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VOLUME 8 NUMBER 5 LERMAGAZINE.COM
May2016 features 24 ORTHOTIC DEVICES FOR THE WIN Managing metatarsalgia in athletic populations Evidence from the literature supports the use of rocker shoes, carefully COVER STORY positioned metatarsal pads, and orthotic interventions to reduce excessive 18 plantar pressure in the forefoot region. Smoking and knee OA: By Howard Kashefsky, DPM, FACFAS FROM CLINICAL CONTROVERSY TO THERAPEUTIC POSSIBILITY 29 Skin care issues related Perplexing studies suggesting that smoking may be protective against knee osteoarthritis (OA) to orthotic device wear should not deter efforts to discourage smoking. But if researchers can pinpoint specific ingredients associated with the protective effect, that could have significant implications for the development The care and prevention of skin issues may not get as much attention in of new OA therapies. orthotics as in prosthetics, but such issues can significantly affect patient By Barbara Boughton outcomes. Here, lower extremity experts share the tips and tricks they use to manage dermatological challenges related to orthotic devices. IN THE MOMENT By Lori Roniger sports medicine/13 CAI and the CNS: Excitability may influence instability 37 Using subsensory noise Strength training in runners has bonus benefits for physiological performance to improve balance, gait fMRI study supports use of multiple exercises to prevent hamstring injury Using specially designed insoles to deliver stochastic resonance to the rehabilitation/15 plantar surface of the feet has the potential to significantly improve static Gender, gait, and knee OA: Kinematic data have rehab implications balance, dynamic balance, and gait mechanics in healthy, young individu- Leg strength, velocity predict functional issues in older adults with poor mobility als as well as elderly people and others with somatosensory deficits. Metabolic activity suggests Achilles tendons are still healing at 6 months By Daniel Miranda, PhD; Wen-Hao Hsu, ScD; and James Niemi, MS 47 Hip strength asymmetry plus... and patellofemoral pain Hip strength asymmetry has been observed in patients with existing OUT ON A LIMB / 11 NEW PRODUCTS / 58 patellofemoral pain syndrome (PFPS) and potentially could be used to Stumping for SR in sports The latest in lower extremity devices and technologies screen for at-risk individuals. However, new findings suggest this type Stochastic resonance technology might be the best rehab intervention nobody in /61 of asymmetry does not appear to be associated with early stage PFPS. MARKET MECHANICS sports is talking about. At least not yet. News from lower extremity companies and organizations By Franklin Caldera, DO, MBA; and Christopher Plastaras, MD By Jordana Bieze Foster By Emily Delzell
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Platelet-rich plasma But it gets better. The Wyss team has also found that the use injections. Kinesiology of SR in young, healthy, recreational athletes is associated with tape. Foam rolling. improved performance on an agility task. The .12-second Compression garments. improvement in time may not seem like much, but the authors Blood-flow restriction pointed out that, when the same agility drill was performed at the training. Elite athletes have 2015 National Football League Combine, .13 seconds separated always been at the leading the fastest time from the eighth-fastest time. edge of the latest tech- Now, I suspect that most sports leagues would consider the use niques believed to help of vibrating insoles during competition an unfair advantage— speed recovery from injury, something I wouldn’t want to be accused of advocating. But the often long before they’ve findings also appear to support the idea of using SR to improve been subjected to rigorous rehabilitation of athletes after an injury. scientific study. So why isn’t the sports world For example, although strength deficits and asymmetries are often buzzing about stochastic resonance (SR)? associated with poor outcomes after injury, multiple studies have also shown that simply strengthening a weak muscle doesn’t SR is a process in which introducing low levels of “noise” to translate to improved biomechanics—the body has to learn how a system heightens sensory signal recognition; for example, to use that stronger muscle. Doesn’t it seem like using SR to introducing subsensory electrical stimulation to the plantar enhance sensorimotor function might be a logical way to try to surface of the feet via a vibrating insole heightens a person’s bridge that gap? sensorimotor perception in ways that have been associated with improvements in balance and gait. Some of the most interesting recent work in this area has been done at the Wyss Institute for Stochastic resonance technology might Biologically Inspired Engineering at Harvard Medical School in be the best rehab intervention nobody in Boston, by authors who have summarized a portion of their work sports is talking about. At least not yet. in this issue (see “Using subsensory noise to improve balance, gait,” page 37.)
As you might imagine, the most obvious applications for this type Granted, SR has not yet been formally studied in elite athletes. of technology involve people with sensory impairment related to But a lack of published evidence has hardly ever stopped elite aging or conditions such as stroke or diabetic neuropathy; in athletes—and the practitioners they work with—from trying those populations it could help reduce the risk of falls and fall- absolutely anything to speed recovery after an injury. And what’s related injury. But the Wyss researchers have found that SR also known about SR so far suggests it has the potential to do just that. has positive effects in young, healthy individuals, helping to It might be the best rehab intervention nobody in sports is enhance balance control in response to fatiguing exercise. Since talking about. At least not yet. fatigue is associated with increased injury risk in otherwise healthy people, the findings suggest SR could potentially reduce that risk. Jordana Bieze Foster, Editor
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TM in the moment: sports medicine
CAI and the CNS Excitability may influence instability
By Larry Hand
For individuals with chronic ankle instabil- ity (CAI), the somatosensory feedback nec- essary for postural adjustments, walking, and running may be hampered by a de- crease in soleus spinal reflex excitability, according to a new study in the Journal of Athletic Training.
The findings of the multicenter study add to the body of evidence suggesting that central nervous system (CNS) issues, as well as me- Istockphoto.com #80926209 chanical joint laxity, contribute to CAI. “A successful reorganization of the sensorimotor system after in Kyoto, Japan, told LER by email. an initial ankle sprain is the critical point when individuals suffer According to this supraspinal modulation theory, the CNS in chronic ankle instability or become copers [individuals who do not healthy people and copers modulates neural activity within the mo- develop chronic instability after an ankle sprain] who break the tor pathways to prevent the excessive ankle supination that is a cycle of recurrent injuries and disabilities seen in CAI,” correspon- mechanism of ankle injury, Terada said. A decrease in soleus spinal ding author Masafumi Terada, PhD, ATC, an assistant professor in the College of Sport and Health Sciences at Ritsumeikan University Continued on page 14 Strength training in runners has bonus fMRI study supports use of multiple benefits for physiological performance exercises to prevent hamstring injury Long-term periodized strength After 20 and 40 weeks, the A multicenter functional mag- increases were seen for the training has physiological per- runners in the intervention group netic resonance imaging (fMRI) gracillis (95%), semitendinosis formance benefits in distance demonstrated significant im- study indicates that no single ex- (65%), and the short (51%) and runners, according to research provement from baseline for run- ercise activates all of the ham- long (14%) heads of the biceps from the University of Limerick ning economy and velocity at string and synergist muscles in femoris. The Nordic hamstring in Ireland. maximal oxygen uptake—mea- professional soccer players, sug- curl was associated with in- Investigators randomized 20 sures of physiological perform- gesting a combination of exer- creases in the gracillis (39%), competitive distance runners to a ance—as well as maximal and cises may be optimal for ham- semitendinosis (16%), and the control group or an intervention relative strength. The runners in string injury prevention. short head of the biceps femoris group that completed a 40-week the control group had no signifi- Investigators performed (14%). The Russian belt exercise fMRI on 36 professional soccer periodized strength-training pro- cant changes from baseline for was the only one associated with players before and after per- gram. A 20-week preseason train- any of the outcome measures. an increase in the semimembra- ing program, with two sessions forming four hamstring exer- nosis muscle (7%). The findings were epub- per week, focused on building cises: Nordic hamstring curl, fly- The findings were epub- lished in April by the Journal of maximal and reactive strength. A wheel leg curl, Russian belt, and lished in April by the Interna- Strength and Conditioning Re- 20-week in-season training pro- conic-pulley exercise. Each ex- tional Journal of Sports Medi- search. gram, with one session per week, ercise session included four sets cine. –Jordana Bieze Foster –Jordana Bieze Foster focused on maintaining maximal of eight repetitions. Source: and relative strength while build- Source: The flywheel leg curl was Fernandez-Gonzalo R, Tesch PA, Lin- ing explosive strength. Beattie K, Carson BP, Lyons M, et al. associated with the greatest nehan RM, et al. Individual muscle use Physiology, body composition, The effect of strength training on per- increase in T2 contrast shift in hamstring exercises by soccer play- formance indicators in distance run- ers assessed using functional MRI. and strength were assessed at ners. J Strength Cond Res 2016 Apr 21. (indicating muscle activation) Int J Sports Med 2016 Apr 26. [Epub baseline and at 20 and 40 weeks. [Epub ahead of print] from pre- to postexercise: T2 ahead of print]
lermagazine.com 05.16 13 in the moment: sports medicine
Continued from page 13
reflex excitability in patients They found that individuals taneous electrical stimulation, seems to be related to a func- with CAI would suggest the ini- with chronic instability had joint manipulations, and reflex tional deficit as opposed to a tial ankle injury triggers an al- lower Hmax:Mmax ratios than conditioning protocols may be mechanical one,” said McKeon, teration in that neuromotor both copers and healthy con- effective in increasing the who was not involved with the process, he said. trols. However, no difference ex- soleus spinal excitability.” study. “And it lines up well with Terada and colleagues con - isted between copers and con- Without a prospective study, the idea that we see lots of im- ducted a case control study to trols. In addition, there were no however, it is difficult to know the provement in people as we see if spinal reflex excitability significant differences among the true neurophysiologic mecha- have them undergo dynamic in- differences exist among individ- groups for anterior-posterior or nism underlying the between- terventions.” uals with CAI, copers, and con- mediolateral ankle laxity. group differences in soleus McKeon echoed Terada’s trols. They measured ankle lax- The slow-twitch fibers in spinal reflex excitability, he comments regarding possible ity in 37 individuals with CAI, the soleus muscle are mostly noted. neurophysiologic explanations 30 copers, and 26 healthy con- innervated by small alpha mo- Patrick McKeon, PhD, ATC, for the findings. trols using an ankle arthrometer. toneurons, Terada explained, so FACSM, an assistant professor They also assessed the maxi- the study findings suggest that of exercise and sports sciences “One of the mechanisms mum Hoffmann reflex and max- some people may restore their at Ithaca College in New York, that might be driving it is a imal muscle response for the ability to reflexively recruit alpha told LER in a phone interview change in the motor neuron ex- soleus muscle in response to motoneurons after ankle injury, that the study’s findings suggest citability,” he speculated. “But electrical stimulation; since and some may not. CAI might be more related to this study really can’t establish slow-twitch fibers involved in “Therapeutic interventions the coordination and control of any cause and effect.” the Hoffmann reflex make up that can increase the H-reflex dynamic stabilizers than the Source: most of the soleus muscle, a in the soleus may help to break function of static stabilizers. Bowker S, Terada, M, Thomas AC, et al. greater Hmax:Mmax ratio indi- the cycle of recurrent injuries “It really does fit in well with Neural excitability and joint laxity in chronic ankle instability, coper, and cates greater spinal reflex ex- and disabilities seen in CAI,” he the body of evidence that’s say- control groups. J Athl Train 2016 Apr 11. citability of the soleus muscle. said. “Lower-intensity transcu- ing chronic ankle instability [Epub ahead of print]
14 05.16 lermagazine.com in the moment:rehabilitation
Gender, gait, and knee OA Kinematic data have rehab implications
By Katie Bell
Women with and without knee osteo - arthritis (OA) demonstrate greater knee abduction and hip adduction during gait than their male counterparts, according to research from Canada that supports the concept of gender-specific rehabilitation in this population.
