Comprehensive Gait Analysis of Healthy Older Adults Who Have Undergone Long-Distance Walking.

Many older adults do not adhere to the recommended physical activity levels. This study examines the gait changes upon long-distance walking among healthy older adults. Gait tests of 24 adults aged 65 or more were conducted at baseline and at the end of 30 and 60 min of treadmill walking. Spatial temporal, kinematic, and kinetic gait data were computed. Perceived level of exertion was evaluated for each subject. Ten subjects (group B) perceived higher exertion levels than the remaining 14 subjects (group A). After walking, group B had significant reductions in dominant-side ankle joint range of motion and power, suggesting lower-leg muscle fatigue, which appeared to be compensated by significantly increased nondominant-side knee and hip motions. These changes were not observed in group A. Differences in gait parameters between groups A and B implied that some biomechanical factors might contribute to the lack of walking of some older adults.

Assessment of biomedical engineering knowledge using true-false questions.

The COVID-19 pandemic has caused a shift from on-campus to remote online examinations, which are usually difficult to invigilate. Meanwhile, closed-ended question formats, such as true-false (TF), are particularly suited to these examination conditions, as they allow automatic marking by computer software. While previous studies have reported the score characteristics in TF questions in conventional supervised examinations, this study investigates the efficacy of using TF questions in online, unsupervised examinations at the undergraduate level of Biomedical Engineering. We examine the TF and other question-type scores of 57 students across three examinations held in 2020 under online, unsupervised conditions. Our analysis shows significantly larger coefficient of variance (CV) in scores in TF questions (42.7%) than other question types (22.3%). The high CV in TF questions may be explained by different answering strategies among students, with 13.3 ± 17.2% of TF questions left unanswered (zero marks) and 16.4 ± 11.5% of TF questions guessed incorrectly (negative marks awarded). In unsupervised, open-book examination where sharing of answers among students is a potential risk; questions that induce a larger variation in responses may be desirable to differentiate among students. We also observed a significant relationship (r = 0.64, p < 0.05) between TF scores and the overall subject scores, indicating that TF questions are an effective predictor of overall student performance. Our results from this initial analysis suggests that TF questions are useful for assessing biomedical-theme content in online, unsupervised examinations, and are encouraging for their ongoing use in future assessments.

Regulation of HAS expression in human synovial lining cells of TMJ by IL-1beta.

Hyaluronan (HA), a major glycosaminoglycan of synovial fluid, is synthesised by a class of membrane-bound HA synthase (HAS) proteins. In the present study, we investigated the regulatory roles of IL-1beta on HAS gene expression and HA production by the fibroblastic synovial lining cells. The synovial lining cells from synovial membrane in human temporomandibular joint (TMJ) were cultured and characterised using immunocytochemistry with CD14, CD44, and vimentin monoclonal antibodies. With or without treatment with IL-1beta, the production of HA was detected with radiometric assay and the expression of HAS mRNAs were analysed with a semi-quantitative reverse transcribed polymerase chain reaction (RT-PCR). HA synthesis was significantly augmented with 1ng/ml of IL-1beta for both 24 and 48h stimulation, however the production of HA declined if stimulated with 10ng/ml of IL-1beta. The expression of HAS2 and 3 mRNA were enhanced about 4.2- and 7.2-fold after 4h stimulation with 1ng/ml of IL-1beta, respectively. From these results, it is concluded that IL-1beta functions on regulating HAS expression and consequently promoting the secretion of HA in synovial lining cells from TMJ.

Magnitude and variability of loading on the osseointegrated implant of transfemoral amputees during walking.

