Gait retraining to reduce the knee adduction moment through real-time visual feedback of dynamic knee alignment

Joaquin A Barrios, Kay M Crossley, Irene S Davis, Joaquin A Barrios, Kay M Crossley, Irene S Davis

Abstract

Varus knee alignment is a risk factor for medial knee osteoarthritis and is associated with high knee adduction moments. Therefore, reducing the knee adduction moment in varus-aligned individuals with otherwise healthy knees may reduce their risk for developing osteoarthritis. A gait modification that improves dynamic knee alignment may reduce the adduction moment, and systematic training may lead to more natural-feeling and less effortful execution of this pattern. To test these hypotheses, eight healthy, varus-aligned individuals underwent a gait modification protocol. Real-time feedback of dynamic knee alignment was provided over eight training sessions, using a fading paradigm. Natural and modified gait were assessed post-training and after 1 month, and compared to pre-training natural gait. The knee adduction moment, as well as hip adduction, hip internal rotation and knee adduction angles were evaluated. At each training session, subjects rated how effortful and natural-feeling the modified pattern was to execute. Post-training, the modified pattern demonstrated an 8 degrees increase in hip internal rotation and 3 degrees increase in hip adduction. Knee adduction decreased 2 degrees , and the knee adduction moment decreased 19%. Natural gait did not differ between the three visits, nor did the modified gait pattern between the post-training and 1 month visits. The modified pattern felt more natural and required less effort after training. Based on these results, gait retraining to improve dynamic knee alignment resulted in significant reductions in the knee adduction moment, primarily through hip internal rotation. Further, systematic training led to more natural-feeling and less effortful execution of the gait pattern.

Conflict of interest statement

Conflict of Interest Statement: There are no financial or personal relationships with other people or organizations that could inappropriately bias this work.

Copyright 2010 Elsevier Ltd. All rights reserved.

Figures

Figure 1
Figure 1
Clinical measurement of tibial mechanical axis with a caliper-inclinometer device using procedures modified from Hinman and colleagues (2006).
Figure 2
Figure 2
Actual screen image depicting the knee adduction angle data of a varus-aligned subject during training against a shaded region representing ± 1 standard deviation of a normative mean for knee adduction angle. Knee adduction is positive, and the previous two stance-phases are shown. Note the downward deflection in knee adduction angle in early stance, around the same time that peak KEAM occurs.
Figure 3
Figure 3
Chart depicting time spent walking on the treadmill during each session, and the respective time with visual feedback for each session. For the first four sessions, subjects received feedback 100% of the session. By visit 8, feedback was provided for 10% the session.
Figure 4
Figure 4
How effortful and natural-feeling the modified gait pattern was perceived across training sessions. Effort: 0 = effortless, 10 = maximal effort. Naturalness: 0 = natural, 10 = maximally unnatural. Error bars depict standard deviations.
Figure 5
Figure 5
Ensemble averaged curves comparing the modified gait post-training to the baseline visit, depicting decreases in KEAM and knee adduction, and increases in hip adduction and internal rotation. Error bars depict standard deviations.
Figure 6
Figure 6
Average percentage of walking between training sessions during which subjects reported using the modified pattern. Error bars depict standard deviations.

