A 3 - D Point of View Objectives

The Physical Therapist’s Role in

Assessment for AFOs

A 3-D Point of View

OPTA Annual Conference

4/13/2018

Jennifaye V. Brown, PT, PhD, NCS

Ohio University College of Health Sciences and Professions

School of Rehabilitation & Communication Studies Division of Physical Therapy1

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Slide 2

Learning

Objectives

Develop & modify

Develop & modify the subjective exam & objective assessment skills needed to complete an AFO eval via a case study

EvaluateEvaluate the results of the subjective exam and outcome measures to recommend an AFO

ValidateValidate choice of questions and objective measures used to assess the need for an AFO

JustifyJustify optimal positioning for the LE assessment based on impairments and function during specific gait phases

ExplainExplain the components that comprise a patient-focused examination for an AFO

2Jennifaye V. Brown, PT, PhD, NCS - Ohio University

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Slide 3 Agenda

12 minutes: Patient-Centered Care & Social Determinants of

Health

10 minutes: 3-D Technology: Changing the AFO Fabrication

Process

46 minutes: AFO Evaluation: Patient-Centered Examination

17 minutes: Case Study

5 minutes: Questions & Answers


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Patient-Centered Care &

Social Determinants of Health


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Slide 5 Physical Therapy & Patient-Centered Care

“has yet to adopt and integrate the construct [PCC] in research”1(p.120)

& clarify its definition in practice

Outcome studies have measures that assess patient perspectives, but

are we really asking, gathering & applying client perspectives in

clinical practice?

I say NO: all custom AFOs tend to look the same & require that a client

buys a shoe half size larger & wider for brace accommodation


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Slide 6 To Improve PCC1

Consensus: PCC definition

Operationalize PCC

Establish methodology:

evidence for practice

Communication

Shared Decision-making

Client Education

Client Empowerment

Research Practice


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Social Determinants of Health

Neighborhood & Built Environment

Health & Health Care

Economic Stability

Education

Social & Community Context

Jennifaye V. Brown, PT, PhD, NCS - Ohio University 7

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Slide 8 SDOH Model applied to these pictures in terms

of AFO fabrication2


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Slide 9

3-D Technology:

Changing the AFO Fabrication Process

1. Scanning

2. CAD-CAM Technology

3. 3-D Printing9Jennifaye V. Brown, PT, PhD, NCS - Ohio University

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Scanning3-5

Traditional Non-Traditional

10http://lermagazine.com/products/biosculptor-afo-scanning-table

Jennifaye V. Brown, PT, PhD, NCS - Ohio University

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Slide 11 CAD-CAM Technology3-4

Traditional Non-Traditional

11https://www.researchgate.net/profile/Mark_Sivak

/publication - Flow DiagramJennifaye V. Brown, PT, PhD, NCS - Ohio University

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Slide 12 3-D Printing

12https://jneuroengrehab.biomedcentral.com/articles/10.1186/1743

-0003-8-1Jennifaye V. Brown, PT, PhD, NCS - Ohio University

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Finished Product


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Slide 14 Cha et al 2017


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Slide 15

AFO Evaluation:

Patient-Centered Examination


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Hanna & Harvey, 20016

Functional Transfers - STSGait Assessment

1. Posture

2. Alignment

3. Symmetry

4. Speed

5. Control during all phases of:

a. Weight acceptance

b. Single limb support

c. Swing limb advancementJennifaye V. Brown, PT, PhD, NCS - Ohio University

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Slide 17 Alignment

Structural Deformities

Bony deformity

Soft tissue shortening

Muscle contracture

Flexible Deformities

Muscle imbalance due to

weakness

Muscle stiffness

Dominant neuromuscular activity

(spasticity)

Abnormal tone

Improper muscle length-tension

relationship alters kinetic

moment at jt during movementJennifaye V. Brown, PT, PhD, NCS - Ohio University 17

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Slide 18 Case Study Analysis

STRENGTHS

1. Addresses lower quarter gait

impairments in detail

2. Provides LE biomechanics

Variety of static positions

Orthopedic tests, procedures &

outcomes

WEAKNESSES

1. No neuromuscular tests, procedures

& outcomes

2. Neglects distal malalignment/

neuromuscular impairments

relationship trunk dyscontrol

/proximal malalignment

3. No resources related to

neuromuscular assessment & txJennifaye V. Brown, PT, PhD, NCS - Ohio University 18

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Clinical Conclusion

Literature Answers Question, But Skewed

1. Orthopedic focus

2. Trunk dyscontrol/pelvis and proximal malalignment may be cause of distal foot & ankle problems requiring AFO

3. Interventions for trunk dyscontrol/pelvis & proximal malalignment optimize effectiveness, function & acceptance of AFO

What is missing…..

