A rehabilitation treadmill with software for providing real-time gait analysis and visual feedback

Review of Real-Time Biomechanical Feedback Systems in Sport and Rehabilitation

Real-time biomechanical feedback (BMF) is a relatively new area of research. The potential of using advanced technology to improve motion skills in sport and accelerate physical rehabilitation has been demonstrated in a number of studies. This paper provides a literature review of BMF systems in sports and rehabilitation. Our motivation was to examine the history of the field to capture its evolution over time, particularly how technologies are used and implemented in BMF systems, and to identify the most recent studies showing novel solutions and remarkable implementations. We searched for papers in three research databases: Scopus, Web of Science, and PubMed. The initial search yielded 1167 unique papers. After a rigorous and challenging exclusion process, 144 papers were eventually included in this report. We focused on papers describing applications and systems that implement a complete real-time feedback loop, which must include the use of sensors, real-time processing, and concurrent feedback. A number of research questions were raised, and the papers were studied and evaluated accordingly. We identified different types of physical activities, sensors, modalities, actuators, communications, settings and end users. A subset of the included papers, showing the most perspectives, was reviewed in depth to highlight and present their innovative research approaches and techniques. Real-time BMF has great potential in many areas. In recent years, sensors have been the main focus of these studies, but new types of processing devices, methods, and algorithms, actuators, and communication technologies and protocols will be explored in more depth in the future. This paper presents a broad insight into the field of BMF.

Investigating the Effect of Real-Time Center of Pressure (CoP) Feedback Training on the Swing Phase of Lower Limb Kinematics in Transfemoral Prostheses with SACH foot

Transfemoral amputee often encounters reduced toe clearance resulting in trip-related falls. Swing phase joint angles have been shown to influence the toe clearance therefore, training intervention that targets shaping the swing phase joint angles can potentially enhance toe clearance. The focus of this study was to investigate the effect of the shift in the location of the center of pressure (CoP) during heel strike on modulation of the swing phase joint angles in able-bodied participants (n=6) and transfemoral amputees (n=3). We first developed a real-time CoP-based visual feedback system such that participants could shift the CoP during treadmill walking. Next, the kinematic data were collected during two different walking sessions- baseline (without feedback) and feedback (shifting the CoP anteriorly/posteriorly at heel strike to match the target CoP location). Primary swing phase joint angle adaptations were observed with feedback such that during the mid-swing phase, posterior CoP shift feedback significantly increases (p<0.05) the average hip and knee flexion angle by 11.55 degrees and 11.86 degrees respectively in amputees, whereas a significant increase (p<0.05) in ankle dorsiflexion, hip and knee flexion angle by 3.60 degrees, 3.22 degrees, and 1.27 degrees respectively compared to baseline was observed in able-bodied participants. Moreover, an opposite kinematic adaptation was seen during anterior CoP shift feedback. Overall, results confirm a direct correlation between the CoP shift and the modulation in the swing phase lower limb joint angles.

Human Gait Analysis Metric for Gait Retraining

The combined gait asymmetry metric (CGAM) provides a method to synthesize human gait motion. The metric is weighted to balance each parameter's effect by normalizing the data so all parameters are more equally weighted. It is designed to combine spatial, temporal, kinematic, and kinetic gait parameter asymmetries. It can also combine subsets of the different gait parameters to provide a more thorough analysis. The single number quantifying gait could assist robotic rehabilitation methods to optimize the resulting gait patterns. CGAM will help define quantitative thresholds for achievable balanced overall gait asymmetry. The study presented here compares the combined gait parameters with clinical measures such as timed up and go (TUG), six-minute walk test (6MWT), and gait velocity. The comparisons are made on gait data collected on individuals with stroke before and after twelve sessions of rehabilitation. Step length, step time, and swing time showed a strong correlation to CGAM, but the double limb support asymmetry has nearly no correlation with CGAM and ground reaction force asymmetry has a weak correlation. The CGAM scores were moderately correlated with TUG and strongly correlated to 6MWT and gait velocity.

