Pain, disability, and quality of life in participants after concurrent onabotulinumtoxinA treatment of upper and lower limb spasticity: Observational results from the ASPIRE study.

INTRODUCTION: Upper and lower limb spasticity is commonly associated with central nervous system disorders including stroke, traumatic brain injury, multiple sclerosis, cerebral palsy, and spinal cord injury, but little is known about the concurrent treatment of upper and lower limb spasticity with botulinum toxins. OBJECTIVE: To evaluate onabotulinumtoxinA (onabotA) utilization and to determine if concurrent onabotA treatment of the upper and lower limbs has supported improvements in participants with spasticity. DESIGN: Sub-analysis of a 2-year, international, prospective, observational registry (ASPIRE, NCT01930786). SETTING: International clinic sites (54). PARTICIPANTS: Adult spasticity participants across etiologies, who received ≥1 concurrent onabotA treatment of the upper and lower limbs during the study. INTERVENTION: Participants were treated with onabotA at the clinician's discretion. OUTCOMES: Baseline characteristics and outcomes of disability (Disability Assessment Scale [DAS]), pain (Numeric Pain Rating Scale [NPRS]), participant satisfaction, physician satisfaction, and quality of life (QoL; Spasticity Impact Assessment [SIA]) were evaluated. Adverse events were monitored throughout the study. RESULTS: Of 744 participants enrolled, 730 received ≥1 dose of onabotA; 275 participants received treatment with onabotA in both upper and lower limbs during ≥1 session; 39.3% of participants were naïve to onabotA for spasticity. The mean (SD) total dose per treatment session ranged from 421.2 (195.3) to 499.6 (188.6) U. The most common baseline upper limb presentation was clenched fist (n = 194, 70.5%); lower limb was equinovarus foot (n = 219, 66.9%). High physician and participant satisfaction and improvements in pain, disability and QoL were reported after most treatments. Nine participants (3.3%) reported nine treatment-related adverse events; two participants (0.7%) reported three serious treatment-related severe adverse events. No new safety signals were identified. CONCLUSION: More than a third of enrolled participants received at least one concurrent onabotA treatment of the upper and lower limbs, with reduced pain, disability, and improved QoL after treatment, consistent with the established safety profile of onabotA for the treatment of spasticity.

Improvement of Pain and Function by Using Botulinum Toxin Type A Injection in Patients with an Osteoarthritic Knee with Patellar Malalignment: An Electromyographic Study.

Objective: To determine the pain and electromyographic (EMG) amplitude ratio of the vastus medialis oblique (VMO) to the vastus lateralis (VL) after botulinum toxin type A (BTA) was injected in the bilateral osteoarthritic knee of patients with patellar malalignment for analysis. Material and methods: A total of fifteen patients were recruited; the more symptomatic knee of each patient received a BTA injection (BTA side). The other set of patients were left untreated. In all, fifteen healthy participants comprised the control group. The Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) and numeric rating scale (NRS) for pain were assessed. The EMG amplitude of VL and VMO activity was recorded using an isokinetic dynamometer and synchronized using the BIOPAC MP100. The data were collected before and at 4, 8, and 12 weeks post−BTA injection. Results: The EMG ratios of the patient group were lower than those of the control group at all testing velocities (p < 0.05). The VMO/VL ratio improved significantly on the BTA side only. The VMO/VL ratios on the BTA side were higher than those on the untreated side (p < 0.05). Knee pain decreased significantly after the BTA injection. The EMG ratios were negatively correlated with the NRS and WOMAC scores. Conclusion: BTA injection effectively reduces knee pain and restores the EMG ratio between the VMO and VL.

Individualized OnabotulinumtoxinA Treatment for Upper Limb Spasticity Resulted in High Clinician- and Patient-Reported Satisfaction: Long-Term Observational Results from the ASPIRE Study.

