September 2014 AACPDM 68 th Annual Meeting San Diego, CA 1. Some Guidance. 1. Discuss typical alignment and functional goals in orthotic prescription.

Transcription

1 1. Discuss typical alignment and functional goals in orthotic prescription. 2. Review some available literature guiding orthotic prescription. beliefs vs. evidence and patient vs. the laboratory 3. Explore gait analysis data for evidence suggestive of improved function and/or alignment with the application of orthotics. 4. Consider the short-term and longterm goals in orthotic prescription and how patient goals and compliance influence prescription choice. Why we like orthotics: Improving gait, allow earlier acquisition of gait Providing support and balance for weak muscles Allowing greater efficiency for more proximal muscle groups Help to maintain ROM and integrity of foot alignment/structures Why we don t like orthotics: Worsen gait Patients may prefer to not have them They are expensive They are rapidly outgrown They may slow kids down, reduce floor mobility, more likely to W-sit, challenge floor to stand and sit to stand skills, reduce stair mobility, limit balance reactions Inhibit sensory input to the bottom of the foot, makes negotiating uneven surfaces hard Solid AFO's inhibit force production and push off from the gastroc and contribute to weakness/limit strengthening of the df s and pf s Fit is challenging How do you choose what orthosis to recommend? What you want for the patient? What the patient wants? What the parent wants? What another care provider recommends? Goals?? Some Guidance What does the patient want? Family? To walk To walk more typically To maintain ability to walk Less falls More mobility To keep up with peers To appear more typical Pain free, more comfortable Avoid surgery Lessen surgery Morris C et al September 2014 AACPDM 68 th Annual Meeting San Diego, CA 1

2 24 academics, research scientists and healthcare professionals with expertise in CP Reviewed the evidence and considered current thinking re: management in CP Aim is to enable culturally appropriate activities and participation by: Promoting efficient movement Limiting deformity Reducing pain Employing cognitive/behavioral strategies Healthcare team (orthotist, therapist, physician, bioengineer, etc) must collaborate with the family, taking into consideration medical issues and the family s goals and priorities Classification of functioning should follow the WHO ICF guidelines, and furthermore for CP the GMFCS and MACS: ie: goals for GMFCS I III = gait and deformity goals ie: goals for GMFCS IV V = improving sitting posture, upright standing Swing phase problem? Stance phase problem? Causing problems at the knee? Hip? Correction of these problems may improve mobility. Morris C et al Morris C et al In general AFO s: increase velocity of gait but in diplegics may have little or no effect reduce cadence but in diplegics may have little or no effect Increase step length Increase stride length Increase duration of single support AFO s can improve ankle kinematics Restrict ankle joint motion reduce power generation and absorption at the ankle, but increase 2nd peak of GRF in propulsive phase AFO s can improve knee and hip kinematics and kinetics GRF is manipulated to affect the knee/hip Hinged vs. Flexible (with fine tuning of stiffness) Tuning of sagital plane ankle alignment Tibia with fwd inclination may be beneficial even if ankle must be set in pf to do so Morris C et al Morris C et al O2 consumption may be decreased by AFO use Self selected walking speed increases Stretching to reduce need for achilles lengthenings (Weakness of gastroc-soleus??) Morris C et al Morris C et al September 2014 AACPDM 68 th Annual Meeting San Diego, CA 2

3 STS improves with AFO s on if the wearer is more than one SD below mean speed The use of df is the consistent way to improve STS but use of articulated AFO when there is pf cntrx is controversial (facilitates midfoot breakdown) Stair function is not impaired Can improve standing balance Little effect if at all on sitting and/or UE function Utility of posture and alignment in standing frames is limited Effects on gait? Recommended Data to Gather: Age Sex Type of CP GMFCS level Recent surgery Medication interventions ROM of all lower limb joints (easy or difficult to attain?) Rotational deformity Strength Spasticity Description of gait with and without AFO description Design (custom/prefab) Construction (materials, type, straps/fastenings) Alignment of leg in (sagital, coronal and transverse planes for ankle) Alignment of to ground (sagital plane) Footwear and its design (heel-sole differential, stiffness of sole) Dosage (duration of use) Side effects Morris C et al Morris C et al Morris C, Bowers R, Ross K, Stevens P, Phillips D. Orthotic management of cerebral palsy: Recommendations from a consensus conference, Neuro Rehab 28, Ries, Andy, Rozumalski, Adam, and Schwartz, Michael. Do Ankle Foot Orthoses Improve Gait for Individuals with Cerebral Palsy? Gillette Children s Specialty Healthcare, St. Paul, United States; University of Minnesota- Twin Cities, Minneapolis, United States. Owen E. The importance of being earnest about shank and thigh kinematics especially when using ankle-foot, Prosthetics and Orthotics International 34(3): Aaron Rasmussen, C. P. O. Gillette Children s Specialty Healthcare St. Paul, MN Role of Orthoses Alignment Indications Quantifying AFO stiffness All must do one of the following: Control of motion Correction of deformity Compensation for weakness Carlson, Orthotic management of the Lower Limb of Children with Cerebral Palsy. September 2014 AACPDM 68 th Annual Meeting San Diego, CA 3

