Clinical rating systems for the ankle-hindfoot, midfoot, hallux, and lesser toes

Four rating systems were developed by the American Orthopaedic Foot and Ankle Society to provide a standard method of reporting clinical status of the ankle and foot. The systems incorporate both subjective and objective factors into numerical scales to describe function, alignment, and pain.

Somatotopic representation of action words in human motor and premotor cortex

Since the early days of research into language and the brain, word meaning was assumed to be processed in specific brain regions, which most modern neuroscientists localize to the left temporal lobe. Here we use event-related fMRI to show that action words referring to face, arm, or leg actions (e.g., to lick, pick, or kick), when presented in a passive reading task, differentially activated areas along the motor strip that either were directly adjacent to or overlapped with areas activated by actual movement of the tongue, fingers, or feet. These results demonstrate that the referential meaning of action words has a correlate in the somatotopic activation of motor and premotor cortex. This rules out a unified "meaning center" in the human brain and supports a dynamic view according to which words are processed by distributed neuronal assemblies with cortical topographies that reflect word semantics.

Two simple methods for determining gait events during treadmill and overground walking using kinematic data

The determination of gait events such as heel strike and toe-off provide the basis for defining stance and swing phases of gait cycles. Two algorithms for determining event times for treadmill and overground walking based solely on kinematic data are presented. Kinematic data from treadmill walking trials lasting 20-45s were collected from three subject populations (healthy young, n=7; multiple sclerosis, n=7; stroke, n=4). Overground walking trials consisted of approximately eight successful passes over two force plates for a healthy subject population (n=5). Time of heel strike and toe-off were determined using the two new computational techniques and compared to events detected using vertical ground reaction force (GRF) as a gold standard. The two algorithms determined 94% of the treadmill events from healthy subjects within one frame (0.0167s) of the GRF events. In the impaired populations, 89% of treadmill events were within two frames (0.0334s) of the GRF events. For overground trials, 98% of events were within two frames. Automatic event detection from the two kinematic-based algorithms will aid researchers by accurately determining gait events during the analysis of treadmill and overground walking.

The taste reactivity test. I. Mimetic responses to gustatory stimuli in neurologically normal rats

One or two bottle preference tests, i.e., relative fluid consumption, constitute the primary methodology for determining acceptance or rejection of tastes in animals other than humans. These tests require organisms to initiate and maintain drinking behavior, and, therefore, can not be applied to preparations which do not eat or drink spontaneously. The taste reactivity test, a new method for assessing responses to gustatory stimuli, circumvents this shortcoming. A 50 microliter taste stimulus is injected directly into the oral cavity of a freely moving rat and the immediate response videotaped for frame by frame analysis. Each of the sapid stimuli used (4 concentrations of sucrose, NaCl, HCl, and quinine HCl) generated a stereotyped response derived from a lexicon of 4 mimetic (movements of lingual, masticatory, and facial musculature) and 5 body response components. Responses to taste stimuli were highly consistent within and between rats. For example, sapid sucrose, NaCl and HCl stimuli elicited a response sequence beginning with low amplitude, rhythmic mouth movements, followed by rhythmic tongue protrusions, and then lateral tongue movements. No body movements accompanied these mimetic responses. In contrast, quinine in concentrations at and above 3 X 10(-5) M (1/2 log step above the absolute behavioral threshold for quinine) elicited a response pattern beginning with gaping and proceeding through as many as 5 body responses. These normative data for the intact rat can be directly compared to the taste reactivity of neurally ablated preparations which do not spontaneously feed or drink. Such comparisons can be utlized in determining the neural substrates necessary for the execution and regulation of ingestive behavior.

Event-related synchronization (ERS) in the alpha band--an electrophysiological correlate of cortical idling: a review

EEG desynchronization is a reliable correlate of excited neural structures of activated cortical areas. EEG synchronization within the alpha band may be an electrophysiological correlate of deactivated cortical areas. Such areas are not processing sensory information or motor output and can be considered to be in an idling state. One example of such an idling cortical area is the enhancement of mu rhythms in the primary hand area during visual processing or during foot movement. In both circumstances, the neurons in the hand area are not needed for visual processing or preparation for foot movement. As a result of this, an enhanced hand area mu rhythm can be observed.

