a 3 - d point of view objectives
TRANSCRIPT
Slide 1 The Physical Therapist’s Role in
Assessment for AFOs
A 3-D Point of View
OPTA Annual Conference
4/13/2018
Jennifaye V. Brown, PT, PhD, NCS
Ohio University College of Health Sciences and Professions
School of Rehabilitation & Communication Studies Division of Physical Therapy1
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Slide 2
Learning
Objectives
Develop & modify
Develop & modify the subjective exam & objective assessment skills needed to complete an AFO eval via a case study
EvaluateEvaluate the results of the subjective exam and outcome measures to recommend an AFO
ValidateValidate choice of questions and objective measures used to assess the need for an AFO
JustifyJustify optimal positioning for the LE assessment based on impairments and function during specific gait phases
ExplainExplain the components that comprise a patient-focused examination for an AFO
2Jennifaye V. Brown, PT, PhD, NCS - Ohio University
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Slide 3 Agenda
12 minutes: Patient-Centered Care & Social Determinants of
Health
10 minutes: 3-D Technology: Changing the AFO Fabrication
Process
46 minutes: AFO Evaluation: Patient-Centered Examination
17 minutes: Case Study
5 minutes: Questions & Answers
3Jennifaye V. Brown, PT, PhD, NCS - Ohio University
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Slide 4
Patient-Centered Care &
Social Determinants of Health
4Jennifaye V. Brown, PT, PhD, NCS - Ohio University
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Slide 5 Physical Therapy & Patient-Centered Care
“has yet to adopt and integrate the construct [PCC] in research”1(p.120)
& clarify its definition in practice
Outcome studies have measures that assess patient perspectives, but
are we really asking, gathering & applying client perspectives in
clinical practice?
I say NO: all custom AFOs tend to look the same & require that a client
buys a shoe half size larger & wider for brace accommodation
5Jennifaye V. Brown, PT, PhD, NCS - Ohio University
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Slide 6 To Improve PCC1
Consensus: PCC definition
Operationalize PCC
Establish methodology:
evidence for practice
Communication
Shared Decision-making
Client Education
Client Empowerment
Research Practice
6Jennifaye V. Brown, PT, PhD, NCS - Ohio University
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Slide 7 Social Determinants of Health
Neighborhood & Built Environment
Health & Health Care
Economic Stability
Education
Social & Community Context
Jennifaye V. Brown, PT, PhD, NCS - Ohio University 7
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Slide 8 SDOH Model applied to these pictures in terms
of AFO fabrication2
8Jennifaye V. Brown, PT, PhD, NCS - Ohio University
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Slide 9
3-D Technology:
Changing the AFO Fabrication Process
1. Scanning
2. CAD-CAM Technology
3. 3-D Printing9Jennifaye V. Brown, PT, PhD, NCS - Ohio University
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Slide 10 Scanning3-5
Traditional Non-Traditional
10http://lermagazine.com/products/biosculptor-afo-scanning-table
Jennifaye V. Brown, PT, PhD, NCS - Ohio University
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Slide 11 CAD-CAM Technology3-4
Traditional Non-Traditional
11https://www.researchgate.net/profile/Mark_Sivak
/publication - Flow DiagramJennifaye V. Brown, PT, PhD, NCS - Ohio University
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Slide 12 3-D Printing
12https://jneuroengrehab.biomedcentral.com/articles/10.1186/1743
-0003-8-1Jennifaye V. Brown, PT, PhD, NCS - Ohio University
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Slide 13 Finished Product
13Jennifaye V. Brown, PT, PhD, NCS - Ohio University
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Slide 14 Cha et al 2017
14Jennifaye V. Brown, PT, PhD, NCS - Ohio University
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Slide 15
AFO Evaluation:
Patient-Centered Examination
15Jennifaye V. Brown, PT, PhD, NCS - Ohio University
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Slide 16 Hanna & Harvey, 20016
Functional Transfers - STSGait Assessment
1. Posture
2. Alignment
3. Symmetry
4. Speed
5. Control during all phases of:
a. Weight acceptance
b. Single limb support
c. Swing limb advancementJennifaye V. Brown, PT, PhD, NCS - Ohio University
