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Research Report

A Comparison of Oxygen Consumption During

Walking Between Children With and Without
Below-Knee Amputations

Background and Purpose. Dzferences, if any, in ermgv costs during walking Lisa M Herbert
of children with below-knee amputations ( B a ) and those of children without Jack R Engsberg
amputations have not been quantzjied. The purpose of this investigation was to Kathl G Tedford
compare measures of heart rate and oxygen consumption during walking (1) Susan K Grimston
between children with BkX and long residual limbs and children with BkX and
short residual limbs and (2)between children with BK4s and children without am-
putations. Susjects. Twenty-fourchildren volunteered to partinpate in this investi-
gation. Ten of the children, aged 6 to 18 years, had BkX, and 14 children, aged 6
to 17 years, were without amputations. Methods. The subjects walked for 2 min-
utes at each of the following four speeds: (1) chosen walking speed (CWS), (2)20%
below CWS, (3)20% above CWS, and (4)fied speed of 1.2m/x Heart rate and
a?cygen uptake were measured at each speed. Results. The results indicated (1) that
there were no signzjicant dzferences between children with long residual limbs and
those with short resiUual limbs; (2)that oxygen consumption was 15% greater for
children with BkAs compared with children witbout amputations; (3)that there were
no dzfferences in heart rates between children without amputations and those with
BkAs or within c h i h with BkX; and (4) that children with BkX did not choose
speeds dzffwentjbm their peers without amputations, regardless of stump length.
ConcZuston and Discussion. The results indicated that children with BkAs had
higher energy needsfor walking than children who had no amputation. Whether
the increased enetgv needs prevent or inhibit children with B k X f i m having a
lifstyle comparable to that of children without amputations is currently unknown
and warrantsfurther research. [HerbertW.l,Engsberg JR, Tedford KG, Grimston SK
A comparison of q g e n consumption during walking between children with and
without below-knee amputations. Pbys Ther. 19%; 74:943-950.1

Key Words: Below-knee amputation, Children, Energy cost, Heart rate, Oxygen

It has been previously reported that

LM Herbe:rt, is Graduate Student, Human Performance laboratory, University of Calgary, Calgary, the kinematics and kinetics of chil-
Alberta, Canada T2N 1N4. dren with below-knee amputations
JR Engsbe:rg, PhD, is Biomechanist and Director, Motion Analysis laboratory, St Louis Children's (BKAs) are significantly different dur-
Hospital, One Childrens' Place, St Louis, MO 63110-1077 (USA). Address all correspondence to Dr ing ambulation when compared with
those of children without arnputa-
KG Tedford, RPT,is Physiotherapist, Alberta Children's Hospital. Calgary, Alberta Canada T2T 5C7. tions.14 These differences have been
attributed to prosthetic limb mechani-
SK Grimston, PhD, is Human Biologist, Division of Endocrinology and Metabolism, Washington
University Medical Center, 216 S Kingshighway, St Louis, MO 63178. cal deficiencies-5 Although quantify-
ing mechanical differences provides
This study was approved by the Institutional Review Board of the University of Calgary.
information useful for the improve-
This research was supported by the Alberta Children's Hospital Foundation, the Alberta Heritage ment of prosthetic limbs, it does not
Foundation for Medical Research, and the Variety Club of Southern Alberta Tent 61. address how the mechanical differ-
This article was submitted November 27, 1992, and war accepted May 17, 1934.

Physical Therapy /Volume 74, Number 10/0ctober 1994 943 / 51

Table 1. Characteristics of Children With Below-Knee Amputations (n=IO)

