Gait & Posture 53 (2017) 236–240

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Gait & Posture

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Gait ground reaction force characteristics in deaf and hearing children

Amir Ali Jafarnezhadgeroa , Mahdi Majlesib,* , Elaheh Azadianc
a
Department of Physical Education and Sport Sciences, Faculty of Educational Science and Psychology, University of Mohaghegh Ardabili, Ardabil, Iran
b
Department of Sport Biomechanics, Faculty of Humanities, Islamic Azad University, Hamedan Branch, Hamedan, Iran
c
Department of Motor Behavior, Faculty of Humanities, Islamic Azad University, Hamedan Branch, Hamedan, Iran

A R T I C L E I N F O A B S T R A C T

Article history:
Received 17 August 2016 The link between gait parameters and hearing loss is not well understood. The objective of this study was
Received in revised form 7 February 2017 to investigate the effects of the gait ground reaction forces, their time to peak, vertical loading rate,
Accepted 10 February 2017 impulses and free moment during gait in deaf and hearing children. Thirty male children were equally
divided into a healthy group and a group with hearing loss problems (Deaf group). Ground reaction forces
Keywords: were analyzed during barefoot walking. MANOVA test was used for between group comparisons. The
Ground reaction forces significance level was set at p<0.05 for all analyses. Hearing loss was associated with increased
Impulse propulsion lateral-medial ground reaction force (p=0.031), its time to peak (p=0.008), and lateral- medial
Free moment
impulse (p=0.018). Similar vertical reaction forces were observed in both groups (p>0.05). Positive peak
Hearing loss
of free moments in the healthy group was significantly greater than that in the deaf group (p=0.004). In
Gait
conclusion, the results reveal that gait ground reaction force components in deaf children may have
clinical values for rehabilitation of these subjects.
© 2017 Elsevier B.V. All rights reserved.

1. Introduction in children with congenital or early acquired severe-to-profound

Hearing loss is one of the most common sensory disorders in
developed countries [1,2] and is usually diagnosed early in life.
According to the recent reports of the World Health Organization,
approximately 5% of the world’s population have a disabling
hearing loss. Hearing impairment in children has been demon-
strated to negatively affect different aspects of life, including
educational achievement, physical functioning, and even life
expectancy [3,4].
The vestibular system is an organ that detects the sensations of
physical balance. It plays an important role in the spatial
relationship between the human body and the environment [5].
In view of the above, it appears that children with sensorineural
hearing loss suffer from an inadequacy of the sensory information
provided by the vestibular system, as a result of inner ear damage
[6]. This can predispose them to problems with balance and
difficulties with motor coordination and make it hard for them to
perform tasks and functions that depend on balance, such as
walking.
Previous studies [7,8] have shown that balance disorders, motor
development deficit [9,10] and sensory integration disorders [11]
* Corresponding author.
E-mail addresses: amiralijafarnezhad@gmail.com (A.A. Jafarnezhadgero),
majlesi11@gmail.com (M. Majlesi), azadian1@yahoo.com (E. Azadian).
hearing loss are probable. Moreover, a recent systematic review of
literature by Rajendran et al. [12] confirms that children with
hearing loss may have problems with walking. For example, It had
been demonstrated that in addition to short, irregular steps [13]
and slower gait speed [8,14], they need greater help when walking
[13]. It is reported that greater hearing loss is independently
associated with slower gait speed. Hearing loss can also increase
the cognitive load, negatively affect the executive and physical
functioning which would result in a poorer social performance all
of which may lead to slower gait speed [14].
Although few studies have focused on gait analysis of these
subjects [8,12–14], the biomechanical variables during activities
such as walking reported in such people are not typically
addressed.
Walking constitutes a complex task that requires the coordi-
nated functioning of multiple biomechanical variables. Correction
of walking patterns is recently recommended as a part of
rehabilitation protocol [15]. Therefore, biomechanical variables
of the gait have clinical significance and are used to provide
feedbacks that are useful for evaluating the treatment effects or for
planning the rehabilitation programs [16–18].
From among the gait parameters, kinetic variables are of greater
importance due to their higher reliabilities [19,20]. Gait ground
reaction forces (GRFs), their time to peak (TTP), vertical loading
rate, impulses and free moment (FM) are among the most

