Pedobarographic statistical parametric mapping (pSPM): a pixel-level approach to foot pressure image analysis

Traditional pedobarographic analyses conduct statistical tests on single pressure values extracted from discrete anatomical regions, a process which yields a low-resolution view of the continuous foot-ground interaction and which can involve substantial user interaction for region definition. Using image processing techniques derived from a cerebral imaging methodology called 'statistical parametric mapping' (SPM), we describe a fully automatic method that requires no anatomical assumptions or region definitions and that generates high-resolution continuous statistical maps across the entire plantar foot surface. Here, we demonstrate both pedobarographic SPM (pSPM) and its robustness to arbitrary foot postures by producing statistical maps for a sample of nine healthy young adults walking: normally, with everted feet, and with inverted feet. After spatially smoothing pedobarographic images, within-subjects (WS) and between-subjects (BS) registration were performed using an optimal rigid body transformation and an optimum affine transformation, respectively. Statistical tests were performed over all 742 foot pixels of the 270 registered images using a linear mass-univariate model and the resulting SPMs were compared qualitatively with results obtained using a traditional ten-region technique. SPMs were found to provide a qualitatively improved view of pedobarographic changes, but the more important finding was that regional pedobarographic statistics can misrepresent the trends of their constituent pixels and thus potentially lead to misinterpretations of foot function. Since pSPM is fully non-interactive, is robust to arbitrary foot posture, and provides rapid and easily interpretable results, it appears to be a suitable alternative to regionalization for routine pedobarographic analyses in both laboratory and clinic.     

The relationship between speed, contact time and peak plantar pressure in terrestrial walking of bonobos

The aim of this paper is twofold. Firstly, we investigate whether contact times, as recorded by pedobarographic systems during quadrupedal and bipedal walking of bonobos, can be used to reliably calculate actual velocities, by applying formulae based on lateral-view video recordings. Secondly, we investigate the effect of speed on peak plantar pressures during bipedal and quadrupedal walking of the bonobo. Data were obtained from 4 individuals from a group of bonobos at the Animal Park Planckendael. From our study, we can conclude that both walking speeds calculated from contact times and lower leg length or simply from recorded contact times are good estimators for walking speed, when direct observation of the latter is impossible. Further, it was found that effects of speed on peak plantar pressures and vertical forces are absent or at least subtle in comparison to a large variation in pressure patterns. In bonobos, the same pressure patterns are used at all walking speeds, and, in consequence, we do not expect major changes in foot function.     

Structural and functional predictors of regional peak pressures under the foot during walking

The objective of this study was to identify structural and functional factors which are predictors of peak pressure underneath the human foot during walking. Peak plantar pressure during walking and eight data sets of structural and functional measures were collected on 55 asymptomatic subjects between 20 and 70 yr. A best subset regression approach was used to establish models which predicted peak regional pressure under the foot. Potential predictor variables were chosen from physical characteristics, anthropometric data, passive range of motion (PROM), measurements from standardized weight bearing foot radiographs, mechanical properties of the plantar soft tissue, stride parameters, foot motion in 3D, and EMG during walking. Peak pressure values under the rearfoot, midfoot, MTH1, and hallux were measured. Heel pressure was a function of linear kinematics, longitudinal arch structure, thickness of plantar soft tissue, and age. Midfoot pressure prediction was dominated by arch structure, while MTH1 pressure was a function of radiographic measurements, talo-crural joint motion, and gastrocnemius activity. Hallux pressure was a function of structural measures and MTP1 joint motion. Foot structure and function predicted only approximately 50% of the variance in peak pressure, although the relative contributions in different anatomical regions varied dramatically. Structure was dominant in predicting peak pressure under the midfoot and MTH1, while both structure and function were important at the heel and hallux. The predictive models developed in this study give insight into potential etiological factors associated with elevated plantar pressure. They also provide direction for future studies designed to reduce elevated pressure in "at-risk" patients.     

