a comparison of gait with solid, dynamic

8/2/2019 A Comparison of Gait With Solid, Dynamic

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A Comparison of Gait With

Solid, Dynamic, and NoAnkle-Foot Orthoses inChildren With Spastic

Cerebral PalsySandra A Radtka, Stephen R Skinner,

Danielle M Dixon, M Elise Johanson

SIVAPORN LIMPANINLACHAT 5436899 PTPT/D


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Decreased

stride length

Pathologicalgait

patterns

INTRODUCTIONChildren

spastic CP

Decreased

walking speed

Excessive knee

flexion/hyper-

extension

Hip flexion,

adduction, and

medial rotation

Anterior pelvic

tilt

Abnormaljoint

motions

Muscle

timing

Temporal-distance

characteristic

Dynamic equinusExcessive ankle

plantar flexion

Abnormal timing of triceps surae group in

equinus gait pattern Tibialis anterior muscle>>shortened

activity during swing & prolonged activity

into mid-stance

Hamstring & quadriceps femoris muscle

group >> present prolonged activity duringstance


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Equinus gait patternINTRODUCTION

LE orthosesSolid AFO

(polypropylene)

control ankle by using 3-force system

reduce excessive ankle plantar flexionduring stance

cover posterior calf & mediolateral borders& sole of foot

straps across the anterior upper tibia &front of the ankle


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The rationale for design, purpose, and use ofinhibitive AFO is purposed based on inhibitive &tone-reducing cast. (past 10 year)

INTRODUCTION

Improved

stride length Change in stretchsensitivities of ankleplantar flexors

Increased

ambulation

abilityImprovedpassive ankle

dorsiflexion

No changes bony

alignment offoot & ankle

Casting

(studies)

Improved foot-

floor contact

during gait


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Several authors recommend using inhibitive AFO>> more flexible

>> lightweight

>> easily worn with regular shoe than the cast

No research compare inhibitive cast & AFO ongait in children with spastic CP

inhibitive AFOs compare with no AFO

>> increased standing duration

>> improve knee motion

INTRODUCTION


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Dynamic AFO witha plantar-flexion stop

INTRODUCTION

Footplate

Abnormal m. activity

Biomachanical change

- excessive ankleplantar flexion

- motion of LE,pelvis & trunkduring standing &gait


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Dynamic AFO with aplantar-flexion stop 2.4 mm thick polypropylene

enclosing the forefoot and ankle

with anterior trim lines at thecenter of dorsum of foot &cover 1/3 of the posterior calf

Toe loop stabilize the first digit

Anterior forefoot strap

Ankle strap

INTRODUCTION

Thinner, more flexible, &shorter than solid AFO


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Pathological

gait Patterns

of children with

spastic CP

Frameworkjoint

motions

Muscle

timing

Temporal-

distancecharacteristicLE

orthoses

castSolid AFO

DAFO

DAFOwith

plantar-flexion stop

DAFOwith freeplantar-

flexion SMOHinged

AFO


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To compare the effects of DAFOs witha plantar-flexion stop, polypropylene solidAFOs, and no AFOs on the gait of children

with spastic CP

Examined the effects of DAFO on

improving joint motion and on producingmore normal muscle timing during gait inchildren with spastic CP.

AIM of This Study


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Research Question

Are there effects of DAFOs

with a plantar-flexion stop,polypropylene solid AFOs, and no AFOson the gait of children with spastic CP?


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There would be differences in the timing of lower-extremity muscle activity;

joint motions in the lower extremity, pelvis,and trunk;

temporal-distance characteristics

during ambulation with DAFOs, solidAFOs, and no AFOs.

Hypotheses


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Method-Subject10 Children with spastic CP

- 4 spastic hemiplegia

- 6 spastic diplegia

-Plantigrade foot in weightbearing during standing

-Excessive ankle plantar flexionduring stance phase of gait-Passive ankle dorsiflexion to 5oor more with knees extended

-Passive hip extension of -10o orless (Thomas Test)

- passive hamstring musclelength of 60o or more (SLR Test)

- mild to moderate spasticity ofLE(score1or 2 - Ashworth scale)

- no use of assistive devices- no orthopedic surgery duringthe past year & for duration of

the study

- 5 wore solid AFO > 1 yr- 5 wore hinged AFO > 1 yr- 8 receive PT for gaittraining from once amonths to twice a week not control type of PT

- 2 not receive PT

- 4 girls- 6 boys


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Method-procedure10 Children with spastic CP

No orthosis - initial 2-week periodSolid AFOs - 1 month

DAFO with plantar flexion stop - 1 month

No orthosis - 2-week period


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Gait measure -at the end of each of four intervention

Method-procedure (1) surface electromyography (EMG) of the

gluteus maximus

hamstring

quadriceps femoris triceps surae

tibialis anterior muscle groups

to determine timing of these lower-extremity

muscle groups during the stance phase

Electrodes were applied longitudinal to the direction of the fibersof five muscle groups of the lower extremity with the greatest degree ofexcessive ankle plantar flexion during stance without orthoses, asdetermined by visual observation.


