Hi, everyone. We're going to get started now. Sorry for the delay. This is lectures of a non-gait analysis, and it's for CME credit. Our first speaker is going to be Dr. Donna Bloodworth from Baylor College of Medicine. Good morning. Welcome. I'm Donna Bloodworth. I have nothing to disclose. We're going to talk about bracing. We're doing this a little bit reverse order, so we'll talk about bracing first, then we'll get back to gait analysis. But what we're going to look at today is bracing for lower motor neuron disorders. Sometimes I might drift into upper motor neuron a little bit just because it's a little bit hard to separate them. But we'll hopefully at the end, you'll be comfortable with bracing prescription, materials, what you can manipulate at the knee and ankle, and how to help your patients have a more stable and efficient gait. Because after all, that's the actual goal of bracing the lower limb. So since 1973, we've named braces based on the joints that they cross. I forgot to ask about a pointer. There we go. Pointer. Let me just see. Point, point, point, point. Good. There we go. So we are crossing the ankle and the foot. And this is an AFO, ankle foot orthotic. Here, we're crossing the knee, the ankle, and the foot. We have a KAFO. If we added a joint and a waist belt, we could get to an HKAFO. Some other examples would be a WHO, W-H-O, wrist hand orthotic. This one's probably looks like a resting one for nighttime, probably for carpal tunnel. It could be a functional, what we commonly call carpal tunnel splint. And we get back to some of the common names that we might see at Walgreens or what we order. And that's OK. It's just that you can have a specific name for this that's based on the joints they cross. Lumbosacral orthotic, thoracolumbosacral orthotic, TLSO. And then this is a type of AFO. You might not think of it that way. You might go, that looks like a fracture walker to me. It is. The manufacturer would call it a cam walker, constraining ankle motion. And it helps with fracture sprains. Still a type of AFO, described possibly by its purpose, but probably much clearer than what came before 1973, which was a mix of provincial and eponymous monikers. Not super helpful, could in no way either tell you about where the brace was used on the body part or what it did, constrain, assist, or stop motion. So an improvement since 1973. So we know how to name the braces. We also want to be able to describe them by what they're made out of. So super old school, this is a turn of the century leather and buckle belt. It has buckles with a belt. It's leather, shaped like a knee, probably from 1900. If I had to guess, it was made probably as a knee constraining device, possibly for a patient with polio. It's very simple by design, very elegant. The neatest thing about bracing is just how ingenious we all are as humans trying to problem solve. But this is just old school. We still use leather. You don't see buckles much anymore, kind of replaced by Velcro. But this is really a charming old brace that warms an old physiatrist's heart. But it's just kind of cool. And you guys are welcome to play with these after the talk. We've replaced metal, which is very old school. You're like, eh, that's an old polio brace. Yes, it is. But metal's still the workhorse of the brace world. We've gone from iron, which I've seen some of my patients coming from Africa actually have these beautiful crafted. They almost look like a smith did them, or a machinist, rather than an orthotist. Made out of actual iron, they're very heavy. We've kind of tried to move through the periodic table to lighter things like aluminum. There is some titanium. But this is still a workhorse. It's helpful with, it's a double metal upright, double action ankle. We'll talk about that in a bit. Has a leather calf band, but a Velcro closure. And it's still very useful for patients with edema, because the plastic can kind of cut, or make skin pressure. And it's still very useful for patients with very delicate diabetic skin, or Charcot deformities, where I just wouldn't really trust plastic. Since the late 60s, when I would have been in grade school, we've had thermoplastics. And then finally, in the last quarter of a century, we've gotten to carbon fiber. I don't have one of those. Couldn't find a good find on eBay. But you do see the carbon fiber ground reaction force. And they try to use those in polio patients to get stuff lighter. So we're looking for less weight. You'd be surprised. This really only weighs 2 and 1 1⁄2 pounds with the shoe. This is a pound and 1⁄2. It's a hybrid. It's a plastic metal combo. If I put the shoe on it, it gets back up to 2 and 1⁄2 pounds. But by itself, it's a pound and 1⁄2. Sometimes that pound is a deal breaker for somebody trying to ambulate. So we do move toward lighter materials as we try to keep our patients walking, if that's one of their clinical goals. The big benefit of a lower limb orthotic is just to get the foot, which is often pointed down or curved in, to interact with the horizontal surface of the floor properly. We're just trying to align surfaces interacting. We can assist motion with a brace, especially you think of dorsiflexion through swing to pick up foot drop. I know this isn't an upper motor neuron talk. I know who I'm talking to. But we can control spastic muscles, where we've got equinovarus. And we can constrain that and limit it. We can help non-physiologic range of motion, especially at the knee with recurvatum genu or back knee, when we have, in a lower motor neuron setting, hamstring weakness from sciatic neuropathy or a sacral radic. Maybe it's some higher tibial neuropathy. But the overall goal of lower limb bracing is to assist, constrain, or stop undesirable motion, so that we can have the foot interact in a stable and efficient way with the floor, which is normally horizontal, unless we're outside. And then you get into lumps and bumps and ramps and curbs and different stuff, but for just a horizontal walking surface. So we know how to name the braces based on the anatomy of the cross. We're familiar with the materials they might be made out of. And we know what the purpose is, is to help the foot align with the floor and improve gait efficiency. There's also a useful tool, and this comes from Rancho Los Amigos, that's just two things to look at about whether or not bracing might help your patient. One, they're moderately to severely spastic. I know, a different talk for a different day. But we're all neurologists. We live between upper motor neuron and lower motor neuron sometimes. And then is weakness a manual muscle testing of four or less? So very spastic patients or weak patients, not super weak, MMT4, might be helped by lower limb bracing. So now we get to the part with what you can do to the normal foot. What you can do to the normally ankle, the most common lower limb brace you're going to prescribe is an ankle foot orthotic. I can probably count on one hand, maybe I need to, the number of KFOs I've prescribed in the last five to 10 years. You just don't do a lot of it. Patients, unless they're polio patients, and they kind of