Reduction of knee range of motion during continuous passive motion due to misaligned hip joint centre

When using continuous passive motion (CPM) devices, appropriate setting of the device and positioning of the patient are necessary to obtain maximum range of motion (ROM). In this study, the ROMs in both the knee joint and CPM device during CPM treatment were measured using a motion analysis system for three different CPM devices. Additionally, the trajectories of the angles at the knee for hip joint misalignments were evaluated using kinematic models of the three CPM devices. The results showed that discrepancies in ROM between the knee joints and the CPM device settings during CPM treatment were revealed regardless of the CPM device and that the effect of misalignment is dependent on the design of the CPM device. The present technology could be applied for the development of a better design configuration for the CPM device to reduce the discrepancy in ROM at the knee joint.     

Biomechanical model and evaluation of a linear motion squat type exercise

A biomechanical model of a squat exercise performed on a device using a bar that is restricted to a linear motion was developed. Hip and knee moments were evaluated at varying foot positions. The range of motion of the exercise was limited by the knee joint angle beginning at an 80 degrees angle (flexed) to a 179 degrees joint angle (extended). Variations in foot placement were evaluated for differences in torque applied about the transverse axes of the user's knee and hip joints. Because the user's feet were positioned farther forward (anterior), the moment about the knee decreased whereas the moment about the hip increased. Positive moments were those that resulted in forces to flex the knee and hip joints. Positive knee moments were determined in all conditions when the knee was flexed and became negative when the knee was at or near full extension. The model always produced positive moments about the hip. Thus, foot position is a critical factor in hip and knee moments, and therefore in the muscle groups stressed, in a linear motion squat type exercise.     

Three-dimensional motion of the upper extremity joints during various activities of daily living

Highly reliable information on the range of motion (ROM) required to perform activities of daily living (ADL) is important to allow rehabilitation professionals to make appropriate clinical judgments of patients with limited ROM of the upper extremity joints. There are, however, no data available that take full account of corrections for gimbal-lock and soft tissue artifacts, which affect estimation errors for joint angles. We used an electromagnetic three-dimensional tracking system (FASTRAK) to measure the three-dimensional ROM of the upper extremity joints of healthy adults (N=20, age range 18–34) during 16 ADL movement tasks. The ROM required for the performance of each movement was shown in terms of the joint angle at the completion of the task, using a new definition of joint angle and regression analysis to compensate for estimation errors. The results of this study may be useful in setting goals for the treatment of upper extremity joint function.     

Age and gender differences in peak lower extremity joint torques and ranges of motion used during single-step balance recovery from a forward fall.

Previous studies have found substantial age and gender group differences in the ability of healthy adults to regain balance with a single step after a forward fall. It was hypothesized that differences in lower extremity joint strengths and ranges of motion (ROM) may have contributed to these observed differences. Kinematic and forceplate data were therefore used with a rigid-link biomechanical model simulating stepped leg dynamics to examine the joint torques and ROM used by subjects during successful single-step balance recoveries after release from a forward lean. The peak ROM and torques used by subjects in the study were compared to published estimates or measured values of the available maxima. No significant age or gender group differences were found in the mean ROM used by the subjects for any given initial lean angle. As initial lean angle increased, larger knee ROM and significantly larger hip ROM were used in the successful recoveries. There were substantial gender differences and some age group differences in peak lower extremity joint torques used in successful recoveries. Both young and older females often used nearly maximal joint torques to recover balance. Subjects' maximum joint strengths in plantarflexion and hip flexion were not good predictors of single-step balance recovery ability, particularly among the female subjects.     

