The effect of a soft active back support exosuit on trunk motion and thoracolumbar spine loading during squat and stoop lifts

Back support exosuits aim to reduce tissue demands and thereby risk of injury and pain. However, biomechanical analyses of soft active exosuit designs have been limited. The objective of this study was to evaluate the effect of a soft active back support exosuit on trunk motion and thoracolumbar spine loading in participants performing stoop and squat lifts of 6 and 10 kg crates, using participant-specific musculoskeletal models. The exosuit did not change overall trunk motion but affected lumbo-pelvic motion slightly, and reduced peak compressive and shear vertebral loads at some levels, although shear increased slightly at others. This study indicates that soft active exosuits have limited kinematic effects during lifting, and can reduce spinal loading depending on the vertebral level. These results support the hypothesis that a soft exosuit can assist without limiting trunk movement or negatively impacting skeletal loading and have implications for future design and ergonomic intervention efforts.

Using inertial measurement units to estimate spine joint kinematics and kinetics during walking and running

Optical motion capture (OMC) is considered the best available method for measuring spine kinematics, yet inertial measurement units (IMU) have the potential to collect data outside the laboratory. When combined with musculoskeletal modeling, IMU technology may be used to estimate spinal loads in real-world settings. To date, IMUs have not been validated for estimates of spinal movement and loading during both walking and running. Using OpenSim Thoracolumbar Spine and Ribcage models, we compare IMU and OMC estimates of lumbosacral (L5/S1) and thoracolumbar (T12/L1) joint angles, moments, and reaction forces during gait across six speeds for five participants. For comparisons, time series are ensemble averaged over strides. Comparisons between IMU and OMC ensemble averages have low normalized root mean squared errors (< 0.3 for 81% of comparisons) and high, positive cross-correlations (> 0.5 for 91% of comparisons), suggesting signals are similar in magnitude and trend. As expected, joint moments and reaction forces are higher during running than walking for IMU and OMC. Relative to OMC, IMU overestimates joint moments and underestimates joint reaction forces by 20.9% and 15.7%, respectively. The results suggest using a combination of IMU technology and musculoskeletal modeling is a valid means for estimating spinal movement and loading.

Validity of evaluating spinal kinetics without participant-specific kinematics

Musculoskeletal models are commonly used to estimate in vivo spinal loads under various loading conditions. Typically, participant-specific measured kinematics (PSMK) are coupled with participant-specific models, but obtaining PSMK data can be costly and infeasible in large studies or clinical practice. Thus, we evaluated two alternative methods to estimate spinal loads without PSMK: 1) ensemble average kinematics (EAK) based on kinematics from all participants; and 2) using separately measured individual kinematics (SMIK) from multiple other participants as inputs, then averaging the resulting loads. This study compares the dynamic spine loading patterns and peak loads in older adults performing five lifting tasks using PSMK, EAK and SMIK. Median root mean square errors of EAK and SMIK methods versus PSMK ranged from 18 to 72% body weight for compressive loads and from 2 to 25% body weight for shear loads, with median cross-correlations ranging from 0.931 to 0.991. The root mean square errors and cross-correlations between repeated PSMK trials fell within similar ranges. Compressive peak loads evaluated by EAK and SMIK were not different than PSMK in 12 of 15 cases, while by comparison repeated PSMK trials were not different in 13 of 15 cases. Overall, the resulting spine loading magnitudes and profiles using EAK or SMIK were not notably different than using a PSMK approach, and differences were not greater than between two PSMK trials. Thus, these findings indicate that these approaches may be used to make reasonable estimates of dynamic spinal loading without direct measurement of participant kinematics.

An Exploratory Study of Walking, Listening, and Remembering in Younger and Middle-Aged Adults

PURPOSE

The purpose of this study was to assess how needing to listen and remember information while walking affects speech perception, memory task performance, and gait in younger and middle-aged adults.

