Publications by authors named "Michael A Hunt"

115 Publications

The effects of cholesterol accumulation on Achilles tendon biomechanics: A cross-sectional study.

PLoS One 2021 16;16(9):e0257269. Epub 2021 Sep 16.

Department of Physical Therapy, Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada.

Familial hypercholesterolemia, a common genetic metabolic disorder characterized by high cholesterol levels, is involved in the development of atherosclerosis and other preventable diseases. Familial hypercholesterolemia can also cause tendinous abnormalities, such as thickening and xanthoma (tendon lipid accumulation) in the Achilles, which may impede tendon biomechanics. The objective of this study was to investigate the effect of cholesterol accumulation on the biomechanical performance of Achilles tendons, in vivo. 16 participants (10 men, 6 women; 37±6 years) with familial hypercholesterolemia, diagnosed with tendon xanthoma, and 16 controls (10 men, 6 women; 36±7 years) underwent Achilles biomechanical assessment. Achilles biomechanical data was obtained during preferred pace, shod, walking by analysis of lower limb kinematics and kinetics utilizing 3D motion capture and an instrumented treadmill. Gastrocnemius medialis muscle-tendon junction displacement was imaged using ultrasonography. Achilles stiffness, hysteresis, strain and force were calculated from displacement-force data acquired during loading cycles, and tested for statistical differences using one-way ANOVA. Statistical parametric mapping was used to examine group differences in temporal data. Participants with familial hypercholesterolemia displayed lower Achilles stiffness compared to the control group (familial hypercholesterolemia group: 87±20 N/mm; controls: 111±18 N/mm; p = 0.001), which appeared to be linked to Achilles loading rate rather than an increased strain (FH: 5.27±1.2%; controls: 4.95±0.9%; p = 0.413). We found different Achilles loading patterns in the familial hypercholesterolemia group, which were traced to differences in the centre of pressure progression that affected ankle moment. This finding may indicate that individuals with familial hypercholesterolemia use different Achilles loading strategies. Participants with familial hypercholesterolemia also demonstrated significantly greater Achilles hysteresis than the control group (familial hypercholesterolemia: 57.5±7.3%; controls: 43.8±10%; p<0.001), suggesting that walking may require a greater metabolic cost. Our results indicate that cholesterol accumulation could contribute to reduced Achilles function, while potentially increasing the chance of injury.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0257269PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8445482PMC
September 2021

Wearable Real-Time Haptic Biofeedback Foot Progression Angle Gait Modification to Assess Short-Term Retention and Cognitive Demand.

IEEE Trans Neural Syst Rehabil Eng 2021 14;29:1858-1865. Epub 2021 Sep 14.

Foot progression angle gait (FPA) modification is an important part of rehabilitation for a variety of neuromuscular and musculoskeletal diseases. While wearable haptic biofeedback could enable FPA gait modification for more widespread use than traditional tethered, laboratory-based approaches, retention, and cognitive demand in FPA gait modification via wearable haptic biofeedback are currently unknown and may be important to real-life implementation. Thus, the purpose of this study was to assess the feasibility of wearable haptic biofeedback to assess short-term retention and cognitive demand during FPA gait modification. Ten healthy participants performed toe-in (target 10 degrees change in internal rotation) and toe-out (target 10 degrees change in external rotation) haptic gait training trials followed by short-term retention trials, and cognitive multitasking trials. Results showed that participants were able to initially respond to the wearable haptic feedback to modify their FPA to adopt the new toe-in (9.7 ± 0.8 degree change in internal rotation) and toe-out (8.9 ± 1.0 degree change in external rotation) gait patterns. Participants retained the modified gait pattern on average within 3.9 ± 3.6 deg of the final haptic gait training FPA values. Furthermore, cognitive multitasking did not influence short-term retention in that there were no differences in gait performance during retention trials with or without cognitive multitasking. These results demonstrate that wearable haptic biofeedback can be used to assess short-term retention and cognitive demand during FPA gait modification without the need for traditional, tethered systems.
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http://dx.doi.org/10.1109/TNSRE.2021.3110202DOI Listing
September 2021

The Influence of Running on Lower Limb Cartilage: A Systematic Review and Meta-analysis.

Sports Med 2021 Sep 3. Epub 2021 Sep 3.

Motion Analysis and Biofeedback Laboratory, University of British Columbia, Vancouver, BC, Canada.

Background: Running is a popular activity practiced worldwide. It is important to understand how running affects joint health to provide recommendations to sports medicine practitioners and runners.

Objective: Our aim was to summarize the influence of running on lower limb cartilage morphology and composition using quantitative magnetic resonance imaging (MRI).

Methods: Prospective repeated-measures studies evaluating cartilage using MRI before and after running were included. Data sources included Pubmed, Embase, CINAHL, SportDiscus, Web of Science, and Cochrane Central Registry of Controlled Trials. Qualitative analyses considered the number and methodological quality ratings of studies based on the QualSyst tool, and recommendations were based on the strength of evidence (strong, moderate, limited, or very limited). Quantitative analysis involved meta-analyses, for which effect sizes were calculated as Hedge's g standardized mean differences.

Results: We included 43 articles, assessing seven outcomes (lesions, volume, thickness, glycosaminoglycan content, and T1ρ, T2, and T2* relaxation times). Nineteen articles were rated as high quality, 24 were rated as moderate quality, and none were rated as low quality. Qualitative analyses suggest that running may cause an immediate reduction in knee cartilage volume, thickness, as well as T1ρ and T2 relaxation times immediately; however, these changes did not persist. Meta-analyses revealed a small and moderate decrease immediately following a single running bout in T2 relaxation time in the medial femur and tibia, respectively. Qualitative analyses indicated that the influence of repeated exposure to running on cartilage morphology and composition was limited. Despite conflicting evidence regarding pre-existing knee cartilage lesions, moderate evidence suggests that running does not lead to the formation of new lesions. Repeated running exposure did not cause changes to foot and ankle cartilage thickness or composition.

Conclusions: Changes to lower limb cartilage following running are transient. Immediate changes to cartilage morphology and composition, which likely reflect natural fluid dynamics, do not persist and were generally not significant when pooled statistically. Results suggest that cartilage recovers well from a single running bout and adapts to repeated exposure. Given that moderate evidence indicates that running does not lead to new lesions, future trials should focus on clinical populations, such as those with osteoarthritis.

Trial Registration: Not applicable.
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http://dx.doi.org/10.1007/s40279-021-01533-7DOI Listing
September 2021

Smartphone Inclinometry Is a Valid and Reliable Tool for Measuring Frontal Plane Tibial Alignment in Healthy and Osteoarthritic Knees.

Phys Ther 2021 Jul;101(7)

Motion Analysis and Biofeedback Laboratory, University of British Columbia, Vancouver, British Columbia, Canada.

Objective: Frontal plane knee alignment plays an integral role in tibiofemoral knee osteoarthritis development and progression. Accessible methods for obtaining direct or indirect measures of knee alignment may help inform clinical decision making when specialized equipment is unavailable. The present study evaluated the concurrent validity, as well as intersession (within-rater) and interrater (within-session) reliability of smartphone inclinometry for measuring static frontal plane tibial alignment-a known proxy of frontal plane knee alignment.

