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Walking and balance in children and adolescents with lower-limb amputation: A review of literature
Accepted Manuscript Walking and balance in children and adolescents with lower-limb amputation: A review of literature
Arezoo Eshraghi, Zahra Safaeepour, Mark Daniel Geil, Jan Andrysek PII: DOI: Reference:
S0268-0033(18)30245-6 doi:10.1016/j.clinbiomech.2018.09.017 JCLB 4606
To appear in:
Clinical Biomechanics
Received date: Accepted date:
22 June 2018 12 September 2018
Please cite this article as: Arezoo Eshraghi, Zahra Safaeepour, Mark Daniel Geil, Jan Andrysek , Walking and balance in children and adolescents with lower-limb amputation: A review of literature. Jclb (2018), doi:10.1016/j.clinbiomech.2018.09.017
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ACCEPTED MANUSCRIPT Walking and balance in children and adolescents with lower-limb amputation: a review of literature Arezoo Eshraghi;a Zahra Safaeepour;b Mark Daniel Geil;c Jan Andryseka a Bloorview Research Institute, Holland Bloorview Kids Rehabilitation Hospital, Toronto, Ontario, Canada b Orthotics and prosthetics Department, University of Social Welfare and Rehabilitation Sciences, Tehran, Iran c Kennesaw State University, Kennesaw, Georgia, USA
Dr. Zahra Safaeepour Email: [email protected]
Dr. Mark Daniel Geil Email: [email protected]
Dr. Jan Andrysek Email: [email protected]
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Dr. Arezoo Eshraghi Email: [email protected]
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Authors:
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Abstract word count: 203 Main text word count: 7563
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Corresponding Author: Jan Andrysek Email: [email protected] Address: 150 Kilgour Road, Bloorview Research Institute, Holland Bloorview Kids Rehabilitation Hospital, Toronto, Ontario, M4G 1R8, Canada
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ACCEPTED MANUSCRIPT Walking and balance in children and adolescents with lowerlimb amputation: a review of literature
Abstract
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Background: Children with lower limb loss face gait and balance limitations. Prosthetic
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rehabilitation is thus aimed at improving functional capacity and mobility throughout the
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developmental phases of the child amputee. This review of literature was conducted to determine
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the characteristics of prosthetic gait and balance among children and adolescents with lower-limb amputation or other limb loss. Methods: Both qualitative and quantitative studies were included
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in this review and data were organized by amputation etiology, age range and level of
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amputation. Findings: The findings indicated that the structural differences between children with lower-limb amputations and typically developing children lead to functional differences.
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Significant differences with respect to typically developing children were found in
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spatiotemporal, kinematic, and kinematic parameters and ground-reaction forces. Children with transtibial amputation place significantly larger load on their intact leg compared to the
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prosthetic leg during balance tasks. In more complex dynamic balance tests, they generally score
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lower than their typically developing peers. Interpretation: There is limited literature pertaining to improving physical therapy protocols, especially for different age groups, targeting gait and balance enhancements. Understanding gait and balance patterns of children with lower-limb amputation will benefit the design of prosthetic components and mobility rehabilitation protocols that improve long-term outcomes through adulthood. Keywords: Walking; Amputation; Pediatric; Adolescents; Lower limb; Prostheses; Gait; Balance; Mobility; Rehabilitation; Therapy
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ACCEPTED MANUSCRIPT 1. Introduction Limb loss or deficiency during childhood is devastating for both by the family and the child. Lower limb amputation (LLA) is associated with mobility and physical activity limitations [1], [2]. Rehabilitation of children and adolescents with LLA is dependent mainly on etiology,
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amputation level and age among other factors. In terms of etiology, dysvascular amputations
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predominate in the adult population [3], while most childhood limb losses stem from congenital
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deficiency, followed by infection and trauma. The incidence of congenital limb deficiencies is said to range from 3.5 to 7.1 per 10,000 per 10,000 births [4].
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Among the important aspects specific to pediatric amputation are surgical intervention,
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physical therapy for balance and gait training, appropriate timing for prosthetic fitting, and choice of appropriate prosthetic components. Physical therapy goals are quite different for
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congenital and traumatic children amputees. Those with congenital deficiency naturally develop
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abilities to perform activities by incorporating the impaired limbs into their movement strategies [5]. Thus, physical therapists often act as a mentor to the child and family by foreseeing the
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immediate and future functional challenges. Whereas in traumatic cases, the primary goal is to
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restore the function the child had before amputation. Lending to their growth and development, children experience self-organization of multiple developing subsystems (brain, body, and
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behavior) needed to complete complex tasks. In terms of balance control, both typical and amputee infants and children should learn a new perception-action system [6] in each postural milestone, such as crawling and walking. For each posture, they should maintain their bodies within a dynamic base of support [7]. As gait and balance are re-established, reorganization of the motor pattern takes place in order to optimize the functions of the locomotor system [8]. Such reorganization is however not independent of the prosthetic device that assists the
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ACCEPTED MANUSCRIPT individual in performing physical activities. Since “children are not just small adults,” pediatric prostheses need to consider the specific needs of the child [9]–[11]. These include the expected functional and mechanical demands on the pediatric residual limb and prosthesis as well as activity types and levels [11]. As a child grows into adolescence, body weight and limb length
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allow use of adult prosthetic components. Hence, a unique feature of pediatric amputees is
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continuous bony growth of residual limb until skeletal maturity [11]. Further, in many cases
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pediatric amputees present with multiple limb deficiencies, with residua having abnormal shapes, thus making prosthetic rehabilitation and fitting an ongoing challenge [11]. Aside from the
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aforementioned physical, physiological and functional elements, it is important to note that
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children with limb loss also commonly experience various ongoing psychosocial challenges, including peer pressure, stigmatization, and gaining acceptance [12][13]. Restoration of mobility
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function, including gait and balance, are fundamental to prosthetic rehabilitation as evidenced in
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a strong base of existing literature, however, primarily in adults. Gait analyses of adults with LLA have shown slower walking speeds, shorter step lengths, lower cadences and lower peak
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stance-phase knee flexion on the prosthetic side [14]–[17] compared with non-amputees. Adults
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with LLA also have decreased loading on the prosthetic limb which increases loading on the intact limb [18], poorer balance compared to able-bodied individuals [19]–[21] and use the intact
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limb as a primary means of control during static and dynamic tasks, while relying heavily on visual information [21], [22]. Moreover, joint mobility and muscle strength may be reduced due to the loss of the biological ankle joint and related muscles. Therefore, adults with LLA are reported to have a higher risk of falling in comparison to able-bodied individuals [23]. A significant body of literature and comprehensive systematic reviews focusing on gait and balance exist that inform prosthetic practices in adults with LLA [24]–[27]. Although we may
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ACCEPTED MANUSCRIPT learn from research on adult amputees to address certain mobility challenges of pediatric prosthetic users, exploring typical mobility patterns of children with LLA is necessary in designing age-specific prosthetic rehabilitation strategies. Understanding how pediatric lowerlimb amputees ambulate with and adapt to prostheses over time may provide insight into gait and
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balance rehabilitation procedures. For instance, physiotherapists often try to train the pediatric
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amputee to simulate the gait of typically developing (TD) children [28]. Yet, since the structures
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of the prosthetic and anatomical limbs are different, the function might be so as well. Therefore, in recognition of the unique care needed for the pediatric amputee population, this review aimed
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to consolidate the leading literature relating the gait and balance of children who use prosthetic
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devices for ambulation. This study can serve as a useful reference for clinical practitioners
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providing care to children with limb deficiency and loss.
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2. Methods Search strategy
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A literature search was performed in MEDLINE (from 1980), EMBASE (from 1980),
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CINAHL (from 1982) and the Web of Science (from 1980) using the following keywords and their synonyms: child*, pediatr*, preschool, adolescen*, school-aged, teen*, infant, amput*,
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ambulat*, mobil*, walk*, locomotion*, prosthes* and artificial limb. Keywords related to the levels of amputation (e.g. Syme, transfemoral, transtibial, etc.) were also added to the final syntax. References from the identified studies were also examined to extend the search. Studies were selected based on the following inclusion criteria:
the studies involved pediatric and juvenile subjects with unilateral/bilateral amputation of a lower limb;
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the studies examined measures of walking and balance and functional performance with prosthesis, either quantitatively or qualitatively (survey, questionnaire, …);
English language.
Case reports, retrospective studies, studies that expressed development and mechanical
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testing of prosthetic components, animal studies, surgical procedures, conference papers (expect
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from full text ones), letters and editorials were excluded. Also, studies that included both
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pediatric and adult population were disregarded, because the results were reported as whole (not
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individually) for the pediatric group. Two authors (AE and ZS) independently assessed the selected papers. Where there was disagreement, the paper(s) was reviewed by a third author
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(JA). Using a standardized checklist, data were abstracted regarding each study’s population, outcome measures and findings. These data were independently verified by 2 authors (AE and
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ZS). Figure 1. shows the flow diagram of study inclusion process.
3. Results
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After reviewing and filtering the studies against our inclusion criteria, 42 studies were found
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eligible to be included in this literature review. Specifics of these studies are presented in Table 1.. Overall, 63% of the studies were conducted before year 2000, while only 37% were published
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between 2000 and 2016. The majority of studies (85%) were done in North America (US and Canada), while only 5% were conducted in the developing countries. The highest numbers of amputee participants in a single study were 258 [29] and 73 [30]. Almost all the studies included both females and males, yet no study evaluated the effect of sex on gait and balance of child amputees. The main biomechanical parameters used relating to gait and balance (based on the number of articles that evaluated them) were walking speed (n=21), joint angles (n=11), ground
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ACCEPTED MANUSCRIPT reaction forces (n=9), joint moments (n=8), joint powers (n=7), and center of pressure (n=3). The main physiological parameters used were energy cost (n=6), heart rate (n=4) and VO2 (n=2). The most frequent amputation levels studied (n = number of papers) in children were transtibial (TT, n=24), followed by transfemoral (TF, n=19), knee disarticulation (KD, n=13), Syme ankle
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disarticulation (n=12), hip disarticulation (HD, n=5), and partial foot (PF, n=1). In terms of
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etiology, 28 studies included both congenital deficiencies and acquired amputation, four only
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studied children with acquired amputation, and two involved only children with congenital
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deficiency. Eight studies did not report the etiology of participants.
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4. Discussion 4.1. Gait
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4.1.1. TD children vs. children with LLA
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Kinetic analyses have also shown structural differences between LLA and TD children, leading to functional differences. For instance, significant differences in joint moments and
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ground reaction forces of lower extremity have been reported among the non-prosthetic and
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prosthetic legs of children with LLA and the TD children during walking [31], [32]. Six studies included both TD children and children with LLA to compare walking
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performance and ability. Catani et al. (1993) analysed the gait of children after Van Nes rotationplasty [33]. The Van Nes procedure is a common limb-salvage alternative to segmental replacement via a custom knee endoprothesis and above-knee amputation [11]. Using a force plate and motion analysis, they measured angular displacement of lower limb joints and spatiotemporal parameters. Significant differences were observed in stride duration, stride length, cadence, and velocity (1.29 vs. 0.90 m/s) between the TD children and children with LLA.
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ACCEPTED MANUSCRIPT Significant differences with respect to the TD children were found in stride duration, stride length, cadence, velocity, and stance-swing ratio, and in ground-reaction forces parameters, which define the propulsive phase in the prosthetic side and the acceptance phase in the sound side. The study concluded that rotationplasty has biomechanical/functional advantages, offering
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a coordinate and smooth gait pattern.
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Engsberg et al. (1993) collected video data of a walking stride from three children with TT
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amputation and 11 TD children during four sessions at six-month intervals. Frontal and lateral views of the participants were captured using two 16-mm cameras. They used a seven-segment
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model (trunk, head, arms, legs, thighs and feet) to determine the center of pressure (CoP)
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locations during gait. The trunk segment of children with TT amputation showed a larger forward flexion compared with the TD children. Trunk lean towards the intact side was a trend
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seen in children with TT amputation, compared to the TD children.
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In another study, Engsberg et al. (1994) studied differences in relation among indices of oxygen uptake and effort between children with TT amputation (n=10) and TD children [34].
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There is evidence that adults with amputation walk at higher energy cost than non-amputee
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adults [35]. However, in this study oxygen uptake for the children with TT amputation was not considerably different than the TD control group although the children with TT amputation did
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exhibit higher medial/lateral truck displacements than the TD children, which may be linked to greater instability based on adult studies [36]. Adult studies have also shown that TT amputees adopt certain compensatory strategies for the restrictions caused by the loss of a limb. Examples are the increased hip extensor moments and reduced knee extensor moments after heel strike for forward progression during walking as well as differences in the amplitude of net hip and knee joint powers and moments of the
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ACCEPTED MANUSCRIPT prosthetic leg compared to able-bodied controls [37]. Early diagnosis of movement deviations can prevent secondary complications such as arthritis and low-back pain; thus, it is important to study mechanisms contributing to movement coordination in TD and amputee children. Centomo et al. (2007) studied motor strategies used by children with TT amputation and TD
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children during a stepping-in-place task [38]. They believed stepping-in-place can be an
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alternative to gait analysis as it challenges the control of whole body equilibrium through a
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combination of reciprocal rhythmic movement of lower limb and multi-joint coordination. The subjects were asked to raise their legs alternately with the thigh angle never exceeding 90° of
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flexion (relative to vertical). This task had 3 phases: “weight acceptance” (the knee extended
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during support), “propulsion” and “swing phase”. During propulsion, a significant difference in the hip moment was seen between the two groups. The net hip joint moment was extensor in TD
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children, while it was flexor in the children with TT amputation. This was supported by another
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study by Engsberg et al. (1992) reporting that the Centre of Mass (COM) was more anterior in the sagittal plane during gait for the children with TT amputation over TD children [39]. While
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there are reports about asymmetry between legs for obstacle avoidance and gait in adults with TT
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amputation [40][41], this same level of asymmetry was not seen in children with TT amputation performing similar motions.
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One of the most important and commonly used indicators of successful locomotion is speed [42][24], and its main components, step length and cadence. Overall, the walking velocity was lower for children with LLA than TD children [30], [33], [43], [44], which is similar to the studies on adults with LLA [16], [18], [45]. The range of velocity during level walking and running was 0.56 - 1.6 and 2.5 - 2.7 m/s, respectively. However, Jeans et al. (2011) reported that over 70% of their subjects with KD, Syme and TT amputations showed a walking velocity that
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ACCEPTED MANUSCRIPT was not significantly different from the able-bodied controls [30]. This was similar to Herbert et al. (1994) for children with TT amputation [34]. Only children with TF amputation showed significantly lower walking speed from TD children (80% of normal). Only Zernicke et al. (1985) [46] and Schneider et al. (1993) [47] evaluated gait during various walking speeds (self-
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selected, slow and fast).
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The energy efficiency, evaluated by oxygen consumption, is one of the key measures of
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quantifying function during walking. The most commonly used metabolic variables are heart rate (resting & walking), VO2 rate (resting & walking) and VO2 cost. The difference in energy
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efficiency between adults with and without limb loss has been studied both through treadmill
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[20], [48] and over-ground [49]–[51] walking protocols. Overall, there is evidence that energy cost of adults with LLA during walking is greater than non-amputees. There is controversy in
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findings in the pediatric population, with some showing an increase by 15% in the VO2 cost in
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amputee children compared to the TD values [52], while others reported no difference [30], [44], [53], [54]. Based on Jeans (2011), children with LLA (Syme, TT, or KD) walked with oxygen
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cost and speed similar to the TD children in the same age group. However, the HD and TF
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groups exhibited a higher VO2 cost than the TD subjects and those with a Syme, TT, or KD amputation level. The heart rate was significantly higher in the HD group than that in the TD
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group. Compared with the control group, the bilateral group (Syme and TT) walked with a significantly higher mean heart rate and slower mean self-selected walking speed. In summary, study results are not consistent when it comes to energy cost of walking. Studies have also shown structural differences between children with LLA and TD children, leading to functional differences. Significant differences between children with LLA and TD
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ACCEPTED MANUSCRIPT children were found in spatiotemporal, kinematic, kinetic, and ground-reaction forces parameters.
4.1.2. Age differences & Gait
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When TD children first start to walk, immature control of gait and posture leads to large
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stride-to-stride fluctuations and frequent falls [55]. By the time children are three years old, their
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gait begins to mature [56], and a more stable walking pattern replaces unsteady gait. However, the development of locomotor function and neuromuscular control continue to change beyond
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the age of 3 [57], [58], although walking variability is said to decline after this age [59]. Some
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investigators suggest that a mature gait pattern is developed in children after the age of seven [56], [60][61], when the child can participate in exercise and is less dependent on his/her parents.
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However, there are findings denoting that mature stride dynamics may not be entirely developed
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even in 7-yr-old TD children, and that maturation of different aspects of stride dynamics happens at different ages [62].
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Both maturation of the central nervous system and learning contribute to the evolution of
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mature gait. Sutherland et al. (1980) identified five main determinants of gait maturity: velocity, cadence, step length, duration of the single support phase, and the ratio of the pelvic span to
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ankle spread [58]. Beck et al. (1981) measured the distance and temporal parameters and ground reaction forces in 11 months to 14 years children and concluded that, after the age of 5, changes resulted more from height than age [63]. Norlin et al. (1981) reported that temporal and spatial gait parameters were dependent on age up to the age of 8 years, but thereafter leg length was more dominant [64].
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ACCEPTED MANUSCRIPT The age range of children with LLA in the studies included in this review was widely variable; from toddlers (13 months) [65], [66] to 20 years-old adolescents [67], [68]. Overall, those studies that included a wide range of ages in their work did not report their findings separately for different age groups, which makes it difficult to recognize gait patterns by age.
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those at elementary years [44], [69], [70] and adolescents [71].
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However, there were studies that only focused on a certain age group, such as toddlers [66][65],
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Few research groups have focused on toddlers and infants at the age of crawling (as young as 13 months) and the main motivation for them was to explore more about the Early Knee
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protocol. There is evidence suggesting that a child with LLA (regardless of amputation cause)
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should be fit as soon as he/she starts to pull up into stand [72]–[74]. In standard practice, children were not provided with an articulating knee joint until the age of 4 or 5. But recently, prosthetic
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knee joints are available for infants and toddlers [72], [73], [75]. When no knee joint is added to
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the prosthesis, or the knee joint is locked into full extension, stability is ensured during locomotion; however, gait deviations develop to ensure swing-phase clearance, and age-
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appropriate activities are delayed [73][76].
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Wilk et al. (1999) [73] and later Geil et al. [65], [66] conducted studies on older toddlers and young children, (2-8 years). They both compared the effect of locked and unlocked prosthetic
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knee conditions and reported in a similar way that subjects used prosthesis knee flexion in the unlocked condition, and had less hip hiking, vaulting and circumduction. According to these studies, when offered an articulating knee, toddlers with TF and KD amputation can make use of prosthetic knee function during crawling. Moreover, several different crawling patterns exhibited improved symmetry and the crawling speed was increased.
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ACCEPTED MANUSCRIPT Jeans et al. (2014) divided LLA participants into two groups, adolescents (10-19 years old) and young children (4-9 years old), to explore age-dependent differences [77]. Minor differences were found in the gait variables. The young children showed less passive prosthetic ankle plantar flexion than the adolescents. While neither age group achieved plantar flexion, the young
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children had significantly lower plantar flexion than the adolescents. The knee was also in a
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more neutral position in mid-stance phase in the adolescent group, while the young children had
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knee hyperextension.
In summary, a limited number of studies reported on age-related differences. These studies
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found differences primarily for the kinematics of gait, at the hip, knee and ankle. The majority of
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4.1.3. Amputation level & Gait
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them were focused on crawling of toddlers with an articulating vs. locked knee joint.
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Regardless of age, an amputation is recommended to be done at the most distal level possible [30], [78]. Generally, the longer the residuum the better the gait, as a longer lever arm
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generates more power and makes prosthesis fitting easier. Yet, sometimes children end up with
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an overly long residual limb in an attempt to preserve the growth plates, which will make it challenging to accommodate prosthetic components, such as a knee unit. Several studies on gait
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patterns of children with LLA have included two or more levels of amputation; however, only few studies have differentiated and reported the gait patterns for each level. The most frequent amputation levels included in studies on gait of children were TT (n=14) and TF (n=14), followed by KD (n=11), Syme (n=10), HD (n=4) and distal foot (n=1). Ashley et al., (1992) compared walking function of children with various levels of LLA and concluded that limitations in locomotor ability were correlated to the level of amputation [43].
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ACCEPTED MANUSCRIPT Also, those participants with more distal levels of amputation had a better ability to increase their cadence, whereas those with more proximal levels depended on changes in stride length to alter their speed of walking. The reduced ability of TF or KD amputees to change cadence was attributed to the type of prosthetic knee they were using (safety knee or constant friction).
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Interestingly, when Jeans et al. (2011) compared level-ground gait in children with different
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levels of amputation, rates of velocity and oxygen consumption for those with KD were similar
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to TT [30]. But it should be noted that on uneven terrain, the mechanical knee joint cannot quickly adapt, causing gait difficulty. The TF and HD groups showed a higher VO2 cost than
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those with lower levels of amputation, which was in line with the results of a later study by Chu
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et al. (2016) [71]. The HD group had significantly higher heart rate during walking than that in the Syme and TD groups. As one could expect based on adult studies [79], those with bilateral
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TT amputations walked with a significantly slower mean self-selected speed and a significantly
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higher mean heart rate. No difference was seen between TT and Syme groups with respect to heart rate and oxygen consumption, suggesting that these mild gait deviations do not increase
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cardiovascular demand during walking. In comparison to Syme amputees, those with Van Nes
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amputation exhibited lower oxygen cost [80]. In terms of kinematic data, Jeans et al. (2014) found minor differences in prosthetic ankle
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motion (< 4°) between children with Syme and TT amputations [77]. Differences in the external hip rotation of the two groups was also about 8°. Children with Syme amputation exhibited greater coronal-plane hip power than the TT, yet cadence parameters were not significantly different between these two amputation levels. In summary, amputation level can play an important role in the gait and mobility of pediatric lower limb amputees. Lower-level amputees are better able to modulate spatiotemporal
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ACCEPTED MANUSCRIPT parameters, and to some extent kinematic and kinetic gait parameters. Similar to the adult literature, faster walking speeds and lower energy expenditure appear to be associated with more distal levels of amputation. Amputation is recommended to be done at the lowest possible level
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for the pediatric population, keeping in mind the space needed for prosthetic components.
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4.1.4. Etiology & Gait
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From the studies that investigated gait of children with LLA, 19 included both congenital and acquired amputations, two included only congenital cases, three only focused on acquired
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amputations, and two did not report the etiology. From these studies, only Ulger & Sener (2011)
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specifically aimed to compare functional status of children (8-17 years old) with congenital limb deficiency versus acquired lower limb loss following prosthetic rehabilitation (n=20) [81].
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Children walked at a self-selected comfortable speed along a 12-m walkway, footprints were
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used to measure step lengths, stride length, step width, foot angle, and cadence. In the baseline assessment and after three weeks of prosthesis use, the congenital group
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showed better gait patterns, weight bearing values, and Amputee Mobility Predictor (AMP)
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scores than the acquired group. This finding is similar to earlier studies that observed those with congenital deficiency have a greater likelihood to be independent in daily living activities, even
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if they are not fitted with a prosthesis [82]. In contrast, there were no significant differences between the congenital and acquired groups after six months, yet both groups showed an improvement in their gait patterns, and weight bearing and functional level values. Also, both groups could bear weight on the amputated side in a similar way (about 40%) after six months of prosthesis use. In summary, only one study had a sufficiently large sample size to allow an examination of trends relating to etiology.
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4.2. Balance & Stability 4.2.1. TD children vs. children with LLA Balance improvements are important to enhance overall mobility, physical function, self-
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efficacy, and independence among children with LLA [27]. The maintenance of postural stability
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is an essential requirement of functional mobility, which necessitates the ability to produce
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adequate joint torques by limb muscles to maintain stability of the trunk and legs [83], [84] and to control the movement of the COM and shifting load between the legs [85]. Physical therapy
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protocols stress training amputees to move the COM over the prosthesis, and to bear more
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weight through the prosthetic leg [86].
Overall, eight studies quantitatively evaluated balance and stability among children with
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LLA, from which seven made comparisons to TD children. The main body of work (four
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articles) was done by Engsberg et al. from 1989-1994, which mainly measured foot pressure, weight distribution during standing, COM locations and segment angular orientations during
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walking, and ground reaction force during running of children with TT amputation. The first
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study of this series (using an EMED pressure plate) did not report significant difference in the weight distribution under the intact and prosthetic limbs of children with TT amputation (n=3) as
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compared to TD children (n=10) [87]. However, the anterior-posterior distribution of weight under both intact and prosthetic feet was significantly different as the TT subjects applied significantly more load on the intact heel and prosthetic forefoot than the TD children. The studies concluded that asymmetrical loading patterns may apply high loads on the joints of the lower limbs of children TT amputation.
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ACCEPTED MANUSCRIPT Later in 1992, Engsberg et al. again assessed the weight distribution on a larger number of TD children (n=200) to that of TT (n=21) amputees during standing [88]. Children with TT amputations applied more load on their intact limb than their prosthetic limb; however, this was not different from the TD children in terms of load distribution between non-dominant and
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dominant limbs. About 90% of the weight on the prosthetic foot was concentrated on the
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forefoot. The load on the intact foot of TT subjects was evenly distributed between the rearfoot
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and forefoot, similar to that of the TD children. Overall, children with TT amputation place significantly greater weight on their intact leg compared to the prosthetic leg.
