Hello, good afternoon. I hope everybody's doing well and that you are all able to cope with this idea of doing our meetings virtually. I am Alberto Scanasi and I work in the gait and motion analysis laboratory at Moss Rehab. And with me is Dr. Danielle Moon, who is also an attending physician at the gait and motion analysis laboratory at Moss Rehab. This is an exciting course for us. I think I've done this course many times over the years at the academy and always get invited to come back. So trying to do this virtually has been a challenge, but we hope that you're going to enjoy it as much and that you will get a good educational experience. So without further ado, I'm going to get started and just disclose that we have no relevant conflict of interest for this presentation. These are the educational objectives. I hope that we will get to review basic principles of human gait, evaluate gait using video-enhanced observation, identify the timing of gait problems and the appropriate orthotic interventions, and then to select and prescribe the appropriate orthotic device to address the gait dysfunction. Finally, how do we assess functional gait improvements? We know that human gait is a complex task. It's a cyclical behavior that involves primarily the lower limbs, and it is done in a way that allows one limb at a time to have a contact with the ground. This allows the superincumbent body to move from point A to point B. We know that it is a learned pattern and that it requires little concentration, at least for healthy individuals. It is, as I mentioned before, a complex sequence of joint motions, which is highly organized, and it has very good repetibility with very tight variability. And so we know that the standard deviations of gait parameters are very small and that we, in fact, can use gait as a signature for an individual. Most of us can recognize a person by the way they walk, at least my staff recognizes when I come into their space when I'm walking in. There are two major features of gait. I'm going to talk about the fact that it is intended to translate the center of gravity, and one can use center of body mass or center of mass as part of that, and it maintains upright support of the center of mass. So these are important features because being able to stay erect is an important part of how we do walking. The center of mass is located anterior to the S2 during quiet standing. It is dynamic, meaning that its location can vary, and it varies either by changes in posture or changes in your anatomical composition. So a person who has a prominent abdomen, like a pregnant woman, would have a different position for the center of mass. Center of mass location is important because it determines in an important part where the ground reaction force is, and we'll talk about the ground reaction force in just a second. So the ground reaction force really is important because it can be seen as a way to exert pushing forces against the ground, and what you see in this image is the ability to visualize the ground of force. That's that red line that you see over-imposed or superimposed on the human body. That line, in this case, in our gait laboratory, gets produced by using a force platform, a sophisticated scale that it's embedded on the ground, and they can measure forces in a vertical as well as shear in an anterior-posterior and medial-lateral directions. And then we use a visual effect to generate this line on top of the body in real time. We know that the ground reaction exerts essentially a push, a pull on joints, and that the body really reacts to that by turning either muscle activation or a force activation, or using tendons and ligaments to control the forces. You may remember that Newton had described this in a very elegant way by saying to every action, there is a reaction of equal magnitude and of equal force and inverse magnitude. And so the idea here is that the third law of Newton applies very clearly to what we do in walking. And many people have stated that walking is essentially a continuous falling and that the ground reaction force is of great value on that. Okay, let's review some gait terminology first, as you all know, there's a stance and a swing phase. In normal individuals walking at a normal velocity, stance phase is usually 0 to 60% of the gait cycle, whereas swing phase is 60 to 100%. This may vary. And in addition, double support occupies 20% of the entire gait cycle. Here's a normal gait cycle in pictures and you can see stance phase starts at initial contact and ends at pre-swing in the last slide of that sequence. And then swing phase starts once the foot is off the ground and continues until the initial contact occurs. And here's a normal gait cycle in pictures, and you can see stance phase starts at initial contact occurs. Again, here you can see at the beginning and end of stance phase is double support, which occupies approximately 10% at the beginning and then 10% at the end before toe off occurs. Here's another slide showing initial contact, you can see it occurs in normal individuals at the heel. However, in our patients, it may occur at the midfoot or the forefoot, depending on their pathology and presentation. Following initial contact is a loading response. During loading response, it occurs at a contralateral toe off and continues on until the stance tibia is vertical with the ground. Followed by mid stance, where during mid stance, the