Muscle contributions to support during gait in an individual with post-stroke hemiparesis

Walking requires coordination of muscles to support the body during single stance. Impaired ability to coordinate muscles following stroke frequently compromises walking performance and results in extremely low walking speeds. Slow gait in post-stroke hemiparesis is further complicated by asymmetries in lower limb muscle excitations. The objectives of the current study were: (1) to compare the muscle coordination patterns of an individual with flexed stance limb posture secondary to post-stroke hemiparesis with that of healthy adults walking very slowly, and (2) to identify how paretic and non-paretic muscles provide support of the body center of mass in this individual. Simulations were generated based on the kinematics and kinetics of a stroke survivor walking at his self-selected speed (0.3 m/s) and of three speed-matched, healthy older individuals. For each simulation, muscle forces were perturbed to determine the muscles contributing most to body weight support (i.e., height of the center of mass during midstance). Differences in muscle excitations and midstance body configuration caused paretic and non-paretic ankle plantarflexors to contribute less to midstance support than in healthy slow gait. Excitation of paretic ankle dorsiflexors and knee flexors during stance opposed support and necessitated compensation by knee and hip extensors. During gait for an individual with post-stroke hemiparesis, adequate body weight support is provided via reorganized muscle coordination patterns of the paretic and non-paretic lower limbs relative to healthy slow gait.     

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.     

Muscle contributions to propulsion and support during running

Muscles actuate running by developing forces that propel the body forward while supporting the body’s weight. To understand how muscles contribute to propulsion (i.e., forward acceleration of the mass center) and support (i.e., upward acceleration of the mass center) during running we developed a three-dimensional muscle-actuated simulation of the running gait cycle. The simulation is driven by 92 musculotendon actuators of the lower extremities and torso and includes the dynamics of arm motion. We analyzed the simulation to determine how each muscle contributed to the acceleration of the body mass center. During the early part of the stance phase, the quadriceps muscle group was the largest contributor to braking (i.e., backward acceleration of the mass center) and support. During the second half of the stance phase, the soleus and gastrocnemius muscles were the greatest contributors to propulsion and support. The arms did not contribute substantially to either propulsion or support, generating less than 1% of the peak mass center acceleration. However, the arms effectively counterbalanced the vertical angular momentum of the lower extremities. Our analysis reveals that the quadriceps and plantarflexors are the major contributors to acceleration of the body mass center during running.     

Muscle contributions to support and progression over a range of walking speeds

Muscles actuate walking by providing vertical support and forward progression of the mass center. To quantify muscle contributions to vertical support and forward progression (i.e., vertical and fore-aft accelerations of the mass center) over a range of walking speeds, three-dimensional muscle-actuated simulations of gait were generated and analyzed for eight subjects walking overground at very slow, slow, free, and fast speeds. We found that gluteus maximus, gluteus medius, vasti, hamstrings, gastrocnemius, and soleus were the primary contributors to support and progression at all speeds. With the exception of gluteus medius, contributions from these muscles generally increased with walking speed. During very slow and slow walking speeds, vertical support in early stance was primarily provided by a straighter limb, such that skeletal alignment, rather than muscles, provided resistance to gravity. When walking speed increased from slow to free, contributions to support from vasti and soleus increased dramatically. Greater stance-phase knee flexion during free and fast walking speeds caused increased vasti force, which provided support but also slowed progression, while contralateral soleus simultaneously provided increased propulsion. This study provides reference data for muscle contributions to support and progression over a wide range of walking speeds and highlights the importance of walking speed when evaluating muscle function.     

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.     

Effects of bilateral medial knee osteoarthritis on intra- and inter-limb contributions to body support during gait

Patients with knee OA show altered gait patterns, affecting their quality of living. The current study aimed to quantify the effects of bilateral knee OA on the intra-limb and inter-limb sharing of the support of the body during gait. Fifteen patients with mild, 15 with severe bilateral knee OA, and 15 healthy controls walked along a walkway while the kinematic and kinetic data were measured. Compared with the controls, the patients significantly reduced their knee extensor moments and the corresponding contributions to the total support moment in the sagittal plane (p<0.05). For compensation, the mild OA group significantly increased the hip extensor moments (p<0.05) to maintain close-to-normal support and a more symmetrical inter-limb load-sharing during double-limb support. The severe OA group involved compensatory actions of both the ankle and hip, but did not succeed in maintaining a normal sagittal total support moment during late stance, nor a symmetrical inter-limb load-sharing during double-limb support. In the frontal plane, the knee abductor moments and the corresponding contributions to the total support moment were not affected by the changes in the other joints, regardless of the severity of the disease. The observed compensatory changes suggest that strengthening of weak hip muscles is essential for body support during gait in patients with knee OA, but that training of weak ankle muscles may also be needed for patients with severe knee OA.     

Muscle contributions to mediolateral and anteroposterior foot placement during walking

Foot placement is critical to balance control during walking and is primarily controlled by muscle force generation. Although gluteus medius activity has been associated with mediolateral foot placement, how other muscles contribute to foot placement is not clear. Furthermore, although dynamic walking models have suggested that anteroposterior foot placement can be passively controlled, the extent to which muscles actively contribute to anteroposterior foot placement has not been determined. The objective of this study was to identify individual muscle contributions to mediolateral and anteroposterior foot placement during walking in healthy adults. Dynamic simulations of walking were developed for six older adults and a segmental power analysis was performed to determine the individual muscle contributions to the mediolateral and anteroposterior power delivered to the foot segment. The simulations revealed the ipsilateral swing limb gluteus medius, iliopsoas, rectus femoris and hamstrings and the contralateral stance limb gluteus medius and ankle plantarflexors were primary contributors to both mediolateral and anteroposterior foot placement. Muscle contributions to foot placement were found to be highly influenced by their contributions to pelvis power, which was dominated by those muscles crossing the hip joint. Thus, impaired balance control may be improved by focusing rehabilitation interventions on optimizing the coordination of those muscles crossing the hip joint and the ankle plantarflexors.     

