Real-time knee adduction moment feedback for gait retraining through visual and tactile displays

The external knee adduction moment (KAM) measured during gait is an indicator of tibiofemoral joint osteoarthritis progression and various strategies have been proposed to lower it. Gait retraining has been shown to be an effective, noninvasive approach for lowering the KAM. We present a new gait retraining approach in which the KAM is fed back to subjects in real-time during ambulation. A study was conducted in which 16 healthy subjects learned to alter gait patterns to lower the KAM through visual or tactile (vibration) feedback. Participants converged on a comfortable gait in just a few minutes by using the feedback to iterate on various kinematic modifications. All subjects adopted altered gait patterns with lower KAM compared with normal ambulation (average reduction of 20.7%). Tactile and visual feedbacks were equally effective for real-time training, although subjects using tactile feedback took longer to converge on an acceptable gait. This study shows that real-time feedback of the KAM can greatly increase the effectiveness and efficiency of subject-specific gait retraining compared with conventional methods.     

Gait retraining to reduce the knee adduction moment through real-time visual feedback of dynamic knee alignment

Varus knee alignment is a risk factor for medial knee osteoarthritis and is associated with high knee adduction moments. Therefore, reducing the knee adduction moment in varus-aligned individuals with otherwise healthy knees may reduce their risk for developing osteoarthritis. A gait modification that improves dynamic knee alignment may reduce the adduction moment, and systematic training may lead to more natural-feeling and less effortful execution of this pattern. To test these hypotheses, eight healthy, varus-aligned individuals underwent a gait modification protocol. Real-time feedback of dynamic knee alignment was provided over eight training sessions, using a fading paradigm. Natural and modified gait were assessed post-training and after 1 month, and compared to pre-training natural gait. The knee adduction moment, as well as hip adduction, hip internal rotation and knee adduction angles were evaluated. At each training session, subjects rated how effortful and natural-feeling the modified pattern was to execute. Post-training, the modified pattern demonstrated an 8° increase in hip internal rotation and 3° increase in hip adduction. Knee adduction decreased 2°, and the knee adduction moment decreased 19%. Natural gait did not differ between the three visits, nor did the modified gait pattern between the post-training and 1 month visits. The modified pattern felt more natural and required less effort after training. Based on these results, gait retraining to improve dynamic knee alignment resulted in significant reductions in the knee adduction moment, primarily through hip internal rotation. Further, systematic training led to more natural-feeling and less effortful execution of the gait pattern.     

Partitioning of knee joint internal forces in gait is dictated by the knee adduction angle and not by the knee adduction moment

Medial knee osteoarthritis is a debilitating disease. Surgical and conservative interventions are performed to manage its progression via reduction of load on the medial compartment or equivalently its surrogate measure, the external adduction moment. However, some studies have questioned a correlation between the medial load and adduction moment. Using a musculoskeletal model of the lower extremity driven by kinematics–kinetics of asymptomatic subjects at gait midstance, we aim here to quantify the relative effects of changes in the knee adduction angle versus changes in the adduction moment on the joint response and medial/lateral load partitioning. The reference adduction rotation of 1.6° is altered by ±1.5° to 3.1° and 0.1° or the knee reference adduction moment of 17 N m is varied by ±50% to 25.5 N m and 8.5 N m. Quadriceps, hamstrings and tibiofemoral contact forces substantially increased as adduction angle dropped and diminished as it increased. The medial/lateral ratio of contact forces slightly altered by changes in the adduction moment but a larger adduction rotation hugely increased this ratio from 8.8 to a 90 while in contrast a smaller adduction rotation yielded a more uniform distribution. If the aim in an intervention is to diminish the medial contact force and medial/lateral load ratio, a drop of 1.5° in adduction angle is much more effective (causing respectively 12% and 80% decreases) than a reduction of 50% in the adduction moment (causing respectively 4% and 13% decreases). Substantial role of changes in adduction angle is due to the associated alterations in joint nonlinear passive resistance. These findings explain the poor correlation between knee adduction moment and tibiofemoral compartment loading during gait suggesting that the internal load partitioning is dictated by the joint adduction angle.     

