334 IEEE TRANSACTIONS ON NEURAL SYSTEMS AND REHABILITATION ENGINEERING, VOL. 22, NO.
2, MARCH 2014
Real-Time Knee Adduction Moment Feedback
Training Using an Elliptical Trainer
Sang Hoon Kang, Member, IEEE, Song Joo Lee, Yupeng Ren, Senior Member, IEEE, and
Li-Qun Zhang, Senior Member, IEEE
Abstract—The external knee adduction moment (EKAM) is as-
sociated with knee osteoarthritis (OA) in many aspects including
presence, progression, and severity of knee OA. Despite of its
importance, there is a lack of EKAM estimation methods that can
provide patients with knee OA real-time EKAM biofeedback for
training and clinical evaluations without using a motion analysis
laboratory. A practical real-time EKAM estimation method, which
utilizes kinematics measured by a simple six degree-of-freedom
goniometer and kinetics measured by a multi-axis force sensor
underneath the foot, was developed to provide real-time feedback
of the EKAM to the patients during stepping on an elliptical
trainer, which can potentially be used to control and alter the
EKAM. High reliability (ICC(2,1): 0.9580) of the real-time EKAM
estimation method was verified through stepping trials of seven
subjects without musculoskeletal disorders. Combined with ad-
vantages of elliptical trainers including functional weight-bearing
stepping and mitigation of impulsive forces, the real-time EKAM
estimation method is expected to help patients with knee OA
better control frontal plane knee loading and reduce knee OA
development and progression.
Index Terms—Center of pressure (COP), knee adduction mo-
ment, knee osteoarthritis (OA), real-time biofeedback.
I. INTRODUCTION
A LTHOUGH the frontal plane knee motion is much more
limited than the sagittal plane motion, knee osteoarthritis
(OA) may be closely associated with excessive loadings in-
cluding external knee adduction moment (EKAM) within the
limited frontal plane adduction range of motion. This paper
proposes a practical and reliable real-time EKAM estimation
Manuscript received April 17, 2013; revised September 16, 2013; accepted
October 18, 2013. Date of publication November 14, 2013; date of current ver-
sion March 05, 2014. This work was supported in part by grants from the Na-
tional Science Foundation, the National Institutes of Health, and the National
Institute on Disability and Rehabilitation Research. L.-Q. Zhang and Y. Ren
have equity positions in Rehabtek LLC, which received NSF funding in devel-
oping the custom elliptical trainer in this study.
L.-Q. Zhang is with the Rehabilitation Institute of Chicago, and Departments
of Physical Medicine and Rehabilitation, Orthopaedic Surgery, and Biomed-
ical Engineering, Northwestern University, Chicago, IL 60611 USA (e-mail:
l-zhang@northwestern.edu).
S. H. Kang is with the Rehabilitation Institute of Chicago, and Departments
of Physical Medicine and Rehabilitation, and Biomedical Engineering, North-
western University, Chicago, IL 60611 USA (e-mail: sanghoon.kang@north-
western.edu).
S. J. Lee is with Department of Biomedical Engineering, Northwestern Uni-
versity, Evanston, IL 60201 USA (e-mail: song-lee@northwestern.edu).
Y. Ren is with the Rehabilitation Institute of Chicago, Chicago, IL 60611
USA, and also with Rehabtek LLC, Wilmette, IL 60091 USA (e-mail: yupeng.r
@gmail.com).
Color versions of one or more of the figures in this paper are available online
at http://ieeexplore.ieee.org.
Digital Object Identifier 10.1109/TNSRE.2013.2291203
1534-4320 © 2013 IEEE. Personal use is permitted, but republication/redistribution requires IEEE permission.
See http://www.ieee.org/publications_standards/publications/rights/index.html for more information.
method using an elliptical trainer (ET) with a six degree-of-
freedom (DOF) goniometer.
Biomechanically, the EKAM includes the adduction moment
about the knee joint due to the ground reaction force (GRF) and
inertial forces [1]; is equal in magnitude and opposite in direc-
tion to the internal knee adduction moment due to muscles, soft
tissues, and knee joint contact forces [1]; and can be estimated
in vivo [2], [3]. Since increase in the EKAM reflects increase
in the compressive load in the medial tibiofemoral compart-
ment [4], the EKAM is commonly used as a surrogate measure
of the compressive load [5]–[9] that is difficult to measure in
vivo and noninvasively and compute [4]. Clinically, the EKAM
during gait is a useful marker for knee function, especially in
knee OA—which affected more than 27 million Americans [10]
and contributed to functional impairments and reduced indepen-
dence in older adults [11]. The EKAM is correlated with the
severity of medial compartment knee OA [5]–[8]—the patho-
genesis of which is highly related to the aberrant compressive
load in the medial knee compartment [4], [6], [12]; and an in-
creased EKAM is a strong predictor of medial knee OA pro-
gression[9]. Specifically, the peak EKAM is a strong predictor
of medial compartment knee OA presence [13], radiographic
disease severity [13], the presence of OA symptoms [14], and
clinical outcomes following surgical realignment of the limb
for varus gonarthrosis [15]. Thus, reduction of the peak EKAM
is often a major goal of knee OA rehabilitation [2], [5]–[9],
[16]–[22], which may be achieved by training/improving the pa-
tients’ dynamic and static control of knee adduction DOF. In a
recent study, it was found that real-time peak EKAM feedback
is helpful to reduce peak EKAM on a treadmill in a motion anal-
ysis laboratory setting [3]. Therefore, it is important to estimate
the EKAM in real-time for biofeedback gait trainings and out-
come evaluations.
