Motion Analysis in Interdisciplinary Healthcare Education ... · NONLINEAR ANALYSIS FOR HUMAN...

2nd Annual MARC Symposium

November 4-5, 2016

Motion Analysis in Interdisciplinary

Healthcare Education and Practice

Samuel Merritt University Motion Analysis Research Center 400 Hawthorne Avenue, Suite 101

Oakland, CA 95609

www.samuelmerritt.edu/marc

Special Thanks to Our Sponsors

Copyright © 2016 Samuel Merritt University. All Rights Reserved.

TABLE OF CONTENTS

TUTORIALS ....................................................................................................................................................... 1

WORKSHOPS .................................................................................................................................................. 11

ORAL PRESENTATIONS ............................................................................................................................... 19

POSTER PRESENTATIONS ........................................................................................................................... 47

AUTHOR INDEX ............................................................................................................................................. 59

NOTES .............................................................................................................................................................. 60

Organizing Committee

Drew Smith, PhD Professor and Director, Motion Analysis Research Center, Samuel Merritt University

Stephen Hill, PhD Assistant Professor and Laboratory Manager, Motion Analysis Research Center, Samuel Merritt University

Kate Hayner, EdD, OTR/L Director, Department of Occupational Therapy, Samuel Merritt University

Rolando Lazaro, PhD, PT, GCS Department of Physical Therapy, Samuel Merritt University

Timothy Dutra, DPM, MS California School of Podiatric Medicine, Samuel Merritt University

Cherri Choate, DPM California School of Podiatric Medicine, Samuel Merritt University

Carla Ross Associate Director, Development and Alumni Affairs, Samuel Merritt University

Amy Anderson, Administrative Assistant, Office of Academic Affairs, Samuel Merritt University

2nd Annual MARC Symposium November 4-5, 2016

1

TUTORIALS


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Friday, November 4, 2016

Tutorials (60-hr duration)

Time Session Location Moderator(s)

8:30 Beyond Straight Walking: Using Transitional Movement for Gait Assessment

Bechtel Dr. Arnaud Gouelle

9:30

Nonlinear Analysis for Human Movement Variability Bechtel Professor Nick Stergiou

Crutches, Camwalkers and iWalks: What's the Difference? Biophysical Answers for Clinical Rx

MARC Dr. Tim Dutra

Ms. Kathleen Edmunds Dr. Stephen Hill

10:30 Break

11:00

Using Foot Orthoses to Improve Postural Control Fontaine Dr. Doug Richie Jr.

Exploring the Continuum of Motion Analysis Techniques in the Clinic: One-Size Does Not Fit All!

Bechtel Professor Drew Smith

Dr. Stephen Hill

12:00 Lunch


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BEYOND STRAIGHT WALKING: USING TRANSITIONAL MOVEMENTS FOR GAIT ASSESSMENT

Arnaud Gouelle

Gait and Balance Academy, ProtoKinetics LLC

Email: [email protected]

INTRODUCTION

Understanding steady state gait does not tell the entire story about walking in daily life. People walk forward, backward, jump, run, go up and down slopes and stairs, they cross obstacles and carry loads. Yet, before they can walk they must initiate the movement; and often overlooked, is the need for gait termination, we must be able to safely stop.

A complete picture of a patient's ability, therefore, needs to evaluate these different sequences. This can be done through semi-subjective or subjective tests and scales, based on observation of the performance of a specific task by the subject. For example, the Timed Up and Go [1] is widely used and it includes both sit-to-stand and stand-to-sit transitions, walking straight, turn around, and it requires balance control and the ability to sequence tasks. However, the scoring of the TUG is only the test duration.

The advent of clinical assessments with wearable or instrumented technology provides additional performance parameters far and above the traditional scales and tests. In fact, some transitional movements are being widely studied in the literature, but their transition to clinical application is still limited. Gait initiation [2-4] has been used as an investigative tool to provide insight into postural control and the changes that occur with advancing age and disability. Gait initiation has been shown to be a sensitive indicator of balance dysfunction, but it is rarely integrated into standard clinical protocols or practice. How a person manages obstacle avoidance [4-5] should also be considered because many sub-tasks have to be utilized: the avoidance of tripping, slipping and the achievement of a safe landing area.

CLINICAL SIGNIFICANCE

Assessing transitional movements should provide valuable insight into the patient’s various mobility skills and may identify areas of weakness that require therapeutic intervention/attention.

LEARNING OUTCOMES

1. Review different sequence testing, such as Time Up and Go, gait initiation and termination, obstacle crossing, assessed with and without technology

2. Explore the valuable endpoints for each test 3. Analyze transitional movement in specific patients.

OUTLINE

Gait initiation and termination: Definition, Protocol, Example in patients

Sit-to stand and Stand-to-sit: Definition, Protocol, Example in patients

Instrumented Time Up and Go and turning: Definition, Protocol, Example in patients

Obstacle crossing

ASSESSMENT OF LEARNING (Optional)

We will offer a web-link to access a quiz based on the content of the tutorial.

REFERENCES

1. D. Podsiadlo, S. Richardson. The timed ‘Up & Go’: a test of basic functional mobility for frail elderly persons. J. Am. Geriatr. Soc. 1991;39(2):142-148.

2. Y. Brénière, M.C. Do. When and how does steady state gait movement induced from upright posture begin? J. Biomech. 1986;19:1035-1040.

3. T.A. Buckley, B.A. Munkasy, T.G. Tapia-Lovler, E.A. Wikstrom. Altered gait termination strategies following a concussion. Gait Posture 2013;38:549-551.

4. A.H. Vrieling, H.G. van Keeken, T. Schoppen, A.L. Hof, B. Otten, J.P.K. Halbertsma, K. Postema. Gait adjustments in obstacle crossing, gait initiation and gait termination after a recent lower limb amputation. Clin.. Rehabil. 2009:23:659-671.

5. C.R. Lowrey, A. Watson, L.A. Vallis. Age-related changes in avoidance strategies when negotiating single and multiple obstacles. Exp. Brain. Res. 2007;182(3):289-299.

DISCLOSURE STATEMENT

Arnaud Gouelle is employed by ProtoKinetics LLC, provider of the Zeno electronic walkway.


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NONLINEAR ANALYSIS FOR HUMAN MOVEMENT VARIABILITY

Nicholas Stergiou1, 2 1University of Nebraska Omaha; 2University of Nebraska Medical Center


INTRODUCTION

This tutorial is an introduction to nonlinear analysis methods. The purpose of this tutorial is to briefly introduce the participants to a value of nonlinear methods for the analysis of biological time series data (1-6).


Fields studying movement generation, including robotics, psychology, cognitive science, and neuroscience, utilize concepts and tools related to the pervasiveness of variability in biological systems. The concepts of variability and complexity and the nonlinear tools used to measure these concepts open new vistas for physical therapist practice and research in movement dysfunction of all types. Because mounting evidence supports the necessity of variability for health and functional movement, this tutorial argues for changes in the way therapists view variability, both in theory and in action. This tutorial aims to create a springboard for new directions in physical therapist research and practice.

LEARNING OUTCOMES

By the end of this tutorial, participants will learn the following:

1. Understand the basic concepts in nonlinear analysis.

2. Describe what how such techniques can be used to study human movement variability.

3. Understand the value of this approach for physical therapists and clinicians.

OUTLINE

1. Theoretical Background for Nonlinear Analysis of Human Movement Variability

2. Theoretical Modelling of Human Movement Variability.

3. Clinical Examples

REFERENCES

1. Stergiou N, Decker LM. (2011). Human Movement Science. Oct;30(5):869-88.

2. Harrison SJ, Stergiou N. (2015). Nonlinear Dynamics, Psychology, and Life Sciences. 19(4):345-94.

3. Hunt N, McGrath D, Stergiou N. (2014). Nature Scientific Reports. Aug;4:5879.

4. Wurdeman SR, Myers SA, Jacobsen AL, Stergiou N. (2013). Journal of Rehabilitation Research and Development, Aug;50(5):671-86.

5. Stergiou N, Kent JA, McGrath D. (2015). Kinesiology Review. 5:15 – 22.

6. Haworth JL, Kyvelidou A, Fisher W, Stergiou N. (2015). Frontiers in Psychology. Mar:17;6:281.


This work was supported by the Center for Research in Human Movement Variability of the University of Nebraska at Omaha and the NIH (P20GM109090 and R15HD086828).


5

CRUTCHES, CAMWALKERS AND IWALKS: WHAT’S THE DIFFERENCE? BIOPHYSICAL ANSWERS FOR CLINICAL RX

Timothy Dutra1, Kathleen Edmunds1 and Stephen Hill2 1California School of Podiatric Medicine and 2Motion Analysis Research Center, Samuel Merritt University

Email: [email protected] / [email protected]

INTRODUCTION

The purpose of the workshop is to explore differences in biomechanical and fatigue/exertion measures of ambulation between three mobility devices in comparison to normal unassisted gait. The three mobility devices are: axillary crutches, a controlled ankle movement (CAM) walker, and a hands free crutch (iWALK2.0). Measures will include step length, single leg stance time, cadence, ground reaction forces and muscle activity while ambulating. Additional measures of exertion during ambulation and during stairclimbing will be presented.


Functional off-loading utilizing mobility devices are often necessary for the rehabilitation of ankle sprains or fractures, post-operative recovery, and diabetic foot ulcers. A literature review of mobility devices for the foot and ankle revealed studies of metabolic cost, cardiovascular response, pressure force and healing rate.

Foley (2014) compared the metabolic cost and cardiovascular response to stair ascending and descending with walkers and canes in older adults. When measured at slower speeds, the metabolic cost was not significantly increased with the assistive devices compared with unassisted stair ascending and descending. Kocher (2016) compared the wheeled knee walker (scooter) and axillary crutches for differences in measured heart rates. Heart rate increased over time with the axillary crutches compared with the wheeled knee walker. Thys (1996) measured the energy consumed and the mechanical work performed during swing-through crutch gait. The stabilization of the body on the crutches required isometric and/or antagonistic contractions which are not necessary in normal walking. These contractions led to a reduction of the efficiency of positive work.

Effectiveness of off-loading devices to treat diabetic foot ulcers is another area of research focus. Peak pressure was most reduced (by 65.8%) for the bivalved total contact cast as compared to a custom-molded insole shoe, a cast MABAL shoe, and a prefabricated pneumatic walking brace (Beuder, 2005). Morono (2013) concluded that non-removable was more effective than removable CAM walkers in ulcer healing, presumably because of improved patient compliance (Morono, 2013).

This workshop will provide clinicians with an evidence based model to determine appropriate treatment for patients requiring unilateral foot off-loading.

LEARNING OUTCOMES

By the conclusion of this tutorial, participants will be able to:

1. Compare various mobility devices with respect to the metabolic cost and biomechanical measures

2. Consider proper fit and training requirements 3. Identify functional off-loading choices based upon

objective parameters

METHODOLOGY

One female adult subject was tested using various mobility devices with the Zeno electronic walkway, wireless EMG (Delsys Trigno) and a 9 camera Qualisys motion capture system.

OUTLINE

A: Spatial Temporal Gait Parameters (15 mins)

An exploration on the electronic walkway of the spatial temporal gait parameters such as stride length, stride width, velocity, single support % mean, stance (% of cycle), cadence (stepping rate) mean and variability (standard deviation) of measures that contribute to the disruption of normal gait.

bilat

Stride Length Mean (cm)

131.1 116.3 127.4 135.2 116.0

SD 3.3 4.0 2.7 6.3 4.8

bilat

Stride Width Mean(cm)

6.3 11.6 9.3 NA 19.6

SD 1.1 1.1 1.6 NA 1.5

bilat

Velocity Mean (cm/s)

120.0 104.0 115.6 97.8 97.9

SD 3.8 4.0 4.5 5.7 5.2

R

Single Support

Mean (%) 36.7 35.8 36.2 NA 32.6

SD 0.6 1.3 1.3 NA 1.7

R

Stance Mean (%)

64.6 62.7 62.8 69.8 52.4

SD 0.6 0.9 0.8 3.1 1.6

bilat Cadence (steps-min)

Mean 108.9 107.3 108.8 43.4 101.7


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B: Ground Reaction Forces and Muscle Activity (15 mins)

An investigation of ground reactions via force plates, and muscle activity of bilateral: external oblique, erector spinae, quadriceps, hamstrings, and gastrocnemius using surface electromyography (EMG) to determine balance and muscular demand required for appropriate choice of device.

iWALK findings from case study:

1. Additional demand imposed by device includes greater activation of trunk muscles.

2. The right hamstring, gastrocnemius, and quadriceps EMG activity indicates potential for preservation of muscle tone during rehabilitation.

3. Weight bearing through the right hip and knee has potential to decrease bone loss on affected side.

4. Gait pattern for the iWalk indicates a 1:1 ratio for swing and stance phase.

C: Metabolic Cost (15 mins)

A summary of VO2 oxygen update and heart rate to determine the economy of energy consumption for maximum patient compliance will be presented.

QUESTIONS & ANSWERS (15 mins)


iWALKFree, Inc loaned the iWalk for this workshop as well as assisted with data collection.

REFERENCES

1. Beuder, B.J., et al., (2005). Plantar pressure in off-loading devices used in diabetic ulcer treatment. Wound Repair and Regeneration, 13, 537–542.

2. Foley, M. & Bowne, B. (2014). Comparison of metabolic cost and cardiovascular response to stair ascending and descending with walkers and canes in older adults. Archives of Physical Medicine and Rehabilitation, 95(9), 1742 – 1749.

3. Kocher, B.K., Chalupa, R. L., Lopez, D. M. & Kirk, K. L. (2016). Comparative study of assisted ambulation and perceived exertion with the wheeled knee walker and axillary crutches in healthy subjects. Foot and Ankle International, 1-6.

4. Morona, J.K., Buckley, E. S., Jones, S. & Reddin, E.A. (2013). Comparison of the clinical effectiveness of different off-loading devices for the treatment of neuropathic foot ulcers in patients with diabetes: a systematic review and meta-analysis. Diabetes/Metabolism Research and Reviews, 2, 183–193.

5. Thys, H., Willemstt, P. A. & Saelst, P. (1996). Energy cost, mechanical work and muscular efficiency in swing-through gait with elbow crutches. Journal of Biomechanics, 19(12), 1035-40.


7

USING FOOT ORTHOSES TO IMPROVE POSTURAL CONTROL

Douglas H. Richie Jr.

California School of Podiatric Medicine, Samuel Merritt University

Samuel Merritt University


INTRODUCTION

Deficits in postural control have been implicated as a risk factor for traumatic falls in the elderly as well as the ankle sprain in the active athlete. (1) Postural control is the ability of a human to maintain his or her center of mass over the supportive foot. (2) Postural control can be thought of as a mechanism to maintain balance whereby a person is able to remain upright during stance and gait. Postural sway is the deviation of the center of mass determined during quiet stance on both feet or on a single foot.(3) Postural control is dependent upon both an afferent (sensory) and efferent (motor) loop of the neuromuscular system.(4) There is increasing evidence that higher centers for cognitive processing of information are essential for postural control. (5) Foot orthoses can affect both afferent and efferent components of postural control in a positive fashion. This is verified by studies which show that foot orthoses can control foot motion, reduce biomechanical stresses, support arches, improve shock absorption, increase proprioceptive capabilities, position the subtalar joint in a more mechanically stable position, and improve muscle activity in the lower extremity. ( 6-9) To this date there have been twelve studies documenting improvements in postural control in various groups of subjects treated with foot orthoses. (10-22)


Falls are the leading cause of injury in older adults. (23,24) Falls are the leading cause of accidental death in people over age 85. (24) The ankle sprain is the most common injury in sport. Loss of postural control has been identified as a risk factor for both events. (25) Mitigating this risk factor with the simple intervention of a prefabricated or custom foot orthosis can be an important component of a rehabilitation program. Foot orthoses have already been integrated into successful falls prevention programs for the elderly. (26)

LEARNING OUTCOMES

By the end of this tutorial, participants will learn the following:

1. Components and mechanism of postural control 2. How foot orthoses affect postural control

3. How foot orthoses can be integrated into rehabilitation programs for various patient population who have deficits in postural control

OUTLINE

1. The components of postural control 2. The “inverted pendulum” model of postural control 3. The biomechanics of the ankle strategy and hip

strategy 4. Muscle activation patterns for correction of

postural sway 5. Studies of foot orthoses on postural control 6. Theories of influence of foot orthoses on postural

control 7. Strategies to implement foot orthoses for

improvement of postural control in the clinical setting

REFERENCES 1. Richie DH. Functional instability of the ankle and role of

neuromuscular control. Comprehensive review. J Foot Ankle Surg. 2003; 42(5):79-86.

2. Hertel J. Functional anatomy, pathomechanics, and pathophysiology of lateral ankle instability. J Athl Train. 2002; 37(4):364–375.

3. Hubbard TJ, Kramer LC, Denegar CR, Hertel J. Contributing factors to chronic ankle instability. Foot Ankle Int. 2007;28(3):343–354.

4. Riemann BL. Is there a link between chronic ankle instability and postural instability? J Ath Train. 2002; 37(4):386–393.

5. Caulfield B, Crammond T, O’Sullivan A, Reynolds S, Ward T. Altered ankle muscle activation during jump landing in participants with functional instability of the ankle joint. J Sport Rehabil. 2004; 13(3):189–200.

6. Mundermann A, Nigg BM, Humble RN, Stefanyshyn DJ. Foot orthotics affect lower extremity kinematics and kinetics during running. Clin Biomech (Bristol, Avon). 2003;18(3):254–262.

7. Nigg BM, Nurse MA, Stefanyshyn DJ. Shoe inserts and orthotics for sport and physical activities. Med Sci Sports Exerc. 1999;31(7 suppl):S421–S428.

8. Denegar CR, Miller SJ III. Can chronic ankle instability be prevented? Rethinking management of lateral ankle sprains. J Athl Train. 2002;37(4): 430–435.

9. Mundermann A, Nigg BM, Humble RN, Stefanyshyn DJ. Consistent immediate effects of foot orthoses on comfort and lower extremity kinematcs, kinetics, and muscle activity. J Appl Biomech. 2004;20(1):71–84.

10. HamlynC,DochertyCL,KlossnerJ.Orthoticintervention and postural stability in participants with functional ankle instability after an accommodation period. J Athl Train. 2012;47(2):130–135.

