Cost of walking and locomotor impairment

doi:10.1016/S1050-6411(98)00046-7

Journal of Electromyography and Kinesiology

Volume 9, Issue 2, April 1999, Pages 149-157

https://doi.org/10.1016/S1050-6411(98)00046-7 Get rights and content

Abstract

The aim of the present study was to evaluate the importance and the necessity of metabolic measurements to quantify locomotor impairment in a clinical context. Oxygen consumption, heart rate, pulmonary ventilation and walking speed were measured during locomotion in 14 normal subjects, used as a control group, and 82 patients with different pathologies [hemiparetic, paraparetic, tetraparetic, orthopaedic and paraplegic patients, who walked using a reciprocating gait orthosis (RGO)]. The subjects were characterized on the basis of a cumulative impairment score (CIS), based on clinical scales commonly used to evaluate impairment and disability in locomotion. Appropriate indices of energy, cardiac and ventilatory costs expressed per metre walked, globally called physiological costs, were obtained. It resulted that the most comfortable speed (MCS) of normal subjects was significantly higher than that of each group of patients. Normal subjects' physiological costs were found to be significantly lower than those of patients who needed either a device or the help of a person to walk. All measured parameters correlated significantly with each other. The MCS was found to be the most correlated parameter with the CIS (r=0.8), and therefore it must be considered the best single measurement, if only one is to be used. Measurements more precise than MCS, such as the physiological costs, may be necessary in clinical trials.

Introduction

The need for a simple method to estimate walking impairment in the clinical setting has been frequently stressed 1, 2. Many authors 3, 4, 5, 6, 7, 8, 9 suggest that the metabolic energy cost of walking increases in patients with locomotor impairment. Olgiati et al. [2] suggest that this is a result of spastic co-contraction of agonist–antagonist muscles and of an inefficiency of body kinematics which results in a waste of mechanical energy. Furthermore, some suggest that the greater cost is also due to a reduced natural walking speed, because generally disabled people adopt a very slow walking speed 9, 10. Indeed, normal walking has the minimum cost at the normal natural speed, which is the speed the normal subject spontaneously adopts (about 1.3 m s⁻¹). Below and above this speed the cost increases 11, 12.

It has been assumed that the change in heart rate per unit of distance is a good indicator of the energy cost [13]. Measuring the heart rate (HR) is more easily done than measuring metabolic energy cost, which requires the measurement of oxygen intake ( $V ̇_{O_{2}}$ ).

An increase in breathing rate and volume, in addition to an increase in heart rate, is often seen during ambulation in disabled patients. This is also presumed to be the result of the greater energy cost of ambulation [7].

The purpose of this study is to address a number of the questions raised above. First, we wanted to establish how reliable the metabolic energy cost is as an indicator of the walking impairment in patients suffering from neurological or orthopedic diseases. Second, we wanted to determine whether the heart rate per unit of distance could be a good substitute for the metabolic energy cost. Third, we wanted to test the walking speed, because the speed adopted by impaired patients is much slower than that of normal subjects 1, 6, 8 and, therefore we wanted to test whether the walking speed could be used by itself as an indicator of walking impairment. Our hypothesis, however, is that both physiological costs (such as energy cost, ventilatory cost and cardiac cost) and walking speed are important measures in a clinical setting; i.e., we hypothesize that the use of a single parameter only could sometimes be misleading.

Section snippets

Materials and methods

Ninety-six subjects (14 normal controls and 82 disabled patients) participated in this study (see Table 1). Informed consent was obtained, and the patients, selected from a rehabilitation center, were assessed clinically and studied in a locomotion laboratory.

The patients were divided into five groups on the basis of their diagnosis. Group A consisted of 31 hemiparetic patients (23 cerebral stroke, three neural tumor and five trauma). Group B consisted of 21 paraparetic patients (five tumor,

Results

In Table 2 the descriptive statistics of each group of subjects is shown. For each parameter considered (MCS, WEC, WCC, WVC and CIS), the mean values and the standard deviations are presented.

In Fig. 1 the mean values of the steady-state WEC, WVC and WCC measurement of each subject are plotted as a function of walking speed. For the normal subjects, who walked at different speeds, the values at each speed were plotted. For each physiological cost, these values were used to build a second-order

Discussion

Although a simple method to assess locomotor impairment is desirable in the clinical setting, the results of this study show that more than one measure may be useful for a more comprehensive evaluation of a patient. If the main goal is to have a single measure of locomotor impairment, the speed spontaneously adopted by the patient should be used as a parameter of judgment.

