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DOFOOTORTHOTICSHAVEANIMMEDIATEEFFECTONTHEGAITMECHANICS OFINIDIVIDUALSWITHCHRONICINCOMPLETESPINALCORDINJURY? By KRISTENLYNJAGGER ADISSERTATIONPRESENTEDTOTHEGRADUATESCHOOL OFTHEUNIVERSITYOFFLORIDAINPARTIALFULFILLMENT OFTHEREQUIREMENTSFORTHEDEGREEOF DOCTOROFPHILOSOPHY UNIVERSITYOFFLORIDA 2002 Thisworkisdedicatedtomyfather,RobertThorntonJagger,andmygrandfather, ErnestThorntonJagger,forpassingonthedesiretosucceed. ACKNOWLEDGEMENTS Iwouldliketoofferspecialthankstoeachofmyacademiccommitteemembersfor theirassistanceduringthisdissertationprocess.Dr.'sChow,Tillman,Cauraugh,Vander Griend,Falsetti,andSidersprovidedleadershipandguidancethathelpedmetogrowas astudent,ateacher,andaresearcher. IalsoextendmyheartfeltappreciationtoMikeJonesatShepherdCenterandBen JohnsonatGeorgiaStateUniversityinAtlanta,Georgia.Withouttheirsupport throughouttherecruitinganddatacollectionprocessesIwouldnothavebeenableto pursuethislineofresearch. Mostofall,Iwouldliketoacknowledgemyfamilyandfriendsfortheirroleinmy doctoralpursuits.IthankJoyforgivingunconditionaldailysupportandbeingapartof my"thinktank";Chris,forhelpingmakesenseofthesenseless;Mum,foralways showingmethesilverlining;andDad,foraskingmethequestionsthatnooneelse would. iii TABLEOFCONTENTS page ACKNOWLEDGEMENTS i" ABSTRACT vii CHAPTER 1 INTRODUCTION 1 2 REVIEWOFLITERATURE 5 HumanSpinalCordAnatomy 5 SpinalCordInjury 7 ClassificationofSpinalCordInjury 8 ComplicationsofSpinalCordInjury 9 NormalHumanGait 11 PhasesofGait 12 Weightacceptance 12 Singlelimbsupport 13 Limbadvancement 14 NormalJointMechanicsDuringGait 14 TheFoot 15 RoleoftheFootDuringGait 17 TheAnkle 20 RoleofAnkleDuringGait 20 TheKnee 21 RoleoftheKneeDuringGait 21 TheHip 23 RoleoftheHipDuringGait 23 ElectromyographyDuringNormalGait 24 Anklemusculature 24 Kneemusculature 26 Hipmusculature 27 FootOrthotics 28 RelevantOrthoticResearch 30 iv 3 MATERIALSANDMETHODS 33 Subjects 33 Methodology 34 DataReduction 39 ClinicalGaitMeasures 40 FrontalPlaneJointMechanicsMeasures 42 EMGMeasures 45 StatisticalAnalysis 45 4 RESULTS 50 EffectsofOrthoticIntervention 50 ClinicalGaitVariables 50 Gaitvariablecomparisonswithintheless-involved lowerextremity 51 Gaitvariablecomparisonswithinthemore-involved lowerextremity 51 FrontalPlaneJointMechanics 52 Jointmechanicscomparisonswithinthe less-involvedlowerextremity 53 Jointmechanicscomparisonswithinthe more-involvedlowerextremity 54 Electromyography 54 ElectromyographicChangesIntheLess-Involved LowerExtremity 55 ElectromyographicChangesIntheMore-Involved LowerExtremity 56 5 DISCUSSION 66 OrthoticIntervention 66 ClinicalGaitVariables 66 Clinicalgaitcomparisonswithintheless-involved lowerextremity 67 Clinicalgaitcomparisonswithinthemore-involved lowerextremity 68 FrontalPlaneJointMechanics 68 Jointmechanicscomparisonswithinthe less-involvedlowerextremity 69 Jointmechanicscomparisonswithinthe more-involvedlowerextremity 75 Symmetry 76 GaitSymmetry 76 FrontalPlaneJointMechanicsSymmetry 80 Electromyography 82 SummaryandConclusions 89 V APPENDIX A CONSENTFORM 91 B SUBJECTINTAKEFORM 98 REFERENCES 99 BIOGRAPHICALSKETCH 105 vi AbstractofDissertationPresentedtotheGraduateSchool oftheUniversityofFloridainPartialFulfillmentofthe RequirementsfortheDegreeofDoctorofPhilosophy DOFOOTORTHOTICSHAVEANIMMEDIATEEFFECTONTHEGAITMECHANICS OFINIDIVIDUALSWITHCHRONICINCOMPLETESPINALCORDINJURY? By KristenLynJagger December,2002 Chair:JohnW.Chow MajorDepartment;ExerciseandSportSciences Researchregardingtheeffectivenessoffootorthoticsduringfunctionalactivitiesis primarilylimitedtotheable-bodiedpopulation.Noresearchdeterminingtheimpactof orthoticinterventiononspecificgaitmechanicsofambulatoryindividualsafterspinal cordinjury(SCI)hasbeenidentified,eventhoughthisgroupoftenexhibitspoorfootand anklealignment.Purpose:Thisresearchwasdesignedtoascertainiforthotic interventionhadanimmediateeffectongaitmeasuresandfrontalplanekinematicsand kineticsinambulatoryindividualswithSCI.Methods:Ninecommunityambulatorswith anAmericanSpinalInjuryAssociation"D"classificationwererecruited.Priortotesting subjectsweremeasuredandfittedwithtemporaryorthotics.Testingincludedbothshoe- onlyandorthoticconditions,administeredinrandomorder.Asix-cameraopticalmotion analysissystemcapturedthree-dimensionalmotionat120Hz,whileforceplateand electromyographic(EMG)data,collectedat1200Hz,providedinformationregarding groundreactionforcesandmuscleactivity,respectively.Aninversedynamicapproach wasusedtocalculatefrontalplanejointangles,moments,andpowersattheankle. vii