Forward Walking Research Articles

Effectiveness of Home Based Telerehabilitation for Forward Versus Backward Stepping Strategy in Ground Walking Training on Functional Mobility and Balance Among Spastic Diplegic Cerebral Palsy-- A Simple Experimental Study

Background: The primary focus of physiotherapy interventions for children with CP is to improve locomotor function and functional activities. It is suggested that walking training activates neural circuits that mediate central pattern generators to activate limb muscles repetitively and produced rhythmic movements. Additionally, it adjusts control between agonist and antagonist muscles, leading to enhanced walking speed, and static and functional balance. The purpose of the study is to find out the effectiveness of home based telerehabilitation for forward stepping vs backward stepping strategy in ground walking training on functional mobility and balance among spastic diplegic cerebral palsy. Methodology: A simple experimental study was conducted on 24 spastic diplegic cerebral palsy who fulfill the selection criteria were selected for this study at the telerehabilitation Unit. A clear explanation was given to every subject and parents/guardian about the procedures and a written consent was obtained from them. Twenty spastic diplegic children were evaluated in person in the department for pre-training and post-training were used as a study design with total study duration was six weeks. (from April 2021 to May 2021). The subjects in group A&B were consisting of 12 subjects and they were treated with home based telerehabilitation for forward and backward ground walking training. Along with that both the group children received routine physiotherapy. Both the groups were received intervention for 15-30 minutes per session, 5 days in a week for a period of 6 weeks. The pre and post score values of balance and functional mobility were measured by using, GMFM walking dimension, modified timed get up and go test and Pediatric Berg balance scale. The values were recorded and documented. Result: In the statistical analysis of pretest values of both group A and group B were calculated. The pre mean values of PBS for both groups were 33.33 and 33.38. The T-value was 0.3721 the obtained t-value is lesser than the table value and the P-value showed there were no significant in pretest comparison. The posttest mean values of PBS for both groups were 46.08 and 46.33.The T-value was 2.38967,the obtained t-value is greater than the table value. and the P-value showed there were significant in posttest comparison. Alternative hypothesis was accepted. Hence the statistical report states that there were statistically significant differences in posttest comparison. The post score values of the Gross Motor Function Meaure-88, Pediatric Berg Balance Scale and TUG test score in all the variables showed significant difference. Conclusion: The study concluded that the 6 weeks of backward stepping strategy in ground walking home based telerehabilitation training program along with regular physiotherapy treatment showed statistically significant improvement in balance and functional mobility among spastic diplegic children when compared to forward stepping strategy in ground walking home based telerehabilitation training program.

Comparing the effects of retro and forward walking on serum adiponectin levels in obese young adults

ObjectivesRetro walking or backward walking expends greater energy and places less stress on joints compared with forward walking at a similar speed. This study conducted in obese young men was primarily aimed at comparing the effects of backward walking with forward walking on adiponectin levels. The secondary aim was to describe the effects of concomitant factors, namely C-reactive protein, body mass index (BMI), waist to height ratio, and waist to hip ratio, on adiponectin levels in obese young men. MethodsIn this randomized comparative study, 102 participants underwent either retro walking or forward walking treadmill training four times a week for 12 weeks before and after which adiponectin, C-reactive protein, BMI, waist to height ratio, and waist to hip ratio were measured. Comparison of the measured values before and after intervention and between the groups was done, and the influence of C-reactive protein, BMI, waist to height ratio, and waist to hip ratio on adiponectin levels was determined. ResultsAdiponectin levels were significantly increased (p < 0.001) and C-reactive protein, BMI, waist to height ratio, and waist to hip ratio were significantly decreased (p ≤ 0.001) post-intervention. The participants who underwent retro walking training showed a significantly higher change in C-reactive protein levels, BMI, and waist to hip ratio compared to the forward walking group (p < 0.001). Adiponectin levels were influenced by BMI (p < 0.001). ConclusionRetro walking training leads to a greater increase in adiponectin and reduction in C-reactive protein, BMI, waist to height ratio, and waist to hip ratio compared to forward walking, and adiponectin levels are influenced by BMI. Retro walking treadmill training can be preferentially used to decrease cardiovascular risk factors.

The relationship between the backward walking and proprioception, trunk control, and muscle strength in children with cerebral palsy.

