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Application Of The Dorsiflexion
Retrainer For Post-CVA Footdrop And
Diabetic Peripheral Neuropathy:
A Case Report
Allison Legakis, SPT
UCSF/SFSU Graduate Program in Physical
Therapy
INTRODUCTION: STROKE
What is stroke?
Sudden death of brain cells in a localized area
due to inadequate blood flow.
 Blockage
 Hemorrhage
Statistics:
795, 000 strokes per year ..
 (~25% at least the second stroke)
(Loyd-jones et al. 2010)
COMMON POST-STROKE DEFICITS
DF
Decreased
strength
and ROM
Decrease
d Balance
Decreased
Motor
control
Transfer and
Foot Drop
Gait
during gait
Deficits
20% of all stroke survivors have footdrop
2008)
(Ring et al
INTRODUCTION: DIABETES AND
DIABETIC PERIPHERAL NEUROPATHY
(DPN)
 Diabetes Mellitus type 2 (DM2)?
 Metabolic disease with high blood sugar from no response to
insulin
 Statistics
 Prevalence of 8% in 2008
 30% of population in 2050
[Villamizar 2010].
(Clyde 2011)
 Total cost was $174 billion in 2007
[ADA]
 Peripheral Neuropathy
 Disease of the nerves affecting:
 Sensation
 Autonomic functions
 Strength
 Statistics
 Prevalence of 26.4% of DM2 population in 2008
[Villamizar 2010]
DIABETIC PERIPHERAL NEUROPATHY
DEFICITS
Decreased
Ankle
Sensory
Input
Ankle
Decreased
Motor Output
Ankle of
Absence
Reflexes
Incidence Unknown
Decreased
Foot drop
Function
during gait
and Gait
GAIT DYSFUNCTION AND FOOT DROP
Post-Stroke
Foot Drop
and other
Stroke
Deficits
Diabetic Foot
Problems due
to Peripheral
Neuropathy
Foot drop
and Gait
Dysfunction
Gap in literature for these comorbidities
CONSEQUENCES OF POST-STROKE
FOOT DROP & PERIPHERAL
NEUROPATHY
Difficulty clearing foot  compensations
Increased
 Fall
incidence ofenergy
up to 73%expenditure
in first 6 months post-stroke Forster 1995
Difficulty
 DPN
patientsmaneuvering
17x more likely obstacles
to fall Stein 2006
 Fear of falling is associated with increased fall rate
Pang 2008
FALLS!!!
Coleman WC. 1987
STANDARD TREATMENT FOR FOOT
DROP
Dynamic:
Static:
-Strengthening
-Neuromuscular Electrical
Stimulation (NMES)
-Ankle-Foot Orthoses /
Braces
-Neuroprostheses
BOTH:
-Motor recruitment techniques
(PNF or NDT manual
facilitation)
Duncan 2005
Sabut et al 2010
Scianni et al 2010
Bly 1997
ISSUES WITH STANDARD
TREATMENT
Not all patients are appropriate
Severe Sensory loss
 DPN patients may not perceive threatening stimuli
Static:
Dynamic:
-Strengthening
-NMES
-AFOs / Braces
-Neuroprostheses
BOTH:
-Motor recruitment techniques
(PNF or manual facilitation)
Stein 2006
Hamton 1979
http://www.bioness.com
CLINICAL PROBLEMS
 Gait training + treatments for footdrop are critical
 DPN patients are not appropriate for all standard
treatment
 Need active + task-specific techniques 
neuroplasticity
 The Dorsiflexion Retrainer (DR) may provide an
alternative active approach but no guidelines exist.
