Research Papers

The Feasibility of Using Augmented Auditory Feedback From a Pressure Detecting Insole to Reduce the Knee Adduction Moment: A Proof of Concept Study

[+] Author and Article Information
Christopher Ferrigno

Department of Anatomy and Cell Biology,
Rush University Medical Center,
1611 W. Harrison Street,
Suite 111,
Chicago, IL 60612
e-mail: christopher_ferrigno@rush.edu

Ina S. Stoller

Department of Orthopedic Surgery,
Rush University Medical Center,
1611 W. Harrison Street,
Suite 111,
Chicago, IL 60612
e-mail: ina.stoller@gmx.de

Najia Shakoor

Section of Rheumatology,
Rush University Medical Center,
1611 W. Harrison Street,
Suite 510,
Chicago, IL 60612
e-mail: najia_shakoor@rush.edu

Laura E. Thorp

Department of Anatomy and Cell Biology,
Rush University Medical Center,
600 S. Paulina,
Suite 507,
Chicago, IL 60612
e-mail: laura_thorp@rush.edu

Markus A. Wimmer

Department of Orthopedic Surgery,
Rush University Medical Center,
1611 W. Harrison Street,
Suite 205,
Chicago, IL 60612
e-mail: markus_a_wimmer@rush.edu

1Corresponding author.

Manuscript received July 6, 2015; final manuscript received November 4, 2015; published online January 27, 2016. Editor: Beth A. Winkelstein.

J Biomech Eng 138(2), 021014 (Jan 27, 2016) (7 pages) Paper No: BIO-15-1332; doi: 10.1115/1.4032123 History: Received July 06, 2015; Revised November 04, 2015

The objective of this work was to conduct a proof of concept study utilizing auditory feedback from a pressure-detecting shoe insole to shift plantar pressure medially in order to reduce the knee adduction moment (KAM). When compared with normal walking, 32 healthy subjects significantly reduced their peak KAM using feedback (p < 0.001). When compared with medial thrust gait, an established gait modification, walking with pressure-based feedback was equally effective at reducing the peak KAM, yet it successfully mitigated other potentially detrimental gait measures such as the peak knee flexion moment (KFM), knee internal rotation moment (KIrM), and a reduction in speed.

