Improving the design of the curved rocker shoe for people with diabetes

Jonathan D Chapman

PhD Thesis 2014

AbstractIntroductionFoot ulceration and re-ulceration are a serious problem in people with diabetes as the outcome can be lower limb amputation, reducing quality of life and increasing mortality. The pathogenesis of foot ulceration is multifactorial with neuropathy, alterations in foot structure, callus formation and increased plantar foot pressure. The most effective intervention for reducing plantar pressure is the curved rocker outsole. To date this design has been prescribed from clinical intuition rather than scientific evidence. Therefore the studies within this thesis aimed to improve our understanding of how to best to design, and also prescribe, a rocker sole.
MethodsEthical approval was obtained from the University of Salford and the NHS. Study 1 investigated the independent effect of varying the three outsole design features (apex angle, apex position and rocker angle) on plantar pressure in 24 people with diabetes and healthy participants. In-shoe pressure data was collected using Pedar-x and analysed using Matlab. Study 2 investigated the effect of varying apex position in combination with rocker angle, in 87 people with diabetes, and aimed to establish how many people would receive sufficient offloading when wearing a pre-defined rocker design. Study 3 investigated a new method of prescribing a rocker sole using artificial neural networks with an input of gait variables on 78 people with diabetes. Gait data was collected using Vicon and analysed using Visual-3D and Matlab.
ResultsThe results of Study 1 suggested that fixing apex angle at 95° would be a suitable compromise to offload the high risk areas (medial forefoot). It also suggested that apex position and rocker angle needed more investigation. Therefore, in Study 2 the combined effect of two rocker angles and four apex positions were investigated. Despite some inter- subject variability, this study showed that over 60% of participants received sufficient offloading when walking in a mean optimal design. Furthermore, over 60% of people received sufficient offloading with the smaller rocker angle of 15°. The results in Study 3showed there was low accuracy when predicting an individual optimal shoe using gait variables as inputs (34-49%).
ConclusionsThis project has shown it is possible to significantly reduce plantar pressures in people with diabetes with a well-designed rocker shoe (95° apex angle, individual apex position and 15° rocker angle). This finding paves the way for future clinical trials which could provide robust clinical evidence for the use of rocker shoes.
Source: http://usir.salford.ac.uk/31862/1/PhD_Thesis_Jonathan_D_Chapman_2014.pdf

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Club Foot Appeal

Algeos are looking for your help to support a fantastic charity called the http://www.infantclubfootappeal.org

Algeos have helped the charity set up a fully functional O&P workshop which will enable the team to produce suitable O&P devices.

 

Our container of products leaves Liverpool for Zanzibar on Monday 28^th July. If anyone would like to make any generous donations we are in need of the following items.

Your help and support would be really appreciated and the people of Tanzania would be eternally grateful.

 

·         Paediatric & adult shoes / boots to treat clubfoot

·         Paediatric & adult insoles to treat clubfoot

·         Paediatric & adult shoes

·         Paediatric & adult insoles

·         Paediatric & adult AFO's

·         Nimco or similar style

·         Scoliosis brace

·         Foot supports

·         Leg braces

·         Skull guards

Please contact Algeos directly if you can help provide some of these items. Many thanks in advance, your support is very much appreciated and your generosity will make a huge difference.

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Blatchford - Orthotist - South West

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Blatchford - Orthotist - Carlisle

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The immediate effects of fitting and tuning solid ankle–foot orthoses in early stroke rehabilitation

Bruce Carse, Roy Bowers, Barry C Meadows, Philip Rowe

Abstract

Background: Ankle-foot orthoses are known to have a generally positive effect on gait in stroke, however the specifc type of AFO and the time point at which it is provided are highly variable in the currently available literature.

Objective: The objective was to determine the immediate spatiotemporal and kinematic effect of custom-made solid ankle–foot orthoses in early stroke rehabilitation, compared to shod walking.

Methods: Five male and three female participants were recruited to the study (n = 8), with a mean age of 57 (16) years who were 3.5 (3) weeks post-stroke. Each received a custom-made solid ankle–foot orthosis to a predefined set of design criteria and tuned using heel wedges to control the shank inclination angle during shod walking. Repeated spatiotemporal and three-dimensional gait measures were taken pre- and immediately post-intervention.

Study design: A pre–post-test experimental study.

