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Prosthetics and Orthotics International
http://poi.sagepub.com/content/32/1/57
The online version of this article can be found at:

DOI: 10.1080/03093640701669108
2008 32: 57 Prosthet Orthot Int
D. A. Wright, L. Marks and R. C. Payne
A comparative study of the physiological costs of walking in ten bilateral amputees

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A comparative study of the physiological costs of walking
in ten bilateral amputees
D. A. WRIGHT
1
, L. MARKS
2
, & R. C. PAYNE
3
1
School of Sport and Education, Brunel University, Uxbridge, Middlesex,
2
North West London Hospitals
Trust, Royal National Orthopaedic Hospital, Brockley Hill, Stanmore, Middlesex, UK, and
3
Royal
Veterinary College, Hawkshead Lane, Hateld, Hertfordshire, UK
Abstract
The physiological cost of walking is greater in bilateral amputees (BA) than in both unilateral amputee
and non-pathological gait. The aim of this study was to describe the physiological costs and other
standard gait characteristics in a sample population of BA, walking at self-selected (comfortable) speeds.
Amputees had bilateral trans-tibial, bilateral trans-femoral or trans-tibial/trans-femoral amputations as a
result of trauma or congenital defects. All amputees wore their own prosthetic limbs which were either
full-length prostheses or short non-articulating pylon prostheses (SNAPPs). The results were compared
with a base line data set collected from a non-pathological control group. It was anticipated that
amputees with high-level amputations would walk at the slowest speeds, have the highest physiological
costs and lowest perception of walking ability. However, varying walking speeds resulted in varying
exercise intensities, exercise heart rates and perceptions of walking that could not be directly related to
amputation levels. It is therefore concluded that bilateral amputee gait is complex, varied and not easily
categorized.
Keywords: Human, prosthetic, gait, energetics, lower, limb
Introduction
During steady state, non-pathological walking, the selection of an optimum speed (normally
between 1.1 m/s and 1.4 m/s) and use of specic gait determinants serves to maintain gait
efciency (Saunders et al. 1953; Perry 1992). Limb pathologies such as lower-limb
amputation can result in a decrease in walking speed, which is known to reduce gait
efciency (Detrembleur et al. 2005). Abnormal movement patterns associated with amputee
gait are also likely to decrease the mechanical efciency of walking because body segment
movements become disjointed and typically awkward. This in turn affects the smoothness of
the pendular-like movement of the centre-of-mass (CoM); additional mechanical work is
needed to move the CoM and energy recovery during each step is signicantly lower when
compared to non-pathological walkers (Gitter et al. 1995; Tesio et al. 1998; Detrembleur
et al. 2005).
Correspondence: R. C. Payne, Royal Veterinary College, Hawkshead Lane, Hateld, Herts, UK. E-mail: rpayne@rvc.ac.uk
Prosthetics and Orthotics International
March 2008; 32(1): 57 67
ISSN 0309-3646 print/ISSN 1746-1553 online 2008 ISPO
DOI: 10.1080/03093640701669108
at Fund Diag.Est Imstico PARENT on November 13, 2013 poi.sagepub.com Downloaded from
Bilateral lower limb amputees (BA) nd walking increasingly more difcult as the level of
amputations increase (Waters et al. 1976). It is thus not surprising that research has found
bilateral amputee gait to be less efcient when compared to unilateral amputee and inevitably
non-pathological gait (Huang et al. 1979; Wainapel et al. 1985; Crouse et al. 1990; Hoffman
et al. 1997; Wu et al. 2001; Perry 2004). However, much of what we know about BA gait is
derived from case study (single patient) data (Wainapel et al. 1985; Crouse et al. 1990; Wu
et al. 2001; Perry 2004). Whilst this information is important for rehabilitation of the
individual, and comparison and performance studies between different types of limbs are
important for prosthetic manufactures, information gained from a larger population will help
researchers and clinicians to uncover relationships between form and function in BA gait
which could help inform future clinical decision making.
The aims of this study are: (i) To determine the physiological cost of walking, and (ii) to
record basic stride characteristics in a sample population of BA with differing levels of
amputation. It is hypothesized that of all lower-limb amputees, bilateral transfemoral
amputees (TF/TF) will experience the greatest physiological costs during walking, simply
because they have lost the greatest proportion of tissue and are likely to walk at the slowest
speeds. The objectives are to quantitatively assess aspects of gait in each individual walking for
a set duration (2, 4 or 6 min) at their self-selected walking speed whilst wearing the prostheses
that they have been rehabilitated with. Each individuals perceived exertion levels (Borg 1982)
during the walking test will be measured and a self-assessment questionnaire, adapted from
Boonstra et al. (1996), investigating their perceived walking ability will also be completed.
