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Effect of Unilateral Knee Extension Restriction on the Lumbar Region during Gait

Effect of Unilateral Knee Extension Restriction on the Lumbar Region during Gait Hindawi Journal of Healthcare Engineering Volume 2022, Article ID 1151753, 8 pages https://doi.org/10.1155/2022/1151753 Research Article Effect of Unilateral Knee Extension Restriction on the Lumbar Region during Gait 1,2 3 1 Shintaro Nakatsuji , Masayuki Kawada , Yasufumi Takeshita , 1,2 2 3 3 Yuta Matsuzawa , Kazutaka Hata, Sota Araki , and Ryoji Kiyama Doctoral Program, Division of Health Sciences, Graduate School of Health Sciences, Kagoshima University, 8-35-1 Sakuragaoka, Kagoshima City, Kagoshima 890-8544, Japan Miyakonojo Rehabilitation Academy, 5822-9 Oiwada-cho, Miyakonojo City, Miyazaki 885-0062, Japan Department of Physical Šerapy, School of Health Sciences, Faculty of Medicine, Kagoshima University, 8-35-1 Sakuragaoka, Kagoshima City, Kagoshima 890-8544, Japan Correspondence should be addressed to Masayuki Kawada; kawada@health.nop.kagoshima-u.ac.jp Received 20 December 2021; Accepted 20 July 2022; Published 22 August 2022 Academic Editor: Georgian Badicu Copyright © 2022 Shintaro Nakatsuji et al. ­is is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Unilateral knee extension restriction might change trunk alignment and increase mechanical load on the lumbar region during walking. We aimed to clarify lumbar region mechanical load during walking with restricted knee extension using a muscu- loskeletal model simulation. Seventeen healthy adult males were enrolled in this study. Participants walked 10 m at a comfortable ° ° velocity with and without restricted right knee extension of 15 and 30 using a knee brace. L4–5 joint moment, joint reaction force, and muscle forces around the lumbar region during walking were calculated for each condition. Peaks of kinetic data were compared among three gait conditions during 0%–30% and 50%–80% of the right gait cycle. Lumbar extension moment at early stance of the bilateral lower limbs was signi”cantly increased in the 30 restricted condition (p ≤ 0.021). Muscle force of the multi”dus showed peaks at stance phase of the contralateral side during walking, and the erector spinae showed force peaks at early stance of the bilateral lower limb. Muscle force of the multi”dus and erector spinae increased with increasing degree of knee —exion (p ≤ 0.010), with a large e˜ect size (η = 0.273–0.486). ­e joint force acting on L4–5 showed two peaks at early stance of the bilateral lower limbs during the walking cycle. ­e anterior and vertical joint force on L4–5 increased by 14.2%–36.5% and 10.0%– 23.0% in walking with restricted knee extension, respectively (p ≤ 0.010), with a large e˜ect size (η = 0.149–0.425). Restricted knee joint extension changed trunk alignment and increased the muscle force and the vertical and anterior joint force on the L4–5 joint during walking; this tendency became more obvious with increased restriction angle. Our results provide important information for therapists engaged in the rehabilitation of patients with knee contracture. Knee joint plays an important role during walking. It 1. Introduction supports the body weight in the stance phase and adjusts the Increased musculoskeletal stress repeated during daily ac- lower limb length by changing the relative angle between the tivities leads to pain or movement disorders. ­us, lower leg and thigh in the swing phase [1]. ­ese knee knowledge of the load on joints and muscles during daily functions contribute to e¦cient and safe walking. Unilateral activity and exercise is useful information for understanding restriction of knee extension caused by knee osteoarthritis or the clinical condition of patients and planning an appro- orthopaedic surgery increases posterior tilt, lateral tilt to the priate therapeutic program during musculoskeletal reha- a˜ected side of the pelvis, lumbar kyphosis, and lateral tilt of bilitation. Dysfunction of the lower limbs a˜ects the the trunk in the standing position [2–6]. During walking, kinematics and kinetics of the entire body during stance. unilateral restriction of knee extension also changes the gait 2 Journal of Healthcare Engineering walking, and this tendency would be more obvious as re- kinematics as follows: it increases anterior tilt of the pelvis and trunk, and increases lateral tilt towards the unaffected striction of the knee angle increased. side during the stance phase [7]. ,ese changes in the postural alignment of the entire body are associated with low back pain. A previous study reported that 58.1% of patients 2. Materials and Methods with knee osteoarthritis have low back pain [8]; this rela- 2.1. Participants. Seventeen healthy adult males with no tionship between knee dysfunction and low back pain is orthopaedic or neurological disorders influencing normal called knee-spine syndrome [9, 10]. gait in the lumbar region and lower limbs (age, 26.0± 2.2 y; Kinetic changes during walking with a restricted ex- height, 1.69± 0.05 m; weight, 62.5± 5.6 kg; average± - tension of the knee joint have been analysed in previous standard deviation; 16 right footed and 1 left footed) par- studies where knee joint force was bilaterally increased ticipated in this study. ,e Medical clearance was during loading response depending on the degree of re- preliminarily obtained by a physical therapist’s interview. striction of the knee joint [11–13]. Knee extension re- ,e participants were given a written and oral explanation of striction also increases the vertical component of ground the purpose and content of the study, and their consent was reaction force and the external knee flexion moment, obtained in writing in accordance with the principles which increases the demand for muscle activity in the stipulated in the Declaration of Helsinki. Participants were lower extremities [14–17]. Gait kinematics and kinetics advised that participation in the research was voluntary and due to restriction of knee extension might increase the they would incur no disadvantage even if they decided not to load on the lumbar region during the loading response participate in the research or withdrew their consent. ,is phase of the restricted lower limb during gait and is re- study was approved by the Ethics Committee on Epide- lated to low back pain. Although knowledge regarding a miology and Clinical Research of the Faculty of Medicine, change in the lumbar load during walking, caused by the Kagoshima University (number, 180095Epi ver2). restriction of knee extension, is necessary for therapists engaged in the rehabilitation of patients with knee in- juries, there is a dearth of studies that have analysed this issue. 