Examination of knee joint moments on the function of knee-ankle-foot orthoses during walking.

The goal of this study was to investigate clinically relevant biomechanical conditions relating to the setup and alignment of knee-ankle-foot orthoses and the influence of these conditions on knee extension moments and orthotic stance control during gait. Knee moments were collected using an instrumented gait laboratory and concurrently a load transducer embedded at the knee-ankle-foot orthosis knee joint of four individuals with poliomyelitis. We found that knee extension moments were not typically produced in late stance-phase of gait. Adding a dorsiflexion stop at the orthotic ankle significantly decreased the knee flexion moments in late stance-phase, while slightly flexing the knee in stance-phase had a variable effect. The findings suggest that where users of orthoses have problems initiating swing-phase flexion with stance control orthoses, an ankle dorsiflexion stop may be used to enhance function. Furthermore, the use of stance control knee joints that lock while under flexion may contribute to more inconsistent unlocking of the stance control orthosis during gait.

Preliminary evaluation of a commercially available videogame system as an adjunct therapeutic intervention for improving balance among children and adolescents with lower limb amputations.

OBJECTIVES: To examine the safety, feasibility, and balance performance effects of a 4-week home-based balance therapy program using a commercially available videogame system. DESIGN: A pilot study involving a preintervention and postintervention design was conducted with measurements taken at baseline, immediately postintervention (week 5), and at follow-up (week 13) for retention. SETTING: University hospital outpatient clinic and participants' places of residence. PARTICIPANTS: Children and adolescents with unilateral lower limb amputation (n=6; 3 transfemoral [TF] and 3 Van Ness) and age-matched, typically developing individuals (n=10) for baseline comparison. INTERVENTION: Two videogames involving weight shifting in standing were each played at home for 20 min/d, 4d/wk for a period of 4 weeks. A physical therapist provided initial instruction and monitoring. MAIN OUTCOME MEASURES: Postural control characteristics using center of pressure (COP) displacements during quiet standing; functional balance using the Community Balance and Mobility Scale (CB&M); and compliance, safety, and feasibility using custom questionnaires. RESULTS: Average playing times for the first 3 weeks ranged from 16.0 to 21.1 minutes for the 2 games. At baseline, the children and adolescents with TF amputation had substantially greater COP displacements than the Van Ness group and typically developing children and adolescents. Immediately postintervention, the COP displacements decreased in the TF amputees, resulting in values that were closer to those of the typically developing children. The average increase in CB&M score from baseline to follow-up was 6 points across participants. CONCLUSIONS: In-home, videogame-based balance training therapies can achieve excellent compliance in children and adolescents with lower limb amputation. With proper instructions and monitoring, the therapeutic intervention can be safely administered. Some improvements in postural control characteristics were seen in children and adolescents with balance deficits immediately postintervention, but long-term retention remains unclear.

Test-retest reliability of discrete gait parameters in children with cerebral palsy.

OBJECTIVES: To examine the test-retest reliability of discrete gait parameters in children with cerebral palsy (CP) in Gross Motor Function Classification System (GMFCS) levels I, II, and III; to calculate the measurement error between testing sessions of these parameters in the total sample and within GMFCS subgroups using the standard error of measurement; and to evaluate the minimal detectable change (MDC) to identify discrete gait parameters that are most sensitive to change in children with CP. DESIGN: Test-retest reliability study. SETTING: Rehabilitation facility with human movement laboratory. PARTICIPANTS: Ambulatory children with CP (N=28). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Intraclass correlation coefficients (ICCs), standard error of measurement, and MDC of discrete gait parameters. RESULTS: Parameters measured in the sagittal plane and temporal-spatial parameters were highly reliable across all GMFCS levels (ICC range, .84-.97), while test-retest reliability in the frontal and transverse planes varied from poor to excellent (ICC range, .46-.91). Using MDC as a guide, hip and pelvis parameters in the transverse and frontal planes were least responsive for GMFCS levels I and III (MDC ranges, 8.3 degrees -18.0 degrees and 2.7 degrees -23.4 degrees , respectively), whereas ankle kinematics were the least responsive for level II (MDC range, 8.2 degrees -11.9 degrees ). Reliability was dependent on mobility level, with children in GMFCS level III exhibiting greater test-retest variability overall. CONCLUSIONS: Our findings suggest that select discrete gait parameters measured using computerized gait analysis are reliable and potentially responsive measures of performance and can be used as outcome measures in intervention studies.

