Knee Ankle Foot Orthosis Research Articles

Online data analysis for a Knee-Ankle-Foot-Orthosis with neuro-control

Online data analysis for a Knee-Ankle-Foot-Orthosis with neuro-control

S114054 密着型歩行補助機の実用性向上と支援効果の検証([S11405]機素潤滑設計部門 第17回卒業研究コンテスト(5))

A close fitting type walking assistance device was developed. This device is equipped with actuators in a backpack. The power of the actuator is transmitted to each leg joint with a flexible shaft and a worm gear. Therefore, the width and the weight of the device were reduced. In addition, this device can be transformed from Knee-Ankle-Foot-Orthosis (KAFO) to AnkleFootOrthosis (AFO) according to the level of paralyze condition of one's leg, by detaching the knee joint from the device. We improved it for a convenient utilization as follows: 1) compact and light weight, 2) flexibility of adjustment for various individual body sizes, 3) taking into account the gravity compensation according to each walking phase. To confirm the effectiveness of the device, a verification experiment of the gait training was performed to a healthy person. In evaluating the posture of gait, we measured the vertical height, the adduction and abduction angle of a hip joint. By wearing the device, the vertical movement of the hip is decreased by 8%, and the adduction and abduction angle movement of the hip joint is decreased by 30%. Furthermore, all subjects felt the assist power of the foot joint. As a result, the improvement of the posture of gait suggests that this device is effective for the rehabilitation.

2P1-F10 実用化に向けた密着型歩行補助機の開発と支援効果の検証(福祉ロボティクス・メカトロニクス(1))

A Closed-Fitting-Type walking assistance device was developed. The device has actuators on board in a backpack. It uses a system of power transmission that used a Flexible-shaft and a Worm-gear. As a result, the device compacted size and reduced weight of each leg joints. In addition, as for the device, choice of an Ankle-Foot-Orthosis (AFO) and a Knee-Ankle-Foot-Orthosis (KAFO) is possible by a paralysis level. In order to practical use of the device, we improved the three points: "Compact-size and Light-weighting", Adaptability" and "A walk movement performance improvement". Then we gave a verification experiment to confirm the effectiveness of the device. As a result, the support effect of the device was confirmed by the feeling.

족저굴곡과 무릎 신전 토크를 이용한 보행 재활 훈련용 장하지 보조기 개발

The purpose of this study was to test the effectiveness of a prototype KAFO (Knee-Ankle-Foot Orthosis) powered by two artificial pneumatic muscles during walking. We had previously built powered AFO (Ankle-Foot Orthosis) and KO (Knee Orthosis) and used it effectively in studies on assistance of plantaflexion and knee extension motion. Extending the previous study to a KAFO presented additional challenges related to the assistance of gait motion for rehabilitation training. Five healthy males were performed gait motion on treadmill wearing KAFO equipped with artificial pneumatic muscles to power ankle plantaflexion and knee extension. Subjects walked on treadmill at 1.5 km/h under four conditions without extensive practice: 1) without wearing KAFO, 2) wearing KAFO with artificial muscles turned off, 3) wearing KAFO powered only in plantaflexion under feedforward control, and 4) wearing KAFO powered both in plantaflexion and knee extension under feedforward control. We collected surface electromyography, foot pressure and kinematics of ankle and knee joint. The experimental result showed that a muscular strength of wearing KAFO powered plnatarfexion and knee extension under feedforward control was measured to be lower due to pneumatic assistance and foot pressure of wearing KAFO powered plnatarfexion and knee extension under feedforward control was measured to be greater due to power assistance. In the result of motion analysis, the ankle angle of powered KAFO in terminal stance phase was found a peak value toward plantaflexion and there were difference of maximum knee flexion range among condition 2, 3 and 4 in mid-swing phase. The current orthosis design provided plantaflexion torque of ankle jonit in terminal stance phase and knee extension torque of knee joint in mid-swing phase.