4 A specific treatment goal Helps to personalize the purpose for the orthosis Will increase the likelihood of success Alignment issues which can be improved with Available ROM & muscle power Stability in stance Clearance in swing Prepositioning of the foot in terminal swing Adequate step length Energy conservation Patients activity level/types of activities Goals of patient/parent/ physician/pt/ot Be aware of how ankle angle, shoe heel height, toe plate flexibility, and other factors affect gait Unfortunately, we can not always achieve all orthotic goals with a single orthotic design Foot are the foundation for lower limb management each and every more proximal orthosis is first and foremost an FO ("Atlas of Orthoses and Assistive Devices" ) September 2014 AACPDM 68 th Annual Meeting San Diego, CA 4

5 3 point pressure system for talipes varus 3 point pressure system for talipes valgus In children with neuromuscular disorders, pes valgus is the 2nd most common foot deformity Equinus is the most common position we deal with in this group Carlson and Berglund, An Effective Orthotic Design for Controlling the Unstable Subtalar Joint. Carlson and Berglund, An Effective Orthotic Design for Controlling the Unstable Subtalar Joint. A patient with forefoot varus may display hindfoot valgus (eversion) during weight bearing as a method of compensation for the forefoot deformity September 2014 AACPDM 68 th Annual Meeting San Diego, CA 5

6 Brief discussion of materials used in fabrication Review of some common lower extremity and their indications Thermoplastics Copolymer vs. polypropylene Carbon fiber Provides improved midfoot and forefoot control, primarily through plantar surface forces Improved midfoot and forefoot control can affect rearfoot position Effective in controlling flexible deformities of the subtalar and midtarsal joints: calcaneal eversion/inversion midfoot instability forefoot adduction/ abduction Provides improved heel, midfoot, and forefoot alignment Provides improved medial-lateral ankle stability Standard trimlines allow normal 1 st, 2 nd, and 3 rd rocker Provides clearance during swing, pre-positions the foot for initial contact Controls lowering of the foot toward the ground Allows dorsiflexion necessary for tibial advancement over the foot Flexibility can be finetuned for a variety of treatment goals September 2014 AACPDM 68 th Annual Meeting San Diego, CA 6

7 Provides m-l stability Plantar flexion stop can affect genu recurvatum in stance and foot clearance in swing Typically allows free dorsiflexion Adjustable ankle joints can be used, but have limitations (bulk, durability) Must have adequate ROM Dorsiflexion is obtained through the midtarsal joint, not the ankle joint aka the little ankle Anatomical motion does not occur at mechanical ankle joint, thus causing pressure and fit issues with the orthosis Provides maximum stability in frontal and sagittal planes Provides tri-planar immobilization of the ankle-foot complex Ankle angle affects knee and hip motion Properties and indications are similar to solid AFO. Floor reaction AFO has an anterior proximal tibial shell which promotes knee extension in mid through terminal stance Note foot progression angle BRUCE measures the angle of the ankle when bending the AFO and the force it produces Finds a relationship between ankle angle/force Gait lab can separate the force provided by an AFO and the force provided by the patient B R U C E BRUCE Current practice = Stiff to Flexible Cannot reverse Short Term: Is there an ideal stiffness for a pls AFO? Long Term: By using a specific patients' gait lab data can we predict (and provide) the optimal stiffness of AFO? September 2014 AACPDM 68 th Annual Meeting San Diego, CA 7

