Chirurgia Narządów Ruchu i Ortopedia Polska, 76(5), 305-312, 2011
Three point crutch gait from the perspective of biomechanics and kinesiology.
State of knowledge and idea behind the research
Lechosław B. Dworak 1,2,3, Michał Murawa 1, Marek Owsian 2,
Jacek Mączyński 1, Jarosław Kabaciński 1, Agata Rzepnicka 1
1
Department of Biomechanics, University School of Physical Education in Poznan
2
3
Department of Bionics, University of Arts in Poznań,
Faculty of Physiotherapy, Poznan University of Medical Sciences
Summary
The study characterizes the idea behind the research project which consists in biomechanical and kinesiological analysis of three point
crutch gait. The structure of the study is in part similar to an earlier publication of the authors [1], which discussed swing through gait.
By defining the three point crutch gait and describing its general kinematic structure as well as synthetically analyzing the state of knowledge, the authors formulated the purpose of the study, the adopted research model – including the description of the modern and integrated measurement systems that were used and which consisted of: 2 AMTI force plates integrated into a measurement walkway, a set
of 6 optoelectronic cameras of the BTS System as well as a multichannel kinesiological electromyography performed with the use of
the NORAXON System. All phases of the research were characterized, presenting the adopted research protocol in its entirety.
Key words: three point crutch gait, biomechanics, kinesiology, kinematic structure, conception and research model
Chód trójpunktowy o kulach z perspektywy biomechaniki i kinezjologii.
Stan wiedzy i koncepcja badań
Streszczenie
W pracy scharakteryzowano koncepcję projektu badawczego ukierunkowanego na biomechaniczną i kinezjologiczną analizę chodu
trójpunktowego o kulach (three point crutch gait). Struktura pracy jest częściowo podobna do wcześniejszej publikacji autorów [1], odnoszącej się jednak do chodu kangurowego (swing through gait). Poprzez, definicję i ogólną strukturę kinematyczną chodu trójpunktowego o kulach oraz syntetyczną analizę stanu wiedzy, sformułowano cele pracy, przyjętą metodykę badań – w tym opis zastosowanych
nowoczesnych i zintegrowanych torów pomiarowych, które składały się z: 2 platform dynamometrycznych AMTI wbudowanych w pomost pomiarowy, zestawu 6 kamer optoelektronicznych Systemu BTS, wielokanałowej elektromiografii kinezjologicznej z użyciem Telemetrycznego Systemu NORAXON. Scharakteryzowano także wszystkie etapy badań laboratoryjnych, ukazując całościowo przyjęty
protokół pomiarowy.
Słowa kluczowe: chód trójpunktowy, biomechanika, kinezjologia, struktura kinematyczna, koncepcja i model badań
Problem formulation
The genesis of interest in biomechanical, kinesiological
and ergonomic aspects of crutch gait is related to several
previous works of this paper’s author team [2-7], inspired
among others by lectures given to physiotherapy as well as
architecture and design students.
It is, however, particularly related to two research projects of the Polish Ministry of Science and Higher Education (No N N404 1973 33 and No N N404 2715 40), realized
in form of supervisor’s grants: Biomechanical analysis of
three-point crutch gait in patients after lower limb injuries [8],
Biomechanical and kinesiological analysis of swing-through gait
in patients after lower limb injuries [9].
Crutch gait may be defined as a form of overland cyclical limb locomotion characterized by the fact that the supporting and propelling phases do not only occur during
support with lower limbs (limb) but also with upper limbs
holding mobility aids [1].
This paper discusses one of the types of crutch gait –
the three point crutch gait. In Dega and Senger’s systematics
of gait [10], it is categorized in the group of two-dimensional gaits.
Three point crutch gait is one of the most frequently
used crutch gaits. It is recommended because of symmetrical movement of crutches during the swing and stance
phases, which is easy to learn as far as coordination is concerned. It is characterized by the possibility to partly (significantly) relieve weight bearing from the diseased lower
limb [11-17].
Three point crutch gait: kinematic description from
the perspective of biomechanics and kinesiology
In their attempt to characterize biomechanically and
kinesiologically three point crutch gait, the authors used
widely accepted criteria for describing the kinematics and
kinetics of locomotion movements, applying them to gait
cycle and its phases [18-21].