knee,andhip.MeanandpeakEMGdatawererecordedfromfivesubjectsforqualitative comparison.Statistics:A2x2doublymultivariaterepeatedmeasuresmultivariate analysisofvariancewasusedtodiscerntheeffectoforthoticsoneachleg.Results: Orthoticssignificantlyincreasedthestanceduration,stepduration,andratioofstance ontheless-involvedlimb.Orthoticsreducedthegaitvelocity,swingduration,maximum hipabductionangle,maximumanklepowergeneration,andthemaximumkneepower absorptionontheless-involvedlimb.Onlythemaximumanklesupinationanglefromthe more-involvedlimbwasdecreasedbyorthoticintervention.Qualitativeresultsofthe meanandpeakEMGamplitudessuggestincreasesIntibialisantehorandrectusfemoris muscleactivitywithorthoticintervention.Conclusions:Thereisanimmediateeffectof orthoticinterventiononselectedgaitandbiomechanicalvariableswithintheless- involvedlimb.Thereislessimmediateinfluenceonthemore-involvedextremity.Results ofthisstudyjustifyfurtherresearchinthisarea. viii CHAPTER1 INTRODUCTION IntheUnitedStatestherearemorethan11,000newcasesofspinalcordinjury(SCI) reportedeachyear,withmostoccurringinindividualsbetweensixteenandthirtyyearsof age.®°OneofthemajorconsequencesofSCIisparalysisorparesisofmusclesbelowthe levelofinjuryoftenresultingintheinabilitytowalk.AsaresultmanypersonswithSCI must,atleastinthemoreacutephasesoftheirrecovery,usewheelchairsforhousehold orcommunitymobility.Cun-ently,between183,000and230,000Americancitizenswith SCIfunctionatleastinpartfromtheirwheelchairs.®"Still,despiteitscatastrophicnature, SCInolongerguaranteesthatanindividualwillnecessarilyfunctionfromawheelchairfor his/herentirelifetime.WithinthepastfewdecadesSCIhasbeenclassifiedintotwomajor categories:completeandincompleteinjuries.Incompleteinjuriesaredefinedasapartial orcompletepreservationofsensoryandmotorfunctionbelowthelevelofthespinalcord lesion.^^Personswithincompletespinalcordinjuriescomprisethemajorityofinjuriesat 50.8%.Incontrast,completeinjuries(nomotororsensorysparingbelowthelevelofthe lesion)accountfor45.8%.^ Duetoadvancesinemergencymedicalinterventionandspinalcordtrauma management,moreindividualswithSCIaresurvivingtheirinitialinjuriesandtheeariy stagesoftheircare.Inadditiontheseindividualsaremorelikelytohaveincomplete injuries.^^®°InpartbecauseofthegrowingnumberofpersonswithincompleteSCI, therapistscannolongerassumethatpersonswithSCIneedonlytobetaughttechniques andprescribedequipmentwhichallowthemtoadapttotheirinjuries.Therehabilitation philosophyisshiftingfrompureadaptationtoafocusonmotorrecovery. 1 2 Ongoingresearchatmodelcarecentersaroundthenationisbeingconductedto ascertainthedegreeofcentralnervoussystemplasticityfollowingSCI.Thisresearch trendfocusesontherecoveryofwalkingthroughbody-weight-supportedtreadmilltraining (BWSTT).®°Forthistrainingthepatientisplacedinatorsoharnessthatprovidesvariable body-weightsupport.Trainedindividualsassistandcontrolthepatient'slowerextremity andtmnkmovementatdifferenttreadmillspeeds.Thegeneralpurposeofthistrainingisto stimulatecentralpatterngenerators(CPG)tocreatearhythmiclocomotorpatternthat increasestheindividual'scapacityforambulation.Centralpatterngeneratorsareneural networkslocatedinthecentralnervoussystemthatareresponsibleforcreatingapattern ofrepetitivemotoractions.^Itisthoughtthatcommandsforinitiationandterminationof theserhythmicgeneratorsoriginateatsupraspinallevels^®andthatthegenerators themselvesliewithinthespinalcordoffelines.^^ EvidenceforthepresenceofCPGsinhumansismoretenuous,butaccordingto MacKay-Lyons'*°,"The'bestguess'atthispointisacautiousaffirmation."Centralpattern generatorsinhumansarethoughttoberesponsibleforthepresenceofelectromyographic activityduringgaitthatisnotmeasurableduringvoluntarymusclecontractions.^®^Recent studiesoftheelectromyographicoutputfromindividualswithspinalcordinjuryduring treadmilllocomotionhaveshownthatloadingandunloadingofthelimbsenhancesthe activityoftheantigravitymuscles.^" Ithasyettobeseen,however,ifthesesame electromyographiccharacteristicsarenotedduringovergroundambulation. Although,withadvancedtreatmenttechniques,thereisnewhopeforindividualswith SCItoregaintheabilitytowalk,rehabilitationfollowingSCIremainsextremelycostly. Cun'entestimatesformedicalcareinthefirstyearpost-injuryrangefrom$168,627to $572,178andfrom$11,817to$102,491foreachsubsequentyeardependingonthelevel andseverityofinjury.®"Carefulmanagementofthecostofrehabilitativeservicesofferedto personswithSCIhasbecomeimperativeforfacilitiesandinsurershopingtomaintaintheir

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116 Pages·2002·3.7 MB·English

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