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Background: Individuals with spastic hemiplegic cerebral palsy are typically high functioning and walk without assistive devices. The involved limb is usually smaller and shorter, although it is not clear whether the difference in muscle volume has an impact on walking capacity.Questions/purposes: We determined the volume of muscles important for propulsion and related that volume to concentric muscle work during walking on the hemiplegic and noninvolved sides in patients with cerebral palsy.Patients and Methods: We studied 46 patients (mean age, 17.6 years; range, 13-24 years) with spastic hemiplegic cerebral palsy. We assessed muscle volume using MRI and concentric muscle work in the sagittal plane from the hip, knee, and ankle using three-dimensional gait analysis. Patients were classified by Winters' criteria to assess the involvement of cerebral palsy and movement pattern during walking.Results: On the hemiplegic side, muscles were smaller, except for the gracilis muscle, and concentric muscle work from the ankle plantar flexors, knee extensors, and hip flexors and extensors was lower compared to the noninvolved side. Hip extensor work was higher on the hemiplegic and the noninvolved sides compared to a control group of 14 subjects without cerebral palsy. Hemiplegic to noninvolved volume ratios correlated with work ratios (r = 0.40-0.66). The Winters classification and previous calf muscle surgery predicted work ratios.Conclusions: Our observations of smaller muscles on the hemiplegic side and changes in muscle work on both sides can help us distinguish between primary deviations that may potentially be treatable and compensatory mechanisms that should not be treated. [ABSTRACT FROM AUTHOR]

The metabolic energy rate of individual muscles is impossible to measure without invasive procedures. Prior studies have produced models to predict metabolic rates based on experimental observations of isolated muscle contraction from various species. Such models can provide reliable predictions of metabolic rates in humans if muscle properties and control are accurately modeled. This study aimed to examine how muscle-tendon model individualization and metabolic energy models influenced estimation of muscle-tendon states and time-series metabolic rates, to evaluate the agreement with empirical data, and to provide predictions of the metabolic rate of muscle groups and gait phases across walking speeds. Three-dimensional musculoskeletal simulations with prescribed kinematics and dynamics were performed. An optimal control formulation was used to compute muscle-tendon states with four levels of individualization, ranging from a scaled generic model and muscle controls based on minimal activations, inclusion of calibrated muscle passive forces, personalization of Achilles and quadriceps tendon stiffnesses, to finally informing muscle controls with electromyography. We computed metabolic rates based on existing models. Simulations with calibrated passive forces and personalized tendon stiffness most accurately estimate muscle excitations and fiber lengths. Interestingly, the inclusion of electromyography did not improve our estimates. The whole-body average metabolic cost was better estimated with a subset of metabolic energy models. We estimated metabolic rate peaks near early stance, pre-swing, and initial swing at all walking speeds. Plantarflexors accounted for the highest cost among muscle groups at the preferred speed and were similar to the cost of hip adductors and abductors combined. Also, the swing phase accounted for slightly more than one-quarter of the total cost in a gait cycle, and its relative cost decreased with walking speed. Our prediction might inform the design of assistive devices and rehabilitation treatment. The code and experimental data are available online., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2024 Luis et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Recent years have witnessed breakthroughs in assistive exoskeletons; both passive and active devices have reduced metabolic costs near preferred walking speed by assisting muscle actions. Metabolic reductions at multiple speeds should thus also be attainable. Musculoskeletal simulation can potentially predict the interaction between assistive moments, muscle-tendon mechanics, and walking energetics. In this study, we simulated devices' optimal assistive moments based on minimal muscle activations during walking with prescribed kinematics and dynamics. We used a generic musculoskeletal model with tuned muscle-tendon parameters and computed metabolic rates from muscle actions. We then simulated walking across multiple speeds and with two ideal actuation modes-motor-based and spring-based-to assist ankle plantarflexion, knee extension, hip flexion, and hip abduction and compared computed metabolic rates. We found that both actuation modes considerably reduced physiological joint moments but did not always reduce metabolic rates. Compared to unassisted conditions, motor-based ankle plantarflexion and hip flexion assistance reduced metabolic rates, and this effect was more pronounced as walking speed increased. Spring-based hip flexion and abduction assistance increased metabolic rates at some walking speeds despite a moderate decrease in some muscle activations. Both modes of knee extension assistance reduced metabolic rates to a small extent, even though the actuation contributed with practically the entire net knee extension moment during stance. Motor-based hip abduction assistance reduced metabolic rates more than spring-based assistance, though this reduction was relatively small. Our study also suggests that an assistive strategy based on minimal muscle activations might result in a suboptimal reduction of metabolic rates. Future work should experimentally validate the effects of assistive moments and refine modeling assumptions accordingly. Our computational workflow is freely available online., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2024 Luis et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Introduction: Wearable exoskeletons are emerging technologies for providing movement assistance and rehabilitation for people with motor disorders. In this study, we focus on the specific gait pathology dropfoot, which is common after a stroke. Dropfoot makes it difficult to achieve foot clearance during swing and heel contact at early stance and often necessitates compensatory movements., Methods: We developed a soft ankle exoskeleton consisting of actuation and transmission systems to assist two degrees of freedom simultaneously: dorsiflexion and eversion, then performed several proof-of-concept experiments on non-disabled persons. The actuation system consists of two motors worn on a waist belt. The transmission system provides assistive force to the medial and lateral sides of the forefoot via Bowden cables. The coupling design enables variable assistance of dorsiflexion and inversion at the same time, and a force-free controller is proposed to compensate for device resistance. We first evaluated the performance of the exoskeleton in three seated movement tests: assisting dorsiflexion and eversion, controlling plantarflexion, and compensating for device resistance, then during walking tests. In all proof-of-concept experiments, dropfoot tendency was simulated by fastening a weight to the shoe over the lateral forefoot., Results: In the first two seated tests, errors between the target and the achieved ankle joint angles in two planes were low; errors of <1.5° were achieved in assisting dorsiflexion and/or controlling plantarflexion and of <1.4° in assisting ankle eversion. The force-free controller in test three significantly compensated for the device resistance during ankle joint plantarflexion. In the gait tests, the exoskeleton was able to normalize ankle joint and foot segment kinematics, specifically foot inclination angle and ankle inversion angle at initial contact and ankle angle and clearance height during swing., Discussion: Our findings support the feasibility of the new ankle exoskeleton design in assisting two degrees of freedom at the ankle simultaneously and show its potential to assist people with dropfoot and excessive inversion., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2024 Zhang, Liu, Wang and Gutierrez-Farewik.)

The workflow to simulate motion with recorded data usually starts with selecting a generic musculoskeletal model and scaling it to represent subject-specific characteristics. Simulating muscle dynamics with muscle-tendon parameters computed from existing scaling methods in literature, however, yields some inconsistencies compared to measurable outcomes. For instance, simulating fiber lengths and muscle excitations during walking with linearly scaled parameters does not resemble established patterns in the literature. This study presents a tool that leverages reported in vivo experimental observations to tune muscle-tendon parameters and evaluates their influence in estimating muscle excitations and metabolic costs during walking. From a scaled generic musculoskeletal model, we tuned optimal fiber length, tendon slack length, and tendon stiffness to match reported fiber lengths from ultrasound imaging and muscle passive force-length relationships to match reported in vivo joint moment-angle relationships. With tuned parameters, muscle contracted more isometrically, and soleus's operating range was better estimated than with linearly scaled parameters. Also, with tuned parameters, on/off timing of nearly all muscles' excitations in the model agreed with reported electromyographic signals, and metabolic rate trajectories varied significantly throughout the gait cycle compared to linearly scaled parameters. Our tool, freely available online, can customize muscle-tendon parameters easily and be adapted to incorporate more experimental data., (© 2024. The Author(s).)

