Responses of human ankle muscles to mediolateral balance perturbations during walking.

During walking our balance is maintained by muscle action. In part these muscle actions automatically respond to the imbalance. This paper considers responses to balance perturbations in muscles around the ankle, peroneus longus (PL), tibialis anterior (TA) and soleus (SO). It is investigated if their action is related to previously observed balance mechanisms: the 'braking reaction' and the mediolateral ankle strategy. Subjects walked on a treadmill and received pushes to the left and pulls to the right in various phases of the gait cycle. Muscle actions were divided into medium latency R1 (100-150 ms), long latency R2 (170-250 ms), and late action R3 (270-350 ms). Short latency responses, before 100 ms, were not observed but later responses were prominent. With inward perturbations (e.g. pushes to the left shortly before or during stance of the right foot) responses in RPL were seen. The forward roll-over of the CoP was briefly stalled in mid stance, so that the heel was not lifted. Stance was shortened. With outward perturbations, pushes to the left shortly before or during stance of the left foot, responses in all three muscles, LTA, LSO, and LPL were seen. Our interpretation is that these muscle activations induce a 'braking reaction' but could also contribute to the 'mediolateral ankle strategy'. The resultant balance correction is small but fast, and so diminishes the need for later corrections by the stepping strategy.

Responses of human hip abductor muscles to lateral balance perturbations during walking.

Lateral stability during gait is of utmost importance to maintain balance. This was studied on human subjects walking on a treadmill who were given 100-ms perturbations of known magnitude and timing with respect to the gait cycle by means of a computer-controlled pneumatic device. This method has the advantage that the same perturbations can be given at different phases of the stride cycle, thereby allowing an analysis of the phase dependency of the responses in the primary muscles involved. After an inward push, e.g., a push toward the left during right stance, the left foot in the step to follow is placed more to the left (outward strategy). The hypothesis was that this movement is caused by automatic unvoluntary muscle activity. This turned out to be the case: the abduction movement follows EMG responses in the left abductor muscle, gluteus medius, in response to the push. Two responses, with latencies of 100 and 170 ms, and a late reaction >270 ms can be discerned. All three responses are phase dependent; they show facilitation in swing and no response in stance, in contrast to the normal walking activity (background). This independence of the background activity suggests a premotoneuronal gating of these responses, reminiscent of phase-dependent modulation of electrically elicited reflexes. It is concluded that facilitating pathways are opened independent of normal background activation to enable appropriate actions to restore balance after a mediolateral perturbation.

Psychological factors unrelated to activity level in patients with chronic musculoskeletal pain.

BACKGROUND: Enhancement of physical activities is an important goal in rehabilitation programmes for patients with chronic musculoskeletal pain (CMP). A relationship between activity level and psychological factors is suggested but studied scarcely. AIM: To explore the relationship between the activity level and psychological factors in patients with CMP. METHODS: Study design is cross-sectional, explorative. Participants are patients with CMP, included for outpatient multidisciplinary pain rehabilitation. MEASURES: Activity level was measured by the RT3 accelerometer during 1 week; pain intensity was measured with a 100-mm visual analogue scale; depression, somatization and distress were measured with Symptom Checklist-90-Revised (SCL-90-R), coping strategy with the Utrecht Coping List (UCL, scales active coping, passive coping, avoiding), fear of movement measured with Tampa Scale of Kinesiophobia (TSK), scale activity avoidance. Depending on data distribution, correlations between the mean number of activity counts and psychological factors were tested with Pearson or Spearman correlation coefficients. RESULTS: Fifty three patients were included: age mean 39.9 years [standard deviation (SD) 11.3]; activity counts per day mean 198,243 (SD 78,000); pain intensity mean 58 (SD 27.7); SCL-90-R mean 149.4 (SD 42.5); UCL active coping mean 17.9 (SD 3.7); UCL passive coping mean 12.3 (SD 3.7); UCL avoiding mean 15.3 (SD 3.0); TSK total mean 35.4 (SD 7.4); TSK activity avoidance mean 16.9 SD (4.7). Correlations between psychological factors and the mean number of activity counts per day ranged from r = -0.27 to r = 0.01 and were all non-significant (p ≥ 0.05). CONCLUSION: Psychological factors and activity level were unrelated in patients with CMP.