INTRODUCTION: OnabotulinumtoxinA treatment for spasticity is dependent on numerous factors and varies according to selected treatment goals. OBJECTIVE: To examine real-world onabotulinumtoxinA treatment utilization and effectiveness in patients with upper limb spasticity over 2 years from the Adult Spasticity International Registry (ASPIRE) study. DESIGN: Multicenter, prospective, observational registry (NCT01930786). SETTING: Fifty-four international clinical sites in North America, Europe, and Asia. PATIENTS: Adults (naïve or non-naïve to botulinum toxins for spasticity) with upper limb focal spasticity related to upper motor neuron syndrome across multiple etiologies. INTERVENTIONS: OnabotulinumtoxinA administered at clinician's discretion. MAIN OUTCOME MEASURES: OnabotulinumtoxinA utilization, clinician and patient satisfaction. RESULTS: Four hundred eighty-four patients received ≥1 treatment of onabotulinumtoxinA for upper limb spasticity. Patients were on average 55.1 years old, 50.8% male, predominantly Caucasian (72.3%), and 38.6% were naïve to botulinum toxins. Stroke was the most frequently reported underlying etiology (74.0%). Most patients (81.2%) had moderate to severe spasticity at baseline. The most commonly treated upper limb clinical presentation was clenched fist (79.1% of patients). Across all presentations, onabotulinumtoxinA doses ranged between 5-600U. Electromyography (EMG) was most often utilized to localize muscles (≥57.0% of treatment sessions). Clinicians (92.9% of treatment sessions) and patients (85.7%) reported being extremely satisfied/satisfied that treatment helped manage spasticity, and clinicians (98.6%) and patients (92.2%) would definitely/probably continue onabotulinumtoxinA treatment. One hundred seventy-nine patients (37.0%) reported 563 adverse events (AEs); 15 AEs in 14 patients (2.9%) were considered treatment related. Sixty-nine patients (14.3%) reported 137 serious AEs; 3 serious AEs in 2 patients (0.4%) were considered treatment related. No new safety signals were identified. CONCLUSIONS: ASPIRE captured the real-world individualized nature of onabotulinumtoxinA utilization for upper limb spasticity over 2 years, with consistently high clinician- and patient-reported satisfaction. Data in this primary analysis will guide clinical use of onabotulinumtoxinA, as well as provide insights to improve educational programs on spasticity management.

Effect of shoe heel height and total-contact insert on muscle loading and foot stability while walking.

BACKGROUND: Women wearing high-heeled shoes often complain of foot instability and low-back pain. Previous studies have demonstrated that using total-contact inserts (TCIs) in running shoes reduces impact on leg muscles and alters rearfoot motion. This study investigated how shoe heel height and use of TCIs in high-heeled shoes affect the wearer's rearfoot complex, muscle loading, and subjective comfort. METHODS: Fifteen inexperienced high heel wearers walked under 6 test conditions formed by the cross-matching of shoe insert (with and without TCI) and heel height (1.0, 5.1, and 7.6 cm) at a speed of 1.3 m/s. The measures of interest were rearfoot kinematics; muscle activities by electromyography (EMG) of the tibialis anterior (TA), medial gastrocnemius (MG), quadriceps (QUA), hamstrings (HAM), and erector spinae (ES); and subjective comfort rating by visual analogue scale for each test condition. RESULTS: The statistical results showed that elevated heel height significantly increased plantar flexion (P < .001) and inversion (P < .01) at heel strike, prolonged TA-MG co-contraction (P < .001) and QUA activation period (P < .001), and increased root mean square (RMS) EMG in all measured muscles (TA, MG, QUA, ES: P < .001; HAM: P < .01). The use of TCIs reduced the rearfoot inversion angle (P < .01) and RMS EMG in both QUA and ES muscles (P < .01) and increased comfort rating (P < .001). CONCLUSIONS: These findings suggest that wearing high-heeled shoes adversely affects muscle control and reduces loads in QUA and ES muscles. CLINICAL RELEVANCE: The use of a TCI may improve comfort rating and foot stability.

Changes in windlass effect in response to different shoe and insole designs during walking.

Windlass effect occurs during the pre-swing phase of gait cycle in which the peak tensile strain and force of the plantar aponeurosis (PA) is reached. The increased dorsiflexion angle of the 1st metatarsophalangeal (MTP) joint is the main causing factor. The aim of this study was to investigate thoroughly in finding the appropriate shoe and insole combination that can effectively decrease the windlass effect. Foot kinematic analyses of 10 normal volunteers (aged 25.2±2.1 years, height of 167.4±9.1 cm, and weight of 66.2±18.1 kg) were performed during gait under the conditions of barefoot, standard shoe (SS) with flat insole (FI) or carbon fiber insole (CFI), and rocker sole shoe (RSS) with FI or CFI. The shoe cover consisting of transparent polymer was used for accurate measurement of kinematic data as specific areas on the cover can be cut away for direct placement of reflective markers onto the skin. Under barefoot condition, the mean of maximum dorsiflexion angle of the 1st MTP joint was measured to be 48.0±7.3°, and decreased significantly to 28.2±5.7° when wearing SS with FI, and 24.1±5.7° when wearing SS with CFI. This angle was further decreased to around 13° when wearing RSS with FI or CFI. Subjects wearing footwear alone can increase the minimum medial longitudinal angle and decrease the maximum plantarflexion angle of metatarsus related to the calcaneus as compared with barefoot condition, resulting in flatter medial foot arch. Results suggested that RSS is the effective footwear in reducing the windlass effect regardless the type of insole inserted. The findings in this study provided us with the evidences in finding the appropriate footwear for treating foot disorders such as plantar fasciitis by effectively reducing the windlass effect.

