Learning from an equitable, data-informed response to COVID-19: Translating knowledge into future action and preparation.

Introduction: The COVID-19 pandemic revealed numerous barriers to effectively managing public health crises, including difficulties in using publicly available, community-level data to create learning systems in support of local public health decision responses. Early in the COVID-19 pandemic, a group of health care partners began meeting to learn from their collective experiences. We identified key tools and processes for using data and learning system structures to drive equitable public health decision making throughout different phases of the pandemic. Methods: In fall of 2021, the team developed an initial theory of change directed at achieving herd immunity for COVID-19. The theoretical drivers were explored qualitatively through a series of nine 45-min telephonic interviews conducted with 16 public health and community leaders across the United States. Interview responses were analyzed into key themes to inform potential future practices, tools, and systems. In addition to the interviews, partners in Dallas and Cincinnati reflected on their own COVID-19 experiences. Results: Interview responses fell broadly into four themes that contribute to effective, community driven responses to COVID-19: real-time, accessible data that are mindful of the tension between community transparency and individual privacy; a continued fostering of public trust; adaptable infrastructures and systems; and creating cohesive community coalitions with shared alignment and goals. These themes and partner experiences helped us revise our preliminary theory of change around the importance of community collaboration and trust building and also helped refine the development of the Community Protection Dashboard tool. Conclusions: There was broad agreement amongst public health and community leaders about the key elements of the data and learning systems required to manage public health responses to COVID-19. These findings may be informative for guiding the use of data and learning in the management of future public health crises or population health initiatives.

Net external energy of the biologic and prosthetic ankle during gait initiation.

The net external energy of the biologic human ankle joint and of some lower limb prosthetic ankle-foot systems was examined during gait initiation. The purpose of the study was to better understand the ankle's behavior during the acceleration phase of walking for use in the design of improved lower limb prostheses and orthoses. Quantitative gait data were collected from 10 able-bodied subjects and 10 persons with unilateral transtibial amputations during gait initiation. The behaviors of the biologic and prosthetic 'ankle' joints were examined by analyzing the relationship between sagittal plane ankle angles and moments. Net external energy at the ankle was estimated by calculating the area under the moment versus angle curves (hysteresis) created during the loading and unloading phases. Results indicate that able-bodied persons utilize energy input from the trailing ankle after the first step is made in gait initiation, most likely to help transition the body into steady-state walking. The passive prosthetic ankle-foot systems tested were unable to put energy into the system during gait initiation.

Roll-over shapes of the able-bodied knee-ankle-foot system during gait initiation, steady-state walking, and gait termination.

A few investigators have described the movement of the center of pressure (COP) of the ground reaction force and the activation patterns of the lower limb muscles during gait initiation and termination. This study examines the effective rocker (roll-over shape) behavior of the knee-ankle-foot (KAF) system during gait initiation, steady-state walking (i.e. constant speed gait), and gait termination. The KAF roll-over shapes were characterized by transforming COP data of 10 able-bodied subjects from a laboratory-based coordinate system into a leg-based coordinate system. The resulting roll-over shapes (effective rockers) were characterized using a circular arc model. The KAF roll-over shapes exhibit an overall "flexed" orientation during the first step of gait initiation and an "extended" orientation during the last step of gait termination. Understanding the behavior of the anatomical KAF system during gait initiation and termination may aid in the design of prosthetic components, i.e. mechanical devices that replace complete anatomical structures. Prostheses that intend to mimic the overall behavior of physiological KAF systems (biomimetic designs) could be manufactured using approaches that are much simpler than attempting to reconstruct the complexity of the lower limb.

Temporal symmetries during gait initiation and termination in nondisabled ambulators and in people with unilateral transtibial limb loss.

This study investigated the temporal characteristics of gait initiation and gait termination. Ten nondisabled adult volunteers and ten people with unilateral transtibial limb loss performed starting and stopping for slow, normal, and fast walking speeds. We used kinematic and anthropomorphic data to determine the body center of mass (BCOM) position of each subject. The BCOM acceleration was derived by double-differentiating the position data. An averaged BCOM acceleration was calculated by a filtering of the instantaneous acceleration data at a cutoff frequency set by the cadence for elimination of the step-to-step variation. We used this averaged acceleration to calculate the time the volunteers needed to initiate and terminate gait. The results support the hypothesis that both nondisabled ambulators and the subjects with unilateral transtibial limb loss initiate and terminate gait in approximately two steps, regardless of the steady-state walking speed.

