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A new upper extremity sparing non-weight bearing orthosis

A new upper extremity sparing non-weight bearing orthosis
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  Short communication A new upper extremity sparing non-weight bearing orthosis Cengiz Yilmaz a, *, Ugur Dal b , A. Taner Erdog˘an c , Mehmet Colak a a Mersin University Medical School, Department of Orthopaedics and Traumatology, Turkey b Mersin University Medical School, Department of Physiology, Turkey c Mersin University Physical Education and Sports Institute, Turkey 1. Introduction Mostly preferred orthoses for mobilization without bearingweight with one lower extremity are the axillary (AC) and theforearm(FC)supportedcrutches.Thesedevicesrequiretwotofourtimes of body weight to be transferred through the upperextremities. Besides impairment of walking comfort, this maycause serious complications [1–4]. Young patients tolerateincreased energy expenditure when mobilizing with orthosesbut may lead to cardiopulmonary stress in the elderly [2]. Besidesdiscomfort, inability to use the hand for activities of daily livingfurther decreases the quality of life.To increase quality of life during non-weight bearing mobiliza-tion, we designed a balanced, stable, and inexpensive orthosis(Fig. 1). The orthosis, which will be mentioned as UESO (upperextremity sparing orthosis), may be used for distal tibia, ankle andfoot injuries. It transfers load through the distal femur andnecessitates upper extremity only for balance purposes. Wedesigned the study to compare this orthosis with AC and FC interms of energy requirement and perceived exertion. 2. Materials and methods Following ethical board approval a pilot study and power analysis wasperformed. 10 healthy male volunteers with average age 23.2 (20–30) were usedas subjects. Previous experience in using walking aid was an exclusion criterion.AfterstandardadjustmentsforACandFC,theUESOwasadjustedsothatthedistalendwas2–3 cmshorterthanthelowerextremity.Theideallengthwasdeterminedtoobtain a comfortable clearance during swing phase during the pilot study. With thedominant foot on ground and the other bearing no weight, subjects performedfamiliarization walks on ground with all three orthoses in the predeterminedrandomized order. Another familiarization gait was performed on treadmill. Crutchwalkingbasewidthwasmeasuredtovarybetween45and55cmongroundwalkingvideorecordingsandthusa60cmwidetreadmillwasselected.Groundgaitvelocitieswere determined by infrared sensors placed on start and finish points of the 10mcentralsectionofa14 mcourse.Twowalkingtrialsperorthosiswereperformedandthe velocity was calculated as the average of these trials.The subjects were then made to walk on the treadmill at the previouslydetermined pace for 5 min with each orthosis and oxygen expenditure measure-ments were done. After every 5 min walk Borg scale scoring, which assessesperceivedexertionwasapplied[5].Bothgroundandtreadmillgaitswerescoredforobservedstabilitybyablindedtrainedobserver.Theobserverpointedthescoreonafive point scale with one being ‘‘Severely unstable’’ and five ‘‘Perfect stability’’ [6].Energy expenditure measurements of orthosis aided gaits were assessed viaindirect calorimetry method. Oxygen expenditure values of the last minute of eachwalking cycle were accepted as the steady state values and were averaged at 10 sintervals for analysis [3].Repeated measures test was used for comparing the data and Bonferronicorrection was applied for multiple comparisons. After substantiating normaldistribution of data with Shapiro–Wilk’s test, Pearson correlation test wasperformed for walking velocity and oxygen consumption parameters.  P   valuesbelow 0.05 were considered significant.Gait & Posture 32 (2010) 661–663 A R T I C L E I N F O  Article history: Received 9 September 2009 Received in revised form 26 July 2010 Accepted 6 August 2010 Keywords: OrthosisCrutchNon-weight bearingMobilization A B S T R A C T Objectives:  Axillary and forearm crutches are commonly utilized in the treatment of foot and ankleinjuries. In order to decrease the energy expenditure during mobilization, to prevent upper extremitycomplications, and to let the upper extremity free for other usages, we designed a new orthosis. Thestudy is conducted to compare walking energy parameters of this newly designed orthosis with theaxillary and forearm crutches. Materials and methods:  10 healthy young male volunteers walked on treadmill with three differentorthoses in randomized order. Oxygen expenditure, oxygen cost, rate of perceived exertion (Borg scale),and observer stability assessment were analyzed. Results:  Concerning oxygen consumption, perceived exertion, and observer stability assessment, thenewdevicewasfoundsuperiortotheotherdevices( P  < 0.05).Theneworthosiswassuperiortoforearmcrutches concerning oxygen cost ( P   = 0.027) but not significantly different from the axillary crutches( P   = 0.062). Discussion:  Comparedtofrequentlyusedorthoses,thedevelopeddeviceprovidesmobilizationusinglessor similar amount of energy. Additionally it spares one upper extremity to be used for other activities.   