Chosen Length Ten children (1 female, 9 male) with

Body Walking of BKAs and 14 children (8 female, 6
Age Height Mass Speed Termlnal Suspenslon Resldual male) without amputations volun-
(y) (cm) (kg) (mls) Gender Devlce Method Llmba
teered as subjects for this study. De-
scriptive measures for the children
Seattle Condylar Long with BKAs and the children without
Seattle Condylarlsleeve Short amputations are given in Tables 1 and
Seattle Condylar Long 2, respectively. All children with BKAs
Dynamic Condylar Long had a prosthesis for at least 4 years
Seattle Sleeve Long
and said they were comfortable with
the fit of the prosthesis. To compare
Sleeve Short
children with different residual limb
Seattle Sleeve Short
lengths, the children with BKAs were
Flex Sleeve Short
placed into two groups by a physical
Sach Sleeve Long therapist according to the interna-
Seattle Condylar Long tional classification of amputations.
One group consisted children with
BKAs and residual limbs of less than
two thirds of intact limb length. The
"Long residual limb=greater than 67% of intact limb length (note: all children with a long residual other group consisted of those chil-
limb had a congenital defect); short residual limb=less than 67% but greater than 33% of intact dren who had a stump length equal
limb length (note: all children with a short residual limb had a traumatic amputation). to o r greater than two thirds of intact
'Subject walked at each speed only once. limb length. These groups were con-
sidered short- and long-limbed, re-
ences affect energy costs in children It is currently unknown whether it is spectively, and were similar to the
with BKAs. possible to generalize these differ- grouping of Gonzala et aL7 Medical
ences in energy costs between adults histories indicated that, except for the
Studies comparing the energy costs with and without BKAs to children. A amputation in the children with BKAs,
during walking in adults with BKAs preliminary study conducted in our all children were in good health and
have shown that they have the same laboratory indicated that children with had no known medical problems.
energy costs as adults without ampu- BKAs (n=3) consumed 10% more Subjects and parents were familiar-
tati~ns.~lOThis similarity was oxygen than did children without ized with the testing procedures and
achieved, however, because the per- amputations (n=2) when walking at equipment prior to signing human
sons with amputations walked at the same speeds.1 Due to the small consent forms.
slower speeds. When the adults with numbers in each group, it was not
BKAs walked at the same speed as possible to generalize these trends to Procedure
adults without amputations, their the larger populations of children
energy costs were approximately 32% with BKAs. Oxygen uptake (in milliliters per
greater.Wonzalez et a17 found that kilogram per minute) was measured
adults with BKAs and long residual The purpose of our investigation was using a Quinton Instruments Model
limbs (greater that 8% of total body to compare physiological measures of 2 4 7 2 Treadmill System* and a Hori-
height) had a 10% increase in oxygen heart rate and VO, during walking (1) zon Metabolic Measurement Cart
consumption (iro,) compared with between children with BKAs and long System.+The gas analyzers were cali-
adults without amputations, whereas residual limbs and children with BKAs brated before and after each test.
adults with BKAs and short residual and short residual limbs and (2) be- Volume and temperature were cali-
limbs (less than 6% of total body tween children with BKAs and chil- brated prior to each test. Heart rate
height) had a 40% increase when the dren without amputations. (in beats per minute) was monitored
groups performed the same activities. during testing using a Polar Sport
Tester PE 3000.~The Sport Tester
system consists of a transmitter that is
attached to an electrode belt. The
'Quinton Instruments, 2121 Terry Ave, Seattle, WA 98121. electrode belt was secured around
the subject's chest at the level of the
'Sensormedics Corp, 1630 S State College Blvd, Anaheim, CA 92806.
fifih intercostal space below the left
*polar USA Inc, 470 West Ave, Stamford, CT 06902. nipple. The Sport Tester system per-

52 / 944 Physical Therapy/Volume 74, Number 10/0ctober 1994

Table 2. Characteristics of Children Without Amputations (n =14)

Age (Y)
Walking Speed
(mls) Gender
2-minute test for a group of 18 chil-
dren without known impairments and
for a group of 13 children with cere-
bral palsy reflected a steady-state
level. This result was confirmed in a
pilot investigation1 conducted prior to
this study. Finally, to assess the repeat-
ability of the measures, 2 children
without amputations who were not
involved in the study were retested 1
week after the initial testing session
(Tab. 3).