Copyright © 2016 by ASME
Topics: Pressure , Thrust , Feedback , Knee
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Brault, M. W. , Hootman, J. M. , Helmick, C. G. , Theis, K. A. , and Armour, B. S. , 2009, “ Prevalence and Most Common Causes of Disability Among Adults—United States, 2005,” Morb. Mortal. Wkly. Rep., 58, pp. 421–426.
Ahlbäck, S. , 1968, “ Osteoarthrosis of the Knee. A Radiographic Investigation,” Acta Radiol. Diagn. (Stockh), 277(Suppl.), pp. 7–72.
Schipplein, O. D. , and Andriacchi, T. P. , 1991, “ Interaction Between Active and Passive Knee Stabilizers During Level Walking,” J. Orthop. Res., 9(1), pp. 113–119. [CrossRef] [PubMed]
Kutzner, I. , Trepczynski, A. , Heller, M. O. , and Bergmann, G. , 2013, “ Knee Adduction Moment and Medial Contact Force—Facts About Their Correlation During Gait,” PLoS ONE, 8(12), p. e81036. [CrossRef] [PubMed]
Mündermann, A. , Asay, J. L. , Mündermann, L. , and Andriacchi, T. P. , 2008, “ Implications of Increased Medio-Lateral Trunk Sway for Ambulatory Mechanics,” J. Biomech., 41(1), pp. 165–170. [CrossRef] [PubMed]
Shull, P. B. , Silder, A. , Shultz, R. , Dragoo, J. L. , Besier, T. F. , Delp, S. L. , and Cutkosky, M. R. , 2013, “ Six-Week Gait Retraining Program Reduces Knee Adduction Moment, Reduces Pain, and Improves Function for Individuals With Medial Compartment Knee Osteoarthritis,” J. Orthop. Res., 31(7), pp. 1020–1025. [CrossRef] [PubMed]
Chang, A. , Hurwitz, D. , Dunlop, D. , Song, J. , Cahue, S. , Hayes, K. , and Sharma, L. , 2007, “ The Relationship Between Toe-Out Angle During Gait and Progression of Medial Tibiofemoral Osteoarthritis,” Ann. Rheum. Dis., 66(10), pp. 1271–1275. [CrossRef] [PubMed]
Fregly, B. J. , Reinbolt, J. A. , Rooney, K. L. , Mitchell, K. H. , and Chmielewski, T. L. , 2007, “ Design of Patient-Specific Gait Modifications for Knee Osteoarthritis Rehabilitation,” IEEE Trans. Biomed. Eng., 54(9), pp. 1687–1695. [CrossRef] [PubMed]
Schache, A. G. , Fregly, B. J. , Crossley, K. M. , Hinman, R. S. , and Pandy, M. G. , 2008, “ The Effect of Gait Modification on the External Knee Adduction Moment is Reference Frame Dependent,” Clin. Biomech., 23(5), pp. 601–608. [CrossRef]
Walter, J. P. , D'Lima, D. D. , Colwell, C. W., Jr. , and Fregly, B. J. , 2010, “ Decreased Knee Adduction Moment Does Not Guarantee Decreased Medial Contact Force During Gait,” J. Orthop. Res., 28(10), pp. 1348–1354. [CrossRef] [PubMed]
Gerbrands, T. A. , Pisters, M. F. , and Vanwanseele, B. , 2014, “ Individual Selection of Gait Retraining Strategies is Essential to Optimally Reduce Medial Knee Load During Gait,” Clin. Biomech., 29(7), pp. 828–834. [CrossRef]
Barrios, J. A. , Crossley, K. M. , and Davis, I. S. , 2010, “ Gait Retraining to Reduce the Knee Adduction Moment Through Real-Time Visual Feedback of Dynamic Knee Alignment,” J. Biomech., 43(11), pp. 2208–2213. [CrossRef] [PubMed]
Simic, M. , Hunt, M. A. , Bennell, K. L. , Hinman, R. S. , and Wrigley, T. V. , 2012, “ Trunk Lean Gait Modification and Knee Joint Load in People With Medial Knee Osteoarthritis: The Effect of Varying Trunk Lean Angles,” Arthritis Care Res., 64(10), pp. 1545–1553. [CrossRef]
Cochrane, C. K. , Takacs, J. , and Hunt, M. A. , 2014, “ Biomechanical Mechanisms of Toe-Out Gait Performance in People With and Without Knee Osteoarthritis,” Clin. Biomech., 29(1), pp. 83–86. [CrossRef]
Simic, M. , Wrigley, T. V. , Hinman, R. S. , Hunt, M. A. , and Bennell, K. L. , 2013, “ Altering Foot Progression Angle in People With Medial Knee Osteoarthritis: The Effects of Varying Toe-In and Toe-Out Angles are Mediated by Pain and Malalignment,” Osteoarthritis Cartilage, 21(9), pp. 1272–1280. [CrossRef] [PubMed]
