Gait symmetry measures: A review of current and prospective methods

Cyclogram-based evaluation of inter-limb gait symmetry in Prader-Willi Syndrome

BACKGROUND

Prader-Willi syndrome (PWS) is characterized by a complex clinical condition, whose typical features lead to impaired motor and functional skills. To date, limited data is available as regards symmetry of gait in PWS.

RESEARCH QUESTION

The aim of this study was to characterize lower-limb asymmetry during gait in a group of Prader-Willi Syndrome (PWS) individuals by using the synchronized cyclograms and to compare it with those of two different control groups, a normal-weight group and an obese group.

METHODS

A total of 18 PWS, 30 normal weight (NW) and 28 obese individuals (OG) matched for age, sex and height were assessed via 3D gait analysis. Gait spatio-temporal parameters were computed together with angle-angle diagrams, characterized in terms of their geometric features (i.e. area, orientation, and trend symmetry index).

RESULTS

Individuals with PWS exhibit reduced speed, stride length and cadence and increased duration of both stance and double support phase than the other groups. OG was characterized by the same pattern when compared to NW. With respect to inter-limb symmetry, individuals with PWS exhibited significantly larger cyclogram areas at hip joint with respect to the other two groups (203.32 degrees2 vs. 130.73 degrees2 vs. 111.59 degrees2) and significantly higher orientation angle (4.17° vs. 2.11° vs. 1.22°) and Trend Symmetry (3.72 vs. 2.02 vs. 1.21) with respect to the other two groups at knee joint; no differences were found at ankle joint. Both individuals with PWS and those of OG exhibited reduced ROM at knee and ankle joints with respect with normal weight, but no statistically significant differences were observed between PWS and OG.

SIGNIFICANCE

The obtained results may provide novel and useful insights to understand better the impairments in motor control associated with this pathological state, supporting clinics in the identification of the best rehabilitation program for this rare pathological state, aimed to improve stability and motor control.

Gait asymmetry and symptom laterality in Parkinson's disease: two of a kind?

BACKGROUND

The laterality of motor symptoms is considered a key feature of Parkinson's disease (PD). Here, we investigated whether gait and turning asymmetry coincided with symptom laterality as determined by the MDS-UPRDS part III and whether it was increased compared to healthy controls (HC).

METHODS

We analyzed the asymmetry of gait and turning with and without a cognitive dual task (DT) using motion capture systems and wearable sensors in 97 PD patients mostly from Hoehn & Yahr stage II and III and 36 age-matched HC. We also assessed motor symptom asymmetry using the bilateral sub-items of the MDS-UPDRS-III. Finally, we examined the strength of the association between gait asymmetry and symptom laterality.

RESULTS

Participants with PD had increased gait but not more turning asymmetry compared to HC (p < 0.05). Only 53.7% of patients had a shorter step length on the more affected body side as determined by the MDS-UPDRS-III. Also, 54% took more time and 29% more steps during turns toward the more affected side. The degree of asymmetry in the different domains did not correlate with each other and was not influenced by DT-load.

CONCLUSIONS

We found a striking mismatch between the side and the degree of asymmetry in different motor domains, i.e., in gait, turning, and distal symptom severity in individuals with PD. We speculate that motor execution in different body parts relies on different neural control mechanisms. Our findings warrant further investigation to understand the complexity of gait asymmetry in PD.

Transfemoral prosthetic simulators versus amputees: ground reaction forces and spatio-temporal parameters in gait

This study aimed to compare the ground reaction forces (GRFs) and spatio-temporal parameters as well as their asymmetry ratios in gait between individuals wearing a transfemoral prosthetic simulator (TFSim) and individuals with unilateral transfemoral amputation (TFAmp) across a range of walking speeds (2.0-5.5 km h-1). The study recruited 10 non-disabled individuals using TFSim and 10 individuals with unilateral TFAmp using a transfemoral prosthesis. Data were collected using an instrumented treadmill with built-in force plates, and subsequently, the GRFs and spatio-temporal parameters, as well as their asymmetry ratios, were analysed. When comparing the TFSim and TFAmp groups, no significant differences were found among the gait parameters and asymmetry ratios of all tested metrics except the vertical GRFs. The TFSim may not realistically reproduce the vertical GRFs during the weight acceptance and push-off phases. The structural and functional variations in prosthetic limbs and components between the TFSim and TFAmp groups may be primary contributors to the difference in the vertical GRFs. These results suggest that TFSim might be able to emulate the gait of individuals with TFAmp regarding the majority of spatio-temporal and GRF parameters. However, the vertical GRFs of TFSim should be interpreted with caution.

Determination of Gait Events and Temporal Gait Parameters for Persons with a Knee-Ankle-Foot Orthosis

Gait event detection is essential for controlling an orthosis and assessing the patient's gait. In this study, patients wearing an electromechanical (EM) knee-ankle-foot orthosis (KAFO) with a single IMU embedded in the thigh were subjected to gait event detection. The algorithm detected four essential gait events (initial contact (IC), toe off (TO), opposite initial contact (OIC), and opposite toe off (OTO)) and determined important temporal gait parameters such as stance/swing time, symmetry, and single/double limb support. These gait events were evaluated through gait experiments using four force plates on healthy adults and a hemiplegic patient who wore a one-way clutch KAFO and a pneumatic cylinder KAFO. Results showed that the smallest error in gait event detection was found at IC, and the largest error rate was observed at opposite toe off (OTO) with an error rate of -2.8 ± 1.5% in the patient group. Errors in OTO detection resulted in the largest error in determining the single limb support of the patient with an error of 5.0 ± 1.5%. The present study would be beneficial for the real-time continuous monitoring of gait events and temporal gait parameters for persons with an EM KAFO.

Center of Mass Estimation for Impaired Gait Assessment Using Inertial Measurement Units

Injury or disease often compromise walking dynamics and negatively impact quality of life and independence. Assessing methods to restore or improve pathological gait can be expedited by examining a global parameter that reflects overall musculoskeletal control. Center of mass (CoM) kinematics follow well-defined trajectories during unimpaired gait, and change predictably with various gait pathologies. We propose a method to estimate CoM trajectories from inertial measurement units (IMUs) using a bidirectional Long Short-Term Memory neural network to evaluate rehabilitation interventions and outcomes. Five non-disabled volunteers participated in a single session of various dynamic walking trials with IMUs mounted on various body segments. A neural network trained with data from four of the five volunteers through a leave-one-subject out cross validation estimated the CoM with average root mean square errors (RMSEs) of 1.44cm, 1.15cm, and 0.40cm in the mediolateral (ML), anteroposterior (AP), and inferior/superior (IS) directions respectively. The impact of number and location of IMUs on network prediction accuracy was determined via principal component analysis. Comparing across all configurations, three to five IMUs located on the legs and medial trunk were the most promising reduced sensor sets for achieving CoM estimates suitable for outcome assessment. Lastly, the networks were tested on data from an individual with hemiparesis with the greatest error increase in the ML direction, which could stem from asymmetric gait. These results provide a framework for assessing gait deviations after disease or injury and evaluating rehabilitation interventions intended to normalize gait pathologies.

Utilizing mobile robotics for pelvic perturbations to improve balance and cognitive performance in older adults: a randomized controlled trial

Late-life balance disorders remain a severe problem with fatal consequences. Perturbation-based balance training (PBT), a form of rehabilitation that intentionally introduces small, unpredictable disruptions to an individual's gait cycle, can improve balance. The Tethered Pelvic Assist Device (TPAD) is a cable-driven robotic trainer that applies perturbations to the user's pelvis during treadmill walking. Earlier work showcased improved gait stability and the first evidence of increased cognition acutely. The mobile Tethered Pelvic Assist Device (mTPAD), a portable version of the TPAD, applies perturbations to a pelvic belt via a posterior walker during overground gait, as opposed to treadmill walking. Forty healthy older adults were randomly assigned to a control group (CG, n = 20) without mTPAD PBT or an experimental group (EG, n = 20) with mTPAD PBT for a two-day study. Day 1 consisted of baseline anthropometrics, vitals, and functional and cognitive measurements. Day 2 consisted of training with the mTPAD and post-interventional cognitive and functional measurements. Results revealed that the EG significantly outperformed the CG in several cognitive (SDMT-C and TMT-B) and functional (BBS and 4-Stage Balance: one-foot stand) measurements while showcasing increased confidence in mobility based on FES-I. To our knowledge, our study is the first randomized, large group (n = 40) clinical study exploring new mobile perturbation-based robotic gait training technology.