METHOD

Four gait parameters (stride duration, step variability, whole-body center of mass acceleration, and mediolateral head acceleration) were measured when younger and middle-aged participants stood or walked on a treadmill while they simultaneously completed a speech-on-speech perception task and a preload memory task, singly and in combination.

RESULTS

Speech perception was significantly poorer for middle-aged than for younger participants. Performance on the speech perception measure did not differ significantly between walking and standing for either group of participants, but the additional cognitive load of the memory task reduced performance on the speech perception task. Memory task performance was significantly poorer when combined with the speech perception task than when measured in isolation for both participant groups, but no further declines were noted when participants were also walking. Mediolateral head acceleration, which has been linked to loss of balance, was significantly greater during multitask trials, as compared to when participants were only walking without being required to listen or remember. Post hoc analysis showed that dual- and multitask influences on mediolateral head acceleration were more prominent for middle-aged than for younger participants. Stride duration was longer in the multitask condition than when participants were only walking.

CONCLUSIONS

Results of this exploratory study indicate that gait may be impacted when individuals (both younger and middle-aged) are listening and remembering while walking. Data also substantiate prior findings of early age-related declines in the perception of speech in the presence of understandable speech maskers.

EMG Validation of a Subject-Specific Thoracolumbar Spine Musculoskeletal Model During Dynamic Activities in Older Adults

Musculoskeletal models can uniquely estimate in vivo demands and injury risk. In this study, we aimed to compare muscle activations from subject-specific thoracolumbar spine OpenSim models with recorded muscle activity from electromyography (EMG) during five dynamic tasks. Specifically, 11 older adults (mean = 65 years, SD = 9) lifted a crate weighted to 10% of their body mass in axial rotation, 2-handed sagittal lift, 1-handed sagittal lift, and lateral bending, and simulated a window opening task. EMG measurements of back and abdominal muscles were directly compared to equivalent model-predicted activity for temporal similarity via maximum absolute normalized cross-correlation (MANCC) coefficients and for magnitude differences via root-mean-square errors (RMSE), across all combinations of participants, dynamic tasks, and muscle groups. We found that across most of the tasks the model reasonably predicted temporal behavior of back extensor muscles (median MANCC = 0.92 ± 0.07) but moderate temporal similarity was observed for abdominal muscles (median MANCC = 0.60 ± 0.20). Activation magnitude was comparable to previous modeling studies, and median RMSE was 0.18 ± 0.08 for back extensor muscles. Overall, these results indicate that our thoracolumbar spine model can be used to estimate subject-specific in vivo muscular activations for these dynamic lifting tasks.

Using static postures to estimate spinal loading during dynamic lifts with participant-specific thoracolumbar musculoskeletal models

Static biomechanical simulations are sometimes used to estimate in vivo kinetic demands because they can be solved efficiently, but this ignores any potential inertial effects. To date, comparisons between static and dynamic analyses of spinal demands have been limited to lumbar joint differences in young males performing sagittal lifts. Here we compare static and dynamic vertebral compressive and shear force estimates during axial, lateral, and sagittal lifting tasks across all thoracic and lumbar vertebrae in older men and women. Participant-specific thoracolumbar full-body musculoskeletal models estimated vertebral forces from recorded kinematics both with and without consideration of dynamic effects, at an identified frame of peak vertebral loading. Static analyses under-predicted dynamic compressive and resultant shear forces, by an average of about 16% for all three lifts across the thoracic and lumbar spine but were highly correlated with dynamic forces (average r² > .95). The study outcomes have the potential to enable standard clinical and occupational estimates using static analyses.

Lower back kinetic demands during induced lower limb gait asymmetries

BACKGROUND

Gait asymmetries are common in many clinical populations (e.g., amputation, injury, or deformities) and are associated with a high incidence of lower back pain. Despite this high incidence, the impact of gait asymmetries on lower back kinetic demands are not well characterized due to experimental limitations in these clinical populations. Therefore, we artificially and safely induced gait asymmetry during walking in healthy able-bodied participants to examine lower back kinetic demands compared to their normal gait.

