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Voluntary Thigh Muscle Strength with Resection Stump-Dependent Blood Flow and Vasodilation in an Amputated Lower Leg with Total Surface Bearing Prosthesis during Dynamic Knee Extensor: A Case Trial

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Open Journal of Therapy and Rehabilitation, 2019, 7, 151-169
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ISSN Online: 2332-1830
ISSN Print: 2332-1822
DOI:
10.4236/ojtr.2019.74011 Nov. 15, 2019 151 Open Journal of Therapy and Rehabilitation
Voluntary Thigh Muscle Strength with
Resection Stump-Dependent Blood Flow and
Vasodilation in an Amputated Lower Leg with
Total Surface Bearing Prosthesis during
Dynamic Knee Extensor: A Case Trial
Takuya Osada1,2*, Masahiro Ishiyama1, Ryuichi Ueno1
1Rehabilitation Center, Tokyo Medical University Hospital, Tokyo, Japan
2Cardiac Rehabilitation Center, Tokyo Medical University Hospital, Tokyo, Japan
Abstract
Background: The magnitude of the hyperemic response due to repeated
thigh stump exercise on incremental contraction intensity might be useful
information in localized exercise tolerance for devising cardiovascular physi-
cal therapy for amputees. The effect of exercise on amputated leg blood flow
(LBF) may potentially be altered due to voluntary muscle contractions after
loss of the lower leg compared with the healthy leg.
Case Presentation: A
57-year-old male patient with Burger disease attempted 3 min unilateral re-
peat/dynamic knee extensor exercise at a target muscle contraction frequency
(1 s thigh muscle contraction and 1 s relaxation, 90 repetitions) with each leg
<right transtibial amputated leg (AL) using a total surface-
bearing prosthesis
(TSB) and left non-AL> at six different contraction intensities (rubber resis-
tance belt). Simultaneous measurement of blood velocity/flow (Doppler ul-
trasound) in the femoral artery, blood pressure, leg vascular conductance
(LVC), and peak muscle strength (PMS) were performed during the 3
min
exercise period. The maximum voluntary contraction by one-legged isome-
tric knee muscle contraction was 14.7 kg in non-AL and 7.9
kg in the AL with
prosthesis. The relative PMS was defined as “PMS/maximum voluntary con-
traction × 100 (%)”. Pre-exercise LBF was lower in the AL (200 ±
25 ml/min)
than the non-AL (275 ± 74 ml/min). Both the non-
AL and AL showed good
positive linear relationships between absolute-/relative-PMS and LBF or LVC
during 30 s at steady-state before the end
of the exercise period. Furthermore,
there was also similarity seen in the increase rate in LBF and/or LVC for the
incremental relative PMS compared with the absolute PMS. Conclusion: In
How to cite this paper:
Osada, T., Ishi-
yama, M
. and Ueno, R. (2019)
Voluntary
Thigh Muscle Strength with Resection
Stump
-Dependent Blood Flow and Vaso-
dilation in an Amputated Lower Leg with
Total Surface Bearing Prosthesis during
Dy-
namic Knee Extensor: A Case Trial
.
Open
Journal of T
herapy and Rehabilitation
,
7,
151
-169.
https:
//doi.org/10.4236/ojtr.2019.74011
Received:
October 17, 2019
Accepted:
November 12, 2019
Published:
November 15, 2019
Copyright © 201
9 by author(s) and
Scientific
Research Publishing Inc.
This work is licensed under the Creative
Commons Attribution International
License (CC BY
4.0).
http://creativecommons.org/licenses/by/4.0/
Open Access
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10.4236/ojtr.2019.74011 152 Open Journal of Therapy and Rehabilitation
this case, the muscle strength depended on blood flow increase/vasodilation
was seen in this “AL” using a TSB prosthesis for repeated dynamic knee ex-
tensor exercise. The present amputees l
imb muscle strengthening with the
resection stump closely related
to the degree of hyperemia in the amputated
limb.
Keywords
Exercising Leg Blood Flow, Vasodilation, Transtibial Amputation, Total
Surface Bearing Prosthesis, Doppler Ultrasound
1. Introduction
For leg amputees, physical and exercise therapy can have important roles in
promoting activities of daily living for the prevention of joint contracture and
walking disability [1] [2] [3] [4]. Therefore, it may be acceptable that motor
function such as the joint range of motion in the knee/hip and improving muscle
strength to benefit the metabolic cost of walking are high priorities when using a
prosthesis [5]-[10].
Recently, the cause of leg amputation is most often due to the ischemia fol-
lowing peripheral vascular disease and/or microcirculatory disorder based on
arteriosclerosis with diabetes mellitus, peripheral vascular disease, or Burger’s
disease, which may potentially limit the blood flow/oxygen supply feeding the
vascular bed for the needs of the hyperemic state in exercise [11]. Consequently,
dysfunction of the hyperemic state in vascular disease may be seen in limb ske-
letal muscle [12].