Design and validation of an unconstrained loading system to measure the envelope of motion in the rabbit knee joint

An unconstrained loading system was developed to measure the passive envelope of joint motion in an animal model commonly used to study ligament healing and joint arthritis. The design of the five-degree-of-freedom system allowed for unconstrained knee joint loading throughout flexion with repeated removal and reapplication of the device to a specimen. Seven New Zealand White rabbit knees were subjected to varus, valgus, internal and external loads, and the resulting envelopes of motion were recorded using an electromagnetic tracking device. Intra-specimen reproducibility was excellent when measured in one specimen, with maximal rotational differences of 0.6 and 0.3 deg between the fourth and fifth testing cycles for the varus (VR) and valgus (VL) envelopes, respectively. Similarly, the maximal internal (INT) and external (EXT) envelope differences were 0.5 and 0.4 deg, respectively, between the fourth and fifth cycles. Good inter-animal envelope reproducibility was also observed with consistent motion pathways for each loading condition. A maximal VR-VL laxity of 17.9 +/- 2.3 deg was recorded at 95 deg flexion for the seven knees tested. The maximal INT-EXT laxity of 75.2 +/- 4.8 deg occurred at 50 deg flexion. Studies on measurement reproducibility of re-applying individual testing components demonstrated a maximal error of 1.2 +/- 0.7 deg. Serial removal and re-application (test-retest) of the complete measuring system to one cadaveric knee demonstrated maximal envelope differences of less than 0.7 deg for VR-VL rotation and 2.1 deg for INT-EXT rotation. Our results demonstrate that the measuring system is reproducible and capable of accurate evaluation of knee joint motion. Baseline in vitro data were generated on normal joint kinematics for future in-vivo studies with this system, evaluating ligament healing and disease progression in arthritis models.     

Range of motion specificity resulting from closed and open kinetic chain resistance training after anterior cruciate ligament reconstruction

The purpose of this study was to examine whether joint angle specificity occurs in open and closed kinetic chain resistance training of the knee extensors after anterior cruciate ligament reconstruction (ACLR). Isokinetic knee extensor strength was measured at 60 and 210 degrees.s(-1) in 32 patients, 2 and 6 weeks after surgery. Between test sessions, patients participated in a 4-week program of injured leg resistance training of the knee extensors in either open kinetic chain (OKC) knee extension or leg press exercises. Isokinetic testing knee range of motion (ROM) was divided into 5 equal portions from flexion to extension, and the mean torque was calculated over those divisions: 0-20%, 20-40%, 40-60%, 60-80%, and 80-100% ROM. Analysis of variance indicated that there were no significant differences between patients in the knee extension or leg press exercise groups.     

Reproduction of in vivo motion using a parallel robot

Although alterations in knee joint loading resulting from injury have been shown to influence the development of osteoarthritis, actual in vivo loading conditions of the joint remain unknown. A method for determining in vivo ligament loads by reproducing joint specific in vivo kinematics using a robotic testing apparatus is described. The in vivo kinematics of the ovine stifle joint during walking were measured with 3D optical motion analysis using markers rigidly affixed to the tibia and femur. An additional independent single degree of freedom measuring device was also used to record a measure of motion. Following sacrifice, the joint was mounted in a robotic/universal force sensor test apparatus and referenced using a coordinate measuring machine. A parallel robot configuration was chosen over the conventional serial manipulator because of its greater accuracy and stiffness. Median normal gait kinematics were applied to the joint and the resulting accuracy compared. The mean error in reproduction as determined by the motion analysis system varied between 0.06 mm and 0.67 mm and 0.07 deg and 0.74 deg for the two individual tests. The mean error measured by the independent device was found to be 0.07 mm and 0.83 mm for the two experiments, respectively. This study demonstrates the ability of this system to reproduce in vivo kinematics of the ovine stifle joint in vitro. The importance of system stiffness is discussed to ensure accurate reproduction of joint motion.     

Adding weights to stretching exercise increases passive range of motion for healthy elderly

Stretching exercise is effective for increasing joint range of motion (ROM). However, the Surgeon General's Report and the American College of Sports Medicine cite a lack of studies identifying strategies capable of increasing the effectiveness of stretching exercise. This investigation evaluated adding modest weight (0.45-1.35 kg) to a stretching exercise routine (Body Recall [BR]) on joint ROM. Forty-three subjects ages 55-83 years participated in 1 of 2 training groups, BR, BR with weights (BR+W), or a control group (C). ROM was evaluated at the neck, shoulder, hip, knee, and ankle before and after 10 weeks of exercise. Using ANCOVA, significant differences (p < 0.01) were observed for right and left cervical rotation, hip extension, ankle dorsiflexion, ankle plantar flexion, and shoulder flexion. Post hoc analysis revealed that cervical rotation (left and right), hip extension, and ankle dorsiflexion for BR+W subjects differed significantly from BR and C (p < 0.01). Significant differences with shoulder flexion and ankle plantar flexion were found for both BR and BR+W in comparison to C (p < 0.01). Results indicate that addition of weights enhanced the effectiveness of stretching exercise for increasing joint ROM with 4 of the 6 selected measurements. Thus, a modest intensity exercise program that is within the reach of most elderly may significantly affect joint ROM and flexibility.     