Hip joint loading during walking and running, measured in two patients

The resultant hip joint force, its orientation and the moments were measured in two patients during walking and running using telemetering total hip prostheses. One patient underwent bilateral joint replacement and a second patient, additionally suffering from a neuropathic disease and atactic gait patterns, received one instrumented hip implant. The joint loading was observed over the first 30 and 18 months, respectively, following implantation. In the first patient the median peak forces increased with the walking speed from about 280% of the patient's body weight (BW) at 1 km h-1 to approximately 480% BW at 5 km h-1. Jogging and very fast walking both raised the forces to about 550% BW; stumbling on one occasion caused magnitudes of 720% BW. In the second patient median forces at 3 km h-1 were about 410% BW and a force of 870% BW was observed during stumbling. During all types of activities, the direction of the peak force in the frontal plane changed only slightly when the force magnitude was high. Perpendicular to the long femoral axis, the peak force acted predominantly from medial to lateral. The component from ventral to dorsal increased at higher force magnitudes. In one hip in the first patient and in the second patient the direction of large forces approximated the average anteversion of the natural femur. The torsional moments around the stem of the implant were 40.3 N m in the first patient and 24 N m in the second.

Unified theory regarding A/P and M/L balance in quiet stance

1. Control of posture in quiet stance has been quantified by center of pressure (COP) changes in the anterior-posterior (A/P) and medial-lateral (M/L) directions from a single force platform. Recording from a single force platform, researchers are unable to recognize two separate mechanisms that become evident when two force platforms are used. Depending on the stance position taken, many combinations of an ankle mechanism and a hip (load/unload) mechanism are evident. In side-by-side stance, A/P balance is totally under ankle (plantar/dorsiflexor) control, whereas M/L balance is under hip (abductor/adductor) control. In tandem stance, the A/P balance is dominated by the hip mechanism, with mixed and small or sometimes negligible contributions by the ankle plantar/dorsiflexors: for M/L balance, the reverse is evident; ankle invertors/evertors dominate, with mixed and small contribution from the hip load/unload mechanism. In an intermediate 45 degrees stance position, both ankle and hip mechanisms contribute to the net balance control in totally different ways. In the M/L direction the two strategies reinforce, whereas in the A/P direction the ankle mechanism must overcome and cancel most of the inappropriate contribution by the hip load/unload mechanism. A spatial plot of the separate mechanisms reveals the fact that the random-looking COP scatter plot is nothing more than a spatial and temporal summation of two separate spatial plots. A straight line joining the individual COPs under each foot is the load/unload line controlled by the hip mechanism. At right angles to this load/unload line in the side-by-side and tandem positions is the independent control line by the ankle muscles. In an intermediate standing position, the separate control lines exist, but now the ankle control is not orthogonal to the load/unload line; rather, it acts at an angle of approximately 60 degrees. The direction of these ankle control and load/unload lines also allows us to pinpoint the muscle groups responsible at the ankle and hip in any of the stance positions.

Development and validation of a novel rating system for scoring standing foot posture: the Foot Posture Index

INTRODUCTION

The limitations of clinical methods for appraising foot posture are well documented. A new measure, the Foot Posture Index is proposed, and its development and validation described.

METHODS

A four-phase development process was used: (i) to derive a series of candidate measures, (ii) to define an appropriate scoring system, (iii) to evaluate the validity of components and modify the instrument as appropriate, and (iv) to investigate the predictive validity of the finalised instrument relative to static and dynamic kinematic models. Methods included initial concurrent validation using Rose's Valgus Index, determination of inter-item reliability, factor analysis, and benchmarking against three dimensional kinematic models derived from electromagnetic motion tracking of the lower limb.

RESULTS

Thirty-six candidate components were reduced to six in the final instrument. The draft version of the instrument predicted 59% of the variance in concurrent Valgus Index scores and demonstrated good inter item reliability (Cronbach's alpha = 0.83). The relevant variables from the motion tracking lower limb model predicted 58-80% of the variance in the six components retained in the final instrument. The finalised instrument predicted 64% of the variance in static standing posture, and 41% of the variance in midstance posture during normal walking.

CONCLUSION

The Foot Posture Index has been subjected to thorough evaluation in the course of its development and a final version is proposed comprising six component measures that performed satisfactorily during the validation process. The Foot Posture Index assessment is quick and simple to perform and allows a multiple segment, multiple plane evaluation that offers some advantages over existing clinical measures of foot posture.