Symptomatic pulmonary embolism among stroke patients in Taiwan: a retrospective cohort study.

BACKGROUND: Stroke patients are at particular risk for developing pulmonary embolism (PE), which is a cardiovascular emergency associated with a high mortality rate. Little information is available on symptomatic PE in Asian stroke patients. OBJECTIVE: To determine the frequency of symptomatic PE in ischemic and hemorrhagic stroke patients; to identify common characteristics and risk factors of symptomatic PE in Taiwanese stroke patients; and to compare the difference between fatal PE and nonfatal PE among these stroke patients. METHODS: This is a retrospective cohort study of stroke patients admitted between January 2002 and December 2009 to a tertiary referral center in Northern Taiwan. We used the International Classification of Diseases, Ninth Revision, Clinical Modification codes to identify eligible patients. We determined annual frequency and risk factors of symptomatic PE. We also compared the difference between ischemic stroke patients with fatal and nonfatal PE. RESULTS: Among the admitted stroke patients, 21,129 (78.87%) had ischemic strokes and 5,662 (21.13 %) had hemorrhagic strokes. There were 14 (0.066%) ischemic and 1 hemorrhagic stroke (0.018%) patients included in this study. Of the recruited stroke patients, 64.29% had past heart disease history, especially atrial fibrillation (42.86%). Patients with fatal PE showed a significantly lower poststroke Glasgow Coma Scale (GCS) motor component than patients with nonfatal PE. CONCLUSIONS: Symptomatic PE is not common in stroke patients in Taiwan. Clinicians need to keep this fatal disease in mind, especially for persons with heart disease like atrial fibrillation. Stroke patients with impaired poststroke GCS motor components seemed to have a greater mortality risk if they have symptomatic PE.

Effects of an anterior ankle-foot orthosis on postural stability in stroke patients with hemiplegia.

OBJECTIVE: To evaluate the effects of an anterior leaflet ankle-foot orthosis (AFO) on postural stability in stroke patients with hemiplegia. DESIGN: Twenty-one stroke patients with hemiplegia resulting from new-onset stroke and ten normal subjects were included in this study. The SMART balance master system was used to assess the postural stability by measuring the ankle strategy, maximal stability, and velocity of center-of-gravity (COG) movement under the following six conditions: (1) eyes open and fixed support (EOFS), (2) eyes closed and fixed support (ECFS), (3) sway-referenced vision and fixed support (SVFS), (4) eyes open and sway-referenced support (EOSS), (5) eyes closed and sway-referenced support (ECSS), and (6) sway-referenced vision and support (SVSS). Each patient was tested with and without an anterior AFO as compared with normal subjects. RESULTS: When wearing an anterior AFO, patients used ankle strategy more than hip strategy to maintain postural stability in all the six sensory conditions (P < 0.05). An anterior AFO also provided stroke patients with better maximal stability under relatively challenging conditions such as SVFS, EOSS, and ECSS (P < 0.05), but the effect was not apparent in the conditions without external perturbation (EOFS and ECFS) and the most difficult condition (SVSS). The velocity of COG movement was lowered when wearing an anterior AFO in stroke patients, and significant differences existed in the EOFS, ECFS, ECSS, and SVSS conditions (P < 0.05). CONCLUSIONS: In the early stage of recovery, the use of an anterior AFO may assist stroke patients with hemiplegia to improve their postural stability.

Relationship between the EMG ratio of muscle activation and bony structure in osteoarthritic knee patients with and without patellar malalignment.

