Introduction: Patients with lower limb amputation have marked gait asymmetries which may increase when an adequate rehabilitation process is not provided, compromising the fundamental objectives of gait and increasing risk factors. Objective: To analyze the degree of use of mechanical energy, dynamic stability and kinematic variables of clinical interest in the gait of a patient with transfemoral amputation who did not undergo a rehabilitation process. Materials and methods: Based on a 3D reconstruction, angular values for hip, knee and ankle were quantified and the mechanical energy exchange and dynamic stability were estimated at three different gait speeds. Results: Variations in spatiotemporal parameters were observed along with changes in speed, which are not consistent with the results obtained in other studies in amputees. The angular values, mainly of the knee and ankle, show asymmetries that can be associated with a decrease in the use of mechanical energy while increasing stability at different speeds. Marcha normal.
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Corresponding author: Catalina Benrey-Reyes. Email: acbenreyr unal. Introduction: Amputation generates various biomechanical and structural changes, creating deficiencies in balance, equilibrium and proprioception.
Altered proprioception affects the bodily-space component, as well as postural control and other physical qualities, which require a specific management with physiotherapy intervention. This research was conducted considering that proprioceptive assessment is an adequate and effective tool in physiotherapy but is poorly documented in the literature regarding this population.
Objective: To propose and validate a proprioceptive assessment battery in transtibial amputees with prostheses. Materials and methods: Descriptive-purposeful study in which information was gathered to propose a battery test based on scientific evidence available. Conclusions : By means of the BEPAT it will possible to obtain objective and quantitative information on functional alterations, which will improve prosthesis prescription and rehabilitative treatment, as well as strengthen investigative processes in this field.
Conclusione s. Proprioception is understood as the ability of the joint to determine position in space and detect movement kinesthesia and the sense of resistance acting on it 1.
It is also considered an integrative quality of movement 2 that depends on specific structures, which allow signaling to register and respond to somatosensory information and its changes 3. This quality is affected by amputation, defined as the complete and definitive resection of part or a complete limb 2. Therefore, a peripheral alteration leading to loss of static support structure, of the dynamic joint complex function and sensory, exteroceptive and proprioceptive information are presented 4.
As transtibial amputation is more prevalent in Colombia, this research focuses on this type of amputation, which causes ankle joint proprioceptors and plantar skin receptors loss. This generates changes that directly or indirectly affect proprioception 5 , so physiotherapeutic management is required. Specific tools are necessary to assess the current proprioceptive condition of subjects with amputation and the impact of physiotherapy on intervention, since, after conducting a literature review and consulting with experts on the management of amputee patients in different institutions around the country, no information was found about the existence of such tools to assess proprioception in amputees.
For this reason, the objective of this research is to propose and validate content and to propose a battery for proprioceptive assessment in transtibial amputees with prosthesis, to measure the alteration in proprioceptive response secondary to amputation, according to the specific characteristics and needs of people with this level of amputation.
This work was structured as a descriptive-purposeful study, and was developed in four phases 1 : literature review 2 , classification and analysis of information 3 , design and proposal of the battery based on the best evidence found, and obtaining content and construct validity 4.
In this phase, a literature review of the research topic in different databases was conducted, which allowed us to establish the conceptual basis and clarify the key concepts. Likewise, the search was limited to the last five years in English and Spanish languages Table 1. For protocol foundation, 72 original works were used and selected according to their affinity with the objective of this research, and following the inclusion and exclusion criteria established Table 1.
Table 1. Documents found and selected for the creation of the battery according to the revised databases. Source: Own elaboration based on the data obtained in the study. After conducting the literature review, the found documents were evaluated according to the classification of the evidence proposed by The Centre for Evidence-Based Medicine in Oxford CEBM 6.
Hence, selecting relevant information was possible for the conceptual basis of the construction of the assessment battery, framed in the literature found an in experience of professionals working with the amputee patients Figure 1. Figure 1. Classification of papers according to the level of scientific evidence. For this research, the target population consisted of the studies found in online databases, investigation records, graduation projects and thesis with sufficient information to generate the construct, which allowed stipulating the necessary components for the battery.
The following inclusion and exclusion criteria were established Table 2. Table 2. Inclusion and exclusion criteria for the selection of information. Proprioceptive evaluation methods.
Based on the information gathered from the best available evidence and expertise, the proposed design and validation of content and BEPAT construction was performed. Seven specific tests were established for each item of the assessment battery to evaluate the different proprioception components taking into account the classification of the found evidence. This way, they can be supported and implemented in this population.
At this point, the degree in which the battery measures the proprioceptive condition of a subject with transtibial amputation with prosthesis was explored. Content validity is understood as a qualitative assessment of the questionnaire scope, that is, if it covers all dimensions of the phenomenon to be measured, since an instrument is considered to be content valid, if all aspects to be measured are contemplated 7.
Now, construct validity is defined as the degree to which an instrument measures the evaluative dimension for which it was designed. This validity determines the relationship of the instrument with theory and theoretical conceptualization 7. The result of this research was the proprioceptive assessment battery for the population described.
This is complemented by a format for general assessment of the current condition of the patient, the manual application, and the content and construct validation phase done with expert opinion. The assessment battery was determined according to the components of proprioception: statesthesia, kinesthesia and effector activities 8. By performing seven tests, evaluating different specific components of proprioception, through proprioceptive receptors was sought.