This study directly measured the load acting on the abutment of the osseointegrated implant system of transfemoral amputees during level walking, and studied the variability of the load within and among amputees. Twelve active transfemoral amputees (age: 54 +/- 12 years, mass: 84.3 +/- 16.3 kg, height: 17.8 +/- 0.10 m) fitted with an osseointegrated implant for over 1 year participated in the study. The load applied on the abutment was measured during unimpeded, level walking in a straight line using a commercial six-channel transducer mounted between the abutment and the prosthetic knee. The pattern and the magnitude of the three-dimensional forces and moments were revealed. Results showed a low step-to-step variability of each subject, but a high subject-to-subject variability in local extrema of body-weight normalized forces and moments and impulse data. The high subject-to-subject variability suggests that the mechanical design of the implant system should be customized for each individual, or that a fit-all design should take into consideration the highest values of load within a broad range of amputees. It also suggests specific loading regime in rehabilitation training are necessary for a given subject. Thus the loading magnitude and variability demonstrated should be useful in designing an osseointegrated implant system better able to resist mechanical failure and in refining the rehabilitation protocol.

Using computational simulation to aid in the prediction of socket fit: a preliminary study.

This study illustrates the use of computational analysis to predict prosthetic socket fit. A simple indentation test is performed by applying force to the residual limb of a trans-tibial amputee through an indenter until the subject perceives the onset of pain. Computational finite element (FE) analysis is then applied to evaluate the magnitude of pressure underlying the indenter that initiates pain (pain threshold pressure), and the pressure at the prosthetic socket-residual limb interface. The assessment of socket fit is examined by studying whether or not the socket-limb interface pressure exceeds the pain threshold pressure of the limb. Based on the computer-aided assessment, a new prosthetic socket is then fabricated and fitted to the amputee subject. Successful socket fit is achieved at the end of this process. The approach of using computational analysis to aid in assessing socket fit allows a more efficient evaluation and re-design of the socket even before the actual fabrication and fitting of the prosthetic socket. However, more thorough investigations are required before this approach can be widely used. A subsequent part of this paper discusses the limitations and suggests future research directions in this area.

Kinetics of transfemoral amputees with osseointegrated fixation performing common activities of daily living.

BACKGROUND: Direct anchorage of a lower-limb prosthesis to the bone through an implanted fixation (osseointegration) has been suggested as an excellent alternative for amputees experiencing complications from use of a conventional socket-type prosthesis. However, an attempt needs to be made to optimize the mechanical design of the fixation and refine the rehabilitation program. Understanding the load applied on the fixation is a crucial step towards this goal. METHODS: The load applied on the osseointegrated fixation of nine transfemoral amputees was measured using a load transducer, when the amputees performed activities which included straight-line level walking, ascending and descending stairs and a ramp as well as walking around a circle. Force and moment patterns along each gait cycle, magnitudes and time of occurrence of the local extrema of the load, as well as impulses were analysed. FINDINGS: Managing a ramp and stairs, and walking around a circle did not produce a significant increase (P>0.05) in load compared to straight-line level walking. The patterns of the moment about the medio-lateral axis were different among the six activities which may reflect the different strategies used in controlling the prosthetic knee joint. INTERPRETATIONS: This study increases the understanding of biomechanics of bone-anchored osseointegrated prostheses. The loading data provided will be useful in designing the osseointegrated fixation to increase the fatigue life and to refine the rehabilitation protocol.

Gait analysis of low-cost flexible-shank transtibial prostheses.

The latest lower-limb prosthetic designs have been incorporated with dynamic elastic response (DER) components to enhance prosthesis flexibility, which are suggested to be beneficial to gait. Although DER prosthetic. feet are preferred by most transtibial amputees and their benefits to gait are supported by some biomechanical studies, many are still utilizing the simple conventional solid ankle cushioned heel (SACH) designs because of the lower cost. The monolimb, a transtibial prosthesis with the socket and the shank molded from a single piece of thermoplastic material, perhaps is an alternative to DER feet for providing flexibility at the shank. In addition to shank flexibility, low cost and light weight are other characteristics of monolimbs. In spite of the potential benefits, little analysis has been done to examine the simple-structured monolimb prosthesis. The main aim of this study is to evaluate the gait and perception of unilateral transtibial amputees using a flexible elliptical-shank monolimb as compared to a thicker circular-shank monolimb and a conventional rigid-shank prosthesis. Results suggested that a properly designed monolimb may potentially offer similar functional advantages to the relatively expensive DER feet.

