The effect of a frontal plane gait perturbation bout on knee biomechanics and muscle activation in older adults and individuals with knee osteoarthritis


      • Osteoarthritis and asymptomatic groups responded similarly to gait perturbations.
      • Minimal changes to knee biomechanics after gait perturbations.
      • Reduced and less prolonged muscle activation after gait perturbations
      • Results support investigations in gait perturbation training for knee osteoarthritis



      Walking can be a challenging task for individuals with knee osteoarthritis and many older adults. The purpose was to determine the immediate effect of a frontal plane perturbation bout during walking on knee biomechanics and muscle activation patterns in these groups.


      44 asymptomatic older adults and 32 individuals with knee osteoarthritis were recruited. Sagittal and frontal plane knee biomechanics and muscle activation levels were calculated and recorded during treadmill walking. After a baseline collection at 6-min, a random series of unexpected medial/lateral walkway surface perturbations were delivered over approximately 24 min. Data was collected immediately after the perturbations. Discrete measures extracted from biomechanical waveforms, and principal component analysis to analyze muscle activation were utilized to determine time effects and interactions using analysis of variance models (alpha = 0.05).


      After the perturbation bout, sagittal plane range of motion was significantly increased in the osteoarthritis group (Effect Size = 0.24) and in both groups peak knee adduction moment (Effect Size = 0.10) and difference between peak flexion and extension moments (Effect Size = 0.16) were significantly increased. Muscle amplitudes in both groups were significantly reduced (PP1-scores) after perturbation bout, whereas significant time-based gait cycle activation pattern alterations identified by PP2- and PP3-scores were related to group and muscle assignment.


      Perturbations were tolerated by all participants, resulting in significant alterations to biomechanical outcomes and muscle activation levels and patterns. Demand on the knee joint was not increased after perturbations. Gait perturbation training in these groups may be feasible using a frontal plane perturbation bout.


