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Chapter 15 - Atlas of Limb Prosthetics: Surgical, Prosthetic, and Rehabilitation Principles

The Energy Expenditure of Amputee Gait

Robert L. Waters, M.D.
Although there is a considerable body of literature on the physiologic energy expenditure of
amputee gait, a direct comparison of the results of the different studies is difficult for the
following reasons. First, young (usually traumatic) amputees are not consistently distinguished
from older (usually vascular) amputees, and there are significant differences between these two
groups with respect to gait performance. Second, there is often no distinction between
amputees who use upper-limb assistive devices and those who do not. Third, the adequacy of
prosthetic fit and prosthetic gait experience is not always specified. Therefore the majority of
the data presented in this review are based on investigations that utilized consistent procedures
conducted in the Pathokinesiology Laboratory of Rancho Los Amigos Medical Center.

ENERGY SOURCES
After several minutes of exercise at a constant sub-maximal work load, the rate of oxygen
consumption reaches a level sufficient to meet the energy demands of the tissues, and a
"steady-state" condition is achieved that reflects the energy expended during the activity.

Aerobic Oxidation
The functional unit of energy for muscle contraction is adenosine triphosphate (ATP). In aerobic
oxidation (citric acid cycle), carbohydrates and fats are oxidized through a series of enzymatic
reactions leading to the production of ATP. The net equation for the aerobic metabolism of
glucose is as follows:

Reproduced w ith
permission from
Bow ker HK,
Michael JW (eds):
Atlas of Limb
Prosthetics:
Surgical, Prosthetic, and
Rehabilitation Principles.
Rosemont, IL, American Academy
of Orthopedic Surgeons, edition 2,
1992, reprinted 2002.
Much of the material in this text
has been updated and published
in Atlas of Amputations and Limb
Deficiencies: Surgical,
Prosthetic, and Rehabilitation
Principles (retitled third edition of
Atlas of Limb Deficiencies),
American Academy or
Orthopedic Surgeons. Click for
more information about this text.

Funding for digitization

of the Atlas of Limb
Prosthetics w as
provided by the
Northern Plains Chapter of the
American Academy of Orthotists
& Prosthetists

Glucose + 36ADP + 36Pi + 36H+ + 602> 6C02 + 36ATP + 42H20,

where ADP is adenosine diphosphate.

Anaerobic Oxidation
A second type of oxidative reaction is available that does not require oxygen. The net equation
for the glycolytic metabolism of glucose is as follows:

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Glucose + 2Pi + 2ADP > 2 Lactate + 2ATP.

The lactate is buffered in the blood by bicarbonate, and this leads to the formation of C02, which
is exhaled in the expired air; this can be summarized by the following reactions:
Lactate + NaHC03 > Na lactate + H20 + C02(gas).

Aerobic vs. Anaerobic Metabolism

During continuous exercise there is an interplay between the aerobic and anaerobic metabolic
pathways that depends on the exercise work load. During mild or moderate exercise the
oxygen supply to the cell and the capacity of aerobic energy-producing mechanisms are
usually sufficient to satisfy ATP requirements. During more strenuous exercise both anaerobic
and aerobic oxidation processes occur. The serum lactate and expired C02 levels rise, thus
reflecting the additional anaerobic activity. The respiratory exchange ratio (RER) is defined as
the ratio of expired carbon dioxide (C02) to inspired oxygen (02). When exercise is performed
at more strenuous work rates above the anaerobic threshold, the RER rises and reflects the
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contribution of anaerobic energy production required to meet the additional ATP demands.
The amount of energy that can be produced by anaerobic means is limited. As reflected in the
above equations, approximately 19 times more energy is produced by the aerobic oxidation of
carbohydrates than by anaerobic oxidation. Anaerobic oxidation is also limited by the
individual's tolerance to acidosis resulting from the accumulation of lactate. From a practical
standpoint, the anaerobic pathway provides muscle with an immediate supply of energy for
sudden and short-term strenuous activity.
If exercise is performed at a constant rate at which the aerobic processes can supply the
necessary ATP production, an individual can sustain exercise for a prolonged time without an
easily definable point of exhaustion.

