Gait parameters associated with falls in female patients with end-stage hip osteoarthritis

doi:10.21203/rs.3.rs-5210350/v1

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Gait parameters associated with falls in female patients with end-stage hip osteoarthritis

https://doi.org/10.21203/rs.3.rs-5210350/v1

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Osteoarthritis of the hip (hip OA) may increase the risk of falls. To decrease fall risk, it is important to assess the gait characteristics of patients with hip OA in detail. This study aimed to investigate the gait characteristics of patients with hip OA caused by falls by simultaneously assessing foot and waist trajectories via an inertial measurement unit (IMU). The subjects were 77 patients with hip OA, 17 of whom had fallen in the past year. Compared with the nonfall group, the fall group was older and had higher fall scores and lower JOA hip scores. With respect to gait characteristics, the stride length on the nonaffected side was significantly shorter in the fall group than in the nonfall group. Stride velocity gait asymmetry was also significantly lower in the fall group than in the nonfall group. The amount of lifting of the waist on the affected and nonaffected sides was significantly lower in the falling group than in the nonfalling group. It was suggested that the fall group might be adapting to stabilization and adjusting to a stable and safe gait pattern because of the effects of falls, new gait characteristics regarding falls in patients with hip OA were found.

Musculoskeletal disorders, including osteoarthritis (OA), are among the most important disabling factors worldwide. Among the 291 conditions worldwide, hip and knee OA is the 11th highest contributor to disability worldwide and the 38th highest contributor to disability¹⁾. OA is increasing globally, partly due to the aging of the population, and OA in the hip is projected to grow more than OA in the knee between 2020 and 2050²⁾. Patient hip OA is common in females ³⁾ and is a chronic progressive disease characterized by the degeneration and wear of articular cartilage, resulting in joint destruction and reactive bone growth (osteochondria and osteophytes)^4),5). Limited range of motion (ROM), inguinal pain, and limping are characteristics, and their effects cause activity limitations and quality of life⁶⁾⁻⁸⁾. Patients with OA have a greater risk of death than healthy individuals do, with a history of internal disease and gait disturbance cited as major risk factors⁹⁾. Hip and knee OA can result in reduced foot clearance, difficulty in obstacle avoidance, gait disturbances, and balance issues, thereby increasing the risk of falls¹⁰⁾. It has also been reported that the risk of falling is increased in elderly women with self-reported lower extremity arthralgia and back pain¹⁰⁾. Patients with end-stage female hip OA had a greater incidence of falls within one year, and fall risk was associated with claudication and knee extension muscle strength¹¹⁾. Elderly patients with hip OA have experienced falls or near falls, possibly due to gait disturbances related to hip OA¹²⁾. However, since most falls can occur during forward gait¹³⁾, an accurate and detailed assessment of the gait of patients with hip OA is important to prevent falls.

Regarding the gait characteristics of patients with hip OA, it is well known that walking speed decreases due to short stride length and short affected limbs steps^14–16). The step length^17–19) and stance time ^15,20) of the affected limb are shortened, resulting in asymmetry in step length and swing time between the affected and unaffected limbs. Additionally, the lateral distance of the foot during the swing phase is greater on the unaffected limb than on the affected limb²¹⁾. In patients with hip OA, the variability of walking on the treadmill was greater on the affected side than in healthy controls (HCs), but the variability was lowest when the gait speed was close to the self-selected walking speed²²⁾. On the other hand, total hip arthroplasty (THA) is a treatment for hip OA, but even one year after surgery, gait speed remains slower than that of HCs²³⁾. Stride and trunk variability are greater in patients with hip OA than in HCs, with improved stride variability but insufficient improvement in trunk variability one year after THA surgery²⁴⁾. Patients with hip OA often exhibit exaggerated lateral bending of the pelvis and trunk to the affected side during gait, which is called Duchenne limp^25),26). Patients with hip OA with Duchenne claudication had a greater thoracic angle during gait²⁷⁾. Patients with early hip OA also have greater pelvic movement than HCs²⁸⁾. However, although there are many reports on spatiotemporal parameters in patients with hip OA, few reports have investigated the associations between spatiotemporal parameters and falls. In addition, variability in swing time and stride length has been implicated in predicting fall risk in elderly individuals ²⁹⁾, but there have been no reports in patients with hip OA. Therefore, this study aimed to investigate the associations between the spatiotemporal parameters of gait characteristics and falls during walking exercise in patients with hip OA. To achieve the aim of the study, the risk of falling was scored and assessed in this study via a questionnaire. Gait movements were analyzed by measuring foot and waist trajectories simultaneously via a wearable inertial measurement unit (IMU). In recent years, there has been an increase in gait analysis with IMU sensors, which have provided an accessible and affordable alternative to traditional optical gait analysis systems³⁰⁾. Mao et al. proposed a system to estimate the foot trajectory in three dimensions during walking by attaching the IMUs on shanks just above both ankles ³¹⁾. The gait indices such as the stride length, position of maximum foot clearance, and stride speed (Speed) estimated by this system strongly correlate with those measured by the optical motion-capture system. This system can also evaluate parameters such as stride length, stride duration, stance duration, swing duration, lateral distance of the foot during the swing phase, and the standard deviation of each gait parameter.

