Motion analysis and postural stability of transtibial prosthesis users

The aims of the thesis were to critically evaluate motion analysis methods used during investigations of transtibial prosthesis users, and to propose improvements to these methods. Additionally, the aim was to evaluate if vibratory feedback could be used to improve postural stability in transtibial prosthesis users and how being a prosthesis user influenced muscular response to postural perturbations. Methodological issues make interpretation of kinematics of transtibial prosthetic users difficult and motion of the prosthetic foot is not the same in different designs of prosthetic feet or compared to an intact limb. Vibratory feedback can be used to improve some aspects of postural stability, and automatic postural responses are slower in transtibial prosthesis users than in able-bodied controls. These findings contribute to the understanding of how researchers model motion of transtibial prosthesis users and how this group maintains postural stability with a prosthesis. The relationship of the bodys centre of mass (CoM) to the base of support (BoS). A state of unbalance would be one where the CoM is outside of the BoS. The measure of state of balance can be assessed using many tests of postural stability. The area contained within the perimeter of contact and the support surface.
The vertical position of the centre of mass.

Balance

Base of Support (BoS) Centre of Gravity (CoG) Centre of Mass (CoM)

The net three-dimensional position of the weighted average of all mass segments in a body. The calculated mean bi-planar position of all vertical forces applied to the top surface of a forceplate. The length of time for a muscular reaction to reach a predetermined threshold.

Centre of Pressure (CoP)

EMG Onset Latency

Functional Joint Centre (FJC)

A joint location used in motion analysis which is analytically determined from previously captured motion data. The vector sum of the individual x-,y-,zcomponents of all the forces applied by an object to the surface of a forceplate. The origin of the GRF is the CoP.

Ground Reaction Force (GRF)

Instant Centre of Rotation (ICR)

The calculated 2-dimensional centre of rotation at any point in time. Requires knowing the position of two segments in relation to each other at two subsequent points in time. The area of mechanics which describes the translations and rotations of bodies without description of the forces or moments producing movements. The maximum distance a person is able to shift their CoG from a central position without falling or shifting foot position. The basic building block of motion analysis. These are the objects attached to body segments and/or joints in order to describe the position of the object in relation to some previously determined frame of reference. These markers can be active or passive. The field of study which focuses on describing/analyzing how things move.

Kinematics

Limits of Stability (LoS)

Marker

Motion Analysis

Postural Stability

The dynamic process which monitors and maintains upright stance. The process of not falling. The term used to describe the relative stability of a person in an upright position. An externally applied challenge to a postural task. Can include physical, cognitive, optical, vestibular, or pharmacological perturbations. An amputation which bisects the tibia. Can be due to trauma or disease. Results in the total removal of the ankle, but leaves some remnant of the tibia. A device used to convert electrical charge via a controller into a mechanical vibration.

Postural Perturbation

Transtibial Amputation

Vibratory Tactor

Individuals with a unilateral transtibial amputation (TTA) have had a complete removal of the anatomical ankle. This lack of an ankle joint presents many challenges in physical function as they must conduct the same tasks as able-bodied individuals, but with a prosthesis. Although advances in prosthetic technology mean that transtibial prosthetic users can perform many of the activities ablebodied individuals are able to, they must compensate as a result of the prosthetic limb.As part of the process of improving performance researchers are often interested in quantifying physical function of

prosthetic users. One common method used to evaluate physical function as it relates to physical movement is three-dimensional motion analysis. In a clinical or research setting, motion analysis often refers to the study of motion of the human body. This can be accomplished using many different technologies. In the context of this thesis motion analysis refers to stereophotogrammetry, in which multiple video cameras capture the motion of markers placed on an individual whilst a motor task is conducted. By using a number of cameras it is possible to analytically determine three-dimensional position of markers based on the two-dimensional coordinates provided by individual cameras. This coordinate data is then used individually, or combined with further variables (such as kinetics and electromyography EMG) to make clinical decisions regarding: a diagnosis of disease assessment of disease severity , the progress of an intervention , prediction of the outcome of an intervention. In order to model three-dimensional human movement researchers must first record the three dimensional position of markers placed on the body. Markers used can be active (powered transmitter) or passive (reflective). They can be placed directly on the skin with double sided tape or attached as rigid clusters of markers on a backing plate which is subsequently fixed to the body using elastic or velcro (Figure 1). Once marker position has been established in threedimensional space, the next step is to define body segments and to define where the joints, connections between these segments, are located (Figure 2). As the movement of interest is actually that of the skeletal structures within the body, and it is not always possible to directly mount markers to the skeleton, it is necessary to model the motion utilizing movements from the surface of the body. For example, markers could be on the skin, clothing or, in the case of many orthopaedic applications, on a device such as a prosthetic limb.

