Doctor of Philosophy (Ph.D.)
Degree Granting Department
Kyle B. Reed, Ph.D.
Seok Hun Kim, Ph.D.
Stephanie Carey, Ph.D.
Jonathan Gaines, Ph.D.
William Lee, Ph.D.
Rehabilitation Devices, Biomechanics, Prosthetics, Neuro-Degenerative Impairement, Clinical Evaluation Metrics
Human gait is a complex process that involves the coordination of the central nervous and muscular systems. A disruption to the either system results in the impairment of a person’s ability to walk. Impairments can be caused by neurological disorders such as stroke and physical conditions like amputation. There is not a standardized method to quantitatively assess the gait asymmetry of affected subjects. The purpose of this research is to understand the fundamental aspects of asymmetrical effects on the human body and improve rehabilitation techniques and devices. This research takes an interdisciplinary approach to address the limitations with current rehabilitation methodologies.
The goal of my Doctoral research is to understand the fundamental effects of asymmetry caused by physical and neurological impairments. The methods discussed in this document help in developing better solutions to rehabilitate impaired individuals’ gait. I studied four major hypothesis in regards to gait asymmetry. The first hypothesis is the potential of asymmetric systems to have symmetric output. The second hypothesis is that a method that incorporates a wider range of gait parameter asymmetries can be used as a measure for gait rehabilitation. The third hypothesis is that individuals can visually identify subtle gait asymmetries. Final hypothesis is to establish the relationship between gait quality and function. Current approaches to rehabilitate impaired gait typically focus on achieving the same symmetric gait as an able-body person. This cannot work because an impaired person is inherently asymmetric and forcing them to walk symmetrically causes them to adopt patterns that are not beneficial long term. Instead, it is more prudent to embrace the asymmetry of the condition and work to minimize in specific gait parameters that may cause more harm over the long run. Combined gait asymmetry metric (CGAM) provides the necessary means to study the effect of the gait parameters and it is weighted to balance each parameter’s effect equally by normalizing the data. CGAM provides the necessary means to study the effect of the gait parameters and is weighted towards parameters that are more asymmetric. The metric is also designed to combine spatial, temporal, kinematic, and kinetic gait parameter asymmetries. It can also combine subsets of the different gait parameters to provide a more thorough analysis. CGAM will help define quantitative thresholds for achievable balanced overall gait asymmetry.
The studies in this dissertation conducted on able-body and impaired subjects provides better understanding of some fundamental aspects of asymmetry in human gait. Able body subjects test devices that aim to make an individual’s gait more asymmetric. These perturbations include a prosthetic and stroke simulator, addition of distal mass, and leg length alterations. Six able-body subjects and one amputee participated in the experiment that studied the effect of asymmetric knee height. The results which consisted of analyses of individual gait parameters and CGAM scores revealed that there is evidence of overall reduction of asymmetry in gait for both able-body subject on prosthetic simulators and transfemoral amputee. The transfemoral amputee also walked with a combination of distal mass with lowered knee height. Although this configuration showed better symmetry, the configuration is detrimental in terms of energy costs. Analyzing the data of gait with the stroke simulator showed that the subject’s gait does undergo alterations in terms of overall gait asymmetry. The distal mass and leg length alteration study has revealed some significant findings that are also reflected in the prosthetic study with distal mass. A leg length discrepancy (LLD) or the change of limb mass can result in asymmetric gait patterns. Although adding mass and LLD have been studied separately, this research studies how gait patterns change as a result of asymmetrically altering both leg length and mass at a leg’s distal end. Spatio-temporal and kinetic gait measures are used to study the combined asymmetric effects of placing LLD and mass on the opposite and same side. There were statistically significant differences for the amount of mass and leg length added for all five parameters. When LLD is added to longer leg, the temporal and kinetic gait parameters of the shorter limb and the altered limb’s spatial parameter become more asymmetric. Contrary to the hypothesis, there was no significant interaction between the amount of mass and leg length added. There were cases in all perturbations where a combination of mass and LLD make a gait parameter more symmetric than a single effect. These cases exhibit the potential for configurations with lower overall asymmetries even though each parameter has a slight asymmetry as opposed to driving one parameter to symmetry and other parameters to a larger asymmetry. CGAM analysis of the results revealed that the addition of distal mass contributes more towards overall asymmetry than LLD. Analyzing 11 gait parameters for LLD and mass on the same side showed that the overall asymmetry decreased for the combination of small LLD and mass. This is consistent with the findings from analyzing five individual gait parameters.