Toe-out gait in patients with knee osteoarthritis partially transforms external knee adduction moment into flexion moment during early stance phase of gait: a tri-planar kinetic mechanism

Altered gait kinematics and kinetics are observed in patients with medial compartment knee osteoarthritis. Although various kinematic adaptations are proposed to be compensatory mechanisms that unload the knee, the nature of these mechanisms is presently unclear. We hypothesized that an increased toe-out angle during early stance phase of gait shifts load away from the knee medial compartment, quantified as the external adduction moment about the knee. Specifically, we hypothesized that by externally rotating the lower limb anatomy, primarily about the hip joint, toe-out gait alters the lengths of ground reaction force lever arms acting about the knee joint in the frontal and sagittal planes and transforms a portion of knee adduction moment into flexion moment. To test this hypothesis, gait data from 180 subjects diagnosed with medial compartment knee osteoarthritis were examined using two frames of reference. The first frame was attached to the tibia (reporting actual toe-out) and the second frame was attached to the laboratory (simulating no-toe-out). Four measures were compared within subjects in both frames of reference: the lengths of ground reaction force lever arms acting about the knee joint in the frontal and sagittal planes, and the adduction and flexion components of the external knee moment. The mean toe-out angle was 11.4 degrees (S.D. 7.8 degrees , range -2.2 degrees to 28.4 degrees ). Toe-out resulted in significant reductions in the frontal plane lever arm (-6.7%) and the adduction moment (-11.7%) in early stance phase when compared to the simulated no-toe-out values. These reductions were coincident with significant increases in the sagittal plane lever arm (+33.7%) and flexion moment (+25.0%). Peak adduction lever arm and moment were also reduced significantly in late stance phase (by -22.9% and -34.4%, respectively) without a corresponding increase in sagittal plane lever arm or flexion moment. These results indicate that toe-out gait in patients with medial compartment knee osteoarthritis transforms a portion of the adduction moment into flexion moment in early stance phase, suggesting that load is partially shifted away from the medial compartment to other structures.     

Reduction in knee adduction moment via non-invasive biomechanical training: a longitudinal gait analysis study

Biomechanical non-invasive interventions have been previously reported to reduce pain and facilitate superior levels of function in patients with medial knee osteoarthritis [OA]. One such treatment is the AposTherapy, a customized program utilizing a foot-worn biomechanical device allowing center of pressure modification and continuous perturbation during gait. The influence of this intervention on objective gait metrics has yet to be determined. The aim of the current study was to prospectively examine changes in kinetic and kinematic parameters in patients enrolled in this treatment program. Twenty-five females with symptomatic bilateral medial compartment knee OA were enrolled in the customized daily treatment program. All patients underwent barefoot gait analysis testing and completed subjective questionnaires prior to treatment initiation and on two follow-up visits. Significantly reduced knee adduction moment (KAM) magnitude was noted during barefoot walking after three and nine months of treatment. On average, the knee adduction impulse and the 1st and 2nd KAM peaks were reduced by 13%, 8.4%, and 12.7%, respectively. Furthermore, moment reduction was accompanied by elevated walking velocity, significant pain reduction, and increased functional activity. In addition to symptomatic improvement, our results suggest that this treatment program can alter kinetic gait parameters in this population. We speculate that these adaptations account for the symptomatic and functional improvement reported for this intervention.     

Predicting changes in knee adduction moment due to load-altering interventions from pressure distribution at the foot in healthy subjects

The purpose of this pilot study of healthy subjects was to determine if changes in foot pressure patterns associated with a lateral wedge can predict the changes in the knee adduction moment. We tested two hypotheses: (1) increases or decreases in the knee adduction moment and ankle eversion moment due to load-altering footwear interventions can be predicted from foot pressure distribution and (2) changes in magnitude of the knee adduction moment and ankle eversion moment due to lateral wedges can be predicted from pressure distribution at the foot during walking. Fifteen healthy adults performed walking trials in three shoes: 0 degrees , 4 degrees , and 8 degrees laterally wedged. Maximum heel pressure ratio, first peak knee adduction moment, and peak ankle eversion moment were assessed using a pressure mat, motion capture system, and force plate. Increases or decreases in the knee adduction moment and ankle eversion moment were predicted well from foot pressure distribution. However, the magnitude of the pressure change did not predict the magnitude of the peak knee adduction moment change or peak ankle eversion moment change. Factors such as limb alignment or trunk motion may affect the knee adduction moment and override a direct relationship between the pressure distribution at the shoe-ground interface and the load distribution at the knee. However, changes (increases or decreases) in the peak knee adduction moment due to load-altering footwear interventions predicted from pressure distribution during walking can be important when evaluating these types of interventions from a clinical perspective.     