PROPOSED SOLUTION:
THE DORSIFLEXION RETRAINER
Patent Pending: Joe Volskai, P
PURPOSES
Primary
 Describe the application of the Dorsiflexion
Retrainer (DR) for gait training for a 45 year old
female with a left CVA and DPN
Secondary
 Describe the observed changes in gait parameters
during the course of treatment with the Dorsiflexion
Retrainer
CASE DESCRIPTION
 Patient Profile:
 45 y.o. hispanic female with diagnosis of L CVA
 Impaired speech / Spanish-speaking
 Medical History:
 History of 4-5 prior CVAs in the last 10 years
 Longstanding DM type 2 with PN (not evident until Tx)
 Prior level of function:
 Independent community ambulator
 Not a regular exerciser
 Both verbal and written informed consent was obtained from the patient
regarding written and video case study analysis
EXAMINATION:
ANKLE DORSIFLEXION ROM &
STRENGTH
Measurement
Dorsiflexion ROM
Manual Muscle Test
(MMT)
Initial
L
R
0o static
NT in gait
4/5
2-/5
 ROM Psychometrics: IRR: 0.42-0.96 (Kachingwe 2005) (Menadue 2006)

Sitting; with goniometer (Norkin 1995)
 Strength Psychometrics: IRR: 0.90 (Cuthbert 2007)

MMT in sitting described by Kendall
Pre-DR
L
R
Neutral 20o
PF
4/5
2/5
EXAMINATION: GAIT QUALITY &
FUNCTION
FIM = Functional Independence Measure (07)
Initial Exam
Before DR
-Unstable initial contact
Quality
NT
-Variable foot placement
-Flaccid in swing (200 PF)
Distance
NT
FIM = 2; 50-149 ft with FWW
NT
FIM = 2; Max A
Level of
Assistanc
e
Psychometrics: ICC .96 motor domain, (Hamilton 1994)
EXAMINATION: GAIT PARAMETERS
PRE-DR
Gait Parameter
Measured with:
-10 m-walk
-Stop watch
-Video analysis
6/16 and 6/17
Time
# Steps on R
# Total steps
Step Length
Stride Length
Cadence
18.36 sec
11.75 steps
23 steps
10.43”
20”
1.40 steps/sec
Gait Velocity
0.54 m/ sec
Psychometrics: ICC .63 intra‐rater reliability (Perry,
1992)
EXAMINATION: GAIT PRE-DR
EXAMINATION: OTHER FACTORS
Psychosocial Factors:
Patient cried 1-2x / day verbalizing that she
wanted to return home to her family and dog
Moderate fear of falling
Cognitive Factors:
Difficulty following directions
 Sensory exam
EVALUATION AND PROGNOSIS
Findings:

DF ROM and strength in gait

Gait quality, distance, parameters &
independence
…consistent with foot drop post-CVA with concurrent
DPN
Prognosis:
 Fair; due to comorbidities and history of 4+ CVAs
PROBLEMS AND GOALS
Problem List
Decreased DF strength
Goals
Increase DF strength by 1 MMT grade
Foot drop
Impaired gait parameters
Heelstrike 75% of the time during 10 m walk
Increased assistance for gait
Increase walking ability to Min A with FWW
Decreased gait function
Psychosocial considerations
Improve gait parameters by 20%
Increase walking distance to 150 feet
Improve motivation; remain focused on
goals 80% of the time during therapy.
TREATMENT SUMMARY
Frequency:
 2-3 x a day for 30-60 minute sessions
Duration:
 4 weeks total, last week-DR
Interventions:
 40% -additional impairments
 60% -gait impairments
STANDARD TREATMENT APPROACH
Type of treatment
Rationale
Strengthening exercises
-Improved strength and activity in acute
stroke patients (Scianni 2010)
Dynamic foot drop
interventions
-Improved DF strength and gait velocity
NDT/PNF Manual Facilitation
-Demonstrated greater gains in gait
speed, vs. strengthening alone (Scianni 2010)
Gait Training
-Ambulation improvement is dependent
on the intensity of gait training (Sinikka 2004)
(Ng 2007)
Kleim et al 2008
Rossi 2010
INTERVENTIONS: TIMELINE
INTERVENTION: STANDARD
TREATMENT
Type of
Treatment
Initial Treatment
Interim Treatment
Strengthening
exercises
Toe raises 2 x 10; 2x/day
Standing balance ex
Facilitative PNF - LE patterns
NMES 2 x 5 min, 2 days
Dynamic foot
drop interventions
Bioness; 3 trials 10+
placements
AFO during gait 2 trials x 20 feet
Manual
Facilitation
Supine:
NDT at hip, knee, ankle
PNF LE patterns
Ambulation:
