Joint Instability Clinical Trial
Official title:
Gait Adaptations to Passive Dynamic Ankle-Foot Orthosis Use
This study will collect information on the different ways that people walk, that is, their
gait, when they use ankle braces. Patients will visit NIH on at least three and as many as
nine separate occasions. A physical therapist will perform a physical examination to
determine how patients move, how strong they are and what their comfortable walking speed is.
Then patients will sit on a chair while a camera apparatus takes special pictures of their
legs, a procedure lasting up to 2 hours. Patients will be asked to return to learn how to
walk with the custom Passive Dynamic Ankle-Foot Orthosis (PD-AFO)-a unique ankle brace
designed to improve walking ability by providing natural support to the lower limb.
Patients 4 and older who are in good health and able to walk repeatedly a distance of 15
meters (approximately 49 feet) independently and unsupervised may be eligible for this study.
With this training, patients may return several times to learn how to walk with the brace,
but for their protection, they will not be allowed to take it or use it outside the research
team's supervision. The researchers will examine the leg to ensure that the brace fits and
will ask questions about it. Each training visit will require up to 1.5 hours. When patients
have learned to walk with the brace, they will be asked to visit again and walk while
scientific pictures are taken of their legs. During the walking test, patients will wear
T-shirts and shorts. Patients' arms and legs will be wrapped with a soft, rubber-like
material, to allow small plastic reflective balls to be attached. Firm material known as a
shell can be attached to the rubber sleeves, with Velcro or a self-sticking bandage. The
small balls may also be attached to the skin, with an adhesive. Also, there may be a test of
the muscles, through the use of electromyography, or EMG. The test involves attachment of
small metal electrodes to the surface of the skin, again with an adhesive. There should not
be discomfort with that test.
As patients walk several times, scientific cameras will record the positions of the
reflective balls. Pictures do not involve patients' faces or other parts of the body.
Afterward, a unique chair system called a Biodex will measure the leg muscle strength.
Patients will be asked to sit on the chair and place their leg in a foot in an apparatus, a
special structure that measures strength. They will repeatedly push against the apparatus,
doing so for 3 seconds. Each time patients push, the researchers will touch a small magnetic
device to the skin, which will cause the muscles to push harder. Although this procedure
should not cause any discomfort, it may feel unusual. If they wish, patients can ask to stop
the test at any time. Few risks are involved in participating in this series of activities.
There is a slight chance of mild skin irritation from the adhesives used on the skin or from
the soft, rubber-like material. But the material is worn for only a brief period, and skin
reactions are rare. Also, that material may feel tight, but if it causes discomfort or
prevents moving, patients can ask a researcher to adjust it. There is a slight chance of skin
irritation from use of the PD-AFO, but adjustment can be made to make patients comfortable.
Patients may experience some muscle soreness caused by participating in the muscle strength
tests. However, they will be safely monitored by a physical therapist when they try on the
brace to adjust to its feel and fit, as well as during testing of gait.
This study will not have a direct benefit for participants. However, participants will be
paid for their time, with minimum compensation of $50.
Ankle-Foot Orthoses are a common form of ankle joint bracing prescribed for patients with
impaired joint function. Passive Dynamic Ankle-Foot Orthoses (PD-AFOs) constitute a special
class of ankle braces designed to enhance gait function by providing natural support to the
lower limb as it progresses over the stance foot. However, a fundamental design
characteristic of all PD-AFOs is that they are not capable of replicating all dynamic
characteristics of the natural ankle complex. As a result, the efficient use of PD-AFOs
during gait requires the wearer to develop an adapted, lower limb movement control strategy
that effectively optimizes positive PD-AFO characteristics while compensating for
characteristics detrimental to gait function. The long term goal of this research effort is
to predict a patient's ability to adapt to PD-AFO use and to customize PD-AFO characteristics
to optimize that adaptation. The purpose of this series of studies is to further refine our
existing methods of constructing custom PD-AFOs and to document the movement control
adaptations produced by normal and healthy strength impaired subjects in response to PD-AFO
use.
The research plan is comprised of three phases: technology refinement (pilot) effort (n=5),
normal subject study (n=10), and an impaired subject study (n=20). During the technology
refinement phase, we will refine our existing methods for PD-AFO customization and pilot test
the PD-AFO accommodation gait training methods and movement control assessment measurements.
The normal and impaired subject studies will be used to document PD-AFO use under a strength
substitution paradigm (normal subject study) and a strength enhancement paradigm (impaired
subject study).
Subjects in all study phases will participate in each of three visit types. Initially,
subjects will participate in a screening and PD-AFO tuning visit that contains a
neuromuscular screening examination, a preferred walking speed test, and measurement for a
custom fitting PD-AFO. Following the manufacturing of the custom PD-AFO, subjects will return
for their PD-AFO receipt and accommodation training visit. During this visit, the PD-AFO will
be further customized and evaluated for comfort and performance and the subject will undergo
supervised gait training in PD-AFO use. Following successful accommodation to PD-AFO use,
subjects will return for their third visit and undergo instrumented gait analyses under three
conditions (targeted walking velocity without the PD-AFO, self selected walking velocity with
the PD-AFO, and targeted walking velocity with the PD-AFO) and finally, objective
plantarflexor strength testing.
Walking velocity will be statistically compared between with and without PD-AFO conditions to
determine the accommodation effect for self selected conditions and to test for differences
between targeted walking conditions. The magnitude of peak natural ankle plantarflexion
moments will be statistically compared to determine the efficacy of the strength substitution
and strength enhancement paradigms. The nature and extent of movement control adaptations
will be explored by contrasting the various biomechanical (kinematic and kinetic) variables
between with and without PD-AFO conditions having congruent walking speeds. Results of the
neurological examination and objective strength testing will be used to rationalize the
existence of different movement control adaptations between subjects and form the basis for
developing an initial predictive model.
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