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of Electromyography and Kinesiology 21 (2011) 712–718 Contents lists available at ScienceDirect Journal of

Contents lists available at ScienceDirect

Journal of Electromyography and Kinesiology

journal homepage: www.elsevier .com/locate/jelekin Analysis of the center of pressure displacement, ground

Analysis of the center of pressure displacement, ground reaction force and muscular activity during step exercises

Marcelo Camargo Saad a , , Lilian Ramiro Felício a , Catia de Lourdes Masullo a , Rogério Ferreira Liporaci b , Debora Bevilaqua-Grossi c

a Orthopedics, Traumatology and Rehabilitation, Faculdade de Medicina de Ribeirão Preto, USP, Brazil b Department of Medical Clinic, Faculdade de Medicina de Ribeirão Preto, USP, Brazil c Department of Biomechanics, Medicine and Locomotive Apparatus Rehabilitation, Faculdade de Medicina de Ribeirão Preto, USP, Brazil

article info

Article history:

Received 15 July 2010 Received in revised form 22 July 2011 Accepted 22 July 2011

Keywords:

Anterior knee pain Steps Closed kinetic chain Force plate Ground reaction forces Electromyography

abstract

Anterior Knee Pain (AKP) is considered as one of the most common, yet misunderstood, knee pathologies. The aim of this study was to evaluate the displacement area of the center of pressure, Ground Reaction Force (GRF), and the electromyography activity of the hip and the quadriceps muscles in healthy and AKP individuals during the step-up and step-down exercises. Both groups (Control group and AKP group) were composed of 15 volunteers submitted to the exercises on a force plate. The AKP group presented greater displacement area of the center of pressure for all the situations evaluated than the Control group ( p < 0.05), as well as a lesser magnitude of the GRF during the step-down exercise. The AKP group pre- sented lower electromyography activity than the Control group in all situations evaluated. AKP individ- uals do not have muscle imbalances; they present a lower electromyography activity of the stabilizing muscles of the patella and hip and show greater instability in activities such as step up and down com- pared to normal subjects.

2011 Elsevier Ltd. All rights reserved.

1. Introduction

Anterior Knee Pain (AKP) is one of the most common disorders of the knee joint ( Baker et al., 2002; Coqueiro et al., 2005 ) com- monly affecting young sedentary women ( Salsich et al., 2002 ). Although the etiological factors of AKP are still controversial, sev- eral authors point out biomechanical and structural factors may be associated with the pain, which is aggravated during functional activities ( Shellock, 2003; Coqueiro et al., 2005; Grelsamer and Stein, 2006 ). The imbalance between dynamic patellar stabilizers, mainly Vastus Medialis Obliquus (VMO), Vastus Lateralis Obliquus (VLO), and Vastus Lateralis Longus (VLL), could lead to patellar malalign- ment and patella abnormal tracking inside the femoral trochlea during knee flexion, and cause pain in the anterior knee region ( McGinty et al., 2000 ; Cowan et al., 2003 ; Bevilaqua-Grossi et al., 2004 ). Recently, in addition to the patella-stabilizer muscles, the influence of the hip stabilizer muscles on the knee function such as Gluteus Medius (GM) was also evaluated ( Powers et al., 2003; Boling et al., 2006 ), because a lesser electromyography (EMG)

Corresponding author. Address: Avenida Bandeirantes, 3900, Monte Alegre, CEP 14049-900 Ribeirão Preto, São Paulo, Brazil. Tel.: +55 16 91882576; fax: +55 16 3602 4413. E-mail address: marfisiousp@yahoo.com.br (M.C. Saad).

1050-6411/$ - see front matter 2011 Elsevier Ltd. All rights reserved. doi: 10.1016/j.jelekin.2011.07.014

