Quantitative assessment of gait determinants during single stance via a three-dimensional model--Part 2. Pathological gait

A three-dimensional model for normal gait formulated in Part 1 is now altered to simulate the dynamics of pathological walking. Mechanisms fundamental to the production of a normal gait pattern are systematically removed, in order to assess contributions from individual gait determinants. Four separate pathological cases are studied: a model neglecting ankle plantarflexor activity; absence of stance knee flexion-extension and foot and knee interaction; both pelvic list and transverse pelvic rotation removed; and finally, a model with all major gait determinants missing. These are used collectively to show that stance knee flexion-extension and foot and knee interaction successively dominate lower-extremity dynamical response during the single support phase of normal gait. The hip abductor muscles, while effecting pelvic list, serve to stabilize this limb, rather than actively determine whole-body vertical acceleration. Mechanisms compensating for a loss in joint motion are also explored. Complete ankle loss may be successfully compensated with increased hip abductor muscle activity; the loss of both ankle and knee, however, demand unacceptable levels of vertical pelvic displacement.     

Quantitative evaluation of the major determinants of human gait

Accurate knowledge of the isolated contributions of joint movements to the three-dimensional displacement of the center of mass (COM) is fundamental for understanding the kinematics of normal walking and for improving the treatment of gait disabilities. Saunders et al. (1953) identified six kinematic mechanisms to explain the efficient progression of the whole-body COM in the sagittal, transverse, and coronal planes. These mechanisms, referred to as the major determinants of gait, were pelvic rotation, pelvic list, stance knee flexion, foot and knee mechanisms, and hip adduction. The aim of the present study was to quantitatively assess the contribution of each major gait determinant to the anteroposterior, vertical, and mediolateral displacements of the COM over one gait cycle. The contribution of each gait determinant was found by applying the concept of an ‘influence coefficient’, wherein the partial derivative of the COM displacement with respect to a prescribed determinant was calculated. The analysis was based on three-dimensional measurements of joint angular displacements obtained from 23 healthy young adults walking at slow, normal and fast speeds. We found that hip flexion, stance knee flexion, and ankle-foot interaction (comprised of ankle plantarflexion, toe flexion and the displacement of the center of pressure) are the major determinants of the displacements of the COM in the sagittal plane, while hip adduction and pelvic list contribute most significantly to the mediolateral displacement of the COM in the coronal plane. Pelvic rotation and pelvic list contribute little to the vertical displacement of the COM at all walking speeds. Pelvic tilt, hip rotation, subtalar inversion, and back extension, abduction and rotation make negligible contributions to the displacements of the COM in all three anatomical planes.     

Muscular contributions to hip and knee extension during the single limb stance phase of normal gait: a framework for investigating the causes of crouch gait

Crouch gait, a troublesome movement abnormality among persons with cerebral palsy, is characterized by excessive flexion of the hips and knees during stance. Treatment of crouch gait is challenging, at present, because the factors that contribute to hip and knee extension during normal gait are not well understood, and because the potential of individual muscles to produce flexion or extension of the joints during stance is unknown. This study analyzed a three-dimensional, muscle-actuated dynamic simulation of walking to quantify the angular accelerations of the hip and knee induced by muscles during normal gait, and to rank the potential of the muscles to alter motions of these joints. Examination of the muscle actions during single limb stance showed that the gluteus maximus, vasti, and soleus make substantial contributions to hip and knee extension during normal gait. Per unit force, the gluteus maximus had greater potential than the vasti to accelerate the knee toward extension. These data suggest that weak hip extensors, knee extensors, or ankle plantar flexors may contribute to crouch gait, and strengthening these muscles--particularly gluteus maximus--may improve hip and knee extension. Abnormal forces generated by the iliopsoas or adductors may also contribute to crouch gait, as our analysis showed that these muscles have the potential to accelerate the hip and knee toward flexion. This work emphasizes the need to consider how muscular forces contribute to multijoint movements when attempting to identify the causes of abnormal gait.     