The knee adduction moment measured with an instrumented force shoe in patients with knee osteoarthritis

The external knee adduction moment (KAdM) during gait is an important parameter in patients with knee osteoarthritis (OA). KAdM measurement is currently restricted to instruments only available in gait laboratories. However, ambulatory movement analysis technology, including instrumented force shoes (IFS) and inertial and magnetic measurement systems (IMMS), can measure kinetics and kinematics of human gait free of laboratory restrictions. The objective of this study was a quantitative validation of the accuracy of the KAdM in patients with knee OA, when estimated with an ambulatory-based method (AmbBM) versus a laboratory-based method (LabBM). AmbBM is employing the IFS and a linked-segment model, while LabBM is based on a force plate and optoelectronic marker system. Effects of ground reaction force (GRF), centre of pressure (CoP), and knee joint position measurement are evaluated separately. Twenty patients with knee OA were measured. The GRFs showed differences up to 0.22 N/kg, the CoPs showed differences up to 4 mm, and the medio-lateral and vertical knee position showed differences to 9 mm, between AmbBM and LabBM. The GRF caused an under-estimation in KAdM in early stance. However, this effect was counteracted by differences in CoP and joint position, resulting in a net 5% over-estimation. In midstance and late stance the accuracy of the KAdM was mainly limited by use of the linked-segment model for joint position estimation, resulting in an under-estimation (midstance 6% and late stance 22%). Further improvements are needed in the estimation of joint position from segment orientation.     

Training multi-parameter gaits to reduce the knee adduction moment with data-driven models and haptic feedback

The purpose of this study was to evaluate gait retraining for reducing the knee adduction moment. Our primary objective was to determine whether subject-specific altered gaits aimed at reducing the knee adduction moment by 30% or more could be identified and adopted in a single session through haptic (touch) feedback training on multiple kinematic gait parameters. Nine healthy subjects performed gait retraining, in which data-driven models specific to each subject were determined through experimental trials and were used to train novel gaits involving a combination of kinematic changes to the tibia angle, foot progression and trunk sway angles. Wearable haptic devices were used on the back, knee and foot for real-time feedback. All subjects were able to adopt altered gaits requiring simultaneous changes to multiple kinematic parameters and reduced their knee adduction moments by 29-48%. Analysis of single parameter gait training showed that moving the knee medially by increasing tibia angle, increasing trunk sway and toeing in all reduced the first peak of the knee adduction moment with tibia angle changes having the most dramatic effect. These results suggest that individualized data-driven gait retraining may be a viable option for reducing the knee adduction moment as a treatment method for early-stage knee osteoarthritis patients with sufficient sensation, endurance and motor learning capabilities.     

A variable-stiffness shoe lowers the knee adduction moment in subjects with symptoms of medial compartment knee osteoarthritis

The purpose of this study was to evaluate the effectiveness of variable-stiffness shoes in lowering the peak external knee adduction moment during walking in subjects with symptomatic medial compartment knee osteoarthritis. The influence on other lower extremity joints was also investigated. The following hypotheses were tested: (1) variable-stiffness shoes will lower the knee adduction moment in the symptomatic knee compared to control shoes; (2) reductions in knee adduction moment will be greater at faster speeds; (3) subjects with higher initial knee adduction moments in control shoes will have greater reductions in knee adduction moment with the intervention shoes; and (4) variable-stiffness shoes will cause secondary changes in the hip and ankle frontal plane moments. Seventy-nine individuals were tested at self-selected slow, normal, and fast speeds with a constant-stiffness control shoe and a variable-stiffness intervention shoe. Peak moments for each condition were assessed using a motion capture system and force plate. The intervention shoes reduced the peak knee adduction moment compared to control at all walking speeds, and reductions increased with increasing walking speed. The magnitude of the knee adduction moment prior to intervention explained only 11.9% of the variance in the absolute change in maximum knee adduction moment. Secondary changes in frontal plane moments showed primarily reductions in other lower extremity joints. This study showed that the variable-stiffness shoe reduced the knee adduction moment in subjects with medial compartment knee osteoarthritis without the discomfort of a fixed wedge or overloading other joints, and thus can potentially slow the progression of knee osteoarthritis.     