11. Sesma AR, Mattacola CG, Uhl TL, Nitz AJ, McKeon PO. Effect of foot orthotics on single- and double-limb dynamic


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balance tasks in patients with chronic ankle instability. Foot Ankle Spec. 2008;1(6):330–337.

12. GuskiewiczKM,PerrinDH.Effectoforthoticsonpostural sway following inversion ankle sprain. J Orthop Sports Phys Ther. 1996;23(5):326–331.

13. CorbinDM,HartJM,McKeonPO,IngersollCD,HertelJ. The effect of textured insoles on postural control in double and single leg stance. J Sport Rehabil. 2007;16(4):363– 372.

14. Orteza LC, Vogelbach WD, Denegar CR. The effect of molded and un- molded orthotics on balance and pain while jogging following inversion ankle sprain. J Athl Train. 1992;27(1):80–84.

15. Ochsendorf DT, Mattacola CG, Arnold BL. Effect of orthotics on postural sway after fatigue of the plantar exors and dorsi exors. J Athl Train. 2000;35(1):26–30.

16. Mattacola CG, Dwyer MK, Miller AK, Uhl TL, McCrory JL, Malone TR. Effect of orthoses on postural stability in asymptomatic subjects with rearfoot malalignment during a 6-week acclimation period. Arch Phys Med Rehabil. 2007;88(5):653–660.

17. Corbin DM, Hart JM, McKeon PO, Ingersoll CD, Hertel J. The effect of textured insoles on postural control in double and single limb stance. J Sport Rehabil. 2007;16(4):363–372.

18. Hertel J, Denegar CR, Buckley WE, Sharkey NA, Stokes WL. Effect of rearfoot orthotics on postural sway after lateral ankle sprain. Arch Phys Med Rehabil. 2001;82(7):1000–1003.

19. Percy ML, Menz HB. Effects of prefabricated foot orthoses and soft insoles on postural stability in professional soccer players. J Am Podiatr Med Assoc. 2001;91(4):194–202.

20. Hertel J, Denegar CR, Buckley WE, Sharkey NA, Stokes WL. Effect of rear-foot orthotics on postural control in healthy subjects. J Sport Rehabil. 2001;10(1):36–47.

21. Rome K, Brown CL. Randomized clinical trial into the impact of rigid foot orthoses on balance parameters in excessively pronated feet. Clin Rehabil. 2004;18(6):624–630.

22. Murphy SL. Deaths: Final data for 1998. National Vital Statistics Reports, vol. 48, no. 11. Hyattsville (MD): National Center for Health Statistics; 2000.

23. Alexander BH, Rivara FP, Wolf ME. The cost and frequency of hospitalization for fall-related injuries in older adults. American Journal of Public Health 1992; 82(7):1020-3.

24. Murphy SL. Deaths: Final data for 1998. National Vital Statistics Reports, vol. 48, no. 11. Hyattsville (MD): National Center for Health Statistics; 2000.

25. Alexander BH, Rivara FP, Wolf ME. The cost and frequency of hospitalization for fall-related injuries in older adults. American Journal of Public Health 1992; 82(7):1020-3.

26. Hootman J, Dick R, Angel J. Epidemiology of collegiate injuries for 15 sports: summary and recommendations for injury prevention initiatives. J Athl Train 2007; 42(2):311-319.

27. Spink et al. Effectiveness of a multifaceted podiatry intervention to prevent falls in community dwelling older people with disabling foot pain: randomized controlled trial. BMJ 2011;342:d3411 doi:10.1136/bmj.d3411

ADDITIONAL REFERENCES: 28. Hiller CE, Kilbreath SL, Kathryn M. Refshauge KM. Chronic

ankle instability: evolution of the model. J Ath Train 2011; 46(2):133–141.

29. Donovan L, Hertel J. A new paradigm for rehabilitation of patients with chronic ankle instability. Phys Sportsmed. 2012; 40(4):41-51.

30. Richie DH. Chronic ankle instability: can orthotics help? Podiatry Today. 2006; 19(10):48-57.

31. Richie DH. Functional instability of the ankle and role of neuromuscular control. Comprehensive review. J Foot Ankle Surg. 2003; 42(5):79-86.

32. Gross MT, Mercer VS, Lin FC. Effects of foot orthoses on balance in older adults. J Orthop Sports Phys Ther. 2012; 42(7):649-57

33. De Morais Barbosa C, Barros Bértolo M, Marques Neto JF, et al. The effect of foot orthoses on balance, foot pain and disability in elderly women with osteoporosis: a randomized clinical trial.Rheumatology (Oxford). 2013; 52(3):512-22.

34. Rome K, Richie DH, Hatton AL. Can orthoses and insoles have an impact on postural stability?Podiatry Today. 2010; 23(10):46-51.

35. McKeon PO, Stein AJ, Ingersoll CD, Hertel J. Altered plantar-receptor stimulation impairs postural control in those with chronic ankle instability. J Sport Rehabil. 2012; 21(1):1-6

36. Nawata K, Nishihara S, Hayashi I, Teshima R. Plantar pressure distribution during gait in athletes with functional instability of the ankle joint: preliminary report. J Orthop Sci. 2005; 10(3):298–301.

37. Nyska M, Shabat S, Simkin A, et al. Dynamic force distribution during level walking under the feet of patients with chronic ankle instability. Br J Sports Med. 2003; 37(6):495–497.

38. Schmidt H, Sauer LD, Lee SY, Saliba S, Hertel J. Increased in-shoe lateral plantar pressures with chronic ankle instability. Foot Ankle Int. 2011; 32(11):1075-80.

39. Liang-Ching T, Yu B, Mercer VS, Gross MT. Comparison of different structural foot types for measures of standing postural control. J Orthop Sports Phys Ther. 2006; 36(12):942-953.

40. Hertel J, Gay MR, Denegar CR. Differences in postural control during single-leg stance among healthy individuals with different foot types. J Ath Train. 2002; 37(2):129-132.

41. Ki SW, Leung AK, Li AN. Comparison of plantar pressure distribution patterns between foot orthoses provided by the CAD-CAM and foam impression methods. Prosthet Orthot Int. 2008; 32(3):356-362.

42. Nester CJ, van der Linden ML, Bowker P. Effect of foot orthoses on the kinematics and kinetics of normal walking gait. Gait Posture. 2003; 17(2):180-7.

43. Kakihana W, Akai M, Yamasaki N, et al. Changes of joint moments in the gait of normal subjects wearing lateral wedged insoles. Am J Phys Med Rehabil. 2004; 83(4):273-278.

44. Kakihana W, Torii S, Akai M, et al. Effect of a lateral wedge on joint moments during gait in subjects with recurrent ankle sprain. Am J Phys Med Rehabil. 2005; 84(11):858-864.


9

EXPLORING THE CONTINUUM OF MOTION ANALYSIS TECHNIQUES IN THE CLINIC: ONE-SIZE DOES NOT FIT ALL!

Andrew Smith and Stephen Hill

Motion Analysis Research Center, Samuel Merritt University

Email: [email protected] / [email protected]

INTRODUCTION

With the growth in numbers of state-of-the-art motion analysis laboratories, predominately located in universities and dedicated research centers, there has been an explosion of published literature that detail quite sophisticated applications of motion analysis techniques and technology to a wide range of human activities. Thirty-plus years ago, when most motion analysis employed cinematography and consumer grade video cameras, employing the then contemporary motion analysis techniques in clinics was not uncommon. However, as motion analysis technology increased in both sophistication and cost, both in terms of money and time, the gap between the more academic research based and day-to-day clinical practice based motion analysis has widened.

Taking gait analysis as arguably the most common type of motion analysis seen in the clinic, this tutorial will briefly review the history of motion analysis; describe the more common tools found in modern motion analysis laboratories, such as the Motion Analysis Research Center (MARC) at Samuel Merritt University; and present some cutting-edge tools that close the technology gap between dedicated motion analysis research facilities and clinical practices.


Motion analysis laboratories in universities and research centers need access to patient populations as participants in research studies. Clinicians have experience working with a wide range of clinical populations, but often have little time to participate in research as investigators. New lower-cost tools, including smartphone apps, can offer clinicians ways to validate interventions outside of laboratories.

LEARNING OUTCOMES

By the end of this tutorial, the participant will learn:

1. An historical overview of the use of motion analysis.

2. About current technologies found in many motion analysis centers.

3. About new technologies that offer clinicians more options to get objective, valid, and reliable human motion data in the clinic.

OUTLINE

This tutorial will be divided into three sections:

1. A brief history of motion analysis and description of the main measurement tools used in human motion analysis.

2. Description of modern analysis tools and techniques and their impact on clinical practice.

3. Review of available tools for clinicians that combine ease of use, lower cost, and validity and reliability, including smartphone apps and consumer off-the-shelf solutions.

REFERENCES

1. Baker, R. (2007). A history of gait analysis before the advent of modern computers. Gait & Posture, 26, 331-342.

2. Del Din, S. et al. (2016). Measuring gait with an accelerometer-based wearable: influence of device location, testing protocol and age. Physiological Measurement, 37, 1785-1797.

3. Ferrarello, F. et al. (2013). Tools for observational gait analysis with stroke: a systematic review. Physical Therapy, 93, 1673–1685.

4. Hanlon, M & Anderson, R. (2009). Real-time gait event detection using wearable sensors. Gait & Posture, 30, 523-527.

5. Rathinam, C. et al. (2014). Observational gait assessment tools for paediatrics – a systematic review. Gait & Posture, 40, 279-285.

6. Springer, S. et al. (2016). Validity of the Kinect for gait assessment: a focused review. Sensors, 16, 194-206.

7. Tao, W. et al. (2012). Gait analysis using wearable sensors. Sensors, 12, 2255-2283.


The authors report that there are no conflicts of interest to disclose.


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11

WORKSHOPS


12

Friday, November 4, 2016

Workshops (90-min duration)

Time Session Location Moderator(s)

1:00

Balance Evaluation Systems Test (BESTest): A Systems Approach to Balance Evaluation

Bechtel Dr. Laurie King

Practical Demonstration on Walking and Running Gait Evaluations and Simulated Foot Orthosis Function in Gait

MARC Dr. Kevin Kirby

2:30 Break

3:00

The Treatment Direction Test - the use of adhesive strapping to determine the efficacy as well as guide the foot orthoses prescription

Fontaine Professor Tom McPoil

Translation of Motor Control Principles to Practical Applications in Neurological Rehabilitation

Bechtel Professor Mindy Levin

4:30 Day Wrap-Up – Bechtel Room

4:45 Wine and Cheese Reception - Bechtel Room


13

BALANCE EVALUATION SYSTEMS TEST (BESTest); A SYSTEMS APPROACH TO BALANCE EVALUATION.

Laurie A. King

Oregon Health & Science University


INTRODUCTION

Balance problems are the most common reason for falls and decreased quality of life. However, balance control is based on many underlying complex systems that can be affected by disease and injury. It is important to evaluate the specific systems affected in each patient with a balance problem in order to develop effective treatments. However, current balance evaluation tests do not differentiate different types of balance problems. The purpose of this workshop is to learn a systems approach to differentiate balance disorders. In this workshop, the clinician will learn about the Balance Evaluation Systems Test (BESTest) to differentiate balance into 6 underlying systems: Biomechanical, Stability Limits, Postural Responses, Anticipatory Postural Adjustments, Sensory Orientation, and Dynamic Balance during Gait and Cognitive Effects. This unique evaluation tool is appropriate for any age of ambulatory patients with Parkinson’s Disease, Cerebellar Ataxia, Vestibular Disorders, Neuropathy, Head Injury, Multiple Sclerosis, Stroke, Cerebral Palsy, Cognitive Deficits, and others.


Use of the BESTest will give clinicians a new tool for quantifying balance and differentiating balance deficits to design more effective treatments. The BESTest is a sensitive, quantitative balance assessment that may improve patient care by identifying subtle deficits and changes with therapy.

LEARNING OUTCOMES

By the end of this workshop, participants will learn the following:

• a systems approach to balance control

• The BESTest as a clinical tool to measures balance sub systems

• the difference between the BESTest, MiniBESTest, brief BESTest and iBESTEST

OUTLINE

• Introduce systems approach to Balance control (30 min)

• Introduce BESTest (30 min)

Practice push and release test

• Introduce miniBEST and shorter versions of the BESTest (30 min)

REFERENCES

1. Horak, FB, Wrisley, D, and Frank, J, The Balance Evaluation Systems Test (BESTest) to differentiate balance deficits. Physical Therapy, 89(5):484-98, 2009

2. Franchignoni, Franco, et al. "Using psychometric techniques to improve the Balance Evaluation Systems Test: the mini-BESTest." Journal of Rehabilitation Medicine 42.4 (2010): 323-331.

3. Duncan, Ryan P., et al. "Comparative utility of the BESTest, Mini-BESTest, and Brief-BESTest for predicting falls in individuals with Parkinson disease: a cohort study." Physical therapy 93.4 (2013): 542-550.




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PRACTICAL DEMONSTRATION ON WALKING AND RUNNING GAIT EVALUATIONS AND SIMULATED FOOT ORTHOSIS FUNCTION DURING GAIT

Kevin Kirby



SUMMARY

Practical walking and running gait evaluation techniques will be reviewed and demonstrated with live subjects in this workshop. The concept that altering the plantar locations, magnitudes and temporal patterns acting on the plantar with foot orthoses will affect gait kinematics will also be demonstrated in this workshop.

REFERENCES

1. Kirby KA: Foot and Lower Extremity Biomechanics IV: Precision Intricast Newsletters, 2009-2013. Precision Intricast, Inc., Payson, AZ, 2014.


The author reports that there are no conflicts of interest to disclose.


15

THE TREATMENT DIRECTION TEST - THE USE OF ADHESIVE STRAPPING TO DETERMINE EFFICACY AS WELL AS GUIDE THE FOOT ORTHOSES PRESCRIPTION

Thomas G. McPoil

School of Physical Therapy, Regis University


INTRODUCTION

Evidence exists suggesting that a pronated foot posture or an increase in foot pronation can be factors in the development of overuse lower extremity and foot injuries, including plantar fasciitis, medial tibial stress syndrome, and anterior knee pain. Since overuse lower extremity and foot injuries are multi-factorial, the key question for the clinician is determining if modifying foot posture and/or foot mobility will lead to a reduction in the patient’s pain and symptoms as well as improve functional levels of activity. While a common intervention that can be used to modify foot posture and/or foot mobility is a foot orthosis, the cost of the device to the patient without knowing if controlling foot posture and/or mobility can effectively decrease the patient’s symptoms and function can preclude the clinician from prescribing. This session will provide the participant with: 1) a review of the current literature that has examined the effect of foot posture and mobility as a potential factor in the development of overuse injuries in the lower extremity and foot; 2) the evidence to support the use of the Treatment Direction Test (TDT) using adhesive tape to determine if foot orthoses should be considered as a treatment intervention; and 3) in the case of a positive TDT, current evidence which supports the use of the change in foot position created by the adhesive tape to guide the amount of posting of the foot orthosis.


The TDT, which utilizes adhesive strapping to modify foot posture or control foot mobility, provides the clinician with an efficient and cost-effective method for determining not only if controlling foot mobility improves symptoms and function but also can guide the orthosis prescription.

LEARNING OUTCOMES


1. State the basic principles of performing a treatment direction test using adhesive strapping;

2. Describe adhesive strapping techniques, both above and below the ankle that can be utilized to perform a treatment direction test; and,

3. Describe how to objectively assess the change in foot position created by the adhesive strapping and

how to use these objective changes to appropriately post a foot orthoses.

OUTLINE

30 minutes – Clinical applications of the Treatment Direction Test

30 minutes – Description of augmented low-Dye and reverse-6 adhesive strapping procedures

30 minutes – Use of the Treatment Directions test to guide foot orthoses description

ASSESSMENT OF LEARNING

Guided Question & Answer Session

REFERENCES

1. Newell T, Simon J, Docherty CL: Arch-taping techniques for altering navicular height and plantar pressures during activity. J Athl Train 2015;50:825-832.

2. Cornwall MW, McPoil TG, Fair A: The effect of exercise and time on the height and width of the medial longitudinal arch following the modified reverse-6 and the modified augmented low-Dye taping procedures. Int J Sports Phys Ther 2014;9:635-643.

3. Cornwall MW, Lebec M, DeGuyter J, McPoil TG: The reliability of the modified reverse-6 taping procedure with elastic tape to alter the height and width of the medial longitudinal arch. Int J Sports Phys Ther 2013;8:381-392.

4. Franettovich MM, Murley GS, David BS, Bird AR: A comparison of augmented low-Dye Taping and ankle bracing on lower limb muscle activity during walking in adults with flat-arched foot posture. J Sci Med Sport 2012;15:8-13.

5. Cheung RT, Chung RC, Ng GY. Efficacies of different controls for excessive foot pronation: a meta-analysis. Br J Sports Med 2011;45: 743–751.

6. Franettovich M, Chapman AR, Blanch P, Vicenzino B. Augmented low-Dye tape alters foot mobility and neuromotor control of gait in individuals with and without exercise related leg pain. J Foot Ankle Res 2010;3:5.

7. Meier K, McPoil TG, Cornwall MW, Lyle T. Use of antipronation taping to determine foot orthosis


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prescription: a case series. Research in sports medicine 2008;16(257):257–271.

8. Franettovich M, Chapman A, Blanch P, Vicenzino B. A physiological and psychological basis for antipronation taping from a critical review of the literature. Sports Med 2008;38:617-31.

9. Vicenzino B, McPoil TG, Russell T, Peisker S. Antipronation tape changes foot posture but not plantar ground contact during gait. The Foot 2006;16(2):91–97.

10. Vicenzino B, Franettovich M, McPoil T, Russell T, Skardoon G. Initial effects of anti-pronation tape on the medial longitudinal arch during walking and running. British Journal of Sports Medicine 2005;39: 939–943.

11. Smith M, Brooker S, Vicenzino B, McPoil T. Use of anti-pronation taping to assess suitability of orthotic prescription: Case report. Australian Journal of Physiotherapy 2004;50: 111–113.

12. Vicenzino B. Foot orthotics in the treatment of lower limb conditions: A musculoskeletal physiotherapy perspective. Manual Therapy 2004;9: 185–196.