A numerical approach to evaluate the fatigue life of monolimb.

Monolimb refers to a transtibial prosthesis with the prosthetic socket and the shank being molded into one piece of thermoplastic material. Shank flexibility of a monolimb can improve gait and comfort. However, fatigue failure of monolimbs under cyclic walking load is an important concern. This study is to evaluate the fatigue life of a monolimb designed for a transtibial amputee, based on finite element analysis, the statistical Miner's rule and reliability analysis. Stress uncertainty due to modeling error and the scatter in fatigue test data were considered. Results indicated that the accuracy of fatigue life evaluation of monolimb depends significantly on the precision of stress estimation. In addition, relationship between fatigue failure probability and the number of walking steps was suggested providing a reference for clinicians to determine the interval of the inspection for the monolimb.

A robust design procedure for improvement of quality of lower-limb prosthesis.

Lower-limb prostheses are used to restore amputee's walking. Monolimb is one of the designs referring to socket and the shank being molded into one piece of thermoplastic material. Appropriate shank flexibility of a monolimb can improve gait of an amputee. However, during the fabrication, the variations of design variables are inevitably produced which may lead the unexpected shank deflection and directly influence on gait efficiency of an amputee. This paper presents a robust design procedure for improvement of quality of the monolimb by simultaneously minimizing performance variations caused by variations in design variables and bringing the mean value of performance on target. The robust design procedure embodies the integration of response surface methodology with genetic algorithms. Response surface models are developed for the responses of monolimb as functions of design variables over the region of interest and genetic algorithms are employed to find the robust solution. A robust design of monolimb is performed for an amputee subject and the results show that the robust design can design a "robust" monolimb which provides specified performance targets that are minimally sensitive to the variations of design variables. This indicates that robust design may have the potential application in improving the quality of the prescribed prosthesis.

Fatigue test of low-cost flexible-shank monolimb trans-tibial prosthesis.

Monolimb refers to a kind of trans-tibial prostheses with the socket and shank moulded into one piece of thermoplastic material. If properly designed, the shank of a monolimb can deflect which may compensate for the lost ankle plantarflexion and dorsiflexion to some extent. However, provision of shank flexibility is usually accompanied by reduced structural strength of the entire prosthesis. In the recent work using finite element analysis and the Taguchi method, the dimensions of the shank for the monolimb were derived which aimed at giving high shank flexibility and reasonable strength to resist static load. Yet, fatigue testing has not been performed. Fatigue failure may happen when a relatively low level of load is applied repeatedly. This study aimed to document the fatigue life of two flexible-shank monolimbs, by applying cyclic force of 800 N at the forefoot region for 500,000 cycles. Results showed that the design of the foot bolt adaptor played an important role in the structural integrity of the monolimb. One monolimb completed the fatigue test of 500,000 cycles without visual material yield, but with 3.8 degrees change in dorsiflexion angle when the load was removed.

Quantifying the regional load-bearing ability of trans-tibial stumps.

This paper reports findings of experiments aiming to (1) compare the load tolerant ability over different regions of stumps of lower limb amputees, (2) study the effect of walking on the load tolerant ability, and (3) examine the distal-end weight-bearing ability supported by different interface materials. The method was to apply increasing load to the stump up to the pain level through a force transducer or a digital scale, considering the effect of regional difference, walking, and interface materials. The results show that the patellar tendon and the distal end of the fibula were the best and worst load-tolerant region, respectively. Walking with prostheses tended to increase the load-tolerant ability, which is thought to be due to the massage-like effect of the socket. Different interface materials did not significantly alter the distal-end weight-bearing ability. However, there was a great difference in the distal-end weight-bearing ability among different subjects.

Design of monolimb using finite element modelling and statistics-based Taguchi method.