Istockphoto.com #1783390 Gender should be taken into account when studying the biome- chanical etiology of knee OA, and the development of gender-specific analysis and rehabilitation protocols are necessary, the authors wrote. 40 to 79 years. The OA group had a 100-mm knee pain visual “I believe this study provides very strong evidence that rehabili- analog scale (VAS) above 20 mm on most days of the week preceding tation programs and [prevention] strategies need to be subgroup- enrollment and a Kellgren-Lawrence (KL) grade less than three, indi- specific,” said study author Reed Ferber, PhD, ATC, an associate pro- cating mild to moderate radiographic OA. The researchers assessed fessor in the faculties of kinesiology and nursing at the University of 112 kinematic variables as the participants walked on a treadmill at Calgary in Alberta. self-selected speeds ranging from 1 m/s to 1.3 m/s. The study included 100 participants with knee OA (55 women), Women with knee OA had greater knee abduction at touchdown aged 33 to 72 years, and 43 healthy individuals (25 women), aged Continued on page 16 Leg strength, velocity predict functional Metabolic activity suggests Achilles issues in older adults with poor mobility tendons are still healing at 6 months Leg strength and speed of leg tion and declines in function Metabolic activity evident six points, and was negatively re- movement are predictive of over the two-year follow-up. months after an Achilles tendon lated to patient-reported out- functional decline in older adults The findings, which were rupture—when rehabilitation pro- comes at six months. Glucose with poor mobility, according to epublished in April by the tocols typically allow running uptake was also higher in the research from Boston, MA. Archives of Physical Medicine and other high-load activities— tendon core than the periphery In 391 adults 65 years or and Rehabilitation, suggest that suggests the tendon is still heal- at three and six months. Vascu- older with self-reported mobility interventions targeting these ing at that time, according to re- lar flow activity was significantly variables—particularly trunk ex- modifications, investigators from search from Denmark. higher in repaired tendons than Harvard Medical School as- tensor endurance and leg ve- Investigators from Bispeb- intact tendons at three and six sessed variables related to leg locity, which may be less familiar jerg Hospital in Copenhagen months but had normalized by strength, speed of leg move- to clinicians than leg strength as used positron emission tomog- 12 months. ment, knee and ankle range of predictors of mobility-related raphy (PET) and power Doppler The findings were epub- motion, and trunk stability. The function—could help to optimize ultrasonography to assess researchers then followed the rehabilitation and disability pre- Achilles tendon metabolism and lished in April by the European participants for two years, annu- vention in this geriatric popula- vascularization in 23 patients Journal of Nuclear Medicine and ally assessing mobility-related tion. –Jordana Bieze Foster three, six, and 12 months after Molecular Imaging. function using the Late Life Func- Source: surgeons repaired their ruptured –Jordana Bieze Foster tion and Disability Instrument. Ward RE, Beauchamp MK, Latham NK, tendons. Source: et al. Neuromuscular impairments con- Eliasson P, Couppe C, Lonsdale M, et Weaker leg strength, lower tributing to persistently poor and declin- Relative glucose uptake on trunk extensor endurance, and ing lower-extremity mobility among PET scans, an indicator of meta- al. Ruptured human Achilles tendon has elevated metabolic activity up to 1 slower leg velocity at baseline older adults: New findings informing bolic activity, was significantly geriatric rehabilitation. Arch Phys Med year after repair. Eur J Nucl Med Mol were associated with greater Rehabil 2016 Apr 4. [Epub ahead of higher in repaired tendons than Imaging 2016 Apr 13. [Epub ahead of odds of persistently poor func- print] intact tendons at all three time print]
lermagazine.com 05.16 15 in the moment:rehabilitation
Continued from page 15
and during swing, and a greater patients with knee OA have rather than kinematics, Ferber that gender should be a consid- maximum peak hip adduction been inconsistent, perhaps in said the gender differences ob- eration in the study and man- angle during stance, compared part because a number of char- served in the current study may agement of knee OA. with men with knee OA; similar acteristics of knee OA—including not extend to kinetic variables. “In general, I think our pres- differences were also seen be- pain—can affect gait in ways that A systematic review and meta- ent state of knowledge is that tween women and men without may obscure other associations; analysis the Calgary group com- sex differences should be ac- knee OA. However, no differ- the inclusion criteria in the cur- pleted in 2013 did not find con- counted for in OA gait studies ences in the discrete variables rent study were designed to ad- sistent evidence that external (and indeed in studies involving were evident between healthy dress some of these issues, he knee adduction moment differs imaging, biomarkers, strength, men and men with knee OA or said. between those with and without etc). We are beginning to un- between healthy women and “Certainly, it is well known knee OA or between disease cover different pathomechanical women with knee OA. The data that higher pain values can in- severity levels. processes for men and women, were epublished in April by the fluence gait kinematics, and “In fact, we found that only which, once are established, will online journal BMC Musculo - most previous studies have temporospatial and kinematic help with person-specific inter- skeletal Disorders. used a mixed cohort of knee gait alterations associated with ventions,” Hubley-Kozey wrote “Our classification method OA patients with mild to mod- knee OA increased in magni- in an email to LER. shows a maximum classification erate and severe pain and tude with increasing disease Sources: accuracy of eighty-three percent symptoms,” Ferber said. “We severity,” he said. Phinyomark A, Osis ST, Hettinga BA, et between OA male and OA fe- tried to investigate a homoge- Cheryl Hubley-Kozey, PhD, al. Gender differences in gait kinematics for patients with knee osteoarthritis. BMC male patients. So, a small pro- neous cohort so that the influ- a professor in the schools of Musculoskelet Disord 2016;17(1):157. portion of males have gait kine- ence of pain would be mini- physiotherapy and biomedical Mills K, Hunt MA, Ferber R. Biomechan- matic patterns similar to females mized.” engineering and associate dean ical deviations during level walking as- and vice versa,” Ferber said. Although many knee OA in- (research) in the faculty of health sociated with knee osteoarthritis: a systematic review and meta-analysis. Previous assessments of terventions are designed to ad- professions at Dalhousie Univer- Arthritis Care Res 2013;65(10):1643- gender-specific gait patterns in dress frontal plane kinetics sity in Halifax, Canada, agreed 1665.
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TM Experts say perplexing studies suggesting that smoking may be protective against the development of knee osteoarthritis (OA) should not deter clinicians’ efforts to discourage smoking—even in patients who are at risk for OA. But, if researchers can pinpoint specific ingredients associated with the protective effect, that could have significant implications for the development of new OA therapies.
By Barbara Boughton
Istockphoto.com #23074274
18 05.16 lermagazine.com A protective effect? Smoking tobacco has long been recog- nized as the most preventable cause of morbidity and early mortal- Yet in recent years, a great deal of research has begun to show a ity in the US.1 Smoking contributes to many poor lower extremity modest to significant protective effect of smoking on knee OA. No outcomes, including increased risk of osteoporosis-related fractures, one, of course, is arguing that lower extremity clinicians should en- complications following orthopedic surgery, and musculoskeletal courage their patients to smoke, or refrain from counseling smoking cessation. Researchers hope that learning more about the possible pain.2 link between tobacco and OA will lead to insights about specific in- Yet smoking remains a persistent and widespread habit among gredients in tobacco or nicotine that may be protective, so those Americans—including patients who need healthcare for orthopedic components could be isolated for the development of new arthritis and musculoskeletal conditions. In fact, studies have estimated that medications. one out of every five patients who receive outpatient physical ther- In one of the largest recent studies on OA and smoking, pub- apy smoke or use tobacco.1,3 Organizations such as the American lished in Osteoarthritis and Cartilage in 2014, researchers in Singa- Academy of Orthopaedic Surgeons (AAOS) have begun to recom- pore found smokers had a significantly lower risk for severe knee mend that clinicians should take a more active role in screening pa- OA resulting in total knee arthroplasty than nonsmokers in a cohort 2 tients for smoking and counseling them about smoking cessation. of more than 63,000 Chinese men and women. Smokers had a At the same time, a number of controversial but large review 51% decreased risk of total knee arthroplasty compared with peo- and population-based scientific studies have reported that smoking ple who had never smoked.15 may be protective against the development of osteoarthritis (OA), “Our study is limited in that it used total knee replacement as a particularly knee osteoarthritis. Several large studies in China and surrogate for knee osteoarthritis—so you can’t really say from our Australia have also found that, among OA patients, smokers are less study whether smoking was associated with onset or progression of likely than nonsmokers to undergo total knee arthroplasty for severe osteoarthritis,” said Katy Leung, MBChB, director of research in the symptoms. department of rheumatology and immunology at Singapore General The research has generated controversy, as well as concern Hospital. “Yet, an important strength of our study is that we had very among lower extremity clinicians who are well acquainted with years detailed data on patients who quit smoking, and we found that the of research showing poor outcomes among patients with OA who protective effective of smoking declined quickly after quitting.” also smoke. “The research that shows a protective effect of smoking on knee osteoarthritis is intriguing and interesting, but I’m not con- vinced that there’s enough evidence to support the notion that smoking has a beneficial effect,” said Janet Bezner, PhD, PT, DPT, associate professor of physical therapy at Texas State University in San Marcos. “There really isn’t enough information in the research studies I’ve seen to support the conclusion that smoking has a pro- tective effect on knee osteoarthritis—or to change our advice to pa- tients about the hazards of tobacco.” Smokers are at increased risk for nonunion of fractures and de- layed healing after orthopedic surgery,2,4-6 said AAOS spokes - person Alan Reznik, MD, an orthopedic surgeon and sports medicine specialist in New Haven, CT, and one of the authors of the recent AAOS statement on smoking. Since smoking damages the inner walls of arteries and slows down microcirculation, blood flow that aids healing is often compromised, Reznik added. Smokers are also at in- creased risk for mortality and serious morbidities such as deep infection, heart attack, and stroke and sepsis after sur- gery, including orthopedic surgery,7-10 he said. “Smokers who have other risk factors such as obesity and diabetes are often not candidates for elective orthopedic surgeries such as arthroplasties, because they are at such heightened risk for complications,” he said. Smokers who quit just weeks or months before surgery appear to reduce their risk for adverse events, and that risk de- creases further if the patients quit smoking a year or more before surgery, according to the AAOS statement.2,10,11 “The hazards of smoking are well documented,” Bezner said. “We know that smokers are more likely to have back pain and chronic musculoskeletal pain—and smokers heal more slowly from tendon and muscular injuries.”12-14 Istockphoto.com #3665279
