Responses to gait perturbations in stroke survivors who prospectively experienced falls or no falls

Background: Steady-state gait characteristics appear promising as predictors of falls in stroke survivors. However, assessing how stroke survivors respond to actual gait perturbations may result in better fall predictions. We hypothesize that stroke survivors who fall have a diminished ability to adequately adjust gait characteristics after gait is perturbed. This study explored whether gait characteristics of perturbed gait differ between fallers and non fallers. Method: Chronic stroke survivors were recruited by clinical therapy practices. Prospective falls were monitored over a six months follow up period. We used the Gait Real-time Analysis Interactive Lab (GRAIL, Motekforce Link B.V., Amsterdam) to assess gait. First we assessed gait characteristics during steady-state gait and second we examined gait responses after six types of gait perturbations. We assessed base of support gait characteristics and margins of stability in the forward and medio-lateral direction. Findings: Thirty eight stroke survivors complete our gait protocol. Fifteen stroke survivors experienced falls. All six gait perturbations resulted in a significant gait deviation. Forward stability was reduced in the fall group during the second step after a ipsilateral perturbation. Interpretation: Although stability was different between groups during a ipsilateral perturbation, it was caused by a secondary strategy to keep up with the belt speed, therefore, contrary to our hypothesis fallers group of stroke survivors have a preserved ability to cope with external gait perturbations as compared to non fallers. Yet, our sample size was limited and thereby, perhaps minor group differences were not revealed in the present study.     

Symmetrical gaits of Cebus apella: implications for the functional significance of diagonal sequence gait in primates

Quadrupedal locomotion of primates is distinguished from the quadrupedalism of many other mammals by several features, including a diagonal sequence (DS) footfall used in symmetrical gaits. This presumably unique feature of primate locomotion has been attributed to an ancestral adaptation for cautious arboreal quadrupedalism on thin, flexible branches. However, the functional significance of DS gait remains largely hypothetical. The study presented here tests hypotheses about the functional significance of DS gait by analyzing the gait mechanics of a primate that alternates between DS and lateral sequence (LS) gaits, Cebus apella. Kinematic and kinetic data were gathered from two subjects as they moved across both terrestrial and simulated arboreal substrates. These data were used to test four hypotheses: (1) locomotion on arboreal supports is associated with increased use of DS gait, (2) DS gait is associated with lower peak vertical substrate reaction forces than LS gait, (3) DS gait is associated with greater forelimb/hind limb differentiation in force magnitudes, and (4) DS gait offers increased stability. Our results indicate that animals preferred DS gait on the arboreal substrate, and LS gait while on the ground. Peak vertical substrate reaction forces showed a tendency to be lower in DS gait, but not consistently so. Pole ("arboreal") forces were lower than ground forces in DS gait, but not in LS gait. The preferred symmetrical gait on both substrates was a grounded run or amble, with the body supported by only one limb throughout most of the stride. During periods of bilateral support, the DS gait had predominantly diagonal support couplets. This benefit for stability on an arboreal substrate is potentially outweighed by overstriding, its associated ipsilateral limb interference in DS gait and hind foot positioning in front of the hand on untested territory. DS gait also did not result in an optimal anchoring position of the hind foot under the center of mass of the body at forelimb touchdown. In sum, the results are mixed regarding the superiority of DS gait in an arboreal setting. Consequently, the notion that DS gait is an ancestral adaptation of primates, conditioned by the selection demands of an arboreal environment, remains largely hypothetical.     

Variations in Kinematics during Clinical Gait Analysis in Stroke Patients

In addition to changes in spatio-temporal and kinematic parameters, patients with stroke exhibit fear of falling as well as fatigability during gait. These changes could compromise interpretation of data from gait analysis. The aim of this study was to determine if the gait of hemiplegic patients changes significantly over successive gait trials. Forty two stroke patients and twenty healthy subjects performed 9 gait trials during a gait analysis session. The mean and variability of spatio-temporal and kinematic joint parameters were analyzed during 3 groups of consecutive gait trials (1–3, 4–6 and 7–9). Principal component analysis was used to reduce the number of variables from the joint kinematic waveforms and to identify the parts of the gait cycle which changed during the gait analysis session. The results showed that i) spontaneous gait velocity and the other spatio-temporal parameters significantly increased, and ii) gait variability decreased, over the last 6 gait trials compared to the first 3, for hemiplegic patients but not healthy subjects. Principal component analysis revealed changes in the sagittal waveforms of the hip, knee and ankle for hemiplegic patients after the first 3 gait trials. These results suggest that at the beginning of the gait analysis session, stroke patients exhibited phase of adaptation,characterized by a “cautious gait” but no fatigue was observed.     