Method for quantitative estimation of thermal thresholds in patients

A quantitative method for the examination of thermal sensibility was applied in 26 normal subjects and in patients with various neurological disorders. The stimulation technique resembled Békésy audiometry: the patient reversed the direction of the temperature change of a thermode whenever warm, cold, or thermal pain thresholds were reached. The resulting temperature curve enables a quantitative description of the subject's thermal sensibility and of the degree of impairment displayed by neurological patients.

Validation of the foot and ankle outcome score for ankle ligament reconstruction

We studied the validity and reliability of the Foot and Ankle Outcome Score (FAOS) when used to evaluate the outcome of 213 patients (mean age 40 years, 85 females) who underwent anatomical reconstruction of the lateral ankle ligaments with an average postoperative follow-up of 12 years (range, three to 24 years). The FAOS is a 42-item questionnaire assessing patient-relevant outcomes in five separate subscales (Pain, Other Symptoms, Activities of Daily Living, Sport and Recreation Function, Foot- and Ankle-Related Quality of Life). The FAOS met set criteria of validity and reliability. The FAOS appears to be useful for the evaluation of patient-relevant outcomes related to ankle reconstruction.

The hindfoot alignment view

A modification of Cobey's method for radiographically imaging the coronal plane alignment of the hindfoot is described. Using this view, we estimated the moment arm between the weightbearing axis of the leg and the contact point of the heel. Normative data on 57 asymptomatic adult subjects are presented. The weightbearing line of the tibia falls within 8 mm of the lowest calcaneal point in 80% of subjects and within 15 mm of the lowest calcaneal point in 95% of subjects. The technique for measuring coronal plane hindfoot alignment is reliable, with an interobserver correlation coefficient of 0.97. This radiographic technique should help in the evaluation of complex hindfoot malalignments.

Control of whole body balance in the frontal plane during human walking

A whole-body inverted pendulum model was used to investigate the control of balance and posture in the frontal plane during human walking. The model assessed the effects of net joint moments, joint accelerations and gravitational forces acting about the supporting foot and hip. Three video cameras and two force platforms were used to collect kinematic and kinetic data from repeat trials on four subjects during natural walking. An inverse solution was used to calculate net joint moments and powers. Whole body balance was ensured by the centre of mass (CM) passing medial to the supporting foot, thus creating a continual state of dynamic imbalance towards the centerline of the plane of progression. The medial acceleration of the CM was primarily generated by a gravitational moment about the supporting foot, whose magnitude was established at initial contact by the lateral placement of the new supporting foot relative to the horizontal location of the CM. Balance of the trunk and swing leg about the supporting hip was maintained by an active hip abduction moment, which recognized the contribution of the passive accelerational moment, and countered a large destabilizing gravitational moment. Posture of the upper trunk was regulated by the spinal lateral flexors. Interactions between the supporting foot and hip musculature to permit variability in strategies used to maintain balance were identified. Possible control strategies and muscle activation synergies are discussed.

Spatio-temporal parameters of gait measured by an ambulatory system using miniature gyroscopes

In this study we describe an ambulatory system for estimation of spatio-temporal parameters during long periods of walking. This original method based on wavelet analysis is proposed to compute the values of temporal gait parameters from the angular velocity of lower limbs. Based on a mechanical model, the medio-lateral rotation of the lower limbs during stance and swing, the stride length and velocity are estimated by integration of the angular velocity. Measurement's accuracy was assessed using as a criterion standard the information provided by foot pressure sensors. To assess the accuracy of the method on a broad range of performance for each gait parameter, we gathered data from young and elderly subjects. No significant error was observed for toe-off detection, while a slight systematic delay (10 ms on average) existed between heelstrike obtained from gyroscopes and footswitch. There was no significant difference between actual spatial parameters (stride length and velocity) and their estimated values. Errors for velocity and stride length estimations were 0.06 m/s and 0.07 m, respectively. This system is light, portable, inexpensive and does not provoke any discomfort to subjects. It can be carried for long periods of time, thus providing new longitudinal information such as stride-to-stride variability of gait. Several clinical applications can be proposed such as outcome evaluation after total knee or hip replacement, external prosthesis adjustment for amputees, monitoring of rehabilitation progress, gait analysis in neurological diseases, and fall risk estimation in elderly.

