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Gait and postural control after total knee arthroplasty
Umeå University, Faculty of Medicine, Department of Community Medicine and Rehabilitation, Physiotherapy.
2014 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

The aim of the thesis was to investigate deficits and compensatory strategies after total knee arthroplasty (TKA) in different conditions during gait and quiet standing. Although TKA is considered the gold standard treatment for end-stage knee osteoarthritis, it is associated with a number of implications. Reduced physical function after osteoarthritis is partly, but apparently not fully, remedied by surgery. The two most common deficits are reduced knee muscle strength and limited range of knee joint motion (ROM), partly due to prosthesis mechanics. Reduced postural control has also been shown shortly after surgery. In spite of sufficient passive knee joint ROM for normal ambulation, gait patterns are characterized by reduced knee flexion. Several factors such as reduced knee muscle strength, reduced proprioception, habitual strategies or fear of movement may be suggested as explanations for difficulties in gait and posture. As an effect, compensatory strategies may result. In order to focus on the implications of TKA, participants had to be less than 65 years of age and healthy, TKA being the only factor different form controls. The same 23 individuals with unilateral TKA ~ 19 months post-operative and 23 controls participated in all studies.

 

3D whole body kinematics was used to assess gait and posture and electromyography was used to record muscle activity. Isokinetic measurements were used to determine dynamic knee muscle strength. Gait in the frontal and sagittal planes were assessed. The tasks included in the test protocol were negotiation up and down stairs, gait on hard and soft surface, quiet standing with sensory modulation (with and without vision and on soft surface), and single limb stance.  Primary outcome variables addressed were: knee and hip joint kinematics in frontal and sagittal planes, upper body inclination, postural sway and relative knee muscle activity as an indicator of relative effort. Background factors used to explain group differences in the primary outcomes were derived from demographics, clinical examination, and questionnaires. Demographic factors were age, body mass index (BMI), and time since surgery. Clinical examinations were conducted for passive knee joint ROM, joint position sense, knee muscle strength, anterior knee joint laxity, and leg length. Questionnaires assessed fear of movement, pain, and knee related function and quality of life. The results showed that knee flexion was reduced during stair descent in both the prosthetic and the contralateral knee in the TKA group compared to controls. Although reduced passive knee joint flexion in the TKA group was sufficient for normal stair descent, it was the only factor identified that explained reduced knee flexion in stair descent. As knee muscle strength was significantly reduced in the TKA group, it is reasonable to suggest that as a contributing factor. Furthermore, the TKA group also displayed increased hip adduction during stair descent, which may indicate both a compensatory strategy as well as reduced hip muscle strength. In stair ascent, no significant group differences were found in relative knee muscle activity as expected due to knee muscle weakness. Nor were there any indications of compensatory forward inclination of the trunk to reduce knee joint moments. Instead, probably compensating for muscle weakness, the TKA group ascended stairs at a significantly slower speed. Surface modulation during level gait showed that reduced knee flexion in the prosthetic knee during the stance phase when walking on a hard surface was further decreased during gait on a soft surface. Knee and hip adduction at the stance phase were not affected by surface conditions. Nevertheless, the TKA group displayed increased knee adduction and hip adduction compared to controls, particularly in the prosthetic side. In addition, the TKA group displayed increased step width on the soft compared to hard surface. Single-limb stance for 20 seconds failed in 30 % of the TKA group and in 4 % of the control group. Those in the TKA group who were able to perform single-limb stance performed equally well as controls. During bilateral quiet standing, postural sway was similar in both groups, and inability to stand on one leg did not affect bilateral stance. Older age, higher BMI and reduced quadriceps strength determined the failure to maintain single-limb stance in the TKA group.