Movement Asymmetries: From Their Molecular Origin to the Analysis of Movement Asymmetries in Athletes

Asymmetry plays a major role in biology at all scales. This can be seen in the helix of DNA, the fact that the human heart is on the left side, or that most people use their right hand. A single protein such as Myosin 1D can induce helical motion in another molecule. This causes cells, organs, and even entire bodies to twist in a domino effect, causing left-right behaviour. More generally, athlete movements are often asymmetric and, during the physical rehabilitation after injury, the asymmetry is visually discernible. Herein, we review the molecular basis of the movement asymmetries and report on the available knowledge on the few therapeutics investigated so far such as meloxicam. From a more rehabilitative perspective, it is very important to use effective methods to control the process of resolving the injury-related movement asymmetry through the complex use of specialised exercises, measurements, and gait analysis, which can all provide useful information on the effectiveness of the rehabilitation plans. If for each athlete, the normal range of asymmetry is known, the asymmetry can be individually treated and the evolution can be monitored over time. Appropriate measures should be taken if the movement asymmetry is outside this range. In addition, genetic, physiological, and psychological factors relevant to athlete health should be considered in the process of assessing and improving exercise asymmetry, which we also discuss in this review. The main proposal of this work is that the movement asymmetries in athletes should be individually treated, while taking into account the athlete's genetics, physical condition, and previous injuries.

Spatiotemporal Gait Parameters and Gait Asymmetry in Patients With Lumbar Disc Herniation, Treated With Microdiscectomy: A Prospective, Observational Study

OBJECTIVE

The aim of this study was to emphasize on the interaction of spatial and temporal gait parameters and analyse the gait asymmetry in the patients with lumbar disc herniation (LDH) before and after microdiscectomy.

METHODS

This was a prospective, observational study conducted on 59 cases of LDH planned for lumbar microdiscectomy, and healthy control group with 54 participants for analysis was performed prior to surgery and 15 days after surgery. The spatiotemporal gait parameters were measured using a "Win-Track" gait analysis platform system. All the participants walked barefoot for 10 times with their normal walking speed in the same day. The 3 flawless walking data were recorded and the arithmetic means were computed. The gait symmetry index was used to calculate the walking asymmetry. The pain intensity of the patients was recorded shortly before performing the analysis by a visual analogue scale.

RESULTS

In the postoperative assessment LDH patients had significantly shorter temporal parameters, longer spatial parameters, faster walking speed, and more cadence than the preoperative assessment (p < 0.05). There were improvements in the asymmetry values of the postoperative gait parameters compared to the preoperative values, but these differences were not significant (p > 0.05). In addition, there was a significant difference in all parameters in terms of gait asymmetry between the postoperative assessment and the healthy controls (p < 0.05).

CONCLUSION

These results can guide the patient-specific evaluating and implementation of gait rehabilitation programs, and design protocols before or after surgery in the LDH patients.

Gait asymmetry in children with Duchenne muscular dystrophy: evaluated through kinematic synergies and muscle synergies of lower limbs

BACKGROUND

Gait is a complex, whole-body movement that requires the coordinated action of multiple joints and muscles of our musculoskeletal system. In the context of Duchenne muscular dystrophy (DMD), a disease characterized by progressive muscle weakness and joint contractures, previous studies have generally assumed symmetrical behavior of the lower limbs during gait. However, such a symmetric gait pattern of DMD was controversial. One aspect of this is criticized, because most of these studies have primarily focused on univariate variables, rather than on the coordination of multiple body segments and even less investigate gait symmetry under a motor synergy of view.

METHODS

We investigated the gait pattern of 20 patients with DMD, compared to 18 typical developing children (TD) through 3D Gait Analysis. Kinematic and muscle synergies were extracted with principal component analysis (PCA) and non-negative matrix factorization (NNMF), respectively. The synergies extracted from the left and right sides were compared with each other to obtain a symmetry value. In addition, bilateral spatiotemporal variables of gait, such as stride length, percentage of stance and swing phase, step length, and percentage of double support phase, were used for calculating the symmetry index (SI) to evaluate gait symmetry as well.

RESULTS

Compared with the TD group, the DMD group walked with decreased gait velocity (both p < 0.01), stride length (both p < 0.01), and step length (both p < 0.001). No significant difference was found between groups in SI of all spatiotemporal parameters extracted between the left and right lower limbs. In addition, the DMD group exhibited lower kinematic synergy symmetry values compared to the TD group (p < 0.001), while no such significant group difference was observed in symmetry values of muscle synergy.

CONCLUSIONS

The findings of this study suggest that DMD influences, to some extent, the symmetry of synergistic movement of multiple segments of lower limbs, and thus kinematic synergy appears capable of discriminating gait asymmetry in children with DMD when conventional spatiotemporal parameters are unchanged.

Spatiotemporal parameters from remote smartphone-based gait analysis are associated with lower extremity functional scale categories

Objective

Self-report tools are recommended in research and clinical practice to capture individual perceptions regarding health status; however, only modest correlations are found with performance-based results. The Lower Extremity Functional Scale (LEFS) is one well-validated measure of impairment affecting physical activities that has been compared with objective tests. More recently, mobile gait assessment software can provide comprehensive motion tracking output from ecologically valid environments, but how this data relates to subjective scales is unknown. Therefore, the association between the LEFS and walking variables remotely collected by a smartphone was explored.

Methods

Proprietary algorithms extracted spatiotemporal parameters detected by a standard integrated inertial measurement unit from 132 subjects enrolled in physical therapy for orthopedic or neurological rehabilitation. Users initiated ambulation recordings and completed questionnaires through the OneStep digital platform. Discrete categories were created based on LEFS score cut-offs and Analysis of Variance was applied to estimate the difference in gait metrics across functional groups (Low-Medium-High).

Results

The main finding of this cross-sectional retrospective study is that remotely-collected biomechanical walking data are significantly associated with individuals' self-evaluated function as defined by LEFS categorization (n = 132) and many variables differ between groups. Velocity was found to have the strongest effect size.

Discussion

When patients are classified according to subjective mobility level, there are significant differences in quantitative measures of ambulation analyzed with smartphone-based technology. Capturing real-time information about movement is important to obtain accurate impressions of how individuals perform in daily life while understanding the relationship between enacted activity and relevant clinical outcomes.

Effect of unilateral ankle loading on gait symmetry in young adults

BACKGROUND

Walking requires constant adjustments to the changing environment. An asymmetrical perturbation can affect the gait symmetry, cause gait adaptations, and potentially induce retention of the adapted gait after removal of the perturbation. A unilateral ankle load has the potential to create asymmetry and facilitate the emergence of new gait patterns. However, few studies have examined the effect of unilateral loading on muscular adjustments during walking. The purpose of this study was to investigate gait adaptations and muscular adjustments after unilaterally loading or unloading the ankle.

RESEARCH QUESTION

What are the effects of unilateral loading and unloading on gait spatiotemporal parameters and muscle activation in young adults?

METHODS

Twenty young adults (10 M/10 F) walked on a treadmill at their preferred walking speeds in 3 conditions: 1) a 2-minute baseline trial; 2) three 5-minute trials with a load (3 % of bodyweight) on the dominant ankle (Loading); and 3) one 5-minute trial with the load removed (Unloading). Inertial measurement units (IMUs) and electromyography sensors (EMGs) were used for data collection. Early and late adaptation and post-adaptation were assessed using the first 5 strides and the last 30 strides of loading and unloading conditions. Outcome measures included symmetry index (SI) of spatiotemporal parameters, range-of-motion (ROM) of the lower body joints, and EMG integrals of leg muscles. Repeated measures ANOVA was conducted for statistical analysis (α = 0.05).

RESULTS

SI of swing phase percentage demonstrated rapid adaptation after unilateral loading or unloading. Stride length demonstrated an aftereffect following unloading. Young adults reduced ankle ROMs bilaterally in early adaptation and increased loaded-side knee and hip ROMs in late adaptation. Additionally, they increased the tibialis anterior activity bilaterally immediately after unilateral loading.

SIGNIFICANCE

Young adults showed an aftereffect in some variables after unilateral unloading, signifying that unilateral ankle loading can induce short term learning of a new gait pattern.

Overground Robotic Gait Trainer mTPAD Improves Gait Symmetry and Weight Bearing in Stroke Survivors

Stroke is a leading cause of disability, impairing the ability to generate propulsive forces and causing significant lateral gait asymmetry. We aim to improve stroke survivors' gaits by promoting weight-bearing during affected limb stance. External forces can encourage this; e.g., vertical forces can augment the gravitational force requiring higher ground reaction forces, or lateral forces can shift the center of mass over the stance foot, altering the lateral placement of the center of pressure. With our novel design of a mobile Tethered Pelvic Assist Device (mTPAD) paired with the DeepSole system to predict the user's gait cycle percentage, we demonstrate how to apply three-dimensional forces on the pelvis without lower limb constraints. This work is the first result in the literature that shows that with an applied lateral force during affected limb stance, the center of pressure trajectory's lateral symmetry is significantly closer to a 0% symmetry (5.5%) than without external force applied (-9.8%,p<0.05). Furthermore, the affected limb's maximum relative pressure (p) significantly increases from 233.7p to 234.1p (p<0.05) with an applied downward force, increasing affected limb loading. This work highlights how the mTPAD increases weight-bearing and propulsive forces during gait, which is a crucial goal for stroke survivors.