Methods for Gait Analysis During Obstacle Avoidance Task

In this study, we present algorithms developed for gait analysis, but suitable for many other signal processing tasks. A novel general-purpose algorithm for extremum estimation of quasi-periodic noisy signals is proposed. This algorithm is both flexible and robust, and allows custom adjustments to detect a predetermined wave pattern while being immune to signal noise and variability. A method for signal segmentation was also developed for analyzing kinematic data recorded while performing on obstacle avoidance task. The segmentation allows detecting preparation and recovery phases related to obstacle avoidance. A simple kernel-based clustering method was used for classification of unsupervised data containing features of steps within the walking trial and discriminating abnormal from regular steps. Moreover, a novel algorithm for missing data approximation and adaptive signal filtering is also presented. This algorithm allows restoring faulty data with high accuracy based on the surrounding information. In addition, a predictive machine learning technique is proposed for supervised multiclass labeling with non-standard label structure.

Gaitography on lower-limb amputees: Repeatability and between-methods agreement

BACKGROUND:

Gaitography is gait parametrization from center-of-pressure trajectories of walking on an instrumented treadmill. Gaitograms may be useful for prosthetic gait analyses, as they can be rapidly and unobtrusively collected over multiple gait cycles without constraining foot placement. However, its reliability must still be established for prosthetic gait.

OBJECTIVES:

To evaluate (a) within-method test-retest repeatability and (b) between-methods agreement for temporal gait events (foot contact, foot off) and gait characteristics (e.g. step times, single-support duration).

STUDY DESIGN:

Cohort study with repeated measurements.

METHODS:

Ten male proficient prosthetic walkers with a unilateral trans-femoral or trans-tibial amputation were equipped with a pressure-insole system and were invited to walk on separate days on an instrumented treadmill.

RESULTS:

We found better between-methods reproducibility than within-method repeatability in temporal gait characteristics. Step times, stride times, and foot-contact events matched well between the two methods. In contrast, insole-based foot-off events were detected one-to-two samples earlier. Likewise, a similar bias was observed for temporal gait characteristics that incorporated foot-off events.

CONCLUSION:

Notwithstanding small systematic biases, the good between-methods agreement indicates that temporal gait characteristics may be determined interchangeably with gaitograms and insoles in persons with a prosthesis. However, the relatively poorer test-retest repeatability hinders longitudinal assessments with either method.

CLINICAL RELEVANCE:

Clinical practice could potentially benefit from gaitography as an efficient, unobtrusive, easy to use, automatized, and patient-friendly means to objectively parametrize prosthetic gait, with immediate availability of test results allowing for prompt clinical decision-making. Temporal gait parameters demonstrate good between-methods agreement, but poorer within-method repeatability hinders detecting prosthetic gait changes.

Characterization and validation of a split belt treadmill for measuring hindlimb ground-reaction forces in able-bodied and spinalized felines

BACKGROUND

The measurement of ground reaction forces (GRFs) in animals trained to locomote on a treadmill after spinal cord injury (SCI) could prove valuable for evaluating training outcomes; however, quantitative measures of the GRFs in spinal felines are limited.

NEW METHOD

A split belt treadmill was designed and constructed to measure the GRFs of feline hindlimbs during stepping. The treadmill consists of two independent treadmill assemblies, each mounted on a force plate. The design allows measurements of the vertical (Fz), fore-aft (Fy) and mediolateral (Fx) ground-reaction forces for both hindlimbs while the forelimbs are resting on a platform.

RESULTS

Static and dynamic noise tests revealed little to no noise at frequencies below 6Hz. Validation of the force plate measurements with a hand-held force sensor force showed good agreement between the two force readings. Peak normalized (to body mass) vertical GRFs for intact cats were 4.89±0.85N/kg for the left hindlimb and 4.79±0.97N/kg for the right. In comparison, trained spinalized cats peak normalized vertical GRFs were 2.20±0.94N/kg for the left hindlimb and 2.85±0.99N/kg for the right.

COMPARISON WITH OTHER EXISTING METHODS

Previous methods of measuring GRFs used stationary single force plates or treadmill mounted to single force plate. Using independent treadmills for each hindlimb allows measurement of the individual hindlimb's GRFs in spinalized cats following body-weight supported treadmill training.

CONCLUSIONS

The split belt force treadmill enables the simultaneous recording of ground-reaction forces for both hindlimbs in cats prior to spinalization, and following spinalization and body-weight-supported treadmill training (BWST).