http://dx.doi.org/10.1016/j.gaitpost.2017.02.006
0966-6362/© 2017 Elsevier B.V. All rights reserved.
 A.A. Jafarnezhadgero et al. / Gait & Posture 53 (2017) 236–240 237

important kinetic variables that could affect walking [21]. Vertical
loading rate are thought to demonstrate the “ratio” with which the
vertical GRF component develops at heel contact [22]. It has been
suggested that vertical loading rate is an important variable for
assessing the overload of lower limb musculoskeletal tissues
[23,24]. An average vertical loading rate greater than 70, 72 and
100N/kg/s has been associated with a risk of stress fractures
[18,25], patellofemoral pain [26,27], and plantar fasciitis [28],
respectively. The FM corresponds to the torque about the vertical
axis exerted on the foot and acting at the center of pressure [29].
Similarly, FM is considered as the torsional force that placed on the
lower extremity during the stance phase [21,30,31], and has been
proposed to be as a possible predictor of tibial stress fracture
[32,33].
Determining if hearing loss is independently related to gait
GRFs characteristics is an important first step toward understand-
ing whether hearing rehabilitative trainings and interventions
could possibly help improve physical functioning. The objective of
the current study was to analyze the GRFs, their TTP, loading rate,
impulse, and FM during gait in deaf and hearing children. We
hypothesized that hearing loss is associated with altered gait GRFs
characteristics in children.
selected speed. Successful trials included four consecutive foot
strikes with full-marker-visibility. Despite careful measurement,
some trials had to be omitted due to irregularities in the
kinematics. From among six trials recorded, three which showed
better qualities were selected.
2.2.2. Gait kinetics
The GRFs was measured by two Kistler Force Platforms (Type
9281, Kistler Instrument AG, Winterthur, Switzerland) at a
frequency of 1000Hz. The GRF data were then filtered using a
fourth-order low-pass Butterworth filter with a 20Hz cut-off
frequency.
The GRF values were recorded along vertical (z), medio-lateral
(x) and anterior-posterior (y) directions (see Fig. 1). The vertical
GRF bimodal curve in normal walking contains two peaks
including the first peak on heal contact (FzHC) and the second
peak on the push-off phase (FzPO). There is also a downfall in
between the two peaks (FzDF) [37].
From the medio-lateral curve also, three values were recorded
corresponding to the positive peak which occurred initially (FxHC),
followed the two consecutive negative peaks at the middle (FxMS)

2. Material and methods

2.1. Participants

Fifteen deaf children with bilateral hearing impairment (mean

age=11.26
1.79years) and fifteen matched healthy control children
(mean age=10.53
1.55years), were purposefully selected. Sample
size estimates software (G*3-Power) revealed that for a statistical
power of 0.80 at an effect size of 0.80 with an alpha level of 0.05 a
sample size of at least 14 subjects was required [34].
Children with hearing loss were recruited from deaf schools
(alaghbandian) in Hamedan, Iran. A questionnaire was developed
to record the following characteristics: date of birth, medical
condition, sever and date of deafness. Severe hearing losses were
greater than 75dB, and all subjects were congenital deaf. Deaf
children who showed neuro-motor or orthopedic dysfunctions or
medication affecting the central nervous system were excluded.
None of participants reported any secondary neurological or
orthopedic condition including lower limb injury in the six months
prior to data collection. Hearing status and the presence or absence
of learning disabilities was ascertained via parent or teacher
report. Subjects and their parents were fully informed about the
aim and protocol of the study and signed an informed consent.
Ethics approval was obtained from the research council of the
Hamedan branch of Islamic Azad University and informed consent
forms were obtained from the children’s parents.