8 Thank You! Atlas of Orthoses and Assistive Devices. 3rd. 1. St. Louis: Mosby, Print. Carlson, J. Martin, and Gene Berglund. "An Effective Orthotic Design for Controlling the Unstable Subtalar Joint." Orthotics and Prosthetics (1979): Print. Carlson, J. Martin. "Orthotic Management of the Lower Limb of Children with Cerebral Palsy." (2001): Print. Clinical Aspects of Lower Extremity Orthotics. Second Edition. Winnipeg: Canadian Association for Prosthetics and Orthotics, Goldberg, Bertram, and John D. Hsu. Atlas of Orthoses and Assistive Devices. Third Edition. St. Louis: Mosby, Kroll, G. (2008) Meeting Treatment Objectives Through Proper Orthotic Design & Application [PowerPoint Slides]. Gillette Children s Specialty Healthcare: Assistive Technology Department. Sohrweide, S. (2008) Clinical Evaluation of Foot Deformities. [PowerPoint Slides]. Gillette Children s Specialty Healthcare: Center for Gait and Motion Analysis Ries, Andy, Rozumalski, Adam, and Schwartz, Michael. Do Ankle Foot Orthoses Improve Gait for Individuals with Cerebral Palsy?. Gillette Children s Specialty Healthcare, St. Paul, United States; University of Minnesota- Twin Cities, Minneapolis, United States. Data guiding prescription Introduce/review gait analysis Elements of a gait analysis Terms kinematics and kinetics Gait graphs Understand role of gait analysis data in prescription Knowledgeable participant in presented case studies that utilize gait analysis data to guide prescription It provides useful information about the intricacies of an individual s gait, as well as how far the individual s walking pattern deviates from normal Split screen video Augments kinematics/kinetics Physical exam Provides useful information about many things that gait analysis does not directly measure (boney torsion, foot deformity, strength, motor control etc.) Kinematics Quantitative 3-dimensional measurement of motion Kinetics Measurement of moment and power generation Dynamic EMG On-off signals of individual muscles Metabolic energy assessment Oxygen consumption Pedobarography Dynamic foot pressure September 2014 AACPDM 68 th Annual Meeting San Diego, CA 8

9 Split screen video Augments kinematics/kinetics Physical exam Provides useful information about many things that gait analysis does not directly measure (boney torsion, foot deformity, strength, motor control etc.) Kinematics Quantitative 3-dimensional measurement of motion Kinetics Measurement of moment and power generation Dynamic EMG On-off signals of individual muscles Metabolic energy assessment Oxygen consumption Pedobarography Dynamic foot pressure Split screen video Augments kinematics/kinetics Physical exam Provides useful information about many things that gait analysis does not directly measure (boney torsion, foot deformity, strength, motor control etc.) Kinematics Quantitative 3-dimensional measurement of motion Kinetics Measurement of moment and power generation Dynamic EMG On-off signals of individual muscles Metabolic energy assessment Oxygen consumption Pedobarography Dynamic foot pressure Split screen video Augments kinematics/kinetics Physical exam Provides useful information about many things that gait analysis does not directly measure (boney torsion, foot deformity, strength, motor control etc.) Kinematics Quantitative 3-dimensional measurement of motion Kinetics Measurement of moment and power generation Dynamic EMG On-off signals of individual muscles Metabolic energy assessment Oxygen consumption Pedobarography Dynamic foot pressure Split screen video Augments kinematics/kinetics Physical exam Provides useful information about many things that gait analysis does not directly measure (boney torsion, foot deformity, strength, motor control etc.) Kinematics Quantitative 3-dimensional measurement of motion Kinetics Measurement of moment and power generation Dynamic EMG On-off signals of individual muscles Metabolic energy assessment Oxygen consumption Pedobarography Dynamic foot pressure Split screen video Augments kinematics/kinetics Physical exam Provides useful information about many things that gait analysis does not directly measure (boney torsion, foot deformity, strength, motor control etc.) Kinematics Quantitative 3-dimensional measurement of motion Kinetics Measurement of moment and power generation Dynamic EMG On-off signals of individual muscles Metabolic energy assessment Oxygen consumption Pedobarography Dynamic foot pressure Split screen video Augments kinematics/kinetics Physical exam Provides useful information about many things that gait analysis does not directly measure (boney torsion, foot deformity, strength, motor control etc.) Kinematics Quantitative 3-dimensional measurement of motion Kinetics Measurement of moment and power generation Dynamic EMG On-off signals of individual muscles Metabolic energy assessment Oxygen consumption Pedobarography Dynamic foot pressure September 2014 AACPDM 68 th Annual Meeting San Diego, CA 9

