Influence of footwear on stabilometric dimensions and muscle activity

Pranab Nag, Anjali Nag, Heer Vyas & Priyanka Shah Shukla


Background: Properties of footwear exert an influence on centre of pressure (CoP) displacement parameters, muscle activity and user's postural control. Thereby, selection of footwear aid to manage postural stability and fall problems.

Objective: The study applies stabilometry, force exertion and electromyography when women stood and walked by donning footwear with different characteristics and in barefoot.

Method: Women volunteers aged (30.2 ± 5.6 year), and having BMI (27.6 ± 7.4) participated in the study. The footwear included in the study were of four different designs, laced shoe (2.5 cm heel), flat heeled (9 cm heel), and pointed heel (7 cm and 13 cm heel). Female subjects (N = 15) stood and walked after putting on footwear and in bare feet.

Results: The weighted force (kgf) distribution derived as the square root of the sum of squares of three forces at x, y and z coordinates was minimal in laced shoes, suggesting the relative stability in comparison to bare feet and other footwear. ANOVA showed that the footwear had discernible effect on the medio-lateral CoP displacement and CoP speed during standing, and anterior posterior CoP range while walking. The leg muscle activity, both soleus and tibaials anterior, was significantly higher in pointed heel (13 cm heel) while standing, suggesting that heels exert an influence on leg muscle activity and postural control mechanism.

Conclusion: Laced shoes gave relatively better postural stability to the wearer.

Potential implications: This work gives a valuable insight to consideration of biomechanical parameters for footwear manufacturers and wearers.


Regular Articles

Influence of footwear on stabilometric dimensions and muscle activity



Regular Articles

Influence of footwear on stabilometric dimensions and muscle activity



Knee Loading Deficits During Dynamic Tasks in Individuals Following Anterior Cruciate Ligament Reconstruction

Pratt KA, Sigward SM


Study Design Controlled laboratory study, cross-sectional. Background Well-documented deficits in sagittal plane knee loading during dynamic tasks indicate that individuals limit the magnitude of knee loading following anterior cruciate ligament reconstruction (ACLR). It is unknown how these individuals modulate the speed of knee flexion during loading, which is particularly important as they progress to running during rehabilitation. Objective To investigate how individuals following ACLR perform dynamic knee loading tasks compared to healthy controls. Methods Two groups of recreationally active individuals participated: 15 healthy controls and 15 individuals post-ACLR (ACLR group). Participants performed 3 trials of overground running and a single-limb loading (SLL) task. Sagittal plane range of motion, peak knee extensor moment, peak knee flexion angular velocity, peak knee power absorption, and rate of knee extensor moment were calculated during deceleration. A mixed-factor multivariate analysis of variance was performed to compare differences in variables between groups (ACLR and control), limbs (within ACLR), and tasks (within control). Results Knee power absorption, knee flexion angular velocity, and rate of knee extensor moment were lower in reconstructed limbs (for the SLL task: 5.6 W/kg, 325.8°/s, and 10.5 Nm/kg/s, respectively; for running: 11.8 W/kg, 421.4°/s, and 38.2 Nm/kg/s, respectively) compared to nonsurgical limbs (for the SLL task: 9.7 W/kg, 432.0°/s, and 19.1 Nm/kg/s, respectively; for running: 18.8 W/kg, 494.1°/s, and 72.8 Nm/kg/s, respectively) during both tasks (P<.001). The magnitudes of between-limb differences in knee flexion angular velocity were similar in both tasks. Conclusion Despite lower loading demands during SLL, individuals post-ACLR exhibit deficits in knee dynamics during SLL and running, suggesting an inability or reluctance to dynamically accommodate forces at the knee when progressing to running in rehabilitation.