grew up using a KFO, they're great decorations for a closet. People just don't use KFOs all that much. But we do prescribe a lot of AFOs. So at the ankle, we can stop, assist, or allow. And we can stop, assist, and allow for plantar flexion or dorsiflexion. In general, there's not a lot of help with patients who have lower limb weakness to allow plantar flexion. So mostly we're just stopping it. Let's just say we're always stopping plantar flexion. But on the dorsiflexion part, we can assist it through swing, because we're trying to clear that toe. We may stop it so that we have a stable push-off during the end of terminal stance. If this, if you're allowed to, if you have a weak gastroc, which if you think about it, you're pushing off, and it holds your foot at 90 degrees as you push off. If it's weak and can't do its job, and we allow dorsiflexion, as your center of gravity passes over the weak joint, in this case the ankle, the gastroc's not functional for us or not functional well. As your center of gravity passes over the weak limb, you get collapse. And that's what would happen if we didn't make this a rigid system. So if we lock dorsiflexion or stop it, we help that terminal stance phase where we're trying to push off. You can also assist dorsiflexion. I can put a spring in the back channel of this that's compressed in terminal stance. And it'll help the toe pop up as we release into pre-swing. There's also, pardon me, AFO, plastic hinged plantar flexion stop. But this is called the Tamarack joint. And it actually is spring loaded. And for what extension you can get for it in terminal stance, its elasticity will be restored to the patient in initial swing. And it'll help pop the toe up. So things you can do to two aspects of motion, dorsiflexion or plantar flexion, are normally stop plantar flexion. And then on the dorsiflexion side, allow it to be free. Assist it with a spring. Or stop it to help more stance phase gait needs. So now we're looking at just kind of different types of braces. All my little friends I brought with me in my suitcase. The first brace we'll look at is just commonly called a posterior leaf spring. If we wanted to prescribe it, and you don't have to know how to make Bactrim to prescribe it, brace prescriptions not done in a vacuum. Work with a trusted orthotist or physical therapist. They really help you kind of dial in and titrate and adjust the brace. So work with your whole team to come up with braces. And you get better at it. I knew nothing about this like 30 years ago. But I'm the brace clinic lady in Harris County in Houston. So I've been doing this for a while. And I'm always learning. It's a fun job. You help people walk better. And they're really very gratified by that. So this is AFO, obviously. That's what we call it. It's made out of plastic if you want to specify material. The trim line is posterior to the mallea line. It only has an ability to do a job in the sagittal plane. And it's so flimsy. There's so little material. It can only really pop up a one pound foot. So my last friend I'm going to get off the table. So this is your posterior trim line behind the mallea line, also fondly called a posterior leaf spring AFO, made out of plastic. It's distensible with your body weight. And it's dispensable with my weak little scrawny arms. In terminal stance, it would be distended. It would store elastic energy. You're seeing how long I can do this, aren't you? It would store elastic energy. And then as we get into toe off for initial swing, it would pop the toe up and help clear the toe through swing. It's the only job this little brace can do. So it's kind of helpful. Kind of helpful. It is helpful for perineal neuropathy and isolation. Beyond that, unless you have a very petite woman who's not moving, and it could be a petite gentleman as well, you don't like to over brace. Unless you're, this will not help medial lateral instability. And it can't stop posterior translation of the tibia. But in a petite, small, slow moving person, you might get away with this much brace if you just didn't want to weight them down with something more substantial or heavy. But again, it would be in consideration with the team, sort of looking at options. All right, our next AFO, still plastic, but with a trim line that's anterior to the malleoli. You can almost see a little bump where the malleoli lives. This is not hinged. It is solid. And dorsiflexion and plantarflexion are just set at 90 degrees. So this is going to stop plantarflexion, and it's going to stop dorsiflexion, all at 90 degrees. It's not adjustable at all because it encases the malleoli. It now has a coronal plane feature and can stabilize and encase the ankles and create a medial lateral stability simply by constraining medial lateral stability. This brace isn't a favorite for me. I don't prescribe a lot of them unless the patient's been weak for a very, very long time. They have no hope for ankle motion restoration because I just can't adjust it. The patient probably may have been a, maybe a, had spina bifida as a little one and has kind of come up in these braces. It's still ambulatory, doesn't move very well, probably uses cane and cane crutches or walker. But this brace is not adjustable once you make it. Again, we're back to our double metal upright here. And this brace is the one pictured there. Your double metal upright now, so AFO, metal upright, double channel ankle. We'll talk about that in a minute. This one is heavy but can do the job of just plantar flexion assist in a diabetic with edema with questionable skin. If we put a spring in the back channel, that can be compressed. It's a lot of brace for simple peroneal neuropathy, but they're conditioned to do that. So it's a brace for simple peroneal neuropathy, but they're conditions where you might want it. You can also stop the front and the back channel and have something that allows no motion, has medial, lateral, sagittal, or frontal control, as well as very rigid sagittal control. And you can allow dorsiflexion by backing out the front stops and allow some motion, which patients like. These braces, also plastic but hinged, have a plantar flexion stop. This one allows dorsiflexion. Some patients don't like you to take their translation of the tibia away as they move from loading to mid stance to terminal stance. Our little blue brace and these come in all sorts of colors. You can put patterns on them Some of my patients have like the Texans. Finally, we're proud of the Texans. Um, I said that um, and then there's somebody they put like shoes you kind of for little kids and stuff You can laminate these with lots of stuff. And again, this is hinged plastic interior trim line It has some dorsal flexion assist and you don't have to know that this called the Tamarack joint You just tell them you want a dorsal flexion assist at posterior stop I have the brace this double action ankle is the same thing that's on the Shoe version whatever I did with that. I have no idea walked away. Oh, there it is in front of my face Um, so this is called the double action ankle and you're like double action what? dorsiflexion and