Data Reduction and Analysis

Oxygen consumption relative to dis-

tance (SVO,) (in milliliters per kilo-
gram per meter) and heart rate at the
2-minute marks along with the corre-
sponding walking speed and physical
characteristics for each subject were
entered into a computer file for statis-
tical analysis. A physiological cost
index (PC9 was derived using the
following equation:

(1) PC1= (hw -rhr)/s

"Subject walked at each speed only once.

where "hw" is heart rate while walk-

mitted continuous monitoring of bolic cart and was fit onto each
ing (in beats per minute), "rhr" is
heart rate. child's head along with the mouth-
heart rate at rest (in beats per
piece and a noseclip. To record pre-
minute), and "s" is average walking
Subjects were familiarized with the test heart rates, the subjects were
speed (in meters per minute).lz Per-
treadmill (approximately 3-5 min- asked to stand in a relaxed manner
centage of maximum heart rate
utes) and then asked to select their for 2 minutes prior to starting the test.
(%MHR) was derived for each walk-
freely chosen walking speed (CWS). They then walked for 2 minutes at
ing speed using the following
The CWS for each subject was deter- each of the four speeds in a randomly
mined by increasing and decreasing assigned order. No rest was given
the speed of the treadmill until the between speeds, and changes to the (2) %MHR=sshr/age h r x 100
subject verbally communicated new speeds were made with the sub-
which speed was the most comfort- jects on the treadmill. In this way, the
where "sshr" is the steady-state exer-
able and approximated the speed subjects were permitted to gradually
cise heart rate (in beats per minute)
the subject would likely choose if he adapt to new speeds. All tests were
and "age hr" is the age-predicted
o r she were walking about during repeated, with the exception of the
maximum heart rate (220-age) (in
an average day. The CWS plus 20% fixed-speed test, which each subject
beats per m i n ~ t e )Data
. ~ for the two
and CWS minus 20% were then calcu- completed only once. For some
trials at the same speeds were aver-
lated. Sul~jectswere fitted with a head- smaller subjects (Tabs. 1 and 2), the
aged for each subject.
gear apparatus and then familiarized treadmill protocol was modified such
with each of the three speeds while that they were only tested once at Two multivariate analyses of variance
wearing the headgear. In addition, a each speed. After the treadmill tests
(MANOVAs) were used to determine
fixed speed of 1.2 m/s was also tested were completed, each subject was
significant differences in physiological
because it had been used in related seated in a chair and heart rate was
measures between children with BKAs
investigations.l-3 The subjects then again monitored for 2 minutes. Heart
and long residual limbs and children
rested until their heart rate returned rate and VO, were measured every 30
with BKAs and short residual limbs
to the pre-warm-up state. seconds, but only the final 30 seconds
and between children with BKAs and
in each of the 2-minute intervals was those without amputations. The
The headgear system, designed to used for calculations. Rose et all1
within-group factor was walking
secure the mouthpiece to the expired determined that the VO, measured
speed. The MANOVAs were necessary
air hose, was connected to a meta- during the final 30 seconds of a
because the dependent variables (ie,

Physical 'Therapy/Volume 74, Number 10/0ctober 1994

Table 3. Mean Physiological M e a s u m t s f i m Retesting Trvo Subjecfi

heart rate, PCI, %MHR, S V O ~were
correlated. Statistical significance were
based on a probability level of <.05.
The post hoc test used in this investi-
gation was an F test.

Because the population density in


Measure Day CWSa CWS CWS Flxed the region where the study was
conducted was low, the number of 1
Subject 1
HRb (blmin) 1 102 102 104 98
subjects with amputations available
for this study was limited. A test to I
determine the power associated
2 102 99 104 104
with the investigation was therefore
SVO,~(mL performed.12
kg-' rn-') 1 0.2538 0.2861 0.2344 0.1431
2 0.2910 0.2852 0.2490
722 Results
PCld (blm) 1 0.5128 0.4892 0.4583 0.2222
2 Comparison Within Children I
MHRe(%) 1 Wlth Below-Knee Amputations
2 I
Subject 2 There were no differences between
HR (blmin) 1 the children with BKAs and long resid-
2 ual limbs and the children with BKAs
SVO, (mL and short residual limbs with regard to
kg-' m-') 1 personal characteristics (ie, CWS, rest-
2 ing heart rate, age, height, body mass,
PC1 (blm) 1 and gender) (Tab. 1). In addition,
there were no differences between the
two groups of children with an ampu- 1

MHR (%) 1
tation with respect to the physiological
characteristics (ie, heart rate, SVO,,-
PCI, %MHR) (Tab. 4).
"CWS=chosen walking speed. d~~~=physiological
cost index. I
hean an rate.
C ~ ~ o , = o x y g econsumption
n relative to distance.
eMHR=maximum hean rate. Comparison Between Children
With Below-Knee Amputations l
and Those Without Amputations

There were no differences between I

Table 4. Means (?Standard Ewors) for Four Physiological Measures ~ u r i n Four
g the children with BKAs and the chil- I

Walking Speeds for Children With Below-Knee Amputations With Long and Short dren without amputations for age,
Residual Limbs (n height, and weight. Only one female
child with a BKA was available for
Speed testing. There were also no differ-
Physiological Resldual ences between groups for VO, as a
Measureb Llmb 20% Below CWSc CWS 20% Above CWS Flxed
function of age.