The effect of the stability threshold on time to stabilization and its reliability following a single leg drop jump landing

Fransz DP, Huurnink A, de Boode VA, Kingma I, van Dieën JH


We aimed to provide insight in how threshold selection affects time to stabilization (TTS) and its reliability to support selection of methods to determine TTS. Eighty-two elite youth soccer players performed six single leg drop jump landings. The TTS was calculated based on four processed signals: raw ground reaction force (GRF) signal (RAW), moving root mean square window (RMS), sequential average (SA) or unbounded third order polynomial fit (TOP). For each trial and processing method a wide range of thresholds was applied. Per threshold, reliability of the TTS was assessed through intra-class correlation coefficients (ICC) for the vertical (V), anteroposterior (AP) and mediolateral (ML) direction of force. Low thresholds resulted in a sharp increase of TTS values and in the percentage of trials in which TTS exceeded trial duration. The TTS and ICC were essentially similar for RAW and RMS in all directions; ICC's were mostly 'insufficient' (<0.4) to 'fair' (0.4-0.6) for the entire range of thresholds. The SA signals resulted in the most stable ICC values across thresholds, being 'substantial' (>0.8) for V, and 'moderate' (0.6-0.8) for AP and ML. The ICC's for TOP were 'substantial' for V, 'moderate' for AP, and 'fair' for ML. The present findings did not reveal an optimal threshold to assess TTS in elite youth soccer players following a single leg drop jump landing. Irrespective of threshold selection, the SA and TOP methods yielded sufficiently reliable TTS values, while for RAW and RMS the reliability was insufficient to differentiate between players.

Combined Effects of Fatigue and Surface Instability on Jump Biomechanics in Elite Athletes

Prieske O, Demps M, Lesinski M, Granacher U


The present study aimed to examine the effects of fatigue and surface instability on kinetic and kinematic jump performance measures. Ten female and 10 male elite volleyball players (18±2 years) performed repetitive vertical double-leg box jumps until failure. Pre and post fatigue, jump height/performance index, ground reaction force and knee flexion/valgus angles were assessed during drop and countermovement jumps on stable and unstable surfaces. Fatigue, surface condition, and sex resulted in significantly lower drop jump performance and ground reaction force (p≤0.031, 1.1≤d≤3.5). Additionally, drop jump knee flexion angles were significantly lower following fatigue (p=0.006, d=1.5). A significant fatigue×surface×sex interaction (p=0.020, d=1.2) revealed fatigue-related decrements in drop jump peak knee flexion angles under unstable conditions and in men only. Knee valgus angles were higher on unstable compared to stable surfaces during drop jumps and in females compared to males during drop and countermovement jumps (p≤0.054, 1.0≤d≤1.1). Significant surface×sex interactions during countermovement jumps (p=0.002, d=1.9) indicated that knee valgus angles at onset of ground contact were significantly lower on unstable compared to stable surfaces in males but higher in females. Our findings revealed that fatigue and surface instability resulted in sex-specific knee motion strategies during jumping in elite volleyball players.

Coactivation of Lower Limb Muscles during Gait in Patients with Multiple Sclerosis

Julien Boudarham, Sophie Hameau, Raphael Zory, Alexandre Hardy, Djamel Bensmail, Nicolas Roche


Coactivation of agonist and antagonist lower limb muscles during gait stiffens joints and ensures stability. In patients with multiple sclerosis, coactivation of lower limb muscles might be a compensatory mechanism to cope with impairments of balance and gait.

The aim of this study was to assess coactivation of agonist and antagonist muscles at the knee and ankle joints during gait in patients with multiple sclerosis, and to evaluate the relationship between muscle coactivation and disability, gait performance, dynamic ankle strength measured during gait, and postural stability.

The magnitude and duration of coactivation of agonist-antagonist muscle pairs at the knee and ankle were determined for both lower limbs (more and less-affected) in 14 patients with multiple sclerosis and 11 healthy subjects walking at a spontaneous speed, using 3D-gait analysis.

In the patient group, coactivation was increased in the knee muscles during single support (proximal strategy) and in the ankle muscles during double support (distal strategy). The magnitude of coactivation was highest in the patients with the slowest gait, the greatest motor impairment and the most instability.

Increased muscle coactivation is likely a compensatory mechanism to limit the number of degrees of freedom during gait in patients with multiple sclerosis, particularly when postural stability is impaired.

Quantitative assessment of the effects of 6 months of adapted physical activity on gait in people with multiple sclerosis: a randomized controlled trial

Massimiliano Pau, Federica Corona, Giancarlo Coghe, Elisabetta Marongiu, Andrea Loi, Antonio Crisafulli, Alberto Concu, Manuela Galli, Maria Giovanna Marrosu & Eleonora Cocco


Purpose: The purpose of this study is to quantitatively assess the effect of 6 months of supervised adapted physical activity (APA i.e. physical activity designed for people with special needs) on spatio-temporal and kinematic parameters of gait in persons with Multiple Sclerosis (pwMS).