This study was planned to determine the factors affecting backward walking in children with cerebral palsy (CP). The study included 30 children with CP, with a mean age of 10.43 ± 2.76years. Backward walking abilities were evaluated with the 3-Meter Back Walk Test (3MBWT). A digital goniometer was used to evaluate proprioception, the Trunk Control Measurement Scale (TCMS) was used for trunk control, a digital muscle dynamometer was used for muscle strength, and the Gillette Functional Assessment Questionnaire (FAQ) was used for gait evaluation. When the spasticity of children at levels I and II according to the Gross Motor Function Classification System (GMFCS) was compared, a significant difference was found in favor of level I in hamstring, gastro-soleus, and gastrocnemius spasticity (p < 0.05). When the results of the 3MBWT, TCMS, and FAQ were compared, a significant difference was found in favor of level I (p < 0.05). No significant relationship was revealed between the 3MBWT and lower extremity proprioception and TCMS (p > 0.05). A significant negative correlation was observed between the 3MBWT and FAQ (p < 0.05). No significant correlation was found between the 3MBWT and lower extremity muscle strengths (p > 0.05). A significant positive correlation was found only between hip extension proprioception and iliopsoas muscle strength (p = 0.023). There was no significant correlation between the FAQ and lower extremity muscle strength (p > 0.05). It was revealed that the backward walking ability increased as the forward walking function improved in children with CP, but it was not affected by proprioception, trunk control, and muscle strength. NCT05088629 (10/11/2021).

Forward Jump Random Walk on a Cycle Graph and Its Hitting Time

Forward Jump Random Walk on a Cycle Graph and Its Hitting Time

Comparative study between effect of Retrowalking and self-selected pace forward walking on improving pain and function in people with osteoarthritis knee

Comparative study between effect of Retrowalking and self-selected pace forward walking on improving pain and function in people with osteoarthritis knee

Dual-task related frontal cerebral blood flow changes in older adults with mild cognitive impairment: A functional diffuse correlation spectroscopy study.

In a worldwide aging population with a high prevalence of motor and cognitive impairment, it is paramount to improve knowledge about underlying mechanisms of motor and cognitive function and their interplay in the aging processes. We measured prefrontal cerebral blood flow (CBF) using functional diffuse correlation spectroscopy during motor and dual-task. We aimed to compare CBF changes among 49 older adults with and without mild cognitive impairment (MCI) during a dual-task paradigm (normal walk, 2- forward count walk, 3-backward count walk, obstacle negotiation, and heel tapping). Participants with MCI walked slower during the normal walk and obstacle negotiation compared to participants with normal cognition (NC), while gait speed during counting conditions was not different between the groups, therefore the dual-task cost was higher for participants with NC. We built a linear mixed effects model with CBF measures from the right and left prefrontal cortex. MCI (n = 34) showed a higher increase in CBF from the normal walk to the 2-forward count walk (estimate = 0.34, 95% CI [0.02, 0.66], p = 0.03) compared to participants with NC, related to a right- sided activation. Both groups showed a higher CBF during the 3-backward count walk compared to the normal walk, while only among MCI, CFB was higher during the 2-forward count walk. Our findings suggest a differential prefrontal hemodynamic pattern in older adults with MCI compared to their NC counterparts during the dual-task performance, possibly as a response to increasing attentional demand.

Backward Walking Styles and Impact on Spatiotemporal Gait Characteristics.

Forward walking (FW) is a common balance assessment tool. However, its sensitivity is limited by the ceiling effect. Reverse gait, such as backward walking (BW), has been reported to have more advantages than FW for balance assessment. Three factors related to postural instability (i.e., increased speeds, restricted arm swing, and reduced visual feedback) during BW were investigated to determine BW conditions that have the potential to predict falls. Three-dimensional analyses were used to analyze seven walking conditions. FW and BW at self-selected and fast speeds were analyzed to identify the effects of speed. Walking with normal arm swings, crossed arms, and abducted arms during BW was tested to determine the effects of arm position. BW with closed and open eyes was compared to investigate the effects of visual feedback. BW had a significantly shorter step length than FW at high speeds. When the arms were abducted, the stance phase (%) was significantly lower compared to when arms were crossed during BW. Moreover, BW with closed eyes revealed significantly higher mediolateral center of mass (COM) displacements than with open eyes. We observed that BW with fast speeds, a crossed arm position, and closed eyes has the potential to help assess fall risk because it requires higher balance ability through spatiotemporal and COM adjustment.