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Finally, in the same population as the two previous studies, performance and static balance
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of the TT group was studied [89] during jumping, squatting, standing on the dominant leg and balance beam. Significant differences were observed in single and double leg jumps between the
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children with LLA and TD children. The balance scores of the prosthetic limb were significantly
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lower than the intact limb and those of the TD children. The TT subjects jumped a significantly shorter distance on their prosthetic leg as compared to the TD children. Moreover, the jumping
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style was different between the TD subjects and children with TT amputation, as the TT group
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showed less knee and ankle flexion and greater distribution of weight on the heels and on the intact leg than the TD group. Many of the children with TT amputation could not even assume
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the required position to start the balance tests on their prosthetic limb; this was attributed to the lack of proprioception through the prosthetic foot and ankle for which the children did not compensate with their knee and hip joints. This was assumed to improve through exercise or at later age [55]. In the only study of its type, Andrysek et al. (2012) found some improvements in postural control characteristics of children and adolescents with balance deficits immediately after the use
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ACCEPTED MANUSCRIPT of Wii Fit videogame system at home, but long-term retention needs to be explored [90]. Significant differences were seen in the centre of pressure (CoP) measures between amputee and TD children; the TT amputees (n=3) showed much higher CoP displacements. In a recent pilot study, Feick et al. (2016) studied relationships among balance and mobility
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measures in children with LLA and TD children (6-13 years old) [44]. Mobility and balance were
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tested using the 6-min walk test, the 10-m walk test, and the Community Balance and Mobility
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scale. A force plate was used to evaluate postural control during quiet standing with eyes open. The CoP measurements of static balance were different between the amputee and TD groups.
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This was partly attributed to the fact that the TD group was mainly male and a year younger. For
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children with LLA, a strong relationship was seen between better postural control and higher walking speed.
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Also, postural control strategies and balance in children (10-15 Y) with Syme amputation
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were evaluated in a study, but during quiet standing while wearing backpacks loaded with 0, 10, 20, and 25 percent of body weight [91]. The children with LLA demonstrated bilateral symmetry
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in maintaining static balance, even with heavy loads. It was concluded that TD children adapt to
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increasing posterior loads differently than those with limb loss by relying on medio-lateral shifts in CoP rather than the expected antero-posterior shifts.
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In summary, children with TT amputation place significantly greater weight on their intact leg compared to the prosthetic leg during dynamic balance tasks. In more complex ‘dynamic’ balance tests, they generally scored lower. One study also presents evidence of a correlation between gait and balance performance.
4.2.2. Age differences & Balance
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ACCEPTED MANUSCRIPT Maintaining balance during walking is a complicated task as it requires a compromise between the forward propulsion of the body and maintaining the body’s lateral stability [92]. Even walking on a flat ground, without obstacles, is a very challenging balance problem for young ambulators. In fact, it is extremely difficult to support the whole-body weight through one
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leg at a time during the swing phase of gait. The first step for children is building postural
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strategies, while in the second step, they should learn to adopt the most appropriate strategy to
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maintain task efficiency and balance control.
Assaiante and Amblard (1988) introduced a set of interpretations with regard to
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development of balance control in humans during their life span [93]. The first period covers
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from birth to the acquisition of the upright stance. The second period extends from the upright stance up to around the age of six, characterized by the development of the coordination between
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the upper and lower body parts. The third period is around the age of seven years up to a yet
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unknown age. Adolescence may be a turning point in balance control development. During this period the head stabilization is essential for the descending temporal organization of balance
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control. The last period is during adulthood, which combines the main features of the previous
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period with a new skill involving selective control of the degrees of freedom at the neck and the articulated operation of the head–trunk [94].
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The motor strategies to maintain balance rely on sensory inputs. Children and adults use different combinations of sensory inputs [95]. However, certain sensory systems may predominate at specific stages in maturity. For instance, the importance of visual input to balance control varies during the life span. During infancy and childhood (and up to the age of 6), visual cues have a prominent role in the control of static postural balance [95]. While the literature on
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ACCEPTED MANUSCRIPT balance and postural stability of children with LLA included all age ranges from 1-18 years, no study compared the balance and postural stability among different age groups.
4.2.3. Amputation level, Etiology & Balance
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After balance training through Wii Fit videogame system, lower CoP displacements were
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seen in children with TF amputation than those with Van Ness rotationplasty [90]. This was the
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only study that compared between balance and stability parameters based on amputation level. Also, no study compared the differences in balance measures between various amputation
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causes, which is mainly due to small sample size in each group with a certain amputation cause.
4.3. Prosthetic components
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The function of an individual with limb loss is significantly affected by prosthetic
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components. The higher the level of LLA, the greater the role played by the components in mobility and balance, as more joints and muscles are missing. Prosthetic prescription is very
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different for a child than an adult with an identical amputation level. Parents also play an
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important role in rehabilitation decisions at an early age of the child [11]. In the late 1980s, manufacturers started producing pediatric component lines [11]. Despite a steady increase in
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components, selection is still limited in pediatric population compared to adults. Further, lack of evidence on the effectiveness of different pediatric components prevents from sound clinical judgement. Consequently, clinicians mostly make choices based on personal experience and intuition. The prosthetic socket is the foundation of a functional prosthesis and must be intimate, comfortable, and anatomically appropriate. No matter how advanced prosthesis components
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ACCEPTED MANUSCRIPT (e.g., knee and foot) are, a poor socket fit may negate their advantages. We did not find any study that evaluated the effect of socket and suspension design on a child amputee’s mobility. In terms of types of sockets used, the patellar tendon bearing (PTB) was the highest with the majority of studies conducted on TT. Many studies did not report the type of socket and/or
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suspension.
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Several studies evaluated the effect of different prosthetic feet on gait and balance of
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children with LLA, primarily for TT amputation. The main prosthetic foot, as expected, was the SACH foot as the conventional foot type. The SACH foot simulates only plantar flexion through
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compression of a rubber heel, while the single axis foot allows both dorsiflexion and plantar
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flexion about a hinged joint. Before the advent of energy-storing feet, most of the studies attributed asymmetries between the limbs to the shortfalls of foot types [96].
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A few studies from 1981-1985 made comparisons between the CAPP (UCLA Child
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Amputee Prosthetic Project) and SACH feet for TF and KD amputation levels [46], [97], [98]. The SACH foot showed a significantly larger functional base of support than CAPP, while
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fluctuations of CoP about a mean position while standing were lower with the CAPP foot [97].
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During walking, stride and step length as well as walking speed decreased with the CAPP compared to the SACH. As walking speed increased, stride and step lengths increased for both
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feet [98]. The CAPP foot showed smaller range of thigh motion and less hip flexion. The CAPP enhanced stability of prosthetic knee during stance [46]. With the CAPP, CoP was located under the forefoot during stance, while it was seen with the SACH only 57% of stance time. It is good to note that the SACH foot is still commonly used, while the CAPP use has been discontinued. As one of the first energy-absorbing and releasing foot types, the Seattle foot [99] produced a small increase in stride length and walking speed compared to the SACH among children with
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ACCEPTED MANUSCRIPT TT amputation, and it was less resistant to passive dorsiflexion in mid-stance. The Seattle allowed a normal knee extensor moment during stance, while a knee flexor moment dominated the stance phase with the SACH. The energy cost of walking was slightly lower with the Seattle foot [54]. Another energy-storing foot, the Flex-foot, returned more energy (over 65%) than the
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SACH [47]. Also, during fast walking, the SACH required greater joint powers and moments
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from the intact limb, while in self-selected walking speeds, greater powers and moments were
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generated by the intact limb with the Flex foot.
A recent study by Jeans et al. (2014) between low (SACH), medium (Dynamic response
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foot) and high performance (Flex-foot Cheetah) feet showed that ankle motion was greater in
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children with TT and Syme amputations using high-performance feet compared with lowperformance and medium-performance feet [77]. However, peak power of the prosthetic ankle,
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which is important for push-off, did not show significant difference among the feet.
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Six studies evaluated the effect of the prosthetic knee joint on gait and balance of children. Dealing with the concept of ‘Early Knee Protocol’ for toddlers [65], [73], a few studies
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attempted to prove that it is not a good practice to delay the prescription of an articulating
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prosthetic knee joint until children can walk independently with a non-articulating knee (age of 4 or 5). Wilk et al. (1999) compared the effects of articulating and non-articulating knees on the
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gait of 2-7 year-old children and reported decreased pelvic hiking, circumduction and hip rotation on the prosthetic limb and decreased vaulting on the intact limb [73]. A mean increase of 49° of knee flexion was also observed. After one year, the children exhibited a more normalized gait pattern. Likewise, Geil and colleagues showed that a locked knee could impede locomotion and typical development [65], [66], [100]. All children with LLA were able to successfully ambulate
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ACCEPTED MANUSCRIPT with an articulating prosthetic knee with no stability issues. They also noted that crawling speed of amputee infants and toddlers increased with an articulating knee prosthesis. When offered an articulating knee prosthesis, toddlers as young as 13 months can incorporate prosthetic knee function during crawling. Moreover, the Early Knee protocol can decrease the adoption of
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swing-phase foot clearance adaptations while walking is developing [100].
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Most prosthetic knee joints for children with TF and KD amputations utilize four- and six-
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bar linkages, which enable better control during stance phase than single-axis knees. A new prosthetic single-axis knee joint, automatic stance-phase lock knee (ASPL), was developed by
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Andrysek et al. [69], [70]. The knee is claimed to provide better stability by ensuring that it
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remains fully extended until weight bearing, decreasing the extent of incidences of knee instability. Preliminary findings on six amputee children showed that the ASPL knee joint
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showed comparable biomechanical performance to polycentric pediatric prosthetic knee joints.
4.4. Qualitative evaluation of gait & balance
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A limited number of studies (n=5) focused on qualitative assessment of lower-limb
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prosthetic gait and balance in children with LLA. Some of the questionnaires that were used included the Child-Health Assessment Questionnaire (Child-HAQ) [101], Prosthesis Evaluation
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Questionnaire (PEQ) [71], Prosthesis Evaluation Scale (PES) [29], Pediatric Outcomes Data Collection Instrument (PODCI) [77] and Amputee Mobility Predictor (AMP) [81]. Five questions of the Dutch version of the Child-HAQ relevant to leg function were used in a study by Boonstra et al. (2000) [101]. The authors did not use the answers by children as they acknowledged the Dutch version of the questionnaire was not validated on children. Parents answered questions regarding prosthesis use, functional status, and secondary complications.
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ACCEPTED MANUSCRIPT Complications including having a second operation, skin problems, phantom sensation, and pain were frequent. Most of the children used prostheses in their daily activities. The functional abilities were found to be generally satisfactory; 95% of children could walk and 93% of the children were able to do cycling.
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Chu et al. (2016) assessed quality of life of children with LLA through the Chinese version
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of Prosthesis Evaluation Questionnaire (PEQ) [71]. The PEQ scores showed no significant
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difference between TT and TF prosthetic users. The average PEQ score was 72.7, which was in the range of values reported from older populations. Prosthetic compliance was good with daily
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wear time of above 12 h/day in both groups. A limitation of this study was that the authors
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adopted the Chinese version of PEQ from another study (the study was a conference proceeding).
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The ability to perform daily activities was studied on 13 children with LLA using a four-
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point scale [102]. No detail was provided about the type of questions or activities that were assessed. It was only reported that 84.7% of children with LLA became independent walkers
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without walking aids, 61.5% actively participated in recreational activities with peers, while
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others played football and table-tennis. Vannah et al., (1999) used a two-part survey developed based on the Prosthesis Evaluation
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Scale (PES) originally developed for adults, and the core module of the AAOS/COMSS Lower Limb Outcomes Data Collection Package, Version 1.1 [29]. These questionnaires evaluated prosthetic use, satisfaction and complications as well as overall lower-limb functional status. 88% of the subjects wore their prostheses 9 hours or more per day. The most common reasons for prosthetic issues reported were pain, especially during strenuous activities and walking on
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ACCEPTED MANUSCRIPT uneven ground, and component break-downs. The children favored these qualities in a prosthesis: function, comfort and cosmetics. The Pediatric Outcomes Data Collection Instrument (PODCI) surveys functional status in children and adolescents (2-19 years old) pre- and post-intervention [103]. Tested on 64 children
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with Syme and TT amputation, the PODCI scores for global functioning and sports/physical
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functioning were significantly higher in the young children than in the adolescent group, while
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there was no difference between the amputation levels [77]. This difference was attributed to the fact that when young children participate in sports, these activities do not need elite skills, yet
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adolescents have to work for the team and functional differences may start to make them distinct
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from their TD peers.
Ulger & Sener (2011) used the Amputee Mobility Predictor (AMP) Questionnaire to
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compare functional status of pediatric amputees after three weeks and six months of prosthetic
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rehabilitation [81]. The congenital group, without the prosthesis, showed higher scores than the acquired group initially and after three weeks of training. Lower AMP values of the acquired
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group were attributed to the effect of the trauma experienced, disappointment, being dependent
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on parents, and fear of not being able to walk again. Yet, after rehabilitation, they achieved functional levels equal to the congenital group. The majority of subjects wore their prostheses
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more than 8h a day. The authors did not compare function according to the amputation levels. It was reported that the AMP is a relatively easy instrument and could be completed in 15min or less, with a simple scoring system. The overall limitations of the study designs are summarized below:
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ACCEPTED MANUSCRIPT i.
No study has used a questionnaire validated on children with LLA. They either developed their own survey [70], or selected a few questions from or modified an adult version without any validation done on pediatric populations [29], [101]. The metrics are different, which makes it difficult to reach to a conclusion.
iii.
The questionnaires did not assess each prosthetic component separately; thus, it is difficult
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ii.
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to relate satisfaction/dissatisfaction, for instance, to the prosthetic fit such as socket design
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or the component itself.
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5. Conclusions
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This comprehensive review of literature attempted to shed light on gait and balance characteristics of children and adolescents with LLA. The study also identified gaps and
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limitations in research and development of prosthetic components aimed at improving gait and
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balance of children.
While it appears that many prosthetic principles apply similarly to adults and children,
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prosthetists face a unique range of practical and theoretical considerations for pediatric clients
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[104]. A 75-year-old adult (with diabetes) whose leg is amputated above the knee will not probably be more mobile than he/she was before the amputation. However, a child who is born
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with a limb deficiency, or has an amputation, is on a dynamic trajectory of physical, cognitive and social development. Children make up only a small portion of the population. However, based on the disabilityadjusted life years (DALY), and the many years that the pediatric amputee is expected to live and thrive in the community, setting them off on the right foot and prosthesis early in life is an important function of rehabilitation professionals. Unfortunately, based on the current review,
26
ACCEPTED MANUSCRIPT the literature pertaining to this population is sparse, and only 5% of the research has been conducted in the developing countries, while a great number of children with LLA, especially those with congenital deficiencies, may live in these countries. However, this finding may be somewhat biased due to inclusion of only English articles in this review. Further, comparison of
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the results is challenging, because factors such as age, sample size, data collection methods, and
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selection of parameters confound findings.
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No studies compared the balance and postural stability among different age groups or studied the effect of gender or sex on gait and balance of children with LLA. Most studies also
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did not have adequate statistical power to allow comparisons of the differences in balance
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measures across amputation causes. One solution may be conducting international multi-centre studies as an opportunity to increase sample sizes. While important for prosthetic design
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purposes and mobility, the muscle activation patterns of children when walking or balancing
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with prostheses has been rarely studied [105]. Likewise, there is limited literature pertaining to
balance enhancements.
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improving physical therapy protocols, especially for different age groups, targeting gait and
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In terms of prosthetic components, while there have been attempts to design and test pediatric-specific systems [69][106], there is still room for more work. Moreover, there are some
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specialized pediatric components, such as running prostheses, but there is no published study on biomechanical evaluations in the pediatric population. For instance, there are ankle joints in sizes for the children and adolescents with LLA, but for younger children, especially for 7- to 8-yearolds, these joints are still too large and heavy. The advancement in these designs is very slow or not available because of the small number of children in need of such components. A report from United States says that about 50 percent of all prostheses are made for patients aged 61 and over,
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ACCEPTED MANUSCRIPT while only 3.4 to 5.1 percent are produced for 1 to 10-year-old patients [107]. Thus, manufacturers consider investment in pediatric components as disproportionate for a limited return. Manufacturers produce advanced high performance prosthetic technology mainly for the adult market; however, it is the young and active children and adolescents who have the greatest
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need and ability to utilize them.
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Several overall conclusions can be drawn from this review. This review highlights the need
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for additional research on children with limb loss, especially as prosthetic technology improves, potentially enabling increased levels of function in children and adolescents. Like adults,
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pediatric gait is affected in many ways by a LLA. These effects are related to amputation level
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and prosthesis components. Both static and dynamic balance are affected by LLA, with asymmetries in weight distribution. Rehabilitation produced short-term improvements in
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standing postural control. Research has not investigated the role of socket fit in pediatric
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amputee gait. Very young children with limb loss above the knee may benefit from early prescription of a functioning knee joint. Dynamic, energy storing prosthetic feet can be effective
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in children, particularly at higher locomotion speeds.
Funding: This research did not receive any specific grant from funding agencies in the public,
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commercial, or not-for-profit sectors.
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ACCEPTED MANUSCRIPT References [1]
J. B. Bussmann, E. A. Grootscholten, and H. J. Stam, “Daily physical activity and heart rate response in people with a unilateral transtibial amputation for vascular disease.,” Arch. Phys. Med. Rehabil., vol. 85, no. 2, pp. 240–244, Feb. 2004. J. B. Bussmann, H. J. Schrauwen, and H. J. Stam, “Daily physical activity and heart rate
T
[2]
[3]
CR
Rehabil., vol. 89, no. 3, pp. 430–434, Mar. 2008.
IP
response in people with a unilateral traumatic transtibial amputation.,” Arch. Phys. Med.
K. Ziegler-Graham, E. J. MacKenzie, P. L. Ephraim, T. G. Travison, and R. Brookmeyer,
US
“Estimating the prevalence of limb loss in the United States: 2005 to 2050.,” Arch. Phys.
[4]
AN
Med. Rehabil., vol. 89, no. 3, pp. 422–429, Mar. 2008.
P. L. Ephraim, T. R. Dillingham, M. Sector, L. E. Pezzin, and E. J. Mackenzie,
M
“Epidemiology of limb loss and congenital limb deficiency: a review of the literature.,”
[5]
ED
Arch. Phys. Med. Rehabil., vol. 84, no. 5, pp. 747–761, May 2003. R. Morrissy, B. Giavedoni, and C. Coulter-O’Berry, “The limb-deficient child,” in Lovell
PT
and Winter’s Pediatric Orthopedics, R. Morrissy and S. Weinstein, Eds. Philadelphia, PA:
[6]
CE
Lippincott, Williams, & Wilkins, 2001. K. Adolph, “Learning to learn in the development of action,” in Action as an organizer of
AC
perception and cognition during learning and development: Minnesota Symposium on Child Development, & C. A. N. (Eds. . J. Lockman, J. Reiser, Ed. Hillsdale, NJ: Erlbaum Press, 2005, pp. 91–122. [7]
K. E. Adolph, S. E. Berger, and A. J. Leo, “Developmental Continuity? Crawling, Cruising, and Walking,” Developmental science, vol. 14, no. 2. pp. 306–318, Mar-2011.
[8]
A. S. Soares, E. Y. Yamaguti, L. Mochizuki, A. C. Amadio, and J. C. Serrao,
29
ACCEPTED MANUSCRIPT “Biomechanical parameters of gait among transtibial amputees: a review.,” Sao Paulo Med. J., vol. 127, no. 5, pp. 302–309, Sep. 2009. [9]
T. P. Klassen, L. Hartling, J. C. Craig, and M. Offringa, “Children are not just small adults: the urgent need for high-quality trial evidence in children.,” PLoS Med., vol. 5, no.
T
8, p. e172, Aug. 2008.
CR
Pharmacol., vol. 79, no. 3, pp. 351–353, Mar. 2015.
IP
[10] A. Ferro, “Paediatric prescribing: why children are not small adults.,” Br. J. Clin.
[11] J. I. Krajbich, M. S. Pinzur, B. K. Potter, and P. M. Stevens, Atlas of Amputations and
AN
Academy of Orthopaedic Surgeons, 2016.
US
Limb Deficiencies: Surgical, Prosthetic, and Rehabilitation Principles, no. v. 3. American
[12] B. Sayed Ahmed et al., “Factors impacting participation in sports for children with limb
M
absence: a qualitative study.,” Disabil. Rehabil., vol. 40, no. 12, pp. 1393–1400, Jun.
ED
2018.
[13] World Health Organization, “International Classification of Functioning, Disability and
PT
Health. Children & Youth Version.,” Geneva, 2007.
CE
[14] L. Torburn, J. Perry, E. Ayyappa, and S. L. Shanfield, “Below-knee amputee gait with dynamic elastic response prosthetic feet: a pilot study.,” J. Rehabil. Res. Dev., vol. 27, no.
AC
4, pp. 369–384, 1990.
[15] J. Perry, L. A. Boyd, S. S. Rao, and S. J. Mulroy, “Prosthetic weight acceptance mechanics in transtibial amputees wearing the Single Axis, Seattle Lite, and Flex Foot.,” IEEE Trans. Rehabil. Eng., vol. 5, no. 4, pp. 283–289, Dec. 1997. [16] A. M. Boonstra, V. Fidler, and W. H. Eisma, “Walking speed of normal subjects and amputees: aspects of validity of gait analysis.,” Prosthet. Orthot. Int., vol. 17, no. 2, pp.
30
ACCEPTED MANUSCRIPT 78–82, Aug. 1993. [17] T. Schmalz, S. Blumentritt, and R. Jarasch, “Energy expenditure and biomechanical characteristics of lower limb amputee gait: the influence of prosthetic alignment and different prosthetic components.,” Gait Posture, vol. 16, no. 3, pp. 255–263, Dec. 2002.
T
[18] L. Nolan, A. Wit, K. Dudzinski, A. Lees, M. Lake, and M. Wychowanski, “Adjustments
CR
Posture, vol. 17, no. 2, pp. 142–151, Apr. 2003.
IP
in gait symmetry with walking speed in trans-femoral and trans-tibial amputees.,” Gait
[19] E. Isakov, J. Mizrahi, H. Ring, Z. Susak, and N. Hakim, “Standing sway and weight-
AN
vol. 73, no. 2, pp. 174–178, Feb. 1992.
US
bearing distribution in people with below-knee amputations,” Arch. Phys. Med. Rehabil.,
[20] J. G. Buckley, S. F. Jones, and K. M. Birch, “Oxygen consumption during ambulation:
M
comparison of using a prosthesis fitted with and without a tele-torsion device.,” Arch.
ED
Phys. Med. Rehabil., vol. 83, no. 4, pp. 576–580, Apr. 2002. [21] A. H. Vrieling et al., “Balance control on a moving platform in unilateral lower limb
PT
amputees.,” Gait Posture, vol. 28, no. 2, pp. 222–228, Aug. 2008.
CE
[22] N. Vanicek, S. Strike, L. McNaughton, and R. Polman, “Postural responses to dynamic perturbations in amputee fallers versus nonfallers: a comparative study with able-bodied
AC
subjects.,” Arch. Phys. Med. Rehabil., vol. 90, no. 6, pp. 1018–1025, Jun. 2009. [23] W. C. Miller, A. B. Deathe, M. Speechley, and J. Koval, “The influence of falling, fear of falling, and balance confidence on prosthetic mobility and social activity among individuals with a lower extremity amputation.,” Arch. Phys. Med. Rehabil., vol. 82, no. 9, pp. 1238–1244, Sep. 2001. [24] Y. J. Sagawa, K. Turcot, S. Armand, A. Thevenon, N. Vuillerme, and E. Watelain,
31
ACCEPTED MANUSCRIPT “Biomechanics and physiological parameters during gait in lower-limb amputees: a systematic review.,” Gait Posture, vol. 33, no. 4, pp. 511–526, Apr. 2011. [25] P. X. Ku, N. A. Abu Osman, and W. A. B. Wan Abas, “Balance control in lower extremity amputees during quiet standing: A systematic review,” Gait Posture, vol. 39,
T
no. 2, pp. 672–682, Feb. 2014.
IP
[26] Z. Safaeepour, A. Eshraghi, and M. Geil, “The effect of damping in prosthetic ankle and
CR
knee joints on the biomechanical outcomes: A literature review.,” Prosthet. Orthot. Int., vol. 41, no. 4, pp. 336–344, Aug. 2017.
US
[27] J. M. van Velzen, C. A. M. van Bennekom, W. Polomski, J. R. Slootman, L. H. V van der
AN
Woude, and H. Houdijk, “Physical capacity and walking ability after lower limb amputation: a systematic review.,” Clin. Rehabil., vol. 20, no. 11, pp. 999–1016, Nov.
M
2006.
ED
[28] J. Engsberg, K. G. Tedford, J. Harder, and J. P. Mills, “Timing changes for stance, swing
255–262, 1990.