Methods: Twenty healthy individuals and 38 patients with knee osteoarthritis were measured for frontal plane tibial alignment by a pair of raters using smartphone inclinometry, manual inclinometry, and 3-dimensional motion capture simultaneously. Healthy participants were measured on 2 separate days. Bland-Altman analysis, supplemented with intraclass correlation coefficient (ICC)(2,k), was used to assess concurrent validity. ICC(2,k), SEM, and minimum detectable change with 95% confidence limits (MDC95) were used to assess measurement reliability.

Results: Compared against motion capture, smartphone inclinometry measured frontal plane tibial alignment with a mean difference of 0.7 and 1.1 degrees (biased toward varus) for healthy participants and participants with knee osteoarthritis, respectively (ICC[2,k] ≥ 0.87). Smartphone inclinometry measurements demonstrated adequate intersession (within-rater) relative (ICC[2,k] = 0.91) and absolute (SEM = 0.7 degrees; MDC95 = 1.8 degrees) reliability, which outperformed manual inclinometry (ICC[2,k] = 0.85; SEM = 1.0 degrees; MDC95 = 2.6 degrees). Interrater (within-session) reliability of smartphone inclinometry was acceptable in both cohorts (ICC[2,k] = 0.93; SEM = 0.4 degrees to 1.2 degrees; MDC95 = 1.2 degrees to 3.2 degrees).

Conclusion: Smartphone inclinometry is sufficiently valid and reliable for measuring frontal plane tibial alignment in healthy individuals and patients with medial tibiofemoral knee osteoarthritis.

Impact: Smartphones are readily accessible by clinicians and researchers. Our assessment of measurement validity and reliability supports the use of smartphone inclinometry as a clinically available tool to measure frontal plane tibial alignment without medical imaging or specialized equipment.
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http://dx.doi.org/10.1093/ptj/pzab091DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8248042PMC
July 2021

Tibiofemoral Contact Measures During Standing in Toe-In and Toe-Out Postures.

J Appl Biomech 2021 Mar 8;37(3):233-239. Epub 2021 Mar 8.

The University of British Columbia.

Knee osteoarthritis is thought to result, in part, from excessive and unbalanced joint loading. Toe-in and toe-out gait modifications produce alterations in external knee joint moments, and some improvements in pain over the short- and long-term. The aim of this study was to probe mechanisms of altered joint loading through the assessment of tibiofemoral contact in standing with toe-in and toe-out positions using an open magnetic resonance scanner. In this study, 15 young, healthy participants underwent standing magnetic resonance imaging of one of their knees in 3 foot positions. Images were analyzed to determine contact in the tibiofemoral joint, with primary outcomes including centroid of contact and contact area for each compartment and overall. The centroid of contact shifted laterally in the lateral compartment with both toe-in and toe-out postures, compared with the neutral position (P < .01), while contact area in the medial and lateral compartments showed no statistical differences. Findings from this study indicate that changes in the loading anatomy are present in the tibiofemoral joint with toe-in and toe-out and that a small amount of lateralization of contact, especially in the lateral compartment, does occur with these altered lower limb orientations.
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http://dx.doi.org/10.1123/jab.2020-0206DOI Listing
March 2021

Relationships Between Stepping-Reaction Movement Patterns and Clinical Measures of Balance, Motor Impairment, and Step Characteristics After Stroke.

Phys Ther 2021 05;101(5)

Biomedical Physiology and Kinesiology, Simon Fraser University, Burnaby, Canada.

Objective: Successful stepping reactions, led by either the paretic or nonparetic leg, in response to a loss of balance are critical to safe mobility poststroke. The purpose of this study was to measure sagittal plane hip, knee, ankle, and trunk kinematics during 2-step stepping reactions initiated by paretic and nonparetic legs of people who had stroke and members of a control group.

Methods: Principal component analysis (PCA) was used to reduce the data into movement patterns explaining interlimb coordination of the stepping and stance legs. Correlations among principal components loading scores and clinical measures of balance ability (as measured on the Community Balance and Mobility scale), motor impairment (as measured on the foot and leg sections of the Chedoke-McMaster Stroke Assessment), and step characteristics (length and velocity) were used to examine the effect of stroke on stepping reaction movement patterns.

Results: The first 5 principal components explained 95.9% of the movement pattern of stepping reactions and differentiated between stepping reactions initiated by paretic legs, nonparetic legs, or the legs of controls. Moderate-strong associations (ρ/r > 0.50) between specific principal component loading scores and clinical measures and step characteristics were dependent on the initiating leg. Lower levels of motor impairment, higher levels of balance ability, and faster and longer steps were associated with stepping reactions initiated by the paretic leg that comprised paretic leg flexion and nonparetic leg extension. Step initiation with the nonparetic leg showed associations between higher scores on clinical measures and movement patterns of flexion in both paretic and nonparetic legs.

Conclusions: Movement patterns of stepping reactions poststroke were influenced by the initiating leg. After stroke, specific movement patterns showed associations with clinical measures depending on the initiating leg, suggesting that these movement patterns are important to retraining of stepping reactions. Specifically, use of flexion patterning and assessment of between-leg pattern differentiation may be important aspects to consider during retraining of stepping reactions poststroke.

Impact: Evidence-based interventions targeting balance reactions are still in their infancy. This investigation of stepping reactions poststroke addresses a major gap in research.
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http://dx.doi.org/10.1093/ptj/pzab069DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8164842PMC
May 2021

Using the VERT wearable device to monitor jumping loads in elite volleyball athletes.

PLoS One 2021 22;16(1):e0245299. Epub 2021 Jan 22.

Centre for Hip Health and Mobility, Vancouver Coastal Health Research Institute, Vancouver, British Columbia, Canada.

Sport is becoming increasingly competitive and athletes are being exposed to greater physical demands, leaving them prone to injuries. Monitoring athletes with the use of wearable technology could provide a way to potentially manage training and competition loads and reduce injuries. One such technology is the VERT inertial measurement unit, a commercially available discrete wearable device containing a 3-axis accelerometer, 3-axis gyroscope and 3-axis magnetometer. Some of the main measurement outputs include jump count, jump height and landing impacts. While several studies have examined the accuracy of the VERT's measures of jump height and jump count, landing impact force has not yet been investigated. The objective of this research study was to explore the validity of the VERT landing impact values. We hypothesized that the absolute peak VERT acceleration values during a jump-land cycle would fall within 10% of the peak acceleration values derived simultaneously from a research-grade accelerometer (Shimmer). Fourteen elite university-level volleyball players each performed 10 jumps while wearing both devices simultaneously. The results showed that VERT peak accelerations were variable (limits of agreement of -84.13% and 52.37%) and had a propensity to be lower (mean bias of -15.88%) when compared to the Shimmer. In conclusion, the validity of the VERT device's landing impact values are generally poor, when compared to the Shimmer.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0245299PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7822237PMC
May 2021

Knee-specific gait biomechanics are reliable when collected in multiple laboratories by independent raters.

J Biomech 2021 01 24;115:110182. Epub 2020 Dec 24.