NDT and PNF at knee, ankle
Gait Training
2 x 15 ft; 2 PTs
hand railing
4 x 25 feet; 1 PT
hand railing  FWW
http://orthomedics.us/FES.aspx
RATIONALE FOR APPLICATION OF THE
DR
Initial / Interim Treatment
Modified Treatment
Strengthening exercises
Dynamic foot drop
interventions
NDT Manual Facilitation
DR
Gait Training
Gait Training
TREATMENT RATIONALE : DR
No contraindications or precautions
Active-assisted technique neuroplasticity
Decreased PT labor
Task-specific technique  walking
 Goals
 Cardiovascular training
 other comorbidities
TREATMENT: DR DETAILS
Ambulation:
With and without DR
 10 meter walk – FWW  greater distances
 Min A  SBA
 Each session /day (1 week)
OUTCOMES: (R) ANKLE ROM +
STRENGTH
Initial exam
Before DR
After DR
MMT Grade
2-/5
2/5
2+/5
Static ROM
Gait ROM
00
NT
-200 PF
+50
neutral DF
http://foothealth.about.com
OUTCOMES: GAIT QUALITY
Initial exam
Before DR
-Unable to heelstrike
-Unstable foot contact
-Unable to ambulate -Circumduction
-Difficulty clearing foot
http://walkingfit.ucr.edu/
After DR
-Heelstrike consistent
-Even foot contact
-Forward progression of LE
-Neutral DF in swing
OUTCOMES: GAIT FUNCTION
 Based on Functional Independence Measures(FIM) scores
Walking Ability
Walking
Distance
Initial exam
Before DR
After DR
NT
FIM =2; Max A
FIM =5 ; SBA
NT
FIM =2; 50-150
ft
FIM =3; >150 ft
http://www.homehealthmedicalequipment.com/frwhwa.ht
ml
OUTCOMES: GAIT PARAMETERS
– TIME
7 sec
18.3
sec
11.7
sec
Days of DR Treatment
- # STEPS ON R
OUTCOMES: GAIT PARAMETERS
2 steps
11.7
steps
# Steps
on Right
9.93
steps
Days of DR Treatment
- TOTAL# STEPS
OUTCOMES: GAIT PARAMETERS
5 steps
23.0
steps
Total #
of Steps
17.6
steps
Days of DR Treatment
– STEP LENGTH
OUTCOMES: GAIT PARAMETERS
3 ¼”
13.68”
15-
10.43
”
Distance
(Inches)
Days of DR Treatment
– STRIDE LENGTH
OUTCOMES: GAIT PARAMETERS
26.43”
20.0”
Distance
(Inches)
Days of DR Treatment
6.43”
OUTCOMES: GAIT PARAMETERS
– CADENCE
.11 stp/sec
1.51
1.40
steps/se
c
step/sec
Steps/sec
Days of DR Treatment
– VELOCITY
OUTCOMES: GAIT PARAMETERS
0.32 m/sec
0.86
steps/se
c
0.54
m/sec
Steps/sec
Days of DR Treatment
OUTCOMES: OTHER FACTORS
Psychosocial Factors:
 Able to focus on goals / motivated
 Only referred to family and dog every 2-3 days.
 Excitement for visitors instead of wishing to
return home.
 No observed falls
Cognitive Factors
 Improved ability to follow directions
OUTCOMES VIDEO
DISCUSSION
Goals
Outcome
Increase DF strength by 1 MMT grade
Met
Heelstrike 75% of the time for 10m walk
Met
Improve above gait parameters by 20%
Met
Increase walking ability (based on FIM)
from Max A to Min A with FWW
Increase distance walked; 150 feet with
FWW and Min A.
Met
Improve motivation; remain focused on
goals 80% of the time during therapy.
Met
Met
DISCUSSION: DR TRAINING
COMPONENTS
Physiological
Mechanisms
Training Components
•
•
•
•
•
Strengthening exercise
Dynamic foot intervention
Facilitation at ankle in gait
Gait training
Energy conservation
•
•
•
•
•
Motor patterns
Confidence
Neural Adaptations
Neuroplasticity
Cardiovascular
changes
DISCUSSION: ANKLE STRENGTH
Training
Component
• Strengthening Ex
• Dynamic foot
interventions
• Facilitation at
ankle in gait
• Gait training
• Energy
conservation
Physiological
Mechanisms
• Motor Patterns
• Confidence
• Neural
Adaptations
• Neuroplasticity
• Cardiovascular
changes
Rationale/Literature
• Neuroplastic changes
(Mortiani 1979/ Rossi 2010)
• Growth and metaboblic
changes in neural &
muscular cells
(Mortiani 1979/ Rossi 2010)
• Long-Term Potentiation
(Rossi 2010)
DISCUSSION: ANKLE STRENGTH
Alternate explanations:
 1 - Strength training prior to use of DR
 Repetitive DR & anti-gravity position  demand on muscles
 2- Natural/Spontaneous recovery (Cramer 2008)
 Duncan (2005): improvements with structured progressive
exercise program > spontaneous recovery