PT
and double support in a recent child below the knee amputee,” Ped Exer Sci., vol. 2, pp.
CE
[29] W. M. Vannah, J. R. Davids, D. M. Drvaric, Y. Setoguchi, and B. J. Oxley, “A survey of function in children with lower limb deficiencies.,” Prosthet. Orthot. Int., vol. 23, no. 3,
AC
pp. 239–244, Dec. 1999. [30] K. A. Jeans, R. H. Browne, and L. A. Karol, “Effect of Amputation Level on Energy Expenditure During Overground Walking by Children with an Amputation,” J. Bone Jt. Surg. - Am. Vol., vol. 93A, no. 1, pp. 49–56, Jan. 2011. [31] R. Lewallen, G. Dyck, A. Quanbury, K. Ross, and M. Letts, “Gait kinematics in belowknee child amputees: a force plate analysis.,” J. Pediatr. Orthop., vol. 6, no. 3, pp. 291–
32
ACCEPTED MANUSCRIPT 298, 1986. [32] J. R. Engsberg, A. G. Lee, J. L. Patterson, and J. A. Harder, “External loading comparisons between able-bodied and below-knee-amputee children during walking.,” Arch. Phys. Med. Rehabil., vol. 72, no. 9, pp. 657–661, Aug. 1991.
T
[33] F. Catani et al., “Gait analysis in patients after Van Nes rotationplasty.,” Clin. Orthop.
IP
Relat. Res., no. 296, pp. 270–277, Nov. 1993.
CR
[34] J. Engsberg, L. Herbert, S. Grimston, T. Fung, and J. Harder, “Relation among indices of effort and oxygen uptake in below-knee amputee and able-bodied children.,” Arch. Phys.
US
Med. Rehabil., vol. 75, no. 12, pp. 1335–1341, Dec. 1994.
AN
[35] R. L. Waters and S. Mulroy, “The energy expenditure of normal and pathologic gait.,” Gait Posture, vol. 9, no. 3, pp. 207–231, Jul. 1999.
M
[36] M. J. Major, R. L. Stine, and S. A. Gard, “The effects of walking speed and prosthetic
ED
ankle adapters on upper extremity dynamics and stability-related parameters in bilateral transtibial amputee gait.,” Gait Posture, vol. 38, no. 4, pp. 858–863, Sep. 2013.
PT
[37] D. A. Winter and S. E. Sienko, “Biomechanics of below-knee amputee gait.,” J. Biomech.,
CE
vol. 21, no. 5, pp. 361–367, 1988. [38] H. Centomo, D. Amarantini, L. Martin, and F. Prince, “Kinematic and kinetic analysis of a
AC
stepping-in-place task in below-knee amputee children compared to able-bodied children.,” IEEE Trans. Neural Syst. Rehabil. Eng., vol. 15, no. 2, pp. 258–265, Jun. 2007. [39] J. R. Engsberg, K. G. Tedford, and J. A. Harder, “Center of mass location and segment angular orientation of below-knee-amputee and able-bodied children during walking.,” Arch. Phys. Med. Rehabil., vol. 73, no. 12, pp. 1163–1168, Dec. 1992. [40] S. W. Hill, A. E. Patla, M. G. Ishac, A. L. Adkin, T. J. Supan, and D. G. Barth, “Altered
33
ACCEPTED MANUSCRIPT kinetic strategy for the control of swing limb elevation over obstacles in unilateral belowknee amputee gait.,” J. Biomech., vol. 32, no. 5, pp. 545–549, May 1999. [41] E. Isakov, H. Burger, J. Krajnik, M. Gregoric, and C. Marincek, “Knee muscle activity during ambulation of trans-tibial amputees.,” J. Rehabil. Med., vol. 33, no. 5, pp. 196–
T
199, Sep. 2001.
IP
[42] E. Isakov, H. Burger, J. Krajnik, M. Gregoric, and C. Marincek, “Influence of speed on
CR
gait parameters and on symmetry in trans-tibial amputees.,” Prosthet. Orthot. Int., vol. 20, no. 3, pp. 153–158, Dec. 1996.
US
[43] R. K. Ashley, G. T. Vallier, and S. R. Skinner, “Gait analysis in pediatric lower extremity
AN
amputees.,” Orthop. Rev., vol. 21, no. 6, pp. 745–749, Jun. 1992. [44] E. Feick et al., “A pilot study examining measures of balance and mobility in children
M
with unilateral lower-limb amputation.,” Prosthet. Orthot. Int., vol. 40, no. 1, pp. 65–74,
ED
Feb. 2016.
[45] J. M. Czerniecki, “Rehabilitation in limb deficiency. 1. Gait and motion analysis.,” Arch.
PT
Phys. Med. Rehabil., vol. 77, no. 3 Suppl, pp. S3-8, Mar. 1996.
CE
[46] R. F. Zernicke, M. G. Hoy, and W. C. Whiting, “Ground reaction forces and center of pressure patterns in the gait of children with amputation: Preliminary report,” Arch. Phys.
AC
Med. Rehabil., vol. 66, no. 11, pp. 736–741, Nov. 1985. [47] K. Schneider, T. Hart, R. F. Zernicke, Y. Setoguchi, and W. Oppenheim, “Dynamics of below-knee child amputee gait: SACH foot versus Flex foot.,” J. Biomech., vol. 26, no. 10, pp. 1191–1204, Oct. 1993. [48] D. Hunter, E. Smith Cole, J. M. Murray, and T. D. Murray, “Energy expenditure of below-knee amputees during harness-supported treadmill ambulation.,” J. Orthop. Sports
34
ACCEPTED MANUSCRIPT Phys. Ther., vol. 21, no. 5, pp. 268–276, May 1995. [49] M. B. Taylor, E. Clark, E. A. Offord, and C. Baxter, “A comparison of energy expenditure by a high level trans-femoral amputee using the Intelligent Prosthesis and conventionally damped prosthetic limbs.,” Prosthet. Orthot. Int., vol. 20, no. 2, pp. 116–121, Aug. 1996.
T
[50] M. S. Orendurff, A. D. Segal, G. K. Klute, M. L. McDowell, J. A. Pecoraro, and J. M.
IP
Czerniecki, “Gait efficiency using the C-Leg.,” J. Rehabil. Res. Dev., vol. 43, no. 2, pp.
CR
239–246, 2006.
[51] J. Perry, J. M. Burnfield, C. J. Newsam, and P. Conley, “Energy expenditure and gait
US
characteristics of a bilateral amputee walking with C-leg prostheses compared with stubby
AN
and conventional articulating prostheses.,” Arch. Phys. Med. Rehabil., vol. 85, no. 10, pp. 1711–1717, Oct. 2004.
M
[52] L. M. Herbert, J. R. Engsberg, K. G. Tedford, and S. K. Grimston, “A comparison of
ED
oxygen consumption during walking between children with and without below-knee amputations.,” Phys. Ther., vol. 74, no. 10, pp. 943–950, Oct. 1994.
PT
[53] A. W. M. van der Windt, I. Pieterson, J. W. van der Eijken, A. Peter Hollander, R.
CE
Dahmen, and B. A. de Jong, “Energy expenditure during walking in subjects with tibial rotationplasty, above-knee amputation, or hip disarticulation,” Arch. Phys. Med. Rehabil.,
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vol. 73, no. 12, pp. 1174–1180, Dec. 1992. [54] G. R. Colborne et al., “Analysis of mechanical and metabolic factors in the gait of congenital below knee amputees. A comparison of the SACH and Seattle feet.,” Am. J. Phys. Med. Rehabil., vol. 71, no. 5, pp. 272–278, Oct. 1992. [55] A. Shumway-Cook and M. H. Woollacott, Motor Control: Theory and Practical Applications. Baltimore, MD: Williams & Wilkins, 1995.
35
ACCEPTED MANUSCRIPT [56] D. H. Sutherland, R. A. Olshen, E. N. Biden, and M. P. Wyatt, The Development of Mature Walking. Oxford, UK: MacKeith, 1988. [57] S. Preis, A. Klemms, and K. Muller, “Gait analysis by measuring ground reaction forces in children: changes to an adaptive gait pattern between the ages of one and five years.,”
T
Dev. Med. Child Neurol., vol. 39, no. 4, pp. 228–233, Apr. 1997.
IP
[58] D. H. Sutherland, R. Olshen, L. Cooper, and S. L. Woo, “The development of mature
CR
gait.,” J. Bone Joint Surg. Am., vol. 62, no. 3, pp. 336–353, Apr. 1980. [59] D. S. Slaton, “Gait cycle duration in 3-year-old children.,” Phys. Ther., vol. 65, no. 1, pp.
US
17–21, Jan. 1985.
AN
[60] M. P. Murray, P. A. Jacobs, D. R. Gore, G. M. Gardner, and L. A. Mollinger, “Functional performance after tibial rotationplasty.,” J. Bone Joint Surg. Am., vol. 67, no. 3, pp. 392–
M
399, Mar. 1985.
ED
[61] M. Stanger, “Limb deficiencies and amputations,” in Physical therapy for children, V. L. D. Campbell SK, Palisano RJ, Ed. Elsevier Saunders, 2006.
PT
[62] J. M. Hausdorff, L. Zemany, C. Peng, and A. L. Goldberger, “Maturation of gait
CE
dynamics: stride-to-stride variability and its temporal organization in children.,” J. Appl. Physiol., vol. 86, no. 3, pp. 1040–1047, Mar. 1999.
AC
[63] R. J. Beck, T. P. Andriacchi, K. N. Kuo, R. W. Fermier, and J. O. Galante, “Changes in the gait patterns of growing children.,” J. Bone Joint Surg. Am., vol. 63, no. 9, pp. 1452– 1457, Dec. 1981. [64] R. Norlin, P. Odenrick, and B. Sandlund, “Development of gait in the normal child.,” J. Pediatr. Orthop., vol. 1, no. 3, pp. 261–266, 1981. [65] M. D. Geil and C. Coulter-O’Berry, “Temporal and spatial parameters of crawling in
36
ACCEPTED MANUSCRIPT children with limb loss: implications on prosthetic knee prescription.,” J. Prosthetics Orthot., vol. 22, no. 1, pp. 21–25, Jan. 2010. [66] M. D. Geil, C. Coulter-O’Berry, M. Schmitz, and C. Heriza, “Crawling Kinematics in an Early Knee Protocol for Pediatric Prosthetic Prescription.,” J. Prosthetics Orthot., vol. 25,
T
no. 1, pp. 22–29, Jan. 2013.
IP
[67] M. McMulkin, O. WR, M. RD, and R. RS, “Comparison of three pediatric prosthetic feet
CR
during functional activities.,” J. Prosthetics Orthot., vol. 16, no. 3, pp. 78–86, Jul. 2004. [68] S. Thomas, B. CE, D. Helper, N. Turner, M. Moor, and K. JI, “Comparison of the Seattle
AN
Orthot., vol. 12, no. 1, pp. 9–14, Jan. 2000.
US
lite foot and Genesis II prosthetic foot during walking and running.,” J. Prosthetics
[69] J. Andrysek et al., “Preliminary Evaluation of an Automatically Stance-Phase Controlled
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Pediatric Prosthetic Knee Joint Using Quantitative Gait Analysis,” Arch. Phys. Med.
ED
Rehabil., vol. 88, no. 4, pp. 464–470, Apr. 2007. [70] J. Andrysek, S. Naumann, and W. L. Cleghorn, “Design and quantitative evaluation of a
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stance-phase controlled prosthetic knee joint for children.,” IEEE Trans. Neural Syst.
CE
Rehabil. Eng., vol. 13, no. 4, pp. 437–443, Dec. 2005. [71] C. K. G. Chu and M. S. Wong, “Comparison of prosthetic outcomes between adolescent
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transtibial and transfemoral amputees after Sichuan earthquake using Step Activity Monitor and Prosthesis Evaluation Questionnaire.,” Prosthet. Orthot. Int., vol. 40, no. 1, pp. 58–64, Feb. 2016. [72] D. R. Cummings and S. L. Kapp, “Lower-Limb Pediatric Prosthetics: General Considerations and Philosophy,” JPO J. Prosthetics Orthot., vol. 4, no. 4, 1992. [73] B. Wilk, H. Karol, and S. Halliday, “Transition to an articulating knee prosthesis in
37
ACCEPTED MANUSCRIPT pediatric amputees,” J Prosthet Orthot, vol. 11, no. 3, pp. 69–74, 1999. [74] D. E. Krebs, J. E. Edelstein, and M. A. Thornby, “Prosthetic management of children with limb deficiencies.,” Phys. Ther., vol. 71, no. 12, pp. 920–934, Dec. 1991. [75] J. Andrysek, S. Naumann, and W. L. Cleghorn, “Design characteristics of pediatric
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prosthetic knees.,” IEEE Trans. Neural Syst. Rehabil. Eng., vol. 12, no. 4, pp. 369–378,
IP
Dec. 2004.
CR
[76] B. Giavedoni, C. Coulter-O’Berry, and M. Geil, “The impact of articulated knees on infants and toddlers,” Am Acad Orthot Prosthet J Proc, 2002.
US
[77] K. A. Jeans, L. A. Karol, D. Cummings, and K. Singhal, “Comparison of Gait After Syme
AN
and Transtibial Amputation in Children,” J. Bone Jt. Surg. - Am. Vol., vol. 96A, no. 19, pp. 1641–1647, Oct. 2014.
M
[78] R. L. Waters, J. Perry, D. Antonelli, and H. Hislop, “Energy cost of walking of amputees:
ED
the influence of level of amputation.,” J. Bone Joint Surg. Am., vol. 58, no. 1, pp. 42–46, Jan. 1976.
PT
[79] P.-F. Su, S. A. Gard, R. D. Lipschutz, and T. A. Kuiken, “Gait characteristics of persons
2007.
CE
with bilateral transtibial amputations.,” J. Rehabil. Res. Dev., vol. 44, no. 4, pp. 491–501,
AC
[80] E. Fowler, R. Zernicke, Y. Setoguchi, and W. Oppenheim, “Energy Expenditure during Walking by Children Who Have Proximal Femoral Focal Deficiency,” J. Bone Jt. Surg. Am. Vol., vol. 78, no. 12, pp. 1857–1862, 1996. [81] O. Ulger, G. Sener, and U. O., “Functional outcome after prosthetic rehabilitation of children with acquired and congenital lower limb loss,” J. Pediatr. Orthop. Part B, vol. 20, no. 3, pp. 178–183, 2011.
38
ACCEPTED MANUSCRIPT [82] K. Bosch, J. Gerss, and D. Rosenbaum, “Preliminary normative values for foot loading parameters of the developing child,” Gait Posture, vol. 26, no. 2, pp. 238–247, 2007. [83] C. D. MacKinnon and D. A. Winter, “Control of whole body balance in the frontal plane during human walking.,” J. Biomech., vol. 26, no. 6, pp. 633–644, Jun. 1993.
T
[84] J. J. Eng and D. A. Winter, “Kinetic analysis of the lower limbs during walking: what
IP
information can be gained from a three-dimensional model?,” J. Biomech., vol. 28, no. 6,
CR
pp. 753–758, Jun. 1995.
[85] D. A. Winter, A. E. Patla, M. Ishac, and W. H. Gage, “Motor mechanisms of balance
US
during quiet standing.,” J. Electromyogr. Kinesiol., vol. 13, no. 1, pp. 49–56, Feb. 2003.
AN
[86] E. Isakov, “Gait rehabilitation: a new biofeedback device for monitoring and enhancing weight-bearing over the affected lower limb.,” Eura. Medicophys., vol. 43, no. 1, pp. 21–
M
26, Mar. 2007.
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[87] J. R. Engsberg, T. L. Allinger, and J. A. Harder, “Standing pressure distribution for
155, Dec. 1989.
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normal and below-knee amputee children,” Prosthet. Orthot. Int., vol. 13, no. 3, pp. 152–
CE
[88] J. R. Engsberg, K. G. Tedford, M. J. Springer, and J. A. Harder, “Weight distribution of below-knee amputee and able-bodied children during standing.,” Prosthet. Orthot. Int.,
AC
vol. 16, no. 3, pp. 200–202, Dec. 1992. [89] K. Tedford, J. Engsberg, J. Patterson, and J. Harder, “A comparison of lower limb performance and balance scores between below-knee amputee and able-bodied children.,” Physiother. Canada, vol. 46, no. 3, pp. 190–195, 1994. [90] J. Andrysek et al., “Preliminary Evaluation of a Commercially Available Videogame System as an Adjunct Therapeutic Intervention for Improving Balance Among Children
39
ACCEPTED MANUSCRIPT and Adolescents With Lower Limb Amputations,” Arch. Phys. Med. Rehabil., vol. 93, no. 2, pp. 358–366, Jan. 2012. [91] M. D. Geil, K. J. Wasco, J. Wu, C. Coulter, Z. Safaeepour, and Y. Tai Wang, “A Pilot Investigation of the Effect of Postural Control Strategies and Balance in Children with
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Unilateral Lower-Limb Amputation,” JPO J. Prosthetics Orthot., vol. 28, no. 4, 2016.
IP
[92] C. Assaiante, S. Mallau, S. Viel, M. Jover, and C. Schmitz, “Development of postural
CR
control in healthy children: a functional approach.,” Neural Plast., vol. 12, no. 2–3, pp. 109–172, 2005.
US
[93] C. Assaiante, B. Amblard, and A. Carbiane, “Peripheral vision and dynamic equilibrium
AN
control in five to twelve year old children,” vol. 812, B. Amblard, A. Berthoz, and F. Clarac, Eds. Amsterdam: Elsevier (Excerpta Medica), 1988, pp. 75–84.
M
[94] C. Assaiante and B. Amblard, “Ontogenesis of head stabilization in space during
ED
locomotion in children: influence of visual cues,” Exp Brain Res, vol. 93, no. 499, 1993. [95] C. Assaiante, “Development of locomotor balance control in healthy children.,” Neurosci.
PT
Biobehav. Rev., vol. 22, no. 4, pp. 527–532, Jul. 1998.
CE
[96] B. Brouwer et al., “Running patterns of juveniles wearing SACH and single-axis foot components,” Arch. Phys. Med. Rehabil., vol. 70, no. 2, pp. 128–134, Feb. 1989.
AC
[97] L. A. Clark and R. F. Zernicke, “Balance in lower limb child amputees.,” Prosthet. Orthot. Int., vol. 5, no. 1, pp. 11–18, Apr. 1981. [98] M. G. Hoy, W. C. Whiting, and R. F. Zernicke, “Stride kinematics and knee joint kinetics of child amputee gait.,” Arch. Phys. Med. Rehabil., vol. 63, no. 2, pp. 74–82, Feb. 1982. [99] D. Hittenberger, “The Seattle Foot®,” Orthot. Prosthetics, vol. 40, no. 3, pp. 17–23, 1986. [100] M. Geil and C. Coulter, “Analysis of locomotor adaptations in young children with limb
40
ACCEPTED MANUSCRIPT loss in an early prosthetic knee prescription protocol.,” Prosthet. Orthot. Int., vol. 38, no. 1, pp. 54–61, Feb. 2014. [101] A. M. Boonstra et al., “Children with congenital deficiencies or acquired amputations of the lower limbs: functional aspects,” Prosthet. Orthot. Int., vol. 24, no. 1, pp. 19–27, Apr.
T
2000.
IP
[102] G. Sener, K. Yigiter, K. Bayar, and F. Erbahceci, “Effectiveness of prosthetic
CR
rehabilitation of children with limb deficiencies present at birth.,” Prosthet. Orthot. Int., vol. 23, no. 2, pp. 130–134, Aug. 1999.
US
[103] D. D. Allen, G. E. Gorton, D. J. Oeffinger, C. Tylkowski, C. A. Tucker, and S. M. Haley,
AN
“Analysis of the pediatric outcomes data collection instrument in ambulatory children with cerebral palsy using confirmatory factor analysis and item response theory
M
methods.,” J. Pediatr. Orthop., vol. 28, no. 2, pp. 192–198, Mar. 2008.
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[104] P. Lenka, A. R. Chowdhury, and R. Kumar, “Design & Development of Lower Extremity Paediatric Prosthesis, a Requirement in Developing Countries,” Indian J. Phys. Med.
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Rehabil., vol. 19, no. 1, pp. 8–12, 2008.
CE
[105] H. Centomo, D. Amarantini, L. Martin, and F. Prince, “Muscle adaptation patterns of children with a trans-tibial amputation during walking,” Clin. Biomech., vol. 22, no. 4, pp.
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457–463, May 2007.
[106] P. Taboga and A. M. Grabowski, “Axial and torsional stiffness of pediatric prosthetic feet.,” Clin. Biomech., vol. 42, pp. 47–54, Feb. 2017. [107] J. Philipps Otto, “Is pediatric progress in O&P keeping pace with kids?,” The O&P Edge, Apr-2016.
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ACCEPTED MANUSCRIPT Figure captions
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Figure 1. Flow diagram. Flow diagram of study inclusion process.
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ACCEPTED MANUSCRIPT Table 1. Specifications of studies included in this review: participants, prosthetic components, objectives, outcome measures and summary of findings. Prosthesis
Objective & Method
Outcome measures
Findings
Andrysek et al., 2005
6 Amp. 7-13 Yr TF Congenital (4) & Acquired (2)
Foot: NR Socket: NR Knee: Total Knee Junior, Otto Bock 3R66
Modelling & questionnaire survey
Custom questionnaire (15 questions about activities, knee give out, walk, run, uneven ground and inclines and stairs)
6 Amp. 7-13 Yr TF Congenital (4) & Acquired (2)
Foot: SpringLite, Seattle, TruPer Socket: NR Knee: ASPL Total Knee Junior Otto Bock 3R66
Case series & crossover trial.
NR
Pre & Post pilot study
Decreased frequency of falls with the prototype compared to other knees, especially in highly active children. The children also reported worrying less about the knee collapsing during walking. No differences for stance-phase stability during different activities. Higher gait velocities with the ASPL knee joint, associated with increased temporal interlimb asymmetry, joint moments and powers, and excessive prosthetic knee range of motion in swing. Increased pelvic motions with ASPL knee compared with conventional knees. At baseline, TF amputees had greater CoP displacements than the Van Ness group and TD children.
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Comparing functional efficiency of a stance-phase controlled knee vs. non-stancecontrolled knees
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Subjects
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Andrysek et al., 2007
Gait performance of ASPL vs. pediatric conventional knees
Pelvic obliquity; pelvic tilt & rotation RoM; hip, knee & ankle RoM; joint moments & powers; Cadence; speed; stride length
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Andrysek et al., 2012
6 Amp., 10 TD 8-18 Yr TF (3), Van Nes (3) Acquired
Examine the safety, feasibility, and balance
Centre of pressure displacements during quiet standing; Questionnaire survey (Community
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Balance & Mobility Scale)
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Walking function/gait analysis
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Knee: Constant friction/safety knee
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56 Amp. in total; only 31 participated in testing 1.08-18 Yr (Mean = 10.2) Syme’s (8), TF/KD (9), TT (10), distal foot (4) Acquired & Congenital
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Ashley et al., 1992
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performance of a 4-week homebased balance therapy program using a videogame system (comparison between baseline, after 5 weeks, after 13 weeks
Questionnaire survey; Stride dimensions; walking speed; cadence; Ambulatory heart rate
Immediately post intervention, the CoP displacements decreased in the TF amputees; values were closer to those of TD children. The average increase in CB&M score from baseline to follow-up was 6 points across participants. Amputee children have slower walking speed, lower cadence, longer stride length and higher heart rates than TD. Compliance with prosthetic wearing was best with Syme’s amputees (97%) vs. 71% of TF/KD. All distal foot amputees, 94% of Syme’s, 84% of TT and 59% of TF/KD could run with Prosth. Constant friction/safety knee limited TF ability to modify cadence. Limitations in locomotor ability is proportional to amputation level.