2.2. Measurement and Procedures. A motion analysis system Lumbar load during gait is usually analysed by muscle consisting of eight infrared cameras was used to measure gait activity measured using electromyography. Various studies with and without restricted extension of the right knee joint. report that increased trunk sway increases the stress on ,e sampling frequency was 100 Hz for the infrared camera. lumbar muscles during gait [18–21]. However, action po- Retroreflective markers were placed in accordance with the tential obtained from electromyography correlates with plug-in-gait model; we also placed markers on the medial muscle force only in isometric contractions, but not in epicondyle and medial malleolus, and plates with three reflex concentric and eccentric contractions. ,us, the muscle markers on the bilateral thigh and shank [27, 28]. Right knee ° ° action potential does not necessarily reflect the mechanical extension was restricted by 15 and 30 using a knee brace stress of the muscle. ,ese issues make it difficult to analyse with bilateral struts [6, 7, 29]. Flexion of the right knee joint lumbar load during movement. was not restricted. First, we confirmed whether the maxi- Meanwhile, musculoskeletal model simulation becomes mum knee extension angle during walking was restricted as useful for estimating the muscle force of whole-body intended. Participants randomly performed 10-m walking muscles in human movement science. A musculoskeletal with and without a restricted knee joint at a comfortable model simulation can noninvasively quantify the joint load, speed five times after several rounds of practice in each gait based on inverse dynamics and an optimization method condition. from the kinematic data obtained by motion capture ,e noise was removed from the kinematic data mea- [22–26]. Musculoskeletal model simulation can estimate sured by the motion capture system using a Butterworth both joint force and muscle force. In other words, a mus- low-pass filter with a cut-off frequency of 6 Hz. ,en, the culoskeletal model simulation contributes to our under- kinematic data were input to the musculoskeletal model standing of the relationship between load on muscle and (AnyBody 7.1, AnyBody Technology, Aalborg, Denmark). joints and kinematic human movement. ,e internal joint moment, muscle force, and joint reaction To date, the mechanical load on the lumbar region force around the lumbar region during walking were esti- during walking with unilateral restricted knee extension has mated by musculoskeletal model simulation. ,e effect of not been clarified due to a lack of studies employing the extension limitation of the right knee joint on the musculoskeletal model simulation. ,e purpose of this study mechanical load of joints and muscles around the lumbar is to clarify the mechanical load on the lumbar region during region was analysed. walking with restricted knee extension, comparing the load ,e MoCap full-body model of the AnyBody Managed during normal walking, using musculoskeletal model sim- Model Repository v.2.1.1 was used as the musculoskeletal ulation. Mechanical load on the lumbar region was esti- model. ,e degrees of freedom of this model were 42, and mated by the lumbar muscle force, internal joint moment, the L4–5 intradiscal joint was defined as a joint with 3 and joint force on L4–5. We hypothesized that unilateral degrees of freedom. For the muscle contraction model, we restriction of knee extension increased the mechanical load used a Hill-type model that considered characteristics such of the lumbar region at the ipsilateral stance phase during as parallel contraction elements and passive elements of Journal of Healthcare Engineering 3 muscles, in-line tendon elasticity, and pinnate angle of distribution could not be assumed. Tukey’s test or Wil- muscle fibres [30]. coxon’s rank-sum test with Bonferroni correction was used as post hoc tests. Meanwhile, η ,e ground reaction force was also estimated by the was calculated to estimate optimization method for further kinetic analysis. Twenty- the effect size in ANOVA and the Friedman test. Effect size 2 2 four points of contact with the floor were defined on the was classified into small (η � 0.01), medium (η � 0.06), and bilateral sole of the musculoskeletal model, and the presence large (η > 0.14), according to a previous study [37]. SPSS or the absence of contact was determined by the distance to Statistics 26.0 was used as the statistical software, and the the floor and the relative acceleration [31]. ,e ground threshold of significance was established at 0.05. reaction force was estimated so that it balanced the sum of the mass-acceleration product of all body segments and the 3. Results gravity acting on the whole body [32]. ,en, the joint ° ° moment, joint reaction force, and muscle force around the Gait velocities under 15 and 30 restricted knee conditions lumbar region during walking were calculated using inverse were 0.88± 0.18 m/s and 0.86± 0.18 m/s, respectively, dynamics and optimization methods. Optimization was showing a significantly slower velocity than normal walking performed to minimize the sum of the cubes of the muscle of 1.11± 0.11 m/s (Table 1). ,e maximum right knee ex- load expressed by the ratio of the exerted muscle output to tension angle was -4.2± 4.9 during normal walking, ° ° ° the maximum muscle strength of each muscle [33]. ,e -17.0± 7.7 in the 15 restricted condition, and -27.3± 0.2 in muscle force of the bilateral lumbar multifidus and erector the 30 restricted condition, respectively (Table 1). Similarly, spinae was calculated. ,e muscle force of the erector spinae a decreased knee extension angle was also observed in the and iliocostalis muscles was calculated as the sum of forces left knee joint of the unrestricted side. Trunk flexion angle generated by those fibres crossing L4–5. ,e joint reaction throughout a gait cycle was increased with an increment in force acting on L4 from L5 was estimated based on the local knee restriction angle (Figure 1(a); Table 1). coordinate system of L5, referring to the recommendation L4–5 moment showed peaks during early stance of the by the International Society of Biomechanics [34, 35]. We bilateral lower limb. Lumbar extension moment at the early initially examined the validity of the joint moment, the joint stance of the restricted side was significantly increased by ° ° reaction force of L4–5, and the muscle force of the lumbar 1.7- and 2.2-fold under the 15 and 30 restricted conditions region estimated by predicted ground reaction force com- compared with normal walking, respectively (Figure 1(c); pared with those calculated using measured