Marjolein M. van der Krogt

How robust is human gait to muscle weakness

Humans have a remarkable capacity to perform complex movements requiring agility, timing, and strength. Disuse, aging, and disease can lead to a loss of muscle strength, which frequently limits the performance of motor tasks. It is unknown, however, how much weakness can be tolerated before normal daily activities become impaired. This study examines the extent to which lower limb muscles can be weakened before normal walking is affected. We developed muscle-driven simulations of normal walking and then progressively weakened all major muscle groups, one at the time and simultaneously, to evaluate how much weakness could be tolerated before execution of normal gait became impossible. We further examined the compensations that arose as a result of weakening muscles. Our simulations revealed that normal walking is remarkably robust to weakness of some muscles but sensitive to weakness of others. Gait appears most robust to weakness of hip and knee extensors, which can tolerate weakness well and without a substantial increase in muscle stress. In contrast, gait is most sensitive to weakness of plantarflexors, hip abductors, and hip flexors. Weakness of individual muscles results in increased activation of the weak muscle, and in compensatory activation of other muscles. These compensations are generally inefficient, and generate unbalanced joint moments that require compensatory activation in yet other muscles. As a result, total muscle activation increases with weakness as does the cost of walking. By clarifying which muscles are critical to maintaining normal gait, our results provide important insights for developing therapies to prevent or improve gait pathology.

How much muscle strength is required to walk in a crouch gait

Muscle weakness is commonly cited as a cause of crouch gait in individuals with cerebral palsy; however, outcomes after strength training are variable and mechanisms by which muscle weakness may contribute to crouch gait are unclear. Understanding how much muscle strength is required to walk in a crouch gait compared to an unimpaired gait may provide insight into how muscle weakness contributes to crouch gait and assist in the design of strength training programs. The goal of this study was to examine how much muscle groups could be weakened before crouch gait becomes impossible. To investigate this question, we first created muscle-driven simulations of gait for three typically developing children and six children with cerebral palsy who walked with varying degrees of crouch severity. We then simulated muscle weakness by systematically reducing the maximum isometric force of each muscle group until the simulation could no longer reproduce each subjects gait. This analysis indicated that moderate crouch gait required significantly more knee extensor strength than unimpaired gait. In contrast, moderate crouch gait required significantly less hip abductor strength than unimpaired gait, and mild crouch gait required significantly less ankle plantarflexor strength than unimpaired gait. The reduced strength required from the hip abductors and ankle plantarflexors during crouch gait suggests that weakness of these muscle groups may contribute to crouch gait and that these muscle groups are potential targets for strength training.

Robust passive dynamics of the musculoskeletal system compensate for unexpected surface changes during human hopping

When human hoppers are surprised by a change in surface stiffness, they adapt almost instantly by changing leg stiffness, implying that neural feedback is not necessary. The goal of this simulation study was first to investigate whether leg stiffness can change without neural control adjustment when landing on an unexpected hard or unexpected compliant (soft) surface, and second to determine what underlying mechanisms are responsible for this change in leg stiffness. The muscle stimulation pattern of a forward dynamic musculoskeletal model was optimized to make the model match experimental hopping kinematics on hard and soft surfaces. Next, only surface stiffness was changed to determine how the mechanical interaction of the musculoskeletal model with the unexpected surface affected leg stiffness. It was found that leg stiffness adapted passively to both unexpected surfaces. On the unexpected hard surface, leg stiffness was lower than on the soft surface, resulting in close-to-normal center of mass displacement. This reduction in leg stiffness was a result of reduced joint stiffness caused by lower effective muscle stiffness. Faster flexion of the joints due to the interaction with the hard surface led to larger changes in muscle length, while the prescribed increase in active state and resulting muscle force remained nearly constant in time. Opposite effects were found on the unexpected soft surface, demonstrating the bidirectional stabilizing properties of passive dynamics. These passive adaptations to unexpected surfaces may be critical when negotiating disturbances during locomotion across variable terrain.