Subjects and methods
Ten male individuals with bilateral amputations participated in this study. Apart from their
amputations, each individual was to be healthy with no other relevant medical problems or
disabilities. Eight BA were recruited from The Royal National Orthopaedic Limb-Fitting
Centre (RNOH Stanmore, UK) and a further two were selected from the Preston Limb-
Fitting Centre (Disablement Services Centre, Preston, UK). Two had transtibial/transtibial
(TT/TT) amputations and wore full-length prostheses (FLPs), three had transfemoral/
transtibial (TF/TT) amputations and wore FLPs, two had transfemoral/transfemoral (TF/TF)
amputations and wore FLPs, one had bilateral knee disarticulations (KD/KD) and wore
FLPs, one had TT/TF and wore short non-articulating pylon prostheses (SNAPPs) and one
had TF/TF amputations and wore SNAPPs. Subject data including prosthetic type/design are
summarized in Table I. The mean age of the amputees was 40.5 years (+11.9 years) with a
range of 26 59 years. To enable comparison with able-bodied gait, a non-amputee (NA)
control group matched for gender and age was also examined.
Experiments were undertaken in the morning and all subjects had a light breakfast (i.e.,
cereal/toast and a hot drink) several hours before testing. The subjects wore their own
prostheses and walking stick use (if required) was permitted. The Ethics Committee at the
Royal National Orthopaedic Hospital (Stanmore) and Brunel University granted ethical
approval for the study. Subjects were required to attend a single testing session. Initially,
subjects completed a questionnaire relating to their perceived walking ability at normal
speeds. The questionnaire was based on multiple-choice questions (see the Appendix).
Low scores (6 was the lowest) indicated that the amputee perceived their walking ability to be
excellent and high scores (28 was the highest) indicated that walking was impossible.
Subjects were asked to walk for 6 min without stopping, but a 2- or 4-min option was
also offered for those who were not condent in walking for 6 min non-stop. Only amputees
9
S-TF/TF
and 10
S-TF/TF
(wearing SNAPPs) chose to walk for 6 min, all remaining amputees
58 D. A. Wright et al.
at Fund Diag.Est Imstico PARENT on November 13, 2013 poi.sagepub.com Downloaded from
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Physiological costs of walking in bilateral amputees 59
at Fund Diag.Est Imstico PARENT on November 13, 2013 poi.sagepub.com Downloaded from
selected the 2-min option. Subjects were instructed to walk at their normal walking speed. To
avoid sharp turns, a 30 m circular level walkway was demarcated in the gait laboratory.
Subjects were free to stop or abandon the test if needed. In order to directly compare data
between the amputees, gait parameters were only recorded during the rst 2 min of exercise
(however long they chose to walk for): time to complete 30 m, exercise heart rate (with a Polar
heart rate monitor), perceived level of exertion (Borg 1982) and number of steps taken over a
30 m stretch. Later, walking speed, cadence (number of steps per minute), step length (left
initial contact to right initial contact), body mass index (BMI), exercise intensity and
physiological cost index (PCI) were calculated. A detailed description of each parameter is
provided below.
Basic gait parameters
The physiological cost index (PCI; Butler et al. 1984) is a reliable estimation of metabolic
energy expenditure (Bailey and Ratcliffe 1995). PCI was calculated as follows:
PCIbeats=m
exerciseHR restingHR
velocity
Resting heart rate was recorded in the lab after the subject had been seated in a chair for
10 minutes. Exercise intensity was calculated as a percentage of the subjects estimated
maximum heart rate (Max HR220 age) using the following equation:
Intensity
ExerciseHR
Max HR
100
The Borg (1982) level of perceived exertion is a measure of the subjects perception of
exertion during exercise. The participant assigns a numerical value (6 20) to their perceived
level of exertion as shown in Table II.
Table II. Borgs rate of perceived exertion (RPE) (Borg 1982).
