Feasibility of a gait retraining strategy for reducing knee joint loading: increased trunk lean guided by real-time biofeedback

The purpose of this feasibility study was to examine changes in frontal plane knee and hip walking biomechanics following a gait retraining strategy focused on increasing lateral trunk lean and to quantify reports of difficulty and joint discomfort when performing such a gait modification. After undergoing a baseline analysis of normal walking, 9 young, healthy participants were trained to modify their gait to exhibit small (4°), medium (8°), and large (12°) amounts of lateral trunk lean. Training was guided by the use of real-time biofeedback of the actual trunk lean angle. Peak frontal plane external knee and hip joint moments were compared across conditions. Participants were asked to report the degree of difficulty and the presence of any joint discomfort for each amount of trunk lean modification. Small (4°), medium (8°), and large (12°) amounts of lateral trunk lean reduced the peak external knee adduction moment (KAM) by 7%, 21%, and 25%, respectively, though the peak KAM was only significantly less in the medium and large conditions (p<0.001). Increased trunk lean also significantly reduced the peak external hip adduction moments (p<0.001). All participants reported at least some difficulty performing the exaggerated trunk lean pattern and three participants reported ipsilateral knee, hip, and/or lower spine discomfort. Results from this study indicate that a gait pattern with increased lateral trunk lean can effectively reduce frontal plane joint moments. Though these findings have implications for pathological populations, learning this gait pattern was associated with some difficulty and joint discomfort.     

Implications of increased medio-lateral trunk sway for ambulatory mechanics

The purposes of this study was to test a mechanism to reduce the knee adduction moment by testing the hypothesis that increased medio-lateral trunk sway can reduce the knee adduction moment during ambulation in healthy subjects, and to examine the possibility that increasing medio-lateral trunk sway can produce similar potentially adverse secondary gait changes previously associated with reduced knee adduction moments in patients with knee osteoarthritis. Nineteen healthy adults performed walking trials with normal and increased medio-lateral trunk sway at a self-selected normal walking speed. Standard gait analysis was used to calculate three-dimensional lower extremity joint kinematics and kinetics. Knee and hip adduction moments were lower (-65.0% and -57.1%, respectively) for the increased medio-lateral trunk sway trials than for the normal trunk sway trials. Knee flexion angle at heel-strike was 3 degrees higher for the increased than for the normal trunk sway trials. Knee and hip abduction moments were higher for the increased medio-lateral trunk sway trials, and none of the other variables differed between the two conditions. Walking with increased medio-lateral trunk sway substantially reduces the knee adduction moment during walking in healthy subjects without some of the adverse secondary effects such as increased axial loading rates at the major joints of the lower extremity. This result supports the potential of using gait retraining for walking with increased medio-lateral trunk sway as treatment for patients with degenerative joint disease such as medial compartment knee osteoarthritis.     

Experimental quadriceps muscle pain impairs knee joint control during walking.

Pain is a cardinal symptom in musculoskeletal diseases involving the knee joint, and aberrant movement patterns and motor control strategies are often present in these patients. However, the underlying neuromuscular mechanisms linking pain to movement and motor control are unclear. To investigate the functional significance of muscle pain on knee joint control during walking, three-dimensional gait analyses were performed before, during, and after experimentally induced muscle pain by means of intramuscular injections of hypertonic saline (5.8%) into vastus medialis (VM) muscle of 20 healthy subjects. Isotonic saline (0.9%) was used as control. Surface electromyography (EMG) recordings of VM, vastus lateralis (VL), biceps femoris, and semitendinosus muscles were synchronized with the gait analyses. During experimental muscle pain, the loading response phase peak knee extensor moments were attenuated, and EMG activity in the VM and VL muscles was reduced. Compressive forces, adduction moments, knee joint kinematics, and hamstring EMG activity were unaffected by pain. Interestingly, the observed changes persisted when the pain had vanished. The results demonstrate that muscle pain modulated the function of the quadriceps muscle, resulting in impaired knee joint control and joint instability during walking. The changes are similar to those observed in patients with knee pain. The loss of joint control during and after pain may leave the knee joint prone to injury and potentially participate in the chronicity of musculoskeletal problems, and it may have clinically important implications for rehabilitation and training of patients with knee pain of musculoskeletal origin.     