Results: With the solid ankle–foot orthosis, walking velocity increased from 0.22 (0.2) to 0.36 (0.3) m/s (p < 0.05), overall average step length increased from 0.28 (0.1) to 0.37 (0.1) m (p < 0.05), cadence increased from 45 (19) to 56 (19) steps/min (p < 0.05) and step length symmetry ratio increased from 0.65 (0.2) to 0.74 (0.2) (not significant). No clear changes were observed in the joint kinematics of the hip and knee.

Conclusion: In our small group of early stroke patients who were fitted with a solid ankle–foot orthosis, immediate significant improvements occurred in walking speed, step length and cadence, when compared to walking with shoes only.

Clinical relevance This study provides evidence about the immediate effects of custom solid ankle–foot orthoses on gait of early stroke survivors. Ankle–foot orthosis design specifications are fully described for replication. This study suggests that observing global segment orientation may be more useful than joint angles when fitting and tuning ankle–foot orthoses for optimal ankle–foot orthosis/footwear alignment.

Source: http://poi.sagepub.com/content/early/2014/06/16/0309364614538090.abstract

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Ottobock - Prosthetist (Maternity Cover) - Stoke on Trent

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Dorset Orthopaedic - Experienced Prosthetist, Hampshire

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Optimising the effects of rigid ankle foot orthoses on the gait of children with cerebral palsy (CP) – an exploratory trial

Kavi C. Jagadamma, kjagadamma@qmu.ac.uk Fiona J. Coutts, Thomas H. Mercer, Janet Herman, Jacqueline Yirrell, Lyndsay Forbes, and Marietta L. van der Linden

Disability and Rehabilitation: Assistive Technology

Vol. 0: 1-7

DOI: 10.3109/17483107.2014.908244

Abstract

Purpose: This exploratory trial investigated the effects of rigid ankle foot orthoses (AFO) with an optimally cast Angle of the Ankle in the AFO (AAAFO) on the gait of children with Cerebral Palsy (CP), and whether tuning of the AFO – Footwear Combination (AFO-FC) further affected gait. Methods: Eight children with CP underwent gait analysis and tuning of their AFO-FCs using a 3-D motion analysis system. Comparisons were carried out for selected gait parameters between three conditions – barefoot, non-tuned AFO-FC and tuned AFO-FC. Results: In comparison to barefoot gait, walking with a non-tuned AFO-FC produced significant (p < 0.05) improvements in several key gait parameters. Compared to the non-tuned AFO-FC, on average a tuned AFO-FC produced a significant reduction in peak knee extension and knee ROM during gait. However, when examined as case studies, it was observed that the type of gait pattern demonstrated while wearing a non-tuned AFO-FC affected the outcomes of tuning. Conclusions: The findings of the current study indicate the potential benefits of using rigid AFO-FC with optimal AAAFO and tuning of AFO-FCs. This study emphasises the need for categorising children with CP based on their gait patterns when investigating the effects of interventions such as AFOs.Implications for Rehabilitation

	Rigid ankle foot orthoses (AFO) cast at an optimal angle to accommodate the length of gastrocnemius muscle may positively influence walking in children with Cerebral Palsy (CP).
	Tuning of the AFO-Footwear Combination (AFO-FC) has potential benefits to the walking of children with CP, depending on their gait abnormalities.
	When investigating the effects of interventions such as AFOs, it is important to categorise children with CP based on their gait abnormalities.

Keywords: AFO , ankle foot orthosis , cerebral palsy , gait , tuning

http://informahealthcare.com/doi/abs/10.3109/17483107.2014.908244

Foot drop in MS: Experiences of using functional electrical stimulation (FES) or orthotic devices

Summary

Foot drop is a symptom experienced by some people with multiple sclerosis. It is caused by a disruption in the nerve pathway to and from the brain, which results in an inability to lift the foot and toes properly when walking. To improve walking and reduce the risk of trips or falls, foot drop can be treated using two types of device. Functional electrical stimulation (FES) uses small electrical charges to force the foot into a more natural position for walking. An ankle-foot orthoses (AFO) is a device made of plastic or carbon fibre that holds the foot and ankle in a correct position during walking.

This study aimed to explore the experiences and satisfaction with FES and AFO in people with MS who had foot drop.

10 participants took part in the study and were split into two groups, the first group was made up of people using FES (six participants) and the second used AFO (four participants). The groups were questioned and encouraged to discuss their experiences of using the devices.

A similar number of positive and negative aspects were described for FES and AFO. In both groups the participants said that their device had reduced their fatigue, improved their gait (the pattern of walking), reduced trips and falls and increased their confidence. The negative aspects mentioned by both groups included the implications for shoes and clothing, for example users had found it difficult to concealtheir device under their clothes for social occasions.