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Slide 17 Alignment
Structural Deformities
Bony deformity
Soft tissue shortening
Muscle contracture
Flexible Deformities
Muscle imbalance due to
weakness
Muscle stiffness
Dominant neuromuscular activity
(spasticity)
Abnormal tone
Improper muscle length-tension
relationship alters kinetic
moment at jt during movementJennifaye V. Brown, PT, PhD, NCS - Ohio University 17
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Slide 18 Case Study Analysis
STRENGTHS
1. Addresses lower quarter gait
impairments in detail
2. Provides LE biomechanics
Variety of static positions
Orthopedic tests, procedures &
outcomes
WEAKNESSES
1. No neuromuscular tests, procedures
& outcomes
2. Neglects distal malalignment/
neuromuscular impairments
relationship trunk dyscontrol
/proximal malalignment
3. No resources related to
neuromuscular assessment & txJennifaye V. Brown, PT, PhD, NCS - Ohio University 18
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Slide 19 Clinical Conclusion
Literature Answers Question, But Skewed
1. Orthopedic focus
2. Trunk dyscontrol/pelvis and proximal malalignment may be cause of distal foot & ankle problems requiring AFO
3. Interventions for trunk dyscontrol/pelvis & proximal malalignment optimize effectiveness, function & acceptance of AFO
What is missing…..
1. Assessment of neuromuscular components as primary factors
2. Consider other contributing systems
3. Consider comorbidities, SDOH & PCC approach 19
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Slide 20
AFO Examination Components7
20Jennifaye V. Brown, PT, PhD, NCS - Ohio University
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Slide 21 Key Components for AFO Examination
1. Postural Observation: Compare to Normal foot in WB & NWB
2. Assess Foot Appearance & Subsequent Compensations; Musculoskeletal Abnormalities
3. ROM: Open Chain & Close Chain
4. Strength & Voluntary Control
5. Spasticity & Tone
6. Sensation: Proprioception, Kinesthesia, Monofilament Testing
7. Balance
8. Edema
9. Pain Jennifaye V. Brown, PT, PhD, NCS - Ohio University 21
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Slide 22 Key Components for AFO Examination
10. Vision
11. Functional Mobility Assessment: STS & Falls
12. Gait: Speed & Quality
13. Personal Effects
14. Level of Function: Prior & Current
15. Goals
Jennifaye V. Brown, PT, PhD, NCS - Ohio University 22
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Slide 23 You have to Look, Listen & Feel…..
I. Postural Observation
Jennifaye V. Brown, PT, PhD, NCS - Ohio University
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Slide 24
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The Normal Foot
1. Lateral border WB except area under
cuboid
2. WB on medial calcaneus, longitudinal
arch, first MTH
3. Second toe is to ankle joint
4. Anterior & to tibia is a crease convex
on the dorsum of midfoot
Jennifaye V. Brown, PT, PhD, NCS - Ohio University
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Slide 25 Primary Functions of the Foot7-8
I. Mobile Adapter: LRMSt
A. Adapt to ground surface
B. Facilitate shock absorption
STJ pronated - allows foot mobility, which s MTJ motion, allowing adaptation to different surfaces, therefore mobile adaptor
II. Rigid Base for Propulsion During Gait: TStPSw
For propulsion, STJ is supinated & MTJbecomes rigid
-HOW?
1. Bone Congruency
2. Capsular Tension
3. Muscle Mechanics
STJ=Subtalar Jt MTJ= Midtarsal Jt
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Jennifaye V. Brown, PT, PhD, NCS - Ohio University
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Slide 26
Picture=IC; LR MS TS PSw
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Jennifaye V. Brown, PT, PhD, NCS - Ohio University
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Slide 27 CKC Pronation CKC Supination
Tibia: int. rot. (ion)
Talus: ADD & PF(ion)
Calcaneus: everts (ion)
Tibia: ext. rot.(ion)
Talus: ABD & DF(ion)
Calcaneus: inverts (ion)Jennifaye V. Brown, PT, PhD, NCS - Ohio University 27
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Slide 28
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II. Foot Appearance7-8
Pronator Supinator
Jennifaye V. Brown, PT, PhD, NCS - Ohio University
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Slide 29
Giallonardo LM. Clinical evaluation of foot and ankle dysfunction. Phys Ther. 1988; 68:1850-1856.