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ACCEPTED MANUSCRIPT Boonstra et al., 2000
88 Amp. 1-18 Yr All levels except toe amputation Acquired & congenital
NR
Qualitative survey
6 Amp. 9-17 Yr TT Congenital (1) & Acquired (5)
Foot: SACH Single-axis (SA) Socket: PTB
Use and functional performance of lower limb amputee children
Child-health assessment questionnaire (Child-HAQ): 5 questions about Dressing and grooming; Rising from chair or floor; walking; physical activity
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Brouwer et al., 1989
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Running patterns (extent and location of kinematic and kinetic asymmetries) of juveniles with SACH & SA feet
Speed; step length; step time; stance time; peak vertical ground reaction force; joint angle and moments
Most children (95%) could walk; 93% more than 100m and 93% of the children aged 4 years or over were able to cycle. The functional abilities of 88 Dutch children with congenital leg deficiencies or leg amputations were found to be generally satisfactory. Most of the children used prostheses in their daily activities. Secondary complications were, however, frequent. SACH and SA feet performed almost identically. Slower step speed on the affected side was related to significantly lower vertical ground reaction forces. None of the feet could simulate natural footankle function, with resulting significant interlimb asymmetries. The ipsilateral knee displayed marked reduction of the initial flexor wave, paired with a reduced extensor moment. 45
ACCEPTED MANUSCRIPT Catani et al., 1993
10 Amp. 10 TD Amp. 7.5-14 Yr (mean=10.7); TD (mean = 29.9 Yr) Van Nes rotationplasty Acquired (cancer)
Prosthesis with one degree of freedom (flex/ext) at the pseudoknee at the level of malleoli
Gait Analysis of patients after Van Nes rotationplasty
Stride time; stride length; cadence; speed; swing time; ground reaction time; vertical & fore-aft ground reaction force; hip & pseudo knee angles
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Centomo et al., 2007
8 Amp.; 8 TD Amp.: 8-16 (12) Yr; TD (12) TT Congenital (5) & meningococcemia disease (3)
Foot: Seattle
Motor solutions used by TD and TT children during a stepping-inplace task
Peak joints angular excursion, moment, and power
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Centomo et al., 2007
Muscle adaptation patterns during walking
Resultant, agonist and antagonist moments, power, cocontraction index, step length, swing time, stance time, speed,
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6 Amp: 11 ± 5 Yr; 6 TD: 12 (SD 4) Yr TT Congenital (4) & meningococcemia disease (2)
Foot: Seattle Light
Significant differences were found in stride duration, stride length, cadence, speed, and stance-swing ratio, and in ground-reaction forces parameters between TD and Amp. subjects. There were differences in some kinematic parameters as well. Pseudo-knee allows a smooth and coordinate gait pattern. Even if TT and TD children did the task with almost the same kinematics, the kinetic data revealed completely different mechanisms to achieve the stepping-in-place task, and TT children had a symmetrical interlimb strategy. Stepping-in-place task could offer a transition task to physical therapists for TT children. TT children altered their muscle patterns to perform locomotion. These changes produced a diminution of cocontraction during single limb support for 46
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Chu et al., 2016
5 Amp. Mean=11.3 Yr (SD 25.7 months) TF(2); KD(3) Acquired & congenital
Foot: SACH, CAPP Knee: 4-bar modular, Constantfriction
Postural stability using two prosthetic feet
Total base of support dimensions; CoP
Prospective qualitative study
Step count; PEQ questionnaire
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Clark & Zernicke, 1981
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cadence and stride length
21 Amp. 14.6 (SD 2.3) Yr TT (11) & TF (10) Acquired
Foot: FlexFoot, Assure (TT & TF) Socket: PTB supracondylar (TT), Suction socket (TF) Knee: Total Knee 2000
Daily step activities and prosthesisrelated quality of life of amputee adolescents
both the amputated and non-amputated limbs compared to TD children and, thus, could create joint instability. Step length, swing time, stance time and single limb support time were not statistically different between TT and TD children. No significant difference was observed for stride length and average speed and cadence. Total base of support did not differ for the two types of prosthetic feet, but the functional base of support for SACH foot was significantly larger than CAPP. Fluctuations of centre of pressure about a mean position in normal standing was less with CAPP foot. TT amputees had significantly higher levels of step activity than TF in all Step Activity Monitors measures. Prosthetic compliance was good with daily wearing time of above 12h/day in both groups. 47
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Engsberg et al., 1989
8 Amp. 8-18 Yr TT Congenital
Foot: SACH, Seattle Socket: PTB
Mechanical and metabolic factors during gait with two prosthetic feet
Walking speed, stride length, stride time, cadence, stance/swing time ratio, joint angles, joints moments, joint powers, energy cost of walking, subjective preference for ambulatory activities and cosmesis
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Colborne et al., 1992
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3 Amp; 10 TD 7-9 Yr TT NR
Foot: SACH
Differences in standing ground-shoe pressure distribution between TT and normal children
Ground-shoe pressure distribution; Foot-bod weight ratio for standing; Forefoot-whole foot weight
PEQ scores showed no significant difference between two groups. Higher levels of step activity of TT amputees suggest that they have had lower energy expenditure and more capacity for ambulation. The Seattle foot produced a small increase in stride length and walking speed. The Seattle foot was less resistant to passive dorsiflexion in midstance. A knee flexor moment dominated the stance phase while walking with the SACH foot, while Seattle foot allowed a normal extensor moment. On the sound side, the hip produced most of the positive work, while the ankle output was below normal. The energy cost of walking was slightly lower with the Seattle foot. The weight distribution between prosthetic and non-prosthetic limbs of TT children was not significantly 48
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Foot: SACH, Seattle, Flex foot, Single axis Socket and suspension: PTB, PTS Sleeve, Figure of 8, Thigh corset, Condylar
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21 Amp; 200 TD 5-17 Yr TT NR
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Engsberg et al., 1992
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ratio for standing
Weight distributions of TT amputee and able-bodied children during two different standing positions (1. both feet together on the pressure plate; 2. feet placed 20cm apart)
Foot pressure (Foot force to body weight ratio, forefoot force to wholefoot force ratio)
different from the feet of TD children. The anteriorposterior weight distribution for the prosthetic and non-prosthetic feet was significantly different from that of the TD children. Asymmetrical loading patterns of the TT amputee children during standing may be a logical result of the morphological differences between the prosthetic and non-prosthetic limb, which may be placing abnormally high loads on the joints of their lower extremities. TT amputee children placed more weight on their nonprosthetic limb than their prosthetic limb, yet this was not different from TD children in respect of weight distribution between dominant and non-dominant limbs. Approximately 90% of the load on the prosthetic foot was placed on the forefoot. The load on the non-prosthetic foot was evenly 49
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Engsberg et al., 1993
3 Amp.; 10 TD 7-9 Yr (mean=8) TT NR
Foot: SACH
Intersegmental knee and hip forces for TT amputee and TD children during standing
Ground reaction pressure, leg, thigh, knee and trunk angles in the Sagittal and frontal plane; Q-angle
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Engsberg et al., 1991
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3 Amp.; 11 TD Amp. mean=7.5 Yr; TD mean=8.4 Yr TT Congenital (2) & Acquired (1)
Foot: SACH
Center of mass locations and segment angular orientations of the gait of TT children to TD children
Center of Mass locations at touchdown, midsupport, and takeoff of support
distributed between the forefoot and rearfoot like that of TD children. Except for more weight on the forefoot of the prosthetic leg, TT children stood in the same way as TD children. In some instances, the intersegmental forces for TT children were significantly greater than those of the TD children, and in other instances, significantly lower. In all cases, the values were substantially less than corresponding values for walking and running. The frontal plane prosthetic knee angle, the sagittal plane prosthetic and non-prosthetic knee angles, and the sagittal plane trunk angle were all greater for the TT children when compared to TD. In the sagittal plane, CoM was lower and more anterior for the TT children; primarily due to the greater forward flexion of the trunk.
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22 Amp.; 225 TD Amp: 6-16; TD: 7-12 TT NR
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Engsberg et al., 1993
21 Amp.; 200 TD Amp (5-17 Yr); TD (7-12 Yr) TT NR
Foot: SACH, Flex foot Seattle, Single axis Socket and suspension: PTB, PTS Sleeve, Figure of 8, Thigh corset, Condylar
Normative ground reaction force data for TD and TT children during walking
Average normalized force-time curves
Normative ground reaction force data for TD and TT amputee children during running
Vertical forcetime; anteroposterior force-time; mediolateral force-time; maximum force during the latter phase of support
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Engsberg et al., 1993
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Foot: SACH Seattle Flex foot Single axis Socket and suspension: PTB, PTS Sleeve, Figure of 8, Thigh corset, Condylar
The location of the CoM in the frontal plane tended to remain on the nonprosthetic side of the body for the TT children during the entire gait cycle, whereas CoM location of the TD children moved from one side to the other due to the trunk leaning towards the nonprosthetic side of the body. TT children had an asymmetrical gait pattern with a dominant role of the nonprosthetic limb. This dominant role was related to a greater rate of loading, magnitude of loading, impulse, and time of loading as compared with prosthetic limbs and with the limbs of TD children. No significant differences for the discrete variables between: 1) right and left legs; 2) gender; and 3) age in TD children. Differences seen between the three types of foot with the nonprosthetic leg, indicating greater forces than the
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Feick et al., 2016
Foot: Seattle, SACH, Dynamic foot, Flex foot Socket and suspension: Greisinger, Condylar, Sleeve
Relationships among simple methods for measuring effort in TT amputee and TD children
Foot: Lowprofile energy returning feet (Syme’s).
Prospective cross-sectional study
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10 Amp.; 13 TD Amp: 6-18 Yr; TD: 7-17 Yr TT NR
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10 Amp.; 10 TD Amp: 9.6 (SD 2.6) Yr (7–13); AB: 9.7 (SD 2.4) Yr (6–12)
Relationships among balance
Actual & predicted oxygen uptake (during final I5 seconds of each trial), heart rate (before testing, during the final 10 seconds of each trial, and after test), physiological cost index, maximum heart rate, the relative exercise intensity, and vertical displacement of a surface marker on the sacrum; selfselected walking speed CoP RMS; Gait symmetry index (Step time, step length, stance time, swing
prosthetic and TD legs. Greater values were obtained for the maximum force in the lateral direction and for the time spent applying force in the lateral direction. No significant differences were found for foot types or suspensions. Significant differences existed between the nonprosthetic and prosthetic values of the TT children, and between the TT and TD children. Oxygen uptake for the TT children was not significantly different than TD children Significant correlations between oxygen uptake and the four measured variables were all between 0.91 and 0.92. Medial/lateral displacements of the surface marker were slightly greater for the TT children than TD children.
No significant differences in gender, age, height, weight, or self-reported engagement in 52
ACCEPTED MANUSCRIPT Syme’s (3), TT (3), TF & KD (3) Congenital (5) & Acquired (5)
Energy returning feet (TF & TT) Socket and suspension: Segmented sockets (Syme’s). Locking silicone liner (TT). Ischial containment sockets, silicone liner (TF) Knee: 4-bar knee
16 Amp. 7.3-17 Yr
Constant friction singleaxis (for Syme’s) Socket and suspension: Thigh corset
Energy expenditure during walking
Oxygen cost (energy per unit of body mass expended per distance walked); walking speed;
Foot: Freedom Renegade, Seattle Light, Ossur Elation, College Park Truper
Effect of postural control strategies and balance in children with unilateral
Total excursion of CoP in AP & ML, mean velocity of CoP; vertical GRF; 95%
time, single support time, double support time); Physiological Cost Index; Walking speed; Community Balance and Mobility (CB&M) scale; heel-to-heel base of support
Fowler et al., 1996
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and mobility measures in children with unilateral lower-limb amputation and TD children
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4 Amp.; 5 TD Amp: 12.25 (SD 2.2) Yr; TD: 12.8 (SD 4.1) YR Syme’s Congenital fibular
recreational activities between the amputee and TD groups. Significantly lower walking speed, distance, and functional balance were seen in children with amputation compared to TD children. For children with amputation, reduced energy expenditure was associated with narrower step width and more symmetrical gait; better postural control and balance were associated with faster walking speeds. Van Nes subjects had a mean oxygen cost of 0.12 milliliter per kilogram of body mass per meter, lower than that of the subjects with Syme amputation. The subjects with Van Nes procedure walked faster. A significant decrease in the oxygen cost as a function of increasing age was observed for both groups. Amputee children showed an unexpected nonlinear response as weight increased vs. normal 53
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lower-limb amputation (Quiet standing with backpacks loaded with 0, 10, 20, and 25 percent of BW) Crawling pattern with nonarticulating vs. articulating knee prosthesis
confidence ellipse of CoP excursion; Weight-bearing contribution
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5 Amp. 13-23 Months KD (2); TF (3) Congenital (3) & acquired and congenital (2)
Foot: TRS infant foot, Seattle child’s play foot Socket and suspension: Total elastic suspension belt Knee: Otto Bock 3R38
Crawling pattern, speed, and cadence
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5 Amp. 13-23 months KD (2); TF (3) Congenital (3) & acquired and congenital (2)
Foot: TRS infant foot, Seattle child’s play foot Socket and suspension: Total elastic suspension belt Knee: Otto Bock 3R38
Crawling kinematics with non-articulating vs. articulating knee prosthesis
Peak knee flexion, hip abduction and adduction angles, max angles between the shoulders and PSIS
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Foot: Infant foot, College Park Truper, Seattle Socket and suspension: Total elastic suspension belt™, Spirit liner
Before-and-after experimental design
Peak swing knee flexion angle; hip hiking (vertical excursion of the prosthetic side ASIS marker); Circumduction angle (angle of the ipsilateral femur segment
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7 Amp. 1.5–7.7 Yr KD(4); TF(3) Congenital (5) & Acquired (2)
Swing phase clearance adaptations in walking with locked vs. unlocked knee
controls. Postural control mechanisms used by the children with amputation may be different from their TD control. The locked knee condition reduced speed and cadence. With one exception, the children exhibited a more typical “stepthrough” crawling pattern with unlocked knee and a less efficient “step-to” pattern with locked knee. All participants achieved flexion (mean, 97.76°) of prosthetic knee in unlocked condition. Compensatory movements were variable and frequently greater in locked condition. Bilateral asymmetry and a variety of crawling patterns emerged, indicating volatility in this stage of motor development. Subjects utilized the articulating knee in walking, with an average of 70.4° of peak swing phase knee flexion. Some clearance adaptations were present with the flexing knee; 54
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Herbert et al., 1994
10 Amp.; 14 TD Amp: 6-18; TD: 6-17 TT NR
Foot: SACH, Seattle Knee: Constantfriction knee
Compare joint moments using anthropometrics from cadaver studies vs. direct measurements of the residual limb
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Moment of inertia; Center of gravity; Segment mass; peak joint moments
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in the frontal plane); Vaulting (contralateral ankle plantarflexion angle during swing phase)
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Knee: Otto Bock 3R38, Otto Bock 3R66, Pediatric total knee
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Oxygen consumption during walking between amputee and TD
Heart rate; Oxygen uptake Subjects walked for 2 minutes at each of the following four speeds: chosen walking speed (CWS), 20% below CWS, 20% above CWS, and fixed speed of 1.2 m/s.
more were present and their magnitude was increased when the knee was locked. Statistically significant increase in circumduction seen. Peak hip and knee flexor and extensor moments during swing were significantly greater calculated using cadaver data. These differences were greater while walking fast as compared to slow speeds. No significant difference between these two methods for peak hip and knee moments during stance. A significant difference was found for peak ankle joint moments during stance, but the magnitude was not clinically important. No significant differences between children with long and short residual limbs. Oxygen consumption was 15% greater for TT children compared with TD. No differences in heart rates between TD and 55
5 Amp. 7.9-12.8 Yr KD (3); Proximal femoral focal deficiency (2) NR
Foot: Single axis Knee: Constant friction knee
Effect of variable knee friction on the swing phase of gait in juvenile amputees
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5 Amp. Mean = 11.3 Yr KD (3); TF (2) Congenital (1) & Acquired (4)
Foot: SACH, CAPP Knee: Constant friction, 4-bar modular KD
Gait kinetics & kinematics of amputee children in 3 different speeds with SACH vs. CAPP feet
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Resting VO2 rate, resting heart rate, walking VO2 rate, walking VO2cost, walking heart
Stride length, step length and walking speed decreased and stride width increased with CAPP. As walking speed increased, stride and step lengths increased for both foot types. Foot angles increased with walking speed. Joint angles were significantly different between the intact and prosthetic limbs. Maximum hip flexion angle and total range of thigh movement were different between the two feet; the CAPP showed less hip flexion and smaller range of thigh motion. Unilateral TF and HD amputations resulted in significantly reduced walking speed (80% and 72% of normal,
Speed; stride length; cadence; swing time; stance time; shank period (double the swing time); shank excursion (the amount of knee flexion); knee ROM Stride length; stride width; step length; toein & toe-out angles; stride time; walking speed; cadence; max knee & thigh flex & ext angles; thigh & knee RoM; knee moment; knee force
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TT or within those with TT. Children with TT did not choose speeds different from the TD. Knee RoM was altered by changing the amount of knee friction. The knee flexion remained constant during gait.
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73 Amp; 45 TD: Children (6-12 yr); Teenagers (13-18 yr) Amp:
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Effect of level of amputation in children on the self-selected walking speed and oxygen cost
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ACCEPTED MANUSCRIPT Syme’s (11.1 SD 2.7); TT (12.5 SD 3.8); KD (14.0 SD 3.5); TF(14.0 SD 2.1); HD (12.0 SD 5.0); Bilateral TT (11.6 SD 5.1) TD: 6-12 Yr (n=24) & 13-18 Yr (n=21) Syme’s (29), TT(13), KD(14), TF(5), HD(5); Bilateral TT (7) Congenital (42) & Trauma (13) & Disease (18)
rate, selfselected walking speed
Foot: Flex foot, Dynamic response foot, SACH
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Difference between the performance of amputee children with TD children
Gait differences between children with Syme and TT amputation. Effect of type of prosthetic foot on gait and questionnaire survey outcomes
Ankle plantar flexion, Ankle RoM, hip RoM, ankle & hip power, hip external rotation, knee hyperextension, Pediatric Outcomes Data Collection Instrument (PODCI)
respectively) and increased VO2 cost (151% and 161% of normal, respectively). Heart rate was significantly increased in the HD group (124% of normal). Children with a bilateral amputation walked significantly slower (87% of normal) than the TD, with an elevated heart rate (119% of normal) but a similar energy cost. Children with a Syme, TT, or KD walked with essentially the same speed and oxygen cost as did TD children in the same age group. Kinematic differences of <4° in total prosthetic ankle motion and 8° in external hip rotation were seen between the Syme and TT groups. Ankle power was greater in the TT group, whereas the Syme group had greater coronal-plane hip power. Ankle motion was greater with highperformance feet (9%) compared with medium(59%) and low57
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Lewallen et al., 1986
6 Amp. 8-17 Yr TT Congenital (1) & Acquired (5)
Foot: SACH Socket and suspension: Supracondylar PTB socket
Gait kinematics and joint moments in sagittal plane between TD and amputee children using force plate data. Determine whether limb loss results in higher forces across joints of intact leg
Stance & swing time, step length to height ratio, joint RoM, walking speed, ground reaction force, joint moment
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16 Amp. 7.2–20 Yr Syme’s (11), TT (5) Congenital (13) & Acquired (3)
Foot: Seattle Lightfoot, College Park TruStep®, Otto Bock Luxon Max®
Effect of different pediatric prosthetic feet (multiaxial dynamic vs. energy-storing feet) on function during highperformance functional activities
Speed, cadence, stride length, step length, max plantar flexion in-stance, dorsi/plantar RoM, peak power absorption, peak power generation, cutting drill time, sprinting time, vertical jump height, long jump distance, oxygen cost on the treadmill; subjective rating of feet
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Schneider et al., 1993
Compare gait symmetry with SACH & Flex foot during selfselected and fast walking
Walking speed, joint angles, joint powers, joint moments, vertical & foreaft ground reaction force, centre of
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12 Amp. 6-16 Yr (mean = 10.9 SD 3.2) TT Congenital (9) & Acquired (3)
Foot: SACH, Flex foot
performance (31%). Joint moments in the sagittal plane of the intact limb were normal or below normal during level walking. With a good prosthesis fit, forces across the joints of intact and prosthetic legs will not increase (not leading to degenerative arthritis). No significant differences among the three prosthetic feet in highperformance functional activities, or oxygen cost on the treadmill. No significant differences among the three feet for speed, cadence, stride length, or prosthetic side step length. TruStep® had significantly greater dorsiflexion and plantarflexion motion and greater peak power generation in late stance during walking. Marked asymmetries in power, moment and ground reaction force between the intact and prosthetic legs. Asymmetries 58
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13 Amp. PFFD (6); TF (2); TT (5) Congenital & Acquired
Foot: SACH Socket and suspension: Quadrilateral (TF), PTB/PTS (TT)
Ability to perform ADL (Questionnaire survey)
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4-point questions (not reported)
21 Amp; 200 TD Amp: 6-16 Yr; TD: 7-12 Yr TT NR
Foot: SACH, Flex Seattle, Single axis Socket and suspension: PTS, PTB Condylar Sleeve Fig of 8 Thigh corset
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pressure excursions
Compare performance and static balance between healthy and TT children
Performance & strength tests: Standing broad jump, vertical jump, squat against wall for time, grip strength Balance tests: times tests based on BruininksOseretsky gross motor test - Standing on dominant leg on floor - Standing on dominant leg on balance beam - Standing on balance beam with eyes closed
were less pronounced with flex foot than SACH. During fast walking, SACH needed greater output from the intact limb. Comfortable walking speed, greater moments and powers were generated by the intact limb with Flex foot. The flex foot returned more energy (over 65%) than SACH foot (less than 20%). 84.7% became independent walkers (without walking aid) 61.5% actively participated in recreation with peers Significant differences were observed in single and double leg jumps between the amputee and TD children. No difference was seen for the vertical jump and timed squat. The balance scores of the prosthetic limb was significantly lower than the intact limb and those of the TD children. The TT subjects could jump a significantly lower distance on their prosthetic 59
10 Amp. 11-20 Yr TT Congenital (7) & Acquired (3)
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41 Amp. 8-17 Yr TT (7), TF (5), HD (2), PFFD (7) Congenital (21) & Acquired (20)
Foot: Seattle Lite, Genesis II
Walking and running characteristics with two different prosthetic feet
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Speed, stride length, cadence, dorsiflexion (IC), max dorsiflexion (stance), max plantar flexion (swing), peak power absorption, peak power generation, absorption area, generation area; energy consumption; satisfaction survey
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Compare functional status of children with acquired vs. congenital lower limb loss after 3 weeks and 6 months of prosthetic rehabilitation
Foot angle, step length, stride length, step width, speed, cadence, weight bearing, Amputee Mobility Predictor (AMP) Questionnaire
leg as compared to the TD children. Less knee and ankle flexion was seen during jumping among amputee children than the TD; they placed more weight on the heels and on the intact leg. No significant differences in gait parameters, although peak dorsiflexion was increased with the Genesis foot in comparison with the Seattle foot. The Genesis foot had an increase in power absorption and generation in comparison with the Seattle foot. No significant differences were found in energy consumption and agility tests. The congenital group had better gait patterns, weight bearing values and AMP scores in the initial assessment and after 3 weeks. No significant differences between the two groups after 6 months. After 6 months, the functional level, gait pattern and weight bearing values improved in both the groups. 60
ACCEPTED MANUSCRIPT Vannah et al., 1999
258 Amp. TT (80), AD (113), TF (30), PFFD (37), KD (28), PF (5), HD (5), Congenital (72%) & Acquired (28%)
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Survey on function and prosthesis technical problems
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26 Amp. 8-20 Yr (mean=14 SD 4) Van nes (15); TF (6); HD (5) Acquired (tumor)
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Energy expenditure during walking on a treadmill
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7 Amp. 1.5-6.1 Yr Syme’s (2); KD (5) Congenital (6) & Acquired (1)
Foot: SACH Seattle SAFE II Socket and suspension: Ischial or distal bearing Knee: Century 22 Total knee, DAW 4-bar knee, Otto Bock 3R39
Prosthesis wear time, pain level, perspiration, activity,
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Comparing gait with articulating & nonarticulating knee prosthesis (6camera Vicon) - baseline with non-articulating knee - after gait training with articulating knee - after 1 year of using articulating knee
Walking speed; oxygen consumption (Vo2), carbondioxide production (VCo2), respiratory exchange ratio (RER). and expiratory tidal volume; Heart rate Walking speed; step length; pelvic tilt; pelvic rotation; pelvic obliquity; hip flex/ext; peak hip abd; hip rotation; knee flex/ext; ankle flex/ext (sound limb)
Children who wear prostheses achieve full use status at a higher rate than the Adult population and are much more active. The most common reasons for temporary loss of limb use were pain, prosthesis failure tissue breakdown and perspiration. Children with a Van nes walk faster than those with TF or HD. No differences between the groups in energy expenditure per unit time or per unit distance.
Baseline speed and pelvis motion (sagittal, coronal & transverse), peak hip abduction were higher than normal values; greater step lengths for both legs. Sound limb had greater hip flexion & rotation than normal subjects. After gait training with articulating, knee, speed, cadence, hip flex/ext were lower than normal; hip RoM still higher for sound limb than 61
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prosthetic. Hip peak abduction greater than normal. After 1 year, speed increased, pelvic rotation decreased compared to baseline and 2nd visit. Asymmetry in hip rotation between sound and prosthetic limb decreased. Knee flexion increased from 32° to 49°. 42 Zernicke 5 Amp. Foot: SACH, Comparison of Vertical & fore- With the CAPP, et al., Mean = 11.3 (SD CAPP gait parameters aft ground centre of pressure 1985 2.1) Yr Knee: during slow, reaction forces; is located under KD (3), TF (2) Constantnormal and fast centre of the forefoot all Congenital (1) & friction knee, walking with pressure through stance, Acquired (4) 4-bar modular SACH vs. location; stride while with KD unit CAPP feet time, stride SACH foot, it is length, walking under forefoot speed, only 57% of the stance time. CAPP foot enhanced stability of prosthetic knee during stance. Fore-aft ground reaction forces in the prosthetic leg were significantly less than the intact limb. NR = not reported; AB = able-bodied; Amp. = amputee; TT = transtibial; TF = transfemoral; KD = knee disarticulation; HD = hip disarticulation; PF = partial foot; AD = ankle disarticulation
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Highlights
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This review of literature studied gait and balance of children with lower limb loss. Amputation level plays important role in mobility of pediatric lower limb amputees. Lower energy expenditure is associated with more distal amputation levels. Amputee children bear more weight on intact leg during dynamic balance tasks.