There is still a lack of understanding of thigh-stump exercise blood flow and/or
vasodilation in relation to amputated limb muscle activity, nevertheless slight
leg passive motion and/or active voluntary muscle contraction could initiate
an increase in muscle metabolism with vasodilation relating to “leg oxygen up-
take”.
Therefore, blood flow may be a more important concern when prescribing
exercise for amputees with potentially reduced exercise tolerance [13].
As part of cardiovascular rehabilitation, muscle blood flow stimuli due to
physical activity/aerobic exercise may have a major role in oxygen transport
for muscle metabolism in the limb, which is closely related to “exercise toler-
ance corresponding to systemic maximum oxygen uptake” [14] and/or “muscle
strength power” [15]. During dynamic knee extensor exercise, increased leg
oxygen uptake will be directly proportional to the work performed in the muscle
[16] [17].
Oxygen uptake by the leg is theoretically calculated as the product of “arterial
blood flow in the working leg” and the arteriovenous oxygen difference in the
exercising leg. Thus, an evaluation of leg blood flow (LBF) dynamics feeding the
contracting major thigh muscles to the incremental workload can contribute to
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understanding the muscle blood flow supply and vasodilation due to exercise
and circulatory factors limiting work capacity in the thigh stump of the ampu-
tated leg (AL).
Ultrasound Doppler devices can provide high temporal resolution of blood
velocity. Pulsatile blood velocity profile in the conduit artery at systole and dias-
tole may be detected at rest, synchronized with the cardiac beat and blood pres-
sure [18] [19] [20]. Based on this technique, rapid changes in blood velocity can
be measured with muscle contraction and relaxation and/or cardiac beat-to-beat
in different states of exercise, muscle contraction time/frequency and workload,
and in relation to vasodilatation/vasoconstriction [21] [22]. In previous reports
from healthy legs on exercise LBF measured by Doppler ultrasound, there were
positive linear correlations between unilateral LBF and workload during steady-
state rhythmic unilateral leg exercise [17] [23] [24] [25] [26].
Using the above-mentioned Doppler technique, we have recently reported a
clinical intervention for LBF magnitude in an amputated lower leg with a patella
tendon bearing (PTB) prosthesis during unilateral dynamic knee extensor exer-
cise at incremental exercise intensity [27]. This initial brief report involved an
unexpected result with no significant thigh LBF increases in the AL using a PTB
prosthesis during incremental absolute/relative peak muscle contraction (work-
load), although workload-dependent LBF increases were seen in the non-AL,
which was in agreement with previous findings.
It is still necessary, however, to investigate the time course of the magnitude of
thigh stump LBF in amputees and/or using another prosthesis such as a widely
known total surface-bearing (TSB) prosthesis during exercise.
Thus, a present case was preliminary clinical intervention trial with a TSB
prosthesis in an attempt to measure exercising limb circulatory response in pa-
tients with an AL or non-AL in order to understand whether there is a close re-
lationship between LBF/vasodilation and muscle contraction strength in the AL.
2. Case Presentation
2.1. Participant
A male (57 yr 8 mo, 168.2 cm, 57.4 kg) with trans-tibial amputation of the right
lower leg due to Burger’s disease and diabetes (at age 53 yr 6 mo) participated in
the study. The left anklebrachial index was 1.13. The length of the resected
stump was 18.0 cm from the knee joint space to the stump-end, which supported
walking using a TSB prosthesis. The weight of the TSB was 1.4 kg. The range of
knee angle motion in the AL was maintained for activities of daily living using
the TSB. The circumference of the thigh was 45.5 cm at maximum, 39.8 cm at 10
cm above the patella, and 36.2 cm at 5 cm above the patella in the non-AL, and
44.5 cm at maximum, 34.6 cm at 10 cm above the patella, and 36.5 cm at 5 cm
above the patella in the AL. The length between the greater trochanter and the
knee joint space was 39 cm in both legs. The lower leg length was 38 cm in the
non-AL. His cardiovascular condition was well controlled. The study was con-
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ducted in accordance with the principles of the Declaration of Helsinki (1964)
and with approval of the Institutional Ethics Committee of the authors’ institu-
tion (approval No. 2016-080). The participant gave written consent and was in-
formed for the nature and purpose of the study and for further publication, as
well as potential risks and discomfort. The participant was informed that with-
drawal from the study was possible at any time without consequences.