RPE
6
7 Very, very light
8
9 Very light
10
11 Fairly light
12
13 Somewhat hard (corresponds to approximately 60 80% of maximum heart rate)
14
15 Hard (corresponds to approximately 90% of maximum heart rate)
16
17 Very hard
18
19 Very, very hard
20
60 D. A. Wright et al.
at Fund Diag.Est Imstico PARENT on November 13, 2013 poi.sagepub.com Downloaded from
Results
The NA controls compared well with previously published data on non-pathological gait
(Hamill and Knutzen 1992; Winter 2005) and their data were therefore used in a comparison
with the bilateral amputee data. The NA controls generally had relatively fast walk speeds,
long step lengths, low PCIs and EIs compared to BA. The NA also had the lowest RPE and
PWA scores compared to BA wearing FLP. Physiological parameters and gait characteristics
are provided in Table III; the subjects are ordered according to mean walking speed from top
(fastest, 2
TT/TT
at 1.3 ms
71
) to bottom (slowest, 8
TF/TF
at 0.68 ms
71
). Subjects walking at
the fastest mean speeds (e.g., NAs, and amputees 2
TT/TT
and 1
TT/TT
) had both a relatively
long step length and a high cadence. Subjects walking at the slowest speeds (amputees 6
TF/TF
and 8
TF/TF
) had a relatively short step length and/or slow cadence. With the exception of
amputees 1
TT/TT
and 4
TT/TF
, exercise heart rate was always greater (480 bpm) than the
mean of the NA. In amputees 6
TF/TF
and 8
TF/TF
slower walking speeds did not result in lower
exercise heart rates.
For all BA, the physiological costs (PCI) of walking and exercise intensity (EI) were greater
than those calculated for the NA controls (Table III). Yet, there was no denite pattern
between the amputees and we did not necessarily observe the greatest PCI and EI in the
amputees with bilateral TF amputations (Table III). Amputees 6
TF/TF
, 8
TF/TF
, 3
TT/TF
and
5
TT/TF
had poor perceptions of their walking ability and reported the test to be somewhat
hard on the Borg scale of perceived exertion, which were matched with high values of PCI
and/or EI (Table III). This relationship between walking perception and physiological cost
was also observed in amputees 2
TT/TT
and 7
TF/TF
. Others (amputees 1
TT/TT
and 4
TF/TF
) had
lower levels of EI and PCI with high RPE or poor PWA scores, whereas amputees 9
S-TF/TF
and 10
S-TF/TF
(who walked with SNAPPs) had higher physiological costs, yet perceived
walking very, very light.
Discussion
This study provides novel data on the diversity in step characteristics, physiological costs and
perception of walking in people with differing levels of bilateral amputations when compared
with walking in a NA control group. All BA studied here had undergone prosthetic
rehabilitation and were considered by their limb tters to be successful walkers. The data
revealed that in a (relatively small) group of BA, walking speeds, exercise intensities, exercise
heart rates and perceptions of walking ability/performance were highly variable and not
necessarily linked to levels of amputation (i.e., TT/TT, TT/TF and TF/TF).
Walking speed
Amputees were instructed to walk at a self-selected walking speed, which was in all cases, as
expected, slower than the mean speed of the NA control group (see Table III). It was
hypothesized that walking speed would decrease as the level of amputations increased. This
hypothesis was only partially accepted as although amputees 2
TT/TT
and 1
TT/TT
had the
lowest levels of amputations and walked at the fastest speeds, the remaining amputees all
walked at a range of speeds (from 1.05 and 1.00 m/s in amputees 3
TT/TF
and 7
TF/TF
to
0.68 m/s in amputee 8
TF/TF
), which could not be related to level of amputations or type of
prostheses worn (i.e., type of FLPs or SNAPPs, Table III). Similar to non-pathological gait
(Sutherland 1997; and data collected from the authors NA control group), in this studys BA,
walking speed was linked to both cadence and step length. Amputees with the fastest walking
Physiological costs of walking in bilateral amputees 61
at Fund Diag.Est Imstico PARENT on November 13, 2013 poi.sagepub.com Downloaded from
T
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62 D. A. Wright et al.
at Fund Diag.Est Imstico PARENT on November 13, 2013 poi.sagepub.com Downloaded from
speeds used either a long step length and/or a fast cadence. BA may therefore select walking
speeds for reasons other than or in addition to the level of their amputations such as walking
situation and cardiovascular tness levels.