2.2. Instruments and examination

2.2.1. Gait kinematics

A four camera Vicon system (Oxford Metrics, Oxford, UK) was
used to record three-dimensional lower-body kinematic data
(100Hz). All children performed barefoot walking trials being fitted
with retro-reflective markers according to the Plug-in Gait [35,36].
A total of 16 retro-reflective markers were positioned on the skin
overlying specific bony landmarks or anatomical positions of the
lower body. Markers were attached bilaterally on lower limbs
landmarks, including: anterior-superior iliac spine, posterior-
superior iliac spine, lateral epicondyle of the knee, lower lateral
one-third surface to the thigh, lateral malleolus, lower one-third of
Fig. 1. A time-normalized traces of the ground reaction forces of healthy (thick solid
the shank, over second metatarsal head, and on the calcareous. line is average, thin solid lines are
1 SD variability bands) and deaf (thick dash line
Participants were granted some practice trials before actual trials. is mean, thin dash lines are
1 SD variability bands) groups during walking. *: Level
Each participant was asked to walk 10m in six trials with self- of significance (p<0.05).
238 A.A. Jafarnezhadgero et al. / Gait & Posture 53 (2017) 236–240

and the final (FxPO) portion of the gait cycle [21]. Additionally, on Table 2
GRF of Z, Y, and X axes in different stance phases for control and experimental group
the anterior-posterior curve, two peaks were recorded as the
are presented. Data are (mean
SD).
braking reaction force (FyHC) and propulsion (FyPO) forces.
Loading rate was defined as the slope between the initial and GRF groups Sig. d
FzHC on vertical GRF curve [38]. Impulse also was calculated using Deaf Healthy
the trapezoidal integration method for x, y, and z axes as follows FzHC 118.61
35.05 128.47
25.00 0.382 0.32
[39]: FzDF 87.47
15.67 80.52
16.72 0.250 0.42

 X ! FzPO 119.71
25.10 121.08
18.77 0.867 0.06
n1
F1 þ Fn FxHC 9.85
4.94 7.82
4.46 0.248 0.43
Impulse ¼ Dt þ Fi FxMS 9.28
7.47 11.04
3.11 0.408 0.33
2 i¼2 FxPO 13.36
7.11 8.52
4.12 0.031* 0.86
FyHC 33.64
18.92 39.08
8.91 0.320 0.39
Free moment of the foot was computed as following [40]:
FyPO 40.17
13.51 47.63
9.25 0.089 0.65
Free moment ¼ Mz þ ðFx  COPyÞ  ðFy  COPxÞ *
Significance level p<0.05.
Where, Mz is the moment about the vertical axis; x and y are the
horizontal components of the center of pressure (COP); Fx and Fy
Table 3
are the horizontal components of the GRF. Then in free moment
The time to peak of GRF components for healthy and deaf group. Data are (mean
curve, the first peak (negative; abductor moment) and the second
SD).
peak (positive; adductor moment) were recorded for the statistical
analysis. All GRF and free moment values were normalized with RF groups Sig. d