BACKGROUND: Monolimb is a transtibial prosthesis having the socket and shank molded into one piece of thermoplastic material. If properly designed, the shank of a monolimb can have a controlled deflection during walking which simulates the ankle joint motions to some extent. However, there is no clear guidance for the design of monolimb considering the dilemma between shank flexibility and structural integrity. METHODS: Finite element analysis was used to simulate structural tests based on ISO10328 on monolimbs of different configurations. Statistics-based Taguchi method was employed to identify the significance of each design factor in controlling the deformation and stress within monolimbs. The design factors considered were the thickness of the thermoplastics, anteroposterior and medialateral dimensions of the elliptical shank, and depth of the posterior seam line. By progressively fine-tuning the design factors, the monolimb configuration was optimized giving offering appropriate flexibilities of the shank and would not structurally fail in normal uses. Experimental structural test was used to validate the finite element model. FINDINGS: Anteroposterior dimension of the shank was shown to be the most important design factor determining the peak von Mises stress values, deformation and dorsiflexion angles of monolimbs. Depth of seam line appears much less important than the other three factors. A monolimb fulfilling the design requirements was suggested. Experimental test results reasonably matched with the finite element results. INTERPRETATION: Finite element analysis and Taguchi method was shown to be an effective method in optimizing the structural design of prostheses. Further prosthetic design can be facilitated based on the degree of importance of the design factors on the structural behavior of the prosthesis. Gait analysis of amputees using the suggested monolimb design is needed in the future.

A quasi-dynamic nonlinear finite element model to investigate prosthetic interface stresses during walking for trans-tibial amputees.

BACKGROUND: To predict the interface pressure between residual limb and prosthetic socket for trans-tibial amputees during walking. METHODS: A quasi-dynamic finite element model was built based on the actual geometry of residual limb, internal bones and socket liner. To simulate the friction/slip boundary conditions between the skin and liner, automated surface-to-surface contact was used. Besides variable external loads and material inertia, the coupling between the large rigid displacement of knee joint and small elastic deformation of residual limb and prosthetic components were also considered. RESULTS: Interface pressure distribution was found to have the same profile during walking. The high pressures fall over popliteal depression, middle patella tendon, lateral tibia and medial tibia regions. Interface pressure predicted by static or quasi-dynamic analysis had the similar double-peaked waveform shape in stance phase. INTERPRETATION: The consideration of inertial effects and motion of knee joint cause 210% average variation of the area between the pressure curve and the horizontal line of pressure threshold between two cases, even though there is only a small change in the peak pressure. The findings in this paper show that the coupling dynamic effects of inertial loads and knee flexion must be considered to study interface pressure between residual limb and prosthetic socket during walking.

High-intensity stepwise conditioning programme for improved exercise responses and agility performance of a badminton player with knee pain.

OBJECTIVE: To examine the effect of a high-intensity stepwise conditioning programme combined with multiple recovery measures on physical fitness, agility, and knee pain symptoms of an injured player. DESIGN: A single case study. SETTING: University-based conditioning training laboratory. PARTICIPANTS: One 26-year-old male world-class badminton player (height, 190.0 cm; weight, 79.3 kg; left dominant hand; playing experience, 16 years; former world champion) with patellar tendinosis and calcification of his left knee. HIGH-CONDITIONING STEPWISE CONDITIONING PROGRAMME: The player received seven conditioning sessions over three weeks. During the programme, there was a gradual increase in training duration and load across sessions while cold therapy, manual stretches and massage were administered after each session to minimise inflammation. MAIN OUTCOME MEASURES: The training outcome was evaluated with three different testing methods: standard step test, badminton-specific agility test, and tension-pain rating. RESULTS: The conditioning programme reduced knee pain symptoms and improved actual performance and cardiopulmonary fitness during the agility task. The player was able to return to sport and compete within a month. CONCLUSIONS: A high-intensity stepwise conditioning programme improved the physical fitness while sufficient recovery measures minimised any possible undesirable effects and promoted faster return to elite level competition.

Does long-distance walking improve or deteriorate walking stability of transtibial amputees?

