Improvement of prostheses requires knowledge of how the body adapts. A transradial prosthesis without a dynamic wrist component may cause awkward compensatory motion leading to fatigue, injury or rejection of the prosthesis. This work analyzed the movements of shoulder, elbow and torso during four tasks: drinking from a cup, opening a door, lifting a box and turning a steering wheel. The main purpose of this study was to determine if using a basic transradial prosthesis that lacks motion of the forearm and wrist would cause significant compensatory motion of the shoulder, elbow and torso during the tasks. The second purpose of the study was to determine if the location of added mass would affect compensatory movements during these tasks. A group of able-bodied participants were asked to complete the tasks, without and with a brace, simulating a basic transradial prosthesis to determine if bracing is an appropriate way to study prosthetic use. Transradial prosthesis wearers also completed the tasks without and with added mass at the elbow or at the wrist to determine if distribution of mass has an effect on the motions. Using a motion capture system movements of the shoulder, elbow and torso were analyzed. For the bilateral tasks, the degree of asymmetry (DoA) was calculated for each subject. Statistical analysis was completed within subject comparing the mass interventions and between subjects comparing the control, braced and prosthesis wearing groups. While opening a door and lifting a box, prosthesis users compensated predominantly by bending the torso sideways toward affected side. During the steering wheel task, amputees used more elbow flexion to accommodate for the lack of forearm rotation. While drinking from a cup, compensation occurred by bending the cervical spine, although this was not measured. Adding mass increased the joint forces and moments during the box lift. This research can be used for transradial prosthesis design improvements as well as improving methods of prosthesis fitting and therapeutic training by providing quantitative data of compensatory motion. The data from this study is being used to develop a model for an upper limb prosthesis.

The physiological energy requirements of prosthetic gait in lower-limb amputees have been observed to be significantly greater than those for able-bodied subjects. However, existing models of energy flow in walking have not been very successful in explaining the reasons for this additional energy cost. Existing mechanical models fail to capture all of the components of energy cost involved in human walking. In this thesis, a new model is developed that estimates the physiological cost of walking for an able-bodied individual; the same cost of walking is then computed using a variation of the model that represents a bi-lateral below-knee amputee. The results indicate a higher physiological cost for the amputee model, suggesting that the model more accurately represents the relative metabolic costs of able-bodied and amputee walking gait. The model is based on a two-dimensional multi-body mechanical model that computes the joint torques required for a specified pattern of joint kinematics. In contrast to other models, the mechanical model includes a balance controller component that dynamically maintains the stability of the model during the walking simulation. This allows for analysis of many consecutive steps, and includes in the metabolic cost estimation the energy required to maintain balance. A muscle stress based calculation is used to determine the optimal muscle force distribution required to achieve the joint torques computed by the mechanical model. This calculation is also used as a measure of the metabolic energy cost of the walking simulation. Finally, an optimization algorithm is applied to the joint kinematic patterns to find the optimal walking motion for the model. This approach allows the simulation to find the most energy efficient gait for the model, mimicking the natural human tendency to walk with the most efficient stride length and speed.

The physiological energy requirements of prosthetic gait in lower-limb amputees have been observed to be significantly greater than those for able-bodied subjects. However, existing models of energy flow in walking have not been very successful in explaining the reasons for this additional energy cost. Existing mechanical models fail to capture all of the components of energy cost involved in human walking. In this thesis, a new model is developed that estimates the physiological cost of walking for an able-bodied individual; the same cost of walking is then computed using a variation of the model that represents a bi-lateral below-knee amputee. The results indicate a higher physiological cost for the amputee model, suggesting that the model more accurately represents the relative metabolic costs of able-bodied and amputee walking gait. The model is based on a two-dimensional multi-body mechanical model that computes the joint torques required for a specified pattern of joint kinematics. In contrast to other models, the mechanical model includes a balance controller component that dynamically maintains the stability of the model during the walking simulation. This allows for analysis of many consecutive steps, and includes in the metabolic cost estimation the energy required to maintain balance. A muscle stress based calculation is used to determine the optimal muscle force distribution required to achieve the joint torques computed by the mechanical model. This calculation is also used as a measure of the metabolic energy cost of the walking simulation. Finally, an optimization algorithm is applied to the joint kinematic patterns to find the optimal walking motion for the model. This approach allows the simulation to find the most energy efficient gait for the model, mimicking the natural human tendency to walk with the most efficient stride length and speed.