This is a protocol for comprehensive analysis of gait and affecting factors in individuals with incomplete paraplegia due to spinal cord injury (SCI). A SCI is a devastating event affecting both sensory and motor functions. Due to better care, the SCI population is changing, with a greater proportion retaining impaired ambulatory function. Optimizing ambulatory function after SCI remains challenging. To investigate factors influencing optimal ambulation, a multi-professional research project was grounded with expertise from clinical rehabilitation, neurophysiology, and biomechanical engineering from Karolinska Institutet, the Spinalis Unit at Aleris Rehab Station (Sweden's largest center for specialized neurorehabilitation), and the Promobilia MoveAbility Lab at KTH Royal Institute of Technology. Ambulatory adults with paraplegia will be consecutively invited to participate. Muscle strength, sensitivity, and spasticity will be assessed, and energy expenditure, 3D movements, and muscle function (EMG) during gait and submaximal contractions will be analyzed. Innovative computational modeling and data-driven analyses will be performed, including the identification of clusters of similar movement patterns among the heterogeneous population and analyses that study the link between complex sensorimotor function and movement performance. These results may help optimize ambulatory function for persons with SCI and decrease the risk of secondary conditions during gait with a life-long perspective.

Introduction: Recent advancements in reinforcement learning algorithms have accelerated the development of control models with high-dimensional inputs and outputs that can reproduce human movement. However, the produced motion tends to be less human-like if algorithms do not involve a biomechanical human model that accounts for skeletal and muscle-tendon properties and geometry. In this study, we have integrated a reinforcement learning algorithm and a musculoskeletal model including trunk, pelvis, and leg segments to develop control modes that drive the model to walk., Methods: We simulated human walking first without imposing target walking speed, in which the model was allowed to settle on a stable walking speed itself, which was 1.45 m / s . A range of other speeds were imposed for the simulation based on the previous self-developed walking speed. All simulations were generated by solving the Markov decision process problem with covariance matrix adaptation evolution strategy, without any reference motion data., Results: Simulated hip and knee kinematics agreed well with those in experimental observations, but ankle kinematics were less well-predicted., Discussion: We finally demonstrated that our reinforcement learning framework also has the potential to model and predict pathological gait that can result from muscle weakness., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2023 Su and Gutierrez-Farewik.)

Introduction: Electromechanically-assisted gait training has been introduced in stroke rehabilitation as a means to enable gait training with a large number of reproducible and symmetrical task repetitions, i.e. steps. However, few studies have evaluated its impact on gait pattern functions. This study includes persons with no independent ambulation function at the start of a 4-week neurorehabilitation period in the sub-acute phase after stroke. The primary aim of the study was to evaluate whether the addition of electromechanically-assisted gait training to conventional training resulted in better gait pattern function than conventional training alone. The secondary aim was to identify correlations between overall gait quality and standardized clinical assessments., Participants and Methods: Seventeen patients with no independent ambulation function who participated in a Prospective Randomized Open Blinded End-point study in the sub-acute phase after stroke were randomized into two groups; one group ( n = 7) to undergo conventional training only (CONV group) and the other group ( n = 10) to undergo conventional training with additional electromechanically-assisted gait training (HAL group). All patients were assessed with 3D gait analysis and clinical assessments after the 4-week intervention period. Overall gait quality as per the Gait Profile Score (GPS), as well as kinematic, and kinetic and other spatiotemporal metrics were collected and compared between intervention groups. Correlations between biomechanical and clinical outcomes were evaluated., Results: Both the CONV and HAL groups exhibited similar gait patterns with no significant differences between groups in any kinematic, kinetic parameters or other spatiotemporal metrics. The GPS for the paretic limb had a median (IQR) of 12.9° (7.8°) and 13.4° (4.3°) for the CONV and HAL groups, respectively ( p = 0.887). Overall gait quality was correlated with independence in walking, walking speed, movement function and balance. We found no added benefit in gait pattern function from the electromechanically-assisted gait training compared to the conventional training alone., Discussion: This finding raises new questions about how to best design effective and optimal post-stroke rehabilitation programs in patients with moderate to severe gait impairments to achieve both independent walking and optimal gait pattern function, and about which patients should be in focus in further studies on the efficacy of electromechanically-assisted gait training., Clinical Trial Registration: The study was retrospectively registered at ClinicalTrials.gov, identifier (NCT02410915) on April 2015., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2023 Wall, Palmcrantz, Borg and Gutierrez-Farewik.)

Mechanical loading has been described as having the potential to affect bone growth. In order to experimentally study the potential clinical applications of mechanical loading as a novel treatment to locally modulate bone growth, there is a need to develop a portable mechanical loading device enabling studies in small bones. Existing devices are bulky and challenging to transfer within and between laboratories and animal facilities, and they do not offer user-friendly mechanical testing across both ex vivo cultured small bones and in vivo animal models. To address this, we developed a portable loading device comprised of a linear actuator fixed within a stainless-steel frame equipped with suitable structures and interfaces. The actuator, along with the supplied control system, can achieve high-precision force control within the desired force and frequency range, allowing various load application scenarios. To validate the functionality of this new device, proof-of-concept studies were performed in ex vivo cultured rat bones of varying sizes. First, very small fetal metatarsal bones were microdissected and exposed to 0.4 N loading applied at 0.77 Hz for 30 s. When bone lengths were measured after 5 days in culture, loaded bones had grown less than unloaded controls (p < 0.05). Next, fetal rat femur bones were periodically exposed to 0.4 N loading at 0.77 Hz while being cultured ex vivo for 12 days. Interestingly, this loading regimen had the opposite effect on bone growth, i.e., loaded femur bones grew significantly more than unloaded controls (p < 0.001). These findings suggest that complex relationships between longitudinal bone growth and mechanical loading can be determined using this device. We conclude that our new portable mechanical loading device allows experimental studies in small bones of varying sizes, which may facilitate further preclinical studies exploring the potential clinical applications of mechanical loading., (© 2023. The Author(s).)

Background: Although model personalization is critical when assessing individuals with morphological or neurological abnormalities, or even non-disabled subjects, its translation into routine clinical settings is hampered by the cumbersomeness of experimental data acquisition and lack of resources, which are linked to high costs and long processing pipelines. Quantifying the impact of neglecting subject-specific information in simulations that aim to estimate muscle forces with surface electromyography informed modeling approaches, can address their potential in relevant clinical questions. The present study investigates how different methods to fine-tune subject-specific neuromuscular parameters, reducing the number of electromyography input data, could affect the estimation of the unmeasured excitations and the musculotendon forces., Methods: Three-dimensional motion analysis was performed on 8 non-disabled adult subjects and 13 electromyographic signals captured. Four neuromusculoskeletal models were created for 8 participants: a reference model driven by a large set of sEMG signals; two models informed by four electromyographic signals but calibrated in different fashions; a model based on static optimization., Findings: The electromyography-informed models better predicted experimental excitations, including the unmeasured ones. The model based on static optimization obtained less reliable predictions of the experimental data. When comparing the different reduced models, no major differences were observed, suggesting that the less complex model may suffice for predicting muscle forces with a small set of input in clinical gait analysis tasks., Interpretation: Quantitative model performance evaluation in different conditions provides an objective indication of which method yields the most accurate prediction when a small set of electromyographic recordings is available., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2023 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Accurate and timely movement intention detection can facilitate exoskeleton control during transitions between different locomotion modes. Detecting movement intentions in real environments remains a challenge due to unavoidable environmental uncertainties. False movement intention detection may also induce risks of falling and general danger for exoskeleton users. To this end, in this study, we developed a method for detecting human movement intentions in real environments. The proposed method is capable of online self-correcting by implementing a decision fusion layer. Gaze data from an eye tracker and inertial measurement unit (IMU) signals were fused at the feature extraction level and used to predict movement intentions using 2 different methods. Images from the scene camera embedded on the eye tracker were used to identify terrains using a convolutional neural network. The decision fusion was made based on the predicted movement intentions and identified terrains. Four able-bodied participants wearing the eye tracker and 7 IMU sensors took part in the experiments to complete the tasks of level ground walking, ramp ascending, ramp descending, stairs ascending, and stair descending. The recorded experimental data were used to test the feasibility of the proposed method. An overall accuracy of 93.4% was achieved when both feature fusion and decision fusion were used. Fusing gaze data with IMU signals improved the prediction accuracy.

