AACPDM 67th Annual Meeting
Milwaukee 2013
INSTRUCTIONAL COURSE IC11
Thursday, October 17th: 2:00 pm – 4:00 pm
THE IMPORTANCE OF BEING EARNEST ABOUT
SHANK AND THIGH KINEMATICS
ESPECIALLY WHEN DESIGNING, ALIGNING AND TUNING
ANKLE-FOOT ORTHOSIS FOOTWEAR COMBINATIONS
PRE-SESSION INFORMATION PACK
Presenters
Deborah Gaebler-Spira MD
Elaine Owen MSc SRP MCSP
Stephania Fatone PhD BPO(Hons)
Donald McGovern CPO FAAOP
Professor of Pediatrics and Physical Medicine and
Rehabilitation, Rehabilitation Institute of Chicago,
Chicago, IL
Clinical Specialist Physiotherapist,
Child Development Centre, Bangor, UK
Research Associate Professor,
Dept of Physical Medicine & Rehabiliatation
Northwestern University, Chicago, IL
Orthotist and Prosthetist
Rehabilitation Institute of Chicago, Chicago, IL
Suggested Pre-Reading
This instructional course is based on the experiences of the presenters in designing, aligning and tuning AFO
Footwear Combinations. A review paper which summarises the approach and its background won the
International Society of Prosthetics and Orthotics (UK) George Murdoch Prize 2008 now published as Owen
E (2010) The importance of being earnest about shank and thigh kinematics especially when using anklefoot orthoses. Prosthetics and Orthotics International 34(3): 254-269. An editorial by Stefania Fatone
outlines the challenges in lower-limb orthotic research and the transfer of knowledge to clinical practice:
Fatone S (2010) Prosthetics and Orthotics International 34(3) 235-237.
Additional handouts and information, including full reference lists, will be distributed at the session. This
will include a CD that will include:
Forms for clinical use
Coloured poster versions of algorithms;
Designing, Aligning and Tuning AFO-Footwear Combinations
Determining the sagittal angle of the ankle in an AFO
Owen E (2004) MSc thesis
Owen E (2004) Proceedings of a Seminar presented at ESMAC (European Society of
Movement Analysis in Adults and Children)
INTRODUCTION TO INTERVENTIONS WITH AFO FOOTWEAR COMBINATIONS
REVIEW OF ICF MODEL, HOW AFOFCs HAVE THE POTENTIAL TO IMPROVE ALL ASPECTS OF ICF
DR.DEBORAH GAEBLER-SPIRA
The primary outcome measure of any study should directly relate to the hypothesized benefit of the intervention and the
measures chosen should be reliable, valid and relevant. There is increasing interest in finding out which interventions
improve all aspects of the ICF; activities and participation as well as the impairment, at the body function and structure level.
A recent ISPO Consensus Conference (2009) made several conclusions and recommendations on orthotic interventions in
Cerebral Palsy, which also have wider relevance.

 Dialogue between the orthotist and the team is essential, when deciding on treatment goals and the biomechanical
requirements to achieve the goals.

 The role of the orthotist is to formulate the design, fit, align, deliver and review the orthosis which will in theory,
achieve the biomechanical requirements desired by the team.

 Adherence is likely to be higher when there is clear agreement between the physiotherapist and orthotist regarding
usage, and the family understands the rationale for the prescription.

 When an orthosis is prescribed consideration must be given as to when and for how long it must be worn. The
optimum duration of use and the occurence of side effects.

 For ambulant children available evidence from gait lab studies suggests that an AFO that prevent plantarflexion can
improve gait efficiency, temporalspatial parameters and ankle kinematics.

 The indirect effects of AFOs on the kinematics and kinetics of knee and hip joints have been demonstarted; these
can be optimised by tuning the AFO.

 AFOs reduce energy costs of walking but it is as yet unclear how they influence phasic activity of gait, muscle
length, muscle strength, how the assessment of AFOs in the gait laboratory predict the childs mobility and gait
efficiency in their usual environments.
ELAINE OWEN
The ISPO review of orthotic interventions remarked that many studies provided inadequate information on the
orthosis being investigated and only rarely did papers provide adequate information on the footwear being used with orthoses.
This has also been commented on in reviews by Owen (MSc 2004) and Ridgewell (2010).
When drug interventions are prescribed there are three vital components to the prescription: the name of drug, the
dosage of the drug, the frequency of administration of the drug. When orthotic interventions are prescribed all three
components of the prescription should also be fulfilled:The name of the orthotic intervention ............................................AFO Footwear Combination
The dosage of the orthotic intervention...........................................The triplanar design of the AFO and Footwear
The frequency of administration of the orthotic intervention.........When and how long to use the AFO-FC
In order to answer the question as to the dosage and the frequency of administration required for the orthotic intervention to
be successful, we have to be clear about the orthotic aims and the desired outcomes that the clinicians, the patient, their
family and carers have for the intervention. Also, how the amount of usage, required to achieve the outcomes, can acceptably
be integrated into the lifestyle of the patient, family and carers. Prescribing an AFO-FC that is well matched to the patients
needs and desired outcomes is essential (Harlaar et al 2010).The aims and the intended outcomes for the orthotic intervention
relate to many aspects of the ICF.
Body Functions - the physiological functions of the body systems
Body Structures- the anatomical parts of the body such as organs, limbs and their components
Activity
- the execution of a task or action by an individual
Participation
-involvement in a life situation
The International Classification of Functioning Disability and Health (ICF). WHO 2001 ISBN 92 4 154544 5
The ICF Children and Youth Version (ICF-CY). WHO 2007 ISBN 978 92 4 1547321
Recent Developments in Healthcare for Cerebral Palsy: ISPO. Free download available from www.ispoint.org
Ridgewell E (2010) P&O International 34(3):129-145: Harlaar et al (2010) P&O International 34(3): 327-335.
AACPDM INSTRUCTIONAL COURSE 2012
OWEN, GAEBLER-SPIRA, FATONE, McGOVERN
OBJECTIVES AND OUTCOMES FOR AFOFC INTERVENTIONS – AN ‘INSIDE OUT’ AND ‘ICF MODEL’ APPROACH
SKELETAL STRUCTURE
BONES JOINTS LIGAMENTS
BODY STRUCTURES & FUNCTION
MUSCULOTENDINOUS
UNITS
BODY STRUCTURES & FUNCTION
DEVELOPMENTAL MATURATION
MOTOR LEARNING
BODY STRUCTURES & FUNCTION
ACTIVITIES
FUNCTIONAL & OTHER
OBJECTIVES
BODY STRUCTURES & FUNCTION
ACTIVITIES & PARTICIPATION
To manage deformities which are
preventable, reducible, irreducible but
can be stabilized.