OBJECTIVE: The aim of this study was to compare muscle activation patterns and patellofemoral joint morphologies between patients with knee osteoarthritis with and without patellar malalignment. SUBJECTS: The subjects were divided into 3 groups. Group A comprised 11 patients with symptomatic knee osteoarthritis without patellar malalignment. Group B comprised 14 patients with symptomatic knee osteoarthritis with patellar malalignment. Group C comprised 10 age-matched subjects with non-knee osteoarthritis as controls. METHODS: Isokinetic dynamometry with surface electromyography was used to measure maximal muscle activity in terms of vastus medialis oblique/vastus lateralis ratios. Merchant's view was taken to analyse the bony anatomy of the patellofemoral joint. Recordings were made at angular velocities of 80, 120 and 240 masculine/sec. RESULTS: The electromyographic ratios of group B were lower than groups A and C for all testing velocities (p<0.05). Group B also had larger sulcus angles, lateral patellar tilt and displacement. The electromyographic ratios correlated negatively with sulcus angles. CONCLUSION: Subjects with knee osteoarthritis with patellar malalignment exhibited an imbalance in quadriceps contraction, as confirmed by altered vastus medialis oblique/vastus lateralis ratios associated with larger sulcus angles of the patellofemoral joints. The sulcus angle may be an important contributing factor in causing abnormal patellar tracking in knee osteoarthritis.

Sonographic features of soft tissue tumors in the hand and forearm.

BACKGROUND: High-resolution sonography is well suited for screening soft tissue masses because of its safety, low cost, and real-time, dynamic imaging. The purpose of our study was to elaborate the preoperative sonographic features of soft tissue tumors of the hand and forearm and the corresponding histologic results. METHODS: Thirty-one soft tissue tumors of the hand and forearm were evaluated by ultrasound preoperatively. The mobility, consistency, echogenicity, margin, and color Doppler signal of each tumor were assessed. Dynamic study was also performed. The pathologic diagnosis was obtained after subsequent surgery. RESULTS: The pathologic diagnoses of these soft tissue lesions were lipoma (n = 6), ganglion cyst (n = 6), neurilemmoma (n = 3), neurofibroma (n = 3), giant cell tumor (n = 10), tenosynovitis (n = 2), and malignant lymphoma (n = 1). An adjacent tendon or communication duct extending to the joint space could be found in most giant cell tumors and ganglion cysts; a traceable nerve could be found in most nerve sheath tumors. All benign tumors appeared well-defined. The only malignant tumor appeared ill-defined without a color Doppler signal. CONCLUSION: Sonography enables a reliable diagnosis of the cystic or solid nature of soft-tissue lesions, accurate estimation of the volume, and precise three-dimensional localization of the abnormality. Examiners should perform a dynamic examination and trace the adjacent structure to obtain more diagnostic clues.

Ultrasound-guided shoulder injections in the treatment of subacromial bursitis.

OBJECTIVE: To investigate the treatment effectiveness between ultrasound-guided and blind injection techniques in the treatment of subacromial bursitis. DESIGN: A total of 40 patients with sonographic confirmation of subacromial bursitis were recruited into this study. These patients were divided into blind and ultrasound-guided injection groups. The shoulder abduction range of motion was compared before injections and 1 wk after the completion of injections in both groups. RESULTS: The shoulder abduction range of motion before injection in the blind injection group was 71.03 +/- 12.38 degrees and improved to 100 +/- 18.18 degrees 1 wk after the injection treatments. However, the improvement did not reveal significant statistical differences (P > 0.05). The shoulder abduction range of motion before injection in the ultrasound-guided injection group was 69.05 +/- 14.72 degrees and improved to 139.29 +/- 20.14 degrees 1 wk after the injection treatments (P < 0.05). CONCLUSIONS: Ultrasound may be used as an adjuvant tool in guiding the needle accurately into the inflamed subacromial bursa. The ultrasound-guided injection technique can result in significant improvement in shoulder abduction range of motion as compared with the blind injection technique in treating patients with subacromial bursitis.

Improvement of muscle strength in osteoarthritic knee patients after intraarticular knee injection of hyaluronan.