Internal kinetic changes in the knee due to high tibial osteotomy are well-correlated with change in external adduction moment: An osteoarthritic knee model

In-vivo quantification of loads in the constitutive structures of the osteoarthritic knee can provide clinical insight, particularly when planning a surgery like the opening-wedge high tibial osteotomy (HTO). A computational knee model was created to estimate internal kinetics during walking gait. An optimization approach partitioned loads between the muscles, ligaments, medial and lateral contact surfaces of the tibial–femoral joint. Three kinetic measures were examined in 30 HTO patients: external knee adduction moment (EKAM), medial compartment load (ML) and the medial-to-lateral compartment loads ratio (MLR). Three time points were compared: immediately pre-HTO, 6 and 12 months post-HTO. Three hypotheses were tested: (1) HTO reduces an EKAM, an ML and an MLR, (2) these measures are not significantly different at 6 and 12 months post-HTO, and (3) the change in the impulse of EKAM due to a HTO is well-correlated with the impulse of an MLR.The three hypotheses were confirmed. First peak of an EKAM during stance phase was reduced significantly by 1.70% BW-ht. ML and MLR at the same instance were reduced significantly by 0.56%BW and 1.0, respectively. These measures were not significantly different between 6 and 12 months post-HTO. Changes in impulse of an EKAM and an MLR were moderately well-correlated between the pre-HTO and 6 months post-HTO time points (R²=0.5485). Therefore, the external measure EKAM-impulse is a good proxy of the internal kinetic measure of an MLR-impulse, explaining about 55% of the variance in the change due to a HTO intervention.     

Joint moment contributions to swing knee extension acceleration during gait in children with spastic hemiplegic cerebral palsy

Inadequate peak knee extension during the swing phase of gait is a major deficit in individuals with spastic cerebral palsy (CP). The biomechanical mechanisms responsible for knee extension have not been thoroughly examined in CP. The purpose of this study was to assess the contributions of joint moments and gravity to knee extension acceleration during swing in children with spastic hemiplegic CP. Six children with spastic hemiplegic CP were recruited (age=13.4±4.8 years). Gait data were collected using an eight-camera system. Induced acceleration analysis was performed for each limb during swing. Average joint moment and gravity contributions to swing knee extension acceleration were calculated. Total swing and stance joint moment contributions were compared between the hemiplegic and non-hemiplegic limbs using paired t-tests (p<0.05). Swing limb joint moment contributions from the hemiplegic limb decelerated swing knee extension significantly more than those of the non-hemiplegic limb and resulted in significantly reduced knee extension acceleration. Total stance limb joint moment contributions were not statistically different. Swing limb joint moment contributions that decelerated knee extension appeared to be the primary cause of inadequate knee extension acceleration during swing. Stance limb muscle strength did not appear to be the limiting factor in achieving adequate knee extension in children with CP. Recent research has shown that the ability to extend the knee during swing is dependent on the selective voluntary motor control of the limb. Data from individual participants support this concept.     

Associations among knee adduction moment, frontal plane ground reaction force, and lever arm during walking in patients with knee osteoarthritis

The adduction moment about the knee during walking gait has been proposed as an indirect measure of dynamic knee joint load. However, the relative contributions of the variables primarily used to calculate the knee adduction moment have not been investigated. The objectives of this paper were to: (1) describe and compare the magnitude and temporal characteristics of the knee adduction moment, frontal plane lever arm, and frontal plane ground reaction force (GRF) during gait in patients with knee osteoarthritis (OA) and, (2) examine the associations among these variables. Results indicated that both the knee adduction moment and the frontal plane GRF varied considerably throughout stance and exhibited the characteristic "double-hump" pattern, while the frontal plane lever arm magnitude varied only slightly during stance. Knees with OA had significantly greater peak knee adduction moments and frontal plane lever arms, but significantly less peak frontal plane GRF than knees without OA. Pearson product moment correlations indicated a higher association between peak knee adduction moment and peak frontal plane lever arm than between peak knee adduction moment and peak frontal plane GRF, particularly in knees with OA. These results suggest that the frontal plane lever arm assessed during walking is an important variable in the examination of knee OA, and warrants further investigation.     

