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Energy cost of walking of amputees: the influence of level of amputation
RL Waters, J Perry, D Antonelli and H Hislop
J Bone Joint Surg Am. 1976;58:42-46.
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The Journal of Bone and Joint Surgery
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Energy
The
BY
ROBERT
1..
WATERS,
M.D.*,
Cost
of Walking
Influence
of Level
JACQL.ELIN
PERRY,
M.D.*,
DOWNEY,
I,o,ii
ABSTRACT:
A comparison
of selected
ters and the energy
cost of prosthetic
made
in seventy
patients
with unilateral
vascular
amputations.
below the knee,
and
in
both
groups
forty normal
of amputees
lower
the
Amputations
at the Syme’s
of amputees,
subjects
also
performance
level
of function
performed
of the
is the
at the
level
and
Ra,u/io
Los
group
amputation.
When
preservation
amputation
level.
should
be
It is a common
clinical
experience
that below-theknee amputees
physically
outperform
above-the-knee
amputees,
and surgeons
concerned
primarily
with maintaining maximum
walking
ability
try to amputate
at the lowest
possible
level.
Other
surgeons,
concerned
primarily
with
patient
most
morbidity,
likely
assure
These
surgeons
than below
it.
Published
energy
cost
inconclusive
or varied
amputation
select the level of amputation
prompt
healing
after one
are
more
apt to amputate
data
that
might
allow
that will
operation.
above
the
comparison
knee
of walking,
assessed
or because
only one level of
It is well known
that
2.4.6.8.9,12
oxygen
uptake
depends
on walking
The purpose
of this study was
cost of walking
by the same method
putation:
above
the knee,
below
the
level.
Testing
was performed
during
speed.
to measure
the energy
at three levels of amknee,
and at Syme’s
unrestrained
walking
at the patient’s
chosen
velocity.
The findings
are compared
with those
for a group
of normal
subjects
tested
by the same method.
Material
decade
seventy
As controls,
from the
unilateral
and
five normal
persons
third to the seventh
amputees
studied
*
42
7601
quadrilateral
socket;
all with
used a patellar
tendon-bearing
East
Imperial
Highway.
Downey,
AND
of each sex in each
were studied.
The
were selected
using
California
or pressure
six months.
used a total-
90242.
HISLOP,
PH.D.*,
tients
Some
tation
with a Syme’s
amputation
used end-bearing
sockets.
of the amputees
were older patients
in whom
ampuwas
performed
for arterial
insufficiency,
while
others,
cause
considerably
younger,
of trauma
(Table
I).
Each
meters
subject
walked
in circumference
a modified
analyses.
had
around
while
amall pa-
their
amputation
a measured
expired
be-
track
air was
60.5
collected
in
Douglas
bag for oxygen
and carbon
dioxide
Heart
rate, respiratory
rate, and cadence
were
telemetered
by transducers
attached
volumes
were corrected
to standard
and humidity.
Each
test walk
minutes.
The first three minutes
data were collected
during
the
to the subject.
All gas
temperature,
pressure,
lasted
approximately
served
as a warm-up
following
two minutes
five
and
of
steady
state as indicated
by a constant
heart rate and respiratory
rate. Two tests were performed:
the first at the
unrestrained
speed
and the second
at the fastest
possible
speed.
obtained
The values
for oxygen
during
the fast walk
subject’s
maximum
aerobic
consumption
were used
and heart
to predict
rate
the
capacity.
Results
ported
The control
by others
Gait
data
were
similar
to those
previously
re-
Velocit-c
The
walking
speed
in the
controls
averaged
eighty-
two meters
per minute
(men,
eighty-seven
and women,
seventy-four)
and did not vary with age. This value progressively
decreased
in the amputee
population
the higher
the level
of
below-the-knee
minute
tation,
amputation:
amputation
for patients
with
it was seventy-one
and for those with traumatic
fifty-two
meters
per minute
TABLE
a below-the-knee
socket;
and
HELEN
Do;i,u’v
Methods
these criteria:
None had stump
pain, swelling,
sores.