Reproducibility and validity of video screen measurements of gait in children with spastic cerebral palsy

PURPOSE To determine the reproducibility and validity of video screen measurement (VSM) of sagittal plane joint angles during gait. METHODS 17 children with spastic cerebral palsy walked on a 10m walkway. Videos were recorded and 3d-instrumented gait analysis was performed. Two investigators measured six sagittal joint/segment angles (shank, ankle, knee, hip, pelvis, and trunk) using a custom-made software package. The intra- and interrater reproducibility were expressed by the intraclass correlation coefficient (ICC), standard error of measurements (SEM) and smallest detectable difference (SDD). The agreement between VSM and 3d joint angles was illustrated by Bland-Altman plots and limits of agreement (LoA). RESULTS Regarding the intrarater reproducibility of VSM, the ICC ranged from 0.99 (shank) to 0.58 (trunk), the SEM from 0.81 degrees (shank) to 5.97 degrees (trunk) and the SDD from 1.80 degrees (shank) to 16.55 degrees (trunk). Regarding the interrater reproducibility, the ICC ranged from 0.99 (shank) to 0.48 (trunk), the SEM from 0.70 degrees (shank) to 6.78 degrees (trunk) and the SDD from 1.95 degrees (shank) to 18.8 degrees (trunk). The LoA between VSM and 3d data ranged from 0.4+/-13.4 degrees (knee extension stance) to 12.0+/-14.6 degrees (ankle dorsiflexion swing). CONCLUSION When performed by the same observer, VSM mostly allows the detection of relevant changes after an intervention. However, VSM angles differ from 3d-IGA and do not reflect the real sagittal joint position, probably due to the additional movements in the other planes.

Walking speed modifies spasticity effects in gastrocnemius and soleus in cerebral palsy gait

BACKGROUND The calf muscles of children with cerebral palsy are often spastic, which can lead to an equinus gait pattern. Although spasticity is defined as a velocity-dependent increase in muscle tone, very little is known about the effect of walking speed on muscle-tendon behavior of spastic muscles during gait. The aim of this study was to investigate gastrocnemius and soleus length and lengthening velocity during gait in spastic muscles with and without static contractures compared to non-spastic muscles, as well as the effect of walking speed, and the interacting effect of walking speed and spasticity on muscle-tendon length and lengthening velocity. METHODS Seventeen ambulatory children with spastic cerebral palsy and 11 typically developing children, aged 6-12, walked at comfortable, slow, and fast walking speeds. 3D kinematic data were collected and muscle-tendon lengths and velocities were calculated using musculoskeletal modeling. Spasticity and contractures of calf muscles were measured during standardized physical examination. FINDINGS Spastic calf muscles showed a deviating muscle-tendon length pattern with two peaks in stance, which was found to be irrespective of muscle contracture. This deviating pattern became more pronounced as walking speed increased. In swing, spastic calf muscles were stretched approximately one third slower than normal, while in stance, spastic calf muscles were stretched twice as fast as normal, with peak velocity occurring earlier in the gait cycle. INTERPRETATION The increasingly deviating muscle-tendon length pattern at faster walking speed indicates a velocity-dependent spasticity effect. This impairs walking especially at faster speeds, and may therefore limit comfortable walking speed.

How Crouch Gait Can Dynamically Induce Stiff-Knee Gait

Children with cerebral palsy frequently experience foot dragging and tripping during walking due to a lack of adequate knee flexion in swing (stiff-knee gait). Stiff-knee gait is often accompanied by an overly flexed knee during stance (crouch gait). Studies on stiff-knee gait have mostly focused on excessive knee muscle activity during (pre)swing, but the passive dynamics of the limbs may also have an important effect. To examine the effects of a crouched posture on swing knee flexion, we developed a forward-dynamic model of human walking with a passive swing knee, capable of stable cyclic walking for a range of stance knee crouch angles. As crouch angle during stance was increased, the knee naturally flexed much less during swing, resulting in a ‘stiff-knee’ gait pattern and reduced foot clearance. Reduced swing knee flexion was primarily due to altered gravitational moments around the joints during initial swing. We also considered the effects of increased push-off strength and swing hip flexion torque, which both increased swing knee flexion, but the effect of crouch angle was dominant. These findings demonstrate that decreased knee flexion during swing can occur purely as the dynamical result of crouch, rather than from altered muscle function or pathoneurological control alone.