Gaitography applied to prosthetic walking

During walking on an instrumented treadmill with an embedded force platform or grid of pressure sensors, center-of-pressure (COP) trajectories exhibit a characteristic butterfly-like shape, reflecting the medio-lateral and anterior-posterior weight shifts associated with alternating steps. We define "gaitography" as the analysis of such COP trajectories during walking (the "gaitograms"). It is currently unknown, however, if gaitography can be employed to characterize pathological gait, such as lateralized gait impairments. We therefore registered gaitograms for a heterogeneous sample of persons with a trans-femoral and trans-tibial amputation during treadmill walking at a self-selected comfortable speed. We found that gaitograms directly visualize between-person differences in prosthetic gait in terms of step width and the relative duration of prosthetic and non-prosthetic single-support stance phases. We further demonstrated that one should not only focus on the gaitogram's shape but also on the time evolution along that shape, given that the COP evolves much slower in the single-support phase than in the double-support phase. Finally, commonly used temporal and spatial prosthetic gait characteristics were derived, revealing both individual and systematic differences in prosthetic and non-prosthetic step lengths, step times, swing times, and double-support durations. Because gaitograms can be rapidly collected in an unobtrusive and markerless manner over multiple gait cycles without constraining foot placement, clinical application of gaitography seems both expedient and appealing. Studies examining the repeatability of gaitograms and evaluating gaitography-based gait characteristics against a gold standard with known validity and reliability are required before gaitography can be clinically applied.

Does visual feedback during walking result in similar improvements in trunk control for young and older healthy adults?

BACKGROUND

Most current applications of visual feedback to improve postural control are limited to a fixed base of support and produce mixed results regarding improved postural control and transfer to functional tasks. Currently there are few options available to provide visual feedback regarding trunk motion while walking. We have developed a low cost platform to provide visual feedback of trunk motion during walking. Here we investigated whether augmented visual position feedback would reduce trunk movement variability in both young and older healthy adults.

METHODS

The subjects who participated were 10 young and 10 older adults. Subjects walked on a treadmill under conditions of visual position feedback and no feedback. The visual feedback consisted of anterior-posterior (AP) and medial-lateral (ML) position of the subject's trunk during treadmill walking. Fourier transforms of the AP and ML trunk kinematics were used to calculate power spectral densities which were integrated as frequency bins "below the gait cycle" and "gait cycle and above" for analysis purposes.

RESULTS

Visual feedback reduced movement power at very low frequencies for lumbar and neck translation but not trunk angle in both age groups. At very low frequencies of body movement, older adults had equivalent levels of movement variability with feedback as young adults without feedback. Lower variability was specific to translational (not angular) trunk movement. Visual feedback did not affect any of the measured lower extremity gait pattern characteristics of either group, suggesting that changes were not invoked by a different gait pattern.

CONCLUSIONS

Reduced translational variability while walking on the treadmill reflects more precise control maintaining a central position on the treadmill. Such feedback may provide an important technique to augment rehabilitation to minimize body translation while walking. Individuals with poor balance during walking may benefit from this type of training to enhance path consistency during over-ground locomotion.

Reliability of spatiotemporal and kinetic gait parameters determined by a new instrumented treadmill system

Background

Despite the emerging use of treadmills integrated with pressure platforms as outcome tools in both clinical and research settings, published evidence regarding the measurement properties of these new systems is limited. This study evaluated the within– and between–day repeatability of spatial, temporal and vertical ground reaction force parameters measured by a treadmill system instrumented with a capacitance–based pressure platform.

Methods

Thirty three healthy adults (mean age, 21.5 ± 2.8 years; height, 168.4 ± 9.9 cm; and mass, 67.8 ± 18.6 kg), walked barefoot on a treadmill system (FDM–THM–S, Zebris Medical GmbH) on three separate occasions. For each testing session, participants set their preferred pace but were blinded to treadmill speed. Spatial (foot rotation, step width, stride and step length), temporal (stride and step times, duration of stance, swing and single and double support) and peak vertical ground reaction force variables were collected over a 30–second capture period, equating to an average of 52 ± 5 steps of steady–state walking. Testing was repeated one week following the initial trial and again, for a third time, 20 minutes later. Repeated measures ANOVAs within a generalized linear modelling framework were used to assess between–session differences in gait parameters. Agreement between gait parameters measured within the same day (session 2 and 3) and between days (session 1 and 2; 1 and 3) were evaluated using the 95% repeatability coefficient.