In conclusion both groups considered that the benefits to them from wearing the device were more important and outweighed any problems.

This study highlights the importance of a health professional taking the individual's experiences and preferences into account, when selecting and prescribing a device to manage foot drop.

Source: http://www.mstrust.org.uk/research/updates/articles/update140520.jsp?utm_medium=email&utm_source=MS+Trust&utm_campaign=4174715_Research+update+140520+AGAIN&dm_i=157R,2HH8B,EDBPM9,91P2X,1#item01

Bulley C, Mercer TH, Hooper JE , et al.
Experiences of functional electrical stimulation (FES) and ankle foot orthoses (AFOs) for foot-drop in people with multiple sclerosis..
Disabil Rehabil Assist Technol. 2014 May 6. [Epub ahead of print]
abstract

Lancashire Teaching Hopsitals NHS Trust SMRC - Band 7 Prosthetist

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HCPC Prosthetist/Orthotist Panel Member

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Prevention of Recurrent Foot Ulcers With Plantar Pressure–Based In-Shoe Orthoses: The CareFUL Prevention Multicenter Randomized Controlled Trial

Jan S. Ulbrecht, Timothy Hurley, David T. Mauger and Peter R. Cavanagh

Abstract

OBJECTIVE To assess the efficacy of in-shoe orthoses designed based on shape and barefoot plantar pressure in reducing the incidence of submetatarsal head plantar ulcers in people with diabetes, peripheral neuropathy, and a history of similar prior ulceration.

RESEARCH DESIGN AND METHODS Single-blinded multicenter randomized controlled trial with subjects randomized to wear shape- and pressure-based orthoses (experimental, n = 66) or standard-of-care A5513 orthoses (control, n = 64). Patients were followed for 15 months, until a study end point (forefoot plantar ulcer or nonulcerative plantar forefoot lesion), or to study termination. Proportional hazards regression was used for analysis.

RESULTS There was a trend in the composite primary end point (both ulcers and nonulcerative lesions) across the full follow-up period (P = 0.13) in favor of the experimental orthoses. This trend was due to a marked difference in ulcer occurrence (P = 0.007) but no difference in the rate of nonulcerative lesions (P = 0.76). At 180 days, the ulcer prevention effect of the experimental orthoses was already significant (P = 0.003) when compared with control, and the benefit of the experimental orthoses with respect to the composite end point was also significant (P = 0.042). The hazard ratio was 3.4 (95% CI 1.3–8.7) for the occurrence of a submetatarsal head plantar ulcer in the control compared with experimental arm over the duration of the study.

CONCLUSIONS We conclude that shape- and barefoot plantar pressure–based orthoses were more effective in reducing submetatarsal head plantar ulcer recurrence than current standard-of-care orthoses but they did not significantly reduce nonulcerative lesions.

Source: http://care.diabetesjournals.org/content/early/2014/04/18/dc13-2956.abstract

Peacocks Medical Group Job Advertisement - Senior Orthotist, Hampshire

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OAPL Job Advert - Brisbane, Australia - Senior Prosthetist

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The effect of AFO stiffness on the knee joint during the heel strike phase of gait in stroke patients

Madeline Singer, Toshiki Kobayahi, Lucas Lincoln, Michael Orendurff and K. Bo Foreman

Stroke patients suffering from foot drop are often prescribed ankle-foot orthoses (AFOs) to improve foot clearance during gait. However, excessive restriction of plantarflexion (PF) during the heel strike phase of gait has been shown to cause biomechanical changes at the knee joint. This pilot study aimed to determine how increasing the PF stiffness of an AFO affects knee joint kinematics and kinetics during heel strike in hemiplegic stroke patients with varying levels of active ankle range of motion. We hypothesized that increased PF resistance would cause an increase in anterior tibial rotation at heel strike with resulting increases in knee flexion angle and knee extension moment. To test this hypothesis, 5 stroke patients with foot drop were clinically evaluated, instrumented with reflective markers, and fitted with a spring modified AFO (Orthocare Innovations). A compression spring in the posterior aspect of the AFO was changed to increase the external dorsiflexion torque from 0.3 Nm/deg (Spring 1) to 2.0 Nm/deg (Spring 2). Kinematic and kinetic data were collected during walking on an instrumented treadmill (Bertec) in a motion analysis lab. Five steps with each spring were examined. Two patients exhibited an increase in knee flexion angle and knee extension moment with the stiffer spring. Clinical findings revealed that these 2 patients had minimal active PF while the other 3 patients had full active PF. From these initial results, we cautiously conclude that stroke patients with decreased active PF cannot overcome excessive PF resistance during the heel strike phase of gait, and as a result exhibit compensation strategies at the knee joint. These results will be used to create a more objective method for the prescription of AFOs in hopes to improve the long-term quality of life for stroke patients.