activity or delay in the activation of GM in relation to the thigh muscles seems to affect the knee function ( Brindle et al., 2003 ). Therefore, alterations in alignment of the lower limb during functional activities, due to weakness of proximal muscles during unipodal support could lead to alterations in the postural control. This is considered an important factor while patients with AKP per- form physical and dynamic activities, i.e., step up and step down. This alteration in postural control would increase body oscillation and imbalance in the medial/lateral plane of movement (frontal plane) in this type of patients ( Gribble and Hertel, 2004; Horak, 2006 ). Therefore, patients with AKP may present more postural oscillation than in healthy individuals. Exercises in closed kinetic chain such as the step are indicated in the intermediate and final phases of AKP rehabilitation treat- ment ( Cowan et al., 2001 ). Functionally, two of the most painful activities of daily life for AKP individuals are to step up and down ( Brechter and Powers, 2002 ). During these activities, the maximum load exerted on patellofemoral joint can reach approximately 3.5 times the body weight, demonstrating the overload to which the joint is submitted during daily activities ( Magee, 2006 ). Clinically, the pain could lead to alterations during physical activities, which would be exacerbated by exercises such as step up and down and walk ramps ( Salsich et al., 2001 ). During unipo- dal support in these activities, the AKP individuals may use a dif- ferent motor strategy that would lead the trunk into an anterior

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position causing a decrease of the knee flexion and an increase in the center of pressure displacement ( Brechter and Powers, 2002 ). The Ground Reaction Force (GRF) has been used as indicator of the overload level in the musculoskeletal system during the weight-bearing phase on the ground where the greater mechanical overload occurs in the lower limb ( Amadio et al., 1999 ). Subjects with AKP did not demonstrate increased lower limb loading during the gait ( Powers et al., 1999 ). Equivocal changes in the GRF, how- ever, have been reported in subjects with AKP compared to healthy subjects ( Levinger and Gilleard, 2007 ). Thus, the amount of avail- able normative data on vertical GRF parameters during stair ambu- lation is diverse and still limited ( Stacoff et al., 2005; Stacoff et al., 2007 ). The GRF response pattern is not known in individuals with AKP during step activities. Thus, the hypothesis is that when pain occurs due to load imposed on the lower limbs during the stepping exercise, the patterns of movement, electromyography activity, and GRF response can be altered and these consequently can in- crease the overload on the patellofemoral joint. Therefore, the aim of this study was to evaluate the postural control during the step-up and step-down activities through the analysis of the displacement area of the center of pressure, over- load on the lower limbs, by GRF, and electromyography activity of the stabilizing muscles of the patella and hip. It is hypothesized that during the step up and down activities, individuals with AKP present (1) poor postural control, (2) a lesser magnitude of peaks of the GRF during weight bearing, and (3) a lesser EMG activity of the stabilizing muscles of the patella and hip.

2. Methods

2.1. Subjects

Thirty female sedentary volunteers were selected, evaluated, and divided into two groups according to inclusion and exclusion criteria ( Table 1 ). Fifteen volunteers were in the Control Group (CG) (average age, 23.3 ± 2.1 years; height, 160.40 ± 3.4 cm; weight, 53.47 ± 2.2 kg), and 15 volunteers were in the Anterior Knee Pain Group (AKPG) (average age, 23.16 ± 2.3 years; height, 159.66 ± 2.8 cm; weight, 58.66 ± 3.8 kg). All volunteers for both the groups presented the right lower limb as dominant, and in the AKPG, all volunteers reported their right leg as the affected leg (knee with pain). All subjects were informed about the procedures to be carried out during the research and they signed an informed consent form

Table 1 Inclusion and exclusion criteria for Control Group (CG) and Anterior Knee Pain Group (AKPG).

Control group Inclusion criteria Presence of at least two signals observed in the function evaluation showing AKP Absence of pain verified through the Visual Analogue Scale (VAS) during the last month

Exclusion criteria History of lesion or surgery in the musculoskeletal system, hip, knee, or ankle Individuals with neurological, cardiovascular, or rheumatologic diseases

Anterior knee pain group Inclusion criteria Pain in at least 3 cm in VAS during the last month Report of pain in at least two functional activities Three signals indicating AKP observed during functional evaluation

Exclusion criteria History of lesion or surgery in the musculoskeletal system, hip, knee, or ankle Individuals with neurological, cardiovascular, or rheumatologic diseases

approved by the Committee for Ethics in Research (Process HCRP no. 8089/2007).