BACKGROUND: Falls are common in transtibial amputees which are linked to their poor stability. While amputees are encouraged to walk more, they are more vulnerable to fatigue which leads to even poorer walking stability. The objective of this study was to evaluate the dynamic stability of amputees after long-distance walking. METHODS: Six male unilateral transtibial amputees (age: 53 (SD: 8.8); height: 170cm (SD: 3.4); weight: 75kg (SD: 4.7)) performed two sessions (30minutes each) of treadmill walking, separated by a short period of gait tests. Gait tests were performed before the walking (baseline) and after each session of treadmill walking. Gait parameters and their variability across repeated steps at each of the three conditions were computed. FINDINGS: There were no significant differences in walking speed, step length, stance time, time of occurrence, and magnitude of peak angular velocities of the knee and hip joint (P>0.05). However, variability of knee and hip angular velocity after 30-minute walking was significantly higher than the baseline (P<0.05) and after a total of 60-minute walking (P<0.05). The variability of lateral sway velocity after 30-minute walking was significantly higher than the baseline (P<0.05). INTERPRETATION: The significant increase in variability after 30-minute walking could indicate poorer walking stability when fatigue was developed, while the significant reduction after 60-minute walking might indicate the ability of amputees to restore their walking stability after further continuous walking.

Load transfer mechanics between trans-tibial prosthetic socket and residual limb--dynamic effects.

The effects of inertial loads on the interface stresses between trans-tibial residual limb and prosthetic socket were investigated. The motion of the limb and prosthesis was monitored using a Vicon motion analysis system and the ground reaction force was measured by a force platform. Equivalent loads at the knee joint during walking were calculated in two cases with and without consideration of the material inertia. A 3D nonlinear finite element (FE) model based on the actual geometry of residual limb, internal bones and socket liner was developed to study the mechanical interaction between socket and residual limb during walking. To simulate the friction/slip boundary conditions between the skin and liner, automated surface-to-surface contact was used. The prediction results indicated that interface pressure and shear stress had the similar double-peaked waveform shape in stance phase. The average difference in interface stresses between the two cases with and without consideration of inertial forces was 8.4% in stance phase and 20.1% in swing phase. The maximum difference during stance phase is up to 19%. This suggests that it is preferable to consider the material inertia effect in a fully dynamic FE model.

Finite element modeling of the contact interface between trans-tibial residual limb and prosthetic socket.

Finite element method has been identified as a useful tool to understand the load transfer mechanics between a residual limb and its prosthetic socket. This paper proposed a new practical approach in modeling the contact interface with consideration of the friction/slip conditions and pre-stresses applied on the limb within a rectified socket. The residual limb and socket were modeled as two separate structures and their interactions were simulated using automated contact methods. Some regions of the limb penetrated into the socket because of socket modification. In the first step of the simulation, the penetrated limb surface was moved onto the inner surface of the socket and the pre-stresses were predicted. In the subsequent loading step, pre-stresses were kept and loadings were applied at the knee joint to simulate the loading during the stance phase of gait. Comparisons were made between the model using the proposed approach and the model having an assumption that the shape of the limb and the socket were the same which ignored pre-stress. It was found that peak normal and shear stresses over the regions where socket undercuts were made reduced and the stress values over other regions raised in the model having the simplifying assumption.

Evaluation of the Microsoft Kinect as a clinical assessment tool of body sway.