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measure active periods for each muscle group fortwo trials (total of 10 gait cycles)

normalized to the gait cycle as an averagepercentage of the stance phase.

EMG muscle timing, defined as the duration ofmuscle firing, of the five muscle groups wasdetermined for each testing session.


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(2) contact-closing footswitches was used toobtain temporal-distance gait characteristics,including walking speed (distance over time [m/min.])

cadence(steps per min.)

stride length (distance [cm.] between two consecutiveinitial contacts on one foot)

determined from footswitch signals by a computersoftware program

placed along the entire plantar surfaces of bothfeet and taped to the feet for tests without AFOsand to the shoes for tests with the orthoses.

Method-procedure


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Electromyographic & footswitch data >> record simultaneouslywith CODAS data-collection softwares.

Each subject ambulated on a 10-m walkway at a self- selected

speed for at least two trials, with a rest period allowed between trials to

prevent fatigue.

Collect data 1 trial when subject sitting or lying without moving &

all muscle rest


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(3) 3-D motion analysis system (Motion AnalysisTMII

)to determine joint motions of the trunk, pelvis, hip,knee, and ankle at initial contact and mid-stance.

used to collect joint angle displacement

Consisted of 6 cameras, a video monitor, a video processor

(VP-320),and a computer. Gait data were collected for 4 to 6 seconds over a 1.5-m

length of the walkway

Method-procedure


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Twenty-one retroreflective markers

anatomical landmarks on the upper extremities, lowerextremities, and pelvis, bilaterally, for the tests withoutAFOs.

tape ankle, heel, and toe markers on the orthosis andshoe over anatomical landmarks for tests with orthoses.

recorded images from the markers in the sagittal,coronal, and transverse planes at a sampling rateof 60 frames per second


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Joint motions were averaged for each testingsession

Use the greatest amount of excessive ankleplantar flexion in stance during ambulationwithout orthoses.

Use the same limb as measure surface EMG in all4 tests

h d li bili


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Method- Reliability

high ICC (EMG)

high ICC (footswitches)

high ICC (3-D motion analysis)except hip rotation at initial

contact &mid-stance and hipadduction/abduction, and trunk

rotation at mid-stance


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Data Analysis Descriptive Statistic

Temporal-distance gait characteristics

LE, pelvis, and trunk joint angles at initialcontact & mid-stance

Muscle timing for 5 LE muscle groups duringstance phase for 4 interventions


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Two-way analysis of Variance (ANOVA)-repeated measure (adjusted alpha level) Test effects of diagnosis, intervention, andinteraction of diagnosis and intervention on

temporal-distance gait characteristics, jointmotions, and muscle timing.

All sig. ANOVA tests Sixpost hocpairwise- compare bet.interventions with Tukeys Honestly SignificantDifference (HSD) p=.05

Data Analysis


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Clinical recommendations >> the mostappropriate orthoses for each subject based onclinical assessment of temporal-distance gaitcharacteristics and joint motions

Two-way analysis of Variance (ANOVA)-repeated measure (adjusted alpha level) To examine the differences among subjects with the

clinical recommendation of solid AFO, DAFO, oreither orthosis on temporal-distance gaitcharacteristics (P < .02) and joint motions at initialcontact and mid-stance (P


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Power & effect size>>examine the probability ofmaking a Type II error

For all nonsignificant dependent variableseffect size


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No differences at the P


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The meanstride lengthwas increasedand the meancadence was

decreased withboth solid AFOsand DAFOswhen comparedwith noorthoses. (Table2 & 4)

Results Temporal-Distance GaitCharacteristics


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Discussion- Temporal-Distance GaitCharacteristics

Improved stride length with the DAFO comparedwith no orthoses consistent with the results of

the inhibitive cast studies.

Some studies Walking speed can be increased

by a longer stride length or a faster cadence.

This study; increased stride length for both

orthoses

no difference in walking speed whencompare DAFO, solid AFO and no orthoses increased stride length was not enough toproduce a corresponding increase in walkingspeed.


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No differences between the diagnoses of spasticdiplegia and hemiplegia for joint motions of thelower extremity, pelvis, and trunk at initialcontact and mid-stance (Table7&8) (P


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Results Joint Motions

Only the effects of the interventions for ankle motions atinitial contact and mid-stance were significant.(P


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Results Joint Motions The amount of

ankle plantarflexion at initial

contact and mid-stance in theinterventions withno orthoses wasreduced with bothsolid AFOs and

DAFOs (Table 5 &6).


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Discussion- Joint Motions

Hylton proposed that DAFO's contoured footplate and totalsurface contact produces correct biomechanical alignmentof the foot and ankle that improves distal stability andreduces compensatory, abnormal motions at the ankle andmore proximal joints.