While amputee gait has been studied in great detail, the influence of prosthetic foot sagittal and coronal plane stiffness on amputee walking biomechanics is not well understood. In order to investigate the effects of sagittal and coronal plane foot stiffness on amputee walking, a framework for manipulating the stiffness of a prosthetic foot needs to be developed. The sagittal and coronal plane stiffness of a low profile carbon fiber prosthetic foot was manipulated through coupling with selective-laser-sintered prosthetic ankles. The carbon fiber foot provided an underlying non-linear stiffness profile while the ankle modified the overall stiffness of the ankle-foot combination. A design of experiments was performed to determine the effect of four prosthetic ankle dimensions (keel thickness, keel width, space between the ankle top and bottom faces, and the location of the pyramid connection) on ankle-foot sagittal and coronal plane stiffness. Ankles were manufactured using selective laser sintering and statically tested to determine stiffness. Two of the dimensions, space between the ankle top and bottom faces and the location of the pyramid connection, were found to have the largest influence on both sagittal and coronal plane stiffness. A third dimension, keel thickness, influenced only coronal plane stiffness. A number of prosthetic ankle-foot combinations were created that encompassed a range of sagittal and coronal plane stiffness levels that were lower than that of the low profile carbon fiber foot alone. To further test the effectiveness of the framework to manipulate sagittal and coronal plane stiffness, two ankle-foot combinations, one stiffer than the other in the sagittal and coronal planes, were used in a case study analyzing amputee walking biomechanics. Differences in stiffness were large enough to cause noticeable changes in amputee kinematics and kinetics during turning and straight-line walking. Future work will expand the range of ankle-foot stiffness levels that can be created using this framework. The framework will then be used to create ankle-foot combinations to investigate the effect of sagittal and coronal plane stiffness on gait mechanics in a large sample of unilateral transtibial amputees. / text

Unilateral, below-knee amputees have altered gait mechanics, which can significantly affect mobility. For example, amputees often have asymmetric leg loading as well as higher metabolic cost and an increased risk of falling compared to non-amputees. Below-knee amputees lose the functional use of the ankle muscles, which are critical in non-amputee walking for providing body support, forward propulsion and leg-swing initiation. The ankle muscles also regulate angular momentum in non-amputees, which is important for providing body stability and preventing falls. Thus, compensatory mechanisms in amputee walking are developed to accomplish the functional tasks normally provided by the ankle muscles. In Chapters 2 and 3, three-dimensional forward dynamics simulations of amputee and non-amputee walking were generated to identify compensatory mechanisms and their effects on joint loading and metabolic cost. Results showed that the prosthesis provided body support, but did not provide sufficient body propulsion or leg-swing initiation. As a result, compensations by the residual leg gluteus maximus, gluteus medius, and hamstrings were needed. The simulations also showed the intact leg tibio-femoral joint contact impulse was greater than the residual leg and that the vasti and hamstrings were the primary contributors to the joint impulse on both the intact and residual legs. The amputee simulation had higher metabolic cost than the non-amputee simulation, which was primarily due to prolonged muscle activity from the residual leg gluteus maximus, gluteus medius, hamstrings, vasti and intact leg vasti and ankle muscles. In Chapter 4, whole-body angular momentum in amputees and non-amputees was analyzed. Reduced residual leg propulsion resulted in a smaller range of sagittal plane angular momentum in the second half of the gait cycle. Thus, to conserve angular momentum, reduced braking was needed in the first half of the gait cycle. Decreased residual leg braking appears to be an important mechanism to regulate sagittal plane angular momentum in amputee walking, but was also associated with a greater range of angular momentum that may contribute to reduced stability in amputees. These studies have provided important insight into compensatory mechanisms in below-knee amputee walking and have the potential to guide rehabilitation methods to improve amputee mobility. / text

