Gait Analysis Data for Evidence Suggestive of Improved Function And/Or Alignment with The

Subjective versus Objective evaluations for lower limb orthotic prescription: beliefs vs. evidence and the laboratory versus patient environment

1. Discuss typical alignment and functional goals in orthotic prescription.

2. Review some available literature guiding orthotic prescription.

3. Explore gait analysis data for evidence suggestive of improved function and/or alignment with the

beliefs vs. evidence application of orthotics. and patient environment vs. the laboratory 4. Consider the short-term and long- term goals in orthotic prescription and how patient goals and compliance influence prescription choice.

. Why we like orthotics: . Improving gait, allow earlier acquisition of gait . Providing support and balance for weak muscles . Allowing greater efficiency for more proximal muscle groups . Help to maintain ROM and integrity of foot alignment/structures . How do you choose what orthosis . Why we don’t like orthotics: to recommend? . Worsen gait . What you want for the patient? . Patients may prefer to not have them . . They are expensive What the patient wants? . They are rapidly outgrown . What the parent wants? . They may slow kids down, reduce floor . What another care provider mobility, more likely to W-sit, challenge floor recommends? to stand and sit to stand skills, reduce stair mobility, limit balance reactions . Goals?? . Inhibit sensory input to the bottom of the foot, makes negotiating uneven surfaces hard . Solid AFO's inhibit force production and push off from the gastroc and contribute to weakness/limit strengthening of the df’s and pf’s . Fit is challenging

Some Guidance

What does the patient want? Family? . To walk . To walk more typically . To maintain ability to walk . Less falls . More mobility . To keep up with peers . To appear more typical . Pain free, more comfortable . Avoid surgery . Lessen surgery

Morris C et al. 2011

October 2013 AACPDM 67th Annual Meeting Milwaukee, WI 1 Subjective versus Objective evaluations for lower limb orthotic prescription: beliefs vs. evidence and the laboratory versus patient environment

. 24 academics, research scientists and healthcare professionals with expertise in CP . Reviewed the evidence and considered current thinking re: orthoses management in CP . Aim is to enable culturally appropriate activities and participation by: . Promoting efficient movement . Limiting deformity . Swing phase problem? . Reducing pain . Employing cognitive/behavioral strategies . Stance phase problem? . Healthcare team (orthotist, therapist, . Causing problems at the knee? Hip? physician, bioengineer, etc) must . Correction of these problems may collaborate with the family, taking into consideration medical issues and improve mobility. the family’s goals and priorities . Classification of functioning should follow the WHO ICF guidelines, and furthermore for CP the GMFCS and MACS: . ie: goals for GMFCS I – III = gait and deformity goals . ie: goals for GMFCS IV – V = improving sitting posture, upright standing

Morris C et al. 2011 Morris C et al. 2011

. AFO’s can improve ankle kinematics . In general AFO’s: . Restrict ankle joint motion . increase velocity of gait .  reduce power generation and absorption at the ankle, but… . …but in diplegics may have little or no .  effect increase 2nd peak of GRF in propulsive phase . reduce cadence . AFO’s can improve knee and hip . …but in diplegics may have little or no effect kinematics and kinetics . Increase step length . GRF is manipulated to affect the knee/hip . Increase stride length . Hinged vs. Flexible (with fine tuning of . Increase duration of single support stiffness) . “Tuning” of sagital plane ankle alignment . Tibia with fwd inclination may be beneficial even if ankle must be set in pf to do so

Morris C et al. 2011 Morris C et al. 2011

. O2 consumption may be decreased . Stretching to reduce need for by AFO use achilles lengthenings . Self selected walking speed . (Weakness of gastroc-soleus??) increases

Morris C et al. 2011 Morris C et al. 2011

October 2013 AACPDM 67th Annual Meeting Milwaukee, WI 2 Subjective versus Objective evaluations for lower limb orthotic prescription: beliefs vs. evidence and the laboratory versus patient environment