This study aims to investigate gait parameters and waist trajectory during walking in unilateral patients with end-stage hip OA who have experienced a fall in the past year via IMU sensors.

Participants

The participants were 82 female patients with end-stage unilateral hip OA (mean age 65.7 ± 7.2 years; 44 with left-sided OA and 38 with right-sided OA) who visited the orthopedic department of Tamagawa Hospital, Nissan Koseikai, from 2022–2023. We excluded patients if they had neurological, vascular, or other lower extremity musculoskeletal conditions or psychiatric disorders that affected gait or functional performance. We also excluded patients with a self-reported lack of sensation in the foot or lower limb those who were unable to walk short distances (20 m) without an assistive device and patients with pain in the hip on the unaffected side. Additionally, patients with end-stage deformity or pain in the contralateral hip joint were excluded. This study was approved by the Institutional Review Board of Nissan Tamagawa Hospital and the Tokyo Institute of Technology for research ethics committee. All participants provided written informed consent before participation. All methods were performed in accordance with the Helsinki Declaration and relevant guidelines and regulations.

Fall assessment

The participants were surveyed via a questionnaire detailing the number and circumstances of falls over the past year¹¹⁾. The circumstances of the falls were surveyed: location (indoors, outdoors, stairs), time (morning, daytime, nighttime), direction (forward, sideways, backward), cause (slipping, tripping, losing balance, colliding with something), and injury (none, abrasion, contusion, fracture). Falls due to traffic accidents, bicycles, vertigo, and other special environmental factors were excluded. The Fall Risk Index (FRI-21) is a self-administered questionnaire consisting of 21 items: 8 items related to physical function, 8 items related to disease or geriatric syndromes, and 5 items related to environmental factors; it is often used as a simple fall risk screening method³²⁾.

Assessment of physical function

The hip joint ROM angles were determined by passively moving the patients’ legs and measuring the maximum angles via a goniometer. The pelvis was stabilized to prevent rotation or tilting when the passive ROM was measured by an experienced physical therapist³³⁾. ROM was performed with the patient in the supine position, except for the measurement of the angle of external and internal hip rotation. The external and internal rotation angles were measured while the knee was in the prone position at 90° flexion. Knee extension muscle strength was measured while the participants were in a seated position via a handheld dynamometer (µTAS F-1, Anima Co., Ltd.), with the sensor pad fixed to the distal lower leg. The maximum isometric contraction was measured three times on each side for five seconds, with the highest value recorded as the weight ratio (kgf/kg). Hip abduction muscle strength was measured similarly to that of the patient in the supine position and the sensor pad was fixed to the distal thigh. The minimum joint space (MJS) was measured via plain X-rays by an orthopedic surgeon. Hip function was assessed via the JOA hip score, which includes pain (40 points), ROM (20 points), walking ability (20 points), and activities of daily living (20 points), totaling 100 points. The JOA hip score is designed for the Japanese lifestyle and strongly correlates with the Harris hip score³⁴⁾. Hip pain during walking was measured via a visual analog scale (VAS). The stage of hip OA was classified by an orthopedic surgeon according to the Kellgren–Lawrence classification.