Introduction: Research interest in exoskeleton assistance strategies that incorporate the user's torque capacity is growing rapidly. However, the predicted torque capacity from users often includes uncertainty from various sources, which can have a significant impact on the safety of the exoskeleton-user interface., Methods: To address this challenge, this paper proposes an adaptive control framework for a knee exoskeleton that uses muscle electromyography (EMG) signals and joint kinematics. The framework predicted the user's knee flexion/extension torque with confidence bounds to quantify the uncertainty based on a neuromusculoskeletal (NMS) solver-informed Bayesian Neural Network (NMS-BNN). The predicted torque, with a specified confidence level, controlled the assistive torque provided by the exoskeleton through a TCP/IP stream. The performance of the NMS-BNN model was also compared to that of the Gaussian process (NMS-GP) model., Results: Our findings showed that both the NMS-BNN and NMS-GP models accurately predicted knee joint torque with low error, surpassing traditional NMS models. High uncertainties were observed at the beginning of each movement, and at terminal stance and terminal swing in self-selected speed walking in both NMS-BNN and NMS-GP models. The knee exoskeleton provided the desired assistive torque with a low error, although lower torque was observed during terminal stance of fast walking compared to self-selected walking speed., Discussion: The framework developed in this study was able to predict knee flexion/extension torque with quantifiable uncertainty and to provide adaptive assistive torque to the user. This holds significant potential for the development of exoskeletons that provide assistance as needed, with a focus on the safety of the exoskeleton-user interface., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2023 Zhang, Zhang, Zhu, Wang and Gutierrez-Farewik.)

Resistance exercise on Earth commonly involves both body weight and external load. When developing exercise routines and devices for use in space, the absence of body weight is not always adequately considered. This study compared musculoskeletal load distribution during two flywheel resistance knee-extension exercises, performed in the direction of (vertical squat; S) or perpendicular to (horizontal leg press; LP) the gravity vector. Eleven participants performed these two exercises at a given submaximal load. Motion analysis and musculoskeletal modelling were used to compute joint loads and to simulate a weightless situation. The flywheel load was more than twice as high in LP as in S ( p  < 0.001). Joint moments and forces were greater during LP than during S in the ankle, hip and lower back ( p  < 0.01) but were similar in the knee. In the simulated weightless situation, hip and lower-back loadings in S were higher than corresponding values at Earth gravity ( p  ≤ 0.01), whereas LP joint loads did not increase. The results suggest that LP is a better terrestrial analogue than S for knee-extension exercise in weightlessness and that the magnitude and direction of gravity during resistance exercise should be considered when designing and evaluating countermeasure exercise routines and devices for space.

There is an increasing demand for accurately predicting human movement intentions. To be effective, predictions must be performed as early as possible in the preceding step, though precisely how early has been studied relatively little; how and when a person's movement patterns in a transition step deviate from those in the preceding step must be clearly defined. In this study, we collected motion kinematics, kinetics and electromyography data from 9 able-bodied participants during 7 locomotion modes. Twelve types of steps between the 7 locomotion modes were studied, including 5 continuous steps (taking another step in the same locomotion mode) and 7 transitions steps (taking a step from one locomotion mode into another). For each joint degree of freedom, joint angles, angular velocities, moments, and moment rates were compared between continuous steps and transition steps, and the relative timing during the transition step at which these parameters diverged from those of a continuous step, which we refer to as transition starting times, were identified using multiple analyses of variance. Muscle synergies were also extracted for each step, and we studied in which locomotion modes these synergies were common (task-shared) and in which modes they were specific (task-specific). The transition starting times varied among different transitions and joint degrees of freedom. Most transitions started in the swing phase of the transition step. These findings can be applied to determine the critical timing at which a powered assistive device must adapt its control to enable safe and comfortable support to a user.

Accurately predicting joint torque using wearable sensors is crucial for designing assist-as-needed exoskeleton controllers to assist muscle-generated torque and ensure successful task performance. In this paper, we estimated ankle dorsiflexion/plantarflexion, knee flexion/extension, hip flexion/extension, and hip abduction/adduction torques from electromyography (EMG) and kinematics during daily activities using neuromusculoskeletal (NMS) models and long short-term memory (LSTM) networks. The joint torque ground truth for model calibrating and training was obtained through inverse dynamics of captured motion data. A cluster approach that grouped movements based on characteristic similarity was implemented, and its ability to improve the estimation accuracy of both NMS and LSTM models was evaluated. We compared torque estimation accuracy of NMS and LSTM models in three cases: Pooled, Individual, and Clustered models. Pooled models used data from all 10 movements to calibrate or train one model, Individual models used data from each individual movement, and Clustered models used data from each cluster. Individual, Clustered and Pooled LSTM models all had relatively high joint torque estimation accuracy. Individual and Clustered NMS models had similarly good estimation performance whereas the Pooled model may be too generic to satisfy all movement patterns. While the cluster approach improved the estimation accuracy in NMS models in some movements, it made relatively little difference in the LSTM neural networks, which already had high estimation accuracy. Our study provides practical implications for designing assist-as-needed exoskeleton controllers by offering guidelines for selecting the appropriate model for different scenarios, and has potential to enhance the functionality of wearable exoskeletons and improve rehabilitation and assistance for individuals with motor disorders.

Abstract: Sjöberg, M, Eiken, O, Norrbrand, L, Berg, HE, and Gutierrez-Farewik, EM. Lumbar loads and muscle activity during flywheel and barbell leg exercises. J Strength Cond Res 37(1): 27-34, 2023-It is anticipated that flywheel-based leg resistance exercise will be implemented in future long-duration space missions, to counter deconditioning of weight-bearing bones and postural muscles. The aim was to examine low back loads and muscle engagements during flywheel leg press (FWLP) and flywheel squat (FWS) and, for comparisons, free-weight barbell back squat (BBS). Eight resistance-trained subjects performed 8 repetition maximums of FWLP, FWS, and BBS. Motion analysis and inverse dynamics-based musculoskeletal modeling were used to compute joint loads and muscle forces. Muscle activities were measured with electromyography (EMG). At the L4-L5 level, peak vertebral compression force was similarly high in all exercise modes, whereas peak vertebral posteroanterior shear force was greater ( p < 0.05) in FWLP and BBS than in FWS. Among the back-extensor muscles, the erector spinae longissimus exerted the greatest peak force, with no difference between exercises. Peak force in the lumbar multifidus was lower ( p < 0.05) during FWLP than during FWS and BBS. Peak EMG activity in the lumbar extensor muscles ranged between 31 and 122% of maximal voluntary isometric contraction across muscles and exercise modes, with the greatest levels in the lumbar multifidus. The vertebral compression forces and muscle activations during the flywheel exercises were sufficiently high to presume that when implementing such exercise in space countermeasure regimens, they may be capable of preventing muscle atrophy and vertebral demineralization in the lumbar region., (Copyright © 2021 National Strength and Conditioning Association.)