LENGTH
Obtain/maintain correct length
Obtain/maintain the correct length of
muscle to tendon ratio
Obtain/maintain optimal “extensibilité”
of muscle belly
Normalise lengthening and
shortening of MTUs in gait cycle
SEGMENT & JOINT KINEMATICS
STANDING & GAIT
Obtain normal developmental order of
segment kinematics- learn to 1st
couple shank and foot, then couple
shank and thigh.
Obtain normal developmental order of
joint kinematics
CHANGING & MAINTAINING BODY
POSITION
WALKING AND MOVING
STIFFNESS (TONE)
Neural
Non Neural
Components:
Components:
Spasticity
Elastic
Dystonia
Plastic
Tonic Reflexes
Viscous
Contractile
Structural Shortening
KINETICS & MOTOR LEARNING
STANDING, FIRST STEPS, GAIT
Prevent/reduce uncontrolled
generation of abnormal internal and
external moments when learning to
stand, step and walk.
BONES/SEGMENTS
Prevent abnormal bony structure/
growth
Reduce abnormal bony structure /
growth
Stabilise abnormal bony structure
Maintain normal bony structure/ growth
Add length to a segment
Improve shape of a segment
JOINTS
Optimise joint alignment
appropriate for age
Prevent joint deformity
Reduce joint deformity
Stabilise joint deformity
Limit range of motion of a joint
Prevent excessive motion of a joint
Increase range of motion of a joint
LIGAMENTS
Prevent ligamentous laxity
Reduce ligamentous laxity
Stabilise ligamentous laxity
Prevent ligamentous shortening
Reduce ligamentous shortening
Maintain optimal ligamentous length
Normalise/optimise appropriate
stretching of the joints during the gait
cycle
Obtain /maintain as near muscle tone
as normal.
Minimise abnormal increase in tone
and normalise muscle tone during
gait cycle
Obtain optimal position of spastic
reaction within available range.
STRENGTH
Obtain /Maintain as near normal
strength as possible
Maximise use of muscle strength
during gait cycle
Compensate for weak muscle actions
SELECTIVITY & TIMING
Obtain/Maintain optimal selectivity
and timing
SITTING & UPPER LIMB
Obtain/maintain/improve sitting balance;
trunk posture in sitting; arm and hand
function in sitting & standing.
STANDING
Normalise/optimise the kinematics of the
segments and joints, and the kinetics (forces
and moments).
Obtain/maintain/improve standing balance
and ability to shift CoM.
Obtain/maintain controlled rates of
generation of normal/optimal internal
and external moments
CHANGE POSITION/TRANSFERS
Pull to stand; Kneel to stand; Sit to stand;
Stand to squat; Bending down; Small steps;
Transfers; Stairs.
Facilitate motor learning, from
repetition of the generation of normal
kinematics and kinetics in standing
and gait
WALKING & GAIT
Normalise / optimise the kinematics of the
segments and joints, and the kinetics (forces,
moments and powers) of walking and gait.
Provide correct postural feedback
.
Improve spatiotemporal measures of gait:
velocity; cadence; step/stride length;
distance.
Maintain/improve gait efficiency/ energy
expenditure.
OTHER
Pain reduction
Reduce/redistribute the load on tissues so as
to protect tissues or promote healing
Cosmesis
Ride a bicycle
ALIGNMENT OF SEGMENTS AND JOINTS
DEFINITION OF THE ALIGNMENT OF A JOINT The spatial relationship between the skeletal
segments which comprise the joint (International Standards Organisation ISO 855:2003)
DEFINITION OF THE ANGLE OF THE ANKLE IN AN AFO (AA-AFO) The angle of the line of
the shank relative to the line of the foot in the AFO. Described in degrees of plantarflexion, dorsiflexion
or plantigrade .
DEFINITION OF THE ALIGNMENT OF A SKELETAL SEGMENT The spatial relationship
between the ends of a segment (International Standards Organisation ISO 855:2003)
The alignment of segments is most usefully measured relative to the horizontal or the vertical. The angle
between the segment and the vertical is measured in degrees and described in degrees of incline or recline
from the vertical. Observe the illustration of the movement and alignment of the segments relative to the
vertical during the gait cycle (Winter 1990). The thigh and shank move from a reclined to an inclined
position, passing through vertical. There is no place in the gait cycle when both the shank and thigh are
vertical. The foot moves from an inclined to reclined position, passing through horizontal
There is currently no agreed nomenclature for the angle of a segment relative to the vertical by the ISO.
The current mostc
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DEFINITION OF THE SEGMENT TO VERTICAL ANGLE
The angle of the segment relative to the vertical, measured in the sagittal plane. The angle is described as
inclined if the segment is leaning forward from the vertical and reclined if leaning backward from the
vertical. It is described in degrees from the vertical, vertical being 0 degrees.
The Segment to Vertical Angle can be measured in standing, during a gait cycle or other activities. It can
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DEFINITION OF THE SHANK TO VERTICAL ANGLE OF AFO-FOOTWEAR
COMBINATION
The angle of the line of the shank relative to the vertical when standing in an AFO-FC with the weight
equally distributed between heel and toe, measured in the sagittal plane.The angle is described as inclined
if the segment is inclined/leaning forward from the vertical and reclined if reclined/leaning backward
from the vertical. It is described in degrees from the vertical, vertical being 0 degrees.
Shank to Vertical Angle is independent of the Ankle Angle in an AFO
Plantarflexion
Plantigrade
Dorsiflexion
ALIGNMENT OF ANKLE JOINT
Reclined
from
vertical
Vertical
Inclined
from
vertical
ALIGNMENT OF AFO-FC
Refs: Owen E (2004) MSc Thesis, (2010) P&O International 34(3) 254-269.
SEGMENTS RELATIVE TO THE VERTICAL
Winters DA 1990; Wiley: Reproduced with permission.
Vertical
Inclined
Reclined
SEGMENT TO VERTICAL ANGLE
BIOMECHANICAL OPTIMISATION AND TUNING OF AFO-FCs
Thewor
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of selecting the optimum design of an AFO-FC.‘
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whole process of designing, aligning and tuning the AFO-FC . Tuning is best reserved for the process of using
gait trials to adjust the design and alignment of the AFO and Footwear. Adjustments are made in order to
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adjustments to the AFO and/or footwear segment and joint kinematics and kinetics can be normalised or
optimised. Normalising shank kinematics is key to succeeding.