Predictors of Barefoot Plantar Pressure during Walking in Patients with Diabetes,Peripheral Neuropathy and a History of Ulceration

ObjectiveElevated dynamic plantar foot pressures significantly increase the risk of foot ulceration in diabetes mellitus. The aim was to determine which factors predict plantar pressures in a population of diabetic patients who are at high-risk of foot ulceration.MethodsPatients with diabetes, peripheral neuropathy and a history of ulceration were eligible for inclusion in this cross sectional study. Demographic data, foot structure and function, and disease-related factors were recorded and used as potential predictor variables in the analyses. Barefoot peak pressures during walking were calculated for the heel, midfoot, forefoot, lesser toes, and hallux regions. Potential predictors were investigated using multivariate linear regression analyses. 167 participants with mean age of 63 years contributed 329 feet to the analyses.ResultsThe regression models were able to predict between 6% (heel) and 41% (midfoot) of the variation in peak plantar pressures. The largest contributing factor in the heel model was glycosylated haemoglobin concentration, in the midfoot Charcot deformity, in the forefoot prominent metatarsal heads, in the lesser toes hammer toe deformity and in the hallux previous ulceration. Variables with local effects (e.g. foot deformity) were stronger predictors of plantar pressure than global features (e.g. body mass, age, gender, or diabetes duration).ConclusionThe presence of local deformity was the largest contributing factor to barefoot dynamic plantar pressure in high-risk diabetic patients and should therefore be adequately managed to reduce plantar pressure and ulcer risk. However, a significant amount of variance is unexplained by the models, which advocates the quantitative measurement of plantar pressures in the clinical risk assessment of the patient.     

The Relationships between Foot Arch Volumes and Dynamic Plantar Pressure during Midstance of Walking in Preschool Children

Objectives

The purpose of this study was to examine the correlation between the foot arch volume measured from static positions and the plantar pressure distribution during walking.

Methods

A total of 27 children, two to six years of age, were included in this study. Measurements of static foot posture were obtained, including navicular height and foot arch volume in sitting and standing positions. Plantar pressure, force and contact areas under ten different regions of the foot were obtained during walking.

Results

The foot arch index was correlated (r = 0.32) with the pressure difference under the midfoot during the foot flat phase. The navicular heights and foot arch volumes in sitting and standing positions were correlated with the mean forces and pressures under the first (r = −0.296∼−0.355) and second metatarsals (r = −0.335∼−0.504) and midfoot (r = −0.331∼−0.496) during the stance phase of walking. The contact areas under the foot were correlated with the foot arch parameters, except for the area under the midfoot.

Conclusions

The foot arch index measured in a static position could be a functional index to predict the dynamic foot functions when walking. The foot arch is a factor which will influence the pressure distribution under the foot. Children with a lower foot arch demonstrated higher mean pressure and force under the medial forefoot and midfoot, and lower contact areas under the foot, except for the midfoot region. Therefore, children with flatfoot may shift their body weight to a more medial foot position when walking, and could be at a higher risk of soft tissue injury in this area.     

Regional peak plantar pressures are highly sensitive to region boundary definitions

Traditional pedobarographic analyses subsample pressure data over a number of discrete anatomical regions of interest (ROIs). To our knowledge, the sensitivity of these data to ROI boundary definitions has not been previously addressed. Eight subjects each performed 20 trials of self-paced walking; commercial software was used to define 10 ROIs for each of the 160 total peak pressure images, and regional peak pressures (RPPs) were extracted for each image (total: 1600 values). We then asked three specific questions regarding RPP sensitivity to ROI boundary definition: (1) Is the ROI centroid representative of the RPP location? (2) How frequently do RPPs lie on the ROI boundary? and (3) By how much do RPP values change if the ROI boundary is changed by one pixel (resolution: 5.08×7.62 mm)? We found that the RPP locations differed from the ROI centroid in 80% of the cases and that the RPPs lay on the ROI boundary with a probability of 65%. We also found that a single-pixel change in the ROI boundary caused a mean RPP change of 10.8%. The most sensitive region was the midfoot for which a single-pixel ROI change yielded a median 29.4% change in RPP. These results indicate that RPP data are biased by regionalization schemes, which delineate pressure fields based on anatomy rather than on the field's geometric properties, and ultimately that regionalization may constitute a poor method of quantifying complex pressure fields. RPP sensitivity should be considered when making statistical inferences regarding foot function.     