The spring in the arch of the human foot

Large mammals, including humans, save much of the energy needed for running by means of elastic structures in their legs and feet. Kinetic and potential energy removed from the body in the first half of the stance phase is stored briefly as elastic strain energy and then returned in the second half by elastic recoil. Thus the animal runs in an analogous fashion to a rubber ball bouncing along. Among the elastic structures involved, the tendons of distal leg muscles have been shown to be important. Here we show that the elastic properties of the arch of the human foot are also important.

Center of mass velocity-position predictions for balance control

The purposes of this analysis were to predict the feasible movements during which balance can be maintained, based on environmental (contact force), anatomical (foot geometry), and physiological (muscle strength) constraints, and to identify the role of each constraint in limiting movement. An inverted pendulum model with a foot segment was used with an optimization algorithm to determine the set of feasible center of mass (CM) velocity-position combinations for movement termination. The upper boundary of the resulting feasible region ran from a velocity of 1.1 s-1 (normalized to body height) at 2.4 foot lengths behind the heel, to 0.45 s-1 over the heel, to zero over the toe, and the lower boundary from a velocity of 0.9 s-1 at 2.7 foot lengths behind the heel, to zero over the heel. Forward falls would be initiated if states exceeded the upper boundary, and backward falls would be initiated if the states fell below the lower boundary. Under normal conditions, the constraint on the size of the base of support (BOS) determined the upper and lower boundaries of the feasible region. However, friction and strength did limit the feasible region when friction levels were less than 0.82, when dorsiflexion was reduced more than 51%, or when plantar flexion strength was reduced more than 35%. These findings expand the long-held concept that balance is based on CM position limits (i.e. the horizontal CM position has to be confined within the BOS to guarantee stable standing) to a concept based on CM velocity-position limits.

Rear-foot, mid-foot and fore-foot motion during the stance phase of gait

This paper proposes a new protocol designed to track a large number of foot segments during the stance phase of gait with the smallest possible number of markers, with particular clinical focus on coronal plane alignment of the rear-foot, transverse and sagittal plane alignment of the metatarsal bones, and changes at the medial longitudinal arch. The shank, calcaneus, mid-foot and metatarsus were assumed to be 3D rigid bodies. The longitudinal axis of the first, second and fifth metatarsal bones and the proximal phalanx of the hallux were also tracked independently. Skin markers were mounted on bony prominences or joint lines, avoiding the course of main tendons. Trajectories of the 14 markers were collected by an eight-camera motion capture system at 100 Hz on a population of 10 young volunteers. Three-dimensional joint rotations and planar angles were calculated according to anatomically based reference frames. The marker set was well visible throughout the stance phase of gait, even in a camera configuration typical of gait analysis of the full body. The time-histories of the joint rotations and planar angles were well repeatable among subjects and consistent with clinical and biomechanical knowledge. Several dynamic measurements were originally taken, such as elevation/drop of the medial longitudinal arch and of three metatarsal bones, rear-foot to fore-foot rotation and transverse plane deformation of the metatarsus. The information obtained from this protocol, consistent with previous clinical knowledge, enhanced our understanding of the dynamics of the human foot during stance.

Attentional demands for static and dynamic equilibrium

Upright standing and walking tasks require the integration of several sources of sensory information. In a normal and highly predictable environment, locomotor synergies involving several muscles may take place at lower spinal levels with neural circuitry tuned by local loops of assistance or self-organizing processes generated in coordinative networks. When ongoing regulation of gait is necessary (obstacles, changes in direction) supraspinal involvement is necessary to perform movements adapted to the environment. Using a classical information processing framework and a dual-task methodology, it is possible to evaluate the attentional demands for performing static and dynamic equilibrium tasks. The present experiment evaluates whether the attentional requirements for a control sitting condition and for standing and walking conditions vary with the intrinsic balance demands of the tasks. The results show that standing and walking conditions required more attention than sitting in a chair. The attentional cost for walking was also significantly greater than for standing. For the walking task, reaction times when subjects were in single-support phase (small base of support) were significantly longer than those in double-support phase, suggesting that the attentional demands increased with an increase in the balance requirements of the task. Balance control requires a continuous regulation and integration of sensory inputs; increasing balance demands loads the higher level cognitive system.