Muscle contributions to support and progression during single-limb stance in crouch gait

Pathological movement patterns like crouch gait are characterized by abnormal kinematics and muscle activations that alter how muscles support the body weight during walking. Individual muscles are often the target of interventions to improve crouch gait, yet the roles of individual muscles during crouch gait remain unknown. The goal of this study was to examine how muscles contribute to mass center accelerations and joint angular accelerations during single-limb stance in crouch gait, and compare these contributions to unimpaired gait. Subject-specific dynamic simulations were created for ten children who walked in a mild crouch gait and had no previous surgeries. The simulations were analyzed to determine the acceleration of the mass center and angular accelerations of the hip, knee, and ankle generated by individual muscles. The results of this analysis indicate that children walking in crouch gait have less passive skeletal support of body weight and utilize substantially higher muscle forces to walk than unimpaired individuals. Crouch gait relies on the same muscles as unimpaired gait to accelerate the mass center upward, including the soleus, vasti, gastrocnemius, gluteus medius, rectus femoris, and gluteus maximus. However, during crouch gait, these muscles are active throughout single-limb stance, in contrast to the modulation of muscle forces seen during single-limb stance in an unimpaired gait. Subjects walking in crouch gait rely more on proximal muscles, including the gluteus medius and hamstrings, to accelerate the mass center forward during single-limb stance than subjects with an unimpaired gait.     

Statistical method for prediction of gait kinematics with Gaussian process regression

We propose a novel methodology for predicting human gait pattern kinematics based on a statistical and stochastic approach using a method called Gaussian process regression (GPR). We selected 14 body parameters that significantly affect the gait pattern and 14 joint motions that represent gait kinematics. The body parameter and gait kinematics data were recorded from 113 subjects by anthropometric measurements and a motion capture system. We generated a regression model with GPR for gait pattern prediction and built a stochastic function mapping from body parameters to gait kinematics based on the database and GPR, and validated the model with a cross validation method. The function can not only produce trajectories for the joint motions associated with gait kinematics, but can also estimate the associated uncertainties. Our approach results in a novel, low-cost and subject-specific method for predicting gait kinematics with only the subject's body parameters as the necessary input, and also enables a comprehensive understanding of the correlation and uncertainty between body parameters and gait kinematics.     

Identifying gait asymmetry using gyroscopes--a cross-correlation and Normalized Symmetry Index approach

Injury to a lower limb may disrupt natural walking and cause asymmetrical gait, therefore assessing the gait asymmetry has become one of the important procedures in gait analysis. This paper proposes the use of wireless gyroscopes as a new instrument to determine gait asymmetry. It also introduces two novel approaches: normalized cross-correlations (Cc(norm)) and Normalized Symmetry Index (SI(norm)). Cc(norm) evaluates the waveform patterns generated by the lower limb in each gait cycle. SI(norm) provides indications on the timing and magnitude of the bilateral differences between the limbs while addressing the drawbacks of the conventional methods. One-way ANOVA test reveals that Cc(norm) can be considered as single value indicator that determines the gait asymmetry (p<0.01). The experiment results showed that SI(norm) in asymmetrical gait were different from normal gait. SI(norm) in asymmetrical gait were found to be approximately 20% greater than SI(norm) in normal gait during pre-swing and initial swing.     

Gait Pattern Differences between Children with Mild Scoliosis and Children with Unilateral Cerebral Palsy

This study was conducted to investigate the effects of asymmetrical body posture alone, i.e., the effects seen in children with mild scoliosis, vs. the effects of body posture control impairment, i.e., those seen in children with unilateral cerebral palsy on gait patterns. Three-dimensional instrumented gait analysis (3DGA) was conducted in 45 children with hemiplegia and 51 children with mild scoliosis. All the children were able to walk without assistance devices. A set of 35 selected spatiotemporal gait and kinematics parameters were evaluated when subjects walked on a treadmill. A cluster analysis revealed 3 different gait patterns: a scoliotic gait pattern and 2 different hemiplegic gait patterns. The results showed that the discrepancy in gait patterns was not simply a lower limb kinematic deviation in the sagittal plane, as expected. Additional altered kinematics, such as pelvic misorientation in the coronal plane in both the stance and swing phases and inadequate stance phase hip ad/abduction, which resulted from postural pattern features, were distinguished between the 3 gait patterns. Our study provides evidence for a strong correlation between postural and gait patterns in children with unilateral cerebral palsy. Information on differences in gait patterns may be used to improve the guidelines for early therapy for children with hemiplegia before abnormal gait patterns are fully established. The gait pathology characteristic of scoliotic children is a potential new direction for treating scoliosis that complements the standard posture and walking control therapy exercises with the use of biofeedback.     