Usage Follow-Up After a Knee-Ankle-Foot Orthoses Selection and Training Program in Spinal Cord Injury Patients

In Brief Selection of a standing method for spine trauma rehabilitation is a challenging process. Although most authors agree that the use of knee-ankle-foot orthoses (KAFOs) is the most desirable method, other authors report high rates of treatment failure. The purpose of this study is to report a patient selection and training program to optimize KAFO usage. This study was performed at an outpatient rehabilitation facilityin Buenos Aires, Argentina. The results of a KAFO selection and training program were retrospectively reviewed. Patients were classified according to their medical, physical, and psychological condition. The potential users were trained, and those qualified for prescription were given the KAFO. Those patients with KAFO were followed up to evaluate their use, at least 1 year after prescription. Ninety-four adult spinal cord injured patients were classified on the basis of KAFO Patient Selection Program criteria. Those included in the adaptation process started the training phase of the program. If training was successfully completed, KAFO was prescribed. Efficacy of the KAFO Patient Selection Program for KAFO prescription based on long-term compliance was analyzed. KAFO usage at an average follow-up of 27 months was more than 80%. KAFO prescription should not be taken lightly. Our selection and training program was helpful in identifying those patients who would benefit from this device and continue to use it at an average of 2 years on follow-up. Selection of a standing method for spine trauma rehabilitation is a challenging process. While most authors agree that the use of knee ankle foot orthoses (KAFOs) is the most desirable method, other authors report high rates of treatment failure. The purpose of this study is to report a patient selection and training program to optimize KAFO usage. Our program was helpful in identifying those patients that would benefit from this device and continue to use it at an average 2 years on follow-up.

The Effect of Stance Control Orthoses on Gait Characteristics and Energy Expenditure in Knee-Ankle-Foot Orthosis Users

Stance Control knee-ankle foot orthoses (SCO) differ from their traditional locked knee counterparts by allowing free knee flexion during swing while providing stability during stance. It is widely accepted that free knee flexion during swing normalizes gait and therefore improves walking speed and reduces the energy requirements of walking. Limited research has been carried out to evaluate the benefits of SCOs when compared to locked knee-ankle foot orthoses (KAFOs). The purpose of this study was to evaluate the effectiveness of SCOs used for patients with lower limb pathology. Energy expenditure and walking velocity were measured in 10 subjects using an orthosis incorporating a Horton Stance Control knee joint. A GAITRite walkway was used to measure temporospatial gait characteristics. A Cosmed K4b2 portable metabolic system was used to measure energy expenditure and heart rate during walking. Two conditions were tested: Walking with stance control active (stance control) and walking with the knee joint locked. Ten subjects completed the GAITRite testing; nine subjects completed the Cosmed testing. Walking velocity was significantly increased in the stance control condition (p < 0.001). There was no difference in the energy cost of walking (p = 0.515) or physiological cost index (PCI) (p = 0.093) between conditions. This study supports previous evidence that stance control knee-ankle foot orthoses increase walking velocity compared to locked knee devices. Contrary to expectation, the stance control condition did not decrease energy expenditure during walking.