Effect of Multicomponent Home-Based Training on Gait and Muscle Strength in Older Adults After Hip Fracture Surgery: A Single Site Randomized Trial

OBJECTIVE

To investigate the effect of 16-week home-based physical therapy interventions on gait and muscle strength.

DESIGN

A single-blinded randomized controlled trial.

SETTING

General community.

PARTICIPANTS

Thirty-four older adults (N=34) post hip fracture were randomly assigned to either experimental group (a specific multi-component intervention group [PUSH], n=17, 10 women, age=78.6±7.3 years, 112.1±39.8 days post-fracture) or active control (a non-specific multi-component intervention group [PULSE], n=17, 11 women, age=77.8±7.8 years, 118.2±37.5 days post-fracture).

INTERVENTION

PUSH and PULSE groups received 32-40 sessions of specific or non-specific multi-component home-based physical therapy, respectively. Training in the PUSH group focused on lower extremity strength, endurance, balance, and function for community ambulation, while the PULSE group received active movement and transcutaneous electrical nerve stimulation on extremities.

MAIN OUTCOME MEASURES

Gait characteristics, and ankle and knee muscle strength were measured at baseline and 16 weeks. Cognitive testing of Trail Making Test (Part A: TMT-A; Part-B: TMT-B) was measured at baseline.

RESULTS

At 16 weeks, both groups demonstrated significant increases in usual (P<.05) and fast (P<.05) walking speed, while there was no significant difference in increases between the groups. There was only 1 significant change in lower limb muscle strength over time (non-fractured side) between the groups, such that PUSH did better (mean: 4.33%, 95% confidence interval:1.43%-7.23%). The increase in usual and fast walking speed correlated with the baseline Trail-making Test-B score (r=-0.371, P=.037) and improved muscle strength in the fractured limb (r=0.446, P=.001), respectively.

CONCLUSION

Gait speed improved in both home-based multicomponent physical therapy programs in older adults after hip fracture surgery. Muscle strength of the non-fractured limb improved in the group receiving specific physical therapy training. Specific interventions targeting modifiable factors such as muscle strength and cognitive performance may assist gait recovery after hip fracture surgery.

Normalized kinematic walking symmetry data for individuals who use lower-limb prostheses: considerations for clinical practice and future research

Introduction

Individuals who use unilateral transtibial or transfemoral prostheses have negative secondary health effects associated with decreased kinematic (e.g., spatiotemporal and joint angle) walking symmetry between prosthetic and intact limbs. Research studies have quantified kinematic walking symmetry, but studies can be difficult to compare owing to the inclusion of small sample sizes and differences in participant demographics, biomechanical parameters, and mathematical analysis of symmetry. This review aims to normalize kinematic walking symmetry research data across studies by level of limb loss and prosthetic factors to inform considerations in clinical practice and future research.

Methods

A search was performed on March 18, 2020, in PubMed, Scopus, and Google Scholar to encompass kinematic walking symmetry literature from the year 2000. First, the most common participant demographics, kinematic parameters, and mathematical analysis of symmetry were identified across studies. Then, the most common mathematical analysis of symmetry was used to recalculate symmetry data across studies for the five most common kinematic parameters.

Results

Forty-four studies were included in this review. The most common participant demographics were younger adults with traumatic etiology who used componentry intended for higher activity levels. The most common kinematic parameters were step length, stance time, and sagittal plane ankle, knee, and hip range of motion. The most common mathematical analysis was a particular symmetry index equation.

Conclusions

Normalization of data showed that symmetry tended to decrease as level of limb loss became more proximal and to increase with prosthetic componentry intended for higher activity levels. However, most studies included 10 or fewer individuals who were active younger adults with traumatic etiologies.

Clinical Relevance

Data summarized in this review could be used as reference values for rehabilitation and payer justification. Specifically, these data can help guide expectations for magnitudes of walking symmetry throughout rehabilitation or to justify advanced prosthetic componentry for active younger adults under 65 years of age with traumatic etiologies to payers.

Automated recognition of asymmetric gait and fatigue gait using ground reaction force data

Introduction: The purpose of this study was to evaluate the effect of running-induced fatigue on the characteristic asymmetry of running gait and to identify non-linear differences in bilateral lower limbs and fatigued gait by building a machine learning model. Methods: Data on bilateral lower limb three-dimensional ground reaction forces were collected from 14 male amateur runners before and after a running-induced fatigue experiment. The symmetry function (SF) was used to assess the degree of symmetry of running gait. Statistical parameter mapping (Paired sample T-test) algorithm was used to examine bilateral lower limb differences and asymmetry changes pre- and post-fatigue of time series data. The support vector ma-chine (SVM) algorithm was used to recognize the gait characteristics of both lower limbs before and after fatigue and to build the optimal algorithm model by setting different kernel functions. Results: The results showed that the ground reaction forces were asymmetrical (SF > 0.5) both pre-and post-fatigue and mainly concentrated in the medial-lateral direction. The asymmetry of the medial-lateral direction increased significantly after fatigue (p < 0.05). In addition, we concluded that the polynomial kernel function could make the SVM model the most accurate in classifying left and right gait features (accuracy of 85.3%, 82.4%, and 82.4% in medial-lateral, anterior-posterior and vertical directions, respectively). Gaussian radial basis kernel function was the optimal kernel function of the SVM algorithm model for fatigue gait recognition in the medial-lateral and vertical directions (accuracy of 54.2% and 62.5%, respectively). Moreover, polynomial was the optimal kernel function of the anterior-posterior di-rection (accuracy = 54.2%). Discussion: We proved in this study that the SVM algorithm model depicted good performance in identifying asymmetric and fatigue gaits. These findings can provide implications for running injury prevention, movement monitoring, and gait assessment.

The Influence of Transtibial Prosthesis Type on Lower-Body Gait Adaptation: A Case Study

Gait parameters are altered and asymmetrical in individuals with transtibial amputation. The purpose of this study was to evaluate and compare the effect of four different prosthetic feet on lower-limb biomechanics during gait. A 34-year-old man with transtibial amputation performed four gait analysis sessions with four foot-ankle prostheses (Variflex, Meridium, Echelon, and Kinterra). Kinematic and kinetic parameters and gait symmetry were analyzed in different prosthetic conditions. The type of prosthesis had little effect on the participant's spatiotemporal parameters. Throughout the stance phase, increased hip angle, reduced knee flexion and ankle dorsiflexion were observed in the amputated leg. For kinetic parameters, reduced propulsive force (SI = 0.42-0.65), reduced knee extension moment (mainly during Echelon and Kinterra conditions, SI = 0.17 and 0.32, respectively), and increased knee abduction moment (mainly during the Variflex and Meridium, SI = 5.74 and 8.93, respectively) were measured in the amputated leg. Lower support moments were observed in the amputated leg as compared to the unaffected leg, regardless of the type of prosthesis (SI = 0.61-0.80). The prostheses tested induced different lower-limb mechanical adaptations. In order to achieve the clinical goal of better gait symmetry between lower limbs, an objective gait analysis could help clinicians to prescribe prosthetic feet based on quantitative measurement indicators to optimize gait rehabilitation.

Present and future of gait assessment in clinical practice: Towards the application of novel trends and technologies

Background

Despite being available for more than three decades, quantitative gait analysis remains largely associated with research institutions and not well leveraged in clinical settings. This is mostly due to the high cost/cumbersome equipment and complex protocols and data management/analysis associated with traditional gait labs, as well as the diverse training/experience and preference of clinical teams. Observational gait and qualitative scales continue to be predominantly used in clinics despite evidence of less efficacy of quantifying gait.

Research objective

This study provides a scoping review of the status of clinical gait assessment, including shedding light on common gait pathologies, clinical parameters, indices, and scales. We also highlight novel state-of-the-art gait characterization and analysis approaches and the integration of commercially available wearable tools and technology and AI-driven computational platforms.

Methods

A comprehensive literature search was conducted within PubMed, Web of Science, Medline, and ScienceDirect for all articles published until December 2021 using a set of keywords, including normal and pathological gait, gait parameters, gait assessment, gait analysis, wearable systems, inertial measurement units, accelerometer, gyroscope, magnetometer, insole sensors, electromyography sensors. Original articles that met the selection criteria were included.