Impaired subjects include individuals with stroke and amputees. The clinical trials for individuals with stroke involve training with the Gait Enhancing Mobile Shoe (GEMS) that pro- vides an asymmetric effect on the subject’s step length and time. Training with the GEMS showed improvement in clinical measures such as timed up and go (TUG), six minute walk test (6MWT), and gait velocity. The subjects also showed lower step length symmetry as intended by the GEMS. The ground reaction force asymmetries became more asymmetric as the spatial and temporal parameters became more symmetric. This phenomenon shows evidence that when an individual with stroke is corrected, for spatial and temporal symmetry is at the expense of kinetic symmetry. The CGAM scores also reflected similar trends to that of spatial and temporal symmetry and the r2 correlation with the gait parameters proved that double limb support asymmetry has no correlation with CGAM while ground reaction force asymmetry has a weak correlation. Step length, step, and swing time showed high correlation to CGAM. I also found the r2 correlation between the clinical measures and the CGAM scores. The CGAM scores were moderately correlated to 6MWT and gait velocity but had a weak correlation with TUG. CGAM has positive correlation with TUG and has negative correlation with 6MWT and gait velocity. This gives some validation to CGAM as a potential metric that can be used to evaluate gait patterns based on their asymmetries.
Transfemoral amputees were tested for their gait with varied prosthetic knee heights to study the asymmetrical effects and trained split-belt treadmill. Asymmetric knee heights showed improvement in multiple gait parameters such as step length, vertical, propulsive, and braking force asymmetry. It also decreased hip and ankle angle asymmetries. However, these improvements did lead other parameters to become more asymmetric. The CGAM scores reflect this and they show overall improvement. Although the lowest knee height showed improvement, the input from the amputee suggested that the quality of gait decreased with the lowest knee height. These exploratory results did show that a slightly lower knee height may not affect the quality of gait but may provide better overall symmetry. Another exploratory study with split-belt treadmill training, similar to the protocol followed for individuals with stroke, showed definitive improvement in double limb support, swing time, step length and time symmetry. This was also reflected in the improvements seem post training in the CGAM scores as well. I found the r2 correlation of the CGAM and the gait parameters including gait velocity. Step length and swing time show consistent correlation for individual subjects and all the data combined to CGAM. Gait velocity shows a moderate correlation to CGAM for one subject and a high correlation to the other one. However, the combined data of gait velocities does not have any correlation with CGAM. These results show that CGAM can successfully represent the overall gait parameter asymmetry. The trends seen in the gait parameters is closely reflected in the CGAM scores.
This research combines the study of asymmetry with people’s perception of human gait asymmetry, which will help in estimating the thresholds for perceivable asymmetrical changes to gait. Sixteen videos were generated using motion capture data and Unity game engine. The videos were chosen to represent the largest variation of gait asymmetries. Some videos were also chosen based on CGAM values that were similar but had large variation in underlying gait parameters. The dataset consisted of results of perturbation experiments on able-body subjects and asymmetric knee height prosthesis on transfemoral amputee. These videos were rated on a seven point Likert scale by subjects from 7 being normal to 1 being abnormal. Thirty one subjects took part in the experiment, out of which only 22 subject’s data was used because they rated at least 3 videos. The results show that the subjects were able to differentiate asymmetric gait with perturbations to able-body gait without perturbation at a self-selected speed. r2 correlation analysis showed that hip angle had mild correlation to the Likert scale rating of the 16 different gait patterns. Multivariate linear regression analysis with a linear model showed significant contribution of ankle and hip angles, vertical, propulsive, and braking forces. It is interesting that the majority of parameters that showed significance are not perceivable visually. Ankle and hip angles are visually perceivable and this significance revealed that subjects seemed to perceive asymmetric ankle and hip angles as abnormal. However, the subjects do not perceive asymmetric knee angles as completely abnormal with evidence of no significance, no correlation, and neutral Likert rating for gait patterns that perturbed knee angles.
Scholar Commons Citation
Ramakrishnan, Tyagi, "Rehabilitating Asymmetric Gait Using Asymmetry" (2017). USF Tampa Graduate Theses and Dissertations.