Three point crutch gait is divided into two phases, both
for the diseased limb and the crutches: stance and swing.
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L. B. Dworak et al.
Fig. 1. Schematic diagram of three point crutch gait cycle kinematics. Adaptation and modification on the basis of www.walkeasy.com.
Ryc. 1. Schemat kinematyki cyklu chodu trójpunktowego o kulach. Adaptacja i modyfikacja na podstawie www.walkeasy.com.
Assumptions
The following assumptions have been made in order
to define the biokinematic structure of three point crutch
gait:
1. One lower limb is diseased (D) and requires support
(in our case it will be the left limb; Fig. 1 and Fig. 2);
3. The swing phases of crutches and the diseased limb
are performed with pendular motion, simultaneously
(symmetry in time);
4. The patient moves with alternating step, crossing the
front line of the supporting foot.
According to this convention, three point crutch gait
cycle begins and ends with the first contact of the diseased
limb foot and crutches with the ground (Fig. 1).
Descriptive kinematic structure of correct three point
crutch gait cycle
1. The stance phase of the diseased limb
and crutches (stance phase, StPh)
It begins with the first contact of the diseased limb foot
and crutches with the ground (initial contact, IC) and ends
the moment this limb and crutches loose contact with
ground (initial swing). It is divided into 3 microphases
characteristic to the movement sequence of the body.
1.1. Shifting body weight onto the diseased limb foot
and crutches (loading response, LR).
Fig. 2. Sequence of characteristic foot and crutch positions during
the cycle phases of three point crutch gait. Assumption: left limb
diseased (D), right limb healthy (H). Grey and black colors signify
part and full load on the limb respectively. Symbols " and !
represent the positions of crutches during stance (loaded) and
swing phases respectively. Arrows placed on the projections of feet
of D and H limb represent the swing phases of these limbs.
Ryc. 2. Sekwencje charakterystycznych położeń stóp i kul w fazach
cyklu chodu trójpunktowego o kulach. Założenie: lewa kończyna
chora (D), prawa zdrowa (H). Barwa szara lub czerń oznaczają
odpowiednio częściowe lub pełne obciążenie kończyny. Symbole
" i ! oznaczają kolejno położenie kul w fazach podporowych (obciążenia) i wymachowych. Strzałki umieszczone w rzutach stóp
kończyny D i H oznaczają fazy wymachowe tych kończyn.
2. The stance phases of the diseased limb and crutches
happen simultaneously (symmetry in time) and as a
result one achieves the unweighting of this limb;
Its main qualities are simultaneous loading of crutches
with patient's body mass and reduction of load on the diseased limb, related to shifting the COM forward from rear
position. It is characterized by 4 points of support (both
crutches and both feet are in contact with ground). In this
sense it is a phase of double support of lower limbs as well
as lower limbs and crutches (double support, DS). The equivalent of this in figure 2 are sequences 1 and 2.
1.2. Mid stance (MS).
It can be distinguished by the loading of crutches with
patient’s body mass and reduction of the load on the diseased limb. It is characterized by 3 points of support (three
point crutch gait), as both crutches and the diseased limb
foot are in contact with ground, because the healthy limb
begins and continues its forward swing phase. The name
of the three point crutch gait is derived from this characteristic locomotion sequence.
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Three point crutch gait biomechanics and kinesiology
1.3. Terminal stance (TS)
It can be distinguished by increased loading of the
diseased limb, in preparation for the swing phase that
follows it, and by generation of COM propelling forces
during the stance phase.
2. The swing phase of the diseased limb and crutches
(SwPh)
It begins when the diseased limb foot and crutches loose contact with the ground (simultaneously), and ends
the moment the diseased limb foot and crutches enter in
contact with ground. Similarly to the stance phase, it divides into 3 microphases.
2.1. Initial swing (IS)
It is marked by the moment the diseased limb foot and
crutches loose contact with ground initiating their symmetrical swing (diseased limb and crutches). In the supporting sense, during this microphase the body has only 1
point of support (healthy limb foot is loaded).