Motion Analysis and Biofeedback Laboratory, University of British Columbia, 2177 Wesbrook Mall, Vancouver, BC V6T 1Z3, Canada; Department of Physical Therapy, University of British Columbia, 212 Friedman Building, 2177 Wesbrook Mall, Vancouver, BC V6T 1Z3, Canada. Electronic address:

Multi-centre gait biomechanics studies provide the opportunity to increase sample size and the confidence in results, yet differences between centres may introduce additional error. While previous investigations have compared gait biomechanics from different laboratories assessed by different raters, estimates of relative reliability, measurement error, and thresholds for real change are still unknown. These metrics are imperative to interpret multi-centre study results. Therefore, we examined the reliability of gait biomechanics assessed in two different laboratories, by two different raters, and using the same study sample. Twelve healthy participants underwent gait assessments by two raters in two laboratories at different institutions. Identical protocols were used to collect five walking trials per participant. Discrete data were examined for knee joint angles and moments, gait speed, and stride length. Reliability was assessed using the intraclass correlation coefficient (ICC), standardized error of the measurement (SEM), minimum detectable difference (MDD), and Bland and Altman plots. All spatiotemporal, joint angle, and joint moment measures had ICCs = 0.83-0.94, except for the knee adduction moment peak in late stance (ICC = 0.69 and 0.72). The knee adduction moment SEMs indicate that measurement errors due to the laboratory effect are between 0.19% and 0.31% body weight times height (0.03-0.05 Nm/kg). Meanwhile, measurement error for the knee flexion-extension angle is <2°. Our results are similar to previous test-retest reliability results from a single laboratory, and multiple laboratories, while adding previously unreported reliability metrics necessary for interpreting multi-centre study results.
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http://dx.doi.org/10.1016/j.jbiomech.2020.110182DOI Listing
January 2021

Learning Gait Modifications for Musculoskeletal Rehabilitation: Applying Motor Learning Principles to Improve Research and Clinical Implementation.

Phys Ther 2021 02;101(2)

Motion Analysis and Biofeedback Laboratory, University of British Columbia, Vancouver, BC, Canada.

Gait modifications are used in the rehabilitation of musculoskeletal conditions like osteoarthritis and patellofemoral pain syndrome. While most of the research has focused on the biomechanical and clinical outcomes affected by gait modification, the process of learning these new gait patterns has received little attention. Without adequate learning, it is unlikely that the modification will be performed in daily life, limiting the likelihood of long-term benefit. There is a vast body of literature examining motor learning, though little has involved gait modifications, especially in populations with musculoskeletal conditions. The studies that have examined gait modifications in these populations are often limited due to incomplete reporting and study design decisions that prohibit strong conclusions about motor learning. This perspective draws on evidence from the broader motor learning literature for application in the context of modifying gait. Where possible, specific gait modification examples are included to highlight the current literature and what can be improved on going forward. A brief theoretical overview of motor learning is outlined, followed by strategies that are known to improve motor learning, and finally, how assessments of learning need to be conducted to make meaningful conclusions.
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http://dx.doi.org/10.1093/ptj/pzaa207DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7899063PMC
February 2021

Reliability of tibiofemoral contact area and centroid location in upright, open MRI.

BMC Musculoskelet Disord 2020 Nov 30;21(1):795. Epub 2020 Nov 30.

Centre for Hip Health and Mobility, University of British Columbia, 7/F - 2635 Laurel Street, Robert HN Ho Research Centre, Vancouver, BC, V5Z 1M9, Canada.

Background: Imaging cannot be performed during natural weightbearing in biomechanical studies using conventional closed-bore MRI, which has necessitated simulating weightbearing load on the joint. Upright, open MRI (UO-MRI) allows for joint imaging during natural weightbearing and may have the potential to better characterize the biomechanical effect of tibiofemoral pathology involving soft tissues. However open MRI scanners have lower field strengths than closed-bore scanners, which limits the image quality that can be obtained. Thus, there is a need to establish the reliability of measurements in upright weightbearing postures obtained using UO-MRI.

Methods: Knees of five participants with prior anterior cruciate ligament (ACL) rupture were scanned standing in a 0.5 T upright open MRI scanner using a 3D DESS sequence. Manual segmentation of cartilage regions in contact was performed and centroids of these contact areas were automatically determined for the medial and lateral tibiofemoral compartments. Inter-rater, test-retest, and intra-rater reliability were determined and quantified using intra-class correlation (ICC), standard error of measurement (SEM), and smallest detectable change with 95% confidence (SDC). Accuracy was assessed by using a high-resolution 7 T MRI as a reference.

Results: Contact area and centroid location reliability (inter-rater, test-retest, and intra-rater) for sagittal scans in the medial compartment had ICC values from 0.95-0.99 and 0.98-0.99 respectively. In the lateral compartment, contact area and centroid location reliability ICC values ranged from 0.83-0.91 and 0.95-1.00 respectively. The smallest detectable change in contact area was 1.28% in the medial compartment and 0.95% in the lateral compartment. Contact area and centroid location reliability for coronal scans in the medial compartment had ICC values from 0.90-0.98 and 0.98-1.00 respectively, and in the lateral compartment ICC ranged from 0.76-0.94 and 0.93-1.00 respectively. The smallest detectable change in contact area was 0.65% in the medial compartment and 1.41% in the lateral compartment. Contact area was accurate to within a mean absolute error of 11.0 mm.

Conclusions: Knee contact area and contact centroid location can be assessed in upright weightbearing MRI with good to excellent reliability. The lower field strength used in upright, weightbearing MRI does not compromise the reliability of tibiofemoral contact area and centroid location measures.
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http://dx.doi.org/10.1186/s12891-020-03786-1DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7702694PMC
November 2020

Influence of foot posture on immediate biomechanical responses during walking to variable-stiffness supported lateral wedge insole designs.

Gait Posture 2020 09 27;81:21-26. Epub 2020 Jun 27.

Motion Analysis and Biofeedback Laboratory, University of British Columbia, 212 - 2177 Wesbrook Mall, Vancouver, BC V6T 1Z3, Canada; Department of Physical Therapy, University of British Columbia, 212 - 2177 Wesbrook Mall, Vancouver, BC, V6T 1Z3. Electronic address:

Background: Novel designs of lateral wedge insoles with arch support can alter walking biomechanics as a conservative treatment option for knee osteoarthritis. However, variations in foot posture may influence individual responses to insole intervention and these effects are not yet known.

Research Question: How does foot posture influence biomechanical responses to novel designs of lateral wedge insoles with arch support?

Methods: This exploratory biomechanical investigation categorized forty healthy volunteers (age 23-34) into pronated (n = 16), neutral (n = 15), and supinated (n = 9) foot posture groups based on the Foot Posture Index. Three-dimensional gait analysis was conducted during walking with six orthotic insole conditions: flat control, lateral wedge, uniform-stiffness arch support, variable-stiffness arch support, and lateral wedge + each arch support. Frontal plane knee and ankle/subtalar joint kinetic and kinematic outcomes were compared among insole conditions and foot posture groups using a repeated measures analysis of variance.

Results: The lateral wedge alone and lateral wedge + variable-stiffness arch support were the only insole conditions effective at reducing the knee adduction moment. However, the lateral wedge + variable-stiffness arch support had a smaller increase in peak ankle/subtalar eversion moment than the lateral wedge alone. Supinated feet had smaller ankle/subtalar eversion excursion and moment impulse than neutral and pronated feet, across all insole conditions.

Significance: Supinated feet have less mobile ankle/subtalar joints than neutral and pronated feet and, as a result, may be less likely to respond to biomechanical intervention from orthotic insoles. Supported lateral wedge insoles incorporating an arch support design that is variable-stiffness may be better than uniform-stiffness since reductions in the knee adduction moment can be achieved while minimizing increases in the ankle/subtalar eversion moment.
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http://dx.doi.org/10.1016/j.gaitpost.2020.06.026DOI Listing
September 2020

The use of a single sacral marker method to approximate the centre of mass trajectory during treadmill running.

