Lower Extremity Review

R E H A B I L I TAT I O N | T R A U M A | D I A B E T E S | B I O M E C H A N I C S | S P O RT S M E D I C I N E

FEBRUARY 13 / VOLUME 5 / NUMBER 3

KICKBOXING: A creative approach to improving balance in patients with multiple sclerosis SURGERY

Assessing alternatives to first MTP joint fusion FOOTWEAR

Rotational traction and football injuries CEREBRAL PALSY

The uninvolved limb in spastic hemiplegia

plus SPECIAL SECTION:

Teachings from the East POSITIVE OUTCOMES FOR SUCCESSFUL PRACTITIONERS

R E H A B I L I TAT I O N | T R A U M A | D I A B E T E S | B I O M E C H A N I C S | S P O RT S M E D I C I N E

APRIL 13 / VOLUME 5 / NUMBER 4

PEDIATRICS

Orthosis use in kids with Down syndrome PATIENT PERSPECTIVE

Microfracture surprises tarnish the experience DIABETES

Surgical management of ankle fractures OSTEOARTHRITIS

Clinical significance of bone bruises on MRI

POSITIVE OUTCOMES FOR SUCCESSFUL PRACTITIONERS

Exer-gaming for rehabilitation

R e h a b i l i tat i o n | T r au m a | D i a b e t e s | B i o m e c h a n i c s | Sp o rt s M e d i c i n e

January 13 / volume 5 / number 2

The Value of

walking in children with CP: A matter of perception Sports Medicine

Lower extremity effects of detraining in athletes Footwear

Choosing children’s shoes: Mechanical considerations OSTEOARTHRITIS

The therapeutic potential of whole body vibration O&P

Trends and techniques in materials science

Positive Outcomes for Successful Practitioners

The Value of

walking in children with CP: A matter of perception

By Barbara E. Gibson, BMR(PT), MSc, PhD he achievement of independent walking is a major focus of rehabilitation for children with cerebral palsy (CP).

Even when mobility could be achieved more easily through the use of assistive technologies such as wheelchairs, independent walking is typically pursued as a major rehabilitation goal and other forms of mobility are often discouraged. Despite these efforts, it is well established that many children with CP do not achieve or maintain functional walking, and will increasingly rely on wheelchairs for some or all of their mobility needs as they age.1-3 The reasons why walking is a highly prioritized goal for children with CP remain underexplored. There is literature to support the physiological benefits, including maintenance of muscle length, bone density, and cardiovascular fitness.4-6 However walking and “standing on your own two feet” also symbolize largely taken-for-granted virtues—rectitude, dignity, autonomy—that have not been explored. Moreover, the perspectives and experiences of parents and children regarding walking and walking therapies remain largely absent from professional debates. We conducted a study to examine how beliefs about the value of walking inform the therapy priorities and perceptions of “success” in children with CP and their parents.7

Methods The study utilized a qualitative design based in a critical social science approach. Critical approaches focus on individuals’ experiences and behaviors within the context of the larger sociopolitical themes that shape people’s values and perspectives.8 The methods and analytical techniques used in the study have been described in detail elsewhere.9 Briefly, face-to-face individual qualitative interviews were conducted with six children with CP and six parents using a semistructured interview guide. Children were aged between 9 and 18 years; three were in Gross Motor Function Classification System (GMFCS)10 level III and three were in level IV. A range of child-centered interviewing methods were adapted according to children’s ages, abilities, and levels of engagement.11 Examples included captioning of pictures, sentence completion exercises, role playing with puppets, and story creation with pictures. All interviews were audio-recorded digitally, transcribed, and imported into the NVivo 8.0 qualitative software program. Analysis involved multiple stages of coding, memoing, and team analytical meetings.

Analyses combined inductive and deductive explorations, consistent with the study’s conceptual framework.12,13

Independent walking is a typical goal of rehabilitation in children with cerebral palsy. But that expectation can lead to frustration in parents and children, many of whom feel that they are more mobile and more functional when using assistive devices.

Results The results are summarized below and reported in more detail elsewhere.7,9 All names are pseudonyms and the interviewer is represented as “I.”

The parents: Do something/try anything All parents described walking as a primary long-term goal that was pursued regardless of whether other mobility options such as a wheelchair were part of their children’s lives. Their accounts revealed a set of related concepts, including: maintaining hope, staying vigilant, and trying any intervention that was financially and practically feasible –even therapies that they labeled as “quackery.”