An analysis of the mechanisms for reducing the knee adduction moment during walking using a variable stiffness shoe in subjects with knee osteoarthritis

Variable stiffness shoes that have a stiffer lateral than medial sole may reduce the external knee adduction moment (EKAM) and pain during walking in patients with medial compartment knee osteoarthritis (OA). However, the mechanism by which EKAM may be reduced in the OA knee with this intervention remains unclear. Three hypotheses were tested in this study: (1) The reduction in EKAM during walking with the variable stiffness shoe is associated with a reduction in GRF magnitude and/or (2) frontal plane lever arm. (3) A reduction in frontal plane lever arm occurs either by moving the center of pressure laterally under the shoe and/or by dynamically reducing the medial component of GRF. Thirty-two subjects (20 male, 12 female; age: 58.7 ± 9.3 years; height: 1.62 ± 0.08 m; mass: 81.3 ± 14.6 kg) with medial compartment knee osteoarthritis were studied walking in a gait laboratory. The frontal plane lever arm was significantly reduced (1.62%, 0.07%ht, p=0.02) on the affected side while the magnitude of the GRF was not significantly changed. The reduction in the lever arm was weakly correlated with a medial shift in the COP. However, the combined medial shift in the COP and reduction in the medial GRF explained 50% of the change of the frontal plane lever arm. These results suggest that the medial shift in the COP at the foot produced by the intervention shoe stimulates an adaptive dynamic response during gait that reduces the frontal plane lever arm.     

A neural network model to predict knee adduction moment during walking based on ground reaction force and anthropometric measurements

The external knee adduction moment (KAM) is a major variable for the evaluation of knee loading during walking, specifically in patients with knee osteoarthritis. However, assessment of the KAM is limited to locations where full motion laboratories are available. The purpose of this study was to develop and test a simple method to predict the KAM using only force plate and anthropometric measurements. Three groups of 28 knees (asymptomatic, mild osteoarthritis, and severe osteoarthritis) were studied. Walking trials were collected at different speeds using a motion capture system and a force plate. The reference KAM was calculated by inverse dynamics. For the prediction, inter-subject artificial neural networks were designed using 11 inputs coming from the ground reaction force and the mechanical axis alignment. The predicted KAM curves were similar to the reference curves with median mean absolute deviation (MAD) of 0.36%BW*Ht and median correlation coefficient of 0.966 over 756 individual trials. When comparing mean group curves, the median MAD was 0.09%BW*Ht and the median correlation coefficient 0.998. The peak values and the angular impulses extracted from the predicted and reference curves were significantly correlated, and the same significant differences were obtained among the three groups when the predicted or when the reference curves were used for 95% of the comparisons. In conclusion, this study demonstrated that a simple method using a generic artificial neural network can predict the KAM curve during walking with a high level of significance and provides a practical option for a broader evaluation of the KAM.     

The passive elastic moment at the knee and its influence on human gait

The elastic component of the passive moment at the knee was measured in situ. The force needed to manually range the knee from approximately 90 degrees of flexion to full extension was measured. Hip and ankle angle were held fixed. The passive knee moment, computed from the force and knee angle data, was compared to the total knee moment required for normal gait. This comparison suggested that the passive moment can contribute a significant portion of the total joint moment during some phases of the gait cycle.     

Evaluation of a patient-specific cost function to predict the influence of foot path on the knee adduction torque during gait

A large external knee adduction torque during gait has been correlated with the progression of knee osteoarthritis (OA). Though foot path changes (e.g. toeing out) can reduce the adduction torque, no method currently exists to predict whether an optimal foot path exists for a specific patient. This study evaluates a patient-specific optimization cost function to predict how foot path changes influence both adduction torque peaks. Video motion and ground reaction data were collected from a patient with knee OA performing normal, toe out, and wide stance gait. Joint and inertial parameters in a dynamic, 27 degree-of-freedom, full-body gait model were calibrated to the patient's normal gait data. The model was then used in gait optimizations that predicted how the patient's adduction torque peaks would change due to changes in foot path. The cost function tracked the patient's normal gait data using weight factors calibrated to toe out gait and tested using wide stance gait. For both gait motions, the same cost function weights predicted the change in both adduction torque peaks to within 7% error. With further development, this approach may eventually permit the design of patient-specific rehabilitation procedures such as an optimal foot path for patients with knee OA.     