In this work, we predicted ankle joint torque by combining a neuromusculoskeletal (NMS) solver-informed artificial neural network (hybrid-ANN) model with transfer learning based on joint angle and muscle electromyography signals. The hybrid-ANN is an ANN augmented with two kinds of features: 1) experimental measurements - muscle signals and joint angles, and 2) informative physical features extracted from the underlying NMS solver, such as individual muscle force and joint torque. The hybrid-ANN model accuracy in torque prediction was studied in both intra- and inter-subject tests, and compared to the baseline models (NMS and standard-ANN). For each prediction model, seven different cases were studied using data from gait at different speeds and from isokinetic ankle dorsi/plantarflexion motion. Additionally, we integrated a transfer learning method in inter-subject models to improve joint torque prediction accuracy by transferring the learned knowledge from previous participants to a new participant, which could be useful when training data is limited. Our results indicated that better accuracy could be obtained by integrating informative NMS features into a standard ANN model, especially in inter-subject cases; overall, the hybrid-ANN model predicted joint torque with higher accuracy than the baseline models, most notably in inter-subject prediction after adopting the transfer learning technique. We demonstrated the potential of combining physics-based NMS and standard-ANN models with a transfer learning technique in different prediction scenarios. This procedure holds great promise in applications such as assistance-as-needed exoskeleton control strategy design by incorporating the physiological joint torque of the users.

Muscle-driven simulations have been widely adopted to study muscle-tendon behavior; several generic musculoskeletal models have been developed, and their biofidelity improved based on available experimental data and computational feasibility. It is, however, not clear which, if any, of these models accurately estimate muscle-tendon dynamics over a range of walking speeds. In addition, the interaction between model selection, performance criteria to solve muscle redundancy, and approaches for scaling muscle-tendon properties remain unclear. This study aims to compare estimated muscle excitations and muscle fiber lengths, qualitatively and quantitatively, from several model combinations to experimental observations. We tested three generic models proposed by Hamner et al., Rajagopal et al., and Lai-Arnold et al. in combination with performance criteria based on minimization of muscle effort to the power of 2, 3, 5, and 10, and four approaches to scale the muscle-tendon unit properties of maximum isometric force, optimal fiber length, and tendon slack length. We collected motion analysis and electromyography data in eight able-bodied subjects walking at seven speeds and compared agreement between estimated/modelled muscle excitations and observed muscle excitations from electromyography and computed normalized fiber lengths to values reported in the literature. We found that best agreement in on/off timing in vastus lateralis, vastus medialis, tibialis anterior, gastrocnemius lateralis, gastrocnemius medialis, and soleus was estimated with minimum squared muscle effort than to higher exponents, regardless of model and scaling approach. Also, minimum squared or cubed muscle effort with only a subset of muscle-tendon unit scaling approaches produced the best time-series agreement and best estimates of the increment of muscle excitation magnitude across walking speeds. There were discrepancies in estimated fiber lengths and muscle excitations among the models, with the largest discrepancy in the Hamner et al. model. The model proposed by Lai-Arnold et al. best estimated muscle excitation estimates overall, but failed to estimate realistic muscle fiber lengths, which were better estimated with the model proposed by Rajagopal et al. No single model combination estimated the most accurate muscle excitations for all muscles; commonly observed disagreements include onset delay, underestimated co-activation, and failure to estimate muscle excitation increments across walking speeds., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2022 Luis, Afschrift, De Groote and Gutierrez-Farewik.)

Estimation of joint torque during movement provides important information in several settings, such as effect of athletes' training or of a medical intervention, or analysis of the remaining muscle strength in a wearer of an assistive device. The ability to estimate joint torque during daily activities using wearable sensors is increasingly relevant in such settings. In this study, lower limb joint torques during ten daily activities were predicted by long short-term memory (LSTM) neural networks and transfer learning. LSTM models were trained with muscle electromyography signals and lower limb joint angles. Hip flexion/extension, hip abduction/adduction, knee flexion/extension and ankle dorsiflexion/plantarflexion torques were predicted. The LSTM models' performance in predicting torque was investigated in both intra-subject and inter-subject scenarios. Each scenario was further divided into intra-task and inter-task tests. We observed that LSTM models could predict lower limb joint torques during various activities accurately with relatively low error (root mean square error ≤ 0.14 Nm/kg, normalized root mean square error ≤ 8.7%) either through a uniform model or through ten separate models in intra-subject tests. Furthermore, a transfer learning technique was adopted in the inter-task and inter-subject tests to further improve the generalizability of LSTM models by pre-training a model on multiple subjects and/or tasks and transferring the learned knowledge to a target task/subject. Particularly in the inter-subject tests, we could predict joint torques accurately in several movements after training from only a few movements from new subjects.

People walk on different types of terrain daily; for instance, level-ground walking, ramp and stair ascent and descent, and stepping over obstacles are common activities in daily life. Movement patterns change as people move from one terrain to another. The prediction of transitions between locomotion modes is important for developing assistive devices, such as exoskeletons, as the optimal assistive strategies may differ for different locomotion modes. The prediction of locomotion mode transitions is often accompanied by gait-event detection that provides important information during locomotion about critical events, such as foot contact (FC) and toe off (TO). In this study, we introduce a method to integrate locomotion mode prediction and gait-event identification into one machine learning framework, comprised of two multilayer perceptrons (MLP). Input features to the framework were from fused data from wearable sensors-specifically, electromyography sensors and inertial measurement units. The first MLP successfully identified FC and TO, FC events were identified accurately, and a small number of misclassifications only occurred near TO events. A small time difference (2.5 ms and -5.3 ms for FC and TO, respectively) was found between predicted and true gait events. The second MLP correctly identified walking, ramp ascent, and ramp descent transitions with the best aggregate accuracy of 96.3%, 90.1%, and 90.6%, respectively, with sufficient prediction time prior to the critical events. The models in this study demonstrate high accuracy in predicting transitions between different locomotion modes in the same side's mid- to late stance of the stride prior to the step into the new mode using data from EMG and IMU sensors. Our results may help assistive devices achieve smooth and seamless transitions in different locomotion modes for those with motor disorders.

The aim was to compare the musculoskeletal load distribution and muscle activity in two types of maximal flywheel leg-extension resistance exercises: horizontal leg press, during which the entire load is external, and squat, during which part of the load comprises the body weight. Nine healthy adult habitually strength-training individuals were investigated. Motion analysis and inverse dynamics-based musculoskeletal modelling were used to compute joint loads, muscle forces, and muscle activities. Total exercise load (resultant ground reaction force; rGRF) and the knee-extension net joint moment (NJM) were slightly and considerably greater, respectively, in squat than in leg press ( p ≤ 0.04), whereas the hip-extension NJM was moderately greater in leg press than in squat ( p = 0.03). Leg press was performed at 11° deeper knee-flexion angle than squat ( p = 0.01). Quadriceps muscle activity was similar in squat and leg press. Both exercise modalities showed slightly to moderately greater force in the vastii muscles during the eccentric than concentric phase of a repetition ( p ≤ 0.05), indicating eccentric overload. That the quadriceps muscle activity was similar in squat and leg press, while rGRF and NJM about the knee were greater in squat than leg press, may, together with the finding of a propensity to perform leg press at deeper knee angle than squat, suggest that leg press is the preferable leg-extension resistance exercise, both from a training efficacy and injury risk perspective., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2021 Sjöberg, Berg, Norrbrand, Andersen, Gutierrez-Farewik, Sundblad and Eiken.)