lermagazine.com 05.16 19 Continued from page 19 Two large population-based studies conducted in Australia Recent basic science experiments indicate that nicotine can found a beneficial effect of smoking on knee OA, as well. This re- aid collagen synthesis in chondrocytes,16 which suggests to Leung search concluded smoking decreased the risk for lower limb total and colleagues that there could be practical implications drawn joint replacement, and the association held true when the re- from their study’s findings. searchers controlled for age, comorbidities, body mass index (BMI), 19,20 “The development of chemopreventive agents from nicotine and socioeconomic status. analogues may provide an effective means to reduce the progres- “Both of our studies were consistent in their findings,” said lead sion and lessen the burden of severe OA,” they wrote in their paper. researcher of both studies George Mnatzagainian, PhD, MPH, an That line of thinking, however, is still in the very early stages. epidemiologist at Australian Catholic University in Melbourne. “There was a protective effect of smoking, and both male and fe- male smokers had less risk for lower limb total joint replacement than nonsmokers. We also found a dose-response effect between years of smoking and reduced risk for having a total joint replace- ment [with more years of smoking linked to a greater decrease in risk for TKA than fewer smoking years].” Contradictory findings In a 2015 editorial in Osteoarthritis & Cartilage that analyzed recent studies and reports on the link between OA and smoking,21 David Felson, MD, a professor of medicine and epidemiology at Boston University in Massachusetts, noted that a “preponderance of evi- dence suggests that smokers are modestly protected against de- veloping radiographic OA in the knee and hip.” Yet Felson and Zhang also observed that smoking may have contradictory effects on OA. Research such as the 2011 meta-analysis indicated that, while smokers had less OA disease than nonsmokers, they were at “modestly increased risk of painful OA,” Felson and Zhang wrote. A recent study highlighted the contradictory and complex ef- fects of smoking on knee OA.22 In 2250 patients with radiographic evidence of knee OA, researchers from the University of Massachu- setts Medical School in Worcester studied the effect of smoking his- tory on knee pain, stiffness, physical function, and OA progression as indicated by joint space width. Changes in knee-specific symp- toms, such as pain, stiffness, and physical function were measured at baseline and annually over 72 months. Joint space width was evaluated by x-ray at baseline and annually over 48 months. In their analyses, the researchers controlled for potential confounders, such as age, gender, education, income, race, BMI, symptom-related multijoint OA, alcohol consumption, and Short Form-12 physical and mental health scores. In a cross-sectional analysis performed at baseline, the re- searchers found patients with a history of greater than 15 pack-years of smoking had worse pain and stiffness than patients who had never smoked. Their findings also revealed a contradictory result: Patients with less than 15 pack-years of smoking at baseline had better joint space width than patients who never smoked—but they had worse overall function. Istockphoto.com #44340762 The researchers also measured changes in WOMAC (Western Ontario and McMaster Universities Arthritis Index) symptoms from “There are hundreds of ingredients in cigarettes, so it’s not yet baseline to 72 months, and changes in joint space width from base- appropriate at this time to make any conclusions about which in- line to 48 months. This more robust longitudinal analysis found no gredients might have a protective effect,” Leung said. “More re- association between smoking history or pack-years of smoking and search on this question needs to be done.” changes in OA symptoms or joint space width. In 2011, researchers performed a meta-analysis of 48 studies “We suspect that the small and conflicting findings from the and found a significant inverse association between smoking and cross-sectional study are [less reliable and] due to residual con- the development of knee OA.17 Yet a large population-based study founding,” the researchers wrote in their paper. of 9064 Koreans older than 50 years, published in 2016, did not “Our study showed clearly that there was no relationship be- find a significant association between knee and hip OA and smoking tween smoking and knee osteoarthritis,” said lead author Catherine 18 or indirect or side stream smoke. Continued on page 22
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BAUERFEIND.COM Continued from page 20 Cessation counseling Dubé, EdD, research associate professor in the Department of Other clinicians interviewed by LER also emphasized the impor- Quantitative Health Sciences at the University of Massachusetts tance of continuing to counsel OA patients who smoke about the Medical School. “We do not believe there is a protective effect of health hazards of their habit. A discussion about smoking before smoking on osteoarthritis.” elective surgery, such as total knee arthroplasty, presents an oppor- Dubé acknowledged that previous population-based studies tunity to intervene and discuss smoking cessation methods and pro- had found a strong association between smoking and reduced grams, said V. Franklin Sechriest II, MD, chief of orthopedic surgery prevalence of knee OA, as well as a reduced risk for total knee at the Minneapolis Veteran Affairs Health Center System. arthroplasty. “It’s difficult to assess the quality of these studies, and the gen- eralizability of their results,” she said. Dubé also noted a number of studies have actually found that, because smoking has a negative effective on bone mineral density, the habit can cause increased cartilage loss.23,24 “Chronic smoking also creates a pro-inflammatory state, and since inflammatory mediators play an important role in osteo - arthritis, one would expect that smoking would have an overall neg- ative effect on symptoms and disease progression,” she said. In their paper, Dubé and colleagues noted that, while some chemical exposures in cigarette smoking could be beneficial, it might be almost impossible to narrow down which ingredients were protective. Cigarettes have hundreds of ingredients associated with at least 69 known carcinogens, and more than 7000 chemicals when burned, Dubé and colleagues noted in their study. Still, it’s important for research to provide more clarity about the relationship between smoking and OA, so that smokers do not find a reason to continue smoking, Dubé said. Istockphoto.com #43787028
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22 05.16 lermagazine.com “It’s crucial to discuss the risks of smoking with any patient un- can play in helping patients to stop smoking. dergoing surgery,” Sechriest said. “If patients can’t quit smoking be- “We should be screening patients for smoking, and asking if we fore undergoing surgery, then it’s vital to aggressively counsel them can help with quitting,” she said. “Although we can’t prescribe stop- afterward about tobacco cessation. I usually tell my patients that, if smoking medications, we can refer patients to stop-smoking they want a good outcome after surgery without complications, it programs.” will help to quit smoking.” But Bezner has found that physical therapists often don’t take Sechriest also noted that smokers should be monitored more advantage of opportunities to address smoking cessation with their closely than nonsmokers after orthopedic surgeries to ensure healing. patients.1 Bezner emphasized the important role that physical therapists “Physical therapists have reported that they do not feel pre- pared to provide smoking cessation counseling, although they feel that they should ask patients about smoking habits and provide ad- vice to stop smoking,” Bezner wrote in a 2015 review article on pro- moting health and wellness in physical therapy.1 Bezner advises taking an educational approach to patients who smoke, and informing them about the risks of smoking, as well as the benefits and rewards of quitting. Patients should also be asked to identify any barriers or roadblocks they’ve encountered when try- ing to quit, and advised about ways they might be able to overcome these roadblocks, she added. If an OA patient is both obese and a smoker, or if an obese pa- tient who smokes is at risk for OA, it’s often best to start by advising them about starting an appropriate exercise program—as long as they can handle physical activity. “Once they take that first step and start exercising,” Bezner said, “they realize pretty quickly how much smoking is limiting them.”
Barbara Boughton is a freelance writer based in the San Francisco Bay Area.
References are available at lermagazine.com.
PFS
lermagazine.com 05.16 23 Managing metatarsalgia in athletic populations
By Howard Kashefsky, DPM, FACFAS
Metatarsalgia is a common foot disorder. The term metatarsalgia resulting in increased pressure under the metatarsal heads. Exam- refers to a pain syndrome in the forefoot and not to a specific diag- ples include hallux rigidus, long or short metatarsal bones, and pos- nosis.1 Pain is confined to the area across the plantar forefoot, in- sibly pes cavus. Treatment should be focused on offloading the cluding the second through fourth metatarsal heads. However, it is metatarsal heads and should mechanically direct force away from frequently accompanied by deformity of the first and fifth rays, as the point of pressure. well as the toes.2 Secondary metatarsalgia is defined as pain that does not orig- Many different diagnoses have been identified as the cause of inate within the metatarsal area. Conditions such as rheumatoid the painful forefoot. Excessive stress may result in ligamentous arthritis, sesamoiditis, and equinus can all lead to localized pain at strain, synovitis, capsulitis, stress fracture, or degenerative arthritis. the ball of the foot. The origin of metatarsalgia can be multifactorial. Metatarsalgia may be associated with a tight Achilles tendon (equi- Scranton found that 31 of 98 patients had two or more mechanical nus), cerebral palsy, stroke, multiple sclerosis, or other neurological etiologies for primary metatarsalgia, and that often, primary and sec- diseases. Metatarsalgia also results from pathological alterations in ondary metatarsalgia existed together.19 Effective treatment will ad- forefoot structure due to hallux valgus, hallux limitus, rheumatoid dress the area of pain, the function of the foot, and, if necessary, the arthritis, osteomyelitis, or osteochondrosis (Freiberg disease). Cir- systemic disease. culatory or metabolic disorders may also be associated with Scranton found 23 different diagnoses of metatarsalgia in 98 metatarsalgia.3-8 Brachymetatarsia, an arrest of normal metatarsal patients. Forty-five patients had primary metatarsalgia, 12 of whom growth and development with a resultant short ray, may cause had static disorders and 12 of whom had iatrogenic (postoperative) symptoms.9 A Morton neuroma or other nerve injuries may be as- etiologies. Thirty-three patients had secondary metatarsalgia, 11 of sociated with forefoot pain.10 Hammertoes can occur in association whom had rheumatoid arthritis and 10 of whom had sesamoiditis. with joint dislocation, and may contribute.11 Twenty patients experienced pain under the forefoot.19 Cavus foot and pes planus foot types have both been associ- Viladot has classified metatarsal pathomechanics as an over- ated with metatarsalgia. Cavus foot type as well as pes planus with load of anterior support or an irregular distribution of the metatarsal hypermobile first and fifth rays have been associated with increased load.20 Irregular metatarsal load syndromes are further separated shearing at the forefoot.12,13 Metatarsal weightbearing is increased into four groups: first ray overload, first ray insufficiency, central ray with the cavus foot because a disproportionate amount of weight is overload, and central ray insufficiency. borne by the heel and forefoot. It is not uncommon to observe re- tracted or clawed toes with cavus feet, which decreases the ability Metatarsalgia in athletes to unload the metatarsals at push-off.14 The pes planus foot type (re- Metatarsalgia is common in sports, including rock climbing, running, sulting from genu valgum, rearfoot valgus, or forefoot varus) remains and cycling. A potential cause of these injuries is excessive plantar pronated during midstance and inhibits proper supination, which pressure in the forefoot region.21,22 compromises the propulsive function of the forefoot. In particular, pain associated with metatarsal stress fracture has Although plantar fat pad loss makes sense intuitively as a cause plagued military personnel throughout history but has now become of metatarsalgia, a study by Waldecker suggests the two may not more common in the civilian population with the increasing popu- be associated; more research needs to be done.15 Unintended ia- larity of recreational long-distance running, aerobics, and jumping trogenic metatarsalgia after bunion surgery can be the result of a sports.23,24 Metatarsal stress fractures and metatarsalgia also are fairly short first metatarsal or elevation of the first ray.16,17 common among competitive athletes, especially runners.25-27 Buda et al identified metatarsalgia in 12.5% of 144 rock climbers.28 Classifications Cycling is associated with metatarsalgia.29 Carbon fiber cycling Helal et al classified metatarsalgia as either primary or secondary.18 shoes have become popular for their stiffness, but the stiffer mate- Primary metatarsalgia is structural—an anatomical abnormality rial is also associated with 18% higher peak plantar pressures in Sponsored by an educational grant from medi USA.
