Amputation
Conditions
Keywords
Stability, Locomotion, Motor Control, Trip, Falls, Upper Limb Loss, Prosthesis, Arm
Brief summary
Recent investigations have suggested that persons with upper limb loss experience a high prevalence of falls with a quarter of reported falls resulting from a trip. Moreover, studies indicate that missing part of an arm may negatively impact balance and that use of a prosthesis exacerbates this problem. While the investigators are beginning to understand the effects of upper limb loss on balance, the understanding of how Veterans with upper limb loss respond to walking disturbances is incomplete. Therefore, the aims of this study are to observe the effects of upper limb loss and wearing a prosthesis on the preparation and recovery of Veterans who trip during walking. The investigators plan to use unique treadmill technology to deliver controlled, yet unexpected, perturbations to Veterans with upper limb loss and non-amputee controls, and assess walking stability through body dynamics. Results from this study will help us understand why Veterans with upper limb loss fall as a critical first step to addressing this problem through balance-targeted interventions that are integrated into patient care.
Detailed description
The primary aim of this pilot study is to characterize the proactive and reactive locomotor response of Veterans with upper limb loss (ULL) to a trip during walking. The investigators' recent VA-funded investigations have suggested that persons with ULL experience a high prevalence of falls and demonstrate postural control mechanisms that may impair stability. Specifically, nearly half of individuals with ULL at or proximal to the wrist level experience at least one fall per year and almost a third will experience two or more falls. Further, use of a prosthesis increases the likelihood of falling by six times, 25% of reported falls resulted from tripping, and nearly a third of individuals who experience a fall suffer a fall-related injury. Falls can have considerable economic burden on the VHA and lead to long-term diminished quality of life. The investigators' biomechanical studies suggest that persons with unilateral ULL display greater postural sway during standing than able-bodied individuals which increases when wearing a prosthesis, and right/left asymmetry in locomotor stability dynamics that may increase the risk of falling toward the impaired limb side and during sound limb side strides. These findings emphasize the need for additional research to better understand the mechanisms Veterans with ULL use to control balance and how wearing a prosthesis affects these strategies. As the investigators' previous research was concerned with steady-state characterization of postural control, the investigators now plan to build on this work by studying the effects of ULL and wearing a prosthesis on locomotor stability when responding to a trip disturbance during walking. In this context, locomotor stability is defined as the ability to recover from a perturbation and return to steady-state gait. The investigators will address the study aims by analyzing trip-induced proactive and reactive locomotor strategy differences in two study comparisons: 1) Veterans with unilateral transradial level ULL against matched able-bodied controls (with and without one arm bound), and 2) Veterans with unilateral transradial ULL when wearing their customary prosthesis against not wearing their prosthesis. Controlled, yet unexpected, simulated trips will be delivered through the investigators' custom-built treadmill which permits programmable belt velocity disturbances and allows participants to continue walking following recovery. The investigators will characterize the proactive and reactive locomotor stability mechanisms through a set of biomechanical (angular momentum, arm and trunk kinematics) variables. Biomechanical variables will be quantified using an optical motion capture system. The investigators expect that Veterans with ULL will demonstrate altered locomotor stability mechanisms compared to controls, and these differences will exist between wearing and not wearing their customary prosthesis. Results from this study will help us characterize the underlying mechanisms of locomotor stability in Veterans with ULL and identify the factors associated with their increased prevalence of trip-related falls. Such knowledge is a critical first step to addressing this public health problem through stability-targeted rehabilitation interventions aimed at reducing falls, fall-related injuries, and associated VHA costs in this Veteran patient group. The investigators will use the outcomes from this pilot study to guide future VA Merit Award proposals to develop and assess physical training intervention methods and wearable and prosthetic technology to improve stability in Veterans with ULL. The VHA is an ideal venue to pursue this work as one of its main priorities is to elevate the standard-of-care for Veterans with limb loss.
Interventions
OTHERPerturbation
Participants from both cohorts will experience a simulated trip while walking on the treadmill. The trip is induced through a rapid acceleration and deceleration of the treadmill belt speed.
Sponsors
VA Office of Research and Development
Study design
Allocation
RANDOMIZED
Intervention model
CROSSOVER
Primary purpose
BASIC_SCIENCE
Masking
NONE
Masking description
No masking.
Intervention model description
Participants will receive a small treadmill belt disturbance while walking.
