Evaluation of immediate impact of cane use on energy expenditure during gait in patients with knee osteoarthritis

doi:10.1016/j.gaitpost.2011.11.003

Gait & Posture

Volume 35, Issue 3, March 2012, Pages 435-439

https://doi.org/10.1016/j.gaitpost.2011.11.003 Get rights and content

Abstract

Purpose

The aim of the present study was to assess the immediate impact of cane use on energy expenditure during gait in patients with knee OA analyzing VO₂.

Methods

An observational, cross-sectional study was carried out on 64 symptomatic patients with a diagnosis of knee OA. The assessment of energy expenditure was performed through an analysis of expired gases using the portable K4 apparatus (Cosmed, Model K4 b2, Italy) during the six-min walk test (6MWT). Two tests were performed with a cane and two without a cane on two different days within a seven-day period.

Results

The patients walked farther on the test without the cane (p < 0.001). Oxygen expenditure (VO₂) and the O₂ cost of walking at the end of the 6MWT increased approximately 50% and 80% during cane-assisted gait when compared to gait without the use of a cane (p < 0.001). Pain (Borg scale) decreased approximately 20% at the end of the 6MWT with cane-assisted gait in comparison to gait without a cane (p < 0.001).

Conclusion

Cane use causes an immediate increase in energy expenditure (VO₂) during gait and O₂ cost of walking and an immediate decrease of pain during gait. It is necessary to do a more prolonged follow up in order to assess the impact of daily cane use on energy expenditure among these patients and determine whether adaptation occurs. Furthermore, it is necessary to study whether daily cane use has a positive impact on important parameters in these patients, such as pain, function and quality of life.

Highlights

► We assessed the immediately impact of cane use in patients with OA. ► The energy expenditure and walking cost were immediately increased. ► Pain decreased during gait while using the cane for the first time.

Introduction

Osteoarthritis (OA) is one of the most common joint diseases worldwide [1]. The evolution of OA is slow and leads to joint stiffness, progressive deformity and loss of function, thereby affecting quality of life [2]. The knee is the most commonly affected weight-supporting joint and knee OA can result in functional disability [3].

In healthy individuals, weight load occurs in both the medial and lateral compartments of the knees. During the midstance phase of gait, about 60–80% of the load is distributed through the medial compartment of the knee, which is one of the reasons knee OA frequently involves this compartment [4]. Varus deformity may occur in knee OA and contribute toward the progression of the disease by causing increased load to the medial compartment of the knee, with subsequent damage to the articular cartilage and subchondral bone in this area [5]. Thus, alleviating weight load in both compartments and especially in medial compartment should be one of the aims of treatment with such patients [6].

Rehabilitation professionals often recommend the use of a cane to decrease weight load and pain on the joints of the lower limbs when walking [7]. The literature suggests that the use of a cane reduces joint stress, increases tolerance to exercise and enhances the independence of individuals with OA; the cane also helps the contralateral side, which is often overloaded [8]. In patients with knee OA, a cane should be used on the contralateral side to the affected knee, thereby reducing the length of peak adduction and making gait more efficient [6], [9].

Gait alterations in patients with knee OA may occur as a result of muscle weakness, pain, deformity and instability. Thus, balance during gait is affected, with a subsequent increase in energy expenditure, which, in turn, accentuates fatigue [10]. One study assessed energy expenditure in paraplegic individuals (incomplete injury at the C6 to L2 level) during gait with a walker or crutches and demonstrated less energy expenditure with the use of crutches than the walker [11]. However, both crutches and walkers require greater energy expenditure than normal gait. Studies on healthy individuals using a cane have also demonstrated an increase in energy expenditure when compared to normal gait [12], [13].

