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 Table of Contents  
ORIGINAL ARTICLE
Year : 2018  |  Volume : 7  |  Issue : 2  |  Page : 75-79

Stride, energy expenditure, and user's satisfaction in person with postpolio residual paralysis: A comparative study between pneumatic control and drop-lock knee joint using knee-ankle-foot orthosis


Departments of and Prosthetics and Orthotics, ISIC-IRS, New Delhi, India

Date of Web Publication2-May-2018

Correspondence Address:
Ms. Prachi Prava Pattnaik
ISIC-IRS, New Delhi - 110 070
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijhas.IJHAS_61_1

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  Abstract 


BACKGROUND: Persons with postpolio residual paralysis (PPRP) present gait abnormalities due to residual lower extremity pareses and joint deformities.[1,2] An increase in energy cost results from lower extremity muscle weakness. Lower extremity orthoses are prescribed to reduce gait abnormalities, to enable standing and walking, and to maintain or improve physical performance. The present study is to determine the effectiveness of the newly designed pneumatic control knee joint [Figure 2] with respect to stride parameter, energy expenditure, and user's satisfaction in comparison to drop-lock knee joint [Figure 1] in knee-ankle-foot orthosis (KAFO) in a patient with PPRP.{Figure 1}{Figure 2}
METHODS: Purposive sampling was done for the study, and thirty patients were recruited. The stride parameter, energy expenditure, and user's satisfaction were measured between drop-lock knee joint KAFO and pneumatic control knee joint KAFO. An adaptation period of 1 h was provided with pneumatic control KAFO.
RESULTS: A paired t-test was conducted for estimating step length and stride length for subjects using drop-lock KAFO and Pnuematic control KAFO. Pneumatic Control KAFO showed a higher significance in both step length with (t = −5.150, P = 0.000) and Stride length (t = −5.026, P = 0.000). A paired t-test conducted for cadence shows a signifi cant difference (t = 1.066, P = 0.295) in favor of drop-lock KAFO. The speed shows a signifi cant difference (t = −4.704, P = 0.000) in favor of pneumatic control KAFO. Physiological cost index while walking with pneumatic control KAFO was signifi cantly lower than those walking with drop-lock KAFO (t = −5.575, P value = 0.000). The user's satisfaction for the subjects using the drop-lock KAFO and the pneumatic control KAFO shows a significant difference (t = −9.798, P = 0.000) in favor of pneumatic control KAFO.
CONCLUSION: The study concludes the pneumatic control KAFO to have significantly greater value as compared to drop-lock KAFO in terms of stride parameter and energy expenditure and user's satisfaction in subjects with PPRP.

Keywords: Energy expenditure, drop-lock knee-ankle-foot orthosis, pneumatic control knee-ankle-foot orthosis, stride parameter, user's satisfaction


How to cite this article:
Pattnaik PP, Kumar R, Kumari P. Stride, energy expenditure, and user's satisfaction in person with postpolio residual paralysis: A comparative study between pneumatic control and drop-lock knee joint using knee-ankle-foot orthosis. Int J Health Allied Sci 2018;7:75-9

How to cite this URL:
Pattnaik PP, Kumar R, Kumari P. Stride, energy expenditure, and user's satisfaction in person with postpolio residual paralysis: A comparative study between pneumatic control and drop-lock knee joint using knee-ankle-foot orthosis. Int J Health Allied Sci [serial online] 2018 [cited 2018 Nov 21];7:75-9. Available from: http://www.ijhas.in/text.asp?2018/7/2/75/231692


  Introduction Top


India was reported having largest polio-endemic country in the world, accounting for 20% during 2000.[3] The development of orthotic technology has been halted due to eradication of polio in developed countries.[4] The orthotic goal was to decrease the increasing physical weakness, in order to increase safety and stability and improve walking ability and safety with less pain. People suffering from postpolio residual paralysis (PPRP) require extensive orthotic and therapy interventions.[5]