2.2. Procedures and recording data

The subjects’ skin was prepared for EMG instrumentation in a standard procedure ( Basmajian and De Luca, 1985 ). The EMG mod- ule (Myosystem Br-1 P84, Data Hominis Tecnologia Ltda, Uberlân- dia MG/Brazil) with a high-pass filter of 10 Hz–5 kHz, three magnification stages, 10 G O impedance in differential mode, card A/D converter of 12-bit dynamic resolution band, input band rang- ing from 10 mV to + 10 mV, digital electromyography signals with acquisition frequency of 2000 Hz, 12-bit resolution, and

simultaneous sampling of signals. The myoelectric signals were registered through differential surface active electrodes with a gain

of 20 times (EMG System) and placed in parallel arrangement over

the GM, VMO, VLL, and VLO muscle fibers. The GM electrode was placed 50% on the line from the iliac crest to the greater trochanter (SENIAM project). On the VMO, the elec- trode was positioned 4 cm above the superior medial border of the patella ( Hanten and Schulties, 1990 ) with an inclination of 55

( Hanten and Schulties, 1990 ) in relation to the center of the patella and the anterior superior iliac spine ( Lieb and Perry, 1968 ). On the VLL, the electrode was fixed at 15 cm from the superolateral border of the patella with a 13.6 inclination. To fix the electrode on the VLO, the lateral femoral epicondyle was located following the ini- tial and middle parts of the muscle with a 50.4 inclination ( Bevil- aqua-Grossi et al., 2005 ). A stair with three steps of 20 cm height each was used ( Brechter and Powers, 2002 ; Cowan et al., 2002 ) and a force plate (AMTI- OR6-7-1000 model) was positioned on the first step of the stair ( Fig. 1 ). Individuals were positioned in front of the first step of the stair and were told to go up and/or down the step following

a predetermined cadence of 30 steps/min ( McCrory et al., 2007 ),

controlled by a metronome (Korg ). Each volunteer performed 3 times each activity, step up and step down. The tests were per- formed separately for both the lower limbs to verify the effect of the dominant limb on the results of the parameters analyzed dur- ing the exercises. The tested lower limb was randomly selected to start the exercise. The volunteer was asked to step up once and step down in sequence. This procedure was repeated 3 times. The same activity was performed with the other leg. After collec- tion, all data were normalized and processed for further analysis.

all data were normalized and processed for further analysis. Fig. 1. Lay out of the force

Fig. 1. Lay out of the force plate and the stair with the step height measures used for the activity.

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2.3. Data processing

The displacement area of the center of pressure of the individ- uals was measured through BioDynamicsBr software (Data Homi- nis Tecnologia Ltda). The software created an ellipse that concentrated about 85% of the data acquired from the force plate during the exercises. The ellipse area was calculated by the soft- ware using the formula Area = p ab , where a = semi-major axis, b = semi-minor axis, and p = 3.1416 ( Fig. 2 ). The area was the best way to estimate the displacement area of the center of pressure of the individual that was on the force plate ( Oliveira et al., 1996; Bonfim and Barela, 2007 ). The GRF values were normalized by dividing them with the par- ticipant’s body weight ( Stacoff et al., 2005 ). The analysis of the ver- tical component of GRF was evaluated using three specific points considering that they present, two peaks and one valley, where the peaks had higher values than the body weight. The first peak (peak 1) occurs after the foot contacted the ground when the leg receives the bodyweight. The second peak (peak 2) occurs at the end of the stance phase when the foot disengages contact with the ground surface. This is the phase that the subject applies an im- pulse to initiate the next step. The valley between these peaks is slightly smaller than the body weight, which occurs when the foot is in a flat position in relation to the ground, and represents the walking swing phase ( Fig. 3 ). The expected standard for the GRF vertical component of a walking cycle is a curve-shaped ‘‘M’’ registered while walking on flat ground ( Fig. 3 A). It has been reported that this form may be al- tered when walking on stairs or during the step activities, where

peak 2 is greater than peak 1 during the step up ( Fig. 3 B) and peak 1 becomes greater than peak 2 during the step down ( Christina and Cavanagh, 2002 ; Riener et al., 2002 ) ( Fig. 3 C). The muscular activity was processed by the Myosystem I soft- ware 3.5 version. EMG signals were further band pass filtered at 20–500 Hz to obtain the values of the integral of the linear enve- lope. The magnitude of muscle activity was computed from the area under the linear envelope or integrated EMG, for the duration of the muscle activity. The area under the linear envelope was cal- culated using a trapezoidal estimation technique. These values were normalized by the average of the filtered values of the activ- ities because this method presents less variability ( Knutson et al., 1994 ) and more efficiency and applicability when compared to other methods ( Winter, 1984; Yang and Winter, 1984; Burden et al., 2003 ), especially in dynamic activities.