Overground versus self-paced treadmill walking in a virtual environment in children with cerebral palsy

Treadmill walking offers several advantages for clinical gait analysis and gait training, but may affect gait parameters. We compared walking on a self-paced treadmill in a virtual environment (TM+) with overground walking in a conventional gait lab (CGL), and with natural walking (NW) outside a lab environment on a GaitRite measurement mat, for 11 typically developing (TD) children and 9 children with cerebral palsy (CP). Spatiotemporal parameters and subjective scores on similarity to normal walking were compared between all three conditions, while kinematic parameters and Gait and Motion Analysis Profile Scores (GPS and MAP) were compared between CGL and TM+. Subjects walked slower and with shorter strides in both lab conditions compared to NW. Stride width was 3-4 cm wider in TM+ than in CGL and NW. Mean kinematic curves showed a few differences between CGL and TM+: on the treadmill children with CP walked with on average 2° more pelvic tilt, 7° more knee flexion at initial contact, and more deviating knee and ankle kinematics as indicated by the MAP scores. These differences may in part be due to increased fatigue in TM+ as a result of longer continuous walking time. Our results indicate that differences between self-paced treadmill walking in a VR and walking in a conventional gait lab are generally small, but need to be taken into account when performing gait analysis on a treadmill.

Effects of fatigue of plantarflexors on control and performance in vertical jumping.

INTRODUCTION We investigated the effects of a mismatch between control and musculoskeletal properties on performance in vertical jumping. METHODS Six subjects performed maximum-effort vertical squat jumps before (REF) and after the plantarflexors of the right leg had been fatigued (FAT) while kinematic data, ground reaction forces, and EMG of leg muscles were collected. Inverse dynamics was used to calculate the net work at joints, and EMG was rectified and smoothed to obtain the smoothed rectified EMG (SREMG). The jumps of the subjects were also simulated with a musculoskeletal model comprising seven body segments and 12 Hill-type muscles, and having as only input muscle stimulation. RESULTS Jump height was approximately 6 cm less in FAT jumps than in REF jumps. In FAT jumps, peak SREMG level was reduced by more than 35% in the right plantarflexors and by approximately 20% in the right hamstrings but not in any other muscles. In FAT jumps, the net joint work was reduced not only at the right ankle (by 70%) but also at the right hip (by 40%). Because the right hip was not spanned by fatigued muscles and the reduction in SREMG of the right hamstrings was relatively small, this indicated that the reduction in performance was partly due to a mismatch between control and musculoskeletal properties. The differences between REF and FAT jumps of the subjects were confirmed and explained by the simulation model. Reoptimization of control for the FAT model caused performance to be partly restored by approximately 2.5 cm. CONCLUSION The reduction in performance in FAT jumps was partly due to a mismatch between control and musculoskeletal properties.

The effect of walking speed on hamstrings length and lengthening velocity in children with spastic cerebral palsy

Children with cerebral palsy often walk with reduced knee extension in terminal swing, which can be associated with short length or slow lengthening velocity of hamstrings muscles during gait. This study investigated the role of two factors that may contribute to such short and slow hamstrings: walking speed and spasticity. 17 children with spastic cerebral palsy and 11 matched typically developing children walked at comfortable, slow, and fast walking speed. Semitendinosus muscle-tendon length and velocity during gait were calculated using musculoskeletal modeling. Spasticity of the hamstrings was tested in physical examination. Peak hamstrings length increased only slightly with walking speed, while peak hamstrings lengthening velocity increased strongly. After controlling for these effects of walking speed, spastic hamstrings acted at considerably shorter length and slower velocity during gait than normal, while non-spastic hamstrings did not (all P<0.001). These data are important as a reference for valid interpretation of hamstrings length and velocity data in gait analyses at different walking speeds. The results indicate that the presence of spasticity is associated with reduced hamstrings length and lengthening velocity during gait, even at constant walking speed.

Kinetic comparison of walking on a treadmill versus over ground in children with cerebral palsy.

Kinetic outcomes are an essential part of clinical gait analysis, and can be collected for many consecutive strides using instrumented treadmills. However, the validity of treadmill kinetic outcomes has not been demonstrated for children with cerebral palsy (CP). In this study we compared ground reaction forces (GRF), center of pressure, and hip, knee and ankle moments, powers and work, between overground (OG) and self-paced treadmill (TM) walking for 11 typically developing (TD) children and 9 children with spastic CP. Considerable differences were found in several outcome parameters. In TM, subjects demonstrated lower ankle power generation and more absorption, and increased hip moments and work. This shift from ankle to hip strategy was likely due to a more backward positioning of the hip and a slightly more forward trunk lean. In mediolateral direction, GRF and hip and knee joint moments were increased in TM due to wider step width. These findings indicate that kinetic data collected on a TM cannot be readily compared with OG data in TD children and children with CP, and that treadmill-specific normative data sets should be used when performing kinetic gait analysis on a treadmill.