Original Article: The effects of challenging walking conditions on kinematic synergy and stability of gait in people with knee osteoarthritis: A study protocol


1 Rehabilitation Research Center, Department of Physiotherapy, School of Rehabilitation Sciences, Iran University of Medical Sciences, Tehran, Iran

2 Department of Mechanical Engineering, Sharif University of Technology, Tehran, Iran,

3 Department of Neuromedicine and Movement Science, Faculty of Medicine and Health Science, Norwegian University of Science and Technology, Trondheim, Norway


Background: Knee osteoarthritis (KOA) may considerably change the gait parameters, including the gait variability patterns. Uncontrolled manifold (UCM) analysis has been used to evaluate the relationship between motor control and gait variability as a useful index for assessing the multi-segmental movements' coordination during walking. To our knowledge, no research has evaluated the alterations in the gait kinematic parameters during normal and narrow path walking in individuals with KOA as compared to asymptomatic people. Materials and Methods: In this cross-sectional study, individuals diagnosed with mild to moderate medial KOA and asymptomatic people will walk at their comfortable preferred speed on a treadmill. A motion capture system will be used to record at least 50 successful gait cycles. The kinematic variability of joints during gait will be analyzed using UCM, with the center of mass (COM) displacement considered as the performance variable. The primary outcome measure will be the lower limb synergy index. Variability of the COM displacement and changes in angles and angular velocities of lower extremity joints will be assessed as the secondary outcomes. Results: The results of this protocol study provide information on the lower limb kinematic synergy during gait on normal and narrow paths for individuals with KOA and asymptomatic controls. Conclusion: This information will help the researchers and clinicians understand KOA patients' gait variability characteristics more deeply. Moreover, it may lead to an enhanced evidence-based approach for clinical decision-making concerning improving gait stability and decreasing the falling risk in these people.