All had worn a prosthesis
for at least
All those with an above-the-knee
amputation
contact
putation
E.E.*,
of the
of walking
at different
levels of amputation
are
either
because
of small numbers
of subjects
speed
was
ANTONELLI,
Ho.sjnta/.
of
was studied.
In both groups
was significantly
better
the
chief concern,
lowest
possible
DANIEL
.4 iiugos
the knee,
compared
a control
of Amputation
CALIFORNIA
gait paramewalking
was
traumatic
and
above
were
of Amputees:
traumatic
meters
per
above-the-knee
(p < 0.05)
(Table
Weight
Prosthetic
ampuII).
I
SUBJECTS
Level
of
Duration
Amputation
n
Age
(Yrs.
Vascular
)
(??i)
(kg)
of
Use
( Yrs.)
amputees
Above
the
Below
the knee
knee
Syme
Traumatic
Height
13
60
1.76
70
1.2
13
IS
63
57
1.71
1.69
71
79
1.4
1.1
31
29
1.72
1 .77
72
80
10.0
9.5
OF BONE
AND
amputees
Above
the
knee
15
Below
the
knee
14
ThE
JOURNAL
JOINT
SURGERY
COST
ENERGY
OF
WALKING
TABLE
UNREsTRA1NEo
(MEAN
AND
(,nI,nin
Vascular
Above
amputees
the knee
)
the
36
knee
Syme
Traumatic
Above
Below
amputees
the knee
the
knee
)
(Steps/niii
72
±18
±15
Below
Stride
Cadence
Length
(,i )
tN
AsltuTEEs
STANDARD
DEVIATION)
Net
Maximum
Relative
Oxygen
Oxygen
Aerobic
Energy
Uptake
Cost
Capacity
Cost
Rate
Velocity
43
AMPUTEES
II
WALKINO
VALUES
OF
of
(nil/kg-mm
)
(in1Ikg-n
)
(nh/kg-ntin
1.00
±0.20
12.6
±2.9
0.35
±0.06
±7
) (Per
20
Heart
)
((flt
126
±0.13
87
±7
1.02
±0.13
11.7
±1.6
0.26
±0.05
28
±5
42
105
±17
0.82
±0.06
54
±10
98
±13
1.10
±0.16
11.5
0.21
±0.06
27
±8
43
±1.5
108
±13
0.85
±0.08
52
±14
87
±13
1.20
±0.18
12.9
±3.4
0.25
±0.05
35
±6
37
III
±12
0.90
±0.07
71
±10
99
±9
1.44
±0.16
15.5
±2.9
0.20
±0.05
45
±9
35
106
±11
0.83
±0.08
Syme’s
amputation
was
below-the-knee
amputees,
minute
at the below-the-knee
at the above-the-knee
level.
with
traumatic
amputation,
fifty-four
meters
per minute;
for
forty-five;
and for above-the-
knee
amputees,
from
13 to 66 per cent of normal.
At the two amputation
levels
thirty-six.
The
decrease
in velocity
available
for
ranged
compari-
son,
the younger
patients
walked
faster
than the older
ones:
patients
with traumatic
above-the-knee
amputation
walked
sixteen
meters
per minute
faster
than those with
vascular
above-the-knee
amputation,
and
those
with
traumatic
below-the-knee
meters
per minute
faster
amputation
than those
walked
twenty-six
with vascular
below-
steps per minute
tion was faster
with above-the-knee
The
data
ninety-eight
eighty-seven
steps
steps
level,
and seventy-two
steps
Similarly,
among
the patients
the cadence
of ninety-nine
for patients
with below-the-knee
than the eighty-seven
steps
amputation.
recorded
per
per
(Table
amputapatients
for
II) are to be compared
with
the normal
cadence
of 1 16 steps per minute,
not varying
with age or sex, and with the normal
stride length
of I .50
meters
for men and 1 .28 meters
for women
(average,
1.40).
amputation.
results
for cadence
and
stride
length
also
showed
that the amputees
had a slower
cadence
and reduced
stride
length.
The cadence
for amputees
was slower
than that for
the controls
and also depended
on the level of amputation.