Modeling and optimal control of an energy-storing prosthetic knee

Advanced prosthetic knees for transfemoral amputees are currently based on controlled damper mechanisms. Such devices require little energy to operate, but can only produce negative or zero joint power, while normal knee joint function requires alternative phases of positive and negative work. The inability to generate positive work may limit the user's functional capabilities, may cause undesirable adaptive behavior, and may contribute to excessive metabolic energy cost for locomotion. In order to overcome these problems, we present a novel concept for an energy-storing prosthetic knee, consisting of a rotary hydraulic actuator, two valves, and a spring-loaded hydraulic accumulator. In this paper, performance of the proposed device will be assessed by computational modeling and by simulation of functional activities. A computational model of the hydraulic system was developed, with methods to obtain optimal valve control patterns for any given activity. The objective function for optimal control was based on tracking of joint angles, tracking of joint moments, and the energy cost of operating the valves. Optimal control solutions were obtained, based on data collected from three subjects during walking, running, and a sit-stand-sit cycle. Optimal control simulations showed that the proposed device allows near-normal knee function during all three activities, provided that the accumulator stiffness was tuned to each activity. When the energy storage mechanism was turned off in the simulations, the system functioned as a controlled damper device and optimal control results were similar to literature data on human performance with such devices. When the accumulator stiffness was tuned to walking, simulated performance for the other activities was sub-optimal but still better than with a controlled damper. We conclude that the energy-storing knee concept is valid for the three activities studied, that modeling and optimal control can assist the design process, and that further studies using human subjects are justified.     

6R instrumented spatial linkages for anatomical joint motion measurement--Part 1: Design.

Six-revolute-joint instrumented spatial linkages (6R ISLs) have become often-used devices to measure the complete six-degree-of-freedom motion of anatomical joints. Accuracy of motion measurement depends on ISL design and calibration technique. In this paper, a design process is outlined that uses computer graphics and numerical methods as aids in developing 6R ISLs that (i) physically assemble within the desired range of motion of the joint; (ii) do not collide with either the experimental apparatus or the subject joint; (iii) avoid singular linkage configurations that can cause forces to be applied to the joint; and (iv) measure selected anatomical motions most accurately. It is found that a certain subgroup of 6R linkages are suitable for accurate measurement of specific motions, and can be the basis for new ISL designs. General guidelines are developed that can assist in the generation of unique linkage designs for different anatomical joints. The design process is demonstrated in the creation of an ISL to measure knee motion.     

The effect of lunate position on range of motion after a four-corner arthrodesis: a biomechanical simulation study

A four-corner arthrodesis of the wrist is a salvage procedure for the treatment of specific wrist disorders, to achieve a movable, stable and pain free joint. However, a partial arthrodesis limits the postoperative range of motion (ROM). The goal of this study is to understand the mechanism of the reduction of the ROM and to evaluate the effect of the orientation of the lunate in the four-corner arthrodesis on the range of motion by using a biomechanical model, containing articular contacts and ligaments. Multi-body models of a normal wrist and a four-corner arthrodesis wrist with different orientation of the lunate were used for simulations of flexion-extension motion (FEM) and radial-ulnar deviation motion (RUD). The ROM of the postoperative wrist was reduced from 145° to 82° of the total arc of FEM and from 73° to 41.5° of the total arc of RUD. The model simulations show that the range of motion reduction is caused by overtension of the extrinsic wrist ligaments. Different positioning of the lunate changes the balance between the contact forces and ligament forces in the wrist. This explains the effect on the postoperative range of motion. The 20° flexed lunate did not give any gain in the extension motion of the wrist, caused joint luxation in flexion and limitation in RUD. The 30° extended lunate caused overtension of the extrinsic ligaments attached to the lunate. The ROM in this case is dramatically reduced. The model simulations suggest that the neutral position of the lunate seems to be most favorable for mobility of the wrist after a four-corner arthrodesis procedure.     