Results and significance

Clinical gait analysis remains highly observational and is hence subjective and largely influenced by the observer's background and experience. Quantitative Instrumented gait analysis (IGA) has the capability of providing clinicians with accurate and reliable gait data for diagnosis and monitoring but is limited in clinical applicability mainly due to logistics. Rapidly emerging smart wearable technology, multi-modality, and sensor fusion approaches, as well as AI-driven computational platforms are increasingly commanding greater attention in gait assessment. These tools promise a paradigm shift in the quantification of gait in the clinic and beyond. On the other hand, standardization of clinical protocols and ensuring their feasibility to map the complex features of human gait and represent them meaningfully remain critical challenges.

Gait Analysis of Bilateral Knee Osteoarthritis and Its Correlation with Western Ontario and McMaster University Osteoarthritis Index Assessment

Background and objectives: Objective, accurate, and intuitive evaluation of knee joint function in patients with knee osteoarthritis (KOA) is important. This study aimed to clarify the gait characteristics of patients with bilateral KOA and their correlation with Western Ontario and McMaster University Osteoarthritis Index (WOMAC). Materials and Methods: 20 patients with bilateral KOA and 20 conditionally matched healthy individuals were enrolled in the experimental and control groups, respectively. Footscan and CODA motion gait analysis systems were used to analyse the gait parameters. Gait spatiotemporal parameters and knee joint motion parameters were collected. Weight-bearing balance and walking stability were assessed using discrete trends of relevant gait indicators. Patients in the experimental group were evaluated using WOMAC. Pearson’s correlation analysis was performed on the gait data and WOMAC score data of the experimental group. Results: Velocity, cadence, step length, and stride length of the experimental group were significantly lower than those of the control group (p < 0.01). Step time and gait cycle were significantly greater in the experimental group than in the control group (p < 0.01). Total stance and double-stance times of the experimental group were significantly greater than those of the control group (p < 0.01), whereas the single-stance time was shorter than that of the control group (p < 0.01). The range of motion and maximum flexion angle in the experimental group were significantly lower than those in the control group (p < 0.01), and the minimum angle of knee extension was greater than that in the control group (p < 0.01). The discrete trend of weight-bearing balance and walking stability gait index in the experimental group was greater than that in the control group. The WOMAC score and gait analysis were significantly correlated (p < 0.05). Conclusions: The gait function of patients with KOA is significantly worse than that of normal people. The WOMAC scale and gait analysis can be used to assess KOA severity from different perspectives with good consistency.

Factors leading to falls in transfemoral prosthesis users: a case series of sound-side stumble recovery responses

Background

Transfemoral prosthesis users’ high fall rate is related to increased injury risk, medical costs, and fear of falling. Better understanding how stumble conditions (e.g., participant age, prosthesis type, side tripped, and swing phase of perturbation) affect transfemoral prosthesis users could provide insight into response deficiencies and inform fall prevention interventions.

Methods

Six unilateral transfemoral prosthesis users experienced obstacle perturbations to their sound limb in early, mid, and late swing phase. Fall outcome, recovery strategy, and kinematics of each response were recorded to characterize (1) recoveries versus falls for transfemoral prosthesis users and (2) prosthesis user recoveries versus healthy adult recoveries.

Results

Out of 26 stumbles, 15 resulted in falls with five of six transfemoral prosthesis users falling at least once. By contrast, in a previously published study of seven healthy adults comprising 214 stumbles using the same experimental apparatus, no participants fell. The two oldest prosthesis users fell after every stumble, stumbles in mid swing resulted in the most falls, and prosthesis type was not related to strategy/fall outcomes. Prosthesis users who recovered used the elevating strategy in early swing, lowering strategy in late swing, and elevating or lowering/delayed lowering with hopping in mid swing, but exhibited increased contralateral (prosthetic-side) thigh abduction and trunk flexion relative to healthy controls. Falls occurred if the tripped (sound) limb did not reach ample thigh/knee flexion to sufficiently clear the obstacle in the elevating step, or if the prosthetic limb did not facilitate a successful step response after the initial sound-side elevating or lowering step. Such responses generally led to smaller step lengths, less anterior foot positioning, and more forward trunk flexion/flexion velocity in the resulting foot-strikes.

Conclusions

Introducing training (e.g., muscle strength or task-specific motor skill) and/or modifying assistive devices (e.g., lower-limb prostheses or exoskeletons) may improve responses for transfemoral prosthesis users. Specifically, training or exoskeleton assistance could help facilitate sufficient thigh/knee flexion for elevating; training or prosthesis assistance could provide support-limb counteracting torques to aid in elevating; and training or prosthesis assistance could help initiate and safely complete prosthetic swing.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12984-022-01070-y.

Effects of personal protective clothing on firefighters' gait analyzed using 3D motion capture system

OBJECTIVES

The effects of personal protective clothing (PPC) on firefighters' gait were investigated to develop high-performance PPC.

METHODS

Thirteen participants participated in human trials with three types of PPC (firefighter protective clothing (FPC); semi-enclosed chemical protective clothing (CPC_semi); full-enclosed chemical protective clothing (CPC_full)) and T-shirt (CON). A 3D motion capture system was used to obtain gait parameters (step length, step width, stride frequency, gait speed, and toe-out angle) and the range of motion (ROM) of the joints (hip, knee, and ankle).

RESULTS

PPCs produced an increase in step width (23.4%, p > 0.05), but the gait speed (9.1%) and stride frequency (6.4%) decreased compared with the CON results. ROM is affected by the PPC type and joint. FPC and CPC_semi had no significant effect in terms of the ROM of the hip and knee besides the landing angle of the knee. However, CPC_full had a significant effect on the maximum extension angle of the hip and maximum flexion angle of the knee, which reached up to 27.2%.

CONCLUSION

The ROM of the firefighter's lower limbs were limited by PPC. This study offers insights into next-generation PPC design and development, as well as guidelines for training and firefighting.

Synchronized Cyclograms to Assess Inter-Limb Symmetry during Gait in Post-Stroke Patients

The aim of this study was to assess the inter-limb symmetry during gait in post-stroke patients using the synchronized cyclograms technique. In total, 41 individuals with stroke (21 left and 20 right hemiplegic patients; age: 57.9 ± 12.8 years; time stroke event 4.6 ± 1.8 years) and 48 age-, sex-, and height-matched individuals (control group: CG; age: 54.4 ± 12.5 years) were assessed via 3D gait analysis. Raw kinematic data were processed to compute spatio-temporal parameters (speed, stride length, cadence, stance, swing, and double support phases duration) and angle–angle diagrams (synchronized cyclograms), which were characterized in terms of area, orientation, and trend symmetry indices. The results reveal that all spatio-temporal parameters are characterized by abnormal values, with reduced speed, stride length, cadence, and swing phase duration and increased stance and double support phases duration. With respect to inter-limb symmetry, higher values were found in post-stroke individuals for all the considered parameters as patients generally exhibited a cyclogram characterized by larger areas, higher orientation, and trend symmetry parameters with respect to CG. The described alterations of gait asymmetry are important from a clinical point of view as the achievement of symmetry in gait represents a crucial objective in the rehabilitation of hemiplegic people.

Identifying the Effects of Age and Speed on Whole-Body Gait Symmetry by Using a Single Wearable Sensor

Studies on gait symmetry in healthy population have mainly been focused on small range of age categories, neglecting Teenagers (13–18 years old) and Middle-Aged persons (51–60 years old). Moreover, age-related effects on gait symmetry were found only when the symmetry evaluation was based on whole-body acceleration than on spatiotemporal parameters of the gait cycle. Here, we provide a more comprehensive analysis of this issue, using a Symmetry Index (SI) based on whole-body acceleration recorded on individuals aged 6 to 84 years old. Participants wore a single inertial sensor placed on the lower back and walked for 10 m at comfortable, slow and fast speeds. The SI was computed using the coefficient of correlation of whole-body acceleration measured at right and left gait cycles. Young Adults (19–35 years old) and Adults (36–50 years old) showed stable SI over the three speed conditions, while Children (6–12 years old), Teenagers (13–18 years old), Middle-Aged persons and Elderly (61–70 and 71–84 years old) exhibited lower SI values when walking at fast speed. Overall, this study confirms that whole-body gait symmetry is lower in Children and in Elderly persons over 60 years of age, showing, for the first time, that asymmetries appear also during teenage period and in Middle-Aged persons (51–60 years old).