Adaptive neuro-control for a Knee-Ankle-Foot-Orthosis with patient feedback

Event Abstract Back to Event Adaptive neuro-control for a Knee-Ankle-Foot-Orthosis with patient feedback Jan-Matthias Braun1, 2*, Vishal Patel2, 3, Poramate Manoonpong1, 2, 4, Florentin Wörgötter1, 2, 4 and Bernhard Graimann3 1 Georg-August University Göttingen, III. Physical Institute – Biophysics, Germany 2 Bernstein Focus Neurotechnology Göttingen, BFNT-G, Germany 3 Otto Bock HealthCare GmbH, R&D, Germany 4 Bernstein Center for Computational Neuroscience, BCCNN-G, Germany A Knee-Ankle-Foot-Orthosis (KAFO) is a modular lower-extremity orthosis prescribed to people with gait disability which might be e.g. caused by diseases or injury to brain or spinal-cord. The KAFO should support, correct and assist the movement of the corresponding affected joints. Traditional KAFOs are restricted by a gait depending switch of the joints based on (electro-) mechanic non-adaptive switches. So common disturbances (floor unevenness, obstacles, ramps) can not be mastered in a satisfactory way. Novel approaches include active elements into the orthosis, which do not directly act on the movement, but, instead, adjust the compliance generating the very difficult problem of efficient control of such actuators. Thus new technologies have to be developed to improve control, to overcome the shortcomings of traditional non-adaptive approaches, solving the problem of efficient actuator control. As development of advanced orthotic devices is additionally held back by the vast number of possible indications as well as by the wide range of neuromuscular variability within a specific patient group (Yakimovich et al., 2009), the development of advanced devices is imposing the need for individual (online) adaptation of gait parameters to allow adaptation (1) to changing environments like slopes, stairs etc. and (2) to the individual patients physiological conditions using neuro-control as inspired by RunBot (Manoonpong et al., 2007). In this poster we present a novel type of KAFO based on a controllable hydraulic damper, derived from OttoBock's C-Leg©, concentrating on the adaptation to the patient by means of direct feedback to the desired neuro-control implemented in the orthosis which allows the patient to actively interact with the controller. As the underlying technique is based on muscle like damping modulation a comparison to natural joint elasticity (Peter et al., 2009) is presented. Figure 1: Prototype of new KAFO with hydraulic damper. Figure 1 Acknowledgements We acknowledge support by BFNT Göttingen. Keywords: computational neuroscience Conference: Bernstein Conference on Computational Neuroscience, Berlin, Germany, 27 Sep - 1 Oct, 2010. Presentation Type: Presentation Topic: Bernstein Conference on Computational Neuroscience Citation: Braun J, Patel V, Manoonpong P, Wörgötter F and Graimann B (2010). Adaptive neuro-control for a Knee-Ankle-Foot-Orthosis with patient feedback. Front. Comput. Neurosci. Conference Abstract: Bernstein Conference on Computational Neuroscience. doi: 10.3389/conf.fncom.2010.51.00022 Copyright: The abstracts in this collection have not been subject to any Frontiers peer review or checks, and are not endorsed by Frontiers. They are made available through the Frontiers publishing platform as a service to conference organizers and presenters. The copyright in the individual abstracts is owned by the author of each abstract or his/her employer unless otherwise stated. Each abstract, as well as the collection of abstracts, are published under a Creative Commons CC-BY 4.0 (attribution) licence (https://creativecommons.org/licenses/by/4.0/) and may thus be reproduced, translated, adapted and be the subject of derivative works provided the authors and Frontiers are attributed. For Frontiers’ terms and conditions please see https://www.frontiersin.org/legal/terms-and-conditions. Received: 20 Sep 2010; Published Online: 23 Sep 2010. * Correspondence: Mr. Jan-Matthias Braun, Georg-August University Göttingen, III. Physical Institute – Biophysics, Göttingen, Germany, j-mb@mmmi.sdu.dk Login Required This action requires you to be registered with Frontiers and logged in. To register or login click here. Abstract Info Abstract The Authors in Frontiers Jan-Matthias Braun Vishal Patel Poramate Manoonpong Florentin Wörgötter Bernhard Graimann Google Jan-Matthias Braun Vishal Patel Poramate Manoonpong Florentin Wörgötter Bernhard Graimann Google Scholar Jan-Matthias Braun Vishal Patel Poramate Manoonpong Florentin Wörgötter Bernhard Graimann PubMed Jan-Matthias Braun Vishal Patel Poramate Manoonpong Florentin Wörgötter Bernhard Graimann Related Article in Frontiers Google Scholar PubMed Abstract Close Back to top Javascript is disabled. Please enable Javascript in your browser settings in order to see all the content on this page.

Comparison of the effects of sliding-type and hinge-type joints of knee-ankle-foot orthoses on temporal gait parameters in patients with paraplegia

Onogi K, Kondo I, Saitoh E, Kato M, Oyobe T. Comparison of the effects of sliding-type and hingetype joints of knee-ankle-foot orthoses on temporal gait parameters in patients with paraplegia. Jpn J Compr Rehabil Sci 2010; 1: 1-6. Objective: To determine the effi cacy of sliding-type medial hip joint (Primewalk system) and a hinge-type medial hip joint (Walkabout system) of knee-anklefoot orthoses in improving the temporal gait parameters in patients with paraplegia. Methods: The subjects were 7 consecutively recruited patients with paraplegia (6 men and 1 woman; age, 20-45 years). All subjects had got used to the Walkabout system and were trained using the Primewalk system for at least 1 month before the measurements of the temporal gait parameters. The average gait velocity, cadence, and stride length were measured. The pelvic rotation angle was additionally measured in 1 patient. Results: The average gait velocity was higher, cadence was faster, and stride was longer with the Primewalk system than with the Walkabout system. The value for the step length divided by the pelvic rotation angle was larger with the Primewalk system than with the Walkabout system. Conclusion: The Primewalk system improved the gait effi ciency by the sliding mechanism that set the virtual axis of the orthoses hip joint higher than that of the