Tibiofemoral kinematics and condylar motion during the stance phase of gait

Accurate knowledge of the dynamic knee motion in-vivo is instrumental for understanding normal and pathological function of the knee joint. However, interpreting motion of the knee joint during gait in other than the sagittal plane remains controversial. In this study, we utilized the dual fluoroscopic imaging technique to investigate the six-degree-of-freedom kinematics and condylar motion of the knee during the stance phase of treadmill gait in eight healthy volunteers at a speed of 0.67 m/s. We hypothesized that the 6DOF knee kinematics measured during gait will be different from those reported for non-weightbearing activities, especially with regards to the phenomenon of femoral rollback. In addition, we hypothesized that motion of the medial femoral condyle in the transverse plane is greater than that of the lateral femoral condyle during the stance phase of treadmill gait. The rotational motion and the anterior–posterior translation of the femur with respect to the tibia showed a clear relationship with the flexion–extension path of the knee during the stance phase. Additionally, we observed that the phenomenon of femoral rollback was reversed, with the femur noted to move posteriorly with extension and anteriorly with flexion. Furthermore, we noted that motion of the medial femoral condyle in the transverse plane was greater than that of the lateral femoral condyle during the stance phase of gait (17.4±2.0 mm vs. 7.4±6.1 mm, respectively; p<0.01). The trend was opposite to what has been observed during non-weightbearing flexion or single-leg lunge in previous studies. These data provide baseline knowledge for the understanding of normal physiology and for the analysis of pathological function of the knee joint during walking. These findings further demonstrate that knee kinematics is activity-dependent and motion patterns of one activity (non-weightbearing flexion or lunge) cannot be generalized to interpret a different one (gait).     

Modeling of the knee joint load in rehabilitative knee extension exercises under water

A biomechanical and hydrodynamic theoretical model has been developed in order to calculate the knee joint load during underwater knee extension exercises. The hydrodynamic force has been evaluated within the framework of a strip-theory approach, when a blunt rectangular resistive device is applied proximally to the shank to increase its frontal area. Analytical expressions of the patellar tendon force (F(PT)), the axial (phi(n)) and the shear (phi(t)) component of the tibiofemoral joint load have been derived as a function of joint angle (theta), angular velocity (theta ), angular acceleration (theta ), resistive device density, length (L(x)), width (L(z)) and thickness, and average hydrodynamic drag and added mass coefficients. An inverse dynamic problem has been solved, assuming for theta and theta a dependence on theta consistent with the experimental kinematic data available in the literature. The results highlight that the characteristics of the resistive device and the level of muscular activation can be adjusted reciprocally in order to control the peak value of F(PT), phi(n) and phi(t), and the position of these peaks within the joint range of motion (ROM). No anterior cruciate ligament (ACL) stress is observed (phi(t)>0) over the whole ROM, independent of the level of muscular activation, for a light resistive device with L(x) < or = 0.3 m and L(z) < or = 0.4 m. This work highlights that aquatic exercises can be usefully and safely implemented in the rehabilitation program following ACL surgery, and whenever it is important to avoid excessive shear joint forces that constrain the tibial plateau anterior translation with respect to the femur.     

The envelope of passive knee joint motion

The purpose of this study is to create an accurate experimental database for the passive (in vitro) freedom-of-motion characteristics of the human knee joint on a subject to subject basis, suitable for the verification and enhancement of mathematical knee-joint models. Knee-joint specimens in a six degree-of-freedom motion rig are moved through flexion under several combinations of external loads, including tibial torques, axial forces and AP-forces. Euler rotation angles and translation vectors, describing the relative, spatial motions of the joint are measured using an accurate Roentgen Stereo Photogrammetric system. Conceptually the joint is considered as a two degrees-of-freedom of motion mechanism (flexion-tibial rotation), whereby the limits of internal and external tibial rotation are defined at torques of +/- 3 Nm. The motion pathways along these limits are defined as the envelopes of passive knee joint motion. It is found that these envelope pathways are consistent and hardly influenced by additional axial forces up to 300 N and AP-forces of 30 N. Within the envelope of motion, however, the motion patterns are highly susceptible to small changes in the external load configuration. It is shown that the external tibial rotation during extension ('screw-home mechanism') is not an obligatory effect of the passive joint characteristics, but a direct result of the external loads. Anatomical differences notwithstanding, the inter-individual discrepancies in the motion patterns of the four specimens tested, showed to be relatively small in a qualitative sense. Quantitative differences can be explained by small differences in the alignment of the coordinate systems relative to the joint anatomy and by differences in rotatory laxity.     