Altered control strategy between leading and trailing leg increases knee adduction moment in the elderly while descending stairs

The aim of the study was to examine the external knee adduction moments in a group of older and younger adults while descending stairs and thus the possibility of an increased risk of knee osteoarthritis due to altered knee joint loading in the elderly. Twenty-seven older and 16 younger adults descended a purpose-built staircase. A motion capture system and a force plate were used to determine the subjects' 3D kinematics and ground reaction forces (GRF) during locomotion. Calculation of the leg kinematics and kinetics was done by means of a rigid, three-segment, 3D leg model. In the initial portion of the support phase, older adults showed a more medio-posterior GRF vector relative to the ankle joint, leading to lower ankle joint moments (P<0.05). At the knee, the older adults demonstrated a more medio-posterior directed GRF vector, increasing in knee flexion and adduction in the second part of the single support phase (P<0.05). Further, GRF magnitude was lower in the initial and higher in the mid-portions of the support phase for the elderly (P<0.05). The results show that older adults descend stairs by using the trailing leg before the initiation of the double support phase more compared to the younger ones. The consequence of this altered control strategy while stepping down is a more medially directed GRF vector increasing the magnitude of external knee adduction moment in the elderly. The observed changes between leading and trailing leg in the elderly may cause a redistribution of the mechanical load at the tibiofemoral joint, affecting the initiation and progression of knee osteoarthritis in the elderly.     

Increased hip internal abduction moment and reduced speed are the gait strategies used by women with knee osteoarthritis

The purpose of this study was to identify the gait strategies in women with mild and moderate knee osteoarthritis (OA). Forty women diagnosed with OA of the knee and 40 healthy women participated in the study. Toe-out progression angle, trunk lateral lean, hip internal abduction moment and gait speed were measured using Qualisys ProReflex System and two force plates. Principal component analysis was applied to extract features from the gait waveforms data that characterized the waveforms main modes of temporal variation. Discriminant analysis with a stepwise model was conducted to determine which strategies could best discriminate groups. According to the discriminant model, the PC2 of the internal abduction moment of the hip and the gait speed were the most discriminatory variables between the groups. The OA group showed decreased gait speed, decreased hip internal abduction moment during the loading response phase, and increased hip internal abduction moment during the mid and terminal stance phases. Interventions that may increase hip internal abduction moment, such as the strengthening of the hip abductors muscles, may benefit women with knee OA. Training slower than normal gait speeds must be considered in light of potential adverse implications on overall physical function, daily tasks, and safety.     

Predicting clinical outcomes in neuroblastoma with genomic data integration

Background

Neuroblastoma is a heterogeneous disease with diverse clinical outcomes. Current risk group models require improvement as patients within the same risk group can still show variable prognosis. Recently collected genome-wide datasets provide opportunities to infer neuroblastoma subtypes in a more unified way. Within this context, data integration is critical as different molecular characteristics can contain complementary signals. To this end, we utilized the genomic datasets available for the SEQC cohort patients to develop supervised and unsupervised models that can predict disease prognosis.

Results

Our supervised model trained on the SEQC cohort can accurately predict overall survival and event-free survival profiles of patients in two independent cohorts. We also performed extensive experiments to assess the prediction accuracy of high risk patients and patients without MYCN amplification. Our results from this part suggest that clinical endpoints can be predicted accurately across multiple cohorts. To explore the data in an unsupervised manner, we used an integrative clustering strategy named multi-view kernel k-means (MVKKM) that can effectively integrate multiple high-dimensional datasets with varying weights. We observed that integrating different gene expression datasets results in a better patient stratification compared to using these datasets individually. Also, our identified subgroups provide a better Cox regression model fit compared to the existing risk group definitions.

Conclusion

Altogether, our results indicate that integration of multiple genomic characterizations enables the discovery of subtypes that improve over existing definitions of risk groups. Effective prediction of survival times will have a direct impact on choosing the right therapies for patients.

Reviewers

This article was reviewed by Susmita Datta, Wenzhong Xiao and Ziv Shkedy.