Gait alteration strategies for knee osteoarthritis: a comparison of joint loading via generic and patient-specific musculoskeletal model scaling techniques

Musculoskeletal model predictions sensitivity to upper body mass scaling during gait

Musculoskeletal modeling based on inverse dynamics provides a cost-effective non-invasive means for calculating intersegmental joint reaction forces and moments, solely relying on kinematic data, easily obtained from smart wearables. On the other hand, the accuracy and precision of such models strongly hinge upon the selected scaling methodology tailored to subject-specific data. This study investigates the impact of upper body mass distribution on internal and external kinetics computed using a comprehensive musculoskeletal model during level walking in both normal weight and obese individuals. Human motion data was collected using seventeen body worn inertial measuring units for nineteen (19) healthy subjects. The results indicate that variations in segmental masses and centers of mass, resulting from diverse mass scaling techniques, significantly affect ground reaction force estimations in obese subjects, particularly in the vertical component, with a root mean square error (RMSE) of 54.7 ± 23.8 %BW; followed by 12.3 ± 8.0 %BW (medio-lateral); and 6.2 ± 3.2 %BW (antero-posterior). The vertical component of hip, knee, and ankle joint reaction forces also exhibit sensitivity to personalized mass distribution variations. Importantly, the degree of deviation in model predictions increases with body mass index. Statistical analysis using single sample Wilcoxon-Signed Rank test for non-normal data and t-test for normal data, revealed significant differences (p < 0.05) in the computed errors in kinetic parameters between the two scaling approaches. The body shape-based scaling approach significantly impacts musculoskeletal modeling in clinical applications where the upper body mass distribution is crucial, such as in spinal deformities, obesity, and low back pain. This approach accounts for the body shape inherent variability within the same BMI category and enhances the predicted joint kinetics.

Effects of gait modifications on tissue-level knee mechanics in individuals with medial tibiofemoral osteoarthritis: A proof-of-concept study towards personalized interventions

Gait modification is a common nonsurgical approach to alter the mediolateral distribution of knee contact forces, intending to decelerate or postpone the progression of mechanically induced knee osteoarthritis (KOA). Nevertheless, the success rate of these approaches is controversial, with no studies conducted to assess alterations in tissue-level knee mechanics governing cartilage degradation response in KOA patients undertaking gait modifications. Thus, here we investigated the effect of different conventional gait conditions and modifications on tissue-level knee mechanics previously suggested as indicators of collagen network damage, cell death, and loss of proteoglycans in knee cartilage. Five participants with medial KOA were recruited and musculoskeletal finite element analyses were conducted to estimate subject-specific tissue mechanics of knee cartilages during two gait conditions (i.e., barefoot and shod) and six gait modifications (i.e., 0°, 5°, and 10° lateral wedge insoles, toe-in, toe-out, and wide stance). Based on our results, the optimal gait modification varied across the participants. Overall, toe-in, toe-out, and wide stance showed the greatest reduction in tissue mechanics within medial tibial and femoral cartilages. Gait modifications could effectually alter maximum principal stress (~20 ± 7%) and shear strain (~9 ± 4%) within the medial tibial cartilage. Nevertheless, lateral wedge insoles did not reduce joint- and tissue-level mechanics considerably. Significance: This proof-of-concept study emphasizes the importance of the personalized design of gait modifications to account for biomechanical risk factors associated with cartilage degradation.

Towards Tailored Rehabilitation by Implementation of a Novel Musculoskeletal Finite Element Analysis Pipeline

Tissue-level mechanics (e.g., stress and strain) are important factors governing tissue remodeling and development of knee osteoarthritis (KOA), and hence, the success of physical rehabilitation. To date, no clinically feasible analysis toolbox has been introduced and used to inform clinical decision making with subject-specific in-depth joint mechanics of different activities. Herein, we utilized a rapid state-of-the-art electromyography-assisted musculoskeletal finite element analysis toolbox with fibril-reinforced poro(visco)elastic cartilages and menisci to investigate knee mechanics in different activities. Tissue mechanical responses, believed to govern collagen damage, cell death, and fixed charge density loss of proteoglycans, were characterized within 15 patients with KOA while various daily activities and rehabilitation exercises were performed. Results showed more inter-participant variation in joint mechanics during rehabilitation exercises compared to daily activities. Accordingly, the devised workflow may be used for designing subject-specific rehabilitation protocols. Further, results showed the potential to tailor rehabilitation exercises, or assess capacity for daily activity modifications, to optimally load knee tissue, especially when mechanically-induced cartilage degeneration and adaptation are of interest.