Methods: Twenty-two pwMS with Expanded Disability Status Scale scores ranging from 1.5 to 5.5 were randomly assigned either to the intervention group (APA, n = 11) or the control group (CG, n = 11). The former underwent 6 months of APA consisting of 3 weekly 60-min sessions of aerobic and strength training, while CG participants were engaged in no structured PA program. Gait patterns were analyzed before and after the training using three-dimensional gait analysis by calculating spatio-temporal parameters and concise indexes of gait kinematics (Gait Profile Score – GPS and Gait Variable Score – GVS) as well as dynamic Range of Motion (ROM) of hip, knee, and ankle joints.

Results: The training originated significant improvements in stride length, gait speed and cadence in the APA group, while GPS and GVS scores remained practically unchanged. A trend of improvement was also observed as regard the dynamic ROM of hip, knee, and ankle joints. No significant changes were observed in the CG for any of the parameters considered.

Conclusions: The quantitative analysis of gait supplied mixed evidence about the actual impact of 6 months of APA on pwMS. Although some improvements have been observed, the substantial constancy of kinematic patterns of gait suggests that the full transferability of the administered training on the ambulation function may require more specific exercises.

·  Implications for rehabilitation

·  Adapted Physical Activity (APA) is effective in improving spatio-temporal parameters of gait, but not kinematics, in people with multiple sclerosis.

·  Dynamic range of motion during gait is increased after APA.

·  The full transferability of APA on the ambulation function may require specific exercises rather than generic lower limbs strength/flexibility training.

Relationship between kinematic knee deviations and femoral anteversion in children with cerebral palsy.

Piccinini L, Cimolin V, Turconi AC, Galli M.


The aim of the study was to determine the possible correlation between the degree of femoral anteversion and the quantitative data obtained by 3D Gait Analysis (GA) and then to investigate the relationship between femoral anteversion and the reduced knee flexion during swing phase in childrenwith Cerebral Palsy. Twenty-­-seven diplegic children with severe rectus femoris spasticity and 20 healthy children (CG) were considered. Clinical evaluation of femoral anteversion, Duncan Ely test and Gait Analysis were performed in all patients. From Gait Analysis data some indices were identified and calculated and statistical analysis performed. Clinical evaluations made the distinction between patients with excessive femoralanteversion (Group 1) and those with normal value (Group 2). Both groups showed a blunt maximum of knee flexion in swing (KMSw), representative of rectus femoris spasticity, but two different gait strategies were found for the timing of KMSw. Group 1 exhibited a reduced KMSw value with its timing close to normal value and an excessive hip internal rotation (Mean Hip Rotation index), correlated to high femoral anteversion; Group 2 presented a limited KMSw and a significant delay of its timing, with Mean Hip Rotation index close to Control Group. No differences were found for other indices. The results demonstrated that the presence of reduced KMSw only can be directly connected to excessive femoral anteversion; the coexistence of reduced KMSw and its delayed timing reveals that the rectus femoris spasticity may be due to rectus spasticity added to an incorrect motor selective control. The results are clinically crucial for treatment strategies (derotative femoral osteotomy vs rectus transfer).

Effects of gastrocnemius fascia lengthening on gait pattern in children with cerebral palsy using the Gait Profile Score

Luiz Alfredo Braun Ferreira, Veronica Cimolin, Pier Francesco Costici, Giorgio Albertini, Claudia Santos Oliveira, Manuela Galli