2.2. Exercise Model
The rhythmic knee extensor exercise model used in the present case allowed for
stable and validated measurements of blood velocity in the conduit femoral ar-
tery above the bifurcation using Doppler ultrasound [17] [23] [24] [28] (Figure
1). The knee extensor quadriceps muscle group was used to represent the activa-
tion of the large thigh muscle group, and previous research on LBF in relation to
dynamic or static knee extensor exercise during incremental contraction power
output has contributed to the evaluation of the magnitude of thigh muscle con-
traction-induced blood flow [18] [19] [23] [24] [28] [29]. The LBF value using
an invasive thermodilution method obtained in similar experimental conditions
by Andersen
et al.
[14] was similar to those obtained by non-invasive Doppler
ultrasound [17].
2.3. Study Protocol
The participant’s thigh was positioned horizontally, with the knee joint bent (90
degree flexion) in a sitting position (Figure 1). The maximum voluntary con-
traction (MVC) in the isometric knee extensor was measured using a strain
gauge (see the section on MVC measurement) attached to each leg.
The participant was familiarized with kicking with his toe to reach a target
point corresponding to 70 degree flexion from 90 degree flexion following the
pace of a metronome as a target muscle contraction frequency before the test.
The required range of motion in the knee angle was only 20 degrees, which was
considered to be appropriate for stable repeated knee extensor exercise with a
TSB for 3 min.
Following 1 min of pre-exercise, the participant performed 3 min of unilateral
repeat/dynamic knee extensor exercise at the target muscle contraction frequen-
cy of <1 s muscle contraction (active knee extension) and 1 s relaxation (passive
knee flexion) following an audible metronome, for a total of 90 repetitions with
each leg (right AL using the TSB or left non-AL) at six different contraction
strengths using rubber resistance bands while in the sitting position. Then, the
participant had an at least 5 - 7-min recovery phase after the end of each exercise
session.
The absolute value for muscle contraction strength due to repeated knee ex-
tension was displayed in real time on a monitor connected to the strain gauge
and amplifier.
The muscle contraction strength was adjusted using thin, medium, heavy, extra
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Figure 1. Scheme of one-legged dynamic knee extensor exercise and study protocol. Prior
to the experiment, maximum voluntary contraction (MVC) was measured. A unilateral
repeated/dynamic knee extensor exercise was performed at the target knee extensor fre-
quency [1 s dynamic-active thigh muscle contraction and 1 s passive muscle relaxation
(passive flexion movement): 90-duty cycles] for 3 min using six different rubber resis-
tance bands on each leg following 1 min pre-exercise (Pre-Ex). The right amputated low-
er leg performed the exercise using a total surface bearing (TSB) prosthesis. Kicking with
the toe was directed at a target point corresponding to 70-degree flexion of the knee joint
angle from 90-degree flexion (knee angle motion: 20 degrees) in time with the pace of an
audible metronome at the target muscle contraction frequency. The recovery phase took
7 min after the end of each exercise session. Blood velocity in the femoral artery (Doppler
ultrasound) was measured continuously at pre-exercise, during exercise, and in recovery.
Blood flow was calculated as the product of cross-sectional area and blood velocity. Si-
multaneous recording of muscle strength (strain-gauge sensor), blood pressure, leg vas-
cular conductance (blood flow/blood pressure), and heart rate was also performed via the
data acquisition system. A: active knee extension, P: passive flexion movement.
heavy, special heavy, and super heavy rubber bands (see the section on rubber
bands). The recovery time was sufficient for the hemodynamic parameters to
return to the resting control levels between exercise sessions. The parameters
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(blood velocity, blood pressure, heart rate, and muscle contraction strength)
were recorded simultaneously at pre-exercise, during exercise, and in recovery.
Steady-state during exercise was defined from 150 s to 180 s (76 - 90th duty
kicking cycles) for the evaluation of peak muscle strength-dependent increases
in LBF and vasodilation.
2.4. Maximum Voluntary Contraction (MVC)
Before starting the experiment, the MVC was measured as the maximum muscle
contraction strength throughout a unilateral knee extensor isometric muscle
contraction of each leg with the subject’s thigh positioned horizontally and the
knee joint bent (90 degree flexion) in the sitting position, in accordance with the
previously validated procedure [27] [29].
MVC (in kg) was determined from the average of three repeated measure-
ments using a strain gauge connected to a strain amplifier and gauge meter
(Meiko Co. Ltd, Tokyo, Japan) and was recorded continuously on a computer
using a PowerLab data acquisition system (Chart v.4.2.3 software; ADInstru-
ments, Sydney, Australia) (Figure 1). The MVC was defined as the peak value of
the muscle contraction strength curve profile. The peak muscle strength during
exercise was also evaluated using the relative (percentage of) MVC (peak muscle
strength/MVC × 100, %).