. Recommended Data to Gather: . Age . Sex . STS improves with AFO’s on if the . Type of CP wearer is more than one SD below . GMFCS level mean speed . Recent surgery . The use of df is the consistent way to . Medication interventions improve STS . ROM of all lower limb joints (easy or . …but use of articulated AFO when difficult to attain?) there is pf cntrx is controversial . Rotational deformity (facilitates midfoot breakdown) . Strength . Stair function is not impaired . Spasticity . Can improve standing balance . Description of gait with and without orthoses . Little effect if at all on sitting . AFO description and/or UE function . Design (custom/prefab) . Construction (materials, type, straps/fastenings) . Utility of posture and alignment in . Alignment of leg in orthoses (sagital, coronal and standing frames is limited transverse planes for ankle) . Alignment of orthoses to ground (sagital plane) . Effects on gait? . Footwear and its design (heel-sole differential, stiffness of sole) . Dosage (duration of use) . Side effects

Morris C et al. 2011 Morris C et al. 2011

. Morris C, Bowers R, Ross K, Stevens P, Phillips D. Orthotic management of cerebral palsy: Recommendations from a consensus conference, 2011. Neuro Rehab 28, 37-46. . Ries, Andy, Rozumalski, Adam, and Schwartz, Michael. “Do Ankle Foot Orthoses Improve Gait for Individuals with Cerebral Palsy?” Gillette Children’s Specialty Aaron Rasmussen, C. P. O. Healthcare, St. Paul, United States; Gillette Children’s Specialty Healthcare University of Minnesota- Twin St. Paul, MN Cities, Minneapolis, United States. . Owen E. The importance of being earnest about shank and thigh kinematics especially when using ankle-foot orthoses, 2010. Prosthetics and Orthotics International 34(3): 254-269.

. Role of Orthoses . All orthoses must do one of the . Alignment following:

. Indications . Control of motion

. Quantifying AFO . Correction of deformity stiffness . Compensation for weakness

Carlson, “Orthotic management of the Lower Limb of Children with Cerebral Palsy.”

October 2013 AACPDM 67th Annual Meeting Milwaukee, WI 3 Subjective versus Objective evaluations for lower limb orthotic prescription: beliefs vs. evidence and the laboratory versus patient environment

. A specific treatment goal . Helps to “personalize” the purpose for the . Alignment issues which can be orthosis improved with orthoses . Will increase the . Available ROM & muscle power likelihood of success

. Stability in stance . Clearance in swing . Prepositioning of the foot in terminal swing . Adequate step length . Energy conservation

. Patients activity level/types of activities

. Goals of patient/parent/ physician/PT/OT

. Be aware of how ankle angle, shoe heel height, toe plate flexibility, and other factors affect gait

. Foot orthoses are the . Unfortunately, we can not foundation for lower always achieve all orthotic limb management… goals with a single orthotic each and every more design proximal orthosis is first

and foremost an FO”

("Atlas of Orthoses and Assistive Devices" 209-224)

October 2013 AACPDM 67th Annual Meeting Milwaukee, WI 4 Subjective versus Objective evaluations for lower limb orthotic prescription: beliefs vs. evidence and the laboratory versus patient environment

. 3 point pressure system for . talipes varus 3 point pressure system for talipes valgus

.In children with neuromuscular disorders, pes valgus is the 2nd most common foot deformity .Equinus is the most common “position“ we deal with in this group

Carlson and Berglund, “An Effective Orthotic Design for Controlling the Unstable Subtalar Joint. Carlson and Berglund, “An Effective Orthotic Design for Controlling the Unstable Subtalar Joint.” ”

. A patient with forefoot varus may display hindfoot valgus (eversion) during weight bearing as a method of compensation for the forefoot deformity

October 2013 AACPDM 67th Annual Meeting Milwaukee, WI 5 Subjective versus Objective evaluations for lower limb orthotic prescription: beliefs vs. evidence and the laboratory versus patient environment

. Thermoplastics . Brief discussion of . Copolymer vs. materials used in polypropylene fabrication . Review of some common lower extremity orthoses and their indications

. Carbon fiber

.Effective in controlling flexible deformities of . Provides improved midfoot and the subtalar and forefoot control, primarily midtarsal joints: through plantar surface forces .calcaneal . Improved midfoot and forefoot eversion/inversion control can affect rearfoot .midfoot instability position .forefoot adduction/ abduction