1. Assessment of neuromuscular components as primary factors

2. Consider other contributing systems

3. Consider comorbidities, SDOH & PCC approach 19

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Slide 20

AFO Examination Components7


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Slide 21 Key Components for AFO Examination

1. Postural Observation: Compare to Normal foot in WB & NWB

2. Assess Foot Appearance & Subsequent Compensations; Musculoskeletal Abnormalities

3. ROM: Open Chain & Close Chain

4. Strength & Voluntary Control

5. Spasticity & Tone

6. Sensation: Proprioception, Kinesthesia, Monofilament Testing

7. Balance

8. Edema

9. Pain Jennifaye V. Brown, PT, PhD, NCS - Ohio University 21

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Key Components for AFO Examination

10. Vision

11. Functional Mobility Assessment: STS & Falls

12. Gait: Speed & Quality

13. Personal Effects

14. Level of Function: Prior & Current

15. Goals


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Slide 23 You have to Look, Listen & Feel…..

I. Postural Observation


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Slide 24

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The Normal Foot

1. Lateral border WB except area under

cuboid

2. WB on medial calcaneus, longitudinal

arch, first MTH

3. Second toe is to ankle joint

4. Anterior & to tibia is a crease convex

on the dorsum of midfoot


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Primary Functions of the Foot7-8

I. Mobile Adapter: LRMSt

A. Adapt to ground surface

B. Facilitate shock absorption

STJ pronated - allows foot mobility, which s MTJ motion, allowing adaptation to different surfaces, therefore mobile adaptor

II. Rigid Base for Propulsion During Gait: TStPSw

For propulsion, STJ is supinated & MTJbecomes rigid

-HOW?

1. Bone Congruency

2. Capsular Tension

3. Muscle Mechanics

STJ=Subtalar Jt MTJ= Midtarsal Jt

25


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Slide 26

Picture=IC; LR MS TS PSw

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Slide 27 CKC Pronation CKC Supination

Tibia: int. rot. (ion)

Talus: ADD & PF(ion)

Calcaneus: everts (ion)

Tibia: ext. rot.(ion)

Talus: ABD & DF(ion)

Calcaneus: inverts (ion)Jennifaye V. Brown, PT, PhD, NCS - Ohio University 27

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28

II. Foot Appearance7-8

Pronator Supinator


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Slide 29

Giallonardo LM. Clinical evaluation of foot and ankle dysfunction. Phys Ther. 1988; 68:1850-1856.

Foot Appearance & Subsequent

Compensations9


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Slide 30 II. Musculoskeletal Abnormalities7

Hallux Valgus &

Claw Toes

Hammer Toes


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What Looks Abnormal?


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Slide 32 II. Neuromuscular Abnormalities

1. Toe Grasping (A)

2. Inversion (B)

3. Eversion (C)

4. Dorsiflexion (D)

32

Pathological

Reflexes – LE10


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Slide 33 III. Range of Motion

AFO will be used in WB,

therefore measure Ankle ROM

in WB

1. Loading Response

2. Terminal Stance


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SUPINE Ankle ROM

R1= 1st resistance to passive movement

R2= final position of foot- no more range to be gained

0-3 degree change or less consider contractureJennifaye V. Brown, PT, PhD, NCS - Ohio University 34

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Slide 35 III. Range of Motion

hind- or forefoot

Immobility or compensatory varus or valgus


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Slide 36 IV. Strength/Voluntary Control

Extensor Synergy

Patterns


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Force Control:

Generate Movement in Different Postures

Hislop & Montgomery11

With CNS lesion, innervations to mm not impaired but control of mm impaired

“MMT was (and is) designed to evaluate patients with a lower motor neuron disorder manifested by flaccid weakness or paralysis”11(p.344)

Authors suggest Upright Motor Control Test12 for individuals with Selective Control or Pattern Motion

Selective Control: move a single jt without activating mov’t in adjacent or neighboring jt of same extremity11(p.344)

Pattern Motion: inability to perform fractionated mov’t e.g. wrist extension w/o mov’t at elbow & fingers or knee extension w/o pflx & inversion –stereotypical synergy patterns 11(p.344)


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Slide 38 Force Control:

Generate Movement in Different Postures

Upright Motor Control Test12 :

Incorporate effects of upright posture & WB

Simulates walking activity

Inter-tester reliability 96% for flexion portion of test & 90% for extension

portion of test

Latest version in Hislop & Montgomery11 Chapter 8


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Slide 39 Upright Motor Control Test11-12

39Hip Flexion Knee Flexion Knee Extension

Ankle DF Ankle PF

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Assessment of Force Control


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Slide 41 Dynamometry13

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Figure 1. Measurement of plantar and dorsal flexion strength by hand-held dynamometer