planar flexion um and So what you have is a little half circle from sort of three o'clock to nine o'clock and that's That's in here. And I know you can't see it. But again, we can have play time after the After this talk's over. This is basically three o'clock and nine o'clock and then you have this Channel that's open here where the little half Half circle lives and it gets stopped at about 11 o'clock in the back and about one o'clock in the front So you can have motion Around this joint from sort of one o'clock to three o'clock and you can go into dorsiflexion Or you can allow planar flexion from 11 o'clock to nine o'clock um Or you can put in stops That push down into the channel The um Little holes. This is called a double action or double channel ankle this little Hole or pinhole is the posterior channel. This is the anterior channel anterior channel stops Um planar dorsiflexion posterior channel stops planar flexion Um, you can also Put a spring in the back that you compress In at terminal stance and that would allow a little pop-up as you go into initial swing There's not really a way to assist planar flexion because when i'm planar flexing going up on my gastroc i'm moving my whole 150 pounds There's no spring short of the front end of a car that's going to move 150 pounds, but you can stop dorsiflexion Which is an indirect help if I don't sink deeply Into dorsiflexion I've indirectly or passively helped planar flexion. So if we stop dorsiflexion I somehow took the hinge out and allow the toe to go over at terminal stance the patient won't Sink as their center of gravity passes over All right, so just as we look at again just trying to learn to prescribe And again, you don't have to know how to make these you don't have to be like a Plastics chemist, um, it's a team team effort. Um, Um, we again afo most common thing you're going to prescribe plastic The trim line is interior because it's hinged This is a dorsiflexion assist mechanism and there's a planar flexion stop in the back. That's all it is This is just a dorsiflexion assist afo hinge plastic This one is Plastic also the trim lines interior. It's hinged. There's a little teeny tiny plastic, uh planar flexion stop in the back Um, obviously for a pediatric patient And then this is a metal upright afo with a posterior stop and also an anterior stop Which is allowing us as our center of gravity passes over that weak gastroc weak s1 radic sciatic neuropathy tibial neuropathy weak gastroc cmt patient um as they pass over with this rigid external frame It holds that 90 degrees for us and gives us a lever arm to push off of So Again some patients don't want their ankle locked up. You might allow dorsiflexion as long as the gastroc's not weak But if you do have gastroc weakness you want to stop that um Ankle at 90 and you do that in the interior channel And you're you might question. Well, why do we really have to stop planar flexion? And because that's sort of our only choice for that and we almost always do it. I just saw a patient who had some weird incompetent musculoskeletal incompetent ankle joint with this like medial lateral roll and I actually I think it's probably the Second afo i've prescribed in 30 plus years where I allowed dorsiflexion planar flexion Because what he really had was this msk Medial lateral incompetency So we are allowing he can use the gastroc and the tibiant. He's just the joint itself is incompetent So If you had hamstring weakness, which is active through stance you think you you may not think well All right, so you also have plantar flexion stops on your plastic braces, and again, please come see these. They came all the way from Houston in a suitcase, so they're really happy to get out. This is a little tiny plantar flexion stop. It can get worn down over time. It's no more substantial than a pencil eraser. So it wears down over time. You sometimes have to replace them, and it makes a big difference in the patient's gait when you do. So when you see these come in, just inspect them to make sure the height looks appropriate and it's not like worn down to a nub. This one's slightly different, but again, this is your plantar flexion stop right there. All right, so summary slide. If we're just dealing with a swing problem and a foot drop, just dorsiflexion assist. You probably don't need to do anything to plantar flexion. You can get away with a PLS, posterior leaf spring. If you're dealing with gastroc weakness, you're going to have to stop dorsiflexion and probably stop plantar flexion. As we move up the kinetic chain, if you have quadriceps weakness, you're definitely going to stop dorsiflexion because that keeps the tibia from going forward. Be very, very careful on the plantar flexion stop. The patient may rely on just a smidge of hyperextension at the knee to be stable. Work with your therapist, work with your orthotist, because again, we're talking about center of gravity and close kinetic chains and lines of force. I didn't talk a lot about hip weakness because you really can't, one of the first rules of brace club is you can't brace proximal weakness. I know somebody out there disagrees with me. It's okay. You have to be able to flex the hip to advance the limb. You can work around extensor weakness with canes or walkers. So I can probably put you in KFOs and get around like gluteal weakness. And sometimes that's how some of our lower spinal cord injured patients ambulate if they want to do that. It's not super efficient, but they can stand or ambulate with canes, high braces. Myopathy is not really going to be a braceable condition because it's a proximal weakness problem. This slide is a summary for the next 18 slides. So if you want to not pay attention anymore, here you go. This all came out of a paper that Dr. Tan and I did. And we were looking at the literature for what the current bracing needs were with patients with lower motor neuron conditions. So there's not a lot of info on ALS, Eaton-Lambert, myopathy, limb girdle dystrophy, which is a little surprising. Bracing is helpful, not surprisingly, for polio, CMT, Charcot-Marie-Tooth, Guillain-Barre, about half the time. It's used in a post-op setting with myotonia and probably only indicated as a resting splint with Duchenne's. It actually can make those little kids fall, affect their ability to stand up, get upstairs, get off the floor. So we don't actively brace them. There's a shout out for other adaptive devices, canes, wheelchairs, in the literature for polyneuropathy, Guillain-Barre, myasthenia for wheelchair use, which I was a little surprised by, and inclusion body myositis. There is some physiologic benefit that's been demonstrated by brace use in patients with diabetic peripheral neuropathy and Charcot-Marie-Tooth. And then there's that, and we all know this, there's a longitudinal, my needs are going to change as I get older, recommended longitudinal multidisciplinary follow-up, very strong in the literature for both polio and diabetic peripheral neuropathy. So again, not a whole lot on anterior horn cell disease. Some other areas were mentioned, other anatomic areas mentioned for maybe useful orthotics