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Figure 1
Arezoo Eshraghi, Zahra Safaeepour, Mark Daniel Geil, Jan Andrysek PII: DOI: Reference:
S0268-0033(18)30245-6 doi:10.1016/j.clinbiomech.2018.09.017 JCLB 4606
To appear in:
Clinical Biomechanics
Received date: Accepted date:
22 June 2018 12 September 2018
Please cite this article as: Arezoo Eshraghi, Zahra Safaeepour, Mark Daniel Geil, Jan Andrysek , Walking and balance in children and adolescents with lower-limb amputation: A review of literature. Jclb (2018), doi:10.1016/j.clinbiomech.2018.09.017
This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT Walking and balance in children and adolescents with lower-limb amputation: a review of literature Arezoo Eshraghi;a Zahra Safaeepour;b Mark Daniel Geil;c Jan Andryseka a Bloorview Research Institute, Holland Bloorview Kids Rehabilitation Hospital, Toronto, Ontario, Canada b Orthotics and prosthetics Department, University of Social Welfare and Rehabilitation Sciences, Tehran, Iran c Kennesaw State University, Kennesaw, Georgia, USA
Dr. Zahra Safaeepour Email: [email protected]
Dr. Mark Daniel Geil Email: [email protected]
Dr. Jan Andrysek Email: [email protected]
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Dr. Arezoo Eshraghi Email: [email protected]
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Abstract word count: 203 Main text word count: 7563
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Corresponding Author: Jan Andrysek Email: [email protected] Address: 150 Kilgour Road, Bloorview Research Institute, Holland Bloorview Kids Rehabilitation Hospital, Toronto, Ontario, M4G 1R8, Canada
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ACCEPTED MANUSCRIPT Walking and balance in children and adolescents with lowerlimb amputation: a review of literature
Abstract
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Background: Children with lower limb loss face gait and balance limitations. Prosthetic
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rehabilitation is thus aimed at improving functional capacity and mobility throughout the
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developmental phases of the child amputee. This review of literature was conducted to determine
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the characteristics of prosthetic gait and balance among children and adolescents with lower-limb amputation or other limb loss. Methods: Both qualitative and quantitative studies were included
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in this review and data were organized by amputation etiology, age range and level of
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amputation. Findings: The findings indicated that the structural differences between children with lower-limb amputations and typically developing children lead to functional differences.
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Significant differences with respect to typically developing children were found in
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spatiotemporal, kinematic, and kinematic parameters and ground-reaction forces. Children with transtibial amputation place significantly larger load on their intact leg compared to the
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prosthetic leg during balance tasks. In more complex dynamic balance tests, they generally score
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lower than their typically developing peers. Interpretation: There is limited literature pertaining to improving physical therapy protocols, especially for different age groups, targeting gait and balance enhancements. Understanding gait and balance patterns of children with lower-limb amputation will benefit the design of prosthetic components and mobility rehabilitation protocols that improve long-term outcomes through adulthood. Keywords: Walking; Amputation; Pediatric; Adolescents; Lower limb; Prostheses; Gait; Balance; Mobility; Rehabilitation; Therapy
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ACCEPTED MANUSCRIPT 1. Introduction Limb loss or deficiency during childhood is devastating for both by the family and the child. Lower limb amputation (LLA) is associated with mobility and physical activity limitations [1], [2]. Rehabilitation of children and adolescents with LLA is dependent mainly on etiology,
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amputation level and age among other factors. In terms of etiology, dysvascular amputations
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predominate in the adult population [3], while most childhood limb losses stem from congenital
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deficiency, followed by infection and trauma. The incidence of congenital limb deficiencies is said to range from 3.5 to 7.1 per 10,000 per 10,000 births [4].
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Among the important aspects specific to pediatric amputation are surgical intervention,
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physical therapy for balance and gait training, appropriate timing for prosthetic fitting, and choice of appropriate prosthetic components. Physical therapy goals are quite different for
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congenital and traumatic children amputees. Those with congenital deficiency naturally develop
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abilities to perform activities by incorporating the impaired limbs into their movement strategies [5]. Thus, physical therapists often act as a mentor to the child and family by foreseeing the
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immediate and future functional challenges. Whereas in traumatic cases, the primary goal is to
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restore the function the child had before amputation. Lending to their growth and development, children experience self-organization of multiple developing subsystems (brain, body, and
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behavior) needed to complete complex tasks. In terms of balance control, both typical and amputee infants and children should learn a new perception-action system [6] in each postural milestone, such as crawling and walking. For each posture, they should maintain their bodies within a dynamic base of support [7]. As gait and balance are re-established, reorganization of the motor pattern takes place in order to optimize the functions of the locomotor system [8]. Such reorganization is however not independent of the prosthetic device that assists the
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ACCEPTED MANUSCRIPT individual in performing physical activities. Since “children are not just small adults,” pediatric prostheses need to consider the specific needs of the child [9]–[11]. These include the expected functional and mechanical demands on the pediatric residual limb and prosthesis as well as activity types and levels [11]. As a child grows into adolescence, body weight and limb length
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allow use of adult prosthetic components. Hence, a unique feature of pediatric amputees is
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continuous bony growth of residual limb until skeletal maturity [11]. Further, in many cases
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pediatric amputees present with multiple limb deficiencies, with residua having abnormal shapes, thus making prosthetic rehabilitation and fitting an ongoing challenge [11]. Aside from the
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aforementioned physical, physiological and functional elements, it is important to note that
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children with limb loss also commonly experience various ongoing psychosocial challenges, including peer pressure, stigmatization, and gaining acceptance [12][13]. Restoration of mobility
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function, including gait and balance, are fundamental to prosthetic rehabilitation as evidenced in
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a strong base of existing literature, however, primarily in adults. Gait analyses of adults with LLA have shown slower walking speeds, shorter step lengths, lower cadences and lower peak
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stance-phase knee flexion on the prosthetic side [14]–[17] compared with non-amputees. Adults
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with LLA also have decreased loading on the prosthetic limb which increases loading on the intact limb [18], poorer balance compared to able-bodied individuals [19]–[21] and use the intact
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limb as a primary means of control during static and dynamic tasks, while relying heavily on visual information [21], [22]. Moreover, joint mobility and muscle strength may be reduced due to the loss of the biological ankle joint and related muscles. Therefore, adults with LLA are reported to have a higher risk of falling in comparison to able-bodied individuals [23]. A significant body of literature and comprehensive systematic reviews focusing on gait and balance exist that inform prosthetic practices in adults with LLA [24]–[27]. Although we may
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ACCEPTED MANUSCRIPT learn from research on adult amputees to address certain mobility challenges of pediatric prosthetic users, exploring typical mobility patterns of children with LLA is necessary in designing age-specific prosthetic rehabilitation strategies. Understanding how pediatric lowerlimb amputees ambulate with and adapt to prostheses over time may provide insight into gait and
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balance rehabilitation procedures. For instance, physiotherapists often try to train the pediatric
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amputee to simulate the gait of typically developing (TD) children [28]. Yet, since the structures
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of the prosthetic and anatomical limbs are different, the function might be so as well. Therefore, in recognition of the unique care needed for the pediatric amputee population, this review aimed
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to consolidate the leading literature relating the gait and balance of children who use prosthetic
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devices for ambulation. This study can serve as a useful reference for clinical practitioners
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providing care to children with limb deficiency and loss.
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2. Methods Search strategy
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A literature search was performed in MEDLINE (from 1980), EMBASE (from 1980),
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CINAHL (from 1982) and the Web of Science (from 1980) using the following keywords and their synonyms: child*, pediatr*, preschool, adolescen*, school-aged, teen*, infant, amput*,
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ambulat*, mobil*, walk*, locomotion*, prosthes* and artificial limb. Keywords related to the levels of amputation (e.g. Syme, transfemoral, transtibial, etc.) were also added to the final syntax. References from the identified studies were also examined to extend the search. Studies were selected based on the following inclusion criteria:
the studies involved pediatric and juvenile subjects with unilateral/bilateral amputation of a lower limb;
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the studies examined measures of walking and balance and functional performance with prosthesis, either quantitatively or qualitatively (survey, questionnaire, …);
English language.
Case reports, retrospective studies, studies that expressed development and mechanical
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testing of prosthetic components, animal studies, surgical procedures, conference papers (expect
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from full text ones), letters and editorials were excluded. Also, studies that included both
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pediatric and adult population were disregarded, because the results were reported as whole (not
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individually) for the pediatric group. Two authors (AE and ZS) independently assessed the selected papers. Where there was disagreement, the paper(s) was reviewed by a third author
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(JA). Using a standardized checklist, data were abstracted regarding each study’s population, outcome measures and findings. These data were independently verified by 2 authors (AE and
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ZS). Figure 1. shows the flow diagram of study inclusion process.
3. Results
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After reviewing and filtering the studies against our inclusion criteria, 42 studies were found
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eligible to be included in this literature review. Specifics of these studies are presented in Table 1.. Overall, 63% of the studies were conducted before year 2000, while only 37% were published
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between 2000 and 2016. The majority of studies (85%) were done in North America (US and Canada), while only 5% were conducted in the developing countries. The highest numbers of amputee participants in a single study were 258 [29] and 73 [30]. Almost all the studies included both females and males, yet no study evaluated the effect of sex on gait and balance of child amputees. The main biomechanical parameters used relating to gait and balance (based on the number of articles that evaluated them) were walking speed (n=21), joint angles (n=11), ground
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ACCEPTED MANUSCRIPT reaction forces (n=9), joint moments (n=8), joint powers (n=7), and center of pressure (n=3). The main physiological parameters used were energy cost (n=6), heart rate (n=4) and VO2 (n=2). The most frequent amputation levels studied (n = number of papers) in children were transtibial (TT, n=24), followed by transfemoral (TF, n=19), knee disarticulation (KD, n=13), Syme ankle
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disarticulation (n=12), hip disarticulation (HD, n=5), and partial foot (PF, n=1). In terms of
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etiology, 28 studies included both congenital deficiencies and acquired amputation, four only
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studied children with acquired amputation, and two involved only children with congenital
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deficiency. Eight studies did not report the etiology of participants.
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4. Discussion 4.1. Gait
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4.1.1. TD children vs. children with LLA
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Kinetic analyses have also shown structural differences between LLA and TD children, leading to functional differences. For instance, significant differences in joint moments and
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ground reaction forces of lower extremity have been reported among the non-prosthetic and
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prosthetic legs of children with LLA and the TD children during walking [31], [32]. Six studies included both TD children and children with LLA to compare walking
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performance and ability. Catani et al. (1993) analysed the gait of children after Van Nes rotationplasty [33]. The Van Nes procedure is a common limb-salvage alternative to segmental replacement via a custom knee endoprothesis and above-knee amputation [11]. Using a force plate and motion analysis, they measured angular displacement of lower limb joints and spatiotemporal parameters. Significant differences were observed in stride duration, stride length, cadence, and velocity (1.29 vs. 0.90 m/s) between the TD children and children with LLA.
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ACCEPTED MANUSCRIPT Significant differences with respect to the TD children were found in stride duration, stride length, cadence, velocity, and stance-swing ratio, and in ground-reaction forces parameters, which define the propulsive phase in the prosthetic side and the acceptance phase in the sound side. The study concluded that rotationplasty has biomechanical/functional advantages, offering
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a coordinate and smooth gait pattern.
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Engsberg et al. (1993) collected video data of a walking stride from three children with TT
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amputation and 11 TD children during four sessions at six-month intervals. Frontal and lateral views of the participants were captured using two 16-mm cameras. They used a seven-segment
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model (trunk, head, arms, legs, thighs and feet) to determine the center of pressure (CoP)
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locations during gait. The trunk segment of children with TT amputation showed a larger forward flexion compared with the TD children. Trunk lean towards the intact side was a trend
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seen in children with TT amputation, compared to the TD children.
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In another study, Engsberg et al. (1994) studied differences in relation among indices of oxygen uptake and effort between children with TT amputation (n=10) and TD children [34].
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There is evidence that adults with amputation walk at higher energy cost than non-amputee
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adults [35]. However, in this study oxygen uptake for the children with TT amputation was not considerably different than the TD control group although the children with TT amputation did
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exhibit higher medial/lateral truck displacements than the TD children, which may be linked to greater instability based on adult studies [36]. Adult studies have also shown that TT amputees adopt certain compensatory strategies for the restrictions caused by the loss of a limb. Examples are the increased hip extensor moments and reduced knee extensor moments after heel strike for forward progression during walking as well as differences in the amplitude of net hip and knee joint powers and moments of the
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ACCEPTED MANUSCRIPT prosthetic leg compared to able-bodied controls [37]. Early diagnosis of movement deviations can prevent secondary complications such as arthritis and low-back pain; thus, it is important to study mechanisms contributing to movement coordination in TD and amputee children. Centomo et al. (2007) studied motor strategies used by children with TT amputation and TD
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children during a stepping-in-place task [38]. They believed stepping-in-place can be an
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alternative to gait analysis as it challenges the control of whole body equilibrium through a
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combination of reciprocal rhythmic movement of lower limb and multi-joint coordination. The subjects were asked to raise their legs alternately with the thigh angle never exceeding 90° of
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flexion (relative to vertical). This task had 3 phases: “weight acceptance” (the knee extended
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during support), “propulsion” and “swing phase”. During propulsion, a significant difference in the hip moment was seen between the two groups. The net hip joint moment was extensor in TD
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children, while it was flexor in the children with TT amputation. This was supported by another
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study by Engsberg et al. (1992) reporting that the Centre of Mass (COM) was more anterior in the sagittal plane during gait for the children with TT amputation over TD children [39]. While
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there are reports about asymmetry between legs for obstacle avoidance and gait in adults with TT
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amputation [40][41], this same level of asymmetry was not seen in children with TT amputation performing similar motions.
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One of the most important and commonly used indicators of successful locomotion is speed [42][24], and its main components, step length and cadence. Overall, the walking velocity was lower for children with LLA than TD children [30], [33], [43], [44], which is similar to the studies on adults with LLA [16], [18], [45]. The range of velocity during level walking and running was 0.56 - 1.6 and 2.5 - 2.7 m/s, respectively. However, Jeans et al. (2011) reported that over 70% of their subjects with KD, Syme and TT amputations showed a walking velocity that
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ACCEPTED MANUSCRIPT was not significantly different from the able-bodied controls [30]. This was similar to Herbert et al. (1994) for children with TT amputation [34]. Only children with TF amputation showed significantly lower walking speed from TD children (80% of normal). Only Zernicke et al. (1985) [46] and Schneider et al. (1993) [47] evaluated gait during various walking speeds (self-
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selected, slow and fast).
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The energy efficiency, evaluated by oxygen consumption, is one of the key measures of
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quantifying function during walking. The most commonly used metabolic variables are heart rate (resting & walking), VO2 rate (resting & walking) and VO2 cost. The difference in energy
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efficiency between adults with and without limb loss has been studied both through treadmill
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[20], [48] and over-ground [49]–[51] walking protocols. Overall, there is evidence that energy cost of adults with LLA during walking is greater than non-amputees. There is controversy in
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findings in the pediatric population, with some showing an increase by 15% in the VO2 cost in
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amputee children compared to the TD values [52], while others reported no difference [30], [44], [53], [54]. Based on Jeans (2011), children with LLA (Syme, TT, or KD) walked with oxygen
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cost and speed similar to the TD children in the same age group. However, the HD and TF
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groups exhibited a higher VO2 cost than the TD subjects and those with a Syme, TT, or KD amputation level. The heart rate was significantly higher in the HD group than that in the TD
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group. Compared with the control group, the bilateral group (Syme and TT) walked with a significantly higher mean heart rate and slower mean self-selected walking speed. In summary, study results are not consistent when it comes to energy cost of walking. Studies have also shown structural differences between children with LLA and TD children, leading to functional differences. Significant differences between children with LLA and TD
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ACCEPTED MANUSCRIPT children were found in spatiotemporal, kinematic, kinetic, and ground-reaction forces parameters.
4.1.2. Age differences & Gait
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When TD children first start to walk, immature control of gait and posture leads to large
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stride-to-stride fluctuations and frequent falls [55]. By the time children are three years old, their
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gait begins to mature [56], and a more stable walking pattern replaces unsteady gait. However, the development of locomotor function and neuromuscular control continue to change beyond
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the age of 3 [57], [58], although walking variability is said to decline after this age [59]. Some
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investigators suggest that a mature gait pattern is developed in children after the age of seven [56], [60][61], when the child can participate in exercise and is less dependent on his/her parents.
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However, there are findings denoting that mature stride dynamics may not be entirely developed
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even in 7-yr-old TD children, and that maturation of different aspects of stride dynamics happens at different ages [62].
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Both maturation of the central nervous system and learning contribute to the evolution of
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mature gait. Sutherland et al. (1980) identified five main determinants of gait maturity: velocity, cadence, step length, duration of the single support phase, and the ratio of the pelvic span to
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ankle spread [58]. Beck et al. (1981) measured the distance and temporal parameters and ground reaction forces in 11 months to 14 years children and concluded that, after the age of 5, changes resulted more from height than age [63]. Norlin et al. (1981) reported that temporal and spatial gait parameters were dependent on age up to the age of 8 years, but thereafter leg length was more dominant [64].
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ACCEPTED MANUSCRIPT The age range of children with LLA in the studies included in this review was widely variable; from toddlers (13 months) [65], [66] to 20 years-old adolescents [67], [68]. Overall, those studies that included a wide range of ages in their work did not report their findings separately for different age groups, which makes it difficult to recognize gait patterns by age.
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those at elementary years [44], [69], [70] and adolescents [71].
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However, there were studies that only focused on a certain age group, such as toddlers [66][65],
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Few research groups have focused on toddlers and infants at the age of crawling (as young as 13 months) and the main motivation for them was to explore more about the Early Knee
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protocol. There is evidence suggesting that a child with LLA (regardless of amputation cause)
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should be fit as soon as he/she starts to pull up into stand [72]–[74]. In standard practice, children were not provided with an articulating knee joint until the age of 4 or 5. But recently, prosthetic
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knee joints are available for infants and toddlers [72], [73], [75]. When no knee joint is added to
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the prosthesis, or the knee joint is locked into full extension, stability is ensured during locomotion; however, gait deviations develop to ensure swing-phase clearance, and age-
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appropriate activities are delayed [73][76].
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Wilk et al. (1999) [73] and later Geil et al. [65], [66] conducted studies on older toddlers and young children, (2-8 years). They both compared the effect of locked and unlocked prosthetic
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knee conditions and reported in a similar way that subjects used prosthesis knee flexion in the unlocked condition, and had less hip hiking, vaulting and circumduction. According to these studies, when offered an articulating knee, toddlers with TF and KD amputation can make use of prosthetic knee function during crawling. Moreover, several different crawling patterns exhibited improved symmetry and the crawling speed was increased.
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ACCEPTED MANUSCRIPT Jeans et al. (2014) divided LLA participants into two groups, adolescents (10-19 years old) and young children (4-9 years old), to explore age-dependent differences [77]. Minor differences were found in the gait variables. The young children showed less passive prosthetic ankle plantar flexion than the adolescents. While neither age group achieved plantar flexion, the young
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children had significantly lower plantar flexion than the adolescents. The knee was also in a
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more neutral position in mid-stance phase in the adolescent group, while the young children had
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knee hyperextension.
In summary, a limited number of studies reported on age-related differences. These studies
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found differences primarily for the kinematics of gait, at the hip, knee and ankle. The majority of
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4.1.3. Amputation level & Gait
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them were focused on crawling of toddlers with an articulating vs. locked knee joint.
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Regardless of age, an amputation is recommended to be done at the most distal level possible [30], [78]. Generally, the longer the residuum the better the gait, as a longer lever arm
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generates more power and makes prosthesis fitting easier. Yet, sometimes children end up with
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an overly long residual limb in an attempt to preserve the growth plates, which will make it challenging to accommodate prosthetic components, such as a knee unit. Several studies on gait
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patterns of children with LLA have included two or more levels of amputation; however, only few studies have differentiated and reported the gait patterns for each level. The most frequent amputation levels included in studies on gait of children were TT (n=14) and TF (n=14), followed by KD (n=11), Syme (n=10), HD (n=4) and distal foot (n=1). Ashley et al., (1992) compared walking function of children with various levels of LLA and concluded that limitations in locomotor ability were correlated to the level of amputation [43].
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ACCEPTED MANUSCRIPT Also, those participants with more distal levels of amputation had a better ability to increase their cadence, whereas those with more proximal levels depended on changes in stride length to alter their speed of walking. The reduced ability of TF or KD amputees to change cadence was attributed to the type of prosthetic knee they were using (safety knee or constant friction).
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Interestingly, when Jeans et al. (2011) compared level-ground gait in children with different
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levels of amputation, rates of velocity and oxygen consumption for those with KD were similar
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to TT [30]. But it should be noted that on uneven terrain, the mechanical knee joint cannot quickly adapt, causing gait difficulty. The TF and HD groups showed a higher VO2 cost than
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those with lower levels of amputation, which was in line with the results of a later study by Chu
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et al. (2016) [71]. The HD group had significantly higher heart rate during walking than that in the Syme and TD groups. As one could expect based on adult studies [79], those with bilateral
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TT amputations walked with a significantly slower mean self-selected speed and a significantly
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higher mean heart rate. No difference was seen between TT and Syme groups with respect to heart rate and oxygen consumption, suggesting that these mild gait deviations do not increase
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cardiovascular demand during walking. In comparison to Syme amputees, those with Van Nes
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amputation exhibited lower oxygen cost [80]. In terms of kinematic data, Jeans et al. (2014) found minor differences in prosthetic ankle
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motion (< 4°) between children with Syme and TT amputations [77]. Differences in the external hip rotation of the two groups was also about 8°. Children with Syme amputation exhibited greater coronal-plane hip power than the TT, yet cadence parameters were not significantly different between these two amputation levels. In summary, amputation level can play an important role in the gait and mobility of pediatric lower limb amputees. Lower-level amputees are better able to modulate spatiotemporal
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ACCEPTED MANUSCRIPT parameters, and to some extent kinematic and kinetic gait parameters. Similar to the adult literature, faster walking speeds and lower energy expenditure appear to be associated with more distal levels of amputation. Amputation is recommended to be done at the lowest possible level
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for the pediatric population, keeping in mind the space needed for prosthetic components.
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4.1.4. Etiology & Gait
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From the studies that investigated gait of children with LLA, 19 included both congenital and acquired amputations, two included only congenital cases, three only focused on acquired
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amputations, and two did not report the etiology. From these studies, only Ulger & Sener (2011)
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specifically aimed to compare functional status of children (8-17 years old) with congenital limb deficiency versus acquired lower limb loss following prosthetic rehabilitation (n=20) [81].
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Children walked at a self-selected comfortable speed along a 12-m walkway, footprints were
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used to measure step lengths, stride length, step width, foot angle, and cadence. In the baseline assessment and after three weeks of prosthesis use, the congenital group
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showed better gait patterns, weight bearing values, and Amputee Mobility Predictor (AMP)
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scores than the acquired group. This finding is similar to earlier studies that observed those with congenital deficiency have a greater likelihood to be independent in daily living activities, even
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if they are not fitted with a prosthesis [82]. In contrast, there were no significant differences between the congenital and acquired groups after six months, yet both groups showed an improvement in their gait patterns, and weight bearing and functional level values. Also, both groups could bear weight on the amputated side in a similar way (about 40%) after six months of prosthesis use. In summary, only one study had a sufficiently large sample size to allow an examination of trends relating to etiology.
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4.2. Balance & Stability 4.2.1. TD children vs. children with LLA Balance improvements are important to enhance overall mobility, physical function, self-
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efficacy, and independence among children with LLA [27]. The maintenance of postural stability
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is an essential requirement of functional mobility, which necessitates the ability to produce
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adequate joint torques by limb muscles to maintain stability of the trunk and legs [83], [84] and to control the movement of the COM and shifting load between the legs [85]. Physical therapy
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protocols stress training amputees to move the COM over the prosthesis, and to bear more
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weight through the prosthetic leg [86].
Overall, eight studies quantitatively evaluated balance and stability among children with
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LLA, from which seven made comparisons to TD children. The main body of work (four
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articles) was done by Engsberg et al. from 1989-1994, which mainly measured foot pressure, weight distribution during standing, COM locations and segment angular orientations during
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walking, and ground reaction force during running of children with TT amputation. The first
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study of this series (using an EMED pressure plate) did not report significant difference in the weight distribution under the intact and prosthetic limbs of children with TT amputation (n=3) as
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compared to TD children (n=10) [87]. However, the anterior-posterior distribution of weight under both intact and prosthetic feet was significantly different as the TT subjects applied significantly more load on the intact heel and prosthetic forefoot than the TD children. The studies concluded that asymmetrical loading patterns may apply high loads on the joints of the lower limbs of children TT amputation.
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ACCEPTED MANUSCRIPT Later in 1992, Engsberg et al. again assessed the weight distribution on a larger number of TD children (n=200) to that of TT (n=21) amputees during standing [88]. Children with TT amputations applied more load on their intact limb than their prosthetic limb; however, this was not different from the TD children in terms of load distribution between non-dominant and
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dominant limbs. About 90% of the weight on the prosthetic foot was concentrated on the
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forefoot. The load on the intact foot of TT subjects was evenly distributed between the rearfoot
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and forefoot, similar to that of the TD children. Overall, children with TT amputation place significantly greater weight on their intact leg compared to the prosthetic leg.