Equipment and Gait Measurement

Three IMU sensors (TSND121, ATR-Promotion) were used for gait measurement (Figure. 1a). Two sensors were attached above the lateral malleoli using special bands to measure acceleration and angular velocity and estimate gait parameters (Fig. 1b). The third IMU sensor was attached above the L3 lumbar vertebra via a band (Fig. 1c). The acceleration and angular velocity ranges were ± 8 G and ± 1000 dps, respectively, with a sampling frequency of 100 Hz. The TSND121 sensor measures 37 mm × 46 mm × 12 mm and weighs approximately 22 g.

The spatiotemporal gait parameters were estimated via the method proposed by Mao et al³¹⁾, which involves the double integration of linear acceleration converted from IMU orientation data. To reduce integration drift errors, a linear error model applied to an inverted pendulum model was introduced to estimate update velocities during midstance. The motion of the IMU during mid-stance can be modeled as a rotational motion in three-dimensional space. The position vectors r and angular velocity in the laboratory coordinate system were calculated from the estimated orientation of the IMU³¹⁾. With this method, we estimated the maximum foot clearance, stride length, stride speed, stride duration, stance duration, and swing duration for the left and right lower limbs. We also defined the waist trajectory as a graph visualizing the time evolution of displacement of the waist duration walking from the IMU attached to the waist as proposed by Kobayashi et al. and calculated the symmetry of lateral sway of the waist trajectory and the amount and symmetry of the left and right lifting³⁵⁾.

The participants walked 16 m (10 m with 3 m aids before and after) at a self-selected speed (comfortable), down a straight, flat corridor in comfortable, flat-soled shoes. All participants were measured without any walking aids.

Statistical analysis

The participants were divided into fallers (those who experienced falls in the past year) and nonfallers. Basic information, FRI-21 score, medical history, physical function of the affected and unaffected sides, gait parameters and their symmetry, walking pain, and waist lateral displacement during walking were assessed for normality via the Shapiro‒Wilk test and equal variance by Levene's test. Comparisons were made via Student’s t test and the Mann‒Whitney U test.

Among the 82 participants, 19 patients with hip OA had fallen at least once in the past year. In addition, 53 patients had experienced a near-miss of a fall in the past year. Thirty-two percent had injuries when they fell, in the following order: fractures (5%), abrasions (12%) and bruises (15%). Among the 19 patients, the most common place of fall was outdoors (52%), followed by indoors (32%) and stairs (16%). Falls occurred during the day (67%), with only a few occurring at night (28%) and in the morning (5%). The most common direction of fall was forward (67%), followed by sideways (29%) and backward (4%). The main causes of falls were tripping (48%), losing balance (33%) and slipping (19%).

Data from 77 of the 82 participants were included in the analysis after incomplete data were excluded. Among these 77 participants, 17 had experienced falls in the past year. In terms of basic information, the faller group was significantly greater in terms of age (t(42) = -2.73, p = 0.009, r = 0.3873, 95% CI [-7.044, -1.056]) and FRI-21 score (t(75) = -2.11, p = 0.038, r = 0.2366, 95% CI [-2.945, -0.084]), was significantly greater, but there were no differences in the other groups (Table 1).

Table 1

Participant demographics
Variables	Fallers(n=17)	Nonfallers (n=60)	p value	95%CI	r
Age(years)	69.0 ± 4.6	65.0 ± 7.5	0.009	-7.044 -1.056	0.387
Height(cm)	153.8 ± 3.2	155.3 ± 6.0	0.202	-0.783 3.612	0.180
Weight(kg)	52.7 ± 8.7	54.3 ± 9.1	0.510	-3.303 6.589	0.076
BMI(kg/m²)	20.9(19.5,24.6)	22.1(19.7,24.6)	0.759		0.034
History of present illness(years)	5.2(2,10)	6.0(2,10)	0.951		0.006
Fall risk index	9.8 ± 2.6	8.3 ± 2.6	0.038	-2.945 -0.084	0.237
mean ± SD, median (interquartile range)

There were no significant differences in hip ROM, hip abductor muscle strength, or knee extension muscle strength between the faller and nonfaller groups on the affected and unaffected sides. Similarly, there were no significant differences in the 10-meter walking speed or number of steps between the groups (Supplementary Table S1). The overall JOA hip score was significantly lower in the affected (t(75) = 2.61, p = 0.011, r = 0.288, 95% CI [2.113, 15.767]) and unaffected (W = 673.5, p = 0.044, r = 0.228) groups than in the nonfaller group. In addition, in the JOA hip score subcategories, only the activities of daily living (ADL) score was significantly lower in the faller group than in the nonfaller group (W = 675, p = 0.038, r = 0.236) (Table 2).