in other anatomic areas. Anecdotally, I've prescribed AFOs for early ALS, but the progression to wheelchair and eventually Hoyer lift is unrelenting, sadly. With post-polio syndrome, there were some interesting nuggets on this slide. You're like, well, you can brace polio, but you can't brace spinal cord, and that's because the sensation's intact on the polio patients. Polio patients rely on joint position sense, joint integrity for their ambulatory ability. One of the things to know is that if you see knee hyperextension more than 10 degrees, that's unstable and it's unsafe, just something to look for on your clinical exam. Again, the shout out for longitudinal and multidisciplinary follow-up because it's not only the post-polio syndrome with the muscle affectations, but the whole musculoskeletal cardiovascular system is getting older. In these patients, the last polio outbreak was before I was born. It was 1957, so I was born in 62. All those polio patients from the last U.S. outbreak are getting older, folks. So they're just having natural aging, and that adds to the senescence, just adds to mobility issues as it would for any person that's getting older. Again, we look at orthotic material, trying to make it lighter to prolong ambulation if that's the patient's goal. Some interesting stuff, loss of ADL, loss of ADL independence related to age, ethnicity, wheelchair use, and use of AFOs in childhood. A lot of my polio folks I see now coming from Central America, Mexico, weren't braced as kids, and it's interesting to see them transition into brace. It's a little, it's kind of hard to get them to accept it sometimes. Not surprisingly, the reason we use orthotics is to help gait be more stable, to prevent falls or trips, or help balance, and not surprisingly, we use dorsiflexion restraint if patients have gastroc weakness, because that's how we help gastroc weakness, in the stance phase of gait at terminal stance. And for the most part, if the brace helps the patient, they really like it. So polio patients in particular are orthotophiles, they really are. We have, did I hit that? They have looked at lighter bracing paradigms. They've also looked at adding devices to the knee, that anything with technology is going to make it more expensive, heavier, and fussy in humid or not ideal environmental conditions. So just watch out for that. It probably did help with falls. It didn't necessarily improve gait speed or step, which is sort of the functional outcome, but we could measure some physiologic range of motion stuff it did help with. So as you think about, oh, should I get my patient one of those computerized knees I've heard about to assist gait cost, weight, might prevent falls, but it's really a titration. And you'd also want to really get kind of the 411 from the orthotist and know, okay, how many times is this thing in the shop to be repaired? I think about that with prosthetics, where like a vacuum unit instead of just passive suction, you're just, it's, you're always in the shop. It's fussy. It's a Maserati. It's fussy. With neuropathies, not a lot of information on specific neuropathies. You can use any type of AFO that's appropriate for the condition that you're trying to help. And again, another shout out for assistive devices. They may be helpful. Charcot-Marie-Tooth tends to have sort of all the way around weakness at the lower limb. You may need, you're probably going to need a more substantial brace, either something hinged in in the plastic version. I really, my favorite brace, if I can get away with it, and the patient doesn't have edema or skin problems, is this old hybrid. It takes up a lot of room at the throat of the, throat of the shoe, but it's very adjustable. It goes in just about any shoe that has the same shape as the footplate. I like this brace for adjustability and ability to do its job. And the Charcot-Marie-Tooth brace users of interest versus non-orthotic users tend to feel like they don't walk as well. The non-brace users were shown clinically to be stronger, and they think probably what's happening is that the ankle's just getting stiffened, and that is helping the patient's gait. They have looked at, like post-polio, they have looked at lighter materials in Charcot-Marie-Tooth, and these folks do, are able to walk faster as a result. And steppage gait is helped, and the patient can walk longer. So we can walk, they're two kind of functional outcomes, so faster or longer with bracing for CMT patients. With diabetic neuropathy, there surprisingly wasn't a lot on ankle-foot orthotics, but there was a lot on inserts, and there is a huge, glaring, awful, bad typo in this, folks. It didn't decrease standing static balance. Total contact inserts increase static balance. Your balance is better, so please fix that typo, and I apologize for a few, I was looking at that going, oh my god. No, static balance is better. Dynamic balance as we move around is not probably improved. And again, some of the benefit of any orthotic is probably due to stiffening of the ankle. AIDP, if you're doing, taking care of Guillain-Barre in-house, possibly at the rehab, I don't think acute care, we're going to discharge them with AFOs, but in the rehab phase, anywhere from slightly more than half to almost 70 percent of patients are discharged with bilateral AFOs. So I guess that's good news with our Guillain-Barre population because they get back to ambulation, but they may be brace users. And there was one complication in this group with a DVT. I don't know if that was the brace's fault or just the change in mobility, but there was one complication reported in the literature if you'd like to check that out. Myasthenia gravis has discussion of orthotics for other areas. Again, a shout out for other walker or adaptive aids for gait, wheelchair cane walkers. Eaton-Lambert, I didn't find anything in the last 10 years of literature. As a rehab doc, I don't often see myopathies till they're already wheelchair users. Sometimes the therapist trying to preserve gait will end around and bring them to me. I did have one very dedicated, eager, petite outpatient who was able to use semi-rigid AFOs for about two years before she finally succumbed and became a wheelchair mobilizer, full-time wheelchair user. But just something to think about as we reach out and interact collegially is you might include rehab sooner or just the orthotic portion sooner to try to help your patients. But it's a proximal weakness problem, and we're probably not going to brace our way out of a proximal weakness problem. Inclusion biting myositis was just sort of interesting because of kind of what's associated with what. Dysphagia coincides with knee extension strength of, that's 22 foot pounds. I'm not sure what 22 foot pounds does, but that's what it correlates with. Pinch grip difficulty, not surprisingly, correlates with a decreased ability to do ADLs. But very interesting, starts to correlate with falls, which as a function doctor I'm very concerned about. And then about 10 years into the disorder, they become cane users, and five years after they become cane users, they become wheelchair