Foot contact forces can be used to personalize a wearable robot during human walking

Individuals with below-knee amputation (BKA) experience increased physical effort when walking, and the use of a robotic ankle-foot prosthesis (AFP) can reduce such effort. The walking effort could be further reduced if the robot is personalized to the wearer using human-in-the-loop (HIL) optimization of wearable robot parameters. The conventional physiological measurement, however, requires a long estimation time, hampering real-time optimization due to the limited experimental time budget. This study hypothesized that a function of foot contact force, the symmetric foot force-time integral (FFTI), could be used as a cost function for HIL optimization to rapidly estimate the physical effort of walking. We found that the new cost function presents a reasonable correlation with measured metabolic cost. When we employed the new cost function in HIL ankle-foot prosthesis stiffness parameter optimization, 8 individuals with simulated amputation reduced their metabolic cost of walking, greater than 15% (p < 0.02), compared to the weight-based and control-off conditions. The symmetry cost using the FFTI percentage was lower for the optimal condition, compared to all other conditions (p < 0.05). This study suggests that foot force-time integral symmetry using foot pressure sensors can be used as a cost function when optimizing a wearable robot parameter.

Comparison of Treadmill Gait Between a Pediatric-Aged Individual With SYNGAP1-Related Intellectual Disability and a Fraternal Twin

SYNGAP1-related Intellectual Disability (SYNGAP1-ID) is a rare neurodevelopmental condition characterized by profound intellectual disability, gross motor delays, and behavioral issues. Ataxia and gait difficulties are often observed but have not yet been characterized by laboratory-based kinematic analyses. This investigation identified gait characteristics of an individual with SYNGAP1-ID and compared these with a neurotypical fraternal twin. Lower limb kinematics were collected with a 12-camera motion capture system while both participants walked on a motorized treadmill. Kinematic data were separated into strides, and stride times calculated. Sagittal plane hip, knee, and ankle joints were filtered and temporally normalized to 100 samples. Minimum and maximum joint angles, range of motion (ROM) and angular velocities were obtained for each joint by stride and averaged for each participant. ROM symmetry between left and right joints was also calculated. Discrete relative phase (DRP) was used to assess coordination and variability between joints within a single limb and compared across limbs. Phase portraits were calculated by joint, and their areas were computed with a MATLAB script. Statistical parametric mapping (SPM) was used to assess differences in joint angle waveforms between participants. P1, the individual with SYNGAP1-ID, displayed significantly reduced stride times relative to the fraternal twin, i.e., P2. A majority of minimum, maximum angles, ROMs, and angular velocities were significantly different between P1 and P2. Phase portrait areas were consistently less in P1 relative to P2 and there were differences in knee and ankle symmetries. DRP showed no differences between individuals, suggesting that P1’s coordinative events remained similar to those observed during neurotypical gait (P2). SPM revealed significant differences between the left and right legs at the knee and ankle joints of P1 while P2 joint left and right waveforms were nearly identical for all joints. Additionally, SPM revealed there were significant differences between P1 and P2 for all joints. This investigation identified several major gait features of an individual with SYNGAP1-ID and provided a comprehensive characterization of these features by utilizing both linear and non-linear analyses. While limited in generalizability, this report provides a strong quantitative appraisal of gait in an individual with SYNGAP1-ID as well as an analysis pathway for future investigations.

Alzheimer's Disease Detection Using Comprehensive Analysis of Timed Up and Go Test via Kinect V.2 Camera and Machine Learning

Alzheimer's disease (AD) is a progressive neurodegenerative disease affecting cognitive and functional abilities. However, many patients presume lower cognitive or functional abilities because of aging and do not undergo clinical assessments until the symptoms become too advanced. Developing a low-cost and easy-to-use AD detection tool, which can be used in any clinical or non-clinical setting, can enable widespread AD assessments and diagnosis. This paper investigated the feasibility of developing such a tool to detect AD vs. healthy control (HC) from a simple balance and walking assessment called the Timed Up and Go (TUG) test. We collected joint position data of 47 HC and 38 AD subjects as they performed TUG in front of a Kinect V.2 camera. Our signal processing and statistical analyses provided a comprehensive analysis of balance and gait with 12 significant features for discriminating AD from HC after adjusting for age and the Geriatric Depression Scale. Using these features and a support vector machine classifier, our model classified the two groups with an average accuracy of 97.75% and an F-score of 97.67% for five-fold cross-validation and 98.68% and 98.67% for leave-one-subject out cross-validation. These results demonstrate the potential of our approach as a new quantitative complementary tool for detecting AD among older adults. Our work is novel as it presents the first application of Kinect V.2 camera and machine learning to provide a comprehensive and quantitative analysis of the TUG test to detect AD patients from HC. This study supports the feasibility of developing a low-cost and convenient AD assessment tool that can be used during routine checkups or even at home; however, future investigations could confirm its clinical diagnostic value in a larger cohort.

The effects of small variations in shoe heel height on gait in people with a transtibial amputation

BACKGROUND

Shoe heel height is considered to influence prosthetic alignment, walking comfort, and gait symmetry in people with a transtibial amputation (TTA). However, research on the effect of heel height is scarce, and no evidence is available on the effects of variations smaller than 20 mm. These small heel height variations between store-bought shoes are often overlooked by people with an amputation and may cause secondary musculoskeletal problems in the long term.

OBJECTIVE

To examine the effects of small increases in heel height on gait symmetry in people with a TTA and healthy individuals.

STUDY DESIGN

Experimental repeated measures study.

METHODS

Fourteen participants with a TTA and 15 healthy controls were included. Pressure data, spatiotemporal data, and experienced walking comfort were measured during walking with four heel height conditions: original height and increased heights of 3, 5, and 8 mm. Symmetry in center of pressure velocity (VCOP), gait parameters, and experienced walking comfort were compared between the heel heights and between healthy controls and prosthetic walkers.

RESULTS

Increased heel height resulted in a significant decrease in VCOP symmetry (P = 0.001) and experienced walking comfort (P < 0.001). The VCOP trajectory of the prosthetic leg mainly differed within the first 14.5% of the stance phase. Healthy individuals showed better VCOP symmetry in all conditions (P < 0.001).

CONCLUSIONS

Healthcare professionals should advice their clients to be alert of small heel height differences between store-bought shoes, especially those larger than 5 mm. A prosthetic alignment adjustment should be considered when purchasing new shoes.

Sensitivity of discrete symmetry metrics: Implications for metric choice

Gait asymmetry is present in several pathological populations, including those with Parkinson’s disease, Huntington’s disease, and stroke survivors. Previous studies suggest that commonly used discrete symmetry metrics, which compare single bilateral variables, may not be equally sensitive to underlying effects of asymmetry, and the use of a metric with low sensitivity could result in unnecessarily low statistical power. The purpose of this study was to provide a comprehensive assessment of the sensitivity of commonly used discrete symmetry metrics to better inform design of future studies. Monte Carlo simulations were used to estimate the statistical power of each symmetry metric at a range of asymmetry magnitudes, group/condition variabilities, and sample sizes. Power was estimated by repeated comparison of simulated symmetric and asymmetric data with a paired t-test, where the proportion of significant results is equivalent to the power. Simulation results confirmed that not all common discrete symmetry metrics are equally sensitive to reference effects of asymmetry. Multiple symmetry metrics exhibit equivalent sensitivities, but the most sensitive discrete symmetry metric in all cases is a bilateral difference (e.g. left—right). A ratio (e.g. left/right) has poor sensitivity when group/condition variability is not small, but a log-transformation produces increased sensitivity. Additionally, two metrics which included an absolute value in their definitions showed increased sensitivity when the absolute value was removed. Future studies should consider metric sensitivity when designing analyses to reduce the possibility of underpowered research.

Individuals with a COVID-19 history exhibit asymmetric gait patterns despite full recovery

COVID-19 is a multisystem infectious disease affecting the body systems. Its neurologic complications include -but are not limited to headache, loss of smell, encephalitis, and cerebrovascular accidents. Even though gait analysis is an objective measure of the neuro-motor system and may provide significant information about the pathophysiology of specific diseases, no studies have investigated the gait characteristics in adults after full recovery from COVID-19. This was a cross-sectional, controlled study that included 12 individuals (mean age, 23.0 ± 4.1 years) with mild-to-moderate COVID-19 history (COVD) and 20 sedentary controls (CONT; mean age, 24.0 ± 3.6 years). Gait was evaluated using inertial sensors on a motorized treadmill. Spatial-temporal gait parameters and gait symmetry were calculated by using at least 512 consecutive steps for each participant. The effect-size analyses were utilized to interpret the impact of the results. Spatial-temporal gait characteristics were comparable between the two groups. The COVD group showed more asymmetrical gait patterns than the CONT group in the double support duration symmetry (p = 0.042), single support duration symmetry (p = 0.006), loading response duration symmetry (p = 0.042), and pre-swing duration symmetry (p = 0.018). The effect size analyses of the differences showed large effects (d = 0.68-0.831). Individuals with a history of mild-to-moderate COVID-19 showed more asymmetrical gait patterns than individuals without a disease history. Regardless of its severity, the multifaceted long-term effects of COVID-19 need to be examined and the scope of clinical follow-up should be detailed.