Physiological cost and exercise intensity
In previous work, both bilateral and unilateral amputees were found to reduce their chosen
walking speed so that their physiological energy costs are comparable with able-bodied
individuals (Huang et al. 1979; Gonzalez and Corcoran 1994). The present study did not
observe this relationship (Table III). Of the BA tested, the authors expected those with
bilateral TT amputations to have the fastest gaits with lower levels of physiological cost,
because they have fewer joints and musculature missing compared to those with TF
amputations. With the exception of amputee 2
TT/TT
, this relationship was not observed in our
study: Although all EI and PCI scores were greater (up to 5-fold) in BA when compared to
NA, the data were varied between amputees and differences could not easily be related to
either level of amputations or type of prosthetic design (Table III). There are several possible
reasons for this. Firstly, it is generally assumed that a symmetric gait is energetically most
efcient (Waters and Mulroy 1999; Mattes et al. 2000). In this study, disjointed gait patterns
were common, which could be a cause of high PCI and EI. Assistive gait may also have
increased energy expenditure in amputees 3
TT/TF
, 6
TF/TF
and 8
TF/TF
(Christensen 2002;
Chen et al. 2004). Furthermore, increased body weight caused by a sedentary lifestyle can
affect the respiratory, cardiovascular, muscular and metabolic systems (Waters and Mulroy
1999). Overweight/obese walkers will experience elevated rates of oxygen consumption which
can be greater than those recorded in fast walking in normal adults (i.e., decrease the
individuals maximal aerobic capacity VO
2
max (Saltin et al. 1968; Bassey et al. 1971;
Mattsson et al. 1997). The amputees studied here reported a decrease in physiological activity
since undergoing amputations, and half of the group (1
TT/TT
, 2
TT/TT
, 3
TT/TF
, 4
TT/TF
and 9
S-
TF/TF
) are medically classed as overweight (World Health Organization 1997) (see Table
III). Stewart and Jain (1992) found that cardiovascular disease (associated with obesity) is a
major cause of premature death among amputees. To help reduce this risk, a loss of just 20%
body weight has shown to reduce the rate of oxygen consumption during walking by
approximately 30% (Foster et al. 1995). Improved locomotion function could improve
cardiovascular health in BA and could by extension help reduce the risk of premature death
caused by obesity.
Walking perception
Perceived exertion is related to the physical sensations (e.g., increased heart rate, increased
respiration or breathing rate, increased sweating, and muscle fatigue) experienced during
walking. Although this is a subjective measure, a persons exertion rating has been shown to
provide a fairly good estimate of the actual heart rate and level of exercise intensity during
physical activity (i.e., RPE level 13 corresponds to approximately 60% of maximum EI) (Borg
1998). The authors also observed this relationship in 6 of the 10 BA (2
TT/TT
, 3
TT/TF
, 5
TF/TT
,
6
TF/TF
, 7
TF/TF
and 8
TF/TF
). However, amputees 1
TF/TT
and 4
TF/TF
had high RPE with low
PC/EI, and amputees 9
S-TF/TF
and 10
S-TF/TF
had high PC/EI with low RPE. This would
suggest that psychological factors (walking condence, self belief, motivation etc.) could be
very important in gait performance. The bilateral amputees studied here found walking
challenging; eight of the ten subjects chose the shortest duration (2 min) walk test and ve
were clinically overweight. Thus it is perhaps not surprising that a high proportion of BA
Physiological costs of walking in bilateral amputees 63
at Fund Diag.Est Imstico PARENT on November 13, 2013 poi.sagepub.com Downloaded from
eventually abandon their limbs in favour of a wheelchair, become increasingly less active and
are less likely to lead independent lifestyles. The link between psychology and physical
performance needs further investigation if one is to tackle problem gait in amputees.
The amputees wearing SNAPPs (9
S-TF/TF
and 10
S-TF/TF
) were the most condent walkers
with the highest levels of PWA and the lowest RPE (similar to the NA results see Table III).
This could be because SNAPPs do not replace the missing distal limb and thus the amputee
has a lower centre of gravity and is likely to feel more stable than the FLP- wearing amputees.
Both SNAPPs amputees were also ex-army soldiers and were extremely active and highly
motivated pre-amputation and might have been more able and determined (both physically
and psychologically) to withstand the added physiological costs of walking post amputation.
In previous studies, (Wainapel et al. 1985; Crouse et al. 1990; Wu et al. 2001; Perry 2004) the
physiological energy cost, metabolic energy expenditure and heart rate during walking was
found to be lower in amputees when they wore SNAPPs compared to FLPs. The authors
were unable to compare gait in amputees walking in different prosthetic designs (i.e., FLPs
versus SNAPPs) because changes in prosthetic design are often accompanied by changes in
limb/stump morphology so that other/old prostheses no longer t. In fact, a SNAPP-wearing
amputee was excluded from this study at its inception as he lost a signicant amount of weight
after their adoption and could not wear the limbs until they had been re-tted. The results
obtained in this study and those reported elsewhere in case studies (Wainapel et al. 1985;
Crouse et al. 1990; Wu et al. 2001; Gitter et al. 2002) suggest that SNAPPs can offer practical
benets for those BA experiencing difculty in ambulating with FLPs or those permanently
conned to a wheelchair. Further research is needed to quantify the mechanical, physiological
and energetic advantages and disadvantages of this design.