References

    1. Murphy L, Schwartz TA, Helmick CG, Renner JB, Tudor G, Koch G, Dragomir A, Kalsbeek WD, Luta G, Jordan JM. Lifetime risk of symptomatic knee osteoarthritis. Arthritis & Rheumatism. 2008;59:1207–1213.
    1. Brouwer GM, van Tol AW, Bergink AP, Belo JN, Bernsen RMD, Reijman M, Pols HAP, Bierma-Zeinstra SMA. Association between valgus and varus alignment and the development and progression of radiographic osteoarthritis of the knee. Arthritis & Rheumatism. 2007;56:1204–1211.
    1. Andriacchi TP. Dynamics of knee malalignment. Orthopedic Clinics North America. 1994;25:395–403.
    1. Barrios JA, Davis IS, Higginson JS, Royer TD. Lower extremity walking mechanics of young individuals with asymptomatic varus knee alignment. Journal of Orthopaedic Research. 2009 doi: 10.1002/jor.20904.
    1. Miyazaki T, Wada M, Kawahara H, Sato M, Baba H, Shimada S. Dynamic load at baseline can predict radiographic disease progression in medial compartment knee osteoarthritis. Annals of Rheumatic Disease. 2002;61:617–622.
    1. Mundermann A, Dyrby CO, Hurwitz DE, Sharma L, Andriacchi TP. Potential strategies to reduce medial compartment loading in patients with knee osteoarthritis of varying severity. Arthritis & Rheumatism. 2004;50:1172–1178.
    1. Andrews M, Noyes FR, Hewett TE, Andriacchi TP. Lower limb alignment and foot angle are related to stance phase knee adduction in normal subjects: a critical analysis of the reliability of gait analysis data. Journal of Orthopaedic Research. 1996;14:289–295.
    1. Teichtahl AJ, Morris ME, Wluka AE, Baker R, Wolfe R, Davis SR, Cicuttini FM. Foot rotation—a potential target to modify the knee adduction moment. Journal of Science in Medicine & Sport. 2006;9:67–71.
    1. Lin C, Lai K, Chou Y, Ho C. The effect of changing the foot progression angle on the knee adduction moment in normal teenagers. Gait & Posture. 2001;14:85–91.
    1. Guo M, Axe MJ, Manal K. The influence of foot progression angle on the knee adduction moment during walking and stair climbing in pain free individuals with knee osteoarthritis. Gait & Posture. 2007;26:436–441.
    1. Hurwitz DE, Ryals AB, Case JP, Block JA, Andriacchi TP. The knee adduction moment during gait is more closely correlated with static alignment than radiographic disease severity, toe out angle and pain. Journal of Orthopaedic Research. 2002;20:101–107.
    1. Rutherford DJ, Hubley-Kozey CL, Deluzio KJ, Stanish WD, Dunbar M. Foot progression angle and the knee adduction moment: a cross-sectional investigation in knee osteoarthritis. Osteoarthritis & Cartilage. 2008;16:883–889.
    1. Mundermann A, Asay JL, Mundermann L, Andriacchi TP. Implications of increased medio-lateral trunk sway for ambulatory mechanics. Journal of Biomechanics. 2008;41:165–170.
    1. Fregly BJ, Reinbolt JA, Rooney KL, Mitchell KH, Chmielewski TL. Design of a patient-specific gait modifications for knee osteoarthritis rehabilitation. IEEE Transactions on Biomedical Engineering. 2007;54:1687–1695.
    1. Fregly BJ. Computational assessment of combinations of gait modifications for knee osteoarthritis rehabilitation. IEEE Transactions on Biomedical Engineering. 2008;55:2104–2106.
    1. Fregly BJ, D'Lima DD, Coldwell CW. Effective patterns for offloading the medial compartment of the knee. Journal of Orthopaedic Research. 2009 doi: 10.1002/jor.20843.
    1. Davis IS. Gait retraining in runners. Orthopedic Practice. 2005;17:8–13.
    1. Barrios JA, Higginson JS, Royer TD, Davis IS. Static and dynamic correlates of the knee adduction moment in healthy knees ranging from normal to varus-aligned. Clinical Biomechanics. 2009 doi: 10.1016/j.clinbiomech.2009.07.016.
    1. Blandin Y, Toussaint L, Shea CH. Specificity of practice: interaction between concurrent sensory feedback information and terminal feedback. Journal of Experimental Psychology. 2008;34:994–1000.
    1. Winstein CJ. Knowledge of results and motor learning—implications for physical therapy. Physical Therapy. 1991;71:140–149.
    1. Cohen J. Statistical power analysis for the behavioral sciences. 2nd. Hillsdale, NJ: Lawrence Earlbaum Associates; 1988.
    1. Roos EM, Roos HP, Lohmander LS, Ekdahl C, Beynnon BD. Knee Injury and Osteoarthritis Outcome Score (KOOS) -- development of a self-administered outcome measure. Journal of Orthopaedic & Sports Physical Therapy. 1998;28:88–96.
    1. Hinman RS, May RL, Crossley KM. Is there an alternative to the full-length radiograph for determining knee joint alignment in osteoarthritis? Arthritis & Rheumatism. 2006;55:306–313.
    1. Hicks JL, Richards JG. Clinical applicability of using spherical fitting to find hip joint centers. Gait & Posture. 2005;22:138–145.
    1. Grood ES, Suntay WJ. A joint coordinate system for the clinical description of three-dimensional motions: application to the knee. Journal of Biomechanical Engineering. 1983;105(2):136–144.
    1. Dempster WT, Gabel WC, Felts WJ. The anthropometry of the manual work space for the seated subject. American Journal of Physical Anthropology. 1959;17:289–317.
    1. Zeni JA, Ricahrds JG, Higginson JS. Two simple methods to determine gait events during treadmill and overground walking using kinematic data. Gait & Posture. 2008;27:710–714.
    1. van Hedel HJA, Dietz V. The influence of age on learning a locomotor task. Clinical Neurophysiology. 2004;115:2134–2143.
    1. Butler RJ, Marchesi S, Royer T, Davis IS. The effect of a subject-specific amount of lateral wedge on knee mechanics in patients with medial knee osteoarthritis. Journal of Orthopaedic Research. 2007;25:1121–1127.
    1. Carr A. Barriers to the effectiveness of any intervention in OA. Best Practice & Research: Clinical Rheumatology. 2001;15:645–656.

Source: PubMed

Sponsor e collaboratori

Condizioni mediche

Interventi farmacologici

3
Sottoscrivi