users. The three-fourths of these patients use an assisted device of some type. They've looked at KAFOs, and this is a actual, this is a computerized stance control. In these patients, they have, it doesn't actually help gait be better, and the patients that did the best with this bracing had less weakness. Myotonia, not a whole lot except that we use passive bracing after surgery. The adult onset muscular dystrophies, AFOs probably improve walking speed and quality of life. Limb girdle dystrophy, really surprised there wasn't a lot on this, but can't, treatment in general can include AFOs. Duchenne's dystrophy, if there's any PD folks out there, they are not, falls increase when we try to put them in braces. There may be some permanent injury if you encourage them to involve themselves in eccentric contractions. Again, falls increased when they tried these kids in AFOs. It makes it hard, it doesn't help function, so I'm like the function doctor, it doesn't help function. Harder to get off the floor, harder to climb stairs. You can promote passive standing if that's a goal for the patient with probably a KAFO. So with that, claim your credit, all, oh lord, we're pushing the wrong thing. All my references are here if you'd like to check them out. I apologize for that one typo on increasing static balance, and I hope this helped you learn. Please come play with the braces after the talk if you would like to. Thank you for your attention. Our next speaker will be Dr. Faye Tan on approach to gait in adult onset and M disorders. Good morning. How's everybody? We're still okay? Need a stretch or anything? So Zach Simmons, editor of Muscle & Nerve, invited us to give this presentation, not the presentation, but the invited paper for Muscle & Nerve. So don't worry, it's coming out to Muscle & Nerve soon. And why is because he didn't feel like everyone was comfortable with gait analysis and certainly, you know, just dabbling into the bracing is very hard, right? How many people? Raise your hand. I'm a gait expert. No? And that's why he wanted. So unbelievable that Zach Simmons himself would say that he would like to know more about gait, right? You know, it's like Zach knows so much, right? So my section kind of covers the approach to gait. So we're gonna go like 0 to 60 on starting with some basic, which are the PM&R folks here? Okay, so we're gonna go 0 to 60. You guys know your basic gait, but can you please be patient for our neurologists? Yeah, okay. Let me get started with that. Nothing to disclose. So here is the walking sign in Australia. I just throw some of those in because I was there recently. Normal gait, this kind of, we upended the sequence because of some AV and our pet orthotist couldn't join us, so we'll kind of cover what she's gonna cover. Who walks on two limbs? You know, walking and running is unique to humans. You know, okay, so they, penguins, they waddle, right? I was at the zoo, obviously, and I think kangaroos kind of cheat a little because they get that tail. So it's three limbs when they rest. They hop. Okay, not only do we walk on two limbs, every day you walk, you should just, amazing, right? We walk with, look at that crazy big backpack on this guy, and he's balancing, and he's, you know, awesome guy. So these are the things we're gonna cover real quick, and we're just trying to get you better at gait analysis. So when we're done, we're gonna actually do some gait analysis, and we're gonna, just in your mind, think, if you think that you have trouble at the end of this week, and your feet are aching in any way, maybe the shoes, you got Dr. B right here, and we can just figure out what's going on. Shoe up. Okay, so gait efficiency. We watch the Olympics obsessively as PM and our doctors, and one commentator said something really brilliant, which is about the center of gravity. So if you cannot move your center of gravity, which is just above your pelvis, you know, for a neuromuscular patient, the less you move that, the better they are. I always tell them, you've got a dollar, and when you spend the dollar, that's it. You're tired. You're not going to do anything else today. So the more you move that thing around, the less things that they can do, right? Okay, so how are we going to do that exactly? The lower their center of gravity, the less likely they're going to tip over. That's, you know, sports car. That's why they quote, hug the road. Interesting. I have to throw some space medicine in there. Astronauts, when they float around, all of the- they don't have the weight pulling down on- they don't get ankle edema. It all shifts up to their head, so when they get home, they actually tip over because their head's heavier. So here we go, right? Hugging the road, monster trucks, higher center of gravity, you know, intuitively in a car like that, you're not supposed to turn real fast or you're going to be flipping. So quickie quick, I know our PM&R lovers already know this. If they don't, here it is for the boards. Six determinants of gait, written a while ago, 1953, by Saunders, Inman, Everett. It's like so classic. It's like biblical, and six of them, three have to do with controlling your pelvis, two at the knee, and one ankle foot. So if I were to take, you know, your pelvis, which is an oval, right, and I twist it this way, right, this way, and you walk. If I can twist it, your leg is effectively longer. So the first one's rotation, obliquity is this way, it absorbs if your leg is too long, and then shifting a little bit this way and that. That should be 101 for our PM&R folks. You know, I say that, but then not everyone really truly understands these determinants of gait. Knee flexion is helpful when you are at the peak of stance, you want your leg shorter so that you don't have to move that center of gravity up, so you can bend your knee a little bit, and at the end of stance, you can stretch out your leg. Knee extension, again, make your leg longer to save energy. Ankle foot, I actually, to my attending, I said I didn't believe in ankle foot when I was a resident, and I got hauled into his office and told to memorize this book from beginning to end. So if you don't believe in ankle foot, try, has anyone broke their ankle skiing or whatever, or had to wear an ankle brace? It is so hard when they take out your ankle joint to walk. All right, so now I want you to focus on the yellow part. This is the leg, the yellow part. We're just going to real quick go over the phases of the gait cycle and their initial contact, referring to the foot. You load onto the foot, which is the next part, and you can see the knee kind of bends and does what, these, all these figures are already in the journal article, so don't worry. Mid stance, right, that's where you're bearing all your weight on that one leg, and then terminal stance when the heel comes up. Basic 101, but then we're going to get a little bit more advanced. Keep your eye on the yellow. This is swing, pre-swing, okay, getting ready to swing, initial swing, mid swing, terminal swing. Everybody got those eight phases down because I want to get fancified. The key to learning gait cycle, how many people