 Task-specific program of DR  greater improvements than
Duncan
DISCUSSION: DORSIFLEXION
ROM
Training
Component
• Strengthening Ex
• Dynamic foot
interventions
• Facilitation at ankle
in gait
• Gait training
• Energy conservation
Physiological
Mechanisms
•
•
•
•
•
Motor Patterns
Confidence
Neural Adaptations
Neuroplasticity
Cardiovascular
changes
Rationale/Literatur
e
• Improved NM response of
the proprioceptors (Nelson
1986)
• Provides feedback with a
guided motion  DF (Butler
2010)
• Isolate specific NM units
and biomechanical
components of joint motion
(Engle 1989)
• Long-Term Potentiation
(Rossi 2010)
DISCUSSION: GAIT QUALITY /
FUNCTION
Training
Components
• Strengthening Ex
• Dynamic foot
interventions
• Facilitation at
ankle in gait
• Gait training
• Energy
conservation
Physiological
Mechanisms
•
•
•
•
•
Motor Pattern
Confidence
Neural Adaptations
Neuroplasticity
Cardiovascular
changes
Rationale/Literature
• (…) due to improved
biomechanics and
neural control, motor
skill learning, and
task-specific training
(Shepherd 2001)
• Confidence  less
compensatory mvts
• CV changes 
efficiency (Mylinski 2005,
Kumaran 2009, McArdle 2006)
DISCUSSION: GAIT PARAMETERS
Training
Components
• Strengthening Ex
• Dynamic foot
interventions
• Facilitation at
ankle in gait
• Gait training
• Energy
conservation
Physiological
Mechanisms
•
•
•
•
•
Motor Pattern
Confidence
Neural Adaptations
Neuroplasticity
Cardiovascular
changes
Rationale/Literature
• Improvements in gait
quality/function
• Spatiotemporal gait
parameters increased
with aerobic training in
patients poststroke (Tang
2008)
• (..) treatment of temporal
asymmetry should focus
on ankle impairments (Lin
2006)
• Intensive, task-specific
program with whole-body
interventions improved
gait outcomes in persons
with chronic stroke (Combs 2010)
DISCUSSION: GAIT PARAMETERS
Minimal Clinically Important Difference
(MCID)
Values for 10 MWT:
0.86m/sec >
Gait Velocity:
0.16m/sec (Kesar 2011)
1 wk of DR: 19m/min>
8 wks conventional PT: 11.4m/min
(Goldie et al)
DISCUSSION: GAIT PARAMETERS
Increased DF
Strength
Confidence
Increased
Gait Velocity
Decreased
Circumductio
n
Improved
Step and
Stride length
Increased
Cadence
 Improved confidence  Improved gait velocity
(Pang 2008)
 Improved stride length  Improved walking rate
(Suzuki 1999).
Less time to
Complete 10
m walk
DISCUSSION: PSYCHOSOCIAL
ISSUES
 Pang (2008)
Confidence
Motivation
Positive
reinforcement
Improved
outcomes
DISCUSSION: The DR
Advantages
 Easy to assemble and adjust
 Can target eversion or inversion
 Remains dynamic in gait cycle
 Low-cost, requires little time
 No electrical stimulation
 Able to wear personal shoegear
Disadvantages
 Slightly different placement for each use
 Occasionally slips if not secure
http://www.theradapt.com/store/ShowProduct.aspx?ID=32
68
LIMITATIONS
 PT intern with limited experience in treating comorbid
PN and CVA patients
 Communication difficulties due to aphasic Spanish-
speaking individual with cognitive deficits
 Inconsistent video angles while gathering data
  Difficulty in analyzing data
FUTURE WORK
 Provide guidelines
 Compare DR to other treatments
 Provide treatment for foot drop in other patient
populations
 Vary the environments -uneven surfaces / obstacles
http://www.jamaicagleaner.com/gleaner/20100912/focus/focus1.html
CONCLUSION
Improvements in dorsiflexion strength, gait quality,
function, and parameters may be attributed to the DR in
this patient
Therefore, the DR may provide an appropriate
alternative for the treatment of foot drop during gait in
individuals with comorbid CVA deficits and DPN.
ACKNOWLEDGEMENTS
Thank you …
 Joe Volskai, PT
 Emily Hellmuth, MS, DPTc
 Natazha Bernie, MS, DPTc
 Liz Carter, MS, DPTc
 Ryan Johnson, MS, DPTc
 Marsha Melnik, PT
 Carla-Krystin Andrade, PhD
 Linda Wanek, PhD