Manal, K. , Gardinier, E. , Buchanan, T. S. , and Snyder-Mackler, L. , 2015, “ A More Informed Evaluation of Medial Compartment Loading: The Combined Use of the Knee Adduction and Flexor Moments,” Osteoarthritis Cartilage, 23(7), pp. 1107–1111. [CrossRef] [PubMed]
Chehab, E. F. , Favre, J. , Erhart-Hledik, J. C. , and Andriacchi, T. P. , 2014, “ Baseline Knee Adduction and Flexion Moments During Walking are Both Associated With 5 Year Cartilage Changes in Patients With Medial Knee Osteoarthritis,” Osteoarthritis Cartilage, 22(11), pp. 1833–1839. [CrossRef] [PubMed]
Studenski, S. , Perera, S. , Patel, K. , Rosano, C. , Faulkner, K. , Inzitari, M. , Brach, J. , Chandler, J. , Cawthon, P. , Connor, E. B. , Nevitt, M. , Visser, M. , Kritchevsky, S. , Badinelli, S. , Harris, T. , Newman, A. B. , Cauley, J. , Ferrucci, L. , and Guralnik, J. , 2011, “ Gait Speed and Survival in Older Adults,” J. Am. Med. Assoc., 305(1), pp. 50–58. [CrossRef]
Simic, M. , Hinman, R. S. , Wrigley, T. V. , Bennell, K. L. , and Hunt, M. A. , 2011, “ Gait Modification Strategies for Altering Medial Knee Joint Load: A Systematic Review,” Arthritis Care Res., 63, pp. 405–426.
Levinger, P. , Menz, H. B. , Morrow, A. D. , Bartlett, J. R. , Feller, J. A. , and Bergman, N. R. , 2013, “ Relationship Between Foot Function and Medial Knee Joint Loading in People With Medial Compartment Knee Osteoarthritis,” J. Foot Ankle Res., 6(1), p. 33. [CrossRef] [PubMed]
Kerrigan, D. C. , Lelas, J. L. , Goggins, J. , Merriman, G. J. , Kaplan, R. J. , and Felson, D. T. , 2002, “ Effectiveness of a Lateral-Wedge Insole on Knee Varus Torque in Patients With Knee Osteoarthritis,” Arch. Phys. Med. Rehabil., 83(7), pp. 889–893. [CrossRef] [PubMed]
Hinman, R. S. , Bowles, K. A. , Payne, C. , and Bennell, K. L. , 2008, “ Effect of Length on Laterally-Wedged Insoles in Knee Osteoarthritis,” Arthritis Care Res., 59(1), pp. 144–147. [CrossRef]
Hinman, R. S. , Bowles, K. A. , Metcalf, B. B. , Wrigley, T. V. , and Bennell, K. L. , 2012, “ Lateral Wedge Insoles for Medial Knee Osteoarthritis: Effects on Lower Limb Frontal Plane Biomechanics,” Clin. Biomech., 27(1), pp. 27–33. [CrossRef]
Erhart, J. C. , Mündermann, A. , Elspas, B. , Giori, N. J. , and Andriacchi, T. P. , 2010, “ Changes in Knee Adduction Moment, Pain, and Functionality With a Variable-Stiffness Walking Shoe After 6 Months,” J. Orthop. Res., 28(7), pp. 873–879. [CrossRef] [PubMed]
Jenkyn, T. R. , Erhart, J. C. , and Andriacchi, T. P. , 2011, “ An Analysis of the Mechanisms for Reducing the Knee Adduction Moment During Walking Using a Variable Stiffness Shoe in Subjects With Knee Osteoarthritis,” J. Biomech., 44(7), pp. 1271–1276. [CrossRef] [PubMed]
Boyer, K. A. , Federolf, P. , Lin, C. , Nigg, B. M. , and Andriacchi, T. P. , 2012, “ Kinematic Adaptations to a Variable Stiffness Shoe: Mechanisms for Reducing Joint Loading,” J. Biomech., 45(9), pp. 1619–1624. [CrossRef] [PubMed]
Shakoor, N. , Lidtke, R. H. , Sengupta, M. , Fogg, L. F. , and Block, J. A. , 2008, “ Effects of Specialized Footwear on Joint Loads in Osteoarthritis of the Knee,” Arthritis Rheum., 59(9), pp. 1214–1220. [CrossRef] [PubMed]
Shakoor, N. , Lidtke, R. H. , Wimmer, M. A. , Mikolaitis, R. A. , Foucher, K. C. , Thorp, L. E. , Fogg, L. F. , and Block, J. A. , 2013, “ Improvement in Knee Loading After Use of Specialized Footwear for Knee Osteoarthritis,” Arthritis Rheum., 65(5), pp. 1282–1289. [CrossRef] [PubMed]
Ferrigno, C. , Thorp, L. E. , Shakoor, N. , and Wimmer, M. A. , 2014, “ Center of Plantar Pressure Can Predict Changes in Tibiofemoral Contact Load,” Osteoarthritis Cartilage, 22(Suppl.), pp. S92–S93. [CrossRef]