24 05.16 lermagazine.com the forefoot, leading Jarboe and Quesada to recommend that com- pressure at the first and second metatarsal heads and slight in- petitive or professional cyclists suffering from metatarsalgia or is- creases laterally. In addition, contact duration decreased at all chemia should be especially careful not to aggravate these foot metatarsal head locations, and pressure-time integral (PTI) de- conditions.30 creased at the first, second, third, and fourth metatarsals. Location of met pads seems to be crucial for plantar pressure Treatment reduction, as a research group in Taiwan demonstrated.43 Metatarsal Multiple studies support the use of treatment focused on reducing pads, each measuring 55 mm in length, 36 mm in width, and 10 forefoot plantar pressure.31-34 Postema et al reported a reduction in mm in height, were uniformly used in 10 individuals with a history forefoot plantar pressure and force impulse both with a rocker sole of primary metatarsalgia. The greatest pressure reduction was and with custom foot orthoses in individuals with a history of achieved when the metatarsal pad was placed just proximal to the metatarsalgia.32 Individuals with current pain preferred a custom- site of peak metatarsal head pressure. The study revealed positional molded insole more often than those without pain. differences as small as 4 mm could influence the metatarsal pad’s The efficacy of rocker shoes for reducing forefoot plantar pres- ability to reduce plantar pressures at the metatarsal heads. How- sure during walking has been well documented in both healthy in- ever, for clinicians to use the same type of assessment to place a dividuals and patients with forefoot problems such as metatarsal pad for each patient is impractical. metatarsalgia.35-39 Sobhani et al found that running in rocker shoes Because one of the most important outcomes of treatment is was associated with a significant reduction in all pressure parame- pain relief, in 2006 the same Taiwanese research group assessed ters in the central and lateral fore- the correlation between the use of foot as well as reduced force a metatarsal pad and subjective time integral and maximum mean symptoms.44 Thirteen patients with pressure in the medial forefoot.40 secondary metatarsalgia wore Although the study participants metatarsal pads positioned under (all healthy runners) found the and just proximal to the second rocker shoes less comfortable metatarsal head for two weeks. Im- than standard running shoes, the provements in visual analog pain authors concluded rocker shoes scores were statistically correlated might be beneficial for runners with reduction in PTI and, more who are recovering from meta - strongly, with reduction in maxi- tarsalgia or stress fractures in the mum peak pressure. forefoot region. Additional studies of second- Treatment with metatarsal ary metatarsalgia have focused pri- pads is a common standalone marily on pain relief with the use of therapy for metatarsalgia. A 1990 met pads in combination with foot study by Holmes and Timmer- orthoses in patients with rheuma- man used pedobarography to toid arthritis.45,46 These studies determine the effect of meta - found that metatarsal pads were tarsal pads on pressure under associated with statistically signifi- the metatarsal heads in 10 cant decreases in peak plantar asymptomatic volunteers.41 They pressures, pressure-time intervals, found that the met pads were as- and patients’ pain, along with in- sociated with significantly re- creased quality of life. These stud- duced pressure at the second ies also found the use of a custom metatarsal head for all partici- orthosis without the pad provided pants; pressure reduction with a frequent decrease of peak pres- met pad use decreased for each sures and decreased metatarsal subsequent lesser meta tarsal pain in varying amounts. head lateral to the second meta - In a 2006 study of 20 patients tarsal. with diabetes, Mueller et al found Another study of metatarsal that both a total contact insert and pads, published in 1994, ex- a metatarsal pad were associated panded on this idea by measur- Istockphoto.com #1312713 with statistically significant reduction ing the intervention’s effect on of pressure under the metatarsal peak pressures in eight discrete plantar locations on the hindfoot, heads.47 Patients were analyzed while wearing just a shoe, a shoe midfoot, and forefoot.42 In 10 asymptomatic individuals, met pad with total contact orthoses, and a shoe with the same orthoses but use was associated with statistically significant increases in plantar with a metatarsal pad added. The total contact orthoses in this study pressure at the metatarsal shaft region, suggesting offloading of the increased the foot contact area by an average of 27%, primarily in metatarsal heads. Although there were no statistically significant changes in any other plantar region, there was a mild decrease in Continued on page 26
Sponsored by an educational grant from medi USA.
lermagazine.com 05.16 25 Continued from page 25 Custom versus ready-made orthoses for metatarsalgia have the arch. The orthoses reduced metatarsal peak pressures by 19% been studied. Kelly and Winson found both custom and prefabri- to 24% and PTI by 16% to 23%. The addition of a metatarsal pad, cated insoles were associated with reduced plantar forefoot pres- sure in patients with lesser metatarsalgia, however, the custom although it did not increase contact area, reduced peak pressure group reported a 16% higher compliance rate and greater self- by an additional 15% to 20%, and PTI by an additional 22% to 32%. reported symptom improvement.50 The authors reported that adding the metatarsal pad increased the Ki et al found orthoses with minimum arch fill were far more pressure peak at the second metatarsal shaft by an amazing 308%, effective than flat insoles for redistributing peak plantar pressures in indicating that, although the pad 30 healthy volunteers.51 They also did not increase the surface area, demon strated that, the greater the it redistributed pressure from the contact in the arch area, the greater metatarsal head to the shaft. the decrease in rearfoot and fore- Treatment of metatarsalgia foot pressures. The paper also re- with foot orthoses alone has also vealed that custom devices made been researched. The purpose of using either CAD-CAM technology orthotic therapy is to increase the or foam impression were far supe- patient’s tolerance of weightbear- rior to flat insoles for reducing fore- ing, facilitate proper foot function, foot plantar pressures. and normalize gait. The orthosis Orthotic therapy should be should balance weight distribution used only with suitable footwear. across the metatarsals by correct- Metatarsalgia patients should use ing or compensating for any bio- shoes with a low heel, stiff sole, and mechanical malalignments that large, rounded toe box.14,52-54 alter foot biomechanics. A variety of orthotic ap- Orthotic design proaches may be used to alter the weightbearing load at the meta - considerations tarsals. Shaft padding relieves the Orthotic design should be tailored symptomatic metatarsal head by to each individual case. The dis- transferring the load to the proximal proportionately high weightbear- metatarsal shaft. The first, second, ing areas in the cavus foot can be and fifth metatarsals can be padded reduced by adding support along with flexible materials, while the the lateral and medial longitudinal third and fourth metatarsals can be arches.14 The pes planus foot re- supported with pear-shaped meta - quires control of forefoot or rear- tarsal pads.55-57 The success of shaft foot varus by medial posting.48 padding requires placing the sup- Medial column instability due to port just proximal to the metatarsal excessive rearfoot pronatory mo- head and not underneath it. tion often leads to dorsiflexion of A topcover and a forefoot ex- the first ray and subsequent over- tension can be used to add cush- loading of the second, limiting the Istockphoto.com #9954686 ioning, which dampens force. first metatarsophalangeal joint Research suggests softer top- motion.49 A wide orthotic plate made from a cast with the first ray cover materials give patients more comfort and increase their tol- plantar flexed helps maintain contact with the more medial aspect erance of orthotic devices,58 which may have implications for of the foot, allows greater motion of the big toe, and enhances multiple pathologies. Materials such as closed-cell neoprene, plas- weightbearing under the first metatarsal head, decreasing pressure tazote, and Poron can add shock absorption under the forefoot. under the second metatarsal head.49 Topcovers require periodic replacement, dependent on patient In general, the following steps14 established in 1985 are still weight, moisture, and frequency of use. Since compression of very valid for orthotic management of metatarsalgia: soft materials over time negates the benefits of shock absorption 1. Perform a complete clinical examination; the patient needs, noncompliance and loss of effectiveness can re- 2. Establish a diagnosis; sult if these materials are not replaced. Poron extensions that main- 3. Determine which orthotic features will help achieve treat- tain their ability to cushion the metatarsal heads also attenuate ment goals; pressure by delaying compression. 4. Fabricate the device from the correct materials; 5. Determine the therapeutic benefit of each of the device’s Howard Kashefsky, DPM, is the director of podiatry services at the features; University of North Carolina Hospitals in Chapel Hill. 6. Analyze the effect of the device on the patient’s gait; and 7. Reevaluate the orthosis periodically. References are available at lermagazine.com.
Sponsored by an educational grant from medi USA.
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Skin care issues related to orthotic device wear
Te care and prevention of skin issues may not get as much attention in orthotics as in prosthetics, but such issues can signifi- cantly affect patient outcomes. Here, lower extremity experts share the tips and tricks they use to manage dermatological challenges related to orthotic devices.
By Lori Roniger
Modern orthotic devices are designed to fit more intimately than in the past, a development that allows for more effective biomechan- ical correction. But this evolution has also led to an increase in the incidence of lower extremity skin issues related to structural or environmental stresses. Other trends, such as a greater number of people living with type 2 diabetes, diabetes-related peripheral neuropathy, and stroke, have increased the population of patients using ankle foot orthoses (AFOs) and other lower extremity orthotic devices who are suscep- tible to skin breakdown and other issues. And those with spinal cord injuries and decreased sensation in their lower extremities can pres- ent skin-related challenges for practitioners. “You really didn’t have too many skin-related issues in the past,” said Harry “JR” Brandt Jr, CO, LO, BOCO, director at Collier Orthotics and Prosthetics in Pleasant Hill, CA, of older-style devices. Brandt, who has worked as an orthotist for 35 years, pointed out that socks and silicone liners are often discussed in prosthetics and in relation to protecting the existing limb, but there’s less of that type of discussion with regard to orthotic devices. He noted, how- ever, that practitioners are increasingly utilizing thermoplastic or- thotic devices with more contact points, which can provide greater control but also lead to more skin issues. “It’s important to manage that tissue correctly to reduce or elim- inate the forces involved,” he said. Josh Ahlstrom, CPO, an orthotist and prosthetist with Midwest Orthotics and Technology who is based in Indianapolis, IN, focuses on the pediatric population and encounters skin issues in some of Making modifications to improve the fit his patients. “One of the problems that leads to skin irritation is trying to take of an orthotic device, including design a mobile object and put it in something that doesn’t let it move,” changes to realign a patient’s anatomy, Ahlstrom said. can help minimize the risk of skin issues. The goal, he said, is to equalize pressure distribution all around the foot and to put patients in a brace that moves when the foot moves. An AFO-SMO (supramalleolar orthosis) combination is a
lermagazine.com 05.16 29 Continued from page 29
The Noodle TA AFO
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Photo courtesy of Allard USA.
Medicare total contact brace that allows the foot to have natural movement, Code PCS L19 he said. HC 32 Skin issues that practitioners see and seek to prevent in pa- tients who use lower extremity orthotic devices include pressure and diabetic ulcers, blisters, calluses, fungal infections, and prob- If for any reason during the initial 30 day trial period the lems related to perspiration and edema. At the very least, these is- practitioner or wearer is not completely satisfied with sues can negatively impact patient’s quality of life and compliance The Noodle TA AFO it may be returned for a refund. with device wear; at worst, they can significantly increase the risk of amputation. Sock watch One of the key ways clinicians help patients protect their skin is by Kinetic recommending they wear appropriate socks. While there’s some variety in the type of socks and sock material that practitioners pre- Research fer and recommend, they all strive to help keep patients’ skin dry. “You can have the best-fitting AFO that you’ve ever seen, and Carbon Fiber Specialists if you get them in a thin nylon sock [or any sock that doesn’t provide effective perspiration wicking] and an ill-fitting shoe, it basically 800-919-3668 negates what you’ve just accomplished through this wonderful fit- www.KineticResearch.com ting, and you end up back in the office with pressure sores around the toes,” Brandt said.
30 05.16 lermagazine.com He recommends athletic socks that contain padding and are made of acrylic fibers and yarns, polyesters, nylon, and wool. Brandt FOOTWEAR • ORTHOSES • BRACES said these socks help to wick away perspiration and keep skin dry and less susceptible to shear forces. He usually recommends a boot sock or uniform sock with some compression. “We Want Your Most He also tells patients lacking sensation to wear white socks so that if a sore starts to blister it will show on the sock. Difcult Cases” David Misener, CPO, who practices at Clinical Prosthetics and Orthotics in Albany, NY, said that, even in patients with normal skin !"##"$%&'$(")*+&,-. integrity, perspiration is a significant issue that can affect the skin where the orthotic device makes contact. This can affect all types of patients and present problems during any season of the year where he practices. Although complaints about perspiration can come from almost any patient, he said, they can be much more of a problem with total contact designs that don’t allow air to circulate or moisture to evaporate. Misener suggests patients wear wicking clothing, socks that contain wool blends, or good quality athletic socks. “I find more often than not that the patients have a particular preference,” he said. Ahlstrom, who noted that his pediatric population can experi- ence skin irritation, blisters, increased reddening, and calluses with lower extremity orthotic devices, recommends that socks fit appro- priately and don’t have wrinkles or creases that can create pressure CUSTOM ORTHOSES points on the skin. Although there are some great AFO socks, he said, those can be relatively expensive, and a well-fitted cotton ath- FREE letic sock can do the trick in most cases. Impression Box Ahlstrom also advises his young patients, some of whom have OSES “particularly sweaty little feet,” to change socks during the day ORTH FREE Shipping around lunchtime. “Changing socks throughout the day can do wonders for re- ducing blisters,” he said. Sean McKale, CO, an orthotist with Midwest Orthotics in ! Chicago, doesn’t get fancy with his sock recommendations, telling patients to go for cotton versus acrylic socks. “They wear what they want to wear,” McKale said. “Some pa- tients wear taller socks and some ankle socks. There doesn’t seem to be too much of a problem.” Jason Jennings, CPO, area clinic manager with Hanger Clinic in Houston, also recommends cotton socks, as well as changing them at least every eight hours year-round, in part because of the Texas heat. Likewise, the sock recommendations of Chris Toelle, LCO, re- Made in gional area clinic manager for Hanger in Sarasota, FL, are influenced the USA by the warm, humid climate there. He said thick nylon and wool socks for AFOs are “intolerable” there, but socks made of cooling materials, blends, and military-inspired materials are good choices. Trusted Quality for over 25 Years He said a traditional sock can be very hot under a lower extremity orthotic device and cause skin to break down and look like it has just emerged from a pool. For feet that are slipping or uncomfortable in orthotic devices, Tracey Vlahovic, DPM, an associate professor at Temple University School of Podiatric Medicine in Philadelphia who focuses on skin issues, recommends socks containing copper or silver fibers.1,2 “It won’t cure sweaty feet, but it can certainly make them more comfortable,” Vlahovic said. The embedded fibers can also be de- odorizing or antimicrobial, which can help with athlete’s foot.