RESEARCH QUESTION

Are lower back kinetic demands different during artificially induced asymmetries than those during normal gait?

METHODS

L5/S1 vertebral joint kinetics and trunk muscle forces were estimated during gait in twelve healthy men and women with a musculoskeletal lower back model that uniquely incorporated participant-specific responses using an EMG optimization approach. Five walking conditions were conducted on a force-measuring treadmill, including normal unperturbed "symmetrical" gait, and asymmetrical gait induced by unilaterally altering leg mass, leg length, and ankle joint motion in various combinations. Gait symmetry index and lower back kinetics were compared with repeated-measures ANOVAs and post hoc tests (α = .05).

RESULTS

The perturbations were successful in producing different degrees of step length and stance time gait asymmetries (p < .01). However, lower back kinetic demands associated with asymmetrical gait were similar to, or only moderately different from normal walking for most conditions despite the observed asymmetries.

SIGNIFICANCE

Our findings indicate that the high incidence of lower back pain often associated with gait asymmetries may not be a direct effect of increased lower back demands. If biomechanical demands are responsible for the high incidence of lower back pain in such populations, daily tasks besides walking may be responsible and warrant further investigation.

EMG optimization in OpenSim: A model for estimating lower back kinetics in gait

Participant-specific musculoskeletal models are needed to accurately estimate lower back internal kinetic demands and injury risk. In this study we developed the framework for incorporating an electromyography optimization (EMGopt) approach within OpenSim (https://simtk.org/projects/emg_opt_tool) and evaluated lower back demands estimated from the model during gait. Kinematic, external kinetic, and EMG data were recorded from six participants as they performed walking and carrying tasks on a treadmill. For evaluation, predicted lumbar vertebral joint forces were compared to those from a generic static optimization approach (SOpt) and to previous studies. Further, model-estimated muscle activations were compared to recorded EMG, and model sensitivity to day-to-day EMG variability was evaluated. Results showed the vertebral joint forces from the model were qualitatively similar in pattern and magnitude to literature reports. Compared to SOpt, the EMGopt approach predicted larger joint loads (p<.01) with muscle activations better matching individual participant EMG patterns. L5/S1 vertebral joint forces from EMGopt were sensitive to the expected variability of recorded EMG, but the magnitude of these differences (±4%) did not impact between-task comparisons. Despite limitations inherent to such models, the proposed musculoskeletal model and EMGopt approach appears well-suited for evaluating internal lower back demands during gait tasks.

Are lower back demands reduced by improving gait symmetry in unilateral transtibial amputees?

BACKGROUND

Gait asymmetry and a high incidence of lower back pain are typical for people with unilateral lower limb amputation. A common therapeutic objective is to improve gait symmetry; however, it is unknown whether better gait symmetry reduces lower back pain risk. To begin investigating this important clinical question, we examined a preexisting dataset to explore whether L5/S1 vertebral joint forces in people with unilateral lower limb amputation can be improved with better symmetry.

METHODS

L5/S1 compression and resultant shear forces were estimated in each participant with unilateral lower limb amputation (n = 5) with an OpenSim musculoskeletal model during different levels of guided gait asymmetry. The amount of gait asymmetry was defined by bilateral stance times and guided via real-time feedback. A theoretical lowest L5/S1 force was determined from the minimum of a best-fit quadratic curves of L5/S1 forces at levels of guided asymmetry ranging from -10 to +15%. The forces found at the theoretical lowest force and during the 0% asymmetry level were compared to forces at preferred levels of asymmetry and to those from an able-bodied group (n = 5).

FINDINGS

Results indicated that the forces for the people with unilateral lower limb amputation group at the preferred level of asymmetry were not different then at their 0% asymmetry condition, theoretical lowest L5/S1 forces, or the able-bodied group (all p-values > .23).

INTERPRETATION

These preliminary results challenge the premise that restoring symmetric gait in people with unilateral lower limb amputation will reduce risk of lower back pain.