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        • Altman R.D.
        Classification of disease: osteoarthritis.
        Semin. Arthritis Rheum. 1991; 20: 40-47
        • Andriacchi T.
        • Mundermann A.
        • Smith R.L.
        • et al.
        A framework for the in vivo pathomechanics of osteoarthritis at the knee.
        Ann. Biomed. Eng. 2004; 32: 447-457
        • Astephen J.L.
        • Deluzio K.J.
        • Caldwell G.E.
        • Dunbar M.J.
        Biomechanical changes at the hip, knee, and ankle joints during gait are associated with knee osteoarthritis severity.
        J. Orthop. Res. 2008; 26: 332-341
        • Baker M.
        • Stanish W.
        • Rutherford D.
        Walking challenges in moderate knee osteoarthritis: a biomechanical and neuromuscular response to medial walkway surface translations.
        Hum. Mov. Sci. 2019; 68102542
        • Bauby C.E.
        • Kuo A.D.
        Active control of lateral balance in human walking.
        J. Biomech. 2000; 33: 1433-1440
        • Childs J.D.
        • Sparto P.J.
        • Fitzgerald G.K.
        • et al.
        Alterations in lower extremity movement and muscle activation patterns in individuals with knee osteoarthritis.
        Clin. Biomech. 2004; 19: 44-49
        • Dean J.C.
        • Alexander N.B.
        • Kuo A.D.
        The effect of lateral stabilization on walking in young and old adults.
        IEEE Trans. Biomed. Eng. 2007; 54: 1919-1926
        • Deluzio K.J.
        • Astephen J.L.
        Biomechanical features of gait waveform data associated with knee osteoarthritis: an application of principal component analysis.
        Gait Posture. 2007; 25: 86-93
        • Dunphy C.
        • Casey S.
        • Lomond A.
        • Rutherford D.
        Contralateral pelvic drop during gait increases knee adduction moments of asymptomatic individuals.
        Hum. Mov. Sci. 2016; 49: 27-35
        • Elkarif V.
        • Kandel L.
        • Rand D.
        • et al.
        Kinematics following gait perturbation in adults with knee osteoarthritis: scheduled versus not scheduled for knee arthroplasty.
        Gait Posture. 2020; 81: 144-152
        • Farrar J.T.
        • Young J.P.J.
        • LaMoreaux L.
        • et al.
        Clinical importance of changes in chronic pain intensity measured on an 11-point numerical pain rating scale.
        Pain. 2001; 94: 149-158
        • Felson D.
        • Niu J.
        • McClennan C.
        • et al.
        Knee buckling: prevalence, risk factors, and associated limitations in function.
        Ann. Intern. Med. 2007; 147: 534-540
        • Fitzgerald G.K.
        • Piva S.R.
        • Irrgang J.J.
        Reports of joint instability in knee osteoarthritis: its prevalence and relationship to physical function.
        Arthritis Rheum. 2004; 51: 941-946
        • Foroughi N.
        • Smith R.
        • Vanwanseele B.
        The association of external knee adduction moment with biomechanical variables in osteoarthritis: a systematic review.
        Knee. 2009; 16: 303-309
        • Foucher K.C.
        • Pater M.L.
        • Grabiner M.D.
        Task-specific perturbation training improves the recovery stepping responses by women with knee osteoarthritis following laboratory-induced trips.
        J. Orthop. Res. 2020; 38: 663-669
        • Freisinger G.M.
        • Schmitt L.C.
        • Wanamaker A.B.
        • et al.
        Tibiofemoral osteoarthritis and Varus-Valgus laxity.
        J. Knee Surg. 2017; 30: 440-451
        • Fritz C.O.
        • Morris P.E.
        • Richler J.J.
        Effect size estimates: current use, calculations, and interpretation.
        J. Exp. Psychol. Gen. 2012; 141: 2-18
        • Harding G.T.
        • Hubley-Kozey C.L.
        • Dunbar M.J.
        • et al.
        Body mass index affects knee joint mechanics during gait differently with and without moderate knee osteoarthritis.
        Osteoarthr. Cartil. 2012; 20: 1234-1242
        • Heiden T.L.
        • Lloyd D.G.
        • Ackland T.R.
        Knee joint kinematics, kinetics and muscle co-contraction in knee osteoarthritis patient gait.
        Clin. Biomech. 2009; 24: 833-841
        • Hermens H.J.
        • Freriks B.
        • Disselhorst-Klug C.
        • Rau G.
        Development of recommendations for SEMG sensors and sensor placement procedures.
        J. Electromyogr. Kinesiol. 2000; 10: 361-374
        • Hubley-Kozey C.L.
        • Deluzio K.J.
        • Landry S.C.
        • et al.
        Neuromuscular alterations during walking in persons with moderate knee osteoarthritis.
        J. Electromyogr. Kinesiol. 2006; 16: 365-378
        • Hubley-Kozey C.L.
        • Hill N.A.
        • Rutherford D.J.
        • et al.
        Co-activation differences in lower limb muscles between asymptomatic controls and those with varying degrees of knee osteoarthritis during walking.
        Clin. Biomech. 2009; 24: 407-414
        • Hubley-Kozey C.L.
        • Moyer R.
        • Stanish W.D.
        • et al.
        Inflammatory biomarkers, endogenous analgesia and gait characteristics in those with moderate medial compartment knee osteoarthritis who experience increased pain after 30 minutes of continuous walking.
        Osteoarthr. Cartil. 2020; 28: S38-S39
        • Kaufman K.
        • Hughes C.
        • Morrey B.F.
        • et al.
        Gait characteristics of patients with knee osteoarthritis.
        J. Biomech. 2001; 34: 907-915
        • King L.K.
        • Kendzerska T.
        • Waugh E.J.
        • Hawker G.A.