contralateral toe is off the ground. So this is push off on the contralateral foot. And then this continues until the center of gravity of the body is over the stance foot. And then finally, there's terminal stance, where it starts with the tibia vertically, I mean, the tibia is vertical, the center of gravity over the foot, and then ends with initial contact. And then lastly, you have pre swing, which begins with the initial contact of the foot of the contralateral foot and then toe off. During swing phase, it begins with initial swing, where the foot comes off the ground. And this continues until the foot reaches maximal knee flexion. Mid swing occurs starts when the knee is at maximal flexion, and then continues until the swing limb tibia is vertical to the ground. And finally, we have terminal swing, which continues on until the swing limb makes initial contact. And then the cycle begins all over again. In addition to single and double limb support, you also need to keep an eye on the base of support, which is the distance between the feet and stance, as you can see in the picture on your right. In a normal adult, the base of support is six to 10 centimeters. In addition, you want to keep track of their spatial parameters. The key thing I like to look at is the step links. Step link meaning the heel to opposite heel distance, so it'd be right heel to left heel or left heel to right heel. Another thing is stride length, which is the heel to the ipsilateral heel. So, you know, this is a distance from the right heel strike to the next right heel strike. Another parameter to keep track of is velocity. Oftentimes, this is self-selected, but you can ask them to walk faster, as fast as they can, and you can collect this data as well. And cadence, which is the number of steps per unit of time, such as the number of steps per minute. And walking velocity is considered a predictor of health. A change in the range of velocities is a good indicator of a gait improvement. In addition, you want to look at the symmetry of the gait. So are the left and right step links equal? Etc. So now is our first polling question. So what is normal walking velocity? A, 1.2 to 1.4 meters per second. B, 0.1 to 0.14 meters per second. C, 0.5 to 0.6 meters per second. And D, 3 to 3.5 miles per second. Or meters per second. No, I'm sorry. I said miles. I meant meters. Okay. So most of you have the right answer. It is A, 1.2 to 1.4 meters per second. So normal adult velocity is 1.2 to 1.4, or average 1.3 meters per second, 3 miles per hour if you put it up to the hour, or 80 meters per minute. Cadence, which is the steps per minute or steps per hour, and normal adult is 90 to 120 steps per minute. It's important to note what the gait speed is in the individual because this can determine if they're a household ambulator, a limited community ambulator, community ambulator, or a unrestricted ambulator. Also important to keep in mind is the operational features of gait. What's the purpose of our ability to walk? The main purpose is to advance our center of gravity to go from point A to point B. In addition to that, I think most people are familiar with clearance, which is our ability to clear the swing limb without dragging or tripping over it, as well as positioning this limb. We want to be able to position it in front of us. And finally, what I think is one of the most important features is upright stability, which is our ability to keep our body upright and not collapse to the ground. Kinematics describes where the limb is in space. This refers to the movement of the limb, and more specifically, the joint angle or the angular velocity. This can be collected in great detail using motion analysis technology. Here you can see some sample kinematic curves. On the top, you have hip flexion extension, knee flexion extension, ankle dorsiflexion, plantar flexion. The positive axis refers to flexion of the hip and knee and dorsiflexion of the ankle. The gray bar refers to the normal range during normal velocity, 1.2 to 1.4 meters per second. If you overlap these together, you can see there that it's a organized, coordinated, complex sequence of joint motions that occur. And here you can see this figure shows you some of the degrees. And again, it's important to note that the range of motion for an ankle during walking is 0 to 20 degrees. That's the question I often ask my residents. And this figure shows the muscles being activated during gait. Brace biomechanics. The brace functions to control either a deforming force, correct a deformity, accommodate a deformity, or assist a motion. It's important to be aware that brace must apply at least three points of pressure to control angular movement of bowel joint. This shows you could be any joint, but let's say, for example, this is the ankle. You can see there's a force applied anterior to the ankle at the ankle joint or near it. And you also need two counter forces applied on the other side to control the motion of the ankle joint. OK. Back to you, Dr. Yee. I want to briefly talk about a study that we published a few years ago in which we looked at the effect of an ankle foot orthosis on the temporal spatial parameters of gait, specifically in patients with hemiparietis. And so what we found is that patients who received an orthotic devices were 42 subjects. And we collected data with and without the brace. And what we see is that patients' self-selected velocity, cadence, stance