Early aging and postural control while listening and responding

It is not unusual for communication to take place while people are involved in another activity. This paper describes a study that measures the impact of listening while also completing an active postural control task. The focus was on whether the combination of listening and balancing was more detrimental to middle-aged adults than it was to younger adults as age-related changes in both hearing and postural control can occur within this age range. Speech understanding in the presence of noise and speech maskers was measured when participants (n = 15/group) were simply standing still, as well as when they were asked to complete a balancing-with-feedback postural control task, requiring different levels of effort. Performance on the postural control task also was measured in isolation. Results indicated that dual-task costs for postural control were larger when the masker was speech (vs noise) for the middle-aged group but not for the younger group. Dual-task costs in postural control increased with degree of high-frequency hearing loss even when age was controlled. Overall, results suggest that postural control in middle-aged adults can be compromised when individuals are communicating in challenging environments, perhaps reflecting an increased need for cognitive resources to successfully understand messages.

Are psychophysically chosen lifting loads based on joint kinetics?

Tables of maximal acceptable weight limits (MAWL) are used to select safe lifting loads and help reduce workplace injuries. However, their subjective basis provides little information on the underlying load selection rationale, and few studies have examined MAWLs in relation to full-body joint demands. Therefore, link-segment biomechanical modeling was applied for 18 participants during three sagittal 4.3 lifts/minute tasks at chosen MAWL levels. Each lift produced unique kinematics, kinetics, MAWL loads and most highly stressed joints. Lifting from the lowest starting position most heavily challenged the L5/S1 joint, whereas more upright starting postures stressed the shoulder. Lifting loads above and below MAWL level demonstrated consistent joint loading patterns. The normalized peak moments of the highest stressed joint were similar across the lifts at ∼70-75% of the joint maximum. Our results suggest that MAWLs may be chosen based on perception of the most stressed joint for the specific lift.

Stabilisation times after transitions to standing from different working postures

Transitioning to standing after maintaining working postures may result in imbalance and could elicit a fall. The objective of this study was to quantify the magnitude of imbalance using a stabilisation time metric. Forty-five male participants completed three replications of conditions created by one of four working postures (bent at waist, squat, forward kneel, reclined kneel) and three durations within posture. Participants transitioned to quiet standing at a self-selected pace. Stabilisation time, based on changes in centre of pressure velocity, was used to indicate the initiation of steady state while standing. Stabilisation time was significantly affected by static postures but not duration within posture. The largest stabilisation times resulted from transitions initiated from a bent at waist posture. The smallest were associated with the kneeling postures, which were not significantly different from each other. Findings may lead to recommendations for redesign of tasks, particularly in high-risk environments such as construction. Statement of Relevance: Task performance on the jobsite often requires individuals to maintain non-erect postures. This study suggests that working posture affects stabilisation during transition to a standing position. Bending at the waist and squatting resulted in longer stabilisation times, whereas both kneeling postures evaluated resulted in greater imbalance but for a shorter duration.

Using horizontal heel displacement to identify heel strike instants in normal gait

Heel strike instants are an important component of gait analyses, yet accurate detection can be difficult without a force plate. This paper presents two novel techniques for kinematic heel strike instant (kHSI) detection which examined maximal resultant horizontal heel displacement (HHD). Each of these HHD techniques calculates HHD from a selected reference location of either the stance ankle or stance heel to the swing heel. The proposed techniques, along with other previously established techniques, were validated against a 10N force plate threshold. Fifty-four healthy adults walked overground at both normal and fast speeds while wearing athletic shoes. The reported true and absolute errors were as low as 3.2 (4.4) and 5.7 (3.4)ms, respectively, across 8678kHSI when using the stance ankle as a reference, which significantly outperformed (p<0.0001) the established techniques. Gait speed was shown to have a significant effect (p<0.0001) on HHD-determined kHSI, as well as the three other techniques evaluated, highlighting the need for condition-specific identification of kHSI.