2010 Elsevier B.V. All rights reserved. * Corresponding author. Tel.: +90 324 3364313; fax: +90 324 3364313. E-mail address: (C. Yilmaz). Contents lists available at ScienceDirect Gait & Posture journal homepage: 0966-6362/$ – see front matter    2010 Elsevier B.V. All rights reserved.doi:10.1016/j.gaitpost.2010.08.001  3. Results Walking velocities for AC, FC and the UESO were 36, 35.6, and32 m/min respectively. Oxygen consumption was lower for UESOcompared to AC and FC. The difference in oxygen cost betweenUESO and FC was statistically significant, but the differencebetweenUESOandACwasnot.BorgpointsobtainedforUESOweresignificantlylowerthanthosefortheothertwo.Statistical P  valuesfor oxygen consumption, oxygen cost and perceived exertion (PE)comparisons are shown in Table 1. Observer scores for stability atground walking were comparable for all three devices, but UESOreceived statistically significant higher points than AC at treadmillwalking (Table 1). No significant difference in Borg scale andobserver scores was detected between AC and FC. Coefficient( r   = 0.141)betweenvelocityandconsumptionvalues(Chart1)wasfoundouttobestatisticallynotsignificant( P   = 0.693)whichmeansthat UESO users’ lower oxygen consumption is not directly relatedto walking velocity. 4. Discussion Themostlyuseddevicesforthreepointwalkingareaxillaryandforearm supported crutches. Frankly, using crutches withoutbearing weight on one extremity increases the energy used[7,8]. UESO was compared to AC and FC in terms of usage comfort,stability, oxygen consumption and oxygen cost on treadmill.UESO users consumed less oxygen independent from walkingvelocity.Groundwalkingspeedofahealthyadultisbetween60and100 m/min. The walking velocity decreases to 55–62m/min whenwalking without bearing weight on one extremity using AC.Normally, there is a linear correlation between walking velocityand energy consumed. When using crutches, oxygen consumptionand energy cost increases despite decreased rate [7]. The averagewalking velocity with devices was measured as 32–36 m/min. Thedifference between walking velocities determined in our study andthe others was interpreted as the lack of experience of the subjectswalkingwithdeviceinourstudy.Unlikeconventionaldevices,UESOrequires negligible upper extremity power which may result inloweroxygenconsumption.Whenoxygencostwascalculatedusingthe consumption values, UESO was superior to FC but not differentfrom AC.Borg scale is a valid and reliable tool in assessing perceivedworkload of performance requiring and repetitive motor activitiesby the subject [9]. The Borg scale scores obtained for UESO weresignificantly lower than those for the crutches. Furthermore, thescores given by theunbiased observer forstability were consistentwith the Borg scale points.Limitationofthepresentstudywastheshortadjustmentperiodsto orthoses when compared to clinical usage, which may actuallytake few days. The scores obtained represent only the experimenttime but not those of a longer usage time. Patellar tendinitis, [ Fig. 1.  Walking with upper extremity sparing orthosis (UESO). Load transfer is through the knee and thigh. Upper extremity on effected side is used only for keeping thebalance during gait (inset picture).  Table 1 (A)Statistical P  valuesofdifferencesbetweengroupsregardingO 2 consumption,O 2 costandperceivedexertion(PE).(B)Meansofscoresgivenbyunbiasedobserverforstability.(A) Statistical  P   valuesO 2  consumption O 2  cost PEAC–FC 1 0.783 0.28AC–UESO 0.004 0.062 0.013FC–UESO 0.005 0.027 0.009(B) Observer pointsAC FC UESOGround walking 3.5 3.7 3.5Treadmill walking 3.4 3.7 3.9 [ Chart 1.  Oxygen consumption vs. velocity chart of data obtained from UESO group. C. Yilmaz et al./Gait & Posture 32 (2010) 661–663 662  pre-patellar bursitis, anterior knee pain may develop because of usingUESOforalongerterm.Thesubjectswerehealthywhichmaynot represent the actual condition of an injured individual. Arandomizedclinicaltrialhasbeeninitiatedtotesttheseparameters.Dataobtainedfromtreadmillwalking,althoughusedfrequentlyforsimilar studies [10], may differ from ground walking.UESO, while walking without bearing weight, lets one upperextremity free for other usages and may thus be preferred overconventional crutches.  Acknowledgments TheauthorsspeciallythankAssociateProfessorS.NecatYilmaz,Bora Resitoglu, Ilter Helvacioglu, and Professor Huseyin Beydagi. Conflict of interest statement Therearenofinancialorotherconflictsofinterestregardingourwork in this paper. References [1] Waring 3rd WP, Werner RA. Clinical management of carpal tunnel syndromein patients with long-term sequelae of poliomyelitis. J Hand Surg [Am]1989;14:865–9.[2] Bhambhani YN, Clarkson HM, Gomes PS. Axillary crutch walking: effects of three training programs. Arch Phys Med Rehabil 1990;71:484–9.[3] Maltais D, Bar-Or O, Galea V, Pierrynowski M. Use of orthoses lowers the O(2)cost of walking in children with spastic cerebral palsy. Med Sci Sports Exerc2001;33:320–5.[4] Malkan DH. Bilateral ulnar neuropraxia: a complication of elbow crutches.Injury 1992;23:426.[5] Borg GA. Psychophysical bases of perceived exertion. Med Sci Sports Exerc1982;14:377–81.[6] Basford JR, Rhetta HL, Schleusner MP. Clinical evaluation of the rocker bottomcrutch. Orthopedics 1990;13:457–60.[7] Waters RL, Mulroy S. The energy expenditure of normal and pathologic gait.Gait Posture 1999;9:207–31.[8] Annesley AL, Almada-Norfleet M, Arnall DA, Cornwall MW. Energy expendi-tureofambulationusingtheSure-Gaitcrutchandthestandardaxillarycrutch.Phys Ther 1990;70:18–23.[9] O’Sullivan SB. Perceived exertion. A review. Phys Ther 1984;64:343–6.[10] Traballesi M, Porcacchia P, Averna T, Brunelli S. Energy cost of walkingmeasurements in subjects with lower limb amputations: a comparison studybetween floor and treadmill test. Gait Posture 2008;27:70–5. C. Yilmaz et al./Gait & Posture 32 (2010) 661–663  663
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