Continued on page 32 877-524-0639 • Branier.com
lermagazine.com 05.16 31 Continued from page 31 Dry ideas Although choosing the right socks to wear under lower extremity orthotic devices and changing them frequently can help reduce per- spiration problems, some practitioners, like Vlahovic, also recom- mend other strategies for keeping their patients dry. Sweaty feet are probably “the biggest thing” she sees related to orthotic devices, she said. She noted that leather orthotic topcovers can increase sweat- ing in some patients or make it feel like the foot is slipping, so using a different topcover material can be helpful. If the underlying cause of sweaty feet is hyperhidrosis, however, the use of topical aluminum chloride solution (Drysol) under a physi- cian’s direction can be effective at reducing sweating, she said. If that doesn’t control the problem, Botox injections are another rea- sonable treatment.3 Jennings, working in Texas, recommends simply applying com- mercial antiperspirant directly on lower extremity skin. To reduce friction caused by sweaty feet and wet socks, Ahlstrom likes to apply thin, adhesive, low-friction interface material manufactured with polytetrafluoroethylene (PTFE) film directly to the inside of a brace. It can be cut into any shape and can reduce shear forces and prevent tackiness even if a sock is wet, he said. McKale said that, for some of his patients who wear a molded inner boot that controls side-to-side motion and experience greater sweat accumulation, he modifies their boots by adding small air holes, each the size of a belt buckle hole, using a hand punch tool. Jennings noted that fungal infections, like athlete’s foot, can occur anywhere on the body, including the ankles and thighs, but are sometimes mistaken for a rash. If an over-the-counter antifungal Photo courtesy of Surestep. medication doesn’t help, patients should be referred to a physician.
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32 05.16 lermagazine.com FOOTWEAR • ORTHOSES • BRACES “We Want Your Most Difcult Cases”
!"##"$%&'$(")*+&,-.
Photo courtesy of Richie Brace. CUSTOM FOOTWEAR Put a shoe on it Although it’s important for socks and lower extremity orthotic de- vices to work well together in order to protect skin, Brandt empha- SHO sized the importance of helping patients select appropriate footwear ES when initially evaluating them, so that all components work together ! as a unit. “A large percentage of patients wear shoes that are too big or small or ill-fitting,” Brandt said. When fitting the orthotic device, he’ll sometimes recommend shoes that are a half-size bigger or a different type of shoe, such as styles with a deeper toe box or athletic shoes that come in a range of widths that can accommodate extra volume. Pros and cons of contact Practitioners also noted the type of lower extremity orthotic device used and proper fitting are also key for avoiding skin issues. McKale, who tends to fit patients with carbon-fiber AFOs that have an open design, says this style is less problematic for the skin Made in than total contact polypropylene AFOs that have less air flow. the USA “I don’t deal with a lot of skin issues,” McKale said. “The advan- tage of a carbon-fiber system is less total contact.” He noted some AFOs come with removable liners that can be washed, which may help avoid skin issues. A total contact AFO, however, can be a good choice for some Trusted Quality for over 25 Years patients. If, for example, a posterior-leaf type design creates skin is- sues at high-pressure areas, the total contact design can help dis- tribute that pressure, Brandt said. Modifications Brandt noted that certain modifications to improve the fit of an or- thotic device can be helpful for preventing skin issues. He recom- mends paying special attention to bony prominences, taking time
Continued on page 34 877-524-0639 • Branier.com
lermagazine.com 05.16 33 Continued from page 33 to identify those areas appropriately when casting, and wrapping them with elastic bandages to accentuate them and compress the soft tissue evenly. “The challenge of course goes up exponentially if there are skin or [muscle] tone or vascular issues,” Misener said. Pressure issues, sores, and abrasions can occur when there is too much pressure over a specific area, he said. “Our goal is to reduce the peak pressures at that point,” Mis- ener said. Design changes or dynamic stopping can help realign the anatomy in ways that minimize the risk of skin issues, he said. For example, stroke patients who develop pressure sores when using a brace dynamically can benefit from a structure created within the device to address pronation or supination. Toelle, who sees a large population of young and old patients with diabetes in southwest Florida, said he prefers to fit lower ex- tremity orthotic devices for people with diabetes in the afternoon, when they’re at their worst in terms of edema. If the device ends up a little too big at times when the edema is less severe, padding or socks can help. A removable diabetic insert can help adjust pres- sure to the bottom of the foot over time while using the same brace. Toelle said he sees a lot of skin issues related to AFO use in patients with drop foot from multiple diagnoses, such as stroke, di- abetes, or cardiac or blood flow issues. He also uses a lot of stance- control devices and knee ankle foot orthoses (KAFOs) in stroke patients with weaknesses in the extremities; because these devices cover a larger area of the leg, they are even more likely to be asso- ciated with skin issues than lower-profile devices. Photo courtesy of Arizona AFO. Working with children, Ahlstrom uses a lot of very flexible plastic.
34 05.16 lermagazine.com FOOTWEAR • ORTHOSES • BRACES “We Want Your Most Difcult Cases”
!"##"$%&'$(")*+&,-.
Photo courtesy of Bauerfeind.
He said this can wrap around the foot to create total contact and SEBRING BRACE even pressure distribution and help avoid common hot spots. Over- pronation in children can produce redness at the navicular, medial malleolus, the lateral portion of the calcaneus, and the fifth meta- tarsal head. AFO’s Change is good Sometimes patients require a change in device; for example, a teenaged patient with spina bifida who came to Brandt after an old ! solid-ankle AFO had created a large pressure wound. To address the pressure issue, he fit the patient with a total contact two-piece AFO that distributed pressure over a larger area. To provide an inti- mate fit, a cast was custom-made for the patient. He noted the pa- tient was at a key developmental point at which the orthotic solutions that had worked in the past might not work in the future. Patients with an existing wound typically need to transition to a CROW (Charcot restraint orthotic walker) boot or another type of walker until the wound heals. In particular, diabetic ulcers and pres- sure ulcers should be offloaded immediately, which can be done by creating room in the orthosis or padding around the area, Jennings said. Ahlstrom recalled a child with cerebral palsy who had been get- Made in ting bigger, heavier, and more difficult to manage in terms of tone the USA and pronation. He wore a traditional AFO of rigid plastic but was developing a significant callus over the navicular bone. He was then switched to an SMO, fit into the AFO, to address the callus issue with a more forgiving material without sacrificing stability. “A lot of times skin irritation is a result of trying to get the body Trusted Quality for over 25 Years to do something that it maybe doesn’t want to do,” Ahlstrom said. “The goal in orthotics is to try to put the body in better alignment so it can function the way it’s designed to function. It’s good to move forward with techniques and materials that work with the body and not against it.”
Lori Roniger is a freelance writer based in San Francisco, CA.
References are available at lermagazine.com. 877-524-0639 • Branier.com
lermagazine.com 05.16 35
Using subsensory noise to improve balance, gait
Using specially designed insoles to deliver stochastic resonance to the plantar sur- face of the feet has the potential to signifi- cantly improve static balance, dynamic balance, and gait mechanics in healthy, young individuals as well as elderly people and others with somatosensory deficits.
By Daniel Miranda, PhD; Wen-Hao Hsu, ScD; and James Niemi, MS
The existence of noise (in this context, a random, unwanted signal) in most systems or environments is typically considered a problem. In fact, engineers and scientists have spent decades pursuing ways to reduce or eliminate noise in a range of applications. Noise- cancelling headphones and photo-processing software are two ex- amples of applications in which reducing noise is critical to obtain- ing crisp sounds and sharp images, respectively. However, physicists and scientists from the 1980s to the mid- 1990s reported applications for which the introduction of nonlinear noise to certain systems or environments enhanced the detection and transmission of weak signals.1 This phenomenon, coined sto- chastic resonance (SR), indicates that the flow of information through certain systems is improved by the inclusion of a specific level of noise. At the time, it was hypothesized that the sensory sys- tems and perceptual processes may be able to take advantage of this phenomenon to improve the detection of weak stimuli.2 Collins and colleagues confirmed this hypothesis in a series of experiments involving human participants, in which subsensory SR noise improved tactile sensation by acting as a suitable pedestal for enhancing the detection of weak, normally undetectable, stimula- tions (Figure 1).3 Early insoles and standing balance This was an exciting finding because it suggested the introduction of SR to the human sensory system might enhance the detection of weak stimuli in persons with sensory deficits caused by normal aging, stroke, diabetes, or other neurological disorders in addition 4 Introducing stochastic resonance to the to individuals with intact, normally functioning systems. From a clin- ical perspective, in the lower extremities, this sensory feedback pro- human sensory system enhances the vides important information to the human balance control system detection of weak stimuli, which can help that, when diminished, is associated with an increased risk of falling. improve balance and reduce fall risk. Collins hypothesized that the application of SR to the soles of the feet might improve standing balance, with eventual applications in walking and fall prevention.5 To test this hypothesis, Priplata and
lermagazine.com 05.16 37 Continued from page 37 Spatiotemporal parameters of gait Certain spatiotemporal gait characteristics, which are quantifiable measures of gait function, have been associated with fall risk in peo- ple with sensory deficits. These characteristics have been tradition- ally separated into two categories: those associated with the rhythmic stepping parameters of gait, such as stride length and stride time; and those associated with the balance control parame- ters of gait, such as stride width and double-support time (the time both feet are in contact with the ground).11 High variability in the rhythmic stepping parameters of gait is generally associated with gait instability and fall risk, as is high vari- ability in the sway parameters measured during standing bal- ance.12,13 Interestingly, both high and low variability in the balance control parameters of gait have been associated with gait instability, with the understanding that some moderate level of variability is re- quired for stability.12,14,15 For example, some step-width variability is important biomechanically because it provides a certain level of adaptability to limb movements and allows an individual to adapt and maintain stability during walking. With low step-width variability, there is no flexibility to respond to perturbations. On the other hand, high step-width variability is typically associated with crossing one foot in front of the other dur- ing walking, which can narrow and offset the base of support and is Figure 1. The theory behind how stochastic resonance (SR) may improve tactile sen- a clinical indicator of unsteady walking. sation is illustrated here. A weak stimulus below an individual’s threshold of percep- tion is enhanced by the inclusion of subsensory stochastic resonance noise. The Using SR to improve dynamic balance subsensory SR noise acts as a pedestal from which the transmission capabilities of From a clinical perspective, SR applied to the plantar surface of the stimuli are enhanced, allowing the human sensory system to detect subthreshold feet could improve dynamic balance during gait in two ways: first, stimuli. by reducing high variability in the rhythmic stepping parameters of colleagues designed a series of experiments using a pair of large gait; and second, by increasing the variability in the balance control stationary devices modeled after insoles (Figure 2A).6-8 parameters of gait for the least variable walkers or decreasing the Their experiments measured sway parameters during quiet variability for the most variable walkers. Using a tethered sandal device similar to the pair shown in Fig- standing in young participants, elderly participants, patients with di- ure 2B, Galica and colleagues aimed to evaluate the effects of SR abetes, and patients with stroke. Their findings indicated that appli- applied