Cunha JE, Barbosa GM, Castro PA, Luiz BL, Silva AC, Russo TL, et al. Knee osteoarthritis induces atrophy and neuromuscular junction remodeling in the quadriceps and tibialis anterior muscles of rats. Sci Rep 2019;9:6366.  Back to cited text no. 1
Ro DH, Lee J, Lee J, Park JY, Han HS, Lee MC. Effects of knee osteoarthritis on hip and ankle gait mechanics. Adv Orthop 2019;2019:9757369.  Back to cited text no. 2
Tokuda K, Anan M, Takahashi M, Sawada T, Tanimoto K, Kito N, et al. Biomechanical mechanism of lateral trunk lean gait for knee osteoarthritis patients. J Biomech 2018;66:10-7.  Back to cited text no. 3
Arvin M, Hoozemans MJ, Pijnappels M, Duysens J, Verschueren SM, van Dieën JH. Where to step? Contributions of stance leg muscle spindle afference to planning of mediolateral foot placement for balance control in young and old adults. Front Physiol 2018;9:1134.  Back to cited text no. 4
Bruijn SM, van Dieën JH. Control of human gait stability through foot placement. J R Soc Interface 2018;15:20170816.  Back to cited text no. 5
Eckardt N, Rosenblatt NJ. Healthy aging does not impair lower extremity motor flexibility while walking across an uneven surface. Hum Mov Sci 2018;62:67-80.  Back to cited text no. 6
Rankin BL, Buffo SK, Dean JC. A neuromechanical strategy for mediolateral foot placement in walking humans. J Neurophysiol 2014;112:374-83.  Back to cited text no. 7
Reimann H, Fettrow T, Jeka JJ. Strategies for the control of balance during locomotion. Kinesiol Rev 2018;7:18-25.  Back to cited text no. 8
Mazaheri M, Negahban H, Soltani M, Mehravar M, Tajali S, Hessam M, et al. Effects of narrow-base walking and dual tasking on gait spatiotemporal characteristics in anterior cruciate ligament-injured adults compared to healthy adults. Knee Surg Sports Traumatol Arthrosc 2017;25:2528-35.  Back to cited text no. 9
Schrager MA, Kelly VE, Price R, Ferrucci L, Shumway-Cook A. The effects of age on medio-lateral stability during normal and narrow base walking. Gait Posture 2008;28:466-71.  Back to cited text no. 10
Tawy GF, Rowe P, Biant L. Gait variability and motor control in patients with knee osteoarthritis as measured by the uncontrolled manifold technique. Gait Posture 2018;59:272-7.  Back to cited text no. 11
Papi E, Rowe PJ, Pomeroy VM. Analysis of gait within the uncontrolled manifold hypothesis: Stabilisation of the centre of mass during gait. J Biomech 2015;48:324-31.  Back to cited text no. 12
Qu X. Uncontrolled manifold analysis of gait variability: Effects of load carriage and fatigue. Gait Posture 2012;36:325-9.  Back to cited text no. 13
Tokuda K, Anan M, Sawada T, Tanimoto K, Takeda T, Ogata Y, et al. Trunk lean gait decreases multi-segmental coordination in the vertical direction. J Phys Ther Sci 2017;29:1940-6.  Back to cited text no. 14
Latash ML, Huang X. Neural control of movement stability: Lessons from studies of neurological patients. Neuroscience 2015;301:39-48.  Back to cited text no. 15
Street BD, Gage W. The effects of an adopted narrow gait on the external adduction moment at the knee joint during level walking: Evidence of asymmetry. Hum Mov Sci 2013;32:301-13.  Back to cited text no. 16
Taş S, Güneri S, Baki A, Yıldırım T, Kaymak B, Erden Z. Effects of severity of osteoarthritis on the temporospatial gait parameters in patients with knee osteoarthritis. Acta Orthop Traumatol Turc 2014;48:635-41.  Back to cited text no. 17
Shih HS, Gordon J, Kulig K. Trunk control during gait: Walking with wide and narrow step widths present distinct challenges. J Biomech 2021;114:110135.  Back to cited text no. 18
Arvin M, Mazaheri M, Hoozemans MJ, Pijnappels M, Burger BJ, Verschueren SM, et al. Effects of narrow base gait on mediolateral balance control in young and older adults. J Biomech 2016;49:1264-7.  Back to cited text no. 19
Butler RJ, Barrios JA, Royer T, Davis IS. Frontal-plane gait mechanics in people with medial knee osteoarthritis are different from those in people with lateral knee osteoarthritis. Phys Ther 2011;91:1235-43.  Back to cited text no. 20
Weidow J, Mars I, Kärrholm J. Medial and lateral osteoarthritis of the knee is related to variations of hip and pelvic anatomy. Osteoarthritis Cartilage 2005;13:471-7.  Back to cited text no. 21
Altman R, Asch E, Bloch D, Bole G, Borenstein D, Brandt K, et al. Development of criteria for the classification and reporting of osteoarthritis. Classification of osteoarthritis of the knee. Diagnostic and Therapeutic Criteria Committee of the American Rheumatism Association. Arthritis Rheum 1986;29:1039-49.  Back to cited text no. 22
Altman RD, Gold GE. Atlas of individual radiographic features in osteoarthritis, revised. Osteoarthritis Cartilage 2007;15 Suppl A: A1-56.  Back to cited text no. 23
Faul F, Erdfelder E, Buchner A, Lang AG. Statistical power analyses using G* Power 3.1: Tests for correlation and regression analyses. Behav Res Methods 2009;41:1149-60.  Back to cited text no. 24
Vasheghani-Farahani A, Tahmasbi M, Asheri H, Ashraf H, Nedjat S, Kordi R. The persian, last 7-day, long form of the international physical activity questionnaire: Translation and validation study. Asian J Sports Med 2011;2:106-16.  Back to cited text no. 25
Karimi MT. Influences of joint motion restriction on the performance of normal subjects and their implications on development of orthosis for spinal cord injured individuals. J Phys Med Rehabil Sci 2011;13:122-31.  Back to cited text no. 26
Dal U, Erdogan T, Resitoglu B, Beydagi H. Determination of preferred walking speed on treadmill may lead to high oxygen cost on treadmill walking. Gait Posture 2010;31:366-9.  Back to cited text no. 27
Kelly VE, Schrager MA, Price R, Ferrucci L, Shumway-Cook A. Age-associated effects of a concurrent cognitive task on gait speed and stability during narrow-base walking. J Gerontol A Biol Sci Med Sci 2008;63:1329-34.  Back to cited text no. 28
Rosenblatt NJ, Hurt CP. Recommendation for the minimum number of steps to analyze when performing the uncontrolled manifold analysis on walking data. J Biomech 2019;85:218-23.  Back to cited text no. 29
Ebadi S, Ansari NN, Henschke N, Naghdi S, van Tulder MW. The effect of continuous ultrasound on chronic low back pain: Protocol of a randomized controlled trial. BMC Musculoskelet Disord 2011;12:59.  Back to cited text no. 30
Krishnan V, Rosenblatt NJ, Latash ML, Grabiner MD. The effects of age on stabilization of the mediolateral trajectory of the swing foot. Gait Posture 2013;38:923-8.  Back to cited text no. 31
Rosenblatt NJ, Hurt CP, Latash ML, Grabiner MD. An apparent contradiction: Increasing variability to achieve greater precision? Exp Brain Res 2014;232:403-13.  Back to cited text no. 32
Robert T, Bennett BC, Russell SD, Zirker CA, Abel MF. Angular momentum synergies during walking. Exp Brain Res 2009;197:185-97.