The aim of the present study was to investigate the efficacy of the GPS regarding the quantification of changes in gait following the gastrocnemius fascia lengthening in children with CP. Nineteen children with CP were selected and evaluated in the preoperative period (PRE session) and approximately one year postoperatively (POST session; mean 13.1  5.1 months) using 3D gait analysis and computing the GPS and GVSs. As the GPS represents the difference between the patient’s data and the average from the reference dataset, the higher the value of GPS is, more compromised gait of the subject. A statistically significant improvement in mean GPS was found in the POST session (PRE: 13.38  58; POST: 10.26  2.418; p < 0.05), with an improvement close to 23%. Moreover, the GVSs demonstrated statistically significant improvements in ankle dorsi-plantarflexion (PRE: 22.20  16.368; POST: 11.50  6.578; p < 0.05) and pelvic rotation (PRE: 9.53  3.878; POST: 6.47  2.988; p < 0.05). A strong correlation (r = 0.75; p < 0.05) was found between the preoperative GPS and the percentage of GPS improvement. The results demonstrated that the gastrocnemius fascia lengthening produced a global gait pattern improvement, as showed by the GPS value, which decreased after surgery. Besides this, the GVS permitted to better evidence the joints more compromised by the pathology and their improvement due to the surgery, in this case not only the GVS of the ankle joint but also of the pelvis were characterized by higher GVS values.

Effect of Transcranial Direct-Current Stimulation Combined with Treadmill Training on Balance and Functional Performance in Children with Cerebral Palsy: A Double-Blind Randomized Controlled Trial

Natália de Almeida Carvalho Duarte, Luanda Andreá Collange Grecco, Manuela Galli, Felipe Fregni, Cláudia Santos Oliveira


Background: Cerebral palsy refers to permanent, mutable motor development disorders stemming from a primary brain lesion, causing secondary musculoskeletal problems and limitations in activities of daily living. The aim of the present study was to determine the effects of gait training combined with transcranial direct-current stimulation over the primary motor cortex on balance and functional performance in children with cerebral palsy.

Methods: A double-blind randomized controlled study was carried out with 24 children aged five to 12 years with cerebral palsy randomly allocated to two intervention groups (blocks of six and stratified based on GMFCS level (levels I-II or level III).The experimental group (12 children) was submitted to treadmill training and anodal stimulation of the primary motor cortex. The control group (12 children) was submitted to treadmill training and placebo transcranial direct-current stimulation. Training was performed in five weekly sessions for 2 weeks. Evaluations consisted of stabilometric analysis as well as the administration of the Pediatric Balance Scale and Pediatric Evaluation of Disability Inventory one week before the intervention, one week after the completion of the intervention and one month after the completion of the intervention. All patients and two examiners were blinded to the allocation of the children to the different groups.

Results: The experimental group exhibited better results in comparison to the control group with regard to anteroposterior sway (eyes open and closed; p,0.05), mediolateral sway (eyes closed; p,0.05) and the Pediatric Balance Scale both one week and one month after the completion of the protocol.

Conclusion: Gait training on a treadmill combined with anodal stimulation of the primary motor cortex led to improvements in static balance and functional performance in children with cerebral palsy.

Role of gait analysis in the process of clinical decision making concerning post-stroke patients.

Castagna A., Rabuffetti M, Montesano A., Ferrarin A.