REPLICATING NORMAL
SHANK AND THIGH KINEMATIC
AND GRF ALIGNMENT TO KNEE
Entrance to
Midstance
Midstance
Exit from
Midstance
REPLICATING NORMAL
SHANK, THIGH, PELVIS AND TRUNK KINEMATIC
AND GRF ALIGNMENT TO KNEE AND HIP
Entrance to
midstance
Midstance
Exit from
midstance
Refs: Owen2010) P&O Int 34(3):254-269; ( 2004) MSc & ESMAC Seminar. Winter DA Wiley1990
This abstract is published in Gait and Posture. Owen E (2009) Gait and Posture 30S: S49 ©Gait & Posture
HOW SHOULD WE DEFINE THE ROCKERS OF GAIT AND ARE THERE THREE OR FOUR?
Owen E, Child Development Centre, Bangor, UK
SUMMARY
A three-event ankle model of the rockers in gait is inadequate. A four-event model is preferable.
CONCLUSION
Definitions of four rockers are proposed: The mechanisms of the ankle and foot that produce shank kinematic during stance
phase of the gait cycle (GC); First rocker during loading response (LR), heel is the pivot, movement at the ankle joint; Second
rocker during mid-stance (MST), ankle is the pivot, movement at the ankle joint; Third rocker during terminal stance (TST),
forefoot is the pivot, movement at the metatarsal-phalangeal joints; Fourth rocker during pre-swing (PSW), forefoot is the pivot,
movement at the metatarsal-phalangeal and ankle joints.
INTRODUCTION
Perry first described the three rockers of gait, ascribing them to three subdivisions of theGC;‘
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nded the description of the forefoot rocker
to include PSW.2 She attributes the purpose of the rockers to production of tibial advancement during stance, an essential element
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involving plantarflexion during LR, second involving dorsiflexion, and third involving plantarflexion or movement from
dorsiflexion towards plantarflexion, with varying interpretations of the division between second and third rockers.
METHOD AND RESULT
Tabulation of kinematic data by subdivisions of the GC reveals four events and three pivots producing the normal shank
kinematic of stance.
PROPOSED NAME
PIVOT
JOINT producing
tibial advancement
ANKLE JOINT
MTPJs
SHANK
KINEMATIC
degrees relative to
vertical
FOOT KINEMATIC
LR
1st ROCKER
Heel
MST
2nd ROCKER
Ankle
TST
3rd ROCKER
Forefoot / MTPJs
PSW
4th ROCKER
Forefoot / toes
Ankle
Ankle
MTPJs
MTPJs & Ankle
Plantigrade to
10° Plantarflex
Dorsiflex 25° to 0°
10° Plantarflex to
10° Dorsiflex
0° to 0°
Virtually locked in
Dorsiflex 10-12-7°
0° to Dorsiflex 25°
7° Dorsiflex to
20° Plantarflex
Dorsiflex 25°-55°
25° to 10° Recline
10° Recline to
10° Incline
10° to 25° Incline
25° to 50°
Incline
25° Incline to
Horizontal
Horizontal
Horizontal to
20° Recline
20° Recline to
60° Recline
DISCUSSION
Confining interpretation of the rockers to ankle kinematic does not recognise: 1) The original purpose of describing the rockers;
to describe the pivot mechanisms by which normal shank kinematic is produced during stance. 2) The original differentiation
between second and third rocker; heel rise, at 30% GC, at the start of TST, the pivot transferring from the ankle to the forefoot.
More recent descriptions differentiate these rockers by the point at which the ankle starts to move towards plantarflexion, or the
end of TST, neither of which coincide with the start of heel rise. 3) Four events of ankle kinematic in stance, rather than three. A
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dorsiflexion.1, 2 The movement that advances the shank occurs at the metatarsal-phalangeal joints. The stiffness of the ankle in TST
is essential for heel rise and the ability to achieve maximum knee extension at 40% GC, maximum hip extension at 50% GC.1, 2
These omissions may lead to inappropriate or suboptimal interventions.
REFERENCES
1. Perry J (1974) Clin.Orthop Rel Res 102:118-31
2. Perry J (1992) Gait Analysis. McGraw Hill: New York
3. Perry J (2008) In: AAOS Atlas of Orthoses and Assistive Devices. Mosby: Philadelphia
HOW SHOULD WE DEFINE THE ROCKERS OF GAIT
AND ARE THERE THREE OR FOUR?
Normal shank kinematics
produced by the 4 rockers of gait
15-25°
20-25°
REC
5-10°
10°
REC
1st Rocker
5-10°
10°
REC
10-12°
10°
INC
2nd Rocker
10-12°
10°
INC
20-25°
INC
3rd Rocker
Terminal Stance
First rocker in loading response using ankle movement
Pivot at heel
45°
INC
3rd Rocker
Preswing
First rocker in loading response using ankle movement
Pivot at heel
Second rocker in midstance using ankle movement
Pivot at ankle
Third rocker in terminal stance using MTPJ movement
Third rocker in preswing using MTPJ movement
Quasistiffness of
ankle joint in
dorsiflexion
Refs: Owen E (2009) Gait and Posture 30S: S49; (2010) Prosthetics and Orthotics International 34 (3);
Course Manual
This abstract is published in 2005 in Gait & Posture (online edition) 22S: S36-S37 ©Gait & Posture
Algorithm is also in Owen E (2010) Prosthetics ans Orthotics International 34(3) 254-269
A CLINICAL ALGORITHM FOR THE DESIGN AND TUNING OF ANKLE-FOOT ORTHOSIS FOOTWEAR
COMBINATIONS (AFOFCs) BASED ON SHANK KINEMATICS
Owen E, MSc MCSP. Child Development Centre, Bangor, North Wales, UK. LL57 2EE.
SUMMARY
Eight years experience of designing and tuning AFOFCs for a population of children with cerebral palsy, spina bifida and
other conditions (n=141) on the ORLAU Transportable Video Vector Generator Gait Laboratory, which provides combined
kinematic and kinetic analysis, has enabled the formulation of an algorithm which will facilitate the design and kinetic and/or
kinematic tuning of AFOFCs.
REFERENCES
Owen E (2002) Gait & Posture 16, Supp 1, S132-S133. Owen E (2004) Gait & Posture 20S, S86. Owen E (2004)
Proceedings of ESMAC Seminars 2004 : Owen E (2004) MSc thesis. Glasgow: Univ of Strathclyde
This abstract is published in 2005 in Gait & Posture (online edition) 22S: S38-S39 ©Gait & Posture
Algorithm is also in Owen E (2010) Prosthetics ans Orthotics International 34(3) 254-269
PROPOSED CLINICAL ALGORITHM FOR DECIDING THE SAGITTAL ANGLE OF THE ANKLE IN AN
ANKLE-FOOT ORTHOSIS FOOTWEAR COMBINATION
Owen E, MSc, MCSP Child Development Centre, Bangor, North Wales, UK. LL57 2EE.