The Immediate Effect of Backward Walking on External Knee Adduction Moment in Healthy Individuals.

Backward walking (BW) has been recommended as a rehabilitation intervention to prevent, manage, or improve diseases. However, previous studies showed that BW significantly increased the first vertical ground reaction force (GRF) during gait, which might lead to higher loading at the knee. Published reports have not examined the effects of BW on medial compartment knee loading. The objective of this study was to investigate the effects of BW on external knee adduction moment (EKAM). Twenty-seven healthy adults participated in the present study. A sixteen-camera three-dimensional VICON gait analysis system, with two force platforms, was used to collect the EKAM, KAAI, and other biomechanical data during BW and forward walking (FW). The first (P < 0.001) and second (P < 0.001) EKAM peaks and KAAI (P=0.02) were significantly decreased during BW when compared with FW. The BW significantly decreased the lever arm length at the first EKAM peak (P=0.02) when compared with FW. In conclusion, BW was found to be a useful strategy for reducing the medial compartment knee loading even though the first peak ground reaction force was significantly increased.

Evaluation of Error-State Kalman Filter Method for Estimating Human Lower-Limb Kinematics during Various Walking Gaits.

Inertial measurement units (IMUs) offer an attractive way to study human lower-limb kinematics without traditional laboratory constraints. We present an error-state Kalman filter method to estimate 3D joint angles, joint angle ranges of motion, stride length, and step width using data from an array of seven body-worn IMUs. Importantly, this paper contributes a novel joint axis measurement correction that reduces joint angle drift errors without assumptions of strict hinge-like joint behaviors of the hip and knee. We evaluate the method compared to two optical motion capture methods on twenty human subjects performing six different types of walking gait consisting of forward walking (at three speeds), backward walking, and lateral walking (left and right). For all gaits, RMS differences in joint angle estimates generally remain below 5 degrees for all three ankle joint angles and for flexion/extension and abduction/adduction of the hips and knees when compared to estimates from reflective markers on the IMUs. Additionally, mean RMS differences in estimated stride length and step width remain below 0.13 m for all gait types, except stride length during slow walking. This study confirms the method's potential for non-laboratory based gait analysis, motivating further evaluation with IMU-only measurements and pathological gaits.

Path-integral quantum Monte Carlo calculations of light nuclei

We describe a path-integral ground-state quantum Monte Carlo method for light nuclei in continuous space. We show how to efficiently update and sample the paths with spin-isospin dependent and spin-orbit interactions. We apply the method to the triton and alpha particle using both local chiral interactions with next-to-next-to-leading-order %(N$^2$LO) and the Argonne interactions. For operators, like the total energy, that commute with the Hamiltonian, our results agree with Green's function Monte Carlo and auxiliary field diffusion Monte Carlo calculations. For operators that do not commute with the Hamiltonian and for Euclidean response functions, the path-integral formulation allows straightforward calculation without forward walking or the increased variance typical of diffusion methods. We demonstrate this by calculating density distributions, root mean square radii, and Euclidean response functions for single-nucleon couplings.

Association between Backward Walking and Cognition in Parkinson Disease: A Systematic Review.

Backward walking often occurs in everyday life. It is more complex than forward walking and is associated with decreased coordination. However, it is unclear if a reduced backward walking performance is associated with impaired cognition. This could be particularly relevant as gait and cognitive deficits commonly occur in Parkinson’s disease. The objective of this systematic review was to synthesize the evidence on the association between backward walking and cognition in persons with Parkinson’s disease. The electronic databases PubMed and Web of Science were systematically searched, and the quality of eligible studies was assessed. Two studies met the inclusion criteria, but study protocols, investigated population, and outcome measures differed substantially. One study showed lower backward walking speed in patients with Parkinson’s disease with poorer attention test performances. The second study showed a weak correlation between executive cognitive functions and backward walking speed. Given the low number of studies, the heterogenous study design, and the inconsistent results, the present review highlights the need to further investigate the association between backward walking and cognition in patients with Parkinson’s disease.

Effect of Backward and Forward Walking on Lower Limb Strength, Balance, and Gait in Multiple Sclerosis: A Randomized Feasibility Trial.