The peak EKAM in [3] was estimated as the maximum of cross
product of moment arm from knee joint center to GRF and GRF
in the frontal plane during the first 40% of stance [3] instead of
3-D inverse dynamics calculation. This approximation may be
convenient compared to the 3-D inverse dynamics calculation,
but can yield EKAM of wrong magnitude and/or polarity [23],
[24]. Indeed, 3-D inverse dynamics calculation is difficult to im-
plement, especially outside motion analysis laboratories (e.g.,
for large clinical trials, routine clinical evaluations, and train-
ings), due to the complex computation involved and the usual re-
quirement of complex and expensive custom-made motion cap-
ture systems potentially occupying large space and requiring ex-
tensive setup [2], [3], [5], [12], [25], [26]. Therefore, a practical
and reliable real-time EKAM estimation method is needed.
KANG et al.: REAL-TIME KNEE ADDUCTION MOMENT FEEDBACK TRAINING USING AN ELLIPTICAL TRAINER 335

Fig. 1. Modified ET. (a) Sagittal plane view of the ET with a right leg (step length: ). (b) Compact and inexpensive 6-DOF goniometer attached to a
subject’s right leg on the ET. ET was instrumented with a 6-axis F/T sensor (blue box written F/T, ) underneath each footplate and a precision potentiometer
measuring distance along the angled linear guide. and denote COM of shank and foot, respectively. , , and , the
constant lengths, were 0.24 m, 1.19 m, and 0.77 m, respectively. Upper part of the 6-DOF goniometer was firmly strapped to the flat and bony anteromedial surface
of tibia/shank to reduce slip of the goniometer on subject’s skin, and the lower part was attached to the lateral side of the footplate while aligning one potentiometer
of the goniometer with lateral malleolus. The easily removable long steel rods as alignment guides at the lateral and front sides of the footplate assisted initial
alignment of the ankle and knee joints. .

ETs are widely used in many homes, fitness facilities, and
medical settings for exercise and research purposes [27]–[29].
ETs can be used for gait trainings, considering that ETs allow
closed-chain functional body weight-bearing stepping [30]
similar to over-ground walking [27], [31], and mitigate the
delivery of impulsive GRF related to musculoskeletal injuries
(e.g., knee OA) [28]. Furthermore, it was demonstrated that
training on multi-axis ETs, having additional motorized piv-
oting and/or mediolateral sliding DOFs at each footplate, is
promising for the prevention and rehabilitation of knee injuries
with improvements in functional activities [29], [30], [32]–[35].
Thus, the goal of this research is to develop a practical and
reliable real-time EKAM estimation method on a modified ET
equipped with a 6-axis force/torque (F/T) sensor and a 6-DOF
goniometer at each footplate. Specifically, we propose an esti-
mation method that enables us to estimate the EKAM on the ET
in real-time throughout the whole step cycle by solving the 3-D
inverse dynamics instead of an approximated computation [3],
[36]—GRF’s lever arm to knee joint center times GRF—with
lower-limb kinematics measured with a compact 6-DOF go-
niometer instead of a complex motion capture system in typ-
ical motion analysis laboratories. If successful, the EKAM of
patients with knee OA can 1) be fed back to the patients in
real-time for effective training on the multi-axis ETs, and 2) be
used for outcome evaluations. To test the proposed method’s
feasibility, EKAMs of seven healthy subjects at three different
stepping conditions (i.e., regular stepping, knee-adducted step-
ping, and knee-abducted stepping) were estimated in real-time
by using the proposed method, and corroborated with that esti-
mated offline by using kinematic data from an optoelectric mo-
tion capture system (Optotrak 3020, Northern Digital, Waterloo,
ON, Canada) at the same trials. A partial preliminary study was
reported before [29].
II. EXTERNAL KNEE ADDUCTION MOMENT ESTIMATION
METHOD ON AN ELLIPTICAL TRAINER
A 3-D inverse dynamics, tailored for the EKAM estimation
during stepping on a modified ET [Fig. 1(a) and (b)] is pre-
sented below, followed by an introduction of the modified ET
with ankle kinematics measured using a 6-DOF goniometer.
A. Modified Elliptical Trainer With the 6-DOF Goniometer
An ET (Reebok Spacesaver RL) was modified and instru-
mented with 6-axis F/T sensors (JR3, Woodland, CA, USA)
that measured 3-D force and moment vectors
on both sides underneath the footplates [Fig. 1(a)] with several
safety mechanisms [34]. Gravitational and inertial forces and
moments of the footplate were calculated and subtracted from
the measured forces and moments. A precision potentiometer
located at the ET’s front end measured the distance from
the potentiometer to the anterior end of the long beam
( to ). To accurately measure 3-D ankle angles (i.e.,
dorsiflexion/planar-flexion, inversion/eversion, and internal/
external rotation), the upper part of the 6-DOF goniometer,
similar to a 6-DOF knee goniometer in previous studies [37],
[38], was firmly strapped to the flat and bony anteromedial
336 IEEE TRANSACTIONS ON NEURAL SYSTEMS AND REHABILITATION ENGINEERING, VOL. 22, NO. 2, MARCH 2014

surface of tibia/shank using neoprene bands, and the lower part positions of the two beams, unless subjects changed the direc-
was attached lateral to the footplate, with no motion relative to tion of stepping. With and thus obtained, the center of the
the foot strapped to the footplate [Fig. 1(b)] [30], [33]–[35]. F/T sensor position could be calculated by replacing
in (1) with [Fig. 1(a)].
