Clustering trunk movements of children and adolescents with neurological gait disorders undergoing robot-assisted gait therapy: the functional ability determines if actuated pelvis movements are clinically useful.

INTRODUCTION: Robot-assisted gait therapy is frequently used for gait therapy in children and adolescents but has been shown to limit the physiological excursions of the trunk and pelvis. Actuated pelvis movements might support more physiological trunk patterns during robot-assisted training. However, not every patient is expected to react identically to actuated pelvis movements. Therefore, the aim of the present study was to identify different trunk movement patterns with and without actuated pelvis movements and compare them based on their similarity to the physiological gait pattern. METHODS AND RESULTS: A clustering algorithm was used to separate pediatric patients into three groups based on different kinematic reactions of the trunk to walking with and without actuated pelvis movements. The three clusters included 9, 11 and 15 patients and showed weak to strong correlations with physiological treadmill gait. The groups also statistically differed in clinical assessment scores, which were consistent with the strength of the correlations. Patients with a higher gait capacity reacted with more physiological trunk movements to actuated pelvis movements. CONCLUSION: Actuated pelvis movements do not lead to physiological trunk movements in patients with a poor trunk control, while patients with better walking functions can show physiological trunk movements. Therapists should carefully consider for whom and why they decide to include actuated pelvis movements in their therapy plan.

The FreeD module's lateral translation timing in the gait robot Lokomat: a manual adaptation is necessary.

BACKGROUND: Pelvic and trunk movements are often restricted in stationary robotic gait trainers. The optional FreeD module of the driven gait orthosis Lokomat offers a combined, guided lateral translation and transverse rotation of the pelvis and may therefore support weight shifting during walking. However, from clinical experience, it seems that the default setting of this timing does not correspond well with the timing of the physiological pelvic movement during the gait cycle. In the software, a manual adaptation of the lateral translation's timing with respect to the gait cycle is possible. The aim of this study was to investigate if such an offset is indeed present and if a manual adaptation by the therapist can improve the timing towards a more physiological pattern comparable to physiological overground walking. METHODS & RESULTS: Children and adolescents with neurologic gait disorders and a Gross Motor Function Classification System level I-IV completed two different walking conditions (FreeD Default and FreeD Time Offset) in the Lokomat. The medio-lateral center of mass positions were calculated from RGB-Depth video recordings with a marker-less motion capture algorithm. Data of 22 patients (mean age: 12 ± 3 years) were analyzed. Kinematic analyses showed that in the FreeD Default condition, the maximum lateral center of mass excursion occurred too early. In the FreeD Time Offset condition, the manual adaptation by the therapists led to a delay of the maximum center of mass displacement by 8.2% in the first phase of the gait cycle and by 4.9% in the second phase of the gait cycle compared to the FreeD Default condition. The maximum lateral center of mass excursion was closer to that during physiological overground walking in the FreeD Time Offset condition than in the FreeD Default condition. CONCLUSION: A manual adaptation of the timing of the FreeD module in the Lokomat shifts pelvis kinematics in a direction of physiological overground walking. We recommend therapists to use this FreeD Time Offset function to adjust the phase of weight shifting for each patient individually to optimize the kinematic walking pattern when a restorative therapy approach is adopted.

A Comparison of Bilateral and Unilateral Drop Jumping Tasks in the Assessment of Vertical Stiffness.

This study sought to compare vertical stiffness during bilateral and unilateral drop jumping. Specifically, the intersession reliabilities and force-deformation profiles associated with each task were to be examined. On 3 occasions, following familiarization, 14 healthy males (age: 22 [2] y; height: 1.77 [0.08] m; and body mass: 73.5 [8.0] kg) performed 3 bilateral, left leg and right leg drop jumps. All jumps were performed from a drop height of 0.18 m on to a dual force plate system. Vertical stiffness was calculated as the ratio of peak ground reaction force (GRF) to the peak center of mass (COM) displacement. Unilateral drop jumping was associated with higher GRF and greater COM displacement (both Ps < .001), but vertical stiffness was not different between tasks when considering individual limbs (P = .98). A coefficient of variation of 14.6% was observed for bilateral vertical stiffness during bilateral drop jumping; values of 6.7% and 7.6% were observed for left and right limb vertical stiffness during unilateral drop jumping. These findings suggest that unilateral drop jumps may exhibit greater reliability than bilateral drop jumps while eliciting similar vertical stiffness. It is also apparent that higher GRFs during unilateral drop jumping are mitigated by increased COM displacement.