2.5. Voluntary Muscle Contraction Strength Using Rubber Bands
Six different TheraBands were used to test muscle contraction strength. The
stiffness of each band was previously validated by the manufacturer [30] [31]
[32]: thin (yellow, 1.3 kg), medium (red, 1.7 kg), heavy (green, 2.1 kg), extra
heavy (blue, 2.6 kg), special heavy (black 3.3 kg), and super heavy (silver, 4.6 kg),
the values of which formally represent the degree of strength required to stretch
the rubber band 30 cm to 60 cm in the TheraBand product information [33].
The peak muscle contraction strength (in kg) of every knee extensor kick was
evaluated using a strain gauge and amplifier [27]. The rubber band was tied in a
loop, enclosing the ankle, with a sensor fixed in the chair strut connected to the
strain gauge with amplifier (Meiko Co. Ltd, Tokyo, Japan), and values were rec-
orded continuously on a computer using a PowerLab data acquisition system
(Figure 1). The peak muscle contraction strength was defined as the peak value
at the maximum amplitude of the muscle contraction strength curve (muscle
contraction-relaxation cycle) during active knee extensor kicking via the acquisi-
tion system.
2.6. Blood Velocity and Diameter in the Femoral Artery
The high temporal resolution of Doppler ultrasound enables the continuous
measurement of blood velocity (a time- and space-averaged and amplitude-
weighted “mean blood velocity”) in the conduit femoral artery during knee ex-
tensor exercise [17] [18] [19] [20] [23] [24] [28] [29] [34] [35].
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The beat-to-beat blood velocity profile in the femoral artery was measured
continuously using a 7.5 MHz pulsed Doppler ultrasound (GE Logiq 3, Tokyo,
Japan) with a videotape recorder (AG-7350-P, Panasonic, Tokyo, Japan). The
coefficient of variation (<5%) for the repeated blood velocity measurements
represented the criteria for quality control of the operator’s technique (first au-
thor) at pre-exercise as well as during exercise [18] [19] [23] [24] [28] [29]
[35]-[44].
The mean femoral arterial vessel diameter (distance between the proximal and
distal intima in the artery) at the pulsatile diastolic phase for each beat was cal-
culated over approximately five beats.
The value of the pre-exercise vessel diameter was used to calculate the femoral
arterial LBF at pre-exercise, during one-legged repeated dynamic knee exten-
sions, and in recovery, because the diameter does not significantly vary between
pre-exercise and knee extensor exercise [23] [36] [45] [46].
LBF was calculated as the product of blood velocity and the cross-sectional
area, which has been validated previously and shown to produce accurate abso-
lute values both at rest and during rhythmical/dynamic thigh muscle contrac-
tions [17] [18] [19] [20] [23] [24] [28] [29].
2.7. Blood Pressure and Heart Rate
Blood pressure and heart rate were measured simultaneously using an auricular
plethysmography device with oscillometric calibration, through a cuff tourniquet
placed on the upper right arm (RadiaPress RBP-100, KANDS, Aichi, Japan).
These values and the muscle contraction strength curve (muscle contraction-
relaxation phase) from the stretched rubber band with strain-gauge connection,
strain amplifier, and gauge meter (Meiko Co. Ltd., Tokyo, Japan) were recorded
continuously on a computer using a PowerLab data acquisition system (Chart
v.4.2.3 software; ADInstruments, Sydney, Australia) with 1 min pre-exercise,
during a 3 min exercise period, and in 5 min recovery (Figure 1). The mean
values of blood pressure and heart rate (defined as R-R interval of blood pres-
sure curve) were extracted at the same time as the determinants of beat-by-beat
blood velocity value.
2.8. LBF and Leg Vascular Conductance (LVC)
The time- and space-averaged and amplitude-weighted “mean blood velocity” in
the femoral artery was measured by automatically by averaging the separate va-
riables in each cardiac cycle. LBF in the femoral artery was calculated by multip-
lying the cross-sectional area [area =
π
× (pre-exercise vessel diameter/2)2] by
the mean the blood velocity at pre-exercise, during exercise, and in recovery.
The LVC was calculated as LBF divided by blood pressure (LBF/blood pressure)
using the unit ml/min/mmHg.
2.9. Evaluations and Statistics
Mean LBF, blood velocity, blood pressure, LVC, and heart rate were measured as
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the average of every 30 s from the start of exercise (t = 0 in figures), pre-exercise,
during 3 min of exercise, and in the 7-min recovery period.
Statistical comparisons with a linear fitting regression correlation coefficient
(r), and p-value were conducted between mean LBF and mean LVC, and the
mean peak muscle contraction strength (relative value as %MVC) at steady-state
for the 30 s period before the end of exercise was examined. Furthermore, the
slope (corresponding to the increase ratio of LBF to absolute- or relative-muscle
contraction strength) in the regression line was also determined (Microsoft Excel
2010). A p-value < 0.05 was considered significant. All values are mean ± stan-
dard deviation (SD).