B. Kinematics 3) Kinematics of the 6-DOF Goniometer: To measure the
1) Frames of Reference: Several frames of reference—world dorsiflexion/planar-flexion , inversion/eversion , and
frame, ET frame, ankle anatomical frame (AAF), and tibial internal/external rotation angles of ankle in real-time, a
(knee) anatomical frame (TAF)—were defined for the con- low-cost 6-DOF goniometer [Fig. 1(b)] was used without time
venience of the EKAM estimation [Fig. 1(a) and (b)] with consuming preparation [37], [38]. Six coordinate frames of the
palpable anatomic landmarks [39]. For the right leg, the posi- goniometer were numbered 1–6 in sequence from the bottom
tive directions of the , , and axes of the world frame, which frame attached to the footplate to the top frame attached to
was fixed to the ground, were lateral, anterior, and upward the tibia/shank. The goniometer had five rotational DOFs—the
directions, respectively. The ET frame, the orientation of which rotation angles of which were measured with , , , ,
is the same as that of the world frame, was defined with its and —and one translational DOF—the linear movement of
origin at [Fig. 1(a)]. The AAF, whose three orthogonal axes a telescoping link determined by [Fig. 1(b)].
are , , and axes, denoted a frame attached to the foot The goniometer needed a two-step calibration: an offline cal-
with its origin at the midpoint between the tips of medial ibration and an online initial alignment. The former was per-
and lateral malleoli [40]. The -axis (long axis) was defined formed with a calibration plate, on which all five angles of
as the projection of a vector from to the second metatarsal the goniometer’s rotational DOFs were zero and and the
head onto the footplate; -axis as the upward direction vector length of the telescoping link were known constants [37], [38].
orthogonal to the footplate surface from ; and -axis as the Note that the zero angles calibrated were different from the zero
cross product of the - and -axis vectors, similar to [40]. anatomical ankle angles (i.e., 0 dorsiflexion/planar-flexion, 0
TAF ( , , and axes) denoted a frame attached to the inversion/eversion, and 0 internal/external rotation). The latter,
the online initial alignment, was performed to obtain the zero
tibia with its origin at (tibial origin), the midpoint between
anatomical ankle angles before each subject’s stepping on the
the peripheral margins of medial and lateral tibial plateaus
ET. For that, the footplate had slots extended from it in the lat-
[4], [15], [25], [39], [41], [42] instead of the two impalpable
eral and anterior directions for easy attachment of long steel rods
intercondylar eminences [43]. The -axis (long axis) was
as alignment guides perpendicular to the footplate [Fig. 1(b)].
defined as the vector from the to ; -axis as the cross
Looking into the sagittal plane ( plane) of the AAF from
product of the -axis and a vector from the medial to lateral
the lateral side, the two lateral alignment guides overlapped each
tibial plateaus; and -axis as the cross product of - and
other and with the center of the F/T sensor, . Looking into
-axis vectors [43]. Hereafter, the left-leading superscripts
the frontal plane ( plane) of the AAF from the anterior
denote the frame of reference of vectors and matrices: , , ,
side, the two alignment guides at the footplate’s front side over-
and denote the world frame, the ET frame, AAF, and TAF,
lapped each other and with .
respectively. With the footplate at its lowest position and the subject
2) Kinematics of the Elliptical Trainer: The angle bearing 100% body weight (BW) on that leg, the following
between the footplate and the ground, the summation of two steps were taken for the online initial alignment. First,
and (i.e., ), was needed for the EKAM es- projecting into the frontal plane of AAF ( plane), the
timation to determine the foot orientation, θ . second metatarsal head, the midpoint between the medial and
The precision potentiometer located at a known position lateral malleoli, and the tibial tuberosity were aligned with
measured distance from the two alignment guides attached at the footplate’s front side
to the anterior end of the long [Fig. 1(b)]. The midpoint between the peripheral margins of
beam connecting and [Fig. 1(a)]. Because the move- medial and lateral tibial plateaus in the frontal plane could be
ment of was constrained by an oblique linear guide with additionally considered, if needed. Second, projecting into the
[Fig. 1(a)], and determined the and of sagittal plane ( plane), a line connecting subjects’ lateral
. Also, and could be obtained from the following malleolus and the peripheral margin of lateral tibial plateau
kinematic relation of the ET: was aligned with two lateral alignment guides so that the
peripheral margin of lateral tibial plateau, the lateral malleolus,
(1) and were all in a line [Fig. 1(b)]. Dome-shaped rubber
pads (diameter: 0.01 m) were attached to the aforementioned
where and denote the length of the short beam ( to ) points for the alignment. In this way, a posture reaching the
and that of the long beam ( to ), respectively [Fig. 1(a)]. zero anatomical ankle angles was determined.