Total body center of mass (TBCM) is a useful kinematic measurement of body sway. However, expensive equipment and high technical requirement limit the use of motion capture systems in large-scale clinical settings. Center of pressure (CP) measurement obtained from force plates cannot accurately represent TBCM during large body sway movement. Microsoft Kinect is a rapidly developing, inexpensive, and portable posturographic device, which provides objective and quantitative measurement of TBCM sway. The purpose of this study was to evaluate Kinect as a clinical assessment tool for TBCM sway measurement. The performance of the Kinect system was compared with a Vicon motion capture system and a force plate. Ten healthy male subjects performed four upright quiet standing tasks: (1) eyes open (EOn), (2) eyes closed (ECn), (3) eyes open standing on foam (EOf), and (4) eyes closed standing on foam (ECf). Our results revealed that the Kinect system produced highly correlated measurement of TBCM sway (mean RMSE=4.38 mm; mean CORR=0.94 in Kinect-Vicon comparison), as well as comparable intra-session reliability to Vicon. However, the Kinect device consistently overestimated the 95% CL of sway by about 3mm. This offset could be due to the limited accuracy, resolution, and sensitivity of the Kinect sensors. The Kinect device was more accurate in the medial-lateral than in the anterior-posterior direction, and performed better than the force plate in more challenging balance tasks, such as (ECf) with larger TBCM sway. Overall, Kinect is a cost-effective alternative to a motion capture and force plate system for clinical assessment of TBCM sway.

Effects of long-distance walking on socket-limb interface pressure, tactile sensitivity and subjective perceptions of trans-tibial amputees.

PURPOSE: Many trans-tibial amputees could not tolerate long-distance walking. Lack of walking could explain for the increased cardiovascular diseases mortality rate. This study investigated the effects of long-distance walking (LDW) on socket-limb interface pressure, tactile sensitivity of the residual limb, and subjective feedbacks, which potentially identified the difficulties in LDW. METHOD: Five male unilateral trans-tibial amputees walked on a level treadmill for a total of one hour at comfortable speed. Tactile sensitivity of the residual limb and socket-limb interface pressure during over-ground walking were measured before and after the treadmill walking. Modified Prosthesis Evaluation Questionnaires were also administered. RESULTS: After the treadmill walking, the socket-limb interface pressure and the tactile sensitivity at the popliteal depression area were significantly reduced. This corresponds well with the questionnaire results showing that the level of discomfort and pain of the residual limb did not increase. The questionnaire revealed that there were significant increases in fatigue level at the sound-side plantar flexors, which could lead to impaired dynamic stability. CONCLUSIONS: Fatigue of sound-side plantar-flexor was the main difficulty faced by the five subjects when walking long-distances. This finding might imply the importance of refining prosthetic components and rehabilitation protocols in reducing the muscle fatigue. IMPLICATIONS FOR REHABILITATION: • After long-distance walking (LDW) of the trans-tibal amputee subjects, there were significant increases in fatigue level at the plantar flexors. These might explain the reduced walking stability as perceived by the subjects. • LDW did not produce any problems in residual-limb comfort and pain feeling. These were in line with the significant reductions of socket-limb interface pressure and the tactile sensitivity at the popliteal depression after LDW. • Refinements of prosthetic components and rehabilitation protocols should be attempted to reduce the fatigue of the plantar flexors and facilitate LDW.

Effects of heel lifting on transtibial amputee gait before and after treadmill walking: a case study.

BACKGROUND: Prosthetic alignment is usually unchanged once optimized. However, a previous study indicated that long-distance walking significantly altered gait patterns, suggesting some alignment adjustments after walking are required. This study investigated the effects of alignment changes (by inserting a heel lift) on gait of a transtibial amputee before and after treadmill walking. CASE DESCRIPTION AND METHODS: The subject walked, without heel lifts, on a treadmill until perception of fatigue. Gait changes upon heel lifting at the prosthetic side were studied before and after the treadmill walking FINDINGS AND OUTCOMES: For this subject before the treadmill walking, heel lifting induced drop-off with increased prosthetic-side knee flexion at mid-stance and pre-swing. The sound limb outreached to stabilize the gait. After the treadmill walking, the same heel lift did not induce drop-off. It reduced the plantar flexor power generation, potentially delaying its fatigue. CONCLUSION: After walking prosthetic-side heel lifting could be beneficial. CLINICAL RELEVANCE: Many lower-limb amputees have difficulties in long-distance walking due to muscle fatigue. This case study proposes that appropriate alignment changes after some walking potentially relieve fatigue and encourage them to walk longer distances.