HR Long The means and standard errors for

Short the four physiological measures for
SVo, Long the children with BKAs and the chil-
Short dren without amputations are illus-
PC1 Long
trated in Figures 1 through 4. The
two-way repeated-measures MANOVA
(groups [subjects with BKAs and sub-
MHR Long
jects without amputations], walking
speeds 120% below CWS, CWS, 20%
above CWS, and fixed]) conducted for
"No significant difference existed between groups.
the physiological measures (heart
'see Tab. 3 footnotes for description of abbreviations. rate, SVO,, PCI, and %MHR) provided
CCWS=chosenwalking speed. varying results. The multivariate main

54 / 946 Physical Therapy /Volume 74, Number 10/0ctober 1994

effects for groups was significant
(F=3.42; df=4,17; P<.05). The group
univariate F-test results for heart rate
and %MHR were not significant
(F=O.OO; df=1,20; P<.05 and F=O.OO;
df= 1,20;P < .05, respectively),
whereas the group univariate F-test
results for SVO, and PC1 were signifi-
cant (F=9.28; df=1,20; P<.05 and
F=4.86; df= 1,20;P < .05, respectively).
The multivariate main effects for walk-
ing speed were significant (F= 19.69;
df=12,9; P<.05). The speed univariate
test results were significant for heart
rate (F=21.20; df=3,18; P<.05), !$o ',
(F=28.16; df=3,18; P<.05), and
%MHR (F=6.88; df=3,18; P<.05) and
not significant for PC1 (F=2.37;
df=3,18; P<.05). There was no inter-
action effect (P> .05) multivariately o r
univariately. The power test indicated
that for SVO, and PCI, a power of 0.95

20% BELOW CWS CWS 20% ABOVE CWS FIXED or greater existed (a<.05).

Figure 1. Means and standard errors for heart rate of children with below-knee We investigated physiological cost
amputations ( B m ) (n=10) and for children without BMs (n =14). No dzrerences a- differences of walking between chil-
isted between the groups. (CSW=chosen walking speed.) dren with long and short residual
limbs and between children with
BKAs and children without amputa-
tions. A number of limitations are
associated with this investigation. The
small number of children with BKAs
was limited by the number of chil-
dren in the local region. This sample
size, however, was greater than that
previously reported.' In addition,
because there was no significant dif-
* ference between the children with
long residual limbs and those with
short residual limbs, all children with
amputations were combined to form
a single group. That group was com-
pared with the group of children
without amputations.

A further limitation was with regard

to the test-retest evaluation. First, it
20% BELOW CWS CWS 20% ABOVE CWS FIXED would have been desirable to retest
WALKING SPEED children with amputations as well as
those without amputations. Such
retesting, however, was not possible
due to the time frame of the investi-
Figure 2. Means and standard errorsfor oxygen consumption relative to distance gation and the proximity of the chil-
for children with below-knee amputations ( B a ) (n=IO) and for children without dren with amputations to the labora-
amputations (n=14). Asterisks (*) indicate that children with B m consumed signzji-
cantly greater amounts of oxygen (P<.05) when compared with children without am- tory. Second, the results for the test-
putations at each walking speed. This amounted to a 15% increasefor all walking retest evaluation indicated that the
speeds combined (CWS=chosen walking speed,) differences between days was of the

Physical Therapy/Volume 74, Number 10/0ctober 1994

same magnitude as the differences
between groups.
- . Because only 2 chil-

dren were retested, it is impossible to

determine how the day-to-day effect
would have influenced the group
effect. Finally, the age range of the
children was 6 to 18 years. Astrand
and Rodah114 have reponed that VO,
in boys and girls is about the same
until about year 14. At that time, VO,
* increases at a greater rate in boys
than in girls. In our investigation, 6 of
the 7 children aged 14 years or older
* were boys. Of these 6 boys, 4 were
children with amputations and 2 had
no amputations. No difference was
found between groups as a function
of age. If an influence of age had
existed, however, it would probably
have moved the results for the group
of children with BKAs closer to those
20% BELOW CWS CWS 20% ABOVE CWS FIXED of the group of children without
WALKING SPEED amputations.

