Constituent Lower Extremity Work (CLEW) approach: A novel tool to visualize joint and segment work

Work can reveal the mechanism by which movements occur. However, work is less physically intuitive than more common clinical variables such as joint angles, and are scalar quantities which do not have a direction. Therefore, there is a need for a clearly reported and comprehensively calculated approach to easily visualize and facilitate the interpretation of work variables in a clinical setting. We propose the Constituent Lower Extremity Work (CLEW) approach, a general methodology to visualize and interpret cyclic tasks performed by the lower limbs. Using six degree-of-freedom power calculations, we calculated the relative work of the four lower limb constituents (hip, knee, ankle, and distal foot). In a single pie chart, the CLEW approach details the mechanical cost-of-transport, the percentage of positive and negative work performed in stance phase and swing phase, and the individual contributions of positive and negative work from each constituent. This approach can be used to compare the constituent-level adaptations occurring between limbs of individuals with impairments, or within a limb at different gait intensities. In this article, we outline how to generate and interpret the CLEW pie charts in a clinical report. As an example of the utility of the approach, we created a CLEW report using average reference data from eight unimpaired adult subjects walking on a treadmill at 0.8 statures/s (1.4 m/s) compared with data from the intact and prosthetic limbs of an individual with a unilateral amputation walking with an above-knee passive prosthesis.