We only encountered one study addressing energy expenditure during cane-assisted gait in patients with knee OA, the aim of which was to determine whether differences in cane length affect energy expenditure during gait. Cane-assisted gait was shown to require greater energy expenditure than normal gait and a cane reaching the distal fold of the wrist was the length that caused the least impact on energy expenditure. However, the study used heart rate to estimate energy expenditure [14]. No studies were found assessing energy expenditure during cane-assisted gait in individuals with knee OA through an analysis of oxygen expenditure (VO₂).

The aim of the present study was to assess the immediate impact of cane use on energy expenditure during gait in patients with knee OA by analyzing VO₂. The hypothesis was that using a cane for the first time would lead to an increase in oxygen expenditure during gait when compared to gait without the use of a cane.

Section snippets

Design overview

An observational, cross-sectional study was carried out on 64 symptomatic patients with a diagnosis of knee OA based on the criteria of the American College of Rheumatology [15], with scores of 3–7 on the visual analog scale (VAS) for pain in the previous week. The study received approval from the Ethics Committee of the Universidade Federal de Sao Paulo (Brazil) and participants provided informed consent.

Setting and participants

The patients could have unilateral or bilateral knee OA. The cane was used on the

Results

Eighty-nine percent of the patients were women and 11% were men. The mean age of the sample was 61.7 years. Table 1 displays the descriptive data on the sample. Regarding the test order randomization, 35 patients performed the test with cane first and 29 started with the test without the cane.

Table 2 displays the mean and standard deviation of the values obtained on the 6MWT with and without the cane as well as the statistical significances value encountered using the paired t-test. The

Discussion

The aim of the present study was to investigate the immediate impact of cane use on energy expenditure during gait in patients with knee osteoarthritis. The results demonstrate that patients with knee OA using a cane for the first time expend considerably greater energy during walking. This increased energy expenditure is believed to be related to the greater muscle recruitment needed for the use of the cane as well as reduced gait efficiency. However, this is merely speculation, as the present

Conflict of interest

The authors declare they have no conflict of interest.

Acknowledgment

This study was funded by grants provided by FAPESP (2003/087536).