Patients' complaints involving ophthalmologists in the province of Ontario, Canada: a 5-year review.

OBJECTIVE: To present an overview of complaints against ophthalmologists to the regulatory body in the province of Ontario, Canada, during a 5-year period. DESIGN: Retrospective cross-sectional study. METHODS: All completed complaints to the College of Physicians and Surgeons of Ontario (CPSO) involving ophthalmologists from January 2013 to May 2018 were reviewed. Data regarding the prevalence of complaints, physician characteristics, practice location, reason of complaint, and outcomes as decided by the Inquiries, Complaints and Reports Committee (ICRC) were collected. Identified concerns were classified across 3 domains: clinical care and treatment, professionalism and conduct, and practice management. RESULTS: There were 372 complaints involving 211 ophthalmologists out of 448 practicing ophthalmologists in Ontario. A total of 933 issues were raised in the 372 complaints. Complaints related to clinical care and treatment were most common (76.3%), followed by professionalism and conduct (55.4%) and practice management (24.7%). Within these domains, the 5 largest subcategories in order of occurrence were communication, billing practices, consent, procedural mishap, and documentation. Of the 372 investigations, the ICRC took some form of action in 117 cases (31.4%). The most common actionable decisions issued by the ICRC were advice (19.1%), caution (6.2%), and participation in a specified continuing educational or remediation program (3.5%). Four cases (1.1%) were referred to the Discipline Committee. CONCLUSIONS: Almost half of practicing ophthalmologists in Ontario (47%) received at least one formal CPSO complaint within the 5-year study period. Communication was the most common issue raised in complaints.

Forces and moments in knee-ankle-foot orthoses while walking on irregular surfaces: a case series study.

BACKGROUND: Kinetic data provide important information about the mobility performance of individuals with lower limb impairments and their assistive devices; however, there is limited understanding of this in real-life environments. OBJECTIVE: To evaluate the effect of real-life irregular surfaces on forces and moments in knee-ankle-foot orthoses. METHODS: In this case series study, a load cell was used to measure the forces and moments at the knee joint of knee-ankle-foot orthoses of individuals with unilateral muscle weakness as a result of poliomyelitis while walking on different ground surfaces and at different speeds. RESULTS: Significantly higher shear forces and external peak knee flexion moments were found when walking on irregular surfaces. In individual cases, certain irregular ground conditions elicited large increases in peak flexion moments (>50%) when compared to walking on smooth level ground. Forces and moments were significantly higher at faster walking speeds. CONCLUSIONS: Higher external peak knee flexion moments during the stance phase suggest that greater demands for support and stability are placed on individuals and their assistive devices when negotiating real-life ground surfaces. Clinical relevance This study demonstrates that walking on irregular surfaces alters the loads placed on knee-ankle-foot orthoses and that the requirements for knee stabilization increase. This has important clinical implications on the design, prescription, and use of such devices given the structural and functional demands placed on them.

Ankle arthroplasty and ankle arthrodesis: gait analysis compared with normal controls.