Lafayette Manual Muscle Test System

https://www.researchgate.net/figure/284190078_fig1_Figure-1-Measurement-of-plantar-

and-dorsal-flexion-strength-by-hand-held-dynamometer

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Slide 42

V. Spasticity & Tone


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Spasticity Definition

1. Velocity-dependent increase in resistance of a mm or mm grp to passive stretch14

2. Changes in mm bc of UMN lesion and/or prolong positioning known as myoplasticity15

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Evaluation Focus:16

1. Identify clinical pattern of motor

dysfxn & source

2. Identify clients’ ability to control

mm in clinical pattern

3. Differentiate mm stiffness versus

contracture


Scales:17

MAS: Modified Ashworth Scale

Modified Tardieu Scale

King’s Hypertonicity Scale

Tone Assessment Scale

Daily Fxnl Assessment Scales

1. Barthel Index

2. Patient’s Disability Scale

3. Carer Burden Rating Scale

Electrophysiology Measures

1. EMG: H-reflex, F wave, Tendon Reflex & polysynaptic responses

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Slide 44

Spasticity

AssessmentHow do you do it?

Jennifaye V. Brown, PT, PhD, NCS - Ohio University44

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Slide 45 Tone Definition & Concepts:Definition: “…the resistance or ‘stiffness’ in a limb to passive movement” 18

Continuum: flaccidity ↔ hypotonia ↔ normal ↔ spasticity ↔ rigidity15 (p.110)

Flaccidity: complete loss of mm tone15 (p.110)

Hypotonicity: reduction in stiffness of mm to lengthening – spinocerebellar

lesions15 (p.113)

Hypertonia: increase in mm tone compared to normal; manifested as

spasticity or rigidity; based on the clinical presentation & origin15

Rigidity: extrapyramidal tract pathology (basal ganglia & midbrain nuclei); ↑d tone in opposing mm groups on both sides of the limb and it is not

velocity dependent15

45


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Tone Assessment19

Varies in clinical practice: concept of tone vs spasticity

Modified Ashworth Scale19 Supine, but alter position to get mm/pt to relax;

assess available ROM; passively move joint so that mm moves from a

shorten to lengthen position

Score Description

0 No increase in mm tone

1 Slight ↑ in mm tone, manifested by a catch & release or minimal resistance @ the end

ROM when affected part moved in flexion or extension/abduction or adduction, etc.20(p.24)

1+ Slight ↑ in mm tone manifested by a catch f/b minimal resistance through the

remainder (less than half) of the ROM

2 More marked ↑ mm tone through most of the ROM, but affected part(s) easily moved

3 Considerable ↑ in mm tone, passive movement difficult

4 Affected part(s) rigid in flex or ext (abd or add, etc.) 20(p.24)

46


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Slide 47 V. Tone, Spasticity vs Voluntary Control


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Slide 48 VI. Sensation21

Proprioception

Kinesthesia

Move the hemi extremity & pt has to duplicate

the movement with opposite extremity


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Limb Ataxia vs Discoordination Problem

https://www.youtube.com/watch?v=fwG

6CUD6Puw

Ataxia general term which means incoordination

of mov’t & often applied to gait22

Discoordination: proprioceptive deficits NOT

weakness


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Slide 50 Diabetic????

Monofilament Testing23


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Slide 51 VII. Balance Assessment

Romberg

BERG

Ankle, Hip & Stepping

Strategies14 & 24

Rehabmeasures.org


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VIII. Edema25


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Slide 53 IX. Pain Perception26

53Jennifaye V. Brown, PT, PhD, NCS - Ohio UniversityThis Photo by Unknown Author is licensed under CC BY-SA

This Photo by Unknown Author is licensed under CC BY-NC-SAwww.physioprescription.com

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Slide 54 Hemianopsia22


X. Vision

Peripheral Vision24

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XI. Functional Mobility Assessment

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Observe STS & Falls Assessment


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Slide 56 XII. GAIT Observation27-29

56

https://www.google.com/search?q=pictures+of+gait+analysis&tbm=isch&tbo=u&source=univ&sa=X&ve

d=0ahUKEwi4pKmp27XXAhWBLyYKHYDdCR0QsAQIJw&biw=1366&bih=662#imgrc=LjSa7_xjUIIZOM:

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Slide 57 XII. GAIT Observation27-29


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Evidence Across Studies30Middleton, Fritz, Lusardi JAPA, 2015