Balance responses to lateral perturbations in human treadmill walking.

During walking on a treadmill 10 human subjects (mean age 20 years) were perturbed by 100 ms pushes or pulls to the left or the right, of various magnitudes and in various phases of the gait cycle. Balance was maintained by (1) a stepping strategy (synergy), in which the foot at the next step is positioned a fixed distance outward of the 'extrapolated centre of mass', and (2) a lateral ankle strategy, which comprises a medial or lateral movement of the centre of pressure under the foot sole. The extrapolated centre of mass is defined as the centre of mass position plus the centre of mass velocity multiplied by a parameter related to the subject's leg length. The ankle strategy is the fastest, with a mechanical delay of about 200 ms (20% of a stride), but it can displace the centre of pressure no more than 2 cm. The stepping strategy needs at least 300 ms (30% of a stride) before foot placement, but has a range of 20 cm. When reaction time is sufficient, the magnitude of the total response is in good agreement with our hypothesis: mean centre of pressure (foot) position is a constant distance outward of the extrapolated centre of mass. If the reaction time falls short, a further correction is applied in the next step. In the healthy subjects studied here, no further corrections were necessary, so balance was recovered within two steps (one stride).

Abnormal landing strategies after ACL reconstruction.

The objective was to analyze muscle activity and movement patterns during landing of a single leg hop for distance after anterior cruciate ligament (ACL) reconstruction. Nine (six males, three females) ACL-reconstructed patients 6 months after surgery and 11 (eight males, three females) healthy control subjects performed the hop task. Electromyographic signals from lower limb muscles were analyzed to determine onset time before landing. Biomechanical data were collected using an Optotrak Motion Analysis System and force plate. Matlab was used to calculate kinetics and joint kinematics. Side-to-side differences in ACL-reconstructed patients and healthy subjects as well as differences between the patients and control group were analyzed. In ACL-reconstructed limbs, significantly earlier onset times were found for all muscles, except vastus medialis, compared with the uninvolved side. The involved limbs had significantly reduced knee flexion during the take-off and increased plantarflexion at initial contact. The knee extension moment was significantly lower in the involved limb. In the control group, significantly earlier onset times were found for the semitendinosus, vastus lateralis and medial gastrocnemius of the non-dominant side compared with the dominant side. Muscle onset times are earlier and movement patterns are altered in the involved limb 6 months after ACL reconstruction.

Validation of a method to measure the proprioception of the knee.

INTRODUCTION: Proprioception is an important mechanism in knee stability and function. After an injury like an anterior cruciate ligament (ACL) rupture changes appear in knee proprioception which play a major role in rehabilitation. There are several methods to measure proprioception; the threshold to detect passive motion (TTDPM) is often used to quantify proprioception. In this study the reliability and validity were tested of an apparatus, which measures the TTDPM based on the Lund technique of Fridén and Roberts (Sweden). MATERIALS AND METHODS: Sixteen healthy participants were tested on both legs, from start position 20 degrees and 40 degrees, towards extension (TE) and flexion (TF). The same measurement was repeated 12 (6-21) days later. RESULTS: An overall mean TTDPM of 0.58 degrees (95% confidence interval CI=0.53-0.62 degrees ) was found. Thresholds were different depending on direction of motion and start position. TTDPM in 20 degrees TE (0.51 degrees, CI=0.48-0.56 degrees) and in 40 degrees TF (0.54 degrees, CI=0.50-0.58 degrees ) were significantly lower than TTDPM in 40 degrees TE (0.68 degrees , CI=0.63-0.74 degrees) and in 20 degrees TF (0.58 degrees, CI=0.54-0.63 degrees). Thresholds were rising with age. Women had higher thresholds than men. CONCLUSION: The method is a reliable and valid way to measure proprioception. The next step is to use this method on patients with an ACL-rupture and compare these results with healthy subjects.