Background: At the beginning of a sprint, the acceleration of the body center of mass (COM) is driven mostly forward and vertically in order to move from an initial crouched position to a more forward-leaning position. Individual muscle contributions to COM accelerations have not been previously studied in a sprint with induced acceleration analysis, nor have muscle contributions to the mediolateral COM accelerations received much attention. This study aimed to analyze major lower-limb muscle contributions to the body COM in the three global planes during the first step of a sprint start. We also investigated the influence of step width on muscle contributions in both naturally wide sprint starts (natural trials) and in sprint starts in which the step width was restricted (narrow trials)., Method: Motion data from four competitive sprinters (2 male and 2 female) were collected in their natural sprint style and in trials with a restricted step width. An induced acceleration analysis was performed to study the contribution from eight major lower limb muscles (soleus, gastrocnemius, rectus femoris, vasti, gluteus maximus, gluteus medius, biceps femoris, and adductors) to acceleration of the body COM., Results: In natural trials, soleus was the main contributor to forward (propulsion) and vertical (support) COM acceleration and the three vasti (vastus intermedius, lateralis and medialis) were the main contributors to medial COM acceleration. In the narrow trials, soleus was still the major contributor to COM propulsion, though its contribution was considerably decreased. Likewise, the three vasti were still the main contributors to support and to medial COM acceleration, though their contribution was lower than in the natural trials. Overall, most muscle contributions to COM acceleration in the sagittal plane were reduced. At the joint level, muscles contributed overall more to COM support than to propulsion in the first step of sprinting. In the narrow trials, reduced COM propulsion and particularly support were observed compared to the natural trials., Conclusion: The natural wide steps provide a preferable body configuration to propel and support the COM in the sprint starts. No advantage in muscular contributions to support or propel the COM was found in narrower step widths., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2021 Wang, Martín de Azcárate, Sandamas, Arndt and Gutierrez-Farewik.)

Longitudinal bone growth is regulated by mechanical forces arising from physical activity, whose directions and magnitudes depend on activity kinematics and intensity. This study aims to investigate the influence of common physical activities on proximal femoral morphological tendency due to growth at the femoral head growth plate. A subject-specific femur model based on magnetic resonance images of one able-bodied 6-year old child was developed, and the directions of hip contact force were described as load samples at a constant magnitude. Finite element analysis was performed to predict growth rate and growth direction, and expected changes in neck-shaft angle and femoral anteversion were computed corresponding to circa 4 months of growth. For most loading conditions, neck-shaft angle and femoral anteversion decreased during growth, corresponding to the femur's natural course during normal growth. The largest reduction in neck-shaft angle and femoral anteversion was approximately 0.25° and 0.15°. Our results suggest that most common physical activities induce the expected morphological changes in normal growth in able-bodied children. Understanding the influence of contact forces during less common activities on proximal femoral development might provide improved guidelines and treatment planning for children who have or are at risk of developing a femoral deformity., Competing Interests: Declaration of Competing Interests None, (Copyright © 2021. Published by Elsevier Ltd.)

Exoskeletons are increasingly used in rehabilitation and daily life in patients with motor disorders after neurological injuries. In this paper, a realistic human knee exoskeleton model based on a physical system was generated, a human-machine system was created in a musculoskeletal modeling software, and human-machine interactions based on different assistive strategies were simulated. The developed human-machine system makes it possible to compute torques, muscle impulse, contact forces, and interactive forces involved in simulated movements. Assistive strategies modeled as a rotational actuator, a simple pendulum model, and a damped pendulum model were applied to the knee exoskeleton during simulated normal and fast gait. We found that the rotational actuator-based assistive controller could reduce the user's required physiological knee extensor torque and muscle impulse by a small amount, which suggests that joint rotational direction should be considered when developing an assistive strategy. Compared to the simple pendulum model, the damped pendulum model based controller made little difference during swing, but further decreased the user's required knee flexor torque during late stance. The trade-off that we identified between interaction forces and physiological torque, of which muscle impulse is the main contributor, should be considered when designing controllers for a physical exoskeleton system. Detailed information at joint and muscle levels provided in this human-machine system can contribute to the controller design optimization of assistive exoskeletons for rehabilitation and movement assistance., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2021 Zhang, Liu, Wang, Smith and Gutierrez-Farewik.)

Detecting human movement intentions is fundamental to neural control of robotic exoskeletons, as it is essential for achieving seamless transitions between different locomotion modes. In this study, we enhanced a muscle synergy-inspired method of locomotion mode identification by fusing the electromyography data with two types of data from wearable sensors (inertial measurement units), namely linear acceleration and angular velocity. From the finite state machine perspective, the enhanced method was used to systematically identify 2 static modes, 7 dynamic modes, and 27 transitions among them. In addition to the five broadly studied modes (level ground walking, ramps ascent/descent, stairs ascent/descent), we identified the transition between different walking speeds and modes of ramp walking at different inclination angles. Seven combinations of sensor fusion were conducted, on experimental data from 8 able-bodied adult subjects, and their classification accuracy and prediction time were compared. Prediction based on a fusion of electromyography and gyroscope (angular velocity) data predicted transitions earlier and with higher accuracy. All transitions and modes were identified with a total average classification accuracy of 94.5% with fused sensor data. For nearly all transitions, we were able to predict the next locomotion mode 300-500ms prior to the step into that mode.

Lower body segment trajectory and gait phase prediction is crucial for the control of assistance-as-needed robotic devices, such as exoskeletons. In order for a powered exoskeleton with phase-based control to determine and provide proper assistance to the wearer during gait, we propose an approach to predict segment trajectories up to 200 ms ahead (angular velocity of the thigh, shank and foot segments) and five gait phases (loading response, mid-stance, terminal stance, preswing and swing), based on collected data from inertial measurement units placed on the thighs, shanks, and feet. The approach we propose is a long-short term memory (LSTM)-based network, a modified version of recurrent neural networks, which can learn order dependence in sequence prediction problems. The algorithm proposed has a weighted discount loss function that places more weight in predicting the next three to five time frames but also contributes to an overall prediction performance for up to 10 time frames. The LSTM model was designed to learn lower limb segment trajectories using training samples and was tested for generalization across participants. All predicted trajectories were strongly correlated with the measured trajectories, with correlation coefficients greater than 0.98. The proposed LSTM approach can also accurately predict the five gait phases, particularly swing phase with 95% accuracy in inter-subject implementation. The ability of the LSTM network to predict future gait trajectories and gait phases can be applied in designing exoskeleton controllers that can better compensate for system delays to smooth the transition between gait phases.

The aims of this study were (a) to describe the kinematics underlying the phenomenon of the knee of the swing leg passing medially in front of the athlete during the single push (SP) phase of the block sprint start, and (b) to determine the relationships between block phase pelvis range of motion (RoM), 1 st step width and block phase performance. Three-dimensional kinematic data (250 Hz) were collected from eleven competitive sprinters (100 m PB: 11.17 ± 0.41) performing maximal effort block starts. The joint angles of the rear hip with respect to the pelvis and the pelvis segment angles with respect to the laboratory coordinate system were calculated during the block start phase to the end of the 1 st stance. A combination of pelvis list and rotation (not hip adduction) was coupled with the thigh of the swing leg moving medially during the SP phase. A very high positive correlation was found between pelvic list RoM and 1 st step width (r = 0.799, p = 0.003). No other significant correlations were found. Attempting to reduce pelvic RoM or changing frontal and transverse plane hip joint angles to minimise medial thigh motion is unlikely to lead to an improvement to performance.

This study investigated how manipulating first step width affects 3D external force production, centre of mass (CoM) motion and performance in athletic sprinting. Eight male and 2 female competitive sprinters (100m PB: 11.03 ± 0.36 s male and 11.6 ± 0.45 s female) performed 10 maximal effort block starts. External force and three-dimensional kinematics were recorded in both the block and first stance phases. Five trials were performed with the athletes performing their preferred technique (Skating) and five trials with the athletes running inside a 0.3 m lane (Narrow). By reducing step width from a mean of 0.31 ± 0.06 m (Skating) to 0.19 ± 0.03 m (Narrow), reductions were found between the two styles in medial block and medial 1st stance impulses, 1st stance anterior toe-off velocity and mediolateral motion of the CoM. No differences were found in block time, step length, stance time, average net resultant force vector, net anteroposterior impulse nor normalised external power. Step width correlated positively with medial impulse but not with braking nor net anteroposterior impulse. Despite less medially directed forces and less mediolateral motion of the CoM in the Narrow trials, no immediate improvement to performance was found by restricting step width.