Methodological considerations of existing techniques for determining stabilization times following a multi-planar transition

Postural stabilization is required following perturbations or after transitioning to standing. The current research evaluated two available algorithms that utilize within-trial data to quantify standing following multi-planar transitions. Forty-five participants began each trial by assuming a static forward kneeling posture that ended with an auditory signal prompting transition to standing. Data from two force plates was collected at 100Hz for 20s starting with the transition. With one algorithm, using windows of various lengths, stabilization time was defined as when mean center of pressure (CoP) velocity of the current window was less than that for the mean of all subsequent windows. This algorithm produced significantly different stabilization times (1.3-6.9s) depending on the window length. In a second algorithm, a negative exponential mathematical model was fit to data within each trial (R(2)=0.93). This approach was easily implemented and produced results (mean=2.1s) with lower variability (SD=0.9s). Though approaches exist that adequately determine stabilization times in well-constrained uni-planar movements, there are limitations to generalizability. The negative exponential mathematical model evaluated in this study provides a promising method for systematically determining stabilization times for multi-planar movements.

Effects of common working postures on balance control during the stabilisation phase of transitioning to standing

Standing after maintaining working postures may result in imbalance and could elicit a fall. The objective of this study was to assess the magnitude of this imbalance. Forty-five male participants completed three replications of conditions created by four static postures and three durations within posture. Participants transitioned to quiet standing at a self-selected pace. Body segment location and displacement of the centre of pressure (COP) were recorded using a motion capture system and two forceplates, respectively. Balance control measures were calculated during the stabilisation phase. All balance control measures were significantly affected by static posture but not duration within posture. Bending over at waist generally caused the smallest changes in balance control measures, whereas the reclined kneeling posture resulted in the largest. Findings may lead to recommendations for redesign of tasks to reduce the use of certain working postures, particularly in high-risk environments such as construction. STATEMENT OF RELEVANCE: Task performance on the jobsite often requires individuals to maintain non-erect postures. This study suggests that the working posture chosen affects stabilisation during a transition to a standing position. Bending at the waist or squatting seems to have less of an affect on balance control measures, whereas both types of kneeling postures evaluated resulted in greater imbalance.

Balance control during lateral load transfers over a slippery surface

Few studies have measured balance control during manual material handling, and even fewer with environmental cofactors. This study examined the effect of different surface frictions during a stationary manual material handling task. Thirty-six healthy participants completed 180° lateral transfer tasks of a load over high- and low-friction surfaces (μ = 0.86 and μ = 0.16, respectively). Balance measures, stance kinematics and lower extremity muscle activities were measured. Success during the novel slippery surface dichotomised our population, allowing us to investigate beneficial techniques to lateral load transfers over the slippery surface. Stance width reduction by 8 cm and 15° of additional external foot rotation towards the load were used to counter the imbalance created by the slippery surface. There was no clear alteration to lower extremity muscular control to adapt to a slippery surface. Changes in stance seemed to be used successfully to counter a slippery surface during lateral load transfers. STATEMENT OF RELEVANCE: Industries requiring manual material handling where slippery conditions are potentially present have a noticeable increase in injuries. This study suggests stance configuration, more so than any other measure of balance control, differentiates vulnerability to imbalance during material handling over a slippery surface.

The effect of load weight on balance control during lateral box transfers

Few studies have endeavoured to measure balance control during manual material handling. This study examined the effects of load weight during a stationary manual material handling task. In total, 36 healthy participants completed 180° lateral transfer tasks of a loaded (5% of body weight) and an unloaded box. The projection of the centre of mass onto the base of support, as measured via a passive-marker 3-D motion analysis system, was used to quantify balance control. Muscle activities of lower extremity muscles were also measured. When moving the loaded box, individuals ventured ≥ 1 cm closer to the edges of the base of support and increased centre of mass movement up to 14%. In addition, muscle electromyographic activity on both sides of the shank increased. In summary, during loaded configurations, vulnerability to loss of balance was increased and individuals appeared to adapt by increasing co-contraction of the shank muscles suggesting increased ankle stiffness. STATEMENT OF RELEVANCE: Industries requiring manual material handling have a particularly high rate of injuries due to falls. This study suggests that larger load weights during lateral material handling tasks adversely affect balance control and may create a vulnerability to imbalance throughout the entire manoeuvre.