Finite element analysis of a total ankle replacement during the stance phase of gait

Total ankle replacement (TAR) designs have still several important issues to be addressed before the treatment becomes fully acceptable clinically. Very little is known about the performance, in terms of the contact pressures and kinematics of TAR when subjected to daily activities such as level gait. For this purpose, an explicit finite element model of a novel 3-component TAR was developed, which incorporated a previously validated mechanical model of the ankle ligament apparatus. The intermediate mobile polyethylene meniscal bearing was modelled as an elastic-plastic continuum while the articulating surfaces of the tibial and talar metal components as rigid bodies. Overall kinematics, contact pressures and ligament forces were analysed during passive, i.e. virtually unloaded, and active, i.e. stance phase of gait, conditions. Simulation of passive motion predicted similar kinematics as reported previously in an analytical four-bar linkage model. The meniscal bearing was observed to move 5.6 mm posteriorly during the simulated stance and the corresponding antero-posterior displacement of the talar component was 8.3 mm. The predicted pattern and the amount (10.6 degrees ) of internal-external rotation of the ankle complex were found to be in good agreement with corresponding in vivo measurements on normal ankles. A peak contact pressure of 16.8 MPa was observed, with majority of contact pressures below 10 MPa. For most ligaments, reaction forces remain within corresponding physiological ranges. A first realistic representation of the biomechanical behaviour of the human ankle when replaced by prosthetic joints is provided. The applied methodology can potentially be applied to other TAR designs.     

In vivo tibiofemoral cartilage deformation during the stance phase of gait

The knowledge of articular cartilage contact biomechanics in the knee joint is important for understanding the joint function and cartilage pathology. However, the in vivo tibiofemoral articular cartilage contact biomechanics during gait remains unknown. The objective of this study was to determine the in vivo tibiofemoral cartilage contact biomechanics during the stance phase of treadmill gait. Eight healthy knees were magnetic resonance (MR) scanned and imaged with a dual fluoroscopic system during gait on a treadmill. The tibia, femur and associated cartilage were constructed from the MR images and combined with the dual fluoroscopic images to determine in vivo cartilage contact deformation during the stance phase of gait. Throughout the stance phase of gait, the magnitude of peak compartmental contact deformation ranged between 7% and 23% of the resting cartilage thickness and occurred at regions with thicker cartilage. Its excursions in the anteroposterior direction were greater in the medial tibiofemoral compartment as compared to those in the lateral compartment. The contact areas throughout the stance phase were greater in the medial compartment than in the lateral compartment. The information on in vivo tibiofemoral cartilage contact biomechanics during gait could be used to provide physiological boundaries for in vitro testing of cartilage. Also, the data on location and magnitude of deformation among non-diseased knees during gait could identify where loading and later injury might occur in diseased knees.     

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).     

Quantitative analysis of upper limbs during gait: a marker set protocol

Purpose: to develop a marker set for simultaneously assessing upper and lower limb biomechanics during gait.Methods: 24 healthy young subjects (mean age: 23.80 years) were assessed quantitatively using an optoelectronic system, two force platform and a video system. Passive markers were positioned according to the proposed marker set which enables acquiring the upper and lower limb movement simultaneously during Gait Analysis. In addition to the traditional parameters obtained from Gait Analysis, the shoulder and elbow angles were computed from markers coordinates of upper limbs; then, some significant parameters were identified and calculated. From shoulder and elbow position, angles, angular velocities, angular acceleration, moments, and powers were calculated for shoulder and elbow joints. Results: Kinematic and kinetic data were obtained in the three planes (sagittal, frontal, and transversal) for the shoulder and in the sagittal plane for the elbow. Normative ranges were obtained for these parameters from data of healthy participants. Conclusions: The proposed experimental set-up enables simultaneous assessment of upper and lower limb movement during gait. Thus, no further trials are required in addition to those acquired during standard gait analysis in order to assess upper limb motion, which also makes the experimental set-up feasible for clinical applications.     