J Biomech 2020 07 17;108:109886. Epub 2020 Jun 17.

Department of Physical Therapy, University of British Columbia, Vancouver, BC, Canada.

The three-dimensional trajectory of the body's centre of mass (COM) is useful to determine a number of biomechanical outcomes in running research. Previous studies have used the COM to calculate measures such as overstriding, vertical stiffness, and vertical oscillation. The COM is traditionally computed using the segmental analysis method, though this is expensive and time-consuming owing to the need for a full-body marker set. The purpose of this study was to determine whether the COM trajectory can be approximated by a single sacral marker during running. Seventy-one participants underwent a biomechanical running analysis on a treadmill utilizing a full-body marker set. Marker trajectories from the sacral marker and from the COM calculated using the segmental analysis method were compared over the entire gait cycle by computing intraclass correlation coefficient (ICC) and root-mean-square error. Paired t-tests were used to determine if the positions differed in mediolateral, anteroposterior, and vertical directions at three gait events (initial contact, midstance, and toe-off). The trajectories from the two methods exhibited a similar pattern in vertical and anteroposterior directions throughout the gait cycle, displaying strong correlations in these directions (ICC = 0.98 ± 0.01 and 0.83 ± 0.07). Our results suggest that a single sacral marker is a valid proxy for COM trajectory in vertical and anteroposterior directions at key events during the stance phase of running in a female recreational population. Researchers can therefore use a single sacral marker to estimate COM trajectory, rather than a full-body marker set, saving on both time and supplies.
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http://dx.doi.org/10.1016/j.jbiomech.2020.109886DOI Listing
July 2020

What are the perceptions of runners and healthcare professionals on footwear and running injury risk?

BMJ Open Sport Exerc Med 2020 30;6(1):e000767. Epub 2020 Jun 30.

Allan McGavin Sports Medicine Clinic, Vancouver, British Columbia, Canada.

Objectives: There is a gap in research exploring perceptions of runners and healthcare professionals (HCPs) about running footwear and injury risk. The objectives of this study were: (1) to document factors considered by runners when selecting footwear; (2) to compare perceptions on footwear and injury risk in runners and HCPs; and (3) to evaluate the perceived usefulness of an online educational module.

Methods: Using an online survey, we collected information on demographics and perceptions about footwear and injury risk. Runners reported their footwear selection strategy, and HCPs their typical recommendations. An evidence-based educational module was presented, and participants rated its usefulness.

Results: The survey was completed by 2442 participants, of which 1035 completed the optional postmodule questions. Runners reported relying mostly on comfort and advice from retailers when selecting shoes. Perceptions regarding the effects of specific footwear types (minimalist, maximalist), characteristics (softness, drop) and selection strategy (foot type, transition) on biomechanics and injury risk were different between HCPs and runners. Overall, runners perceived footwear as more important to prevent injury than did HCPs (7.6/10, 99% CI 7.4 to 7.7 vs 6.2/10, 99% CI 6.0 to 6.5; p<0.001). Both runners (8.1/10, 99% CI 7.9 to 8.3) and HCPs (8.7/10, 99% CI 8.6 to 8.9) found the educational module useful. A majority of respondents indicated the module changed their perceptions.

Conclusion: Footwear is perceived as important in reducing running injury risk. This online module was deemed useful in educating about footwear evidence. Future studies should evaluate if changes in perceptions can translate to behaviour change and, ultimately, reduced injury risk.
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http://dx.doi.org/10.1136/bmjsem-2020-000767DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7328975PMC
June 2020

Immediate effects of valgus bracing on knee joint moments during walking in knee-healthy individuals: Potential modifying effects of body height.

Gait Posture 2020 07 27;80:383-390. Epub 2020 Jun 27.

Research Health Institute, University of the Sunshine Coast, Sunshine Coast, Australia. Electronic address:

Background: The goal of valgus knee brace treatment is to reduce medial knee joint loading during walking, often indicated by external knee adduction moment (KAM) measures. However, existing healthy-subjects studies have been equivocal in demonstrating KAM reduction with valgus knee bracing.

Research Question: What are the immediate effects of valgus bracing at different tension levels on KAM during walking at a controlled speed and does body height modify the brace-KAM associations?

Methods: Data from 32 knee-healthy participants were analysed in this randomized crossover trial. Participants performed walking trials at controlled speed (1.3 ± 0.065 m/s) both with and without an Ossür Unloader One® brace. During the bracing condition, valgus tension was incrementally increased, from zero tension to normal tension and to maximum tolerable tension.

Results: Valgus bracing minimally increased knee flexion at heel-strike (P < 0.001) in a dose-dependent manner and minimally reduced gait velocity (∼0.015m/s) across all tension levels. Valgus bracing, overall, did not significantly reduce the various KAM measures. However, brace use at maximal tension was associated with a 0.04Nm/kg (9.2 %) increase in first peak KAM amongst participants with a body height of 1.75 m and a 0.03Nm/kg (7.6 %) decrease in first peak KAM amongst participants with a body height of 1.55 m.

Significance: Valgus bracing did not reduce the various KAM measures during walking; however, body height may play a moderating role. Given knee brace sizes vary more in circumference than length, this result may be due to the ratio between effective moment arm length relative to limb length. A deeper understanding of the potential neuro-biomechanical effects of valgus knee bracing and how these effects are potentially modified by body height may be critical to the design of effective knee braces.
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http://dx.doi.org/10.1016/j.gaitpost.2020.06.025DOI Listing
July 2020

Biomechanics during cross-body lunging in individuals with and without painful cam and/or pincer morphology.

Clin Biomech (Bristol, Avon) 2020 06 7;76:105030. Epub 2020 May 7.

Motion Analysis and Biofeedback Laboratory, University of British Columbia, Vancouver, BC, Canada; Department of Physical Therapy, University of British Columbia, Vancouver, BC, Canada. Electronic address:

Background: Femoroacetabular impingement is a patho-mechanical hip condition that can lead to restrictions in hip motion, particularly in end-range hip flexion, adduction and/or internal rotation. Radiographic evidence of femoroacetabular impingement - cam and/or pincer morphology - is prevalent in the general and athletic populations. There is, however, a lack of studies that have analyzed the performance of sport-specific movements in people possessing these morphologies. Therefore, the purpose of this study was to compare cross-body lunge biomechanics between individuals with and without painful cam and/or pincer morphology.

Methods: This was an exploratory, cross-sectional study where nine participants with cam and/or pincer morphology and symptoms, thirteen participants with asymptomatic cam and/or pincer morphology, and eleven pain-free controls performed the cross-body lunge during a single session. Trunk, pelvis, hip, knee and ankle kinematics, as well as hip, knee and ankle kinetics and vertical ground reaction forces were examined.

Findings: Overall, the groups performed the movement similarly, with most variables statistically similar between groups. However, pelvis sagittal plane excursion throughout the entire cross-body lunge was significantly larger in those with cam and/or pincer morphology and symptoms compared to those with asymptomatic cam and/or pincer morphology (P = .046, effect size = 0.98).