INTRODUCTION
Gastrocnemius (GN) is a tri-jointed musculotendinous unit (MTU) crossing the knee, ankle and subtalar joint. It reaches its
maximal length twice in the gait cycle (GC). At initial contact, the knee is extended, the ankle plantigrade, the subtalar joint
supinated and the MTU is lengthening passively. At 40% GC in terminal stance (TST), the knee reaches maximal stance
extension, the ankle is in some dorsiflexion, the subtalar joint neutral and the MTU is lengthening actively. Setting the Angle
of the Ankle in the AFO (AA-AFO) without regard to the tri-jointed requirements of the GN can result in insufficient length
being available to allow knee extension during the GC. In addition, an overstretched GN in TST will reduce the possibility of
MTU force production. The lever arm ratio between the ankle and the knee at 40% GC is 2:3, so small changes in the ankle
angle are amplified at the knee. The Shank Angle to Floor (SAF) measure of an AFO-Footwear Combination is the prime
determinant of gait rather than the AA-AFO. An appropriate SAF for normal gait can be achieved with a dorsiflexed,
plantigrade or plantarflexed AA-AFO. The normal range of GN length in children, measured with knee extended and subtalar
neutral, diminishes with age. At 16yrs, 64% of feet only reach plantigrade and 13% only reach 5° plantarflexion. The use of a
variety of angles of AA-AFO is advantageous and the use of plantarflexion may be essential. Using a plantarflexed AA-AFO
does not necessarily lead to MTU shortening and may increase MTU length.
Intervention
Intervention
CLINICAL MEASUREMENT OF GASTROCNEMIUS LENGTH *
PLANTARFLEXED
PLANTIGRADE
YES
DORSIFLEXED
YES
Is dorsiflexion
fixed?
NO
Intervention planned to increase range?
YES
Intervention planned to increase range?
NO
Can measured angle be sustained
without excessive pressure/discomfort?
Can measured angle be sustained
without excessive pressure/discomfort?
NO
NO
YES
Reduce ankle angle to
a more plantarflexed
angle
NO
Would angle promote
excessive pronation or
supination?
YES
Additional strategies
possible to negate or
minimise risk?
NO
YES
Accept risk of loss of
musculotendinous unit length
OR
Adjust ankle angle to a less
plantarflexed, a plantigrade,
or a dorsiflexed position, and
accept resultant excessive
pronation, supination or poor
knee extension
(not recommended)
YES
Reduce ankle angle to
a plantigrade or
plantarflexed angle
Would angle promote
excessive pronation or
supination?
NO
YES
NO
Is there risk of
gastrocnemius length
becoming shorter?
Are gastrocnemius
and/or soleus
excessively long?
YES
YES
NO
NO
Is there a risk of soleus
length becoming shorter?
YES
NO
Reduce ankle
angle to a
plantigrade or
plantarflexed
angle
Use a
dorsiflexed angle.
Probably no
more than 5°
dorsiflexion unless
fixed deformity
USE THE RESULTANT ANGLE FOR AA-AFO
* Note about measurement
Position to measure gastrocnemius length: Knee extended, foot dorsiflexed, foot in position of supination, neutral or pronation
depending on which is associated with the least range. The supinated foot position will therefore be used for feet that escape into
pronation and the neutral or pronated position will be used for feet that escape into supination.
REFERENCES
Stewart C, Roberts A, Jonkers I (2004) Gait & Posture 20S, : Bleck EE, (1987) Clinics in Developmental Medicine No
99/100. Mac Keith Press/ Blackwell Scientific Publications:Nuzzo RM (1983) Orthopedics 6: 713-723 Nuzzo RM (1983)
Orthopedics 6, 817-830: Owen E (2004) MSc thesis. Glasgow: University of Strathclyde: Reimers J, Pederson B,
Broderson A (1995) J Pediatric Orthopedics PartB 4, 71-73
This abstract is published in Gait & Posture 16, Supp1, S132-S133 (2002) ©Gait & Posture
SHANK ANGLETO FLOORMEASURESOFTUNED‘
ANKLE-FOOT ORTHOSIS FOOTWEAR
COMBI
NATI
ONS’USEDWI
TH CHI
LDRENWI
TH CEREBRALPALSY,SPI
NABI
FI
DAANDOTHER
CONDITIONS.
Owen, E, MCSP
Child Development Centre, Bangor, Gwynedd, North Wales, UK, LL57 2EE.
INTRODUCTION
The footwear that is worn with an AFO is integral in determining the overall biomechanical control provided so
they have been described as an AFO-Footwear Combination (AFOFC) (Meadows 1984). To replicate an AFOFC,
descriptions in all 3 cardinal planes for all the features of the AFO and the footwear are important. Two sets of
sagittal measures are crucial: the angle of the ankle in the AFO (AAAFO) and the position of the lower leg relative
to a vertical to the ground when standing in the AFOFC, the Shank Angle to Floor (SAF). The selection of the basic
design features of the AFOFC is highly critical to achieving orthotic goals. The AFOFC can be tuned by making
fine adjustments to manipulate the Ground Reaction Force (GRF) and its relationship to knee and hip joints in order
to optimise its performance (Meadows 1984, Butler and Nene 1991). One aspect of tuning is to set the SAF of the
AFOFC. Alteration of the SAF by just a few degrees can influence the alignment of the GRF to the joints in
standing and gait considerably (Cook & Cousins 1976, Meadows 1984). This paper reports the results of the tuned
SAFs of solid AFOFCs for a population of children with cerebral palsy (CP), spina bifida (SB) and other conditions
(O).
PATIENTS and METHOD
74 children (CP n=50, SB n=4, O n=20) who were independently ambulant without walking aids and who
required solid AFOFCs had their prescriptions tuned at Bangor CDC on the ORLAU transportable Video Vector
Ge
n
e
r
a
t
orGa
i
tLa
bor
a
t
or
y
.Ch
i
l
dr
e
n
’
sg
a
i
twa
sa
n
a
l
y
s
e
dwh
i
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ewa
l
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r
e
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oot
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they were tuned. The AAAFO, SAF and other prescription details were collected for each AFOFC trial.
RESULTS
Figure 1 shows the SAFs of the latest tuned prescriptions for each of the 74 children using 112 AFOFCs.