Backward walking (BW) interventions have improved gait and balance in persons with stroke, cerebral palsy, and Parkinson disease but have not been studied in persons with multiple sclerosis (MS). We examined the feasibility of a BW intervention and how it affected strength, balance, and gait vs forward walking (FW) in persons with MS. Sixteen persons with MS with a Patient-Determined Disease Steps (PDDS) scale score of 3 to 5 (gait impairment-late cane) were randomized to the FW (n = 8) or BW (n = 8) group. Participants did 30 minutes of FW or BW on a treadmill 3 times per week for 8 weeks (24 visits). Enrollment, adherence rate, and safety were tracked. The Timed Up and Go test, Six-Spot Step Test, single-leg stance, and abbreviated Activities-specific Balance Confidence scale were used to measure balance. Hip and knee flexion and extension strength (isometric peak torque), gait speed, and spatiotemporal gait parameters were measured. A 2×2 factorial multivariate analysis of covariance was used to examine changes in strength, balance, and gait, with the PDDS scale score as the covariate. Treatment adherence rate was 99.7%, with no safety concerns. After controlling for baseline differences in disability (PDDS scale score; P = .041), the BW group improved dominant hip flexion strength preintervention to postintervention compared with the FW group (F 1,13 = 9.03; P = .010). No other significant differences were seen between groups. This was the first study to look at BW as an intervention in persons with MS. Based on its feasibility, safety, and significant finding, BW should be studied in a larger, definitive trial in the future.

Random walk: Random number generation during backward and forward walking- the role of aging.

Deficits in executive function, visuospatial abilities, and cognitive embodiment may impair gait performance. This study aimed to investigate the effect of age on random number generation (RNG) performance during forward and backward locomotion to assess cognitive flexibility and cognitive embodiment during walking. Another aim was to examine the effect of age on the associations of RNG performance during walking with stride time variability (STV), the percentage of double support (DS%), and visuospatial abilities as measured by a spatial orientation test (SOT). Twenty old (age 68.8 ± 5.3, 65% female) and 20 young (age 25.2 ± 2.2, 45% female) adults generated random numbers during backward walking (BW) and forward walking (FW) over-ground and over a treadmill with an internal focus of attention and visual-attentive distraction; six walking conditions in total. To assess cognitive flexibility, sample entropy was calculated for each RNG sequence. The average of the first 5 numbers in each RNG task was calculated to assess the relationship between small/large numbers and movement direction. STV and DS% were recorded using inertial measurement units, and spatial orientation was measured using a computerized test. The older subjects had less flexibility in generating random numbers in three of the six walking conditions. A negative correlation between RNG flexibility and STV was found in older adults during treadmill BW with visual-attentive distraction and forward over-ground walking, whereas no correlations were demonstrated in the young group. The spatial orientation score (a higher value means a worse outcome) correlated positively with RNG flexibility in the older group under all walking conditions, suggesting that older adults with better visuospatial orientation have lower cognitive flexibility, and vice versa. There was no correlation between small/large numbers and direction of motion in either group. The correlation between RNG flexibility and STV may indicate similar executive control of verbal and gait rhythmicity in old adults. Conversely, our results suggest that cognitive flexibility and visuospatial ability may decline differently.

Examining the Influence of Cognition on the Relationship Between Backward Walking and Falls in Persons With Multiple Sclerosis.

Multiple sclerosis (MS) causes motor, cognitive, and sensory impairments that result in injurious falls. Current fall risk measures in MS (ie, forward walking [FW] speed and balance) are limited in their sensitivity. Backward walking (BW) velocity is a sensitive marker of fall risk and correlates with information processing speed (IPS) and visuospatial memory (VSM) in persons with MS. Backward walking is a complex motor task that requires increased cognitive demands, which are negatively affected by MS; however, whether cognitive function modifies the sensitivity of BW as a fall risk assessment in MS remains unknown. This study examines the influence of cognition on the relationship between BW and falls in persons with MS. Measures of BW, FW, IPS, VSM, and retrospective falls were collected. Hierarchical regression tested moderation and included an interaction term predicting number of falls. Covariates for all analyses included age and disease severity. Thirty-eight persons with MS participated. Although BW, IPS, and covariates significantly predicted the number of falls (R 2 = 0.301; P = .016), there was no evidence of moderation. Backward walking, VSM, and covariates also significantly predicted number of falls (R 2 = 0.332, P = .008), but there was no evidence of moderation. The FW models generated comparable results. The relationship between BW velocity and falls was not conditional on IPS or VSM in this sample. Larger-scale studies examining additional cognitive domains commonly affected by MS and prospective falls are needed to characterize neurobiological processes relevant to BW and its clinical application in the assessment of fall risk.