Are the take-off and landing phase dynamics of the volleyball spike jump related to patellar tendinopathy?

OBJECTIVE: The causal mechanism of the chronic sports injury patellar tendinopathy is not well understood. The aim of the present study was to compare ankle and knee joint dynamics during the performance of the volleyball spike jump between healthy volleyball players (n = 8) and asymptomatic volleyball players with previous patellar tendinopathy (n = 7). DESIGN: Cross-sectional. METHODS: Inverse dynamics were used to estimate ankle and knee joint dynamics. From these multiple biomechanical variables, a logistic regression was performed to estimate the probability of the presence or absence of previous patellar tendinopathy among the volleyball players studied. RESULTS: Several biomechanical variables improved the prediction of the presence or absence of previous patellar tendinopathy. For landing, ankle plantar flexion at the time of touch-down, and knee range of motion during the first part of impact, and for take-off, loading rate of the knee extensor moment during the eccentric countermovement phase of take-off were predictive. As interaction effects, the presence or absence of previous patellar tendinopathy were correctly predicted by ankle and knee range of motion during the first part of impact, by loading rate of the knee extensor moment during the eccentric phases of take-off and landing, and by knee angular velocity during the eccentric phases of take-off and landing. CONCLUSION: Smaller joint flexion during the first part of landing impact , and higher rate of knee moment development during the eccentric phases of the spike-jump landing sequence, together with higher knee angular velocities, might be risk factors in the development of patellar tendinopathy in volleyball players.

Uphill and downhill walking in unilateral lower limb amputees.

OBJECTIVE: To study adjustment strategies in unilateral amputees in uphill and downhill walking. DESIGN: Observational cohort study. SUBJECTS: Seven transfemoral, 12 transtibial unilateral amputees and 10 able-bodied subjects. METHODS: In a motion analysis laboratory the subjects walked over a level surface and an uphill and downhill slope. Gait velocity and lower limb joint angles were measured. RESULTS: In uphill walking hip and knee flexion at initial contact and hip flexion in swing were increased in the prosthetic limb of transtibial amputees. In downhill walking transtibial amputees showed more knee flexion on the prosthetic side in late stance and swing. Transfemoral amputees were not able to increase prosthetic knee flexion in uphill and downhill walking. An important adjustment strategy in both amputee groups was a smaller hip extension in late stance in uphill and downhill walking, probably related with a shorter step length. In addition, amputees increased knee flexion in early stance in the non-affected limb in uphill walking to compensate for the shorter prosthetic limb length. In downhill walking fewer adjustments were necessary, since the shorter prosthetic limb already resulted in lowering of the body. CONCLUSION: Uphill and downhill walking can be trained in rehabilitation, which may improve safety and confidence of amputees. Prosthetic design should focus on better control of prosthetic knee flexion abilities without reducing stability.

Balance control on a moving platform in unilateral lower limb amputees.

OBJECTIVE: To study balance control on a moving platform in lower limb amputees. DESIGN: Observational cohort study. PARTICIPANTS: Unilateral transfemoral and transtibial amputees and able-bodied control subjects. INTERVENTIONS: Balance control on a platform that moved in the anteroposterior direction was tested with eyes open, blindfolded and while performing a dual task. MAIN OUTCOME MEASURES: Weight bearing symmetry, anteroposterior ground reaction force and centre of pressure shift. RESULTS: Compared to able-bodied subjects, in amputees the anteroposterior ground reaction force was larger in the prosthetic and non-affected limb, and the centre of pressure displacement was increased in the non-affected limb and decreased in the prosthetic limb. In amputees body weight was loaded more on the non-affected limb. Blindfolding or adding a dual task did not influence the outcome measures importantly. CONCLUSION: The results of this study indicate that experienced unilateral amputees with a high activity level compensate for the loss of ankle strategy by increasing movements and loading in the non-affected limb. The ability to cope with balance perturbations is limited in the prosthetic limb. To enable amputees to manage all possible balance disturbances in real life in a safe manner, we recommend to improve muscle strength and control in the non-affected limb and to train complex balance tasks in challenging environments during rehabilitation.