. Provides improved .Provides clearance during heel, midfoot, and swing, pre-positions the foot forefoot alignment for initial contact . Provides improved .Controls lowering of the medial-lateral ankle foot toward the ground stability .Allows dorsiflexion . Standard trimlines necessary for tibial allow normal 1st, 2nd, advancement over the and 3rd rocker foot .Flexibility can be fine- tuned for a variety of treatment goals

October 2013 AACPDM 67th Annual Meeting Milwaukee, WI 6 Subjective versus Objective evaluations for lower limb orthotic prescription: beliefs vs. evidence and the laboratory versus patient environment

. Provides m-l stability . Dorsiflexion is obtained . Plantar flexion stop can affect genu through the midtarsal recurvatum in stance and foot joint, not the ankle joint clearance in swing . aka the “little ankle” . Typically allows free dorsiflexion . Adjustable ankle joints can be . Anatomical motion does not occur at used, but have limitations (bulk, mechanical ankle joint, durability) thus causing pressure and fit issues with the . Must have adequate ROM orthosis

. Properties and indications are similar . Provides maximum to solid AFO. Floor stability in frontal and reaction AFO has an sagittal planes anterior proximal tibial . Provides tri-planar shell which promotes immobilization of the knee extension in mid ankle-foot complex through terminal . Ankle angle affects stance knee and hip motion . Note foot progression angle

. BRUCE measures the . Current practice = Stiff to angle of the ankle when Flexible bending the AFO and the . Cannot reverse force it produces . Short Term: Is there an ideal . Finds a relationship between ankle stiffness for a pls AFO? angle/force B . Long Term: By using a specific . Gait lab can separate R patients' gait lab data can we the force provided by an predict (and provide) the AFO and the force U optimal stiffness of AFO? provided by the patient C E BRUCE

October 2013 AACPDM 67th Annual Meeting Milwaukee, WI 7 Subjective versus Objective evaluations for lower limb orthotic prescription: beliefs vs. evidence and the laboratory versus patient environment

Thank You! Atlas of Orthoses and Assistive Devices. 3rd. 1. St. Louis: Mosby, 1997. 209-224. Print. Carlson, J. Martin, and Gene Berglund. "An Effective Orthotic Design for Controlling the Unstable Subtalar Joint ." Orthotics and Prosthetics. 33.1 (1979): 39-49. Print. Carlson, J. Martin. "Orthotic Management of the Lower Limb of Children with Cerebral Palsy." (2001): Print. Clinical Aspects of Lower Extremity Orthotics. Second Edition. Winnipeg: Canadian Association for Prosthetics and Orthotics, 1993. Goldberg, Bertram, and John D. Hsu. Atlas of Orthoses and Assistive Devices. Third Edition. St. Louis: Mosby, 1997. Kroll, G. (2008) Meeting Treatment Objectives Through Proper Orthotic Design & Application [PowerPoint Slides]. Gillette Children’s Specialty Healthcare: Assistive Technology Department. Sohrweide, S. (2008) Clinical Evaluation of Foot Deformities. [PowerPoint Slides]. Gillette Children’s Specialty Healthcare: Center for Gait and Motion Analysis Ries, Andy, Rozumalski, Adam, and Schwartz, Michael. “Do Ankle Foot Orthoses Improve Gait for Individuals with Cerebral Palsy?”. Gillette Children’s Specialty Healthcare, St. Paul, United States; University of Minnesota- Twin Cities, Minneapolis, United States.

. Introduce/review gait analysis . Elements of a gait analysis . Terms kinematics and kinetics . Gait graphs . Understand role of gait analysis data in orthoses prescription Data guiding orthoses prescription . Knowledgeable participant in presented case studies that utilize gait analysis data to guide orthoses prescription

. Split screen video . Augments kinematics/kinetics . Physical exam . Provides useful information about many things that gait analysis does not directly measure (boney torsion, foot deformity, strength, motor control etc.) . It provides useful information . Kinematics about the intricacies of an . Quantitative 3-dimensional measurement individual’s gait, as well as how far of motion the individual’s walking pattern . Kinetics deviates from normal . Measurement of moment and power generation . Dynamic EMG . On-off signals of individual muscles . Metabolic energy assessment . Oxygen consumption . Pedobarography . Dynamic foot pressure

