Elsevier

Journal of Biomechanics

Volume 87, 18 April 2019, Pages 127-141
Journal of Biomechanics

Proximal gait adaptations in individuals with knee osteoarthritis: A systematic review and meta-analysis

https://doi.org/10.1016/j.jbiomech.2019.02.027Get rights and content

Abstract

Clarifying proximal gait adaptations as a strategy to reduce knee joint loading and pain for individuals with knee osteoarthritis (OA) contributes to understanding the pathogenesis of multi-articular OA changes and musculoskeletal pain in other joints. We aimed to determine whether biomechanical alterations in knee OA patients during level walking is increased upper trunk lean in the frontal and sagittal planes, and subsequent alteration in external hip adduction moment (EHAM) and external hip flexion moment (EHFM). A literature search was conducted in PubMed, PEDro, CINAHL, and Cochrane CENTRAL through May 2018. Where possible, data were combined into a meta-analysis; pooled standardized mean differences (SMD) of between knee OA patients and healthy adults were calculated using a random-effect model. In total, 32 articles (2037 participants, mean age, 63.0 years) met inclusion criteria. Individuals with knee OA had significantly increased lateral trunk lean toward the ipsilateral limb (pooled SMD: 1.18; 95% CI: 0.59, 1.77) along with significantly decreased EHAM. These subjects also displayed a non-significantly increased trunk/pelvic flexion angle and EHFM. The GRADE approach judged all measures as “very low.” These results may indicate that biomechanical alterations accompanying knee OA are associated with increased lateral trunk lean and ensuing alterations in EHAM. Biomechanical alterations in the sagittal plane were not evident. Biomechanical adaptations might have negative sequelae, such as secondary hip abductor muscle weakness and low back pain. Thus, investigations of negative sequelae due to proximal gait adaptations are warranted.

Introduction

Knee osteoarthritis (OA) contributes to altered gait since individuals try to avoid knee pain, minimize joint force (Winter and Eng, 1995), and avoid feelings of joint instability (Shakoor et al., 2003). The trunk is the heaviest part of the body, and its function can affect the orientation of the ground reaction force vector and knee moment. Alteration of trunk kinematics has been identified as a possible strategy to reduce knee joint loading and knee pain for knee OA patients (Hunt et al., 2010, Linley et al., 2010). In 2013, Mills et al. conducted an extensive review and found that alteration in spatiotemporal parameters, including greater stride duration and decreased cadence are characteristic of knee OA (Mills et al., 2013b). However, they could not identify biomechanical alterations of the trunk during level walking because relatively few studies met their inclusion criteria. Thus, proximal compensatory strategies used by individuals with knee OA remains unclear.

Many previous studies focused on lateral trunk lean toward the ipsilateral limb (Hunt et al., 2008, Hunt et al., 2011, Simic et al., 2012, Takacs et al., 2014, van der Esch et al., 2011). This proximal adaption is suggested to be a dominant means patients use to avoid severe knee pain and cartilage contact stress in the knee joint. Lateral trunk lean of 4, 8, and 12° in healthy adults reduces external peak knee adduction moment (EKAM) by 7, 21, and 25%, respectively, compared to adults with a normal gait (Hunt et al., 2011). However, lateral trunk lean in individuals with knee OA was weakly related with knee pain (Hunt et al., 2008, van der Esch et al., 2011), and increased trunk lean did not immediately improve symptoms (Simic et al., 2012, Takacs et al., 2014). Further, the relationship between lateral trunk lean and EKAM is likely weaker in individuals with moderate to severe knee OA than in those with mild knee OA (Hunt et al., 2008). Thus, the role of proximal adaptation in the frontal plane for knee pain and EKAM in individuals with knee OA requires reconsideration.

Biomechanical alterations in the sagittal plane were not well characterized in previous studies. Sagittal plane motion of the trunk can influence the external knee flexion moment (EKFM) which contributes to greater knee joint contact stress independent of EKAM (Walter et al., 2010), progressive tibial cartilage damage (Chehab et al., 2014), and severe gait-related knee pain (O'Connell et al., 2016). It is plausible that individuals with knee OA lean their trunks anteriorly toward the ipsilateral limb, an adjustment that would successfully reduce EKFM through reduction of the moment arm. However, we are not aware of any review that explores proximal gait adaptations and considers kinematics/kinetics of both frontal and sagittal planes. Updated information concerning biomechanical alterations associated with knee OA during level walking would help clinicians and physical therapists understand proximal gait compensation behavior. This issue is important since effort to limit ipsilateral knee pain may place relatively greater loads on contralateral joints (Shakoor et al., 2002). In turn, such greater loads might affect multi-articular OA changes. Also, proximal adaptations may induce multi-articular muscle soreness (Hunt et al., 2011) and cause hip muscular weakness through decreasing electromyogenic activation (Nuesch et al., 2016, Robbins et al., 2016).

This systematic review aimed to summarize current evidence of proximal biomechanical alterations in individuals with knee OA during level walking, discuss their relevance to knee pain and knee joint moments (EKAM, EKFM), and assess potential negative sequelae of observed proximal gait alterations. We hypothesized that knee OA–associated biomechanical alterations were increased lateral trunk lean toward the ipsilateral limb in conjunction with increased trunk/pelvic flexion and resulting alterations in hip joint moments.

Section snippets

Methods

This study was conducted according to the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) statement (Moher et al., 2009), PRISMA protocols (PRISMA-P) (Shamseer et al., 2015), Meta-analysis of Observational Studies in Epidemiology (MOOSE) checklist (Stroup et al., 2000), and Cochrane Handbook for Systematic Reviews of Interventions (Higgins and Green, 2011). A detailed protocol for this systematic review has not been published and registered.

Study selection

The database search yielded 1666 studies (Supplemental Appendix S1, Fig. 1); thirty-two (Astephen et al., 2008, Bechard et al., 2012, Bejek et al., 2006, Bolink et al., 2012, Brandon and Deluzio, 2011, Butler et al., 2011, Creaby et al., 2012, Duffell et al., 2017, Esrafilian et al., 2013, Federolf et al., 2013, Hunt et al., 2010, Kierkegaard et al., 2015, Kiss, 2011, Levinger et al., 2012, Linley et al., 2010, Liu et al., 2014, McKean et al., 2007, Messier et al., 2005, Messier et al., 1992,

Discussion

This study supports the hypothesis that significantly increased trunk lean and resulting decreased EHAM during level walking are biomechanical characteristics of knee OA patients. Knee OA subjects showed non-significantly increased trunk/pelvic flexion despite a similar EHFM, which is contrary to our hypothesis. Although evidence quality was very low according to the GRADE approach, these findings indicate that individuals with knee OA may have altered kinematics in proximal segment/joint

Conflict of interest statement

The authors did not receive financial support or other benefits from commercial sources for the work reported in this manuscript, or any other financial support that could create a potential conflict of interest or the appearance of a conflict of interest concerning the work.

Acknowledgements

We would like to thank Editage (www.editage.jp) for English language editing.

Role of the funding source

This study was supported in part by a Grant-in-Aid from the Japan Society for the Promotion of Science (https://www.jsps.go.jp/) Research Fellows to HI.

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