They shall be made in bilateral, passive and active way, with and without using prostheses in static and dynamic conditions, which will determine the proprioceptive condition of subjects. Thus, the following tests were proposed:. GTO is located in the tendon structure that responds to muscle stress. The percussion of a tendon is the stimulus that leads to a rapid and instantaneous stretching of muscle and tendon receptors sensitive to stretch.
This test is performed by direct percussion of the patellar tendon 3. The patient should be placed in a sitting position on a chair or couch. In addition, the therapist must directly strike on the patellar tendon, whose expected response is leg extension.
The record of this test will depend on the intensity of the motor response. It is important to note that if the response is hyperreflexia or clonus, the patient shall be deemed with a neurological disorder and, thus, a modification based on their proprioceptive response will be presented 9. The test to measure joint position is based on accuracy to replicate and detect a position, on both active and passive form 1.
Some of the tests seek to identify the replication error or the sensitivity of a position; the higher the error, the more evident altered proprioception is This is one of the most common and easier proprioception measurement 11 tests. Also, it seeks a passive movement in the knee joint, after removing visual signals This is done because the joint position sense JPS provides the body with information about the speed and direction of active and passive movements without visual control In this regard, studies using this test to measure the statesthetic direction 14 , based on position sense through mechanoreceptor sensations, have been reported The test aims to make the subject identify the position of the leg from a passive movement, as well as to make an active move to a position determined by the therapist.
For this test, an angular identifier was designed Figure 2. Its design allows direct support to the stretcher, which facilitates manipulation by the evaluator. Figure 2. Angular identifier. Assessment of joint reproduction is another sub-modality of proprioception, whose measurement is done through the identification of a static joint angle with replication methods This test is a variable of the test mentioned above.
It is performed with and without prosthesis in a sitting position with the angular identifier referred to in the joint position test. This will be actively done on the limb to be evaluated; the subject maintains the position for a few seconds and goes back to the initial position 11 through the reproduction of movements at specific angles At this point, that the subject replicates movement is intended after having passively perceived it in the contralateral limb, that is to say, if the leg to evaluate is the left leg, the therapist must perform the movement with the right leg and keep it at one of five positions established.
With these tests, response of joint receptors and vestibular system is evaluated, which allows maintaining unipodal position due to the changes in acceleration and speed in body adjustments, necessary to achieve muscle activation demanded by this type of testing 3.
Similarly, the test on one foot has been widely used for the measurement of functional joint stability, because it reproduces the forces encountered during activities in a controlled environment 8. It also seeks to determine the time that the person keeps unipodal visual position without support on different surfaces: stable 3 and unstable , as shown in Figure 3.
It is important to clarify that the maximum support time for a healthy leg is 1 minute and 30 seconds on the prosthesis. This was determined according to reports indicating that a percentage of unipodal support on the lower limb with prosthesis decreased significantly compared to the healthy lower limb 4. In addition, the subjects had difficulties in assuming the load the lower limb with prosthesis, caused by alterations in soft tissues affected by amputation and which could be related to a deficit in the support function of body weight, at the level of the lower limb with prosthesis and particularly in knee instability of the sagittal and frontal planes 4.
Figure 3. Example of the unipodal support test a stable surface, b unstable surface. This test complements the unipodal test since both are performed simultaneously, on unstable and stable surfaces.
It also provides information on the activation time and amplitude of the response of the muscle spindle The muscle spindle is a proprioceptive receptor located in the muscle structure.
It senses the length or stretch degree, the mechanical stimulation degree and the speed at which stretching is applied. Similarly, it sends this information to the central nervous system and indirectly influences voluntary muscle control and agonist-antagonist muscle synergy 11, The test is conducted through surface electromyography SEMG This technique detects and analyses the electrical potential produced during muscle contractions.
Thus, surface electrodes transmit information regarding muscle activation. Such is the case of the intensity of muscle contraction, myoelectric manifestation of muscle fatigue and recruitment of motor units, for, subsequently, manifesting activation of muscle spindle To achieve this, a set of five electrodes should be placed as follows: two in the hamstring, two in the extensor muscle group of the knee and one grounding on the tubercle of the tibia For this test, data on activation time and amplitude values that give information about recruitment and muscle activation, will be reported.
The next test is based on some principles of cognitive therapeutic exercise Perfetti method , where each change of position involving support transfers and postural adjustments requires tone, sensation and predisposing factor adjustment for controlling body movement This is based on sense and movement control, and is done by simultaneously establishing a unilateral load support to release contralateral motor control and allow movement.
The notion of load support and alternating discharge represents a high level of perceptual-motor control Also, techniques grade one and two, which serve the purpose of the tests, were chosen 21 :. Postural adjustments due to pressure support and identification of external resistors. The subject is placed in step position, moving back and forth with one leg. Steps will be taken on different platforms. The test will be conducted with closed eyes and in two phases:. Different tension surface: The objective of this test is to identify the differences in resistance of the surfaces to which the subject will be exposed.
Three oval rubber platforms with different levels of hardness density will be used: they are known as stability trainers and have a progressive resistance system depending on colorimetry. Surfaces of different heights: The objective of the test is to identify the difference in angular position of the knee according to the different heights in which the foot is placed in step position.
Revista de la Facultad de Medicina