Knee moment outcomes using inverse dynamics and the cross product function in moderate knee osteoarthritis gait: A comparison study

Inverse dynamics are the cornerstone of biomechanical assessments to calculate knee moments during walking. In knee osteoarthritis, these outcomes have been used to understand knee pathomechanics, but the complexity of an inverse dynamic model may limit the uptake of joint moments in some clinical and research structures. The objective was to determine whether discrete features of the sagittal and frontal plane knee moments calculated using inverse dynamics compare to knee moments calculated using a cross product function. Knee moments from 74 people with moderate knee osteoarthritis were assessed after ambulating at a self-selected speed on an instrumented dual belt treadmill. Standardized procedures were used for surface marker placement, gait speed determination and data processing. Net external frontal and sagittal plane knee moments were calculated using inverse dynamics and the three-dimensional position of the knee joint center with respect to the center of pressure was crossed with the three-dimensional ground reaction forces in the cross product function. Correlations were high between outcomes of the moment calculations (r > 0.9) and for peak knee adduction moment, knee adduction moment impulse and difference between peak flexion and extension moments, the cross product function resulted in absolute values less than 10% of those calculated using inverse dynamics in this treadmill walking environment. This computational solution may allow the integration of knee moment calculations to understand knee osteoarthritis gait without data collection or computational complexity.     

Proximal gait adaptations in individuals with knee osteoarthritis: A systematic review and meta-analysis

Clarifying proximal gait adaptations as a strategy to reduce knee joint loading and pain for individuals with knee osteoarthritis (OA) contributes to understanding the pathogenesis of multi-articular OA changes and musculoskeletal pain in other joints. We aimed to determine whether biomechanical alterations in knee OA patients during level walking is increased upper trunk lean in the frontal and sagittal planes, and subsequent alteration in external hip adduction moment (EHAM) and external hip flexion moment (EHFM). A literature search was conducted in PubMed, PEDro, CINAHL, and Cochrane CENTRAL through May 2018. Where possible, data were combined into a meta-analysis; pooled standardized mean differences (SMD) of between knee OA patients and healthy adults were calculated using a random-effect model. In total, 32 articles (2037 participants, mean age, 63.0 years) met inclusion criteria. Individuals with knee OA had significantly increased lateral trunk lean toward the ipsilateral limb (pooled SMD: 1.18; 95% CI: 0.59, 1.77) along with significantly decreased EHAM. These subjects also displayed a non-significantly increased trunk/pelvic flexion angle and EHFM. The GRADE approach judged all measures as “very low.” These results may indicate that biomechanical alterations accompanying knee OA are associated with increased lateral trunk lean and ensuing alterations in EHAM. Biomechanical alterations in the sagittal plane were not evident. Biomechanical adaptations might have negative sequelae, such as secondary hip abductor muscle weakness and low back pain. Thus, investigations of negative sequelae due to proximal gait adaptations are warranted.     

Kinematics and kinetics of the lower extremities of young and elder women during stairs ascent while wearing low and high-heeled shoes

The effect of the heel height on the temporal, kinematic and kinetic parameters was investigated in 16 young and 11 elderly females. Kinematic and kinetic data were collected when the subjects ascended stairs with their preferred speed in two conditions: wearing low-heeled shoes (LHS), and high-heeled shoes (HHS). The younger adults showed more adjustments in forces and moments at the knee and hip in frontal and transverse planes. Besides a few significantly changes in joint forces and moments, the elder group demonstrated longer cycle duration and double stance phase, larger trunk sideflexion and hip internal rotation, less hip adduction while wearing HHS. Most differences in joint motions between two groups were found at the hip and knee either in LHS or HHS condition. Instead, the differences in moment occurred at the hip joint and only in HHS. The interaction of the heel height and age showed the influences of heel height on trunk rotation, hip abduction/adduction, and knee and hip force and moment at the frontal plane depended on age. These phenomena suggest that younger and elderly women adapt their gait and postural control differently during stair ascent (SA) while wearing HHS.     