In vivo biomechanical behavior of the human heel pad during the stance phase of gait

A technique is introduced for simultaneous measurements of the heel pad tissue deformation and the heel–ground contact stresses developing during the stance phase of gait. Subjects walked upon a gait platform integrating the contact pressure display optical method for plantar pressure measurements and a digital radiographic fluoroscopy system for skeletal and soft tissue motion recording. Clear images of the posterior-plantar aspect of the calcaneus and enveloping soft tissues were obtained simultaneously with the pressure distribution under the heel region throughout the stance phase of gait. The heel pad was shown to undergo a rapid compression during initial contact and heel strike, reaching a strain of 0.39±0.05 in about 150 ms. The stress–strain relation of the heel pad was shown to be highly non-linear, with a compression modulus of 105±11 kPa initially and 306±16 kPa at 30% strain. The energy dissipation during heel strike was evaluated to be 17.8±0.8%. The present technique is useful for biomechanical as well as clinical evaluation of the stress–strain and energy absorption characteristics of the heel pad in vivo, during natural gait.     

A longitudinal study of impact and early stance loads during gait following arthroscopic partial meniscectomy

People following arthroscopic partial medial meniscectomy (APM) are at increased risk of developing knee osteoarthritis. High impact loading and peak loading early in the stance phase of gait may play a role in the pathogenesis of knee osteoarthritis. This was a secondary analysis of longitudinal data to investigate loading-related indices at baseline in an APM group (3 months post-surgery) and a healthy control group, and again 2 years later (follow-up). At baseline, 82 participants with medial APM and 38 healthy controls were assessed, with 66 and 23 re-assessed at follow-up, respectively. Outcome measures included: (i) heel strike transient (HST) presence and magnitude, (ii) maximum loading rate, (iii) peak vertical force (F_z) during early stance. At baseline, maximum loading rate was lower in the operated leg (APM) and non-operated leg (non-APM leg) compared to controls (p≤0.03) and peak F_z was lower in the APM leg compared to non-APM leg (p≤0.01). Over 2 years, peak F_z increased in the APM leg compared to the non-APM leg and controls (p≤0.01). Following recent APM, people may adapt their gait to protect the operated knee from excessive loads, as evidenced by a lower maximum loading rate in the APM leg compared to controls, and a reduced peak F_z in the APM leg compared to the non-APM leg. No differences at follow-up may suggest an eventual return to more typical gait. However, the increase in peak F_z in the APM leg may be of concern for long-term joint health given the compromised function of the meniscus.     

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.     

A finite element model of the lower limb during stance phase of gait cycle including the muscle forces

Background

Results of finite element (FE) analyses can give insight into musculoskeletal diseases if physiological boundary conditions, which include the muscle forces during specific activities of daily life, are considered in the FE modelling. So far, many simplifications of the boundary conditions are currently made. This study presents an approach for FE modelling of the lower limb for which muscle forces were included.

Methods

The stance phase of normal gait was simulated. Muscle forces were calculated using a musculoskeletal rigid body (RB) model of the human body, and were subsequently applied to a FE model of the lower limb. It was shown that the inertial forces are negligible during the stance phase of normal gait. The contact surfaces between the parts within the knee were modelled as bonded. Weak springs were attached to the distal tibia for numerical reasons.

Results

Hip joint reaction forces from the RB model and those from the FE model were similar in magnitude with relative differences less than 16%. The forces of the weak spring were negligible compared to the applied muscle forces. The maximal strain was 0.23% in the proximal region of the femoral diaphysis and 1.7% in the contact zone between the tibia and the fibula.

Conclusions

The presented approach based on FE modelling by including muscle forces from inverse dynamic analysis of musculoskeletal RB model can be used to perform analyses of the lower limb with very realistic boundary conditions. In the present form, this model can be used to better understand the loading, stresses and strains of bones in the knee area and hence to analyse osteotomy fixation devices.

     

Biomechanical analysis of the three-dimensional foot structure during gait: a basic tool for clinical applications

A novel three-dimensional numerical model of the foot, incorporating, for the first time in the literature, realistic geometric and material properties of both skeletal and soft tissue components of the foot, was developed for biomechanical analysis of its structural behavior during gait. A system of experimental methods, integrating the optical Contact Pressure Display (CPD) method for plantar pressure measurements and a Digital Radiographic Fluoroscopy (DRF) instrument for acquisition of skeletal motion during gait, was also developed in this study and subsequently used to build the foot model and validate its predictions. Using a Finite Element solver, the stress distribution within the foot structure was obtained and regions of elevated stresses for six subphases of the stance (initial-contact, heel-strike, midstance, forefoot-contact, push-off, and toe-off) were located. For each of these subphases, the model was adapted according to the corresponding fluoroscopic data, skeletal dynamics, and active muscle force loading. Validation of the stress state was achieved by comparing model predictions of contact stress distribution with respective CPD measurements. The presently developed measurement and numerical analysis tools open new approaches for clinical applications, from simulation of the development mechanisms of common foot disorders to pre- and post-interventional evaluation of their treatment.     