Parents portrayed themselves as active, i.e., as doing something, which was linked with expressions of being a “good” parent who does not give up hope.

Emily’s mom: Parents are all searching for a cure.

You’re all hopeful that there’s something that’s going to cure it. And nobody ever wants to feel that they didn’t do as much as they could for their kid, right?

While all parents were committed to doing something, this did not mean that they adopted an “anything goes” approach.

Parents often actively weighed the benefits and costs (financial and personal) once their child had commenced a therapy. Such trade-offs had their limits but all parents told stories of anxiety and doubt related to their decisions to forgo, stop, or decrease the intensity of an intervention.

The accounts suggested the nature and intensity of walking interventions and parents’ vigilance diminished over time for a variety of reasons. Parents conveyed deep fatigue resulting from systemic barriers encountered in schools, health care, and government funding. Schools, for example, were cited as responsible for reducing a child’s independent walking by imposing requirements of wheelchair or walker use for reasons of safety and efficiency.

The children: Normality and identity All children in some way discussed walking as an end in itself, i.e., the purpose of walking was to improve walking ability. Participants struggled to articulate reasons that exercise or walking were good things to do. They sometimes included specific outcomes, such as improving strength or endurance, but walking as a means for mobility was rarely volunteered. Instead they most frequently suggested that it was “good for me” even when discussing its negative aspects.

Pain and fear associated with different walking interventions were recurring themes: Emily (age 13): My dad kind of, well not really forces me to go, but he kind of wants me to go, to benefit my legs.

I: What are some of the reasons why you might not want to go?

Emily: Because it hurts when I stretch sometimes.

And when I walk for too long, it hurts my ankles. And when I have my AFOs on for too long, it hurts my legs…I can’t really walk. When somebody leaves me alone for too long, and I’m not in my wheelchair, I’m kind of scared I’m going to fall…I want to be in my wheelchair.

Children weighed complex factors related to energy expenditure, the activity, the environment, and their personal preferences when making mobility choices. For example, Lina discussed why crawling was at times a useful option for her: Lina (age 12): In peoples’ houses I crawl…then I don’t have to bring my walker or my canes. And it’s kind of faster if I’m around big obstacles and small obstacles at the same time.

Emily revealed her wheelchair preferences through a role-playing exercise with the interviewer: One mother felt that she had “flunked” as a parent by not pushing harder for more school-based therapy:

He wasn’t getting therapy for three years.

That’s where I flunked. Between here and school he wasn’t getting nothing, so I got him back in the program so he could get his regular therapy. Then they got him the walker, said that the walker would do him good. And now he relies on that walker too much and his endurance has really slowed down.

David’s mom:

Thus, rather than making deliberate supported choices to reduce walking interventions, parents often seemed to have been worn down over time. Their own fatigue associated with diligently pursuing all options, combined with the forces that made these efforts difficult to maintain, eventually resulted in a kind of rationalized resignation.

I: One day her teacher said, ‘Ally, what do you think about using your wheelchair a little bit more often at school?’ What do you think Ally’s going to say to her teacher?

Emily: I want to use it more.

I: And her teacher said, ‘Well, when would it be good to use it?’

Emily: At recess.

I: Why do you think recess would be a good time?

Emily: Cause she can move around and catch up with her friends and stuff.

I: How do you think Ally’s going to feel about that?

Emily: Happy because then she doesn’t hav0e to be so tired anymore.

R e h a b i l i tat i o n | T rau ma | D i a b e t e s | B i o m e c h a n i c s | Sp o rt s M e d i c i n e

Over the Edge Lower Extremity Injuries in February 13 / volume 5 / number 2

SURGERY

Assessing alternatives to first MTP joint fusion FOOTWEAR

Rotational traction and football injuries CEREBRAL PALSY

The uninvolved limb in spastic hemiplegia FOOT ORTHOSES

Trends and techniques in materials science

Positive Outcomes for Successful Practitioners

Over the Edge

Lower Extremity Injuries in

Figure Skaters

Competitive figure skating today is much less about artistry and much more about athleticism than in years past. Training is longer and harder than ever, while the classic unforgiving skate boot design has remained essentially unchanged. And lower extremity injuries in skaters are on the rise.