http://www.fasebj.org/content/28/1_Supplement/919.12.short

Foot orthoses for adults with flexible pes planus: a systematic review

Helen A Banwell, Shylie Mackintosh and Dominic Thewlis

Abstract

Background: Foot orthoses are widely used in the management of flexible pes planus, yet the evidence to support this intervention has not been clearly defined. This systematic review aimed to critically appraise the evidence for

the use of foot orthoses for flexible pes planus in adults.

Methods: Electronic databases (Medline, CINAHL, Cochrane, Web of science, SportDiscus, Embase) were systematically searched in June 2013 for randomised controlled, controlled clinical and repeated measure trials

where participants had identified flexible pes planus using a validated and reliable measure of pes planus and the intervention was a rigid or semi-rigid orthoses with the comparison being a no-orthoses (shoes alone or flat

non-posted insert) condition. Outcomes of interest were foot pain, rearfoot kinematics, foot kinetics and physical function.

Results: Of the 2,211 articles identified by the searches, 13 studies met the inclusion criteria; two were randomised controlled trials, one was a controlled trial and 10 were repeated measure studies. Across the included studies, 59

relevant outcome measures were reported with 17 calculated as statistically significant large or medium effects observed with use of foot orthoses compared to the no orthoses condition (SMD range 1.13 to −4.11).

Conclusions: No high level evidence supported the use of foot orthoses for flexible pes planus. There is good to moderate level evidence that foot orthoses improve physical function (medial-lateral sway in standing (level II) and

energy cost during walking (level III)). There is low level evidence (level IV) that foot orthoses improve pain, reduce rearfoot eversion, alter loading and impact forces; and reduce rearfoot inversion and eversion moments in flexible

pes planus. Well-designed randomised controlled trials that include appropriate sample sizes, clinical cohorts and involve a measure of symptom change are required to determine the efficacy of foot orthoses to manage adult

flexible pes planus.

Source http://www.jfootankleres.com/content/pdf/1757-1146-7-23.pdf

Three simple clinical tests to accurately predict falls in people with Parkinson's disease

Serene S. Paul BAppSc(Phty)(Hons), Colleen G. Canning PhD1, Catherine Sherrington PhD, Stephen R. Lord PhD, DSc3, Jacqueline C. T. Close MD, Victor S. C. Fung PhD, FRACP

ABSTRACT

Falls are a major cause of morbidity in Parkinson's disease (PD). The objective of this study was to identify predictors of falls in PD and develop a simple prediction tool that would be useful in routine patient care. Potential predictor variables (falls history, disease severity, cognition, leg muscle strength, balance, mobility, freezing of gait [FOG], and fear of falling) were collected for 205 community-dwelling people with PD. Falls were monitored prospectively for 6 months using monthly falls diaries. In total, 125 participants (59%) fell during follow-up. A model that included a history of falls, FOG, impaired postural sway, gait speed, sit-to-stand, standing balance with narrow base of support, and coordinated stability had high discrimination in identifying fallers (area under the receiver-operating characteristic curve [AUC], 0.83; 95% confidence interval [CI], 0.77–0.88). A clinical tool that incorporated 3 predictors easily determined in a clinical setting (falling in the previous year: odds ratio [OR], 5.80; 95% CI, 3.00–11.22; FOG in the past month: OR, 2.39; 95% CI, 1.19–4.80; and self-selected gait speed < 1.1 meters per second: OR, 1.86; 95% CI, 0.96–3.58) had similar discrimination (AUC, 0.80; 95% CI, 0.73–0.86) to the more complex model (P = 0.14 for comparison of AUCs). The absolute probability of falling in the next 6 months for people with low, medium, and high risk using the simple, 3-test tool was 17%, 51%, and 85%, respectively. In people who have PD without significant cognitive impairment, falls can be predicted with a high degree of accuracy using a simple, 3-test clinical tool. This tool enables individualized quantification of the risk of falling. 

http://onlinelibrary.wiley.com/doi/10.1002/mds.25404/abstract;jsessionid=C8E52F1FD78D8397FBBD8E6C41B2C0CB.d04t04

Heart of England NHS Foundation Trust Job Advert - Band 6 Senior Orthotist

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