Variation In Interlimb Coordination Of Healthy Adults At Different Backward Walking Speeds

The central pattern generator is demonstrated to produce both rhythmic forward walking (FW) and backward walking (BW). Compared with FW, BW reduces the likelihood of anterior cruciate ligament rupture and osteoarthritis. Because visual feedback is absent in BW, abundant motor units are recruited and interlimb coordination becomes more variable. Walking speed is one of the primary constraints to affect interlimb coordination in FW. However, backward walking speeds that produce the optimal coordination in foot-shank and shank-thigh couplings are unclear in the healthy group. PURPOSE: To explore the effect of different backward walking speeds on the interlimb coordination of healthy adults. METHODS: Forty healthy adults (20 males and 20 females) were recruited, and gait data at preferred backward walking speed (PBWS), maximum backward walking speed (MBWS), 80% MBWS, 60%MBWS and 40% MBWS were collected using a three-dimensional gait analysis system. Continuous relative phase (CRP) method was applied to analyze the interlimb coordination (shank-foot and thigh-shank couplings) at different backward walking speeds and respective CRP was averaged across the subjects. CRPs between the shank-foot and thigh-shank couplings at different speeds were compared using one-way ANOVA. Level of significance was set at 0.05. RESULTS: The average CRP of the shank-foot coupling was the highest at 60% MBWS, reaching 8.61° ± 0.40°, while the average CRP at 80% MBWS was the lowest, which was 6.30° ± 0.11°. The average CRPs of 100% MBWS and 40% MBWS were similar, second only to that of 60% MBWS. For the thigh-shank coupling, the average CRP of 100% MBWS was the largest among five backward walking speeds, while the minimum average CRP was 7. 18° ± 1.27° when BW was performed at 80% MBWS. The interlimb coordination of the thigh-shank and the shank-foot couplings are significantly distinct at different backward walking speeds (P < 0.01). CONCLUSIONS: The interlimb coordination of the shank-foot coupling was the largest when walking backwards at 60% MBWS, while, for the thigh-shank coupling, the largest interlimb coordination was noticed at 100% MBWS. Backward walking speed for optimal locomotion ability varied in different couplings. This study provides a preliminary insight to rehabilitative backward walking training.

Rock-and-Walk Manipulation: Object Locomotion by Passive Rolling Dynamics and Periodic Active Control

This study presents the method of robotic <italic xmlns:mml="http://www.w3.org/1998/Math/MathML" xmlns:xlink="http://www.w3.org/1999/xlink">rock-and-walk</i> manipulation for dynamic, nonprehensile object locomotion. The object, which is in contact with an environmental surface, is basically manipulated to rock from side to side about the contact point periodically by the robot system. In the meantime, the passive dynamics due to gravity enables the object to roll along a zigzag path that leads to a forward walk. Rock-and-walk is a special-purpose method that enables the transport of a certain class of objects, which are too large, heavy to apply other primary methods such as grasping- or pushing-based operations. Our work is motivated by an interesting question in archaeology, how the giant statues of Easter Island (known as “moai”) were transported several hundred years ago, and a recent demonstration performed by archaeologists that it is possible to walk the statue by periodic rocking. We present a detailed study of the dynamics, kinematics, and mechanics of the object-robot-environment system, and devise a feedback control strategy for rock-and-walk gaiting through the effective regulation of the object’s energy and posture. An extensive set of experiments demonstrate the viability and practicality of our approach in diverse settings: Caging-based single-robot manipulation and cable-driven dual-robot manipulation using manipulator arms and aerial robots.