17

TRANSLATING MOTOR CONTROL PRINCIPLES TO PRACTICAL APPLICATIONS IN NEUROLOGICAL REHABILITATION.

Mindy F. Levin

School of Physical and Occupational Therapy, McGill University Centre for Interdisciplinary Research in Rehabilitation


INTRODUCTION

There is increasing interest in understanding the mechanisms of neuroplasticity in the intact brain and how these shape the body’s response to neurological injury and as well as the recovery process (Kleim and Jones 2008). In order to apply this understanding to clinical practice, a good knowledge of motor control and motor learning principles is needed (Levin et al. 2015). This workshop will review the principles of movement production according to current theories of motor control including the action-perception theory, dynamical theory and the equilibrium point theory (Turvey et al. 1982; Latash et al. 2010; O’Brien and Bracewell 2010). In particular, how motor control principles such as redundancy, stability and affordances can be incorporated into clinical practice will be discussed. Emphasis will be placed on distinguishing between outcomes describing motor recovery and compensation (Levin et al. 2009).


Awareness and application of the principles of motor control and motor learning will improve outcomes of sensorimotor motor rehabilitation.

LEARNING OUTCOMES


1. Appreciate the historical perspective and philosophy of motor control;

2. Understand current theories of the production and organization of movement;

3. Be able to critically appraise the merits and drawbacks of different motor control theories as they apply to clinical practice;

4. Appreciate the importance of assessing movement quality in order to evaluate motor behavioural recovery and compensation.

OUTLINE

The workshop will be presented in three sections:

1. Historical and philosophical perspective of motor control

2. Major theories of motor control and their implications for clinical practice

3. Motor recovery in neurological rehabilitation versus compensation and their measurement

ASSESSMENT OF LEARNING (Optional)

Participants will be asked to fill in a feedback assessment at the completion of the workshop.

REFERENCES

1. Kleim, J.A. & Jones, T.A. (2008) Journal of Speech Language & Hearing Research, 51(1): p. S225-39.

2. Latash M.L., Levin M.F., Sholtz J., & Schoner G. (2010) Medicina (Kaunas), 46(6): p. 382-92. www.ncbi.nlm.nih.gov/pmc/articles/PMC3017756/

3. Levin, M.F., Kleim, J.A. & Wolf, S.L. (2009) Neurorehabilitation and Neural Repair, 23(4): p. 313-19.

4. Levin, M.F., Weiss, P.L. & Keshner, E. (2015) Physical Therapy: Special Issue on Innovative Technologies for Rehabilitation and Health Promotion. Physical Therapy, 95(3): p. 415-25.

5. O’Brien, J. & Bracewell, M. A (2010) Advances in Clinical Neuroscience and Rehabilitation, 10(3): p. 23-24.

6. Turvey, M.T., Fitch, H.L. & Tuller, B. (1982) The Bernstein Perspective. In: Human Motor Behavior: An Introduction. J.A.S. Kelso (Ed.) Hillsdale, NJ: Lawrence Erlbaum Associates, p. 239-52.




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19

ORAL PRESENTATIONS


20

Saturday, November 5, 2016

Presentations and Posters

Morning Session (Bechtel Room) 7:30 Registration and Continental Breakfast 8:15 Welcome and Announcements

Keynote Address (40-min + 5-min QA) Time Speaker Title 8:30 Professor Nick Stergiou Harnessing Movement Variability to Treat and Prevent Motor Related Disorders

Theme: Podiatry I (15-min +5-min QA) Moderator: Dr. Cherri Choate Time Speaker Title

9:20 Dr. Kevin Kirby Posterior Tibial Tendon Dysfunction: Mechanical Etiology, Effective Conservative Therapy, and Biomechanics of Surgical Repair

9:40 Professor Tom McPoil Manual Therapy Techniques for the Management of Chronic Plantar Heel Pain 10:00 Dr. Doug Richie Jr. Hallux Valgus and First Ray Hypermobility: Myths and Misconceptions

10:20 Break and Posters (20-min)

Theme: Neuromuscular (15-min +5-min QA) Moderator: Dr. Stephen Hill Time Speaker Title

10:40 Dr. Alexandra Franceschi Case Report: Physical Therapy Management of a Child with Pontine Tumor and Hemorrhage with Consideration of Involved Brainstem Tracts and Nuclei

11:00 Dr. Ka Lam Sam Dynamic Postural Control of Individuals with Autism 11:20 Dr. Ka Lam Sam Visual cognition and dynamic balance in persons with autism spetrum disorder

Keynote Address (40-min + 5-min QA) Time Speaker Title 11:40 Dr. Laurie King Wearable Technology for Mobility Assessment and Rehabilitation

12:25 Lunch and Poster Session (45-min)

Afternoon Session (Bechtel Room)

Keynote Address (40-min + 5-min QA) Time Speaker Title 1:10 Professor Mindy Levin Using Virtual Reality for Motor Learning in Neurological Rehabilitation

Theme: Podiatry II (15-min +5-min QA) Moderator: Dr. Tim Dutra Time Speaker Title 2:00 Dr. Doug Richie Jr. Evaluation of the Adult Acquired Flatfoot Deformity: Static and Dynamic Analysis 2:20 Dr. Kevin Kirby Rearfoot, Midfoot or Forefoot Striking Running: Which is Best?

2:40 Professor Tom McPoil The Longitudinal Arch Angle: A Reliable Clinical Measurement to Classify Static and Dynamic Foot Posture

3:00 Dr. Cherri Choate The Impact of Maximalist Running Shoes on Lower Extremity Kinematics and Kinetics During Walking and Running Compared to Neutral Running Shoes

3:20 Break and Posters (20-min)

Theme: MARC Studies (15-min +5-min QA) Moderator: TBA Time Speaker Title

3:40 Professor Drew Smith Planned vs Unplanned Turns During Normal Gait: A Pilot Study Examining Kinematics, Kinetics, and Muscle Activation Patterns

4:00 Dr. Stephen Hill The Effect of Custom-made Orthotics on Anterior Cruciate Ligament of the Knee During Normal Walking and Cutting Maneuvers

4:20 Dr. Emma Lam Biomechanical Evaluation of Hotel Luxury Bed Making While Using a Mattress Lift Tool and Fitted Sheets

4:40 Professor Drew Smith Effects of an Adjustable Orthotic on Lower Limb Biomechanics

5:00 Awards and Closing Remarks (10-min)


21

HARNESSING MOVEMENT VARIABILITY TO TREAT AND PREVENT MOTOR RELATED DISORDERS

Nicholas Stergiou1, 2 1University of Nebraska Omaha; 2University of Nebraska Medical Center


ABSTRACT

An optimal level of variability enables us to interact adaptively and safely to a continuously changing environment, where often our movements must be adjusted in a matter of milliseconds. A large body of research exists that demonstrates natural variability in healthy movement such as gait and posture (along with variability in other, healthy biological signals e.g. heart rate), and a loss of this variability in ageing and injury, as well as in a variety of neurodegenerative and physiological disorders. In this keynote I submit that this field of research is now in pressing need of an innovative “next step” that goes beyond the many descriptive studies that characterize levels of variability in various patient populations. We need to devise novel therapies that will harness the existing knowledge on biological variability and create new possibilities for those in the grip of disease. I also propose that the nature of the specific physiological limitations present in the neuromuscular apparatus may be less important in the physiological complexity framework than the control mechanisms adopted by the affected individual in the coordination of the available degrees of freedom. The theoretical underpinnings of this framework suggest that interventions designed to restore healthy system dynamics may optimize functional improvements in affected individuals. I submit that interventions based on the restoration of optimal variability and movement complexity could potentially be applied across a range of diseases or dysfunctions as it addresses the adaptability and coordination of available degrees of freedom, regardless of the internal constraints of the individual (1-6).

REFERENCES

1. Stergiou N, Kent JA, McGrath D. (2015). Human Movement Variability and Aging. Kinesiology Review. 5:15 – 22.

2. Stergiou N, Decker LM. (2011). Human movement variability, nonlinear dynamics, and pathology: Is there a connection? Human Movement Science. Oct;30(5):869-88.

3. Stergiou N, Harbourne R, Cavanaugh J. (2006). Optimal Movement Variability: A New Theoretical Perspective for Neurologic Physical Therapy. Journal of Neurologic Physical Therapy. Sep;30(3):120-129.

4. Cavanaugh JT, Guskiewicz KM, Stergiou N. (2005). A nonlinear dynamic approach for evaluating postural

control: New directions for the management of sport-related cerebral concussion. Sports Medicine. 35(11):935-950.

5. Harbourne RT, Stergiou N. (2009). Movement Variability and the Use of Nonlinear Tools: Principles to Guide Physical Therapy Practice. Physical Therapy. Mar;89(3):267-282.

6. Decker LM, Moraiti C, Stergiou N, Georgoulis AD. (2011). New insights into anterior cruciate ligament deficiency and reconstruction through the assessment of knee kinematic variability in terms of nonlinear dynamics. Knee Surgery, Sports Traumatology, Arthroscopy. Oct;19(10):1620-33.


This work was supported by the Center for Research in Human Movement Variability of the University of Nebraska at Omaha and the NIH (P20GM109090 and R15HD086828).


22

POSTERIOR TIBIAL TENDON DYSFUNCTION: MECHANICAL ETIOLOGY, EFFECTIVE CONSERVATIVE THERAPY AND BIOMECHANICS OF SURGICAL REPAIR

Kevin Kirby



SUMMARY

The biomechanics, conservative and surgical treatment of posterior tibial tendon dysfunction (PTTD) will be reviewed in order to discuss the biomechanical nature of PTTD, how posterior tibial tendon injury is caused and allows progression of PTTD, and how prompt aggressive treatment of PTTD can restore normal function and prevent further disability.

REFERENCES

1. Ellis SJ, Williams BR, Garg R, et al. Incidence of plantar lateral foot pain before and after the use of trial metal wedges in lateral column lengthening. Foot Ankle Int. 2011;32(7):665–73.

2. Jeng CL, Bluman EM, Myerson MS. Minimally invasive deltoid ligament reconstruction for stage IV flatfoot deformity. Foot Ankle Int. 2011;32(1):21–30.

3. Smith JT, Bluman EM. Update on stage IV acquired adult flatfoot disorder: when the deltoid ligament becomes dysfunctional. Foot Ankle Clin. 2012;17(2):351–60.

4. Khazen G, Khazen C. Tendoscopy in stage I posterior tibial tendon dysfunction. Foot Ankle Clin. 2012;17(3):399–406.

5. Neville C, Lemley FR. Effect of ankle-foot orthotic devices on foot kinematics in Stage II posterior tibial tendon dysfunction. Foot Ankle Int. 2012; 33: 406– 414.




23

MANUAL THERAPY TECHNIQUES FOR THE MANAGEMENT OF CHRONIC PLANTAR HEEL PAIN

Thomas G. McPoil



INTRODUCTION

Chronic plantar heel pain (CPHP) is one of the most common foot conditions treated by health care providers. It has been estimated that approximately 2 million Americans are treated for chronic plantar heel pain yearly. Although the medical diagnosis of plantar fasciitis is often used for these individuals, a pathoanatomical based diagnosis is difficult in light of the numerous types of soft tissue structures in the plantar heel region. Past studies have demonstrate that the development of symptoms associated with CPHP can occur in both pes planus or pes cavus foot types. Because of the frequency of diagnosis, numerous clinical practice guidelines have been developed to guide the clinician in using best evidence to development an optimal plan of care for individuals with CPHP.


Although numerous interventions have been described for the management of plantar fasciitis, it is critical that the health care provider understand the level of evidence to support these various interventions as well as expected duration of the treatment effect provided by the intervention.

INTERVENTIONS

Based on recent Clinical Practice Guidelines focusing on conservative care for individuals with CPHP, there is high quality evidence to support: 1) plantar fascia-specific and gastrocnemius/soleus stretching (duration of 1 week to 4 months); 2) the use of anti-pronation taping for immediate (up to 3 weeks) of pain reduction and improved function as well as to determine if foot orthoses are justified; 3) foot orthoses, either prefabricated or custom fabricated or fitted, to support the medial longitudinal arch and cushion the heel to reduce pain and improve function from 2 weeks to 1 year; 4) the use of night splints for 1 to 3 months; 5) therapeutic exercise, specifically strengthening of the proximal hip musculature and intrinsic muscles of the foot; 6) footwear education; and 7) manual therapy. There are good levels of evidence to support the use of manual therapy, consisting of joint and soft tissue mobilization procedures, to treat specific deficits in lower extremity joint mobility as well as calf flexibility. The focus of this presentation will be on specific manual therapy techniques that have been used in

clinical trials involving individuals diagnosed with CPHP/plantar fasciitis.

MANUAL THERAPY TECHNIQUES

Specific foot manual therapy techniques that have been used in clinical trials include: 1) talocrural joint anterior to posterior glide performed in either a supine or prone position; 2) a subtalar joint medial to lateral glide performed in side lying with the involved side down; 3) first tarsometatarsal joint dorsal glide performed in prone; and 4) a talocrural OR subtalar joint distraction manipulation performed in supine. In addition to the manual therapy techniques performed in the clinic, the patient should be instructed to perform an anterior to posterior talocrural joint self-mobilization as part of their home program. The typical dosage for the mobilization techniques is five (5) 30 to 45 second bouts for each technique with the intensity (grade 3 or 4) based on patient tolerance. The subtalar OR talocrural joint manipulation technique is performed for an analgesic effect and one study has demonstrated this technique can be of benefit up to six (6) months from the onset of symptoms. Since the subtalar and talocrural joint are so closely related anatomically, to effectively manipulate a specific joint requires the use of the respective close-pack and loose-pack positions for each joint. To perform a subtalar joint manipulation, the foot should be held in an everted position with the ankle dorsiflexed as much as possible. To perform a talocrural joint manipulation, the foot should be placed in an inverted position with the ankle in a 15 to 20 degree plantarflexed position. A pilot study using video fluoroscopy involving three individuals with no history of ankle or foot injury and normal joint range of motion demonstrated that the use of the closed-pack and loose-pack positioning enhances movement at the respective joints.


24

Since the effect of the manipulation is analgesic in nature, the joint selected for the manipulation is discretionary since both joints are innervated by the tibial nerve. In addition to reviewing the evidence to support manual therapy interventions, videotapes of each of the mobilization and manipulation techniques will be shown during this session.

REFERENCES

1. Martin RL, Davenport TE, Reischl SF, McPoil TG, et al: Heel Pain – Plantar Fasciitis: Revision 2014. J Orthop Sports Phys Ther. 2014; 44:A1-A23.

2. McPoil TG, Martin RL, Cornwall MW, Wukich DK,et al. Heel pain—plantar fasciitis: clinical practice guidelines linked to the International Classification of Function, Disability, and Health. J Orthop Sports Phys Ther. 2008; 38:A1-A18.

3. Landorf KB, Menz HB. Plantar heel pain and fasciitis. Clin Evid (Online). 2008;2008:1111.

4. Brantingham JW, Bonnefin D, Perle SM, et al. Manipulative therapy for lower extremity conditions: update of a literature review. J Manipulative Physiol Ther. 2012;35:127-166.

5. Cleland JA, Abbott JH, Kidd MO, et al. Manual physical therapy and exercise versus electrophysical agents and exercise in the management of plantar heel pain: a multicenter randomized clinical trial. J Orthop Sports Phys Ther. 2009;39:573-585.

6. Young B, Walker MJ, Strunce J, Boyles R: A combined treatment approach emphasizing impairment-based manual physical therapy for plantar heel pain: A case series. J Orthop Sports Phys Ther. 2004; 34:725-733.




25

HYPERMOBILITY OF THE FIRST RAY: MYTHS AND MISCONCEPTIONS




INTRODUCTION

The first ray of the human foot has been implicated in more pathologies than any other skeletal segment of the lower extremity. (1) Specifically, hypermobility of the first ray has been associated with hallux valgus, hallux rigidus, 2nd MTP pathology, neuroma, metatarsalgia, plantar fasciitis and flatfoot deformity. (2)


Clinicians often evaluate foot function by assessing motion of the 1st MTPJ and sagittal plane motion of the first ray. (4) Also, radiographic measurements of position of the first ray are taken to determine etiology and surgical interventions for hallux valgus and hallux rigidus. Several studies have demonstrated that standard traditional techniques for measurement of first ray position are misleading and innacurate. (5-7)

OVERVIEW

The history of study of first ray function will be presented along with previous theories of hypermobility of this segment and its association with a host of foot pathologies. Methods of measuring range of motion of the first ray will reviewed for accuracy and relevance. (6,8)

Clinicians rely on measurement of first ray position, depicted by static weight bearing radiographs and often make erroneous conclusions about first ray hypermobility. The cause/effect relationship of of first ray elevatus and its relationship to hallux valgus and hallux rigidus will be discussed. (9-11)

Surgical procedures have been designed to address hypermobility of the first ray. A review of the efficacy of these procedures will be presented.

REFERENCES

1. Van Beek C, Greisberg J. Mobility of the first ray. Foot and Ankle Int. 32:9, Sept. 2011.

2. Roukis TS, Scherer PR, Anderson CF. Position of the first ray and motion of the first metatarsophalangeal joint. J Am Podiatr Med Assoc. 1996; 86(11):538-46.

3. Nawoczenski DA, Baumhauer JF, Umberger BR. Relationship between clinical measurements and

motion of the first metatarsophangeal joint during gait. J Bone Joint Surg. 1999; 81(3):370-6.

4. Horton, G; Park, Y; Myerson, M: Role of metatarsus primus elevatus in the pathogenesis of hallux rigidus. Foot Ankle Int. 20:777 –780, 1999.

5. Coughlin MJ, Shurnas PS: Hallux Rigidus: Demographics, Etiology, and Radiographic Assessment. Foot & Ankle International/Vol. 24, No. 10/October 2003, pp 731-743.

6. Roukis TS: Metatarsus primus elevatus in hallux rigidus: Fact or fiction? JAPMA 95: 221, 2005

7. Wong DW, Zhang M, Yu J, Leung AK. Biomechanics of first ray hypermobility: an investigation on joint force during walking using finite element analysis. Med Eng Phys. 2014 Nov;36(11):1388-93.