Foot Appearance & Subsequent
Compensations9
Jennifaye V. Brown, PT, PhD, NCS - Ohio University 29
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Slide 30 II. Musculoskeletal Abnormalities7
Hallux Valgus &
Claw Toes
Hammer Toes
Jennifaye V. Brown, PT, PhD, NCS - Ohio University 30
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Slide 31 What Looks Abnormal?
Jennifaye V. Brown, PT, PhD, NCS - Ohio University 31
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Slide 32 II. Neuromuscular Abnormalities
1. Toe Grasping (A)
2. Inversion (B)
3. Eversion (C)
4. Dorsiflexion (D)
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Pathological
Reflexes – LE10
Jennifaye V. Brown, PT, PhD, NCS - Ohio University
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Slide 33 III. Range of Motion
AFO will be used in WB,
therefore measure Ankle ROM
in WB
1. Loading Response
2. Terminal Stance
Jennifaye V. Brown, PT, PhD, NCS - Ohio University
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Slide 34 SUPINE Ankle ROM
R1= 1st resistance to passive movement
R2= final position of foot- no more range to be gained
0-3 degree change or less consider contractureJennifaye V. Brown, PT, PhD, NCS - Ohio University 34
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Slide 35 III. Range of Motion
hind- or forefoot
Immobility or compensatory varus or valgus
Jennifaye V. Brown, PT, PhD, NCS - Ohio University
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Slide 36 IV. Strength/Voluntary Control
Extensor Synergy
Patterns
36Jennifaye V. Brown, PT, PhD, NCS - Ohio University
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Slide 37 Force Control:
Generate Movement in Different Postures
Hislop & Montgomery11
With CNS lesion, innervations to mm not impaired but control of mm impaired
“MMT was (and is) designed to evaluate patients with a lower motor neuron disorder manifested by flaccid weakness or paralysis”11(p.344)
Authors suggest Upright Motor Control Test12 for individuals with Selective Control or Pattern Motion
Selective Control: move a single jt without activating mov’t in adjacent or neighboring jt of same extremity11(p.344)
Pattern Motion: inability to perform fractionated mov’t e.g. wrist extension w/o mov’t at elbow & fingers or knee extension w/o pflx & inversion –stereotypical synergy patterns 11(p.344)
Jennifaye V. Brown, PT, PhD, NCS - Ohio University 37
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Slide 38 Force Control:
Generate Movement in Different Postures
Upright Motor Control Test12 :
Incorporate effects of upright posture & WB
Simulates walking activity
Inter-tester reliability 96% for flexion portion of test & 90% for extension
portion of test
Latest version in Hislop & Montgomery11 Chapter 8
Jennifaye V. Brown, PT, PhD, NCS - Ohio University 38
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Slide 39 Upright Motor Control Test11-12
39Hip Flexion Knee Flexion Knee Extension
Ankle DF Ankle PF
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Slide 40 Assessment of Force Control
40Jennifaye V. Brown, PT, PhD, NCS - Ohio University
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Slide 41 Dynamometry13
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Jennifaye V. Brown, PT, PhD, NCS - Ohio University
Figure 1. Measurement of plantar and dorsal flexion strength by hand-held dynamometer
Lafayette Manual Muscle Test System
https://www.researchgate.net/figure/284190078_fig1_Figure-1-Measurement-of-plantar-
and-dorsal-flexion-strength-by-hand-held-dynamometer
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Slide 42
V. Spasticity & Tone
Jennifaye V. Brown, PT, PhD, NCS - Ohio University 42
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Slide 43 Spasticity Definition
1. Velocity-dependent increase in resistance of a mm or mm grp to passive stretch14
2. Changes in mm bc of UMN lesion and/or prolong positioning known as myoplasticity15
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Evaluation Focus:16
1. Identify clinical pattern of motor
dysfxn & source
2. Identify clients’ ability to control
mm in clinical pattern
3. Differentiate mm stiffness versus
contracture
Jennifaye V. Brown, PT, PhD, NCS - Ohio University
Scales:17
MAS: Modified Ashworth Scale
Modified Tardieu Scale
King’s Hypertonicity Scale
Tone Assessment Scale
Daily Fxnl Assessment Scales
1. Barthel Index
2. Patient’s Disability Scale
3. Carer Burden Rating Scale
Electrophysiology Measures
1. EMG: H-reflex, F wave, Tendon Reflex & polysynaptic responses
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Slide 44
Spasticity
AssessmentHow do you do it?