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Finally, in the same population as the two previous studies, performance and static balance
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of the TT group was studied [89] during jumping, squatting, standing on the dominant leg and balance beam. Significant differences were observed in single and double leg jumps between the
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children with LLA and TD children. The balance scores of the prosthetic limb were significantly
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lower than the intact limb and those of the TD children. The TT subjects jumped a significantly shorter distance on their prosthetic leg as compared to the TD children. Moreover, the jumping
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style was different between the TD subjects and children with TT amputation, as the TT group
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showed less knee and ankle flexion and greater distribution of weight on the heels and on the intact leg than the TD group. Many of the children with TT amputation could not even assume
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the required position to start the balance tests on their prosthetic limb; this was attributed to the lack of proprioception through the prosthetic foot and ankle for which the children did not compensate with their knee and hip joints. This was assumed to improve through exercise or at later age [55]. In the only study of its type, Andrysek et al. (2012) found some improvements in postural control characteristics of children and adolescents with balance deficits immediately after the use
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ACCEPTED MANUSCRIPT of Wii Fit videogame system at home, but long-term retention needs to be explored [90]. Significant differences were seen in the centre of pressure (CoP) measures between amputee and TD children; the TT amputees (n=3) showed much higher CoP displacements. In a recent pilot study, Feick et al. (2016) studied relationships among balance and mobility
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measures in children with LLA and TD children (6-13 years old) [44]. Mobility and balance were
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tested using the 6-min walk test, the 10-m walk test, and the Community Balance and Mobility
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scale. A force plate was used to evaluate postural control during quiet standing with eyes open. The CoP measurements of static balance were different between the amputee and TD groups.
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This was partly attributed to the fact that the TD group was mainly male and a year younger. For
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children with LLA, a strong relationship was seen between better postural control and higher walking speed.
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Also, postural control strategies and balance in children (10-15 Y) with Syme amputation
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were evaluated in a study, but during quiet standing while wearing backpacks loaded with 0, 10, 20, and 25 percent of body weight [91]. The children with LLA demonstrated bilateral symmetry
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in maintaining static balance, even with heavy loads. It was concluded that TD children adapt to
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increasing posterior loads differently than those with limb loss by relying on medio-lateral shifts in CoP rather than the expected antero-posterior shifts.
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In summary, children with TT amputation place significantly greater weight on their intact leg compared to the prosthetic leg during dynamic balance tasks. In more complex ‘dynamic’ balance tests, they generally scored lower. One study also presents evidence of a correlation between gait and balance performance.
4.2.2. Age differences & Balance
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ACCEPTED MANUSCRIPT Maintaining balance during walking is a complicated task as it requires a compromise between the forward propulsion of the body and maintaining the body’s lateral stability [92]. Even walking on a flat ground, without obstacles, is a very challenging balance problem for young ambulators. In fact, it is extremely difficult to support the whole-body weight through one
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leg at a time during the swing phase of gait. The first step for children is building postural
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strategies, while in the second step, they should learn to adopt the most appropriate strategy to
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maintain task efficiency and balance control.
Assaiante and Amblard (1988) introduced a set of interpretations with regard to
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development of balance control in humans during their life span [93]. The first period covers
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from birth to the acquisition of the upright stance. The second period extends from the upright stance up to around the age of six, characterized by the development of the coordination between
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the upper and lower body parts. The third period is around the age of seven years up to a yet
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unknown age. Adolescence may be a turning point in balance control development. During this period the head stabilization is essential for the descending temporal organization of balance
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control. The last period is during adulthood, which combines the main features of the previous
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period with a new skill involving selective control of the degrees of freedom at the neck and the articulated operation of the head–trunk [94].
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The motor strategies to maintain balance rely on sensory inputs. Children and adults use different combinations of sensory inputs [95]. However, certain sensory systems may predominate at specific stages in maturity. For instance, the importance of visual input to balance control varies during the life span. During infancy and childhood (and up to the age of 6), visual cues have a prominent role in the control of static postural balance [95]. While the literature on
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ACCEPTED MANUSCRIPT balance and postural stability of children with LLA included all age ranges from 1-18 years, no study compared the balance and postural stability among different age groups.
4.2.3. Amputation level, Etiology & Balance
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After balance training through Wii Fit videogame system, lower CoP displacements were
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seen in children with TF amputation than those with Van Ness rotationplasty [90]. This was the
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only study that compared between balance and stability parameters based on amputation level. Also, no study compared the differences in balance measures between various amputation
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causes, which is mainly due to small sample size in each group with a certain amputation cause.
4.3. Prosthetic components
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The function of an individual with limb loss is significantly affected by prosthetic
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components. The higher the level of LLA, the greater the role played by the components in mobility and balance, as more joints and muscles are missing. Prosthetic prescription is very
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different for a child than an adult with an identical amputation level. Parents also play an
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important role in rehabilitation decisions at an early age of the child [11]. In the late 1980s, manufacturers started producing pediatric component lines [11]. Despite a steady increase in
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components, selection is still limited in pediatric population compared to adults. Further, lack of evidence on the effectiveness of different pediatric components prevents from sound clinical judgement. Consequently, clinicians mostly make choices based on personal experience and intuition. The prosthetic socket is the foundation of a functional prosthesis and must be intimate, comfortable, and anatomically appropriate. No matter how advanced prosthesis components
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ACCEPTED MANUSCRIPT (e.g., knee and foot) are, a poor socket fit may negate their advantages. We did not find any study that evaluated the effect of socket and suspension design on a child amputee’s mobility. In terms of types of sockets used, the patellar tendon bearing (PTB) was the highest with the majority of studies conducted on TT. Many studies did not report the type of socket and/or
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suspension.
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Several studies evaluated the effect of different prosthetic feet on gait and balance of
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children with LLA, primarily for TT amputation. The main prosthetic foot, as expected, was the SACH foot as the conventional foot type. The SACH foot simulates only plantar flexion through
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compression of a rubber heel, while the single axis foot allows both dorsiflexion and plantar
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flexion about a hinged joint. Before the advent of energy-storing feet, most of the studies attributed asymmetries between the limbs to the shortfalls of foot types [96].
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A few studies from 1981-1985 made comparisons between the CAPP (UCLA Child
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Amputee Prosthetic Project) and SACH feet for TF and KD amputation levels [46], [97], [98]. The SACH foot showed a significantly larger functional base of support than CAPP, while
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fluctuations of CoP about a mean position while standing were lower with the CAPP foot [97].
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During walking, stride and step length as well as walking speed decreased with the CAPP compared to the SACH. As walking speed increased, stride and step lengths increased for both
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feet [98]. The CAPP foot showed smaller range of thigh motion and less hip flexion. The CAPP enhanced stability of prosthetic knee during stance [46]. With the CAPP, CoP was located under the forefoot during stance, while it was seen with the SACH only 57% of stance time. It is good to note that the SACH foot is still commonly used, while the CAPP use has been discontinued. As one of the first energy-absorbing and releasing foot types, the Seattle foot [99] produced a small increase in stride length and walking speed compared to the SACH among children with
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ACCEPTED MANUSCRIPT TT amputation, and it was less resistant to passive dorsiflexion in mid-stance. The Seattle allowed a normal knee extensor moment during stance, while a knee flexor moment dominated the stance phase with the SACH. The energy cost of walking was slightly lower with the Seattle foot [54]. Another energy-storing foot, the Flex-foot, returned more energy (over 65%) than the
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SACH [47]. Also, during fast walking, the SACH required greater joint powers and moments
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from the intact limb, while in self-selected walking speeds, greater powers and moments were
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generated by the intact limb with the Flex foot.
A recent study by Jeans et al. (2014) between low (SACH), medium (Dynamic response
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foot) and high performance (Flex-foot Cheetah) feet showed that ankle motion was greater in
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children with TT and Syme amputations using high-performance feet compared with lowperformance and medium-performance feet [77]. However, peak power of the prosthetic ankle,
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which is important for push-off, did not show significant difference among the feet.
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Six studies evaluated the effect of the prosthetic knee joint on gait and balance of children. Dealing with the concept of ‘Early Knee Protocol’ for toddlers [65], [73], a few studies
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attempted to prove that it is not a good practice to delay the prescription of an articulating
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prosthetic knee joint until children can walk independently with a non-articulating knee (age of 4 or 5). Wilk et al. (1999) compared the effects of articulating and non-articulating knees on the
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gait of 2-7 year-old children and reported decreased pelvic hiking, circumduction and hip rotation on the prosthetic limb and decreased vaulting on the intact limb [73]. A mean increase of 49° of knee flexion was also observed. After one year, the children exhibited a more normalized gait pattern. Likewise, Geil and colleagues showed that a locked knee could impede locomotion and typical development [65], [66], [100]. All children with LLA were able to successfully ambulate
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ACCEPTED MANUSCRIPT with an articulating prosthetic knee with no stability issues. They also noted that crawling speed of amputee infants and toddlers increased with an articulating knee prosthesis. When offered an articulating knee prosthesis, toddlers as young as 13 months can incorporate prosthetic knee function during crawling. Moreover, the Early Knee protocol can decrease the adoption of
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swing-phase foot clearance adaptations while walking is developing [100].
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Most prosthetic knee joints for children with TF and KD amputations utilize four- and six-
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bar linkages, which enable better control during stance phase than single-axis knees. A new prosthetic single-axis knee joint, automatic stance-phase lock knee (ASPL), was developed by
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Andrysek et al. [69], [70]. The knee is claimed to provide better stability by ensuring that it
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remains fully extended until weight bearing, decreasing the extent of incidences of knee instability. Preliminary findings on six amputee children showed that the ASPL knee joint
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showed comparable biomechanical performance to polycentric pediatric prosthetic knee joints.
4.4. Qualitative evaluation of gait & balance
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A limited number of studies (n=5) focused on qualitative assessment of lower-limb
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prosthetic gait and balance in children with LLA. Some of the questionnaires that were used included the Child-Health Assessment Questionnaire (Child-HAQ) [101], Prosthesis Evaluation
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Questionnaire (PEQ) [71], Prosthesis Evaluation Scale (PES) [29], Pediatric Outcomes Data Collection Instrument (PODCI) [77] and Amputee Mobility Predictor (AMP) [81]. Five questions of the Dutch version of the Child-HAQ relevant to leg function were used in a study by Boonstra et al. (2000) [101]. The authors did not use the answers by children as they acknowledged the Dutch version of the questionnaire was not validated on children. Parents answered questions regarding prosthesis use, functional status, and secondary complications.
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ACCEPTED MANUSCRIPT Complications including having a second operation, skin problems, phantom sensation, and pain were frequent. Most of the children used prostheses in their daily activities. The functional abilities were found to be generally satisfactory; 95% of children could walk and 93% of the children were able to do cycling.
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Chu et al. (2016) assessed quality of life of children with LLA through the Chinese version
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of Prosthesis Evaluation Questionnaire (PEQ) [71]. The PEQ scores showed no significant
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difference between TT and TF prosthetic users. The average PEQ score was 72.7, which was in the range of values reported from older populations. Prosthetic compliance was good with daily
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wear time of above 12 h/day in both groups. A limitation of this study was that the authors
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adopted the Chinese version of PEQ from another study (the study was a conference proceeding).
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The ability to perform daily activities was studied on 13 children with LLA using a four-
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point scale [102]. No detail was provided about the type of questions or activities that were assessed. It was only reported that 84.7% of children with LLA became independent walkers
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without walking aids, 61.5% actively participated in recreational activities with peers, while
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others played football and table-tennis. Vannah et al., (1999) used a two-part survey developed based on the Prosthesis Evaluation
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Scale (PES) originally developed for adults, and the core module of the AAOS/COMSS Lower Limb Outcomes Data Collection Package, Version 1.1 [29]. These questionnaires evaluated prosthetic use, satisfaction and complications as well as overall lower-limb functional status. 88% of the subjects wore their prostheses 9 hours or more per day. The most common reasons for prosthetic issues reported were pain, especially during strenuous activities and walking on
24
ACCEPTED MANUSCRIPT uneven ground, and component break-downs. The children favored these qualities in a prosthesis: function, comfort and cosmetics. The Pediatric Outcomes Data Collection Instrument (PODCI) surveys functional status in children and adolescents (2-19 years old) pre- and post-intervention [103]. Tested on 64 children
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with Syme and TT amputation, the PODCI scores for global functioning and sports/physical
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functioning were significantly higher in the young children than in the adolescent group, while
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there was no difference between the amputation levels [77]. This difference was attributed to the fact that when young children participate in sports, these activities do not need elite skills, yet
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adolescents have to work for the team and functional differences may start to make them distinct
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from their TD peers.
Ulger & Sener (2011) used the Amputee Mobility Predictor (AMP) Questionnaire to
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compare functional status of pediatric amputees after three weeks and six months of prosthetic
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rehabilitation [81]. The congenital group, without the prosthesis, showed higher scores than the acquired group initially and after three weeks of training. Lower AMP values of the acquired
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group were attributed to the effect of the trauma experienced, disappointment, being dependent
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on parents, and fear of not being able to walk again. Yet, after rehabilitation, they achieved functional levels equal to the congenital group. The majority of subjects wore their prostheses
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more than 8h a day. The authors did not compare function according to the amputation levels. It was reported that the AMP is a relatively easy instrument and could be completed in 15min or less, with a simple scoring system. The overall limitations of the study designs are summarized below:
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ACCEPTED MANUSCRIPT i.
No study has used a questionnaire validated on children with LLA. They either developed their own survey [70], or selected a few questions from or modified an adult version without any validation done on pediatric populations [29], [101]. The metrics are different, which makes it difficult to reach to a conclusion.
iii.
The questionnaires did not assess each prosthetic component separately; thus, it is difficult
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ii.
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to relate satisfaction/dissatisfaction, for instance, to the prosthetic fit such as socket design
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or the component itself.
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5. Conclusions
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This comprehensive review of literature attempted to shed light on gait and balance characteristics of children and adolescents with LLA. The study also identified gaps and
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limitations in research and development of prosthetic components aimed at improving gait and
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balance of children.
While it appears that many prosthetic principles apply similarly to adults and children,
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prosthetists face a unique range of practical and theoretical considerations for pediatric clients
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[104]. A 75-year-old adult (with diabetes) whose leg is amputated above the knee will not probably be more mobile than he/she was before the amputation. However, a child who is born
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with a limb deficiency, or has an amputation, is on a dynamic trajectory of physical, cognitive and social development. Children make up only a small portion of the population. However, based on the disabilityadjusted life years (DALY), and the many years that the pediatric amputee is expected to live and thrive in the community, setting them off on the right foot and prosthesis early in life is an important function of rehabilitation professionals. Unfortunately, based on the current review,
26
ACCEPTED MANUSCRIPT the literature pertaining to this population is sparse, and only 5% of the research has been conducted in the developing countries, while a great number of children with LLA, especially those with congenital deficiencies, may live in these countries. However, this finding may be somewhat biased due to inclusion of only English articles in this review. Further, comparison of
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the results is challenging, because factors such as age, sample size, data collection methods, and
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selection of parameters confound findings.
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No studies compared the balance and postural stability among different age groups or studied the effect of gender or sex on gait and balance of children with LLA. Most studies also
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did not have adequate statistical power to allow comparisons of the differences in balance
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measures across amputation causes. One solution may be conducting international multi-centre studies as an opportunity to increase sample sizes. While important for prosthetic design
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purposes and mobility, the muscle activation patterns of children when walking or balancing
ED
with prostheses has been rarely studied [105]. Likewise, there is limited literature pertaining to
balance enhancements.
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improving physical therapy protocols, especially for different age groups, targeting gait and
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In terms of prosthetic components, while there have been attempts to design and test pediatric-specific systems [69][106], there is still room for more work. Moreover, there are some
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specialized pediatric components, such as running prostheses, but there is no published study on biomechanical evaluations in the pediatric population. For instance, there are ankle joints in sizes for the children and adolescents with LLA, but for younger children, especially for 7- to 8-yearolds, these joints are still too large and heavy. The advancement in these designs is very slow or not available because of the small number of children in need of such components. A report from United States says that about 50 percent of all prostheses are made for patients aged 61 and over,
27
ACCEPTED MANUSCRIPT while only 3.4 to 5.1 percent are produced for 1 to 10-year-old patients [107]. Thus, manufacturers consider investment in pediatric components as disproportionate for a limited return. Manufacturers produce advanced high performance prosthetic technology mainly for the adult market; however, it is the young and active children and adolescents who have the greatest
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need and ability to utilize them.
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Several overall conclusions can be drawn from this review. This review highlights the need
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for additional research on children with limb loss, especially as prosthetic technology improves, potentially enabling increased levels of function in children and adolescents. Like adults,
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pediatric gait is affected in many ways by a LLA. These effects are related to amputation level
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and prosthesis components. Both static and dynamic balance are affected by LLA, with asymmetries in weight distribution. Rehabilitation produced short-term improvements in
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standing postural control. Research has not investigated the role of socket fit in pediatric
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amputee gait. Very young children with limb loss above the knee may benefit from early prescription of a functioning knee joint. Dynamic, energy storing prosthetic feet can be effective
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in children, particularly at higher locomotion speeds.
Funding: This research did not receive any specific grant from funding agencies in the public,
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commercial, or not-for-profit sectors.
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ACCEPTED MANUSCRIPT References [1]
J. B. Bussmann, E. A. Grootscholten, and H. J. Stam, “Daily physical activity and heart rate response in people with a unilateral transtibial amputation for vascular disease.,” Arch. Phys. Med. Rehabil., vol. 85, no. 2, pp. 240–244, Feb. 2004. J. B. Bussmann, H. J. Schrauwen, and H. J. Stam, “Daily physical activity and heart rate
T
[2]
[3]
CR
Rehabil., vol. 89, no. 3, pp. 430–434, Mar. 2008.
IP
response in people with a unilateral traumatic transtibial amputation.,” Arch. Phys. Med.
K. Ziegler-Graham, E. J. MacKenzie, P. L. Ephraim, T. G. Travison, and R. Brookmeyer,
US
“Estimating the prevalence of limb loss in the United States: 2005 to 2050.,” Arch. Phys.
[4]
AN
Med. Rehabil., vol. 89, no. 3, pp. 422–429, Mar. 2008.
P. L. Ephraim, T. R. Dillingham, M. Sector, L. E. Pezzin, and E. J. Mackenzie,
M
“Epidemiology of limb loss and congenital limb deficiency: a review of the literature.,”
[5]
ED
Arch. Phys. Med. Rehabil., vol. 84, no. 5, pp. 747–761, May 2003. R. Morrissy, B. Giavedoni, and C. Coulter-O’Berry, “The limb-deficient child,” in Lovell
PT
and Winter’s Pediatric Orthopedics, R. Morrissy and S. Weinstein, Eds. Philadelphia, PA:
[6]
CE
Lippincott, Williams, & Wilkins, 2001. K. Adolph, “Learning to learn in the development of action,” in Action as an organizer of
AC
perception and cognition during learning and development: Minnesota Symposium on Child Development, & C. A. N. (Eds. . J. Lockman, J. Reiser, Ed. Hillsdale, NJ: Erlbaum Press, 2005, pp. 91–122. [7]
K. E. Adolph, S. E. Berger, and A. J. Leo, “Developmental Continuity? Crawling, Cruising, and Walking,” Developmental science, vol. 14, no. 2. pp. 306–318, Mar-2011.
[8]
A. S. Soares, E. Y. Yamaguti, L. Mochizuki, A. C. Amadio, and J. C. Serrao,
29
ACCEPTED MANUSCRIPT “Biomechanical parameters of gait among transtibial amputees: a review.,” Sao Paulo Med. J., vol. 127, no. 5, pp. 302–309, Sep. 2009. [9]
T. P. Klassen, L. Hartling, J. C. Craig, and M. Offringa, “Children are not just small adults: the urgent need for high-quality trial evidence in children.,” PLoS Med., vol. 5, no.
T
8, p. e172, Aug. 2008.
CR
Pharmacol., vol. 79, no. 3, pp. 351–353, Mar. 2015.
IP
[10] A. Ferro, “Paediatric prescribing: why children are not small adults.,” Br. J. Clin.
[11] J. I. Krajbich, M. S. Pinzur, B. K. Potter, and P. M. Stevens, Atlas of Amputations and
AN
Academy of Orthopaedic Surgeons, 2016.
US
Limb Deficiencies: Surgical, Prosthetic, and Rehabilitation Principles, no. v. 3. American
[12] B. Sayed Ahmed et al., “Factors impacting participation in sports for children with limb
M
absence: a qualitative study.,” Disabil. Rehabil., vol. 40, no. 12, pp. 1393–1400, Jun.
ED
2018.
[13] World Health Organization, “International Classification of Functioning, Disability and
PT
Health. Children & Youth Version.,” Geneva, 2007.
CE
[14] L. Torburn, J. Perry, E. Ayyappa, and S. L. Shanfield, “Below-knee amputee gait with dynamic elastic response prosthetic feet: a pilot study.,” J. Rehabil. Res. Dev., vol. 27, no.
AC
4, pp. 369–384, 1990.
[15] J. Perry, L. A. Boyd, S. S. Rao, and S. J. Mulroy, “Prosthetic weight acceptance mechanics in transtibial amputees wearing the Single Axis, Seattle Lite, and Flex Foot.,” IEEE Trans. Rehabil. Eng., vol. 5, no. 4, pp. 283–289, Dec. 1997. [16] A. M. Boonstra, V. Fidler, and W. H. Eisma, “Walking speed of normal subjects and amputees: aspects of validity of gait analysis.,” Prosthet. Orthot. Int., vol. 17, no. 2, pp.
30
ACCEPTED MANUSCRIPT 78–82, Aug. 1993. [17] T. Schmalz, S. Blumentritt, and R. Jarasch, “Energy expenditure and biomechanical characteristics of lower limb amputee gait: the influence of prosthetic alignment and different prosthetic components.,” Gait Posture, vol. 16, no. 3, pp. 255–263, Dec. 2002.
T
[18] L. Nolan, A. Wit, K. Dudzinski, A. Lees, M. Lake, and M. Wychowanski, “Adjustments
CR
Posture, vol. 17, no. 2, pp. 142–151, Apr. 2003.
IP
in gait symmetry with walking speed in trans-femoral and trans-tibial amputees.,” Gait
[19] E. Isakov, J. Mizrahi, H. Ring, Z. Susak, and N. Hakim, “Standing sway and weight-
AN
vol. 73, no. 2, pp. 174–178, Feb. 1992.
US
bearing distribution in people with below-knee amputations,” Arch. Phys. Med. Rehabil.,
[20] J. G. Buckley, S. F. Jones, and K. M. Birch, “Oxygen consumption during ambulation:
M
comparison of using a prosthesis fitted with and without a tele-torsion device.,” Arch.
ED
Phys. Med. Rehabil., vol. 83, no. 4, pp. 576–580, Apr. 2002. [21] A. H. Vrieling et al., “Balance control on a moving platform in unilateral lower limb
PT
amputees.,” Gait Posture, vol. 28, no. 2, pp. 222–228, Aug. 2008.
CE
[22] N. Vanicek, S. Strike, L. McNaughton, and R. Polman, “Postural responses to dynamic perturbations in amputee fallers versus nonfallers: a comparative study with able-bodied
AC
subjects.,” Arch. Phys. Med. Rehabil., vol. 90, no. 6, pp. 1018–1025, Jun. 2009. [23] W. C. Miller, A. B. Deathe, M. Speechley, and J. Koval, “The influence of falling, fear of falling, and balance confidence on prosthetic mobility and social activity among individuals with a lower extremity amputation.,” Arch. Phys. Med. Rehabil., vol. 82, no. 9, pp. 1238–1244, Sep. 2001. [24] Y. J. Sagawa, K. Turcot, S. Armand, A. Thevenon, N. Vuillerme, and E. Watelain,
31
ACCEPTED MANUSCRIPT “Biomechanics and physiological parameters during gait in lower-limb amputees: a systematic review.,” Gait Posture, vol. 33, no. 4, pp. 511–526, Apr. 2011. [25] P. X. Ku, N. A. Abu Osman, and W. A. B. Wan Abas, “Balance control in lower extremity amputees during quiet standing: A systematic review,” Gait Posture, vol. 39,
T
no. 2, pp. 672–682, Feb. 2014.
IP
[26] Z. Safaeepour, A. Eshraghi, and M. Geil, “The effect of damping in prosthetic ankle and
CR
knee joints on the biomechanical outcomes: A literature review.,” Prosthet. Orthot. Int., vol. 41, no. 4, pp. 336–344, Aug. 2017.
US
[27] J. M. van Velzen, C. A. M. van Bennekom, W. Polomski, J. R. Slootman, L. H. V van der
AN
Woude, and H. Houdijk, “Physical capacity and walking ability after lower limb amputation: a systematic review.,” Clin. Rehabil., vol. 20, no. 11, pp. 999–1016, Nov.
M
2006.
ED
[28] J. Engsberg, K. G. Tedford, J. Harder, and J. P. Mills, “Timing changes for stance, swing
255–262, 1990.
PT
and double support in a recent child below the knee amputee,” Ped Exer Sci., vol. 2, pp.