Stumbling with optimal phase reset during gait can prevent a humanoid from falling

The human biped walking shows phase- dependent transient changes in gait trajectory in response to external brief force perturbations. Such responses, referred to as the stumbling reactions, are usually accompanied with phase reset of the walking rhythm. Our previous studies provided evidence, based on a human gait experiment and analyses of mathematical models of gait in the sagittal plane, that an appropriate amount of phase reset in response to a perturbation depended on the gait phase at the perturbation and could play an important role for preventing the walker from a fall, thus increasing gait stability. In this paper, we provide a further material that supports this evidence by a gait experiment on a biped humanoid. In the experiment, the impulsive force perturbations were applied using push-impacts by a pendulum-like hammer to the back of the robot during gait. The responses of the external perturbations were managed by resetting the gait phase with different delays or advancements. The results showed that appropriate amounts of phase resetting contributed to the avoidance of falling against the perturbation during the three-dimensional robot gait. A parallelism with human gait stumbling reactions was discussed.Electronic Supplementary Material Supplementary material is available for this article at and is accessible for authorized users.     

Muscle contracture emulating system for studying artificially induced pathological gait in intact individuals

When studying pathological gait it is important to correctly identify primary gait anomalies originating from damage to the central nervous and musculoskeletal system and separate them from compensatory changes of gait pattern, which is often challenging due to the lack of knowledge related to biomechanics of pathological gait. A mechanical system consisting of specially designed trousers, special shoe arrangement, and elastic ropes attached to selected locations on the trousers and shoes is proposed to allow emulation of muscle contractures of soleus (SOL) and gastrocnemius (GAS) muscles and both SOL-GAS. The main objective of this study was to evaluate and compare gait variability as recorded in normal gait and when being constrained with the proposed system. Six neurologically and orthopedically intact volunteers walked along a 7-m walkway while gait kinematics and kinetics were recorded using VICON motion analysis system and two AMTI forceplates. Statistical analysis of coefficient of variation of kinematics and kinetics as recorded in normal walking and during the most constrained SOL-GAS condition showed comparable gait variability. Inspection of resulting group averaged gait patterns revealed considerable resemblance to a selected clinical example of spastic diplegia, indicating that the proposed mechanical system potentially represents a novel method for studying emulated pathological gait arising from artificially induced muscle contractures in neurologically intact individuals.     

A mobile gait monitoring system for abnormal gait diagnosis and rehabilitation: a pilot study for Parkinson disease patients

Conventional gait rehabilitation treatment does not provide quantitative information on abnormal gait kinematics, and the match of the intervention strategy to the underlying clinical presentation may be limited by clinical expertise and experience. Also the effect of rehabilitation treatment may be reduced as the rehabilitation treatment is achieved only in a clinical setting. In this paper, a mobile gait monitoring system (MGMS) is proposed for the diagnosis of abnormal gait and rehabilitation. The proposed MGMS consists of Smart Shoes and a microsignal processor with a touch screen display. It monitors patients' gait by observing the ground reaction force (GRF) and the center of GRF, and analyzes the gait abnormality. Since visual feedback about patients' GRFs and normal GRF patterns are provided by the MGMS, patients can practice the rehabilitation treatment by trying to follow the normal GRF patterns without restriction of time and place. The gait abnormality proposed in this paper is defined by the deviation between the patient's GRFs and normal GRF patterns, which are constructed as GRF bands. The effectiveness of the proposed gait analysis methods with the MGMS has been verified by preliminary trials with patients suffering from gait disorders.     

A study of gait acceleration and synchronisation in healthy adult subjects

Accelerometry-based gait analysis is widely recognised as a promising tool in healthcare and clinical settings since it is unobtrusive, inexpensive and capable of providing insightful information on human gait characteristics. In order to expand the application of this technology in daily environments, it is desirable to develop reliable gait measures and their extraction methods from the acceleration signal that can differentiate between normal and atypical gait. Important examples of such measures are gait cycle and gait-induced acceleration magnitude, which are known to be closely related to each other depending on each individual's physical condition. In this study, we derive a model equation with two parameters which captures the essential relationships between gait cycle and gait acceleration based on experiments and physical modelling. We also introduce as a new gait parameter a set of indexes to evaluate the synchronisation behaviour of gait timing. The function and utility of the proposed parameters are examined in 11 healthy subjects during walking under various selected conditions.     