Interpretation: The results of this study show that cross-body lunge performance is similar across individuals with and without painful cam and/or pincer morphology. However, future research should aim to better understand pelvis biomechanics during sporting activities, as pelvis sagittal plane excursion may have important implications in rehabilitation and sport performance.
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http://dx.doi.org/10.1016/j.clinbiomech.2020.105030DOI Listing
June 2020

Validity and reliability of wearable inertial sensors in healthy adult walking: a systematic review and meta-analysis.

J Neuroeng Rehabil 2020 05 11;17(1):62. Epub 2020 May 11.

Motion Analysis and Biofeedback Laboratory, University of British Columbia, Vancouver, BC, Canada.

Background: Inertial measurement units (IMUs) offer the ability to measure walking gait through a variety of biomechanical outcomes (e.g., spatiotemporal, kinematics, other). Although many studies have assessed their validity and reliability, there remains no quantitive summary of this vast body of literature. Therefore, we aimed to conduct a systematic review and meta-analysis to determine the i) concurrent validity and ii) test-retest reliability of IMUs for measuring biomechanical gait outcomes during level walking in healthy adults.

Methods: Five electronic databases were searched for journal articles assessing the validity or reliability of IMUs during healthy adult walking. Two reviewers screened titles, abstracts, and full texts for studies to be included, before two reviewers examined the methodological quality of all included studies. When sufficient data were present for a given biomechanical outcome, data were meta-analyzed on Pearson correlation coefficients (r) or intraclass correlation coefficients (ICC) for validity and reliability, respectively. Alternatively, qualitative summaries of outcomes were conducted on those that could not be meta-analyzed.

Results: A total of 82 articles, assessing the validity or reliability of over 100 outcomes, were included in this review. Seventeen biomechanical outcomes, primarily spatiotemporal parameters, were meta-analyzed. The validity and reliability of step and stride times were found to be excellent. Similarly, the validity and reliability of step and stride length, as well as swing and stance time, were found to be good to excellent. Alternatively, spatiotemporal parameter variability and symmetry displayed poor to moderate validity and reliability. IMUs were also found to display moderate reliability for the assessment of local dynamic stability during walking. The remaining biomechanical outcomes were qualitatively summarized to provide a variety of recommendations for future IMU research.

Conclusions: The findings of this review demonstrate the excellent validity and reliability of IMUs for mean spatiotemporal parameters during walking, but caution the use of spatiotemporal variability and symmetry metrics without strict protocol. Further, this work tentatively supports the use of IMUs for joint angle measurement and other biomechanical outcomes such as stability, regularity, and segmental accelerations. Unfortunately, the strength of these recommendations are limited based on the lack of high-quality studies for each outcome, with underpowered and/or unjustified sample sizes (sample size median 12; range: 2-95) being the primary limitation.
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http://dx.doi.org/10.1186/s12984-020-00685-3DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7216606PMC
May 2020

Portable, automated foot progression angle gait modification via a proof-of-concept haptic feedback-sensorized shoe.

J Biomech 2020 06 13;107:109789. Epub 2020 Apr 13.

Department of Physical Therapy, University of British Columbia, Vancouver, BC, Canada; Motion Analysis and Biofeedback Laboratory, University of British Columbia, Vancouver, BC, Canada. Electronic address:

Modifying the foot progression angle (FPA) is a non-pharmacological, non-surgical treatment option for knee osteoarthritis, however current widespread adoption has been limited by the requirement of laboratory-based motion capture systems. We present the first customized haptic feedback-sensorized shoe for estimating and modifying FPA during walking gait, which includes an electronic inertial and magnetometer module in the sole for estimating FPA, and two vibration motors attached to the medial and lateral shoe lining for providing vibrotactile feedback. Feasibility testing was performed by comparing FPA performance while wearing the haptic feedback-sensorized shoe with the training targets. Participants performed five walking trials with five randomly-presented FPA targets (10° toe-in, 0°, 10° toe-out, 20° toe-out, and 30° toe-out) of 2 min each on a treadmill. Overall average FPA performance error across all conditions was 0.2 ± 4.1°, and the overall mean absolute FPA performance error across all conditions was 3.1 ± 2.6°. Reducing the size of the no-feedback window resulted in less performance error during walking. This study demonstrates that a novel haptic feedback-sensorized shoe can be used to effectively train FPA modifications. The haptic feedback-sensorized shoe could potentially be used for FPA gait modification outside of specialized camera-based motion capture laboratories as a conservative treatment for knee osteoarthritis or other related clinical applications requiring FPA assessment and modification in daily life.
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http://dx.doi.org/10.1016/j.jbiomech.2020.109789DOI Listing
June 2020

Patient-reported outcome measures for hip-related pain: a review of the available evidence and a consensus statement from the International Hip-related Pain Research Network, Zurich 2018.

Br J Sports Med 2020 Jul 17;54(14):848-857. Epub 2020 Feb 17.

Division of Orthopaedic Surgery, Oslo University Hospital, Oslo, Norway.

Hip-related pain is a well-recognised complaint among active young and middle-aged active adults. People experiencing hip-related disorders commonly report pain and reduced functional capacity, including difficulties in executing activities of daily living. Patient-reported outcome measures (PROMs) are essential to accurately examine and compare the effects of different treatments on disability in those with hip pain. In November 2018, 38 researchers and clinicians working in the field of hip-related pain met in Zurich, Switzerland for the first International Hip-related Pain Research Network meeting. Prior to the meeting, evidence summaries were developed relating to four prioritised themes. This paper discusses the available evidence and consensus process from which recommendations were made regarding the appropriate use of PROMs to assess disability in young and middle-aged active adults with hip-related pain. Our process to gain consensus had five steps: (1) systematic review of systematic reviews; (2) preliminary discussion within the working group; (3) update of the more recent high-quality systematic review and examination of the psychometric properties of PROMs according to established guidelines; (4) formulation of the recommendations considering the limitations of the PROMs derived from the examination of their quality; and (5) voting and consensus. Out of 102 articles retrieved, 6 systematic reviews were selected and assessed for quality according to AMSTAR 2 (A MeaSurement Tool to Assess systematic Reviews). Two showed moderate quality. We then updated the most recent review. The updated literature search resulted in 10 additional studies that were included in the qualitative synthesis. The recommendations based on evidence summary and PROMs limitations were presented at the consensus meeting. The group makes the following recommendations: (1) the Hip and Groin Outcome Score (HAGOS) and the International Hip Outcome Tool (iHOT) instruments (long and reduced versions) are the most appropriate PROMs to use in young and middle-aged active adults with hip-related pain; (2) more research is needed into the utility of the HAGOS and the iHOT instruments in a non-surgical treatment context; and (3) generic quality of life measures such as the EuroQoL-5 Dimension Questionnaire and the Short Form Health Survey-36 may add value for researchers and clinicians in this field. We conclude that as none of the instruments shows acceptable quality across various psychometric properties, more methods studies are needed to further evaluate the validity of these PROMS-the HAGOS and iHOT-as well as the other (currently not recommended) PROMS.
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http://dx.doi.org/10.1136/bjsports-2019-101456DOI Listing
July 2020

Consensus recommendations on the classification, definition and diagnostic criteria of hip-related pain in young and middle-aged active adults from the International Hip-related Pain Research Network, Zurich 2018.

Br J Sports Med 2020 Jun 20;54(11):631-641. Epub 2020 Jan 20.

La Trobe Sport and Exercise Medicine Research Centre, La Trobe University, Melbourne, Victoria, Australia.