Force, Power, and Morphology Asymmetries as Injury Risk Factors in Physically Active Men and Women

This study aimed to investigate whether asymmetry of force, power, and tissue morphology are lower limbs (LL) injury risk factors in physically active adults. Fifty-eight men aged 23.8 ± 1.2 years and forty-seven women aged 23.3 ± 1.0 years were examined. Physical activity level was measured by the International Physical Activity Questionnaire, and injury data were collected with the Injury History Questionnaire. The countermovement jump was performed to evaluate force and power. LL tissue composition was evaluated by a bioimpedance analyzer. The symmetry indices were calculated. A comparison between injured and non-injured subjects in both sexes was conducted to determine indices associated with injuries. The symmetry indices cut-off points were calculated to establish values indicating a significant injury risk increase, and logistic regression was performed. The relative peak force asymmetry above 4.049% was associated with increased injury risk in men. The LL skeletal muscle mass asymmetry above 3.584% was associated with a higher injury risk in women. Increased asymmetry in indicated indices by 1% was associated with 19.8% higher injury risk in men and 82.6% in women. Asymmetry proved to be an injury risk factor. However, a more suitable index for men is relative peak force asymmetry, whereas LL skeletal muscle mass asymmetry is more suitable for women.

A Study on Lower Limb Asymmetries in Parkinson’s Disease during Gait Assessed through Kinematic-Derived Parameters

Unilaterality of motor symptoms is a distinctive feature of Parkinson’s Disease (PD) and represents an important co-factor involved in motor deficits and limitations of functional abilities including postural instability and asymmetrical gait. In recent times, an increasing number of studies focused on the characterization of such alterations, which have been associated with increased metabolic cost and risk of falls and may severely compromise their quality of life. Although a large number of studies investigated the gait alterations in people with PD (pwPD), few focused on kinematic parameters and even less investigated interlimb asymmetry under a kinematic point of view. This retrospective study aimed to characterize such aspects in a cohort of 61 pwPD (aged 68.9 ± 9.3 years) and 47 unaffected individuals age- and sex-matched (66.0 ± 8.3 years), by means of computerized 3D gait analysis performed using an optical motion-capture system. The angular trends at hip, knee and ankle joints of pwPD during the gait cycle were extracted and compared with those of unaffected individuals on a point-by-point basis. Interlimb asymmetry was assessed using angle–angle diagrams (cyclograms); in particular, we analyzed area, orientation, trend symmetry and range offset. The results showed that pwPD are characterized by a modified gait pattern particularly at the terminal stance/early swing phase of the gait cycle. Significant alterations of interlimb coordination were detected at the ankle joint (cyclogram orientation and trend symmetry) and at the hip joint (range offset). Such findings might be useful in clinical routine to characterize asymmetry during gait and thus support physicians in the early diagnosis and in the evaluation of the disease progression.

Inter-Limb Asymmetry of Leg Stiffness in National Second-League Basketball Players during Countermovement Jumps

Assessment of the inter-limb asymmetry of leg stiffness is carried out using one-legged jumping tasks. However, the level of asymmetry may vary depending on the performance on one or both lower limbs. Therefore, the purpose of this study was to identify the differences in leg stiffness between the dominant and non-dominant lower limb during a two-legged countermovement jump. The research was conducted on 35 s-league basketball players (body height: 1.90 ± 0.08 m, body mass: 81.9 ± 10 kg, age: 19.5 ± 1.7 years). Each participant performed three countermovement jumps with arm swing to the maximum height. Measurements employed a BTS SMART motion analysis system and two Kistler force plates. Statistically significant differences were found during the comparison of leg stiffness in the dominant and non-dominant lower limbs. Inter-limb asymmetry of leg stiffness reached 22.0% in the countermovement phase and 8.9% in the take-off phase. Significant inter-limb asymmetry of leg stiffness might lead to injury or considerably reduce the performance of athletes. Therefore, an important role is to conduct strength and speed-strength trainings with proper loads to both body sides. Coaches should pay more attention to similar lower limbs movement patterns during two-legged exercises and bilateral strength development.

Descending 13 real world steps: A dataset and analysis of stair descent

BACKGROUND

Stair descent analysis has been typically limited to laboratory staircases of 4 or 5 steps. To date there has been no report of gait parameters during unconstrained stair descent outside of the laboratory, and few motion capture datasets are publicly available.

RESEARCH QUESTION

We aim to collect a dataset and perform gait analysis for stair descent outside of the laboratory. We aim to measure basic kinematic and kinetic gait parameters and foot placement behavior.

METHODS

We present a public stair descent dataset from 101 unimpaired participants aged 18-35 on an unconstrained 13-step staircase collected using wearable sensors. The dataset consists of kinematics (full-body joint angle and position), kinetics (plantar normal forces, acceleration), and foot placement for 30,609 steps.

RESULTS

We report the lower limb joint angle ranges (30° and 8° for hip flexion and extension, 85° and -11° for knee flexion and extension, and 31° and 28° for ankle dorsi- and plantar-flexion). The self-selected speed was 0.79 ± 0.16 m/s, with cycle duration of 0.97 ± 0.18 s. Mean foot overhang as a percentage of foot length was 17.07 ± 6.66 %, and we calculate that foot size explains only 6% of heel placement variation, but 79% of toe placement variation. We also find a minor but significant asymmetry between left and right maximum hip flexion angle, though all other measured parameters were symmetrical.

SIGNIFICANCE

This is the first quantitative observation of gait data from a large number (n = 101) of participants descending an unconstrained staircase outside of a laboratory. This study enables analysis of gait characteristics including self-selected walking speed and foot placement to better understand typical stair gait behavior. The dataset is a public resource for understanding typical stair descent.

A Systematic Review of Non-Pharmacological Interventions to Improve Gait Asymmetries in Neurological Populations

Gait asymmetries are commonly observed in neurological populations and linked to decreased gait velocity, balance decrements, increased fall risk, and heightened metabolic cost. Interventions designed to improve gait asymmetries have varying methods and results. The purpose of this systematic review was to investigate non-pharmacological interventions to improve gait asymmetries in neurological populations. Keyword searches were conducted using PubMed, CINAHL, and Academic Search Complete. The search yielded 14 studies for inclusion. Gait was assessed using 3D motion capture systems (n = 7), pressure-sensitive mats (e.g., GAITRite; n = 5), and positional sensors (n = 2). The gait variables most commonly analyzed for asymmetry were step length (n = 11), stance time (n = 9), and swing time (n = 5). Interventions to improve gait asymmetries predominantly used gait training techniques via a split-belt treadmill (n = 6), followed by insoles/orthoses (n = 3). The literature suggests that a wide range of methods can be used to improve spatiotemporal asymmetries. However, future research should further examine kinematic and kinetic gait asymmetries. Additionally, researchers should explore the necessary frequency and duration of various intervention strategies to achieve the greatest improvement in gait asymmetries, and to determine the best symmetry equation for quantifying gait asymmetries.

Backward vs. Forward Gait Symmetry Analysis Based on Plantar Pressure Mapping

Symmetry is one of the factors analysed in normal and pathological gaits. Backward gait is an area of interest to scientists, in terms of its physiology and therapeutic possibilities. This study aimed to analyse the symmetry of the pressure parameters of backward gait in comparison to forward gait using different symmetry indices. Eighty-one healthy people aged between 19 and 84 years took part in the study. Foot pressure distribution was analysed during forward and backward gaits at self-selected speeds. Mean and maximum pressure values were calculated after dividing the foot into four or ten areas. Delta, Ratio Index, Robinson Index, Gait Asymmetry, and Symmetry Angle were calculated for each area, separately for both forward and backward gaits. Higher ratios of asymmetry were found during backward than during forward gait. Larger ratios of asymmetry were found within toes II–V, forefoot, metatarsals I, II, and III, medial and lateral heel areas. No significant correlation between symmetry indices and age or BMI was found. Results suggested that the lower symmetry of backward gait is caused by a higher number of corrective movements that allow for the maintenance of body balance and global symmetry of gait. This can be realised by increased cortical control of the backward gait, which was a new movement task for all participants.