A multi-segment kinematic model of the foot with a novel definition of forefoot motion for use in clinical gait analysis during walking

A multi-segment kinematic model of the foot was developed for use in a gait analysis laboratory. The foot was divided into hindfoot, talus, midfoot and medial and lateral forefoot segments. Six functional joints were defined: ankle and subtalar joints, frontal and transverse plane motions of the hindfoot relative to midfoot, supination/pronation twist of the forefoot relative to midfoot and medial longitudinal arch height-to-length ratio. Twelve asymptomatic subjects were tested during barefoot walking with a six-camera optical stereometric system and auto-reflective markers organized in triads. Repeatability of the joint motions was tested using coefficients of multiple correlation. Ankle and subtalar joint motions and twisting of the forefoot were most repeatable. Hindfoot motions were least repeatable both within-subjects and between-subjects. Hindfoot and forefoot pronation in the frontal plane was found to coincide with dropping of the medial longitudinal arch between early to mid-stance, followed by supination and rising of the arch in late stance and swing phase. This multi-segment foot model addresses an unfortunate shortcoming in current gait analysis practice-the inability to measure motion within the foot. Such measurements are crucial if gait analysis is to remain relevant in the orthopaedic and rehabilitative treatment of the foot and ankle.     

Quantifying rearfoot-forefoot coordination in human walking

A method is proposed to facilitate the quantification and interpretation of inter-joint/-segment coordination. This technique is illustrated using rearfoot-forefoot kinematic data. We expand existing vector coding techniques and introduce a set of operational terms through which the coordinative patterns between the rearfoot segment and the forefoot segment are summarized: in-phase, anti-phase, rearfoot phase and forefoot phase. The literature on foot mechanics has characterized the stable foot at pushoff by a decreasing medial longitudinal arch angle in the sagittal plane, which is accompanied by forefoot pronation and concurrent rearfoot supination-in other words, anti-phase motion. Nine skin markers were placed on the rearfoot and forefoot segments according to a multi-segment foot model. Three healthy subjects performed standing calibration and walking trials (1.35ms(-1)), while a three-dimensional motion capture system acquired their kinematics. Rearfoot-forefoot joint angles were derived and the arch angle was inferred from the sagittal plane. Coupling angles of rearfoot and forefoot segments were derived and categorized into one of the four coordination patterns. Arch kinematics were consistent with the literature; in stance, the arch angle reached peak dorsiflexion, and then decreased rapidly. However, anti-phase coordination was not the predominant pattern during mid- or late stance. These preliminary data suggest that the coordinative interactions between the rearfoot and the forefoot are more complicated than previously described. The technique offers a new perspective on coordination and may provide insight into deformations of underlying tissues, such as the plantar fascia.     

Footprint analysis of gait using a pressure sensor system.

The purpose of this study was to investigate if the detailed pressure data of the footprints of normal gait add essential information to the spatio-temporal variables of gait. The gait of 62 healthy adult subjects was investigated using GAITRite pressure sensor system. Each footprint was divided into 12 equal trapezoids and after that the hindfoot, midfoot and forefoot analysis was developed. A typical activation pattern of the sensors with two peaks of active area and peak pressure distribution during normal walking was obtained. The first peak reflected the heel strike, and the second peak reflected push-off at the end of the stance phase. The lowest pressure values were in the midfoot, where the lateral part of the foot activated sensors more than the medial part. The footprint patterns of right and left legs were symmetrical and corresponded with the symmetry found in the spatio-temporal variables of gait. The variability for the active area and the peak pressure were more pronounced for the lateral part of the midfoot and a smaller variation was seen in areas with concentrated observations (e.g. 1st, 2nd and 5th lateral trapezoids). Increasing active area in the forefoot was associated with decreasing pressure sensor activity in the midfoot. The footprint patterns identified the symmetry between the legs and at the same time revealed the velocity performance.     

