An Insight into the Acceptable Use & Assessment of Lower-limb Running Prostheses in Disability Sport BRYCE T.J. DYER A thesis submitted in partial fulfilment of the requirements of Bournemouth University for the degree of Doctor of Philosophy July 2013 Bournemouth University COPYRIGHT STATEMENT This copy of the thesis has been supplied on condition that anyone who consults it is understood to recognise that its copyright rests with its author. No quotation from the thesis and no information derived from it may be published without the author’s prior consent. 1 DEDICATION This thesis is dedicated to the memory of Jeff Dyer (1949-2012). A great father, whose mental and physical endurance were without equal. 2 ACKNOWLEDGEMENTS I would like to thank Professor Siamak Noroozi, Dr Philip Sewell & Dr Sabi Redwood for their time, support and guidance which helped make this research project so enjoyable. Furthermore, I would like to thank both Shelley Broomfield and Andy Callaway for their assistance with some of the data collection. This journey would not have been possible without any of them. Several friends and colleagues were also extremely helpful in either offering advice, encouragement or providing insight with respect to the PhD experience. They include: Dr Bob Eves, Dr Mehran Koohgilani, Dr Mihai Dupac, Professor Peter Hogarth and Professor John Vinney. Finally, special thanks go to my partner Michaela who supported my experience and all of the occasional frustrations that sometimes came with it. 3 ABSTRACT Sports technology can be any product or system used to facilitate, train or influence an athlete’s performance. The role of prostheses used for disability sport was initially to help facilitate exercise and then ultimately, competition. In able-bodied sport, controversy has occasionally been caused through the adoption or introduction of sports technology. However, scant attention has been paid to sport with a disability with respect to such concerns. This research project provides a novel contribution to knowledge by investigating the use of lower-limb running prostheses in competition by trans-tibial amputees. A novel study using a mixed method approach has investigated the nature, use and assessment of lower-limb running prostheses. It has proposed that the unchecked introduction of such technology has affected the sport negatively. From this, the study conducted a stakeholder assessment of the sport and provided a proposed series of guidelines for lower-limb prostheses technology inclusion. Finally, the recommendation was made that a proactive approach to such technologies’ inclusion in the future should be implemented. These guidelines were further developed by assessing symmetrical and non- symmetrical lower-limb function and proposed that single and double lower- limb amputees should be separated in competition in the future. To this end, it was proposed that lower-limb symmetry, stiffness and energy return were important means of monitoring prosthesis performance. Ultimately, a dynamic technique which assesses these qualities was proposed as an assessment strategy for further development in the future. 4 CONTRIBUTION TO KNOWLEDGE The novelty or ‘contribution to knowledge’ of this project is that no study to date has investigated the role, perception and impact of running lower-limb prosthesis used specifically in a mixed amputee classification in disability sport. In addition, having investigated such aspects, this study reveals several issues with respect to their use so provides proposed guidelines for the evaluation and assessment of such technology and a proposed technique for doing so. The project uses a novel mixed methods research approach to provide a pragmatic insight into the research objectives and provides direction for future research to build on this study’s recommendations. 5 NOMENCLATURE AS – Amputee Sprinting CV – Coefficient of Variation DERTIS – Dynamic Elastic Response to Timed Impulse Synchronisation ESR – Energy Storage & Return Prostheses ESRF – Energy Storage & Return Footwear FDE – Fixed at Distal End IAAF – International Association of Athletics Federations IOC – International Olympic Committee IP – Able-bodied Inception Period IPC – International Paralympic Committee JOST – Jog On the Spot Test LLP – Lower-limb Prostheses LLRP – Lower-limb Running Prostheses LA – Lower-limb to Limb Asymmetry LS – Lower-limb to Limb Symmetry MMR – Mixed Method Research MP – Able-bodied Modern Period PII – Performance Improvement Index RA – Random Asymmetry SDE – Slide of Distal End SI – Symmetry Index T43 – Double Below-knee Amputee T44 – Single Below-knee Amputee WADA – World Anti-doping Agency 6 LIST OF CONTENTS COPYRIGHT STATEMENT 1 DEDICATION 2 ACKNOWLEDGEMENTS 3 ABSTRACT 4 CONTRIBUTION TO KNOWLEDGE 5 NOMENCLATURE 6 LIST OF CONTENTS 7 CHAPTER 1 – INTRODUCTION 