Quantitative gait analysis is recognised to be the most effective analytical method to study and assess locomotor functions, thus complementing clinical assessment based on scale rating. Therefore scientific research in the human movement field more and more relies upon these methods to produce scientific evidences concerning the pathophysiology of muscoloskeletal system and motor control. The introduction of these methods in clinical settings has not been so successful: besides cost-effectiveness concerns, it is apparent that we are currently lacking strong evidences about the usefullness of gait analysis in the management of clinical cases. The only set where gait analysis is unanimously recognised as appropriate and highly recommended is the design of complex multilevel orthopedic surgery in cerebral palsy The objective of the present work is to present preliminary data from an ongoing research on the assessment of the usefullness of gait analysis in the clinical decision making process of patients suffering motor disorders post-stroke in chronic conditions. The research requires that the clinical management of a poststroke patient is initially performed by traditional clinical approach leading to a clinical decision which is first classified according to general therapy types (surgery, neuromuscolar pharmacological block, orthotic treatment, physiotherapy) and then furtherly specified by the details (which surgery, which muscle, which orthosis, which physical therapy). Obviously a clinical decision cannot be restricted to a single type. Then, the results of a gait analysis (though no costraint are assumed on which protocol apply, in our activity we generally adopt the LAMB plus foot protocol and an 8-channels dynamic electromyography, asking the patient to walk at self-selected and increased speeds) are considered by the decision-maker who revise eventually his/her decision. Three alternative occurrences are expected about the comparison of pregait and post-gait decisions: no change, minor change (when the details of the decided therapy are modified), major change (when the considered therapeutic types are changed) (omitting or including or substituting, for example discarding the toxin option to indicate an orthotic project, or discarding the surgery for physical therapy and toxin). Both pregait and post-gait decisions were scored on a ten-points scale by the decision-maker according to his/her confidence in it. In the present work we consider 10 post-ictus patients referring for clinical decision making to the SAFLo lab of the IRCCS Don Gnocchi of Milano. The comparison of pre- to post-gait decisions evidenced, out of 10 patients, 5 confirmed decisions (all with a slight increase of A relevant percentage of patients (50%) has a modified treatment plan, and about half of them experience a major change in it Such impact, if confirmed on larger samples, substantially support evidence for the use of gait analysis in clinical decision making of chronic post-stroke subjects. A perusal of the final data set will allow to further evidence if some anamnestic data or clinical signs let to identify a post-stroke confidence, 3 minor changes and 2 major changes. The presented preliminary results confirm the gait analysis potential in a clinical setting for ictus patients A relevant percentage of patients (50%) has a modified treatment plan, and about half of them experience a major change in it. Such impact, if confirmed on larger samples, substantially support evidence for the use of gait analysis in clinical decision making of chronic post-stroke subjects. A perusal of the final data set will allow to further evidence if some anamnestic data or clinical signs let to identify a post-stroke patients subgroup in which GA is effective even in a larger percentage, thus allowing for an even more effective GA prescription. It is relevant to note that the proposed research design strictly allows to evidence if gait analysis influences clinical decisions. Therefore, though expected, it is to be demonstrated that a gait analysis-based decision may produce a better outcome for the patient and/or a reduced cost-effectivness ratio in the management of post stroke patients.

Use of the Gait Deviation Index for the assessment of gastrocnemius fascia lengthening in children with Cerebral Palsy.

Cimolin V, Galli M, Vimercati SL, Albertini G.


Gait analysis (GA) is widely used for clinical evaluations and it is recognized as a central element in the quantitative evaluation of gait, in the planning of treatments and in the pre vs. post intervention evaluations in children with Cerebral Palsy (CP). Otherwise, GA produces a large volume of data and there is the clinical need to provide also a quantitative measure of the patient's overall gait. Starting from this aim some global indexes were proposed by literature as a summary measure of the patient's gait, such as the Gait Deviation Index (GDI). While validity of the GDI is demonstrated for the evaluation of the functional limitation of CP patients, no studies have evaluated with the GDI the pre vs. post surgery gaitcondition in children with CP. The aim of our study was therefore to investigate the effectiveness of the GDI in the quantification of gait changes occurring after surgical intervention (gastrocnemius fascia lengthening for the correction of equinus foot deformity) in patients with CP. 19 children with CP were evaluated pre-operatively (PRE session) and about 1 year (POST: mean 13.1 ± 5.1 months) after gastrocnemius fascia lengtheningusing 3D GA. From GA data the GDI was computed. The results evidenced that the GDI value in the PRE session was 70.4 ± 14.8, showing a moderate global disturbance of the gait patterns of the patients. After the surgical treatment a significant improvement of the GDI mean value was found (82.9 + 7.4; p < 0.05; CG ≥ 100) with an improvement of 18% respect to the PRE session. A strong correlation (ρ = 0.83; p<0.05) existed between the GDI value in the PRE session and the percentage of improvement. Our results demonstrated that GDI seems to be an appropriate outcome measure for the evaluation of the effects of surgical treatment in CP.

Effect of posture-control insoles on function in children with cerebral palsy: Randomized controlled clinical trial.

Neto H. P., Grecco L. A. C., Christovão T. C. L., Braun L. A., Giannasi L. C., Salgado A. S. I., Franco de Moura R. C., Camillo de Carvalho P. D. T., Corrêa J. C. F., Sampaio L. M. M., Galli M., Oliveira C. S.