8. Cornwall MW, McPoil TG, Fishco WD, et al: The influence of first ray mobility on forefoot plantar pressure and hindfoot kinematics during walking. Foot and Ankle Int27:539-547, 2006.

9. Allen MK, Cuddeford TJ, Glasoe WM, DeKam LM, Lee PJ, Wagner KJ, Yack HJ. Relationship between static mobility of the first ray and first ray, midfoot, and hindfoot motion during gait. Foot Ankle Int 25:391–396, 2004.

10. Michael J. Coughlin, M.D.∗; Carroll P. Jones, M.D.∗; Ramo ́n Viladot, M.D.†; Pau Glano ,́ M.D.†; Brett R. Grebing, M.D.‡; Michael J. Kennedy, M.D.§; Paul S. Shurnas, M.D.∥; Fernando Alvarez, M.D.† Hallux Valgus and First Ray Mobility: A Cadaveric Study Foot & Ankle International/Vol. 25, No. 8/August 2004

11. Doty JF, Coughlin MJ. Hallux valgus and hypermobility of the first ray: facts and fiction. Int Orthop. 2013 Sep;37(9):1655-60.

12. Hirose, CB; Johnson, JE: Plantarflexion opening wedge medial cuneiform osteotomy for correction of fixed forefoot varus associated with flatfoot deformity. Foot Ankle Int. 25:568 – 574, 2004.


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CASE REPORT: PHYSICAL THERAPY MANAGEMENT OF A CHILD WITH PONTINE TUMOR AND HEMORRHAGE WITH CONSIDERATION OF INVOLVED BRAINSTEM TRACTS AND NUCLEI

Alexandra Franceschi and Rolando Lazaro

Department of Physical Therapy, Samuel Merritt University


INTRODUCTION

This case report demonstrates the physical therapy management of a pediatric patient with pontine tumor and hemorrhage. Due to the high probability of coma and resulting death, few patients with these diagnoses are seen for physical rehabilitation.

CASE DESCRIPTION

The patient is a twelve-year-old boy with increasing return of consciousness and motor function following high-grade brainstem glioma with associated hemorrhage. On evaluation, impairment of the medial and lateral vestibulospinal, medial corticospinal, and cerebellar tracts were postulated to be contributory to the patient’s lack of postural control. This information was then integrated into interventions that focused on developing segmental head and trunk control while sitting. The function of the intact tectospinal and dorsal column tracts were incorporated in the intervention plan to further optimize functional return.


Assessment of the integrity of the brainstem tracts and nuclei can lead to appropriate clinical decisions to drive change within an impaired brainstem.

CASE DESCRIPTION

The patient is a twelve-year-old boy with increasing return of consciousness and motor function following high-grade brainstem glioma with associated hemorrhage. On evaluation, impairment of the medial and lateral vestibulospinal, medial corticospinal, and cerebellar tracts were postulated to be contributory to the patient’s lack of postural control. This information was then integrated into interventions that focused on developing segmental head and trunk control while sitting. The function of the intact tectospinal and dorsal column tracts were incorporated in the intervention plan to further optimize functional return.

OUTCOMES

Medical interventions in addition to physical therapy resulted in improved head and trunk control while sitting. The patient achieved brief independent sitting and standing with support by the end of his inpatient rehabilitation.

CONCLUSION

In a patient with neurological damage secondary to brainstem involvement, examination of the tracts and nuclei within the brainstem guided physical therapy interventions that optimized functional return. This case report demonstrates that treating the trunk using a segmental approach resulted in positive outcomes related to head and trunk control and supported standing.

SELECTED REFERENCES

1. Butler P. A preliminary report on the effectiveness of trunk targeting in achieving independent sitting balance in children with cerebral palsy. Clinical Rehabil. 1998;12:281-293.

2. Jang J, Song Y, Kim Y. Predictors of 30 day mortality and 90 day functional recovery after primary pontine hemorrhage. J Korean Med Sci. 2011;26:100-107.

3. Jordan L. Hemorrhagic stroke in children. Pediatr Neurol. 2007;36(2)73-80.

4. Lo W. Childhood hemorrhagic stroke: an important but understudied problem. J Child Neurol. 2011;26(9):1174-1185.

5. Mueller S, Chang S. Pediatric brain tumor: current treatment strategies and future therapeutic approaches. Neurotherapeutics. 2009;6(3):570-586.

6. Nishizaki T, Ikeda N, Nakano S, et al. Factors determining the outcome of pontine hemorrhage in the absence of surgical intervention. OJMN. 2012;2:17-20.

7. Ruhland J, Van Kan P. Medial pontine hemorrhagic stroke. Phys Ther. 2003;83(6):552-566.

8. Butler P. A preliminary report on the effectiveness of trunk targeting in achieving independent sitting balance in children with cerebral palsy. Clinical Rehabil. 1998;12:281-293.

9. Taub E, Griffin A, Nick J, et al. Pediatric CI therapy for stroke induced hemiparesis in young children. Dev Neurorehabil. 2007;10:3-18.




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DYNAMIC POSTURAL CONTROL OF INDIVIDUALS WITH AUTISM

Sing Kai Lo1, Andrew Smith2 and Ka-Lam Sam1 1The Education University of Hong Kong and 2Motion Analysis Research Center, Samuel Merritt University


INTRODUCTION

Dynamic postural control has been studied extensively in clinical settings; it is also known as dynamic balance and depends on sensory and cognitive factors. For example, a study investigating the relationship between gross motor skills of lower limb and postural stability in children with autism found that postural stability appeared to influence the ability of children to perform gross motor skills. However, their study did not assess other factors, e.g., visual input, cognitive function, etc.; hence it is unclear whether postural stability will be affected [1]. The authors concluded that visual input and cognition development might be crucial factors that influence postural stability [1]. Two studies that focused on stability and dynamical complexities / sensory contributions also reported that dynamic balance might be associated with visual cognition among individuals with autism [2-3]. In addition, many researchers have observed postural abnormalities, both dynamic and static balance within the category, in people with autism.


Understanding the mechanism and factors affecting postural control in special population, in this case people with autism, may assist in advancing our knowledge and helping us to develop an appropriate intervention/treatment plan for the target population.

METHODS

Five males with autism participated in this study; they were all members of a Special Olympics team; [see Table 1 for basic statistics]. Pro Balance by Lab rehab™ was adopted to assess the dynamic postural control. Participants were asked to stand on a balance disc, an electronic device, with both feet and eyes opened for 30 seconds; they were asked to maintain the equilibrium position (do not fall down) during the period.

Table 1: Participants’ basic statistics

The swaying of body, center of gravity (CoG) were tracked; 3 trials in total, 30 seconds per trial, with a 3-minutes rest between each trial. Participants’ demographic characteristics and Raven scores [4] are shown in Table 1; CoG tracking records are shown in Figure 1.

Figure 1: Tracking of center of gravity (CoG)

RESULTS

Correlation between variables

A moderately high positive correlation was found between dynamic postural control (dynamic balance score) and Raven scores (r = 0.617). There was strong negative association between dynamic postural control and body weight (r = -0.993) and BMI (r = -0.904) [Table 2].

Table 2: Correlation coefficients

** p < .01

Posterior-Anterior and Medio-Lateral degrees

To further investigate the dynamic postural control, three components were used in calculating the dynamic balance score: (i) duration ratio (the percentage duration while standing inside the white area in the center; (ii) A/P° ratio (Anterior/ Posterior degree ratio;


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indicating the forward and backward swaying of the body) [Figure 2]; and (iii) M/L° ratio (Medio/Lateral degree ratio; indicating the inward and outward or left and right swaying of the body [Figure 3].

Figure 2: Posterior-Anterior shifting diagram

Figure 3: Medio-Lateral shifting diagram

DISCUSSION

Neuromuscular conditions of the balance control

In the aspect of neuromuscular conditions, the functioning of somatosensory receptors is a crucial factor which affect the balance/postural control while encountering a changing (dynamic) scenario. After a certain training on extremity and/or trunk strategies, it will programmed inside automatically for those receptors, once the sensors receive any signal from external stimulation, the system of maintaining body equilibrium/balance was activated immediately. If further studies are conducting based on the neuromuscular factor, i.e., for those somatosensory receptors, the use of electromyography (EMG) measure is recommended, since it provides proprioceptive signals (the primary source of autonomic proprioceptive input). Although extremity proprioceptive systems are not entirely understood, they remain an important link in dynamic postural control.

Somatotyping conditions of the postural control

The body anthropometric measurements, such as the body type and/or body shape, are internal factors which may partially affect the balance/postural control in

human body. In layman term, higher center of gravity (CoG) seems to be more difficult to maintain the body balance in a standing position.

Obesity and postural control

The BMI range of the study participants varied from underweight to obese (BMI: 17.35-33.52 in table 1), and the mean (23.36) falls in the overweight category of the Asian population. Physiologists have been investigating the issue of obese and postural/balance control for a few decades; but most of them were applicable for general population only; the conclusion is lower CoG due to obese do not contribute to a better balance control, and might even make the situation worse. Besides, the hot issue these years was the obese and cognition, it was believed that the cognitive deficits lead to obese, but the relationship in-between still needs evidences to prove/support; further work/ discussion should carry out.

Challenging for individuals with autism

Since the unique characteristics of people with autism, i.e., lack of socialization skills, deficit on language/communication, restricted behaviors, etc., which make the exercise inclusion a harder task for accomplishment. A certain research work should do on that in order to justify their needs with evidence; and sufficient support should be provided.

Emphasizing the needs of physical training/activity

However, we still believe that training the muscle strength required for maintaining body balance is important; hence, training plans in those fields are suggested. Second, persistently developing the functional cognition for executing daily basic tasks is crucial as well. Such health services, i.e., occupational therapy, physical therapy, etc., are expected on high demand for persons with autism.

REFERENCES

1. Mache, M.A., & Todd, T.A. (2016). Research in Autism Spectrum Disorders, 23: p.179-187.

2. Stins, J.F. et al. (2015) Gait & Posture, 42(2): p.199-203.

3. Hanaie, R. et al. (2016). Autism Research, n/a.

4. Raven, J. (1981). Manual for Raven’s Matrices.




29

VISUAL COGNITION AND DYNAMIC BALANCE IN PERSONS WITH

AUTISM SPECTRUM DISORDER

Ka-Lam Sam1 Andrew Smith2 and Sing Kai Lo3 1Nanyang Technological University, 2Motion Analysis Research Center, Samuel Merritt University and 3The Education

University of Hong Kong

Email: [email protected]; [email protected]

INTRODUCTION

Autism Spectrum Disorder (ASD) was described in Diagnostic and Statistical Manual of mental disorders 5th edition (DSM-5), mainly in three aspects of daily life below: 1) tenacious deficits in social functioning; 2) restrictive, repetitive pattern of behavior, interests or activities; 3) with or without accompanying intellectual/language/motor impairment [1]. Various studies have found balance difficulties and postural abnormalities in autism [2-3], and some of them designated that the visual cognition might be one of the key possible factors which related to dynamic balance and help on postural control [3-4].

Visual cognition – the ability to perceive an object’s physical properties (such as shape, color and texture) and apply semantic attributes to the object (visual object-recognition); interpret the surrounding environment by processing information that is contained in visible light/ eyesight (visual perception); initially involved parties: visual cortex (dorsal stream; ventral stream).

Dynamic balance – the ability to maintain equilibrium with minimal postural sway in a dynamic scenario; require coordination of input from multiple sensory systems including: vestibular, somatosensory, and visual systems (sensorimotor control); subtype of balance (static/dynamic balance).


Visual cognition and dynamic balance are identified as two spotlight domains for persons with ASD in the recent literatures [2-4]. However, little is known about their relationship and/or contribution to the overall developmental aspect. The purpose of this study is to examine these two domains in persons with autism and try to reveal the relationship in-between.

METHODS

Five males with ASD (age: 20.8 ± 3.71) were recruited from Special Olympics Singapore with informed consent; and eight males without ASD (age: 28.9 ± 4.52) were recruited later in the National Institute of Education Singapore as in comparison group [table 1]. Raven’s Progressive Matrices and Pro Balance by Lab rehab™ were adopted for assessing visual cognition and dynamic balance.

Table 1: Demographics

Group N Height Weight BMI

ASD 5 173±4 74±7 25±7

Non-ASD 8 176±3 71±5 23±6

Note: height in cm; weight in kg; BMI refers to Body Mass Index

Measures

Raven’s Progressive Matrices (RPM) – RPM was developed in United Kingdom by John C. Raven in the year 1937; it is simply a visual cognition test which would take maximum forty minutes to complete; there are five subsets in the test: 12 items for each; time required: 8 minutes for each subset, 40 minutes in total for the whole test [figure 1].

Figure 1: Test of visual cognition

Pro Balance - it was developed in Singapore by Lab rehab™ in the year 2007; it was adopted as an indicator for some exercise rehabilitation programs in health-related sectors, i.e., clinics, hospitals, labs, etc. During the test, participant was asked to stand on a balance disc, an electronic device, with both feet and eyes opened conditions for thirty seconds; he/she was then asked to maintain the balance position for a certain period; the swaying of his/her body, center of gravity (CoG) was tracked; 3 trials in total, 30 seconds per trial, and 3 minutes rest for each trial [figure 2].


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Figure 2: Test of dynamic balance

Statistical analysis

Independent samples t-test, regression analysis, and Pearson correlation analysis were adopted for the analytical procedure; and the results were summarized in the section below.

RESULTS

The results showed that non-ASD group performed better in dynamic balance test (p < .05, d = -1.36) [figure 3]; visual cognition was not a good predictor of dynamic balance and vice versa (p > .05); and, dynamic balance and body weight seems negatively correlated (r = -.993, p < .05).

Figure 3: Comparison of different parameters for assessing dynamic balance

DISCUSSION

Visual cognition and dynamic balance for persons with ASD were two important aspects; the results were redrawn the attention of balance control in people with autism. Similar to the current literatures [2-5], the relationship between visual cognition and dynamic balance were investigated incoherently (inconsistent in those findings). Potential factors affecting the results might possibly be - body height, body weight, body

composition, i.e., body mass index; somatotype, i.e., body shape, and etc. (due to the limited space, detailed discussion for each potential factor, please refer to the full paper/presentation)

Limitations

Since only male subjects were included in this study, it would introduce gender bias; the difference in anatomical might have different CoGs, those differences might possible affect the dynamic balance control in the results; however, autism is a male bias disorder, most of the individuals with autism are boys/men instead of girls/women, 4:1 ratio [1];on the other hand, the limited sample size in this study might lead to statistical threats, over-interpreting the results regardless of how representativeness of the samples are.

Conclusions

The results recently could not confirm that the dynamic balance and visual cognition were two closely related aspects for people with ASD. Besides, it was indicated that lower scores on dynamic balance performance for ASD individuals comparing to their control counterparts. Since various constraints could not be avoided in this study, the interpretation of the initial findings should be sounded with cautious. A comprehensive comparison, considering neuromuscular, mechanical, somatotype, and etc., was recommended in the future explorations/studies.

REFERENCES

1. American Psychiatric Association (2013). APA.

2. Mache, M.A., & Todd, T.A. (2016). Research in Autism Spectrum Disorders, 23: p.179-187.

3. Stins, J.F., et al., (2015). Gait & Posture, 42(2): p.199-203.

4. Hellendoorn, A., et al. (2015). Research in Developmental Disabilities, 39: p.32-42.

5. Hanaie, R., et al. (2016). Autism Research, n/a.

ACKNOWLEDGEMENT

Special thanks Dr. Sock Miang Teo-Koh, President of Special Olympics Singapore, for her invaluable help in collecting the data.




31

THE EMERGING ROLE OF WEARABLE SENSOR

TECHNOLOGY FOR BALANCE AND GAIT REHABILITATION.

Laurie A. King

Oregon Health & Science University


INTRODUCTION

Recent advances in wearable sensor technology are resulting in an increase in available tests and measures of movement to quantify body motion. Movement analysis obtained from wearable sensors is more sensitive than traditional test of mobility and can now be performed at home or in locations outside of the laboratory. Dr. Laurie King will discuss the potential role of body-worn movement monitors for balance and gait assessment and treatment in rehabilitation. Dr. King will present recent research demonstrating the value of inertial measurement units (IMUs) for assessment and treatment of movement disorders in physical therapy. She will demonstrate how IMUs can be used to quantify many different subcomponents of balance and gait that cannot be observed or rated with subjective clinical scales. Based on these measures, therapy can be focused specifically on the underlying impairments to mobility function. A major advantage of new, portable technology of movement monitoring is the potential for measuring quality of movement during daily life, outside of the laboratory.


The role of wearable sensor technology is becoming increasingly important in rehabilitation both for evaluation and treatment. It is important that healthcare professionals understand the pros and cons of this new direction of mobility assessment and treatment.

GOALS:

Understand the advantage in using technology to identify subtle deficits in neurologic populations

Understand the difference between activity and movement monitors

Understand how wearable sensors may be used to identify important subsystems of balance and gait control

Understand how wearable sensors could be used for long periods of monitoring in a home environment

Understand new biofeedback technologies

REFERENCES

1. King, Laurie A., et al. "Instrumenting the balance error scoring system for use with patients reporting persistent balance problems after mild traumatic brain injury." Archives of physical medicine and rehabilitation 95.2 (2014): 353-359.

2. Horak, Fay, Laurie King, and Martina Mancini. "Role of body-worn movement monitor technology for balance and gait rehabilitation." Physical therapy 95.3 (2015): 461-470.

3. Mancini, Martina, et al. "Mobility lab to assess balance and gait with synchronized body-worn sensors." Journal of bioengineering & biomedical science (2012): 007.

4. King, Laurie A., et al. "Do clinical scales of balance reflect turning abnormalities in people with Parkinson’s disease?" Journal of Neurologic Physical Therapy 36.1 (2012): 25.


There are no conflicts of interest to disclose.


32

USING VIRTUAL REALITY FOR MOTOR LEARNING IN NEUROLOGICAL REHABILITATION

Mindy F. Levin

School of Physical and Occupational Therapy, McGill University

Centre for Interdisciplinary Research in Rehabilitation


INTRODUCTION

The primary focus of neurological rehabilitation is the reacquisition of lost motor skills to improve independence in activities of daily living and in the quality of life of the individual. To achieve this, rehabilitation takes advantage of central nervous system neuroplasticity through motor learning mechanisms [5, 11]. However, in order to identify what needs to be learned in order to maximize motor recovery, it is necessary to understand basic concepts of how movements are controlled, as well as what psychological and physical principles are involved in motor planning and motor execution in the healthy nervous system [2, 10].