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).     

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.     

Muscle contributions to whole-body sagittal plane angular momentum during walking

Walking is a complex dynamic task that requires the regulation of whole-body angular momentum to maintain dynamic balance while performing walking subtasks such as propelling the body forward and accelerating the leg into swing. In human walking, the primary mechanism to regulate angular momentum is muscle force generation. Muscles accelerate body segments and generate ground reaction forces that alter angular momentum about the body’s center-of-mass to restore and maintain dynamic stability. In addition, gravity contributes to whole-body angular momentum through its contribution to the ground reaction forces. The purpose of this study was to generate a muscle-actuated forward dynamics simulation of normal walking to quantify how individual muscles and gravity contribute to whole-body angular momentum in the sagittal plane. In early stance, the uniarticular hip and knee extensors (GMAX and VAS), biarticular hamstrings (HAM) and ankle dorsiflexors (TA) generated backward angular momentum while the ankle plantar flexors (SOL and GAS) generated forward momentum. In late stance, SOL and GAS were the primary contributors and generated angular momentum in opposite directions. SOL generated primarily forward angular momentum while GAS generated backward angular momentum. The difference between muscles was due to their relative contributions to the horizontal and vertical ground reaction forces. Gravity contributed to the body’s angular momentum in early stance and to a lesser extent in late stance, which was counteracted primarily by the plantar flexors. These results may provide insight into balance and movement disorders and provide a basis for developing locomotor therapies that target specific muscle groups.     

Quantitative assessment of gait determinants during single stance via a three-dimensional model--Part 1. Normal gait

In this two-part paper, a variety of three-dimensional, dynamical models are constructed for simulating the single support phases of normal and pathological human gait. A major objective of this work is to quantify the influence of individual gait determinants on the ground reaction forces generated during normal, level walking. To this end, Part 1 presents a three-dimensional, seven degree-of-freedom model incorporating five of the six fundamental determinants of gait. On the basis of crude muscle-force and/or joint-moment trajectories, body-segmental motions and ground reaction forces are synthesized open loop. Through a quantitative comparison with experimental gait data, the model's predictions are evaluated. Our simulation results suggest that pelvic list is not as dominant a dynamical determinant as either stance knee flexion-extension or foot and knee interaction. Transverse pelvic rotation, however, makes an important contribution by limiting the magnitude of the horizontal ground reaction prior to opposite heel-strike.     

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.     

Muscle and external load contribution to knee joint contact loads during normal gait

Large knee adduction moments during gait have been implicated as a mechanical factor related to the progression and severity of tibiofemoral osteoarthritis and it has been proposed that these moments increase the load on the medial compartment of the knee joint. However, this mechanism cannot be validated without taking into account the internal forces and moments generated by the muscles and ligaments, which cannot be easily measured. Previous musculoskeletal models suggest that the medial compartment of the tibiofemoral joint bears the majority of the tibiofemoral load, with the lateral compartment unloaded at times during stance. Yet these models did not utilise explicitly measured muscle activation patterns and measurements from an instrumented prosthesis which do not portray lateral compartment unloading. This paper utilised an EMG-driven model to estimate muscle forces and knee joint contact forces during healthy gait. Results indicate that while the medial compartment does bear the majority of the load during stance, muscles provide sufficient stability to counter the tendency of the external adduction moment to unload the lateral compartment. This stability was predominantly provided by the quadriceps, hamstrings, and gastrocnemii muscles, although the contribution from the tensor fascia latae was also significant. Lateral compartment unloading was not predicted by the EMG-driven model, suggesting that muscle activity patterns provide useful input to estimate muscle and joint contact forces.     

Visual and proprioceptive contributions to postural control of upright stance in unilateral vestibulopathy

Preserving upright stance requires central integration of the sensory systems and appropriate motor output from the neuromuscular system to keep the centre of pressure (COP) within the base of support. Unilateral peripheral vestibular disorder (UPVD) causes diminished stance stability. The aim of this study was to determine the limits of stability and to examine the contribution of multiple sensory systems to upright standing in UPVD patients and healthy subjects. We hypothesized that closure of the eyes and Achilles tendon vibration during upright stance will augment the postural sway in UPVD patients more than in healthy subjects. Seventeen UPVD patients and 17 healthy subjects performed six tasks on a force plate: forwards and backwards leaning, to determine limits of stability, and upright standing with and without Achilles tendon vibration, each with eyes open and closed (with blackout glasses). The COP displacement of the patients was significantly greater in the vibration tasks than the controls and came closer to the posterior base of support boundary than the controls in all tasks. Achilles tendon vibration led to a distinctly more backward sway in both subject groups. Five of the patients could not complete the eyes closed with vibration task. Due to the greater reduction in stance stability when the proprioceptive, compared with the visual, sensory system was disturbed, we suggest that proprioception may be more important for maintaining upright stance than vision. UPVD patients, in particular, showed more difficulty in controlling postural stability in the posterior direction with visual and proprioceptive sensory disturbance.     

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.     

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 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.     

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.