time, swing time, double support time, step length, and width of the base of support was collected using something called the gait mat. The gait mat is just an electronic sensor that it's embedded on the ground. And it gives us a report of the appropriate information that I listed before. In this study, we were able to demonstrate a significant increase in walking velocity, in cadence, percent stance, double support, and step length when walking with an AFO. And we also saw an improved symmetry of stance time at a p-value of 0.001 and step length of a p-value of 0.002 when using an AFO. And so we were able to conclude on the basis of this data that in a post-stroke population, an AFO improves their overall gait performance with gains in velocity and symmetry of several of the temporal spatial parameters that we measured. So let's talk a little bit about the orthotic prescription. Whenever I am asked to evaluate a patient to write a prescription for an orthosis, I always like to understand what is the problem. I want to understand where is the problem. And by that, I am referring to the hip, the knee, the ankle. Is it in the affected limb or the contralateral limb? And then when it is occurring, meaning what part of the gait cycle is occurring? Is it a swing problem? Is it a stance problem? If it's a stance problem, does it occur in early or in late stance phase? And then why is it occurring? Is this because the patient has primarily weakness or overactivity or a combination of both? And then I look at the availability of devices that may help us correct the problem or control the problem. And then, of course, of most importance is to remember the use of the correct nomenclature so that we can communicate with the brace maker, with the orthotist, in a manner that he or she can understand. So when I write a prescription for a brace, I try to be very precise in saying, I want a device that has this much motion. I want to have it within this degrees of movement for ankle dorsiflexion or plantar flexion. If I want assistance, I clearly stipulate what kind of assistance I want. If I insist in having dorsiflexion assistance, I place that in my prescription. And then, of course, what is the settings for the brace if I am using a plastic brace versus an articulating brace versus one that it's made out of metal or leather or carbon graphite or any of the other materials that are now available for construction of a brace. Since not everybody has access to a gait laboratory, one of the suggestions that I make frequently is to create a table like this. And this was given to you in our handout. You can see that this has the gait cycle divided by the faces that Dr. Moon suggested to us. And then the different components of the body, head, arms, and trunk, hip, knee, ankle, and foot. And when I'm assessing a patient, I usually will put just a little tick mark in the box that I think I am seeing a problem. And so that starts giving me the joint and the time in the gait that this problem is occurring. And if I have the ability to video the patient, then I just visualize that multiple times and try to fill in these boxes. So let's go into our case scenarios since this is supposed to be a case-based course. So this is the very first case. We have a 72-year-old man with a right hemiparesis post-embolic stroke about eight months prior to his presentation to us. He complains of difficulty walking primarily because he drags his right leg. He has problems with knee buckling. And that occurs when he walks without a brace or the brace that was provided to him by his physician. And his wife complains that he's a very slow walker. When we examined the patient, he has limitations in ankle dorsiflexion with a knee in extension to about minus 10 degrees. That improves when the knee is flexed to about minus five degrees. He has full plantar flexion. He has knee range of motion that is also full. The hip lacks 10 degrees of extension for the right side. He has full range for the left. And he has an ankle modified Ashworth score of two, both with a knee flexed or the knee in extension. So this is a patient walking. So as you can see, he's quite unstable. We are trying to be sure that he doesn't stumble. And I think this is gonna keep playing a few more times so that we get to assess his walking capacity. So I want you to pay attention to his walking because we're gonna discuss that shortly. I usually visualize my patients and I pick either the head or the toes and then move either from the head down or from the toes up. So that way I don't lose anything. For those that you might not be familiar with seeing patients on a double screen like this, where you have a split screen and you're seeing the AP view and the lateral view simultaneously, it just takes a little practice. Your right eye looks at the right side of the screen. Your left eye looks at the left side of the screen. And then you kind of meld them in your brain. So... Good. So we're gonna move forward on this. And this is some of the temporal spatial data for this patient. As you will see on the left side of the screen, you see the full data set, including his footprints. Left is red, right is green. And you also see normative data in the data set that is included. We use normative data that is walking velocity match. This patient walks quite slow, 0.13 meters per second. If you remember, we said that normal walking velocity was 1.2 to 