Thus, one can obtain and by solving (1) for and The rotation matrix, , from the last (sixth) frame of the
with and obtained from the potentiometer measurement goniometer, moving with the TAF, to the AAF was calculated
(i.e., ), and the two beam lengths ( and ). Although two using the five rotation angles ( , , , , and )—the zero
sets of solutions (postures of the two beams) were possible, a angles of which were calibrated offline—as follows [37], [38]:
proper one could be selected during stepping on the ET with a
known initial position of the footplate determined by the initial (2)
KANG et al.: REAL-TIME KNEE ADDUCTION MOMENT FEEDBACK TRAINING USING AN ELLIPTICAL TRAINER 337

where , , and denote rotation matrices about
axis, axis, and axis, respectively; a 3 3 identity
matrix, representing no contribution of the goniometer’s trans-
lational DOF (i.e., ) on 3-D ankle rotation measurement
[37], [38].
Once the online alignment was confirmed, the five angles of
the rotational DOFs of the goniometer, and , the rotation
matrix at the initial alignment, were saved. With the saved
, one could compute the rotation matrix from the TAF to
the AAF, , during stepping on the ET as follows [37], [38]:
(3)
completely describes the 3-D rotation of ankle, and, the-
oretically, any Euler or fixed angle set will result in the same
EKAM, although the resulting equation of the EKAM may be
seemingly different depending on the angle set chosen. The
Euler angle set was chosen to describe the 3-D ankle
angle and, if needed, any other angle set can be
used instead.
C. Modified 3-D Inverse Dynamics
) was generally computed with the assumption:
and . However, in the case of the modified ET, the
assumption may be violated because of the possible existence
of the nonzero and/or , considering that no relative
motion between the foot and the footplate was allowed due to
the foot straps. Thus, on the ET, COP ( and ) could
not be computed from (4) unless and were separately
measured or estimated. It should be noted that the goal of this
specific research was not to determine the COP but to estimate
the EKAM.
Although the COP computation may be difficult on the ET,
the net ankle and knee moments can be computed by utilizing
the given conditions advantageously: no relative motion be-
tween the foot and the footplate indicates that the two can be
reasonably regarded as a one rigid body receiving the forces
and moments measured with the 6-axis F/T
sensor during stepping on the ET. If so, the and
being exerted to the bottom of footplate are directly transmitted
to the top surface of it through the highly rigid footplate, and
exerted to the foot. Thus, the 6-DOF equation of motion of the
foot with respect to the AAF can be described as follows:

A modified 3-D inverse dynamics, which does not require (5)

the location of center of pressure (COP), was developed for θ θ θ
the real-time EKAM estimation. Using the modified inverse dy-
namics introduced in this subsection, internal knee adduction
moment was calculated, and the EKAM was then obtained as (6)
the negative of the calculated internal knee adduction moment
where denotes foot mass; foot inertia matrix; the
[1], [17], [44]. Considering the increase in EKAM applied to
linear acceleration of foot center of mass (COM), ; grav-
tibia reflects increase in medial tibiofemoral compartment com-
itational acceleration; and and denote force and mo-
pressive load [4], the EKAM was estimated with respect to the
ment vectors acting on the ankle origin from the shank, respec-
TAF (Section II-B1) [2], [12], [41] among existing mathemati-
tively. Again, the left-leading superscript means the vectors
cally correct frames [45] that the EKAM magnitude and pattern
and matrices are written with respect to the AAF. Equations (5)
might depend on [36], [45], [46].
and (6) represent translational and rotational 3-DOF dynamics
Generally, the COP—which is required for the well-estab-
about the foot COM , respectively. The ankle force
lished 3-D inverse dynamics calculation of lower-limb—is
and moment can be obtained by solving (5) and (6). The
computed from the relation among the COP and measured
dynamic equations of foot given in (5) and (6) do not require
forces and moments ( and ) with an assumption
the COP, and, if the COP is needed for the real-time EKAM es-
that there is no pure moment (also called couple) exerted on the
timation, a real-time online computation of it is required. Instead
force plate in the horizontal plane (i.e., pure moments about -
of the COP computation in real-time, for each subject, the rota-
axis and -axis are zero). The assumption is valid
tional dynamics of foot, (6), needed the fixed distances from foot
when the foot is not constrained to the ground (or footplate)
COM to the center of the F/T sensor and from
such as over-ground walking [23], [47], [48]. The relation can
foot COM to the ankle origin that can be obtained
be written as follows:
offline. The foot and shank masses and inertia matrices also
are fixed values for each subject, and can be estimated offline
from anthropometric data [23], [47]. Therefore, the COP com-
(4) putation is no longer needed for the computation of the ankle
forces and moments . Thus, the COP computation
where , , and denote , , and is not required for the EKAM estimation (and also other two di-
direction components of measured , respectively; rection—flexion and internal rotation—external knee moments)
and denote the and direction compo- that is, in turn, obtained with the computed and and
nents of measured , respectively; the direction the inertial forces and moments of shank. Thus, the EKAM (and
known distance from to the top surface of the footplate; other two direction external knee moments) on the ET can be es-
and denote and direction distances from timated using the modified 3-D inverse dynamics without com-
to COP, respectively. Note that (4) is a general relation—which puting COP.
can be found in the technical documents from force plate man- This modified 3-D inverse dynamics was utilized for the real-
ufacturers (e.g., AMTI or Bertec)—because of the inclusion time estimation of the EKAM (and other two external knee mo-
of possible nonzero and . From (4), COP (i.e., and ments) with kinematic data from the 6-DOF goniometer (here-
338 IEEE TRANSACTIONS ON NEURAL SYSTEMS AND REHABILITATION ENGINEERING, VOL. 22, NO. 2, MARCH 2014
after called “real-time method”), and also for an offline estima-
tion method (hereafter called “offline method”) with kinematic
data obtained from an optoelectric system (Optotrak 3020). The
Offline method represents typical analysis performed at motion
analysis laboratories.