In this survey, we review the field of human shoulder functional kinematic representations. The central question of this review is to evaluate whether the current approaches in shoulder kinematics can meet the high-reliability computational challenge. This challenge is posed by applications such as robot-assisted rehabilitation. Currently, the role of kinematic representations in such applications has been mostly overlooked. Therefore, we have systematically searched and summarised the existing literature on shoulder kinematics. The shoulder is an important functional joint, and its large range of motion (ROM) poses several mathematical and practical challenges. Frequently, in kinematic analysis, the role of the shoulder articulation is approximated to a ball-and-socket joint. Following the high-reliability computational challenge, our review challenges this inappropriate use of reductionism. Therefore, we propose that this challenge could be met by kinematic representations, that are redundant, that use an active interpretation and that emphasise on functional understanding.

This study aimed to evaluate whether the trajectory of the body's Centre of Mass (CoM) is a sensitive and responsive measure of functional compensations in individuals with knee osteoarthritis (OA) performing the Five Times Sit-to-Stand test (5STS). This prospective study included 21 individuals with OA and 21 age- and gender-matched controls. Motion analysis data was collected while participants performed the 5STS, one month prior and one year after total knee arthroplasty (TKA). Pain was evaluated using a visual analogue scale. Repeated measures ANOVAs were used to evaluate (1) differences in the area under the curve (AUC) of CoM trajectories, and (2) the effect of number of sit-to-stand cycles on the AUC. Preoperatively, individuals with OA displayed a larger contralateral shift (p = 0.009) and forward displacement of the CoM (p < 0.004) than controls. Postoperatively, CoM trajectories of OA individuals were not statistically different from controls. However, upon comparison of specific cycles, OA individuals displayed a larger forward displacement during the final cycle. Pain was significantly reduced postoperatively (p = 0.001). The CoM trajectory appears to be a sensitive and responsive measure of functional compensations. The increased contralateral shift of the CoM represents a strategy to reduce pain by unloading the affected knee. Postoperatively, when pain was substantially reduced, OA individuals were comparable to controls. The increased forward CoM displacement characterises a strategy to reduce muscular effort by reducing the required knee extension moment. Postoperatively, OA individuals were comparable to controls in all cycles but the last, possibly suggesting residual muscle weakness., (Copyright © 2018 Elsevier B.V. All rights reserved.)

Muscle and joint contact force influence stresses at the proximal growth plate of the femur and thus bone growth, affecting the neck shaft angle (NSA) and femoral anteversion (FA). This study aims to illustrate how different muscle groups' activation during gait affects NSA and FA development in able-bodied children. Subject-specific femur models were developed for three able-bodied children (ages 6, 7, and 11 years) using magnetic resonance images. Contributions of different muscle groups-hip flexors, hip extensors, hip adductors, hip abductors, and knee extensors-to overall hip contact force were computed. Specific growth rate for the growth plate was computed, and the growth was simulated in the principal stress direction at each element in the growth front. The predicted growth indicated decreased NSA and FA (of about [Formula: see text] over a four-month period) for able-bodied children. Hip abductors contributed the most, and hip adductors, the least, to growth rate. All muscles groups contributed to a decrease in predicted NSA ([Formula: see text]0.01[Formula: see text]-0.04[Formula: see text] and FA ([Formula: see text]0.004[Formula: see text]-[Formula: see text]), except hip extensors and hip adductors, which showed a tendency to increase the FA ([Formula: see text]0.004[Formula: see text]-[Formula: see text]). Understanding influences of different muscle groups on long bone growth tendency can help in treatment planning for growing children with affected gait.

Aims: To evaluate short and long-term effects of botulinum toxin-A combined with goal-directed physiotherapy in children with cerebral palsy (CP)., Method: A consecutive selection of 40 children, ages 4-12 years, diagnosed with unilateral or bilateral CP, and classified in GMFCS levels I-II. During the 24 months, 9 children received one BoNT-A injection, 10 children two injections, 11 children three injections, and 10 children received four injections. 3D gait analysis, goal-attainment scaling, and body function assessments were performed before and at 3, 12, and 24 months after initial injections., Results: A significant but clinically small long-term improvement in gait was observed. Plantarflexor spasticity was reduced after three months and remained stable, while passive ankle dorsiflexion increased after 3 months but decreased slightly after 12 months. Goal-attainment gradually increased, reached the highest levels at 12 months, and levels were maintained at 24 months., Conclusion: The treatments' positive effect on spasticity reduction was identified, but did not relate to improvement in gait or goal-attainment. No long-term positive change in passive ankle dorsiflexion was observed. Goal attainment was achieved in all except four children. The clinical significance of the improved gait is unclear. Further studies are recommended to identify predictors for positive treatment outcome.

Purpose: To explore whether focusing a target influenced gait in children with cerebral palsy (CP) and typical development (TD)., Methods: Thirty children with bilateral CP (Gross Motor Function Classification System [GMFCS] I-III) and 22 with TD looked at a light at walkway end (Gaze Target) while walking and returned (No Target)., Results: During Gaze versus No Target, children with TD reduced temporal-spatial parameters and movements in the sagittal (SPM) and transverse planes. In comparison, during Gaze Target, children in CP1 (GMFCS I) had larger trunk SPM, children in CP2 (GMFCS II) larger neck (SPM), and children in CP3 (GMFCS III) greater head and neck frontal plane movements, and reduced cadence and single support., Conclusions: Focusing a target altered gait in children with CP. Children in CP1 reduced movements similar to children with TD, children in CP2 behaved nearly unchanged, whereas children in CP3 reduced movements and temporal-spatial parameters, potentially as a consequence of lack of sensory information from lower limbs.

Background: In children with bilateral cerebral palsy (CP) maintaining a standing position can be difficult. The fundamental motor task of standing independently is achieved by an interaction between the visual, somatosensory, and vestibular systems. In CP, the motor disorders are commonly accompanied by sensory and perceptual disturbances. Our aims were to examine the influence of visual stimuli on standing posture in relation to standing ability., Methods: Three dimensional motion analysis with surface electromyography was recorded to describe body position, body movement, and muscle activity during three standing tasks: in a self-selected position, while blindfolded, and during an attention-demanding task. Participants were twenty-seven typically-developing (TD) children and 36 children with bilateral CP, of which 17 required support for standing (CP-SwS) and 19 stood without support (CP-SwoS)., Results: All children with CP stood with a more flexed body position than the TD children, even more pronounced in the children in CP-SwS. While blindfolded, the CP-SwS group further flexed their hips and knees, and increased muscle activity in knee extensors. In contrast, the children in CP-SwoS maintained the same body position but increased calf muscle activity. During the attention-demanding task, the children in CP-SwoS stood with more still head and knee positions and with less muscle activity., Conclusions: Visual input was important for children with CP to maintain a standing position. Without visual input the children who required support dropped into a further crouched position. The somatosensory and vestibular systems alone could not provide enough information about the body position in space without visual cues as a reference frame. In the children who stood without support, an intensified visual stimulus enhanced the ability to maintain a quiet standing position. It may be that impairments in the sensory systems are major contributors to the difficulties to stand erect in children with CP.