There is no agreement on how to classify, define or diagnose hip-related pain-a common cause of hip and groin pain in young and middle-aged active adults. This complicates the work of clinicians and researchers. The International Hip-related Pain Research Network consensus group met in November 2018 in Zurich aiming to make recommendations on how to classify, define and diagnose hip disease in young and middle-aged active adults with hip-related pain as the main symptom. Prior to the meeting we performed a scoping review of electronic databases in June 2018 to determine the definition, epidemiology and diagnosis of hip conditions in young and middle-aged active adults presenting with hip-related pain. We developed and presented evidence-based statements for these to a panel of 37 experts for discussion and consensus agreement. Both non-musculoskeletal and serious hip pathological conditions (eg, tumours, infections, stress fractures, slipped capital femoral epiphysis), as well as competing musculoskeletal conditions (eg, lumbar spine) should be excluded when diagnosing hip-related pain in young and middle-aged active adults. The most common hip conditions in young and middle-aged active adults presenting with hip-related pain are: (1) femoroacetabular impingement (FAI) syndrome, (2) acetabular dysplasia and/or hip instability and (3) other conditions without a distinct osseous morphology (labral, chondral and/or ligamentum teres conditions), and that these terms are used in research and clinical practice. Clinical examination and diagnostic imaging have limited diagnostic utility; a comprehensive approach is therefore essential. A negative flexion-adduction-internal rotation test helps rule out hip-related pain although its clinical utility is limited. Anteroposterior pelvis and lateral femoral head-neck radiographs are the initial diagnostic imaging of choice-advanced imaging should be performed only when requiring additional detail of bony or soft-tissue morphology (eg, for definitive diagnosis, research setting or when planning surgery). We recommend clear, detailed and consistent methodology of bony morphology outcome measures (definition, measurement and statistical reporting) in research. Future research on conditions with hip-related pain as the main symptom should include high-quality prospective studies on aetiology and prognosis. The most common hip conditions in active adults presenting with hip-related pain are: (1) FAI syndrome, (2) acetabular dysplasia and/or hip instability and (3) other conditions without distinct osseous morphology including labral, chondral and/or ligamentum teres conditions. The last category should not be confused with the incidental imaging findings of labral, chondral and/or ligamentum teres pathology in asymptomatic people. Future research should refine our current recommendations by determining the clinical utility of clinical examination and diagnostic imaging in prospective studies.
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http://dx.doi.org/10.1136/bjsports-2019-101453DOI Listing
June 2020

Standardised measurement of physical capacity in young and middle-aged active adults with hip-related pain: recommendations from the first International Hip-related Pain Research Network (IHiPRN) meeting, Zurich, 2018.

Br J Sports Med 2020 Jun 19;54(12):702-710. Epub 2019 Dec 19.

Sports Orthopedic Research Center-Copenhagen (SORC-C), Department of Orthopedic Surgery, Copenhagen University Hospital, Amager-Hvidovre, Denmark.

Hip-related pain can significantly impact quality of life, function, work capacity, physical activity and family life. Standardised measurement methods of physical capacity of relevance to young and middle-aged active adults with hip-related pain are currently not established. The aim of this consensus paper was to provide recommendations for clinical practice and research on standardised measurement methods of physical capacity in young and middle-aged active adults with hip-related pain. Four areas of importance were identified: (1) clinical measures (range of motion, muscle strength, functional impairments), (2) laboratory-based measures (biomechanics and muscle function (muscle activity, size and adiposity)), (3) physical activity, and (4) return to sport/performance. The literature was reviewed, and a summary circulated to the working group to inform discussion at the consensus meeting. The working group developed clinical and research recommendations from the literature review, which were further discussed and modified within the working group at the consensus meeting. These recommendations were then presented to all 38 International Hip-related Pain Research Network (IHiPRN) participants for further discussion, refinement and consensus voting. Therefore, the recommendations voted on were based on a combination of current evidence and expert opinion. The consensus meeting voted on 13 recommendations, six of which were clinically orientated, and seven more research specific. We recommended that clinicians working with young and middle-aged active adults with hip-related pain assess strength using objective methods of measurement, and clinically assess performance of functional tasks, including walking and running. Physical activity should be quantified using both self-reported and objective measures, and patient expectations of recovery should be quantified prior to treatment. It was recommended that return to physical activity (including sport and occupation) be quantified, and sport-specific activities should be assessed prior to return to sport. The IHiPRN participants were uncertain regarding recommendations for range of motion assessment. Research recommendations were that the measurement properties of range of motion, strength and functional performance tests be investigated, reported and improved in both clinical and research settings. Reporting of movement-related parameters (biomechanics and muscle function) should be standardised and the relationship among movement-related parameters, symptoms, function, quality of life, and intra-articular and imaging findings should be investigated. Quantification of return to physical activity (including sport and occupational demands) is required in future research, and the return to sport continuum should be used. Future research is required to determine the best criteria for rehabilitation progression and return to physical activity following hip-related pain management.
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http://dx.doi.org/10.1136/bjsports-2019-101457DOI Listing
June 2020

Physiotherapist-led treatment for young to middle-aged active adults with hip-related pain: consensus recommendations from the International Hip-related Pain Research Network, Zurich 2018.

Br J Sports Med 2020 May 15;54(9):504-511. Epub 2019 Nov 15.

Musculoskeletal Radiology, Corades, LLC, Brookline, Massachusetts, USA.

The 1st International Hip-related Pain Research Network meeting discussed four prioritised themes concerning hip-related pain in young to middle-aged adults: (1) diagnosis and classification of hip-related pain; (2) patient-reported outcome measures for hip-related pain; (3) measurement of physical capacity for hip-related pain; (4) physiotherapist-led treatment for hip-related pain. Thirty-eight expert researchers and clinicians working in the field of hip-related pain attended the meeting. This manuscript relates to the theme of physiotherapist-led treatments for hip-related pain. A systematic review on the efficacy of physiotherapist-led interventions for hip-related pain (published separately) was conducted and found that strong evidence for physiotherapist-led treatments was lacking. Prior to the meeting, draft consensus recommendations for consideration in the meeting were also developed based on the systematic review. The draft consensus recommendations were presented to all of the meeting participants via email, at least 1 week prior to the meeting. At the meeting, these recommendations were discussed, revised and voted on. Six recommendations for clinical practice and five recommendations for research were included and all gained consensus. Recommendations for clinical practice were that (i) Exercise-based treatments are recommended for people with hip-related pain. (ii) Exercise-based treatment should be at least 3 months duration. (iii) Physiotherapist-led rehabilitation after hip surgery should be undertaken. (iv) Patient-reported outcome measures, measures of physical impairment and measures of psychosocial factors should be used to monitor response to treatment. (v) Physical activity (that may include sport) is recommended for people with hip-related pain. (vi) Clinicians should discuss patient expectations, use shared-decision making and provide education. Recommendations for research were (i) Reporting of exercise programmes: Exercise descriptors such as load magnitude, number of repetitions and sets, duration of whole programme, duration of contractile element of exercise, duration of one repetition, time under tension, rest between repetitions, range of motion through which the exercise is performed, and rest between exercise sessions should be reported. (ii) Research should investigate the optimal frequency, intensity, time, type, volume and progression of exercise therapy. (iii) Research should examine the effect of patient education in people with hip-related pain. (iv) Research should investigate the effect of other treatments used in people with hip-related pain (for example: manual therapy, medications, injections). (v) Research should examine the impact of comorbidities and social determinants on treatment effectiveness in people with hip-related pain. Clinicians and researchers working with young to middle-aged active adults with hip-related pain may use these consensus recommendations to guide, develop, test and implement individualised, evidence-based physiotherapist-led rehabilitation programmes.
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http://dx.doi.org/10.1136/bjsports-2019-101458DOI Listing
May 2020

Cartilage recovery in runners with and without knee osteoarthritis: A pilot study.