2.2. Mid swing (MS)
It is characterized by symmetrical forward transfer of
the diseased limb and crutches with pendular motion in
the mid zone of this microphase. Analogically to the previous microphase, this sequence has only 1 point of support (healthy limb foot).
2.3. Terminal swing (TS)
It begins when the swing of the diseased limb and crutches is beginning to stop, and ends, as in the beginning of
the cycle, with the first contact of the diseased limb foot
and crutches with ground (initial contact, IC). Similarly to
the two previous swing microphases, this sequence also incorporates only 1 point of support (healthy limb foot).
Critical analysis of the state of knowledge
– synthetic perspective
In their attempt to analyze the few available publications on three point crutch gait, the authors concentrated
on those which present the problem from the perspective
of biomechanics and kinesiology.
The issue of grading the weight-bearing on the diseased lower limb and teaching patients to relieve weight-bearing as recommended (by a physician or physiotherapist)
during locomotion with three point crutch gait was addressed by such researchers (and their associates) as Gray,
Li, Tveit, Woolson, Hurkmans, Malviya, Youdas, Nowotny-Czupryna, Vasarhelyi, Eng, Hol [13, 22-31].
Li et al. [13], in their study of three point crutch gait
addressed the variability of dynamic (in the values of
307
ground reaction force) and kinematic parameters. The experimental group consisted of 12 healthy persons whose
task was to simulate (on a measurement walkway) three
point crutch gait pattern so as to relieve weight-bearing on
the diseased limb by 10% during the first, by 50% during
the second, and by 90% during the third trial. The authors
found that participants were not able to “feign” the proper
level of weight-bearing relief in the first (10% weight-bearing relief) and the third (90% weight-bearing relief) case,
whereas being relatively accurate in achieving 50% weightbearing relief. During crutch gait, they observed shorter
stance phase and longer swing phase on the diseased side
as compared to the healthy side.
The main goal of the research carried out by Youdas
et al. [27] was evaluation of whether participants of the experiment were able to relieve their right lower limb by
a specific value (50% BW) during ambulation with three
point crutch gait using axillary crutches, forearm crutches,
a cane and a walker. Ten healthy subjects participated in
the experiment. Each of them was instructed and trained
by physiotherapists on how to properly unload their right
lower limb with the use of bathroom scale. The results of
the experiment demonstrated that after proper training it
is possible to repeatedly relieve lower limb by 50% with
the use of axillary crutches and by 56% with the use of
forearm crutches. Whereas in case of ambulation with the
use of a walker, participants were only able to achieve
vertical loading of the lower limb of 64% BW and with the
use of a cane of 76% BW.
Tveit et al. [23], used in their research a system of prototype footwear measurement insoles, which made it possible to record pressure under feet when walking witch
crutches. Six men and nine women who underwent hip
arthroplasty were studied. They were instructed to load
the operated limb with 30% BW when walking. The authors concluded that none of the participants was able to
recreate the recommended amount of weight bearing on
the operated limb, calling into question the practice of recommending patients specific values of weight bearing on
the operated limb.
Similar goal, concerning evaluation of whether partial
weight bearing of lower limb may be reproducible, was set
by Malviya et al. [26]. This time the experimental group
consisted of healthy persons, who were trained in partial
weight bearing of lower limb (25% BW) – with the use of
a bathroom scale. Participants were to recreate indicated
level of weight (25% BW), statically on a force plate, immediately after and 60 minutes after the end of the training.
The results of the study show that using bathroom scales
in order to learn to partially load a lower limb is effective.
Partly contradictory research results, as well as studies
mostly carried out with healthy participants and using methods that do not allow approaching the problem completely, inspired the authors of this study to form a broader
research project.
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L. B. Dworak et al.
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Purpose of the study and research hypotheses
The scientific goal of the research project
The main purpose of this research project is to identify
and evaluate biomechanical kinematic and dynamic parameters of three point crutch gait with partial weight bearing of one (diseased) lower limb, used e.g. by patients
after complete unilateral endoprosthetic hip joint reconstruction.
H2:
H3:
Specific goals
Specific goals are targeted at the following issues and
concern the cycle of the studied gait type:
Group of kinematic parameters:
1) Identify peak angular values and angular ranges in hip
joints, knee joints and ankle joints.
