Nasreen Haideri

Ankle-foot orthoses for preambulatory children with spastic diplegia

We evaluated the effect of articulating and solid ankle-foot orthoses (AFOs) on the transitional movement of sit-to-stand for 15 children aged 2-5 years with spastic diplegia and dynamic equinus. Kinematic and kinetic data were collected for each child. The time to reach stable standing was determined by using a force plate. Seven children were comparable to age-matched normals while barefoot and were slowed by the use of AFOs. Eight patients were more than 1 standard deviation slower than normals while barefoot. All were significantly (p < 0.003) improved by the use of articulating AFOs. The clinical difference between these groups was the presence of equinus during stable standing while barefoot for patients aided by AFOs, whereas the second group remained plantigrade barefoot. We conclude that children with spastic diplegia with uncontrolled dynamic equinus benefit from the use of articulating AFOs for the movement of sit-to-stand.

The effect of scoliosis fusion on spinal motion : A comparison of fused and nonfused patients with idiopathic scoliosis

Study Design. Movement analysis of spinal motion. Objective. To compare spinal motion among females with normal spines, those with idiopathic scoliosis who had not had spinal fusion, and those who had undergone fusion for idiopathic scoliosis. Summary of Background Data. Previous reports have documented loss of spinal motion following fusion for idiopathic scoliosis in adolescents and adults. To our knowledge, comparison to control groups both with and without scoliosis that have not had spinal fusions has not been performed to date. Methods. A total of 91 females between the ages of 15 and 28 years underwent computerized movement analysis. There were 34 fused patients, 32 unfused patients, and 25 healthy controls. The fused patients were divided into 3 groups: (1) 21 patients who had thoracic fusions that extended distally to T11, T12, or L1; (2) 6 patients with thoracic fusions ending at L2; and (3) 7 patients with thoracolumbar or lumbar fusions extending to L3 or L4. Marker triads were placed at C7–T1, T12–L1, and on the pelvis. Forward bend, extension, and left and right lateral bend were measured and divided into thoracic and lumbar motion. Results. There was no difference in any motion between the control and unfused groups. There was overall 25% less total spinal motion in the surgical groups compared to the unfused group. Patients who had thoracic fusions had diminished thoracic motion, especially lateral bending, whereas those who had lumbar fusions had the least lumbar motion, particularly on forward bend and lateral bend maneuvers. There was no compensatory hypermobility of the unfused segments in the surgical group. Conclusions. Diminished spinal motion can be measured in patients who have had spinal fusions. Although stiffness in the operated curves should be expected, compensatory hypermobility in the unfused segments does not occur, resulting in a net loss of flexibility compared to controls.

Comparative study of conventional hip-knee-ankle-foot orthoses versus reciprocating-gait orthoses for children with high-level paraparesis.

We evaluated eight children with thoracic or high lumbar-level paraparesis for metabolic performance while ambulating with custom fabricated thermoplastic hip-knee-ankle-foot orthoses (HKAFOs) and reciprocating-gait orthoses (RGOs). Seven of the eight children had myelomeningocele. Each patient was tested in both systems at self-selected speeds in a crossover study design. At self-selected speeds, the level of exercise intensity for both thoracic and high-lumbar patients with either orthosis was lower than that for normal children. The average metabolic cost of walking in the RGO was twice that of normal children, as compared with six times normal in HKAFOs. For the four thoracic-level patients, there was a significantly higher oxygen cost of ambulation in using HKAFOs versus RGOs. No significant difference in metabolic performance was found for the high-lumbar patients. Velocity of ambulation was faster in the RGOs than in the HKAFOs. For thoracic-level patients, our data suggest that an RGO will provide a faster, more energy-efficient gait than a statically locked HKAFO. For high-lumbar patients, no significant difference was found between the two orthoses. Seven of eight children preferred the RGO over the HKAFO.

Residual gait abnormalities in surgically treated spondylolisthesis.

The authors retrospectively studied seven patients who had in situ fusion as adolescents for high-grade (IV, V) spondylolisthesis unresponsive to more conservative means. All patients achieved solid bony union; their pain was relieved; and hamstring spasm had resolved. The authors sought to determine whether crouch gait or any other abnormalities could be demonstrated in patients exhibiting clinical parameters of success. Each patient underwent gait analysis, radiographic analysis, and a physical examination. Four of seven patients demonstrated slight degrees of forward trunk lean during varying phases of gait accompanied by increased hip flexion. One patient demonstrated increased trunk extension accompanied by limited hip flexion. Two patients were essentially normal. The authors were unable to quantify residual crouch in these patients with solidly fused high-grade spondylolisthesis.