Whether the AAAFO was dorsiflexed, plantigrade or plantarflexed the SAFs of the tuned AFOFCs were all inclined.
For all AFOFCs (n=112) mean SAF=11.36°, SD=2.08, range 7-15°. For AFOFCs used by children with CP (n=69),
mean SAF=11.86°, SD=2.05, range 7-15°. For AFOFCs used by children with SB (n=8), mean = 7.75°, SD=0.46,
range 7-8°. AFOFCs for other children (n=35), mean =11.2°, SD=1.41, range 8-14°.
Number of tuned AFOFCs
30
25
Other diagnosis
20
Spina Bifida
15
Cerebral Palsy
10
5
0
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
SAF of tuned AFOFCs in degrees of incline
Figure 1. Frequency distribution of Shank Angle to Floor of tuned AFOFCs by diagnosis
DISCUSSION
It is possible to measure in a simple manner the AAAFO and SAF. When tuning AFOFCs a good starting point
would be to set the SAF at 10-12° inclined and increase or decrease the SAF as required, with the exception of
AFOFCs for children with SB. The mean tuned SAFs approximate to the SAF of normal gait at midstance. A
possible explanation for the 10-12° inclined SAF being central to the production of stability in stance in both normal
and pathological gait with AFOFCs is that it is determined by anthropometric measures.10-12° inclined is the
position that brings the centre of the knee joint directly over the middle of the foot. Other design features of the
AFOFC need consideration if it is to be tuned optimally for the whole of the gait cycle.
REFERENCES
[1] Butler PB, Nene AV (1991) Physiotherapy 77: 81-88
[2] Cook TM, Cousins B (1976) Archives of Physical Medicine and Rehabilitation 30: 43-46
[3] Meadows CB (1984) PhD Thesis –Glasgow. University of Strathclyde
TUNI
NGFORTHE‘
ENTRANCESTOMST’AND‘
EXI
TSFROM MST’
EXITS FROM
MIDSTANCE
USE OF
ANATOMICAL
3rd ROCKER
USE OF
SIMULATED
3rd ROCKER
Refs: Owen E 2005, 2010 Prosthetics and Orthotics International 34(3) 254-269; Course Manual
ENTRANCES TO
MIDSTANCE
A PROPOSED CLINICAL ALGORITHM FOR DORSIFLEXION FREE AFOFCs BASED ON CALF MUSCLE LENGTH, STRENGTH, STIFFNESS AND SKELETAL ALIGNMENT Owen E (2013) Presentation for ISPO UK MS Annual Scientific Meeting 2013 Is there sufficient gastrocnemius length to allow knee extension with 10° NO
ankle dorsiflexion and a non compromised arch?
YES Is there sufficiently low tone in the calf muscles to allow 10° of ankle NO
dorsiflexion during second rocker of gait cycle?
YES Is there sufficient calf muscle strength to prevent excessive ankle rd
NO
dorsiflexion in stance and create a ‘quasi‐stiff’ ankle in dorsiflexion in 3
rocker? YES Is the triplanar bony alignment of the foot sufficiently stable to be NO
maintained during the dorsiflexion free function of the AFO? YES A dorsiflexion free AFOFC design is likely to be suitable. Determine plantarflexion function. Fixed ankle or dorsiflexion stop AFOFC design required MTPJs free design usually required* 0° pitch/0mm Heel Sole Differential footwear required for full effect on ankle dorsiflexion** Optimal heel design in footwear required * An AFOFC with MTPJ free design is usually required, to allow MTPJ extension during third
rocker, and patients who meet the criteria for a dorsiflexion free AFO usually meet the criteria
for an MTPJ free design. If they do not a rocker sole profile is required on the footwear as
restriction in MTPJ extension may produce excessive ankle dorsiflexion, a compensatory
response required to enable normal shank kinematics if MTPJs are fixed and not compensated
for by a rocker sole profile. ** To obtain 10‐12° of ankle joint dorsiflexion in gait the dorsiflexion free AFO needs to be combined with footwear that has a 0mm Heel Sole Differential (HSD) or 0 degree pitch. For
each degree of pitch in the footwear there will be a reduction of one degree of ankle
dorsiflexion. This is because gait requires normal shank kinematics and ankle joint kinematics
adjust to the pitch of the footwear to achieve this. In normal gait the shank is 10‐12° inclined at the end of mid‐stance. A 10‐12° pitch in the footwear negates the need for ankle
dorsiflexion to achieve this. TEACHING FIRST STEPS - WITH OR WITHOUT WALKING AIDS
A
B
C
When teaching first early steps, or first steps with a new design of AFOFC, to children
with significant problems of muscle stiffness, muscle weakness, balance or other
disabilities, it is a useful to use the following sequence:
A Teach standing in AFOFCs which have optimised inclined SVAs of the AFOFCs.
This is determined by standing trials (B).Choose the SVA that allows the child to obtain
vertical or if possible incline
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pass anterior to the knee joint centre and produce stabilising moments at the knee. The
AFO needs to be combined with footwear that provides a very stable base. This
footwear would have a flat sole profile, with an appropriate rocker design, rounded or
point-loading, at the appropriate percentage of the shoe/boot length, and may also
include a back float. This design will provide a good base of support.
B In standing, encourage translation of the trunk anteriorly and posteriorly, moving the
thigh from a reclined to vertical and inclined positions. Initially, they may need distal
support at the top of the shanks to be able to do this.
C Encourage small steps with the stance leg moving from an MST position to an early
TST position, with the thigh inclined and the GRF becoming aligned anterior to the knee
and posterior to the hip, providing stability in stance.
Ref: Owen E, Course Manual
Implementation Experiences and Case Studies
Using 3D Motion Analysis to Assess Outcomes of AFO-FC Management
Stefania Fatone, PhD & Donald McGovern, CPO, FAAOP
Implementation of AFO FC at the Rehabilitation Institute of Chicago – Donald McGovern, CPO, FAAOP
Some things we have learned since 2007
USE THE ALGORITHMs
• Get Physician/Therapist/Orthotist support
• Create a team based on temporal and geographic availability AND interest – we have an in house core staff of a
Physician, two Orthotists, two Physical Therapists
• External staff through word of mouth, presentations
• Grow slowly, establish a loose protocol – clarify the protocols with experience – e.g. we initially did not stipulate
GMFCS levels, received some inappropriate referrals, currently prefer GMFCS levels l, ll, lll
• Improve gait analysis skills using the four rocker “points of clarity.”