Gait initiation in lower limb amputees.

OBJECTIVE: To study limitations in function and adjustment strategies in lower limb amputees during gait initiation. DESIGN: Observational cohort study. SETTING: University Medical Center. PARTICIPANTS: Amputees with a unilateral transfemoral or transtibial amputation, and able-bodied subjects. MAIN OUTCOME MEASURES: Leading limb preference, temporal variables, ground reaction forces, and centre of pressure shift. RESULTS: Amputees demonstrated a decrease in peak anterior ground reaction force, a smaller or absent posterior centre of pressure shift, and a lower gait initiation velocity. The main adjustments strategies in amputees were more limb-loading on the non-affected limb, prolonging the period of propulsive force production in the non-affected limb and initiating gait preferably with the prosthetic limb. CONCLUSION: Since an intact ankle joint and musculature is of major importance in gait initiation, functional limitations and adjustment strategies in transfemoral and transtibial amputees were similar. Improving prosthetic ankle properties and initiating gait with the prosthetic limb may facilitate the gait initiation process in amputees.

Gait termination in lower limb amputees.

OBJECTIVE: To study the limitations in function and adjustment strategies of lower limb amputees in gait termination. DESIGN: Observational cohort study. SETTING: University Medical Centre. PARTICIPANTS: Unilateral transfemoral and transtibial amputees, and able-bodied control subjects. MAIN OUTCOME MEASURES: Leading limb preference, temporal variables, lower limb joint angles, ground reaction forces, and centre of pressure shift. RESULTS: Compared to able-bodied subjects, amputees showed a decreased peak braking ground reaction force in the prosthetic limb, no anterior centre of pressure shift during leading with the prosthetic limb and an increased mediolateral centre of pressure shift. Amputees used several adjustment strategies to compensate for the limitations in function; leading limb preference for the non-affected limb, longer production of braking force in the non-affected limb, decreased gait termination velocity and more weight-bearing on the non-affected limb. CONCLUSION: Limitations in function and adjustment strategies were mainly similar in transfemoral and transtibial amputees. Due to the lack of active ankle function, amputees were not able to increase the braking force and to shift the centre of pressure anteriorly. Leading with the non-affected limb is favourable for adequate deceleration and balance control, but in daily life not always applicable. It is important that amputees are trained in gait termination during rehabilitation and prosthetic design should focus on a more active role of the prosthetic foot and knee.

Effect of flat insoles with different Shore A values on posture stability in diabetic neuropathy.

The objective of the study was to determine whether insoles with a low Shore A value (15 degrees) as prescribed for patients with a diabetic neuropathy have a negative effect on posture stability because these insoles may reduce somatosensory input under the feet. It was conducted in the Center for Rehabilitation, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands The study was observational and conducted on 30 diabetic patients (aged 37 - 82 years) with a neuropathy. Posture stability (body sway) was assessed in a shoe without insole, on a flat insole with a low Shore A value (15 degrees) and on a flat insole with a higher Shore A value (30 degrees). These assessments were done under four different conditions: (1) eyes open, no dual-task, (2) eyes closed, no dual-task, (3) eyes open, dual-task (mental arithmetic) and (4) eyes closed, dual-task. Additionally 10 healthy controls (aged 27 - 51 years) were assessed similarly. A significantly higher root-mean-square (rms) value of the anterior-posterior velocity, V(y), was found in patients compared with controls (3.4 cm/s vs. 1.2 cm/s, p < 0.05). Also a significant difference in rms value of the anterior-posterior velocity, V(y), was found between eyes open and eyes closed (1.9 cm/s vs. 2.7 cm/s, p < 0.05). No significant effects were found for insoles or dual tasks for the total group. In diabetic patients no significant effect was found of insoles on posture stability. The effect of closed eyes on posture stability was significantly larger for diabetic patients compared to controls. It was found that prescribing insoles with a low Shore A value (15 degrees), compared to insoles with a higher Shore A value (30 degrees) has no significant negative effect on posture stability in patients with a diabetic neuropathy.