had to memorize EMG activity during gait cycle for the boards? Yeah, everybody, right, and did you understand it? Hands go down. You just memorized it, right? You didn't really kind of comprehend it totally, so in order to really decipher this, basic 101, concentric, right, just to review, goes toward eccentric. So why did I tell you that? What's that useful for? Concentric is acceleration, gas pedal, okay. Eccentric is deceleration, brake pedal. Not only does it brake, it stabilizes, so you have to know those two things. So fun facts, eccentric's more physiologic, we do more of it, it's more graceful, it incidentally helps you hypertrophy, not lost to the weightlifters. So weightlifters would, there used to be a sign that said, don't stand on the weight stacks. I still want that sign. Anyone find it in an antique store, I want it. So they go concentric, lift, you know the two gigantic competitive weightlifters that are in the gym 24-7, no matter where you go, they're always there weightlifting, those two. So they go concentric, right, and then they'd hop on the stack to get better, bigger biceps, and they go, right, and that was to eccentrically enlargen their biceps. Insane, injury, not cool. Now look at the red. This is muscle activation during stance. You see, it's the same thing, we're just looking at red now. So during stance phases, you've seen this slide already, what do you see more of, red or green? Right, red is eccentric. What do we say eccentric does? It slows you down, and it stabilizes so you don't be falling on the floor, right. So guess what, these are the muscles that you memorize for the boards, but now look at them in a new light. They're all red. They're all slowing you down. Why? Because you just swung your leg through, and you're hurtling forward, and now something's got to slow you down, over and fall on your face. So you guys can figure out what these little things are, right, glute medius, glute max, quads, hams, dorsiflexors, and gastrocnemius. Wait, wait, there's a touch of green. Why is that? Obviously because at the end of stance, I got to pick up my heel and get started with swing, right. Does this make more sense now, that you know it's all red? Okay, that's a summary slide, so we don't have to go over that. Okay, so now we're going to look at swing. Same slide that you saw before, but now we're going to focus on the swing phase, four phases of swing, pre, initial, mid, and terminal, right. Wait a minute, there's green and red, looks Christmassy, but this one has more green, right, and that's because the iliopsoas, which you can see somewhere, is that it? Iliopsoas, that little green thing right there, it's pulling the leg forward. It's green, right, because it's contracting, it's pulling the leg forward, and the red on either side, stabilizing, as otherwise you'd be like, Seinfeld, did you see when she's dancing? That one, so that would look like that if we didn't have the red ones kind of stabilizing. So yeah, absolutely, tib anterior, that green in the front, right, got to clear the foot to swing through, lots of green. So now when you do gait cycle, it makes sense, right, green, red, a lot easier. That's the summary, I'm not gonna, you can read it later. So now let's put it all together. As far as gait, you got your proximal weakness and your distal weakness. I don't care which neuromuscular disease we're talking about, just figure out if it's proximal weakness, distal, or combo platter, and then you'll kind of know what to do. So that helps with your gait analysis and your bracing. She already said proximal is gait aids, no bracing for myopathies, distal is bracing, okay. So that's just like an aha moment, you know, when I figured out like, wait a minute, and I'm not covering all the other things that affect gait, like loss of sensation and diabetic gait and just a bunch of other things. So proximal weakness, you know, myopathies as the poster child, these are the muscles, these are what happen, and we'll kind of go over it more in a picture format. Everyone knows Trendelenburg is the famous thing with proximal weakness, right? Everyone understand the Trendelenburg? Opposite side? Kind of remember all that from boards? You don't? Okay, we'll go over this little very easy seesaw. I know you remember it. Weight of the legs gonna fall on the opposite side, unless you fire that glute medius on the opposite side, right? So no glute medius in myopathy, what happens to the seesaw? It's gonna fall on the opposite side, right? That was Trendelenburg. All right, Trendelenburg then is where the glutes fire. So to put it all together, glute, glute, glute, glute, right? Glute medius. So guess what? In the, those first four parts of gait, which is stance cycle, you're gonna Trendelenburg. Right, this is proximal. I put a little box around proximal. Then for the next part, you, you can't pull your iliopsoas through, right? It won't let you advance your legs, so you get a short step. So lean over, Trendelenburg, short step. Lean. that's what you're going to be looking for. I just try to put in one slide so it's easier for people. Everybody have that? It's going to be in the paper. Distal weakness. 75% of polyneuropathies, as you know. Here's the actual muscles, just go over it. Dorsiflexors, foot slaps, steppage gait, circumduction, right? And so if you can't do that after a while, you get tired, you're like, why are you wearing bedroom slippers, you know, when you already have unstable gait? That's so dangerous. How many people have come to you in bed bedroom slippers? Yeah, it's like, why? It's because they're shuffling. You're like, I want you in this wonderful shoe with all this wonderfulness. They know. That's because they need a short shuffling gait. Okay, so the bottom half, distal, right? We put a box around that. First half is going to be the foot slap and then you're going to either hip hike or circumduct, right? So the whole gait cycle, right? Foot slap, circumduct, or hip hike, right? Foot slap, circumduct. I need Dr. Glaucum Fleckham to make a YouTube of both of these dances. He loves us, right? Okay. Then there's non-length dependent. That's what I call combo platter. In my brain, in Dr. B's brain, it's both. So you're going to brace the bottom half and give a walking aid for the other half. And then, unfortunate, it's so unstable, you're probably not going to be talking about walking. Okay, let's see. There's asymmetric. I'm not going to go through all of them because Dr. B went over them. And because we want to actually preserve some time to actually do gait and let you guys play, this is meant to be more interactive. We're going to stop there. So straw poll here. What would you guys like to do first? You want to watch Dr. B analyze gait, do her gait magic? We need a runway volunteer. Anyone whose feet are hurting? Otherwise, I will walk. Everybody's too shy? Or would you rather play? Well, before everybody gets up and walks around and plays with the AFOs, we can... Oh, yeah. So the question is, where can you get the posterior stop replaced on your plastic AFOs that are hinged? The orthotic shop that made it should be able to