Results

There were statistically significant differences in the majority (14/16) of temporal, spatial and kinetic gait parameters over the three test sessions (P < .01). The minimum change that could be detected with 95% confidence ranged between 3% and 17% for temporal parameters, 14% and 33% for spatial parameters, and 4% and 20% for kinetic parameters between days. Within–day repeatability was similar to that observed between days. Temporal and kinetic gait parameters were typically more consistent than spatial parameters. The 95% repeatability coefficient for vertical force peaks ranged between ± 53 and ± 63 N.

Conclusions

The limits of agreement in spatial parameters and ground reaction forces for the treadmill system encompass previously reported changes with neuromuscular pathology and footwear interventions. These findings provide clinicians and researchers with an indication of the repeatability and sensitivity of the Zebris treadmill system to detect changes in common spatiotemporal gait parameters and vertical ground reaction forces.

Evaluation of a visual feedback system in gait retraining: a pilot study

Abnormal gait pattern of the frontal plane (i.e. Duchenne gait and Trendelenburg gait) may be caused by a variety of diseases. The aim of this pilot study was to evaluate the instantaneous effect of a visual feedback system on frontal plane pelvis and trunk movements in order to use it in patients with THR in subsequent studies. A total of 24 women (45-65 years) were included in the study. According to acute functional impairments the subjects were assigned to the control group (CG, no gait disorders, n=15, age=59±11 years, BMI=27±4) or to the intervention group (IG, n=9, age=61±4, BMI=29±5), respectively. First, in Measurement 1 (M1) kinematic reference values were captured in a standardized clinical gait analysis (MVN, XSens). Afterwards, the influence of a visual real-time feedback on gait pattern was examined while using the feedback system (M2). While there was a significant difference of IG vs. CG in M1 in the mean inclination regarding pelvis and trunk movements, this was not detected in M2. Therefore it is concluded, especially in subjects with abnormal gait pattern, that the visualization leads to an improvement of the movement pattern of pelvis and trunk in the frontal plane while using the device.

Online gait event detection using a large force platform embedded in a treadmill

Gait research and clinical gait training may benefit from movement-dependent event control, that is, technical applications in which events such as obstacle appearance or visual/acoustic cueing are (co)determined online on the basis of current gait properties. A prerequisite for successful gait-dependent event control is accurate online detection of gait events such as foot contact (FC) and foot off (FO). The objective of the present study was to assess the feasibility of online FC and FO detection using a single large force platform embedded in a treadmill. Center-of-pressure, total force output and kinematic data were recorded simultaneously in 12 healthy participants. Online FC and FO estimates and spatial and temporal gait parameters estimated from the force platform data--i.e., center-of-pressure profiles--were compared to offline kinematic counterparts, which served as the gold standard. Good correspondence was achieved between online FC detections using center-of-pressure profiles and those derived offline from kinematic data, whereas FO was detected 31 ms too late. A good relative and absolute agreement was achieved for both spatial and temporal gait parameters, which was improved further by applying more fine-grained FO estimation procedures using characteristic local minima in the total force output time series. These positive results suggest that the proposed system for gait-dependent event control may be successfully implemented in gait research as well as gait interventions in clinical practice.

Testing of a tri-instrumented-treadmill unit for kinetic analysis of locomotion tasks in static and dynamic loading conditions

In this study, we present a multi-treadmill system instrumented with three force platforms capable of measuring vertical and shear ground reaction forces and moments during both walking and running. Linearity, belts speed variations, repeatability of the measures, cross-talk, natural frequency, instrumental noise, moving part induced noise and drift were investigated. The noise due to vibrations and to moving parts was also investigated having a subject walking and running on the treadmill. The linearity test results showed a high linearity of all three treadmill force platforms, and vertical force natural frequency values of 219, 308, 307Hz, obtained for the three force platforms, were considered appropriate for the investigation of walking and running. The instrumental noise did not appear to be a significant source of error. The characteristics of the noise due to vibrations and moving parts changed when in the presence of a subject walking and running on the treadmill. For walking trials, averaging of gait cycles led to a systematic improvement of the signal to noise ratio, particularly for the medio-lateral component of the force. For running trials, even though averaging was not as beneficial as for walking trials, the greater force amplitude led to a better signal to noise ratio value. This instrumented treadmill demonstrated acceptable accuracy and signal to noise ratios for all ground reaction force components such that it can be useful for a variety of research and clinical gait analysis applications.