III. EXPERIMENTS
A. Subjects
Seven healthy male subjects (age: years; height:
; body mass: ; body mass index:
; leg length: ), who have
no previous history of musculoskeletal injury and neurological
disorder, were recruited for this study. The study was approved
by the institutional review board of Northwestern University. A
written consent was obtained from each participant.
B. Experimental Procedure
Each subject’s anthropometric data—lengths between
anatomic landmarks (e.g., right leg’s second metatarsal head,
medial, and lateral malleoli), right leg length (LL; right anterior
superior iliac spine (ASIS) to right medial malleolus [28]),
height (HT), BW, and the location of COMs, masses, and
inertia matrices of foot and shank—were taken [23], [47], and
entered to the real-time EKAM estimation program, which es-
timates EKAM and other two direction external knee moments
in real-time based on the modified 3-D inverse dynamics. To
compare the estimated EKAM from the real-time method with
that from the offline method for corroboration, lower-limb
motion during stepping on the ET was simultaneously recorded
with the Optotrak 3020. Three marker clusters, each of which
had four optical markers attached to a rigid shell, were placed
on the subject’s right foot, shank, and thigh [49]. The 6-DOF
goniometer was strapped to the flat and bony anteromedial
surface of subject’s tibia with the initial alignment described
above (Section II-B3). while aligning one potentiometer of the
goniometer with the lateral malleolus [Fig. 1(b)]. All subjects
wore shoulder harness for safety [33], [34]. Before collecting
data, subjects practiced stepping on the ET for min and
easy-releasing foot straps [34] were adjusted to minimize foot
motion relative to the footplate. The subjects were then asked
to perform three different types of stepping—regular stepping,
knee-adducted stepping, and knee-abducted stepping—at their
comfortable pace for min per condition with adequate
rest in between. The three types of stepping were selected to
account for not only regular stepping posture but also adducted
or abducted knee postures, considering knee adduction moment
was the focus of this study. During the ET trials, subjects did
not hold onto the ET’s handles. The marker data were collected
using an Optotrak 3020 at 50 Hz sampling rate. The and
from the 6-axis F/T sensor, 3-D ankle angle from the
6-DOF goniometer, and the from the front potentiometer
were sampled at 100 Hz to compute the EKAM using the
real-time method. The measurements made with the Optotrak
3020 were synchronized with all other signals using a trigger.
On completion of the ET trials, palpable anatomic landmarks
[39] were digitized using additional optical markers to establish
relationships between landmarks and marker locations [49].
Fig. 2. Representative EKAM estimation results of a subject during 10 cy-
cles of stepping at the three different conditions. From the top to the bottom
plot, EKAM estimate during regular stepping, that during knee-adducted step-
ping, and that during knee-abducted stepping, respectively. For all three types of
stepping, the EKAM estimated using the proposed goniometer-based real-time
method closely matched that estimated using the offline estimation method with
the Optotrak 3020.
The landmarks include the right leg’s second metatarsal head,
tips of medial and lateral malleoli, the peripheral margins of
the medial and lateral tibial plateaus, the inferior margins of
medial and lateral femoral epicondyles, sacrum, and left and
right ASISs.
C. Data Analysis
3-D knee angle was obtained from the Optotrak 3020 data
[43]. Following [28], the elliptical cycle (EC) was defined as
starting and ending at the time when the footplate reached the
most anterior. Ten cycles of data during each type of stepping
were selected for each subject. The EKAM estimates were nor-
malized 1) to BW times HT (unit: % ) for all three
types of stepping [1], and 2) to BW times LL (unit: % )
for regular stepping to compare results with the reported EKAM
on an ET with the unit of % [28]. The EKAM was time
normalized using the EC (0%–100%) and, for each subject’s
each type of stepping, 10 cycles’ mean was obtained. Other
two direction external knee moments during regular stepping
were normalized in the same manner. Similarly, 3-D ankle and
knee angles were time normalized and averaged across the cy-
cles. For regular stepping, grand mean of seven subjects’ means
(of time normalized 3-D ankle angles and knee moments) was
obtained. Differences in stepping speed among the three con-
ditions were determined with repeated measure ANOVA. The
Pearson correlation coefficient, , was used with linear regres-
sion to test the association between the EKAM estimates from
the real-time method and ankle eversion angle, between the
EKAM estimates from the real-time method and knee adduc-
tion (i.e., varus) angle, and between the EKAM estimates from
the real-time method and that from the offline method. To de-
termine the agreement between the EKAM estimates from the
real-time method and that from the offline method, between the
two sets of EKAM estimates, intraclass correlation coefficient
KANG et al.: REAL-TIME KNEE ADDUCTION MOMENT FEEDBACK TRAINING USING AN ELLIPTICAL TRAINER 339

Fig. 3. Grand mean and standard deviation of 3-D ankle angles [(a)] and external knee moments [(b) and (c)] during regular stepping on the elliptical trainer
(Solid line: mean; shade: one standard deviation). (a) From the top plot to the bottom, ankle dorsiflexion, inversion, and internal rotation angles. (b) 3-D external
knee moments normalized to body . From top to bottom, external flexion, adduction, and internal rotation moment. (c) The same
3-D external knee moments given in (b) are normalized to body leg length instead of body .