Midtarsal break variation in modern humans: Functional causes,skeletal correlates,and paleontological implications

The midtarsal break was once treated as a dichotomous, non-overlapping trait present in the foot of non-human primates and absent in humans. Recent work indicates that there is considerable variation in human midfoot dorsiflexion, with some overlap with the ape foot. These findings have called into question the uniqueness of the human lateral midfoot, and the use of osteological features in fossil hominins to characterize the midfoot of our extinct ancestors. Here, we present data on plantar pressure and pedal mechanics in a large sample of adults and children (n = 671) to test functional hypotheses concerning variation in midfoot flexibility. Lateral midfoot peak plantar pressure correlates with both sagittal plane flexion at the lateral tarsometatarsal joint, and dorsiflexion at the hallucal metatarsophalangeal joint. The latter finding suggests that midfoot laxity may compromise hallucal propulsion. Multiple regression statistics indicate that a low arch and pronation of the foot explain 40% of variation in midfoot peak plantar pressure, independent of age and BMI. MRI scans on a small subset of study participants (n = 19) reveals that curvature of the base of the 4th metatarsal correlates with lateral midfoot plantar pressure and that specific anatomies of foot bones do indeed reflect relative midfoot flexibility. However, while the shape of the base of the 4th metatarsal may reliably reflect midfoot mobility in individual hominins, given the wide range of overlapping variation in midfoot flexibility in both apes and humans, we caution against generalizing foot function in extinct hominin species until larger fossils samples are available. Am J Phys Anthropol 156:543–552, 2015. © 2015 Wiley Periodicals, Inc.     

Forefoot structural predictors of plantar pressures during walking in people with diabetes and peripheral neuropathy

Various foot structures are thought to influence forefoot plantar pressures during walking. High peak plantar pressures (PPP) during walking in people with diabetes mellitus (DM) and peripheral neuropathy (PN) can cause skin breakdown. The question addressed by this study is "What are the primary forefoot structural factors that predict regional PPP during walking in groups of people with and without DM and PN?" Twenty people with DM and PN (mean age 55+/-9 years, 6 female, 14 male, BMI=33+/-8) and 20 people without DM, matched for gender, age, and BMI were tested. Measures of foot structure were taken from three-dimensional images constructed from spiral X-ray computed tomography. Peak plantar pressure data were recorded during walking. Hierarchical multiple regression analysis was used to predict regional PPP at the great toe and five metatarsal heads from selected structural and walking variables. Metatarsal phalangeal joint angle (hammer toe deformity) was the most important variable predicting pressure, accounting for 19-45% of the PPP variance at five of the six locations in the DM group. Soft tissue thickness, hallux valgus, and forefoot arthropathy were the most important predictors of PPP in the control group. Combinations of structural and walking variables accounted for 47-71% of the variance in the DM group and 52-83% of the variance of PPP during walking in the control group. These structural variables, especially hammer toe deformity, should be considered in attempts to develop strategies to reduce excessive forefoot PPP that may contribute to skin breakdown or other injury.     

Modified pressure distribution patterns in walking following reduction of plantar sensation

The aim of the present study was to investigate the influence of reduced plantar sensation on pressure distribution patterns during gait of 40 healthy subjects (25.3+/-3.3 yr, 70.8+/-10.6 kg and 176.5+/-7.8 cm) with no history of sensory disorders. Plantar sensation in the subjects was reduced by using an ice immersion approach, and reduced sensitivity was tested with Semmes-Weinstein monofilaments. All subjects performed six trials of barefoot walking over a pressure distribution platform under normal as well as iced conditions. Plantar cutaneous sensation was significantly reduced after the cooling procedure (p<0.0001). Pressure distribution analysis showed substantially modified plantar pressure distribution patterns during the roll-over process (ROP) under iced conditions. Analysis of peak pressures revealed significant reductions under the toes and under the heel (p<0.001). The contact time and the relative impulse for the whole foot did not change significantly between the two conditions. For the different areas, a significant load shift from the heel and toes towards the central and lateral forefoot and the lateral midfoot was observed. The results indicate the strong influence of reduced afferent information of the sole of the foot on the ROP in walking.     