        Impact of osteoarthritis on difficulty walking: a population-based study.
        Arthritis Care Res. 2018; 70: 71-79
        • Kumar D.
        • Swanik C.B.
        • Reisman D.S.
        • Rudolph K.S.
        Individuals with medial knee osteoarthritis show neuromuscular adaptation when perturbed during walking despite functional and structural impairments.
        J. Appl. Physiol. 2014; 116 (1985): 13-23
        • Lewek M.D.
        • Rudolph K.S.
        • Snyder-Mackler L.
        Control of frontal plane knee laxity during gait in patients with medial compartment knee osteoarthritis.
        Osteoarthr. Cartil. 2004; 12: 745-751
        • Lewek M.D.
        • Ramsey D.K.
        • Snyder-Mackler L.
        • Rudolph K.S.
        Knee stabilization in patients with medial compartment knee osteoarthritis.
        Arthritis Rheum. 2005; 52: 2845-2853
        • Lurie J.D.
        • Zagaria A.B.
        • Ellis L.
        • et al.
        Surface perturbation training to prevent falls in older adults: a highly pragmatic, randomized controlled trial.
        Phys. Ther. 2020; 100: 1153-1162
        • McAndrew P.M.
        • Wilken J.M.
        • Dingwell J.B.
        Dynamic stability of human walking in visually and mechanically destabilizing environments.
        J. Biomech. 2011; 44: 644-649
        • Newell R.S.
        • Hubley-Kozey C.L.
        • Stanish W.D.
        • Deluzio K.J.
        Detecting differences between asymptomatic and osteoarthritic gait is influenced by changing the knee adduction moment model.
        Gait Posture. 2008; 27: 485-492
        • Ofori-Asenso R.
        • Ackerman I.N.
        • Soh S.E.
        Prevalence and correlates of falls in a middle-aged population with osteoarthritis: data from the osteoarthritis initiative.
        Health Soc. Care Commun. 2021; 29: 436-444
        • Page P.
        Beyond statistical significance: clinical interpretation of rehabilitation research literature.
        Int. J. Sports Phys. Ther. 2014; 9: 726-736
        • Rieger M.M.
        • Papegaaij S.
        • Steenbrink F.
        • et al.
        Perturbation-based gait training to improve daily life gait stability in older adults at risk of falling: protocol for the REACT randomized controlled trial.
        BMC Geriatr. 2020; 20: 167
        • Rutherford D.J.
        • Hubley-Kozey C.L.
        • Stanish W.D.
        Knee effusion affects knee mechanics and muscle activity during gait in individuals with knee osteoarthritis.
        Osteoarthr. Cartil. 2012; 20: 974-981
        • Rutherford D.J.
        • Hubley-Kozey C.L.
        • Stanish W.D.
        Changes in knee joint muscle activation patterns during walking associated with increased structural severity in knee osteoarthritis.
        J. Electromyogr. Kinesiol. 2013; 23: 704-711
        • Rutherford D.
        • Baker M.
        • Wong I.
        • Stanish W.
        The effect of age and knee osteoarthritis on muscle activation patterns and knee joint biomechanics during dual belt treadmill gait.
        J. Electromyogr. Kinesiol. 2017; 34: 58-64
        • Rutherford D.J.
        • Moyer R.
        • Baker M.
        • Saleh S.
        High day-to-day repeatability of lower extremity muscle activation patterns and joint biomechanics of dual-belt treadmill gait: a reliability study in healthy young adults.
        J. Electromyogr. Kinesiol. 2020; 51102401
        • Schmitt L.C.
        • Rudolph K.S.
        Muscle stabilization strategies in people with medial knee osteoarthritis: the effect of instability.
        J. Orthop. Res. 2008; 26: 1180-1185
        • Schrijvers J.C.
        • van den Noort J.C.
        • van der Esch M.
        • Harlaar J.
        Neuromechanical assessment of knee joint instability during perturbed gait in patients with knee osteoarthritis.
        J. Biomech. 2021; 118110325
        • Shelburne K.B.
        • Torry M.R.
        • Pandy M.G.
        Contributions of muscles, ligaments, and the ground-reaction force to tibiofemoral joint loading during normal gait.
        J. Orthop. Res. 2006; 24: 1983-1990
        • Smith S.L.
        • Allan R.
        • Marreiros S.P.
        • et al.
        Muscle co-activation across activities of daily living in individuals with knee osteoarthritis.
        Arthritis Care Res. 2019; 71: 651-660
        • Thoma L.M.
        • McNally M.P.
        • Chaudhari A.M.
        • et al.
        Muscle co-contraction during gait in individuals with articular cartilage defects in the knee.
        Gait Posture. 2016; 48: 68-73
        • Turkiewicz A.
        • Petersson I.F.
        • Bjork J.
        • et al.
        Current and future impact of osteoarthritis on health care: a population-based study with projections to year 2032.
        Osteoarthr. Cartil. 2014; 22: 1826-1832
        • van der Esch M.
        • Knoop J.
        • van der Leeden M.
        • et al.
        Self-reported knee instability and activity limitations in patients with knee osteoarthritis: results of the Amsterdam osteoarthritis cohort.
        Clin. Rheumatol. 2012; 31: 1505-1510
        • Zeni J.A.
        • Rudolph K.
        • Higginson J.S.
        Alterations in quadriceps and hamstrings coordination in persons with medial compartment knee osteoarthritis.
        J. Electromyogr. Kinesiol. 2010; 20: 148-154
        • Zhao D.
        • Banks S.A.
        • Mitchell K.H.
        • et al.
        Correlation between the knee adduction torque and medial contact force for a variety of gait patterns.
        J. Orthop. Res. 2007; 25: 789-797