Leg kinematics and kinetics in landing from a single-leg hop for distance. A comparison between dominant and non-dominant leg.

BACKGROUND: Anterior cruciate ligament (ACL) deficiency can be a major problem for athletes and subsequent reconstruction of the ACL may be indicated if a conservative regimen has failed. After ACL reconstruction signs of abnormality in the use of the leg remain for a long time. It is expected that the landing after a single-leg hop for distance (horizontal hop) might give insight in the differences in kinematics and kinetics between uninjured legs and ACL-reconstructed legs. Before the ACL-reconstructed leg can be compared with the contralateral leg, knowledge of differences between legs of uninjured subjects is needed. METHODS: Kinematic and kinetic variables of both legs were measured with an optoelectronic system and a force plate and calculated by inverse dynamics. The dominant leg (the leg with biggest horizontal hop distance) and the contralateral leg of nine uninjured subjects were compared. FINDINGS: No significant differences were found in most of the kinematic and kinetic variables between dominant leg and contralateral leg of uninjured subjects. Only hop distance and hip extension angles differed significantly. INTERPRETATION: This study suggests that there are no important differences between dominant leg and contralateral leg in healthy subjects. As a consequence, the uninvolved leg of ACL-reconstructed patients can be used as a reference. The observed variables of this study can be used as a reference of normal values and normal differences between legs in healthy subjects.

Obstacle crossing in lower limb amputees.

OBJECTIVE: To study limitations in function and adjustment strategies in lower limb amputees during obstacle crossing. DESIGN: Observational cohort study. SUBJECTS: Transfemoral and transtibial amputees and able-bodied control subjects. METHODS: In a motion analysis laboratory unimpeded and obstacle crossing runs were performed. The subjects stepped over an obstacle of 0.1m height and thickness and 1m width. Outcome measures were gait velocity, hip, knee and ankle joint angles and leading limb preference. RESULTS: Whereas able-bodied and transtibial subjects demonstrated an increase in knee flexion during obstacle crossing compared to unimpeded walking, in transfemoral amputees the opposite was seen, namely a decrease in knee flexion. The lack of knee strategy in transfemoral amputees was compensated by circumduction at the hip on the prosthetic side and plantar flexion of the non-affected ankle. Transtibial amputees preferred to cross the obstacle with the prosthetic limb first, while transfemoral amputees preferred the non-affected limb. CONCLUSION: The different leading limb strategy in transfemoral and transtibial amputees could be explained by the restricted flexion and propulsion properties of the prosthetic knee. Training of obstacle crossing tasks during rehabilitation and improvement of prosthetic design may contribute to safe obstacle crossing.

Biomechanical analysis of the single-leg decline squat.