A pneumatically powered knee-ankle-foot orthosis (KAFO) with myoelectric activation and inhibition

BackgroundThe goal of this study was to test the mechanical performance of a prototype knee-ankle-foot orthosis (KAFO) powered by artificial pneumatic muscles during human walking. We had previously built a powered ankle-foot orthosis (AFO) and used it effectively in studies on human motor adaptation, locomotion energetics, and gait rehabilitation. Extending the previous AFO to a KAFO presented additional challenges related to the force-length properties of the artificial pneumatic muscles and the presence of multiple antagonistic artificial pneumatic muscle pairs.MethodsThree healthy males were fitted with custom KAFOs equipped with artificial pneumatic muscles to power ankle plantar flexion/dorsiflexion and knee extension/flexion. Subjects walked over ground at 1.25 m/s under four conditions without extensive practice: 1) without wearing the orthosis, 2) wearing the orthosis with artificial muscles turned off, 3) wearing the orthosis activated under direct proportional myoelectric control, and 4) wearing the orthosis activated under proportional myoelectric control with flexor inhibition produced by leg extensor muscle activation. We collected joint kinematics, ground reaction forces, electromyography, and orthosis kinetics.ResultsThe KAFO produced ~22%–33% of the peak knee flexor moment, ~15%–33% of the peak extensor moment, ~42%–46% of the peak plantar flexor moment, and ~83%–129% of the peak dorsiflexor moment during normal walking. With flexor inhibition produced by leg extensor muscle activation, ankle (Pearson r-value = 0.74 ± 0.04) and knee ( r = 0.95 ± 0.04) joint kinematic profiles were more similar to the without orthosis condition compared to when there was no flexor inhibition (r = 0.49 ± 0.13 for ankle, p = 0.05, and r = 0.90 ± 0.03 for knee, p = 0.17).ConclusionThe proportional myoelectric control with flexor inhibition allowed for a more normal gait than direct proportional myoelectric control. The current orthosis design provided knee torques smaller than the ankle torques due to the trade-off in torque and range of motion that occurs with artificial pneumatic muscles. Future KAFO designs could incorporate cams, gears, or different actuators to transmit greater torque to the knee.

Design and development of anthropometric device for the standardization of sizes of knee-ankle-foot orthoses

An anthropometric device (AD) was designed and developed to collect data on foot and knee of locomotor disabled people. The aim was to standardize the sizes of knee-ankle-foot orthoses (KAFOs) in a standard modular form so that they can be mass produced to cater for fitting to a large number of locomotor disabled people. The anthropometric data collected on large numbers of locomotor disabled people were processed, with the help of a computer programme, to arrive at standard sizes for three modules, i.e. a foot plate (seven sizes), knee pieces (six sizes) and a lateral upright in a universal size. These modules were produced by plastic injection moulding and compression moulding processes using glass-reinforced polypropylene. KAFOs were assembled and fitted to locomotor disabled people. Feedback obtained was encouraging and this vindicated the concept, design and utility of the AD.

The Physiological Cost Index of Walking with an Isocentric Reciprocating Gait Orthosis Among Patients with T12–L1 Spinal Cord Injury

The objective of this study was to compare the Physiological Cost Index of walking with a reciprocating gait orthosis to that of walking with bilateral knee-ankle-foot orthoses (KAFOs) by subjects with paraplegia resulting from T(12) - L(1) spinal cord lesions. Six chronic paraplegic subjects who had T(12) - L(1) spinal cord lesions and who previously wore bilateral KAFOs were recruited. Each subject was fitted with an isocentric reciprocating gait orthosis (IRGO) and received a standardized training program. Subjects were then asked to walk using the two orthotic devices along a 40 m rectangular pathway at a speed that was comfortable for them. The walking speed was measured using a stop watch, and a Polar Heart Rate Monitor was used to measure the heart rate of the subjects. The Physiological Cost Index (PCI) was calculated for comparison. Ambulation using the IRGO (10.46 +/- 2.00 m/min) was significantly faster (p = 0.009) than ambulation using the bilateral KAFOs (5.51 +/- 4.30 m/min). The PCI demonstrated when walking with the IRGO (2.85 +/- 0.77 beats/m) was significantly lower (p = 0.0306) than that of the bilateral KAFOs (6.77 +/- 3.28 beats/m). Paraplegic patients with T(12) - L(1) spinal cord lesions walk faster and more efficiently using the isocentric reciprocating gait orthosis as compared to using the bilateral KAFOs.