2.4. Statistical analysis

To perform the statistical analysis of the comparison between the parameters evaluated in the activities, the following were con- sidered: muscular activity, displacement area of the center of pres- sure and GRF as dependent variables and the types of exercises (step up and step down), and the legs as independent variables. To analyze the effect of exercises, legs, and groups, we used the lin- ear regression model with mixed effects (fixed and random effects) ( McLean et al., 1991 ). The fixed effects were exercises (step up and step down), right leg (dominant for the CG and affected for the AKPG) and left leg (not dominant for the CG and not affected for the AKPG), and the interaction between them. The individuals were

and the interaction between them. The individuals were Fig. 2. Lay out of the software BioDynamicsBr

Fig. 2. Lay out of the software BioDynamicsBr Analysis to calculate the displacement area of the center of pressure.

calculate the displacement area of the center of pressure. Fig. 3. The vertical component of GRF

Fig. 3. The vertical component of GRF graph with the force and valley peaks between them during walking in plane ground (A), during step up (B) and step down (C).

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the random effects with multiple comparisons between the depen- dent-variable and independent-variable levels. These interactions were calculated based on orthogonal contrasts with a significance level of p < 0.05. All statistical procedures were performed through SAS 9 software using the PROC MIXED (Cary, NC, USA).

3. Results

3.1. Displacement area of the center of pressure and GRF

Table 2 shows us, when considered only the activities of step up and step down, that the AKPG present greater average values when compared to the CG; during the step up (69.28 cm 2 vs. 42.96 cm 2 ) and step down (56.63 cm 2 vs. 36.34 cm 2 ). Considering the lower limbs, the AKPG presented a greater average in relation to the CG for both the limbs. When comparing the affected leg (for AKPG) with the dominant leg (for CG) these average values were (66.28 cm 2 vs. 43.77 cm 2 ) during the step up and (58.00 cm 2 vs. 35.06 cm 2 ) during the step down ( Table 2 ). When the not affected leg (for AKPG) was compared with the not dominant (for CG), these average values were (72.28 cm 2 vs. 42.15 cm 2 ) during the step up and (55.26 cm 2 vs. 37.62 cm 2 ) dur- ing the step down ( Table 2 ). Summarizing, the data revealed that for all measures involving the displacement area of the center of pressure, the AKPG pre- sented greater average values when compared to the CG in all rela- tionships ( Table 2 ). The comparative analysis of GRF between the CG and AKPG re- vealed significant differences during the step-down activity with the affected leg (dominant leg for CG). The differences were ob- served during the stage where the leg received the body weight (peak 1) ( Fig. 4 ) as well as at the end of the stance phase to initiate the next step (peak 2) ( Fig. 4 ). These two peaks are smaller in the AKPG when compared to the CG. With regard to the valley between the peaks (cycle swing phase) there were no significant differences for any activities evaluated either between the groups or within the CG and AKPG ( Fig. 4 ). The GRF intra-group analysis revealed that for both the groups, the GRF had increased magnitude in step down in relation to step up for peak 1. For peak 1, the AKPG presented a difference in mag- nitude when the affected and not affected legs were compared; the affected leg presented smaller values in relation to the not affected leg during the step-down activity, and for peak 2, both the groups presented the GRF with a larger magnitude in the step-up activity when compared to the step down ( Fig. 4 ).

3.2. Electromyography

The EMG data analysis revealed that, generally, the muscular activity was always greater in the step-up activities when com-

Table 2 Mean and standard deviation for the displacement area of the center of pressure (cm 2 ). Control group ( n = 15) and Anterior knee pain group (n = 15).