respect to the body weight (BW) and BWHeight, respectively. Deaf Healthy
FzHC 25.73
5.65 23.73
1.79 0.202 0.53
2.3. Statistical analysis FzDF 45.40
8.91 47.20
2.73 0.461 0.30
FzPO 76.40
5.96 77.40
1.24 0.530 0.27
FxHC 5.66
1.29 6.40
1.12 0.108 0.36
Firstly, the normality of the variable distributions was verified
FxMS 25.53
10.99 32.00
13.19 0.156 0.53
using Kolmogorov-Smirnov test. MANOVA test was used for FxPO 64.20
13.92 75.40
5.92 0.008* 1.12
between group comparisons. The significance level was set at FyHC 17.06
4.49 16.60
4.57 0.780 0.10
p<0.05 for all analyses. Statistical analyses was performed using FyPO 88.13
3.94 88.40
1.68 0.811 0.09
SPSS (version 16, SPSS Inc, Chicago, Il). Additionally, the effect size *
Significance level p<0.05.
(d) was calculated as a ratio of mean difference divided by the
pooled standard deviation [41]. Table 3 shows the TTP in both groups. TTP for FxPO in the deaf
group were significantly lower by14% (p=0.008; d=1.12) than those
3. Results that in the healthy group. Other TTP variables between healthy and
deaf groups were not statistically different (p>0.05).
The descriptive analysis of the data obtained about the Vertical loading rates were in the healthy and the deaf groups
participants of the study indicated that there was no statistical similar (p>0.05) (Fig. 2A). Also, z and y impulses in both groups
differences between the groups for age, height, mass or BMI (see were similar (Fig. 2B). However, x impulse of the deaf group was
Table 1). During walking, hearing loss children chose a 12.5% statistically greater (by 47%) than that of the healthy group
reduced preferred walking speed (p=0.013). (p=0.018; d=0.92).
Peak GRF variables for all groups are presented in Table 2. Peak The peak negative free moment (% BWHeight) between the
GRF amplitudes in Fz, Fy, and Fx (except for FxPO) were similar groups was similar (p>0.05) (Fig. 2C). But, the healthy group
between the healthy and the deaf groups (p>0.05). The FxPO in the displayed significantly greater positive free moment by 30% than
deaf group was about 57% greater than that in the healthy group that in the deaf group (p=0.004; d=1.19). Fig. 2D depicts the FM
(p=0.031; d=0.86). During 41–45% of stance phase, the Fz during level walking in the two groups. As shown in the Figure
amplitudes in the deaf group was greater than that in the healthy during 47–64 and 68–94% of stance phase, the free moment
group (p<0.05) (Fig. 1). Furthermore, during 45–66% of stance amplitudes in deaf group were lesser than those in the healthy
phase, the Fx amplitudes in the deaf group was greater than that in group (p<0.05) (Fig. 2D).
the healthy group (p<0.05) (Fig. 1). In addition, during 44–59 and
71–86% of stance phase, the Fy amplitudes in the deaf group was 4. Discussion
lesser than that in the healthy group (p<0.05) (Fig. 1).
It was hypothesized that hearing loss is associated with altered
Table 1 GRFs characteristics. Overall, the GRF patterns in both groups were
Demographic characteristics of hearing and deaf children. similar to those of the previous studies in level walking [21,42–44].
groups Sig. This study is the first to identify that FxPO amplitude and
mediolateral impulse in the deaf subjects are significantly higher
Deaf Healthy
than those in the healthy subjects. The results of the present study
N 15 15 NA
also demonstrated that TTP of FxPO and peak positive FM in the
Age (year) 11.26
1.79 10.53
1.55 0.241
Mass (Kg) 41.1
11.01 34.27
12.12 0.118 deaf group are significantly lower than those in the healthy group.
Height (cm) 1.43
0.10 1.40
0.08 0.402 These confirm the hypothesis of this study and reveal that, the
BMI 19.91
4.18 17.09
4.21 0.076 hearing loss alters the GRF components.
Gender male male NA In the present study, peak amplitudes of Fz and Fy components
Range of age 8–14 8–14
HLI 77.1
1.9 – NA
were similar between the groups. However, during 41–45% of
Gait speed (m/s) 1.06
0.10 1.20
0.18 0.013* stance phase, the Fz amplitudes in the deaf group was greater than
that in the healthy group. Furthermore, in z orientation, large inter-
Note: Values are mean
standard deviation. Abbreviations: n, number of
participants; BMI, body mass index; HLI, hearing loss intensity; NA, not applicable. subject variability was present in the deaf group. This work
*
Significance level p<0.05. provides the first reference data base of gait GRF characteristics in
 A.A. Jafarnezhadgero et al. / Gait & Posture 53 (2017) 236–240
Fig. 2. (A) Vertical loading rate, (B) Impulse values, (C) Negative (abductors) and positive (adductors) peaks of free moment curve, and (D) the free moment time history
pattern in the healthy group (thick solid line is average, thin solid lines are
1 SD variability bands) and in the deaf group (thick dash line is mean, thin dash lines are
1 SD
variability bands) during stance phase of level walking. *: Level of significance (p<0.05).
deaf children. Previous studies have been demonstrated that
decreased walking speed caused significant reduction in the