replace it. It's just kind of screws in or pounds in. You can actually adjust it with an Allen wrench and sort of push it out. It's almost like a mechanical pencil a lot of the time. But yeah, if the patient has moved from wherever it was made, any orthotist can replace the posterior stop for you. These things can be repaid for. Insurance will pay for them again every three to five years, depending on which insurance it is. They do fatigue over time, they're plastic, they're metal. My really active patients can even blow through this thing. I mean, they can wear out the double action ankle, the stops, the rivets that hold it to the shoe. But yeah, the orthotist who made it, fabricated it, should be able to do that for you. And if the patient's in a new domicile area, just have a favorite orthotist that you like, or a couple. So this may not necessarily fall under gait and neuromuscular diseases, but we see a lot of patients with like either like naturally high arches or flat feet and a lot of back issues from that. Can you touch upon that? What would you advise as far as shoes, inserts and stuff like that, because there's a lot out there. I love that question. I think I, that's my. question. I am going to now remove my penny. Okay, so we're going to first go over flat arches and and things like that and I'm going to borrow from Dr. Ploworth. So let's see who does anyone have a where we can see just your legs like that just your a skirt anybody out there I promise we're not going to make fun okay okay all we want to do is is do you mind coming and standing and looking that way and everybody line up if you're not perfectly lined up All right, everybody, line up like you're going to putt on golf, okay, and look, okay, take your shoes off, do you mind? Okay, you really have to line up straight this way, a little space between the feet, okay. So if the Achilles tendon isn't straight up and down, then, yeah, then per the great Dr. Bloworth, you get, I'll come from the front, if you see too many toes, my residents are so funny, they go, too many toes sign, I said, that's not a real sign, but we've trained them, so if you turn in, you'll see too many toes, okay, and I'm going to check for the arch, no, stay like you are, I should be able to get a finger under there, a little tight, so what do y'all think, I'm not teasing you, okay, so what do you think? I'm going to say I can't get my finger under, you see a few toes, pronation, pronated, right, it's not perfectly straight, she's a little pronated, so what do we do, arch support, okay, the intrinsic minus and peripheral neuropathy, next time you're in EMG and they're like this with their toes and they got little bunions, just put your hand underneath the met heads and the little toes go flat, what do we do for that, metatarsal support, so yeah, she needs a shoe, now I embarrass myself, okay, a strong heel, the shoe starts, this is just, I'm not endorsing any brand, a good shoe needs a driving stability which is a strong counter right here and then the foot does heel strike, goes out and 5, 4, 3, 2, 1, when you walk today, are your toes heel strike outer, 5, 4, 3, 2, 1, can you do that with your toes right now, if you're not, then you have not freedom to move your toes around and you're probably going to foot pain by the end of this week because you're wearing pretty shoes but not functional shoes, right, I wore tennis yesterday, it's definitely hurting because I was, right, so this particular one, so you can fix that with a flat arch with an insert, those can be ordered, you know, from Amazon, the pet orthotist would have been brilliant and helped a lot but that, yeah, you can either get ones that bake in the oven, you can get ones that have a certain rigid arch, the insert can be 100 bucks on top of your good shoes, so you could have a good shoe but not the right insert but the components of the shoe, that's what you need, so that's why the wide toe box, so the podiatry society actually says we don't want people in flip flops and sandals, really good looking but it's just not good for you, it radiates up and give you arthritis as the years go on. So yeah, by the end of the day, you have this on your badge. My brain hurts because it radiates all the way up and you're unhappy, right? So you know, when you go to the shoe store, and we really want you guys to start with yourselves so that you can learn. When you go and you say, I know my shoe size, I've stepped in that little, you know, contraption, the metal contraption, raise your hand, who knows what that little slidey thing is for? The little slidey thing, what is that? Okay, so they put that on your met head so that the back of your foot and your total foot may be different. So I'm going to tease my husband. So his, from the heel to his met head is size, I forgot what, you know, 10 or 11. But because he happens to have, so he's got a big foot, but his toes are a little shorter relative to his foot. So he wears, he was wearing, you know, the wrong shoe. So she actually, the pet orthodist actually figured out that he needs a smaller shoe with E width. And you just wouldn't know that unless you saw a professional pet orthodist to figure that out. And just speaking to the mic. When I look at the gait cycle pictures and I think about my patients with femoral mononeuropathy or sporadic inclusion body myositis, it seems like what they need is some stop when they're in that second phase of the swing. And I'm wondering why it's not possible with any bracing option to add that for them. For quadriceps weakness, you can control the knee, one of the, brace club, fight club, so brace club. So in brace club, you can control the knee at the ankle. And if you stop dorsiflexion and plantar flexion, you can see how the patient does. You may be tempted to make a KFO and sort of lock the knee out or the compliance with that's not going to be great. But you can try a KFO. But the only reason you want to do that is because you're going to lock the knee. But you absolutely can control some degree of knee weakness. At some point you hit a tipping point. But stop dorsiflexion, stop plantar flexion. They might need an assistive device, a walker or a cane. But yeah, absolutely, you can do that. Does that help? Yes. Thank you. Hello. I'm wondering if you can talk through when the two scenarios where you have a patient who is gaining strength and you're trying to decide when to hinge the ankle of an AFO and the opposite when someone is getting weaker and you're trying to decide at what point or based on their exam when you switch to a solid ankle? This is just information for your notesmanship. Insurance will not, to answer the beginning of your question. Insurance will not pay for a brace, including Medicare, for a non-ambulatory patient. They may struggle for a while in therapy before you can comfortably in good conscience deem them ambulatory. My bar is very low. My bar is not high. If they can walk 10 feet in parallel bars, I'm like, you're ambulatory. But decide in good conscience what is ambulatory. Because if they're non-ambulatory, you will not get a brace, an orthotic out of an insurer. They're