1.4. So this person is walking 10 times slower and a clear indication why the wife complains that he walks slow. You also will notice that there is asymmetry in the right and left stance times, now with very different duration, where the left stance is very much increased and the swing face is markedly reduced. This clearly indicates a sense of instability. The patient feels unstable. And so spends most time on the left stance where he is more stable, little time on the swing face that allows him to move the other leg quickly. There is also a discrepancy in the step length with a shortened step length for the left side. Well, here's a little poll, Dan, you take it. Okay, what gait problems do you see in stance phase for this patient? A, increased weight bearing on the right foot, B, increased flexion of the right knee in early stance, C, increased flexion of the right knee in mid stance, D, trunk hyperextension, or E, abnormal inversion of the right ankle and foot. So we're gathering some data and we'll give it just a minute longer to see what kinds of answers we get. So some of you were very good at observing the ankle and noticing that he does have some inversion of the right foot and ankle and of course with that there is some plantar flexion. Some of you saw that there is increased flexion of the right knee in the mid stance and we saw that as instability and on a couple of occasions he had hyperextension of the knee but it was really flexion that made him hesitate and made him feel unstable. And then you see that there is a tendency for decreased weight-bearing on the right lower extremity. Some of you thought that it had been increased. So what we see here is that we can identify the gait problems in the stance phase by saying there is reduction in right foot weight bearing or right limb weight bearing. There is knee instability both with some hyperextension but prevalence of flexion. There is some trunk flexion and this may be related really more in due to his intent to compensate for the knee instability. He does need assistance for stability because you saw me and my assistant helping him and then there was no right arm swing. So the next is to look at the swing phase and so Dan you want to take that. So what gait problems do you see in swing phase for this patient? A. Right foot drop with toe drag. B. Decreased right hip and knee flexion. C. Impaired right knee extension and terminal swing phase or D. All of the above. Clearly we have a very astute audience here and you agree that the majority of patient, the majority of the problems in swing were present here. But I want to just take a minute to review that so that we clearly see what's happening here. So when you look at the swing phase this patient has two major problems. One is a problem of limb clearance. He has a foot drag during the swing phase which appears to be related to lack of dorsiflexion. So the term foot drop could be used for that. And you also notice that he has decreased hip and knee flexion. Not only it is decreased but likely is off time. It's not occurring when it needs to occur. We saw problems with limb advancement because if he's dragging his leg is hard for him to advance the leg. And so this results in a limited step length. And the patient lacks the normal terminal swing knee extension that occurs in preparation for loading. We also saw that on the opposite side he has a contralateral short step length. And as we saw in the numerical data I share with you, asymmetrical gait pattern. So the next question is what could we do for him? And as you heard in the introduction of the case, his physician had given him an orthotic device. But he found that orthotic device to not be ideal for walking. So what kinds of changes would you expect after implementing an appropriate ankle foot orthosis? Dan? A. Increase right knee hyperextension mid stance. B. Reduce right knee flexion early stance. C. Controlled right foot drop with less toe drag. D. Increase right hip and knee flexion for clearance. Or E. Both B and C. So again we have an astute audience. They are continuing to vote so we're going to wait a little bit longer give you an opportunity to digest this. And so most of you suggested both B and C with an emphasis in controlling the right foot drop with less toe drag and in achieving right knee flexion in early control of the right knee flexion in early stance phase. One of you suggested increase right hip and knee flexion for clearance. Although that would be an ideal improvement, that is not something we can usually achieve with the implementation of an ankle foot orthosis because it does not provide power to generate increased hip and knee flexion. So here you see the patient who was provided with a molded ankle foot orthosis which was set in 5 degrees of dorsiflexion and has maximum resistance. So it's a very stiff brace and it is set in 5 degrees of dorsiflexion. So I'm going to let him turn around and then we'll watch him walk again. I think I'm gonna let him play one more time so that you get a sense of his walking with the brace on. So if you pay attention there are a few things that are happening. We did correct the ankle foot posture. So I think you all will agree with that. But there is something happening at his knee and he appears unstable at the knee. So the premise that we were going to make him more stable at does not appear to be in play. And you can see that he tends to flex his knee