vertical ground reaction forces during stance phase of walking
[45,46]. Lower walking velocity and higher vertical GRF in deaf
children may be associated with less gait efficiency and higher
proximal joints load, respectively [47]. Furthermore, this study
showed that during 44–59 and 71–86% of stance phase, Fy
amplitudes were in the healthy group greater than those in deaf
group. Thus, a greater effort in the deaf children could be expected
to push the body center of mass forward within the plane of
locomotion (sagittal plane) [48]. We found that people with
hearing loss prefer to walk more slowly than the healthy ones. This
result is in accordance with previous studies on deaf and walking
[8,14] and may have been caused by lower push of force (positive Fy
amplitude) of the foot during supination [49]. John et al. [50]
reported that muscles accounted for more than 92% of the medio-
lateral ground reaction force over all walking speeds. Thus, it is
possible that this has been caused by muscular activation disorders
during gait. However, this deserves more investigations. With
respect to the timing of the force peaks the only consistent
difference was the TTP of FxPO that happened earlier in the deaf
group. These findings may give further support to the hypothesis
that the magnitude and timing of the GRF components will vary
substantially between the healthy and the deaf children.
In the present study, the subjects in the deaf group displayed
higher mediolateral impulse and similar vertical loading rate
compared to the subjects in healthy group. We were not able to
find other studies addressing this issue. Vertical loading rate is a
measure of the impact delivered to the body and they have been
associated with various injuries [25,51,52]. We found that deaf
children exhibited a similar magnitude of loading rate compared to
the healthy subjects, presumably because of the deaf children’s
walking with lower self-selected velocity [8,14]. Lower loading
rates have been related to improvement of lower extremity
compliance during strike phase of gait [19,53]. Deaf children
through decreasing walking velocity, prevent higher vertical
239
loading rate and, therefore, are less prone to injury at lower rates
of loading [52,54]. Therefore, deaf children walk slower for a
number of reasons and the positive impact of this is the
maintenance of normal forces across their joints except for a
few variables.
The present study showed that the peak and amplitudes of
positive FM curve in the deaf group was significantly lower than
that of the healthy group. In general, the FM in both groups exhibits
a biphasic shape whereby the negative FM initially resists inward
rotation, then reverses just before the mid stance to produce a
positive FM that generate a resistance to outward rotation [30].
Our results may suggest that deaf children have lesser resistance to
outward rotation of the foot after mid stance phase. FM has been
proposed to be as a predictor of injuries such as tibial stress
fracture in female athletes [32,33]. However, it would be difficult to
conclude that there is a direct relationship between these variables
and injury based on our data and further study is warranted.
This study has few limitations that must be regarded. The
number of participants of the study was relatively small. However,
the study had sufficient power on statistical tests to determine the
group differences. This study did not address the other kinetic
variables (such as joint moments and powers), kinematic and
muscle activities during gait in different groups. Combination of
kinematics and other kinetic variables with electrical activities of
the effective muscles on walking may bring additional insights to
the investigation of the risk factors in deaf children.
5. Conclusions
The current study demonstrated no differences between deaf
subjects and healthy individuals with respect to peak components
of Fz and Fy. Greater FxPO, Fx amplitudes and impulseobserved in
the deaf group may be impaired control of mediolateral body
motion during walking. Adductor free moments in deaf children
seem higher than those in healthy individuals. Whether these
altered variables in deaf children are the cause of future injuries or
240 A.A. Jafarnezhadgero et al. / Gait & Posture 53 (2017) 236–240
a compensate for vestibular system disorders needs to be
addressed in further studies.
Conflict of interest
The authors do not have any conflict of interest which could
have influenced the results of this study.
Acknowledgements
The authors gratefully acknowledge the financial support for
this work provided by Islamic Azad University, Hamedan Branch,
Hamedan, Iran. We are grateful to Dr. Ali Gholami Mehrdad for
reading and correcting the English text. We also wish to thank the
honorable managing director of the <Alaghbandian School in
Hamedan, Mrs. Banisafar, and all of the subjects who participated
in the study.
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