10 Physical Exam Split screen video Augments kinematics/kinetics Physical exam Provides useful information about many things that gait analysis does not directly measure (boney torsion, foot deformity, strength, motor control etc.) Kinematics Quantitative 3-dimensional measurement of motion Kinetics Measurement of moment and power generation Dynamic EMG On-off signals of individual muscles Metabolic energy assessment Oxygen consumption Pedobarography Dynamic foot pressure Split screen video Augments kinematics/kinetics Physical exam Provides useful information about many things that gait analysis does not directly measure (boney torsion, foot deformity, strength, motor control etc.) Kinematics Quantitative 3-dimensional measurement of motion Kinetics Measurement of moment and power generation Dynamic EMG On-off signals of individual muscles Metabolic energy assessment Oxygen consumption Pedobarography Dynamic foot pressure Split screen video Augments kinematics/kinetics Physical exam Provides useful information about many things that gait analysis does not directly measure (boney torsion, foot deformity, strength, motor control etc.) Kinematics Quantitative 3-dimensional measurement of motion Kinetics Measurement of moment and power generation Dynamic EMG On-off signals of individual muscles Metabolic energy assessment Oxygen consumption Pedobarography Dynamic foot pressure 140+ measurements What is needed to optimize effectiveness of an? Proper skeletal alignment Absence of contractures Adequate strength Adequate motor control September 2014 AACPDM 68 th Annual Meeting San Diego, CA 10

11 The motions of the segments in space and relative to one another Utility objective specific joint angular changes accurate pre and post-treatment measurement accurate comparison of barefoot vs. braced walking Limitations only descriptive, can't distinguish cause of motion disorders error September 2014 AACPDM 68 th Annual Meeting San Diego, CA 11

12 FRONTAL SAGITTAL TRANSVERSE PELVIS HIP KNEE ANKLE/ FOOT Gray = typical range of motion Red = left leg Green = right leg IC STANCE FO SWING Gait analysis permits evaluation of the specific effect of (White et al 2002, Bartonek et al 2007) Motion analysis is routinely performed in and out of Allows us to: Analyze orthotics role in improving/hindering walking Design more functional that are best suited to their specific task (Harrington et al 1984, Van Gestel et al 2008) X = GAIT CYCLE September 2014 AACPDM 68 th Annual Meeting San Diego, CA 12

13 Frequency Frequency Barefoot braced Right Left Retrospective study of 686 Gillette patients (1372 limbs) diplegic CP walking trials collected both barefoot and wearing (SAFO, PLS, HAFO) Gait data analyzed for each trial GDI (Gait Deviation Index) change from barefoot to orthotic was calculated for each limb GDI score is a single number that represents overall gait pathology GDI 100 indicates normal gait kinematics and each decrement of 10 points is one standard deviation from normal. GDI change of 5 = 1 level on the FAQ functional walking scale (Schwartz) Gait changes associated with AFO use among individuals with diplegic CP showed Subjects with poorer kinematics (lower GDI) derived greater benefit from AFOs than those with milder gait deviations Small benefit among subjects using assistive devices Nearly negligible improvement in independent ambulators AFO design was not a statistically significant factor in predicting changes in GDI among either dependent or independent ambulators Distribution of GDI changes suggests that while overall response to AFO wear is underwhelming, there are a significant number of good responders (i.e. GDI changes of > 5) GDI Scores Change in GDI [Orth - BF] Average BF GDI 73.8 (SD 10.2) 60% have positive GDI Change 25% have +5 or better GDI change 13% have -5 or worse GDI change 62% have minimal change (between -5 and +5) Change in Normalized Walking Speed [Orth BF] Change in Normalized Walking Speed [Orth - BF] Control ND BF Speed [Schwartz et al. 08] Average ND BF walking speed (SD 0.112) 88% of slow walkers (ND Speed<0.363) have speed increase Relative increase of 34% 12% of slow walkers have speed decrease Relative decreased of 10% Focus on identifying patient characteristics that lead to meaningful positive gait changes with use of AFO s Random Forest Algorithm predictive model that is essentially a collection of small decision trees; It takes a bunch of data, sifts through it to find the helpful/important information, and then makes a prediction based on that information. RF data available for the case studies we will be looking at Barefoot data will be collected and run through the RF to make prediction on type which would be best for that child Predicted will be made and child will use it for 6 weeks, then return to motion lab Data will be collected in predicted brace, GDI will be calculated and then compared to the actual predicted GDI using the RF. Analyze the existing prescription algorithm in an effort to improve AFO efficacy BRUCE September 2014 AACPDM 68 th Annual Meeting San Diego, CA 13