ground reaction Table 2). ,e difference in L4–5 extension moment of the force. ,e values obtained from the two methods were very restricted side had a large effect size (η = 0.543). Lumbar similar, and intraclass correlation coefficients were very extension moment at early stance of the unrestricted side (2,1) high, 0.97–1.00 (95% confidence level, 0.87–1.00; p< 0.001). showed similar results. ,e lateral lumbar moment to the Trunk angle was defined as the angle of the thorax right, in the 30 restriction condition, was significantly in- segment relative to the global coordinate system. ,orax creased compared to that during normal walking at the early coordinate system was defined by the makers attached to the stance of the unrestricted side (Figure 1(d); Table 2). jugular incision, xiphoid process, and spinous process of the Muscle force of the multifidus showed peaks at the stance C7 vertebra and T8 vertebra, according to the recommen- phase of the contralateral side during walking, and the erector dation by International Society of Biomechanics [36]. ,e spinae showed force peaks at early stance of the bilateral lower walking speed and walking cycle were calculated from the limb (Figure 2). Muscle force of the right multifidus at early trajectory of the markers on both heels. Time of the kine- stance of the unrestricted side was significantly increased to matic and kinetic data was normalized as 100% for the right 3.3- and 4.3-fold compared with normal gait by the 15 and walking cycle duration; joint moment, joint reaction force, 30 restriction of the right knee joint, respectively (Figure 2(a); and muscle force were also normalized by body weight. ,e Table 2). Muscle force at early stance of the left multifidus waveforms for five trials were averaged to produce an en- significantly increased muscle force to 2.3- and 3.3-fold of semble average waveform for each participant. those during normal gait. Similarly, the right erector spinae significantly increased peak force by 28.0% and 54.5% at early stance of the restricted lower limb, and 68.1% and 101.7% at 2.3. Statistical Analysis. Peak values of kinematic and kinetic early stance of the unrestricted lower limb due to the 15 and data of the sagittal and frontal planes were compared among 30 restricted conditions (Figure 2(b); Table 2). ,e left erector three gait conditions during 0%–30% and 50%–80% of the spinae showed similar results to the right erector spinae right gait cycle, according to a previous study [19]. ,ese (Figure 2(b); Table 2). ,e difference in muscle force of the analysis sections correspond to the early stance and early multifidus and erector spinae had a large effect size mid-stance phases of both lower limbs. Trunk angle, joint (η = 0.273–0.486). moment, muscle force, and joint reaction force were A joint force acting on L4–5 showed two peaks at early compared to examine the effect of unilateral knee extension stance of the bilateral lower limb during the walking cycle restriction on the mechanical lumbar load. ,e normality of (Figure 3). ,e anterior force of L4–5 at early stance of the data distribution was confirmed by the Shapiro–Wilk test. unrestricted lower limb was significantly increased by 25.3% ° ° Repeated-measures analysis of variance (ANOVA) was in the 15 restricted condition and 36.5% in the 30 restricted performed if the normal distribution was able to be assumed, condition compared with normal walking (Figure 3(a); or Friedman test was performed in cases where normal Table 2). Vertical force of L4–5 during gait with the 30 4 Journal of Healthcare Engineering Table 1: Gait velocity, knee, and trunk angle during gait under three conditions (mean± standard deviation). 2 2 ° ° Normal 15 30 F or χ p value η ∗∗ ∗∗ Gait velocity (m/s) 1.11± 0.11 0.88± 0.18 0.86± 0.18 F � 30.49 <0.001 0.337 Right knee extension ∗ ∗∗ Angle ( ) −4.2± 4.9 −17.0± 7.7 −27.3± 0.2 † χ � 34.00 <0.001 1.000 ∗ ∗∗ Moment (Nm/kg) 0.51± 0.24 0.73± 0.28 0.86± 0.37 χ �17.29 <0.001 0.509 Left knee extension ∗∗ ∗∗ Angle ( ) −4.9± 5.6 −12.3± 7.7 −17.1± 9.7 † F � 24.14 <0.001 0.290 Moment (Nm/kg) 0.55± 0.22 0.57± 0.29 0.69± 0.33† F � 4.06 0.027 0.043 Trunk angle ( ) ∗∗ ∗∗ 1st 4.9± 3.7 11.1± 6.1 14.6± 6.8 ‡ F � 23.77 <0.001 0.345 Flexion ∗∗ ∗∗ 2nd 4.5± 3.5 11.5± 6.5 14.8± 7.0 † F � 26.09 <0.001 0.363 ∗∗ 1st 1.6± 2.2 2.4± 2.3 3.2± 2.7 χ �10.42 0.005 0.306 Lateral 2nd −0.4± 2.2 −1.2± 2.7 −0.8± 3.3 F � 1.39 0.263 0.013 ∗ ∗∗ 1st indicates the peak of 0%–30%, and 2nd indicates the peak of 50%–80% of the right gait cycle. p< 0.05 vs. Normal; p< 0.01 vs. Normal; †p< 0.05 vs. 15; ‡p < 0.01 vs. 15 . 0 4 ** -4 2 -8 0 ** ** -12 **‡ -2 **† -16 -4 0 20 40 60 80 100 0 20 40 60 80 100 % Gait cycle % Gait cycle Normal Normal 15° 15° 30° 30° (a) (b) 0.5 0.3 **‡ 0.2 0.4 **† ** 0.3 0.1 0.2 0 0.1 -0.1 -0.2 -0.3 -0.1 0 20 40 60 80 100 0 20 40 60 80 100 % Gait cycle % Gait cycle Normal Normal 15° 15° 30° 30° (c) (d) Figure 1: ,e ensemble average of all participants of sagittal trunk motion (a) lateral trunk motion (b) sagittal L4–5 internal joint moment ° ° (c) and lateral L4–5 internal joint moment (d) “Normal” denotes normal walking, and “15 ” and “30 ” indicate the condition concerning the right knee extension restriction. Time was normalized across the whole gait cycle of the right lower limb. ,e shaded regions indicate early ∗ ∗∗ stance of the bilateral lower limbs and peaks that were analysed statistically. and indicate a significant difference between the normal condition at p< 0.05 and p< 0.01, respectively. † and ‡ indicate significant difference between 15 at p< 0.05 and p< 0.01, respectively. restricted knee increased significantly by 10.0% at early walking, respectively (Figure 3(c); Table 2). Differences in stance of the restricted lower limb, and 23.0% at early stance the anterior and vertical forces of L4–5 had a large effect size of the unrestricted lower limb compared with normal (η � 0.149–0.425). Sagittal Motion (º) Sagittal Moment (Nm/kg) Flexion Extension Flexion Extension Lateral Moment (Nm/kg) Lateral Motion (º) Le Right Le Right Journal of Healthcare Engineering 5 Table 2: Internal joint moment, muscle force, and joint force around the L4–5 joint during gait under three conditions (mean± standard deviation). 