Reducing the energy cost of human walking using an unpowered exoskeleton

With efficiencies derived from evolution, growth and learning, humans are very well-tuned for locomotion. Metabolic energy used during walking can be partly replaced by power input from an exoskeleton, but is it possible to reduce metabolic rate without providing an additional energy source? This would require an improvement in the efficiency of the human-machine system as a whole, and would be remarkable given the apparent optimality of human gait. Here we show that the metabolic rate of human walking can be reduced by an unpowered ankle exoskeleton. We built a lightweight elastic device that acts in parallel with the user's calf muscles, off-loading muscle force and thereby reducing the metabolic energy consumed in contractions. The device uses a mechanical clutch to hold a spring as it is stretched and relaxed by ankle movements when the foot is on the ground, helping to fulfil one function of the calf muscles and Achilles tendon. Unlike muscles, however, the clutch sustains force passively. The exoskeleton consumes no chemical or electrical energy and delivers no net positive mechanical work, yet reduces the metabolic cost of walking by 7.2 ± 2.6% for healthy human users under natural conditions, comparable to savings with powered devices. Improving upon walking economy in this way is analogous to altering the structure of the body such that it is more energy-effective at walking. While strong natural pressures have already shaped human locomotion, improvements in efficiency are still possible. Much remains to be learned about this seemingly simple behaviour.

Listening to action-related sentences modulates the activity of the motor system: a combined TMS and behavioral study

Transcranial magnetic stimulation (TMS) and a behavioral paradigm were used to assess whether listening to action-related sentences modulates the activity of the motor system. By means of single-pulse TMS, either the hand or the foot/leg motor area in the left hemisphere was stimulated in distinct experimental sessions, while participants were listening to sentences expressing hand and foot actions. Listening to abstract content sentences served as a control. Motor evoked potentials (MEPs) were recorded from hand and foot muscles. Results showed that MEPs recorded from hand muscles were specifically modulated by listening to hand-action-related sentences, as were MEPs recorded from foot muscles by listening to foot-action-related sentences. This modulation consisted of an amplitude decrease of the recorded MEPs. In the behavioral task, participants had to respond with the hand or the foot while listening to actions expressing hand and foot actions, as compared to abstract sentences. Coherently with the results obtained with TMS, when the response was given with the hand, reaction times were slower during listening to hand-action-related sentences, while when the response was given with the foot, reaction times were slower during listening to foot-action-related sentences. The present data show that processing verbally presented actions activates different sectors of the motor system, depending on the effector used in the listened-to action.

Sensorimotor mapping of the human cerebellum: fMRI evidence of somatotopic organization

Functional magnetic resonance imaging (fMRI) was employed to determine areas of activation in the cerebellar cortex in 46 human subjects during a series of motor tasks. To reduce the variance due to differences in individual anatomy, a specific transformational procedure for the cerebellum was introduced. The activation areas for movements of lips, tongue, hands, and feet were determined and found to be sharply confined to lobules and sublobules and their sagittal zones in the rostral and caudal spino-cerebellar cortex. There was a clear symmetry mirroring at the midline. The activation mapped as two distinct homunculoid representations. One, a more extended representation, was located upside down in the superior cerebellum, and a second one, doubled and smaller, in the inferior cerebellum. The two representations were remarkably similar to those proposed by Snider and Eldred [1951] five decades ago. In the upper representation, an intralimb somatotopy for the right elbow, wrist, and fingers was revealed. The maps seem to confirm earlier electrophysiological findings of sagittal zones in animals. They differ, however, from micromapping reports on fractured somatotopic maps in the cerebellar cortex of mammals. We assume that the representations that we observed are not solely the result of spatial integration of hemodynamic events underlying the fMRI method and may reflect integration of afferent peripheral and central information in the cerebellar cortex.