OBJECTIVE: The objective of this study was to investigate whether the knee concentric and eccentric muscle strengths can be improved in patients with bilateral knee osteoarthritis after intraarticular hyaluronan injections. DESIGN: A total of 25 patients with bilateral knee osteoarthritis and with a radiographic Ahlbäck grading scale of I or II participated in this study. One session of intraarticular knee injection of hyaluronan was given to both knees (weekly intraarticular knee hyaluronan injections for a total of 5 wks). Knee concentric and eccentric muscle strengths were recorded between 10 and 90 degrees of knee flexion. The recordings were done on two angular velocities, 80 and 240 degrees/sec. This study took place in a tertiary medical center with a gait laboratory and a KIN-COM isokinetic dynamometer. RESULTS: An increase in concentric and eccentric muscle strength adjusted for body weight (P < 0.01) was observed in both knees, ranging between 5.1% and 27.7%. CONCLUSION: The decreased knee muscle contraction strength (concentric and eccentric) can be improved in knee osteoarthritis patients with an Ahlbäck grading scale of I or II after five weekly intraarticular knee injections of hyaluronan.

Ultrasound guidance in caudal epidural needle placement.

BACKGROUND: This study was conducted to investigate the feasibility of using ultrasound as an image tool to locate the sacral hiatus accurately for caudal epidural injections. METHODS: Between August 2002 and July 2003, 70 patients (39 male and 31 female patients) with low back pain and sciatica were studied. Soft tissue ultrasonography was performed to locate the sacral hiatus. A 21-gauge caudal epidural needle was inserted and guided by ultrasound to the sacral hiatus and into the caudal epidural space. Proper needle placement was confirmed by fluoroscopy. RESULTS: In all the recruited patients, the sacral hiatus was located accurately by ultrasound, and the caudal epidural needle was guided successfully to the sacral hiatus and into the caudal epidural space. There was 100% accuracy in caudal epidural needle placement into the caudal epidural space under ultrasound guidance as confirmed by contrast dye fluoroscopy. CONCLUSIONS: Ultrasound is radiation free, is easy to use, and can provide real-time images in guiding the caudal epidural needle into the caudal epidural space. Ultrasound may therefore be used as an adjuvant tool in caudal needle placement.

Transmetatarsal amputation prosthesis with carbon-fiber plate: enhanced gait function.

OBJECTIVE: To determine whether the design of a transmetatarsal amputation prosthesis with a carbon-fiber plate would improve gait pattern in patients with transmetatarsal amputations. DESIGN: In the gait laboratory in a tertiary medical center, eight male patients with transmetatarsal amputations were recruited. Nine able-bodied male volunteers were recruited as the control group. A full-length standard shoe and a transmetatarsal amputation prosthesis with a carbon-fiber plate were the footwear used. Our transmetatarsal amputation prosthesis included a custom-molded insole, a mounted toe filler, and a thin, lightweight, carbon-fiber plate incorporated directly beneath the insole. RESULTS: After wearing the transmetatarsal amputation prosthesis with a carbon-fiber plate, the results of the kinetic and kinematic studies were summarized. CONCLUSION: The transmetatarsal amputation prosthesis with a carbon-fiber plate improved gait pattern significantly in patients with transmetatarsal amputations. Drastic shoe modifications are not necessary to have the prosthesis inserted. The carbon-fiber plate functions like the spring-steel shank within the sole of the shoe. The carbon-fiber plate, the toe filler, and the total-contact insole are all mounted as a whole to ensure better foot contact. Therefore, our transmetatarsal amputation prosthesis with a carbon-fiber plate can be a good alternative choice of footwear in patients with transmetatarsal amputations.

Pre-attentive mental processing of music expectation: event-related potentials of a partially violating and resolving paradigm.

Auditory event-related potentials (ERPs) were investigated in an oddball paradigm to verify electrophysiological evidence of music expectation, which is a key component of artistic presentation. The non-target condition consisted of four-chord harmonic chord sequences, while the target condition was manifested by a partially violating third chord and a resolving fourth chord. The results showed that the specific mismatch negativity (MMN) elicited in the resolving chord is as robust as that elicited in the partially violating chord. Moreover, the P3b (P300) elicited in the resolving chord was smaller than the one in the violating chord. Taken together these data indicates that the human brain pre-attentatively may be able to anticipate a subsequent resolving chord when music expectation is generated by a partially violating chord.

Measurement of forefoot varus angle by laser technology in people with flexible flatfoot.