The human ankle during walking: implications for design of biomimetic ankle prostheses.

The non-disabled human ankle joint was examined during walking in an attempt to determine overall system characteristics for use in the design of ankle prostheses. The hypothesis of the study was that the quasi-stiffness of the ankle changes when walking at different walking speeds. The hypothesis was examined using sagittal plane ankle moment versus ankle angle curves from 24 able-bodied subjects walking over a range of speeds. The slopes of the moment versus ankle angle curves (quasi-stiffness) during loading appeared to change as speed was increased and the relationship between the moment and angle during loading became increasingly non-linear. The loading and unloading portions of the moment versus angle curves showed clockwise loops (hysteresis) at self-selected slow speeds that reduced essentially to zero as the speed increased to self-selected normal speeds. Above self-selected normal speeds, the loops started to traverse a counter-clockwise path that increased in area as the speed was increased. These characteristics imply that the human ankle joint could be effectively replaced with a rotational spring and damper for slow to normal walking speeds. However, to mimic the characteristics of the human ankle during walking at fast speeds, an augmented system would be necessary. This notion is supported by the sign of the ankle power at the time of opposite heel contact, which was negative for slow speeds, was near zero at normal speeds, and was positive for fast walking speeds.

Comparison of kinematic and kinetic methods for computing the vertical motion of the body center of mass during walking.

The vertical excursion of the body center of mass (BCOM) was calculated using three different techniques commonly used by motion analysis laboratories. The sacral marker method involved estimating vertical BCOM motion by tracking the position of a reflective marker that was placed on the sacrum of subjects as they walked. The body segmental analysis technique determined the vertical motion of the BCOM from a weighted average of the vertical positions of the centers of mass of individual body segments for each frame of kinematic data acquired during the data trial. Anthropomorphic data from standard tables were used to determine the mass fractions and the locations of the centers of mass of each body segment. The third technique involved calculating BCOM vertical motion through double integration of force platform data. Data was acquired from 10 able-bodied, adult research subjects--5 males and 5 females--walking at speeds of 0.8, 1.2, 1.6, and 2.0 m/s. A repeated measures ANOVA indicated that at the slowest walking speed the vertical excursions calculated by all three techniques were similar, but at faster speeds the sacral marker significantly (p < 0.001) overestimated the vertical excursion of the BCOM compared with the other two methods. The body segmental analysis and force platform techniques were in agreement at all walking speeds. Discrepancies between the sacral marker method and the other two techniques were explained using a simple model; the reciprocal configuration of the legs during double support phase significantly raises the position of the BCOM within the trunk at longer step lengths, corresponding to faster walking speeds. The sacral marker method may provide a reasonable approximation of vertical BCOM motion at slow and freely selected speeds of able-bodied walking. However, the body segmental analysis or force platform techniques will probably yield better estimates at faster walking speeds or in persons with gait pathologies.

Roll-over characteristics of human walking on inclined surfaces.

Roll-over characteristics of able-bodied human subjects walking on ramped surfaces were examined in this study. Ten subjects walked at their normal self-selected speed on a level surface, a 5-deg ramp, and a 10-deg ramped surface. Ramps were designed such that ground reaction forces and center of pressure of the ground reaction forces could be measured on their surfaces. This set-up facilitated calculation of the effective rockers that the ankle-foot (AF) and knee-ankle-foot (KAF) systems conformed to during single-limb stance (contralateral toe off to contralateral heel contact). Since our original "roll-over shapes" were characterized between heel contact and opposite heel contact, we label the shapes found during single-limb stance as "truncated roll-over shapes". We hypothesized that the ankle-foot system would adapt to the various surfaces, creating a roll-over shape that would change in orientation with different levels of inclination. The truncated AF roll-over shapes supported this hypothesis for uphill walking but did not support the hypothesis for downhill walking. However, truncated roll-over shapes of the KAF system did adjust their orientation to match both the positive and negative levels of surface inclination. In general, the ankle appears to be the main adapting joint when walking up inclined surfaces while the knee becomes important for the overall adaptation in downhill walking. Knowledge of physiological lower-limb roll-over characteristics on ramped surfaces may help in the development of biomimetic prostheses and orthoses that will automatically adapt to changes in walking surface inclination.