going to have to do some therapy, leg work, and I'm sorry for that. But they're going to have to do some earnest work with a therapist to try to get upright standing and then weight shifting and gating. That's to get them into an AFO. I like my dopey little adjustable hybrid because it fits in shoes and it's just adjustable. You can lock it up. You can unlock it. You can assist it. It's very, very adjustable. Assuming they don't have edema or bad diabetic skin, Charcot deformities. As they become weaker, again, if you use an adjustable brace with a double action ankle, you can start to titrate down, restrict more, constrain more, stop more. I won't put anybody in a solid ankle. Unless they come to me that way or there is just no motor recovery that's happening and I just need a stable walk to the bathroom or to the kitchen. This brace is very constraining. It's also plastic. I live in Houston. It's still 98 degrees. Maybe it'll be cooler tomorrow. I don't know. But anyway, this can be hot. So if you're from anywhere where it's hot, this could be kind of a deal breaker. They do do some fenestration. Like with kids, I haven't seen a lot of fenestration with adults to just try to make it cooler. But I wouldn't use this unless there is no hope for motor recovery. And we're just trying to ... Does that help? Is that in line with where you're thinking or am I not helping? I love hinged braces because they're adjustable. In my population, I may only get to pay for one brace in a lifetime. I like adjustability for that reason. The downside to the hybrid is it really takes up a lot of space in the shoe at the throat. And you can just see the footprint, pun intended, is just wider at the throat of the potential shoe. So not taking the hinges off if I don't need them gets rid of weight, gets rid of space. But it also ties my hands on adjustability. It's all ... And again, we don't prescribe braces in a vacuum. Dial in your orthotist, dial in your PT. We have a brace clinic. I suspect that a lot of like ... And you might even, if you have a lot of population with gait orthotic needs, you might just want to create a brace clinic. Invite one orthotist, two orthotists, invite a therapist. Their time is sort of uncompensated, but they will get some business from it. Maybe invite several ... You don't want to violate any Stark laws. I don't have any. We have a contractual orthotist at the county. But you just ... It's also a good way to just ... Everybody learns. It's a wonderful environment when we do brace clinic in Houston at the county. I think there's one more question. Hi. Yes. I wanted to ask and see what your experience with PDEs, specifically in neuromuscular diseases, from experience or literature, if there's anything out there for that. PDEs, pulmonary embolism? PDE, posterior dynamic, the little extension that goes in the back with the angle that you can adjust. A PDE and an AFO? I'm not familiar. All right. I saw one more hand. Anybody? Oh. Professor Nguyen. Oh. Hi. Thank you for your time. My question is, a lot of patients come into the clinic and they have their own MacGyvered device that they got off Amazon, whether it be a carbon fiber with a spiral in the front brace, or they have the dorsiflexion little click assist. Is there any danger for them to continue using those, or when would I guide them in a different direction? Yeah, buddy. You can get anything on Amazon. A lot of times the patient has a brace. My population is impoverished. A lot of times the patient has a brace that isn't what I'd prescribe, but my signature was not involved in their choice. They like the brace. They can afford the brace, and it helps their gait and they're not unsafe. I think I would let unsafe just be my conscience on that one, but you can—now where you need to be careful, patients will bring you stuff they bought on eBay. That's where all that came from, eBay. Okay? And it's not made for them. It's never going to fit them. These are custom-made devices, and they cost like custom-made devices. But if the patient can find—often the PLS is over the counter. This little guy, $30 to $45 on Amazon all day long. It's kind of generic. The footplate's a little generic. I had the residents play with the right and the left the other day. You can't tell the difference between the right and the left. They look the same. You can custom do this, but this is fine if the patient is safe. You're like, well, your gastroc's a little weak, and I don't think it's controlling your medial lateral instability. If they're moving safely, they're not rolling their ankle, their knee's not snapping back, it doesn't hurt, they don't have a knee effusion, and they're not falling, I'm okay. But again, you're looking at the safety of it. You're like, I could make you a better one, but Dr. Blunderworth, I don't have $300. Okay. If it's helping their gait, and it's safe. If you just frankly don't agree with what it is, but it's the patient's choice, I mean, you can write a note that says, I really don't agree with this, I don't recommend it. The patient bought it, they want to use it. Yeah. But yeah, you can find this all day long on Amazon. Thank you. I really loved those graphics you made. I'd never seen them like that, so I'm excited to see them. But I did have a quick question about cavus feet. If you guys have any recommendations on, do you brace cavus feet, do we just accommodate them, or has anything been successful? Feet just need to be supported. So, if an arch support helps comfort or stability. I mean, if you go to the diabetic literature and kind of hijack it, you might make the argument that a custom insert is going to help some aspect of balance statically or balance dynamically, or proprioceptive feedback. But if the feet aren't bothering the patient, they're not painful, they don't hurt, and again, we're just trying to, people more than anything need a well-fitting shoe. But if you do need to support the arch for comfort, bring the floor to the patient, you can go down that path. You can get, again, I deal with an impoverished population, I can buy a nice, obvious, well-constructed shoe with a little bit of arch support for $20 at Walmart, and they come in wide, they don't come in really wide, but they come in wide, and you can get a Dr. Scholl's, I think it's called TriComfort arch support to sort of start. One of the biggest problems for patients is they don't know how to embrace and use and utilize and access their outpatient options, which are usually cheaper than involving me and an orthotist. But well-fitting shoe, try an over-the-counter arch support. If it doesn't work, you can move to prescribed or commercially prepared, more expensive options. Does that help? Okay, we'll stop there, and people can come up and play and touch these things. So that concludes the session. Thank you for coming.

gait analysis

lower motor neuron disorders

bracing

Dr. Donna Bloodworth

Baylor College of Medicine

ankle-foot orthotics

knee-ankle-foot orthotics

hip-knee-ankle-foot orthotics

gait biomechanics

orthotic devices

Charcot-Marie-Tooth

CMT

CMT

Charcot-Marie-Tooth Disease

Charcot-Marie-Tooth