BACKGROUND: This study compared patients with isolated end-stage ankle osteoarthritis, after undergoing either total ankle arthroplasty or arthrodesis, using gait analysis and patient-reported outcome measures to elucidate differences between the two treatment options, as compared with a healthy control group. METHODS: Gait analyses were performed on patients with isolated ankle arthritis more than one year after undergoing either total ankle arthroplasty or arthrodesis during a ten-year period. Validated outcome questionnaire data were obtained. Seventeen patients undergoing total ankle arthroplasty, seventeen patients undergoing arthrodesis, and ten matched control subjects were included for comparison. RESULTS: Patients who had undergone arthroplasty, when compared with patients who had undergone arthrodesis, demonstrated greater postoperative total sagittal plane motion (18.1° versus 13.7°; p < 0.05), dorsiflexion (11.9° versus 6.8°; p < 0.05), and range of tibial tilt (23.1° versus 19.1°; p < 0.05). Plantar flexion motion was not equivalent to normal in either group. Ankle moments and power in both treatment groups remained significantly lower compared with the control group (p < 0.05 between each treatment group and the control group for both variables). Gait patterns in both treatment groups were not completely normalized. Improvements in patient-reported Ankle Osteoarthritis Scale and Short Form-36 scores were similar for both treatment groups. CONCLUSIONS: The gait patterns of patients following three-component, mobile-bearing total ankle arthroplasty more closely resembled normal gait when compared with the gait patterns of patients following arthrodesis. Dorsal motion in the sagittal plane was primarily responsible for the differences. Improvement in self-reported clinical outcome scores was similar for both groups. Further investigation is needed to determine why patients who have undergone total ankle arthroplasty do not use the plantar flexion motion in the terminal-stance phase and to explain the limited increase in power generation at toe-off after arthroplasty. Results obtained from this study may be used for future modifications of ankle prostheses and may add to clinicians' ability to inform patients of predicted functional outcomes prior to the treatment of end-stage ankle osteoarthritis.

Measurement of the product attitudes of youth during the selection of assistive technology devices.

PURPOSE: This article proposes a conceptual underpinning for and examines the validity of the Youth Evaluation of Products (YEP) scale when used to measure the AT device attitudes of youth. METHOD: Consumer socialization is promoted to improve the utility of an AT device selection framework for children and youth and inform the development of the YEP scale. A descriptive, qualitative mixed-methods design explored the validity of the scale when used by six manual wheelchair users, aged 11-14 years, to evaluate a new pushrim-activated, power-assisted wheelchair. Three youth participated in a subsequent focus group to share how they assessed wheelchair products. RESULTS: The items and dimensions of the YEP scale corresponded well to participants' views about wheelchairs. CONCLUSIONS: Consumer socialization provides a new way to understand the developing role of youth as AT consumers and the YEP scale is emerging as a way to measure their product attitudes. When integrated with contemporary thinking about the assessment and selection of AT devices, providers and parents may be better able to incorporate the product perspectives of youth during this shared decision-making process. [Box: see text].

Mobility function of a prosthetic knee joint with an automatic stance phase lock.

BACKGROUND: There is a need for a prosthetic knee joint design that is technologically and functionally appropriate for use in developing countries. OBJECTIVES: To develop and clinically evaluate a new type of stance phase controlled prosthetic knee joint that provides stance phase stability without inhibiting swing phase flexion. STUDY DESIGN: A crossover repeated measures study design comparing the new knee joint to the participant's conventional low- or high-end prosthetic knee joint. METHODS: The new knee joint was fitted to fourteen individuals aged 15 to 67 years with unilateral lower limb amputations. Walk tests were performed to measure walking speed. Energy expenditure was estimated using the physiological cost index (PCI). RESULTS: Walking speeds with the new knee joint were on average 0.14 m/s faster than conventional low-end knees (p < 0.0001), but 0.07 m/s slower than conventional high-end prosthetic knees (p = 0.008). The PCI was similar across all three knee joint technologies (p = 0.276). CONCLUSIONS: Mobility function with the new knee joint, in terms of walking speed, was more closely matched to high-end than low-end prosthetic knee joints. Therefore, given its relatively simple design, the new stance phase control mechanism may offer a functional and cost effective solution for active transfemoral amputees. CLINICAL RELEVANCE: This paper describes a new type of prosthetic knee joint mechanism that is intended to be cost-effective while providing high-level stance phase function to active individuals with a transfemoral amputation. Initial clinical testing suggests that the new knee joint may have some functional advantages over existing technologies in this category.