Walking, Power and Work Units

The terms power and work are utilized to describe energy expenditure. The power requirement
(rate of 02 consumption) is the milliliters of 02 consumed per kilogram body weight per minute
(mL/kg-min).
Physiologic work is the amount of energy required to perform a task. Physiologic work (02 cost)
during level walking is the amount of oxygen consumed per kilogram body weight per unit
distance traveled (mL/ kg-m). The 02 cost is determined by dividing the power requirement (rate
of energy expenditure) by the speed of walking. By comparing the energy cost of pathologic gait
to the corresponding value for normal walking, it is possible to determine the gait efficiency.
The rate of 02 consumption relates to the level of physical effort, and the 02 cost determines the
total energy required to perform the task of walking. In the interpretation of data, it is extremely
important to recognize that the velocity is in the denominator and the rate of 02 consumption is
in the numerator of the energy cost calculation. Commonly there is a misinterpretation of the
clinical data concerning the 02 cost and 02 rate. The 02 cost may be elevated, thus indicating a
physiologically inefficient gait, but the rate of 02 uptake may be normal, and the subject will
therefore not experience fatigue during customary walking activities but, however, will be limited
by the slow speed.

Maximal Aerobic Capacity

The maximal aerobic capacity (V02max) is the highest oxygen uptake an individual can attain
during physical work while breathing air at sea level. It is the single best indicator of physical
fitness. Generally an individual is able to reach his V02max within 2 to 3 minutes of
exhausting work.
Age influences the V02max. Up to approximately 20 years of age, the maximum oxygen uptake
increases. Thereafter, the maximum oxygen uptake declines primarily due to a decrease in
both maximum heart rate and stroke volume and generally due to a more sedentary life-style.
Differences in body composition and hemoglobin content are factors that account for a
difference in the V02max between the sexes.
The maximal aerobic capacity also depends on the type of exercise performed. The oxygen
demand is directly related to the muscle mass involved; therefore, the V02max during upperlimb exercise is lower than with the lower limbs. For any given work load, however, heart rate
and intra-arterial blood pressure are higher in upper-limb exercise than lower-limb exercise.

Oxygen Pulse
In the absence of cardiac disease, there is a linear relation between the rate of 02 uptake and
heart rate.
When performing exercise at the same rate of 02 uptake, higher heart rates are associated with
leg exercise than with arm exercise. The ratio of the rate of 02 uptake to heart rate is the
oxygen pulse. The oxygen pulse is higher during arm exercise than during leg exercise.
Deconditioning due to sedentary activity or any disease process that impairs the delivery of
oxygen to the cells also decreases the oxygen pulse.

Training
A physical-conditioning program can increase the aerobic capacity by several processes:
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improving cardiac output, increasing the capacity of the cells to extract oxygen from the blood,
increasing the level of hemoglobin, and increasing the muscular mass (hypertrophy). As a
result, endurance is increased.
A sedentary life-style has the opposite effect on maximum oxygen consumption. Not only
does atrophy of peripheral musculoskeletal structures occur, but there is also a central decline
in stroke volume and cardiac output as a result of inactivity. Any disease process of the
respiratory, cardiovascular, muscular, or metabolic systems that restricts the supply of oxygen
to the cell will also decrease the V02max. Bed rest for 3 weeks can result in a 27% decrease in
the V02max by decreasing cardiac output, stroke volume, and other factors.
A special problem confronting most older vascular amputees is their limited exercise ability.
Physical work capacity and V02max are reduced not only due to the effects of aging but also
due to commonly associated diseases in dysvascular amputees such as arteriosclerotic heart
disease and peripheral vascular disease. Diabetes decreases capillary permeability and
therefore oxygen supply to the muscle due to basement membrane thickening.
The status of physical fitness can be assessed by examining the oxygen pulse, which is the
ratio of the mean rate of 02 uptake and heart rate. In different amputee groups walking without
crutches, the 02 pulse is lower than normal, which suggests that despite successful prosthetic
use, the average amputee leads a less active life-style resulting in a lower level of physical
conditioning. This conclusion is supported by the result of V02max measurements during
one-legged and two-legged exercise in normal subjects and transfemoral amputees.