Effect of peak pressure and pressure gradient on subsurface shear stresses in the neuropathic foot

The pressure distribution on the plantar surface of the foot may provide insights into the stresses within the subsurface tissues of patients with diabetes mellitus and peripheral neuropathy (PN) who are at risk for skin breakdown. The purposes of this study were to (1) estimate the stress distribution in the subsurface soft tissue from a measured surface pressure distribution and determine any differences between values in the forefoot and rearfoot, and (2) determine the relationship between maximum shear stress (MSS) (magnitude and depth) and characteristics of the pressure distribution. The measured in-shoe pressure distributions during walking characterized by the peak plantar pressure and maximum pressure gradient on the plantar surface of the feet for 20 subjects with diabetes, PN and history of a mid foot or forefoot plantar ulcer were analyzed. The effects of peak pressure and maximum pressure gradient at the peak pressure location on the stress components in the subsurface soft tissue were studied using a potential function method to estimate the subsurface tissue stress. The calculated MSSs are larger in magnitude and located closer to the surface in the forefoot, where most skin breakdown occurs, compared to the rearfoot. In addition, the MSS (magnitude and depth) is highly correlated with the pressure gradient (r=-0.77 & 0.61) and the peak pressure (r=-0.61 & 0.91). The peak pressure and the maximum pressure gradient obtained from the surface pressure distribution appear to be important variables to identify where MSSs are located in the subsurface tissues on the plantar foot that may lead to skin break down.     

Effect of heel height on in-shoe localized triaxial stresses

Abnormal and excessive plantar pressure and shear are potential risk factors for high-heeled related foot problems, such as forefoot pain, hallux valgus deformity and calluses. Plantar shear stresses could be of particular importance with an inclined supporting surface of high-heeled shoe. This study aimed to investigate the contact pressures and shear stresses simultaneously between plantar foot and high-heeled shoe over five major weightbearing regions: hallux, heel, first, second and fourth metatarsal heads, using in-shoe triaxial force transducers. During both standing and walking, peak pressure and shear stress shifted from the lateral to the medial forefoot as the heel height increased from 30 to 70mm. Heel height elevation had a greater influence on peak shear than peak pressure. The increase in peak shear was up to 119% during walking, which was about five times that of peak pressure. With increasing heel height, peak posterolateral shear over the hallux at midstance increased, whereas peak pressure at push-off decreased. The increased posterolateral shear could be a contributing factor to hallux deformity. It was found that there were differences in the location and time of occurrence between in-shoe peak pressure and peak shear. In addition, there were significant differences in time of occurrence for the double-peak loading pattern between the resultant horizontal ground reaction force peaks and in-shoe localized peak shears. The abnormal and drastic increase of in-shoe shear stresses might be a critical risk factor for shoe-related foot disorders. In-shoe triaxial stresses should therefore be considered to help in designing proper footwear.     

Flat Feet,Happy Feet? Comparison of the Dynamic Plantar Pressure Distribution and Static Medial Foot Geometry between Malawian and Dutch Adults

In contrast to western countries, foot complaints are rare in Africa. This is remarkable, as many African adults walk many hours each day, often barefoot or with worn-out shoes. The reason why Africans can withstand such loading without developing foot complaints might be related to the way the foot is loaded. Therefore, static foot geometry and dynamic plantar pressure distribution of 77 adults from Malawi were compared to 77 adults from the Netherlands. None of the subjects had a history of foot complaints. The plantar pressure pattern as well as the Arch Index (AI) and the trajectory of the center of pressure during the stance phase were calculated and compared between both groups. Standardized pictures were taken from the feet to assess the height of the Medial Longitudinal Arch (MLA). We found that Malawian adults: (1) loaded the midfoot for a longer and the forefoot for a shorter period during roll off, (2) had significantly lower plantar pressures under the heel and a part of the forefoot, and (3) had a larger AI and a lower MLA compared to the Dutch. These findings demonstrate that differences in static foot geometry, foot loading, and roll off technique exist between the two groups. The advantage of the foot loading pattern as shown by the Malawian group is that the plantar pressure is distributed more equally over the foot. This might prevent foot complaints.     