3. Results
The MVC was 7.9 kg in the AL and 14.7 kg in the non-AL. The stability of mus-
cle contraction cycle, peak muscle strength, and hemodynamic variables during
each knee extension during 30 s steady-state exercise are shown in Table 1.
During exercise, the peak muscle strength for each kick was stable throughout
the 3-min exercise period, and steady-state with the coefficients of variations
below 5% in Figure 2. The heart rate and mean blood pressure during steady-state
Figure 2. The fluctuation for peak muscle contraction in each knee extension during 3
min exercise. The peak muscle strength due to each knee extensor muscle contraction
presented from the onset (Ex-start) to the end of exercise (Ex-end). The magnitude of
peak muscle strength may indicate stable and repeated voluntary kicking for 3 min at the
target muscle strength (see Table 1). In the non-amputated leg, the peak muscle strength
had relatively large variability (describes as the exponential decay) during 30 sec from the
onset of exercise with the black (special heavy) and silver (super heavy) resistance band.
The less fluctuation in peak muscle strength during 30 s steady-state () before the end
of exercise was in an acceptable range for the determination of (peak) muscle contraction
strength-dependent blood flow increase and vasodilation. The maximum voluntary con-
traction (MVC) was different between the non-amputated (14.7 kg) and amputated lower
legs (7.9 kg); therefore, the scale for the relative muscle strength (%MVC, defined as peak
muscle strength/MVC × 100, %) is also shown as a vertical axis on the right side. Circles:
non-amputated leg (non-AL). Squares: amputated leg (AL). The plotted data in various
colors correspond to the resistance band colorsyellow (thin), red (medium), green
(heavy), blue (extra heavy), black (special heavy) and silver (super heavy).
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are shown in Figure 3. There was a significant positive linear relationship be-
tween “peak muscle contraction strength” and “LBF” at steady-state in the
non-AL (r = 0.973, p < 0.01, regression line slope = 104.5) as well as the AL (r =
0.963, p < 0.01, regression line slope = 255.9). Furthermore, the slope in the re-
gression line for the relationship between “relative muscle contraction strength
(%MVC)” and “LBF” may be close between the AL (20.2) and non-AL (15.4) in
Figure 4.
Regarding LVC, there was a significant positive linear relationship between
“peak muscle contraction strength” and “LVC” at steady-state in the non-AL (r
= 0.895, p < 0.05, and regression line slope = 0.90) as well as AL (r = 0.967, p <
0.01, regression line slope = 2.88). Furthermore, the slope in the regression line
for the relationship between “relative muscle contraction strength” and “LVC” was
close between the AL (0.23) and non-AL (0.13) in Figure 5.
4. Discussion
The present case may potentially indicate that muscle strength dependent-LBF
and/or -vasodilation was also seen in a “below-knee amputation of the AL using
TSB prosthesis” as well as in the healthy leg (non-AL) in repeated dynamic knee
extensor exercise. This work is series in our previous case, which involved de-
termination of the time course of magnitude in whole LBF in the exercising
thigh stump using a PTB [27]. These findings are discussed in the following sec-
tion.
Figure 3. Mean blood pressure and heart rate in steady-state exercise. Mean blood pressure
(MBP) tended to increase with an increase in muscle strength both legs except the silver
band (super heavy). The MBP was similar between the green band (heavy) and blue band
(extra heavy) in the non-amputated leg, and was also similar between the red band (me-
dium) and green band (heavy) in the amputated leg. These similarities may be due to the
smaller differences in peak muscle strength presented in Figure 2. The bars in various col-
ors correspond to the resistance band colors.
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Figure 4. The time-course of LBF (A) and relation to absolute and relative muscle strength (B). The
data were determined by averaging (net) every 30 s. The net-leg blood flow (LBF) value for the last 30
s of steady-state exercise ( in A) was used for the correlation between LBF and peak muscle
strength/percentage of maximum voluntary contraction (relative muscle strength) as exercise intensi-
ty (B). Circles: non-amputated leg (non-AL). Squares: amputated leg (AL). The data plotted in various
colors correspond to the resistance band colorsyellow (thin), red (medium), green (heavy), blue
(extra heavy), black (special heavy) and silver (super heavy).
4.1. LBF during Thigh Stump Exercise
It is generally acknowledged that an increase in exercising LBF is directly pro-
portional to the steady-state workload performed in relation to the interplay
between cardiovascular regulation and muscle metabolism [17] [18] [23] [28].