Cadence
ute and
amputees’
0.96
±17
45
±9
three amputation
levels,
averaging
minute
for the Syme’s
amputation,
The
(Beats/,niit
63
The influence
of level of amputation
in vascular
patients
was also significant:
the average
velocity
for patients
with a
the-knee
Respiratory
Quotient
Rate
for normal
subjects
averaged
did not vary
with
age or
cadence
differed
significantly
1 16 steps per mmsex.
The
vascular
(p < 0.05)
at the
Metabolic
The
Cost
energy
cost
was
calculated
in three
ways:
rate
of
expenditure
(amount
of oxygen
consumed
per mmute), energy
cost per meter
(the amount
of oxygen
consumed
per meter walked),
and relative
energy
(‘ost (rate of
oxygen
uptake
divided
by the individual’s
maximum
ability to perform
aerobic
exercise,
or maximum
aerobic
energy
capacity).
Among
oxygen
the
uptake
vascular
per
amputees,
ninute
at
the
the
mean
below-the-knee
rate
of
and
Syme’s-amputation
levels
was
1 1 .7 milliliters
per
kilogram-minute
and 1 1 .5 milliliters
per kilogram-minute.
The value
for patients
with
above-the-knee
amputation
was greater
(1 2.6 milliliters
per kilogram-minute),
but this
difference
was
rate of oxygen
the-knee
minute,
not statistically
significant
uptake
of patients
with
amputation
and the value
(Table
traumatic
was
15.5
milliliters
per
for those with above-the-knee
II). The
belowkilogramampu-
tation was 12.9 milliliters
per kilogram-minute.
The mean
rate of oxygen
uptake
for normal
subjects
was 13.0 ± 2.7
milliliters
per kilogram-minute
and did not vary with age
or sex.
The
FIG.
VOL.
58-A,
NO.
I, JANUARY
1976
I
per
mean
value
of the predicted
for all normal
subjects
kilogram-minute.
This did
capacity
maximwn
aerobic
was thirty-five
milliliters
not vary significantly
with
44
R.
L . WATERS,
JACQUELIN
PERRY,
DANIEL
ANTONELLI,
AND
HELEN
HISLOP
lated to age. In both the vascular
and traumatic
amputation
groups,
the energy
cost was dependent
on the level of amputation
(Table
II). The differences
were significant
at the
0.05
level.
The lower
the level
of amputation
in both
groups
the lower
was the energy
cost per meter.
The mean value of the respirators’
quotient
in the control
0.85.
group
With
was
one
not affected
exception,
tially normal
quotients.
vascular
above-the-knee
respiratory
normal
TRAUMATIC
AMPUTEES
AMPUTEES
sex
but
was
influenced
by age,
ment with the results
of others
decade
of life, aerobic
capacity
per kilogram-minute,
but this
jects
in the sixth
decade.
per cent of directly
untrained
individuals
The maximum
a finding
that
is in agree-
For patients
in the third
averaged
41 ± 7 milliliters
dropped
to 30 ± 8 for sub-
These
values
are well
within
10
of amputation
for patients
was
only
(Table
II). The maxwith vascular
abovetwenty
milliliters
per
kilogram-minute,
eraged
twenty-eight
while
the below-the-knee
amputees
milliliters
per kilogram-minute
avand
the
a Syme
The
patients
with
amputation,
twenty-seven.
maximum
aerobic
capacities
for younger
(traumatic)
amputees
were much higher
but they were also higher
for patients with amputation
below
the knee than for those with
amputation
above
the knee.
The mean
value of the relative
energy
cost
of unrestrained
walking
for the entire
group
of normal
subjects
was 38 per cent and increased
with age because
of the dedine
in the predicted
maximum
aerobic
capacity.
For patients with a vascular
Syme or below-the-knee
amputation
the relative
energy
costs were 43 per cent and 42 per cent,
values
only
slightly
greater
normal
persons
fifty
The value for patients
tation
energy
than
the average
obtained
to fifty-nine
years old (40
with vascular
above-the-knee
was markedly
greater
cost for patients
with
(63 per
traumatic
per cent).
ampu-
cent).
The
amputation
Females
had
a significantly
greater
relative
below
value
than
males
(p < 0.05).