A Method to Measure the Accuracy of Loads in Knee-Ankle-Foot Orthoses Using Conventional Gait Analysis, Applied to Persons With Poliomyelitis

Andrysek J, Redekop S, Matsui NC, Kooy J, Hubbard S. A method to measure the accuracy of loads in knee-ankle-foot orthoses using conventional gait analysis, applied to persons with poliomyelitis. Objectives To determine (1) the forces and moments passing through knee-ankle-foot orthoses (KAFOs) during walking and (2) the accuracy with which these loads can be measured using conventional gait analysis techniques. Design Comparative case series. Setting Rehabilitation facility with human movement laboratory (gait lab). Participants Four patients with poliomyelitis wearing KAFOs. Interventions KAFOs were instrumented with a load cell, and walking data were concurrently collected using conventional gait analysis. Main Outcome Measures Load measurements and gait parameters. Results Predominant orthotic loads (knee joint forces and moments) were composed of knee flexion moments and axial compression forces. With conventional gait analysis, peak knee joint moments were substantially underestimated compared with those directly measured using the load cell. Defining the knee axis anatomically versus at the orthotic axis, tracking it dynamically, and compensating for each patient's corrected knee flexion contracture resulted in considerable improvements in the gait lab estimates of knee joint moments. Conclusions A practical method that directly measures moments and forces in conventional KAFOs has been applied to show that conventional gait analysis techniques substantially underestimate knee joint moments in the KAFOs of persons with poliomyelitis. Underestimation of orthotic loads could result in underdesigned orthotic components and ultimately higher incidence of component failure in clinical applications.

Biomechanical effect of electromechanical knee–ankle–foot-orthosis on knee joint control in patients with poliomyelitis

In this study, an ideal electromechanical KAFO, satisfying stability in the stance and knee flexion in the swing phase during walking, was developed. Biomechanical evaluations were performed on four polio patients by means of three-dimensional gait analyses and energy consumption studies. From the three-dimensional gait analysis on poliomyelitis patients, a considerable amount of knee flexion during the swing phase was observed in controlled-knee gait, which resulted in approximately 33% less energy consumption than in locked-knee gait. The developed electromechanical KAFO in this study was helpful in poliomyelitis patients having partial or complete paralysis of the lower extremity, providing both stability in the stance and free swinging of the knee. This unit was efficient in the transfer of energy.

Single-stage multilevel soft-tissue surgery in the lower limbs with spastic cerebral palsy: Experience from a rehabilitation unit

Background:To assess the effect of single-stage multilevel soft-tissue surgery (Single Event Multiple Level Resections, SEMLR) on deformities and locomotion in patients with cerebral palsy (CP) with static contracture(s) in lower limbs.Patients and Methods:Study included 34 patients (M:F, 23:11) with mean age of 9.53 ± 3.92 years (4–16 years). Among them 22 had diplegia and four each had quadriplegia and right and left hemiplegia. Fourteen patients (41.2%) had their intelligence quotient (IQ) in the normal range (IQ ≥ 80), while others had mental retardation (MR) of varying severity: borderline MR (IQ = 70–79) in 12, mild MR (IQ = 50–69) in 5, and moderate MR (IQ = 35–49) in patients 3. All patients underwent surgery (total number of procedures 153, average 4.5 procedures/patient) over a period of 30 months (April 2005 to September 2007). Improvement in functional abilities and locomotion was assessed using Gross Motor Functional Classification Scale (GMFCS) scores and by physical examination.Results:Significant improvement in function was observed (P = 0.000) after surgery when comparing the preoperative and postoperative GMFCS scores. All patients were maintaining ambulation at a mean follow-up duration of 13.12 ± 6.07 months (3–24 months), with five patients using knee-ankle-foot orthoses (KAFO), 22 using ankle-foot orthoses (AFO), and six patients using knee gaiters. Sixteen patients were using walker, and two were using crutches as assistive devices.Conclusion:This study suggests that CP patients with good trunk control and static contractures at multiple joints in the lower limbs can be made ambulant with single-stage multilevel soft-tissue surgery. It has to be a team effort of the surgeon and the rehabilitation team in the postoperative period for the attainment of satisfactory goal.