The blood velocity and flow in the femoral artery increase linearly with incre-
mental exercise intensities of work rate (for instance, peak muscle force) during
steady-state rhythmic thigh muscle contractions (knee extensor exercise) [23]
[24] [28]. This implies that enhanced vasodilatation is elicited, in relation to the
increased average muscle force exerted at higher workloads, to meet the elevated
metabolic activity.
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Figure 5. The time-course of LVC (A) and relation to absolute and relative muscle strength (B). The
data were determined by averaging (net) every 30 s. The net-leg vascular conductance (LVC) value for
the last 30 s of steady-state exercise ( in A) was used for the correlation between leg vascular con-
ductance and peak muscle strength/percentage of maximum voluntary contraction (relative muscle
strength) as exercise intensity (B). Circles: non-amputated leg (non-AL). Squares: amputated leg (AL).
The data plotted in various colors correspond to the resistance band colorsyellow (thin), red (me-
dium), green (heavy), blue (extra heavy), black (special heavy) and silver (super heavy).
Thus, in the present case leg exercise induced LBF increase and/or leg vasodi-
lation (corresponding to LVC) in left leg in the non-AL with the normal range of
anklebrachial index may be valid during steady-state exercise with stable he-
modynamic parameters (Table 1). Furthermore, the thigh stump-LBF and -LVC
in the AL also depending on the peak muscle contraction strength at the
steady-state thigh exercise in Figure 4 and Figure 5, is in agreement with our
previous findings.
The exercising LBF in healthy subjects has been investigated previously for
limiting factors of exercise tolerance. However, there have been few studies tar-
geting exercising LBF for amputees with potentially limited fitness and lower
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muscle strength, even if there is a need to evaluate residual function in the car-
diovascular system. In addition, it is not easy to compare thigh-stump contrac-
tion induced LBF dynamics among amputees because of differences in the time
periods after amputation, complications, medicines, or physical activity.
We reported recently on an interventional study with another amputee who
performed knee extensor exercise using the same protocol as the present study
[27]. The previous finding included determination of validated measurements of
exercising thigh-stump LBF and its time-course in the amputated leg with PTB
prosthesis using Doppler ultrasound. Furthermore, our clinical target was to
examine whether the degree of muscle contraction intensity in the thigh of the
AL is closely related to LBF and the hyperemic state.
The above-mentioned data in another amputee showed no significant increase
in thigh LBF in the AL with incremental workload (peak muscle strength) but a
close correlation between them in the non-AL.
We speculated that this discrepancy between the AL and non-AL may be due
to a mismatch of the workload-dependent LBF increase in the disused and/or
atrophic thigh muscle-resection stump of the AL compared with the non-AL,
which in the AL may be due to the remaining muscle contractile effort with a
reduced arterial inflow and/or lack of venous return in relation to the arteri-
ovenous pressure gradient and/or hydrostatic pressure through the lower leg
[27].
Prior to this study, we hypothesized the difference in the resection stump
muscle contraction-induced alterations/magnitude in LBF and/or vasodilation
between the AL and non-AL during incremental muscle contraction intensity,
because there is no doubting the lack of venous return from lower leg owing to
its amputation.
In the present case, however, the exercising LBF and/or LVC in the working
thigh muscle using an TSB prosthesis was closely (p < 0.01) related to the peak
muscle contraction strength in AL in Figure 4 and Figure 5. This may indicate
that thigh-stump exercise, even though the lower leg does not exist, may have a
function in increasing blood flow and muscle vasodilation due to the thigh mus-
cle contraction intensity.
Basically, the knee extension uses only the knee extensors of the quadriceps
muscle group, and it therefore may require less activity of the lower leg and
consequently not increase feeding inflow into the lower leg in non-AL. There-
fore, it is expected that the changes in LBF (the rate of increasing LBF) may be
related to muscle contraction strength between AL and non-AL if only the thigh
parts are active.
Of note, the rate of increasing both LBF and LVC, which correspond to the
slope of the linear regression, may be in a similar range between the non-AL and
AL in relative muscle contraction intensity (%MVC) rather than absolute muscle
contraction intensity (slope in LBF; non-AL
vs.
AL: 105
vs.
256 at absolute in-
tensity 15
vs
. 20 at relative intensity in Figure 4, slope in LVC; non-AL
vs.
AL: 0.9
vs
. 2.9 at absolute intensity 0.13
vs.
0.23 at relative intensity in Figure
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5).
This data may potentially suggest that the LBF increase and/or vasodilation
are precisely dependent on the relative intensity rather than absolute muscle
strength. In the present case, the MVC in the AL (8 kg) was half of that in the
non-AL (15 kg), consequently the muscle volume was smaller in the AL than the
non-AL because the circumference was shorter in the AL than the non-AL at 10
cm above the patella, which may potentially indicate the presence of muscle
atrophy in the AL. It can be considered that muscle strength training in the thigh
stump has a significant role in muscle contraction-induced blood flow increases
and/or vasodilation hyperemic state for amputees.