Table 2

Comparison of physical function between fallers and nonfallers in patients with hip OA. The JOA hip score and MJS depict the Japanese Orthopedic Association hip score and the minimum joint space, respectively.
	Fallers(n=17)	Nonfallers (n=60)	p value	95%CI	r
Hip JOA score total Affected Unaffected	52.2 ± 12.5 81.8(75,89)	61.1 ± 12.5 86.8(83,93)	0.011 0.044	2.113 15.767	0.288 0.228
Hip JOA score pain Affected Unaffected	13.5(10,20) 38.5(35,40)	17.8(10,20) 37.9(35,40)	0.140 0.944		0.168 0.007
Hip JOA score gait ability	13.9(10,18)	14.6(15,15)	0.856		0.020
Hip JOA score ADL	14.9(12,18)	16.8(16,20)	0.038		0.236
Minimum joint space(mm) Affected Unaffected	0 3.3 ± 1.3	0 2.8 ± 1.0	0.085	-1.096 0.073	0.199
mean ± SD, median (interquartile range)

An example of each group and HC of the three dimensions estimated of the foot trajectory during walking, obtained from the shank, and an example of each group and HC of a graph of the waist trajectory visualizing the temporal changes in displacement of the waist during walking are shown in Fig. 2a-f.

In terms of gait parameters, the stride length of the unaffected side was significantly shorter in the faller group than in the nonfaller group (t(75) = 2.12, p = 0.037, r = 0.2385, 95% CI [0.006, 0.178]). There were no significant differences in maximum foot clearance, stride time, speed, stance, or swing phase times between the affected and unaffected sides (Fig. 3) or in lateral foot distance during the swing phase (Supplementary Table S2). There were also no significant differences in the standard deviations of gait parameters between the affected and unaffected sides (Supplementary Table S2). In terms of symmetry indices, gait asymmetry (GA) for speed was significantly lower in the faller group than in the nonfaller group (p = 0.049, r = 0.223) (Fig. 4a), but there were no significant differences in the other indices (Table 3). There were no significant differences in the coefficients of variation (CVs) for gait parameters between the faller and nonfaller groups (Supplementary Table S3).

Table 3

Comparison of asymmetry in gait parameters between faller and nonfaller patients with hip OA. Lateral distance (LD).
Gait asymmetry	Fallers(n=17)	Nonfallers (n=60)	p value	95%CI	r
Stride length GA	0.99(0.97,1.01)	0.98(0.97,0.99)	0.116		0.178
Maximum foot clearance GA	0.98(0.85,1.06)	0.98(0.88,1.03)	1.000		-0.001
Stride time GA	1.00 ± 0.01	1.00 ± 0.00	0.809	-0.004 0.005	0.056
Speed GA	0.99(0.98,1.00)	0.98(0.97,0.99)	0.049		0.223
Stance time GA	0.91 ± 0.08	0.93 ± 0.07	0.322	-0.020 0.061	0.114
Swing time GA	1.14 ± 0.12	1.11 ± 0.11	0.301	-0.092 0.029	0.120
LD toe off GA	0.67(0.34,0.92)	0.69(0.27,1.41)	0.632		0.053
LD maximum foot clearance GA	0.57(0.33,0.95)	0.56(0.19,1.32)	0.722		0.040
LD kick out GA	0.53(0.28,1.21)	0.77(0.22,1.41)	0.921		0.011
LD swing down GA	0.38(-0.49,0.85)	0.75(0.17,1.54)	0.067		0.208
mean ± SD, median (interquartile range)

There were no significant differences between the faller and nonfaller groups in terms of the magnitude of lateral sway, asymmetry of lateral swats or asymmetry in the amount of lifting in the hip orbit (Table 4). The amount of waist lifting on the affected side was significantly lower in the faller group than in the nonfaller group (p = 0.019, r = 0.266). The amount of waist lifting on the nonfaller side was also significantly lower in the faller group than in the nonfaller group (p = 0.025, r = 0.257) (Fig. 4b).

