Conservative interventions to improve foot progression angle and clinical measures in orthopedic and neurological patients:A systematic review and meta-analysis

To establish the comparative effects of conservative interventions on modifying foot progression angle (FPA) in children and adults with orthopaedic and neurological disease was the main aim of the literature review. Pubmed, Embase, Cinahl, and Web of Science were systematically searched for studies evaluating the effects of conservative interventions on correcting the FPA. The study protocol was registered with PROSPERO (CRD42020143512). Two reviewers independently assessed studies for inclusion and quality. Studies that assessed conservative interventions that could have affected the FPA and objectively measured the FPA were included. Within group Mean Differences (MD) and Standardized Mean Differences (SMDs) of the interventions were calculated for the change in FPA and gait performance (walking speed, stride/step length) and clinical condition (pain). Intervention effects on FPA were synthesized via meta-analysis or qualitatively. 41 studies were identified. For patients with knee osteoarthritis gait training interventions (MD = 6.69° and MD = 16.06°) were significantly more effective than mechanical interventions (MD = 0.44°) in modifying the FPA towards in-toeing (p < 0.00001). Increasing or decreasing the FPA significantly improved pain in patients with medial knee OA. Results were inconclusive for the effectiveness of gait training and mechanical devices in patients with neurological diseases. Gait feedback training is more effective than external devices to produce lasting improvements in FPA, reduce pain, and maintain gait performance in patients with medial knee OA. However, in neurological patients, the effects of external devices on improvements in FPA depends on the interaction between patient-specific impairments and the technical properties of the external device

Effects of neuromuscular gait modification strategies on indicators of knee joint load in people with medial knee osteoarthritis:A systematic review and meta-analysis

OBJECTIVES: This systematic review aimed to determine the effects of neuromuscular gait modification strategies on indicators of medial knee joint load in people with medial knee osteoarthritis. METHODS: Databases (Embase, MEDLINE, Cochrane Central, CINAHL and PubMed) were searched for studies of gait interventions aimed at reducing medial knee joint load indicators for adults with medial knee osteoarthritis. Studies evaluating gait aids or orthoses were excluded. Hedges’ g effect sizes (ES) before and after gait retraining were estimated for inclusion in quality-adjusted meta-analysis models. Certainty of evidence was assessed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. RESULTS: Seventeen studies (k = 17; n = 362) included two randomised placebo-controlled trials (RCT), four randomised cross-over trials, two case studies and nine cohort studies. The studies consisted of gait strategies of ipsilateral trunk lean (k = 4, n = 73), toe-out (k = 6, n = 104), toe-in (k = 5, n = 89), medial knee thrust (k = 3, n = 61), medial weight transfer at the foot (k = 1, n = 10), wider steps (k = 1, n = 15) and external knee adduction moment (KAM) biofeedback (k = 3, n = 84). Meta-analyses found that ipsilateral trunk lean reduced early stance peak KAM (KAM1, ES and 95%CI: -0.67, -1.01 to -0.33) with a dose-response effect and reduced KAM impulse (-0.37, -0.70 to -0.04) immediately after single-session training. Toe-out had no effect on KAM1 but reduced late stance peak KAM (KAM2; -0.42, -0.73 to -0.11) immediately post-training for single-session, 10 or 16-week interventions. Toe-in reduced KAM1 (-0.51, -0.81 to -0.20) and increased KAM2 (0.44, 0.04 to 0.85) immediately post-training for single-session to 6-week interventions. Visual, verbal and haptic feedback was used to train gait strategies. Certainty of evidence was very-low to low according to the GRADE approach. CONCLUSION: Very-low to low certainty of evidence suggests that there is a potential that ipsilateral trunk lean, toe-out, and toe-in to be clinically helpful to reduce indicators of medial knee joint load. There is yet little evidence for interventions over several weeks