Immediate effects of a controllable knee ankle foot orthosis for functional compensation of gait in patients with proximal leg weakness

Application of intermittent control of the knee joint stiffness in a knee ankle foot orthosis (KAFO) during gait is proposed. The approach combines inertial sensors and an actuator system in order to apply compensation in quadriceps weakness with a wearable device. Two methods, segment-angular rotation based and segment-angular velocity based, are analysed for the control of the knee joint state (intermittent stiffness) based on the inertial sensors signals. Protocolled tests are developed with two post-polio syndrome patients (PPS). In this study, the cases of gait with free-swinging leg and safe stance with the orthotic system are presented in terms of quantified kinematics (average peak angle of knee flexion of 50 degrees ) and evidences of reduction of frequent compensations (e.g. leg lateral movement) in post-polio syndrome patients. The results from immediate inspection indicate an important improvement of the gait patterns in two patients with proximal leg weakness by means of compensations applied by the wearable orthosis.

Poster 6: A Newly Diagnosed Human Immunodeficiency Virus (HIV) Patient With HIV Myelitis: A Case Report

Setting: Rehabilitation unit in a tertiary care hospital. Patient: A 28-year-old man with newly diagnosed human immunodeficiency virus (HIV) and HIV myelitis. Case Description: The patient presented with spasticity and paraparesis. An extensive workup confirmed the diagnosis of HIV with a viral load of 514,000 copies and a CD4 count of 54. HAART therapy was promptly initiated. His initial physical examination revealed a Mini-Mental State Examination score of 25/34. The patient was unable to ambulate. Muscle strength testing revealed significant bilateral leg weakness and spasticity. Assessment/Results: After 3 weeks of comprehensive rehabilitation, the patient was discharged. At that time he had improved tone in his lower extremities. Distal leg weakness remained absent and proximal leg weakness was slightly improved. He was able to ambulate with a front-wheeled walker and locked knee ankle-foot orthoses with moderate assistance. The patient continued to suffer from cognitive deficits and was diagnosed with progressive multifocal leukoencephalopathy. Discussion: With improved treatment, HIV has become a chronic condition. An estimated 1,039,000 to 1,185,000 persons in the United States are living with HIV or acquired immune deficiency virus. Approximately 40,000 persons in the United States become infected with HIV each year. In reviewing the literature, there is very little information about HIV myelitis and no evidence to establish a clear prognosis for the condition. This presented a dilemma from a rehabilitation standpoint because it was unknown whether this was going to be a stable or progressive condition. The fact that the patient also suffered from cognitive decline made his rehabilitation process more difficult. Conclusions: Because of the lack of research and without a clear prognosis of HIV myelitis, it is important to provide the optimal rehabilitation therapy that we can to all patients, with the hope that their condition will improve.

Postural responses during falling with rapid reach-and-grasp balance reaction in patients with motor complete paraplegia

Cross-sectional study. To investigate the kinematic, kinetic and electromyographic (EMG) aspects of postural control during falling with rapid reach-and-grasp balance reaction in thoracic cord-injured individuals wearing knee-ankle-foot orthoses (KAFOs). Institutional Motion Analysis Laboratory. Seven T7-T12 cord-injured subjects with complete motor loss (ASIA classes A and B) participated in this study. Subjects with KAFOs first stood steady with a modified walker and then released their hold on the walker to maintain self-supported standing until falling with grasping. The center of pressure (COP), center of mass (COM) and joint angles were measured together with EMG of the triceps (TRI), T4 paraspinal and abdominal muscles. After release of the walker, there was a rapid increase of COM-COP distance (that is, from 13.32+/-11.79 to 54.29+/-24.56 mm), with COM in front of COP during a forward fall, which was associated with the increases of T4 muscle activities. After the reach-and-grasp reaction, COM moved behind COP, which was associated with the increase of ankle dorsiflexion and the TRI and abdominal muscle activities. The increase of upper back extensor muscle activity might not be enough to correct postural instability during unsupported stance in thoracic spinal cord injury with complete motor loss. The rapid reach-and-grasp reaction is an alternative compensatory mechanism to prevent falling to the ground.