Table 4

Comparison of waist trajectory between fallers and nonfallers in patients with hip OA.
Waist trajectory	Fallers(n=17)	Nonfallers (n=60)	p value	95%CI	r
Lateral sway of the lumber	3.16(2.90,4.31)	3.52(2.78,4.62)	0.425		0.090
Asymmetry lateral sway of the lumber	10.23(4.76,20.56)	13.58(4.98,22.49)	0.469		0.082
Asymmetry of the amount of waist lifting	20.42(7.39,41.78)	23.87(11.33,44.09)	0.876		0.017
The amount of waist lifting affected unaffected	2.75 ± 1.01 3.32 ± 1.07	3.39 ± 0.95 4.06 ± 1.22	0.019 0.025	0.106 1.163 0.095 1.399	0.266 0.257
mean ± SD, median (interquartile range)

In this study, we compared the spatiotemporal parameters of gait and waist trajectory during walking using IMU sensors in patients with unilateral end-stage hip OA divided into those with and without a history of falls in the past year. The faller groups were older and had higher total FRI-21 scores than did the nonfaller groups. Previous reports have shown that fallers with hip OA are older³⁷⁾, and the same was true in this study. The FRI-21 is a simple questionnaire index and may be able to discriminate past falls. The overall JOA hip score was lower in the faller groups than in the nonfaller groups on both the affected and nonaffected sides. In the lower categories, the faller groups were significantly lower in activities of daily living (sitting, standing, squatting and standing up, climbing stairs, getting in and out of cars, buses, etc.). Although there is an association between subjective difficulty in stair climbing and physical functions such as walking speed and muscle strength in elderly individuals³⁸⁾, there were no differences in walking speed or muscle strength in this study. The center of gravity shift and ability to shift the center of gravity and postural correction were associated with fear of falling, and it is possible that the fear of falling increased in the fall group due to previous falls, which may have affected the JOA hip score in activities of daily living.

Next, we compared the spatiotemporal parameters of gait and waist trajectory during walking via the IMU sensor in patients with unilateral end-stage hip OA divided into those with and without a history of falls in the past year. The results suggest that patients with a history of falls have a significantly shorter stride length than those without a history of falls. Patients with a history of falls presented significantly less asymmetry in gait velocity than did those without a history of falls. It was also suggested that patients with a history of falls had significantly smaller waist lift heights than patients without a history of falls. These are the first results revealed by the simultaneous comparison of spatiotemporal parameters of gait and waist trajectory during walking in this study. A more detailed discussion follows.

Gait parameters were significantly shorter on the nonaffected side in the faller groups than in the nonfaller groups, and stride length tended to decrease on the affected side. The falling group of healthy older adults had lower walking speed, longer stance time, lower stride length, and step width, as well as greater variability in spatiotemporal parameters, making it more possible to distinguish between the faller and nonfaller groups in the effect size analysis in terms of walking speed, stride length and stance time of variability ³⁹⁾. hip OA patients to prevent falls. Patients with hip OA may also shorten their stride length to maintain dynamic balance and stabilization⁴⁰⁾ to prevent falls. However, we believe that there was no difference in the other parameters between the faller and nonfaller groups because a decrease in velocity or prolonged stance time in patients with hip OA may lead to an exacerbation of pain during loading. In addition, there were no differences in the standard deviation values or coefficients of variation of gait parameters between the faller and nonfaller groups. Although there are many reports on the relationship between falls and variability in healthy elderly patients³⁹⁾, it is possible that patients with hip OA may pattern their gait more than healthy patients do because of pain and a limited range of motion. Therefore, even after THA surgery, improvements in preoperative gait parameters and gait may take longer²³⁾. In a previous report, a group of patients with hip OA experienced a decrease in walking speed¹¹⁾. This difference between that study and ours is that patients with various gait levels were included because we did not limit the use of walking aids during indoor walking and gait parameter measurements.