(ICC(2,1)) [50] and the limits of agreement (LOA) [51], the 5th
and 95th percentile of differences, were computed. One sample
-test was performed to determine if ankle angle was always dor-
siflexed on the ET during regular stepping. Significance level
was taken as 0.05.
D. Experimental Results
The stepping speed during regular stepping, knee-adducted
stepping and knee-abducted stepping were rev/min,
rev/min and rev/min, respectively. There
was no significant difference between the tasks.
1) Representative Data: Representative EKAM calculated
using the real-time method and the offline method are shown in
Fig. 2. The EKAM estimated using the real-time method closely
matched that using the offline method for all the three types
of stepping. The peak EKAM across cycles was increased in
knee-adducted stepping but decreased in knee-abducted step-
ping compared to that of regular stepping.
2) Feasibility Test Results: Feasibility of the proposed real-
time EKAM estimation method was verified in several different
ways as follows.
First, mean 3-D ankle angle [Fig. 3(a)] and mean normalized
3-D external knee (flexion, adduction, and internal rotation) mo-
ments [Fig. 3(b) and (c)] from the real-time method during reg-
ular stepping were compared with those reported in previous
studies using offline processing of motion capture system data:
knee moments and ankle angles on an ET in [28] and ankle an-
gles on several ETs in [27]. One can find similarities between the
kinematic and kinetic variables obtained in this study and those
in previous ET studies [27], [28], although, in those studies,
subjects’ two feet were not strapped to the footplates. Similar
to [27], the ankle dorsiflexion angle measured had two peaks
( at and at of the EC) and ankle
was always dorsiflexed throughout the whole EC . tion method, the 10 cycles’ peak values of normalized EKAM
Note that the ankle dorsiflexion angle reported in [28] displayed
planar-flexion in the interval of the 0 to of the EC. This
difference in ankle dorsiflexion angle may stem from the differ-
ence in the location of the driving wheel of the two ETs that can
influence on the kinematic structure of ETs and the consequent
subject’s foot trajectory: a front-drive ET was used in [28] and a
rear-drive one was used in this study. The locations of two peaks
of external knee flexion moment (one at and another at
) were similar to those in [28] [Fig. 3(c)]. Differences
between the peak values of the each component of the 3-D ex-
ternal knee moment measured and those in [28] were smaller
than about two standard deviations given in [28].
Second, it was found that the peak value of mean normal-
ized EKAM from the real-time method was strongly and posi-
tively correlated with corresponding mean ankle eversion angle
measured with the goniometer (Fig. 4; ; ).
Biomechanically, the result can be explained as follows. On the
ET, because the foot was strapped to the footplate without rel-
ative foot rotation on the footplate, ankle eversion meant knee
joint’s lateral shift (i.e., tibia rotated away from the median plane
with rotation center at ankle origin) that can lengthen the mo-
ment arm from the knee joint to the GRF [6], and consequently
increase EKAM. Moreover, in turn, the knee joint’s lateral shift
meant, accompanied with possible body lateral leaning, most
probably the increase of knee adduction angle that can increase
EKAM [6], [7], [16].
Third, the peak value of mean normalized EKAM from the
real-time method was also found to be significantly and posi-
tively correlated with the peak value of mean knee adduction
(varus) angle obtained from the Optotrak 3020 data (Fig. 5;
; ). Varus knee alignment is known as one
of the best predictors of a high EKAM [6].
Fourth, to test the reliability of the real-time EKAM estima-
340 IEEE TRANSACTIONS ON NEURAL SYSTEMS AND REHABILITATION ENGINEERING, VOL. 22, NO. 2, MARCH 2014
Fig. 4. Relationship between the peak mean normalized EKAM and corre-
sponding mean ankle eversion angle during three different types of stepping.
A strong and positive correlation between the peak mean EKAM and corre-
sponding mean ankle eversion angle measured with the goniometer.
Fig. 5. Relationship between peak mean normalized EKAM and peak mean
knee adduction (varus) angle during three different types of stepping. Positive
correlation between the peak mean normalized EKAM from the proposed real-
time estimation method and the peak mean knee adduction (i.e., varus) angle
obtained from the Optotrak 3020.
estimate from the real-time method were compared with an-
other estimate from the offline method in the same trials instead
of direct EKAM measurements (Fig. 6). The two estimates
were strongly and positively correlated to each other [Fig. 6(a)];
; ). ICC(2,1) between the two was close
to unity (0.9580; 95% confidence interval: ),
indicating the proposed real-time EKAM estimation method
well agreed with the offline method [50]. Median difference
between the two estimates was smaller
than that of the recently developed artificial
neural network for offline EKAM estimation [12]. Magnitude
of the LOA [ ; Fig. 6(b)] were
smaller than the peak EKAM difference between healthy
controls and patients with knee OA [4]
and between patients with doubtful/minimal knee OA and
moderate/severe knee OA [13], further
supporting the agreement between the two methods. Further,
the slope of the regression line was also close to unity (0.9055;
95% confidence interval: ).