Inverse dynamics calculations during gait with restricted ground reaction force information from pressure insoles

The number of consecutive strides that can be recorded in measurements of gait have been limited due to the number of force plates and dimensions of the measurement field. In addition, the feet are constrained to land on the force plates. A method to calculate the inverse dynamics from the motion and incomplete information from the ground reaction forces (GRF), vertical component and its application point, is presented and compared to the calculations based on force plate measurements. This method is based on the estimation of the three-dimensional GRF during walking with pressure insoles. RMS errors were lower than 20 W for knee joint power compared to those derived from force plate measurements. The errors were larger during double stance phase due to errors in the application point measured with the insoles. This method, with some technical improvement, could be implemented in new gait analysis protocols measuring several consecutive steps either on a treadmill or over ground, depending on the motion-measurement system, without constraining foot placement.

Determining the centre of pressure during walking and running using an instrumented treadmill

In this paper, a new method of determining spatial and temporal gait parameters by using centre of pressure (CoP) data is presented. A treadmill is used which was developed to overcome limitations of regular methods for the analysis of spatio-temporal gait parameters and ground reaction forces during walking and running. The design of the treadmill is based on the use of force transducers underneath a separate left and right plate, which together form the treadmill walking surface. The results of test procedures and measurements show that accurate recordings of vertical ground reaction force can be obtained. These recordings enable a separate analysis of vertical ground reaction forces during double support phases in walking, and the analysis of changes in the centre of pressure (CoP) position during subsequent foot placements. From the CoP data, temporal gait parameters (e.g. duration of left/right support and swing phases) and spatial gait parameters (i.e. left/right step lengths and widths) can be derived.

Variability of step kinematics in young and older adults

Fall-related injuries are the most common and serious medical problems facing older adults. Recent studies of older adults have focused on the variability of step kinematics and the relationship to falling. The accuracy of step variability estimates is proportional to the number of steps that are collected. The use of an instrumented treadmill allows simultaneous collection of spatial and temporal step kinematics for a large number of continuous steps. The current study was conducted to determine the influence of age, walking velocity and handrail use on the variability of step kinematics using a treadmill protocol. Eighteen young adults (average age: 27.7 +/- 3.3 years) and 12 healthy older adults (average age: 73.4 +/- 2.3 years) were recruited from the community. Temporal and spatial gait parameters were quantified using custom designed software from measurements collected during treadmill walking. The primary independent variables were the variability of step length, step width, and step time. Step width variability of older adults was significantly larger than that of young adults. Walking velocity did not influence step kinematic variability. Handrail usage influenced the variability of step length and step width, but not of step time. The present results, and those of previous studies, point to a consistent relationship between age and step width variability. Since step width variability has been implicated in falls, further research is warranted.

Measuring step kinematic variability on an instrumented treadmill: how many steps are enough?

Variability of step kinematics has been associated with falls by older adults. However, between-study differences with regard to the number of steps used to compute variability have varied by an order of magnitude. If the number of steps used to compute variability is too low there is the potential for a statistically spurious outcome. On the other hand, for subjects with mobility impairments a protocol requiring too many steps to estimate variability imposes an unnecessary burden on the subjects. We have determined the minimum number of steps needed to estimate the variability of spatial and temporal step kinematics. More than 700 steps were collected during level walking on an instrumented treadmill. Accurate estimation of step kinematic variability required at least 400 steps. The increased error in estimating the mean and standard deviations of the step kinematic variables with too few steps can impose an experimental cost with regard to statistical design considerations. The extent to which translation of these results can be made to the variability of spatial and temporal step kinematics collected during over-ground walking awaits further research.

Force treadmill for measuring vertical and horizontal ground reaction forces

We constructed a force treadmill to measure the vertical, horizontal and lateral components of the ground-reaction forces (Fz, Fy, Fx, respectively) and the ground-reaction force moments (Mz, My, Mx), respectively exerted by walking and running humans. The chassis of a custom-built, lightweight (90 kg), mechanically stiff treadmill was supported along its length by a large commercial force platform. The natural frequencies of vibration were >178 Hz for Fz and >87 Hz for Fy, i.e., well above the signal content of these ground-reaction forces. Mechanical tests and comparisons with data obtained from a force platform runway indicated that the force treadmill recorded Fz, Fy, Mx and My ground-reaction forces and moments accurately. Although the lowest natural frequency of vibration was 88 Hz for Fx, the signal-to-noise ratios for Fx and Mz were unacceptable. This device greatly decreases the time and laboratory space required for locomotion experiments and clinical evaluations. The modular design allows for independent use of both treadmill and force platform.