UNIVERSIDADE DE LISBOA FACULDADE DE MOTRICIDADE HUMANA DEVELOPMENT OF A GLOBAL GAIT SYMMETRY SCORE USING BIOMECHANICAL PARAMETERS Tese elaborada com vista à obtenção do Grau de Doutor em Motricidade Humana na Especialidade de Biomecânica Orientador: Professor Doutor António Prieto Veloso Coorientador: Doutor W. Scott Selbie Júri: Presidente Reitor da Universidade de Lisboa Vogais: Doutor Kevin Deluzio Professor Catedrático, Faculty of Engineering and Applied Sciences, Department of Mechanical and Materials Engineering, Queen’s University (Kingston, ON, Canadá) Doutor António Prieto Veloso Professor Catedrático, Faculdade de Motricidade Humana, Universidade de Lisboa Doutor Alberto Leardini Investigador Principal, Laboratory of Movement Analysis and Functional Clinical Evaluation of Prothesis, Institute Ortopedico Rizzoli (Bolonha, Itália) Doutor Miguel Tavares da Silva Professor Associado, Instituto Superior Técnico, Universidade de Lisboa Sílvia Arsénio Rodrigues Cabral 2016 UNIVERSIDADE DE LISBOA FACULDADE DE MOTRICIDADE HUMANA DEVELOPMENT OF A GLOBAL GAIT SYMMETRY SCORE USING BIOMECHANICAL PARAMETERS Tese elaborada com vista à obtenção do Grau de Doutor em Motricidade Humana na Especialidade de Biomecânica Tese por compilação de artigos, realizada ao abrigo da alínea a) do nº2 do art.º 31º do Decreto-Lei nº 230/2009 Orientador: Professor Doutor António Prieto Veloso Coorientador: Doutor W. Scott Selbie Júri: Presidente Reitor da Universidade de Lisboa Vogais: Doutor Kevin Deluzio Professor Catedrático, Faculty of Engineering and Applied Sciences, Department of Mechanical and Materials Engineering, Queen’s University (Kingston, ON, Canadá) Doutor António Prieto Veloso Professor Catedrático, Faculdade de Motricidade Humana, Universidade de Lisboa Doutor Alberto Leardini Investigador Principal, Laboratory of Movement Analysis and Functional Clinical Evaluation of Prothesis, Institute Ortopedico Rizzoli (Bolonha, Itália) Doutor Miguel Tavares da Silva Professor Associado, Instituto Superior Técnico, Universidade de Lisboa Sílvia Arsénio Rodrigues Cabral 2016 Declaração de Reprodução da Tese Nome: Sílvia Arsénio Rodrigues Cabral Endereço eletrónico: [email protected] Número do Cartão de Cidadão: 12637955 Título: Development of a global gait symmetry score using biomechanical parameters Orientadores: Professor Doutor António Prieto Veloso Doutor W. Scott Selbie Ano de conclusão: 2016 Designação do ramo de conhecimento do Doutoramento: Motricidade Humana na Especialidade de Biomecânica ______________________________________________________ É AUTORIZADA A REPRODUÇÃO INTEGRAL DESTA TESE/TRABALHO APENAS PARA EFEITOS DE INVESTIGAÇÃO, MEDIANTE DECLARAÇÃO ESCRITA DO INTERESSADO, QUE A TAL SE COMPROMETE. ______________________________________________________ Faculdade de Motricidade Humana – Universidade de Lisboa, 25/08/2016 ____________________________ I II “The important thing is not to stop questioning.” Albert Einstein III IV Dedication To my cherished Father, who I will always remember, my beloved Mother and my dear Husband V VI Acknowledgements First and foremost, I would like to thank my supervisor, Professor António Veloso, for welcoming me into his laboratory and research group, and for believing in me and making me feel as a valuable part of the team since 2009. Throughout this journey, he has continuously supported my decisions, provided me with endless learning opportunities and introduced me to great colleagues and to highly recognized scientists in the biomechanics community, and for that I am ever grateful. He also presented me with various challenges that were essential to the development of new skills and enhancement of existing ones, therefore making me a more independent and confident researcher. I am truly grateful for his continuous support and encouragement throughout this journey. I am also especially grateful to my co-supervisor, Dr W. Scott Selbie, for all his contribution, tremendous support and time devoted to helping me with this work. Despite his busy schedule, and the different time zones, he always found the time and resources to answer all my questions promptly and to sit down with me in person. I am truly grateful for his genuine interest in my work and his inspiring ideas, which made this thesis possible, and for providing me with the opportunity to visit him in Canada on various occasions to enrich my learning process. In this sense, I would like to extend my thanks to his lovely family for welcoming me into their home. During these visits, Scott introduced me to other researchers who, in addition to listening to me and providing me with feedback, also kindly shared their knowledge and ideas which further inspired me. In this regard, I am particularly thankful to Dr Niko Troje and Dr