By Nathan W. Saunders, MA, and Steven T. Devor, PhD, FACSM he sport of ice figure skating in the US has experienced a tremendous increase in participation in the last two decades. United States Figure Skating Association (USFSA) membership has grown from 100,000 members in 1992 to more than 173,000 members in 2012; 73% of current members are women or girls and 64% of all members are younger than 18 years.1 Membership growth has coincided with two major structural changes in the USFSA and International Skating Union rules that skaters must adhere to when competing in officially sanctioned events. The new rules have dramatically increased the physical demands placed on the athletes and, we believe, have resulted in a greatly increased number of skating-related injuries.

First, in 1990, was the elimination of “school figures,” which were characterized by circular patterns drawn on the ice that athletes were required to trace as they skated to demonstrate skill in placing precise turns evenly on round circles.2 The elimination of school figures has permitted skaters to spend considerably more time practicing free skating elements (e.g., jumps, spins, footwork, and lifts).3 Second, in 2004, in an attempt to make judging less subjective, governing bodies reevaluated and ultimately replaced the sixpoint scoring system with the International Judging System (IJS).4 Compared with the traditional scoring system, the IJS: awards points for each specific element in a routine rather than recording a single mark to represent the entire routine; removes some of the subjectivity previously associated with figure skating judging, as now the judges do a much better job of rewarding overall skating quality; and not

only encourages skaters to maximize the difficulty of each element within the overall routine, but also rewards skaters with bonus points for putting the most physically challenging elements of the performance in the second half of the routine.

To achieve success at the elite level in the early 2000s, figure skaters practiced up to six hours per day, six days per week, for 11 months a year.3 The majority of the training focused on jumps, spins, footwork, and lifts. While there are no updated statistics, it is reasonable to assume these challenging skills are presently emphasized even more.

Not surprisingly, injuries are not uncommon.

While pairs skaters and ice dancers typically report a predominance of acute overuse injuries to all body regions, singles skaters incur injuries primarily to the lower extremities.3,5 Fortin and Roberts5 reported that approximately 66% of all self-reported injuries in nationally competitive figure skaters were in the lower extremities, with ankle injuries representing the greatest percentage (27.7% of all self-reported injuries). A significant portion of overuse injuries in figure skating6 and all athletic pursuits are preventable through appropriate training and rest cycles.

Therefore, we aim to highlight the most common overuse injuries in figure skating and discuss etiologies, as well as possible treatment

and prevention strategies. We will also address some general safety concerns and equipment considerations that warrant significant attention.

Chronic lower extremity injuries The proposed etiologies of most preventable figure skating chronic injuries to the lower extremity tend to fall into one or more of the following categories: boot structure and design, training volume, jump mechanics, and muscle inflexibility (Table 1).

Injuries related to boot structure and design.

One of the more curious things about the sport of figure skating is the development

of the skate boot: it was designed to be aesthetically pleasing as opposed to enhancing performance of figure skating skill elements. Even with major advancements in our understanding of skating biomechanics, as well as the availability of less expensive and more durable synthetic materials, the skate boot has remained largely unchanged for more than 100 years.6-8 Figure 1A illustrates a skate likely to be worn as early as the 1920s, while Figure 1B is an example of a currently manufactured custom boot.

Skate boots are composed primarily of multiple layers of leather that are hard and rigid when first purchased and then begin to “break in” with wear and subsequently “break down” with further use. In addition to the continual structural degradation that occurs throughout the life of the boot, its structural integrity changes within a single training session as it absorbs sweat and heat from the skater. Often, there is insufficient time between training sessions for the boots to dry fully, and this leads to a more rapid breakdown of the leather.

A large proportion of skaters’ training is spent breaking in boots or skating in broken-down boots, with little time spent training in optimal equipment. Pelham et al9 found that boots may wear out in

as little as three weeks, yet skaters typically wear the same boots for six months to a year. The resulting inconsistent level of boot ankle support not only contributes to performance inconsistency, and we suggest it may also increase the risk of ankle sprains, especially if the rate of change in boot ankle support exceeds the rate that skaters’ musculoskeletal systems are able to compensate. Our recommendation to boot manufacturers is to replace leather with synthetic materials that dry quickly and are more resistant to acute and long-term changes in structural support. Until such products are readily available, skaters who train daily should have a minimum of two pairs of skates to rotate on alternate days.