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Applied Assessment Method for Varus Thrust during Walking in Patients with Knee Osteoarthritis Using Acceleration Data Measured by an Inertial Measurement Unit
We developed a novel quantitative method to assess varus thrust during walking using acceleration data obtained from an inertial measurement unit (IMU). This study aimed to examine the reliability of the developed index and to evaluate its ability to distinguish patients with knee osteoarthritis (OA) with varus thrust from healthy adults. Overall, 16 patients with knee OA and 16 healthy adults walked on a treadmill with IMUs attached to the tibial tuberosity and lateral femoral condyle. As an index of varus thrust, we used the root mean square (RMS) of acceleration in the mediolateral direction. This value was adjusted by dividing it by swing speed while walking (adjusted RMS, A-RMS) because the RMS of the acceleration was strongly coupled with the speed of motion. The intraclass correlation coefficients of A-RMS of the tibia and femur were 0.85 and 0.73, respectively. Significant differences were observed in the A-RMSs of the tibia and femur, with large effect sizes between the patients with knee OA and healthy adults (Cohen’s d: 1.23 and 0.97, respectively). Our results indicate that A-RMS has good test–retest reproducibility and can differentiate patients with varus thrust from healthy adults.
Knee osteoarthritis (OA) is a chronic degenerative disease that develops and progresses because of aging and other related factors. The symptoms of knee OA include pain, stiffness, reduced joint motion, and abnormal gait patterns [1, 2]. Long-term consequences include reduced physical activity, deconditioning, impaired sleep, fatigue, depression, and disability [3]. Because the rate of symptom progression and disease severity varies among individuals, objective assessments of the symptoms are important not only to determine the extent of progression but also to evaluate the effectiveness of treatment.
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Varus thrust is an abnormal gait pattern frequently (16–46%) observed in patients with medial knee OA [4, 5, 6, 7, 8, 9, 10, 11]. This abnormal gait pattern is defined as an excessive “bowing-out” knee motion in the frontal plane during ambulation as the limb accepts weight with a return toward a more neutral alignment in late stance and swing [4]. Several reports have shown that the varus thrust during walking is associated with knee adduction moments [4, 12, 13, 14]. Mechanical stress on the knee joint is considered one of the factors affecting disease progression. Hence, the varus thrust of the knee joint has been reported to be associated with radiographic severity and disease progression [4, 7, 15]. Moreover, varus thrust has been reported to be associated with pain severity and functional ability [8, 9, 10]. In a prospective cohort study of patients with knee OA, varus thrust was related to increased incidence of pain as well as clinically important worsening pain [11].
A few studies have attempted to quantitatively assess varus thrust during walking using some equipment. Many of these studies were based on observations by experts, such as physical therapists, and generally categorized gait into the presence or absence of varus thrust [4, 5, 6, 7, 8, 9, 10, 11]. A three-dimensional motion analysis system is a tool used to objectively quantify varus thrust [6, 12, 16, 17, 18]. A study reported that patients with OA had a more varus knee angle during early and mid-stance measured by the system versus controls [12]. However, this assessment method has several limitations and is not widely used clinically. Motion analysis systems are expensive, require a long time to prepare for measurements, and involve notable efforts to collect a large amount of data for testing epidemiological hypotheses.
An inertial measurement unit (IMU) is an alternative tool for assessing varus thrust during motion. It is comparatively cheap and requires little preparation for measurement. Acceleration data, which can directly measure the impact transmitted to the location of the sensor, could be good indicators of varus thrust. This is attributable to the fact that the knee is subjected to greater forces and moves in the lateral direction during the beginning of the stance phase in patients with thrust, which would result in greater acceleration. Although several researchers have quantified varus thrust using acceleration data from IMUs [14, 19, 20], the validity of their methods appeared to be insufficient. As the magnitude of acceleration during walking in each part of the body is considered to have a strong relationship with the speed of motion of the measured location [21, 22, 23], we believed that the index representing varus thrust should be adjusted on the basis of the angular velocity. However, to the best of our knowledge, no studies have considered such adjustments in their reports of the assessment of varus thrust. Additionally, these studies did not compare thrust measurements between patients with knee OA and healthy adults, and the cutoff value to determine a normal gait was unclear.
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In this study, we developed a new method to assess varus thrust during walking motion using acceleration data obtained from an IMU attached to the tibia and femur to adjust for the angular velocity obtained from the same IMU. This study aimed to examine the reliability and validity of the developed method by evaluating the test–retest reproducibility of the derived index of varus thrust and whether this index could distinguish patients with knee OA with varus thrust from healthy adults. We hypothesized that the new adjusted method would have a more discriminative ability than the unadjusted method.