14 Show barefoot video Audience response re: design Add physical exam measurements Audience response re: design Add barefoot gait data Audience response re: design Look at gait data in prescribed Discussion 8+4 y/o male CP spastic quadriplegia GMFCS III Surgical history SDR 2009 SEMLS 2011 Bilateral femoral external derotation osteotomy. Right tibial internal derotation osteotomy. Bilateral calcaneal lengthening. Bilateral first metatarsal plantar flexion osteotomy. Bilateral Baker-type gastrocnemius/soleus lengthening. Referred for 1 year post ortho surgery gait lab Family is concerned about patient s endurance, strength and gait pattern. Parental goal is for patient to be able to walk independently with his walker or crutches. Case #1 I would prescribe the following 1. None 2. UCBL 3. SMO 4. PLS 5. HAFO 6. SAFO 7. GRAFO September 2014 AACPDM 68 th Annual Meeting San Diego, CA 14

15 Left Hip extension WNL WNL Anteversion Tibial torsion (BM) Right Knee extension WNL with stretch WNL with stretch Popliteal angle 30 (from vertical) 40 (from vertical) Patella alta yes yes Extensor lag Ankle dorsiflexion ROM (90/0) 25 /10 30 /15 WB foot (RF/MF/FF) val/pla/abd/mild val/pla/abd/mod Hip ext. strength 2+/5 2+/5 Quad strength 5/5 (in available range) 5/5 (in available range) AJ DF strength 2+/5 3-/5 AJ PF strength 2/5 2/5 Spasticity absent absent I would prescribe the following 1. None 2. UCBL 3. SMO 4. PLS 5. HAFO 6. SAFO 7. GRAFO 0% 0% 0% 0% 0% 0% 0% 0% L R Sagittal Transverse I would prescribe the following 1. None 2. UCBL 3. SMO 4. PLS 5. HAFO 6. SAFO 7. GRAFO 0% 0% 0% 0% 0% 0% 0% 0% Left BF vs. SAFO Right BF vs. SAFO Walking trial conditions GDI Left Right Average Barefoot, walker B SAFO, walker (one of 25% that had +5) Gait deviation index (GDI) is a scaled measure of gait pathology. A GDI value equal to or greater than 100 equates to a normal gait. September 2014 AACPDM 68 th Annual Meeting San Diego, CA 15

16 Linear Parameters Predicted Change in GDI using RF (+ number = improvement) SAFO PLS HAFO SMO UCBL Left 3.9 (+4) Right 3.1 (+9) Case #2 Barefoot video SAFO video 6+8 y/o female Lumbosacral level mylomeningocele Referred for initial gait lab Surgical history Closure of spinal defect Shunting Family concerned about the possible future deterioration of patient s gait and how this may get to the point that patient will be unable to walk. Family goals are for patient to maintain/improve mobility I would prescribe the following 1. None 2. UCBL 3. SMO 4. PLS 5. HAFO 6. SAFO 7. GRAFO 0% 0% 0% 0% 0% 0% 0% 0% September 2014 AACPDM 68 th Annual Meeting San Diego, CA 16

17 Left Right Hip extension 10 (contracture) 10 (contracture) Anteversion Tibial torsion (BM) 0 15 Knee extension WNL WNL with stretch Popliteal angle Patella alta no no Extensor lag no no Ankle dorsiflexion ROM (90/0) 25 /25 25 /20 WB foot (RF/MF/FF) typ/typ/typ typ/typ/typ Hip ext. strength 2+/5 2+/5 Quad strength 5/5 5/5 AJ DF strength 5/5 5/5 AJ PF strength 2-/5 2/5 Spasticity absent absent I would prescribe the following 1. None 2. UCBL 3. SMO 4. PLS 5. HAFO 6. SAFO 7. GRAFO 0% 0% 0% 0% 0% 0% 0% 0% Sagittal L R Transverse I would prescribe the following 1. None 2. UCBL 3. SMO 4. PLS 5. HAFO 6. SAFO 7. GRAFO 0% 0% 0% 0% 0% 0% 0% 0% Left BF vs. GRAFO Right BF vs. GRAFO GDI Walking trial conditions Left Right Average Barefoot B GRAFO (+7) Gait deviation index (GDI) is a scaled measure of gait pathology. A GDI value equal to or greater than 100 equates to a normal gait. September 2014 AACPDM 68 th Annual Meeting San Diego, CA 17