Physiological measures of effort have

Figure 3. Means and standard m r s for physiological cost index (PC4 for children been documented for adults with
with below-knee amputations ( B m ) (n =IO) and for childm without amputations BKAs. There is a paucity of available
(n= 14). Asteri'sks (*) indicate that chi- with BXtls had a signijicantlygreater PC1 value information, however, for children
(P<.05)when compared with children without amputahons at each walking speed 7% with BKAs. Nielsen et a18 and Pagli-
amounted to a 46% increase for all walking speeds combined. (CWS=chosen walking
arulo et alp reponed that adults with
BKAs have a higher energy need than
adults without amputations when
walking at the same speeds (a fixed
speed), and the results of the our
study suggests that this difference in
energy cost extends to children.
0.65 Adults appear to choose an optimal
energy-efficient speed; therefore,
adults with BKAs choose a slower
walking speed.610 Our study demon-
strated no difference in CWS between
children with BKAs and children
K without amputations. A significant
0.55 difference in energy needs (15% for
8 all walking speeds combined), how-
ever, was found at all walking speeds
(Fig. 2). Apparently, children with
BKAs are willing to walk at the same
speed as children without amputa-

tions and to accept the consequences I
of greater energy expenditure. Coo-
20% BELOW CWS CWS 20% ABOVE CWS FIXED per et all5 reponed that the anaerobic
WALKING SPEED threshold for a group of children was
approximately 25
during walhng. In our study, the
children without amputations were at
Figure 4. Means and standard errorsfor percentage of maximum heart rate I
("/aMHR) for children with below-knee amputations (BXtls) (n=IO) and for children 53% of this anaerobic threshold,
without amputations (n= 14). No signijcant diferences existed between the groups. whereas the children with BKAs were
(CWS= chosen walking speed.) at about 56% of the threshold. Thus,