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.     

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.     

Jogging gait kinetics following fatiguing lumbar paraspinal exercise

A relationship exists between lumbar paraspinal muscle fatigue and quadriceps muscle activation. The objective of this study was to determine whether hip and knee joint moments during jogging changed following paraspinal fatiguing exercise. Fifty total subjects (25 with self-reported history of low back pain) performed fatiguing, isometric lumbar extension exercise until a shift in EMG median frequency corresponding to a mild level of muscle fatigue was observed. We compared 3-dimensional external joint moments of the hip and knee during jogging before and after lumbar paraspinal fatigue using a 10-camera motion analysis system. Reduced external knee flexion, knee adduction, knee internal rotation and hip external rotation moments and increased external knee extension moments resulted from repetitive lumbar paraspinal fatiguing exercise. Persons with a self-reported history of LBP had larger knee flexion moments than controls during jogging. Neuromuscular changes in the lower extremity occur while resisting knee and hip joint moments following isolated lumbar paraspinal exercise. Persons with a history of LBP seem to rely more heavily on quadriceps activity while jogging.     

Hip joint moments in symptomatic vs. asymptomatic people with mild radiographic hip osteoarthritis

Our primary objective was to examine external hip joint moments during walking in people with mild radiographic hip osteoarthritis (OA) with and without symptoms and disease-free controls. Three groups were compared (symptomatic with mild radiographic hip OA, n = 12; asymptomatic with mild radiographic hip OA, n = 13; OA-free controls, n = 20). Measures of the external moment (peak and impulse) in the sagittal, frontal and transverse plane during walking were determined. Variables were compared according to group allocation using mixed linear regression models that included individual gait trials, with group allocation as fixed effect and walking speed as a random effect. Participants with evidence of radiographic disease irrespective of symptoms walked 14–16% slower compared to disease-free controls (p = 0.002). Radiographic disease without symptoms was not associated with any altered measures of hip joint moment compared to asymptomatic OA-free controls once speed was taken into account (p ≥ 0.099). People with both mild radiographic disease and symptoms had lower external peak hip adduction moment (p = 0.005) and lower external peak internal rotation moment (p < 0.001) accounting for walking speed. Among angular impulses, only the presence of symptoms was associated with a reduced hip internal rotation impulse (p = 0.002) in the symptomatic group. Collectively, our observations suggest that symptoms have additional mechanical associations from radiographic disease alone, and provide insight into potential early markers of hip OA. Future research is required to understand the implications of modifying walking speed and/or the external hip adduction and internal rotation moment in people with mild hip OA.     

Females and males use different hip and knee mechanics in response to symmetric military-relevant loads

The purpose of this study was to determine if females and males use different hip and knee mechanics when walking with standardized military-relevant symmetric loads. Fifteen females and fifteen males walked on a treadmill for 2-min at a constant speed under three symmetric load conditions (unloaded: 1.71 kg, medium: 15 kg, heavy: 26 kg). Kinematic and kinetics of the hip and knee were calculated in the sagittal and frontal planes of the dominant limb. In females, hip abduction moments (normalized to total mass) and sagittal knee excursion decreased with increased load (p ≤ 0.024). In males, hip frontal excursion and adduction angle increased with load (p ≤ 0.003). Females had greater peak hip adduction angle than males in the unloaded and medium load conditions (p ≤ 0.036). Across sex, sagittal hip and knee excursion, peak knee extension angle, and peak hip and knee flexion angles increased with increased load (p ≤ 0.005). When normalized to body mass, all peak joint moments increased with each load (p ≤ 0.016) except peak hip adduction moment. When normalized to total mass, peak hip adduction moment and knee flexion, extension, and adduction moments decreased with each load (p < 0.001). While hip frontal plane kinetic alterations to load were only noted in females, kinematic changes were noted in males at the hip and females at the knee. Differences in strategies may increase the risk of hip and knee injuries in females compared to males. This study noted load and sex effects that were previously undetected, highlighting the importance of using military-relevant standardized loads and investigating frontal plane adaptations.     