18 Barefoot video GRAFO video Left A : B Right A : B Hip extension 10 : WNL 10 : WNL Anteversion 50 : : 25 Tibial torsion (BM) 0 : : 10 Knee extension WNL : WNL WNL with stretch: WNL Popliteal angle 25 : : 55 Patella alta no : no no : no Extensor lag no : no no : no Ankle dorsiflexion ROM (90/0) 25 /25 : 0 /0 25 /20 : 10 /0 WB foot (RF/MF/FF) typ³ : val/pla/abd typ³ : val/pla/abd Hip ext. strength 2+/5 : 3/5 2+/5 : 3-/5 Quad strength 5/5 : 5/5 5/5 : 5/5 AJ DF strength 5/5 : 3-/5 5/5 : 1/5 AJ PF strength 2-/5 : 2+/5 2/5 : 2+/5 Spasticity absent : absent absent : absent Barefoot video Barefoot L/R kinematics (sagittal) GRAFO video BF vs. GRAFO kinematics (sagittal) BF vs. GRAFO Kinematics (transverse) BF vs. GRAFO Kinetics GDI Walking trial conditions Left Right Average Barefoot B GRAFO (-10) Gait deviation index (GDI) is a scaled measure of gait pathology. A GDI value equal to or greater than 100 equates to a normal gait. September 2014 AACPDM 68 th Annual Meeting San Diego, CA 18

19 Linear Data Predicted Change in GDI using RF (+ number = improvement) SAFO PLS HAFO SMO UCBL Left 1.6 (-15) Right 2.9 (-7) y/o male CP spastic diplegia GMFCS II Referred for orthotic recommendations and repeat gait lab study Surgical history SDR 2004 SEMLS 2003 Bilateral femoral derotational osteotomies. Right gastrocnemius lengthening. Botulinum toxin type A injections to the bilateral gastrocsoleus, medial hamstring and hip adductor musculature. Family is primarily concerned with crouching and improper heel-toe step Family expectations and goals No crouching; maintain good gait habits. Feel better about himself and be able to do more at home and school. Participate more in recreational activities and sports. Free from disability or pain as an adult. I would prescribe the following 1. None 2. UCBL 3. SMO 4. PLS 5. HAFO 6. SAFO 7. GRAFO 0% 0% 0% 0% 0% 0% 0% 0% Left Right Hip extension WNL WNL with stretch Anteversion Tibial torsion (BM) Knee extension -5 (hyperextension) -5 (hyperextension) Popliteal angle Patella alta no no Extensor lag no no Ankle dorsiflexion ROM (90/0) 10 /0 10 /5 WB foot (RF/MF/FF) typ/typ/typ typ/pla/abd/mod Hip ext. strength 5/5 4+/5 Quad strength 5/5 5/5 AJ DF strength 4+/5 4/5 AJ PF strength 4+/5 4/5 Spasticity absent absent September 2014 AACPDM 68 th Annual Meeting San Diego, CA 19

20 Sagittal L R Transverse I would prescribe the following 1. None 2. UCBL 3. SMO 4. PLS 5. HAFO 6. SAFO 7. GRAFO 0% 0% 0% 0% 0% 0% 0% 0% Left BF vs. SAFO vs. SMO Right BF vs. SAFO vs. SMO I would prescribe the following 1. None 2. UCBL 3. SMO 4. PLS 5. HAFO 6. SAFO 7. GRAFO 0% 0% 0% 0% 0% 0% 0% 0% Walking trial conditions GDI Left Right Average Predicted Change in GDI using RF (+ number = improvement) SAFO PLS HAFO SMO UCBL Barefoot B SAFO (+3) Left 2.8 (+1) (+6) 0.5 Right 5.9 (+6) (+7) 1.5 B - SMO (+7) Gait deviation index (GDI) is a scaled measure of gait pathology. A GDI value equal to or greater than 100 equates to a normal gait. September 2014 AACPDM 68 th Annual Meeting San Diego, CA 20

21 Linear data Barefoot SAFO SMO September 2014 AACPDM 68 th Annual Meeting San Diego, CA 21