Jennifaye V. Brown, PT, PhD, NCS - Ohio University44
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Slide 45 Tone Definition & Concepts:Definition: “…the resistance or ‘stiffness’ in a limb to passive movement” 18
Continuum: flaccidity ↔ hypotonia ↔ normal ↔ spasticity ↔ rigidity15 (p.110)
Flaccidity: complete loss of mm tone15 (p.110)
Hypotonicity: reduction in stiffness of mm to lengthening – spinocerebellar
lesions15 (p.113)
Hypertonia: increase in mm tone compared to normal; manifested as
spasticity or rigidity; based on the clinical presentation & origin15
Rigidity: extrapyramidal tract pathology (basal ganglia & midbrain nuclei); ↑d tone in opposing mm groups on both sides of the limb and it is not
velocity dependent15
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Jennifaye V. Brown, PT, PhD, NCS - Ohio University
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Slide 46 Tone Assessment19
Varies in clinical practice: concept of tone vs spasticity
Modified Ashworth Scale19 Supine, but alter position to get mm/pt to relax;
assess available ROM; passively move joint so that mm moves from a
shorten to lengthen position
Score Description
0 No increase in mm tone
1 Slight ↑ in mm tone, manifested by a catch & release or minimal resistance @ the end
ROM when affected part moved in flexion or extension/abduction or adduction, etc.20(p.24)
1+ Slight ↑ in mm tone manifested by a catch f/b minimal resistance through the
remainder (less than half) of the ROM
2 More marked ↑ mm tone through most of the ROM, but affected part(s) easily moved
3 Considerable ↑ in mm tone, passive movement difficult
4 Affected part(s) rigid in flex or ext (abd or add, etc.) 20(p.24)
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Jennifaye V. Brown, PT, PhD, NCS - Ohio University
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Slide 47 V. Tone, Spasticity vs Voluntary Control
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Slide 48 VI. Sensation21
Proprioception
Kinesthesia
Move the hemi extremity & pt has to duplicate
the movement with opposite extremity
Jennifaye V. Brown, PT, PhD, NCS - Ohio University
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Slide 49 Limb Ataxia vs Discoordination Problem
https://www.youtube.com/watch?v=fwG
6CUD6Puw
Ataxia general term which means incoordination
of mov’t & often applied to gait22
Discoordination: proprioceptive deficits NOT
weakness
49Jennifaye V. Brown, PT, PhD, NCS - Ohio University
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Slide 50 Diabetic????