CE
[29] W. M. Vannah, J. R. Davids, D. M. Drvaric, Y. Setoguchi, and B. J. Oxley, “A survey of function in children with lower limb deficiencies.,” Prosthet. Orthot. Int., vol. 23, no. 3,
AC
pp. 239–244, Dec. 1999. [30] K. A. Jeans, R. H. Browne, and L. A. Karol, “Effect of Amputation Level on Energy Expenditure During Overground Walking by Children with an Amputation,” J. Bone Jt. Surg. - Am. Vol., vol. 93A, no. 1, pp. 49–56, Jan. 2011. [31] R. Lewallen, G. Dyck, A. Quanbury, K. Ross, and M. Letts, “Gait kinematics in belowknee child amputees: a force plate analysis.,” J. Pediatr. Orthop., vol. 6, no. 3, pp. 291–
32
ACCEPTED MANUSCRIPT 298, 1986. [32] J. R. Engsberg, A. G. Lee, J. L. Patterson, and J. A. Harder, “External loading comparisons between able-bodied and below-knee-amputee children during walking.,” Arch. Phys. Med. Rehabil., vol. 72, no. 9, pp. 657–661, Aug. 1991.
T
[33] F. Catani et al., “Gait analysis in patients after Van Nes rotationplasty.,” Clin. Orthop.
IP
Relat. Res., no. 296, pp. 270–277, Nov. 1993.
CR
[34] J. Engsberg, L. Herbert, S. Grimston, T. Fung, and J. Harder, “Relation among indices of effort and oxygen uptake in below-knee amputee and able-bodied children.,” Arch. Phys.
US
Med. Rehabil., vol. 75, no. 12, pp. 1335–1341, Dec. 1994.
AN
[35] R. L. Waters and S. Mulroy, “The energy expenditure of normal and pathologic gait.,” Gait Posture, vol. 9, no. 3, pp. 207–231, Jul. 1999.
M
[36] M. J. Major, R. L. Stine, and S. A. Gard, “The effects of walking speed and prosthetic
ED
ankle adapters on upper extremity dynamics and stability-related parameters in bilateral transtibial amputee gait.,” Gait Posture, vol. 38, no. 4, pp. 858–863, Sep. 2013.
PT
[37] D. A. Winter and S. E. Sienko, “Biomechanics of below-knee amputee gait.,” J. Biomech.,
CE
vol. 21, no. 5, pp. 361–367, 1988. [38] H. Centomo, D. Amarantini, L. Martin, and F. Prince, “Kinematic and kinetic analysis of a
AC
stepping-in-place task in below-knee amputee children compared to able-bodied children.,” IEEE Trans. Neural Syst. Rehabil. Eng., vol. 15, no. 2, pp. 258–265, Jun. 2007. [39] J. R. Engsberg, K. G. Tedford, and J. A. Harder, “Center of mass location and segment angular orientation of below-knee-amputee and able-bodied children during walking.,” Arch. Phys. Med. Rehabil., vol. 73, no. 12, pp. 1163–1168, Dec. 1992. [40] S. W. Hill, A. E. Patla, M. G. Ishac, A. L. Adkin, T. J. Supan, and D. G. Barth, “Altered
33
ACCEPTED MANUSCRIPT kinetic strategy for the control of swing limb elevation over obstacles in unilateral belowknee amputee gait.,” J. Biomech., vol. 32, no. 5, pp. 545–549, May 1999. [41] E. Isakov, H. Burger, J. Krajnik, M. Gregoric, and C. Marincek, “Knee muscle activity during ambulation of trans-tibial amputees.,” J. Rehabil. Med., vol. 33, no. 5, pp. 196–
T
199, Sep. 2001.
IP
[42] E. Isakov, H. Burger, J. Krajnik, M. Gregoric, and C. Marincek, “Influence of speed on
CR
gait parameters and on symmetry in trans-tibial amputees.,” Prosthet. Orthot. Int., vol. 20, no. 3, pp. 153–158, Dec. 1996.
US
[43] R. K. Ashley, G. T. Vallier, and S. R. Skinner, “Gait analysis in pediatric lower extremity
AN
amputees.,” Orthop. Rev., vol. 21, no. 6, pp. 745–749, Jun. 1992. [44] E. Feick et al., “A pilot study examining measures of balance and mobility in children
M
with unilateral lower-limb amputation.,” Prosthet. Orthot. Int., vol. 40, no. 1, pp. 65–74,
ED
Feb. 2016.
[45] J. M. Czerniecki, “Rehabilitation in limb deficiency. 1. Gait and motion analysis.,” Arch.
PT
Phys. Med. Rehabil., vol. 77, no. 3 Suppl, pp. S3-8, Mar. 1996.
CE
[46] R. F. Zernicke, M. G. Hoy, and W. C. Whiting, “Ground reaction forces and center of pressure patterns in the gait of children with amputation: Preliminary report,” Arch. Phys.
AC
Med. Rehabil., vol. 66, no. 11, pp. 736–741, Nov. 1985. [47] K. Schneider, T. Hart, R. F. Zernicke, Y. Setoguchi, and W. Oppenheim, “Dynamics of below-knee child amputee gait: SACH foot versus Flex foot.,” J. Biomech., vol. 26, no. 10, pp. 1191–1204, Oct. 1993. [48] D. Hunter, E. Smith Cole, J. M. Murray, and T. D. Murray, “Energy expenditure of below-knee amputees during harness-supported treadmill ambulation.,” J. Orthop. Sports
34
ACCEPTED MANUSCRIPT Phys. Ther., vol. 21, no. 5, pp. 268–276, May 1995. [49] M. B. Taylor, E. Clark, E. A. Offord, and C. Baxter, “A comparison of energy expenditure by a high level trans-femoral amputee using the Intelligent Prosthesis and conventionally damped prosthetic limbs.,” Prosthet. Orthot. Int., vol. 20, no. 2, pp. 116–121, Aug. 1996.
T
[50] M. S. Orendurff, A. D. Segal, G. K. Klute, M. L. McDowell, J. A. Pecoraro, and J. M.
IP
Czerniecki, “Gait efficiency using the C-Leg.,” J. Rehabil. Res. Dev., vol. 43, no. 2, pp.
CR
239–246, 2006.
[51] J. Perry, J. M. Burnfield, C. J. Newsam, and P. Conley, “Energy expenditure and gait
US
characteristics of a bilateral amputee walking with C-leg prostheses compared with stubby
AN
and conventional articulating prostheses.,” Arch. Phys. Med. Rehabil., vol. 85, no. 10, pp. 1711–1717, Oct. 2004.
M
[52] L. M. Herbert, J. R. Engsberg, K. G. Tedford, and S. K. Grimston, “A comparison of
ED
oxygen consumption during walking between children with and without below-knee amputations.,” Phys. Ther., vol. 74, no. 10, pp. 943–950, Oct. 1994.
PT
[53] A. W. M. van der Windt, I. Pieterson, J. W. van der Eijken, A. Peter Hollander, R.
CE
Dahmen, and B. A. de Jong, “Energy expenditure during walking in subjects with tibial rotationplasty, above-knee amputation, or hip disarticulation,” Arch. Phys. Med. Rehabil.,
AC
vol. 73, no. 12, pp. 1174–1180, Dec. 1992. [54] G. R. Colborne et al., “Analysis of mechanical and metabolic factors in the gait of congenital below knee amputees. A comparison of the SACH and Seattle feet.,” Am. J. Phys. Med. Rehabil., vol. 71, no. 5, pp. 272–278, Oct. 1992. [55] A. Shumway-Cook and M. H. Woollacott, Motor Control: Theory and Practical Applications. Baltimore, MD: Williams & Wilkins, 1995.
35
ACCEPTED MANUSCRIPT [56] D. H. Sutherland, R. A. Olshen, E. N. Biden, and M. P. Wyatt, The Development of Mature Walking. Oxford, UK: MacKeith, 1988. [57] S. Preis, A. Klemms, and K. Muller, “Gait analysis by measuring ground reaction forces in children: changes to an adaptive gait pattern between the ages of one and five years.,”
T
Dev. Med. Child Neurol., vol. 39, no. 4, pp. 228–233, Apr. 1997.
IP
[58] D. H. Sutherland, R. Olshen, L. Cooper, and S. L. Woo, “The development of mature
CR
gait.,” J. Bone Joint Surg. Am., vol. 62, no. 3, pp. 336–353, Apr. 1980. [59] D. S. Slaton, “Gait cycle duration in 3-year-old children.,” Phys. Ther., vol. 65, no. 1, pp.
US
17–21, Jan. 1985.
AN
[60] M. P. Murray, P. A. Jacobs, D. R. Gore, G. M. Gardner, and L. A. Mollinger, “Functional performance after tibial rotationplasty.,” J. Bone Joint Surg. Am., vol. 67, no. 3, pp. 392–
M
399, Mar. 1985.
ED
[61] M. Stanger, “Limb deficiencies and amputations,” in Physical therapy for children, V. L. D. Campbell SK, Palisano RJ, Ed. Elsevier Saunders, 2006.
PT
[62] J. M. Hausdorff, L. Zemany, C. Peng, and A. L. Goldberger, “Maturation of gait
CE
dynamics: stride-to-stride variability and its temporal organization in children.,” J. Appl. Physiol., vol. 86, no. 3, pp. 1040–1047, Mar. 1999.
AC
[63] R. J. Beck, T. P. Andriacchi, K. N. Kuo, R. W. Fermier, and J. O. Galante, “Changes in the gait patterns of growing children.,” J. Bone Joint Surg. Am., vol. 63, no. 9, pp. 1452– 1457, Dec. 1981. [64] R. Norlin, P. Odenrick, and B. Sandlund, “Development of gait in the normal child.,” J. Pediatr. Orthop., vol. 1, no. 3, pp. 261–266, 1981. [65] M. D. Geil and C. Coulter-O’Berry, “Temporal and spatial parameters of crawling in
36
ACCEPTED MANUSCRIPT children with limb loss: implications on prosthetic knee prescription.,” J. Prosthetics Orthot., vol. 22, no. 1, pp. 21–25, Jan. 2010. [66] M. D. Geil, C. Coulter-O’Berry, M. Schmitz, and C. Heriza, “Crawling Kinematics in an Early Knee Protocol for Pediatric Prosthetic Prescription.,” J. Prosthetics Orthot., vol. 25,
T
no. 1, pp. 22–29, Jan. 2013.
IP
[67] M. McMulkin, O. WR, M. RD, and R. RS, “Comparison of three pediatric prosthetic feet
CR
during functional activities.,” J. Prosthetics Orthot., vol. 16, no. 3, pp. 78–86, Jul. 2004. [68] S. Thomas, B. CE, D. Helper, N. Turner, M. Moor, and K. JI, “Comparison of the Seattle
AN
Orthot., vol. 12, no. 1, pp. 9–14, Jan. 2000.
US
lite foot and Genesis II prosthetic foot during walking and running.,” J. Prosthetics
[69] J. Andrysek et al., “Preliminary Evaluation of an Automatically Stance-Phase Controlled
M
Pediatric Prosthetic Knee Joint Using Quantitative Gait Analysis,” Arch. Phys. Med.
ED
Rehabil., vol. 88, no. 4, pp. 464–470, Apr. 2007. [70] J. Andrysek, S. Naumann, and W. L. Cleghorn, “Design and quantitative evaluation of a
PT
stance-phase controlled prosthetic knee joint for children.,” IEEE Trans. Neural Syst.
CE
Rehabil. Eng., vol. 13, no. 4, pp. 437–443, Dec. 2005. [71] C. K. G. Chu and M. S. Wong, “Comparison of prosthetic outcomes between adolescent
AC
transtibial and transfemoral amputees after Sichuan earthquake using Step Activity Monitor and Prosthesis Evaluation Questionnaire.,” Prosthet. Orthot. Int., vol. 40, no. 1, pp. 58–64, Feb. 2016. [72] D. R. Cummings and S. L. Kapp, “Lower-Limb Pediatric Prosthetics: General Considerations and Philosophy,” JPO J. Prosthetics Orthot., vol. 4, no. 4, 1992. [73] B. Wilk, H. Karol, and S. Halliday, “Transition to an articulating knee prosthesis in
37
ACCEPTED MANUSCRIPT pediatric amputees,” J Prosthet Orthot, vol. 11, no. 3, pp. 69–74, 1999. [74] D. E. Krebs, J. E. Edelstein, and M. A. Thornby, “Prosthetic management of children with limb deficiencies.,” Phys. Ther., vol. 71, no. 12, pp. 920–934, Dec. 1991. [75] J. Andrysek, S. Naumann, and W. L. Cleghorn, “Design characteristics of pediatric
T
prosthetic knees.,” IEEE Trans. Neural Syst. Rehabil. Eng., vol. 12, no. 4, pp. 369–378,
IP
Dec. 2004.
CR
[76] B. Giavedoni, C. Coulter-O’Berry, and M. Geil, “The impact of articulated knees on infants and toddlers,” Am Acad Orthot Prosthet J Proc, 2002.
US
[77] K. A. Jeans, L. A. Karol, D. Cummings, and K. Singhal, “Comparison of Gait After Syme
AN
and Transtibial Amputation in Children,” J. Bone Jt. Surg. - Am. Vol., vol. 96A, no. 19, pp. 1641–1647, Oct. 2014.
M
[78] R. L. Waters, J. Perry, D. Antonelli, and H. Hislop, “Energy cost of walking of amputees:
ED
the influence of level of amputation.,” J. Bone Joint Surg. Am., vol. 58, no. 1, pp. 42–46, Jan. 1976.
PT
[79] P.-F. Su, S. A. Gard, R. D. Lipschutz, and T. A. Kuiken, “Gait characteristics of persons
2007.
CE
with bilateral transtibial amputations.,” J. Rehabil. Res. Dev., vol. 44, no. 4, pp. 491–501,
AC
[80] E. Fowler, R. Zernicke, Y. Setoguchi, and W. Oppenheim, “Energy Expenditure during Walking by Children Who Have Proximal Femoral Focal Deficiency,” J. Bone Jt. Surg. Am. Vol., vol. 78, no. 12, pp. 1857–1862, 1996. [81] O. Ulger, G. Sener, and U. O., “Functional outcome after prosthetic rehabilitation of children with acquired and congenital lower limb loss,” J. Pediatr. Orthop. Part B, vol. 20, no. 3, pp. 178–183, 2011.
38
ACCEPTED MANUSCRIPT [82] K. Bosch, J. Gerss, and D. Rosenbaum, “Preliminary normative values for foot loading parameters of the developing child,” Gait Posture, vol. 26, no. 2, pp. 238–247, 2007. [83] C. D. MacKinnon and D. A. Winter, “Control of whole body balance in the frontal plane during human walking.,” J. Biomech., vol. 26, no. 6, pp. 633–644, Jun. 1993.
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[84] J. J. Eng and D. A. Winter, “Kinetic analysis of the lower limbs during walking: what
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information can be gained from a three-dimensional model?,” J. Biomech., vol. 28, no. 6,
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pp. 753–758, Jun. 1995.
[85] D. A. Winter, A. E. Patla, M. Ishac, and W. H. Gage, “Motor mechanisms of balance
US
during quiet standing.,” J. Electromyogr. Kinesiol., vol. 13, no. 1, pp. 49–56, Feb. 2003.
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[86] E. Isakov, “Gait rehabilitation: a new biofeedback device for monitoring and enhancing weight-bearing over the affected lower limb.,” Eura. Medicophys., vol. 43, no. 1, pp. 21–
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26, Mar. 2007.
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[87] J. R. Engsberg, T. L. Allinger, and J. A. Harder, “Standing pressure distribution for
155, Dec. 1989.
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normal and below-knee amputee children,” Prosthet. Orthot. Int., vol. 13, no. 3, pp. 152–
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[88] J. R. Engsberg, K. G. Tedford, M. J. Springer, and J. A. Harder, “Weight distribution of below-knee amputee and able-bodied children during standing.,” Prosthet. Orthot. Int.,
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vol. 16, no. 3, pp. 200–202, Dec. 1992. [89] K. Tedford, J. Engsberg, J. Patterson, and J. Harder, “A comparison of lower limb performance and balance scores between below-knee amputee and able-bodied children.,” Physiother. Canada, vol. 46, no. 3, pp. 190–195, 1994. [90] J. Andrysek et al., “Preliminary Evaluation of a Commercially Available Videogame System as an Adjunct Therapeutic Intervention for Improving Balance Among Children
39
ACCEPTED MANUSCRIPT and Adolescents With Lower Limb Amputations,” Arch. Phys. Med. Rehabil., vol. 93, no. 2, pp. 358–366, Jan. 2012. [91] M. D. Geil, K. J. Wasco, J. Wu, C. Coulter, Z. Safaeepour, and Y. Tai Wang, “A Pilot Investigation of the Effect of Postural Control Strategies and Balance in Children with
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Unilateral Lower-Limb Amputation,” JPO J. Prosthetics Orthot., vol. 28, no. 4, 2016.
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[92] C. Assaiante, S. Mallau, S. Viel, M. Jover, and C. Schmitz, “Development of postural
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control in healthy children: a functional approach.,” Neural Plast., vol. 12, no. 2–3, pp. 109–172, 2005.
US
[93] C. Assaiante, B. Amblard, and A. Carbiane, “Peripheral vision and dynamic equilibrium
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control in five to twelve year old children,” vol. 812, B. Amblard, A. Berthoz, and F. Clarac, Eds. Amsterdam: Elsevier (Excerpta Medica), 1988, pp. 75–84.
M
[94] C. Assaiante and B. Amblard, “Ontogenesis of head stabilization in space during
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locomotion in children: influence of visual cues,” Exp Brain Res, vol. 93, no. 499, 1993. [95] C. Assaiante, “Development of locomotor balance control in healthy children.,” Neurosci.
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Biobehav. Rev., vol. 22, no. 4, pp. 527–532, Jul. 1998.
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[96] B. Brouwer et al., “Running patterns of juveniles wearing SACH and single-axis foot components,” Arch. Phys. Med. Rehabil., vol. 70, no. 2, pp. 128–134, Feb. 1989.
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[97] L. A. Clark and R. F. Zernicke, “Balance in lower limb child amputees.,” Prosthet. Orthot. Int., vol. 5, no. 1, pp. 11–18, Apr. 1981. [98] M. G. Hoy, W. C. Whiting, and R. F. Zernicke, “Stride kinematics and knee joint kinetics of child amputee gait.,” Arch. Phys. Med. Rehabil., vol. 63, no. 2, pp. 74–82, Feb. 1982. [99] D. Hittenberger, “The Seattle Foot®,” Orthot. Prosthetics, vol. 40, no. 3, pp. 17–23, 1986. [100] M. Geil and C. Coulter, “Analysis of locomotor adaptations in young children with limb
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ACCEPTED MANUSCRIPT loss in an early prosthetic knee prescription protocol.,” Prosthet. Orthot. Int., vol. 38, no. 1, pp. 54–61, Feb. 2014. [101] A. M. Boonstra et al., “Children with congenital deficiencies or acquired amputations of the lower limbs: functional aspects,” Prosthet. Orthot. Int., vol. 24, no. 1, pp. 19–27, Apr.
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2000.
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[102] G. Sener, K. Yigiter, K. Bayar, and F. Erbahceci, “Effectiveness of prosthetic
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rehabilitation of children with limb deficiencies present at birth.,” Prosthet. Orthot. Int., vol. 23, no. 2, pp. 130–134, Aug. 1999.
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[103] D. D. Allen, G. E. Gorton, D. J. Oeffinger, C. Tylkowski, C. A. Tucker, and S. M. Haley,
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“Analysis of the pediatric outcomes data collection instrument in ambulatory children with cerebral palsy using confirmatory factor analysis and item response theory
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methods.,” J. Pediatr. Orthop., vol. 28, no. 2, pp. 192–198, Mar. 2008.
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[104] P. Lenka, A. R. Chowdhury, and R. Kumar, “Design & Development of Lower Extremity Paediatric Prosthesis, a Requirement in Developing Countries,” Indian J. Phys. Med.
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Rehabil., vol. 19, no. 1, pp. 8–12, 2008.
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[105] H. Centomo, D. Amarantini, L. Martin, and F. Prince, “Muscle adaptation patterns of children with a trans-tibial amputation during walking,” Clin. Biomech., vol. 22, no. 4, pp.
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457–463, May 2007.
[106] P. Taboga and A. M. Grabowski, “Axial and torsional stiffness of pediatric prosthetic feet.,” Clin. Biomech., vol. 42, pp. 47–54, Feb. 2017. [107] J. Philipps Otto, “Is pediatric progress in O&P keeping pace with kids?,” The O&P Edge, Apr-2016.
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ACCEPTED MANUSCRIPT Figure captions
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Figure 1. Flow diagram. Flow diagram of study inclusion process.
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ACCEPTED MANUSCRIPT Table 1. Specifications of studies included in this review: participants, prosthetic components, objectives, outcome measures and summary of findings. Prosthesis
Objective & Method
Outcome measures
Findings
Andrysek et al., 2005
6 Amp. 7-13 Yr TF Congenital (4) & Acquired (2)
Foot: NR Socket: NR Knee: Total Knee Junior, Otto Bock 3R66
Modelling & questionnaire survey
Custom questionnaire (15 questions about activities, knee give out, walk, run, uneven ground and inclines and stairs)
6 Amp. 7-13 Yr TF Congenital (4) & Acquired (2)
Foot: SpringLite, Seattle, TruPer Socket: NR Knee: ASPL Total Knee Junior Otto Bock 3R66
Case series & crossover trial.
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Pre & Post pilot study
Decreased frequency of falls with the prototype compared to other knees, especially in highly active children. The children also reported worrying less about the knee collapsing during walking. No differences for stance-phase stability during different activities. Higher gait velocities with the ASPL knee joint, associated with increased temporal interlimb asymmetry, joint moments and powers, and excessive prosthetic knee range of motion in swing. Increased pelvic motions with ASPL knee compared with conventional knees. At baseline, TF amputees had greater CoP displacements than the Van Ness group and TD children.
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Comparing functional efficiency of a stance-phase controlled knee vs. non-stancecontrolled knees
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Subjects
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Andrysek et al., 2007
Gait performance of ASPL vs. pediatric conventional knees
Pelvic obliquity; pelvic tilt & rotation RoM; hip, knee & ankle RoM; joint moments & powers; Cadence; speed; stride length
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Andrysek et al., 2012
6 Amp., 10 TD 8-18 Yr TF (3), Van Nes (3) Acquired
Examine the safety, feasibility, and balance
Centre of pressure displacements during quiet standing; Questionnaire survey (Community
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Balance & Mobility Scale)
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Walking function/gait analysis
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Knee: Constant friction/safety knee
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56 Amp. in total; only 31 participated in testing 1.08-18 Yr (Mean = 10.2) Syme’s (8), TF/KD (9), TT (10), distal foot (4) Acquired & Congenital
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Ashley et al., 1992
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performance of a 4-week homebased balance therapy program using a videogame system (comparison between baseline, after 5 weeks, after 13 weeks
Questionnaire survey; Stride dimensions; walking speed; cadence; Ambulatory heart rate
Immediately post intervention, the CoP displacements decreased in the TF amputees; values were closer to those of TD children. The average increase in CB&M score from baseline to follow-up was 6 points across participants. Amputee children have slower walking speed, lower cadence, longer stride length and higher heart rates than TD. Compliance with prosthetic wearing was best with Syme’s amputees (97%) vs. 71% of TF/KD. All distal foot amputees, 94% of Syme’s, 84% of TT and 59% of TF/KD could run with Prosth. Constant friction/safety knee limited TF ability to modify cadence. Limitations in locomotor ability is proportional to amputation level.