Use of a Single Wearable Sensor to Evaluate the Effects of Gait and Pelvis Asymmetries on the Components of the Timed Up and Go Test, in Persons with Unilateral Lower Limb Amputation

The Timed Up and Go (TUG) test quantifies physical mobility by measuring the total performance time. In this study, we quantified the single TUG subcomponents and, for the first time, explored the effects of gait cycle and pelvis asymmetries on them. Transfemoral (TF) and transtibial (TT) amputees were compared with a control group. A single wearable inertial sensor, applied to the back, captured kinematic data from the body and pelvis during the 10-m walk test and the TUG test. From these data, two categories of symmetry indexes (SI) were computed: One SI captured the differences between the antero-posterior accelerations of the two sides during the gait cycle, while another set of SI quantified the symmetry over the three-dimensional pelvis motions. Moreover, the total time of the TUG test, the time of each subcomponent, and the velocity of the turning subcomponents were measured. Only the TF amputees showed significant reductions in each SI category when compared to the controls. During the TUG test, the TF group showed a longer duration and velocity reduction mainly over the turning subtasks. However, for all the amputees there were significant correlations between the level of asymmetries and the velocity during the turning tasks. Overall, gait cycle and pelvis asymmetries had a specific detrimental effect on the turning performance instead of on linear walking.

Analysis of Gait Characteristics Using Hip-Knee Cyclograms in Patients with Hemiplegic Stroke

Gait disturbance is a common sequela of stroke. Conventional gait analysis has limitations in simultaneously assessing multiple joints. Therefore, we investigated the gait characteristics in stroke patients using hip-knee cyclograms, which have the advantage of simultaneously visualizing the gait kinematics of multiple joints. Stroke patients (n = 47) were categorized into two groups according to stroke severity, and healthy controls (n = 32) were recruited. An inertial measurement unit sensor-based gait analysis system, which requires placing seven sensors on the dorsum of both feet, the shafts of both tibias, the middle of both femurs, and the lower abdomen, was used for the gait analysis. Then, the hip-knee cyclogram parameters (range of motion, perimeter, and area) were obtained from the collected data. The coefficient of variance of the cyclogram parameters was obtained to evaluate gait variability. The cyclogram parameters differed between the stroke patients and healthy controls, and differences according to stroke severity were also observed. The gait variability parameters mainly differed in patients with more severe stroke, and specific visualized gait patterns of stroke patients were obtained through cyclograms. In conclusion, the hip-knee cyclograms, which show inter-joint coordination and visualized gait cycle in stroke patients, are clinically significant.

Symmetry function - An effective tool for evaluating the gait symmetry of trans-femoral amputees

BACKGROUND

Prostheses can help persons with trans-femoral amputation (TFA) regain normal function, but such individuals still exhibit gait deviations expressed in gait asymmetries. We apply a specialised tool, the Symmetry Function (SF), to evaluate the symmetry of walking in terms of kinematic and dynamic variables and to identify areas with large side deviations (exceeding defined ±5% threshold) in the movement cycle.

RESEARCH QUESTION

Which movements and joints or GRF components revealed the most significant side deviations in the movement cycle? When exactly are they located in the gate cycle?

METHODS

In this retrospective observational study, an instrumented motion analysis system was used to register the gait of fourteen patients after unilateral TFA. Measurements involved evaluating the time series of gait variables characterising a range of motion and the ground reaction force components. Comparison of the prosthetic (involved) limb with the sound (uninvolved) limb in TFA patients was carried out on the basis of the Symmetry Function values.

RESULTS

The Symmetry Function proved to be an effective tool to localise the regions of asymmetry and limb dominance in the full gait cycle. The difference between sides revealed by the Symmetry Function was the highest for the pelvis and the hip. In the sagittal plane, the pelvis was asymmetrically tilted, reaching the highest SF value of more than 25 % at 60 % cycle time. In the transverse plane, the pelvis was even more asymmetrically positioned throughout the entire gait cycle (50 % difference). The hip in the frontal plane reached a 60 % difference throughout the single support phase for the involved and then for the uninvolved limb.

SIGNIFICANCE

The Symmetry Function allows for the detection of gait asymmetries, temporal shifts in the gait phases and may assess the precise in time adaptation of prostheses and rehabilitation monitoring, especially in unilateral impairments.

Gait Parameters in Healthy Preschool and School Children Assessed Using Wireless Inertial Sensor

Background: The objective gait assessment in children has become more popular. Basis parameters for comparison during the examination are advisable. Objectives: The study aim was to investigate the typical gait parameters of healthy preschool and school children, using a wireless inertial sensor as the reference for atypical gait. The additional aim was to compare the specific gait parameters in the younger and older group of children. Methods: One hundred and sixty-one children’s gait parameters were evaluated by a G-Walk BTS G-SENSOR smart analyzer. The children were walking barefoot, at a self-selected speed, on a five-meter walkway, and they turned around and go back twice. Results: Age significantly influences most of the spatiotemporal parameters. The support phase becomes shorter with age. Accordingly, the swing phase becomes longer with age. The results also show that older children need shorter double support and have longer single support. Moreover, the pelvic tilt symmetry index is higher with increasing age. In each age division, the smallest variation in all gait parameters within the oldest group of examined children was observed. A comparison between the left and right side gait parameters shows the higher difference in boys than in girls. A significant difference was calculated in the pelvic obliquity symmetry index. Girls had significantly more symmetrical obliquity than boys. Conclusions: the research indicates the basic parameters of typical children’s gait, which may be a reference to atypical gait in the case of trauma or disability.

Kinematics Adaptation and Inter-Limb Symmetry during Gait in Obese Adults

The main purpose of this study is to characterize lower limb joint kinematics during gait in obese individuals by analyzing inter-limb symmetry and angular trends of lower limb joints during walking. To this purpose, 26 obese individuals (mean age 28.5 years) and 26 normal-weight age- and sex-matched were tested using 3D gait analysis. Raw kinematic data were processed to derive joint-specific angle trends and angle-angle diagrams (synchronized cyclograms) which were characterized in terms of area, orientation and trend symmetry parameters. The results show that obese individuals exhibit a kinematic pattern which significantly differs from those of normal weight especially in the stance phase. In terms of inter-limb symmetry, higher values were found in obese individuals for all the considered parameters, even though the statistical significance was detected only in the case of trend symmetry index at ankle joint. The described alterations of gait kinematics in the obese individuals and especially the results on gait asymmetry are important, because the cyclic uneven movement repeated for hours daily can involve asymmetrical spine loading and cause lumbar pain and could be dangerous for overweight individuals.

A Proposal for a Linear Calculation of Gait Asymmetry

Pathological gait is often associated with a lack of symmetry. A possible way to quantify this feature is to use acceleration data measured by a sensor located on the lower trunk. The most common approach calculates a symmetry index starting from the autocorrelation function, aiming to measure the divergence in motion of the left and right sides of the body. The various methods proposed to implement this approach are based on nonlinear and discontinuous functions, and the interpretation of their output is far from straightforward. The aim of this study was to propose a linear and easier to interpret quantification measure for gait asymmetry. The proposed measure was tested on data from healthy controls and from patients with Multiple Sclerosis and Parkinson’s Disease, and it was shown to negate the flaws present in previous methods and to provide more directly interpretable results.

Age-based comparison of gait asymmetry using unilateral ankle weights

BACKGROUND

The locomotor system is proposed to be able to adapt to asymmetric conditions, which reflects the interaction between interlimb control and task constraints. However, this adaptability may be confounded by intrinsic differences between age groups.

RESEARCH QUESTION

What are the effects of mechanical asymmetry on kinematic symmetry in healthy younger and older adults?

METHODS

Two groups of 10 participants (age 18-25 and 58-65 years) walked (3 km h -1) and ran (9 km h -1) on a treadmill normally, and with unilateral ankle weights (UW). Lower-body kinematic data was collected. Symmetry Index (SI) and bilateral cyclograms were used to evaluate spatiotemporal step-cycle characteristics and joint angles.

RESULTS

Step-cycle characteristics were not significantly different between all comparisons. In running gait, asymmetry in range of motion (SI_RoM) of the knee and bilateral cyclogram minimum bounding box length (L) of the ankle was greater with UW compared to the normal condition. Ankle angle characteristics (SI_RoM ankle and minimum ankle angle) were more asymmetrical for older compared to younger adults, regardless of the UW condition. Interaction effects between age and UW were observed. In running gait, L knee and SI_RoM hip were greater with UW for younger adults, and smaller with UW for older adults. In walking gait, ankle angle at touchdown was greater with UW for younger adults, but smaller with UW for older adults.

SIGNIFICANCE

For both age groups walking and running with UW, symmetry appears to be preserved in step-cycle characteristics, but not in joint angle measures. While adapting to unilateral perturbation, older adults show greater asymmetry in some ankle kinematic measures compared to younger adults while running, suggesting that some kinematic solutions are altered with age, while the majority of symmetry values about the lower limbs were not.