Monofilament Testing23
Jennifaye V. Brown, PT, PhD, NCS - Ohio University 50
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Slide 51 VII. Balance Assessment
Romberg
BERG
Ankle, Hip & Stepping
Strategies14 & 24
Rehabmeasures.org
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Slide 52 VIII. Edema25
Jennifaye V. Brown, PT, PhD, NCS - Ohio University 52
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Slide 53 IX. Pain Perception26
53Jennifaye V. Brown, PT, PhD, NCS - Ohio UniversityThis Photo by Unknown Author is licensed under CC BY-SA
This Photo by Unknown Author is licensed under CC BY-NC-SAwww.physioprescription.com
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Slide 54 Hemianopsia22
54Jennifaye V. Brown, PT, PhD, NCS - Ohio University
X. Vision
Peripheral Vision24
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Slide 55 XI. Functional Mobility Assessment
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Observe STS & Falls Assessment
Jennifaye V. Brown, PT, PhD, NCS - Ohio University
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Slide 56 XII. GAIT Observation27-29
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https://www.google.com/search?q=pictures+of+gait+analysis&tbm=isch&tbo=u&source=univ&sa=X&ve
d=0ahUKEwi4pKmp27XXAhWBLyYKHYDdCR0QsAQIJw&biw=1366&bih=662#imgrc=LjSa7_xjUIIZOM:
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Slide 57 XII. GAIT Observation27-29
Jennifaye V. Brown, PT, PhD, NCS - Ohio University 57
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Slide 58 Evidence Across Studies30Middleton, Fritz, Lusardi JAPA, 2015
0 mph 0.4 mph 0.9 mph 1.3 mph 1.8 mph 2.2 mph 2.7 mph 3.1 mph10 meter walk time 50 sec 25 sec 16.7 sec 12.5 sec 10 sec 8.3 sec 7.1 sec10 foot walk time 15.2 sec 7.6 sec 5 sec 3.8 sec 3 sec 2.5 sec 2.2 sec
m/s58
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Slide 59
2 Minute Walk Test
3 Minute Walk Test
6 Minute Walk Test
10-M Walk Test
10 Foot Walk Test
Gait Analysis: Full BodyRLA National Rehab. Ctr.PT Dept.27
TUG: Timed Up & Go Test
TUG Manual: carry a full cup of water
TUG Cognitive: counting backward from a randomly selected # btwn 20-100
Walking While Talking Test
Dynamic Gait IndexObservation
Balance & Dual Task
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Jennifaye V. Brown, PT, PhD, NCS - Ohio University
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Slide 60 Personal Effects & Lifestyle
Shoes Heel hgt
“Wear & tear” of shoe counter,
sole/heel, insole
SDOH
Client Perspectives
Work/Leisure Clothing
60Jennifaye V. Brown, PT, PhD, NCS - Ohio University
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Slide 61
Case Study
Jennifaye V. Brown, PT, PhD, NCS - Ohio University 61
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Slide 62 Scheets et al31
Fractionated movement deficit (did not display isolated movements-
synergistic patterns severe motor deficits)
Prognosis: for “normal” movement unlikely
Focus: postural stability when performing compensatory movement
strategies and during overall functional activities such as transfers
and gait
62Jennifaye V. Brown, PT, PhD, NCS - Ohio University
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Slide 63 Associated Signs - Related to Task Analysis31
Stiffness of involved limbs & slow
No dissociation of mov’t, 1-2 jts
Associated reactions in attempt to move
Less A-G mov’t, may be unable to stand
Gait: compensatory strategies associated w/ ext synergy of LE; however
stands w/ hip & knee flex
UE hand closure; limited reach range
Postural control: able to sit but asymmetrical
Stability may improve with practice but not symmetry63Jennifaye V. Brown, PT, PhD, NCS - Ohio University
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Slide 64 Synergistic Patterns
Damage at or above red nucleus,
impacting input to the rubrospinal
tract (corticorubrospinal tract)32
Spasticity & variations in tone
hallmark signs of lesion in subcortical
region32-33
Gait w/ extensor synergy pattern;
foot PF; difficulty clearing swing;
compensate: pelvic hike,
circumduction
64Jennifaye V. Brown, PT, PhD, NCS - Ohio University
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Slide 65 What questions do we want to ask….
1. Do you have a brace?
2. How is it helpful?
3. How is it limiting?
4. What is your perception of your walking?
a. Slow vs fast?
b. Quality of how your body moves?
5. Have you had any falls? If yes….
a. When was the last fall
b. What were you doing?
6. Do you get out of the house a lot?
Jennifaye V. Brown, PT, PhD, NCS - Ohio University 65
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Slide 66 What questions do we want to ask….