4.2. Possible Explanation for the Difference in Exercising LBF by
TSB and PTB Prosthesis
There have been few investigations about the relationship of “resection stump
muscle contraction exercise” between “LBF and/or vasodilation” in amputated
lower legs. This might be the reason why there is difficulty in obtaining stable
LBF measurement and evaluation during constant voluntary and rhythmic mus-
cle contractions of the thigh-stump at a target workload. In addition, it may not
be easy to compare the magnitude of LBF between the AL and non-AL during
unilateral leg exercise because of dissimilarity in the exercise model without
prosthesis due to loss of physiological/biomechanical function of the lower leg
muscle mass, limitation in the range of motion of the knee joint, and/or stable
load-setting for the thigh muscle strength.
In our previous report using PTB prosthesis, a below-knee amputee was able
to perform repeated knee extensor movements with a possible comparison of
LBF magnitude between the AL and non-AL [27].
It is, however, still unknown the how the prosthesis impacts on voluntary
muscle contraction strength. The weakness of thigh stump muscle contrac-
tion-induced LBF increases present in the previous case [27] may be due to the
lack of sufficient voluntary muscle force by the PTB prosthesis with characteris-
tic lateral fluctuation of the knee joint [47]. Therefore, we speculated that there
is less uniformity in muscle contraction (larger fluctuation of muscle tension
during repeated kicking contraction) via the socket suspended by the cuff sus-
pension strap on the AL.
To overcome the disadvantages of a PTB prosthesis, a TSB prosthesis has been
widely used for the stability of suspension via a silicon liner with a pin-attachment
locked-adapter, which can coordinate the precise muscle force-generated as an
increase in muscle strength during voluntary thigh muscle contractions. A TSB
prosthesis with vacuum-assisted suction sockets may improve gait symmetry,
residual limb activity [48]; therefore, we assumed that a TSB prosthesis with
good fixation by a socket-silicon linear connecting thigh-stump may improve
functional voluntary thigh muscle force/power during knee extension compared
with a PTB prosthesis. Consequently, it was seen that proper thigh-stump muscle
contraction induced LBF increases through stability with thigh stump exercise.
T. Osada et al.
DOI:
10.4236/ojtr.2019.74011 165 Open Journal of Therapy and Rehabilitation
5. Conclusion
In the present interventional case as preliminary trial, we examined whether an
amputee showed muscle strength dependent on increases in LBF/vasodilation in
an “AL” using a TSB prosthesis during rhythmic muscle exercise. In the present
amputee, limb muscle strengthening in the resected stump closely related with
the degree of hyperemia in the amputated limb.
Only one case is insufficient for the conclusive evidence regarding the rela-
tionship between leg blood flow (LBF)/vasodilation and muscle contraction
strength in the AL, thus further research would need a retrospective study and
enroll more patients. However, cardiovascular rehabilitation may potentially in-
clude new insights into the importance of interactions between muscle strength
and peripheral circulatory adjustment for patients with below-knee amputation
as well as for chronic critical limb ischemia.
Acknowledgements
The first author acknowledges the long-term support of the late professor eme-
ritus Bengt Saltin of The Denmark Copenhagen Muscle Research Centre as well
as the late professor emeritus Hisao Iwane of formerly The Tokyo Medical Col-
lege for contributions leading to the present state of clinical research in envi-
ronmental exercise and applied physiology for rehabilitation. The data in this ar-
ticle were partially presented at the 56th Annual Meeting of the Japanese Associ-
ation of Rehabilitation Medicine in 2019. The study was supported by a Scientif-
ic Research (C) general grant (No. 15K01730) from MEXT and JSPS (to T. Osa-
da).
Conflicts of Interest
The authors declare that there is no conflict of interest associated with this work.
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This review is an attempt to untangle the complexity of transtibial prosthetic socket fit and perhaps find some indication of whether a particular prosthetic socket type might be best for a given situation. In addition, we identified knowledge gaps, thus providing direction for possible future research. We followed the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines, using medical subject headings and standard key words to search for articles in relevant databases. No restrictions were made on study design and type of outcome measure used. From the obtained search results (n = 1,863), 35 articles were included. The relevant data were entered into a predefined data form that included the Downs and Black risk of bias assessment checklist. This article presents the results from the systematic review of the quantitative outcomes (n = 27 articles). Trends indicate that vacuum-assisted suction sockets improve gait symmetry, volume control, and residual limb health more than other socket designs. Hydrostatic sockets seem to create less inconsistent socket fittings, reducing a problem that greatly influences outcome measures. Knowledge gaps exist in the understanding of clinically meaningful changes in socket fit and its effect on biomechanical outcomes. Further, safe and comfortable pressure thresholds under various conditions should be determined through a systematic approach.