Fig. 6. (a) Peak EKAM estimate from the offline method versus that from the
proposed real-time method during the three different stepping. Black dotted
unity slope line represents ideal relationship between the two peak EKAM es-
timates. (b) Bland–Altman plot showing difference from the peak EKAM es-
timates using the Optotrak to that using the proposed method with mean dif-
ference (solid line) and limits of agreement (dashed–dot lines). Each data point
represents the peak EKAM (difference) of a subject at a cycle during one of the
three stepping conditions.
In summary, the proposed EKAM estimation method is reli-
able and can be used for the real-time EKAM estimation.
IV. DISCUSSION AND CONCLUSION
In response to strong clinical and research needs to investi-
gate and control the EKAM, for the first time, a practical real-
time EKAM estimation method on a custom ET based on a
3-D inverse dynamics calculation throughout the whole cycle
was developed, and its feasibility and reliability were verified
through experiments.
The proposed real-time EKAM estimation method is
promising. The EKAM estimate from the proposed real-time
method well agreed with that from the offline method at the
three types of stepping conditions, which accounted for not
only regular stepping posture but also variation of walking pos-
ture that could be potentially found in patients with lower-limb
musculoskeletal injuries. The proposed method utilizes a com-
pact and low-cost 6-DOF goniometer instead of an expensive
motion capture system occupying large designated space in
motion analysis laboratories. The proposed method needed
only short preparation time (a few minutes) for online initial
alignment and no post processing for computing the EKAM
in contrast to other estimation methods requiring cumbersome
KANG et al.: REAL-TIME KNEE ADDUCTION MOMENT FEEDBACK TRAINING USING AN ELLIPTICAL TRAINER
setup and long time of post processing for computing the
EKAM. And the proposed method can be used virtually any-
where the modified ET is installed and is suitable for clinical
and gymnasium settings.
One may note that the knee-adducted stepping of the
healthy subjects, which was similar to the stepping posture
of patients with knee OA, was achieved by their deliberate
voluntary muscle contraction instead of the passive action and
tibiofemoral alignment of patients with knee OA with medial
compartment overloading. On the other hand, the strong and
positive correlation between the peak value of mean normalized
EKAM and corresponding mean ankle eversion angle (Fig. 4)
may seem contradictory to previous studies using “lateral
wedge insoles” [6], [52] that, with the insoles, EKAM was
reduced with potential “ankle eversion” and the more upright
posture of the lower-limb. In studies using “lateral wedge
insoles,” ankle was everted relative to the ground, which is
different from the present study with no rotation between the
foot and footplate. Thus, the contributions of ankle eversion
on EKAM were opposite to each other, although ankle was
everted in both cases.
In this study, the healthy subjects did not hold onto the ET
handles, but patients with knee OA can hold on the handles
during stepping for appropriately challenging training. Al-
though the handle holding may affect the EKAM pattern [34],
the method’s reliability is not affected by the holding.
A. Measurement Methods of Kinematic Variables
Many existing 3-D motion capture system can be used to
measure ankle 3-D angles. However, in choosing a motion
capture system, one needs to consider potential difficulties
including preparation of attaching markers on the lower limbs,
occlusion of the limb of interest by devices and/or other parts
of body for visual motion tracking including marker dropouts
of optoelectric motion capture systems, errors caused by skin
movements in using sensors/markers attached to the skin,
drift in the integration of acceleration/velocity measured from
accelerometer/gyroscope, and distorted direction of magnetic
fields sensed by magnetometer due to the magnetic fields of
electromagnetic motors and/or ferrite structures around [53].
Although the 6-DOF goniometer might slip on subject’s skin,
it was free from the most of the aforementioned difficulties, be-
cause the goniometer could be physically attached to the an-
teromedial bony surface of shank, and directly measured ankle
3-D rotation. The effect of skin movement was small. Addi-
tional analysis showed that root-mean-square deviation
between the ankle internal rotation angle measured from
the goniometer and that from the Optotrak was acceptable (
[54]). Further, mean and absolute deviation (mean:
; absolute: ) of ex-
ternal knee adduction impulse between the offline and real-time
method were similar to those (mean:
absolute: ) reported in a most recent
study [36].
In addition, the 6-DOF goniometer has practical advantages.
It only occupies small space around the footplate, and can be
made at a low-cost compared to other motion capture systems.
Moreover, because its outputs are the six channel analog signals
341
(i.e., ; , 6), the goniometer can be conveniently
connected to any analog to digital (A/D) data acquisition system
with other analog signals including the 6-axis forces/moments
from the 6-axis F/T sensor and locomotion variables, and the
sampling rate of the goniometer data acquisition can be selected
at the user’s discretion within the capability of the data acqui-
sition system. Thus, the goniometer can be an affordable and
practical alternative to other motion capture systems, especially
for usages outside motion analysis laboratories.
The modified 3-D inverse dynamics is not specific to the
6-DOF goniometer. Combined use of inertial measurement
units (IMUs)—a combination of accelerometers, gyroscopes,
and magnetometers—and sandals with two 6-axis F/T sensors
at each side was developed for offline EKAM estimation [36].
Wireless IMUs can potentially also be used to measure the
3-D kinematics in real-time, provided that the aforementioned
potential difficulties associated with the IMUs can be addressed
properly to achieve accurate kinematic measurements for the
real-time EKAM estimation.