Effects of asymmetric load carrying on the biomechanics of walking

The purpose of the study was to investigate the effects of an asymmetric sidepack carrying system on frontal plane joint moments of force in both lower extremities and in the L5/S1 joint during level walking. Ground reaction force data and frontal plane film records were obtained from five males performing three walking conditions: 0, 10 and 20% bodyweight loads in a sidepack supported by the left shoulder. Inverse dynamics were used to calculate the lower extremity moments during stance and a static model of the pelvis was used to calculate the L5/S1 moments during single support for each limb. Normal walking was characterized by symmetric kinetics between left and right limbs and around the L5/S1 joint. The asymmetric loads produced unbalanced lateral trunk muscle dominance between left and right limb stance phases, increased right hip and knee moments and decreased left hip and knee moments. During normal walking, the L5/S1 moment was dominant on the contralateral trunk side for both limbs. The asymmetric loads applied to the left side caused a shift in L5/S1 moment dominance to the right side during left and right single support phases.     

Invariant hip moment pattern while walking with a robotic hip exoskeleton

Robotic lower limb exoskeletons hold significant potential for gait assistance and rehabilitation; however, we have a limited understanding of how people adapt to walking with robotic devices. The purpose of this study was to test the hypothesis that people reduce net muscle moments about their joints when robotic assistance is provided. This reduction in muscle moment results in a total joint moment (muscle plus exoskeleton) that is the same as the moment without the robotic assistance despite potential differences in joint angles. To test this hypothesis, eight healthy subjects trained with the robotic hip exoskeleton while walking on a force-measuring treadmill. The exoskeleton provided hip flexion assistance from approximately 33% to 53% of the gait cycle. We calculated the root mean squared difference (RMSD) between the average of data from the last 15 min of the powered condition and the unpowered condition. After completing three 30-min training sessions, the hip exoskeleton provided 27% of the total peak hip flexion moment during gait. Despite this substantial contribution from the exoskeleton, subjects walked with a total hip moment pattern (muscle plus exoskeleton) that was almost identical and more similar to the unpowered condition than the hip angle pattern (hip moment RMSD 0.027, angle RMSD 0.134, p<0.001). The angle and moment RMSD were not different for the knee and ankle joints. These findings support the concept that people adopt walking patterns with similar joint moment patterns despite differences in hip joint angles for a given walking speed.     

Walking on high heels changes muscle activity and the dynamics of human walking significantly

The aim of the study was to investigate the distribution of net joint moments in the lower extremities during walking on high-heeled shoes compared with barefooted walking at identical speed. Fourteen female subjects walked at 4 km/h across three force platforms while they were filmed by five digital video cameras operating at 50 frames/second. Both barefooted walking and walking on high-heeled shoes (heel height: 9 cm) were recorded. Net joint moments were calculated by 3D inverse dynamics. EMG was recorded from eight leg muscles. The knee extensor moment peak in the first half of the stance phase was doubled when walking on high heels. The knee joint angle showed that high-heeled walking caused the subjects to flex the knee joint significantly more in the first half of the stance phase. In the frontal plane a significant increase was observed in the knee joint abductor moment and the hip joint abductor moment. Several EMG parameters increased significantly when walking on high-heels. The results indicate a large increase in bone-on-bone forces in the knee joint directly caused by the increased knee joint extensor moment during high-heeled walking, which may explain the observed higher incidence of osteoarthritis in the knee joint in women as compared with men.     

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.     