Eligibility
Sex/Gender
ALL
Age
18 Years to 65 Years
Healthy volunteers
Yes
Inclusion criteria
Participant inclusion criteria for all participants include: * age between 18 and 65 years * normal or corrected vision * able to walk unassisted for 20 minutes without undue fatigue or health risks Additional inclusion criteria for participants with ULL include: * unilateral ULL at the transradial level * most recent major upper limb amputation occurred at least one year prior to study * residuum and amputated side in good condition (no scars, infections, pain, etc.) * habitual experience using an upper limb prosthesis for at least one year * a self-reported comfortable prosthetic suspension
Design outcomes
Primary
| Measure | Time frame | Description |
|---|---|---|
| Whole-body Angular Momentum in Sagittal-plane; Momentum of the Body in the Sagittal Plane of Walking Progression | 1 hour | Whole-body angular momentum is the momentum of all limb segments about the Body Center of Mass (BCoM) summed. Whole-body angular momentum is estimated in the sagittal plane, which is the plane of walking progression, and the range of this value is normalized to a person's body mass, height, and walking speed. Whole body angular momentum is minimized by the central nervous system to facilitate postural control. For this study, whole body angular momentum range was averaged across the 12 perturbation trials and then across all participants. To note, the reported whole body angular momentum values are the relative increase from baseline to perturbation recovery that are all measured in the same session. There are no additional sessions as the baseline whole body angular momentum reflects those values before the perturbation trials. |
Secondary
| Measure | Time frame | Description |
|---|---|---|
| Shoulder Angle Flexion-extension Range | 1 hour | Range-of-motion for shoulder joint angle flexion-extension of the impaired or non-dominant arm (Deg) during perturbation recovery; Dynamics used for postural control to regulate and reduce whole-body angular momentum during trip response. |
| Trunk Flexion Angle | 1 hour | Maximum flexion angle (degrees) of the trunk during perturbation recovery. |
| Trunk Flexion Velocity | 1 hour | Maximum trunk flexion velocity (deg/s) during perturbation recovery |
Countries
United States
Participant flow
Recruitment details
10 participants with upper limb absence and 10 healthy controls were screened for eligibility between December 1 2020 and February 10 2022. Individuals with upper limb loss were recruited from clinics providing prosthetics care and education programs for prosthetics. Healthy controls were recruited from the Chicago community.
Pre-assignment details
All 20 participants agreed to participate and completed the study protocol.
Participants by arm
| Arm | Count |
|---|---|
| Healthy Controls Healthy controls without limb loss will receive a treadmill belt disturbance while walking. Able-bodied individuals will walk with both arms free and with one arm bound. | 10 |
| Upper Limb Absence Individuals with upper limb loss between the wrist and elbow will receive a treadmill belt disturbance while walking with and without their prosthesis. | 10 |
| Total | 20 |
Baseline characteristics
| Characteristic | Upper Limb Absence | Total | Healthy Controls |
|---|---|---|---|
| Age, Continuous | 44 years STANDARD_DEVIATION 15 | 44 years STANDARD_DEVIATION 15 | 44 years STANDARD_DEVIATION 16 |
| Race (NIH/OMB) American Indian or Alaska Native | 0 Participants | 0 Participants | 0 Participants |
| Race (NIH/OMB) Asian | 0 Participants | 0 Participants | 0 Participants |
| Race (NIH/OMB) Black or African American | 0 Participants | 2 Participants | 2 Participants |
| Race (NIH/OMB) More than one race | 1 Participants | 1 Participants | 0 Participants |
| Race (NIH/OMB) Native Hawaiian or Other Pacific Islander | 0 Participants | 0 Participants | 0 Participants |
| Race (NIH/OMB) Unknown or Not Reported | 0 Participants | 0 Participants | 0 Participants |
| Race (NIH/OMB) White | 9 Participants | 17 Participants | 8 Participants |
| Sex: Female, Male Female | 4 Participants | 8 Participants | 4 Participants |
| Sex: Female, Male Male | 6 Participants | 12 Participants | 6 Participants |
Adverse events
| Event type | EG000 affected / at risk | EG001 affected / at risk | EG002 affected / at risk | EG003 affected / at risk |
|---|---|---|---|---|
| deaths Total, all-cause mortality | 0 / 10 | 0 / 10 | 0 / 10 | 0 / 10 |
| other Total, other adverse events | 0 / 10 | 0 / 10 | 0 / 10 | 0 / 10 |
| serious Total, serious adverse events | 0 / 10 | 0 / 10 | 0 / 10 | 0 / 10 |
Outcome results
Primary
Whole-body Angular Momentum in Sagittal-plane; Momentum of the Body in the Sagittal Plane of Walking Progression
Whole-body angular momentum is the momentum of all limb segments about the Body Center of Mass (BCoM) summed. Whole-body angular momentum is estimated in the sagittal plane, which is the plane of walking progression, and the range of this value is normalized to a person's body mass, height, and walking speed. Whole body angular momentum is minimized by the central nervous system to facilitate postural control. For this study, whole body angular momentum range was averaged across the 12 perturbation trials and then across all participants. To note, the reported whole body angular momentum values are the relative increase from baseline to perturbation recovery that are all measured in the same session. There are no additional sessions as the baseline whole body angular momentum reflects those values before the perturbation trials.