Ground reaction forces at different speeds of human walking and running

In this study the variation in ground reaction force parameters was investigated with respect to adaptations to speed and mode of progression, and to type of foot-strike. Twelve healthy male subjects were studied during walking (1.0-3.0 m s-1) and running (1.5-6.0 m s-1). The subjects were selected with respect to foot-strike pattern during running. Six subjects were classified as rearfoot strikers and six as forefoot strikers. Constant speeds were accomplished by pacer lights beside an indoor straightway and controlled by means of a photo-electronic device. The vertical, anteroposterior and mediolateral force components were recorded with a force platform. Computer software was used to calculate durations, amplitudes and impulses of the reaction forces. The amplitudes were normalized with respect to body weight (b.w.). Increased speed was accompanied by shorter force periods and larger peak forces. The peak amplitude of the vertical reaction force in walking and running increased with speed from approximately 1.0 to 1.5 b.w. and 2.0 to 2.9 b.w. respectively. The anteroposterior peak force and mediolateral peak-to-peak force increased about 2 times with speed in walking and about 2-4 times in running (the absolute values were on average about 10 times smaller than the vertical). The transition from walking to running resulted in a shorter support phase duration and a change in the shape of the vertical reaction force curve. The vertical peak force increased whereas the vertical impulse and the anteroposterior impulses and peak forces decreased. In running the vertical force showed an impact peak at touch-down among the rearfoot strikers but generally not among the forefoot strikers. The first mediolateral force peak was laterally directed (as in walking) for the rearfoot strikers but medially for the forefoot strikers. Thus, there is a change with speed in the complex interaction between vertical and horizontal forces needed for propulsion and equilibrium during human locomotion. The differences present between walking and running are consequences of fundamental differences in motor strategies between the two major forms of human progression.

Observations on the control of stepping and hopping movements in man

1. The presence of a form of stretch reflex, previously described in the arm by other authors, has been confirmed in the gastrocnemius muscle of the human leg. The electromyographic (e.m.g.) manifestation of this reflex occurred 120 msec (S.E. of mean = 3.5 msec) following a sharply applied, and maintained, dorsiflexing force to the foot. This form of response is referred to in this article as the Functional Stretch Reflex (FSR).2. To determine the contribution of the FSR to the control of normal leg movement, the e.m.g. activity in the above muscle was monitored during single downward steps of 12.7, 25.4 and 38.1 cm and during repetitive, rhythmic, hopping movements on one foot.3. It was found that e.m.g. activity associated with steps to the ground began 141 msec (S.E. of mean = 8.5 msec) before contact with the ground and ended 131 msec (S.E. of mean = 7.6 msec) after contact, when the e.m.g. usually became temporarily inactive.4. It is inferred from these results that the muscular deceleration associated with landing was brought about by the release of a pre-programmed pattern of neuromuscular activity which was inaccessible to reflex activity resulting from the mechanical event of landing, rather than by a stretch reflex.5. It was found that subjects chose their preferred frequency of hopping with great accuracy and consistency. The mean value obtained was 2.06 Hz (S.E. of mean = 0.02 Hz).6. At the preferred frequency, e.m.g. activity began 84 msec (S.E. of mean = 9.6 msec) before and terminated 263 msec (S.E. of mean = 10 msec) after contact with the ground.7. It is inferred that in rhythmical hopping and perhaps also in running, each landing is effected, as in single steps, by a predetermined pattern of neuromuscular activity. However, when hopping at the preferred frequency, the take-off phase of muscular activity is timed to make maximal use of the FSR, i.e. between 120 and 260 msec after initial contact.8. The results emphasize the importance of pre-programming complex muscular contractions suitable for opposing sudden passive stretching forces, and of initiating them prior to the onset of these forces.

Energetics of actively powered locomotion using the simplest walking model

We modified an irreducibly simple model of passive dynamic walking to walk on level ground, and used it to study the energetics of walking and the preferred relationship between speed and step length in humans. Powered walking was explored using an impulse applied at toe-off immediately before heel strike, and a torque applied on the stance leg. Although both methods can supply energy through mechanical work on the center of mass, the toe-off impulse is four times less costly because it decreases the collision loss at heel strike. We also studied the use of a hip torque on the swing leg that tunes its frequency but adds no propulsive energy to gait. This spring-like actuation can further reduce the collision loss at heel strike, improving walking energetics. An idealized model yields a set of simple power laws relating the toe-off impulses and effective spring constant to the speed and step length of the corresponding gait. Simulations incorporating nonlinear equations of motion and more realistic inertial parameters show that these power laws apply to more complex models as well.