (based on the cyclic leg motion of skeleton) and posture lean (based on the angle between leaned torso of skeleton and AOG). Cosine similarity between an imaginary perfect gait pattern and the subject gait patterns produced 100% recognition rate of PG for 4 normal-controls and 3 PWP. Results suggested that the method is a promising tool to be used for PG assessment in home-environment.

Analysis of the positioning of the head, trunk, and upper limbs during gait in children with visual impairment

Background: This study analyzed the positioning of the head, trunk, and upper extremities during gait in children with visual impairment. Methods: A total of 11 children participated in this study: 6 with blindness and 5 with low vision. The kinematics of the positioning of the head, trunk, shoulders, and elbows in each participant was analyzed during the four phases of the gait cycle: foot strike, support, toe-off, and swing. Results: There were significant differences between children with blindness and low vision in the positioning of the trunk in the sagittal plane during the foot strike, support, and swing phases. Conclusions: The analysis identified postural alterations of the head, trunk, shoulder, and elbow during the children’s gait, highlighting the relevance of appropriate stimulation at an early age in orientation and mobility programs, as well as the essential presence of professionals who work with movement.

Granulocyte Colony-stimulating Factor (g-csf) Positive Effects On Muscle Fiber Degeneration And Gait Recovery After Nerve Lesion In Mdx Mice.

G-CSF has been shown to decrease inflammatory processes and to act positively on the process of peripheral nerve regeneration during the course of muscular dystrophy. The aims of this study were to investigate the effects of treatment of G-CSF during sciatic nerve regeneration and histological analysis in the soleus muscle in MDX mice. Six-week-old male MDX mice underwent left sciatic nerve crush and were G-CSF treated at 7 days prior to and 21 days after crush. Ten and twenty-one days after surgery, the mice were euthanized, and the sciatic nerves were processed for immunohistochemistry (anti-p75(NTR) and anti-neurofilament) and transmission electron microscopy. The soleus muscles were dissected out and processed for H&E staining and subsequent morphologic analysis. Motor function analyses were performed at 7 days prior to and 21 days after sciatic crush using the CatWalk system and the sciatic nerve index. Both groups treated with G-CSF showed increased p75(NTR) and neurofilament expression after sciatic crush. G-CSF treatment decreased the number of degenerated and regenerated muscle fibers, thereby increasing the number of normal muscle fibers. The reduction in p75(NTR) and neurofilament indicates a decreased regenerative capacity in MDX mice following a lesion to a peripheral nerve. The reduction in motor function in the crushed group compared with the control groups may reflect the cycles of muscle degeneration/regeneration that occur postnatally. Thus, G-CSF treatment increases motor function in MDX mice. Nevertheless, the decrease in baseline motor function in these mice is not reversed completely by G-CSF.

Strength training improves fall-related gait kinematics in the elderly: a randomized controlled trial

Background: Falls are one of the greatest concerns among the elderly. Among a number of strategies proposed to reduce the risk of falls, improving muscle strength has been applied as a successful preventive strategy. Although it has been suggested as a relevant strategy, no studies have analyzed how muscle strength improvements affect the gait pattern. The aim of this study was to determine the effects of a lower limb strength training program on gait kinematics parameters associated with the risk of falls in elderly women. Methods: Twenty seven elderly women were assigned in a balance and randomized order into an experimental (n = 14: age = 61.1 (4.3) years, BMI = 26.4 (2.8) kg m(-2)) and a control (n = 13; age = 61.6 (6.6) years; BMI = 25.9 (3.0) kg m(-2)) group. The EG performed lower limb strength training during 12 weeks (3 days per week), being training load increased weekly. Findings: Primary outcomes were gait kinematics parameters and maximum voluntary isometric contractions at pre- and post-training period. Secondary outcomes were training load improvement weekly and one repetition maximum every two weeks. The I maximal repetition increment ranged from 32% to 97% and was the best predictor of changes in gait parameters (spatial, temporal and angular variables) after training for the experimental group. Z-score analysis revealed that the strength training was effective in reversing age-related changes in gait speed, stride length, cadence and toe clearance, approaching the elderly to reference values for healthy young women. Interpretation: Lower limb strength training improves fall-related gait kinematic parameters. Thus, strength training programs should be recommended to the elderly women in order to change their gait pattern towards young adults. (C) 2009 Elsevier Ltd. All rights reserved.