Mechanical stimuli play a significant role in the process of endochondral growth. Thus far, approaches to understand the endochondral mechanical growth rate have been limited to the use of approximated location and geometry of the growth plate. Furthermore, growth has been simulated based on the average deflection of the growth plate or of the femoral neck. It has also been reported in the literature that the growth plate lies parallel to one of the principal stresses acting on it, to reduce the shear between epiphysis and diaphysis. Hence the current study objectives were (1) to evaluate the significance of a subject-specific finite element model of the femur and growth plate compared to a simplified growth plate model and (2) to explore the different growth direction models to better understand proximal femoral growth mechanisms. A subject-specific finite element model of an able-bodied 7-year old child was developed. The muscle forces and hip contact force were computed for one gait cycle and applied to a finite element model to determine the specific growth rate. Proximal femoral growth was simulated for two different growth direction models: femoral neck deflection direction and principal stress direction. The principal stress direction model captured the expected tendency for decreasing the neck shaft angle and femoral anteversion for both growth plate models. The results of this study suggest that the subject-specific geometry and consideration of the principal stress direction as growth direction may be a more realistic approach for correct prediction of proximal femoral growth morphology., (Copyright © 2016 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Background: Arthrogryposis Multiplex Congenita (AMC) is a heterogeneous condition characterized by multiple joint contractures at birth. Greater movements in the trunk and pelvis during walking have been observed in children with AMC using orthoses compared to those wearing only shoes. This study investigated gait dynamics in children with AMC and identified compensatory mechanisms that accommodate walking., Methods: Twenty-six children with AMC who walked with orthoses or shoes and a control group consisting of 37 typically-developing children were evaluated in 3D gait analysis. Children with AMC were divided into subgroups based on which joints needed to be stabilized in the sagittal plane; AMC1 used knee-ankle-foot orthoses (KAFOs) with locked knee joints, AMC2 used KAFOs with open knee joints or ankle-foot orthoses, and AMC3 used shoes., Results: The Gait Deviation Index was lower in AMC groups than in the control group, with the lowest in AMC1. Excessive trunk movements in frontal and transverse planes were observed in AMC2 and especially in AMC1. Lower hip flexion moment was found in AMC1, while AMC2 and AMC3 showed similar hip flexion moments as the control group. Knee extension moments were similar between the groups. In the frontal plane there were only small differences between the groups in hip abduction moment. A joint work analysis indicated greater contribution from the hip muscles to overall positive work in AMC groups, particularly in AMC1, than in the control group., Conclusion: All AMC groups showed less hip extension than the control group, but hip flexion moment was significantly lower only in AMC1, which can be attributed to their gait strategy with bilateral locked KAFOs. AMC1, who had weak knee extensors, were helped by their locked KAFOs and therefore showed similar knee extension moment as the other groups. This finding, together with their gait patterns, demonstrates the children's high reliance on hip muscles and presumably trunk muscles to provide propulsion. Our study shows that with adequate orthotic support, children with AMC and even with severe weakness and contractures can achieve walking.

Motion analysis is a common clinical assessment and research tool that uses a camera system or motion sensors and force plates to collect kinematic and kinetic information of a subject performing an activity of interest. The use of force plates can be challenging and sometimes even impossible. Over the past decade, several computational methods have been developed that aim to preclude the use of force plates. Useful in particular for predictive simulations, where a new motion or change in control strategy inherently means different external contact loads. These methods, however, often depend on prior knowledge of common observed ground reaction force (GRF) patterns, are computationally expensive, or difficult to implement. In this study, we evaluated the use of the Zero Moment Point as a computationally inexpensive tool to obtain the GRFs for normal human gait. The method was applied on ten healthy subjects walking in a motion analysis laboratory and predicted GRFs are evaluated against the simultaneously measured force plate data. Apart from the antero-posterior forces, GRFs are well-predicted and errors fall within the error ranges from other published methods. Joint extension moments were underestimated at the ankle and hip but overestimated at the knee, attributable to the observed discrepancy in the predicted application points of the GRFs. The computationally inexpensive method evaluated in this study can reasonably well predict the GRFs for normal human gait without using prior knowledge of common gait kinetics., (Copyright © 2015 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Purpose: To investigate postural orientation and maintenance of joint position during standing in children with bilateral spastic cerebral palsy (BSCP)., Methods: Standing was examined with 3-D motion analysis in 26 children with BSCP, and 19 children typically developing (TD). Two groups of children with cerebral palsy (CP) were analyzed: 15 who were able to maintain standing without support and 11 who needed support., Results: Children with CP stood with more flexion than children TD. In the CP groups, children standing without support stood more asymmetrically with less hip and knee flexion and less movement than those who required support., Conclusion: Children with CP had varying abilities to stand and maintain standing posture with or without support. Both CP groups stood with more flexion than their potential passive joint angle, more obvious in children requiring support. Investigations on how muscle strength and spatial perception influence posture remains to be explored.

Excessive co-contraction causes inefficient or abnormal movement in several neuromuscular pathologies. How synergistic muscles spanning the ankle, knee and hip adapt to co-contraction of ankle muscles is not well understood. This study aimed to identify the compensation strategies required to retain normal walking with excessive antagonistic ankle muscle co-contraction. Muscle-actuated simulations of normal walking were performed to quantify compensatory mechanisms of ankle and knee muscles during stance in the presence of normal, medium and high levels of co-contraction of antagonistic pairs gastrocnemius+tibialis anterior and soleus+tibialis anterior. The study showed that if co-contraction increases, the synergistic ankle muscles can compensate; with gastrocmemius+tibialis anterior co-contraction, the soleus will increase its contribution to ankle plantarflexion acceleration. At the knee, however, almost all muscles spanning the knee and hip are involved in compensation. We also found that ankle and knee muscles alone can provide sufficient compensation at the ankle joint, but hip muscles must be involved to generate sufficient knee moment. Our findings imply that subjects with a rather high level of dorsiflexor+plantarflexor co-contraction can still perform normal walking. This also suggests that capacity of other lower limb muscles to compensate is important to retain normal walking in co-contracted persons. The compensatory mechanisms can be useful in clinical interpretation of motion analyses, when secondary muscle co-contraction or other deficits may present simultaneously in subjects with motion disorders., (Copyright © 2014 Elsevier B.V. All rights reserved.)

This article introduces history-dependent effects in a skeletal muscle model applied to dynamic simulations of musculoskeletal system motion. Force depression and force enhancement induced by active muscle shortening and lengthening, respectively, represent muscle history effects. A muscle model depending on the preceding contractile events together with the current parameters was developed for OpenSim software, and applied in simulations of standing heel-raise and squat movements. Muscle activations were computed using joint kinematics and ground reaction forces recorded from the motion capture of seven individuals. In the muscle-actuated simulations, a modification was applied to the computed activation, and was compared to the measured electromyography data. For the studied movements, the history gives a small but visible effect to the muscular force trace, but some parameter values must be identified before the exact magnitude can be analysed. The muscle model modification improves the existing muscle models and gives a more accurate description of underlying forces and activations in musculoskeletal system movement simulations., (Copyright © 2013 Elsevier Ltd. All rights reserved.)

Background: There are many treatments for idiopathic toe-walking, including casts with or without injection of botulinum toxin A. Combined treatment with casts and botulinum toxin A has become more common even though there have been few studies of its efficacy and safety problems. Our aims were to conduct a randomized controlled trial to test the hypotheses that combined treatment with casts and botulinum toxin A is more effective than casts alone in reducing toe-walking by patients five to fifteen years of age, and that the treatment effect correlates with the extent of coexisting neuropsychiatric problems., Methods: All patients who had been consecutively admitted to the pediatric orthopaedics department of our institution because of idiopathic toe-walking between November 2005 and April 2010 were considered for inclusion in the study. Forty-seven children constituted the study population. The children were randomized to undergo four weeks of treatment with below-the-knee casts either as the sole intervention or to undergo the cast treatment one to two weeks after receiving injections of botulinum toxin A into the calves. Before treatment and three and twelve months after cast removal, all children underwent three-dimensional (3-D) gait analysis. The severity of the idiopathic toe-walking was classified on the basis of the gait analysis, and the parents rated the time that their child spent on his/her toes during barefoot walking. Passive hip, knee, and ankle motion as well as ankle dorsiflexor strength were measured. Before treatment, all children were evaluated with a screening questionnaire for neuropsychiatric problems., Results: No differences were found in any outcome parameter between the groups before treatment or at three or twelve months after cast removal. Several gait-analysis parameters, passive ankle motion, and ankle dorsiflexor strength were improved at both three and twelve months in both groups, even though many children still demonstrated some degree of toe-walking. The treatment outcomes were not correlated with coexisting neuropsychiatric problems., Conclusion: Adding botulinum toxin-A injections prior to cast treatment for idiopathic toe-walking does not improve the outcome of cast-only treatment.