2) Determine angular ranges of pelvis displacement.
3) Describe angular ranges of crutch motion.
4) Determine stance, swing and double support phase
duration.
5) Determine length and width of a step and gait cycle
length.
6) Identify the average optimal gait velocity and step
frequency.
7) Determine the degree of reproducibility of parameters.
Group of dynamic parameters
1) Identify the values of the vertical component, the horizontal anterior-posterior component, as well as horizontal medial-lateral component of ground reaction
forces to lower limbs.
2) Determine the value of the vertical component of
ground reaction force to crutches.
3) Identify real load on the lower limb of the operated
side.
4) Determine weight bearing asymmetry of the crutch on
the healthy side and operated side.
5) Determine statistically significant relationship between
selected kinematic and dynamic parameters.
6) Determine percentage distribution of body weight on
the healthy and the diseased lower limb during a static
trial consisting in free standing.
Group of electromyographic parameters
1) Identification of time structure of electromyographic
activity in selected muscles of lower limbs, standardized for gait cycle.
Research hypotheses
Considering the state of biomechanical knowledge
related to the research project on three point crutch gait, as
well as personal experience and intuition on the subject,
the authors formulated several research hypotheses which
will further undergo verification:
H1: It is expected that there will be significant difference in ground reaction forces between the ope-
H4:
H5:
rated and the healthy limb during gait, which will
prove the presence of significant weight-bearing
relief of the limb with hip joint endoprosthesis.
It is expected that asymmetrical loading of lower
limbs with the vertical component of ground reaction force during the static trial (trials on a stabilometric platform) will be notably higher
in comparison to the dynamic trials (during gait
over two dynamometric platforms).
It is expected that during gait trials, there will be
significant asymmetric loading of the crutches,
with predominance of the healthy limb side.
It is expected that the values of characteristic kinematic parameters describing motion in (main)
joints of lower limbs will be significantly higher on
the healthy limb side as compared to the operated
limb side.
It is expected that the studied group of patients
will show high degree of reproducibility of kinematic parameters, resulting from stable velocity of
locomotion and effective mastering of three point
crutch gait technique.
Research materials and methods
The authors have received consent from the Bioethical
Commission of the Poznan University of Medical Sciences,
(resolution no 618/09) for carrying out this research project.
Materials
The trials were carried out on patients, who were diagnosed with primary unilateral coxarthrosis. The patients
were recruited from several orthopedic wards in Poznan,
Poland, after consulting their senior registrars. The main
criteria for their selection for final analysis and statistical
calculations were: type of undergone surgical procedure,
time from surgery to the trials, type of used crutch gait.
Patients after the surgical procedure of complete unilateral endoprosthetic hip joint reconstruction were used
in the experiment. Fifteen persons were admitted to the final study.
Methods
The trials were carried out in the Biomechanical-Kinesiological Laboratory of the Department of Biomechanics
at USPE in Poznan. Laboratory possesses the ISO 9001:2008
quality management system certificate.
Many research methods were used in this project.
They are illustrated in Figure 3.
This research project used the most modern measurement equipment, similar to that used in leading scientific
centers performing this kind of motion analysis. The entire
measurement system has been integrated to form a joint
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Three point crutch gait biomechanics and kinesiology
309
Fig. 3. Block diagram of the used measurement model.
Ryc. 3. Schemat blokowy zastosowanego modelu badań.
measurement track for simultaneous observation of kinematic, kinetic and electromyographic parameters; thus creating conditions for significantly innovative research.
Measurements were carried out in several phases:
C 1st phase consisted of a static balance test, where percentage distribution of body weight on the diseased
and healthy lower limb was recorded;
C 2nd phase consisted of anthropometric measurements
of patients and their preparation for the main trials
(placing markers on their bodies according to the Vaughan – Davis model [32] and putting electrodes on selected muscles, according to SENIAM guidelines)
(www.seniam.org) – Figure 4.
C 3rd phase consisted of the most important measurement for this research project – the measurement of kinematic, dynamic as well as electromyographic parameters during patient locomotion over a specially designed measurement walkway – Figure 5 and Figure 6.