 

In conclusion, this thesis indicates that reduced knee muscle strength is a common denominator as part of the explanatory factors for reduced performance and compensatory strategies in individuals with TKA. Reduced speed during stair ascent as well as reduced knee flexion during stair descent may be compensations for reduced lower extremity strength. Increased hip adduction may compensate for reduced knee flexion in stair descent, but may also represent hip muscle weakness or reduced motor control as increased hip adduction is found also in level gait. The failure to maintain single-limb stance in the TKA group is also partly explained by reduced knee muscle strength. Muscle weakness may be and indicator for reduced physical capacity in general.

Place, publisher, year, edition, pages
Umeå: Umeå universitetet , 2014. , 84 p.
Series
Umeå University medical dissertations, ISSN 0346-6612 ; 1664
National Category
Physiotherapy
Research subject
Physiotherapy
Identifiers
URN: urn:nbn:se:umu:diva-91482ISBN: 978-91-7601-094-5 (print)OAI: oai:DiVA.org:umu-91482DiVA: diva2:736445
Public defence
2014-09-18, Aulan, Vårdvetarhuset, Umeå, 10:00 (Swedish)
Opponent
Supervisors
Available from: 2014-08-27 Created: 2014-08-06 Last updated: 2014-12-18Bibliographically approved
List of papers
1. Peak knee flexion angles during stair descent in TKA patients
Open this publication in new window or tab >>Peak knee flexion angles during stair descent in TKA patients
Show others...
2014 (English)In: The Journal of Arthroplasty, ISSN 0883-5403, E-ISSN 1532-8406, Vol. 29, no 4, 707-711 p.Article in journal (Refereed) Published
Abstract [en]

Reduced peak knee flexion during stair descent (PKSD) is demonstrated in subjects with total knee arthroplasty (TKA), but the underlying factors are not well studied. 3D gait patterns during stair descent, peak passive knee flexion (PPKF), quadriceps strength, pain, proprioception, demographics, and anthropometrics were assessed in 23 unilateral TKA-subjects ~ 19 months post-operatively, and in 23 controls. PKSD, PPKF and quadriceps strength were reduced in the TKA-side, but also in the contralateral side. A multiple regression analysis identified PPKF as the only predictor (57%) to explain the relationship with PKSD. PPKF was, however sufficient for normal PKSD. Deficits in quadriceps strength in TKA-group suggest that strength is also contributing to smaller PKSD. Increased hip adduction at PKSD may indicate both compensatory strategy and reduced hip strength.

Place, publisher, year, edition, pages
Elsevier, 2014
Keyword
total knee arthroplasty, gait analysis, range of motion, kinematics
National Category
Physiotherapy
Identifiers
urn:nbn:se:umu:diva-80010 (URN)10.1016/j.arth.2013.07.010 (DOI)000334094000017 ()
Available from: 2013-09-06 Created: 2013-09-06 Last updated: 2017-12-06Bibliographically approved
2. Compensatory strategies for muscle weakness during stair ascent in subjects with total knee arthroplasty
Open this publication in new window or tab >>Compensatory strategies for muscle weakness during stair ascent in subjects with total knee arthroplasty
2014 (English)In: The Journal of Arthroplasty, ISSN 0883-5403, E-ISSN 1532-8406, Vol. 29, no 7, 1499-1502 p.Article in journal (Refereed) Published
Abstract [en]

Subjects with total knee arthroplasty (TKA) exhibit decreased quadriceps and hamstring strength. This may bring about greater relative effort or compensatory strategies to reduce knee joint moments in daily activities. To study gait and map out the resource capacity, knee muscle strength was assessed by maximal voluntary concentric contractions, and whole body kinematics and root mean square (RMS) electromyography (EMG) of vastus lateralis and semitendinosus were recorded during stair ascent in 23 unilateral TKA-subjects ~19months post-operation, and in 23 healthy controls. Muscle strength and gait velocity were lower in the TKA group, but no significant group differences were found in RMS EMG or forward trunk lean. The results suggest that reduced walking velocity sufficiently compensated for reduced knee muscle strength.