Knee joint motion and ligament forces before and after ACL reconstruction

The goal of this in vitro study was to investigate the initial postoperative mechanical state of the knee with various types of anterior cruciate ligament (ACL) reconstructions. An experimental knee testing system was developed for the in vitro measurement of ligament forces and three-dimensional joint motion as external loads were applied to fresh knee specimens. Two groups of knee specimens were tested. In test series #1, two intraarticular reconstructions were performed in each of five specimens using semifree and free patellar tendon grafts with bone blocks. In test series #2, a more carefully controlled intraarticular reconstruction was performed in five specimens using a semifree composite graft consisting of the semitendinosus and gracilis tendons augmented with the Ligament Augmentation Device. Ligament force and joint motion data were collected as anteriorly directed tibial loads were applied to the normal joint, the joint with a cut ACL and the reconstructed joint. These knee joint states were compared on the basis of ACL or graft forces, joint motion and load sharing by the collateral ligaments. The dominate result of the study was that the forces and motions defining the mechanical state of the knee after the ACL reconstructions in both test series were highly variable and abnormal when compared to the normal knee state. The higher level of surgical control series #2 did not decrease this variability. There was a poor correlation between motion of the reconstructed knee relative to normal, and the ACL graft force. There was little consistent difference in force and motion results between the surgical procedures tested.     

Wide step width reduces knee abduction moment of obese adults during stair negotiation

PurposeAn increased likelihood of developing obesity-related knee osteoarthritis may be associated with increased peak internal knee abduction moments (KAbM). Increases in step width (SW) may act to reduce this moment. The purpose of this study was to determine the effects of increased SW on knee biomechanics during stair negotiation of healthy-weight and obese participants.MethodsParticipants (24: 10 obese and 14 healthy-weight) used stairs and walked over level ground while walking at their preferred speed in two different SW conditions – preferred and wide (200% preferred). A 2 × 2 (group × condition) mixed model analysis of variance was performed to analyze differences between groups and conditions (p < 0.05).ResultsIncreased SW increased the loading-response peak knee extension moment during descent and level gait, decreased loading-response KAbMs, knee extension and abduction range of motion (ROM) during ascent, and knee adduction ROM during descent. Increased SW increased loading-response peak mediolateral ground reaction force (GRF), increased peak knee abduction angle during ascent, and decreased peak knee adduction angle during descent and level gait. Obese participants experienced disproportionate changes in loading-response mediolateral GRF, KAbM and peak adduction angle during level walking, and peak knee abduction angle and ROM during ascent.ConclusionIncreased SW successfully decreased loading-response peak KAbM. Implications of this finding are that increased SW may decrease medial compartment knee joint loading, decreasing pain and reducing joint deterioration. Increased SW influenced obese and healthy-weight participants differently and should be investigated further.     

Comparison of strain-gage and fiber-optic goniometry for measuring knee kinematics during activities of daily living and exercise

There is increasing interest in wearable sensor technology as a tool for rehabilitation applications in community or home environments. Recent studies have focused on evaluating inertial based sensing (accelerometers, gyroscopes, etc.) that provide only indirect measures of joint motion. Measurement of joint kinematics using flexible goniometry is more direct, and still popular in laboratory environments, but has received little attention as a potential tool for wearable systems. The aim of this study was to compare two goniometric devices: a traditional strain-gauge flexible goniometer, and a fiberoptic flexible goniometer, for measuring dynamic knee flexion/extension angles during activity of daily living: chair rise, and gait; and exercise: deep knee bends, against joint angles computed from a "gold standard" Vicon motion tracking system. Six young adults were recruited to perform the above activities in the lab while wearing a goniometer on each knee, and reflective markers for motion tracking. Kinematic data were collected simultaneously from the goniometers (one on each leg) and the motion tracking system (both legs). The results indicate that both goniometers were within 2-5 degrees of the Vicon angles for gait and chair rise. For some deep knee bend trials, disagreement with Vicon angles exceeded ten degrees for both devices. We conclude that both goniometers can record ADL knee movement faithfully and accurately, but should be carefully considered when high (>120?deg) knee flexion angles are required.     