In each group of patients, the most comfortable speed (MCS) was significantly lower than that of normal subjects. The MCS of

Conclusions

1.
The walking speed spontaneously adopted by a patient is the most reliable index of motor impairment when compared with the clinical scores (CIS). Therefore it should be the best single measure of locomotor impairment if, for practical reasons, there is no time for a complete evaluation.
2.
On the other hand, all the indices we studied are highly correlated with the CIS.
3.
In the majority of patients all the physiological costs are dependent on their slow walking speed; i.e., some factors other than

Acknowledgements

This work was partially supported by a grant from the “Ministero Italiano della Sanità” (CAMARC–II, CEC Programme, Project A-2002, September 1994). We thank Dr Richard Baratta for his useful suggestions regarding the statistical treatment of the data.

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Marco Bernardi was born in Rome, Italy, on 23 April 1961. He received his Medical Doctor degree in 1987 from the University of Rome “La Sapienza” and specialized in Sports Medicine in 1991. Since 1985 he has worked, first as a medical student and then as a qualified doctor, at the Institute of Human Physiology of the same University, where he presently works as Researcher and teaches Human Physiology at the Faculty of Medicine. From February 1993 to June 1994 he conducted research in motor unit recruitment strategy (a research topic in which he is still involved) at the Bioengineering Laboratory of the Louisiana State University Medical Center in New Orleans, LA, USA. His other main areas of scientific interest are exercise physiology both in healthy and physically handicapped subjects, and locomotor recovery of disabled patients. He is a member of the Italian Society of Physiology, the European College of Sport Science, the American College of Sports Medicine and the International Society for Electrophysiology and Kinesiology. He is a scientific consultant for the Rehabilitation Hospital IRCCS Santa Lucia, Rome, Italy. He is President of the Italian Medical Committee of the Italian Sports Federation for the Disabled.

Dr Andrea Macaluso was born in Rome, Italy, on 2 August 1967. He graduated in Medicine and Surgery from the University of Rome “La Sapienza”, Italy, in 1991 and specialized in Sports Medicine in 1996. He has been a visiting scientist at the Department of Rehabilitation Medicine at the Thomas Jefferson University Hospital, Philadelphia, PA, USA. He is now with the Scottish School of Sport Studies at the University of Strathclyde in Glasgow, UK. His research interests are in the field of physiology applied to physical exercise in the elderly and the rehabilitation of disabled people.

Egidio Sproviero was born in Castelluccio Inferiore, Italy, on 30 June 1962. He received the M.D. degree from the University of Rome “La Sapienza” Medical School, Italy, in 1990 and has been a specialist in Sports Medicine since 1994. In 1996 he spent a period of work and study at the Jefferson Medical School, Department of Orthopaedic Surgery, Sports Medicine Center, Philadelphia, PA, USA. He presented his Ph.D thesis on the human cost of walking in 1998. His research interests are related to the functional evaluation of human activities and rehabilitation programs applied to athletes.

Vincenzo Castellano was born in Bari, Italy, on 28 April 1931. He received his Medical Doctor degree from the University of Rome “La Sapienza” in 1955. He is a specialist in Orthopedics, in Physiatrics and in General Surgery. He is a former Head Orthopedist at the Paraplegic Center in Ostia Lido, Rome; a former Physiatrist at the Rehabilitation Hospital IRCCS Santa Lucia in Rome; a former Professor both of the School of Specialization in Physical Medicine and Rehabilitation and of the School of Specialization in Urology at the University of Rome “Tor Vergata”; and former Professor of the School of Rehabilitation Therapy at the Hospital San Giovanni in Rome. He is Chairman of the Biomedical Committee of the Italian Association of Referees of the Italian Soccer Federation (FIGC, Italian Olympic Committee). He is a scientific consultant for the Rehabilitation Hospital IRCCS Santa Lucia in Rome.

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Cost of walking and locomotor impairment

Abstract

Introduction

Section snippets

Materials and methods

Results

Discussion

Conclusions

Acknowledgements

Clin Biomech

Energy cost of level walking

Scand J Rehabil Med

Energy cost of walking in normal children and in those with cerebral palsy: comparison of heart rate and oxygen consumption

J Ped Orthopaed

Oxygen intake and walking speed before and after total hip replacement

Clin Orthop

Energy cost of walking with hip joint impairment

Phys Ther

Walking efficiency after cemented and noncemented total hip arthroplastic

Clin Orthop

Walking efficiency after total hip replacement as determinated by oxygen consumption

J Bone Joint Surg

Increased energy cost of walking in multiple sclerosis: effects of spasticity, atassia and weakness

Arch Phys Med Rehabil

The energy cost of walking with arthritis of the hip and knee

Clin Orthop

The energy cost of level walking in patients with hemiplegia

Scand J Med Sci Sports

The energy cost of human locomotion on land and in water

Int J Sports Med