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Accuracy evaluation of a method to partition ground reaction force and center of pressure in cane-assisted gait using an instrumented cane with a triaxial force sensor
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Gait assistive devices, such as a cane, are often prescribed to improve balance in walking gait for elderly individuals [1–3] and hemiplegic patients [4–7], as well as to reduce loading (force and moment) of the lower limb for patients with gait disorders such as knee osteoarthritis [8–10] and total knee or hip replacement patients [11].
Clarifying the biomechanics of cane-assisted gait in elderly individuals and patients with gait disorders is important for developing better therapeutic interventions in the fields of rehabilitation and orthopedics. However, if the foot and the cane in the ipsilateral hand are placed on the same force plate simultaneously, the force plate cannot separate the forces as it records the sum of the forces. To overcome this indeterminacy problem of the ground reaction force (GRF) and the center of pressure (COP) in cane-assisted gait analysis, a method to partition the GRF and COP using an instrumented cane with a force transducer has been proposed. However, the accuracy and precision of the estimated GRF and COP has not been evaluated previously. We therefore reestablished a framework to partition the foot and cane forces during walking using an instrumented cane with a triaxial force sensor and evaluated the accuracy and precision of the method using a force plate array. Cane-assisted gait of healthy adults and hemiplegic patients were measured. Mean accuracy and precision associated with the GRF and COP measurements were approximately 0.4 ± 1.4 N and 0.2 ± 2.7 mm, respectively, indicating that the separations of the GRF and COP were sufficiently accurate for kinetic gait analysis. Although some methodological limitations certainly apply, this system will serve as a useful tool for improved therapeutic interventions.
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However, musculoskeletal pathology may alter our ability to move, disturbing gait, increasing energy costs and, consequently, reducing our autonomy. For example, the use of walking cane in patients with knee osteoarthritis has been observed to cause an increase in energy expenditure during walking [2]. Leg Length Discrepancy (LLD), whether or not linked to a pathological process, is one of the most frequent musculoskeletal conditions encountered in clinical practice.
The impacts of Leg Length Discrepancy (LLD) on the kinematic and dynamic parameters of walking have been widely discussed. But little is known on total mechanical work and energy cost. These two variables are more representative of the functional impairment undergone by the LLD patients.
To assess the changes of the mechanical work and energy cost of walking in subjects with real LLD and to compare their results with healthy subjects in whom the LLD has been simulated.
The mechanical work and energy cost data of 60 healthy subjects (speed: 4 km/h) with artificial LLD induced by soles (2 and 4 cm), 20 patients (speed: 3.75 ± 0.5 km/h) with real LLD and 20 matched subjects (speed: 3.75 ± 0.5 km/h) were collected. Statistical comparisons between the groups were performed using a t-paired test and ANOVA.
Patients with a real LLD showed a significant decrease in mechanical work and energy cost when compared to norms. Patients with real LLD provide a better recovery when compared to subjects with artificial LLD of 2 cm, and a decrease of energy cost and higher muscular efficiency (mechanical work/energy cost) when compared to subjects with artificial LLD of 4 cm.
Our results showed that patients with a real LLD develop compensatory strategies during gait, probably to minimize the displacement of the body center of mass and consequently reduce the amount of energy expenditure useful for their displacement. Moreover, they adopt a better gait strategy compared to the subjects in whom LLD was simulated.
Effects of differences in visual acuity on gait time and trunk acceleration when older women negotiate stairs
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To investigate the effects of good and poor binocular visual acuity (GBVA and PBVA, respectively) on the gait time, trunk acceleration amplitude, and trunk acceleration ratio of older women when climbing and descending stairs.
In total, 26 older adult women subjects (age between 66–90 years) were enrolled. The BVAs of 13 were ≥ 0.4 logarithm of the minimum angle of resolution (logMAR) (PBVA group); the others had BVAs ≤ 0.3 logMAR (GBVA group). All subjects climbed and descended a flight of three steps while fitted with a tri-axial accelerometer placed over the T2 and L3 spinal processes. Gait time, overall and directional trunk acceleration amplitude, and trunk acceleration ratio were measured when ascending and descending.
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Additionally, Caldwell et al.15 investigated the metabolic costs of other gait modifications such as toe-out walking and a medial shift of the foot (‘walking with the knees closer together’), and showed that toe-out walking required the least amount of energy compared to the other gait modifications. Similar increases in HR to the 5.9% increase in this study have been reported with new cane use in those with knee OA19,27. Importantly, VO2 during normal walking observed in the present study was similar to a previous study of energy expenditure during walking in people with knee OA.
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Increased lateral trunk lean walking on a treadmill resulted in significantly higher levels of steady-state energy expenditure, HR, and perceived exertion, but no difference in knee pain. While increased lateral trunk lean has been shown to reduce biomechanical measures of joint loading relevant to OA progression, it should be prescribed with caution given the potential increase in energy expenditure experienced when it is employed.
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Evaluation of immediate impact of cane use on energy expenditure during gait in patients with knee osteoarthritis

Abstract

Purpose

Methods

Results

Conclusion

Highlights

Introduction

Section snippets

Design overview

Setting and participants

Results

Discussion

Conflict of interest

Acknowledgment

Clin Biomech

Arch Phys Med Rehabil

Gait Posture

J Biomech

Clinics

Arch Phys Med Rehabil

Am Heart J

Gait Posture

Osteoarthritis Cartilage

Osteoarthritis Cartilage

Osteoarthritis Cartilage

Arch Phys Med Rehabil

Osteoarthritis: epidemiology and classification

Physical activity and quality of life in older adults

J Gerontol A: Biol Sci Med Sci

Osteoarthritis: clinical features

The distribution of load across the knee. A comparison of static and dynamic measurements

J Bone Joint Surg Br

The influence of alignment on risk of knee osteoarthritis progression according to baseline stage of disease

Arthritis Rheum