Motor control principles

Various techniques and training environments such as those created using VR technology can be used to exploit motor learning mechanisms based on principles of motor control. Some of these principles of motor control are: the principle of kinematic abundance [1, 7], the relationship between speed and accuracy on task difficulty [3], the influence of perception of the environment [6] and the influences of the affordances of the object on action planning and execution [4, 13]. Kinematic abundance refers to the availability of movement combinations in the system that can be used to solve motor problems. Fitts’ law describes how the relationship between movement speed, distance and requirements for movement accuracy influence the difficulty of the task. According to ecological principles, organization of movement is strongly influenced by the perception of the object location in the environment. This is especially relevant to virtual reality environments since it implies that how a motor task is performed, is related to the quality of the viewing environment and visual cues of the user’s limb interacting with the environment. Finally, also based on ecological notions, how a movement is planned and executed is tightly related to the affordances of that object. These motor control principles are listed in the Table along with suggestions of how they can be incorporated into motor learning tasks implemented in virtual reality and/or real-world training environments.

Motor Control

Principle

Design features of virtual environments

Kinematic abundance

Virtual tasks should involve interacting with objects placed at different distances from the body as well as different locations in the workspace to encourage the learner to find task solutions based on their available kinematic redundancy.

Fitts’ law

Virtual object location should be adjustable so that task difficulty can be graded according to Fitts’ Law by manipulating speed, distance and accuracy requirements of the task.

Perception

The virtual environment should include 3D visual cues such as perspective lines, shading and drop lines to ensure depth perception.

Affordances

Objects included in a virtual training environment should be of various shapes, sizes and locations to encourage varied practice.

Tasks should have purposeful goals

Aside from the inclusion of various tasks in a training environment, it is also important to identify key outcome measures to measure progress in specific domains.

Outcome measures should be able to identify how much of a task is accomplished through the recovery of typical movement patterns at the behavioral level compared to atypical ones (motor compensation [9]. Since most of the outcome measures used in rehabilitation only describe task completion, the effectiveness of a treatment program to enhance recovery versus compensation is often not known. One way to identify motor recovery is to use motion tracking equipment to quantify changes in kinematics.


33

While high quality motion tracking equipment may be available in research labs, it is not often accessible to clinicians. An alternative to motion tracking is the reliance on observational kinematic assessment using clinical scales such as the Reaching Performance Scale for Stroke designed to distinguish compensatory movement patterns from desired movement patterns in the upper limb during two reaching tasks [8]. Another alternative is the use of commercially-available camera systems for motion tracking but precaution should be exercised with these systems as they are still of very low-accuracy [12].


Various techniques and training environments such as those created using virtual reality technology have been developed. Training tasks can be developed and manipulated in these environments to exploit motor control and motor learning mechanisms in order to encourage the best motor recovery [5]. Outcome measures should be used to quantify changes in motor behavior that are based on the principles of motor control and motor learning and specifically to distinguish between true motor recovery and motor compensation.

REFERENCES

1. Bernstein, N.A. (1967) Oxford: Pergamon Press. 2. Feldman, A.G &, Levin, M.F. (1995) Behavioral

Brain Science, 18: p. 723-44. 3. Fitts, P.M. (1954) Journal of Experimental

Psychology, 47: p. 381-91. 4. Gibson, J.J. (1979) Boston MA: Houghton, Mifflin. 5. Kleim, J.A. & Jones, T.A. (2008) Journal of Speech

Language & Hearing Research, 51(1): p. S225-39. 6. Kugler, P.N. & Turvey, M.T. (1987) Hillsdale, NJ:

Erlbaum. 7. Latash, M.L. (2012) Experimental Brain Research,

217(1): p. 1-5. 8. Levin, M.F., Desrosiers, J., Beauchemin, D.,

Bergeron, N. & Rochette, A. (2004) Physical Therapy, 84: p. 8-22.

9. Levin, M.F., Kleim, J.A. & Wolf, S.L. (2009) Neurorehabilitation and Neural Repair, 23(4): p. 313-19.

10. Levin, M.F., Weiss, P.L. & Keshner, E. (2015) Physical Therapy: Special Issue on Innovative Technologies for Rehabilitation and Health Promotion. Physical Therapy, 95(3): p. 415-25.

11. Nudo, R.J. (2003) Journal of Rehabilitation Medicine, 41: p. S7-S10.

12. Pfister, A.1., West, A.M., Bronner, S. & Noah, J.A. (2014) Journal of Medical and Engineering Technology, 38(5): p. 274-80.

13. Rosenbaum, D.A., Vaughan, J., Barnes, H.J., Jorgensen, M.J. (1992), Journal of Experimental Psychology: Learning, Memory and Cognition, 18: p. 1058-73.




34

CLINICAL EXAMINATION OF THE ADULT ACQUIRED FLATFOOT DEFORMITY: STATIC AND DYNAMIC ANALYSIS



Contact: [email protected]

INTRODUCTION

The Adult Acquired Flatfoot is a potentially debilitating condition affecting primarily females after the fourth decade of life. (1) Previously attributed to a rupture of the posterior tibial tendon, this pathology has now been recognized to result from significant failure of key ligament structures in the ankle and hindfoot. (2,3) Progressive deformity and disability results from the sequential rupture of these ligaments. (4) Staging the Adult Acquired Flatfoot relies on assessment of the extent of deformity and loss of stability of ligament structures. (5)


Clinicians treating lower extremity musculoskeletal conditions should be aware of the signs and symptoms of the early stages of Adult Acquired Flatfoot so that effective treatment interventions can be implemented. Accurate staging of the severity of deformity and function are critical in the selection of non-operative and operative treatments. This presentation will review gait criteria and static clinical tests for the clinician to utilize in the assessment of the Adult Acquired Flatfoot.

OVERVIEW

The initial exam of the patient presenting with a symptomatic flatfoot deformity should begin with gait analysis. Many key parameters can be determined by simple visual gait analysis in the clinic setting including asymmetry of flatfoot, proximal compensation, varying severity of hindfoot valgus and forefoot abduction. (6,7)

The static exam includes tests for postural stability and balance, single-foot heel rise, first metatarsal rise, Hubscher maneuver, foot adduction strength, supination lag and Silverskold test. (8,9)

Imaging studies include A-P radiographs looking at talo-navicular coverage and lateral radiographs measuring talus-first metatarsal angle and medial cuneiform height. (10) Magnetic resonance imaging( MR) can detect multiple locations of ligament injury in advanced stages of adult acquired flatfoot. (11)

REFERENCES 1. Kohls-Gatzoulis J, Woods B, Angel JC, Singh D. The

prevalence of symptomatic posterior tibialis tendon dysfunction in women over the age of 40 in England. Foot Ankle Surg. 2009;15(2):75-81.

2. Deland JT, de Asla RJ, Sung IH, Ernberg LA, Potter HG. Posterior tibial tendon insufficiency: which ligaments are involved? Foot Ankle Int. 2005; 26(6):427-35.

3. Balen PF, Helms CA. Association of posterior tibial tendon injury with spring ligament injury, sinus tarsi abnormality, and plantar fasciitis on MR imaging. AJR Am J Roentgenol. 2001; 176(5):1137-1143.

4. Richie DH. Pathomechanics of the adult acquired flatfoot. Foot and Ankle Quarterly. 2005; 17(4);109-124.

5. Classification in Brief: Johnson and Strom Classification of Adult Acquired Flatfoot Deformity. Abousayed MM, Tartaglione JP, Rosenbaum AJ, Dipreta JA. Clin Orthop Relat Res. 2016 Feb; 474(2):588-93.

6. Tome J, Flemister S, Nawoczenski D, Houck J. Comparison of foot kinematics between subjects with posterior tibial tendon dysfunction and healthy controls. J Orthop Sports Phys Ther. 2006; 36(9):635–644.

7. Dyal CM, Feder J, Deland JT, Thompson FM. Pes planus in patients with posterior tibial tendon insufficiency: asymptomatic versus symptomatic foot. Foot Ankle Int. 1997, 18(2):85–88.

8. Niki H, Ching RP, Kiser P, Sangeorzan BJ. The effect of posterior tibial tendon dysfunction on hindfoot kinematics. Foot Ankle Int. 2001; 22(4):292-300.

9. Kulig K, Reischl SF, Pomrantz AB, et al. Nonsurgical management of posterior tibial tendon dysfunction with orthoses and resistive exercise: a randomized controlled trial. Phys Ther. 2009; 89(1):26-37

10. Williamson ER, Chan JY, Burket JC, Deland JT, Ellis SJ. New radiographic paramenter assessing hindfoot alignment in stage II adult-acquired flatfoot deformity. Foot Ankle Int. 2015 Apr; 36(4):417-23.

11. Mengiardi B, Pinto C, Zanetti M. Spring ligament complex and posterior tibial tendon: MR Anatomy and findings in adult acquired flatfoot deformity. Semin Musculoskelet Radiol. 2016 Feb;20(1):104-15.


35

REARFOOT, MIDFOOT OR FOREFOOT STRIKING RUNNING: WHICH IS BEST?

Kevin Kirby



SUMMARY

The definition of rearfoot, midfoot and forefoot striking running footstrike patterns will be reviewed along with the scientific research that analyzes the frequency, injury rate and injury pattern of each footstrike pattern. The influence of shoes and running velocity will also be discussed to provide a more complete analysis of the pros and cons of each running footstrike pattern.

REFERENCES

1. Hatala KG, Dingwall HL, Wunderlich RE, Richmond BG. Variation in foot strike patterns during running among habitually barefoot populations. PLoS One. 2013;8(1):e52548. doi:10.1371/journal.pone.0052548.

2. Bertelsen ML, Jensen JF, Nielsen MH, Nielsen RO, Rasmussen S. Footstrike patterns among novice runners wearing a conventional, neutral running shoe. Gait Posture. 2013;38(2):354–356.

3. Kasmer ME, Liu XC, Roberts KG, Valadao JM. Foot-strike pattern and performance in a marathon. Int J Sports Physio Perform. 2013;8(3):286-292.

4. Kasmer ME, Liu XC, Roberts KG, Valadao JM. The relationship of foot strike pattern, shoe type, and performance in a 50-km trail race. J Strength Cond Res. 7/15/13, doi: 10.1519/JSC.0b013e3182a20ed4

5. Gruber AH, Umberger BR, Braun B, Hamill J. Economy and rate of carbohydrate oxidation during running with rearfoot and forefoot strike patterns. J Appl Physiol. 2013;115(2):194 –201.

6. Ogueta-Alday A, Rodríguez-Marroyo JA, García-López J. Rearfoot striking runners are more economical than midfoot strikers. Med. Sci. Sports Exerc. 2014;46(3):580–585.




36

THE LONGITUDINAL ARCH ANGLE: A RELIABLE CLINICAL MEASUREMENT TO PREDICT DYNAMIC FOOT POSTURE

Thomas G. McPoil



INTRODUCTION

Individuals with extremely flat (pes planus) or high (pes cavus) arch foot postures have been shown to be at risk for the development of numerous orthopaedic foot disorders. The consistency of measuring the LAA in a clinically feasible manner as well as the ability of the LAA to predict dynamic foot posture during activity in a variety of foot types has not been evaluated. Purpose: The purpose of this study was to determine the reliability of the LAA as well as if the clinical method of assessing the LAA could be used to predict the LAA at midstance during walking for supinated, normal, and pronated foot types.


It is critical for the clinician to utilize static measures in the physical examination of the foot that are predictive of foot posture during dynamic activities such as walking. Based on the findings, the LAA can be used to provide the clinician with information about foot posture at that point in walking where the greatest amount of medial arch deformation usually occurs.

METHODS

Initially 92 individuals voluntarily consented to have their feet screened using the Foot Posture Index and Arch Height Ratio. Based on the initial screening 35 individuals (70 feet) were selected for participation with 11 feet classified as supinated, 47 feet classified as normal, and 16 feet classified as pronated. Inclusion criteria included no history of traumatic or overuse injury to either lower extremity 6 months prior to study, no congenital defect to either lower extremity, and no visible signs of foot pathology. The mean age of the 35 individuals (16 female; 19 males) was 25 years. Each participant had ink marks placed on the medial malleolus, navicular tuberosity, and medial aspect 1st metatarsal head of both feet and a standard goniometer was used to measure the LAA (CLINIC_LAA) while they stood with both feet relaxed.

Black markers where then placed over the marks on both feet and a high speed camera (120 Hz) was used to film both feet of each participant

while walking on a treadmill at their preferred speed. The LAA at midstance while walking was determined by the angle formed by two lines drawn between the three markers with the navicular tuberosity serving as the apex. The LAA in midstance (WALK_LAA) was determined using the mean of the middle 5 walking trials.

RESULTS

The Intraclass Correlation Coefficients (ICC) values for intra-rater reliability of the ClinicLAA were 0.98 for rater 1 and 0.96 for rater 2. The ICC for inter-rater reliability was 0.91. The mean for the ClinicLAA for the 70 feet was 143.8o with a standard deviation of 8.97o. The results of the analysis of variance indicated that the ClinicLAA was significantly different between the 3 foot types (F = 12.85; df = 2; p < 0.0001) based on the foot type classification using the AHR.

The results of the t-tests indicated that mean values between the left and right foot were not significantly different for the ClinicLAA (p = 0.61; 95% CI: -5.46,3.20). The correlation between ClinicLAA and WalkLAA was r = 0.96 (r2 = 0.92).

The following regression equation was determine

d to allow the clinician to predict the WalkLAA at midstance during walking using the ClinicLAA measured in relaxed bilateral standing:

WalkLAA = -11.84 + 1.061* ClinicLAA


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DISCUSSION

Recent research has shown that foot posture may be a significant risk factor for the development of lower extremity joint pain. Since individuals with supinated (pes cavus) and pronated (pes planus) foot types have been shown to be at risk for the development of numerous orthopaedic foot disorders, it is important for the clinician to have a reliable measure of the height of the medial longitudinal arch that can also be predictive of foot posture during dynamic activities such as walking. The findings of the current study substantiate the use of the LAA, measured in relaxed standing using a standard goniometer, to predict the LAA at or near midstance in walking. The results indicate the LAA assessed in static standing can explain over 90% of the variance for a wide range of foot types. In addition, the clinical method utilized by the authors to measure the LAA demonstrates high levels of within-session and between-rater reliability. The clinician can use the regression formula provided in this paper to understand how foot posture, assessed in relaxed standing, can change during walking to augment the physical examination.

REFERENCES

1. Feiss HO: A simple method of estimating the common variations and deformities of the foot. Am J Med Sci 1909, 138:213-231.

2. Dahle LK, Mueller MJ, Delitto A, Diamond JE: Visual assessment of foot type and relationship of foot type to lower extremity injury. J Orthop Sports Phys Ther 1991, 14:70-74.

3. Sommer HM, Vallentyne SW: Effect of foot posture on the incidence of medial tibial stress syndrome. Med Sci Sports Exerc 1995, 27:800-804.

4. Jonson SR, Gross MT: Intraexaminer reliability, interexaminer reliability, and mean values for nine lower extremity skeletal measures in healthy naval midshipmen. J Orthop Sports Phys Ther 1997, 25:253-263.

5. McPoil TG, Cornwall MW: Use of the longitudinal arch to predict dynamic foot posture in walking. J Am Podiatr Med Assoc 2005, 95:114-120.




38

THE IMPACT OF MAXIMALIST RUNNING SHOES ON LOWER EXTREMITY KINEMATICS AND KINETICS DURING WALKING AND RUNNING COMAPRED TO NEUTRAL RUNNING SHOES

Cherri Choate and Timothy Dutra



INTRODUCTION

The newest player in the world of athletic footwear is the maximalist shoe. Some of the most distinguishing features of this shoe model include a more contoured and deeper foot bed, 20-30% wider base combined with a rocker shape, and a sole with enhanced thickness and height, especially in the midsole. The popularity of the maximalist shoe arose initially within the ultra-marathon population and has since gained more widespread appeal with the general running population. Certain aspects of the maximalist running shoe influence how forces translate through the body from the initial point of plantar foot pressure[2], center of pressure (COP), and center of mass[1] (COM), along with temporal spatial parameters during stance. Recent literature has explored the effects of minimalist style shoes on runners and compared them to neutral style shoes, but is severely lacking in studies of the maximalist running shoe


Because of the rise in popularity of maximalist shoes, we would like to evaluate the kinematic and kinetic differences between maximalist and neutral running shoes for both walking and running because running shoes are often used for both activities. We believe the inherent design of the general maximalist shoe should decrease plantar pressure, and increase postural stability.

METHODS

Thirty subjects were recruited who were running at least 10 miles per week. Subjects’ mass and height were recorded and body mass index (BMI) was calculated (Mean ±SD mass: 73.96 ±16.67kg; height: 1746.9 ± 102.3mm; BMI: 24.09 ± 4.23kg.m2). Subjects were also evaluated and a Foot Posture Index (FPI) score was given. (-12- +12). [3] Subjects’ shoe size was then determined by use of a Brannock device and correlating shoes of both maximalist and neutral running shoes were tried to fit. Subjects will then undergo a Balance Assessment Protocol using the Sensory Organization Test (SOT) with either bare feet or maximalist shoes. A second SOT in opposite condition was performed following all the gait analysis tests.

Subjects then performed Gait Analysis tests, presented to them in random order sequence: Walking while wearing neutral shoes (5 trials), walking while wearing maximalist shoes (5 trials), running while wearing neutral shoes (5 trials), and running while wearing maximalist shoes (5 trials) . The same trials were tested on the Qualisys 3-D system and F-Scan Pressure system.

Subjects stood on two adjacent force platforms and began walking with the left foot landing on a third force platform following a verbal start cue. Kinematic data was obtained using an 8-camera motion capture system. A 21-marker model was used to calculate joint powers from kinematic and kinetic data that were synchronized and sampled at 100 and 1000 Hz, respectively.

REFERENCES

1. Najafi B, Miller D, Jarrett BD. Does footwear type impact the number of steps required to reach gait steady state? An innovative look at the impact of foot orthoses on gait initiation. Gait Posture. 2010; 32: 29-33.