Introduction: Cerebral palsy (CP) is a posture and movement disorder and different therapeutic modalities, such as the use of braces, have sought to favor selective motor control and muscle coordination in such patients. The aim of the proposed study is to determine the effect of the combination of posture-control insoles and ankle-foot orthoses (AFOs) improving functional limitation in children with CP. Methods/Design: The sample will be composed of 24 children with CP between four and 12 years of age. After the signing of the statement of informed consent, the children will be randomly allocated to two groups: a control group using AFOs alone and na experimental group using both posture-control insoles and AFOs. Evaluations will be performed on five occasions: without any accessory (insoles or AFOs), immediately after, one month after, six months after and one year after AFOs or insole and AFOs use. The evaluation will involve the analysis of gait, static and functional balance, mobility and hypertonia. The three-dimensional assessment of gait will involve the eight-camera SMART-D SMART-D 140W system (BTS Engineering), two Kistler force plates (model 9286BA) and an eight-channel, wireless FREEEMGW electromyography (BTS Engineering). Static balance will be assessed using a Kistler force plate (model 9286BA). Clinical functional balance and mobility will be assessed using the Berg Balance Scale, Timed Up-and-Go Test and Six-Minute Walk Test. The posture-control insoles will be made of ethylene vinyl acetate, with thermal molding for fixation. The fixed orthoses will be made of polypropylene and attached to the ankle region (AFO). The results will be analyzed statistically, with the level significance set to 5% (p < 0.05). 

Use of the Gait Deviation index for the evaluation of patients with Parkinson's disease.

Galli M, Cimolin V, De Pandis MF, Schwartz MH, Albertini G.


The authors aimed to determine whether the Gait Deviation Index (GDI) could be feasible to characterize gait in patients with Parkinson's disease (PD) and evaluate outcomes of levodopa treatment. Twenty-two PD participants were evaluated with clinical examination and 3-D quantitative gaitanalysis (GDI was calculated from gait analysis) in 2 states (OFF and ON) after taking levodopa. Twenty age-matched healthy participants (CG) were included as controls. The GDI value in the OFF state was 83.4 ± 11.5 (statistically different from CG) while clinical scales demonstrated a moderate-severe gait impairment of these patients. Significant improvements are evident from clinical scores and by GDI values in the ON state. The mean GDI for the ON state (GDI(ON): 87.9 ±10.4) was significantly higher than in for the OFF state (GDI(OFF): 83.4 ± 11.5), indicating a globalgait improvement after the treatment. The results show that GDI has lower value as an indicator of pathology in PD patients than in quantifying the effects of levodopa treatment in PD state. 

Use of the Gait Profile Score for the evaluation of patients with joint Hypermobility syndrome/ Ehlers-Danlossyndrome hypermobility type

Celletti C, Galli M, Cimolin V, Castori M, Tenore N, Albertini G, Camerota F.


Gait analysis (GA) is widely used for clinical evaluations in various pathological states, both in children and in adults, such as in patients with joint hypermobility syndrome/Ehlers-Danlos syndrome hypermobility type (JHS/EDS-HT). Otherwise, GA produces a large volume of data and there is the clinical need to provide also a quantitative measure of the patient's overall gait. Starting from this aim some global indexes were proposed by literature as a summary measure of the patient's gait, such as the Gait Profile Score (GPS). While validity of the GPS was demonstrated for theevaluation of the functional limitation of children with Cerebral Palsy, no studies have been conducted in patients JHS/EDS-HT. The aim of our study was therefore to investigate the effectiveness of the GPS in the quantification of functional limitation of patients with JHS/EDS-HT. Twenty-one adult (age: 36.1±12.7 years) individuals with JHS/EDS-HT were evaluated using GA and from GA data the GPS was computed. The results evidenced that the GPS value of patients was 8.9±2.6, statistically different from 4.6±0.9 displayed by the control group. In particular, all values of Gait Variable Scores (GVS) which compose the GPS were higher if compared to controls, with the exception of Pelvic Tilt and Foot Progression. The correlations between GPS/GVS and Lower Extremity Functional Scale (LEFS) showed significant relationship between GPS and the item 11 ("Walking 2 blocks") (ρ=-0.56; p<0.05) and 12 "Walking a mile") of LEFS (ρ=-0.76; p<0.05). Our results showed that GPS and GVS seem to be appropriate outcome measures for the evaluation of the functional limitation during gait of patients with JHS/EDS-HT. 

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