October 2013 AACPDM 67th Annual Meeting Milwaukee, WI 8 Subjective versus Objective evaluations for lower limb orthotic prescription: beliefs vs. evidence and the laboratory versus patient environment

. Split screen video . Split screen video . Augments kinematics/kinetics . Augments kinematics/kinetics . Physical exam . Physical exam . Provides useful information about many . Provides useful information about many things that gait analysis does not directly things that gait analysis does not directly measure (boney torsion, foot deformity, measure (boney torsion, foot deformity, strength, motor control etc.) strength, motor control etc.) . Kinematics . Kinematics . Quantitative 3-dimensional measurement . Quantitative 3-dimensional measurement of motion of motion . Kinetics . Kinetics . Measurement of moment and power . Measurement of moment and power generation generation . Dynamic EMG . Dynamic EMG . On-off signals of individual muscles . On-off signals of individual muscles . Metabolic energy assessment . Metabolic energy assessment . Oxygen consumption . Oxygen consumption . Pedobarography . Pedobarography . Dynamic foot pressure . Dynamic foot pressure

October 2013 AACPDM 67th Annual Meeting Milwaukee, WI 9 Subjective versus Objective evaluations for lower limb orthotic prescription: beliefs vs. evidence and the laboratory versus patient environment

. Split screen video . Augments kinematics/kinetics . Physical exam . Provides useful information about many things that gait analysis does not directly measure (boney torsion, foot deformity, strength, motor control etc.) . Kinematics . Quantitative 3-dimensional measurement of motion . Kinetics . Measurement of moment and power generation . Dynamic EMG . On-off signals of individual muscles . Metabolic energy assessment . Oxygen consumption . Pedobarography . Dynamic foot pressure

. What is needed to optimize effectiveness of an orthoses? 140+ measurements . Proper skeletal alignment . Absence of contractures . Adequate strength

. Adequate motor control Physical Exam Physical

October 2013 AACPDM 67th Annual Meeting Milwaukee, WI 10 Subjective versus Objective evaluations for lower limb orthotic prescription: beliefs vs. evidence and the laboratory versus patient environment

. The motions of the segments in space and relative to one another . Utility . objective specific joint angular changes . accurate pre and post-treatment measurement . accurate comparison of barefoot vs. braced walking . Limitations . only descriptive, can't distinguish cause of motion disorders . error

October 2013 AACPDM 67th Annual Meeting Milwaukee, WI 11 Subjective versus Objective evaluations for lower limb orthotic prescription: beliefs vs. evidence and the laboratory versus patient environment

FRONTAL SAGITTAL TRANSVERSE

PELVIS

HIP

KNEE

ANKLE/ FOOT

. Gait analysis permits evaluation of the specific effect of orthoses (White et al 2002, Bartonek et al 2007) . Gray = typical range of . Motion analysis is routinely performed in motion and out of orthoses . Allows us to: . Red = left leg . Analyze orthotics role in improving/hindering walking . Green = right leg . Design more functional orthoses that are best suited to their specific task (Harrington et al 1984, Van Gestel et al 2008) IC STANCE FO SWING X = GAIT CYCLE

October 2013 AACPDM 67th Annual Meeting Milwaukee, WI 12 Subjective versus Objective evaluations for lower limb orthotic prescription: beliefs vs. evidence and the laboratory versus patient environment

Barefoot braced

. Retrospective study of 686 Gillette . Right patients (1372 limbs) . diplegic CP . walking trials collected both barefoot and wearing orthoses (SAFO, PLS, HAFO) . Gait data analyzed for each trial . GDI (Gait Deviation Index) change from barefoot to orthotic was calculated for each limb . GDI score is a single number that represents overall gait pathology . GDI ≥100 indicates normal gait kinematics and each decrement of 10 points is one . Left standard deviation from normal. . GDI change of 5 = 1 level on the FAQ functional walking scale (Schwartz)