Place, publisher, year, edition, pages
Elsevier, 2014
Keyword
muscular utilization. electromyography. maximal voluntary contraction. kinematics. stairs
National Category
Physiotherapy Orthopedics
Identifiers
urn:nbn:se:umu:diva-89607 (URN)10.1016/j.arth.2014.01.033 (DOI)000338941600033 ()24612738 (PubMedID)
Available from: 2014-06-05 Created: 2014-06-05 Last updated: 2017-05-29Bibliographically approved
3. Postural sway in single-limb and bilateral quiet standing after unilateral total knee arthroplasty
Open this publication in new window or tab >>Postural sway in single-limb and bilateral quiet standing after unilateral total knee arthroplasty
(English)Manuscript (preprint) (Other academic)
Abstract [en]

Aim: To investigate the effects of total knee arthroplasty (TKA) on single limb stance and whether reduced stability in single-limb stance may increase postural sway in bilateral quiet standing.                                                              

Methods: 3D kinematics for center of mass was used to assess postural sway in 23 subjects with TKA and 23 controls. Tests included bilateral quiet standing with and without vision and on a yielding surface, and single-limb stance.                                                                    

Results: 30% of the subjects in the TKA group were unable to maintain single-limb stance for 20 s on any leg. Of the 70%  in the TKA group able to stand on one leg, mean sway velocity in the medio-lateral direction was higher when standing on the prosthetic leg (p=.02), but no differences were found between the TKA and the control group in single-limb stance. Performance in bilateral quiet standing was similar in TKA-subjects able as well as unable to stand on one leg and controls. Reduced quadriceps strength in the contralateral leg, higher BMI, and older age predicted failure to maintain single-limb stance.                  

Conclusion: In subjects able to stand on one leg, performance was considered comparable between the prosthetic and contralateral limb and between groups. Inability to stand on one leg did not affect postural sway in bilateral quiet standing. The results suggest that inability to maintain single-limb stance is explained by reduced physical capacity rather than the knee condition in itself. The present study emphasizes the importance of physical activity to improve strength and functional capacity.

National Category
Physiotherapy
Identifiers
urn:nbn:se:umu:diva-91481 (URN)
Available from: 2014-08-06 Created: 2014-08-06 Last updated: 2014-09-08Bibliographically approved
4. Gait on soft versus hard surface after total knee arthroplasty
Open this publication in new window or tab >>Gait on soft versus hard surface after total knee arthroplasty
(English)Manuscript (preprint) (Other academic)
Abstract [en]

Asymmetric gait patterns are common following total knee arthroplasty (TKA). Gait on even and hard surface is primarily characterized by reduced peak knee flexion in the prosthetic knee, increased contralateral knee adduction angle, and decreased walking speed compared to controls. Natural conditions may however lead to different strategies. Therefore, the objective of the present study was to explore how gait patterns may differ when walking on a soft surface. Methods: 3D kinematics during gait on hard and soft surface were assessed in 23 unilateral TKA-subjects ~19 months post-operative, and in 23 controls. Results: Gait characteristics in TKA-subjects that differed from controls observed on hard surface were amplified on soft surface. Flexion in the prosthetic knee was further decreased and a tendency towards reduced flexion in the contralateral knee was observed. Knee and hip adduction were not affected by surface conditions nevertheless there was a difference between groups, in particular with regard to the prosthetic side. In addition, step width increased on soft surface in TKA-subjects. Conclusion: Gait on an even and soft surface did not amplify asymmetries in TKA-subjects, but decreased knee flexion and increased step-width, albeit with similar gait speed as the control group suggests that the soft surface provided a small but significant challenge making the TKA-subjects precautious.

National Category
Physiotherapy
Identifiers
urn:nbn:se:umu:diva-91480 (URN)
Available from: 2014-08-06 Created: 2014-08-06 Last updated: 2016-02-09Bibliographically approved

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