2 2 ° ° Normal 15 30 F or χ η value L4–5 moment (Nm/kg) ∗∗† 1st 0.17± 0.08 0.29± 0.11 0.38± 0.15 χ �18.47 <0.001 0.543 Extension ∗∗ ∗∗‡ 2nd 0.15± 0.08 0.34± 0.15 0.44± 0.16 F � 29.30 <0.001 0.440 1st −0.20± 0.04 −0.24± 0.06 −0.24± 0.07 F � 4.38 0.021 0.093 Lateral 2nd 0.18± 0.06 0.22± 0.06 0.24± 0.08 F � 7.55 0.002 0.120 Muscle force (%BW) ∗∗ ∗∗ Right 1.64± 1.12 5.42± 2.71 7.03± 3.38 F � 28.81 <0.001 0.433 Multifidus ∗∗ ∗∗‡ Left 1.57± 0.80 3.65± 1.94 5.25± 2.32 F � 27.32 <0.001 0.411 Erector spinae 1st 20.49± 12.25 26.22± 12.05 31.66± 8.77 χ � 9.29 0.010 0.273 Right ∗∗ ∗∗† 2nd 21.55± 7.84 36.23± 11.80 43.47± 12.75 F � 22.67 <0.001 0.407 ∗∗† 1st 23.88± 10.08 33.06± 13.17 40.49± 14.14 χ �15.65 <0.001 0.460 Left ∗∗ ∗∗† 36.33± 10.10 F � 26.42 <0.001 0.486 2nd 15.50± 5.79 29.85± 10.24 L4–5 force (%BW) 1st 17.45± 10.88 18.23± 10.16 19.93± 5.55 χ � 5.06 0.080 0.149 Anterior ∗ ∗∗ 2nd 15.03± 3.82 18.83± 3.96 20.52± 3.30 F � 12.34 <0.001 0.425 1st 2.18± 0.94 1.87± 1.15 1.86± 1.27 F � 2.32 0.115 0.017 Lateral 2nd −2.08± 0.53 −1.93± 1.03 −1.97± 1.11 F � 0.22 0.800 0.004 † 2 1st 130.23± 74.79 136.87± 69.58 143.27± 34.21 χ � 9.29 0.010 0.273 Vertical 2nd 117.46± 18.43 133.43± 23.70 144.49± 21.16 F � 7.50 0.002 0.204 ∗ ∗∗ 1st indicates the peak of 0%–30%, and 2nd indicates the peak of 50%–80% of the right gait cycle. p< 0.05 vs. Normal; p< 0.01 vs. Normal; †p< 0.05 vs. 15 ; ‡p < 0.01 vs. 15 . moment. Forward tilt of the trunk would occur to suppress 4.Discussion an increase in the knee joint extension moment, caused by a ,is is the first study that verified mechanical load on muscles forward shift of the mass of the upper body and reduced and joints of the lumbar region during walking with unilateral moment arm of the ground reaction force around the knee knee extension restriction to our knowledge. Consistent with joint. On the other hand, the forward tilt of the trunk in- our hypothesis, the current results showed that the muscle creased the moment arm of the ground reaction force force and joint reaction force of the lumbar region were around the L4–5 joint, resulting in an increase in L4–5 increased as the degree of knee restriction increased. extension moments. In addition, the difference of lower limb Meanwhile, increased load on the lumbar region was unex- length, owing to the restricted knee joint, increased trunk pectedly observed in the stance phase of the bilateral lower lateral inclination to the restricted side, resulting in in- limb. ,ese findings are important information for therapists creased L4–5 right flexion moment. engaged in the rehabilitation of patients with knee contracture Increased lumbar extension moment was observed also to prevent the secondary disorders such as low back pain. at early stance of the unrestricted lower limb. Maximal ,e extension moment between L4 and L5 was extension angle of the left knee (the unrestricted side) was 0.15–0.17 Nm/kg during normal walking in this study, decreased similarly to the restricted knee joint during adding support to previous studies [19, 20, 38]. Restricted walking. Unilateral restriction of the knee joint caused a knee joint extension increased mechanical load on the difference in bilateral leg length, resulting in asymmetry of lumbar region during walking, despite the decrease in pelvis and trunk motion during gait. Participants with walking speed. Restricted knee extension increased the unilateral restriction of knee extension walked with an lumbar extension and right flexion moment compared with optional flexed knee joint to suppress the asymmetrical normal walking. In particular, the increase in extension trunk movement. On the other hand, this gait alteration moment was large, increasing by 70.6%–123.5% at the 15 increased the bilateral knee extensor muscle load. ,us, restriction and 126.7%–193.3% at the 30 restriction con- compensation through a forward trunk tilt was also observed dition compared with normal walking. Trunk alignment during stance phase of the contralateral lower limb, and an alteration due to restriction of the knee joint would have increased L4–5 extension moment appeared similarly in the increased the lumbar extension moment. Similar to previous stance phase of the restricted side. ,ose increased lumbar findings [6, 7], right knee restriction during walking in- moment required greater muscle force of the bilateral creased trunk flexion and right flexion angle during gait. multifidus and erector spinae than during normal walking. Restriction of knee extension increased the distance between ,e vertical and anterior components of the joint force the ground reaction force vector and the centre of the knee on L4–5 in normal walking were at a maximum between the joint of early stance of the restricted side during walking, loading response phase and the mid-stance phase, ap- resulting in an increase in internal knee joint extension proximately 117%–130% body weight (BW) and 15%–17% 6 Journal of Healthcare Engineering 8 8 ** 6 6 **‡ ** 4 4 ** 2 2 0 0 0 20 40 60 80 100 0 20 40 60 80 100 % Gait cycle % Gait cycle Normal Normal 15° 15° 30° 30° (a) (b) 50 50 **† **† 40 40 **† ** 30 30 ** 20 20 10 10 0 0 0 20 40 60 80 100 0 20 40 60 80 100 % Gait cycle % Gait cycle Normal Normal 15° 15° 30° 30° (c) (d) Figure 2: ,e ensemble average of all participants of the bilateral multifidus (a) and erector spinae (b) “Normal” denotes normal walking, ° ° and “15 ” and “30 ” indicate the right knee extension restriction condition. Time was normalized across the whole gait cycle of the right lower ∗ ∗∗ limb. ,e shaded regions indicate early stance of the bilateral lower limbs, and peaks of those were analysed statistically. and indicate a significant difference between the normal condition at p< 0.05 and p< 0.01, respectively. † and ‡ show significant difference between 15 at p< 0.05 and p< 0.01, respectively. 25 3 160 ** * 1 0 80 -1 -2 0 -3 0 0 20 40 60 80 100 0 20 40 60 80 100 0 20 40 60 80 100 % Gait cycle % Gait cycle % Gait cycle Normal Normal Normal 15° 15° 15° 30° 30° 30° (a) (b) (c) Figure 3: ,e ensemble average of all participants of anterior force (a) lateral force (b) and vertical force (c) acting on the L4–5 joint. ° ° “Normal” denotes normal walking, and “15 ” and “30 ” indicate the right knee extension restriction condition. Time was normalized across the whole gait cycle of the right lower limb. ,e shaded regions indicate early stance of the bilateral lower limbs, and peaks of those were ∗ ∗∗ analysed statistically. and indicate a significant difference between the normal condition at p< 0.05 and p< 0.01, respectively. † shows the significant difference of 15 at p< 0.05. Anterior Force (%BW) Right Erector spinae (%BW) Right Multifidus (%BW) Lateral Force (%BW) Le Right Le Erector spinae (%BW) Le Multifidus (%BW) Vertical Force (%BW) Journal of Healthcare Engineering 7 BW in this study, respectively. Similarly, in a previous study References [39] that analysed the joint force on L4–5 during walking, [1] A. Guzik, M. Druzbicki, ˙ A. Wolan-Nieroda, A. Turolla, and calculated using a musculoskeletal model, the vertical P. 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Effect of Unilateral Knee Extension Restriction on the Lumbar Region during Gait