Control group AKP group a

Difference between groups (%)

Activities

Step

up

42.96 ± 10.22

69.28 * ± 33.36

61.26

Step down

36.34 ± 10.92

56.63 * ± 24.56

55.83

Right leg

Dominant

Affected

Step

up

43.77 ± 11.81

66.28 * ± 21.99

51.42

Step down

35.06 ± 11.70

58.00 * ± 3132

65.43

Left leg

Not dominant Not affected

Step

up

42.15 ± 8.40

72.28 * ± 31.82

71.48

Step down

37.62 ± 10.05

55.26 * ± 15.34

46.88

* p < 0.01. a For AKP group, the right leg is the affected leg.

pared to the step down ones for all muscles. The AKPG presented lower average values of muscular activity in relation to the CG for all situations and for all muscles too. The comparative analysis between the evaluated muscles in the CG and AKPG did not show significant differences in EMG activity for both the groups and both the legs during the activities (step up or step down). However, some differences in the muscle activity were found in the compar- ative analysis between the CG and AKPG during these activities ( Table 3 ). The data also showed that for the activities performed with the right lower limb (affected leg for AKPG and dominant for CG) dur- ing the step up there were no significant differences between the groups for any muscle, but during the step-down activity, the AKPG presented less electromyography activity in relation to the CG for all the muscles evaluated ( Table 3 ). When the activities per- formed with the left lower limb (not affected leg for AKPG and not dominant for CG) were analyzed, both for the step up and step down, the AKPG presented less EMG activity in relation to the CG, but just for the VMO and VLO muscles ( Table 3 ).

4. Discussion

In this study, it was observed that individuals with AKP pre- sented a larger displacement area of the center of pressure in both activities and less stability during these activities. The poor pos- tural control in the medial/lateral plane of movement (frontal plane) can be attributed to the presence of the knee pain that pro- moted less stability while walking on stairs, influencing the func- tion of the lower extremity, especially during locomotion. Clinically, this condition would lead to changes in the walking pattern during the step-up and step-down activities or walking on inclined planes ( Nyland et al., 2002 ) mainly the step down, which involves an eccentric control of the muscles and becomes a more challenging and painful activity for patients with AKP ( Selfe et al., 2007 ). These hypotheses were confirmed by our data. The re- sults also showed large standard deviations for the AKPG that probably occurred due to pain related to the activity. This caused these individuals to present more instability resulting in larger dis- placement areas of the center of pressure and larger standard deviations. An interesting result found in our study was that in the individ- uals of the AKPG, the not-affected leg had greater displacement areas of the center of pressure in the activities compared to the af- fected leg of the individuals themselves. This could be explained by the fact that despite having no pain, this is not the dominant leg and therefore have less control and stability during activities. When compared to the not-affected leg of the AKPG subjects with the not dominant leg of the CG, AKP subjects still have major displacement areas of the center of pressure. This fact probably oc- curs because these are challenging activities for these individuals. These individuals also presented less muscle activity in relation to the CG, which could contribute to larger displacement areas of the center of pressure. Analysis of the GRF that is an indicator of the overload level in the musculoskeletal system during the weight-bearing phase on the ground showed us that during the step-down activity, AKP individuals, as a means of protection and to avoid pain, unload the weight with lesser intensity in the affected leg. Thus, the pain- ful condition was capable of modifying the gait pattern in these individuals. These results were also observed by other authors even for rapid evaluation of fast walking ( Bennell et al., 2006 ) and also during the step up ( Stacoff et al., 2007 ). The GRF peak 2 maintained the same pattern where the AKPG shows a lesser magnitude than the CG during the step down with the affected leg. This phase also led to the overload of the lower

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of Electromyography and Kinesiology 21 (2011) 712–718 Fig. 4. Ground force reaction during weight unload (peak

Fig. 4. Ground force reaction during weight unload (peak 1), end of the stance phase (peak 2), and swing phase (valley). For the AKP group, the right leg is the af fected leg.

Table 3 Mean and standard deviation of the integral of the linear envelope Control group vs. Anterior Knee Pain group.

 

Gmed

VMO

VLO

VLL

Right leg a Step up Control group AKP group Step down Control group AKP group

0.79 ± 0.15 0.70 ± 0.11

0.78 ± 0.15 0.71 ± 0.11

0.79 ± 0.15 0.70 ± 0.11

0.79 ± 0.15 0.70 ± 0.11

0.68 * ± 0.17 0.56 ± 0.11

0.68 ** ± 0.17 0.55 ± 0.11

0.68 * ± 0.17 0.56 ± 0.11

0.68 * ± 0.17 0.56 ± 0.11

Left leg

Step up

Control group

0.79 ± 0.14 0.67 ± 0.12

0.78 * ± 0.14 0.67 ± 0.12

0.78 * ± 0.14 0.67 ± 0.12

0.77 ± 0.16 0.67 ± 0.12

AKP group

Step down

Control group

0.67 ± 0.18 0.55 ± 0.11

0.66 ** ± 0.19 0.54 ± 0.11

0.67 * ± 0.18 0.55 ± 0.11

0.67 ± 0.18 0.55 ± 0.11

AKP group

* p = 0.01. ** p < 0.01.