abstract: Lower-limb prosthesis users have commonly-recognized deficits in gait and posture control. However, existing methods in balance and mobility analysis fail to provide sufficient sensitivity to detect changes in prosthesis users' postural control and mobility in response to clinical intervention or experimental manipulations and often fail to detect differences between prosthesis users and non-amputee control subjects. This lack of sensitivity limits the ability of clinicians to make informed clinical decisions and presents challenges with insurance reimbursement for comprehensive clinical care and advanced prosthetic devices. These issues have directly impacted clinical care by restricting device options, increasing financial burden on clinics, and limiting support for research and development. This work aims to establish experimental methods and outcome measures that are more sensitive than traditional methods to balance and mobility changes in prosthesis users. Methods and analysis techniques were developed to probe aspects of balance and mobility control that may be specifically impacted by use of a prosthesis and present challenges similar to those experienced in daily life that could improve the detection of balance and mobility changes. Using the framework of cognitive resource allocation and dual-tasking, this work identified unique characteristics of prosthesis users’ postural control and developed sensitive measures of gait variability. The results also provide broader insight into dual-task analysis and the motor-cognitive response to demanding conditions. Specifically, this work identified altered motor behavior in prosthesis users and high cognitive demand of using a prosthesis. The residual standard deviation method was developed and demonstrated to be more effective than traditional gait variability measures at detecting the impact of dual-tasking. Additionally, spectral analysis of the center of pressure while standing identified altered somatosensory control in prosthesis users. These findings provide a new understanding of prosthetic use and new, highly sensitive techniques to assess balance and mobility in prosthesis users. / Dissertation/Thesis / Doctoral Dissertation Biomedical Engineering 2017

This dissertation focuses on the investigation and development of an effective prosthetic training and rehabilitation platform with the use of virtual reality to facilitate an effective process to return amputees to the highest level of independence and functioning possible. It has been reported that approximately 10 million people live with a limb loss worldwide, with around 30% being an upper-extremity amputee. The sudden loss of a hand or arm causes the loss of fine, coordinated movements, reduced joint range of motion (ROM), proprioceptive feedback and aesthetic appearance, all which can be improved with the use of a prosthesis and proper training. Current literature has shown prosthetic devices to provide limited function to users in a variety of areas including hand operation, functionality and usability, all which could be improved with proper rehabilitation and training. It has been exhibited that a large percentage of amputees abandon or reject prosthesis use mostly due to limited function and lack of training or knowledge of the device. It has been reported that untrained amputees will adjust their body in an awkward or compensatory body motion rather than repositioning a joint position while performing a task with a prosthetic device. This causes misuse and improper function that has been shown to lead to significant injuries. An effective prosthetic training and rehabilitation regime would be advantageous in returning the patient to the highest level of independence and functioning possible, with proper use of their prosthetic device. A successful training and rehabilitation program would allow an amputee to improve their ability to perform with optimal motion and use all prosthetic control capabilities. This dissertation describes the development of a stick figure model of the user’s motion in real-time and a character avatar animating the individualized optimal goal motions. The real-time model directly corresponds to the user’s motion, with the option to have the character avatar simultaneously animating an optimal goal motion for the user to follow. These were implemented into the Computer Assisted Rehabilitation Environment (CAREN) system (Motek Medical, Amsterdam, Netherlands) to provide real-time visual feedback to the users while performing specified training and rehabilitating tasks. A ten camera Vicon (Oxford, UK) optical motion captured system was used with the CAREN system capabilities to track body and upper extremity prosthetic segments during range of motion (ROM), activities of daily living (ADL), and return to duty (RTD) tasks, with and without the use of the virtual reality visual feedback. Data was collected on five able-bodied subjects and five subjects with a unilateral transradial amputation using their personal prosthetic device. Through investigation and development, a preferred and effective way to display the visualization of the real-time and optimal models were revealed. Testing the subjects with and without the virtual reality visualization, exhibited the effectiveness of providing visual feedback. Results showed subject’s to have improved positing, movement symmetry, joint range of motion, motivation, and overall an improved performance of the series of tasks tested. With the integration of the optimal model visualization, real-time visual feedback, and additional CAREN system capabilities, upper-extremity training and rehabilitation techniques were shown to enhance with the use of virtual reality, through improved task performance, and functional advances. The results of this dissertation introduce an alternative means for clinicians to consider for effectively rehabilitating and training upper-limb amputees. Findings of this dissertation sought to provide useful guidelines and recommendation to aid in the development of a small-scale adaptable option for rehabilitation practitioners and at home use. The techniques investigated in this study could also be applicable for lower-limb amputee, post-stroke, traumatic brain injury, poly-trauma, and other patients with physically limiting disabilities. The techniques investigated in this study are expected to aid in the development of training and rehabilitation procedures for a variety of patient populations, to enhance the effectiveness and assist in improving the overall quality of life of others.