The use of biofeedback for gait retraining: A mapping review

Background: Biofeedback seems to be a promising tool to improve gait outcomes for both healthy individuals and patient groups. However, due to differences in study designs and outcome measurements, it remains uncertain how different forms of feedback affect gait outcomes. Therefore, the aim of this study is to review primary biomechanical literature which has used biofeedback to alter gait-related outcomes in human participants. Methods: Medline, Cinahl, Cochrane, SPORTDiscus and Pubmed were searched from inception to December 2017 using various keywords and the following MeSHterms: biofeedback, feedback, gait, walking and running. From the included studies, sixteen different study characteristics were extracted. Findings: In this mapping review 173 studies were included. The most common feedback mode used was visual feedback (42%, n=73) and the majority fed-back kinematic parameters (36%, n=62). The design of the studies were poor: only 8% (n=13) of the studies had both a control group and a retention test; 69% (n=120) of the studies had neither. A retention test after 6 months was performed in 3% (n=5) of the studies, feedback was faded in 9% (n=15) and feedback was given in the field rather than the laboratory in 4% (n=8) of the studies. Interpretation: Further work on biofeedback and gait should focus on the direct comparison between different modes of feedback or feedback parameters, along with better designed and field based studies

Haptic wearables as sensory replacement, sensory augmentation and trainer - a review

Sensory impairments decrease quality of life and can slow or hinder rehabilitation. Small, computationally powerful electronics have enabled the recent development of wearable systems aimed to improve function for individuals with sensory impairments. The purpose of this review is to synthesize current haptic wearable research for clinical applications involving sensory impairments. We define haptic wearables as untethered, ungrounded body worn devices that interact with skin directly or through clothing and can be used in natural environments outside a laboratory. Results of this review are categorized by degree of sensory impairment. Total impairment, such as in an amputee, blind, or deaf individual, involves haptics acting as sensory replacement; partial impairment, as is common in rehabilitation, involves haptics as sensory augmentation; and no impairment involves haptics as trainer. This review found that wearable haptic devices improved function for a variety of clinical applications including: rehabilitation, prosthetics, vestibular loss, osteoarthritis, vision loss and hearing loss. Future haptic wearables development should focus on clinical needs, intuitive and multimodal haptic displays, low energy demands, and biomechanical compliance for long-term usage

Walking with shorter stride length could improve knee kinetics of patients with medial knee osteoarthritis.

Walking with a shorter stride length (SL) was recently proposed for gait retraining in medial knee osteoarthritis; however it was never assessed in this patient population. This study tested the hypothesis that shortening SL while maintaining walking speed reduces knee adduction (KAM) and flexion (KFM) moments in patients with medial knee osteoarthritis. Walking trials with normal SL and SL reduced by 0.10 m and 0.15 m were recorded for 15 patients (10 men, 55.5 ± 8.7 years old, 24.6 ± 3.0 kg/m &lt;sup&gt;2&lt;/sup&gt; ). SL was modified using an augmented reality system displaying target footprints on the floor. Repeated one-way ANOVAs and post-hoc paired t-tests were performed to compare gait measures between normal and reduced SL. The individual effects of SL reduction were analyzed using descriptive statistics. Group analysis indicated significant decreases in KAM impulse with both SL reductions (p &lt; 0.05). No systematic change was observed in the first peaks KAM and KFM when walking with reduced SL (p &gt; 0.05). Individually, 33 % of the patients decreased the peak KAM, whereas 20 % decreased the KAM impulse. Among these patients with a decrease in peak KAM or in KAM impulse, 0 % and 33 % had a simultaneous increase in peak KFM, respectively. In conclusion, this study showed that SL shortening can decrease kinetic measures associated with the progression of medial knee osteoarthritis in some patients, demonstrating the importance of considering SL modifications on an individual basis. While further research is necessary, notably regarding dose-response relationships and long-term effects, these findings are particularly encouraging because SL reductions could be easily integrated into rehabilitation protocols

Configurable, wearable sensing and vibrotactile feedback system for real-time postural balance and gait training: proof-of-concept