2. Perry JE, Ulbrecht JS, Derr JA, Cavanagh PR. The use of running shoes to reduce plantar pressures in patients who have diabetes. JBJS 1995. 77(12): 1819-28.

3. Redmond AC, Crosbie J, Ouvier RA. Development and validation for a novel rating system for scoring standard foot posture: The Foot Posture Index. Clinical Biomechanics. 2006. 21(1): 89-98.




39

PLANNED VS UNPLANNED TURNS DURING NORMAL GAIT: A PILOT STUDY EXAMINING KINEMATICS, KINETICS, AND MUSCLE ACTIVATION PATTERNS

Audrey Alvarez1, Nicole Cates1, Myles Knutson1, Stephanie Mita1, and Andrew Smith2 1California School of Podiatric Medicine and 2Motion Analysis Research Center, Samuel Merritt University


INTRODUCTION

Hootman et al. (Hootman et al., 2007) identified the ankle is one of the most common body part to be injured in land-based sports. According to Chinn et al. (2013), as many as 70% of individuals who sustain an ankle injury will develop chronic ankle instability (CAI). Pain and limited range of motion (ROM) usually occurs in the injured ankle (Hutson and Speed, 2011). Monaghan et al. (2006) has noted that those with CAI were more likely to contact the floor with an inverted foot just prior to and immediately after heel contact. This finding was also noted by Brown et al. (2008), who also tested a step down task, running, drop jump, and stop jump. They also found that even within a group of subjects with a history of ankle sprain, there may exist three types: ‘copers’, i.e., those with a history of an ankle injury without any subsequent episodes of ‘giving way’; mechanically unstable, i.e., those with measurable laxity in the ankle joint who have subsequent sprains; and functionally unstable, i.e., those without mechanical laxity but who have subsequent sprains.

Most normal locomotion, and many sports, require frequent changes of direction, both planned or unplanned. This study aimed to investigate changes in gait dynamics and muscle activation patterns during planned and unplanned changes-of-direction during normal, level-ground walking. We hypothesize that when attempting to make unplanned turns, subjects will demonstrate significantly different kinematic, kinetic, and muscle activation patterns as compared to planned turns.

METHODS

Ten subjects were recruited to participate in this study: five males and five females. Mean age was 27.8 (±6.0) years and mean heights and masses were 1.69 (±0.09) m and 70.6 (±12.42) kg, respectively.

Subjects’ motion was recorded using a 9-camera, Qualisys three-dimensional (3D) motion capture system. A 12-segment model was used to determine joint-based kinematics and kinetics, and to calculate the kinematics of the center of mass (COM).

Kinetics will be determined using 3D marker data and ground reaction forces (GRF) from two AMTI force platforms as inputs to an inverse-dynamics, link-segment model of the whole body. The force and marker data were used to calculate segment and joint

kinetics and kinematics including linear and angular displacements, velocities, and accelerations along with joint moments of force and powers.

Muscle activation was assessed for six pairs of lower extremity muscles using a telemetered electro-myography (EMG) system (Delsys Trigno). The bilateral muscle pairs studied were rectus femoris, vastus lateralis, biceps femoris, m. medial gastrocnemius, tibialis anterior, and soleus. Signals were sampled at 1,000Hz, band-pass filtered (50-500HZ), full-wave rectified, and low-pass filtered using a critically-damped, 2nd order Butterworth-type digital filter (Winter, 1990).

This within-subject, repeated-measures design study was conducted according to the Declaration of Helsinki and the protocol will approved by the Samuel Merritt University Institutional Review Board prior to the commencement of the assessments. All subjects completed the Cumberland Ankle Instability Tool (CAIT) (Hiller et al., 2006), a 9-item, 30-point scale for measuring the severity of CAI. Participants reporting any serious orthopedic or neuromuscular disorders were excluded from participating in the study.

Each subject completed 3 trials of self-selected paced, normal (0°) walking to establish his or her baseline. Then, subjects were asked to complete trials for 2 different direction-of-walking angles (45° and 90°, both right and left) in the two conditions of planned and unplanned change-of-direction for each leg. For each condition, 3 trials were performed. Therefore, there are 27 trials (3 baseline + [2 direction x 2 legs x 2 planning x 3 trials]) in total. Each trial will consist of walking approximately 9-10 strides, or about 10m.

Planned turns were trials where the subject was told before the start of data collection which leg and which direction would occur. Unplanned turns will be trials where the subject was not be told how to turn until the step immediately prior to the target leg contacting one of the force platforms. In this case, the experimenter gave the instruction verbally. Trials where the subject fails to complete the correct turn were rejected. All trials subsequent to the 3 baseline trials were randomly presented to the subjects. Figure 1 shows the schematic for the experiment.


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Figure 1: Schematic of right (R) and left (L) turns (1, 2, 4, 5) and normal walking (3).

RESULTS

The scores on the CAIT confirmed that this cohort of subjects did not present with CAI. The maximum score for a healthy ankle is 30 and the mean of this group for the left and right ankles were 27.5 (±2.9) and 27.0 (±2.6), respectively.

Gait data revealed some differences between normal gait and both of the turn conditions; however there were no differences between planned and unplanned conditions.

Medial‐Lateral Shear Anterior‐Posterior Shear Compression

Figure 2: Mean hip, knee, and ankle joint force data for planned (P) and unplanned (U) 90° and 45° turns, and no turn trials (n=10)

DISCUSSION

Human beings are remarkably adaptable owing in large part to redundancies in the neuromuscular system and robust motor programs controlling stereotypical movement patterns, such as gait. Even when given an unexpected command to turn 90° about 1s before executing the command, subjects experienced little difficulty in turning successfully.

These data suggest that turning either 45° or 90° does not substantially alter the motor program for walking, which provides evidence for the representation of the local joint coordinate system within the motor program itself.

One limitation of the study was that the turn commands were delivered by one of the experimenters and could have been inconsistent. Further studies will need to have signals given based on the state of the gait cycle prior to the turn, and should be given in both auditory and visual formats.

REFERENCES

1. Chinn, L. et al. (2013). Physical Therapy in Sport, 14. 232-239.

2. Hiller, C. et al. (2006). Archives of Physical Medicine and Rehabilitation, 87, 1235-1241.

3. Hootman, J. et al. (2007). Journal of Athletic Training, 42, 311-319.

4. Hutson, M & Speed, C. (2011). Sports Injuries. Oxford University Press, Oxford UK.

5. Monaghan, K. et al. (2006). Clinical Biomechanics, 21, 168-174.

6. Winter, D. (1990). Biomechanics and Motor Control of Human Movement, Wiley, New York.




41

THE EFFECT OF CUSTOM-MADE ORTHOTICS ON ANTERIOR CRUCIATE LIGAMENT OF THE KNEE DURING NORMAL WALKING AND CUTTING MANEUVERS

Stephen Hill2, Mark Razzante1, Yen Tran1, Christian Curry1, and Tenaya West1 1California School of Podiatric Medicine and 2Motion Analysis Research Center, Samuel Merritt University


INTRODUCTION

Non-contact anterior cruciate ligament (ACL) rupture is a serious and prevalent injury in young athletes. It is estimated that 80,000 to more than 250,000 ACL injuries occur each year, more than half occurring in athletes 15-25 years old [1]. Video studies of these injuries are largely qualitative, but tend to characterize non-contact ACL injuries as occurring early after initial foot contact in landings or cutting maneuvers in knee nearly full knee extension, and many resulted in “valgus collapse” from excessive valgus and/or internal [2] or external rotation of the tibia [3]. The most obvious way for a pronation-controlling device to increase the supination moment at the subtalar joint is for it to direct forces upward, medial to the subtalar joint axis, most likely at the medial plantar surface of the foot [4]. One study [5] compared knee injury rates of a women’s basketball team for 4 years without, and then 9 years with orthotics. They reported these injuries were more likely without orthotics: collateral ligament injury 1.72 times more likely, and ACL 7.4 times more likely. However, presently, no known studies have examined the effects of custom foot orthotics on non-contact anterior cruciate ligament risk with knee joint kinematics and kinetics during vertical jumping and lateral “cut” (acute turn) movements during jogging.


In the podiatric community, utilization of foot orthoses is a common practice with relatively little risk to athletes. There are long rehabilitation periods associated with a ruptured ACL, not to mention surgical repair. Finding a possible means of preventing, or lessening the frequency of ACL ruptures would immediately provide a substantial benefit to athletes across the world.

METHODS

This study has been approved by the Samuel Merritt University Institutional Review Board (SMUIRB#16-012). Fifteen men and fifteen women between 18 and 30 years of age, who currently running at least 10 miles per week will be recruited from Samuel Merritt University campus.

Potential participants will complete a pre-screening email questionnaire to determine that they have no previous surgeries or injuries of the lower extremities,

no related neuromuscular skeletal problems, are fit for athletic movements of jogging with changes of direction or jumping up, and can meet the criteria of a moderately pronated foot type. If they pass that initial pre-screen, then they will be invited to an initial biomechanical examination to determine if they meet the qualifying criteria for the study. To be included, they must have moderately pronated feet, as per the Foot Posture Index [5]. Potential participants will be excluded if they have had a previous ACL injury or significant musculo-skeletal injury within the past year or have a neurologic disorder. If they meet the criteria and would like to participate in the study, they will be cast will have their feet cast in plaster by the co-authors from the California School of Podiatric Medicine to be used to manufacture a pair of foot orthoses (“orthotics”) by the Root Lab as per their standard procedures. The shape of a custom foot orthosis is determined by the individual’s foot anatomy and the anatomic position in which the foot is held during casting: subtalar joint neutral is the generally preferred position for casting [6]. The foot orthoses in the present study are the standard polypropylene devices

In addition, the participants’ feet will be measured with a Brannock Device® for a pair of Brooks Pureflow 5 neutral running shoes (or equivalent). The Pureflow was chosen as it is “lightweight, agile ride” [7]. It has a sufficiently deep heel counter which accommodates foot orthotics effectively when the insole is removed. .

At the first visit to the MARC, the participant’s shoes and orthotics will be inspected for fit. Then the Neurocom Smart EquiTest Balance Manager (Natus Balance & Mobility) platform will be used to administer the Sensory Organization Test (SOT) to evaluate how well a participant uses three related sensory systems: somatosensory, vision, and vestibular.

Twenty-two (22) reflective markers will be affixed with the participant’s skin on typically boney landmarks on the hips, legs and on the shoes, bilaterally will be tracked by a nine-camera Qualisys (Gothenburg, Sweden) Oqus 300 motion capture system. The MARC walkway is instrumented with four AMTI (Newton, MA) tri-axial force platforms (force plates) to measure foot-floor forces. Body motion data will be used to calculate pelvis absolute angles, and relative joint angles for the hips, knees and ankles. Foot-floor forces data will be incorporated with inverse dynamics to calculate net joint moments of force and joint rotational


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powers via Visual3D software (C-Motion, Germantown, MD, USA).

Figure 1. Video of participant performing cross-over cut during gait (3D model of pelvis, thighs, legs, feet overlaid).

The order of the two conditions (shoes vs. shoes plus orthotics) will be quasi-randomized (for balance) for each participant, but that order will be repeated for their second visit four weeks later. Therefore, each participant will act as his/her own control.

Five trials of straight forward jog will be kept following the warm-up. Five trials of cross-over acute turn maneuvers and five trials of single-legged jump will be kept during jogging will be recorded per direction (left, right) per condition (original insole, custom foot orthotic).

Of particular interest, internal tibial rotation, relative internal rotation (with respect to the femur), and kinetics will be calculated using motion of body landmarks from the three-dimensional motion-capture software.

Repeated measures ANOVA will be used with an alpha level of 0.05 to determine whether there is a statistically significant difference between original insole and custom foot orthotic for each measure.

DISCUSSION

The primary goal of this initial study will be determine if the nine-camera Qualisys motion capture system in the MARC will be able to discern a difference in the stance knee internal rotation relative joint angle or moment of force between the shoes only condition and the shoes plus orthotics condition. This potential issue was brought up in a recent study of lower limb biomechanical variables during running and cutting tasks specifically [8]. Magnetic resonance imaging and biplanar fluoroscopy have been employed to measure ACL elongation in static knee positions mimicking valgus collapse [9]. The measures in our present study

may enable us to predict if the ACL stretch approaches the 7 mm threshold for tear, which is within the 1mm resolution of the Qualisys 9 camera motion capture system in the MARC.

REFERENCES

1. Griffin LY et al. (2006) The American Journal of Sports Medicine, 34(9): 1512-1532.

2. Krosshaug T et al. (2007) The American Journal of Sports Medicine, 35(3): 359-367.

3. Olsen O et al. (2004) The American Journal of Sports Medicine, 32(4): 1002-1012.

4. Kirby KA (1992) Journal of the American Podiatric Medical Association, 82: 177–188.

5. Redmond A et al. (2006) Clinical Biomechanics, 21: 89–98.

6. Root (2007) Improving negative casts for prescription foot orthoses. Root Laboratory Inc.: www.root-lab.com

7. www.brooksrunning.com/en_us/pureflow-5-mens-running-shoes

8. Alenezi F (2016) Journal of Electromyography and Kinesiology, 30: 137-142.

9. Utturkar GM et al. (2013) Annals of Biomedical Engineering, 41(1):123–130.




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BIOMECHANICAL EVALUATION OF HOTEL LUXURY BED MAKING WHILE USING A MATTRESS LIFT TOOL AND FITTED SHEETS

Carisa Harris-Adamson1,2, Emma Lam3, Stephen Hill3, and Andrew Smith3 1University of California, Berkeley; 2University of California at San Francisco, 3Samuel Merritt University


INTRODUCTION

The implementation of luxurious bed mattresses in hotels has been implicated as a source of physical exposure associated with MSDs in hotel room cleaners [1-7]. The purpose of this study was to quantify biomechanical and cardiovascular exposure while making beds with and without the interventions of a tool and/or a fitted sheet.

METHODS

Sixteen female hotel room cleaners with at least 6 months experience and no severe pain over the prior week participated in this laboratory-based study of multifactorial crossover design. Personal data, work experience, and discomfort (NPRS) were collected at baseline. Fatigue (BORG-CR10) was collected after each condition. Participants made a queen sized bed eight times with randomized intervention order (tool and sheet). Muscle activity of the flexor digitorum superficialis (FDS), extensor digitorum (ED), biceps brachii (BB) and deltoid (DL) was quantified using surface electromyography (Delsys Trigno, Natick,MA) and summarized via median (APDF 50%) and peak (APDF 90%) amplitude probability distribution functions. Heart rate (HR) (Garmin,Olathe, KS) was collected continuously to assess cardiovascular load. Data were analyzed using a repeated measures ANOVA and a Tukey post-hoc test.

RESULTS

Eleven of 16 individuals were Hispanic and 25% (n=4) had a BMI ≥ 30kg/m2. Discomfort over the past year was moderate in the hands/wrist (X=4.3, SD=3.4) and low back (X=5.0, SD=3.4). Fifty percent reported taking medication for pain and up to 25% reported days off or having difficulty maintaining their work pace due to pain. The average % relative HR (32%) and fatigue in the upper extremity (<2) and back (<3) was consistently lower following tool and fitted sheet use (p<0.05). Average mean ED (X=35%, SD=23) and peak FDS muscle activity (X= 60%, SD=25) were lower with tool use (p<0.05).

Lifting the corner of the mattress to tuck sheets required approximately 9.8kg (22lbs) of force. The average number of lifts per bed was reduced by 40% using the tool alone, 33% by using the fitted sheet alone, and 48% using the fitted sheet and tool together. Over the course of a shift, 300 mattress lifts would be reduced to

156 and with training and practice, the number of lifts would likely be even less. The average increase in time to implement these changes was 18 seconds per bed or an extra six to seven minutes per shift. Seventy-five percent of subjects preferred using the tool and all of the subjects preferred using the fitted sheets. Nine of the 15 individuals felt that moderate to extensive training would be required to properly implement use of the mattress lift tool.

DISCUSSION

Hotel room cleaners are exposed to high cardiovascular and biomechanical loads when making beds. A mattress lift tool, used in conjunction with fitted sheets, reduced some muscle loads and fatigue scores, while substantially reducing the number of total mattress lifts. Both tool and fitted sheet should be considered as interventions that reduce physical exposures associated with making hotel beds when tucking the bedding is required.

REFERENCES

1. Buchanan S, Vossenas P, Krause N, Moriarty J, Frumin E, Shimek JAM, Mier F, Orris P, Punnett L. Occupational injury disparities in the US hotel industry. Am J Ind Med 2009; 53:116-125.

2. Krause N, Rugulies R, Maslach C. Effort-reward imbalance at work and self-rated health of Las Vegas hotel room cleaners. Am J Ind Med 2009;53:372-386.

3. Krause N, Scherzer T, Rugulies R. Physical workload, work intensification, and prevalence of pain in low wage workers: results from a participatory research project with hotel room cleaners in Las Vegas. Am J Ind Med 2005;48:326-337.

4. New York Times. Hotel rooms get plusher, adding to Maids’ injuries. http://www.nytimes.com/2006/04/21/us/21hotel.html?pagewanted=all&_r=0, accessed on 6-14-2013.

5. Premji S and Krause N. Disparities by ethnicity, language, and immigrant status in occupational health experienced among Las Vegas hotel room cleaners. Am J Ind Med 2010;53:960-975.

6. Scherzer PR and Krause N. Work-related pain and injury and barriers to workers compensation among Las Vegas hotel room cleaners. Am J Public Health. 2005;95(3):483-488.


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7. Wial H, Rickert J. U.S. hotels and their workers: room for improvement. The state of U.S. industries: AFL-CIO Working for America Institute. 2002.