Ferrigno, C. , Wimmer, M. A. , Thorp, L. E. , Block, J. A. , Lidtke, R. H. , and Shakoor, N. , 2015, “ Medializing Foot Center of Pressure With Flexible Shoes is Associated With a Medial Knee Load Reduction in Knee Osteoarthritis,” Osteoarthritis Cartilage, 23(Suppl. 2), pp. A98–A99. [CrossRef]
Dowling, A. V. , Fisher, D. S. , and Andriacchi, T. P. , 2010, “ Gait Modification Via Verbal Instruction and an Active Feedback System to Reduce Peak Knee Adduction Moment,” ASME J. Biomech. Eng., 132(7), p. 071007. [CrossRef]
Schmidt, R. A. , and Lee, T. , 2011, Motor Control and Learning: A Behavioral Emphasis, Human Kinetics, Champaign, IL.
Wheeler, J. W. , Shull, P. B. , and Besier, T. F. , 2011, “ Real-Time Knee Adduction Moment Feedback for Gait Retraining Through Visual and Tactile Displays,” ASME J. Biomech. Eng., 133(4), p. 041007. [CrossRef]
Shull, P. B. , Lurie, K. L. , Cutkosky, M. R. , and Besier, T. F. , 2011, “ Training Multi-Parameter Gaits to Reduce the Knee Adduction Moment With Data-Driven Models and Haptic Feedback,” J. Biomech., 44(8), pp. 1605–1609. [CrossRef] [PubMed]
Fregly, B. J. , D'Lima, D. D. , and Colwell, C. W., Jr. , 2009, “ Effective Gait Patterns for Offloading the Medial Compartment of the Knee,” J. Orthop. Res., 27(8), pp. 1016–1021. [CrossRef] [PubMed]
Fregly, B. J. , Rooney, K. L. , and Reinbolt, J. A. , 2005, “ Predicted Gait Modifications to Reduce the Peak Knee Adduction Torque,” ISB XXth Congress—ASB 29th Annual Meeting, Cleveland, OH, July 30–Aug. 5, p. 283.
Kadaba, M. P. , Ramakrishnan, H. K. , and Wootten, M. E. , 1990, “ Measurement of Lower Extremity Kinematics During Level Walking,” J. Orthop. Res., 8(3), pp. 383–392. [CrossRef] [PubMed]
Andriacchi, T. , Natarajan, R. , and Hurwitz, D. , 2005, Musculo-Skeletal Dynamic Locomotion and Clinical Applications, Lippincott, Philadelphia, PA.
Andriacchi, T. , and Strickland, A. , 1985, “ Gait Analysis as a Tool to Assess Joint Kinetics,” Biomechanics of Normal and Pathological Human Articulating Joints, E. Berme , A. Engin , and K. M., Correia da Silva , Eds. Martiuns Nijhoff, Doordrecht, p. 83.
McPoil, T. G. , Cornwall, M. W. , and Yamada, W. , 1995, “ A Comparison of Two In-Shoe Plantar Pressure Measurement Systems,” Lower Extremity, 2, pp. 95–103.
Putti, A. B. , Arnold, G. P. , Cochrane, L. , and Abboud, R. J. , 2007, “ The Pedar® In-Shoe System: Repeatability and Normal Pressure Values,” Gait Posture, 25(3), pp. 401–405. [CrossRef] [PubMed]
Favre, J. , Erhart-Hledik, J. C. , and Andriacchi, T. P. , 2014, “ Age-Related Differences in Sagittal-Plane Knee Function at Heel-Strike of Walking are Increased in Osteoarthritic Patients,” Osteoarthritis Cartilage, 22(3), pp. 464–471. [CrossRef] [PubMed]
Robbins, S. M. K. , and Maly, M. R. , 2009, “ The Effect of Gait Speed on the Knee Adduction Moment Depends on Waveform Summary Measures,” Gait Posture, 30(4), pp. 543–546. [CrossRef] [PubMed]
Mündermann, A. , Dyrby, C. O. , Hurwitz, D. E. , Sharma, L. , and Andriacchi, T. P. , 2004, “ Potential Strategies to Reduce Medial Compartment Loading in Patients With Knee Osteoarthritis of Varying Severity: Reduced Walking Speed,” Arthritis Rheum., 50(4), pp. 1172–1178. [CrossRef] [PubMed]
Zeni, J. A., Jr. , and Higginson, J. S. , 2009, “ Differences in Gait Parameters Between Healthy Subjects and Persons With Moderate and Severe Knee Osteoarthritis: A Result of Altered Walking Speed?” Clin. Biomech., 24(4), pp. 372–378. [CrossRef]
Myer, G. D. , Ford, K. R. , Barber, K. D. , Foss , Goodman, A. , Ceasar, A. , Rauh, M. J. , Divine, J. G. , and Hewett, T. E. , 2010, “ The Incidence and Potential Pathomechanics of Patellofemoral Pain in Female Athletes,” Clin. Biomech., 25(7), pp. 700–707. [CrossRef]