The effect of uphill and downhill walking on gait parameters: A self-paced treadmill study

It has been shown that gait parameters vary systematically with the slope of the surface when walking uphill (UH) or downhill (DH) (Andriacchi et al., 1977; Crowe et al., 1996; Kawamura et al., 1991; Kirtley et al., 1985; McIntosh et al., 2006; Sun et al., 1996). However, gait trials performed on inclined surfaces have been subject to certain technical limitations including using fixed speed treadmills (TMs) or, alternatively, sampling only a few gait cycles on inclined ramps. Further, prior work has not analyzed upper body kinematics. This study aims to investigate effects of slope on gait parameters using a self-paced TM (SPTM) which facilitates more natural walking, including measuring upper body kinematics and gait coordination parameters.Gait of 11 young healthy participants was sampled during walking in steady state speed. Measurements were made at slopes of +10°, 0° and −10°. Force plates and a motion capture system were used to reconstruct twenty spatiotemporal gait parameters. For validation, previously described parameters were compared with the literature, and novel parameters measuring upper body kinematics and bilateral gait coordination were also analyzed.Results showed that most lower and upper body gait parameters were affected by walking slope angle. Specifically, UH walking had a higher impact on gait kinematics than DH walking. However, gait coordination parameters were not affected by walking slope, suggesting that gait asymmetry, left-right coordination and gait variability are robust characteristics of walking. The findings of the study are discussed in reference to a potential combined effect of slope and gait speed. Follow-up studies are needed to explore the relative effects of each of these factors.     

Cortical and spinal control of ankle joint muscles before and during gait initiation

The purpose of this study was to investigate control of the ankle joint muscles before and during gait initiation. Seven healthy humans, aged 20-30 years old, participated in this study. Motor-evoked potentials (MEPs) were recorded from the soleus and the tibialis anterior muscles, and H-reflexes were evoked from the soleus muscle in the stance leg of gait initiation. The soleus H-reflexes were depressed throughout all the periods before and during gait initiation. The soleus MEP amplitudes were decreased in some periods before gait initiation, but were increased in other periods before and during gait initiation. The MEP amplitudes in the tibialis anterior muscle were increased before the onset of the EMG activity, and this increase persisted through gait initiation. The findings indicate that the ankle joint flexor is under intensive cortico-spinal control before and during gait initiation. Both the cortical and spinal pathways are involved in preparing and controlling the activity of the ankle joint extensor for gait initiation.     

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.     

A machine learning approach for automated recognition of movement patterns using basic, kinetic and kinematic gait data

This paper investigated application of a machine learning approach (Support vector machine, SVM) for the automatic recognition of gait changes due to ageing using three types of gait measures: basic temporal/spatial, kinetic and kinematic. The gaits of 12 young and 12 elderly participants were recorded and analysed using a synchronized PEAK motion analysis system and a force platform during normal walking. Altogether, 24 gait features describing the three types of gait characteristics were extracted for developing gait recognition models and later testing of generalization performance. Test results indicated an overall accuracy of 91.7% by the SVM in its capacity to distinguish the two gait patterns. The classification ability of the SVM was found to be unaffected across six kernel functions (linear, polynomial, radial basis, exponential radial basis, multi-layer perceptron and spline). Gait recognition rate improved when features were selected from different gait data type. A feature selection algorithm demonstrated that as little as three gait features, one selected from each data type, could effectively distinguish the age groups with 100% accuracy. These results demonstrate considerable potential in applying SVMs in gait classification for many applications.     

Biomechanics and physiology of gait selection in flying birds

Two wing-beat gaits, distinguished by the presence or absence of lift production during the upstroke, are currently used to describe avian flight. Vortex-visualization studies indicate that lift is produced only during the downstroke in the vortex-ring gait and that lift is produced continuously in the continuous-vortex gait. Tip-reversal and feathered upstrokes represent different forms of vortex-ring gait distinguished by wing kinematics. Useful aerodynamic forces may be produced during tip-reversal upstroke in slow flight and during a feathered upstroke in fast flight, but it is probable that downstroke forces are much greater in magnitude. Uncertainty about the function of these types of upstroke may be resolved when more data are available on wake structure in different flight speeds and modes. Inferring from wing kinematics and available data on wake structure, birds with long wings or wings of high aspect ratio use a vortex-ring gait with tip-reversal upstroke at slow speeds, a vortex-ring gait with a feathered upstroke at intermediate speeds, and a continuous-vortex gait at fast speeds. Birds with short wings or wings of low aspect ratio use a vortex-ring gait with a feathered upstroke at all speeds. Regardless of wing shape, species tend to use a vortex-ring gait for acceleration and a continuous-vortex gait for deceleration. Some correlations may exist between gait selection and the function of the muscular and respiratory system. However, overall variation in wing kinematics, muscle activity, and respiratory activity is continuous rather than categorical. To further our understanding of gait selection in flying birds, it is important to test whether upstroke function varies in a similar manner. Transitions between lifting and nonlifting upstrokes may be more subtle and gradual than implied by a binomial scheme of classification.     