BACKGROUND: The single-leg squat on a 25 degrees decline board has been described as a clinical assessment tool and as a rehabilitation exercise for patients with patellar tendinopathy. Several assumptions have been made about its working mechanism on patellar load and patellofemoral forces, but these are not substantiated by biomechanical evaluations. AIM: To investigate knee moment and patellofemoral contact force as a function of decline angle in the single-leg squat. METHODS: Five subjects performed single-leg eccentric squats at decline angles of 0 degrees, 5 degrees, 10 degrees, 15 degrees, 20 degrees and 25 degrees (with/without a backpack of 10 kg), and 30 degrees on a board that was placed over a forceplate. Kinematic and forceplate data were recorded by the Optotrak system. Joint moments of ankle, knee and hip were calculated by two-dimensional inverse dynamics. RESULTS: Knee moment increased by 40% at decline angles of 15 degrees and higher, whereas hip and ankle moment decreased. Maximum knee and ankle angles increased with steeper decline. With a 10 kg backpack at 25 degrees decline, the knee moment was 23% higher than unloaded. Both patellar tendon and patellofemoral forces increased with higher decline angles, but beyond 60 degrees, the patellofemoral force rose steeper than the tendon force. CONCLUSIONS: All single-leg squats at decline angles >15 degrees result in 40% increase in maximum patellar tendon force. In knee flexions >60 degrees, patellofemoral forces increase more than patellar tendon forces. Higher tendon load can be achieved by the use of a backpack with extra weight.

Assessment of two-dimensional induced accelerations from measured kinematic and kinetic data.

A simple algorithm is presented to calculate the induced accelerations of body segments in human walking for the sagittal plane. The method essentially consists of setting up 2x4 force equations, 4 moment equations, 2x3 joint constraint equations and two constraints related to the foot-ground interaction. Data needed for the equations are, next to masses and moments of inertia, the positions of ankle, knee and hip. This set of equations is put in the form of an 18x18 matrix or 20x20 matrix, the solution of which can be found by inversion. By applying input vectors related to gravity, to centripetal accelerations or to muscle moments, the 'induced' accelerations and reaction forces related to these inputs can be found separately. The method was tested for walking in one subject. Good agreement was found with published results obtained by much more complicated three-dimensional forward dynamic models.

Determining the centre of pressure during walking and running using an instrumented treadmill.

In this paper, a new method of determining spatial and temporal gait parameters by using centre of pressure (CoP) data is presented. A treadmill is used which was developed to overcome limitations of regular methods for the analysis of spatio-temporal gait parameters and ground reaction forces during walking and running. The design of the treadmill is based on the use of force transducers underneath a separate left and right plate, which together form the treadmill walking surface. The results of test procedures and measurements show that accurate recordings of vertical ground reaction force can be obtained. These recordings enable a separate analysis of vertical ground reaction forces during double support phases in walking, and the analysis of changes in the centre of pressure (CoP) position during subsequent foot placements. From the CoP data, temporal gait parameters (e.g. duration of left/right support and swing phases) and spatial gait parameters (i.e. left/right step lengths and widths) can be derived.

Detection of non-standard EMG profiles in walking.

The amplitude of an EMG and the temporal pattern can be used when considering if an EMG profile is normal or not. In the method described in this paper a gain factor of the complete EMG profile was determined and then the profile normalised with this gain factor. This normalised individual profile was then compared with a standard profile, predicted on the basis of walking speed. Deviating profiles were identified when they fell outside the upper and lower 95% limits range for the average profiles of 14 leg muscles. The amount of deviation from the normal profile can be quantified with the normalised mean square difference D2. Gain factors varied over a factor of 4 within a group of 10 normal subjects. For a normal population D2 was below 1. Most muscles had consistent profiles but some patterns could be discerned which showed marked variability among muscles and subjects.

The condition for dynamic stability.

The well-known condition for standing stability in static situations is that the vertical projection of the centre of mass (CoM) should be within the base of support (BoS). On the basis of a simple inverted pendulum model, an extension of this rule is proposed for dynamical situations: the position of (the vertical projection of) the CoM plus its velocity times a factor (square root l/g) should be within the BoS, l being leg length and g the acceleration of gravity. It is proposed to name this vector quantity 'extrapolated centre of mass position' (XcoM). The definition suggests as a measure of stability the 'margin of stability' b, the minimum distance from XcoM to the boundaries of the BoS. An alternative measure is the temporal stability margin tau, the time in which the boundary of the BoS would be reached without intervention. Some experimental data of subjects standing on one or two feet, flatfoot and tiptoe, are presented to give an idea of the usual ranges of these margins of stability. Example data on walking are also presented.