45

EFFECTS OF AN ADJUSTABLE ORTHOTIC ON LOWER LIMB BIOMECHANICS

Kristina Chang1, Silpa Joy1, Lydia Yun1, Scott Lynn3, Nathan Powers3, and Andrew Smith2 1California School of Podiatric Medicine and 2Motion Analysis Research Center, Samuel Merritt University and

3California State University, Fullerton


INTRODUCTION

In 1977, Merton Root proposed the Subtalar Joint Neutral (STJN) Theory. He described this position as a 2:1 ratio of calcaneal inversion to eversion with respect to where the subtalar joint (STJ) is positioned just after heel strike and its position halfway through the stance phase of gait (Root et al., 1977). When structural deformities exist in the foot, the STJ is likely to produce compensatory motions such as excessive pronation, which could lead to various functional problems and pathologies (Tiberio, 1988). Therefore, Root believed that having the STJ in a more “neutral position” would be optimal (Root et al., 1977). The current method used by many podiatrists in an attempt to achieve this “neutral position” is to statically cast the foot and make orthotics from these casts. This method only looks at a patient using a static model without examining the function of the STJ in motion. What is needed are metrics to define a clinical position in which the patient is most optimally aligned to normalize motion of the STJ during movement.


We hypothesize that there is an optimal clinical STJ alignment for each individual that would optimize their gait patterns to minimize the stress on the musculoskeletal system by increasing the area across which forces are applied to the body’s tissues.

METHODS

Eighteen subjects (11 females and seven males) were convenience sampled for this study from the student population of Samuel Merritt University.

Kinematic data were collected using a 9-camera Qualysis (Gothenburg, Sweden) Oqus 300 motion capture system, while ground reaction forces were collected with AMTI force platforms. Marker motion data (collected at 100Hz) along with forceplate data (collected at 1000Hz), were recorded simultaneously using Qualisys Track manager (QTM) software.

All participants were then fitted with the same neutral running shoe for testing with the SelnerTx Adjustable Orthotic (Mechanical Medicine; Manhattan Beach, CA. Patent No. US 2012/051803 A1). The shoe has a medial side and rear window cutout to view navicular drop along with calcaneal inversion and eversion during gait. A hole approximately 40mm high and

40mm wide were cut in the heel counter allowing the rearfoot marker cluster to protrude unobstructed when directly attached to the calcaneus (Rodrigues et al., 2013). Additionally the heel of the shoe were easily opened and closed with a Velcro strap, allowing participants to remove the shoe without moving any of the rigid clusters between conditions (Rodrigues et al., 2013). The orthotic were secured inside of the shoe prior to the individual wearing the shoe.

During the visit to the MARC, the participant’s age, height, and weight were recorded. To categorize the participants’ foot type, the navicular height was divided by truncated foot length, which has been shown to be one of the most valid foot typing measurements (Williams and McClay, 2000). The distance from the floor to the most medial portion of the navicular bone with the subject barefoot was measured to constitute navicular height. This is a modified version of the navicular drop test (Louden et al., 1996), which is used as a clinical measure of foot structure in a loaded position. The same examiner performed all measurements to eliminate the potential for inter-rater variability.

Once the individual is fitted and markers were in place, the participant was asked to perform three walks across the force platform. Once a participant completed their three consecutive walks, the shoe was carefully removed so as to ensure the markers stayed attached to the foot. The adjustable orthotic setting was then be re-adjusted to its next position and the individual will perform three more consecutive walks until each of the selected seven settings of the orthotic has been tested. The test settings of the orthotic were randomly presented to each subject.

The independent variables were the 8 different conditions: without orthotic (WO), adjustable foot orthotic at supination setting #3 (+1.7°), #6 (+3.3°), #9 (+5.1°), and pronation setting #3 (-1.7°), #6 (-3.3°), #9 (-4.9°), and at neutral setting #0. The dependent variables to be examined during the gait cycle were: peak frontal plane knee moment during the stance phase, calcaneal inversion and eversion segment angle (Dixon and McNally, 2008; MacLean et al., 2006; Rodrigues et al., 2013) ROM in the frontal plane during a full gait cycle, and maximum internal tibial rotation during midstance (Chen et al., 2010; Rodrigues et al., 2013).


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RESULTS

Figure 1: Sagittal and frontal plane ankle, knee, and hip angular displacement data

Figure 3: Sagittal and frontal plane ankle, knee, and hip moment

DISCUSSION

This study examined the effects of using an adjustable orthotic on lower extremity kinematics and kinetics during normal walking in a group of healthy, young subjects. As can be seen in Figures 1-4, there were little differences between baseline (WO) condition and the seven settings of the adjustable orthotic in the group of 18 subjects.

This raises two possibilities: either the orthotic had minimal effect on lower extremity biomechanics or subjects were able to adapt to the changes brought about by the orthotic.

Limitations of the study: the number of subjects who normally wore an orthotic was not recorded; subjects were given minimal time (< 5-min) to get used to wearing the orthotic; subjects only wore the orthotic in any setting for less than 10-min.

Figure 2: 3D ankle, knee, and hip joint force data

Figure 4: Ankle, knee, and hip joint power data

REFERENCES

Chen, Y., et al. (2010). Clinical Biomechanics, 25, 265-270.

Dixon, S., et al. (2008). Clinical Biomechanics, 23, 593-600.

Louden, J. et al. (1996). Journal of Orthopedic & Sports Physical Therapy, 24, 91-97.

Maclean, C., et al., (2006). Clinical Biomechanics, 21, 623-630.

Rodrigues, P., et al., (2013). Gait & Posture, 37, 526-531.

Root, M. et al. (1977). Normal and Abnormal Function of the Foot, Clinical Biomechanics Corp., Los Angeles.

Tiberio, D (1988). Journal of the American Physical Therapy Association, 68, 1840-1849.

Williams, D. & McClay, I. (2000). Journal of the American Physical Therapy Association, 80, 864-871.


The SelnerTx Adjustable Orthotics and the neutral running shoes were provided to this study by Mechanical Medicine; Manhattan Beach, CA.


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POSTER PRESENTATIONS


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49

A PILOT STUDY OF THE RELIABILITY OF THE LUMBAR MOTION MONITOR

Nina Chou1, Nickey Kha1, Rachel Sutter1, and Andrew Smith2 1Department of Physical Therapy and 2Motion Analysis Research Center, Samuel Merritt University


INTRODUCTION

Motion analysis and inverse dynamic techniques have been used to estimate external loading of the lumbar spine for nearly 50 years1-3. Often field-based data collection does not lend itself to multiple cameras. A common non-optical based tool is the Lumbar Motion Monitor (LMM), an exoskeleton equipped with an electrogoniometer that replicates the 3D motion of the lumbar spine.

The purpose of the present study was to compare the angular kinematic data from the LMM to two 3D motion capture models: an anatomical model (AMOD) and an optical representation of the LMM itself (OPT-LMM).


While 3D motion capture represents the ‘gold standard’ for human motion analysis, accurately recording human motion in situations where 3D technology is not practical can be achieved using non-optical methods. However, it is essential that these field-based techniques produce accurate and reliable data.

METHODS

Three volunteer subjects participated in the study. All were healthy and with no known history of low back pain. Two subjects were female and one was male.

All 3D motion capture data were collected with a 9-camera Qualisys motion capture system using Qualisys Track Manager (QTM) software, operating at 100Hz sampling rate. Light-reflecting markers were placed on each subject to define the AMOD as follows: C7, T10, Sternum (top and bottom), acromion processes (L and R), iliac crests (L and R), and greater trochanters (L and R). These defined the thorax and pelvis segments. A further eight markers were used to define the OPT-LMM grouped in two clusters of four markers: one on the posterior aspect of the thoracic harness of the LMM and one on the posterior aspect of the pelvic harness of the LMM.

Subjects performed five separate maneuvers: left and right lateral bends, object raise from floor (left) to pelvis height (right), object raise from floor (left) to shoulder height (right), object raise from floor to pelvis height (left), and object raise from floor to shoulder height (left). Each trial began with the subject standing upright with arms at his/her side for a minimum of 3s,

and then the task was performed three times. Data were measured against time in degrees, with velocity and acceleration calculated using central differences formula.

RESULTS

For each subject, the time-based angle data (OPT-LMM, AMOD, and LMM) were time-normalized from start to end of each movement, expressed as 0-100% of the movement cycle. All velocity and acceleration data are expressed as absolute values. Three repeated movements within each measurement system were averaged. Typical results for the left lateral bend are shown in Figure 1.

Data were analyzed for agreement by calculating Pearson product moment correlations (r) for the following pairwise comparisons: OPT-LMM vs. LMM, OPT-LMM vs. AMOD, and AMOD vs. LMM. The results corresponding to the data in Figure 1 are shown in Table 1.

DISCUSSION

Analysis revealed that the three versions of angular displacement had excellent agreement for lumbar flexion and ab/adduction. However lumbar rotation showed less agreement. Angular velocity and acceleration data had much lower agreement between methods. This may be the result of noise in the displacement data, which is amplified when calculating the corresponding velocity and acceleration data.

Also, it was noted that properly securing the two harnesses of the LMM was challenging, especially since the subjects were of smaller stature. The straps are designed to accommodate a wide range of wearers and any excessive looseness in the fit of the LMM may have led to inaccuracies. It is recommended that more attention be paid to filtering of the angular displacement data as well as care in securing the LMM on the subject.

REFERENCES

1. Chaffin, D. (1969). J. Biomechanics 2, 429-441. 2. Gagnon, M. & Smyth, G. (1992). Ergonomics 35, 329-

345. 3. McGill, S. & Norman, R. (1985). J. Biomechanics 8,

877-885.


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Figure 1: Angular kinematics from subject RS performing a lateral bend to the left. Data in left column are LMM, middle column are OPT-LMM, and right column are AMOD plotted as 0-100% of the movement cycle.

Table 1: Pearson product moment correlation data comparing OPT-LMM, LMM, and AMOD methods.




51

PEDAGOGY OF CLINICAL REASONING IN OCCUPATIONAL THERAPY STUDENTS: DOES THE INCORPORATION OF THE EQUITEST BALANCE MANAGER INTO CURRICULUM IMPROVE

CLINICAL REASONING?

Kate Hayner1, Andrew Smith2, Amber Crowley1, and Michelle Thakur1 1Department of Occupational Therapy and 2Motion Analysis Research Center, Samuel Merritt University


INTRODUCTION

A number of different teaching methods have been studied to evaluate the best way to teach occupational therapy (OT) students and clinicians how to interpret what they observe and also apply this knowledge (Brown & Probst, 2001; Coker, 2010; Feyereislova & Nathan, 2014; Hauer, Straub & Wolf 2005; Knecht-Sabres, 2010; Scaffa, & Wooster, 2004). These studies have mainly used subjective measures of clinical reasoning with few objective measures (Brown & Probst, 2001; Coker, 2010; Feyereislova & Nathan, 2014; Hauer, Straub & Wolf, 2005; Knecht-Sabres, 2010; Scaffa & Wooster, 2004). Understanding balance (what it is, how to evaluate it, and how to treat balance problems) is necessary for occupational therapists. At Samuel Merritt University, students learn about balance through lecture and labs but they do not have the experiential opportunity to experience the three distinct systems that principally impact balance: vestibular, somatosensory, and visual. Benson et al. (2013) found that experiential based learning supports the development of skills, reinforces academic knowledge, facilitates the clinical reasoning process, and develops self- confidence.


The pedagogy of teaching new skills and knowledge to students is a topic of great interest. Limited knowledge exists as to how experiential learning affects the acquisition of clinical reasoning skills. This study provides objective findings about the effects of experiential learning on both perceived skills and actual clinical reasoning skills and knowledge of balance of MOT students.

METHODS

This was a non-randomized unblinded study where 38 MOT students were provided 45-min time slots to sign up for an experiential learning activity in the EquiTest Balance Manager (EquiTest), a computerized tool that objectively evaluates the three sensory systems that most impact a person’s balance. The activity consisted of experiencing three protocols on the EquiTest, a clear explanation of the protocols, and a review of the three sensory systems involved with balance. Half of the available times occurred prior to a problem based learning (PBL) activity and half after. All students were given a questionnaire prior to the lecture and lab on balance, and again following the PBL activity (at the

time when half of the class had completed the experiential EquiTest activity). For the half that completed the EquiTest activity after the PBL case, they completed a third survey following their experiential EquiTest activity. The questionnaire evaluated the students’ perceived knowledge of balance and how to evaluate and treat individuals with balance deficits. All students received a PBL case to review in small groups and use clinical reasoning to determine the areas of concern, what to evaluate and what methods would be used as well as treatment interventions. As noted before, only half of the class had the experiential EquiTest activity at this time. All the small groups were made up of those that had or had not had the experiential activity. Responses to the PBL case were reviewed for content and levels of inquiry, as well as suggested approaches to treatment. All PBL answers were evaluated for statistical significance between the group that had the experiential lab prior to the PBL activity and to those that did not. Analysis of the participants’ questionnaire responses across time was completed. Descriptive analysis, linear regression analysis, and t-tests were used to address the goals of this study.

RESULTS

Questionnaire - Perceived skills

Students reported a significantly better understanding of balance following the lecture and lab on balance: post-questionnaire (mean = 2.87±0.34) pre-questionnaire (mean = 1.89±0.61), t37 = -8.86, p < 0.01 (two-tailed). This test was significant at the 99 percent confidence level. Students perceived that they had better evaluation skills in the post-questionnaire (mean = 2.82±0.69) than in the pre-questionnaire (mean = 2.11±0.56), t37 = -6.70, p < 0.01 (two-tailed). This test was significant at the 99 percent confidence level. Scores were significantly different for students’ beliefs about their knowledge of balance, with students perceiving that they had more knowledge in the post-


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questionnaire (mean = 2.39±0.59) than in the pre-questionnaire (mean = 1.82±0.65), t37 = -5.22, p < 0.01 (two-tailed). This test was significant at the 99 percent confidence level.

Perceived Impact of Experiential Learning

All students (n=38) reported that the EquiTest experience was either “helpful” or “very helpful” to their understanding of balance. All students (n=38) reported that the experience in the MARC on the EquiTest Balance Master gave them a better ability to identify sensory impairments, motor impairments and functional limitations related to a client’s balance. Overall, 26 students reported that the EquiTest experience gave them a bit more confidence in their skills in evaluating and treating balance and 12 students reported the EquiTest experience gave them a lot more skill in evaluating and treating balance.

Actual Performance – PBL Case

There were no significant differences found between the EquiTest A group (the group having experienced the EquiTest prior to the PBL experience) and EquiTest B group in responding to the questions on the PBL case regarding identifying potential evaluations, further information needed and treatment, integrating more knowledge of the balance mechanisms, or having clearer goals. There was a difference found in identifying the sensory systems of balance between EquiTest A group and EquiTest B group

DISCUSSION

The students’ performance in the problem-based learning (PBL) case revealed that all students demonstrated sound clinical reasoning skills regardless of whether they experienced the EquiTest before or after the problem-based learning case. Specifically, all students identified potential evaluations and interventions that were appropriate for the client presented in the PBL case regardless of whether or not they had the EquiTest lab experience. But students who experienced the EquiTest before the PBL case integrated more knowledge of the three sensory balance mechanisms compared to those had not yet experienced the EquiTest. This difference in actual performance on the PBL is understood by recognizing that the EquiTest experiential lab only introduced students to the three systems that impact balance and did not introduce treatment ideas. Additionally, all students attended the balance lecture, the lab on evaluation tools for balance,

and the lab in the Movement Analysis Resource Center regardless of having the EquiTest lab experience. This supports the idea that the current course content (e.g., lecture and labs) is used effectively for teaching students entry-level clinical reasoning skills.

Following the EquiTest experience, significant differences were found on several of the students’ self-reported skills in treating and evaluating balance. Significant positive differences were found in students’ perceived understanding of balance, perception of skills in evaluating balance, and perceived skills in treating balance. This indicates that the experiential lab significantly improved the students’ perception of their skills in these areas. This is arguably a positive benefit that any faculty member teaching balance would desire. All students found the EquiTest either helpful or very helpful and improved their confidence in evaluating and treating balance.

REFERENCES

1. Benson, J., Provident, I., & Szucs, K. (2013). An experiential learning lab embedded in a didactic course: Outcomes from a pediatric intervention course. Occupational Therapy in Health Care, 27(1), 46-57. doi: 10.3109/07380577.2012.756599

2. Brown, K. E., & Probst, C. H. (2001). Experiential learning: Exposure to variability among old adults. Journal of Physical Therapy Education, 15(2), 50-52.

3. Coker, P. (2010). Effects of an experiential learning program on the clinical reasoning and critical thinking skills of occupational therapy students. Journal of Allied Health, 39(4), 280-286.

4. Feyereislova, S. & Nathan, D. (2014). How best to teach developmental assessment? A single-blinded randomized study. Archives of Disease in Childhood, 99(12), 1083-1086. doi:10.1136/archdischild- 2013-305536

5. Hauer, P., Straub, C., & Wolf, S. (2005). Learning styles of allied health students using Kolb's LSI- IIa. Journal of Allied Health, 34(3), 177-182.

6. Knecht-Sabres, L. J. (2010). The use of experiential learning in an occupational therapy program: Can it foster skills for clinical practice? Occupational Therapy in Health Care, 24(4), 320-334. doi:10.3109/07380577.2010.514382

7. Scaffa, M. E., Wooster, D. M. (2004). Brief report—effects of problem-based learning on clinical reasoning in occupational therapy. The American Journal of Occupational Therapy, 58, 333-336. doi:10.5014/ajot.58.3.333


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ACHIEVING FLIGHT; RUNNING GAIT ASSESSMENT IN THE NEUROLOGICAL PHYSICAL THERAPY CLINICAL SETTING: A CASE REPORT.

Rebecca Marino, Gail Widener and Andrew Mason

Department of Physical Therapy, Samuel Merritt University


INTRODUCTION

Running analysis in physical therapy is performed primarily in the orthopedic setting. While assessment tools are available for walking gait in individuals with neuromuscular disease, limited information is available for running in the neurological population. The purpose of this case report was to document the outcomes and usability of a running gait assessment tool for use in the outpatient neurological setting.

CLINICAL SIGNIFICANCE This case report provides a tool for running analysis with an overview of proper running mechanics. Often times running is not attempted in the neurological setting. As a basis for recreational activity, it has been shown that if running is not re-learned following neurological insult there can be decreased physical activity [1,2], community access [2,3], and ability to return to work [1-3].