to the plantar feet on the rhythmic stepping parameters of cation of SR to the plantar surface of the feet was associated with gait in healthy young adults, elderly nonfallers, and elderly fallers as reduced postural sway parameters in each of the tested popula- they walked at a self-selected pace on a circular track.13 tions. Interestingly, differential effects of SR were observed between At baseline, the elderly fallers had the highest variability in young people and those with sensory deficits (eg, elderly people, rhythmic stepping parameters (stride time, stance time, swing time), patients with diabetes, patients with stroke). followed by the elderly nonfallers and the healthy, young partici- The authors suggested the young, healthy participants were al- pants. With the introduction of SR to the plantar surface of the feet, ready operating at a near optimum level of sensory function. There- reductions in variability were observed for each of the rhythmic stepping parameters in all three participant populations. Moreover, fore, the capacity for improvement in standing balance with SR the largest reductions were observed in the most variable walkers appears to depend on the baseline level of sensory impairment. The (elderly fallers), followed by the elderly nonfallers, and then the observed balance improvements lead to the question of whether young participants (these participants did not experience statistically the SR phenomenon would be effective in enhancing performance significant reductions). of activities involving dynamic balance, such as walking. This was the first study to show that SR applied to the plantar The vast majority of falls and fall-related injuries in persons with feet during the gait cycle can reduce rhythmic stepping variability sensory deficits occur while walking or doing walking-related activ- in elderly participants who are at risk of falling. ities.9,10 Therefore, the early stationary SR devices needed to be re- Although rhythmic stepping parameters are important for the designed for in-shoe use in order to perform studies investigating clinical potential of SR technology, it’s generally accepted that bal- ance control parameters of gait are more closely associated with dynamic balance activities. Actuators were first placed in sandals to falls and better predict fall risk. As mentioned, affecting the balance permit walking and then tethered with cables to the signal electron- control parameters is a two-way proposition. That is, the most vari- ics and batteries (Figure 2B). This new iteration provided a platform able walkers may need to reduce their variability to steady their to investigate the effects of SR on gait in healthy and at-risk patient populations. Continued on page 40
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%UHFNHQULGJH3NZ\6XLWH*7DPSD)/Ť3+ Ť) * One time setup fee per design and minimum order quantity applies Continued from page 38 improvements associated with SR in that population.6,13 walking, and the least variable walkers may need to increase their During normal locomotion, healthy young persons are not at variability to introduce a certain level of adaptability in limb move- risk for falls or fall-related injuries, and their somatosensory systems ments while walking. Therefore, proprioceptive improvements from are likely operating at an optimal state with a limited capacity to im- SR that would push certain individuals into a more optimal state dif- prove. This eliminates the need for sensory-enhancing SR technol- fer from the proprioceptive improvements that would be effective ogy during typical daily activities. However, sensory deficits do in other individuals, depending on their baseline level of balance occur in healthy, young people performing vigorous activities that 16-18 control variability. cause fatigue. These sensory deficits can place them at higher In a follow-up study, Stephen and colleagues set out to test risk for slip-, trip-, and fall-related injuries when they are competing whether SR exerted a baseline-dependent effect on the balance in long, strenuous athletic activities or military marches. control parameters of gait in elderly participants.12 Using the same With a newly designed three-quarter-length insole device that tethered sandals, similar to the pair shown in Figure 2B, the authors uses a tethered control program (Figure 2C), we set out to test the investigated the effect of SR on stride length and stride width while effect of fatigue. We induced fatigue through a task simulating a participants walked at a constant speed on a treadmill. Confirming strenuous recreational hike or military march and measured its ef- 19 their hypothesis, the results indicated a baseline-dependent effect fects on spatiotemporal gait parameters. Our goals were to deter- of SR, where the least variable walkers demonstrated more variabil- mine if sustained vigorous walking on an inclined surface while ity, and reductions in variability were observed in those who were carrying a backpack load destabilizes gait, and if SR applied to the most variable at baseline. planar surface of the feet has a stabilizing effect. We fitted participants with a backpack weighing approximately Our recent work 30% of their body weight and fitted their standard athletic shoes To this point, the vast majority of research has focused on elderly with the new insole devices. We then asked them to walk at a self- individuals or patients with diabetes or stroke who have the poten- selected pace on a treadmill and tracked their foot position with a tial to benefit most from the sensory improvements gained from SR motion-capture system. The protocol started the participants at level applied to the plantar surface of the feet. Moreover, the observed ground and increased the incline by 2% every five minutes until improvements appear to be greatest for the individuals with the participants reached volitional exhaustion, after which the treadmill largest sensory deficits. This trend appears to be consistent from was returned to level ground. the standing balance studies through to more recent gait studies. Throughout the protocol we applied SR to the plantar surface Despite this, the few studies that have involved healthy, young indi- of the feet in a random fashion, such that pairs of trials were recorded viduals have reported only small or trending balance and gait Continued on page 42
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Figure 2A-2D. Evolution of stochastic resonance (SR) vibrating insoles. A. Stationary SR devices modeled after insoles, designed by Priplata and colleagues.6-8 B. Actuators were first placed in sandals (pictured) to permit walking and then tethered with cables to the signal electronics and batteries.12,13 C. A newly designed three-quarter-length insole device that uses a tethered control program.19,20 D. A prototype of an SR device containing the vibrating elements, battery, and electronics that charge the device wirelessly and allow it to communicate with a computer or smartphone. in which SR was on for one minute and off for one minute. As in all young individuals who are experiencing vigorous activity and the experiments, the subsensory level of the SR signal blinded par- fatigue. ticipants the stimulus condition. We extracted spatiotemporal gait Finally, these results suggest that other athletic populations that characteristics for SR-on and SR-off conditions during the baseline become fatigued during training or competition may get injury pre- level-ground walking period, the period just prior to reaching voli- vention or performance benefits from a sensory-enhancing device, tional exhaustion, and the end level-ground walking period. though additional research is needed. Our results indicated that, without SR, vigorous activity in- creased the variability in the rhythmic stepping and balance control Outstanding questions parameters of gait. Not surprisingly, our healthy, young participants We have substantial evidence that SR applied to the plantar surface had relatively low overall baseline variability. We concluded the un- of the feet improves sway parameters during quiet standing and desirable increase in rhythmic stepping variability led to a compen- spatiotemporal gait parameters during walking in elderly people, satory increase in balance control variability. people with somatosensory deficits, and healthy, young individuals. We believe this is a compensatory response, in which the rela- In parallel, we have seen substantial engineering effort put into the tively low baseline variability is pushed to a heighted state of adapt- sensory improvement devices. They have evolved from bulky static ability to stabilize each participant’s gait during vigorous activity. If gel insoles to a form factor modeled after a standard three-quarter- so, we hypothesized, the introduction of SR would enhance stimulus length insole device. Despite the research promise and device de- detection while fatigued, resulting in a reduction in rhythmic step- velopment, additional research questions remain, and a fine-tuning ping variability and an increase in balance control variability. of the device design is needed to bring this technology to the clinic We observed no effect during any part of the task when SR was or sports equipment store. on compared to when it was off for the rhythmic stepping parame- From a research standpoint, questions about the longevity of ters. However, we did observe an increase in the variability of the beneficial effects, as well as the amplitude range of subthreshold balance control parameters throughout the task when SR was turned on compared to the off condition, independent of fatigue stimulation, still remain. Each study mentioned in this review used state. Therefore, applying SR resulted in additional benefits to bal- a level 10% below each participant’s sensory perception threshold. ance control parameters of gait that may improve stability in healthy, Continued on page 44
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sales@amfit.com . +1-800-356-3668 . AMFIT.COM . @Amfitinc Continued from page 42 The study provided strong evidence that individual sensory per- ception thresholds are relatively stable and that SR technology is not an acute phenomenon. Furthermore, SR levels set at 15% and 30% below the perception threshold were equal to each other in Recent advancements in battery, charging, effectiveness. These findings suggest SR is not an acute phenome- and microelectronic technology could make non, and greatly simplify setting the subsensory threshold stimula- a self-contained stochastic resonance tion level of a future, commercially available device. insole device possible in the near future. Te future of SR devices From a device development standpoint, recent advancements in battery, charging, and microelectronic technology could make a self- However, would 15% or even 30% below the threshold still provide contained insole device possible in the near future. A device similar the desired effect? It is also unclear if the sensory benefits are acute to the prototype shown in Figure 2D could contain the vibrating ele- or persist over a long duration. Furthermore, not much is known ments, battery, and electronics that charge the device wirelessly and about how stable an individual’s sensory perception threshold is. allow it to communicate with a computer or smartphone. Such a de- Does the threshold vary throughout the day or over the course of vice would appear indistinguishable from the replacement insoles multiple days? Most importantly, all of the research to date has been found on drugstore shelves and sports equipment stores. limited to measurements quantifying sway and spatiotemporal gait Most importantly, this device could be deployed in large clinical parameters. These metrics are associated with falling and injury risk, studies to establish a direct link between SR and injury risk in people but it is still unclear if SR technology will translate to actual reduc- with sensory deficits as well as in healthy individuals. The hope is tions in falls and injury rates among at-risk elderly people, patients that, soon, people will be able to come to the clinic or store, have with sensory deficits, athletes, or military personnel. their sensory threshold determined, and then be fitted with a device Some of these questions have been addressed in a recent that improves their sensation with just a little bit of noise. study from Lipsitz and colleagues, who tracked a small group of eld- Daniel Miranda, PhD, is a technology development fellow; Wen-Hao erly persons using the shoe-mounted three-quarter-length insoles Hsu, ScD, is a postdoctoral research fellow; and James Niemi, MS, (shown in Figure 2C).20 The investigators sought to determine is a lead senior staff engineer at the Wyss Institute at Harvard Uni- whether the balance and gait improvements would persist through- versity in Boston. out a day, whether sensory thresholds were consistent, and whether different levels of SR could still achieve the same beneficial effect. References are available at lermagazine.com.
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Hip strength asymmetry has been observed in patients with existing patello femoral pain syndrome (PFPS) and poten tially could be used to screen for at-risk individuals. How- ever, new findings suggest this type of asymmetry does not appear to be associ- ated with early stage PFPS.