In terms of gait parameter symmetry, the faller groups were significantly smaller than the nonfaller groups in terms of speed GA. This was indicated by a greater symmetry of speed in the faller groups than in the nonfaller groups. It has been reported that lower gait symmetry is associated with a greater risk of falls⁴¹⁾. In this study, falls were retrospectively analyzed via questionnaires. The fall evaluation in this retrospective study was preceded by a fall at the time of evaluation and may have been adjusted to a conservative, stable, and safe gait and movement pattern at the time of measurement⁴²⁾, and we believe that the fall group in this study also adjusted to a stable gait pattern, resulting in a high degree of symmetry.

The amount of waist lift was smaller in the faller groups than in the nonfaller groups on both the affected and nonaffected sides. Compared with HCs, hip OA patients have a reduced hip flexion angle while walking⁴³⁾. The main cause of falls in this study was also tripping, and decreased minimum leg clearance has been reported to be associated with falls⁴⁴⁾. It is possible that the nonfaller groups prevented falls by compensating for the decreased hip flexion angle and foot clearance with their hips. In addition, the magnitude of the acceleration of the head and pelvis during walking in younger and older adults was smaller than that in older adults, which may be a compensatory strategy to maintain balance⁴⁵⁾.

Falls can easily lead to fractures and other injuries, which can rapidly decrease quality of life. Fear of falling can also lead to decreased spatiotemporal parameters⁴⁶⁾, decreased physical function and range of activity, and decreased quality of life⁴⁷⁾. Although there was no difference in muscle strength between the faller and nonfaller groups in this study, more than 60% of the participants experienced a near-miss, suggesting that in addition to activity limitations due to hip OA, the fear of falling may have reduced activity. Therefore, interventions to reduce the fear of falling are also necessary to prevent falls. Although exercise instruction has been reported to be effective in preventing falls and reducing fear of falling, we would like to improve fall prevention, fear of falling, and gait by providing visual feedback on the asymmetry of the current gait and the trajectory of the legs and waist, in addition to exercise instruction.

The association with falls cannot be determined unequivocally because of the retrospective nature of studies on falls. The reproducibility of the gait parameters is reduced because of the arbitrary gait speed and the number of measurements. The location of gait measurement is limited and may differ from that of daily walking.

The purpose of this study was to investigate the parameters during walking and hip trajectory during walking, which were related to whether unilateral end-stage hip OA patients had fallen in the past year, via an IMU sensor. The patients in the fall group were older than those in the nonfall group were, and their hip function in the questionnaire was lower than that in the nonfall group was. In terms of gait parameters, there was a decrease in the stride length of the nonaffected lower limb in the fall group compared with the nonfall group, but there were no differences in the other parameters. With respect to gait parameter symmetry, the fall group had a greater GA in terms of stride velocity than did the nonfall group. These findings may indicate that the falling group may be better adapted to stabilization and adjust to a stable and safe gait pattern after a fall. In terms of waist trajectory, the fall group had lower waist lifting on both the affected and nonaffected sides than did the nonfall group. It is possible that this may be a strategy to maintain balance due to postfall, but it is also possible that the nonfall group may compensate at the waist to prevent falls. In this study, new gait characteristics were discovered via detailed evaluation of the gait parameters of the falling and nonfalling groups of patients with unilateral end-stage hip OA. In the future, these gait characteristics should be used to determine the relationship between fall risk and interventions for fall prevention.

Acknowledgements

This work was supported in part by Japan Science and Technology Agency (JST) CREST Grant Number JPMJCR21C5, JST COI-NEXT Grant Number JPMJPF2101, JST-Mirai Program Grant Number JPMJMI24H2, and Japan Society for the Promotion of Science (JSPS) KAKENHI Grant Number 22K17630,

Author contributions

Y.K., H.U., and M.M. designed this study. Y.K. conducted the experiment and analyzed the data. Y.K., H.U., M.M., and Y.M. discussed and interpreted the results. Y.K., H.U. drafted the manuscript, and all authors reviewed the manuscript and approve the final version of the paper for publication.

Date availability

The data that support the findings of this study are available from the corresponding author upon reasonable request.

Competing interests

The authors declare no competing interests.

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Gait parameters associated with falls in female patients with end-stage hip osteoarthritis

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Introduction

Methods

Participants

Fall assessment

Assessment of physical function

Equipment and Gait Measurement

Statistical analysis

Results

Discussion

Limitations of this study

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