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Copyright © 2022 Shintaro Nakatsuji et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
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Hindawi Journal of Healthcare Engineering Volume 2022, Article ID 1151753, 8 pages https://doi.org/10.1155/2022/1151753 Research Article Effect of Unilateral Knee Extension Restriction on the Lumbar Region during Gait 1,2 3 1 Shintaro Nakatsuji , Masayuki Kawada , Yasufumi Takeshita , 1,2 2 3 3 Yuta Matsuzawa , Kazutaka Hata, Sota Araki , and Ryoji Kiyama Doctoral Program, Division of Health Sciences, Graduate School of Health Sciences, Kagoshima University, 8-35-1 Sakuragaoka, Kagoshima City, Kagoshima 890-8544, Japan Miyakonojo Rehabilitation Academy, 5822-9 Oiwada-cho, Miyakonojo City, Miyazaki 885-0062, Japan Department of Physical Šerapy, School of Health Sciences, Faculty of Medicine, Kagoshima University, 8-35-1 Sakuragaoka, Kagoshima City, Kagoshima 890-8544, Japan Correspondence should be addressed to Masayuki Kawada; kawada@health.nop.kagoshima-u.ac.jp Received 20 December 2021; Accepted 20 July 2022; Published 22 August 2022 Academic Editor: Georgian Badicu Copyright © 2022 Shintaro Nakatsuji et al. ­is is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Unilateral knee extension restriction might change trunk alignment and increase mechanical load on the lumbar region during walking. We aimed to clarify lumbar region mechanical load during walking with restricted knee extension using a muscu- loskeletal model simulation. Seventeen healthy adult males were enrolled in this study. Participants walked 10 m at a comfortable ° ° velocity with and without restricted right knee extension of 15 and 30 using a knee brace. L4–5 joint moment, joint reaction force, and muscle forces around the lumbar region during walking were calculated for each condition. Peaks of kinetic data were compared among three gait conditions during 0%–30% and 50%–80% of the right gait cycle. Lumbar extension moment at early stance of the bilateral lower limbs was signi”cantly increased in the 30 restricted condition (p ≤ 0.021). Muscle force of the multi”dus showed peaks at stance phase of the contralateral side during walking, and the erector spinae showed force peaks at early stance of the bilateral lower limb. Muscle force of the multi”dus and erector spinae increased with increasing degree of knee —exion (p ≤ 0.010), with a large e˜ect size (η = 0.273–0.486). ­e joint force acting on L4–5 showed two peaks at early stance of the bilateral lower limbs during the walking cycle. ­e anterior and vertical joint force on L4–5 increased by 14.2%–36.5% and 10.0%– 23.0% in walking with restricted knee extension, respectively (p ≤ 0.010), with a large e˜ect size (η = 0.149–0.425). Restricted knee joint extension changed trunk alignment and increased the muscle force and the vertical and anterior joint force on the L4–5 joint during walking; this tendency became more obvious with increased restriction angle. Our results provide important information for therapists engaged in the rehabilitation of patients with knee contracture. Knee joint plays an important role during walking. It 1. Introduction supports the body weight in the stance phase and adjusts the Increased musculoskeletal stress repeated during daily ac- lower limb length by changing the relative angle between the tivities leads to pain or movement disorders. ­us, lower leg and thigh in the swing phase [1]. ­ese knee knowledge of the load on joints and muscles during daily functions contribute to e¦cient and safe walking. Unilateral activity and exercise is useful information for understanding restriction of knee extension caused by knee osteoarthritis or the clinical condition of patients and planning an appro- orthopaedic surgery increases posterior tilt, lateral tilt to the priate therapeutic program during musculoskeletal reha- a˜ected side of the pelvis, lumbar kyphosis, and lateral tilt of bilitation. Dysfunction of the lower limbs a˜ects the the trunk in the standing position [2–6]. During walking, kinematics and kinetics of the entire body during stance. unilateral restriction of knee extension also changes the gait 2 Journal of Healthcare Engineering walking, and this tendency would be more obvious as re- kinematics as follows: it increases anterior tilt of the pelvis and trunk, and increases lateral tilt towards the unaffected striction of the knee angle increased. side during the stance phase [7]. ,ese changes in the postural alignment of the entire body are associated with low back pain. A previous study reported that 58.1% of patients 2. Materials and Methods with knee osteoarthritis have low back pain [8]; this rela- 2.1. Participants. Seventeen healthy adult males with no tionship between knee dysfunction and low back pain is orthopaedic or neurological disorders influencing normal called knee-spine syndrome [9, 10]. gait in the lumbar region and lower limbs (age, 26.0± 2.2 y; Kinetic changes during walking with a restricted ex- height, 1.69± 0.05 m; weight, 62.5± 5.6 kg; average± - tension of the knee joint have been analysed in previous standard deviation; 16 right footed and 1 left footed) par- studies where knee joint force was bilaterally increased ticipated in this study. ,e Medical clearance was during loading response depending on the degree of re- preliminarily obtained by a physical therapist’s interview. striction of the knee joint [11–13]. Knee extension re- ,e participants were given a written and oral explanation of striction also increases the vertical component of ground the purpose and content of the study, and their consent was reaction force and the external knee flexion moment, obtained in writing in accordance with the principles which increases the demand for muscle activity in the stipulated in the Declaration of Helsinki. Participants were lower extremities [14–17]. Gait kinematics and kinetics advised that participation in the research was voluntary and due to restriction of knee extension might increase the they would incur no disadvantage even if they decided not to load on the lumbar region during the loading response participate in the research or withdrew their consent. ,is phase of the restricted lower limb during gait and is re- study was approved by the Ethics Committee on Epide- lated to low back pain. Although knowledge regarding a miology and Clinical Research of the Faculty of Medicine, change in the lumbar load during walking, caused by the Kagoshima University (number, 180095Epi ver2). restriction of knee extension, is necessary for therapists engaged in the rehabilitation of patients with knee in- juries, there is a dearth of studies that have analysed this issue. 