The knee adduction moment measured with an instrumented force shoe in patients with knee osteoarthritis
Introduction
Osteoarthritis (OA) of the knee is a degenerative joint disease that occurs in a substantial percentage of the elderly population, causing limitations in daily activities. Abnormal or excessive joint loading increases the risk of development and the progression of OA (Andriacchi et al., 2004, Griffin and Guilak, 2005).
The net external knee adduction moment (KAdM) reflects the distribution and magnitude of the load transferred through the medial versus the lateral compartment of the tibiofemoral joint. It is mainly the product of the ground reaction force (GRF) and its lever arm to the knee joint, defined by the centre of pressure (CoP) and the knee joint position. These factors can be influenced by body mass, varus/valgus alignment of the knee joint, foot position, trunk position and walking speed. Patients suffering from medial compartment knee OA have often an increased KAdM during gait, compared to asymptomatic subjects (Foroughi et al., 2009).
The KAdM can be estimated in a gait laboratory, using force plates for three-dimensional (3D) recording of the GRF and CoP, and an optoelectronic marker system for 3D recording of the knee position (Cappozzo et al., 1995, Zatsiorsky, 2002). Despite the increasing interest in measuring the KAdM in knee OA, the clinical use of these laboratory-based systems is limited by the availability of well-equipped gait laboratories, line of sight problems with markers, restricted measurement volume, and constrained foot placement on the force plate (Schepers et al., 2007). Hence, there is a need for new approaches to gait measurements, free of such restrictions.
Instrumented force shoes (IFS) have been introduced for ambulatory assessment of GRF and CoP, as an alternative to force plates (Schepers et al., 2007). An inertial and magnetic measurement system (IMMS) has been used to measure the orientation of body segments from multiple strides when no gait laboratory is available (Luinge and Veltink, 2005, Roetenberg et al., 2007). However, in contrast to an optoelectronic system, direct measurement of segment or joint positions is difficult with the IMMS. When only orientations of body segments are available, positions have to be determined by linking segments to each other, using a linked-segment model based on segment orientation and fixed segment lengths (Faber et al., 2010b).
Although ambulatory movement analysis systems such as IFS and IMMS are promising, little is known about the accuracy of these systems in determination of the KAdM in patients with OA. Therefore, the general goal of this study was to investigate the effects of GRF, CoP and knee joint position measurement on the accuracy of the KAdM, when estimated with an ambulatory-based system in patients with knee OA (AmbBM: in particular the IFS and linked-segment model). This goal was specified in three main objectives: firstly, to study the accuracy of the IFS for measurement of the GRF and CoP during gait in patients with knee OA, in comparison with a force plate. Secondly, to study the accuracy of a linked-segment model based only on segment orientations (using optoelectronic data to simulate IMMS) for measurement of the ankle and knee joint positions, in comparison with direct position measurement via an optoelectronic marker system (actual IMMS were not implemented in this study, in order to restrict validation to the linked-segment model, and to exclude potential technical inaccuracies of the IMMS itself). Finally, to study the overall accuracy of the KAdM estimated with an IFS in combination with a linked-segment model (AmbBM), in comparison to the estimation of KAdM with a force plate and optoelectronic marker system (LabBM).
We hypothesised that the accuracy of the KAdM would mainly be affected by estimation of the knee joint centre when using the linked-segment model.
Section snippets
Subjects
Twenty patients with knee OA participated in the study (four males and sixteen females, age 61±8.8years (mean±standard deviation), body mass 84±16 kg, height 1.67±0.12 m). Patients had medial and/or lateral tibiofemoral radiographic OA, with a Kellgren/Lawrence of at least grade 1 (Altman and Gold, 2007, Kellgren and Lawrence, 1957, Altman et al., 1986), and were recruited from the patient population of the Reade Centre for Rehabilitation and Rheumatology (Amsterdam, the Netherlands). The
Results
Data of 30 legs were included in the analysis. The data of ten legs had to be excluded from analyses, due to unilateral knee OA, limited visibility of the optoelectronic markers, or technical problems with the IFS.
On average, the vertical GRF measured with the IFS was under-estimated by 2% compared to measurement with the force plate (Fig. 2, Table 1, Table 2). Medio-lateral GRF was 10% lower in early stance and 4% lower in midstance. Forward GRF of the IFS was 1–6% higher during the entire
Discussion
The objective of this study was to validate the KAdM using an ambulatory-based method in patients with knee OA. Effects of ground reaction force (GRF), centre of pressure (CoP), and knee joint position measurement are evaluated separately.
Conflict of interest statement
We certify that no party having a direct interest in the results of the research supporting this article has or will confer a benefit on us or on any organisation with which we are associated.
Acknowledgements
This work is part of the FreeMotion project (www.freemotion.tk) funded by the Dutch Ministry of Economic Affairs and Senter Novem. The authors wish to thank all the patients who participated in the study, Tanneke Vogelaar and Kim van Hutten for their assistance with the measurements, and Gert Faber for his advice on data analysis.
References (32)
- et al.
Increased knee joint loads during walking are present in subjects with knee osteoarthritis
Osteoarthritis and Cartilage
(2002) - et al.
Position and orientation in space of bones during movement: anatomical frame definition and determination
Clinical Biomechanics (Bristol, Avon)
(1995) - et al.
Human movement analysis using stereophotogrammetry. part 2: instrumental errors
Gait and Posture
(2005) - et al.
Magnetic distortion in motion labs, implications for validating inertial magnetic sensors
Gait and Posture
(2009) - et al.
Determination of joint moments with instrumented force shoes in a variety of tasks
Journal of Biomechanics
(2010) - et al.
Bottom-up estimation of joint moments during manual lifting using orientation sensors instead of position sensors
Journal of Biomechanics
(2010) - et al.
The association of external knee adduction moment with biomechanical variables in osteoarthritis: a systematic review
Knee
(2009) An explicit expression for the moment in multibody systems
Journal of Biomechanics
(1992)- et al.
Speed dependence of averaged EMG profiles in walking
Gait and Posture
(2002) - et al.
Evaluation of instrumented shoes for ambulatory assessment of ground reaction forces
Gait and Posture
(2007)
The effect of internal and external foot rotation on the adduction moment and lateral–medial shear force at the knee during gait
Journal of Science and Medicine inSport
An inertial and magnetic sensor based technique for joint angle measurement
Journal of Biomechanics
Joint kinematics estimate using wearable inertial and magnetic sensing modules
Gait and Posture
Ambulatory measurement of ankle kinetics for clinical applications
Journal of Biomechanics
The effect of gait modification on the external knee adduction moment is reference frame dependent
Clinical Biomechanics (Bristol, Avon)
ISB recommendation on definitions of joint coordinate system of various joints for the reporting of human joint motion—part I: ankle, hip, and spine.
International Society of Biomechanics. Journal of Biomechanics
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- 1
Present address: School of Health, Glasgow Caledonian University, Cowcaddens Road, Glasgow G4 0BA, Scotland, UK.
- 2
Present address: Xsens Technologies B.V., P.O. Box 559, 7500 AN, Enschede. The Netherlands.