METHODS A running assessment tool was developed using evidence-based research on running mechanics. See Table 1 for the running gait assessment tool. Seven primary articles were chosen to develop the tool

[4-10], with additional articles used to fill in gaps [11-16]. First the phases of running gait needed to be determined. Running and walking gait have similarities but several key differences. Like walking, the phases of running gait can be divided into stance and swing. The difference lies in time spent in each phase. In walking, stance constitutes 60% of the gait cycle, with the remaining 40% in swing. In running the inverse is true, with 40% of the cycle spent in single leg stance, with the remaining 60% in swing. Running stance can be further divided into absorption and propulsion phases; with swing divided into initial, mid, and terminal phases. The assessment tool analyzes each body segment contributing to running mechanics in frontal and sagittal planes. Within the assessment tool, each critical event is indicated by a yes/no box. When the individual demonstrates correct form, yes is marked. Each yes marked during the assessment counts as one point, the higher the score the closer the patient is to ideal running mechanics. There is a maximum of 25 points. Slow motion video analysis is used to aid in scoring.

Table 1.

RESULTS During initial assessment the patient was able to complete a 100-foot run with minimal assistance of two individuals supporting at the elbows. The final score for the initial assessment was 9/25, with significant deficits observed at the knee throughout the running cycle. See Table 2 for initial assessment.

Table 2.

After six weeks of physical therapy the patient improved in balance, strength, and running mechanics. Balance was reassessed using the Berg Balance Scale, with a seven-point improvement, 47 to 54/56. Strength improvements were noted in hip flexion, extension, and abduction, knee flexion, and ankle dorsiflexion. Substantial improvements were noted in running gait. The patient was able to run independently for 10 minutes on a treadmill with one two-minute walking rest break at five minutes. Running mechanics also improved significantly. During initial scoring the patient showed difficulty with control at the pelvis, hip, knee, ankle, and trunk. By week six the patient had improved to 16/25 on the tool with increased control at


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the trunk, pelvis, and hips. See Table 3 for final assessment. Table 3.

DISCUSSION The running tool was able to track changes made between initial and final assessment. Changes may be attributable to a number of factors including strength gains from home exercise, physical therapy interventions, and spontaneous recovery. Limitations of a single subject case report include an inability to generalize conclusions to other populations or attribute changes seen to the interventions. A lack of information on return to running in neurological populations made it difficult to generalize normal running mechanics. Both validity and reliability of the running tool need to be performed in order to ensure usefulness for other patients. Further validation should be completed on the tool to compare it to more costly alternatives of motion analysis. Inter-rater reliability must be examined to determine reliability of use between clinicians. No research could be located comparing the developed running tool to others used in physical therapy settings for patients returning to running post neurologic insult. Due to the nature of the student clinical internship the information gathered was completed over six weeks. The patient was scheduled to continue the running program with another physical therapist. No further information was gathered following the six-week treatment period outlined here. Though limited, research that has been performed on individuals returning to running following neurological insult is promising, showing that return to running is possible with proper rehabilitation and patient motivation [17-19]. Studies show that individuals who are able to return to high level activity following neurological insult have higher levels of participation and better long-term outcomes [3,20,21]. There is a need for physical therapy and other programs to consider rehabilitation for individuals who have the potential for high-level function such as return to running.

REFERENCES 1. Alexanderson H, Dastmalchi M, Esbjörnsson-liljedahl M, Opava

CH, Lundberg IE. Benefits of intensive resistance training in patients with chronic polymyositis or dermatomyositis. Arthritis Rheum. 2007; 57(5):768-777.

2. American Physical Therapy Association. Guide to Physical Therapist Practice. 2nd ed. Alexandria, VA: American Physical Therapy Association; 2001.

3. Rinne B, Pasanen M, Vartianen M et al. Motor performance in physically well-recovered men with traumatic brain injury. J Rehab Med. 2206; 38: 224-229.

4. Nicola TL, Jewison DJ. The anatomy and biomechanics of running. Clin Sports Med. 2012: 31: 187-201.

5. Birrer RB, Buzzermanis S, Delatore MP, et al. Biomechanics of running. In O’Connor F, Wilder R, ed. The textbook of running medicine. New York. McGraw Hill: 2001; 11-19.

6. Adelaar RS. The practical biomechanics of running. Am J Sports Med. 1986; 14(6):497-500.

7. Thordarson DB. Running biomechanics. Clin Sports Med. 1997; 16(2): 239-247.

8. Dicharry J. Kinematics and kinetics of gait: from lab to clinic. Clin Sports Med. 2010; 29: 347-364.

9. Novacheck TF. The biomechanics of running. Gait Posture. 1998; 7: 77-95.

10. Montgomery III WH, Pink M, Perry J. Electromyographic analysis of hip and knee musculature during running. Med Sci Sports Exerc. 1994; 2(2): 272-278

11. Cappellini G, Ivanenko YP, Poppele RE, Lacquaniti F. Motor patterns in human walking and running. J Neurophysiol. 2006; 95(6): 3426-3437.

12. Agresta C, Brown A. Gait retraining for injured and health runners using augmented feedback: a systematic literature review. J Orthop Sports Phys Ther. 2015; 45(8): 576-585.

13. Higginson BK. Methods of running gait analysis. Med Sci Sports Exerc. 2009; 8(3): 136-141.

14. Phinyomark A, Osis S, Hettinga BA, Ferber R. Kinematic gait patterns in health runners: a hierarchical cluster analysis. J Biomech. 2015: 48: 3897-3904.

15. Westwater-Wood S, Adams N, Kerry R. The use of proprioceptive neuromuscular facilitation in physiotherapy practice. Physical Therapy Reviews. 2010;15(1): 23-28.

16. Miller EW, Combs SA, Fish C, Bense B, Owens A, Burch A. Running training after stroke; a single-subject report. Phys Ther. 2008; 88: 511-522.

17. Gardner MB, Holden MK, Leikauskas JM et al. Partial body weight support with treadmill locomotion to improve gait after incomplete spinal cord injury: a single subject experimental design. Phys Ther. 1998;78: 361-374.

18. Moriello G, Frear M, Seaburg K. The recovery of running ability in an adolescent male after traumatic brain injury: a case study. J Neuro Phys Ther. 2009; 33(2): 111-119.

19. Williams GP, Schache A, Morris M. Running abnormalities after traumatic brain injury. Brain Inj. 2013; 27(4): 434-443.

20. Ward I, Roth HR, Kahn JH, Tseng E, Tappan R. Measurement characteristics and clinical utility of the high-level mobility assessment tool among individuals with traumatic brain injury. Arch Phys Med Rehabil. 2014; 95(11): 2229-2230.

21. Williams GP, Morris M. High level mobility outcomes following acquired brain injury: a preliminary evaluation. Brain Inj. 2009; 23(4): 307-312.




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ATHLETIC TESTING USING PERFORMANCE SHOES, LOW-DYE STRAPPING AND CUSTOM FOOT ORTHOTICS, A PILOT STUDY

Logan Mitchell1, Patrick Derby1, Fernando Ramirez1, Stephen Hill2 and Timothy Dutra1 1California School of Podiatric Medicine and 2Motion Analysis Research Center, Samuel Merritt University

[email protected]

INTRODUCTION

Studies regarding foot stabilization are frequently in reference to injury prevention. To date, there have been minimal studies done in reference to improving specific athletic performance using foot orthotics and low-dye strapping. Analyzing these techniques with regards to specific athletic performance will increase understanding in how the foot, and stabilizing the foot, can increase performance. Our purpose was to investigate whether foot stabilization measures can increase specific athletic performance.

Vertical jump and stable landing are an essential physical component to many sports including but not limited to basketball, football and soccer [1][2]. Proper balance is an integration of components obtained from sensory, visual and vestibular stimulation that is relayed to the central nervous system [3]. Along with vertical jump, balance is ubiquitous in sports and also plays a crucial role in athletics not only for injury prevention but also for improved performance [4].


Understand how foot orthotics and low-dye strapping affect an individual’s athletic performance using specific athletic testing, including balance and jump testing.

METHODS

Three current California School of Podiatric Medicine second year students, ages 23, 24, and 27 were used for this study. Each subject was tested for balance acuity on the APDM Mobility Lab Comprehensive Gait & Balance Analysis device to eliminate any possible confounding proprioception conditions. This was performed to detail any underlying balance pathology that would affect the results. ATMI force plates were used to assess vertical jump height, force created, and the time it took to return to balance. Baseline time to balance for each subject was determined by obtaining center of pressure while standing on the ATMI force plate prior to testing. Center of pressure excursion was assessed in the anterior/posterior plane as well as the medial/lateral plane [5]. Baseline values were then compared to the dynamic time to balance obtained after each jump task was performed.

Vertical jump was measured using both a two foot and one foot technique, and the time the subject was in the

air was used to calculate jump height with physical kinematic equations. The two foot technique entailed a subject standing with both feet on the same force plate, then jumping to maximal height before returning to the same force plate. The one foot vertical jump was performed with a three step run up approach. Subjects had three steps to generate speed, and the fourth step was planted on an ATMI force plate before the subject jumped as high as possible. Subjects landed with two feet on a different force plate, and balance was again tested using the same method as above.

Additionally, subjects were recorded using the Qualisys 9- Camera Motion Capture System. This was to digitally represent the biomechanics of the subjects upon the various tests. Each of the tests described above were performed in either a standardized basketball shoe, low dye strapping on each foot or in a custom made foot orthotics.

RESULTS

Because we have not performed the study yet, this section will be hypothesis based. Orthotics with texture have been shown to improve proprioception [6]. We hypothesize that increased proprioceptive feedback at the foot will increase performance measures. Because an orthotic has more mass, and covers more of the plantar foot than the low dye strapping, we expect the orthotic to increase performance and balance most significantly.

DISCUSSION

This research could play an important role in the foot stabilization methods athletes use to achieve peak performance. Increased proprioceptive feedback via orthotics or low dye strapping could help athletes to achieve optimal performance by increasing balance. Also, orthotics and low dye strapping could lead to increased foot stabilization. This study did not assess foot type, but foot type could have an impact on the results of the study. In the future, an examination of orthotic material and texture could be done to see if there is an increase in proprioceptive feedback.

REFERENCES

1. Teramoto M, Cross CL, Willick S. 2016. Predictive Value of National Football League


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Scouting Combine on Future Performance of Running Backs and Wide Receivers. J Strength Cond Res. 30(5): 1379-90

2. Rodriquez-Rosell D, et al. 2016. Traditional vs. sport-specific vertical jump tests: reliability, validity and relationship with the legs strength and spring performance in adult and teen soccer and basketball players. J Strength Cond Res. [Epub ahead of print]

3. Fitzpatrick R, McCloskey DI. 1994. Proprioceptive, visual and vestibular thresholds for the perception of sway during standing in humans. Journal of Physiology. 478(1): 173-186

4. Hrysomallis C. 2011. Balance Ability and Athletic Performance. Sports Med. 41(3): 221-232

5. Karimi MT, Solomonidis S. 2011. The relationship between parameters of static and dynamic stability tests. J res Med Sci. 16(4): 530-535

6. Steinberg N, et al. 2015. Use of a textured insole to improve the association between postural balance and ankle discrimination in young male and female dancers. Med Probl Perform Art. 30(4): 217-223


There were no conflicts of interest or financial rewards with any of the authors.


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MUSCLE STABILIZATION OF THE ANKLE JOINT DURING THE GOLF SWING

Stephanie Tine1, Andrew Smith2, Timothy Dutra1and Stephen Hill2 1California School of Podiatric Medicine and 2Motion Analysis Research Center, Samuel Merritt University


INTRODUCTION

The aim of this pilot study is to examine the muscles stabilizing the ankle joint during a golf swing, and examine if the activity of these muscles change with the addition of a prefabricated foot orthotic to the golf shoe. One study has shown that ankle injuries are one of the more common in golf1. The peroneus longus and brevis muscles have been shown to be primary stabilizers of the lateral ligaments of the ankle joint and help prevent ligamentous injuries2. Investigation into orthotics effect on stabilization at the ankle might provide valuable evidence for enhanced performance and decreased ankle injuries while golfing. Previous research has shown that having a more stable base during a golf swing increases performance3. Orthotics have also been shown to improve balance and proprioception in experienced golfers4.

While there have been many studies looking at muscle activation of the upper body and lower limb above the knee5, the authors of the present study are not aware of any research examining the roles of muscles in stabilization of the ankle joint in golf. Electromyography will be used to examine the intensity of (lower) leg muscle activity. This study will strive to improve the understanding of the contributions of these muscles to ankle function during the five phases of a golf swing, back swing, forward swing, acceleration, early follow through and late follow through6,7. This will assist in better methods of injury prevention on the golf course.


This path of research could lead to better understanding of which muscles need to be undergo more rigorous strength training in golfers to avoid the risk of inversion sprains.

(Reprinted from Bechler)6

METHODS

The participant, a female golfer, performed multiple trials of a full swing with a 5 iron golf club. The anterior tibialis, gastrocnemius medial head, soleus (medial), and peroneus longus were measured during a golf swing using Delsys Trigno (Natick, MA, USA) wireless surface electromyography. After a warm-up, four trials were retained for analysis for each of two conditions: golf shoe and golf shoe with prefabricated orthotics (Superfeet, Ferndale, WA, USA).

RESULTS

For this participant, the first pronounced activity is toward the end of backswing in right gastrocnemius medial head, seen in both conditions. There is also activity of right tibialis anterior with orthotics in that period of time.

Activity reaches a peak during downswing in gastrocnemius, soleus, and peroneus longus in both conditions. Right tibialis without orthotics shows a similar downswing pattern; with orthotics there is a burst from the end of backswing into the beginning of downswing, gap of inactivity around ball-contact followed by a burst in follow-through.

With orthotics, the left gastrocnemius medial head and peroneus longus also show a distinct burst in follow-through, with a gap of activity (almost complete, but not zero signal) at ball-contact. Without the orthotics, there is one main peak during downswing (not distinct trough, only a slight dip in activity near ball contact).

DISCUSSION

Anterior tibialis, gastrocnemius medial head, soleus and peroneus longus muscles exhibited phasic bursts of activity during the golf swing, particularly downswing, and some in follow-through. An apparent gap of inactivity around ball contact with orthotics should be examined further. The anterior tibialis, gastrocnemius medial head, soleus and peroneus longus muscle’s phasic burst suggest the muscles implication in stabilization of the ankle joint, however more subjects’ golf swings need to be analyzed to confirm these findings. Of particular interest is the left peroneus longus muscles phasic burst during a golf swing because there has been research suggesting peroneus longus helps stabilize the lateral ligaments of the ankle joint7. During the follow through phase of the golf swing, there is excessive supination at the ankle joint


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which in theory would be antagonized by peroneus longus and brevis. Therefore, further research should be devoted to examining the left peroneus longus firing during the follow through phase. More evidence is needed to distinguish if there is a difference between muscle stabilization with and without orthotics. This analysis may lead to a better understanding of strength training and orthotic use for improvement in injury prevention training in golfers.

REFERENCES

1. McHardy, A., Pollard, H., Luo, K. One- year follow-up study on golf injuries in Australian amateur golfers. 2007. American Journal of Sports Medicine 35, 1354-1360.

2. Willems, T., Witvrouw, E., Verstuyft, J. Vase, P., De Clercq, D. Proprioception and muscle strength in subjects with a history of ankle sprains and chronic instability. 2002. Journal of Athletic Training 37: 487-493.

3. Stude D.E., Brink D.K. Effects of 9 holes of simulated golf and orthotic intervention on balance and proprioception in experienced golfers. Journal of Manipulative Physiological Therapies 1997;20:590–601.

4. Williams, K.R., Cavanagh, P.R., The mechanics of foot action during the golf swing and implications for shoe design. 1983. Medicine and Science in Sports and Exercise 15, 247-255.

5. Marta S., Silva L., Castro, M.A., Pezarat-Correia, P., Cabri, J. 2012. Electromyography variables during the golf swing: A literature review. Journal of Electromyography and Kinesiology 22, 803-813.

6. Bechler, J. R., Jobe, F. W., Pink, M., Perry, J., Ruwe, P. A. Electromyographic analysis of hip and knee during the golf swing. 1995. Clinical Journal of Sports Medicine 5, 162-166.

7. McHardy, A., Pollard, H., Muscle activity during the golf swing. 2005. British Journal of Sports Medicine 39, 799-804.




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AUTHOR INDEX A

Alvarez, Audrey .......................................................... 39

C

Cates, Nicole .............................................................. 39 Chang, Kristina .......................................................... 45 Choate, Cherri ........................................................... 38 Chou, Nina ................................................................. 49 Crowley, Amber ......................................................... 51 Curry, Christian ......................................................... 41

D

Derby, Patrick ............................................................ 55 Dutra, Timothy ............................................ 5, 38, 55, 57

E

Edmunds, Kathleen ...................................................... 5

F

Franceschi, Alexandra ............................................... 26

G

Gouelle, Arnaud ........................................................... 3

H

Harris-Adamson, Carisa ............................................ 43 Hayner, Kate .............................................................. 51 Hill, Stephen .......................................... 9, 41, 43, 55, 57

J

Joy, Silpa .................................................................... 45

K

Kha, Nickey ................................................................ 49 King, Laurie A. ...................................................... 13, 31 Kirby, Kevin .................................................... 14, 22, 35 Knutson, Myles ........................................................... 39

L

Lam, Emma ................................................................. 43 Lazaro, Rolando ......................................................... 26 Levin, Mindy F. ..................................................... 17, 32 Lo, Sing Kai .......................................................... 27, 29 Lynn, Scott .................................................................. 45

M

Marino, Rebecca ......................................................... 53 Mason, Andrew ........................................................... 53 McPoil, Thomas G. ......................................... 15, 23, 36 Mita, Stephanie ........................................................... 39 Mitchell, Logan ........................................................... 55

P

Powers, Nathan........................................................... 45

R

Ramirez, Fernando ..................................................... 55 Razzante, Mark ........................................................... 41 Richie Jr., Douglas H. ...................................... 7, 25, 34

S

Sam, Ka-Lam ........................................................ 27, 29 Smith, Andrew ............... 9, 27, 29, 39, 43, 45, 49, 51, 57 Stergiou, Nicholas ................................................... 4, 21 Sutter, Rachel .............................................................. 49

T

Thakur, Michelle ......................................................... 51 Tine, Stephanie ........................................................... 57 Tran, Yen .................................................................... 41

W

West, Tenaya ............................................................... 41 Widener, Gail .............................................................. 53

Y

Yun, Lydia ................................................................... 45


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NOTES

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