Knee biomechanics of moderate OA patients measured during gait at a self-selected and fast walking speed

Osteoarthritis (OA) is a chronic disorder resulting in degenerative changes to the knee joint. Three-dimensional gait analysis provides a unique method of measuring knee dynamics during activities of daily living such as walking. The purpose of this study was to identify biomechanical features characterizing the gait of patients with mild-to-moderate knee OA and to determine if the biomechanical differences become more pronounced as the locomotor system is stressed by walking faster. Principal component analysis was used to compare the gait patterns of a moderate knee OA group (n=41) and a control group (n=43). The subjects walked at their self-selected speed as well as at 150% of that speed. The two subject groups did not differ in knee joint angles, stride length, and stride time or walking speed. Differences in the magnitude and shape of the knee joint moment waveforms were found between the two groups. The OA group had larger adduction moment magnitudes during stance and this higher magnitude was sustained for a longer portion of the gait cycle. The OA group also had a reduced flexion moment and a reduced external rotation moment during early stance. Increasing speed was associated with an increase in the magnitude of all joint moments. The fast walks did not, however, increase or bring out any biomechanical differences between the OA and control groups that did not exist at the self-selected walks.     

Propulsion Phase of the Single Leg Triple Hop Test in Women with Patellofemoral Pain Syndrome: A Biomechanical Study

Asymmetry in the alignment of the lower limbs during weight-bearing activities is associated with patellofemoral pain syndrome (PFPS), caused by an increase in patellofemoral (PF) joint stress. High neuromuscular demands are placed on the lower limb during the propulsion phase of the single leg triple hop test (SLTHT), which may influence biomechanical behavior. The aim of the present cross-sectional study was to compare kinematic, kinetic and muscle activity in the trunk and lower limb during propulsion in the SLTHT using women with PFPS and pain free controls. The following measurements were made using 20 women with PFPS and 20 controls during propulsion in the SLTHT: kinematics of the trunk, pelvis, hip, and knee; kinetics of the hip, knee and ankle; and muscle activation of the gluteus maximus (GM), gluteus medius (GMed), biceps femoris (BF) and vastus lateralis (VL). Differences between groups were calculated using three separate sets of multivariate analysis of variance for kinematics, kinetics, and electromyographic data. Women with PFPS exhibited ipsilateral trunk lean; greater trunk flexion; greater contralateral pelvic drop; greater hip adduction and internal rotation; greater ankle pronation; greater internal hip abductor and ankle supinator moments; lower internal hip, knee and ankle extensor moments; and greater GM, GMed, BL, and VL muscle activity. The results of the present study are related to abnormal movement patterns in women with PFPS. We speculated that these findings constitute strategies to control a deficient dynamic alignment of the trunk and lower limb and to avoid PF pain. However, the greater BF and VL activity and the extensor pattern found for the hip, knee, and ankle of women with PFPS may contribute to increased PF stress.     

Strong independent associations between gait biomechanics and pain in patients with knee osteoarthritis

We investigated the simple and multivariate associations between knee pain and gait biomechanics. 279 patients with medial knee osteoarthritis (OA) and discordant changes in pain between limbs after walking completed bilateral three-dimensional gait analysis. For each limb, patients rated their pain before and after a 6-min walk and the change in pain was recorded as an increase (≥1 points) or not (≤0 points). Among paired limbs, the simple and multivariate associations between an increase in pain and the external moments in each orthogonal plane were evaluated using conditional logistic regression. The analyses were then repeated for knee angles. Univariate analyses demonstrated associations in each plane that varied in both magnitude and direction, with larger associations for the knee moments [Odds Ratio (95% confidence interval) = first peak adduction moment: 2.80 (2.02, 3.88), second peak adduction moment: 2.36 (1.73, 3.24), adduction impulse: 6.65 (3.50, 12.62), flexion moment: 0.46 (0.36, 0.60), extension moment: 0.56 (0.44, 0.71), internal rotation moment: 7.54 (3.32, 17.13), external rotation moment: 0.001 (0.00, 0.04)]. Multivariate analyses with backward elimination resulted in a model including only the adduction impulse [5.35 (2.51, 11.42)], flexion moment [0.32 (0.22, 0.46)] and extension moment [0.28 (0.19, 0.42)]. The varus, flexion and extension angles were included in the final multivariate model for the knee angles. When between-person confounding is lessened by comparing limbs within patients, there are strong independent associations between knee pain and multiple external knee moments that vary in magnitude and direction. While controlling for other knee moments, a greater adduction impulse and lower flexion and extension moments were independently associated with greater odds of an increase in pain.