Simulations predict that alterations in balance control contribute to the higher cost of walking with a prosthesis

Abstract

The high metabolic cost of walking in individuals with a transtibial amputation is often attributed to reduced ankle propulsion. However, the cost of stabilizing walking may also increase after amputation, potentially explaining why restoring ankle propulsion does not always normalize metabolic cost. Because the contributions of propulsion and stabilization are difficult to dissociate experimentally, we used simulations to probe the effects of transtibial amputation and different prostheses on walking cost. We simulated gait using a conceptual planar torque-driven model. Leg joint torques were controlled by feedforward and linear, time-varying full state feedback. We computed feedforward torques associated with propulsion and feedback gains for stabilizing walking that minimized expected effort (sum of torques squared) in the presence of sensorimotor noise while imposing stability. We simulated walking for an intact model and three walkers with a prosthesis: a passive, a feedforward-controlled active, and a feedforward and local feedback-controlled active prosthesis. We solved a deterministic approximation of the resultant stochastic optimal control problems for different levels of sensorimotor noise. Feedforward and expected feedback torques were higher for the passive prosthesis walker than for the intact walker. An active prosthesis restored total biological effort (i.e., effort of all but the prosthesis joint) to the level of the intact walker, but this effort was generated by fewer biological joints. Biological feedback effort was higher in prosthesis walkers than in the intact walker. Adding local feedback to an active prosthesis reduced biological feedback effort, but only at low noise levels. Our results suggest that walking with a passive prosthesis increases effort related to both propulsion and stabilization. While active prostheses can support propulsion, local feedback control only marginally reduced stabilization-related effort, suggesting that controllers require sensory information from the rest of the body to fully restore the metabolic cost of walking.