2.2. Measurement and Procedures. A motion analysis system Lumbar load during gait is usually analysed by muscle consisting of eight infrared cameras was used to measure gait activity measured using electromyography. Various studies with and without restricted extension of the right knee joint. report that increased trunk sway increases the stress on ,e sampling frequency was 100 Hz for the infrared camera. lumbar muscles during gait [18–21]. However, action po- Retroreflective markers were placed in accordance with the tential obtained from electromyography correlates with plug-in-gait model; we also placed markers on the medial muscle force only in isometric contractions, but not in epicondyle and medial malleolus, and plates with three reflex concentric and eccentric contractions. ,us, the muscle markers on the bilateral thigh and shank [27, 28]. Right knee ° ° action potential does not necessarily reflect the mechanical extension was restricted by 15 and 30 using a knee brace stress of the muscle. ,ese issues make it difficult to analyse with bilateral struts [6, 7, 29]. Flexion of the right knee joint lumbar load during movement. was not restricted. First, we confirmed whether the maxi- Meanwhile, musculoskeletal model simulation becomes mum knee extension angle during walking was restricted as useful for estimating the muscle force of whole-body intended. Participants randomly performed 10-m walking muscles in human movement science. A musculoskeletal with and without a restricted knee joint at a comfortable model simulation can noninvasively quantify the joint load, speed five times after several rounds of practice in each gait based on inverse dynamics and an optimization method condition. from the kinematic data obtained by motion capture ,e noise was removed from the kinematic data mea- [22–26]. Musculoskeletal model simulation can estimate sured by the motion capture system using a Butterworth both joint force and muscle force. In other words, a mus- low-pass filter with a cut-off frequency of 6 Hz. ,en, the culoskeletal model simulation contributes to our under- kinematic data were input to the musculoskeletal model standing of the relationship between load on muscle and (AnyBody 7.1, AnyBody Technology, Aalborg, Denmark). joints and kinematic human movement. ,e internal joint moment, muscle force, and joint reaction To date, the mechanical load on the lumbar region force around the lumbar region during walking were esti- during walking with unilateral restricted knee extension has mated by musculoskeletal model simulation. ,e effect of not been clarified due to a lack of studies employing the extension limitation of the right knee joint on the musculoskeletal model simulation. ,e purpose of this study mechanical load of joints and muscles around the lumbar is to clarify the mechanical load on the lumbar region during region was analysed. walking with restricted knee extension, comparing the load ,e MoCap full-body model of the AnyBody Managed during normal walking, using musculoskeletal model sim- Model Repository v.2.1.1 was used as the musculoskeletal ulation. Mechanical load on the lumbar region was esti- model. ,e degrees of freedom of this model were 42, and mated by the lumbar muscle force, internal joint moment, the L4–5 intradiscal joint was defined as a joint with 3 and joint force on L4–5. We hypothesized that unilateral degrees of freedom. For the muscle contraction model, we restriction of knee extension increased the mechanical load used a Hill-type model that considered characteristics such of the lumbar region at the ipsilateral stance phase during as parallel contraction elements and passive elements of Journal of Healthcare Engineering 3 muscles, in-line tendon elasticity, and pinnate angle of distribution could not be assumed. Tukey’s test or Wil- muscle fibres [30]. coxon’s rank-sum test with Bonferroni correction was used as post hoc tests. Meanwhile, η ,e ground reaction force was also estimated by the was calculated to estimate optimization method for further kinetic analysis. Twenty- the effect size in ANOVA and the Friedman test. Effect size 2 2 four points of contact with the floor were defined on the was classified into small (η � 0.01), medium (η � 0.06), and bilateral sole of the musculoskeletal model, and the presence large (η > 0.14), according to a previous study [37]. SPSS or the absence of contact was determined by the distance to Statistics 26.0 was used as the statistical software, and the the floor and the relative acceleration [31]. ,e ground threshold of significance was established at 0.05. reaction force was estimated so that it balanced the sum of the mass-acceleration product of all body segments and the 3. Results gravity acting on the whole body [32]. ,en, the joint ° ° moment, joint reaction force, and muscle force around the Gait velocities under 15 and 30 restricted knee conditions lumbar region during walking were calculated using inverse were 0.88± 0.18 m/s and 0.86± 0.18 m/s, respectively, dynamics and optimization methods. Optimization was showing a significantly slower velocity than normal walking performed to minimize the sum of the cubes of the muscle of 1.11± 0.11 m/s (Table 1). ,e maximum right knee ex- load expressed by the ratio of the exerted muscle output to tension angle was -4.2± 4.9 during normal walking, ° ° ° the maximum muscle strength of each muscle [33]. ,e -17.0± 7.7 in the 15 restricted condition, and -27.3± 0.2 in muscle force of the bilateral lumbar multifidus and erector the 30 restricted condition, respectively (Table 1). Similarly, spinae was calculated. ,e muscle force of the erector spinae a decreased knee extension angle was also observed in the and iliocostalis muscles was calculated as the sum of forces left knee joint of the unrestricted side. Trunk flexion angle generated by those fibres crossing L4–5. ,e joint reaction throughout a gait cycle was increased with an increment in force acting on L4 from L5 was estimated based on the local knee restriction angle (Figure 1(a); Table 1). coordinate system of L5, referring to the recommendation L4–5 moment showed peaks during early stance of the by the International Society of Biomechanics [34, 35]. We bilateral lower limb. Lumbar extension moment at the early initially examined the validity of the joint moment, the joint stance of the restricted side was significantly increased by ° ° reaction force of L4–5, and the muscle force of the lumbar 1.7- and 2.2-fold under the 15 and 30 restricted conditions region estimated by predicted ground reaction force com- compared with normal walking, respectively (Figure 1(c); pared with those calculated using measured ground