Hewett, T. E. , Myer, G. D. , Ford, K. R. , Heidt, R. S., Jr. , Colosimo, A. J. , McLean, S. G. , Van Den Bogert, A. J. , Paterno, M. V. , and Succop, P. , 2005, “ Biomechanical Measures of Neuromuscular Control and Valgus Loading of the Knee Predict Anterior Cruciate Ligament Injury Risk in Female Athletes: A Prospective Study,” Am. J. Sports Med., 33(4), pp. 492–501. [CrossRef] [PubMed]
Kean, C. O. , Bennell, K. L. , Wrigley, T. V. , and Hinman, R. S. , 2013, “ Modified Walking Shoes for Knee Osteoarthritis: Mechanisms for Reductions in the Knee Adduction Moment,” J. Biomech., 46(12), pp. 2060–2066. [CrossRef] [PubMed]
Lynn, S. K. , Kajaks, T. , and Costigan, P. A. , 2008, “ The Effect of Internal and External Foot Rotation on the Adduction Moment and Lateral–Medial Shear Force at the Knee During Gait,” J. Sci. Med. Sport, 11(5), pp. 444–451. [CrossRef] [PubMed]
Guo, M. , Axe, M. J. , and Manal, K. , 2007, “ The Influence of Foot Progression Angle on the Knee Adduction Moment During Walking and Stair Climbing in Pain Free Individuals With Knee Osteoarthritis,” Gait Posture, 26(3), pp. 436–441. [CrossRef] [PubMed]
Hunt, M. A. , and Takacs, J. , 2014, “ Effects of a 10-Week Toe-Out Gait Modification Intervention in People With Medial Knee Osteoarthritis: A Pilot, Feasibility Study,” Osteoarthritis Cartilage, 22(7), pp. 904–911. [CrossRef] [PubMed]
Rothman, M. D. , Leo-Summers, L. , and Gill, T. M. , 2008, “ Prognostic Significance of Potential Frailty Criteria,” J. Am. Geriatr. Soc., 56(12), pp. 2211–2216. [CrossRef] [PubMed]
Vermeulen, J. , Neyens, J. C. , Van Rossum, E. , Spreeuwenberg, M. D. , and De Witte, L. P. , 2011, “ Predicting ADL Disability in Community-Dwelling Elderly People Using Physical Frailty Indicators: A Systematic Review,” BMC Geriatr., 11(1), p. 33. [CrossRef] [PubMed]
Fried, L. P. , Tangen, C. M. , Walston, J. , Newman, A. B. , Hirsch, C. , Gottdiener, J. , Seeman, T. , Tracy, R. , Kop, W. J. , Burke, G. , and McBurnie, M. A. , 2001, “ Frailty in Older Adults: Evidence for a Phenotype,” J. Gerontol. Ser. A Biol. Sci. Med. Sci., 56(3), pp. M146–M156. [CrossRef]
Russell, E. M. , Braun, B. , and Hamill, J. , 2010, “ Does Stride Length Influence Metabolic Cost and Biomechanical Risk Factors for Knee Osteoarthritis in Obese Women?” Clin. Biomech., 25(5), pp. 438–443. [CrossRef]
Caldwell, L. K. , Laubach, L. L. , and Barrios, J. A. , 2013, “ Effect of Specific Gait Modifications on Medial Knee Loading, Metabolic Cost and Perception of Task Difficulty,” Clin. Biomech., 28(6), pp. 649–654. [CrossRef]
Shull, P. B. , Shultz, R. , Silder, A. , Dragoo, J. L. , Besier, T. F. , Cutkosky, M. R. , and Delp, S. L. , 2013, “ Toe-in Gait Reduces the First Peak Knee Adduction Moment in Patients With Medial Compartment Knee Osteoarthritis,” J. Biomech., 46(1), pp. 122–128. [CrossRef] [PubMed]
Winstein, C. J. , 1991, “ Knowledge of Results and Motor Learning—Implications for Physical Therapy,” Phys. Ther., 71, pp. 140–149. [PubMed]
Haibach, P. , Reid, G. , and Collier, D. , 2011, Motor Learning and Development, Human Kinetics, Champaign, IL.


Grahic Jump Location
Fig. 3

Pressure-based feedback regions

Grahic Jump Location
Fig. 2

Typical subject walking with pressure-based feedback (left) and medial thrust gait (right)

Grahic Jump Location
Fig. 4

The average amount of change, compared with normal walking, when subjects walked with medial thrust gait and pressure-based feedback in the (a) external KAM during early stance (KAM1) and late stance (KAM2), (b) in the other five external knee moments, and (c) the percent change in walking speed, stride length, and cadence

Grahic Jump Location
Fig. 5

The average KAM and KFM waveform for all three walking conditions. The shaded region represents one standard deviation of the normal walking condition only.



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