By Franklin Caldera, DO, MBA; and Christopher Plastaras, MD
Patellofemoral pain syndrome (PFPS) is one of the most common overuse knee injuries seen in sports medicine and orthopedic clin- ics. Here, the term “overuse” injury refers to the effects of repeated minor trauma to the knee joint. The trauma is usually from recre- ational or competitive jumping or running as a sport or part of a sport. The injury occurs gradually and symptoms may not at first in- terfere with participation.1 The most common symptom of PFPS is diffuse anterior knee pain around the patella. Individuals have difficulty describing the lo- cation of the pain and when doing so may place their hands over the anterior patella in a circular motion (the “circle sign”).2 Pain usu- ally occurs when the knee extensor muscles experience load, such as when ascending or descending stairs or when doing slopes, squatting, kneeling, or running; it can also occur following pro- longed sitting with flexed knees (the “theater sign”).3 PFPS can be seen in both men and women who participate in running and running-related sports. It accounts for approximately 25% of all knee injuries.4 Reliable clinical diagnostic tests have not been developed yet, so diagnosis is typically made based on a clin- Istockphoto.com #22048190 ical exam and exclusion of other causes, such as intraarticular pathologies, patellar tendinopathy, and plica syndrome.5 PFPS and hip abduction in women Many studies have shown that women are at higher risk of devel- oping PFPS than men.6 One study reported the ratio of female to male patients with PFPS is as high as three to one.7 Many factors have been suggested as possible causes of PFPS, including an The easiest way to identify hip strength increased Q angle, patella alta, abnormal or excessive foot pro - nation, vastus medialis muscle weakness, hip abductor weakness, deficits associated with PFPS—to facilitate decreased flexibility of the hamstring muscles, and malalignment of early intervention—would be to assess the femur.8,9 It has also been suggested that anatomic, hormonal, between-limb hip strength symmetry. and neuromuscular factors contribute to women’s greater risk of developing PFPS.10 Several studies have reported that hip kinematics during running
lermagazine.com 05.16 47 Continued from page 47 women with PFPS, and that the symptom improvement was sus- differ between healthy men and women, and these differences may tained six months after the strengthening intervention.21 Ferber et help explain the gender differences in PFPS incidence. In their land- al observed that increased hip strength was associated with re- mark paper on the condition, Powers et al noted that women exhibit duced pain in individuals with PFPS. Those improvements were not greater internal rotation of the femur and larger hip adduction dur- associated with any change in lower extremity kinematics, but the ing running than men.11 Fer- study included both men and women with ber et al reported significantly PFPS.22 Those findings contrast with those of greater peak hip adduction Baldon Rde et al, who found that improve- and hip internal rotation dur- ment in gluteus medius strength had a me- ing the stance phase of run- diating effect on frontal plane trunk and hip ning in female recreational kinematics in female athletes with PFPS.23 runners compared with their It would be clinically useful to be able to male counterparts.12 Willson identify hip strength deficits in the early et al also found female run- stages of PFPS so that strengthening inter- ners had greater hip adduc- ventions could be implemented before tion than male runners both symptoms become severe. The most con- at initial contact and at the venient way to do this would be to compare time of peak vertical ground hip strength in the affected and unaffected reaction force.13 limbs, based on the assumption that hip Studies of female runners strength would be more symmetrical in have also reported that hip healthy individuals than in individuals with or kinematics differ between run- at risk for PFPS. We conducted a study to ad- ners with PFPS and healthy in- dress this issue. dividuals. Noehren et al found greater peak hip adduction and hip internal rotation dur- ing running in women with PFPS than in healthy con- trols;14 in a prospective study, the same group found female runners with greater hip ad- duction at baseline were the ones most likely to develop PFPS.15 Souza and Powers also found greater peak hip internal rotation in female run- ners with PFPS during multiple activities than in healthy con- Istockphoto.com #57541174 trols.16 Cichanowski17 and Ireland18 theorized the kinematics of the lower extremity associated with PFPS might change as a result of deficits in hip muscle strength. Gluteal weakness has been impli- cated in other knee pain syndromes, such as iliotibial band syn- drome.19 In female athletes with unilateral PFPS, Cichanowski et al found less hip abduction strength and hip external rotation strength in the affected leg compared with the unaffected leg and compared with the corresponding limb of healthy controls. Ireland et al also reported that young women with PFPS were more likely than con- trols to demonstrate weak hip abductors and external rotators. In their aforementioned study, Souza and Powers found that female runners with PFPS had less hip abductor strength and hip extensor strength than healthy controls, as well as altered kinematics.16 Istockphoto.com #42628700 The success of hip-strengthening programs in individuals with PFPS also supports the theory that deficits in hip muscle strength contribute to PFPS development. Dolak et al found that improve- Our research ment in hip abductor strength was associated with improvement in In designing our study, we considered studies such as Magalhaes symptoms in women with PFPS.20 Khayambashi et al found similar et al24 and Robinson and Nee.25 These studies investigated hip ab- symptom improvement associated with increased hip strength in duction strength symmetry in female patients with PFPS and Continued on page 50
48 05.16 lermagazine.com
Continued from page 48
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reported 12% and 22% reduction, respectively, in hip strength of the leg with PFPS compared with the unaffected side. Both studies included control groups. Magalhaes et al reported that the hip ab- ductors, lateral rotators, and flexors and extensors on the injured The Exos groundbreaking thermoformable side of those with unilateral PFPS were significantly weaker than in those without the pain syndrome; only the hip abductors, however, material can be fully customized and formed were significantly weaker on the injured side than the uninjured side to a patient within 30 minutes providing in those with PFPS (20%, p < .05). functional stabilization of the foot-ankle In a secondary analysis, Robinson and Nee found that the complex to address PTTD, long term chronic symptomatic limbs of participants with PFPS had less hip extension injuries and post-op rehab. strength (p < .001), less hip abduction strength (p = .007), and less hip external rotation strength (p = .04) compared with the control’s Customizable and easy to fit - with minimal weaker limb. Cichanowski et al also showed less hip abduction, ex- cost to the practice and patient. ternal rotation, and extension strength in female patients with PFPS than in healthy controls.17 Exos Free Motion Ankle. More than a brace. Our study was prospective. We recruited 21 study volunteers A diference in treatment. (female runners with early PFPS) and 36 healthy controls using flyers and recruitment in the vendor section at local road races, half To learn more about the future call marathons, triathlons, and running club meetings in a metropolitan area. The participants were women aged between 18 and 45 years 800-793-6065 or visit djoglobal.com. who ran at least 10 miles per week. We defined early PFPS with the following criteria: a report of unilateral anterior knee pain associated with running once per week for at least six weeks, pain with a single- ©2016 DJO, LLC leg squat, compression of the patella into the femoral condyles, and pain with palpation of the anterior surface of the patella.
Continued on page 52
50 05.16 lermagazine.com
Continued from page 50
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Istockphoto.com #26901568 FoamArt Fitting Kit Available through Justin Blair & After telephone prescreening, we did an assessment using four Company stations to gather further data needed to include or exclude pa- tients. First-station participants filled out an autobiographical ques- tionnaire. At the second station, participants underwent bilateral hip strength testing by a single trained examiner blinded to the groups. Hip strength was tested in a neutral position to recruit the tensor fasciae lata muscle and in an extended position to recruit the glu- teus medius muscle.19 At the third station, an examiner blinded to Apex Foamart®, used to create accurate 3D foot the group measured participants’ height, weight, and leg length dis- crepancy. At the fourth station, participants underwent a focused images, is the industry standard in impression physical examination of the knee by another examiner blinded to foam. Available in 2 mainstream sizes: group assignment. Analysis of baseline characteristics of the group of women with 2” x 6” x 12” 2” x 6” x 14” early unilateral PFPS and controls did not show significant differ- #1123 - Mailer #1124 - Mailer ences between the two for height, weight, age, leg length discrep- #1122 - Bulk #1125 - Bulk ancy, or weekly running mileage. We calculated hip abductor strength complex asymmetry using Contact us today to receive a free sample the Hip Strength Asymmetry Index (HSAI). P values greater than .05 were considered statistically significant. Female runners with early FABRICATING CAPABILITIES symptoms of PFPS did not appear to have clinically significant hip abduction strength asymmetry compared with healthy controls. HSAI values for the hip abductors with 95% confidence intervals SHEETS LAMINATES BLOCKERS PADS DIE-CUTTING WEDGES did not differ significantly between the runners with PFPS and the controls (p = .2272 when tested in the neutral position, p = .6671 when tested in extension). Doing business, made easy! Our study found the affected PFPS limb was stronger than the
Carboplast® is a registered trademarks of Aetrex Worldwide, Inc. weaker limb of the controls (in the neutral position) and not signifi- FoamArt is a registered trademark of OHI, Inc. Continued on page 54
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Continued from page 52 Conclusion cantly different from the unaffected limb in the PFPS patients. Both During our literature review we came across multiple studies that findings were unexpected and in contrast with previous studies. The showed weakness in hip muscle strength in patients with PFPS. asymmetry may be theoretically explained by the fact that the tensor However, it remains unclear if the deficit in hip abduction strength fascia lata and the gluteus medius are engaged during strength test- is a cause or effect of PFPS; it’s the classic “chicken or egg” ques- ing in the neutral position. The tensor fascia lata may be engaged tion—which came first, the symptoms or the underlying hip weak- more significantly in early stages of PFPS; this would help to unload ness? Herbst et al’s27 prospective study showed that female athletes stress on the knee, leading to stronger abductors on the affected who develop PFPS may actually have greater hip abduction strength side when tested in neutral. Our findings of no significant asymmetry at baseline than those who do not develop PFPS, which seems to in the PFPS patients could indicate that the imbalance takes time to suggest that any subsequent strength deficits are more likely to be develop, and therefore may not be measurable until the later stages an effect of PFPS than a cause. of PFPS. Further studies are needed to dissect out which mechanism leads to PFPS. Furthermore, no studies have yet assessed hip mus- Clinical implications cle endurance and PFPS, which may be important as the syndrome Studies have shown that women with PFPS have less hip abduction occurs predominantly in endurance sports. strength on the affected side compared with the hip strength in the The cause of PFPS is still poorly understood and the mecha- 26 20 asymptomatic controls. Dolak et al showed strengthening of hip nism of injury needs further study to facilitate development of clin- abductor muscles during rehabilitation in early phases of PFPS de- ically useful screening tests. Further study of the evolution of creases symptoms more quickly, so, if weakness or asymmetry asso- patellofemoral pain may help to prevent the occurrence of this ciated with worsening of PFPS could be identified early, then pathology. interventions could be implemented before symptoms progress to clinical relevance. We performed our study to develop a prescreening Franklin Caldera, DO, MBA, and Christopher Plastaras, MD, are as- tool for female athletes in the early stages of PFPS, but did not find sistant professors in the Department of Physical Medicine and Re- any evidence of hip abduction strength asymmetry at this early stage. habilitation at the University of Pennsylvania Perelman School of Accepting that hip strength testing is difficult to quantify, we be- Medicine in Philadelphia. Plastaras is also director of the Spine, lieve our methods were the best that are currently available. How- Sports, & Musculoskeletal Medicine Fellowship at the University of ever, our results indicate that, unlike PFPS patients seeking medical Pennsylvania. care, women with early PFPS do not appear to have significant hip abduction strength asymmetry. References are available at lermagazine.com.