• Shoes are always a challenge – create a list as you gain knowledge
o Flat bottom, laces that extend to the toe, removable insole
o May need boys shoes for width, 1-2 sizes larger than customary
E.g. Keeping Pace, K-Swiss, Skater Shoes, basketball shoes, Answer2, Apisfootwear.com
The process is accelerated if client comes to the fitting with shoes that can accept the device, too many
times the client returns with shoes that are too small.
o We have not found a leather type boot to date – some at Apisfootwear.com look promising
o Carbon Footplates can be added to shoes for rigid sole
o Assess the shoe for flatness and soft/hardness of heel
o Consider if shoes are an integral part of the device for insurance reimbursement
A point concerning cosmesis, 30 years ago the vast majority of prosthetic users demanded cosmetic covers, now
several prosthetic users proudly wear their devices unadorned, attitudes on cosmesis change.
AFO FC is a Time Investment
• Introducing AFO FC concepts to the family/client.
• Parents have an easier time understanding “balance the body over the foot” rather then placing the “Center of Mass
over the Base of Support.”
• Have examples of a Tuned AFO, pictures at least.
• Use the just taken impression to demonstrate the amount of Shank to Vertical Inclination expected.
• Demonstrate that the raised foot trim lines that will be in the AFO will require large, deep shoes and a possible high
top style.
• Create a brochure for caretakers appropriate for entire team
• An informational video would be helpful
• Evaluation of the client - PT? Orthotist? Separate? Together?
• Location may dictate who does what, when.
The fitting of the orthoses requires additional time for the dynamic tuning process:
Must be done with at least one video camera
The file needs to be loaded onto a secure computer, which can slow down the video replay for gait assessment
Multiple alignment iterations require repeating the process
Requires dedicated space with some degree of privacy – public hallways impede process
Who should be referred?
• The client may be identified by the PT, Orthotist or Physician
• If by PT, the therapist can discuss the concept and make the arrangements with the Orthotist.
• If by Orthotist, the Orthotist must recommend the client to PT familiar with AFOFC and/or one willing to learn.
• Discuss with client and parent/caretaker. The client must realize that the time, the therapy, and the financial
investment in the tuning process is above standard orthotic intervention alone.
• Educate the physician.
•
•
•
•
•
•
•
•
Identify the patient - motivated, compliant client with supportive caregivers
Dedicated AFO FC Physical Therapist is critical.
Client functional level, start with GMFCS level I and II
Start simple, e.g. young GMFCS, CP hemi with excessive knee hyperextension, no rotation issues, no stiff knee gait,
etc.
History of AFO usage for gait, especially of poor AFO seating
Evaluation - “the Nines” – use the ALGORITHMs
o Functional Soleus lengthening
o Gastrocnemius shortening
o Dundee angle adds clinical relevance
Impaired Motor Control – external force to guide in a specific task, better tackled as you get experience.
RIC currently has a monthly AFO-FC Clinic staffed by a Physician, two Physical Therapists and two Orthotists. We use
two Casio Exilim Ex-FH20 cameras on tripods to record in the coronal and sagittal planes
Off-site orthotists incorporate AFO-FC and use point and shoot camera video – 30 fps is adequate.
o “Trying to analyze gait in pediatrics without the slow motion video is like trying to drive and text at the same
time”
Orthotic Clinical Benefits
• Impression is easier to take
• Modification of the foot and ankle simpler
• Less time spent relieving pressure areas
• Improved lower extremity alignment
• But more time adjusting SVA at the fitting - IF shoes are available.
• More time tuning
The starting point for Tuning an AFO:
• Ankle Angle is determined in the Open Chain Evaluation.
• Bench Angle of the AFO is usually 8-10° of inclination depending on expected shoe wear
• Tuning begins with external or internal wedging with footwear to achieve the optimal SVA of the AFOFC in the
Closed Kinetic Chain evaluation using video recording or a gait lab with vector analysis.
Support child in standing
Measure SVA (goal is usually 10-12°)
Inclined shank with thighs vertical
If the child is a stander already they may spontaneously rock forward and back since they now have
anterior and posterior lever arms
If contractures/spasticity/rotation issues, the client will likely need support since compensations have
been removed
If person is standing well, add some perturbations
If person responds well to perturbations, initiate steps>gait
Video record and assessment using the Four Rocker points of clarity and Algorithms
Point Loading Rockers
Wedge Sources: Alimed Achilles Boot Wedges (CBB66377)
Adjust-a-Lift
Crepe or Black Rigid Plastizote
Other Benefits
Our experience has been that we grow in confidence recommending the concept because ROM has not been lost and
we have seen a decrease in the fitting issues with improved functional gait
1. Naviculars are not calloused.
2. Calcanei are not pumping – dustless heel AFOs.
3. Tolerance for orthotic wear increases.
4. Some ambulating patients (adult and children) report a decrease in fatigue and pain.
5. Improved pelvic rotation with hip extension – especially noteworthy in very young persons with hemiplegia.
6. Improved stride length gained, with long term users stride length gain carries over to non-AFO gait.
7. Observed improved heel toe gait – Example: One client’s physician parent remarked it was the first time the
child had a heel toe gait since the child began walking.
Possible Therapeutic Benefits
• Role in motor learning
• Functional application to home program- Wii board excellent to improve proximal strength and balance, wonderful
for parents to see a child who was unable to stand on the Wii board playing for 30 minutes wearing the AFO FC.
• Lengthening while ambulating – gastrocnemius, hamstrings, hip flexors
• Improve Gastrocnemius to Soleus ratio
• Increase demand on system, especially proximally
• Retrain hip strategy
• In new walkers does the stability in stance phase, especially the 3rd and 4th rocker prevent, reduce, or in any way
have a positive influence on stiff knee gait?
• Role in prevention of atrophy, dysfunction, and pain
It seems…..
• Best acceptance occurs when the client understands the concept AND gratification is immediate.
• Most immediate positive results with young, dystonic, equinus, knee hyperextension or weak soleus clients.
• Young adult clients with joint pain – process is very slow.
• Clientele under five years of age accept AFO FC.
• Those who must now start “learning how to walk again” tend to have difficulty accepting the change (10-20 year
olds).
• It is advisable in some cases to emphasize AFO FC should be used as a gait training device, as opposed to all day AFO.
• Reassessment reimbursement is absent for Orthotists.
Challenges
• Therapists not familiar with AFO FC find it more difficult to accept.
• Clientele with multiple influences - two, three or four different therapy sites each with a different philosophy.
• Therapy focus is often altered with a tuned AFO since proximal issues become more obvious and are often more
difficult to treat.