as he's standing, kind of dropping forward. And so he ends up with a little short step on the opposite side. So I'm going to move forward and show you his data here. And it looks a little different just because of the graphics were pulled differently. But don't worry about that. What you notice here is that first of all his walking speed went up. If you remember he was walking at 0.13 meters per second. He's now walking at 0.23, I think it says, meters per second. So we nearly double his walking velocity. You will also notice that there is improvement in the asymmetry of the swing and stance ratio. And there is also some improvement in the symmetry of the step length, although it continues to be asymmetrical. So we did make good progress. We did make some gains in his walking. And so we could identify those as this patient had improvement in weight bearing through the right leg. There was continued knee instability and we saw improvement in control of the hyperextension. But now he has more early stance phase flexion. Of course, trunk flexion is improved because he no longer needs to lean forward as he is stabilizing his knee through the brace. And we are not providing him assistance anymore. He can walk on his own. The right arm continues to be paralyzed. We did not change that. So here he is using the brace and I want to kind of break down the process that we saw. He went from having essentially a toe first or a flat foot gait to having a heel strike initial contact. And so what you see here is that as he strikes the ground, in order to get his foot down flat to stabilize his knee joint, as you see in the third frame going from left to right, he needs to bring his knee forward because the brace is locked in five degrees of dorsiflexion. And so what you see is that the force line, the red line, is behind the knee joint producing a flexion moment, a flexion torque, a push from behind the knee and making him feel unsteady until the foot is perfectly flat and then the line is now through the knee joint in the last frame. So this indicates that this patient does not have the capacity to transition from heel strike to flat foot in a manner that would not place undue strain on the knee. And that's why we see that sense of instability and hesitation in lifting the left leg and advancing it with a long step. Now when you look at the swing phase in this patient, if you remember the limb clearance, we had some problems with foot drag and the foot drop is now controlled but he still has a toe drag. And there is decreased hip and knee flexion, which appear to be unchanged when compared to the no brace condition. In regards to the limb advancement, there is improvement in the step length, but still it's not as long as we would like to see in a regular or in a normal condition. And then you have an increase in terminal swing knee extension in part because now the limb is ready to contact with heel first. On the opposite limb, we have a contralateral short step length. It is not able to take a long step and we still have asymmetry in his gait, but with a fairly good improvement in both speed and gait symmetry. So when we explore that here, you see in the swing phase, in the first two frames, you see clearly that his foot is dragging. Even though his foot is now in a good position, the toe has difficulty clearing the ground. And when you have a patient who has early swing toe drag, like it's occurring here in the very early phase of the swing phase, don't think is the foot that is causing the problem. Think that it may be proximal lack of hip and knee. So you can see that clearly there as a reason for not being able to clear the limb. I see a question and I will get to it in just a second. Let me just complete the thought here of the ability to advance the limb because we talk about swing phase limb clearance, but then we talked about swing phase limb advancement. And you can see here that he's able to advance the limb better on the right side, but not so well on the left side. So the question, thank you for the question. It says, would you consider a neurotoxin followed by serial casting on the ankle to improve ankle dorsiflexion and then allowing for an AFO in a more neutral position? Yes, you could do that. Now let me clarify that this physician prescribed a brace that was in five degrees of dorsiflexion, so in a more dorsiflexed position than neutral. If you were able to see inside his leg, what I believe would be happening or inside the brace, what it would be happening is that his heel is far away from touching the bottom of the footplate in this brace. And so I would agree with you that reducing the limitations in motion at the ankle would be of great value. He has an Ashward of two and so applying botulinum toxin to the ankle plantar flexors would be of great value, followed by stretching. You could use serial casting to do that or you could just be sure that he's sitting well inside that brace and use the brace as your stretching tool, if you can convince the patient to wear the brace for many hours per day. But that would still not address this issue of the toe drag and that would not address the issue of the contralateral step length because the patient's still having this sense of instability in his transition from heel strike to flat foot. I think a different way to ask this question is should we place this patient on an articulating brace and we'll come back to it in just a