Asymmetric Gait Analysis Using a DTW Algorithm with Combined Gyroscope and Pressure Sensor

Walking is one of the most basic human activities. Various diseases may be caused by abnormal walking, and abnormal walking is mostly caused by disease. There are various characteristics of abnormal walking, but in general, it can be judged as asymmetric walking. Generally, spatiotemporal parameters can be used to determine asymmetric walking. The spatiotemporal parameter has the disadvantage that it does not consider the influence of the diversity of patterns and the walking speed. Therefore, in this paper, we propose a method to analyze asymmetric walking using Dynamic Time Warping (DTW) distance, a time series analysis method. The DTW distance was obtained by combining gyroscope data and pressure data. The experiment was carried out by performing symmetrical walking and asymmetrical walking, and asymmetric walking was performed as a simulation of hemiplegic walking by fixing one ankle using an auxiliary device. The proposed method was compared with the existing asymmetric gait analysis method. As a result of the experiment, a p-value lower than 0.05 was obtained, which proved that there was a statistically significant difference.

Spatio-temporal gait parameters obtained from foot-worn inertial sensors are reliable in healthy adults in single- and dual-task conditions

Inertial measurement units (IMUs) are increasingly popular and may be usable in clinical routine to assess gait. However, assessing their intra-session reliability is crucial and has not been tested with foot-worn sensors in healthy participants. The aim of this study was to assess the intra-session reliability of foot-worn IMUs for measuring gait parameters in healthy adults. Twenty healthy participants were enrolled in the study and performed the 10-m walk test in single- and dual-task ('carrying a full cup of water') conditions, three trials per condition. IMUs were used to assess spatiotemporal gait parameters, gait symmetry parameters (symmetry index (SI) and symmetry ratio (SR)), and dual task effects parameters. The relative and the absolute reliability were calculated for each gait parameter. Results showed that spatiotemporal gait parameters measured with foot-worn inertial sensors were reliable; symmetry gait parameters relative reliability was low, and SR showed better absolute reliability than SI; dual task effects were poorly reliable, and taking the mean of the second and the third trials was the most reliable. Foot-worn IMUs are reliable to assess spatiotemporal and symmetry ratio gait parameters but symmetry index and DTE gait parameters reliabilities were low and need to be interpreted with cautious by clinicians and researchers.

Gait Symmetry Analysis Based on Dynamic Time Warping

Background: Gait deviations may negatively affect the articular surfaces of the lower extremity joints and lead to some minor degenerative changes. The simplest method for gait evaluation is to assess the symmetry of its parameters, assuming that each undisturbed gait should be symmetrical. This study aims to quantify the degree of asymmetry of kinematic and kinetic parameters caused by the presence of different ankle orthosis settings using Dynamic Time Warping (DTW). Methods: Barefoot gait and gait with four different walker settings were investigated in eighteen healthy persons. Kinematic and kinetic parameters were measured using the Vicon system and Kistler plates. Symmetry was assessed using the DTW method. Results: It was shown that the presence of different ankle orthosis settings significantly disturbs the symmetry of all lower limb kinematic parameters and only knee and hip torques. The highest values of asymmetry were noted for the walker set at 15° of dorsiflexion (15DF). Conclusions: The DTW method allowed us to quantify the degree of asymmetry throughout the gait cycle in relation to barefoot walking. Our results suggest that each orthosis position analysed in this study fulfills its protective function, but gait 15DF can lead to the overload of knee and hip joints.

Individuals with Unilateral Mild-to-Moderate Hip Osteoarthritis Exhibit Lower Limb Kinematic Asymmetry during Walking But Not Sit-to-Stand

Asymmetry during gait is associated with the evolution of secondary osteoarthritis. Kinematic asymmetry has been reported in advanced stages of hip osteoarthritis but has not been evaluated in earlier stages of the disease or has it been directly compared with unilateral and bilateral hip osteoarthritis. Our objective was to evaluate within-group symmetry and compare between-group asymmetry for three-dimensional pelvis, hip, knee, and ankle kinematics during walking and sit-to-stand in individuals with unilateral mild-to-moderate hip OA, bilateral mild-to-moderate hip osteoarthritis, and healthy controls. Twelve individuals with unilateral mild-to-moderate hip OA, nine individuals with bilateral mild-to-moderate symptomatic and radiographic hip OA, and 21 age-comparable healthy controls underwent three-dimensional motion analysis during walking and sit-to-stand. Pelvis and lower limb joint angles were calculated using inverse kinematics and between-limb symmetry was assessed for each group. Any resulting asymmetries (most affected minus contralateral limb) were compared between groups. Participants with unilateral hip osteoarthritis exhibited significantly less hip extension (7.90°), knee flexion (4.72°), and anterior pelvic tilt (3.38°) on their affected limb compared with the contralateral limb during the stance phase of walking. Those with unilateral hip osteoarthritis were significantly more asymmetrical than controls for sagittal plane hip and pelvis angles. No significant asymmetries were detected within- or between-groups for sit-to-stand. Individuals with unilateral hip osteoarthritis exhibited lower limb asymmetries consistent with those reported in advanced stages of disease during walking, but not sit-to-stand. Consideration of the possible negative effects of gait asymmetry on the health of the affected and other compensating joints appears warranted in the management of hip OA.

Kinematic Analysis of Lower Limb Joint Asymmetry During Gait in People with Multiple Sclerosis

The majority of people with Multiple Sclerosis (pwMS), report lower limb motor dysfunctions, which may relevantly affect postural control, gait and a wide range of activities of daily living. While it is quite common to observe a different impact of the disease on the two limbs (i.e., one of them is more affected), less clear are the effects of such asymmetry on gait performance. The present retrospective cross-sectional study aimed to characterize the magnitude of interlimb asymmetry in pwMS, particularly as regards the joint kinematics, using parameters derived from angle-angle diagrams. To this end, we analyzed gait patterns of 101 pwMS (55 women, 46 men, mean age 46.3, average Expanded Disability Status Scale (EDSS) score 3.5, range 1–6.5) and 81 unaffected individuals age- and sex-matched who underwent 3D computerized gait analysis carried out using an eight-camera motion capture system. Spatio-temporal parameters and kinematics in the sagittal plane at hip, knee and ankle joints were considered for the analysis. The angular trends of left and right sides were processed to build synchronized angle–angle diagrams (cyclograms) for each joint, and symmetry was assessed by computing several geometrical features such as area, orientation and Trend Symmetry. Based on cyclogram orientation and Trend Symmetry, the results show that pwMS exhibit significantly greater asymmetry in all three joints with respect to unaffected individuals. In particular, orientation values were as follows: 5.1 of pwMS vs. 1.6 of unaffected individuals at hip joint, 7.0 vs. 1.5 at knee and 6.4 vs. 3.0 at ankle (p < 0.001 in all cases), while for Trend Symmetry we obtained at hip 1.7 of pwMS vs. 0.3 of unaffected individuals, 4.2 vs. 0.5 at knee and 8.5 vs. 1.5 at ankle (p < 0.001 in all cases). Moreover, the same parameters were sensitive enough to discriminate individuals of different disability levels. With few exceptions, all the calculated symmetry parameters were found significantly correlated with the main spatio-temporal parameters of gait and the EDSS score. In particular, large correlations were detected between Trend Symmetry and gait speed (with rho values in the range of −0.58 to −0.63 depending on the considered joint, p < 0.001) and between Trend Symmetry and EDSS score (rho = 0.62 to 0.69, p < 0.001). Such results suggest not only that MS is associated with significantly marked interlimb asymmetry during gait but also that such asymmetry worsens as the disease progresses and that it has a relevant impact on gait performances.

Age-related gait development in children with autism spectrum disorder

BACKGROUND

A better understanding of gait development and asymmetries in children with autism spectrum disorder (ASD) may improve the development of treatment programs and thus, patient outcomes.

RESEARCH QUESTION

Does age affect walking kinematics and symmetry in children with ASD?

METHOD

Twenty-nine children (aged 6-14 years old) with mild ASD (level one) were recruited and assigned to one of the three groups based on their ages: 6-8 years (U8), 9-11 years (U11) and 12-14 years (U14). Walking kinematics were captured using an inertia measurement unit system placed bilaterally on participants' foot, lower leg, upper leg, upper arm, pelvis, and thoracic spine. Joint angles were computed and compared among the age groups. Symmetry angles were used to assess the gait symmetry and were compared among the age groups.

RESULTS

Older children exhibited less ankle dorsiflexion and knee flexion angles at heel-strike and greater plantarflexion angles at toe-off compared with younger children. In addition, a decreased pelvis and thorax axial rotation range of motion and increased shoulder flexion/extension range of motion were observed for older children. However, no age-related difference in gait symmetry was observed.

SIGNIFICANCE

These findings could suggest that older children with ASD may develop gait kinematics to a more energy-efficient walking pattern.