Amputees 2
TT/TT
and 7
TF/TF
perceived their walking ability to be good and were the most
condent of the amputees walking in FLPs. In the case of amputee 7
TF/TF
this is likely
because his legs were amputated at birth. Amputee 2
TT/TT
was a condent walker, had one of
the lowest exercise heart rates, walked the fastest and had the lowest physiological costs in
spite of having the most recent amputations (2 yrs). This was likely due to his age (26 yrs) and
his reported high activity levels. Low physiological costs can be linked to the fact that he was
the only amputee to wear energy-storing prosthetic feet (Ossur Variex
TM
foot). The
construction of Variex
TM
feet provides dynamic function and allows energy to be stored
through compression during heel contact and early stance with subsequent energy release
during late stance and push-off. Such designs aim to mimic the missing ankle-foot complex
and associated muscle-tendon function. They have previously been shown to lower
physiological costs of gait, and our results would support this (Nielsen et al. 1988).
Psychological factors may have played an additional role here. Klute and colleagues (2002)
showed that energy-storing/releasing feet lessen the magnitude of stress going through the
residue limbs and improved comfort during walking. Hence, feeling comfortable when
walking lowers EI levels and reduces exercise HR (see also Huang et al. 1979; Garvin et al.
2001).
The present studys results highlight the diversity in locomotor performance within this
sample population. Some BA cope very well with the added physiological demands of
prosthetic walking, whilst others nd this task somewhat difcult (for some it was almost
unmanageable). Further research examining the functionality of the different FLPs currently
available to NHS patients would help us to identify markers of successful rehabilitation and
also could help uncover the reasons behind prosthetic limb abandonment.
In conclusion, BA (regardless of level of amputations and type of prosthetic design) did not
reduce their walking speed to the extent that physiological costs matched those of the NA
control group as has previously been reported. BA with similar levels of amputations, reasons
64 D. A. Wright et al.
at Fund Diag.Est Imstico PARENT on November 13, 2013 poi.sagepub.com Downloaded from
for amputations and prosthetic design had varying physiological costs, step characteristics and
differing levels of perceived walking ability. So much so, that the authors felt that it would
have been inappropriate to group and compare these amputees solely on their level of
amputations and type of prosthetic design (SNAPPs or FLPs). However a relationship was
found between walking perception and physiological cost in over half of the group (i.e., high
RPE and poor PWA matched high PCI and EI). Yet, in the rest of the group amputees had
either low RPE or good PWA with high PCI and EI, and visa versa.
Amputees wearing SNAPPs had the lowest levels of perceived exertion and better
perceptions of walking ability when compared to BA with the same levels of amputations
walking in FLPs. SNAPPs could potentially help non-mobile amputees increase activity levels
and hence aid weight loss. Further research investigating the physiological and psychological
factors (and their interplay) affecting walking performance is needed in order to gain a better
understanding of the problems encountered in BA gait.
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Appendix
Questionnaire: Walking Ability Rating (adapted from Boonstra et al. 1996).
Trial with SNAPPs Trial with FLP
The right limb is TF TT
The left limb is TF TT
Questions for normal walking
I am able to walk without a rest:
5. Less than 50 m
4. Between 50 and 500 m
3. Between 500 and 2,000 m
2. Between 2,000 and 5,000 m
1. More than 5,000 m
I have to be careful not to fall when walking outside:
1. Never
2. Only when walking a long distance or on uneven ground
3. Usually
4. Always
5. I never walk outside
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I am able to walk without a rest:
5. Less than 5 mins
4. Between 5 and 15 mins
3. Between 15 and 30 mins
2. Between 30 and 60 mins
1. Longer than 60 mins
I use a walking cane or crutch or support myself on pieces of furniture or some other support
while walking inside:
1. Never
2. Sometimes
3. Usually
4. Always
I use a walking cane or crutch or some other support or I walk supported by someone else
while walking outside:
1. Never
2. Sometimes
3. Usually
4. Always
I have to be careful not to stub the foot of the prosthesis on uneven ground:
1. Never
2. Only while walking a long distance on uneven ground
3. Usually
4. Always
5. I never walk outside
Score for normal walking: 6 means has excellent ability to ambulate, 28 means does not have
the ability to ambulate
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