a For Control group, the right leg is the dominant leg; for AKP group, the right leg is the affected leg.

limb and consequently to pain causing these individuals to some- how not discharge so much weight on the limb at the start of the new step. The analyses of the EMG activity results revealed that individu- als with AKP had a deficit in the muscle activity compared to the control individuals during functional activities such as step up and down. Sheehy et al. (1998), while analyzing the muscle activity peaks, did not observe differences between the VMO and VLL be- tween healthy individuals and the ones with AKP during the step-up and step-down activities but suggested smaller muscular activity for individuals with AKP. This study has not evaluated the peak of muscular activity but has observed less muscular activ- ity in all muscles evaluated in the AKPG. The presence of imbalance in the EMG activity between the VMO, VLO, and VLL muscles is controversial in the literature and has not been established as the cause of AKP ( Cowan et al., 2001; Coqueiro et al., 2005; Gramani-Say et al., 2006 ). Our results showed that there is no imbalance between the muscles evaluated in the AKPG, but there were differences in muscle activity for the same muscle, mainly VMO and VLO, in relation to the activity per- formed by them during the step-up or step-down activities. During

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the step-up activity that involves a concentric contraction of the quadriceps muscles, the muscles evaluated showed a greater mean in the activation of step descent activity. So, there is no evidence of muscular imbalance between the medial and lateral muscle com- ponents of individuals with AKP during these activities. Even though they play a major role in helping with the knee sta- bilization, the hip muscles are not often evaluated in individuals with AKP. These individuals often presents a pelvic malalignment, hip adduction and increased internal rotation of the femur in func- tional activities, especially those that are in a single leg, as step up and down, due to weakness or lower activity in the stabilizing hip muscles, mainly the GM ( Mascal et al., 2003; Ireland et al., 2003; Earl and Vetter, 2007; Piva et al., 2009 ). However, our study found a difference in the GM EMG activity between the groups just during the step down, which was the most painful activity related for AKP individuals performed with the affected leg. Our results showed that EMG activity in individuals with AKP is smaller compared to normal subjects for all muscles evaluated. This can be attributed to the perception of pain, since patients who perceived greater pain after the exercise, shows a decrease in the activity of the VMO and VLL, whereas patients who reported lower levels of perceived pain after the exercise has a decrease in GM EMG activity ( Ott et al., 2011 ). Although we did not specifically evaluate the pain, these results are according with our results. The muscles may be the source of changes in postural control and could lead to pain during the exercises, mainly step down. This muscle dysfunction can also explain the greater displacement area of the center of pressure in these individuals in all exercises. In addition Anderson and Herrington (2003) suggested that AKP patients adopt strategies during eccentric quadriceps contractions, like in step-down activities to reduce the level of stress placed on the patellofemoral joint and the pain experienced. Then the reduc- tion of EMG activity of the quadriceps would be a strategy to better distribute forces over a greater surface area in the joint and thus reduce stress during increasing knee flexion tasks and thus reduce the perception of pain. Our results reveal the importance of strengthening not only patellar stabilizing muscles but also the hip stabilizing muscles. The weakness or less EMG activity of any of these muscle groups can lead to changes in patterns of postural control during daily functional activities. The painful condition associated with muscle dysfunction should be specially considered to develop the rehabil- itation protocol of these patients. So, recently, muscle strengthening of both the quadriceps as well as the stabilizing hip muscles has been indicated as the treat- ment for these patients ( Sacco et al., 2006; Piva et al., 2009 ). The data analysis has confirmed our hypotheses that individuals with AKP present greater displacement areas of the center of pres- sure, a lesser magnitude of the GRF, and EMG activity of the knee and hip stabilizing muscles in relation to individuals without AKP. Our study has some limitations. First, the fact that all the indi- viduals of the study had the right leg as the dominant and in the case of the AKPG this leg was the dominant and affected leg. Thus, we cannot affirm if we would find the same results if the affected leg in the AKPG was the not the dominant leg or if the left leg was the dominant leg for majority of the individuals. Second, our sam- ple is consecutive, not random. Accordingly, our results cannot be generalized to the population.