Time frame: 1 hour
Population: Data collected for each participant during baseline and when recovering from the perturbation.
| Arm | Measure | Value (MEAN) | Dispersion |
|---|---|---|---|
| Healthy Controls Arms Free | Whole-body Angular Momentum in Sagittal-plane; Momentum of the Body in the Sagittal Plane of Walking Progression | 0.025 Unitless (normalized) | Standard Deviation 0.0006 |
| Upper Limb Absence Without Prosthesis | Whole-body Angular Momentum in Sagittal-plane; Momentum of the Body in the Sagittal Plane of Walking Progression | 0.031 Unitless (normalized) | Standard Deviation 0.006 |
| Healthy Controls One Arm Bound | Whole-body Angular Momentum in Sagittal-plane; Momentum of the Body in the Sagittal Plane of Walking Progression | 0.027 Unitless (normalized) | Standard Deviation 0.009 |
| Upper Limb Absence With Prosthesis | Whole-body Angular Momentum in Sagittal-plane; Momentum of the Body in the Sagittal Plane of Walking Progression | 0.028 Unitless (normalized) | Standard Deviation 0.006 |
Secondary
Shoulder Angle Flexion-extension Range
Range-of-motion for shoulder joint angle flexion-extension of the impaired or non-dominant arm (Deg) during perturbation recovery; Dynamics used for postural control to regulate and reduce whole-body angular momentum during trip response.
Time frame: 1 hour
Population: Range of motion of shoulder flexion-extension of the impaired (individuals with upper limb absence) or non-dominant arm (healthy controls) during perturbation recovery.
| Arm | Measure | Value (MEAN) | Dispersion |
|---|---|---|---|
| Healthy Controls Arms Free | Shoulder Angle Flexion-extension Range | 36 Degrees | Standard Deviation 18 |
| Upper Limb Absence Without Prosthesis | Shoulder Angle Flexion-extension Range | 34 Degrees | Standard Deviation 10 |
| Healthy Controls One Arm Bound | Shoulder Angle Flexion-extension Range | 5 Degrees | Standard Deviation 1 |
| Upper Limb Absence With Prosthesis | Shoulder Angle Flexion-extension Range | 31 Degrees | Standard Deviation 16 |
Secondary
Trunk Flexion Angle
Maximum flexion angle (degrees) of the trunk during perturbation recovery.
Time frame: 1 hour
Population: Controls with both arms free or one arm bound and persons with upper limb absence wearing or not wearing their prosthesis.
| Arm | Measure | Value (MEAN) | Dispersion |
|---|---|---|---|
| Healthy Controls Arms Free | Trunk Flexion Angle | 9.9 Degrees | Standard Deviation 3.1 |
| Upper Limb Absence Without Prosthesis | Trunk Flexion Angle | 10.1 Degrees | Standard Deviation 2.7 |
| Healthy Controls One Arm Bound | Trunk Flexion Angle | 10.1 Degrees | Standard Deviation 4.1 |
| Upper Limb Absence With Prosthesis | Trunk Flexion Angle | 10.2 Degrees | Standard Deviation 2.7 |
Secondary
Trunk Flexion Velocity
Maximum trunk flexion velocity (deg/s) during perturbation recovery
Time frame: 1 hour
Population: Controls with both arms free or one arm bound and persons with upper limb absence with or without their prosthesis.
| Arm | Measure | Value (MEAN) | Dispersion |
|---|---|---|---|
| Healthy Controls Arms Free | Trunk Flexion Velocity | 35.2 Degrees/second | Standard Deviation 6.3 |
| Upper Limb Absence Without Prosthesis | Trunk Flexion Velocity | 34.5 Degrees/second | Standard Deviation 9.3 |
| Healthy Controls One Arm Bound | Trunk Flexion Velocity | 37.2 Degrees/second | Standard Deviation 9.4 |
| Upper Limb Absence With Prosthesis | Trunk Flexion Velocity | 32.9 Degrees/second | Standard Deviation 10.8 |