Two-dimensional video-based analysis of human gait using pose estimation

Human gait analysis is often conducted in clinical and basic research, but many common approaches (e.g., three-dimensional motion capture, wearables) are expensive, immobile, data-limited, and require expertise. Recent advances in video-based pose estimation suggest potential for gait analysis using two-dimensional video collected from readily accessible devices (e.g., smartphones). To date, several studies have extracted features of human gait using markerless pose estimation. However, we currently lack evaluation of video-based approaches using a dataset of human gait for a wide range of gait parameters on a stride-by-stride basis and a workflow for performing gait analysis from video. Here, we compared spatiotemporal and sagittal kinematic gait parameters measured with OpenPose (open-source video-based human pose estimation) against simultaneously recorded three-dimensional motion capture from overground walking of healthy adults. When assessing all individual steps in the walking bouts, we observed mean absolute errors between motion capture and OpenPose of 0.02 s for temporal gait parameters (i.e., step time, stance time, swing time and double support time) and 0.049 m for step lengths. Accuracy improved when spatiotemporal gait parameters were calculated as individual participant mean values: mean absolute error was 0.01 s for temporal gait parameters and 0.018 m for step lengths. The greatest difference in gait speed between motion capture and OpenPose was less than 0.10 m s⁻¹. Mean absolute error of sagittal plane hip, knee and ankle angles between motion capture and OpenPose were 4.0°, 5.6° and 7.4°. Our analysis workflow is freely available, involves minimal user input, and does not require prior gait analysis expertise. Finally, we offer suggestions and considerations for future applications of pose estimation for human gait analysis.     

Biomechanical mechanism of lateral trunk lean gait for knee osteoarthritis patients

The biomechanical mechanism of lateral trunk lean gait employed to reduce external knee adduction moment (KAM) for knee osteoarthritis (OA) patients is not well known. This mechanism may relate to the center of mass (COM) motion. Moreover, lateral trunk lean gait may affect motor control of the COM displacement. Uncontrolled manifold (UCM) analysis is an evaluation index used to understand motor control and variability of the motor task. Here we aimed to clarify the biomechanical mechanism to reduce KAM during lateral trunk lean gait and how motor variability controls the COM displacement. Twenty knee OA patients walked under two conditions: normal and lateral trunk lean gait conditions. UCM analysis was performed with respect to the COM displacement in the frontal plane. We also determined how the variability is structured with regards to the COM displacement as a performance variable. The peak KAM under lateral trunk lean gait was lower than that under normal gait. The reduced peak KAM observed was accompanied by medially shifted knee joint center, shortened distance of the center of pressure to knee joint center, and shortened distance of the knee–ground reaction force lever arm during the stance phase. Knee OA patients with lateral trunk lean gait could maintain kinematic synergy by utilizing greater segmental configuration variance to the performance variable. However, the COM displacement variability of lateral trunk lean gait was larger than that of normal gait. Our findings may provide clinical insights to effectively evaluate and prescribe gait modification training for knee OA patients.     

Etiology and modification of gait instability in older adults: a randomized controlled trial of exercise.

Increased gait instability is common in older adults, even in the absence of overt disease. The goal of the present study was to quantitatively investigate the factors that contribute to gait instability and its potential reversibility in functionally impaired older adults. We studied 67 older men and women with functional impairment before and after they participated in a randomized placebo-controlled, 6-mo multimodal exercise trial. We found that 1) gait instability is multifactorial; 2) stride time variability is strongly associated with functional status and performance-based measures of function that have previously been shown to predict significant clinical outcomes such as morbidity and nursing home admission; 3) neuropsychological status and health-related quality of life play important, independent roles in gait instability; and 4) improvement in physiological capacity is associated with reduced gait instability. Although the etiology of gait instability in older persons with mild-moderate functional impairment is multifactorial, interventions designed to reduce gait instability may be effective in bringing about a more consistent and more stable walking pattern.     

The frequency content of gait

We address amplification of noise in double differentiation of position histories for dynamic analysis of gait. Measurements of the frequency domain characteristics of signal and noise are required to quantitatively assess errors in raw, filtered, and dynamic gait data. The results of a simple technique to determine the frequency content of gait using a population of 12 subjects and a total of 30 gait records is presented.