Knee 2019 Oct 18;26(5):1049-1057. Epub 2019 Aug 18.

Department of Physical Therapy, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada. Electronic address:

Objective: Running is an easy way of meeting physical activity recommendations for individuals with knee osteoarthritis (KOA); however, it remains unknown how their cartilage reacts to running. The objective of this pilot study was to compare the effects of 30 min of running on T2 and T1ρ relaxation times of tibiofemoral cartilage in female runners with and without KOA.

Methods: Ten female runners with symptomatic KOA (mean age 52.6 ± 7.6 years) and 10 without KOA (mean age 52.5 ± 7.8 years) ran for 30 min on a treadmill. Tibiofemoral cartilage T2 and T1ρ relaxation times were measured using magnetic resonance imaging prior to and immediately after the bout of running. Repeated-measures analyses of covariance (ANCOVA) were conducted to examine between-group differences across scanning times.

Results: No Group × Time interactions were found for T2 (P ≥ 0.076) or T1ρ (P ≥ 0.288) relaxation times. However, runners with KOA showed increased T2 values compared with pre-running in the medial and lateral femur 55 min post-running (5.4 to 5.5%, P < 0.022) and in all four tibiofemoral compartments 90 min post-running (6.9 to 11.1%, P < 0.01). A significant group effect was found for T1ρ in the medial femur, with greater values in those with KOA compared with controls.

Conclusion: While Group × Time interactions in T2 and T1ρ relaxation times remained statistically insignificant, the observed significant increases in T2 in runners with tibiofemoral osteoarthritis TFOA may suggest slower and continuing changes in the cartilage and thus a need for longer recovery after running. Future research should investigate the effects of repeated exposure to running.
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http://dx.doi.org/10.1016/j.knee.2019.07.011DOI Listing
October 2019

Individuals with knee osteoarthritis present increased gait pattern deviations as measured by a knee-specific gait deviation index.

Gait Posture 2019 07 29;72:82-88. Epub 2019 May 29.

Motion Analysis and Biofeedback Laboratory, University of British Columbia, Vancouver, Canada; Department of Physical Therapy, University of British Columbia, Vancouver, Canada. Electronic address:

Background: A biomechanical analysis can provide valuable information on osteoarthritis (OA) gait, but important multidimensional interactions are often ignored. The Gait Deviation Index (GDI) was designed to address the issue of data complexity in gait analyses by providing a single, encompassing, value for one's deviation from a normative reference group.

Research Question: The primary aim of this study was to examine differences in a knee-specific GDI among young adults, and older individuals with and without knee OA. Secondarily, we aimed to examine these differences while controlling for gait speed.

Method: Sagittal and frontal plane knee joint angles and moments were used in the computation of a GDI among young adults, and older individuals with and without knee OA. The GDI was calculated such that scores ≥100% were considered typical young-healthy gait and a 10% decrease below 100 equated to 1 standard deviation from typical gait. Scores were first examined using a one-way analysis of variance, and examined again after correcting for gait speed.

Results: The GDI was calculated for three groups: young-healthy adults (n = 52), older individuals without knee OA (n = 56), and individuals with knee OA (n = 191). Those with knee osteoarthritis exhibited a mean GDI of 87.2 (11.1), which was significantly lower than young adults (99.6 (10.6); p < 0.001) and older individuals without knee OA (94.3 (11.0); p < 0.001). Differences in GDI remained consistent after controlling for gait speed. Knee OA gait waveforms displayed significant variability across similar GDIs, specifically in frontal plane patterns.

Conclusion: Those with knee osteoarthritis exhibited lower (worse) GDIs compared to those without knee osteoarthritis and young, healthy individuals. After correcting for gait speed, these findings did not change. The GDI highlighted the significant variability in gait waveforms within individuals with knee OA, but the clinical utility of the GDI score itself remains limited.
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http://dx.doi.org/10.1016/j.gaitpost.2019.05.020DOI Listing
July 2019

Validity and reliability of a shoe-embedded sensor module for measuring foot progression angle during over-ground walking.

J Biomech 2019 May 17;89:123-127. Epub 2019 Apr 17.

Motion Analysis and Biofeedback Laboratory, University of British Columbia, Vancouver, BC, Canada; Department of Physical Therapy, University of British Columbia, Vancouver, BC, Canada. Electronic address:

Wearable systems are becoming increasingly popular for gait assessment outside of laboratory settings. A single shoe-embedded sensor module can measure the foot progression angle (FPA) during walking. The FPA has important clinical utility, particularly in populations with knee osteoarthritis, as it is a target for biomechanical treatments. However, the validity and the day-to-day reliability of FPA measurement using wearable systems during over-ground walking has yet to be established. Two gait analysis sessions on 20 healthy adults were conducted. During both sessions, participants performed natural over-ground walking in a motion capture laboratory and on a 100 m linear section of outdoor athletics track. FPA was measured in the laboratory via marker trajectory data, while the sensor module measured FPA during the outdoor track walking. Validity was examined by comparing the laboratory- and sensor-measured average FPA. Day-to-day reliability was examined by comparing the sensor-measured FPA between the first and second gait analysis sessions. Average absolute error between motion capture and sensor measured FPA were 1.7° and 2.1° at session 1 and 2, respectively. A Bland and Altman plot indicated no systematic bias, with 95% limit of agreement widths of 4.2° - 5.1°. Intraclass correlation coefficient (ICC) analysis resulted in good to excellent validity (ICC = 0.89 - 0.91) and reliability (ICC = 0.95). Overall, the shoe-embedded sensor module is a valid and reliable method of measuring FPA during over-ground walking without the need for laboratory equipment.
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http://dx.doi.org/10.1016/j.jbiomech.2019.04.012DOI Listing
May 2019

Challenging Standing Balance Reduces the Asymmetry of Motor Control of Postural Sway Poststroke.

Motor Control 2019 Jul 1;23(3):327-343. Epub 2019 Jan 1.

1 University of British Columbia.

Ankle plantarflexor muscle impairment contributes to asymmetrical postural control poststroke. This study examines the relationship of plantarflexor electromyography (EMG) with anterior-posterior center of pressure (APCOP) in people poststroke during progressive challenges to standing balance. Ten people poststroke and 10 controls participated in this study. Anteriorly directed loads of 1% body mass (BM) were applied to the pelvis every 25-40 s until 5%BM was reached. Cross-correlation values between plantarflexor EMG and APCOP (EMG:APCOP) position and velocity were compared. EMG:APCOP velocity correlations were stronger than EMG:APCOP position across all muscles ( < .01), and correlations were predominately stronger in the nonparetic compared with the paretic leg ( < .05). Increasing challenge to standing balance reduced asymmetry of EMG:APCOP relationships. These data suggest that sensory information reflected in APCOP velocity interacts more strongly with plantarflexor activity in people poststroke and controls than APCOP position. Furthermore, increasing challenge to standing balance reduces postural control asymmetry between legs poststroke.
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http://dx.doi.org/10.1123/mc.2017-0098DOI Listing
July 2019

Real-Time Biofeedback of Performance to Reduce Braking Forces Associated With Running-Related Injury: An Exploratory Study.