In general, knee-ankle-foot orthosis (KAFO) or AFO is prescribed for polio survivors. Advances in technology have created more options in orthotic design and fabrication that adequately protect and assist paretic and paralyzed lower extremities in gait, standing, and transfer.[6] Persons with quadriceps muscles weakness are often prescribed a KAFO that locks the knee in full extension during both stance-and-swing (S-N-S) phases of gait. Locking the knee results in abnormal gait pattern characterized by hip hiking and leg circumduction during swing.[10] It has been reported that using conventional KAFO reduces gait efficiency by 24% and increases vertical displacement of the center of mass by 65% as well as energy expenditure.[7] Therefore, an increased rate of rejection using KAFO had been found.[10] In technological advancement, the use of stance control, electronic, or mechanical knee joints allow automatic locking during stance phase and automatic unlocking during swing phase.[8],[11]

Stance control KAFOs (SCKAFO) (stance control orthosis [SCO]) differ from traditional-locked knee counterparts by allowing free knee flexion during swing while providing stability during stance. It is widely accepted that free knee flexion during swing normalizes gait and therefore improves walking speed and reduces the energy requirements of walking. Limited research has been carried out to evaluate the benefits of SCOs when compared to locked KAFOs.[9] The current commercial SCKAFO are noisy, bulky, heavy, and expensive and in some cases are not effective in improving kinematic variables and energy expenditure. On the other hand, a pneumatic cylinder or S-N-S pneumatic system with auxiliary valves was introduced to control the knee joint in the transfemoral prosthesis. Although this system provided better control than the mechanical system, it was not applied in orthotic fields because it was just too heavy. Thus, a pneumatic cylinder is incorporated in free KAFO, i.e., light in weight as well as small in size, that permits free knee motion during swing while resisting knee flexion during stance, thereby supporting the limb during weight bearing.

Thus, the aim of this research is to study the effectiveness of a newly designed pneumatic control knee joint with respect to energy expenditure, stride, and user's satisfaction in comparison to drop-lock knee joint in KAFO in a person suffering from PPRP.


  Methods Top


The study was approved by the Institutional Ethics Committee of Indian Spinal Injuries Center-Institute of Rehabilitation Sciences, New Delhi. A sample size of 29 PPRP patients took part in the study according to convenience. The subjects were from Indian Spinal Injuries Center, New Delhi, and Vardhaman Mahaveer Vikalang Sansthan, New Delhi. The subject fulfilling the inclusion criteria and ready to accept the orthosis were selected for walking. The following inclusion criteria were patients having unilateral PPRP, aged 20–40 years, ability to walk for at least 4 min at a comfortable speed, able to walk independently without assistive devices, hip flexor strength at least Grade 3.

Procedure

The subjects participated in the study were screened according to the inclusion criteria, and the patients who consent to participate were included in the study. The detail information about the study was provided about the procedure. The subjects' stride parameter, energy expenditure, and user's satisfaction were measured using drop-lock KAFO. An adaptation period of 1 h provided for pneumatic control KAFO. The stride characters were measured using 10-m paper walk test, energy expenditure by subtracting resting heart rate from walking heart rate divided by speed using pulse oximeter and stopwatch. The user's satisfaction measured with orthotic prosthetic user's survey questionnaire.

Data analysis

Data were analyzed using SPSS Software (version 23). Paired t-test was used to analyze the difference between stride characteristics, energy expenditure, and user's satisfaction with P < 0.05.