Energy Expenditure During Normal Walking

At the chosen walking speed (CWS), the rate of oxygen consumption for young adults aged 20
to 59 years and senior subjects between 60 and 80 years of age does not significantly differ and
averages 12.1 and 12.0 mL/ kg-min. Expressed as a percentage of the V02max, the rate of
oxygen consumption at the CWS requires approximately 32% of the V02max of an untrained
normal subject 20 to 30 years of age and nearly 48% of the V02max of a senior subject 75
years of age. The RER is less than 0.85 for normal subjects of all ages at their CWS, thus
indicating anaerobic metabolism is not required.
Senior subjects have a slightly lower rate of oxygen consumption and average CWS than do
young adults, and this may be a purposeful effort to keep the exercise within the aerobic range.
The fact that walking taxes less than 50% of the V02max in normal subjects in all age
groups and does not require anaerobic activity accounts for the perception that walking requires
little effort in healthy individuals. It is significant that with advancing years older persons
progressively have smaller aerobic reserves to accommodate to the added physiologic penalties
imposed by amputation.

Loading
Loading the body with weights increases the rate of energy expenditure depending on the
location of the loads. Loads placed peripherally on the foot have a much greater effect than do
loads placed over the trunk. Placement of a 20-kg load on the trunk of a male subject did not
result in a measurable increase in the rate of energy expenditure. On the other hand, a 2-kg
load placed on each foot increased the rate of oxygen uptake 30%. This finding is predictible
since forward foot acceleration is much greater than trunk acceleration and, therefore, greater
effort is required. These findings are of clinical significance for patients requiring lower-limb
prostheses and indicate the importance of minimizing weight.

UNILATERAL AMPUTATION
Prosthesis vs. Crutches
Lower-limb amputation with or without prosthetic replacement imposes energy penalties for
ambulation. The patient must choose between walking without a prosthesis and using crutches
or walking with a prosthesis and utilizing the remaining muscles to substitute for lost function
and control the additional mass of the prosthesis.
Crutch walking without a prosthesis with a three-point gait pattern in unilateral amputees may
be a primary or secondary means of transportation when an adequate prosthesis is unavailable
or inadequate. Swing-through crutch locomotion requires a high rate of physical effort in
comparison to normal walking. The arms and shoulder girdle musculature must lift and then
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swing the entire body weight forward with each step. Swing-through crutch-assisted gait is
required in amputees walking without a prosthesis.
A direct comparison of walking in unilateral amputees with and without a prosthesis utilizing a
three-point crutch-assisted gait pattern revealed that all, with the single exception of vascular
transfemoral amputees, had a lower rate of energy expenditure, heart rate, and 02 cost when
using a prosthesis. This difference was insignificant in the vascular transfemoral amputation
group and probably relates to the fact that even with a prosthesis, most of these patients relied
on crutches for some support, thus increasing the energy demand and heart rate.
It may be concluded that a well-fitted prosthesis that results in a satisfactory gait not requiring
crutches significantly reduces the physiologic energy demand. Since crutch walking requires
more exertion than walking with a prosthesis does, crutch walking without a prosthesis should
not be considered an absolute requirement for prosthetic prescription and training.

Unilateral Prosthetic Ambulation

The combined results of two studies in which patients were tested at their CWSs under similar
conditions illustrate the importance of the level of amputation. In the first study, energy
expenditure in unilateral amputees was measured at the transtibial, knee disarticulation, and
transfemoral levels following amputation secondary to trauma. Patients had also worn their
prostheses at least 6 months and did not use upper-limb aids (with the exception of some
transfemoral amputees in the vascular group). In the second study, healthy hip disarticulation
and transpelvic (hemipel-vectomy) amputees were tested at their CWS by utilizing a similar
methodology. These surgical amputees met the following criteria: were young and healthy at
the time of testing, had not received radiation or chemotherapy for at least 6 months prior to
testing, had no evidence of tumor recurrence, had worn their prosthesis for at least 6 months,
and did not utilize crutches.
In the groups of traumatic and surgical amputees described above, the 02 cost progressively
increased at each higher amputation level ranging from the transtibial to the transpelvic levels
(Fig 15-1.). Patients with higher-level amputations had a less efficent gait and higher 02 cost
than did those with lower-level amputations.

Fig 15-1. 02 cost in unilateral am putees w alking w ith a prosthesis at different am putation
levels. TP = transpelvic; HD = hip disarticulation; TF = transfem oral; KD = knee disarticulation;
TT = transtibial.

The average rate of oxygen consumption for different-level amputees was not dependent on level
and was approximately the same as the value for normal subjects (Fig 15-2.) (Table 15-1.).