Transtibial amputation refers to the surgical or traumatic removal of the foot and ankle, leaving some tibial-remnant. The intact knee anatomically and functionally separates a TTA from a more proximal amputation level such as knee-disarticulation or transfemoral amputation. The overall incidence of lower-limb amputation (all amputation distal to the pelvis) rates vary greatly between countries and regions with Europe, with reports between 16 and 34 cases per 100,000 inhabitants. The proportion of TTA of all lower-limb amputation has been reported to be between 28 and 74% depending on the cause of amputation and the region of the publication. The amputation rates and the rates of those who have been successfully fitted with a prosthesis differ greatly. If the cause of amputation is due to disease, successful fitting can be expected in between 50-65% of cases, while in those individuals who have had an amputation due to trauma, the likelihood of a functional recovery is higher. A transtibial prosthesis is typically constructed of a number of common components (Figure 3).

The prosthetic socket is the main component to which a prosthetist has influence over the design. This is the main structural interface between the residual limb and prosthesis with forces being transmitted between the prosthetic limb and socket via this interface. The socket can be made of different materials including plastic and various forms of fibre-composite (carbon-fibre, glass-fibre, etc.). The structural link between the socket and the prosthetic foot is the prosthetic pylon. This component can be rigid, or dynamic offering both rotational and translational shock absorption. There are many different designs of prosthetic feet available commercially and classification of these feet can be difficult. This is due to the fact that classification based on a structural criteria can belong to multiple groups based on a functional criteria. When conducting instrumented gait analysis of prosthesis users it is common to position the markers on the prosthetic limb based on the position of the markers of the intact limb. Sometimes this has been made through approximation and sometimes through a direct measurement from the remaining foot. This creates a source of error at both the knee and the ankle. As the prosthetic socket proximally in many cases prevents the attachment of reflective markers directly to the skin, it is necessary to attach markers to the outside of the prosthetic socket (Figure 4) Prosthetic feet have different FJCs from each other, in addition to that of an anatomical ankle. Reliability of the FJC method is adequate to justify continued use. The use of vibratory feedback as provided by the tested system caused increased mediolateral CoP excursion during standing balance, but reduced reaction times in the limits of stability test. The results suggest the system evaluated may have both beneficial and negative effects on different measures of postural stability. Transtibial prosthesis users have delayed EMG response latency times in muscles of both the intact and prosthetic limb. These delays were in the intact limb for both toes-up and toes-down direction, whereas the prosthetic limb was only delayed in toes-down direction. Limb-position influenced latency times in the intact limb, but not for the prosthetic limb, indicating unilateral compensation when the perturbation was received through the prosthesis.

Reaction times were separated into component directions for analysis. Right and left are reorganized to view shifts towards the prosthesis and towards the intact limb. The additional results show the prosthesis users respond slower in all directions when compared to similarly aged individuals, though the largest improvements with vibration come in the anterior direction, and in the direction of the prosthetic limb

Transtibial prosthesis users have a number of differences in relation to motion analysis and postural stability when compared to able-bodied individuals. The quality of the evidence that researchers are presenting in studies which utilize threedimensional kinematics of transtibial prosthesis users is generally low, but is improving with time. Efforts can be made in this area of research to make a positive systematic shift in the quality of the research presented. Additionally, there are large systematic errors present when rigid-body assumptions derived from the intact musculoskeletal system are applied to the motion of a prosthetic foot. These errors suggest that motion of prosthetic feet are different from each other and from an intact ankle. A simple feedback device, as part of the prosthetic limb, can positively improve the ability of transtibial prosthesis users to make rapid voluntary shifts of their centre of gravity. Additionally, prosthetic users make use of information about the pitch plane rotations of the support surface via the prosthetic limb. When these rotations are received through only the prosthetic limb they cause delayed reactions in the limb with the prosthesis and in the intact limb, indicating bilateral effects of unilateral amputation. Increased weight-bearing on the intact limb reduces the latency of response on the intact limb, but has no significant effect on the prosthetic side.

Bibliografie David Rusaw: Motion analysis and postural stability of transtibial prosthesis users, Department of Orthopaedics, Institute of clinical Sciences, Sahlgrenska Academy at University of Gothenburg, Goteborg 2011

Madalina Buzea Master IMC, an II

Motion analysis and postural stability of transtibial prosthesis users

Obiectivele acestei lucrari au fost de a evalua intr-un mod cat mai critic metodele de analiz pentru micare folosite n timpul investigaiilor de catre utilizatorii de proteze transtibiale, i s propun mbuntiri la aceste metode. In plus, scopul a fost de a evalua dac un feedback otolitic ar putea fi utilizat pentru a mbunti stabilitatea postural a utilizatorilor protezei transtibiale i cum a fi un utilizator de protez influenat de rspunsul muscular la perturbaia postural. Astfel, un simplu dispozitiv de feedback, ca parte a membrelor protetice, poate mbunti n mod pozitiv capacitatea utilizatorilor de proteze transtibiale de a face schimburi rapide si voluntare de centru de greutate. n plus, utilizatorii protezelor fac uz de informaii cu privire la rotaiile planare si la terenul suprafeei de sprijin prin intermediul membrelor protetice.

Buzea Madalina Master IMC An II