0 mph 0.4 mph 0.9 mph 1.3 mph 1.8 mph 2.2 mph 2.7 mph 3.1 mph10 meter walk time 50 sec 25 sec 16.7 sec 12.5 sec 10 sec 8.3 sec 7.1 sec10 foot walk time 15.2 sec 7.6 sec 5 sec 3.8 sec 3 sec 2.5 sec 2.2 sec

m/s58

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Slide 59

2 Minute Walk Test

3 Minute Walk Test

6 Minute Walk Test

10-M Walk Test

10 Foot Walk Test

Gait Analysis: Full BodyRLA National Rehab. Ctr.PT Dept.27

TUG: Timed Up & Go Test

TUG Manual: carry a full cup of water

TUG Cognitive: counting backward from a randomly selected # btwn 20-100

Walking While Talking Test

Dynamic Gait IndexObservation

Balance & Dual Task

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Slide 60 Personal Effects & Lifestyle

Shoes Heel hgt

“Wear & tear” of shoe counter,

sole/heel, insole

SDOH

Client Perspectives

Work/Leisure Clothing


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Case Study


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Slide 62 Scheets et al31

Fractionated movement deficit (did not display isolated movements-

synergistic patterns severe motor deficits)

Prognosis: for “normal” movement unlikely

Focus: postural stability when performing compensatory movement

strategies and during overall functional activities such as transfers

and gait


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Slide 63 Associated Signs - Related to Task Analysis31

Stiffness of involved limbs & slow

No dissociation of mov’t, 1-2 jts

Associated reactions in attempt to move

Less A-G mov’t, may be unable to stand

Gait: compensatory strategies associated w/ ext synergy of LE; however

stands w/ hip & knee flex

UE hand closure; limited reach range

Postural control: able to sit but asymmetrical

Stability may improve with practice but not symmetry63Jennifaye V. Brown, PT, PhD, NCS - Ohio University

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Synergistic Patterns

Damage at or above red nucleus,

impacting input to the rubrospinal

tract (corticorubrospinal tract)32

Spasticity & variations in tone

hallmark signs of lesion in subcortical

region32-33

Gait w/ extensor synergy pattern;

foot PF; difficulty clearing swing;

compensate: pelvic hike,

circumduction


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Slide 65 What questions do we want to ask….

1. Do you have a brace?

2. How is it helpful?

3. How is it limiting?

4. What is your perception of your walking?

a. Slow vs fast?

b. Quality of how your body moves?

5. Have you had any falls? If yes….

a. When was the last fall

b. What were you doing?

6. Do you get out of the house a lot?


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Slide 66 What questions do we want to ask….

1. Tell me about your home environment; community

2. Who and how is your support system? CG, friends visit

3. What do you do for exercise?

4. What do you do for fun/enjoyment?

5. What are your goals for walking?

6. Are these the shoes you typically wear with the brace?

7. What shoes did you typically wear prior to the stroke?

8. Did you bring them with you?Jennifaye V. Brown, PT, PhD, NCS - Ohio University 66

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Outcome Measures

10 MWT: unable

TUG: 26 sec

10’ Walk Test: 14.8 sec

Assessed gait with platform rw to

spd of gait - impacts gait quality

What gait impairments would you

suspect during:

1. swing phase

2. stance phase

1. Tone: MAS (3 quads & pflx); King’s

Hypertonicity Scale; Tone

Assessment Scale

2. Spasticity: (+)

3. Fxnl Mobility Assessment:

5x STS: 42 secs requiring

use of RUE; leans to R

4. Observe shoe for wear & tear; look

at WB surface inner sole


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Slide 68 Outcome Measures

5. ROM:

Knee ext: R1: -15 & R2: -5

Knee flex 90: R1: -5 & R2: -3

6. MTH: great toe upgoing; 1st ray pflx; 2-5 ext at MTH & PIP & DIP flex

7. Foot & Ankle Assessment: rockers (absent); Babinski (+); pathological reflexes

(+ inversion response); compensatory motion due to lack of dflx (forefoot

contact at IC; lateral heel whip at TSt w/ early heel rise)

8. Pain: sharp - 4/10 midstance at infrapatellar & general knee ache at rest


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Slide 69 AFO Recommendations

To provide security, stability & control w/o interfering too much with movement at the foot & ankle.

To meet the functional requirements of the client with minimal restriction

Goal of an AFO (Barber, CPO)

69


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Knowledge Summary

1. AFO Assessment Matters

2. Patient-Centered: Social Determinants of Health

3. Critical Exam Components – Lesion Location, Severity & Size

4. Objective Measures: Cortical, Subcortical, Cerebellum

5. Psychosocial Aspects of Gait

Jennifaye V. Brown, PT, PhD, NCS - Ohio University70

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Slide 71 Thank you for your interest & feedback!


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Slide 72 For participation, please contact:

Jennifaye V. Brown, PT, PhD, NCS

Ohio University [email protected] 740.593.0820


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73

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Slide 74

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A 3 - D Point of View Objectives

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