• Some functional walkers lose their compensations, which temporarily makes walking more difficult – increases
parental concerns, decreases client’s confidence. Absolutely must be discussed with client prior to initiating the
process.
• Encourage parents to record video of client before and after use to maintain a chronological visual record to note
changes/improvements.
• The major concern to everyone who is unfamiliar with AFO FC is loss of ROM; as Algorithm recommends use other
interventions to maintain/improve ROM if it is a concern.
• Weight of shoe wedge, lifts, Point Loading Rocker – especially with large Ankle Angle – modify wedge from crepe to
hollow plastic.
• Cosmesis
• Time spent to don/doff was initially an issue, but all of the present adult clients are independent.
• User fluctuation in motivation – tuning will assist gait, but for the optimal benefits it will take perseverance,
repetition and time.
• Is it reasonable to include shoes as an integral part of the Orthosis for billing?
• Reassessment takes at least one full session - time for clinician to review video in slow motion.
Currently working on two studies involving AFO-FCs:
1. “Improving Lower Extremity Orthotic Management of Children with Cerebral Palsy” funded by a Small Grant
Award from the Orthotic and Prosthetic Education & Research Foundation (OPERF), Co-Principal Investigators:
Stefania Fatone, PhD and Larissa Pavone, MD
2. “Pilot Study: Effect of Two Orthotic Approaches to Ankle Motion Restriction on Activity Level, Balance and Patient
Satisfaction in Children with Cerebral Palsy” funded by Ultraflex Systems Inc., Principal Investigator: Deborah
Gaebler-Spira, PhD
JESSE BROWN VA MEDICAL CENTER MOTION ANALYSIS RESEARCH LABORATORY
CASE STUDY I - DIPLEGIA
KINEMATICS
Trunk Lat Bend
15
3
5
10
5
0
0
20
40
60
80
100
-10
1
-1 0
20
40
80
100
-3
0
0
40
60
80
100
80
100
-10
-20
% gait cycle
Pelvic Tilt
% gait cycle
Pelvic Obliquity
30
20
-5
-15
-5
% gait cycle
60
<Ext Degrees Int>
10
-5
Pelvic Rotation
10
10
5
5
20
15
10
5
0
0
20
40
60
80
100
-5
<Ext Degrees Int>
25
<Down Degrees Up>
<Post Degrees Ant>
Trunk Rotation
5
<Down Degrees Up>
<Post Degrees Ant>
Trunk Forward Tilt
20
0
0
20
40
60
-5
0
20
40
60
80
100
-10
% gait cycle
Hip Flex/Ext
Hip Abd/Add
70
50
<Abd Degrees Add>
<Ext Degrees Flex>
60
40
30
20
10
0
-10 0
20
-20
40
60
-10
% gait cycle
80
20
10
10
5
0
0
20
40
60
80
100
-5
-10
100
Knee Var/Val
10
60
5
Degrees
Degrees
0
30
20
0
20
40
60
80
60
80
100
-20
10
0
20
40
60
80
100
% gait cycle
Clinical Exam
PROM
Thomas Test
Knee Ext
DF (knee 90 deg)
DF (knee ext)
Foot Orientation
<Ext Degrees Int>
<PF Degrees DF>
30
25
20
15
10
5
0
-5 0
-10
-15
-20
100
walked at normal self-selected
comfortable walking speed in two
conditions: no AFO (unmodified shoes)
and with bilateral AFO-FCs (modified
shoes)
% gait cycle
% gait cycle
Ankle DF/PF
80
Condition
-15
40
60
100
-5
-10
20
40
-20
10
0
-10 0
20
CASE STUDY DESCRIPTION
Sex
Male
Height
161.5 cm
Weight
90.5 kg
Age
12 yrs
GMFCS
II
50
40
0
-40
% gait cycle
Knee Flex/Ext
70
0
-10
-30
-15
% gait cycle
% gait cycle
Hip Ext Rot/Int Rot
15
<Ext Degrees Int>
0
0
20
40
60
80
R
12
180
84
84
L
14
180
85
91
100
-10
-20
-30
-40
-50
% gait cycle
% gait cycle
No AFO
normal ± 1SD
AACPDM 2013 INSTRUCTIONAL COURSE
AFO-FC
R
L
R-AFO-FC L-AFO-FC
OWEN, GAEBLER-SPIRA, FATONE, MCGOVERN
JESSE BROWN VA MEDICAL CENTER MOTION ANALYSIS RESEARCH LABORATORY
CASE STUDY I - DIPLEGIA
KINETICS
Vertical GRF
M-L GRF
1.4
0.1
1
0.8
0.6
0.4
0.2
0
20
40
60
80
100
0.06
0.04
0.02
0
-0.02
0
20
-0.04
100
40
60
80
<Abs Watts/kg Gen>
0.6
0.4
0.2
0
60
80
100
-0.2
-0.4
<Var Nm/kg Val>
0.2
20
40
60
80
100
80
100
80
100
80
100
1.5
1
0.5
0
0
1.5
0.4
1
0.3
0.2
0.1
0
20
40
60
80
40
60
% gait cycle
Knee Power
0.5
-0.1 0
20
-1
% gait cycle
-0.3
% gait cycle
80
100
100
-0.2
-0.6
60
% gait cycle
Knee Var/Val Moments
0.4
40
-0.2
-0.5
-0.2
0.6
20
Hip Power
0
100
% gait cycle
40
0
-0.1
2
0
20
0
2.5
0.8
20
0.1
-0.3
1
Knee Flex/Ext Moments
0
80
0.2
Hip Abd/Add Moments
<Add Nm/kg Abd>
<Flex Nm/kg Ext>
1.5
1.3
1.1
0.9
0.7
0.5
0.3
0.1
-0.1
0
-0.3
-0.5
60
% gait cycle
% gait cycle
Hip Flex/Ext Moments
40