For people with motion disorders, posture can impact fatigue, discomfort or deformities in the long term. Orthopedic treatments such as orthoses or orthopedic surgeries which change geometric properties can improve posture in these individuals. In this study, a model has been created to study posture strategies in such situations. A 3D mechanical model consisting of eight rigid segments and 30 muscle groups is used in which varying moment arms along the ranges of motion and biarticular muscles are considered. The method is based on static optimization, both to solve the load sharing in the muscle system and to choose posture strategy. The optimization computes the specific posture with minimal required effort (level of muscle activations), while fulfilling constraints containing subject specific ranges of motion, muscle strength/weakness and external support if present. Anthropometry and strength were scaled to each individual, based on reported pediatric anthropometry and strength values, combined with each individual's physical assessment. A control group of 10 able-bodied subjects as well as three subjects with motion disorders were studied, and simulated posture was compared with experimental data. The simulation showed reasonable to good agreement and ability to predict the effect of motion disorders and of external support. An example of application in parameter studies was also presented wherein ankle orthosis angles were varied. The model allows the user to study muscle activity at the muscle group level, position of center of mass and moments at joints in various situations., (Copyright © 2011 Elsevier Ltd. All rights reserved.)

The purpose of this study was to determine how gait deviation in one plane (i.e. excessive subtalar inversion/eversion) can affect the dynamic function of the tibialis anterior, gastrocnemius, and soleus to accelerate the subtalar, ankle, knee and hip joints, as well as the body center of mass. Induced acceleration analysis was performed based on a subject-specific three-dimensional linkage model configured by stance phase gait data and driven by one unit of muscle force. Eight healthy adult subjects were examined in gait analysis. The subtalar inversion/eversion was modeled by offsetting up to 20° from the normal subtalar angle while other configurations remained unaltered. This study showed that the gastrocnemius, soleus and tibialis anterior generally functioned as their anatomical definition in normal gait, but counterintuitive function was occasionally found in the bi-articular gastrocnemius. The plantarflexors play important roles in the body support and forward progression. Excessive subtalar eversion was found to enlarge the plantarflexors and tibialis anterior's function. Induced acceleration analysis demonstrated its ability to isolate the contributions of individual muscle to a given factor, and as a means of studying effect of pathological gait on the dynamic muscle functions., (Copyright © 2011 Elsevier B.V. All rights reserved.)

Aims: In this study the aim was to evaluate the effect of botulinum toxin A (BoNT-A) treatment on muscle tone, contracture development and gait pattern in young children with cerebral palsy (CP)., Method: Fifteen children with spastic CP (mean age = 16 months) were included in a randomized control study. All received a daily stretching programme and children in the BoNT-A group additionally received two injections, 6 months apart in the gastrocnemius muscle. Outcomes were assessed at baseline, and after 1 and 3.5 years. A 3D gait-analysis was performed at 5 years of age., Results: Plantarflexor muscle tone in the BoNT-A group was significantly reduced after 3.5 years, while the muscle tone at the ankle and knee in the control group remained unchanged. The change-score in knee-flexion muscle tone between the groups was significantly different after 3.5 years. The knee joint ROM was significantly increased at 1 year in the BoNT-A group but reduced at the knee and ankle joints in the control group after 3.5 years. No group differences were found for gait analysis, GMFM-66 or PEDI., Conclusion: Early treatment of BoNT-A in children with spastic CP may decrease muscle tone and decelerate contracture development after 3.5 years. The effect on gait development remains inconclusive.

Background: Numerous recommendations have been made for treating idiopathic toe-walking (ITW), but the treatment results have been questioned. The purpose of this study was to investigate whether botulinum toxin A (BTX) improves the walking pattern in ITW as examined with 3-D gait analysis., Participants and Methods: A consecutive series of 15 children (aged 5-13 years) were enrolled in the study. The children underwent a 3-D gait analysis prior to treatment with a total of 6 units/kg bodyweight Botox(®) in the calf muscles and an exercise program. The gait analysis was repeated 3 weeks and 3, 6, and 12 months after treatment. A classification of toe-walking severity was made before treatment and after 12 months. The parents rated the perceived amount of toe-walking prior to treatment and 6 and 12 months after treatment., Results: Eleven children completed the 12-month follow-up. The gait analysis results displayed a significant improvement, indicating decreased plantarflexion angle at initial contact and during swing phase and increased dorsiflexion angle during midstance at all post-treatment testing instances. According to the parents' perception of toe-walking, 3/11 children followed for 12 months had ceased toe-walking completely, 4/11 decreased toe-walking, and 4/11 continued toe-walking. After 6-12 months, the toe-walking severity classification improved in 9 of the 14 children for whom data could be assessed., Conclusions: A single injection of BTX in combination with an exercise program can improve the walking pattern in children with ITW seen at gait analysis, but the obvious goal of ceasing toe-walking is only occasionally reached.

Ankle fractures are one of the most common lower limb traumas. Several studies reported short- and long-term post-operative results, mainly determined by radiographic and subjective functional evaluations. Three-dimensional gait analysis with a multi-segment foot model was used in the current study to quantify the inter-segment foot motions in 18 patients 1 year after surgically treated ankle fractures. Data were compared to that from gender- and age-matched healthy controls. The correlations between Olerud/Molander ankle score and kinematics were also evaluated. Patients with ankle fractures showed less plantarflexion and smaller range of motion in the injured talocrural joint, which were believed to be a sign of residual joint stiffness after surgery and immobilization. Moreover, the forefoot segment had smaller sagittal and transverse ranges of motion, less plantarflexion and the hallux segment had less dorsiflexion and smaller sagittal range of motion. The deviations found in the forefoot segment may contribute to the compensation mechanisms of the injured ankle joint. Findings of our study show that gait analysis with a multi-segment foot model provides a quantitative and objective way to perform the dynamic assessment of post-operative ankle fractures, and makes it possible to better understand not only how the injured joint is affected, but also the surrounding joints., (Copyright 2009 Elsevier B.V. All rights reserved.)

Purpose: Lower limb contractures and muscle weakness are common in children with arthrogryposis multiplex congenita (AMC). To enhance or facilitate ambulation, orthoses may be used. The aim of this study was to describe gait pattern among individuals wearing their habitual orthotic devices., Methods: Fifteen children with AMC, mean age 12.4 (4.3) years, with some lower limb involvement underwent 3-D gait analysis. Three groups were defined based on orthosis use; Group 1 used knee-ankle-foot orthoses with locked knee joints, Group 2 used ankle-foot orthoses or knee-ankle-foot orthoses with open knee joints and Group 3 used no orthoses., Results: The greatest trunk and pelvis movements in all planes and the greatest hip abduction were observed in Group 1, compared to Groups 2 and 3, as well as to the gait laboratory control group. Maximum hip extension was similar in Groups 1 and 2, but in Group 3, there was less hip extension and large deviations from the control data. Lower cadence and walking speed were observed in Group 1 than in Groups 2 and 3. The step length was similar in all groups and also with respect to the gait laboratory reference values., Conclusions: Children with AMC were subdivided according to orthoses use. Kinematic data as recorded with 3-D gait analysis showed differences among the groups in trunk, pelvis and knee kinematics, and in cadence and walking speed. The step length was similar in all groups and to the gait laboratory reference values, which may be attributable to good hip extension strength in all participants.