reaction Table 2). ,e difference in L4–5 extension moment of the force. ,e values obtained from the two methods were very restricted side had a large effect size (η = 0.543). Lumbar similar, and intraclass correlation coefficients were very extension moment at early stance of the unrestricted side (2,1) high, 0.97–1.00 (95% confidence level, 0.87–1.00; p< 0.001). showed similar results. ,e lateral lumbar moment to the Trunk angle was defined as the angle of the thorax right, in the 30 restriction condition, was significantly in- segment relative to the global coordinate system. ,orax creased compared to that during normal walking at the early coordinate system was defined by the makers attached to the stance of the unrestricted side (Figure 1(d); Table 2). jugular incision, xiphoid process, and spinous process of the Muscle force of the multifidus showed peaks at the stance C7 vertebra and T8 vertebra, according to the recommen- phase of the contralateral side during walking, and the erector dation by International Society of Biomechanics [36]. ,e spinae showed force peaks at early stance of the bilateral lower walking speed and walking cycle were calculated from the limb (Figure 2). Muscle force of the right multifidus at early trajectory of the markers on both heels. Time of the kine- stance of the unrestricted side was significantly increased to matic and kinetic data was normalized as 100% for the right 3.3- and 4.3-fold compared with normal gait by the 15 and walking cycle duration; joint moment, joint reaction force, 30 restriction of the right knee joint, respectively (Figure 2(a); and muscle force were also normalized by body weight. ,e Table 2). Muscle force at early stance of the left multifidus waveforms for five trials were averaged to produce an en- significantly increased muscle force to 2.3- and 3.3-fold of semble average waveform for each participant. those during normal gait. Similarly, the right erector spinae significantly increased peak force by 28.0% and 54.5% at early stance of the restricted lower limb, and 68.1% and 101.7% at 2.3. Statistical Analysis. Peak values of kinematic and kinetic early stance of the unrestricted lower limb due to the 15 and data of the sagittal and frontal planes were compared among 30 restricted conditions (Figure 2(b); Table 2). ,e left erector three gait conditions during 0%–30% and 50%–80% of the spinae showed similar results to the right erector spinae right gait cycle, according to a previous study [19]. ,ese (Figure 2(b); Table 2). ,e difference in muscle force of the analysis sections correspond to the early stance and early multifidus and erector spinae had a large effect size mid-stance phases of both lower limbs. Trunk angle, joint (η = 0.273–0.486). moment, muscle force, and joint reaction force were A joint force acting on L4–5 showed two peaks at early compared to examine the effect of unilateral knee extension stance of the bilateral lower limb during the walking cycle restriction on the mechanical lumbar load. ,e normality of (Figure 3). ,e anterior force of L4–5 at early stance of the data distribution was confirmed by the Shapiro–Wilk test. unrestricted lower limb was significantly increased by 25.3% ° ° Repeated-measures analysis of variance (ANOVA) was in the 15 restricted condition and 36.5% in the 30 restricted performed if the normal distribution was able to be assumed, condition compared with normal walking (Figure 3(a); or Friedman test was performed in cases where normal Table 2). Vertical force of L4–5 during gait with the 30 4 Journal of Healthcare Engineering Table 1: Gait velocity, knee, and trunk angle during gait under three conditions (mean± standard deviation). 2 2 ° ° Normal 15 30 F or χ p value η ∗∗ ∗∗ Gait velocity (m/s) 1.11± 0.11 0.88± 0.18 0.86± 0.18 F � 30.49 <0.001 0.337 Right knee extension ∗ ∗∗ Angle ( ) −4.2± 4.9 −17.0± 7.7 −27.3± 0.2 † χ � 34.00 <0.001 1.000 ∗ ∗∗ Moment (Nm/kg) 0.51± 0.24 0.73± 0.28 0.86± 0.37 χ �17.29 <0.001 0.509 Left knee extension ∗∗ ∗∗ Angle ( ) −4.9± 5.6 −12.3± 7.7 −17.1± 9.7 † F � 24.14 <0.001 0.290 Moment (Nm/kg) 0.55± 0.22 0.57± 0.29 0.69± 0.33† F � 4.06 0.027 0.043 Trunk angle ( ) ∗∗ ∗∗ 1st 4.9± 3.7 11.1± 6.1 14.6± 6.8 ‡ F � 23.77 <0.001 0.345 Flexion ∗∗ ∗∗ 2nd 4.5± 3.5 11.5± 6.5 14.8± 7.0 † F � 26.09 <0.001 0.363 ∗∗ 1st 1.6± 2.2 2.4± 2.3 3.2± 2.7 χ �10.42 0.005 0.306 Lateral 2nd −0.4± 2.2 −1.2± 2.7 −0.8± 3.3 F � 1.39 0.263 0.013 ∗ ∗∗ 1st indicates the peak of 0%–30%, and 2nd indicates the peak of 50%–80% of the right gait cycle. p< 0.05 vs. Normal; p< 0.01 vs. Normal; †p< 0.05 vs. 15; ‡p < 0.01 vs. 15 . 0 4 ** -4 2 -8 0 ** ** -12 **‡ -2 **† -16 -4 0 20 40 60 80 100 0 20 40 60 80 100 % Gait cycle % Gait cycle Normal Normal 15° 15° 30° 30° (a) (b) 0.5 0.3 **‡ 0.2 0.4 **† ** 0.3 0.1 0.2 0 0.1 -0.1 -0.2 -0.3 -0.1 0 20 40 60 80 100 0 20 40 60 80 100 % Gait cycle % Gait cycle Normal Normal 15° 15° 30° 30° (c) (d) Figure 1: ,e ensemble average of all participants of sagittal trunk motion (a) lateral trunk motion (b) sagittal L4–5 internal joint moment ° ° (c) and lateral L4–5 internal joint moment (d) “Normal” denotes normal walking, and “15 ” and “30 ” indicate the condition concerning the right knee extension restriction. Time was normalized across the whole gait cycle of the right lower limb. ,e shaded regions indicate early ∗ ∗∗ stance of the bilateral lower limbs and peaks that were analysed statistically. and indicate a significant difference between the normal condition at p< 0.05 and p< 0.01, respectively. † and ‡ indicate significant difference between 15 at p< 0.05 and p< 0.01, respectively. restricted knee increased significantly by 10.0% at early walking, respectively (Figure 3(c); Table 2). Differences in stance of the restricted lower limb, and 23.0% at early stance the anterior and vertical forces of L4–5 had a large effect size of the unrestricted lower limb compared with normal (η � 0.149–0.425). Sagittal Motion (º) Sagittal Moment (Nm/kg) Flexion Extension Flexion Extension Lateral Moment (Nm/kg) Lateral Motion (º) Le Right Le Right Journal of Healthcare Engineering 5 Table 2: Internal joint moment, muscle force, and joint force around the L4–5 joint during gait under three conditions (mean± standard deviation). 