The mean oxygen
cost was 0. 15 milliliter per kilogram-meter
for males
and 0. 17 milliliter
per kilogram-meter
for females.
The
cost
for males
was
less
because
same amount
kilogram-minute).
they
walked
faster
yet
of oxygen
per minute
(13.0
No differences
occurred
Crutch
Walking
The
piratory
without
rate
for
the
normal
greater
than
controls
(104
did
in
in
Prosthesis
rate of oxygen
consumption,
quotient
were
significantly
heart rate,
increased
and resin all
groups
of amputees
when walking
with crutches
and without a prosthesis.
The increases
ranged
from 1 .3 milliliters
per kilogram-minute
in the group with a vascular
Syme amputation
to 6.9
with traumatic
particular
all patients
milliliters
per kilogram-minute
below-the-knee
amputation
clinical
using
in the group
(Table
III). Of
significance,
tachycardia
crutches.
All the amputee
was noted
in
subgroups
av-
eraged
between
120 and 125 heartbeats
per minute.
In contrast, when walking
with a prosthesis
without
crutches,
the
mean heart rate was less than 1 1 1 beats per minute
in all
groups
except
the vascular
above-the-knee
amputees.
Again
with the exception
of the vascular
above-the-knee
amputees,
the mean
respiratory
quotient
was less in all
groups
when using a prosthesis.
The data on oxygen
consumption,
heart rate, and respiratory
quotient
clearly
mdicate that all amputee
groups
lar above-the-knee
amputation
prosthesi
except
walk
patients
with a vascuwith less effort with a
.
Discussion
for
the knee and above
the knee was 35 per cent,
approximately
the same as for controls
in the third decade
of life
(34 per cent).
For the control
group
of normal
subjects,
the energy
cost
per meter
averaged
0. 16 milliliter
per kilogrammeter.
significantly
it:;
measured
values
for aerobic
capacity
in
of similar
ages i,i3
aerobic
capacity
showed
the influence
of both age and level
imum
aerobic
capacity
the-knee
amputation
0.97,
beats per minute)
did not depend
on age or sex and also
not significantly
differ from that for the amputees
except
the group
with
vascular
above-the-knee
amputation,
which
it averaged
126 beats per minute
(p < 0.02).
2
FIG.
of
0.05).
average
heart
was the group with
which
had an average
<
The
VASCULAR
The exception
amputation
quotient
(p
by age or sex and averaged
all amputee
groups
had essen-
Drillis,
average
walking
were
these
and
later
Finley
Cody,
determined
in an unrestrained
lower,
and the
was the velocity
consumed
the
average
velocity
milliliters
that were
per
re-
Syme’s-amputation
knee level,
and
included
in
their data
control
group
of normal
undergoing
experimental
manner
and
gait pattern.
Compared
with
these
selected
by all our amputee
subgroups
did
the
of pedestrians
unaware
they
being observed.
Over 2,000
people
were
two studies.
The close similarity
between
and the results
from our
indicates
that our subjects
walked
and
velocity,
stride length,
and cadence
in selected
urban
areas
who were
subjects
testing
not
alter
their
data
the velocities
were significantly
higher
the level of amputation
the
selected.
Expressed
as a percentage
lower
of the
value for the normal
group of control
subjects,
the
for vascular
amputees
was 66 per cent
at the
level,
59 per cent at the
44 per cent at the above-the-knee
THE
JOURNAL
OF
BONE
AND
below-thelevel.
JOINT
SURGERY
In
ENERGY
COST
OF
WALKING
TABLE
ENERGY
COST
OF WALKING
WITHOUT
OF
III
A PROSTHESIS
Rate
Velocity
(m/,nin
Vascular
Ahove
Below
thirty
years).
years)
We
group
between
It should
II
15.0
±
2.9
0.97
±
0.09
130
±
32
±
13
14.6
±
1.5
0.92
±
0.14
124
±
20
39
±
14
12.8
±
4.3
1.04
±
0.09
129
±
13
the
knee
65
±
16
15.9
±
5.4
0.95
±
0.08
129
±
17
Below
the
knee
71
±
10
22.4
±
4.3
0.93
±
0.07
135
±
23
87 per cent at the
at the above-the-knee
walked
faster
above or below
in age. However,
also
be taken
into
below-thelevel.
than
traumatic
amputees,
for the same reason.