. Gait changes associated with AFO GDI Scores use among individuals with diplegic 50 CP showed 45 . Subjects with poorer kinematics (lower GDI) 40 derived greater benefit from AFOs than those with milder gait deviations 35 . Small benefit among subjects using assistive 30 devices 25 . Nearly negligible improvement in 20 independent ambulators Frequency 15 . AFO design was not a statistically 10 significant factor in predicting 5 changes in GDI among either 0 dependent or independent ambulators Change in GDI [Orth - BF] . Distribution of GDI changes suggests • Average BF GDI 73.8 (SD 10.2) that while overall response to AFO • 60% have positive GDI Change wear is underwhelming, there are a • 25% have +5 or better GDI change  significant number of good • 13% have -5 or worse GDI change  responders (i.e. GDI changes of > 5) • 62% have minimal change (between -5 and +5)

Change in Normalized Walking Speed [Orth – BF] . Focus on identifying patient characteristics that lead to 60 meaningful positive gait changes with use of AFO’s 50 . Random Forest Algorithm . predictive model that is essentially a collection of small decision trees; It takes a 40 bunch of data, sifts through it to find the helpful/important information, and then 30 makes a prediction based on that information.

Frequency . RF data available for the case studies we 20 will be looking at . Barefoot data will be collected and run through the RF to make prediction on 10 orthoses type which would be best for that child 0 . Predicted orthoses will be made and child will use it for 6 weeks, then return to motion lab . Data will be collected in predicted brace, Change in Normalized Walking Speed [Orth - BF] GDI will be calculated and then compared to the actual predicted GDI using the RF. • Control ND BF Speed 0.363-0.500 [Schwartz et al. ‘08] • Average ND BF walking speed 0.315 (SD 0.112) . Analyze the existing prescription • 88% of slow walkers (ND Speed<0.363) have speed increase algorithm in an effort to improve AFO efficacy • Relative increase of 34%  . BRUCE • 12% of slow walkers have speed decrease • Relative decreased of 10% 

October 2013 AACPDM 67th Annual Meeting Milwaukee, WI 13 Subjective versus Objective evaluations for lower limb orthotic prescription: beliefs vs. evidence and the laboratory versus patient environment

Case #1 . 8+4 y/o male . CP spastic quadriplegia . GMFCS III . Surgical history . SDR 2009 . Show barefoot video . SEMLS 2011 . Audience response re: orthoses design . Bilateral femoral external derotation . Add physical exam measurements osteotomy. . Right tibial internal derotation osteotomy. . Audience response re: orthoses design . Bilateral calcaneal lengthening. . Add barefoot gait data . Bilateral first metatarsal plantar flexion . Audience response re: orthoses design osteotomy. . Bilateral Baker-type gastrocnemius/soleus . Look at gait data in prescribed lengthening. orthoses . Referred for 1 year post ortho . Discussion surgery gait lab . Family is concerned about patient’s endurance, strength and gait pattern. . Parental goal is for patient to be able to walk independently with his walker or crutches.

I would prescribe the following orthoses 1. None 2. UCBL 3. SMO 4. PLS 5. HAFO 6. SAFO 7. GRAFO

October 2013 AACPDM 67th Annual Meeting Milwaukee, WI 14 Subjective versus Objective evaluations for lower limb orthotic prescription: beliefs vs. evidence and the laboratory versus patient environment

Left Right Hip extension WNL WNL Anteversion 25° 10° Tibial torsion (BM) 30° 15° Knee extension WNL with stretch WNL with stretch Popliteal angle 30° (from vertical) 40° (from vertical) Patella alta yes yes Extensor lag 40° 30° I would prescribe the following orthoses Ankle dorsiflexion 25°/10° 30°/15° 1. None ROM (90/0) 2. UCBL WB foot (RF/MF/FF) val/pla/abd/mild val/pla/abd/mod 3. SMO 4. PLS Hip ext. strength 2+/5 2+/5 5. HAFO Quad strength 5/5 (in available range) 5/5 (in available range) 6. SAFO 7. GRAFO AJ DF strength 2+/5 3-/5 AJ PF strength 2/5 2/5 0% 0% 0% 0% 0% 0% 0% 0% Spasticity absent absent 1 2 3 4 5 6 7 8

L R

Sagittal Transverse *

* I would prescribe the following orthoses 1. None 2. UCBL * 3. SMO 4. PLS 5. HAFO 6. SAFO * 7. GRAFO