Stephen Scott, as well as their students, Séamas Weech and Tyler Cluff, and more importantly, to Dr. Kevin Deluzio and everyone in the Human Mobility Research Laboratory, at Queen’s University. Kevin welcomed me into his laboratory, allowing me to collect data for the present thesis, and was essentially a source of good advice, learning and collaboration. I would like to thank all his present and past team members and students, in particular Amy Mourton, Renan Resende and Adam Clansey, for their collaboration, fruitful discussions, and above all their friendship. During my visits to Canada, I had the pleasure to work from Scott’s offices and to meet part of his wonderful team (C-Motion), who made me feel welcome and who complemented my learning experience. I am particularly thankful to Shawn Leclaire and Marcus Brown for all their help and teaching moments, and to Thierry Chevalier for always being available to listen and teach me and for being a friend. In addition to the Canadian team, I am also particularly thankful to Tom Kepple for his collaboration and for being an extremely patient teacher throughout this journey. I would also like to express my gratitude to all the members from the Neuromechanics Research Group for all their support and encouragement, their friendship, and for being VII willing to help and exchange their knowledge. In particular, I am genuinely grateful to Vera Moniz-Pereira, Rita Fernandes and Filomena Carnide. In addition to being great friends beyond my academic life, they are role models and very good colleagues who contributed significantly to my current knowledge and to both my professional and personal growth. Finally, I am forever grateful to Carlos Andrade for his valuable mathematical insights during the initial stages of development of the global indices proposed in this thesis. At last but not least, I am deeply grateful to my closest friends and family, who complete my life, for their love, support and encouragement throughout this long journey. Namely, I would like to thank my beloved mother, Ana Cabral, my sisters, Rita Lopes and Patricia Cabral, their better halves, and my longtime best friends, Ana Marques and Marta Marques, for always being there and for providing me with enjoyable moments. Also I am most deeply grateful to my husband, Pedro Prates, for his everlasting patience, understanding and support throughout another stage in our lives. Finally, I gratefully acknowledge the funding sources that made this work possible, explicitly the PhD grant supported by the Portuguese Foundation for Science and Technology (PhD Grant reference: SFRH/BD/69424/2010), and the congress travel grants awarded by the rectory of the Technical University of Lisbon and the International Society of Biomechanics. VIII Resumo As implicações clínicas de um padrão de marcha assimétrico levaram ao crescente interesse na recuperação da simetria da marcha em populações clínicas. Isto requer uma avaliação precisa e fiável da simetria da marcha na sua globalidade. Dadas as limitações dos índices de simetria pré-existentes, o objectivo desta Tese foi desenvolver e testar um novo índice global de simetria da marcha que abrangesse informação dos membros inferiores, do tronco e da pélvis, ao longo do ciclo completo da marcha. Para alcançar este objectivo, foram realizados quatro estudos. No primeiro, este índice, desenvolvido com base nas diferenças bilaterais de ângulos articulares em 3D, foi testado através da comparação dos resultados obtidos por indivíduos saudáveis em três condições de marcha, nas quais diferentes níveis de assimetria foram induzidos artificialmente. Os segundo e terceiro estudos analisaram a concordância e fiabilidade inter-sessão deste e de outros índices globais, também num grupo saudável. Com base nos resultados obtidos, o primeiro índice foi aperfeiçoado, substituindo os ângulos inter-segmentares pelas posições lineares das articulações. O estudo final testou a capacidade deste novo índice detectar a presença de níveis de assimetria superiores num grupo de indivíduos, cujo padrão de marcha é expectavelmente assimétrico. Estes estudos mostraram que, enquanto os índices baseados em ângulos articulares conseguem detectar alterações agudas na simetria dentro da mesma sessão, a sua baixa repetibilidade entre sessões desaconselha a sua aplicação para avaliar diferenças na simetria ao longo do tempo e entre indivíduos. Por outro lado, o índice proposto nesta Tese apresenta uma boa concordância e fiabilidade inter-sessão, e é sensível ao nível de assimetria tipicamente encontrado em sujeitos com um padrão de marcha assimétrico. Estas conclusões sugerem que este índice poderá ser uma ferramenta útil para a avaliação da simetria da marcha em contexto clínico. Palavras-chave Marcha,