Reinforcing
this
interpretation
is the fact that the heart rate and the respira-
patients
the knee primarthe duration
of
account
when
com-
to death or another
amputadon
in a few
the patients
with traumatic
amputation
for study were younger
(average
age,
duration
longer
(mean,
9.8
correlation
in any
of prosthetic
that recently
ing speed would
logically
of training
were purposely
we included
only subjects
use and gait
fitted
amputees
whose
walk-
be expected
to increase
because
excluded
from this study and
who had worn a prosthesis
for a
accepted
index of the energy
be expected
that the amputees
than
normal
rate of oxygen
their
maximum
aerobic
uptake
capacity,
cost of an activity.
It
would
have a higher
per minute
but with
the group
with vascular
above-the-knee
did not. During
unrestrained
walking,
putees
in the below-the-knee
and Syme’s
groups
imately
had a rate
the same
of oxygen
percentage
in relation
to
the exception
amputation
the vascular
amputation
of
they
amsub-
uptake
per minute
of approxof their
maximum
aerobic
capacity
(42 per cent and 43 per cent) as the control
subjects in the sixth decade
of life (41 per cent).
Similarly,
the
younger
patients
with
traumatic
above-the-knee
and
below-the-knee
amputation
adjusted
their relative
uptakes
(37 and 35 per cent) to values
close to that of the normal
subjects
in the third decade
(34 per cent).
Thus,
with the
exception
of the group
with vascular
above-the-knee
amputation,
the amputees
modified
their
walking
speed
to
keep relative
energy
costs within
normal
limits.
Also,
the
older
VOL.
amputees
58-A.
NO.
walked
I. JANUARY
more
1976
slowly
than
the
tory quotient
during
unrestrained
walking
mately
the same as the values
for normal
younger
were
subjects,
for the patients
with vascular
above-the-knee
These
values
are important
because
approxiexcept
amputation.
at low relative
work rates the adenosine
tniphosphate
for muscle
contraction is principally
supplied
via aerobic
pathways
and an
individual
can sustain
prolonged
exercise
for many
hours
with no easily definable
point ofexhaustion.
When oxygen
demand
exceeds
50 per cent
of the maximum
aerobic
capacity,
anaerobic
mechanisms
are called
on to assist
muscle
adenosine
metabolism.
tniphosphate
durance
decreases
velocity.
minimum
of six months.
We therefore
believe
that age is
the major
reason
for the slower
gait velocity
in vascular
amputees
and the data on energy
cost support
this interpretation.
The rate of oxygen
utilization
per minute
is the commonly
might
Rate
±
and had worn a prosthesis
could
find no significant
be noted
Heart
(Beats/mm
39
knee
paring
the two groups.
The average
age of the vascular
amputees
was sixty
years
and their
experience
with
the
prosthesis
was relatively
short (mean,
1 .2 years)
because
of their primary
disease.
The progression
of vascular
illness usually
leads
years.
In contrast,
who were available
Quotient
)
48
amputees
must
(nl/kg-rnin
Above
with vascular
amputation
ily because
ofdifferences
use
Respiratory
Uptake
amputees
traumatic
amputees
it was
knee level and 63 per cent
prosthetic
CRUTCHES
the
Syme
traumatic
WITH
amputees
the knee
Traumatic
The
AND
of
Oxygen
)
45
AMPUTEES
with
cent
rate
vated
tients
Only
one-nineteenth
is produced
by this
rapidly
above
50 per
as
much
and en-
method
cent.
The energy
cost for unrestrained
walking
for patients
vascular
above-the-knee
amputation
was high (63 per
of the maximum
aerobic
capacity)
. The
average
heart
and respiratory
quotient
also were significantly
eleand were approximately
walked
with crutches
high energy
cost
amputee
subgroups
the same as when these pa(without
a prosthesis).
The
of crutch
walking
with the exception
is well known
of the patients
All
with
vascular
above-the-knee
amputations
had
significantly
lower oxygen
uptake,
heart rate, and respiratory
quotient
when
walking
with a prosthesis.