<Abs Watts/kg Gen>
-0.2 0
0.3
0.08
<Brake % Body Weight Prop>
<Lat % Bodey Weight Med>
% Body Weight
1.2
<Flex Nm/kg Ext>
A-P GRF
0.5
0
0
20
60
-1
-1.5
% gait cycle
40
-0.5
% gait cycle
Ankle Power
Ankle DF/PF Moments
2.5
2
2
<Abs Watts/kg Gen>
<DF Nm/kg PF>
1.5
1
0.5
0
0
-0.5
20
40
60
80
0
-0.5 0
20
-1.5
% gait cycle
AACPDM 2013 INSTRUCTIONAL COURSE
1
0.5
normal ± 1SD
12.0
118.3
130.2
109.3
65.2
60.5
39.5
10.2
40
60
-1
100
Step Width (cm)
Speed (cm/s)
Stride Length (cm)
Cadence (steps/min)
Step Length (cm)
Stance Time (%)
Swing Time (%)
Double Support (%)
1.5
3.3
18.5
15.0
8.8
8.4
0.7
0.7
0.8
No AFO
Avg
19.0
62.1
77.7
95.8
R
L
37.3
66.5
33.5
12.3
36.3
63.3
36.7
17.4
% gait cycle
AFO-FC
Avg R-AFO-FC L-AFO-FC
19.4
82.5
114.9
85.9
61.2
53.5
65.3
65.9
34.7
34.1
16.1
15.1
OWEN, GAEBLER-SPIRA, FATONE, MCGOVERN
JESSE BROWN VA MEDICAL CENTER MOTION ANALYSIS RESEARCH LABORATORY
CASE STUDY II - DIPLEGIA
KINEMATICS
Trunk Forward Tilt
Trunk Lat Bend
0
20
40
60
80
100
-5
-10
% gait cycle
Pelvic Tilt
<Down Degrees Up>
20
15
10
5
0
40
20
60
80
100
100
10
5
0
0
20
5
15
0
0
20
40
60
80
100
-5
-10
0
15
40
60
80
100
5
0
-5 0
40
<Val Degrees Var>
50
40
30
20
10
100
20
40
60
80
100
10
8
6
4
2
0
-2 0
-4
-6
-8
-10
Ankle DF/PF
20
40
60
80
100
0
20
40
60
80
100
-10
<Ext Degrees Int>
5
-10
0
-5 0
20
40
60
80
100
0
20
40
60
% gait cycle
Condition
walked at normal self-selected
comfortable walking speed in two
conditions: no AFO (unmodified shoes)
and with bilateral AFO-FCs (modified
shoes)
Clinical Exam
PROM
Thomas Test
Knee Ext
DF (knee 90 deg)
DF (knee ext)
0
10
5
% gait cycle
10
15
10
CASE STUDY DESCRIPTION
Sex
Male
Height
149 cm
Weight
38 kg
Age
12 yrs
GMFCS
III
Foot Orientation
20
100
% gait cycle
-15
% gait cycle
% gait cycle
80
R
13
183
110
92
L
14
189
95
85
100
-20
-30
-40
-50
-15
-20
80
Knee Var/Val
60
60
-10
-20
% gait cycle
70
-5 0
60
-10
Knee Flex/Ext
0
-10 0
20
-15
-20
40
Hip Ext Rot/Int Rot
20
20
20
-10
% gait cycle
10
0
80
% gait cycle
-5
15
-10
100
0
40
0
80
5
25
10
60
10
Hip Abd/Add
20
40
Pelvic Rotation
10
20
30
20
-10
50
<Abd Degrees Add>
<Ext Degrees Flex>
80
% gait cycle
Hip Flex/Ext
<PF Degrees DF>
60
-5
-15
% gait cycle
<Ext Degrees Flex>
40
<Ext Degrees Int>
<Post Degrees Ant>
25
20
15
Pelvic Obliquity
30
0
Trunk Rotation
20
<Ext Degrees Int>
0
8
6
4
2
0
-2 0
-4
-6
-8
-10
-12
-14
<Ext Degrees Int>
5
<Down Degrees Up>
<Post Degrees Ant>
10
-60
% gait cycle
% gait cycle
No AFO
normal ± 1SD
AACPDM 2013 INSTRUCTIONAL COURSE
AFO-FC
R
L
R-AFO-FC L-AFO-FC
OWEN, GAEBLER-SPIRA, FATONE, MCGOVERN
JESSE BROWN VA MEDICAL CENTER MOTION ANALYSIS RESEARCH LABORATORY
CASE STUDY II - DIPLEGIA
KINETICS
M-L GRF
0.12
1.2
0.1
1
0.8
0.6
0.4
0.2
0
-0.2 0
20
40
60
80
100
0.3
0.08
0.06
0.04
0.02
0
-0.02 0
20
-0.06
Hip Flex/Ext Moments
60
80
100
0.2
0.1
0
0
-0.3
% gait cycle
0.9
0.8
1.5
0.1
-0.1 0
-0.3
20
40
60
80
100
0.6
0.4
0.2
0
-0.2
-0.5
0
20
-0.4
% gait cycle
Knee Flex/Ext Moments
40
60
80
100
<Abs Watts/kg Gen>
2
0.3
80
100
80
100
80
100
80
100
% gait cycle
1
0.5
0
0
20
-1
% gait cycle
40
60
-0.5
% gait cycle
Knee Power
Knee Var/Val Moments
0.6
60
Hip Power
1
0.5
40
-0.2
Hip Abd/Add Moments
0.7
20
-0.1
1.1
<Add Nm/kg Abd>
1
0.5
0.4
0.2
0
0
20
40
60
80
100
-0.2
-0.4
<Var Nm/kg Val>
0.4
0.3
0.2
0.1
0
-0.1 0
20
40
60
80
100
-0.2
<Abs Watts/kg Gen>
<Flex Nm/kg Ext>
40
-0.04
% gait cycle
<Flex Nm/kg Ext>
A-P GRF
<Brake % Body Weight Prop>
1.4
<Lat % Body Weight Med>
% Body Weight
Vertical GRF
0.5
0
0
20
40
60
-0.5
-1
-0.3
-0.6
-0.4
% gait cycle
-1.5
% gait cycle
% gait cycle
Ankle Power
Ankle DF/PF Moments
2.5
2
2
<Abs Watts/kg Gen>
<DF Nm/kg PF>
1.5
1
0.5
0
0
-0.5
20
40
60
80
0
-0.5 0
20
-1.5
% gait cycle
AACPDM 2013 INSTRUCTIONAL COURSE
1
0.5
normal ± 1SD
12.0
118.3
130.2
109.3
65.2
60.5
39.5
10.2
40
60
-1
100
Step Width (cm)
Speed (cm/s)
Stride Length (cm)
Cadence (steps/min)
Step Length (cm)
Stance Time (%)
Swing Time (%)
Double Support (%)
1.5
3.3
18.5
15.0
8.8
8.4
0.7
0.7
0.8
No AFO
Avg
15.3
44.2
58.8
90.8
R
L
28.3
67.9
32.1
15.0
30.4
69.5
30.5
22.8
% gait cycle
AFO-FC
Avg R-AFO-FC L-AFO-FC
19.9
43.6
77.8
68.1
42.7
35.3
69.2
73.0
30.8
27.0
21.0
22.1
OWEN, GAEBLER-SPIRA, FATONE, MCGOVERN