OBJECTIVE: The purpose of this study was to measure the forefoot varus angles in subjects with and without flexible flatfoot (FF) by using laser foot-scanning technology. DESIGN: In the rehabilitation laboratory of a tertiary medical center, 70 subjects with FF, ranging in age from 10 to 50 yr, were recruited. The control group consisted of 30 volunteers without clinical evidence of FF. A total of 100 positive casts were obtained by having their subtalar joints kept in a neutral position. The plantar surface of the positive cast was scanned by a Yeti 3D Foot Scanner. A straight line was drawn between the first and fifth metatarsophalangeal joints. The forefoot varus angle was measured from this line in relation to the line parallel to the ground. RESULTS: The mean forefoot varus angle was calculated to be 5.01 +/- 4.51 degrees in our FF subjects, and 1.23 +/- 1.96 degrees in the control group. Significant statistical difference in forefoot varus angle was noted between these two groups. CONCLUSIONS: The laser foot-scanning technique offers fast and accurate measurement of the forefoot varus angles. An average forefoot varus angle of approximately 5 degrees was observed in subjects with FF, which was significantly greater than the subjects without FF. Therefore, we recommend the concept of incorporating adequate forefoot posting at the medial forefoot area of an insole in treating people with FF.

Improvement of gait by using orthotic insoles in patients with heel injury who received reconstructive flap operations.

OBJECTIVE: To investigate the effect of orthotic insoles in heel injury patients who received reconstructive flap operations. DESIGN: Motion analysis and force platform data were collected in able-bodied subjects and patients with heel injuries during walking without and with the use of the total contact insole. Gait kinetics were collected for the hip, knee, and ankle joints and then compared with Student's t tests. RESULTS: Walking velocity and step length were decreased (P < 0.014 and P < 0.005) for patients not wearing the total contact insole. The affected limbs had longer double-support duration (14.8% of gait cycle, P < 0.037) and shorter single-support duration (34.5% of gait cycle, P < 0.045). Less hip power generation was noted for the affected limbs during both initial contact and preswing phases, 0.17 +/- 0.10 N-m/kg-m and 0.45 +/- 0.20 N-m/kg-m, as compared with that of the able-bodied subjects, 0.36 +/- 0.08 N-m/kg-m and 0.89 +/- 0.22 N-m/kg-m, respectively. Decreased ankle power generation was noted for the affected limbs (1.08 +/- 0.38 N-m/kg-m) during preswing phase as compared with the able-bodied subjects (2.24 +/- 0.33 N-m/kg-m). After fitting of the total contact insole, the affected limbs recovered to a gait pattern similar to that of the able-bodied subjects (P < 0.05). CONCLUSION: Asymmetry of gait pattern after heel injury resulted in altered gait kinetics. Gait symmetry could be recovered in these patients as the total contact insole provides weight acceptance, shock absorption, and cushioning effect for the reconstructed heels.

Sagittal plane loading response during gait in different age groups and in people with knee osteoarthritis.

OBJECTIVE: To investigate the gait patterns and the sagittal ground reaction forces in different age groups and in people with knee osteoarthritis. DESIGN: Motion analysis and force platform data were collected for a total of 55 female subjects capable of independent ambulation. Subjects were divided into three groups consisting of the control group, the elderly group, and the osteoarthritis knee group. Gait parameters of walking velocity, cadence, step length, stride time, single- and double-support time, and sagittal ground reaction forces were obtained during comfortable walking speed. Gait analysis was performed in a tertiary hospital's gait laboratory. Variables were analyzed using a univariate repeated-measures analysis of variance. Statistical significance was set at a value of P < 0.05. RESULTS: The osteoarthritis knee group had slower walking velocity, lower cadence, and longer stride time as compared with the elderly and young control groups (P < 0.05). In ground reaction force studies, the first peak time, expressed in percentage of gait cycle, was significantly longer in the osteoarthritis knee group (20.8 +/- 3.2) as compared with the elderly (17.8 +/- 2.0) and young control groups (17.1 +/- 1.8, P < 0.01). The force during time of minimal midstance was larger in the osteoarthritis knee group (90.9 +/- 5.3) as compared with the elderly and young control groups (P < 0.05). The second peak force was significantly smaller in the osteoarthritis knee group as compared with the young control group (P < 0.01). The force change in the midfoot region in the osteoarthritis knee and elderly groups revealed more loading force onto the midfoot region during midstance as compared with the young control group (P < 0.01). CONCLUSION: Gait parameters in the elderly and osteoarthritis knee patients were characterized by slower walking velocity, lower cadence, shorter step length, longer stride time, and longer double-support time. Less heel contact and push-off forces were noticed in these two groups, with more loading force onto the midfoot during midstance.