15 1.1 Introduction 16 1.2 Objectives 18 1.3 Scope of Research 19 1.4 Beneficiaries 20 1.5 Structure of Thesis 20 1.6 Ethical Approval 22 1.7 Research Publications 23 1.7.1. Journal Papers 23 1.7.2 Conference Publications 24 1.7.3 Selected Public Engagement 25 1.7.4 Prizes 26 1.8 Background 27 7 1.8.1 Amputation & Amputees 27 1.8.2 History of Disability Sport 28 1.8.3 Classification of Lower-limb Amputee Runners 30 1.8.4 Race Distances 32 1.8.5 Disability Sport Governance 32 1.9 Conclusion 33 CHAPTER 2 – TRANSTIBIAL AMPUTEE MOTION & PROSTHETICS TECHNOLOGY: A REVIEW 34 2.1 Introduction 35 2.2 A Brief History of Prostheses 35 2.3 The Function of Running Prostheses 39 2.4 Trans-tibial Amputee Running 42 2.4.1 Lower-limb Amputee Running: A Background 42 2.4.2 The Biomechanics & Kinematics of Amputee Running 43 2.4.3 Amputee Running & Lower-limb Symmetry 44 2.5 Conclusion 46 CHAPTER 3 – TECHNOLOGY’S INCLUSION IN SPORT: A REVIEW 47 3.1 Introduction 48 3.2 Sport Technology Inclusion 48 3.3 Sport Technology Controversy 50 3.4 Disability Sport’s Technology Controversy 53 8 3.4.1 Casey Martin 53 3.4.2 Oscar Pistorius 54 3.5 Sport Technology Revenge Effects 57 3.6 Sport Technology Acceptability Frameworks 58 3.7 Legislation of Lower-limb Prostheses in Disability Sport 61 3.8 Conclusion 67 CHAPTER 4 – RESEARCH METHODS 69 4.1 Introduction 70 4.2 Mixed Method Research 71 4.2.1 Background 71 4.2.2 The Nature of Mixed Method Research 72 4.2.3 Criticism of Mixed Method Research 77 4.2.4 The Application of Mixed Method Research in This Project 79 CHAPTER 5 – THE IMPACT OF LOWER-LIMB PROSTHESES TECHNOLOGY ON RUNNING PERFORMANCE & PARTICIPATION (1976- 2012) 81 5.1 Introduction 82 5.2 Objectives 83 5.3 Methods 82 5.3.1 Performance Improvement 84 5.3.2 Participation Data 87 9 5.3.3 Medal Allocations 87 5.4 Results 87 5.4.1 Performance Improvement of Amputee Sprinting 87 5.4.2 Performance Improvement of Able-bodied 100m: IP 88 5.4.3 Performance Improvement of Able-bodied 100m: MP 89 5.4.4 Participation Data 92 5.4.5 Medal Allocations 93 5.5 Discussion 94 5.6 Conclusions 98 CHAPTER 6 – DEVELOPMENT OF A FRAMEWORK FOR THE ACCEPTABILITY OF LOWER-LIMB PROSTHETICS TECHNOLOGY IN DISABILITY SPORT 100 6.1 Introduction 101 6.2 Objectives 102 6.3 Methods 102 6.3.1 Expert Panel Selection 105 6.3.2 Definition of Consensus 106 6.3.3 Round 1 107 6.3.4 Rounds 2-3 109 6.4 Results 111 6.5 Discussion 115 6.5.1 Proposal of LLP Acceptability Guidelines 117 6.6 Limitations 120 10 6.7 Recommendations 121 6.8 Conclusion 123 CHAPTER 7 – STRIDE CHARACTERISTICS OF SHORT DISTANCE LOWER-LIMB AMPUTEE ELITE RUNNING: A CASE STUDY 125 7.1 Introduction 126 7.2 Objectives 127 7.3 Methods 127 7.3.1 Step Count 128 7.3.2 Step Timing Symmetry 129 7.4 Results 131 7.4.1 Step Count 131 7.4.2 Step Timing Symmetry 132 7.5 Discussion 136 7.5.1 Step Count 136 7.5.2 Step Timing Symmetry 136 7.6 Recommendations 144 7.7 Conclusion 144 CHAPTER 8 – THE FUNCTIONAL DIFFERENCES BETWEEN SYMMETRICAL AND ASSYMETRICAL LOWER-LIMBS: A CASE STUDY 146 8.1 Introduction 147 11 8.1.1 Differences Between Uni-lateral & Bi-lateral Lower-limb Amputee Runners 147 8.2 Objectives 151 8.3 Methods 152 8.3.1 The JOST Protocol 153 8.4 Results 158 8.5 Discussion 162 8.6 Conclusions 163 8.7 Limitations 164 8.8 Acknowledgements 164 CHAPTER 9 – THE NATURE OF ENERGY STORAGE & RETURN PROSTHESES 165 9.1 Introduction 166 9.2 Objectives 167 9.3 Methods 167 9.3.1 Energy Return Technology Run Tests 168 9.3.2 Prostheses Linearity Assessment 170 9.4 Results 172 9.4.1 Run Tests 172 9.4.2 Prostheses Linearity Assessment 174 9.5 Discussion 177 9.6 Conclusion 179 12 9.7 Acknowledgements 180 CHAPTER 10 – AN ASSESSMENT OF LOWER-LIMB PROSTHESIS USING HUMAN PARTICIPATION: A CASE STUDY 181 10.1 Introduction 182 10.2 Objectives 182 10.3 Methods 182 10.3.1 Drop Jumping 183 10.4 Test Protocol 188 10.5 Results 190 10.6 Discussion 192 10.7 Conclusion 195 10.8 Recommendations 195 CHAPTER 11 – EVALUATION, RECOMMENDATIONS FOR ACTION, SUMMARY & FINAL CONCLUSIONS 197 11.1 Summary 198 11.2 Contribution to Knowledge 201 11.3 Evaluation of Overall Research Method 202 11.4 Limitations of Overall Study 203 11.5 Overall Recommendations 204 11.6 Final Statement 205 13 REFERENCES 206 APPENDICES 229 Appendices A 230 A.1 Delphi Round 1 Questionnaire 231 A.2 Delphi Round 1 Themes 233 A.3 Delphi Round 2 Questionnaire 234 A.4 Delphi Round 2 Results 240 A.5 Delphi Round 3 Questionnaire 244 Appendices B 248 B.1 JOST Test Knee Marker Data 249 Appendices C 251 C.1 Prostheses Stiffness Comparison Data 252 Appendices D 253 D.1 Run Test Data 254 Appendices E 256 E.1 Drop Jump Test Data 257 Appendices F 258 F.1 Journal Publications 259 14 CHAPTER 1: INTRODUCTION 15 1.1 INTRODUCTION Lower-limb prostheses (LLP’s) have provided the means for an amputee with a lower-limb amputation to participate in competitive sport (Lewis et al.