Because
we have
not
found
it possible
to fit even
10 per
vascular
above-the-knee
amputations
thesis
at our
fitted met our
conclude
that
hospital,
and
criteria
for
amputation
fewer
cent of patients
with
initially
with a prosthan
one-half
inclusion
in the
below
the knee
older amputee
with vascular
disease.
The amputees
(with the single exception
with vascular
above-the-knee
amputation)
of those
study,
we must
is essential
for
the
of the group
adjusted
their
gait velocity
to keep the rate of energy
expenditure
within
normal
limits.
It is of interest
to see how efficiently
a
well fitted prosthesis
allows
the patient
to walk as cornpared with normal.
The slower
walking
speed of amputees
in all subgroups
is a measure
of the loss in efficiency.
The
oxygen
uptake
and is the best
ent amputation
tion at higher
sidered.
per meter walked
is the true net energy
cost
way to compare
the gait efficiency
at differlevels.
The added
energy
cost of amputalevels
is apparent
when
these
values
are con-
R.
46
The
vascular
L.
JACQUELIN
maximum
aerobic
capacity
or traumatic
amputation
significantly
lower
in normal
than
subjects.
in this
study
PERRY,
in the groups
above
the knee
in the below-the-knee
In a study
traumatic
above-the-knee
same
average
maximum
mined
WATERS,
DANIEL
exercise
or
patients
AND
Reasons
investigated
with
was
amputees
of thirty-seven
ANTONELLI,
with
HELEN
HISLOP
for the reduced
in studies
of
in
normal
aerobic
capacity
were further
one-legged
and two-legged
persons
and
above-the-knee
am-
putees
9,10
These
data
suggested
that
above-the-knee
amputees
adapt their life style to a less active one that
suIts in reduced
physical
conditioning
of the muscles
the remaining
lower extremity.
amputation,
James
reported
the
aerobic
capacity
as was deter-
.
reof
References
I.
ASTRAND.
Aerobic
IRMA.
Work
Capacity
in Men
and
Women
with
Special
Reference
to Age.
Acta
Physiol.
Scandinavica,
Supplementum
169,
1960.
2.
3.
4.
DRII.LI5,
ERDMAN,
Crutches.
5.
6.
FINLEY,
Prosthesis.
RAlSTON,
H. J.: MeasurementofEnergy
Phys.
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Rehab.
40: 415-420,
1959.
RUDOLFS:
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Recording
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of
W. J., II; HET11NGER,
TH.; and SAEZ,
FLORENCIO:
Am.
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Med.
39: 225-232.
1960.
F. R., and CODY,
K. A.: Locomotive
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S.; DATTA.
S. R.;CHATTERJEE,
B. B.; and ROY, B.
J. AppI.
Physiol.
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440-443,
1974.
7.
8.
GLESER,
M.
9.
JAMES,
URBAN:
Rehab.
Med.,
JAMES,
URBAN,
BARD,
live
D.,
Med.
in Healthy
MCBEATH,
12.
ment.
Mol.EN,
VON
Uptake
5: 71-80,
and
A.
J. A. : Endurance
Expenditure
during
Pathological
Gait.
Comparative
and
NORDOREN,
Rate
BENGT:
Unilateral
A.;
Heart
During
Physical
Above-Knee
BAHRKE.
WILHELM;
, 22:
Physiol.
BY
56-A:
Relation
AsIRAN1,
IRMA:
934-938.
1967.
WILLIAM
E.
and
Scandinavian
BERGSTRoM,
AND
The
ABSTRACT:
*
M.D.*,
COLONEL
results
prosthetic
amputees
of
fitting
LOUIS
as well
immediate
DENVER,
S.
as the
96438.
Acad.
Referenceto
Science,
Phys.
74:
Med.
and
Ergometer.
Amputees:
Unilateral
86-109,
Amputees
using
Rehab.
at DifferentSpeeds
Male
Evaluation
with
1958.
Artificial
Legs
or
, 51: 423-426,
1970.
Patellar
Tendon-Bearing
J. AppI.
Physiol.
Correlation
with
Above-Knee
of Assis-
, 34: 438-442,
Stump
Strength.