Effects of lower limb torsion on ankle kinematic data during gait analysis

VICON Clinical Manager software is widely used for gait analysis and has four methods for computing ankle plantarflexion–dorsiflexion motion and transverse plane ankle rotation profiles. The authors evaluated 14 subjects with a diagnosis of spastic cerebral palsy and tibial torsion ranging from 39° internal torsion to 90° external torsion, using the four different processing methods. It was found that clinically measured tibial torsion >20° external or >15° internal led to significant differences in the calculated ankle plantarflexion–dorsiflexion and transverse plane ankle rotation measurements between the four methods. Pearson correlations indicated that these differences increased with increasing external or internal tibial torsion. The variability was enough to affect conclusions of published articles and clinical decision making.

Terminology in Prosthetic Foot Design and Evaluation

Participants in the State-of-the-Science Conference on Prosthetic Foot/Ankle Mechanisms examined the body of scientific evidence that supports the clinical prescription and use of prosthetic foot and ankle mechanisms. This was accomplished through extensive review of literature comprised of clinical reports, perceptive analyses, and biomechanical studies. One consideration in reviewing literature on this subject was the lack of standardization regarding terminology and nomenclature. Standards for nomenclature and evaluation of prosthetic devices are under development. The International Organization for Standardization (ISO) has a technical committee (TC 168) whose missions are: 1. Establishment of a system of nomenclature and related terminology to allow all parties involved in the prosthetic/orthotic treatment of persons with disabilities to apply a standard terminology for the description of a. the users of prosthetic/orthotic devices b. the functional requirements of the devices c. the function of the components and the assembled devices d. the outcome of the delivery of the devices 2. Establishment of a system of test methods for the verification of essential requirements on prosthetic/ orthotic devices related to the safety of the users. The publications that include the standards published by this technical group (Table 1) cover most terminology required to communicate clinical information regarding treatment of patients via prosthetic services (mission 1a–c, above). In addition, a substantial sum of information exists to guide the mechanical testing of prosthetic devices (mission 2). A common nomenclature to guide the design and evaluation of human subjects testing (mission 1d) is lacking. Development of this nomenclature may be slowed because of the wide variety of professionals required to reach a consensus. To accurately communicate information regarding the prescription, fabrication, and evaluation of prosthetic devices, one must appreciate the disparities that can arise because of differences in adopted terminology. The current report highlights potential areas for confusion that warrant consideration, specifically clinical terminology, gait analysis, and the terminology of clinical biomechanics. CLINICAL TERMINOLOGY To understand the characteristics of a prosthetic foot/ankle mechanism, it is important to relate them to a normal foot. Major joints of the human foot include the ankle joint composed of the dome of the talus and distal aspect of the tibia and fibula, the subtalar joint, the midtarsal joint and the metatarso-phalangeal joints. Accordingly, movement of the foot generally is described by motion of the ankle, hindfoot, midfoot, and forefoot. In addition to motion through major joints, the foot has a strong aponeurosis that connects the calcaneus to the forefoot and upholds an arch. Sagittal plane plantar/dorsi flexion occurs through the ankle joint. The hindfoot generally is considered responsible for transverse and coronal plane rotations. According to Tachdjian’s textbook of orthopaedics, the hindfoot inverts and everts into positions of varus and valgus in the coronal plane. When the hindfoot inverts, the rest of the foot rolls onto the outer border of the foot as it supinates. When the hindfoot everts into valgus, the forefoot pronates, increasing weight bearing on the first ray. Thus, pronation and supination are movements that occur in multiple planes. The forefoot contributes to these motions by rotating along the longitudinal axis of the foot (the frontal plane). Forefoot motion in the transverse plane has been described as inversion/ internal rotation or eversion/external rotation. Internal/external rotation is preferred to avoid contradiction of coronal plane movement as described for the hindfoot; however, inversion/eversion often are used in this context. Prosthetic foot designs do not replicate exact characteristics of a normal human foot. Current prosthetic feet demonstrate some of the desired characteristics effectively but remain lacking in others.