Exposures and physiological responses in power tool operations: fastening vs. unfastening threaded hardware

Powered hand tools have the potential to produce reaction forces that may be associated with upper extremity musculoskeletal disorders. This study examined and compared the kinetic and physiological impacts on operator upper extremities between the fastening and unfastening operations. Thirty-two healthy, right-handed male operators used four tools on two joint simulators at different working heights and distances in the laboratory. Three work configurations were simulated: pistol grip tools on a vertical and horizontal surface, and right angle tools on a horizontal surface. Grip force was measured on an instrumented handle attached to each tool. Muscle activity was monitored at the wrist flexor and extensor and the upper trapezius of the right arm. Paired comparisons showed that when pistol grip tools were used, the peak torque to unfasten a joint (3.7 Nm) was significantly less than to fasten the same joint (5.7 Nm). However, the exposure time was longer for unfastening cycles (98 ms more on the horizontal surface, and 107 ms more on the vertical surface). The average grip force scaled to corresponding peak tool torque revealed that the effort to react against torque was greater in unfastening cycles than in fastening cycles for all work configurations. It also showed that as a proximal stabilizer, the upper trapezius muscle had a greater activity in unfastening cycles. The kinetic and physiological responses demonstrated that unfastening fasteners, which has been neglected in the literature, have the potential to increase risk for musculoskeletal disorders and should be considered in ergonomics assessment in the workplace.

Measuring pad–pad pinch strength in a non-human primate: Macaca fascicularis

The primary purpose of this study was to establish a methodology for determining and perhaps predicting (via regression analysis of anthropometric measures) Macaca fascicularis isometric pinch strength for a specific task. The larger purpose of this work was to properly scale a pinching task for the monkeys in order to study dose-response relationships in a non-human primate model for carpal tunnel syndrome. Three female and one male macaque (n=4) of varying size and age were trained to perform a left-handed pad-pad pinch. The task required 60 degrees of wrist flexion at a static pinching distance of 3 cm between the thumb and fingers. Subjects were trained for a period of 20-weeks. After that time, an analysis of performance gradients found that they had each reached a plateau in their force output. Pinch strength for the four animals ranged from 29.4 to 59.8 N. Regression analysis revealed that body mass (kg) and wrist circumference (cm) were both predictive of pinch strength, exhibiting adjusted R(2) values of 0.93 (p=0.024) and 0.96 (p=0.015), respectively. Thus, the results suggest that maximal pinch strength could be acceptably estimated in future subjects using either the wrist circumference or the body mass measures, as both were strong predictors of pad-pad pinch strength.

Towards development of a nonhuman primate model of carpal tunnel syndrome: performance of a voluntary, repetitive pinching task induces median mononeuropathy in Macaca fascicularis

This study investigated changes in median sensory nerve conduction velocity (SNCV) over several weeks of exposure to a voluntary, moderately forceful, repetitive pinching task performed for food rewards by a small sample of young adult female monkeys (Macaca fascicularis). SNCV, derived from peak latency, decreased significantly in the working hands of three of the four subjects. The overall decline in NCV was 25%-31% from baseline. There was no decrease in SNCV in the contralateral, nonworking hands. Several weeks after being removed from the task, SNCV returned to within 87%-100% of baseline. MRI showed enlargement of the affected nerves near the proximal end of the carpal tunnel, at the time of maximal SNCV slowing. This new animal model demonstrates a temporally unambiguous relationship between exposure to a moderately forceful, repetitive manual task and development of median mononeuropathy at the wrist, and recovery of SNCV following termination of task exposure. This study contributes to the pattern of evidence of a causal relationship between manual work, median mononeuropathy, and carpal tunnel syndrome in humans. In the future, this new animal model could be used to characterize dose-response relationships between risk factors and carpal tunnel syndrome.