The use of sequential MR image sets for determining tibiofemoral motion: reliability of coordinate systems and accuracy of motion tracking algorithm

The use of magnetic resonance imaging has been proposed by many investigators for establishment of joint reference systems and kinematic tracking of musculoskeletal joints. In this study, the intraobserver and interobserver reliability of a strategy to establish anatomic reference systems using manually selected fiducial points were quantified for seven sets of MR images of the human knee joint. The standard error of the measurement of the intraobserver and interobserver errors were less than 2.6 degrees, and 1.2 mm for relative tibiofemoral orientation and displacement, respectively. An automated motion tracking algorithm was also validated with a controlled motion experiment in a cadaveric knee joint. The controlled displacements and rotations prescribed in our motion tracking validation were highly correlated to those predicted (Pearson's correlation = 0.99, RMS errors = 0.39 mm, 0.38 degree). Finally, the system for anatomic reference system definition and motion tracking was demonstrated with a set of MR images of in vivo passive flexion in the human knee.     

Inter-segmental coordination: motor pattern in humans stepping over an obstacle with mechanical ankle joint friction

This study examined the influence of a mechanical perturbation of the ankle joint on obstacle avoidance pattern. A decoupled control between the distal joint and the combined (hip-knee) proximal joints was observed according to the task requirement. In this context, a greater mechanical friction at the ankle should be compensated at this joint (local compensation) or alternatively, by regulating more combined proximal joints (knee and/or hip). The leading limb inter-segmental coordination was evaluated in both no constraint and constraint conditions in calculating ranges of motion (ROM), moments of force and powers (from heel-off to obstacle) at the ankle, knee and hip joints. Electromyographic activities were also analyzed. With the constraint, the dorsiflexor moment and the tibialis anterior activity remained unchanged while both ROM and power bursts (absorbed and generated) decreased. The hip and knee ROM remain invariant. At heel-off the absorption by hip extensors decreased and the forthcoming generation by knee flexors increased in the constraint condition. To quantify the inter-joint coordination, principal component analysis was used and indicated a high level of inter-joint coupling (synergy) that decreased with the constraint (i.e. less inter-joint coupling). At the ankle joint, the results suggest that the central command was the same in both conditions thus, not be adapted. At both the hip and knee joints, a combined joints modulation occurred to overcome additional friction.     

Length-tension properties of ankle muscles in chronic human spinal cord injury

Contracture, or loss of range of motion (ROM) of a joint, is a common clinical problem in individuals with spinal cord injury (SCI). In order to measure the possible contribution of changes in muscle length to the loss of ankle ROM, the active force vs. angle curves for the tibialis anterior (TA) and gastrocnemiussoleus (GS) were measured in 20 participants, 10 with SCI, and 10 gender and age matched, neurologically intact (NI) individuals. Electrical stimuli were applied to the TA and GS motor nerves at incremented angles of the entire ROM of the ankle and the resulting ankle and knee torques were measured using a multi-axis load cell. The muscle forces of the TA and GS were calculated from the torque measurements using estimates of their respective moment arms and the resulting forces were plotted against joint angle. The force–angle relation for the GS at the ankle (GSA) was significantly shifted into plantar flexion in SCI subjects, compared to NI controls (t-test, p<0.001). Similar results were obtained based upon the GS knee (GSK) force–angle measurements (p<0.05). Conversely, no significant shift in the force–angle relation was found for the TA (p=0.138). Differences in the passive ROM were consistent with the force–angle changes. The ROM in the dorsiflexion direction was significantly smaller in SCI subjects compared to NI controls (p<0.05) while the plantar flexion ROM was not significantly different (p=0.114). Based upon these results, we concluded that muscle shortening is an important component of contracture in SCI.