An EMG-assisted muscle-force driven finite element analysis pipeline to investigate joint- and tissue-level mechanical responses in functional activities: towards a rapid assessment toolbox

Joint tissue mechanics (e.g., stress and strain) are believed to have a major involvement in the onset and progression of musculoskeletal disorders, e.g., knee osteoarthritis (KOA). Accordingly, considerable efforts have been made to develop musculoskeletal finite element (MS-FE) models to estimate highly detailed tissue mechanics that predict cartilage degeneration. However, creating such models is time-consuming and requires advanced expertise. This limits these complex, yet promising MS-FE models to research applications with few participants and makes the models impractical for clinical assessments. Also, these previously developed MS-FE models have not been used to assess activities other than gait. This study introduces and verifies a semi-automated rapid state-of-the-art MS-FE modeling and simulation toolbox incorporating an electromyography- (EMG) assisted MS model and a muscle-force driven FE model of the knee with fibril-reinforced poro(visco)elastic cartilages and menisci. To showcase the usability of the pipeline, we estimated joint- and tissue-level knee mechanics in 15 KOA individuals performing different daily activities. The pipeline was verified by comparing the estimated muscle activations and joint mechanics to existing experimental data. To determine the importance of EMG-assisted MS approach, results were compared to those from the same FE models but driven by static-optimization-based MS models. The EMG-assisted MS-FE pipeline bore a closer resemblance to experiments compared to the static-optimization-based MS-FE pipeline. Importantly, the developed pipeline showed great potential as a rapid MS-FE analysis toolbox to investigate multiscale knee mechanics during different activities of individuals with KOA. The template FE model of the study is freely available here.

Freedom in Osteoarthritis of the Knee

The first peak of the external knee abduction moment (KAM) is often used as a surrogate measure of the medial compartment loading and has been correlated with pain and progression of knee osteoarthritis (OA). As a result, reducing the KAM is often the target of conservative interventions. OA should be considered as a “Whole Person” disease, including ecological psychosocial aspects. Scientists have developed gait alteration strategies to reduce the KAM. They attempted to force into a new position any particular part without reference to the pattern of the whole. We propose an alternative approach: in the vicinity of a special configuration of the knee, some or all of the components of the knee become overloaded. This study has shown that when six lines $1′,$2′,$3′,$4′,$5′,$6′ are so situated that forces acting along them equilibrate when applied to one degree of freedom, 1° F knee, a certain determinant vanishes. We wish to define the six lines as the knee complex in involution by virtue of some constraint upon the knee.

A review of musculoskeletal modelling of human locomotion

Locomotion through the environment is important because movement provides access to key resources, including food, shelter and mates. Central to many locomotion-focused questions is the need to understand internal forces, particularly muscle forces and joint reactions. Musculoskeletal modelling, which typically harnesses the power of inverse dynamics, unites experimental data that are collected on living subjects with virtual models of their morphology. The inputs required for producing good musculoskeletal models include body geometry, muscle parameters, motion variables and ground reaction forces. This methodological approach is critically informed by both biological anthropology, with its focus on variation in human form and function, and mechanical engineering, with a focus on the application of Newtonian mechanics to current problems. Here, we demonstrate the application of a musculoskeletal modelling approach to human walking using the data of a single male subject. Furthermore, we discuss the decisions required to build the model, including how to customize the musculoskeletal model, and suggest cautions that both biological anthropologists and engineers who are interested in this topic should consider.

Muscle forces and the demands of human walking

Reconstructing the locomotor behavior of extinct animals depends on elucidating the principles that link behavior, function, and morphology, which can only be done using extant animals. Within the human lineage, the evolution of bipedalism represents a critical transition, and evaluating fossil hominins depends on understanding the relationship between lower limb forces and skeletal morphology in living humans. As a step toward that goal, here we use a musculoskeletal model to estimate forces in the lower limb muscles of ten individuals during walking. The purpose is to quantify the consistency, timing, and magnitude of these muscle forces during the stance phase of walking. We find that muscles which act to support or propel the body during walking demonstrate the greatest force magnitudes as well as the highest consistency in the shape of force curves among individuals. Muscles that generate moments in the same direction as, or orthogonal to, the ground reaction force show lower forces of greater variability. These data can be used to define the envelope of load cases that need to be examined in order to understand human lower limb skeletal load bearing.

Review of musculoskeletal modelling in a clinical setting: Current use in rehabilitation design, surgical decision making and healthcare interventions

BACKGROUND

Musculoskeletal modelling is a common means by which to non-invasively analyse movement. Such models have largely been used to observe function in both healthy and patient populations. However, utility in a clinical environment is largely unknown. The aim of this review was to explore existing uses of musculoskeletal models as a clinical intervention, or decision-making, tool.

METHODS

A literature search was performed using PubMed and Scopus to find articles published since 2010 and relating to musculoskeletal modelling and joint and muscle forces.

FINDINGS

4662 abstracts were found, of which 39 relevant articles were reviewed. Journal articles were categorised into 5 distinct groups: non-surgical treatment, orthoses assessment, surgical decision making, surgical intervention assessment and rehabilitation regime assessment. All reviewed articles were authored by collaborations between clinicians and engineers/modellers. Current uses included insight into the development of osteoarthritis, identifying candidates for hamstring lengthening surgery, and the assessment of exercise programmes to reduce joint damage.

INTERPRETATION

There is little evidence showing the use of musculoskeletal modelling as a tool for patient care, despite the ability to assess long-term joint loading and muscle overuse during functional activities, as well as clinical decision making to avoid unfavourable treatment outcomes. Continued collaboration between model developers should aim to create clinically-friendly models which can be used with minimal input and experience by healthcare professionals to determine surgical necessity and suitability for rehabilitation regimes, and in the assessment of orthotic devices.