second. So here again you can see the limitations in the contralateral step length. So we now gave the patient an articulating brace that has five degrees plantar flexion, zero degrees of dorsiflexion and has spring assistance. So let me repeat that it's an articulating AFO that allows five degree plantar flexion, zero degree dorsiflexion and has a spring that essentially brings the foot up to a that neutral position or a higher position. Ah, there is a very interesting question. We'll come back to that Dr. Patel. Give me a minute and we'll go back to addressing your question which refers to the idea of doing some shoe modifications. We'll come back to them I promise. So here is a patient walking with that brace that has an articulation. And so what you see now is that the patient has an improved transition from heel strike to flat foot. The knee goes into a little bit of hyperextension but it's well controlled. But you still notice that the patient is having some difficulty with limb clearance. So if you remember a compensation for limb clearance is usually the use of circumduction and you see a little bit of that here. So someone asked would you consider to control the knee hyperextension the use of a KAFO? That's a very very good question but remember if you use a KAFO you might end up sacrificing two potential things. One is if you lock the brace the ability to flex the knee and swing and so that may impose increased problems with limb clearance and advancement. And if you use the KAFO unlocked you are adding the weight of the device and we might be able to control that in a different way and hopefully we'll be able to show you that shortly. So what we notice is that with this new brace the patient had a slightly further increase in his walking velocity to 0.25 meters per second and there was a slight further improvement in the symmetry of the parameters but if you look at the left side of your screen in the bottom where the little foot prints are you can clearly see that the right foot is dragging you see the toe extending there as a foot drag. So here's another question for you Dan. What changes do you see in the implementation of a carbon graphite ultralight AFO in this patient? A. Right knee hyperextension mid stance phase controlled. B. Controlled right ankle plantar flexion with reduced knee flexion in early stance phase. C. Increased right hip and knee flexion in swing phase. Or D. Right foot drop with no toe drag. So we're letting you answer the question. Thank you for your participation. Really this question and answer is very important. Someone said question is not on the screen but I see the question is on the screen so okay so I'm going to move forward and the great majority of you answer by saying control right ankle plantar flexion with reduced knee flexion in early stance phase if we use an ultralight brace. Some of you thought that we might be able to control the hyperextension and some of you thought that we might be able to increase the right hip and knee flexion in swing phase. Curiously enough most of you did not think that having a lighter brace would give the patient less of a toe drag and I congratulate you on that. That would be a correct assumption. So when we look at this patient using this brace we see clearly that there is improved weight bearing in the right leg. Some knee hyperextension but control knee flexion in early stance. Still a little bit of trunk flexion present and no need for assistance and no change in the arm. This slide is out of place but that's okay. So here you see the patient with his stance phase knee stability and you can see now the red line the line of force being appropriately positioned allowing the better transition from heel strike to flat foot. An important transition that reduces the sense of instability for the knee joint. In the swing phase we talked about this there is improvement in the foot drop but there is still toe drag and we see that there is decreased hip and knee flexion which were unchanged and likely the cause of this foot drag. We also saw improved step length and increased terminal swing knee extension. So here you see the patient's problems during the limb clearance. You see the toe drag and so the leg externally rotates and it's an attempt to improve that. But you do notice that there is an improvement in the step length for that right leg. You can see that the contralateral step length was improved as well. If you compare the right screen, the right image which has the solid molded ankle for orthoses, the heel is still hidden behind the toe of the shoe where on the first frame you can see that you can see the heel and so although it is a very short step length it is an improvement. So we provided this patient with a much more flexible brace that was also very light in weight. So you see the patient walking with this brace. And so what you see is that the patient has a fairly good transition but still having a lot of toe drag and some instability at the knee joint. In fact you see that we are nervously watching him as he's walking with increased knee hyperextension. So there is more knee flexion but you can see that it's occurring late and there is no hip flexion. And so this is in part why this patient is having increased difficulty clearing the limb. So there was a slight decrease in the walking velocity with this device and there was improvement in symmetry but not in the stance phase duration. So