5. Conclusion

The analysis of the results referring to the displacement area of the center of pressure, GRF, and EMG activity showed that individ- uals with AKP during the step-up and step-down activities, com-

monly used in rehabilitation protocols of AKP patients, present a greater displacement area of the center of pressure and lesser EMG activity of the stabilizing muscles of the patella and hip. A les- ser magnitude of the GRF was also observed in the affected leg dur- ing the step-down activity.

Acknowledgments

The author would like to acknowledge the assistance from the FAPESP (The State of São Paulo Research Foundation) and the Uni- versity of São Paulo, Department of Biomechanics, Medicine, and Locomotive Apparatus.

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in gait analysis. Arch Phys Med Rehabil 1984;65:517–21. Lilian Ramiro Felicio received the Bacharel degree (2001)
in gait analysis. Arch Phys Med Rehabil 1984;65:517–21. Lilian Ramiro Felicio received the Bacharel degree (2001)
in gait analysis. Arch Phys Med Rehabil 1984;65:517–21. Lilian Ramiro Felicio received the Bacharel degree (2001)
in gait analysis. Arch Phys Med Rehabil 1984;65:517–21. Lilian Ramiro Felicio received the Bacharel degree (2001)

Lilian Ramiro Felicio received the Bacharel degree (2001) in Physical Therapy from University Center of the Araraquara and the M.S. degree (2007) and cur- rently Sc.D. degree student in Medical Science Applied of Locomotor Apparatus from Department of Biomechanics, Medicine and Rehabilitation of Loco- motor Apparatus, Ribeirão Preto School of Medicine, University of São Paulo – USP (Brazil). She has worked in researches at the Posture and Human Movement Analysis Laboratory since 2003 investigating kinetic and kinematic and muscle actions in therapeutic exercises for the lower limb.

Catia de Lourdes Masullo received the Bacharel degree (2009) in Physical Therapy from University of São Paulo – USP (Brazil) and currently master science degree student in Medical Science Applied of Loco- motor Apparatus from Department of Biomechanics, Medicine and Rehabilitation of Locomotor Apparatus, Ribeirão Preto School of Medicine, University of São Paulo – USP (Brazil). She has worked in researches at the Posture and Human Movement Analysis Labora- tory since 2006 investigating kinetic of lower limb.

Rogério Ferreira Liporaci is graduated in Physical Therapy (2006) from University of São Paulo and master degree student in Medical Science from Medical Clinics Department, Ribeirão Preto Medical School at the University of São Paulo. He is specialized (2007) in Physical Therapy Applied of Orthopedics and Traumatology from Clinical Hospital of Ribeirão Preto Medicine School he is currently student of Biomechanics course from Physical Education School of Campinas University.

Débora Bevilaqua-Grossi is a full professor at the Department of Biomechanics, Medicine and Rehabil- itation of Locomotor Apparatus of Ribeirão Preto Medical School at the University of São Paulo, Brazil. She received an M.Sc degree from Universidade Estadual de Campinas (1996), a Ph.D degree from the same University (1998) and realized her sabbatical in Albert Einsten College of Medicine in EUA (2009). She is chief editor of Brazilian Journal of Physical Therapy and her research has emphasized the human move- ment and posture, working mainly in disorders of the musculoskeletal system.

working mainly in disorders of the musculoskeletal system. Marcelo Camargo Saad graduated in Physical Ther- apy

Marcelo Camargo Saad graduated in Physical Ther- apy from University of São Paulo in 2006 and the M.S. degree (2010) and currently Sc.D. degree student in Medical Sciences Applied of Locomotor Apparatus from Department of Biomechanics, Medicine and Rehabilitation of Locomotor Apparatus, Ribeirão Preto School of Medicine, University of São Paulo – USP (Brazil). He has worked in researches at the Posture and Human Movement Analysis Laboratory since 2004 and the focus of his study is kinetic and kine- matic and electromyography activity in therapeutic exercises for the lower limb.