1. Tell me about your home environment; community
2. Who and how is your support system? CG, friends visit
3. What do you do for exercise?
4. What do you do for fun/enjoyment?
5. What are your goals for walking?
6. Are these the shoes you typically wear with the brace?
7. What shoes did you typically wear prior to the stroke?
8. Did you bring them with you?Jennifaye V. Brown, PT, PhD, NCS - Ohio University 66
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Slide 67 Outcome Measures
10 MWT: unable
TUG: 26 sec
10’ Walk Test: 14.8 sec
Assessed gait with platform rw to
spd of gait - impacts gait quality
What gait impairments would you
suspect during:
1. swing phase
2. stance phase
1. Tone: MAS (3 quads & pflx); King’s
Hypertonicity Scale; Tone
Assessment Scale
2. Spasticity: (+)
3. Fxnl Mobility Assessment:
5x STS: 42 secs requiring
use of RUE; leans to R
4. Observe shoe for wear & tear; look
at WB surface inner sole
67Jennifaye V. Brown, PT, PhD, NCS - Ohio University
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Slide 68 Outcome Measures
5. ROM:
Knee ext: R1: -15 & R2: -5
Knee flex 90: R1: -5 & R2: -3
6. MTH: great toe upgoing; 1st ray pflx; 2-5 ext at MTH & PIP & DIP flex
7. Foot & Ankle Assessment: rockers (absent); Babinski (+); pathological reflexes
(+ inversion response); compensatory motion due to lack of dflx (forefoot
contact at IC; lateral heel whip at TSt w/ early heel rise)
8. Pain: sharp - 4/10 midstance at infrapatellar & general knee ache at rest
68Jennifaye V. Brown, PT, PhD, NCS - Ohio University
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Slide 69 AFO Recommendations
To provide security, stability & control w/o interfering too much with movement at the foot & ankle.
To meet the functional requirements of the client with minimal restriction
Goal of an AFO (Barber, CPO)
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Jennifaye V. Brown, PT, PhD, NCS - Ohio University
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Slide 70 Knowledge Summary
1. AFO Assessment Matters
2. Patient-Centered: Social Determinants of Health
3. Critical Exam Components – Lesion Location, Severity & Size
4. Objective Measures: Cortical, Subcortical, Cerebellum
5. Psychosocial Aspects of Gait
Jennifaye V. Brown, PT, PhD, NCS - Ohio University70
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Slide 71 Thank you for your interest & feedback!
71Jennifaye V. Brown, PT, PhD, NCS - Ohio University
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Slide 72 For participation, please contact:
Jennifaye V. Brown, PT, PhD, NCS
Ohio University [email protected] 740.593.0820
72Jennifaye V. Brown, PT, PhD, NCS - Ohio University
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References1. Cheng L. Leon V, Lang A. Patient-centered care in physical therapy: definition, operationalization,
and outcome measures. Phys Ther Rev. 2016; 21:109-123.
2. Frier A, Barnett F, Devine S. The relationship between social determinants of health, and rehabilitation
of neurological conditions: a systematic literature review. Disabil Rehabil. 2016; 39:941-948.
3. Cha YH, Lee KH, Ryu HJ et al. Ankle-foot orthosis made by 3D printing technique and automated
design software. Applied Bionics and Biomechanics, vol 2017, Article ID 9610468, 6 pages,
2017.doi:10.1155/2017/9610468
4. Walbran M, Turner K, McDaid AJ. Customized 3D printed ankle-foot orthosis with adaptable carbon
fibre composite spring joint. Cogent Engineering. 2016;3(1):1227022.
5. Patterson RJBAM, Campbell RI. Evaluation of a digitized splinting approach with multiple-material
functionality using additive manufacturing technologies. Presented at the Twenty-Third Annual
International Solid Freeform Fabrication Symposium, Austin, TX, 2012.
6. Hanna D, Harvey RL. Review of preorthotic biomechanical considerations. Top Stroke Rehabil.
2001;7:29-37.
7. Alazzawi S, Sukeik M, King D, Vemulapalli K. Foot and ankle history and clinical examination: A guide
to everyday practice. World Journal of Orthopedics. 2017;8(1):21-29. doi:10.5312/wjo.v8.i1.21
Jennifaye V. Brown, PT, PhD, NCS - Ohio University
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74
References
8. Tiberio D. Pathomechanics of structural foot deformities. Phys Ther. 1988; 68:1840-1849.
9. Giallonardo, LM (1988). Clinical evaluation of foot and ankle dysfunction. Phys Ther. 68;1850-1856.
10.Duncan W. Tonic reflexes of the foot. J Bone Joint Surg Am. 1960; 42: 859-868.