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ACCEPTED MANUSCRIPT Boonstra et al., 2000
88 Amp. 1-18 Yr All levels except toe amputation Acquired & congenital
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Qualitative survey
6 Amp. 9-17 Yr TT Congenital (1) & Acquired (5)
Foot: SACH Single-axis (SA) Socket: PTB
Use and functional performance of lower limb amputee children
Child-health assessment questionnaire (Child-HAQ): 5 questions about Dressing and grooming; Rising from chair or floor; walking; physical activity
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Running patterns (extent and location of kinematic and kinetic asymmetries) of juveniles with SACH & SA feet
Speed; step length; step time; stance time; peak vertical ground reaction force; joint angle and moments
Most children (95%) could walk; 93% more than 100m and 93% of the children aged 4 years or over were able to cycle. The functional abilities of 88 Dutch children with congenital leg deficiencies or leg amputations were found to be generally satisfactory. Most of the children used prostheses in their daily activities. Secondary complications were, however, frequent. SACH and SA feet performed almost identically. Slower step speed on the affected side was related to significantly lower vertical ground reaction forces. None of the feet could simulate natural footankle function, with resulting significant interlimb asymmetries. The ipsilateral knee displayed marked reduction of the initial flexor wave, paired with a reduced extensor moment. 45
ACCEPTED MANUSCRIPT Catani et al., 1993
10 Amp. 10 TD Amp. 7.5-14 Yr (mean=10.7); TD (mean = 29.9 Yr) Van Nes rotationplasty Acquired (cancer)
Prosthesis with one degree of freedom (flex/ext) at the pseudoknee at the level of malleoli
Gait Analysis of patients after Van Nes rotationplasty
Stride time; stride length; cadence; speed; swing time; ground reaction time; vertical & fore-aft ground reaction force; hip & pseudo knee angles
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Centomo et al., 2007
8 Amp.; 8 TD Amp.: 8-16 (12) Yr; TD (12) TT Congenital (5) & meningococcemia disease (3)
Foot: Seattle
Motor solutions used by TD and TT children during a stepping-inplace task
Peak joints angular excursion, moment, and power
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Centomo et al., 2007
Muscle adaptation patterns during walking
Resultant, agonist and antagonist moments, power, cocontraction index, step length, swing time, stance time, speed,
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6 Amp: 11 ± 5 Yr; 6 TD: 12 (SD 4) Yr TT Congenital (4) & meningococcemia disease (2)
Foot: Seattle Light
Significant differences were found in stride duration, stride length, cadence, speed, and stance-swing ratio, and in ground-reaction forces parameters between TD and Amp. subjects. There were differences in some kinematic parameters as well. Pseudo-knee allows a smooth and coordinate gait pattern. Even if TT and TD children did the task with almost the same kinematics, the kinetic data revealed completely different mechanisms to achieve the stepping-in-place task, and TT children had a symmetrical interlimb strategy. Stepping-in-place task could offer a transition task to physical therapists for TT children. TT children altered their muscle patterns to perform locomotion. These changes produced a diminution of cocontraction during single limb support for 46
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Chu et al., 2016
5 Amp. Mean=11.3 Yr (SD 25.7 months) TF(2); KD(3) Acquired & congenital
Foot: SACH, CAPP Knee: 4-bar modular, Constantfriction
Postural stability using two prosthetic feet
Total base of support dimensions; CoP
Prospective qualitative study
Step count; PEQ questionnaire
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cadence and stride length
21 Amp. 14.6 (SD 2.3) Yr TT (11) & TF (10) Acquired
Foot: FlexFoot, Assure (TT & TF) Socket: PTB supracondylar (TT), Suction socket (TF) Knee: Total Knee 2000
Daily step activities and prosthesisrelated quality of life of amputee adolescents
both the amputated and non-amputated limbs compared to TD children and, thus, could create joint instability. Step length, swing time, stance time and single limb support time were not statistically different between TT and TD children. No significant difference was observed for stride length and average speed and cadence. Total base of support did not differ for the two types of prosthetic feet, but the functional base of support for SACH foot was significantly larger than CAPP. Fluctuations of centre of pressure about a mean position in normal standing was less with CAPP foot. TT amputees had significantly higher levels of step activity than TF in all Step Activity Monitors measures. Prosthetic compliance was good with daily wearing time of above 12h/day in both groups. 47
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Engsberg et al., 1989
8 Amp. 8-18 Yr TT Congenital
Foot: SACH, Seattle Socket: PTB
Mechanical and metabolic factors during gait with two prosthetic feet
Walking speed, stride length, stride time, cadence, stance/swing time ratio, joint angles, joints moments, joint powers, energy cost of walking, subjective preference for ambulatory activities and cosmesis
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Colborne et al., 1992
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3 Amp; 10 TD 7-9 Yr TT NR
Foot: SACH
Differences in standing ground-shoe pressure distribution between TT and normal children
Ground-shoe pressure distribution; Foot-bod weight ratio for standing; Forefoot-whole foot weight
PEQ scores showed no significant difference between two groups. Higher levels of step activity of TT amputees suggest that they have had lower energy expenditure and more capacity for ambulation. The Seattle foot produced a small increase in stride length and walking speed. The Seattle foot was less resistant to passive dorsiflexion in midstance. A knee flexor moment dominated the stance phase while walking with the SACH foot, while Seattle foot allowed a normal extensor moment. On the sound side, the hip produced most of the positive work, while the ankle output was below normal. The energy cost of walking was slightly lower with the Seattle foot. The weight distribution between prosthetic and non-prosthetic limbs of TT children was not significantly 48
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Foot: SACH, Seattle, Flex foot, Single axis Socket and suspension: PTB, PTS Sleeve, Figure of 8, Thigh corset, Condylar
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21 Amp; 200 TD 5-17 Yr TT NR
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ratio for standing
Weight distributions of TT amputee and able-bodied children during two different standing positions (1. both feet together on the pressure plate; 2. feet placed 20cm apart)
Foot pressure (Foot force to body weight ratio, forefoot force to wholefoot force ratio)
different from the feet of TD children. The anteriorposterior weight distribution for the prosthetic and non-prosthetic feet was significantly different from that of the TD children. Asymmetrical loading patterns of the TT amputee children during standing may be a logical result of the morphological differences between the prosthetic and non-prosthetic limb, which may be placing abnormally high loads on the joints of their lower extremities. TT amputee children placed more weight on their nonprosthetic limb than their prosthetic limb, yet this was not different from TD children in respect of weight distribution between dominant and non-dominant limbs. Approximately 90% of the load on the prosthetic foot was placed on the forefoot. The load on the non-prosthetic foot was evenly 49
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Engsberg et al., 1993
3 Amp.; 10 TD 7-9 Yr (mean=8) TT NR
Foot: SACH
Intersegmental knee and hip forces for TT amputee and TD children during standing
Ground reaction pressure, leg, thigh, knee and trunk angles in the Sagittal and frontal plane; Q-angle
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Engsberg et al., 1991
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3 Amp.; 11 TD Amp. mean=7.5 Yr; TD mean=8.4 Yr TT Congenital (2) & Acquired (1)
Foot: SACH
Center of mass locations and segment angular orientations of the gait of TT children to TD children
Center of Mass locations at touchdown, midsupport, and takeoff of support
distributed between the forefoot and rearfoot like that of TD children. Except for more weight on the forefoot of the prosthetic leg, TT children stood in the same way as TD children. In some instances, the intersegmental forces for TT children were significantly greater than those of the TD children, and in other instances, significantly lower. In all cases, the values were substantially less than corresponding values for walking and running. The frontal plane prosthetic knee angle, the sagittal plane prosthetic and non-prosthetic knee angles, and the sagittal plane trunk angle were all greater for the TT children when compared to TD. In the sagittal plane, CoM was lower and more anterior for the TT children; primarily due to the greater forward flexion of the trunk.
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22 Amp.; 225 TD Amp: 6-16; TD: 7-12 TT NR
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Engsberg et al., 1993
21 Amp.; 200 TD Amp (5-17 Yr); TD (7-12 Yr) TT NR
Foot: SACH, Flex foot Seattle, Single axis Socket and suspension: PTB, PTS Sleeve, Figure of 8, Thigh corset, Condylar
Normative ground reaction force data for TD and TT children during walking
Average normalized force-time curves
Normative ground reaction force data for TD and TT amputee children during running
Vertical forcetime; anteroposterior force-time; mediolateral force-time; maximum force during the latter phase of support
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Engsberg et al., 1993
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Foot: SACH Seattle Flex foot Single axis Socket and suspension: PTB, PTS Sleeve, Figure of 8, Thigh corset, Condylar
The location of the CoM in the frontal plane tended to remain on the nonprosthetic side of the body for the TT children during the entire gait cycle, whereas CoM location of the TD children moved from one side to the other due to the trunk leaning towards the nonprosthetic side of the body. TT children had an asymmetrical gait pattern with a dominant role of the nonprosthetic limb. This dominant role was related to a greater rate of loading, magnitude of loading, impulse, and time of loading as compared with prosthetic limbs and with the limbs of TD children. No significant differences for the discrete variables between: 1) right and left legs; 2) gender; and 3) age in TD children. Differences seen between the three types of foot with the nonprosthetic leg, indicating greater forces than the
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Feick et al., 2016
Foot: Seattle, SACH, Dynamic foot, Flex foot Socket and suspension: Greisinger, Condylar, Sleeve
Relationships among simple methods for measuring effort in TT amputee and TD children
Foot: Lowprofile energy returning feet (Syme’s).
Prospective cross-sectional study
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10 Amp.; 13 TD Amp: 6-18 Yr; TD: 7-17 Yr TT NR
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10 Amp.; 10 TD Amp: 9.6 (SD 2.6) Yr (7–13); AB: 9.7 (SD 2.4) Yr (6–12)
Relationships among balance
Actual & predicted oxygen uptake (during final I5 seconds of each trial), heart rate (before testing, during the final 10 seconds of each trial, and after test), physiological cost index, maximum heart rate, the relative exercise intensity, and vertical displacement of a surface marker on the sacrum; selfselected walking speed CoP RMS; Gait symmetry index (Step time, step length, stance time, swing
prosthetic and TD legs. Greater values were obtained for the maximum force in the lateral direction and for the time spent applying force in the lateral direction. No significant differences were found for foot types or suspensions. Significant differences existed between the nonprosthetic and prosthetic values of the TT children, and between the TT and TD children. Oxygen uptake for the TT children was not significantly different than TD children Significant correlations between oxygen uptake and the four measured variables were all between 0.91 and 0.92. Medial/lateral displacements of the surface marker were slightly greater for the TT children than TD children.
No significant differences in gender, age, height, weight, or self-reported engagement in 52
ACCEPTED MANUSCRIPT Syme’s (3), TT (3), TF & KD (3) Congenital (5) & Acquired (5)
Energy returning feet (TF & TT) Socket and suspension: Segmented sockets (Syme’s). Locking silicone liner (TT). Ischial containment sockets, silicone liner (TF) Knee: 4-bar knee
16 Amp. 7.3-17 Yr
Constant friction singleaxis (for Syme’s) Socket and suspension: Thigh corset
Energy expenditure during walking
Oxygen cost (energy per unit of body mass expended per distance walked); walking speed;
Foot: Freedom Renegade, Seattle Light, Ossur Elation, College Park Truper
Effect of postural control strategies and balance in children with unilateral
Total excursion of CoP in AP & ML, mean velocity of CoP; vertical GRF; 95%
time, single support time, double support time); Physiological Cost Index; Walking speed; Community Balance and Mobility (CB&M) scale; heel-to-heel base of support
Fowler et al., 1996
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and mobility measures in children with unilateral lower-limb amputation and TD children
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Geil et al., 2016
4 Amp.; 5 TD Amp: 12.25 (SD 2.2) Yr; TD: 12.8 (SD 4.1) YR Syme’s Congenital fibular
recreational activities between the amputee and TD groups. Significantly lower walking speed, distance, and functional balance were seen in children with amputation compared to TD children. For children with amputation, reduced energy expenditure was associated with narrower step width and more symmetrical gait; better postural control and balance were associated with faster walking speeds. Van Nes subjects had a mean oxygen cost of 0.12 milliliter per kilogram of body mass per meter, lower than that of the subjects with Syme amputation. The subjects with Van Nes procedure walked faster. A significant decrease in the oxygen cost as a function of increasing age was observed for both groups. Amputee children showed an unexpected nonlinear response as weight increased vs. normal 53
ACCEPTED MANUSCRIPT Deficiency (3) & Trauma (1)
lower-limb amputation (Quiet standing with backpacks loaded with 0, 10, 20, and 25 percent of BW) Crawling pattern with nonarticulating vs. articulating knee prosthesis
confidence ellipse of CoP excursion; Weight-bearing contribution
Geil & Coulter., 2010
5 Amp. 13-23 Months KD (2); TF (3) Congenital (3) & acquired and congenital (2)
Foot: TRS infant foot, Seattle child’s play foot Socket and suspension: Total elastic suspension belt Knee: Otto Bock 3R38
Crawling pattern, speed, and cadence
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Geil et al., 2013
5 Amp. 13-23 months KD (2); TF (3) Congenital (3) & acquired and congenital (2)
Foot: TRS infant foot, Seattle child’s play foot Socket and suspension: Total elastic suspension belt Knee: Otto Bock 3R38
Crawling kinematics with non-articulating vs. articulating knee prosthesis
Peak knee flexion, hip abduction and adduction angles, max angles between the shoulders and PSIS
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Geil & Coulter, 2014
Foot: Infant foot, College Park Truper, Seattle Socket and suspension: Total elastic suspension belt™, Spirit liner
Before-and-after experimental design
Peak swing knee flexion angle; hip hiking (vertical excursion of the prosthetic side ASIS marker); Circumduction angle (angle of the ipsilateral femur segment
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7 Amp. 1.5–7.7 Yr KD(4); TF(3) Congenital (5) & Acquired (2)
Swing phase clearance adaptations in walking with locked vs. unlocked knee
controls. Postural control mechanisms used by the children with amputation may be different from their TD control. The locked knee condition reduced speed and cadence. With one exception, the children exhibited a more typical “stepthrough” crawling pattern with unlocked knee and a less efficient “step-to” pattern with locked knee. All participants achieved flexion (mean, 97.76°) of prosthetic knee in unlocked condition. Compensatory movements were variable and frequently greater in locked condition. Bilateral asymmetry and a variety of crawling patterns emerged, indicating volatility in this stage of motor development. Subjects utilized the articulating knee in walking, with an average of 70.4° of peak swing phase knee flexion. Some clearance adaptations were present with the flexing knee; 54
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Herbert et al., 1994
10 Amp.; 14 TD Amp: 6-18; TD: 6-17 TT NR
Foot: SACH, Seattle Knee: Constantfriction knee
Compare joint moments using anthropometrics from cadaver studies vs. direct measurements of the residual limb
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Moment of inertia; Center of gravity; Segment mass; peak joint moments
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in the frontal plane); Vaulting (contralateral ankle plantarflexion angle during swing phase)
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Knee: Otto Bock 3R38, Otto Bock 3R66, Pediatric total knee
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Oxygen consumption during walking between amputee and TD
Heart rate; Oxygen uptake Subjects walked for 2 minutes at each of the following four speeds: chosen walking speed (CWS), 20% below CWS, 20% above CWS, and fixed speed of 1.2 m/s.
more were present and their magnitude was increased when the knee was locked. Statistically significant increase in circumduction seen. Peak hip and knee flexor and extensor moments during swing were significantly greater calculated using cadaver data. These differences were greater while walking fast as compared to slow speeds. No significant difference between these two methods for peak hip and knee moments during stance. A significant difference was found for peak ankle joint moments during stance, but the magnitude was not clinically important. No significant differences between children with long and short residual limbs. Oxygen consumption was 15% greater for TT children compared with TD. No differences in heart rates between TD and 55
5 Amp. 7.9-12.8 Yr KD (3); Proximal femoral focal deficiency (2) NR
Foot: Single axis Knee: Constant friction knee
Effect of variable knee friction on the swing phase of gait in juvenile amputees
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Hoy et al., 1982
5 Amp. Mean = 11.3 Yr KD (3); TF (2) Congenital (1) & Acquired (4)
Foot: SACH, CAPP Knee: Constant friction, 4-bar modular KD
Gait kinetics & kinematics of amputee children in 3 different speeds with SACH vs. CAPP feet
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Jeans et al., 2011
Resting VO2 rate, resting heart rate, walking VO2 rate, walking VO2cost, walking heart
Stride length, step length and walking speed decreased and stride width increased with CAPP. As walking speed increased, stride and step lengths increased for both foot types. Foot angles increased with walking speed. Joint angles were significantly different between the intact and prosthetic limbs. Maximum hip flexion angle and total range of thigh movement were different between the two feet; the CAPP showed less hip flexion and smaller range of thigh motion. Unilateral TF and HD amputations resulted in significantly reduced walking speed (80% and 72% of normal,
Speed; stride length; cadence; swing time; stance time; shank period (double the swing time); shank excursion (the amount of knee flexion); knee ROM Stride length; stride width; step length; toein & toe-out angles; stride time; walking speed; cadence; max knee & thigh flex & ext angles; thigh & knee RoM; knee moment; knee force
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TT or within those with TT. Children with TT did not choose speeds different from the TD. Knee RoM was altered by changing the amount of knee friction. The knee flexion remained constant during gait.
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73 Amp; 45 TD: Children (6-12 yr); Teenagers (13-18 yr) Amp:
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Effect of level of amputation in children on the self-selected walking speed and oxygen cost
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ACCEPTED MANUSCRIPT Syme’s (11.1 SD 2.7); TT (12.5 SD 3.8); KD (14.0 SD 3.5); TF(14.0 SD 2.1); HD (12.0 SD 5.0); Bilateral TT (11.6 SD 5.1) TD: 6-12 Yr (n=24) & 13-18 Yr (n=21) Syme’s (29), TT(13), KD(14), TF(5), HD(5); Bilateral TT (7) Congenital (42) & Trauma (13) & Disease (18)
rate, selfselected walking speed
Foot: Flex foot, Dynamic response foot, SACH
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64 Amp. 4.7-19.2 Yr Syme’s & TT Congenital (32) & Acquired (9)
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Jeans et al., 2014
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Difference between the performance of amputee children with TD children
Gait differences between children with Syme and TT amputation. Effect of type of prosthetic foot on gait and questionnaire survey outcomes
Ankle plantar flexion, Ankle RoM, hip RoM, ankle & hip power, hip external rotation, knee hyperextension, Pediatric Outcomes Data Collection Instrument (PODCI)
respectively) and increased VO2 cost (151% and 161% of normal, respectively). Heart rate was significantly increased in the HD group (124% of normal). Children with a bilateral amputation walked significantly slower (87% of normal) than the TD, with an elevated heart rate (119% of normal) but a similar energy cost. Children with a Syme, TT, or KD walked with essentially the same speed and oxygen cost as did TD children in the same age group. Kinematic differences of <4° in total prosthetic ankle motion and 8° in external hip rotation were seen between the Syme and TT groups. Ankle power was greater in the TT group, whereas the Syme group had greater coronal-plane hip power. Ankle motion was greater with highperformance feet (9%) compared with medium(59%) and low57
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Lewallen et al., 1986
6 Amp. 8-17 Yr TT Congenital (1) & Acquired (5)
Foot: SACH Socket and suspension: Supracondylar PTB socket
Gait kinematics and joint moments in sagittal plane between TD and amputee children using force plate data. Determine whether limb loss results in higher forces across joints of intact leg
Stance & swing time, step length to height ratio, joint RoM, walking speed, ground reaction force, joint moment
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McMulkin et al., 2004
16 Amp. 7.2–20 Yr Syme’s (11), TT (5) Congenital (13) & Acquired (3)
Foot: Seattle Lightfoot, College Park TruStep®, Otto Bock Luxon Max®
Effect of different pediatric prosthetic feet (multiaxial dynamic vs. energy-storing feet) on function during highperformance functional activities
Speed, cadence, stride length, step length, max plantar flexion in-stance, dorsi/plantar RoM, peak power absorption, peak power generation, cutting drill time, sprinting time, vertical jump height, long jump distance, oxygen cost on the treadmill; subjective rating of feet
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Schneider et al., 1993
Compare gait symmetry with SACH & Flex foot during selfselected and fast walking
Walking speed, joint angles, joint powers, joint moments, vertical & foreaft ground reaction force, centre of
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12 Amp. 6-16 Yr (mean = 10.9 SD 3.2) TT Congenital (9) & Acquired (3)
Foot: SACH, Flex foot
performance (31%). Joint moments in the sagittal plane of the intact limb were normal or below normal during level walking. With a good prosthesis fit, forces across the joints of intact and prosthetic legs will not increase (not leading to degenerative arthritis). No significant differences among the three prosthetic feet in highperformance functional activities, or oxygen cost on the treadmill. No significant differences among the three feet for speed, cadence, stride length, or prosthetic side step length. TruStep® had significantly greater dorsiflexion and plantarflexion motion and greater peak power generation in late stance during walking. Marked asymmetries in power, moment and ground reaction force between the intact and prosthetic legs. Asymmetries 58
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13 Amp. PFFD (6); TF (2); TT (5) Congenital & Acquired
Foot: SACH Socket and suspension: Quadrilateral (TF), PTB/PTS (TT)
Ability to perform ADL (Questionnaire survey)
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4-point questions (not reported)
21 Amp; 200 TD Amp: 6-16 Yr; TD: 7-12 Yr TT NR
Foot: SACH, Flex Seattle, Single axis Socket and suspension: PTS, PTB Condylar Sleeve Fig of 8 Thigh corset
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pressure excursions
Compare performance and static balance between healthy and TT children
Performance & strength tests: Standing broad jump, vertical jump, squat against wall for time, grip strength Balance tests: times tests based on BruininksOseretsky gross motor test - Standing on dominant leg on floor - Standing on dominant leg on balance beam - Standing on balance beam with eyes closed
were less pronounced with flex foot than SACH. During fast walking, SACH needed greater output from the intact limb. Comfortable walking speed, greater moments and powers were generated by the intact limb with Flex foot. The flex foot returned more energy (over 65%) than SACH foot (less than 20%). 84.7% became independent walkers (without walking aid) 61.5% actively participated in recreation with peers Significant differences were observed in single and double leg jumps between the amputee and TD children. No difference was seen for the vertical jump and timed squat. The balance scores of the prosthetic limb was significantly lower than the intact limb and those of the TD children. The TT subjects could jump a significantly lower distance on their prosthetic 59
10 Amp. 11-20 Yr TT Congenital (7) & Acquired (3)
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Ulger & Sener, 2011
41 Amp. 8-17 Yr TT (7), TF (5), HD (2), PFFD (7) Congenital (21) & Acquired (20)
Foot: Seattle Lite, Genesis II
Walking and running characteristics with two different prosthetic feet
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Speed, stride length, cadence, dorsiflexion (IC), max dorsiflexion (stance), max plantar flexion (swing), peak power absorption, peak power generation, absorption area, generation area; energy consumption; satisfaction survey
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Compare functional status of children with acquired vs. congenital lower limb loss after 3 weeks and 6 months of prosthetic rehabilitation
Foot angle, step length, stride length, step width, speed, cadence, weight bearing, Amputee Mobility Predictor (AMP) Questionnaire
leg as compared to the TD children. Less knee and ankle flexion was seen during jumping among amputee children than the TD; they placed more weight on the heels and on the intact leg. No significant differences in gait parameters, although peak dorsiflexion was increased with the Genesis foot in comparison with the Seattle foot. The Genesis foot had an increase in power absorption and generation in comparison with the Seattle foot. No significant differences were found in energy consumption and agility tests. The congenital group had better gait patterns, weight bearing values and AMP scores in the initial assessment and after 3 weeks. No significant differences between the two groups after 6 months. After 6 months, the functional level, gait pattern and weight bearing values improved in both the groups. 60
ACCEPTED MANUSCRIPT Vannah et al., 1999
258 Amp. TT (80), AD (113), TF (30), PFFD (37), KD (28), PF (5), HD (5), Congenital (72%) & Acquired (28%)
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Survey on function and prosthesis technical problems
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van der Windt et al., 1992
26 Amp. 8-20 Yr (mean=14 SD 4) Van nes (15); TF (6); HD (5) Acquired (tumor)
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Energy expenditure during walking on a treadmill
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Wilk et al., 1999
7 Amp. 1.5-6.1 Yr Syme’s (2); KD (5) Congenital (6) & Acquired (1)
Foot: SACH Seattle SAFE II Socket and suspension: Ischial or distal bearing Knee: Century 22 Total knee, DAW 4-bar knee, Otto Bock 3R39
Prosthesis wear time, pain level, perspiration, activity,
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Comparing gait with articulating & nonarticulating knee prosthesis (6camera Vicon) - baseline with non-articulating knee - after gait training with articulating knee - after 1 year of using articulating knee
Walking speed; oxygen consumption (Vo2), carbondioxide production (VCo2), respiratory exchange ratio (RER). and expiratory tidal volume; Heart rate Walking speed; step length; pelvic tilt; pelvic rotation; pelvic obliquity; hip flex/ext; peak hip abd; hip rotation; knee flex/ext; ankle flex/ext (sound limb)
Children who wear prostheses achieve full use status at a higher rate than the Adult population and are much more active. The most common reasons for temporary loss of limb use were pain, prosthesis failure tissue breakdown and perspiration. Children with a Van nes walk faster than those with TF or HD. No differences between the groups in energy expenditure per unit time or per unit distance.
Baseline speed and pelvis motion (sagittal, coronal & transverse), peak hip abduction were higher than normal values; greater step lengths for both legs. Sound limb had greater hip flexion & rotation than normal subjects. After gait training with articulating, knee, speed, cadence, hip flex/ext were lower than normal; hip RoM still higher for sound limb than 61
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prosthetic. Hip peak abduction greater than normal. After 1 year, speed increased, pelvic rotation decreased compared to baseline and 2nd visit. Asymmetry in hip rotation between sound and prosthetic limb decreased. Knee flexion increased from 32° to 49°. 42 Zernicke 5 Amp. Foot: SACH, Comparison of Vertical & fore- With the CAPP, et al., Mean = 11.3 (SD CAPP gait parameters aft ground centre of pressure 1985 2.1) Yr Knee: during slow, reaction forces; is located under KD (3), TF (2) Constantnormal and fast centre of the forefoot all Congenital (1) & friction knee, walking with pressure through stance, Acquired (4) 4-bar modular SACH vs. location; stride while with KD unit CAPP feet time, stride SACH foot, it is length, walking under forefoot speed, only 57% of the stance time. CAPP foot enhanced stability of prosthetic knee during stance. Fore-aft ground reaction forces in the prosthetic leg were significantly less than the intact limb. NR = not reported; AB = able-bodied; Amp. = amputee; TT = transtibial; TF = transfemoral; KD = knee disarticulation; HD = hip disarticulation; PF = partial foot; AD = ankle disarticulation
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This review of literature studied gait and balance of children with lower limb loss. Amputation level plays important role in mobility of pediatric lower limb amputees. Lower energy expenditure is associated with more distal amputation levels. Amputee children bear more weight on intact leg during dynamic balance tasks.
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Figure 1