B. Potential Benefits of Real-Time EKAM Feedback
To reduce the EKAM, gait training studies utilized real-time
biofeedback of various locomotion variables (other than the
EKAM)—kinematic variables including dynamic knee frontal
alignment [6], [7], [16], tibia angle (determined from a line
between the lateral malleolus and lateral femoral epicondyle
intersecting with a vertical line in the frontal plane of the lab-
oratory [21]) as a surrogate measure of foot progression angle
[2], [5] and with other angles of foot progression and/or trunk
sway [5], [21], flexion angle and vertical acceleration of knee
at initial contact [19], and trunk lean angle [20]; and a kinetic
variable, lateral foot pressure [22]—with gait modification
strategies designed prior to the training [5], [7], [17], [21], and
succeeded in reducing the EKAM to a varying degree [7], [18].
Two studies showed long term sustained reduction of EKAM
of patients with knee OA [5], [7], [17]. However, during these
gait trainings, it may not be easy to check whether the chosen
gait training strategy is helpful for each subject or not, at least
until the end of a training session (including a long time of post
processing to compute EKAM), and this might be one possible
reason for the varying degree of reduction of the EKAM across
the studies [7], [18].
The proposed estimation method can provide patients with
EKAM feedback directly and continuously in real-time during
a training session, and, thus, without waiting till the end of the
training session, one can immediately check, for each subject,
if the gait modification strategy s/he took is effective and what
is an effective strategy. In other words, the real-time EKAM
feedback allows us to choose an effective gait modification for
each subject conveniently instead of asking them to follow a
specific gait pattern chosen in advance and wait until the end of
; the training to check the effectiveness of the pattern.
C. Potential Practical and Clinical Usages
The promising experimental results suggest that, combined
with the advantages of elliptical trainers (e.g., functional
weight-bearing stepping and mitigation of impulsive forces)
and its popularity, the proposed real-time EKAM estimation
342 IEEE TRANSACTIONS ON NEURAL SYSTEMS AND REHABILITATION ENGINEERING, VOL. 22, NO. 2, MARCH 2014
method may be used for a (subject-specific) real-time biofeed-
back training of patients with musculoskeletal injuries such
as knee OA, in order to improve their control of frontal plane
knee loading [55], [56], reduce development of knee OA, and
assist clinical evaluations of the patients without using a motion
analysis laboratory. Potentially, the proposed real-time EKAM
estimation method can be used for various clinical evaluations
and therapeutic interventions.
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Sang Hoon Kang (M’12) received the B.S., M.S.,
and Ph.D. degrees in mechanical engineering from
Korea Advanced Institute of Science and Tech-
nology, Daejeon, Korea, in 2000, 2002, and 2009,
respectively.
In 2010, he joined Sensory Motor Performance
Program, Rehabilitation Institute of Chicago,
Chicago, IL, USA, where he is currently a Research
Associate. He is also a Postdoctoral Research
Fellow at the Department of Physical Medicine and
Rehabilitation, and an Instructor at the Department
of Biomedical Engineering, Northwestern University, Chicago, IL, USA. His
current research interests include rehabilitation robotics and biomechanics of
human movement with emphasis on rehabilitation medicine.
343
Song Joo Lee received B.S. and M.S. degrees in
biomedical engineering from the Catholic Univer-
sity of America, Washington, DC, USA, in 2005
and 2007, respectively. She is currently working
toward the Ph.D. degree in biomedical engineering
expecting to graduate in 2013 at Northwestern
University, Evanston, IL, USA.
She was a Research Assistant in Center for
Applied Biomechanics and Rehabilitation Research,
National Rehabilitation Hospital, Washington, DC,
USA. She is a Research Assistant in Sensory Motor
Performance Program, Rehabilitation Institute of Chicago, Chicago, IL, USA.
Her research interest focuses mainly on neuromechanics, biomechanical
modeling, and engineering application for injury prevention and rehabilitation.
Yupeng Ren (SM’11) received the B.S. degree
in mechanical engineering and the M.S. degree in
biomedical engineering from Tsinghua University,
Beijing, China, in 2001 and 2004, respectively.
In 2005, he joined Sensory Motor Performance
Program, Rehabilitation Institute of Chicago,
Chicago, IL, USA, where he is currently a Research
Engineer. He is also a R&D Engineer and conducts
Small Business Innovation Research programs at
Rehabtek LLC, Wilmette, IL, USA. His research
and development interests include robot-assisted
technology, rehabilitation robot application for stroke survivors and children
with cerebral palsy, and home-based robot solutions.
Li-Qun Zhang (SM’06) received the B.E. degree
in electrical engineering from Tsinghua University,
Beijing, China, in 1982, and the M.S. and Ph.D.
degrees in biomedical engineering from Vanderbilt
University, Nashville, TN, USA, in 1988 and 1990,
respectively.
Since 1991, he has been at the Rehabilitation
Institute of Chicago, Chicago, IL, USA, and North-
western University, Chicago, IL, USA, where he
is currently a Senior Research Scientist and Pro-
fessor, respectively. His research interests include
development of intelligent rehabilitation devices to perform diagnosis, pas-
sive stretching and active movement treatments, and outcome evaluations
of impaired limbs in stroke, investigation of reflex and nonreflex factors
contributing to limb impairments at the multi- and single-joint and muscle
fascicle/fiber levels, and investigation of musculoskeletal injury mechanisms
and rehabilitation and prevention of the injuries.