This study, No differences bet. two orthoses

No changes in proximal joint motions of the trunk,pelvis, hip, and knee for both orthoses at initial contact &

mid-stance

Not support the purposed effects of DAFO withplantar-flexion stop on the proximal joint motion

during ambulation.


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Discussion- Joint Motions This study,

No changes in knee motions at initial contact & mid-stance with DAFO

Not consistent with the results of a single-subject

design study by Embrey et al. (found improved kneemotions in a child with CP who received physical therapy inconjunction with the use of a DAFO with free plantarflexion, which was a supramalleolar orthotic (SMO) designallowing plantarflexion.)

This study used 3-D motion analysis to measure motionmore accurately than 2-D videographs use by Embrey etal.


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Muscle timing>> Duration of muscle firingstarting from initial contact at 0%, expressed asa percentage of the stance phase.

Children without pathology (Sutherland D et al., 1988) 0% to 43% for the tibialis anterior muscle

0% to 33% for- the quadriceps femoris muscle

0% to 51% for the lateral hamstring muscle

0% to 48% for the gluteus maximlls muscle

9% to 79% for the triceps surae muscle

Results Muscle Timing


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This study, all muscles active in initial contact

>>normal, except triceps surae muscles (fired

prematurely) (Table10)

No differences between the diagnoses of spastic

diplegia and hemiplegia for timing of all muscle

groups during stance phase. (P


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Abnormal premature and prolonged activity ofthe triceps surae muscle group in a dynamic

equinus gait pattern was not changed by eitherthe solid AFO or the DAFO

But the excessive ankle plantar-flexion motion

during initial contact and mid-stance wasreduced with both orthoses.

Discussion Muscle Timing


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Test subject with barefoot for 2 interventions without

orthoses but wore shoe when test with solid AFO &

DAFO

Measurement error in placing reflective markers

inconsistent on the subject reliability of joint angle

measurement

Small sample size

Discussions Factors affected theoutcomes


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Mild to moderate amount of excessive ankle plantar

flexion during stance

Not use crossover design because of scheduling

constraints (however, no carryover effects from the

first orthoses - no change bet. 2 interventions without

orthoses)

Variability in the physical therapy for gait training

with orthoses

Discussions Factors affected theoutcomes


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5 subjects

recommend

DAFO

( knee, hip, and pelvicmotions)

Results Clinical Recommendations2 subjects

walking speed & stridelength with DAFO

3 subjects

same walking speed &stride length with both

orthoses3 subjects

recommendsolid AFO

( knee and hip jointmotions)

2 subjects

walking speed & stridelength with solid AFO

1 subjects

same walking speed &stride length with both

orthoses


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No differences among the subjects with theclinical recommendation of solidAFO, DAFO, oreither orthosis for temporal-distance gaitcharacteristics (P


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Parents, subjects, and their physical therapists

Advantage>>DAFO was lighter andmore cosmetically

appealing

Disadvantage>>slightly more difficult for the children to

initially learn to independently take in and take off as

compared with the solidAFO.

Discussion


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When selecting the DAFO or solid AFO forchildren with spastic CP and equinus gait patternneed to be consider

Orthotic cosmesis Durability

Cost

Ease of take in and take off the orthosis

Effects on functional mobility such as sit-to-stand

maneuvers or ambulation on uneven surfaces

Individual differences in children (spastic diplegia/hemiplegia heterogenous group show variaton in gait)

Discussion


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Larger sample size

Moderate to severe amounts of dynamic equinusduring ambulation

Receive similar physical therapy for gait training

with orthoses Crossover design for assigning the orthosis worn

initially

Compare joint kinetics include hip, knee, and

ankle joint moments and powers duringambulation with solid AFOs & DAFOs

Further studies


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Compare effects of these 2 devices on gait inchildren with spastic CP

Examine the effects of solid AFOs, DAFOs with aplantarflexion stop, and other orthoses such as

SMOs or hinged AFOs on other functionalactivities sitting to a standing

Supine on floor to a standing

Energy expenditure during ambulation.

Further studies


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THANK YOU


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Solid AFOs

- 4.8 mm thick

- extend distally under toes& on

mediolateral border of foot & proximallyon posterior part of leg to 2.5-5 cm belowknee

- trim lines anterior to both malleoli &straps across the front of ankle & anteriorupper tibia


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DAFO with plantar flexion stop

2.4 mm thick

Enclosing the dorsum of the forefoot and

ankle Cover the posterior part of the leg to

about 5 to 7.5 cm above the malleoli withstraps across the ankle, forefoot, and firstdigit


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INTRODUCTION

Casts Decrease spasticity >> prolonged stretch & pressure on the

tendon of triceps surae muscle & toe flexors.

To inhibit/ decrease abnormal reflexes in LE >> protectingthe foot from tactile-induced reflexes.

Prevent excessive ankle plantar flexion, improve LE m.timing, and normalize movements of the trunk, pelvis, andLE in standing & during gait.

a comparison of gait with solid, dynamic

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