  Results Top


A sample of 29 subjects with unilateral PPRP took part in this study. A paired t-test was used to compare the difference between drop-lock KAFO and pneumatic control KAFO. The group consists of 29 subjects with a mean age of 31.77 ± 7.040 years and mean body mass index was 22.917 ± 1.55 tabled in [Figure 3](a). The various parameters taken in study comparative analysis was tabled in [Figure 3](b). A paired t-test conducted for the comparative study of step length for the subjects using the drop-lock KAFO and the pneumatic control KAFO shows a significant difference (t = −5.150, P = 0.000) in favor of pneumatic control KAFO in [Figure 4]. The comparative study of the results of stride length for drop-lock KAFO and pneumatic control KAFO shows a significant difference (t = −5.026, P = 0.000) in favor of pneumatic control KAFO [Figure 5]. The cadence for the subjects using the drop-lock KAFO and the pneumatic control KAFO shows a significant difference (t = 1.066, P = 0.295) in favor of drop-lock KAFO [Figure 6]. A paired t-test conducted for the comparative study of the results of speed for the subjects using the drop-lock KAFO and the pneumatic control KAFO shows a significant difference (t = −4.704, P = 0.000) in favor of pneumatic control KAFO [Figure 7]. Physiological cost index while walking with pneumatic control KAFO were significantly higher than those walking with drop lock KAFO shown in [Figure 8] with a value of t value = -5.575, P value = 0.000. [Figure 9] represents the significant difference of t value = -9.798, P value = 0.000 for user's satisfaction in favor of pneumatic control KAFO.

Figure 3: (a) Demographic data. (b) Parameter value

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Figure 4: Comparison of step length between drop-lock and pneumatic control knee-ankle-foot orthoses

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Figure 5: Comparison of stride length between drop-lock and pneumatic control knee-ankle-foot orthoses

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Figure 6: Comparison of cadence between drop-lock knee-ankle-foot orthoses and pneumatic control knee-ankle-foot orthoses

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Figure 7: Comparison of speed between drop-lock and pneumatic control knee-ankle-foot orthoses

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Figure 8: Comparison of energy expenditure between drop-lock knee-ankle-foot orthoses and pneumatic control knee-ankle-foot orthoses

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Figure 9: Comparison of user's satisfaction between drop-lock and pneumatic control knee-ankle-foot orthoses

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  Discussion Top


In this study, walking with pneumatic control KAFO significantly increased the step length (mean = 60.04 ± 16.475, P = 0.000) and significantly increased the stride length (mean = 121.876 ± 33.786, P = 0.000) as compared to walking with standard drop-lock KAFO. According to Irby, Bernhardt, Kaufman, SCO significantly increased the step length and stride length. In this study also, walking with a pneumatic control KAFO significantly increased speed compared with walking with a standard drop-lock KAFO. This is supported by earlier studies in which walking with an SCO increased speed and decreased energy expenditure walking with an ordinary KAFO. Another study by Arazpour et al. reported walking with the powered KAFO significantly reduced walking speed (P = 0.015) and the distance walked (P = 0.004), and also, it did not improve physiological cost index values (P = 0.0009) compared to walking with the locked KAFO.

The cadence for walking with drop-lock KAFO (mean = 73.073 ± 15.736) and pneumatic control KAFO (mean = 69.814 ± 17.3084). There was not a statistically significant difference among the two joints, but clinically, there was some difference found. The cadence was better in case of drop-lock KAFO due to low adaptation period provided and lack of confidence of users.

Physiological cost index while walking with a pneumatic control was significantly less than those obtained with a drop-lock KAFO, indicating that the pneumatic control KAFO improved the energy expenditure of subject with PPRP. This is supported by earlier studies in which walking with an SCO decreased energy expenditure walking with an ordinary KAFO.