This study included 16 patients diagnosed with knee OA (10 women) and 16 healthy adults (10 women). The subjects in the knee OA group were recruited from an orthopedic hospital and were scheduled for tibial osteotomy. The inclusion criteria for the knee OA group were as follows: (1) symptomatic knee OA, diagnosed according to the clinical or radiographic classification criteria of the American College of Rheumatology; (2) Kellgren and Lawrence (K-L) classification of II or more; and (3) age 45–80 years. The healthy group consisted of employees aged ≥ 45 years who worked at the institution that recruited the knee OA group. The study excluded those who had difficulty walking unaided or had other musculoskeletal or neurological diseases that clearly affected walking, such as hip OA, spinal canal stenosis, stroke, or Parkinson’s disease. All patients in the knee OA group were confirmed to have varus thrust in the affected knee while walking based on the observation of the therapist in charge. The reliability of this assessment method has been previously reported [10]. The demographic data and basic characteristics of the knee OA group were extracted from their medical records. The Japanese version of the Knee Injury and Osteoarthritis Outcome Score (KOOS) was used to evaluate the disease status [24]. These assessments and gait analyses were performed as preoperative assessments a week before the surgery.
The subjects walked on a treadmill at a comfortable speed chosen by the participant. Before the assessment, subjects practiced sufficiently to familiarize themselves with the walking conditions. Elastic belts were used to secure a total of four IMUs (MVP-RF8; MicroStone, Nagano, Japan) to the bilateral tibial tuberosities and lateral femoral condyles (Figure 1). The IMU was equipped with a three-axis acceleration sensor (range: ±60 m/s
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) and a three-axis gyroscope (range: ±2000 deg/s), and the obtained data were wirelessly transmitted to a personal computer via Bluetooth. Acceleration in the anteroposterior (AP), mediolateral (ML), and vertical (VT) directions and angular velocity in the sagittal, frontal, and horizontal planes were measured at a sampling rate of 200 Hz. To test the reproducibility of the measurements, the subjects performed the same assessments under the same conditions within a week.
The data obtained from the IMUs were analyzed using commercially available software (MATLAB, Release 2019a; MathWorks Japan, Tokyo, Japan) to calculate the index of varus thrust during walking motion. Data for ten strides during stable walking on the affected side in the knee OA group and on the left side in the healthy group were used for the analysis. Angular velocity data were sent through a low-pass filter with a cutoff
In this study, we developed a new method to assess varus thrust during walking motion using acceleration data obtained from an IMU attached to the tibia and femur to adjust for the angular velocity obtained from the same IMU. This study aimed to examine the reliability and validity of the developed method by evaluating the test–retest reproducibility of the derived index of varus thrust and whether this index could distinguish patients with knee OA with varus thrust from healthy adults. We hypothesized that the new adjusted method would have a more discriminative ability than the unadjusted method.
This study included 16 patients diagnosed with knee OA (10 women) and 16 healthy adults (10 women). The subjects in the knee OA group were recruited from an orthopedic hospital and were scheduled for tibial osteotomy. The inclusion criteria for the knee OA group were as follows: (1) symptomatic knee OA, diagnosed according to the clinical or radiographic classification criteria of the American College of Rheumatology; (2) Kellgren and Lawrence (K-L) classification of II or more; and (3) age 45–80 years. The healthy group consisted of employees aged ≥ 45 years who worked at the institution that recruited the knee OA group. The study excluded those who had difficulty walking unaided or had other musculoskeletal or neurological diseases that clearly affected walking, such as hip OA, spinal canal stenosis, stroke, or Parkinson’s disease. All patients in the knee OA group were confirmed to have varus thrust in the affected knee while walking based on the observation of the therapist in charge. The reliability of this assessment method has been previously reported [10]. The demographic data and basic characteristics of the knee OA group were extracted from their medical records. The Japanese version of the Knee Injury and Osteoarthritis Outcome Score (KOOS) was used to evaluate the disease status [24]. These assessments and gait analyses were performed as preoperative assessments a week before the surgery.
The subjects walked on a treadmill at a comfortable speed chosen by the participant. Before the assessment, subjects practiced sufficiently to familiarize themselves with the walking conditions. Elastic belts were used to secure a total of four IMUs (MVP-RF8; MicroStone, Nagano, Japan) to the bilateral tibial tuberosities and lateral femoral condyles (Figure 1). The IMU was equipped with a three-axis acceleration sensor (range: ±60 m/s
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) and a three-axis gyroscope (range: ±2000 deg/s), and the obtained data were wirelessly transmitted to a personal computer via Bluetooth. Acceleration in the anteroposterior (AP), mediolateral (ML), and vertical (VT) directions and angular velocity in the sagittal, frontal, and horizontal planes were measured at a sampling rate of 200 Hz. To test the reproducibility of the measurements, the subjects performed the same assessments under the same conditions within a week.
The data obtained from the IMUs were analyzed using commercially available software (MATLAB, Release 2019a; MathWorks Japan, Tokyo, Japan) to calculate the index of varus thrust during walking motion. Data for ten strides during stable walking on the affected side in the knee OA group and on the left side in the healthy group were used for the analysis. Angular velocity data were sent through a low-pass filter with a cutoff
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