11.Hislop H, Montgomery J. Daniels and Worthingham’s Muscle Testing. Techniques of Manual Examination. 8th ed. Philadelphia, PA: WB Saunders; 2007.
12.Montgomery J. Assessment and treatment of locomotor deficits in stroke. In P. Duncan & M. Radke (Eds.). Stroke rehabilitation. St Louis, MO: Mosby;1987.
13.Martins JC, Aguiar LT, Lara EM. Assessment of the strength of the lower limb muscles in subjects with stroke with portable dynamometry: a literature review. Fisioter Mov. 2016; 29:193-208.
14.Carr, J & Shepherd, R. Neurologic Rehabilitation: Optimizing Motor Performance, 2nd ed. Churchill Livingston, 2010 (reprint 2015).
15.Shumway-Cook A, Woollacott M. Motor Control. Translating Research Into Clinical Practice, 5th ed. Philadelphia, PA: Lippincott Williams & Wilkins;2017.
16.Esquenazi A. Evaluation and management of spastic gait in patients with traumatic brain injury. J Head Trauma Rehabil. 2004;19:109-118.
17.Thibaut A, Chatelle C, Ziegler E, et al. Spasticity after stroke: physiology, assessment and treatment. Brain Inj. 2013; 27:1093–1105.
Jennifaye V. Brown, PT, PhD, NCS - Ohio University
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References18. Patten C, Lexell J & Brown H. Weakness and strength training in persons with post-stroke hemiplegia;
rationale, method, and efficacy. J Rehab Research & Dev. 2004;41(3a):293-312.
19. Bohannon R, Smith M. Interrater reliability of a modified Ashworth scale of muscle spasticity. Phys Ther.
1987; 67: 206–7.
20. Cusick B. Serial Casting for the Restoration of Soft-Tissue Extensibility in the Ankle and Foot. Scientific
Rationale and Clinical Management. Telluride, CO: Progressive GaitWays, LLC; 2007.
21. Kaufman LB, & Schilling DL. (2007). Implementation of a strength training program for a 5-year-old
child with poor body awareness and developmental coordination disorder. Phys Ther, 87, 455-467.
22. Waxman SG. Clinical Neuroanatomy. (27th ed.). New York City, NY: McGraw-Hill Medical; 2013.
23. Smieja M, Hunt DL, Edelman D, et al. Clinical Examination for the Detection of Protective Sensation in
the Feet of Diabetic Patients. Journal of General Internal Medicine. 1999;14(7):418-424.
doi:10.1046/j.1525-1497.1999.05208.x.
24. Umphred, DA. Neurological Rehabilitation, 6th ed. Mosby, 2013.
25. Takeyasu N, Sakai T, Yabuki S, Machu M. Hemodynamic alterations in hemiplegic patients as a cause
of edema in the lower extremities. Int Angiol .1989;8(1):16-21
Jennifaye V. Brown, PT, PhD, NCS - Ohio University
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___________________________________
___________________________________
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Slide 76
76
References
26.Lundy-Ekman L. Neuroscience, Fundamentals for Rehabilitation. (4th ed). St. Louis, MO: Saunders
Elsevier, 2013.
27. The Pathokinesiology Service & The Physical Therapy Department. (2001). Observational Gait Analysis
Handbook. Downey, CA: Los Amigos Research and Education Institute, Inc.
28. Perry J, Burnfield JM. Gait Analysis. Normal & Pathological Function. (2nd ed.). Thorafare, NJ: Slack
Incorporated, 2010.
29. Wallmann HW. Physical matters. Introduction to observational gait analysis. Home Health Care
Management Practice OnlineFirst, published on August 17, 2009 as doi:10.1177/1084822309343277
30. Middleton A, Fritz SL, Lusardi M. Walking speed: the functional vital sign. J Aging Phys Act. 2015;
Apr23(2):314-22.
31. Scheets PL, Sahrmann SA, Norton BJ. Use of movement system diagnoses in the management of
patients with neuromuscular conditions: a multiple-patient case report. Phys Ther. Jun 2007;87(6):654-
669.
32. Rubin M, Safdieh J. Netter’s Concise Neuroanatomy. Philadelphia, PA: Saunders Elsevier, 2007.
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