Abstract Background Postural balance and gait training is important for treating persons with functional impairments, however current systems are generally not portable and are unable to train different types of movements. Methods This paper describes a proof-of-concept design of a configurable, wearable sensing and feedback system for real-time postural balance and gait training targeted for home-based treatments and other portable usage. Sensing and vibrotactile feedback are performed via eight distributed, wireless nodes or “Dots” (size: 22.5 × 20.5 × 15.0 mm, weight: 12.0 g) that can each be configured for sensing and/or feedback according to movement training requirements. In the first experiment, four healthy older adults were trained to reduce medial-lateral (M/L) trunk tilt while performing balance exercises. When trunk tilt deviated too far from vertical (estimated via a sensing Dot on the lower spine), vibrotactile feedback (via feedback Dots placed on the left and right sides of the lower torso) cued participants to move away from the vibration and back toward the vertical no feedback zone to correct their posture. A second experiment was conducted with the same wearable system to train six healthy older adults to alter their foot progression angle in real-time by internally or externally rotating their feet while walking. Foot progression angle was estimated via a sensing Dot adhered to the dorsal side of the foot, and vibrotactile feedback was provided via feedback Dots placed on the medial and lateral sides of the mid-shank cued participants to internally or externally rotate their foot away from vibration. Results In the first experiment, the wearable system enabled participants to significantly reduce trunk tilt and increase the amount of time inside the no feedback zone. In the second experiment, all participants were able to adopt new gait patterns of internal and external foot rotation within two minutes of real-time training with the wearable system. Conclusion These results suggest that the configurable, wearable sensing and feedback system is portable and effective for different types of real-time human movement training and thus may be suitable for home-based or clinic-based rehabilitation applications.https://deepblue.lib.umich.edu/bitstream/2027.42/138819/1/12984_2017_Article_313.pd

Master of Science

thesisComputing and data acquisition have become an integral part of everyday life. From reading emails on a cell phone, to kids playing with motion sensing game consoles, we are surrounded with sensors and mobile devices. As the availability of powerful mobile computing devices expands, the road is paved for applications in previously limited environments. Rehabilitative devices are emerging that embrace these mobile advances. Research has explored the use of smartphones in rehabilitation as a means to process data and provide feedback in conjunction with established rehabilitative methods. Smartphones, combined with sensor embedded insoles, provide a powerful tool for the clinician in gathering data and may act as a standalone training technique. This thesis presents continuing research of a sensor integrated insole system that provides real-time feedback through a mobile platform, the Adaptive Real-Time Instrumentation System for Tread Imbalance Correction (ARTISTIC). The system interfaces a wireless instrumented insole with an Android smartphone application to receive gait data and provide sensory feedback to modify gait patterns. Revisions to the system hardware, software, and feedback modes brought about the introduction of the ARTISTIC 2.0. The number of sensors in the insole was increased from two to 10. The microprocessor and a vibrotactile motor were embedded in the insole and the communications box was reduced in size and weight by more than 50%. Stance time iv measurements were validated against force plate equipment and found to be within 13.5 ± 3.3% error of force plate time measurements. Human subjects were tested using each of the feedback modes to alter gait symmetry. Results from the testing showed that more than one mode of feedback caused a statistically significant change in gait symmetry ratios (p < 0.05). Preference of feedback modes varied among subjects, with the majority agreeing that several feedback modes made a difference in their gait. Further improvements will prepare the ARTISTIC 2.0 for testing in a home environment for extended periods of time and improve data capture techniques, such as including a database in the smartphone application

Effects of external biofeedback interventions in individuals with chronic ankle instability: a scoping review