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Fig 15-2. Rate of 02 consum ption in unilateral am putees w alking w ith a prosthesis at
different am putation levels. TP = transpelvic; HD = hip disarticulation; TF = transfem oral; KD =
knee disarticulation; TT = transtibial.

The CWS depended on the level of amputation and declined at each higher amputation level,
progressing from the transtibial, knee disarticulation, transfemoral, hip disarticulation, and
transpelvic levels in the traumatic and surgical amputee groups. These values averaged 71, 61,
52, 47, and 40 m/min (Fig 15-3.). These findings indicate that amputees slow their CWS to
keep the rate of 02 consumption from rising above normal limits. The reduced speeds at higher
amputation levels are inversely proportional to the increased 02 cost.

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Fig 15-3. Speed in unilateral am putees w alking w ith a prosthesis at different am putation
levels. TP = transpelvic; HD = hip disarticulation; TF = transfem oral; KD = knee disarticulation;
TT = transtibial.

Other investigators who have tested amputees at their CWS have also reported that the rate of
02 uptake was approximately the same as for normal subjects at their CWS. Clearly as more
joints and muscles of the leg are lost due to higher-level amputations, the greater the loss of the
normal locomotor mechanisms; therefore, the greater energy cost and slower speed.

Relationship of Mechanical and Physiologic Energy Expenditure

Human locomotion involves smooth advancement of the body through space. While the goal of
walking is progression in the forward direction, limb motion is based on the need to maintain a
symmetrical, low-amplitude displacement of the center of gravity of the head, arms, and trunk
(HAT) in the vertical and lateral directions. This conserves both kinetic and potential energy and
is the principle of biological "conservation of energy."
Saunders et al. described six determinants of normal gait that minimize energy expenditure.
Ankle motion during stance serves to improve shock absorption and smooth out the points of
inflection of vertical rise and fall of the HAT and the consequent vertical ground reaction force.
Therefore, as long as ankle stability is provided, the loss of ankle and foot motion has a small
effect on mechanical and physiologic energy expenditure. It is not surprising that the
physiologic cost of walking with a well-fitted Syme ankle disarticulation or transtib-ial prosthesis
increased the energy cost minimally.
On the other hand, knee motion plays a more important role in minimizing the vertical rise and
fall of the HAT, and consequently amputation at the transfemoral level substantially increases
the energy cost and lowers the speed to keep the rate of energy expenditure from rising above
normal limits. Since hip motion also plays an important role in minimizing vertical rise and fall of
the HAT, the hip disarticulation or transpelvic-level amputation further increases energy cost and
reduces speed.

Dysvascular Amputees
Dysvascular amputees walking with a prosthesis also selectively adjust their CWS to keep the
02 rate from rising above normal limits. As with traumatic amputees, 02 cost progressively
increases, and the CWS progressively slows at higher amputation levels.
The CWS and rate of 02 uptake were significantly higher for the traumatic transtibial and knee
disarticulation amputees than for the dysvascular transtibial amputees and ankle disarticulation
amputees. (There is no difference in the 02 rate at the transfemoral level due to the fact that
some of the dysvascular transfemoral amputees required crutches involving significant upperlimb exercise reflected by the higher mean heart rate.) It is logical to conclude that the higher
exercise capacity of the typical younger traumatic amputee enables selection of a higher 02
rate and CWS at any given amputation level than that selected by his older dysvascular
counterpart.
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Most older patients who have transfemoral amputations for vascular disease are not successful
long-term prosthetic ambulators. Only a small percentage of these patients are functional
ambulators. If able to walk, most have a very slow gait velocity and an elevated heart rate if
crutch assistance is required. In contrast, traumatic transfemoral amputees have an
adequate gait. It may be concluded that every effort must be made to protect dysvascular limbs
early so that transfemoral amputation does not become necessary. If amputation is required,
every effort should be made to amputate below the knee.

Length of the Residual Limb

Gonzales et al. evaluated transtibial amputees with stumps ranging from 14 to 19 cm in length.
Patients wore a patellar tendon-bearing prosthesis except for one who had a prosthesis with
a thigh corset. No significant differences were noted in speed or energy expenditure between
groups. Of particular clinical importance, a stump as short as 9 cm will result in acceptable
transtibial performance that is superior to performance at reported values at the knee
disarticulation and transfemoral levels.