0% 0% 0% 0% 0% 0% 0% 0%

* 1 2 3 4 5 6 7 8

Left BF vs. SAFO Right BF vs. SAFO

GDI

* Walking trial Left Right Average * conditions

Barefoot, walker 67 66 67 * * B – SAFO, walker 71 75 73 (one of 25% that had +5)

* * Gait deviation index (GDI) is a scaled measure of gait pathology. A GDI value equal to or greater than 100 equates to a normal gait. * *

October 2013 AACPDM 67th Annual Meeting Milwaukee, WI 15 Subjective versus Objective evaluations for lower limb orthotic prescription: beliefs vs. evidence and the laboratory versus patient environment

Linear Parameters

Predicted Change in GDI using RF (+ number = improvement)

SAFO PLS HAFO SMO UCBL

Left 3.9 (+4) 2.0 .5 -1.0 1.5

Right 3.1 (+9) 1.6 -2.0 -3.1 2.8

Case #2

Barefoot video SAFO video

. 6+8 y/o female . Lumbosacral level mylomeningocele . Referred for initial gait lab . Surgical history . Closure of spinal defect . Shunting . Family concerned about the possible future deterioration of patient’s gait and how this may get to the point that patient will be unable to walk. . Family goals are for patient to maintain/improve mobility

I would prescribe the following orthoses 1. None 2. UCBL 3. SMO 4. PLS 5. HAFO 6. SAFO 7. GRAFO

0% 0% 0% 0% 0% 0% 0% 0%

1 2 3 4 5 6 7 8

October 2013 AACPDM 67th Annual Meeting Milwaukee, WI 16 Subjective versus Objective evaluations for lower limb orthotic prescription: beliefs vs. evidence and the laboratory versus patient environment

Left Right Hip extension 10° (contracture) 10° (contracture) Anteversion 50° 35° Tibial torsion (BM) 0° 15° Knee extension WNL WNL with stretch Popliteal angle 25° 25° Patella alta no no Extensor lag no no I would prescribe the following orthoses Ankle dorsiflexion 25°/25° 25°/20° 1. None ROM (90/0) 2. UCBL WB foot (RF/MF/FF) typ/typ/typ typ/typ/typ 3. SMO Hip ext. strength 2+/5 2+/5 4. PLS 5. HAFO Quad strength 5/5 5/5 6. SAFO AJ DF strength 5/5 5/5 7. GRAFO AJ PF strength 2-/5 2/5 0% 0% 0% 0% 0% 0% 0% 0% Spasticity absent absent 1 2 3 4 5 6 7 8

Sagittal L R

Transverse *

* I would prescribe the following orthoses 1. None 2. UCBL 3. SMO * 4. PLS 5. HAFO 6. SAFO * * 7. GRAFO

0% 0% 0% 0% 0% 0% 0% 0%

1 2 3 4 5 6 7 8

Left BF vs. GRAFO Right BF vs. GRAFO GDI

Walking trial Left Right Average conditions

Barefoot 82 75 79

B – GRAFO 89 83 86 (+7)

Gait deviation index (GDI) is a scaled measure of gait pathology. A GDI value equal to or greater than 100 equates to a normal gait.

October 2013 AACPDM 67th Annual Meeting Milwaukee, WI 17 Subjective versus Objective evaluations for lower limb orthotic prescription: beliefs vs. evidence and the laboratory versus patient environment

Left A : B Right A : B Hip extension 10° : WNL 10° : WNL Anteversion 50° : 20° 35° : 25° Tibial torsion (BM) 0° : 20° 15° : 10° Barefoot video GRAFO video Knee extension WNL : WNL WNL with stretch: WNL Popliteal angle 25° : 50° 25° : 55° Patella alta no : no no : no Extensor lag no : no no : no Ankle dorsiflexion 25°/25° : 0°/0° 25°/20° : 10°/0° ROM (90/0) WB foot (RF/MF/FF) typ³ : val/pla/abd typ³ : val/pla/abd Hip ext. strength 2+/5 : 3/5 2+/5 : 3-/5 Quad strength 5/5 : 5/5 5/5 : 5/5 AJ DF strength 5/5 : 3-/5 5/5 : 1/5 AJ PF strength 2-/5 : 2+/5 2/5 : 2+/5 Spasticity absent : absent absent : absent

Barefoot L/R kinematics (sagittal) BF vs. GRAFO kinematics (sagittal)

Barefoot video GRAFO video

BF vs. GRAFO Kinematics BF vs. GRAFO Kinetics (transverse)

GDI

Walking trial Left Right Average conditions

Barefoot 91 76 83

B – GRAFO 76 69 73 (-10)

Gait deviation index (GDI) is a scaled measure of gait pathology. A GDI value equal to or greater than 100 equates to a normal gait.