Vertical stiffness asymmetries during drop jumping are related to ankle stiffness asymmetries.

Asymmetry in vertical stiffness has been associated with increased injury incidence and impaired performance. The determinants of vertical stiffness asymmetry have not been previously investigated. Eighteen healthy men performed three unilateral drop jumps during which vertical stiffness and joint stiffness of the ankle and knee were calculated. Reactive strength index was also determined during the jumps using the ratio of flight time to ground contact time. "Moderate" differences in vertical stiffness (t17  = 5.49; P < 0.001), "small" differences in center of mass displacement (t17  = -2.19; P = 0.043), and "trivial" differences in ankle stiffness (t17  = 2.68; P = 0.016) were observed between stiff and compliant limbs. A model including ankle stiffness and reactive strength index symmetry angles explained 79% of the variance in vertical stiffness asymmetry (R2  = 0.79; P < 0.001). None of the symmetry angles were correlated to jump height or reactive strength index. Results suggest that asymmetries in ankle stiffness may play an important role in modulating vertical stiffness asymmetry in recreationally trained men.

A wearable vibrotactile biofeedback system improves balance control of healthy young adults following perturbations from quiet stance.

Maintaining postural equilibrium requires fast reactions and constant adjustments of the center of mass (CoM) position to prevent falls, especially when there is a sudden perturbation of the support surface. During this study, a newly developed wearable feedback system provided immediate vibrotactile clues to users based on plantar force measurement, in an attempt to reduce reaction time and CoM displacement in response to a perturbation of the floor. Ten healthy young adults participated in this study. They stood on a support surface, which suddenly moved in one of four horizontal directions (forward, backward, left and right), with the biofeedback system turned on or off. The testing sequence of the four perturbation directions and the two system conditions (turned on or off) was randomized. The resulting reaction time and CoM displacement were analysed. Results showed that the vibrotactile feedback system significantly improved balance control during translational perturbations. The positive results of this preliminary study highlight the potential of a plantar force measurement based biofeedback system in improving balance under perturbations of the support surface. Future system optimizations could facilitate its application in fall prevention in real life conditions, such as standing in buses or trains that suddenly decelerate or accelerate.

Quantitative evaluation of the major determinants of human gait.

Accurate knowledge of the isolated contributions of joint movements to the three-dimensional displacement of the center of mass (COM) is fundamental for understanding the kinematics of normal walking and for improving the treatment of gait disabilities. Saunders et al. (1953) identified six kinematic mechanisms to explain the efficient progression of the whole-body COM in the sagittal, transverse, and coronal planes. These mechanisms, referred to as the major determinants of gait, were pelvic rotation, pelvic list, stance knee flexion, foot and knee mechanisms, and hip adduction. The aim of the present study was to quantitatively assess the contribution of each major gait determinant to the anteroposterior, vertical, and mediolateral displacements of the COM over one gait cycle. The contribution of each gait determinant was found by applying the concept of an 'influence coefficient', wherein the partial derivative of the COM displacement with respect to a prescribed determinant was calculated. The analysis was based on three-dimensional measurements of joint angular displacements obtained from 23 healthy young adults walking at slow, normal and fast speeds. We found that hip flexion, stance knee flexion, and ankle-foot interaction (comprised of ankle plantarflexion, toe flexion and the displacement of the center of pressure) are the major determinants of the displacements of the COM in the sagittal plane, while hip adduction and pelvic list contribute most significantly to the mediolateral displacement of the COM in the coronal plane. Pelvic rotation and pelvic list contribute little to the vertical displacement of the COM at all walking speeds. Pelvic tilt, hip rotation, subtalar inversion, and back extension, abduction and rotation make negligible contributions to the displacements of the COM in all three anatomical planes.