Comparison of Immediate Effectiveness between Forward and Backward Walking on Treadmill Training by Measuring Muscle Recruitments, Gait Parameters, and Dynamic Balance

Comparison of Immediate Effectiveness between Forward and Backward Walking on Treadmill Training by Measuring Muscle Recruitments, Gait Parameters, and Dynamic Balance

Reverse six minute walk

Introduction: Exercise helps to combat many health conditions and diseases. Walking is a simple way of exercise to increase aerobic capacity. To provide even greater health benefits we studied backward walking on flat surface. Aims and Objectives: To compare the difference in heart rate when walking forward and walking backward for 6 minutes on a flat surface. Methods: Healthy subjects above 18 years with no comorbidities were recruited for the study. Pre test and post test vitals and distance walked was measured in both 6 Minute Walk Test (6MWT) and Reverse 6MWT. Results: The mean distance walked in 6MWT and Reverse 6MWT was 505.3 meters and 381.7 meters respectively (p=0.00 Statistically significant). The mean Heart Rate (HR) after 6 MWT and Reverse 6MWT was 115.52 and 127.70 respectively (p=0.00 Statistically significant). Conclusion: Reverse walking improves aerobic capacity more than forward walking.

Gains in Daily Stepping Activity in People With Chronic Stroke After High-Intensity Gait Training in Variable Contexts.

Many physical therapist interventions provided to individuals with chronic stroke can lead to gains in gait speed or endurance (eg, 6-Minute Walk Test [6MWT]), although changes in objective measures of participation are not often observed. The goal of this study was to determine the influence of different walking interventions on daily stepping (steps per day) and the contributions of demographic, training, and clinical measures to these changes. In this secondary analysis of a randomized clinical trial, steps per day at baseline and changes in steps per day following 1 of 3 locomotor interventions were evaluated in individuals who were ambulatory and >6months after stroke. Data were collected on 58 individuals who received ≤30 sessions of high-intensity training (HIT) in variable contexts (eg, tasks and environments; n = 19), HIT focused on forward walking (n = 19), or low-intensity variable training (n = 20). Primary outcomes were steps per day at baseline, at post-training, and at a 3-month follow-up, and secondary outcomes were gait speed, 6MWT, balance, and balance confidence. Correlation and regression analyses identified demographic and clinical variables associated with steps per day. Gains in steps per day were observed across all groups combined, with no between-group differences; post hoc within-group analyses revealed significant gains only following HIT in variable contexts. Both HIT groups showed gains in endurance (6MWT), with increases in balance confidence only following HIT in variable contexts. Changes in steps per day were associated primarily with gains in 6MWT, with additional associations with baseline 6MWT, lower-extremity Fugl-Meyer scores, and changes in balance confidence. HIT in variable contexts elicited gains in daily stepping, with changes primarily associated with gains in gait endurance. Providing HIT in variable contexts appears to improve measures of participation (eg, daily stepping) that may be associated with clinical measures of function. Gains in multiple measures of mobility and participation with HIT in variable contexts may improve the efficiency and value of physical therapy services.

Comparison of Effectiveness of Forward Walking vs Retro Walking on Pain and Function in Patients with Postmenopausal Osteoarthritis of Knee

Background and Objectives: Osteoarthritis (OA) is the most common form of arthritis and the leading source of physical disability with severely impaired quality of life in people. The overall prevalence of OA in India is found to be higher in females than in males. Rehabilitation exercises in the form of Closed Kinetic Chain Exercises (CKCE) are an effective way in the management of OA knee. This study aims to evaluate the effectiveness of forward walking versus retrowalking on pain and function in postmenopausal women with OA knee. Methods: 30 postmenopausal females diagnosed with OA knee were randomly allocated into 2 groups. Group A received forward walking while Group B received retrowalking. Both the groups received conventional physiotherapy such as strengthening exercises and Ultrasound along with their assigned interventions. The outcomes were measured in terms of Numerical Pain Rating Scale (NPRS) and Western Ontario and McMaster Universities Arthritis Index (WOMAC) at the start of the intervention and at the end of 6 weeks. Results: The results of the present study showed statistically significant difference within the groups for all outcome measures; but significant difference was found only for WOMAC scores between the groups. Further it was also found that ROM of the knee showed a significant difference both within the groups as well as between the groups. Group B showed better improvement that Group A for pain and function of the knee. Interpretation and Conclusion: The present study concludes that both forward walking and retrowalking are individually effective in reducing pain and improving function of post-menopausal women with OA knee. However, retrowalking results in greater reduction in pain and improved function of postmenopausal women with OA knee. Keywords: Retro walking, Forward Walking, Osteoarthritis, Menopause.