The CAREN-Extended system is a fully immersive virtual environment (VE) that can provide stability-challenging scenarios in a safe, controlled manner. Understanding gait biomechanics when stability is challenged is required when developing quantifiable metrics for rehabilitation assessment. The first objective of this thesis was to examine the VE’s technical aspects to ensure data validity and to design a stability-challenging VE scenario. The second and third objectives examined walking speed changes and kinematic strategies when stability was challenged for able-bodied and unilateral transtibial amputees. The results from this thesis demonstrated: 1) understanding VE operating characteristics are important to ensure data validity and to effectively design virtual scenarios; 2) self-paced treadmill mode for VEs with multiple movement scenarios may elicit more natural gait; 3) gait variability and trunk motion measures are useful when quantitatively assessing stability performance for people with transtibial amputations.

Osteoarthritis (OA) is a debilitating disease affecting roughly 31 million Americans. The incidence of OA is significantly higher for persons who have suffered a transtibial amputation. Abnormal cartilage stress can cause higher OA risk, however it is unknown if there is a connection between exercise type and cartilage stress. To help answer this, a tibiofemoral FEA model was created. Utilizing linear elastic isotropic materials and non-linear springs, the model was validated to experimental cadaveric data. In a previous study, 6 control and 6 amputee subjects underwent gait and cycling experiments. The resultant knee loads were analyzed to find the maximum compressive load and the respective shear forces and rotation moments for each trial, which were then applied to the model. Maximum tibial contact stress values were extracted for both the medial and lateral compartments. Only exercise choice in the lateral compartment was found to be a significant interaction (p<0.0001). No other interactions in either compartment were significant. This suggests that cycling reduces the risk for lateral OA regardless of amputation status and medial OA risk is unaffected. This study also developed a process for creating subject-specific FEA models.

Transtibial amputees are at increased risk of contralateral hip and knee joint osteoarthritis, likely due to abnormal biomechanics. Biomechanical challenges exist for transtibial amputees in gait and cycling; particularly, asymmetry in ground/pedal reaction forces and joint kinetics is well documented and state-of-the-art passive and powered prostheses do not fully restore natural biomechanics. Elliptical training has not been studied as a potential exercise for rehabilitation, nor have any studies been published that compare joint kinematics and kinetics and ground/pedal reaction forces for the same group of transtibial amputees in gait, cycling, and elliptical training. The hypothesis was that hip and knee joint kinematics and kinetics and ground and pedal reaction forces would differ due to exercise (gait, cycling, elliptical) amputee status (amputated, control [non-amputated]), and leg (dominant [intact], non-dominant [amputated]). Ten unilateral transtibial amputees and ten control participants performed the three exercises while kinematic and kinetic data were collected. Hip and knee joint flexion angle, resultant forces, and resultant moments were calculated by inverse dynamics for the dominant and non-dominant legs of both participant groups. Joint biomechanics and measured ground/pedal reaction forces were then compared between exercises, between the dominant and non-dominant legs within each participant group, and across participant groups. Significant differences in hip and knee joint flexion angles and timing, compressive forces, extension-flexion (EF) and adduction-abduction (AddAbd) moments, and anterior-posterior (AP) and lateral-medial (LM) reaction forces were found. Particularly, transtibial amputees showed maximum knee flexion angle asymmetry as compared to controls in all three exercises. Maximum hip and knee compressive forces, EF moments, and AddAbd moments were lowest in cycling and highest in gait. Asymmetry in amputee midstance knee flexion and timing in v gait, coupled with low maximum EF moment for the non-dominant leg, suggests that amputees avoid contraction of the non-dominant quadriceps muscle. Knee flexion angle and EF moment asymmetry in elliptical training suggests that a similar phenomenon occurs. Asymmetry in AP and LM reaction forces in gait, but not other exercises, suggests that exercises that constrain kinematics reduce loading imbalances. The results suggest that cycling and elliptical training should be recommended to transtibial amputees for rehabilitation due to reduced hip and knee joint forces and moments. Elliptical training may be preferred over gait due to decreased joint loading and loading asymmetry, but some asymmetry and differences from control participants still exist. Non-weight bearing exercises such as cycling may be best at reducing overall joint loading and joint load asymmetry but do not eliminate all kinematic and temporal asymmetries. Current state-of-the-art prosthetic leg design is insufficient in restoring natural biomechanics not only in gait but also in cycling and elliptical training. Improved prosthesis kinematics that restore non-dominant knee flexion in amputees to normal levels could help reprogram quadriceps muscle patterns in gait and elliptical training and hip and knee joint biomechanical asymmetries. Further work in comparing contralateral and prosthesis ankle joint biomechanics would help to elucidate the relationship between prosthesis design and its impact on lower limb joint biomechanics.