Quantitative assessment of trunk deformation during running

The trunk has a multi-segmental structure and is composed of the cervical, thoracic, and lumber spines and surrounding soft tissue elements; this allows flexible deformation during dynamic movements. The purpose of this study was to quantitatively assess trunk deformation during dynamic movement. Ten male subjects performed running at four different speeds: 8 km/h, 10 km/h, 12 km/h, and 14 km/h. Forty reflective markers were placed on the backs of these individuals to define 56 small triangular areas, and three-dimensional kinematic data was recorded with a motion capture system. The coefficients of variation (CV) of the horizontal and vertical lengths between two adjacent markers and the standard deviation (SD) of the normal vectors of triangular areas were calculated as measures for translational and angular trunk deformation, respectively. Up to about 14% of CV and 78° of SD appeared as the measure of translational and angular deformation, respectively. These results imply that the trunk underwent a significant amount of position-specific deformation. These findings would be useful in the construction of an optimal trunk segment model to represent the complex and flexible trunk movement during dynamic movements.     

Repetitive gait of passive bipedal mechanisms in a three-dimensional environment

The inherent dynamics of bipedal, kneed mechanisms are studied with emphasis on the existence and stability, of repetitive gait in a three-dimensional environment, in the absence of external, active control. The investigation is motivated by observations that sustained anthropomorphic locomotion is largely a consequence of geometric and inertial properties of the mechanism. While the modeling excludes active control, the energy dissipated in ground and knee collisions is continuously re-injected by considering gait down slight inclines. The paper describes the dependence of the resulting passive gait in vertically constrained and unconstrained mechanisms on model parameters, such as ground compliance and ground slope. We also show the possibility of achieving statically unstable gait with appropriate parameter choices.     

Quantitative footprinting analysis. Binding to a single site

The theory for measuring ligand binding constants from footprinting autoradiographic data associated with a single binding site is derived. If the ligand and DNA cleavage agent compete for a common site, the spot intensities are not proportional to the amount of DNA not blocked by ligand. The analysis of a single site is experimentally illustrated by using results for the anticancer drug actinomycin D interacting with the duplex d(TAGCGCTA)2 as probed with the hydrolytic enzyme DNase I.     

Quantitative assessment of vaginal microflora during use of tampons of various compositions.

Although the effect of vaginal tampons on the microbial flora during menstruation has recently been studied by several investigators, quantitative effects attributable to particular tampon fibers have received less attention. The purposes of the present study were (i) to determine and then to compare the effects of polyacrylate rayon tampons and viscose rayon tampons on the normal vaginal flora, (ii) to compare quantitative bacterial counts obtained from these tampons with those obtained from concomitant vaginal swabs, and (iii) to determine whether either of these tampon types alters the vaginal microflora when compared with the microflora in the same women using all-cotton tampons or external catamenial pads. Tampon and swab samples were obtained at predetermined times from 18 women for an average of seven menstrual cycles. Samples consisting of swabs from women wearing menstrual pads were compared with swab and tampon samples taken at predetermined times during the menstrual cycle from women using cotton, polyacrylate rayon, or viscose rayon tampons. Samples were analyzed for total aerobic, facultative, and anaerobic bacterial counts. Statistical evaluation of the results indicated that, on the whole, total bacterial counts decreased during menstruation and that the numbers of bacteria in tampons tended to be lower than those in swab samples taken at the same time. The tampon type had little effect on the vaginal microflora.     