October 2013 AACPDM 67th Annual Meeting Milwaukee, WI 18 Subjective versus Objective evaluations for lower limb orthotic prescription: beliefs vs. evidence and the laboratory versus patient environment

Linear Data

Predicted Change in GDI using RF (+ number = improvement)

SAFO PLS HAFO SMO UCBL

Left 1.6 (-15) 8.4 5.3 -2.6 0.9

Right 2.9 (-7) 8.6 5.5 -3.6 -2.1

. 10+8 y/o male . CP spastic diplegia . GMFCS II . Referred for orthotic recommendations and repeat gait lab study . Surgical history . SDR 2004 . SEMLS 2003 . Bilateral femoral derotational osteotomies. . Right gastrocnemius lengthening. . Botulinum toxin type A injections to the bilateral gastrocsoleus, medial hamstring and hip adductor musculature. . Family is primarily concerned with crouching and improper heel-toe step . Family expectations and goals . “No crouching; maintain good gait habits.” . Feel better about himself and be able to do more at home and school. . Participate more in recreational activities and sports. . Free from disability or pain as an adult.

Left Right Hip extension WNL WNL with stretch Anteversion 25° 25° Tibial torsion (BM) 15° 25° Knee extension -5° (hyperextension) -5° (hyperextension) Popliteal angle 45° 55°

I would prescribe the following Patella alta no no orthoses Extensor lag no no 1. None Ankle dorsiflexion 10°/0° 10°/5° 2. UCBL ROM (90/0) 3. SMO 4. PLS WB foot (RF/MF/FF) typ/typ/typ typ/pla/abd/mod 5. HAFO Hip ext. strength 5/5 4+/5 6. SAFO 7. GRAFO Quad strength 5/5 5/5 AJ DF strength 4+/5 4/5 AJ PF strength 4+/5 4/5 0% 0% 0% 0% 0% 0% 0% 0% Spasticity absent absent 1 2 3 4 5 6 7 8

October 2013 AACPDM 67th Annual Meeting Milwaukee, WI 19 Subjective versus Objective evaluations for lower limb orthotic prescription: beliefs vs. evidence and the laboratory versus patient environment

L R Sagittal

Transverse

I would prescribe the following orthoses 1. None 2. UCBL 3. SMO 4. PLS 5. HAFO 6. SAFO 7. GRAFO

0% 0% 0% 0% 0% 0% 0% 0%

1 2 3 4 5 6 7 8

Left BF vs. SAFO vs. SMO Right BF vs. SAFO vs. SMO

I would prescribe the following orthoses 1. None 2. UCBL 3. SMO 4. PLS 5. HAFO 6. SAFO 7. GRAFO

0% 0% 0% 0% 0% 0% 0% 0%

1 2 3 4 5 6 7 8

GDI Predicted Change in GDI using RF (+ number = improvement) Walking trial Left Right Average conditions SAFO PLS HAFO SMO UCBL

Barefoot 85 86 85 Left 2.8 (+1) 6.4 5.5 -2.3 (+6) 0.5

Right 5.9 (+6) 6.4 8.2 2.2 (+7) 1.5 B – SAFO 84 93 88 (+3)

B - SMO 91 93 92 (+7)

Gait deviation index (GDI) is a scaled measure of gait pathology. A GDI value equal to or greater than 100 equates to a normal gait.

October 2013 AACPDM 67th Annual Meeting Milwaukee, WI 20 Subjective versus Objective evaluations for lower limb orthotic prescription: beliefs vs. evidence and the laboratory versus patient environment

Linear data Barefoot

SAFO

SMO

October 2013 AACPDM 67th Annual Meeting Milwaukee, WI 21