The user's satisfaction with drop-lock KAFO (mean = 88.83 ± 5.983, P = 0.000) and pneumatic control KAFO (mean = 103.21 ± 6.721) indicating pneumatic control KAFO improved the user's satisfaction level. Mc Millan et al. also found a greater patient satisfaction with an SCO. With an SCO, the patient found it easier to walk and they were more mobile than with a locked KAFO. These data suggested that both the KAFOs are compatible to the unilateral PPRP subjects. This is found that the pneumatic control KAFO was better in terms of step length, stride length, speed, energy expenditure, and user's satisfaction. The cadence using pneumatic control KAFO was minimal. The ultimate effect is to show effect on stride characteristics, energy expenditure, and user's satisfaction in PPRP subjects using two biomechanical KAFOs which may help the clinicians in selecting the KAFO during the prescription of PPRP subjects. The future research will involve postpolio syndrome or postpolio squeal subjects in broadened aspect. As the earlier mentioned, this study uses a small sample of subjects and that to form the same community. The relevance of this study can be increased by taking a large sample of subjects from different sectors of society. This study can be continued with different parameters.


  Conclusion Top


The study concludes that stride characteristics in terms of step length, stride length, and speed while walking with pneumatic control KAFO were significantly greater than those obtained with drop-lock KAFO. The energy expenditure also significantly improved in pneumatic control KAFO. However, there was no significant difference in cadence. Thus, this indicates an improvement in gait of polio survivors. Thus, the hypothesis is that there is a significant difference in between stride parameter, energy expenditure, as well as user's satisfaction in person with PPRP.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Maheswari J. Essential Orthopaedics. 4th ed. New Delhi: Jaypee Brothers Medical Publisher; 2011.  Back to cited text no. 1
    
2.
Abdulraheem IS, Saka MJ, Saka AO. Postpolio syndrome: Epidemiology, pathogenesis and management. J Infect Dis Immun 2011;3:247-57.  Back to cited text no. 2
    
3.
Baliga S, Mcmillan T, Sutherland A, Sharan D. The prevalence and severity of joint problems and disability in patients with poliomyelitis in urban India. Open Orthop J 2015;9:204-9.  Back to cited text no. 3
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Achu K. Development of Prefabricated Knee Ankle Foot Orthosis (PFKAFO) Components, Dissemination and Transfer of Technology; 2007. p. 21-5.  Back to cited text no. 4
    
5.
Hachisuka K, Makino K, Wada F, Saeki S, Yoshimoto N. Oxygen consumption, oxygen cost and physiological cost index in polio survivors: A comparison of walking without orthosis, with an ordinary or a carbon-fibre reinforced plastic knee-ankle-foot orthosis. J Rehabil Med 2007;39:646-50.  Back to cited text no. 5
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6.
Arazpour M, Ahmadi Bani M, Samadian M, Mousavi ME, Hutchins SW, Bahramizadeh M, et al. The physiological cost index of walking with a powered knee-ankle-foot orthosis in subjects with poliomyelitis: A pilot study. Prosthet Orthot Int 2016;40:454-9.  Back to cited text no. 6
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7.
Singh AK, Singh U, Wangjam K, Kiba NJ, Nandabir Y. Acceptability of conventional lower limb orthoses in the rural areas. Int J Pharm Med Res 2001;12:19-24.  Back to cited text no. 7
    
8.
Hsu JD, Michael JW, Fisk JR. AAOS Atlas of Orthoses and Assistive Devices. 4th ed. Philadelphia: Mosby Elsevier; 2008.  Back to cited text no. 8
    
9.
Spring AN, Kofman J, Lemaire ED. Design and evaluation of an orthotic knee-extension assist. IEEE Trans Neural Syst Rehabil Eng 2012;20:678-87.  Back to cited text no. 9
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Rafiaei M, Bahramizadeh M, Arazpour M, Samadian M, Hutchins SW, Farahmand F, et al. The gait and energy efficiency of stance control knee-ankle-foot orthoses: A literature review. Prosthet Orthot Int 2016;40:202-14.  Back to cited text no. 10
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11.
Hwang S, Kang S, Cho K, Kim Y. Biomechanical effect of electromechanical knee-ankle-foot-orthosis on knee joint control in patients with poliomyelitis. Med Biol Eng Comput 2008;46:541-9.  Back to cited text no. 11
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    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9]



 

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