J Orthop Sports Phys Ther 2019 Mar 7;49(3):136-144. Epub 2018 Dec 7.

Background: The high rate of running-related injury may be associated with increased peak braking forces (PBFs) and vertical loading rates. Gait retraining has been suggested by some experts to be an effective method to reduce loading parameters.

Objectives: To investigate whether PBF could be decreased following an 8-session gait retraining program among a group of female recreational runners and which self-selected kinematic strategies could achieve this decrease.

Methods: In this exploratory study, 12 female recreational runners with high PBFs (greater than 0.27 body weight) completed an 8-session gait retraining program with real-time biofeedback of braking forces over the course of a half-marathon training program. Baseline and follow-up kinetics and kinematics were analyzed with a repeated-measures analysis of variance.

Results: There was an average reduction of 15% in PBF (-0.04 body weight; 95% confidence interval [CI]: -0.07, -0.02 body weight; P = .001; effect size, 0.62), accompanied by a 7% increase in step frequency (11.3 steps per minute; 95% CI: 1.8, 20.9 steps per minute; P = .024; effect size, 0.38) and a 6% decrease in step length (-5.5 cm; 95% CI: -9.9, -1.0 cm; P = .020; effect size, 0.40), from baseline to follow-up.

Conclusion: The gait retraining program significantly reduced the PBF among a group of female recreational runners. This was achieved through a combination of increased step frequency and decreased step length. Furthermore, the modified gait pattern was incorporated into the runners' natural gait pattern by the completion of the program. Based on these results, the outlined gait retraining program should be further investigated to assess whether it may be an effective injury prevention strategy for recreational runners. This study was registered with ClinicalTrials.gov (NCT03302975).

Level Of Evidence: Prevention, level 4. J Orthop Sports Phys Ther 2019;49(3):136-144. Epub 7 Dec 2018. doi:10.2519/jospt.2019.8587.
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http://dx.doi.org/10.2519/jospt.2019.8587DOI Listing
March 2019

Kinematic Correlates of Kinetic Outcomes Associated With Running-Related Injury.

J Appl Biomech 2019 Apr 30;35(2):123-130. Epub 2019 Jan 30.

1 The University of British Columbia.

High magnitudes and rates of loading have been implicated in the etiology of running-related injuries. Knowledge of kinematic variables that are predictive of kinetic outcomes could inform clinic-based gait retraining programs. Healthy novice female runners ran on a treadmill while 3-dimensional biomechanical data were collected. Kinetic outcomes consisted of vertical impact transient, average vertical loading rate, instantaneous vertical loading rate, and peak braking force. Kinematic outcomes included step length), hip flexion angle at initial contact, horizontal distance from heel to center of mass at initial contact, shank angle at initial contact, and foot strike angle. Stepwise multiple linear regression was used to evaluate the amount of variance in kinetic outcomes explained by kinematic outcomes. A moderate amount of variance in kinetic outcomes (vertical impact transient = 46%, average vertical loading rate = 37%, instantaneous vertical loading rate = 49%, peak braking force = 54%) was explained by several discrete kinematic variables-predominantly speed, horizontal distance from heel to center of mass, foot strike angle, and step length. Hip flexion angle and shank angle did not contribute to any models. Decreasing step length and transitioning from a rearfoot strike may reduce kinetic risk factors for running-related injuries. In contrast, clinical strategies such as modifying shank angle and hip flexion angle would not appear to contribute significantly to the variance of kinetic outcomes after accounting for other variables.
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http://dx.doi.org/10.1123/jab.2018-0203DOI Listing
April 2019

Regional Vastus Medialis and Vastus Lateralis Activation in Females with Patellofemoral Pain.

Med Sci Sports Exerc 2019 03;51(3):411-420

Department of Physical Therapy, University of British Columbia, Vancouver, British Columbia, CANADA.

Introduction: This study aimed to investigate whether regional activation patterns in the vasti muscles differ between females with and without patellofemoral pain (PFP), and whether muscle activation patterns correlate with knee extension strength.

Methods: Thirty-six females with PFP and 20 pain-free controls performed a standardized knee flexion-extension task. The activation of vastus medialis (VM) and vastus lateralis (VL) was collected using high-density surface EMG and analyzed using principal component (PC) analysis. Spatial locations and temporal coefficients of the PC, and the percent variance they explain, were compared between groups and between the concentric and the eccentric phases of the movement. Correlations were assessed between PC features and knee extension strength.

Results: The spatial weights of PC1 (general vasti activation) and PC2 (reflecting vastus-specific activation) were similar between groups (R > 0.95). Activation patterns in PFP were less complex than controls. Fewer PC features were necessary to reconstruct 90% of the signal for PFP participants in the concentric phase (P < 0.05), and the difference in bias of activation to VM (concentric phase) or VL (eccentric phase) was less between phases for PFP participants (P < 0.05). Smaller difference in vastus-specific activation in concentric and eccentric phases (less task specificity of VM/VL coordination) was related to greater maximal knee extension strength (P < 0.05, R < -0.43).

Conclusion: These data suggest PFP involves a simpler control strategy of VM and VL. The inverse association between task specificity and maximal knee extension strength suggests different presentations of PFP: lower knee extension strength but VM/VL coordination task specificity comparable with controls, or knee extension strength comparable with controls but lower VM/VL coordination task specificity.
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http://dx.doi.org/10.1249/MSS.0000000000001810DOI Listing
March 2019

What are the perceptions about running and knee joint health among the public and healthcare practitioners in Canada?

PLoS One 2018 1;13(10):e0204872. Epub 2018 Oct 1.

Department of Physical Therapy, Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada.

Objectives: To evaluate the perceptions of the general public and healthcare practitioners (HCP) in Canada about the relationship between running and knee joint health, and to explore HCP`s usual recommendations to runners with knee osteoarthritis (KOA).

Methods: Non-runners and runners (with and without KOA) and HCP completed an online survey regarding the safety of running for knee joint health. HCP also provided information related to usual clinical recommendations. Proportions of agreement were compared between non-runners and runners.

Results: A total of 114 non-runners, 388 runners and 329 HCP completed the survey. Overall, running was perceived as detrimental for the knee joint by 13.1% of the general public, while 25.9% were uncertain. More uncertainty was reported regarding frequent (33.9%) and long-distance (43.6%) running. Statistical analyses revealed greater proportions of non-runners perceiving running negatively compared with runners. Overall, 48.4% believed that running in the presence of KOA would lead to disease progression, while 53.1% believed running would lead to premature arthroplasty. In HCP, 8.2%, 9.1% and 22.2% perceived that running in general, running frequently, or running long-distances are risk factors for KOA, respectively. 37.1% and 2.7% of HCP typically recommended patients with KOA to modify their running training or to quit running, respectively.

Conclusion: High rates of uncertainty among the general public and HCP in Canada outline the need for further studies about running and knee joint health. Filling knowledge gaps will help inform knowledge translation strategies to better orientate the general public and HCP about the safety of running for knee joint health.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0204872PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6166953PMC
March 2019
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