56 / 948 Physical Therapy /Volume 74, Number 10/0ctober 1994

both groups of children easily fell children with BKAs and 0.25 would seem reasonable to hypothe-
below the anaerobic threshold value (SD=O.Ol) for children without am- size that the reported differences
reported by Cooper et Whether putations at CWS (Fig. 3). Stage of between the two groups of children
this dfierence prevents children with puberty was not assessed, however, so are a result of the lack of function of
BKAs from performing all the activi- the possibility of differences in stage the prosthesis and the prosthetic
ties of children without amputations of puberty between groups could not limb. Thus, if the goal is to enable
during a typical day is impossible to be determined. The lower PC1 values children with BKAs to walk like chil-
determine from our investigation. for children without amputations may dren without amputations, then re-
This issue, however, warrants further be a reflection of the higher resting search should be directed toward
investigation. heart rate for that group. The differ- developing prostheses that permit the
ences in resting heart rate, however, prosthetic limb to function more like
The CWSs and heart rates recorded in were not significant between the two an intact limb. Such a prosthesis
our investigation are comparable to groups of children. would probably permit dorsiflexion
those previously attained on adults and plantar-flexion movements and
with BKAs. Nielsen et al%nd Pagli- Nielsen et a18 suggested that %MHR provide propulsive forces similar to
arulo et a19 reported a CWS of 1.1 m/s was a good indicator of the relative those generated by children without
(SD=1.3) for adults with BKAs, exercise intensity, and they found a amputations.
whereas in our investigation the CWS %MHR of approximately 65% for
of the children with BKAs averaged CWS. In our study, we found a %MHR Summary
1.05 m/s (SD=0.22). The heart rate of approximately 55% for children
recorded for CWS by Pagliarulo et a19 with and without BKAs. Nielsen et all8 The results of this study indicate (1)
was 106 b/min (SD= lo), whereas the recommended, as a general guideline, that children with BKAs chose walking
heart rate recorded in our investiga- that %MHR should be below 80%. speeds similar to those of children
tion was slightly higher at 114.9 b/min The results of our study, therefore, without amputations, regardless of
(SD= 13.8) (Fig. 1). This difference indicate that the children with BKAs residual limb length; (2) that no dif-
was likely due to the higher resting and those without amputations were ferences existed in heart rates be-
heart rate in children compared with well within their physiological limits tween children with BKAs and chil-
adults.l6 while walking (Fig. 4). dren without amputations or within
children with BKAs with respect to
We recorded an increase of 15% in We found no difference in CWS in the residual limb length; and (3) that an
SVO, for children with BKAs as com- subjects with BKAs when grouped by increase in VO, existed for children
pared with children without amputa- residual limb lengths. In contrast, with BKAs.
tions at their CWS (Fig. 2). In studies Gonzalez et a17 and Waters et all0
of adults, the general consensus was found a higher CWS for adult subjects Children with BKAs had higher en-
an approximate 32% increase in VO,, with a short residual limb BKA com- ergy needs for walking than children
as reflected in SVO, at the CWS.XThe pared with adult subjects with a without amputations. Whether the
higher increase seen in the studies of longer residual limb. Gonzalez et a17 increased energy needs prevent or
adults may be a result of the signifi- suggested that this finding may be inhibit children with BKAs from hav-
cantly slower walking speed for adults due to age, duration of amputation, ing a lifestyle comparable to that of
with BKAs, which would result in an general physical condition, complicat- children without amputations is cur-
increase in SVO, (noting that at a ing illnesses, and prosthetic type and rently unknown and warrants further
slower speed it would take longer to fit. The difference between the investi- research.
walk the same distance). The lower gations with adults and children with
SVO, values with the higher speeds in BKAs warrants further scrutiny. This
our study agree with the results for difference, however, could be related References
adult subjects reported by Nielsen to the percentage of maximum oxy- 1 Engsberg JR, Macintosh BR, Harder JA. Com-
et gen consumption at which the groups parison of effort between below-knee-amputee
feel comfortable during walking. children and normal children. Journal of the
Association of Children's Prosthetic-Orthotic
The PC1 was studied by Butler et all7 Clinics. 1991;26(2):4652.
for children without amputations Other resear~h~.3~5 has shown biome- 2 Engsberg JR, Lee AG, Tedford KG. Norma-
(n=72, age range=3-12 years). They chanical differences between children tive ground reaction force data for able-bodied
reported a mean PC1 of 0.4 (SD= with BKAs and children without am- and below-knee-amputee children during
walking.J Pedian Ombop. 1993;13:169-173.
0.12). They also stated that PC1 is putations. The results of our study 3 Engsberg JR, Tedford KG, Harder JA. Center
independent of age, height, and gen- support the notion that a relationship of mass location and segment angular orienta-
der, but may be affected by puberty. between biomechanical differences tion of below-knee-amputee and able-bodied
There appear, however, to be no previously reported between the two children during walking. Arch PLys Med Reba-
bil. 1992;73:1163-1168.
studies reporting the effects of stage groups could have a significant effect 4 Lewallen R, Dyck G, Quanbury M, et al. Gait
of puberty on PCI. In our study, we on physiological function. Although kinematics in below-knee child amputees: a
recorded PCIs of 0.37 (SD=0.03) for not the focus of this investigation, it

Physical Therapy /Volume 74, Number 10/0ctober 1994

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9 Pagliarulo MA, Waters RL, Hislop HJ. Energy 1990;8:304-309.
cost of walking of below-knee amputees hav-

Call for Reviewers

Physical Therapy is currently seeking qualified individuals to serve as

manuscript reviewers, Reviewers should have:
Extensive experience in area[s) of content expertise
Experience as authors of articles published in peer-reviewed journals

Familiarity with peer review is essential,

If you are interested in becoming a reviewer for the Journal, please send
a cover letter and a copy of your curriculum vitae to:

Physical Therapy
1111 North Fairfax Street
Alexandria, VA 22314-1488

Interested in becoming involved, but not sure you have the
time to review manuscripts?The Journal is also looking for article
abstracters and booWsoftware/videotape reviewers, Send us a
letter expressing your interest and stating your general areas
of expertise, along with a copy of your curriculum vitae.
We look forward to hearing from you.

58 / 950 Physical Therapy/Volume 74, Number 10/0ctober 1994