2 2 ° ° Normal 15 30 F or χ η value L4–5 moment (Nm/kg) ∗∗† 1st 0.17± 0.08 0.29± 0.11 0.38± 0.15 χ �18.47 <0.001 0.543 Extension ∗∗ ∗∗‡ 2nd 0.15± 0.08 0.34± 0.15 0.44± 0.16 F � 29.30 <0.001 0.440 1st −0.20± 0.04 −0.24± 0.06 −0.24± 0.07 F � 4.38 0.021 0.093 Lateral 2nd 0.18± 0.06 0.22± 0.06 0.24± 0.08 F � 7.55 0.002 0.120 Muscle force (%BW) ∗∗ ∗∗ Right 1.64± 1.12 5.42± 2.71 7.03± 3.38 F � 28.81 <0.001 0.433 Multifidus ∗∗ ∗∗‡ Left 1.57± 0.80 3.65± 1.94 5.25± 2.32 F � 27.32 <0.001 0.411 Erector spinae 1st 20.49± 12.25 26.22± 12.05 31.66± 8.77 χ � 9.29 0.010 0.273 Right ∗∗ ∗∗† 2nd 21.55± 7.84 36.23± 11.80 43.47± 12.75 F � 22.67 <0.001 0.407 ∗∗† 1st 23.88± 10.08 33.06± 13.17 40.49± 14.14 χ �15.65 <0.001 0.460 Left ∗∗ ∗∗† 36.33± 10.10 F � 26.42 <0.001 0.486 2nd 15.50± 5.79 29.85± 10.24 L4–5 force (%BW) 1st 17.45± 10.88 18.23± 10.16 19.93± 5.55 χ � 5.06 0.080 0.149 Anterior ∗ ∗∗ 2nd 15.03± 3.82 18.83± 3.96 20.52± 3.30 F � 12.34 <0.001 0.425 1st 2.18± 0.94 1.87± 1.15 1.86± 1.27 F � 2.32 0.115 0.017 Lateral 2nd −2.08± 0.53 −1.93± 1.03 −1.97± 1.11 F � 0.22 0.800 0.004 † 2 1st 130.23± 74.79 136.87± 69.58 143.27± 34.21 χ � 9.29 0.010 0.273 Vertical 2nd 117.46± 18.43 133.43± 23.70 144.49± 21.16 F � 7.50 0.002 0.204 ∗ ∗∗ 1st indicates the peak of 0%–30%, and 2nd indicates the peak of 50%–80% of the right gait cycle. p< 0.05 vs. Normal; p< 0.01 vs. Normal; †p< 0.05 vs. 15 ; ‡p < 0.01 vs. 15 . moment. Forward tilt of the trunk would occur to suppress 4.Discussion an increase in the knee joint extension moment, caused by a ,is is the first study that verified mechanical load on muscles forward shift of the mass of the upper body and reduced and joints of the lumbar region during walking with unilateral moment arm of the ground reaction force around the knee knee extension restriction to our knowledge. Consistent with joint. On the other hand, the forward tilt of the trunk in- our hypothesis, the current results showed that the muscle creased the moment arm of the ground reaction force force and joint reaction force of the lumbar region were around the L4–5 joint, resulting in an increase in L4–5 increased as the degree of knee restriction increased. extension moments. In addition, the difference of lower limb Meanwhile, increased load on the lumbar region was unex- length, owing to the restricted knee joint, increased trunk pectedly observed in the stance phase of the bilateral lower lateral inclination to the restricted side, resulting in in- limb. ,ese findings are important information for therapists creased L4–5 right flexion moment. engaged in the rehabilitation of patients with knee contracture Increased lumbar extension moment was observed also to prevent the secondary disorders such as low back pain. at early stance of the unrestricted lower limb. Maximal ,e extension moment between L4 and L5 was extension angle of the left knee (the unrestricted side) was 0.15–0.17 Nm/kg during normal walking in this study, decreased similarly to the restricted knee joint during adding support to previous studies [19, 20, 38]. Restricted walking. Unilateral restriction of the knee joint caused a knee joint extension increased mechanical load on the difference in bilateral leg length, resulting in asymmetry of lumbar region during walking, despite the decrease in pelvis and trunk motion during gait. Participants with walking speed. Restricted knee extension increased the unilateral restriction of knee extension walked with an lumbar extension and right flexion moment compared with optional flexed knee joint to suppress the asymmetrical normal walking. In particular, the increase in extension trunk movement. On the other hand, this gait alteration moment was large, increasing by 70.6%–123.5% at the 15 increased the bilateral knee extensor muscle load. ,us, restriction and 126.7%–193.3% at the 30 restriction con- compensation through a forward trunk tilt was also observed dition compared with normal walking. Trunk alignment during stance phase of the contralateral lower limb, and an alteration due to restriction of the knee joint would have increased L4–5 extension moment appeared similarly in the increased the lumbar extension moment. Similar to previous stance phase of the restricted side. ,ose increased lumbar findings [6, 7], right knee restriction during walking in- moment required greater muscle force of the bilateral creased trunk flexion and right flexion angle during gait. multifidus and erector spinae than during normal walking. Restriction of knee extension increased the distance between ,e vertical and anterior components of the joint force the ground reaction force vector and the centre of the knee on L4–5 in normal walking were at a maximum between the joint of early stance of the restricted side during walking, loading response phase and the mid-stance phase, ap- resulting in an increase in internal knee joint extension proximately 117%–130% body weight (BW) and 15%–17% 6 Journal of Healthcare Engineering 8 8 ** 6 6 **‡ ** 4 4 ** 2 2 0 0 0 20 40 60 80 100 0 20 40 60 80 100 % Gait cycle % Gait cycle Normal Normal 15° 15° 30° 30° (a) (b) 50 50 **† **† 40 40 **† ** 30 30 ** 20 20 10 10 0 0 0 20 40 60 80 100 0 20 40 60 80 100 % Gait cycle % Gait cycle Normal Normal 15° 15° 30° 30° (c) (d) Figure 2: ,e ensemble average of all participants of the bilateral multifidus (a) and erector spinae (b) “Normal” denotes normal walking, ° ° and “15 ” and “30 ” indicate the right knee extension restriction condition. Time was normalized across the whole gait cycle of the right lower ∗ ∗∗ limb. ,e shaded regions indicate early stance of the bilateral lower limbs, and peaks of those were analysed statistically. and indicate a significant difference between the normal condition at p< 0.05 and p< 0.01, respectively. † and ‡ show significant difference between 15 at p< 0.05 and p< 0.01, respectively. 25 3 160 ** * 1 0 80 -1 -2 0 -3 0 0 20 40 60 80 100 0 20 40 60 80 100 0 20 40 60 80 100 % Gait cycle % Gait cycle % Gait cycle Normal Normal Normal 15° 15° 15° 30° 30° 30° (a) (b) (c) Figure 3: ,e ensemble average of all participants of anterior force (a) lateral force (b) and vertical force (c) acting on the L4–5 joint. ° ° “Normal” denotes normal walking, and “15 ” and “30 ” indicate the right knee extension restriction condition. Time was normalized across the whole gait cycle of the right lower limb. ,e shaded regions indicate early stance of the bilateral lower limbs, and peaks of those were ∗ ∗∗ analysed statistically. and indicate a significant difference between the normal condition at p< 0.05 and p< 0.01, respectively. † shows the significant difference of 15 at p< 0.05. Anterior Force (%BW) Right Erector spinae (%BW) Right Multifidus (%BW) Lateral Force (%BW) Le Right Le Erector spinae (%BW) Le Multifidus (%BW) Vertical Force (%BW) Journal of Healthcare Engineering 7 BW in this study, respectively. Similarly, in a previous study References [39] that analysed the joint force on L4–5 during walking, [1] A. Guzik, M. Druzbicki, ˙ A. Wolan-Nieroda, A. Turolla, and calculated using a musculoskeletal model, the vertical P. 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Published: Aug 22, 2022

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