we see some knee hyperextension. We see no knee flexion in early stance indicating that that's a good approach. We can control the knee well we just need to control the hyperextension. There is some trunk flexion increase particularly because he feels unsteady and still has no improvement in the right arm swing. And so here you can see the knee stability issues but you clearly can see that the foot transitions very nicely from heel to flat foot. So we were able to control his foot position but he still has a foot drag even though we've addressed the issue of the weight of the brace. And there is still improvement in knee flexion but not sufficiently to provide advancement in clearance based on hip position. There is improvement in step length and improvement in the swing knee extension and some improvement in the asymmetry of the gait although some decrease in walking velocity. And I think I'm just going over it again but that was the intent and here you see the contralateral step length how it improved some. Compare the rigid brace on the left side, the limited motion on the middle and the very flexible brace on the tail end. So I'm gonna actually skip this because of time limitations and just to show you that this is the brace the patient using a ultralight carbon graphite brace and you can see that the patient is able to transition from heel strike to flat foot very well. The knee is better positioned but is still limiting enough that he does not come with a very long contralateral step length as we see in the last image. So foot drop is controlled even with a carbon graphite brace there is still a toe drag, there is decreased knee flexion which is unchanged with foot drag. I should have it says hip and knee flexion and there is improved step length with increased terminal swing knee extension but we continue to have problems with his walking velocity although some improvement in the asymmetry of the temporal spatial parameters. And here you see the swing face issues very early in the swing face the toe drags but then it clears very nicely after that and the patient is able to take a nice long step. And if you look at the contralateral side you can see that under the flexible brace we have the best limb advancement which is the third image. So here is a quick question for you Dan. How could you reduce right foot drag in this patient? A, increase dorsiflexion attitude of the MAFO. B, reduce weight of the MAFO. C, provide patient with cane on left side. D, add right leather toe slider and left quarter-inch whole shoe lift. E, provide patient with KAFO with knee set in slight flexion. So we're seeing your responses as they tally up. Okay. Very good. So the great majority of you suggested that what we should do is increase the dorsiflexion attitude of the MAFO. I hope that by now you understand that you could dorsiflex the ankle all the way to the nose of the patient. If the toe drag occurs in early swing phase you will not be able to address the toe drag because the problem is proximal, lack of hip and knee flexion. So what you need to do is address that. And the second largest group was that who suggested add a right leather toe slider and a left quarter-inch whole shoe lift. That is a correct answer. That's what you would like to do. You want to increase the length of the limb on the contralateral side so that the right leg which is not flexing can clear the ground. The application of a KAFO likely would not address the toe drag in this patient. Again because you're adding more weight to an already not very strong hip flexion. So here you see the patient with the proposed modifications. A molded ankle for orthoses and modified shoes that have a heel lift and a toe leather, I'm sorry, a shoe lift and a toe leather slider. So you can see now the patient can clear the limb pretty well. The foot drag is gone. We still have a little bit of that early stance phase knee instability but we'll address that later by changing this brace from a maximum resistance five degree to a maximum resistance neutral position. You can see the patient can walk pretty well on his own and to prove that point here he is walking and his data shows that his walking velocity is increased to 0.34 meters per second. He has improvement in the asymmetry of the parameters including the step length for both sides. So what we find is that this patient had marked improvement in weight bearing for the right leg. There is no knee hyperextension but there's still a little bit of early stance knee flexion. There is still a slight forward trunk presentation but it's not too bad and he does not need assistance to walk. So I think that that allows us to see that we've been able to address the gait deviation by being methodical in the approach and sharing with you our findings. I know we might not have time to get through all of the questions in the 30 seconds that we have left for the seminar but both Dan and I remain available. If you have questions you can reach out to us through our emails which are listed in the references and we gave you handouts for you to look at. And with that let me thank Dan for all his help and effort in putting this course together and to you for being a great audience that participating nicely. Wish you well.

human gait analysis

orthotic interventions

gait dysfunction

center of mass

upright stability

ground reaction force

case study

orthotic devices

individualized prescription