Article
Background: The evolving clinical burden of limb loss secondary to diabetes and peripheral artery disease remains poorly characterized. We sought to examine secular trends in the rate of lower-extremity amputations related to diabetes, peripheral artery disease or both. Methods: We included all individuals aged 40 years and older who underwent lower-extremity amputations related to diabetes or peripheral artery disease in Ontario, Canada (2005-2016). We identified patients and amputations through deterministic linkage of administrative health databases. Quarterly rates (per 100 000 individuals aged ≥ 40 yr) of any (major or minor) amputation and of major amputations alone were calculated. We used time-series analyses with exponential smoothing models to characterize secular trends and forecast 2 years forward in time. Results: A total of 20 062 patients underwent any lower-extremity amputation, of which 12 786 (63.7%) underwent a major (above ankle) amputation. Diabetes was present in 81.8%, peripheral artery disease in 93.8%, and both diabetes and peripheral artery disease in 75.6%. The rate of any amputation initially declined from 9.88 to 8.62 per 100 000 between Q2 of 2005 and Q4 of 2010, but increased again by Q1 of 2016 to 10.0 per 100 000 (p = 0.003). We observed a significant increase in the rate of any amputation among patients with diabetes, peripheral artery disease, and both diabetes and peripheral artery disease. Major amputations did not significantly change among patients with diabetes, peripheral artery disease or both. Interpretation: Lower-extremity amputations related to diabetes, peripheral artery disease or both have increased over the last decade. These data support renewed efforts to prevent and decrease the burden of limb loss.
Article
Background: Lower limb amputees (LLAs) are at increased risk of falling due to the inherent asymmetry resulting from their limb loss, muscle weakness and other neuro-musculoskeletal limitations. Research question: The aim of this study was to evaluate the effects of a personalised exercise programme on falls prevention and gait parameters in LLAs. Methods: Fifteen LLAs, recruited from their local prosthetic services centre, were block randomised, by age and level of amputation, into two groups: exercise group (transfemoral, n = 5; transtibial, n = 2) and control group (transfemoral, n = 5; transtibial, n = 3). The exercise group completed a 12-week programme, focusing on strength, balance, flexibility and walking endurance, delivered in group sessions at the University, and combined with a personalised home exercise programme. Temporal-spatial, 3D kinematic and kinetic gait parameters were collected at baseline and post-intervention. Falls incidence was also followed up at 12 months. Results: The exercise group experienced significantly fewer falls in the one-year period from baseline, compared with the average annual falls rate, obtained at baseline (P = 0.020; d = 1.54). Gait speed in the exercise group increased by 0.21 m∙s-1, to 0.98 m∙s-1 (P < 0.001; d = 0.91), through increased intact limb cadence. In the pre-swing phase, there were significant increases in intact limb peak vertical force, and affected limb peak propulsive (anterior) force for the exercise group. Power absorption and generation significantly increased at both the intact and affected hip joints (H3) and the intact ankle (A1 and A2) for the exercise group, resulting in significant group*time interactions. Significance: This is the first study to document the clinically meaningful benefits of an exercise intervention for falls prevention and gait performance in LLAs. Specialised exercise programmes for community-dwelling LLAs should be implemented as a method to reduce falls and improve walking performance in this population.
Article
The increased morbidity and mortality in traumatic lower limb amputees can be explained by the development of risk factors, among which high blood pressure plays an important role. However, the possible mechanisms underlying increased blood pressure levels observed in this population remain unclear. Thus, we aimed to test the hypothesis that peripheral vascular resistance is increased at rest in patients with traumatic lower limb amputation. In a cross-sectional study, eight patients with traumatic unilateral lower limb amputation (amputee group) and eight healthy individuals without amputation (control group) were included. Resting blood pressure, heart rate, and forearm blood flow were recorded simultaneously and thus, forearm vascular resistance was calculated. The amputee group showed higher systolic (126±2 vs. 118±5 mmHg, P<0.01), diastolic (78±2 vs. 63±3 mmHg, P<0.01), mean blood pressure (94±2 vs. 81±3 mmHg, P<0.01), and heart rate (74±5 vs. 65±8 bpm, P=0.02) compared with the control group. Despite the similar forearm blood flow response between groups, patients with traumatic lower limb amputation presented increased peripheral vascular resistance at rest compared with the control group (31.3±3.8 vs. 25.7±6.5 U, P=0.05). Patients with traumatic amputation present increased peripheral vascular resistance. Our findings clarify one possible mechanism underlying the higher blood pressure levels observed in this population.