Influence of the posterior tibial tendon on the medial arch of the foot: an in vitro kinetic and kinematic study]

INTRODUCTION: The respective contributions of the active and passive structures of the foot to the stability of the medical arch were investigated using an in vitro kinetic and kinematic model. The effect of the tibialis posterior tendon on foot and ankle movements, and plantar pressure distribution of the foot were tested in a cadaveric human foot. METHOD: The stance phase from heel-contact to toe-off of normal walking gait and after tibialis posterior tendon rupture was simulated in eight roentenographically normal human feet (age 66 +/- 19 years, males). Ground reaction force and tibial inclination was simulated by means of a tilting angle and force-controlled translation stage. Plantar pressure was measured using a pressure-measuring platform. The force developed by the flexors and extensor muscles of the foot were simulated via cables attached to 7 force-controlled hydraulic cylinders. Tibial rotation was produced by an electric servo-motor, and foot movements measured with an ultrasonic analysis system. RESULTS: The model was verified against the plantar distribution and kinematics of healthy subjects measured during normal gait. Tibialis posterior deficit did not result in any detectable changes in pressure or force-time integral in the medial regions of the foot--a common sign of flat foot (pressure: midfoot 0.2 < or = 0.9; medial forefoot 0.5 < or = p < or = 0.9; hallux 0.5 < or = p < or = 0.9; force-time integral: midfoot p = 0-871; medial forefoot p = 0.632; hallux p = 0.068). Only small tendential changes in the kinematics of the talus and calcaneus were observed in dorsiflexion (0-58 sec; talus 0.1 < or = p < or = 0.6; calcaneus 0.4 < or = p < or = 0.06) and eversion (talus: 0-60 sec. 0.1 < or = p < or = 0.6; calcaneus: 37-60 sec. 0.2 < or = p < or = 0.7). CONCLUSION: The results of this in vitro study show that defective tibialis posterior alone does not produce significant changes in the kinetics or kinematics of the stance phase of normal gait. This suggests that the development of flat foot observed in degeneration of the tibialis posterior tendon occurs only after fatigue of the passive structures of the foot.     

Assessing the significance of pedobarographic signals using random field theory

Traditional pedobarographic statistical analyses are conducted over discrete regions. Recent studies have demonstrated that regionalization can corrupt pedobarographic field data through conflation when arbitrary dividing lines inappropriately delineate smooth field processes. An alternative is to register images such that homologous structures optimally overlap and then conduct statistical tests at each pixel to generate statistical parametric maps (SPMs). The significance of SPM processes may be assessed within the framework of random field theory (RFT). RFT is ideally suited to pedobarographic image analysis because its fundamental data unit is a lattice sampling of a smooth and continuous spatial field. To correct for the vast number of multiple comparisons inherent in such data, recent pedobarographic studies have employed a Bonferroni correction to retain a constant family-wise error rate. This approach unfortunately neglects the spatial correlation of neighbouring pixels, so provides an overly conservative (albeit valid) statistical threshold. RFT generally relaxes the threshold depending on field smoothness and on the geometry of the search area, but it also provides a framework for assigning p values to suprathreshold clusters based on their spatial extent. The current paper provides an overview of basic RFT concepts and uses simulated and experimental data to validate both RFT-relevant field smoothness estimations and RFT predictions regarding the topological characteristics of random pedobarographic fields. Finally, previously published experimental data are re-analysed using RFT inference procedures to demonstrate how RFT yields easily understandable statistical results that may be incorporated into routine clinical and laboratory analyses.     

Towards an efficient and robust foot classification from pedobarographic images

This paper presents a new computational framework for automatic foot classification from digital plantar pressure images. It classifies the foot as left or right and simultaneously calculates two well-known footprint indices: the Cavanagh's arch index (AI) and the modified AI. The accuracy of the framework was evaluated using a set of plantar pressure images from two common pedobarographic devices. The results were outstanding, as all feet under analysis were correctly classified as left or right and no significant differences were observed between the footprint indices calculated using the computational solution and the traditional manual method. The robustness of the proposed framework to arbitrary foot orientations and to the acquisition device was also tested and confirmed.     

Towards an efficient and robust foot classification from pedobarographic images

This paper presents a new computational framework for automatic foot classification from digital plantar pressure images. It classifies the foot as left or right and simultaneously calculates two well-known footprint indices: the Cavanagh's arch index (AI) and the modified AI. The accuracy of the framework was evaluated using a set of plantar pressure images from two common pedobarographic devices. The results were outstanding, as all feet under analysis were correctly classified as left or right and no significant differences were observed between the footprint indices calculated using the computational solution and the traditional manual method. The robustness of the proposed framework to arbitrary foot orientations and to the acquisition device was also tested and confirmed.