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X-Trac Knee ActivMotion Bar Structured Memory BetterDoctor Support From OPTP Foam Footwear Websites
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Össur Unloader Apex Spring Contender Post-op Quell Nerve Hip OA Brace Shoes and Boots Knee Brace Stimulation
Össur announces the launch of New from Apex is the 2016 Corflex introduces the Con- Quell utilizes NeuroMetrix’s the Unloader Hip, a unique Spring Collection of shoes and tender Post-Op Knee Brace. patented, wearable intensive brace intended to provide relief boots, designed with a fresh fo- The brace features a simple ad- nerve stimulation (WINS) tech- for patients with mild to moder- cus on style. Spring boots in- justment system to minimize fit nology to provide drug free, ate hip osteoarthritis (OA). The clude the Black A4000M and time after surgery and weighs widespread relief from chronic Unloader Hip is designed to im- Brown A4100M, which include just 27 oz. The ZipTrak Tele- pain. Worn just below the knee prove mobility by using com- an ankle strap for adjustability, scoping System adjusts brace and activated by clicking a but- pression to encourage external bungee lace detailing, 5/16" length from 18" to 26" in 1/8" ton, Quell stimulates the sen- rotation and abduction of the removable depth, a full grain increments and allows for the sory nerves to trigger the femoral head during gait, which leather upper, a polyurethane adjustment of intermediate cuffs body’s natural pain relief system helps reduce load on the af- outsole, and a padded tongue to help avoid incision sites. The and block pain signals in the fected joint. Compression of the and collar. Also available are X-Flex Cuff System, which flexes body. Designed for people who affected area also provides pro- classic lace boat shoes and to hug the leg, and a latex-free experience leg and foot pain, prioceptive support. Made of classic strap boat shoes; both foam liner help reduce brace arthritic pain, and nerve pain, breathable Lycra and elastic, the feature 5/16" removable depth migration. QuikZip Buckles al- Quell is FDA-approved for use lightweight brace features the in two layers, full grain leather low for easy application and during the day, while active, and company’s SmartDosing sys- uppers, and nonslip rubber out- strap adjustment for a secure while sleeping at night. The slim, tem, which allows patients to soles. The Spring Collection fit. Lightweight, custom-bend- lightweight device is recharge- adjust the fit to best suit their also includes men’s Bolt and able, aircraft-grade aluminum able; the newest model features comfort and activity level. women’s Breeze athletic knit uprights are notched to assist up to 25% extra battery life. Össur lace ups. in contouring. NeuroMetrix 800/233-6263 Apex Corflex 800/204-6577 ossur.com 800/252-2739 800/426-7353 quellrelief.com apexfoot.com corflex.com
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Vantage Camera Jellyfeet Cloudflyer Coral Bone From Vicon Foot Covers Footwear Supplements
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60 05.16 lermagazine.com market mechanics By Emily Delzell
AOPA continues to fight amputee BOC to drop O&P, pedorthic certifications coverage limitations at policy forum The Owings Mills, MD-based the professions’ credentialing Board of Certification/Accredita- options, according to a BOC re- The Washington, DC-based Capitol Hill in more than 400 tion (BOC)’s Board of Directors lease that also noted the organ- American Orthotic & Prosthetic meetings with legislators, seek- in May approved a plan to sunset ization will continue to provide Association (AOPA) on May 2 ing their support for the new bill the acceptance of new applica- assistance to all BOC-certified wrapped up its 2016 Policy Fo- and related proposed legislation. tions for its orthotist (BOCO), professionals in meeting con- rum with its first-ever O&P Leg- Less than a week before, on prosthetist (BOCP), and pedor- tinuing education requirements, islation-writing Congress. April 21, AOPA reported in a thist (BOCPD) certifications. renewing their certifications, Former Nebraska governor conference call with the media The decision will lead to and helping them deliver the and senator Bob Kerrey led the that private insurers are exploit- greater growth opportunities for highest level of quality patient congress, at which attendees au- ing the proposed LCD to deny the organization and streamline care. thored a bill to address problems coverage to amputees for previ- that are undercutting quality of ously approved medical care care for O&P patients who are and devices. Homisak joins OHI central casting Medicare beneficiaries, accord- During the call two am- Hauppauge, NY-based OHI on strategies for podiatrists and ing an AOPA release. putees told reporters about their May 3 announced the appoint- their staffs. She won the 2010 Rep. Renee Ellmers (R-NC) experiences with United Health- ment of Lynn Homisak, PRT, Podiatry Management Lifetime was the opening keynote speak - care coverage denials. AOPA CHC, as central casting program Achieve ment Award and is in the er for the Policy Forum, and Sen. also produced a February letter consultant for the company’s on- Podiatry Management Hall of Mark Warner (D-VA) and Rep. from six groups, including the demand pedorthic service. Fame. Tammy Duckworth (D-IL) pro- Amputee Coalition, urging Cigna Homisak, principal owner of OHI’s central casting pro- vided insight on the congres- to reverse a late 2015 coverage Seattle-based SOS Healthcare gram, launched in 2014, is avail- sional perspective. All three leg- statement that is being used by Management Solutions, is an able in 20 states, and, accord- islators shared their concerns the company to deny coverage award-winning consultant and ing to the company, contributed about the proposed LCD (local to amputees. management coach known for more than $8 million in revenue coverage determination) and AOPA offered thanks to its developing and facilitating suc- to participating practices in other restraints that hinder ad- 2016 Policy Forum sponsors: cessful practice management 2015. vanced and timely patient care. WillowWood, Spinal Technology, Kerrey also met with eight Ottobock, Becker Orthopedic, Nolaro24 continues live web series senators to explain the bill and Fillauer, Cascade Orthopedic how to “rectify the problems and Supply, Townsend Design, Össur Middlebury, CT-based Nolaro24 hours each, are scheduled injustices unnecessarily burden- Americas, Anatomical Concepts, in May announced dates for its through June 20. Each course ing Medicare beneficiaries and PEL, Knit-Rite, KISS Technolo- upcoming live webinar series on costs $75, and Nolaro24 is of- the O&P professionals commit- gies, Freedom Innovations, Allard biomechanics. The six new we- fering discounts for those who ted to providing care for those USA, SPS, TRS, Cailor Fleming binars, which the ABC (American register for multiple courses. patients,” AOPA reported. And, Insurance, Tamarack Habilitation Board for Certification in Or- Go to nolaro24.com/educa on April 27, 135 O&P providers Technologies, and Ability Dy- thotics, Prosthetics, & Pedorthics) tion.html for complete webinar and patients spent the day on namics. has approved for 1.5 contact descriptions and agendas. IOF evaluates osteoporosis medications ING gives $60K to fund RMPI tuition The International Osteoporosis The panel concluded there The Elwood, IN-based Robert M. ory, NC, donated $60,000 to Foundation (IOF) Fracture Work- was no negative effect of os- Palmer, MD, Institute of Biome- reduce RMPI’s published tui - ing Group in April published its teoporosis medications on frac- chanics (RMPI) reported that tion for some of its pedorthic conclusions on the effect of os- ture healing, and that it is safe OrthoSleeve brand maker ING precertification courses from teoporosis medications on frac- to start osteoporosis medica- Source has committed to a second $4000 to $2500 annually. To ture healing. tions as soon as possible after year of scholarship support for stu- qualify for the reduced tuition, Key conclusions included: both vertebral and nonvertebral dents of the nonprofit institute. submit applications at rmpi.org Delayed fracture healing is com- fracture. However, the panel ING Source, based in Hick- before May 31. mon and practitioners should agreed that, after the occur- strive for early recognition and rence of an atypical femur frac- Book focuses on pain biomechanics treatment; antiresorptives such ture, bisphosphonate therapy Stuart Goldman, DPM, a board- The book emphasizes recog- as bisphosphonates may delay should be stopped. Treatment certified foot and ankle surgeon nizing the root cause of conditions fracture healing, but the risk is with an anabolic agent such as who practices at Help for Your such as arthritis, fibro myalgia, and low; and anabolic agents such teriparatide should be consid- Feet in Owing Mills, MD, recently spinal stenosis, and reducing pain as teriparatide that enhance os- ered to improve healing. published his book, Walking Well through improved gait mechanics. teoblastic bone formation may Osteoporosis International Again: Neutralize the Hidden The book is for sale on have a beneficial effect on frac- epublished the statement on Causes of Pain. Amazon. ture healing. April 25. Continued on page 62
lermagazine.com 05.16 61 market mechanics
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Össur’s new hip OA brace reduces pain JAS acquires Empi Advance ROM line Results from a small study of of the study on April 26. Effingham, IL-based Joint Active JAS is adding the Empi Ad- Reykjavik, Iceland-based Össur’s For its patient with lower Systems (JAS) reported on May vance ROM product line to its new Hip Unloader brace pub- limb loss, Össur on May 4 3 that it has acquired the Empi Static Progressive Stretch (SPS) lished in April showed nine of launched #MyWinningMoment, Advance ROM line of dynamic Range of Motion (ROM) therapy the 14 participants with unilateral an online contest celebrating braces from Empi, a subsidiary to reinforce its role as a single- symptomatic hip osteoarthritis mobility. of San Diego-based DJO Global. source provider for ROM ther- (OA) reported an immediate re- Adults with lower limb loss JAS plans to reintroduce the apy, according to a company re- duction in pain with application can share their stories via photo Empi Advance ROM line by July. lease. of the device. or video on the mywinningmo The brace, which Össur ment.com website through May launched in the US in May (see 31 for a chance to win a four- Spenco runs social media contest “Ös̈ sur Unloader Hip OA Brace,” day, three-night trip for two peo- Waco, TX-based Spenco Medical to one winner. To enter, use the page 59), also significantly de- ple to Reykjavik. is honoring May as National hashtag #SpencoJourney and creased peak hip abduction mo- Entries will be judged based Physical Fitness and Sports post a photo, video, or written ment on the OA side as well as on story, originality, proper use Month by offering an incentive statement to share your fitness peak hip adduction and internal of prosthetic, composition, and to people who share their fitness journey on Twitter, Facebook, or rotation angles during stance. subject. Entrants must be 18 journey on social media. Instagram. The President’s Coun- The study authors, from the years or older with lower limb Spenco, which in April cil on Fitness, Sports & Nutrition University of Iceland in Reykjavik, loss and able to travel before the posted a new video to support sponsors National Physical Fit- concluded the brace appears to end of 2016. foot care awareness (youtube ness and Sports Month. During reduce compressive joint reac- Get more information and .com/watch?v=yO8w3-3Vff4), May, all adults are challenged to tion force at the femoroacetab- submit entries for free at mywin will award a $100 product get 30 minutes of daily physical ular interface and may offer an ningmoment.com. Entries are voucher each week during May activity. alternative for hip OA patients being continually refreshed on not ready for hip replacement. the website, and Össur is also Prosthetics and Orthotics In- showcasing submissions on its Vorum, Nia join for 3D-printed devices ternational epublished the results social media channels. Vancouver, Canada-based CAD- productivity gains are crucial in CAM software company Vorum low-income countries like Ugan - Diabetes drug Invokana under scrutiny in May announced a partnership da, where it is estimated that only with Nia Technologies to deliver 12 practicing orthopedic tech- Beerse, Belgium-based Janssen Committee has asked Janssen 3D-printed orthotics and pros- nologists serve more than Pharmaceutical’s top-selling dia- for more information about thetics to children in developing 90,000 disabled children in betes drug Invokana (canagli- whether Invokana triggered a countries. need of O&P devices, according flozin) continued to come under spike in lower-limb amputations. Nia Technologies, a Cana- to a press release from the com- scrutiny in April and May with An ongoing clinical trial of about dian nonprofit based in Toronto, panies. new lawsuits filed, along with 4000 patients with type 2 dia- will integrate Vorum’s Canfit 3D Clinical trials of 3D PrintAbil- questioning from the European betes treated daily with either design software into its 3D Print- ity for transtibial prosthetic sock- Medicines Agency (EMA) about 100 mg or 300 mg of Invokana Ability solution. 3D PrintAbility is ets and ankle foot orthoses are serious potential adverse effects. or a placebo has so far has shown a digital toolchain designed to scheduled to begin in coming Lawsuits in the US and higher rates of lower limb ampu- significantly reduce the time re- months at CoRSU (Comprehen- Canada allege that patients tation in the Invokana groups. quired to produce customized sive Rehabilitation Services in weren’t warned about serious The Food and Drug Admin- O&P devices for young people Uganda) Rehabilitation Hospital risks, including diabetic ketoaci- istration in 2015 strengthened In- in the developing world. Large in Kisubi. dosis, of the drug, a sodium- vokana’s label warning to include glucose cotransporter-2 (SGLT2). information about an increased In addition, the EMA’s Pharma- risk of bone fractures associated Bauerfeind teams up with Mavs’ Nowitzki covigilance Risk Assessment with use of the drug. Tampa, FL-based Bauerfeind case of Bauerfeind’s GenuTrain USA in April hosted healthcare knee braces, and seats at a Freedom Innovations taps new CEO professionals and business part- game between the Dallas Mav- ners in Dallas for a two-day event ericks and Houston Rockets. In Freedom Innovation’s Board of board’s Technology and Product featuring Dirk Nowitzki, star for- a close game, Nowitzki provided Directors on April 26 named Portfolio Committee. ward for the Dallas Mavericks a critical blocked shot to lead David A. Smith chair and CEO of Smith most recently served and Bauerfeind global brand am- the Mavericks to an 88-86 win. the Irvine, CA-based company. as partner at San Francisco- bassador. Nowitzki met for a Q&A session Former chair and CEO May- based Health Evolution Partners. About 50 attendees came with the Bauerfeind team and nard Carkhuff will assume the Before that he was chair and to the event, which included the spoke about the impact that role of vice chair and chief inno- CEO of PSS World Medical in relaunch of the updated Spinova Bauerfeind’s GenuTrain knee vation officer and chair the Jacksonville, FL. back brace product line, a show- brace has had on his career.
62 05.16 lermagazine.com
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