Clinical scenario: Evidence has demonstrated that about 1 in 3 acute lateral ankle sprains results in chronic ankle instability. Chronic ankle instability (CAI) is a condition characterized by a history of one significant lateral ankle sprain, episodes of the ankle "giving way”, pain, and decreased self-reported function. People with chronic ankle instability show a multitude of mechanical and functional impairments, including a more inverted position of the foot during walking and consequently an increased lateral plantar pressure distribution. These factors contribute to high recurrence of ankle sprains, a decrease in self-reported function and the development of early onset ankle post-traumatic osteoarthritis (OA). Traditional rehabilitation and prevention strategies against the development of CAI have not successfully improved the biomechanics of movement, thus new intervention strategies have been proposed in the last years to specifically target biomechanics impairments in individuals with CAI. Among these, intervention with biofeedback seem to be promising, but the actual effect is still not clear. Purpose: To perform a literature review and examine the effects of biofeedback interventions on biomechanics during gait and functional tasks in individuals with chronic ankle instability. Methods: The following literature databases were searched: Pubmed, PEDro, Cochrane Library and Scopus. The search strategy was based on the combination of different keywords associated with the Boolean operators “AND” or “OR” to create a string. Results were screened based on determined inclusion and exclusion criteria and the articles which were assessed as eligible after the screening phase were included in the qualitative evaluation. Results & discussion: At the end of the study selection, from a total of 178 articles, seven articles were included in the research. Studies assessed interventions using visual biofeedback (n = 4), auditory biofeedback (n = 3), and haptic biofeedback (n = 1). Four articles demonstrated reduced plantar pressure in the lateral column of the foot and a medial shift of the center of pressure after the intervention. One study demonstrated reduced ankle inversion after 8 sessions of biofeedback training and improvements in patient-reported outcomes. Another study found evidence that biofeedback is able to decrease vertical ground reaction force and ankle joint forces. One study demonstrated that biofeedback strategy is effective in altering the plantar pressure distribution causing a medial shift of the center of pressure during 4 different functional tasks (step downs, forward lunges, single-limb static balance, lateral hops). Conclusion: The use of biofeedback in individuals with chronic ankle instability resulted in several positive effects on clinical-oriented outcome as well as patient-reported outcome. Therefore, implementing external biofeedback training into an impairment-based rehabilitation program may allow for a greater improvement in impairments associated with CAI. However, future research to assess long-term effects of external biofeedback strategies in patients with CAI is needed.Clinical scenario: Evidence has demonstrated that about 1 in 3 acute lateral ankle sprains results in chronic ankle instability. Chronic ankle instability (CAI) is a condition characterized by a history of one significant lateral ankle sprain, episodes of the ankle "giving way”, pain, and decreased self-reported function. People with chronic ankle instability show a multitude of mechanical and functional impairments, including a more inverted position of the foot during walking and consequently an increased lateral plantar pressure distribution. These factors contribute to high recurrence of ankle sprains, a decrease in self-reported function and the development of early onset ankle post-traumatic osteoarthritis (OA). Traditional rehabilitation and prevention strategies against the development of CAI have not successfully improved the biomechanics of movement, thus new intervention strategies have been proposed in the last years to specifically target biomechanics impairments in individuals with CAI. Among these, intervention with biofeedback seem to be promising, but the actual effect is still not clear. Purpose: To perform a literature review and examine the effects of biofeedback interventions on biomechanics during gait and functional tasks in individuals with chronic ankle instability. Methods: The following literature databases were searched: Pubmed, PEDro, Cochrane Library and Scopus. The search strategy was based on the combination of different keywords associated with the Boolean operators “AND” or “OR” to create a string. Results were screened based on determined inclusion and exclusion criteria and the articles which were assessed as eligible after the screening phase were included in the qualitative evaluation. Results & discussion: At the end of the study selection, from a total of 178 articles, seven articles were included in the research. Studies assessed interventions using visual biofeedback (n = 4), auditory biofeedback (n = 3), and haptic biofeedback (n = 1). Four articles demonstrated reduced plantar pressure in the lateral column of the foot and a medial shift of the center of pressure after the intervention. One study demonstrated reduced ankle inversion after 8 sessions of biofeedback training and improvements in patient-reported outcomes. Another study found evidence that biofeedback is able to decrease vertical ground reaction force and ankle joint forces. One study demonstrated that biofeedback strategy is effective in altering the plantar pressure distribution causing a medial shift of the center of pressure during 4 different functional tasks (step downs, forward lunges, single-limb static balance, lateral hops). Conclusion: The use of biofeedback in individuals with chronic ankle instability resulted in several positive effects on clinical-oriented outcome as well as patient-reported outcome. Therefore, implementing external biofeedback training into an impairment-based rehabilitation program may allow for a greater improvement in impairments associated with CAI. However, future research to assess long-term effects of external biofeedback strategies in patients with CAI is needed