Serial casting of the ankles in Duchenne muscular dystrophy: can it be an alternative to surgery?

The aim of this non-randomized pilot study was to assess whether serial casting can be used in Duchenne muscular dystrophy (DMD) patients to reduce tendo-achilles (TA) contractures and to allow the fitting of the knee–ankle–foot orthoses (KAFOs) at the end of the functional walking. TA range and age at loss of standing with KAFOs were prospectively assessed in nine DMD patients who underwent serial casting prior to rehabilitation into KAFOs and compared to a group of 20 DMD patients who had TA (group II) or TA and iliotibial band (ITB) surgical resection (group III). TA range after casting was reduced at least to plantargrade/neutral in 8 of the 9 patients studied although patients who had surgery had better correction of TA angles. The mean interval between rehabilitation and loss of standing ability with KAFOs was only minimally different among the three groups 1.8 years (9 months–2.8 years) in group I, 2 years (1 month–4.3 years) in group II, 1.9 years (6 months–4.7 years) in group III. The results of this pilot study suggest that serial casting of the TAs can be considered in DMD patients with moderate TA contractures and in whom there are no significant iliotibial band (ITB) tightness, although this intervention is probably not as effective as surgery in maintaining long-term TA range. This procedure may therefore be considered both in patients with medical contraindication to surgery, and also in patients or families who are not prepared to cope with the stress and discomfort of TA surgery.

Predictive factors for the development of scoliosis in Duchenne muscular dystrophy

Objective Scoliosis is a frequent complication (68–90%) of Duchenne muscular dystrophy (DMD). Prevention of limb deformities, rehabilitation in knee–ankle–foot-orthoses (KAFOs) and glucocorticoids prolong walking and standing, and might reduce scoliosis. We evaluated possible predictive factors for scoliosis development in a large DMD population. Methods Case notes of 123 DMD boys, ⩾17 years, followed at our centre between 1992 and 2002 were reviewed. Univariate analysis was used to relate two outcome measures (age at onset of scoliosis and severity at 17 years) with (i) glucocorticoids treatment; (ii) ages at (a) loss of independent ambulation, (b) rehabilitation into KAFOs, (c) loss of standing, (iii) forced vital capacity (FVC) (%) between 11 and 12 years and (iv) lower limb contractures. Results In total, 37/123 boys (30%) received intermittent prednisolone (0.75 mg/kg/day, 10 day/month) for a median 1-year (2 months–9 years), starting between 7.7 and 12.4 years (mean 9.5). About 96/123 (78%) were rehabilitated into KAFOs at 10.2±1.6 years. Age at loss of ambulation in KAFOs was 12.3±1.9 years and at loss of standing 12.8±2.1 years. About 95/123 (77%) boys developed scoliosis (Cobb angle >30°). Mean age±S.D. at scoliosis onset was 12.7±1.6 years. Forty-three boys (35%) had scoliosis surgery by 15±1.2 years. Later age at loss of ambulation ( p<0.0001) and longer duration of prednisolone treatment ( p=0.01) related to later scoliosis onset. Ages at loss of ambulation and standing were inversely related to scoliosis severity at 17 years ( p<0.005). Hip asymmetry and %FVC at 11–12 years were directly related to scoliosis severity ( p=0.02). Conclusions Our data indicate a significant association between prolonged ambulation and a reduced risk of scoliosis development. Glucocorticoid administration, in our series, appear to be associated with a later onset of scoliosis, but did not alter the severity at 17 years, probably reflecting the shorter overall glucocorticoid exposure in this population.

A new modification of KAFO for assistance in knee extension

In this paper, a dynamic knee – ankle – foot orthosis (KAFO) extension assisted with elastic support, has been described which contributes to stance phase stability and swing phase freedom. The temporal distance factors including velocity, cadence, stride length, and clinical gait assessment score (CGAS) with bare foot and orthosis have been documented. The orthosis enables walking without fully immobilizing the knee.