Crouched postures reduce the capacity of muscles to extend the hip and knee during the single-limb stance phase of gait

Many children with cerebral palsy walk in a crouch gait that progressively worsens over time, decreasing walking efficiency and leading to joint degeneration. This study examined the effect of crouched postures on the capacity of muscles to extend the hip and knee joints and the joint flexions induced by gravity during the single-limb stance phase of gait. We first characterized representative mild, moderate, and severe crouch gait kinematics based on a large group of subjects with cerebral palsy (N=316). We then used a three-dimensional model of the musculoskeletal system and its associated equations of motion to determine the effect of these crouched gait postures on (1) the capacity of individual muscles to extend the hip and knee joints, which we defined as the angular accelerations of the joints, towards extension, that resulted from applying a 1N muscle force to the model, and (2) the angular acceleration of the joints induced by gravity. Our analysis showed that the capacities of almost all the major hip and knee extensors were markedly reduced in a crouched gait posture, with the exception of the hamstrings muscle group, whose extension capacity was maintained in a crouched posture. Crouch gait also increased the flexion accelerations induced by gravity at the hip and knee throughout single-limb stance. These findings help explain the increased energy requirements and progressive nature of crouch gait in patients with cerebral palsy.     

Real-time gait assessment utilizing a new way of accelerometry

Real-time registration of body segment angles is essential in artificial body position control. A new method is presented for the real-time calculation of the lower extremity angles using data obtained from pairs of two one-dimensional accelerometers. It is shown that, assuming rigid-body dynamics and simple hinge joints, relative angles (i.e. angles between segments) can be calculated without integration, thereby solving the problem of integration drift normally associated with accelerometry. During the stance phase of walking, the relative angles can be transformed to absolute angles (i.e. relative to the gravitational field direction) for the different leg segments. The feasibility of relative angle calculation is demonstrated by calculation of the knee angle of a healthy subject. Stability and resolution were demonstrated with measurements during standing. Measurements during standing up, sitting down and walking showed that shock (heel-strike) and skin movements, due to movements of the underlying muscle tissue, are the main error sources. Additional signal processing, e.g. low-pass filtering, can be used to diminish this error. The accuracy of the knee angle found is shown to be high enough to be used in a feedback controller for functional electrostimulation of the lower extremities.     

Multi-sensor assessment of dynamic balance during gait in patients with subacute stroke

The capacity to maintain upright balance by minimising upper body oscillations during walking, also referred to as gait stability, has been associated with a decreased risk of fall. Although it is well known that fall is a common complication after stroke, no study considered the role of both trunk and head when assessing gait stability in this population. The primary aim of this study was to propose a multi-sensor protocol to quantify gait stability in patients with subacute stroke using gait quality indices derived from pelvis, sternum, and head accelerations. Second, the association of these indices with the level of walking ability, with traditional clinical scale scores, and with fall events occurring within the six months after patients’ dismissal was investigated. The accelerations corresponding to the three abovementioned body levels were measured using inertial sensors during a 10-Meter Walk Test performed by 45 inpatients and 25 control healthy subjects. A set of indices related to gait stability were estimated and clinical performance scales were administered to each patient. The amplitude of the accelerations, the way it is attenuated/amplified from lower to upper body levels, and the gait symmetry provide valuable information about subject-specific motor strategies, discriminate between different levels of walking ability, and correlate with clinical scales. In conclusion, the proposed multi-sensor protocol could represent a useful tool to quantify gait stability, support clinicians in the identification of patients potentially exposed to a high risk of falling, and assess the effectiveness of rehabilitation protocols in the clinical routine.     

The influence and biomechanical role of cartilage split line pattern on tibiofemoral cartilage stress distribution during the stance phase of gait

This study presents an evaluation of the role that cartilage fibre ‘split line’ orientation plays in informing femoral cartilage stress patterns. A two-stage model is presented consisting of a whole knee joint coupled to a tissue-level cartilage model for computational efficiency. The whole joint model may be easily customised to any MRI or CT geometry using free-form deformation. Three ‘split line’ patterns (medial–lateral, anterior–posterior and random) were implemented in a finite element model with constitutive properties referring to this ‘split line’ orientation as a finite element fibre field. The medial–lateral orientation was similar to anatomy and was derived from imaging studies. Model predictions showed that ‘split lines’ are formed along the line of maximum principal strains and may have a biomechanical role of protecting the cartilage by limiting the cartilage deformation to the area of higher cartilage thickness.