Bilateral Claudication Results in Alterations in the Gait Biomechanics at the Hip and Ankle Joints

HPER Biomechanics Laboratory, School of Health, Physical Education & Recreation, University of Nebraska at Omaha, 6001 Dodge Street, Omaha, NE 68182-0216, USA.
Journal of Biomechanics (Impact Factor: 2.75). 07/2008; 41(11):2506-14. DOI: 10.1016/j.jbiomech.2008.05.011
Source: PubMed


Claudication is the most common symptomatic manifestation of peripheral arterial disease (PAD), producing significant ambulatory compromise. The purpose of this study was to use advanced biomechanical gait analysis to determine the gait alterations occurring in claudicating patients both before and after onset of claudication pain in their legs. Hip, knee, and ankle joint moments were measured in claudicating patients (age: 64.46+/-8.47 years; body mass: 80.70+/-12.64kg; body height: 1.72+/-0.08m) and were compared to gender-age-body mass-height-matched healthy controls (age 66.27+/-9.22 years; body mass: 77.89+/-10.65kg; body height: 1.74+/-0.08m). The claudicating patients were evaluated both before (pain-free (PF) condition) and after (pain condition) onset of claudication pain in their legs. Thirteen symptomatic PAD patients (26 claudicating limbs) with bilateral intermittent claudication (IC) and 11 healthy controls (22 control limbs) were tested during level walking at their self-selected speed. Compared to controls, PAD hip and ankle joints demonstrated significant angular kinematics and net internal moment changes. Alterations were present both in PF and pain conditions with several of them becoming worse in the pain condition. Both PF and pain conditions resulted in significantly reduced peak hip extensor moment (5.62+/-1.40 and 5.63+/-1.33% BWxBH, respectively) during early stance as compared to controls (7.53+/-1.16% BWxBH). In the pain condition, PAD patients had a significantly reduced ankle plantar flexor moment (7.56+/-1.41% BWxBH) during late stance as compared to controls (8.65+/-1.27% BWxBH). Furthermore, when comparing PF to pain conditions, there was a decreased peak plantar flexor moment (PF condition: 8.23+/-1.37 vs. pain condition: 7.56+/-1.41% BWxBH) during late stance. The findings point to a weakness in the posterior compartment muscles of the hip and calf as being the key factor underlying the PAD gait adaptations. Our findings establish a detailed baseline description of the changes present in PAD patient's joint angles and moments during walking. Since IC is primarily a gait disability, better understanding of the abnormalities in joint and muscle function will enhance our understanding of the gait impairment and may lead to novel, gait-specific treatments.

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    • "As such, we do not know the distribution of work within the joints of the lower limbs, thus making it difficult to target exercise or strength rehabilitation towards a single muscle or joint. However , considering the results from our previous studies strongly indicating decreased performance from the ankle plantar flexors [5] [6] [21] [27] [28], the plantar flexors should be considered a major cause behind the decreased positive work by the affected limb during push-off as well as overall for the entire stance phase. Second, the individual limbs method for calculating external work was initially used for comparing the transition between steps [9]. "
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    ABSTRACT: External work was utilized to measure differences between the unaffected and the affected limb in patients with unilateral peripheral arterial disease compared to healthy controls. Patients with unilateral peripheral arterial disease have shown deficits in peak joint powers during walking in the unaffected and affected legs. However, no research has detailed the amount of work that is being performed by each leg compared to healthy controls even though such an analysis would provide valuable information on the energy output from the affected and the unaffected legs. Two hypotheses were tested: (a) the unaffected and affected leg would perform less work than healthy controls in a pain-free state, and (b) the onset of symptomatic claudication pain would result in further changes in the external work. Results showed that during a pain-free state, both the unaffected and affected legs perform less work than the healthy controls. After onset of claudication pain, the work output by the affected limb becomes further decreased while the unaffected limb experiences changes in negative external work. These findings combined with recent evidence of decreased peak powers in both legs in unilateral peripheral arterial disease patients reflects altered pathomechanics in both limbs compared to healthy controls.
    Medical Engineering & Physics 02/2012; 34(10). DOI:10.1016/j.medengphy.2012.01.004 · 1.83 Impact Factor
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    • ". Such measures cannot identify specific joint muscular responses and contributions during walking. The results of the current study for the joint angle values are in agreement with previously published values for PAD patients by Chen et al. (2008) and Crowther et al. (2007), while joint moment values were also in agreement with those published by Chen et al. (2008). It should also be noted that because these medications are the only drugs approved by the FDA to treat intermittent claudication related symptoms in PAD, many doctors prescribe the drugs to help patients " walk better. "
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    ABSTRACT: Pharmacological treatment has been used to alleviate the claudication symptoms and improve walking performance in peripheral arterial disease (PAD) patients. However, the effects of claudication treatments on gait mechanics have not been objectively identified with biomechanical techniques. For this study, 20 PAD patients were assigned to take either pentoxifylline (n=11) or cilostazol (n=9), the two FDA-approved pharmacological therapies used to treat intermittent claudication symptoms. All patients completed a gait evaluation protocol that involved the acquisition of kinematic and kinetic gait data before use of the medication and after 12 weeks of treatment. Results showed that treatment with either pentoxifylline or cilostazol resulted in limited overall improvement in gait parameters including joint angles and joint moments. Walking speed was unchanged, in either treatment group, as a result of the medication. These results suggest that to improve biomechanical walking parameters of PAD patients, clinicians cannot rely on drug therapies alone.
    Journal of applied biomechanics 08/2010; 26(3):341-8. · 0.98 Impact Factor
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    • "Recently, studies have been performed where biomechanical measures have been used to identify differences between PAD patients and healthy controls [2,3,17-20]. Initial evaluations have clearly identified specific gait deficiencies in PAD patients emphasizing the importance of biomechanical measures to fully characterize the gait handicap in these patients and delineate the underlying mechanisms of this disease. "
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    ABSTRACT: Pharmacological treatment has been advocated as a first line therapy for Peripheral Arterial Disease (PAD) patients suffering from intermittent claudication. Previous studies document the ability of pharmacological treatment to increase walking distances. However, the effect of pharmacological treatment on gait biomechanics in PAD patients has not been objectively evaluated as is common with other gait abnormalities. Sixteen patients were prescribed an FDA approved drug (Pentoxifylline or Cilostazol) for the treatment of symptomatic PAD. Patients underwent baseline gait testing prior to medication use which consisted of acquisition of ground reaction forces and kinematics while walking in a pain free state. After three months of treatment, patients underwent repeat gait testing. Patients with symptomatic PAD had significant gait abnormalities at baseline during pain free walking as compared to healthy controls. However, pharmacological treatment did not produce any identifiable alterations on the biomechanics of gait of the PAD patients as revealed by the statistical comparisons performed between pre and post-treatment and between post-treatment and the healthy controls. Pharmacological treatment did not result in statistically significant improvements in the gait biomechanics of patients with symptomatic PAD. Future studies will need to further explore different cohorts of patients that have shown to improve significantly their claudication distances and/or their muscle fiber morphology with the use of pharmacological treatment and determine if this is associated with an improvement in gait biomechanics. Using these methods we may distinguish the patients who benefit from pharmacotherapy and those who do not.
    Journal of NeuroEngineering and Rehabilitation 06/2010; 7(1):25. DOI:10.1186/1743-0003-7-25 · 2.74 Impact Factor
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