Bilateral Amputees
Few energy expenditure studies have been performed on bilateral amputees. Interpretation of
the data on bilateral traumatic amputees must be made with caution since relatively few
subjects have been studied. Table 15-2 summarizes data on both traumatic and vascular
patients with bilateral amputation. This limited information indicates that the bilateral amputee
expends greater effort than the unilateral amputee does. Of interest, vascular patients with the
Syme ankle disarticulation/Syme ankle disarticulation combination walked faster and had a
lower 02 cost than did vascular patients with the transtibial/transtibial combination. This
parallels the findings among the unilateral amputees demonstrating that performance relates to
amputation level. Traumatic transtibial/transtibial amputees walked faster and at a lower energy
cost than did their vascular transtibial/transtibial counterparts (Table 15-2.).

Gonzales et al. pointed out that in view of the fact that approximately 24% to 35% of diabetic
amputees lose the remaining leg within 3 years, it is important to preserve the knee joint even if
the stump is short since, should a unilateral transtibial amputee undergo another transtibial
amputation, he would still expend 24% less energy than would a patient with a unilateral
transfemoral amputation. Bilateral vascular amputees rarely achieve a functional ambulation
status if one amputation is at the transfemoral level.
Finally, of special interest, Wainapel et al. measured energy expenditure in a 21-year-old
bilateral knee dis-articulation/knee disarticulation patient who walked on stubby prostheses with
a walker. The patient walked faster at a slightly greater rate of oxygen consumption than with
conventional prostheses and crutches. While walking on stubbies is cosmetically unacceptable
for most patients (except for gait training or limited walking in the home), the data from this
single patient illustrates that it can result in a functional gait.
References:
1. Astrand A, Astrand I, Hallback I, et al: Reduction in maximal oxygen uptake with age. J
Appl Physiol 1973; 35:649-654.
2. Astrand PO, Rodahl K: Textbook of Work Physiology, ed 2. New York, McGraw-Hill
International Book Co, 1977.
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3. Astrand PO, Saltin B: Maximal oxygen uptake and heart rate in various types of
muscular activity. J Appl Physiol 1961; 16:977-981.
4. Eberhart HD, Elftman H, Inman VT: Locomotor mechanism of amputee, in Klopsteg PE,
Wilson PD (eds): Human Limbs and Their Substitutes. New York, McGraw-Hill
International Book Co, 1954, pp 472-482.
5. Gonzalez EG, Corcoran PJ, Reyes RL: Energy expenditure in below-knee amputees:
Correlation with stump length. Arch Phys Med Rehabil 1974; 55:111-119.
6. James U, Nordgren B: Physical work capacity measured by bike ergometry (one leg)
and prosthetic treadmill walking in healthy active unilateral above knee amputees. Scand
J Rehabil Med 1973; 5:81-87.
7. Nowrozzi F, Salvanelli ML: Energy expenditure in hip disarticulation and hemipelvectomy
amputees. Arch Phys Med Rehabil 1983; 64:300-303.
8. Saunders JB, Inman VT, Eberhart HD: Major determinants in normal and pathological
gait. J Bone Joint Surg [Am] 1953; 35:543-558.
9. Steinberg FU, Garcia WJ, Roettger RF, et al: Rehabilitation of the geriatric amputee. J
Am Geriatr Soc 1974; 22:62-66.
10. Wainapel SF, March H, Steve L: Stubby prostheses: An alternative to conventional
prosthetic devices. Arch Phys Med Rehabil 1985; 66:264-266.
11. Waters RL, Hislop HJ, Perry J, et al: Energetics: Application to the study and
management of locomotor disabilities. Orthop Clin North Am 1978; 9:351-377.
12. Waters RL, Lunsford BR, Perry J, et al: Energy-speed relation of walking: Standard
tables. J Orthop Res 1988; 6:215-222.
13. Waters RL, Perry J, Antonelli D, et al: The energy cost of walking of amputees-Influence
of level of amputation. J Bone Joint Surg [Am] 1976; 58:42-46.
14. Waters RL, Perry J, Chambers R: Energy expenditure of amputee gait, in Moore WS, et
al (eds): Lower Extremity Amputation. Philadelphia, WB Saunders Co, 1989, pp 250-260.
Chapter 15 - Atlas of Limb Prosthetics: Surgical, Prosthetic, and Rehabilitation Principles

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