Fig. 4. Vaughan–Davis model extended by additional 6 markers placed on the surface of the crutches (source – BTS Analyzer software).
Ryc. 4. Model Vaughan–Davis zmodyfikowany o dodatkowych
6 markerów umieszczonych na powierzchni kul
(źródło – program BTS Analyzer).
The study analyzes several tens of kinematic and
dynamic parameters of three point crutch gait (Tab. I),
extending it with anthropometric measurements (essential
in using the adopted Vaughan–Davis model).
The above listing does not mention the group of
electromyographic parameters, which described symmetrically measured muscles of: vastus medialis, vastus lateralis, tibialis anterior, gastrocnemius medialis, semitendinosus, biceps femoris.
Fig. 5. Schematic diagram of the testing method: integrated measurement stand and measurement tracks for recording
kinematic, kinetic and electromyographic characteristics of three point crutch gait.
Ryc. 5. Schemat ideowy realizowanej metody badań: zintegrowane stanowisko i tory pomiarowe do rejestracji kinematycznych,
kinetycznych i elektromiograficznych charakterystyk chodu trójpunktowego o kulach.
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L. B. Dworak et al.
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Fig. 6. Diagram of the measurement walkway with two integrated AMTI force plates (measurements in cm).
Ryc. 6. Schemat pomostu pomiarowego z wbudowanymi dwoma platformami dynamometrycznymi AMTI (wymiary liniowe w cm).
Table I. Some of the studied and calculated parameters, their meaning and applied units
Tabela I. Niektóre badane-obliczane parametry, ich znaczenia oraz jednostki
Name
Symbol
Unit
H
cm
Anthropometric parameters:
body height
body mass
m
kg
pelvis width
WP
cm
pelvis depth (right, left side)
DP(l,r)
cm
knee width (right, left)
WK(l,r)
cm
ankle width (right, left)
WA(l,r)
cm
lower limb length (right, left)
LLE(l,r)
cm
vertical
RZ
BW
anterior and posterior
RY
BW
lateral
RX
BW
QL, QR
BW
stance phase duration (left, right)
TST PH(l,r)
%GC
swing phase duration (left, right)
TSW PH(l,r)
%GC
TDO SU
%GC
F
Hz
step length
LS
m
step width
WS
m
gait cycle length
LGC
m
V
m/s
crutch-crutch cycle length
Lcr-cr
m
crutch positioning width
Wcr-cr
m
distance between ankle joint center in the diseased lower limb
and the crutch on the same side (ipsilaterally)
Lcr-A
m
HFE
deg
AFD-FP
deg
forward/backward tilt
PT
deg
rising dropping
PO
deg
intern./extern. rotation
PR
deg
sagittal plane
CrT
deg
frontal
CrO
deg
transverse
CrR
deg
Ground reaction force parameters
body weight distribution on left, right limb (in postural stability static tests)
Kinematic parameters:
a) time and space for lower limbs
double support phase duration
step frequency
gait velocity
b) time and space for crutches
c) range of motion of lower limb joints during the gait cycle
hip joint
talocrural
d) range of motion of pelvis
e) range of motion during gait cycle for crutch motion in three planes
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Three point crutch gait biomechanics and kinesiology
Summary
This conceptual study presents a research project,
which aims at analyzing biomechanically and kinesiologically three point crutch gait in patients after complete unilateral endoprosthetic hip joint reconstruction.
In their attempt to describe (from the perspective of
biomechanics and kinesiology) the kinematics of three
point crutch gait against the background of current knowledge, the authors formulated their goals and research
hypotheses. They also characterized the measurement
track they used and listed analyzed parameters.
The results of most of the trials carried out as part of
this project were presented in the doctoral thesis Biomechanical analysis of three-point crutch gait in patients after lower
limb injuries” [33]. They will be successively presented in
a series of publications prepared by the author and his
team.
The study was financed in stages from the following sources:
supervisor’s grant from the Polish Ministry of Science and Higher
Education No N N404 1973 33, a grant for the statutory activity of
the Chair of Biomechanics, USPE in Poznan and of the Department of Bionics at the University of Fine Arts in Poznan.
The authors would like to thank their colleague Krzysztof Kmiecik, MEng for the preparation of illustrations.
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