Amputees.
1973.
Arch.
J.
Scandinavian
Bicycle
Assisted
on
Ergometry
Med.
(One
, 5: 81-87,
Leg)
Ambulation
Determined
a Motor-Driven
and
Prosthetic
Treadmill
Walking
1973.
Treadmill.
by
Oxygen
Internat.
Consumption
Zeitschr.
Measure-
f. angew.
Physiol.,
Medical
School
Center,
and
results
of Medicine,
APO
ofAge
early
upper-
in nine
pawith
corn-
acceptance
a filler
insert
Miami,
San
Francisco,
Florida
33152.
California
and
Other
PROSTHETIC
COLORADO,
use of a rigid dressing
and early or immediate
fitting
has been well documented
for the lower
2.3.4.5.11.13
The advantages
ofthe
method,
which
of Miami
Analysis
Factors
Related
to MaximalOxygen
Uptake.
Amputee
General
Fitzsimo,zs
who were
fitted
No local wound
occurred
and the rate ofprosthetic
A practice
prosthesis,
with
Army
An
CARMONAt,
in eighty-seven
shoulder
dislocation
devices
were reviewed.
University
by
POST-SURGICAL
formed
from liquid
Silastic
foam allowed
to set between
the walls of the practice
prosthesis
and the amputation
stump,
was used
extensively
in this series.
With
the
Silastic
insert
and practice
prosthesis,
prosthetic
training could
be instituted
during
healing
of the amputation wounds,
proximal
wounds,
or fractures.
t Tripler
Special
Above-Knee
the Bicycle
in Healthy
J. Rehab.
ARNE:
IMMEDIATE
Front
The
prosthetic
extremity
on
Upper-Extremity
BURKHALTER,
LIEUTENANT
plications
was high.
Measured
Arch.
in Below-Knee
and BALKE.
BRUNO:
Efficiency
of
994-1000,
July
1974.
of Below-Knee
Amputees
Walking
MICHAEL;
EARLY
tients
with
temporary
Exercise
Capacity
York
for
CostofWalking
Expenditure
Walking
New
Stress
Pedestrians.
Metabolic
Prosthetic
Work
Amputees.
The
extremity
Urban
Prolonged
Energy
Ann.
Work
with
1973.
DOBELN,
post-surgical
for
R. L.:
of
M.:
Ambulation,
1973.
Bone
and Joint
Surg..
N. H.: Energy/Speed
J. AppI.
Capacity
P. J.; and REYES.
111-119,
1974.
55:
Active
J.
VoGEl.,
CORCORAN,
Oxygen
31: 173-185,
13.
and
E. G.;
Rehab.,
GONZALEZ,
1 1.
,
Arch.
,
GANGULI,
Phys.
10.
and
GREGORY,
Devices.
FITTING
COLONEL
MEDICAL
CORPS,
Hospital.
GERALD
UNITED
MAYFIELDt,
STATES
Denver
include
protection
of the wound,
immobilization
of injured
tissues,
used
ever,
AND
ARMY
control
of edema,
and
have made this a widely
technique
after
below-the-knee
fitting
of a metal
shank
with
amputation.
a prosthetic
foot
Howand
shoe on the rigid dressing
has met with variable
success,
and several
authors
have abandoned
this procedure
because
of wound
breakdown
in the presence
of vascular
insufficiency
8,9.13
Immediate
or early
fitting
of upper-extremity
prostheses
offers
the same
temporary
prosthesis
it does in the lower
putees
have
advantages
traumatic
generally
much
their upper
than
and,
in addition,
use of a
does not jeopardize
wound
healing
as
extremity.
Most upper-extremity
amamputations
less involved
in their lower
and
the
by degenerative
extremities.
vessels
are
disease
An additional
in
advantage
is that with early
fitting
of a temporary
prosthesis,
teaching
a two-handed
pattern
of activity
utilizing
one normal
hand and one prosthetic
hook can be instituted
within
a few days
after amputation
i.7.Io.12,
so that onehanded
patterns
of activity
do not develop.
THE
JOURNAL
OF BONE
AND
JOINT
SURGERY