Yes / Purpose: Clubfoot is a common disabling condition that is prevalent across all populations. Approximately, one out of 750 children globally suffers from clubfoot, and around 150,000 to 200,000 children are born with clubfoot every year with 80% of the cases occurring in developing countries. Clubfoot can result in mobility impairments when not properly managed and researchers have argued that understanding knowledge and perceptions are key components to early identification and effective management of clubfoot. The study explored the barriers to clubfoot management from the perspectives of caregivers and healthcare providers in Duayaw Nkwanta, Ghana. Methods: A total of 26 participants made up of 22 caregivers of children with clubfoot and six healthcare providers were purposively sampled for the study guided by a set of inclusion and exclusion criteria. Qualitative data were collected using a semi-structured interview guide through in-depth face-to-face interviews. Interviews were transcribed and analyzed thematically and presented as findings. Results: High cost of treatment, long travel distance, long hours spent at the treatment facility, non-availability of clubfoot treatment services, late reporting of clients for treatment, and non-compliance of parents/caregivers with treatment protocols were identified as the barriers to effective management of clubfoot. Conclusion: These findings have substantial implications for current interventions to effectively manage clubfoot in Ghana.

Several surgically corrective procedures are considered to treat Adult Acquired Flatfoot Deformity (AAFD) patients, relieve pain, and restore function. Procedure selection is based on best practices and surgeon preference. Recent research created patient specific models of Adult Acquired Flatfoot Deformity (AAFD) to explore their predictive capabilities and examine effectiveness of the surgical procedure used to treat the deformity. The models’ behavior was governed solely by patient bodyweight, soft tissue constraints, and joint contact without the assumption of idealized joints. The current work expanded those models to determine if an alternate procedure would be more effective for the individual. These procedures included one hindfoot procedure, the Medializing Calcaneal Osteotomy (MCO), and one of three lateral column procedures: Evans osteotomy, Calcaneocuboid Distraction Arthrodesis (CCDA), Z osteotomy and the combination procedures MCO & Evans osteotomy, MCO & CCDA, and MCO & Z osteotomy all used in combination with a tendon transfer. The combination MCO & Evans and MCO & Z procedures were shown to provide the greatest amount of correction for both forefoot abduction and hindfoot valgus. However, these two procedures significantly increased the joint contact force, specifically at the calcaneocuboid joint, and ground reaction force along the lateral column. With exception to the lateral bands of the plantar fascia and middle spring ligament, the strain present in the plantar fascia, spring, and deltoid ligaments decreased after all procedures. The use of patient specific computational models provided the ability to investigate effects of alternate surgical corrections on restoring biomechanical function in flatfoot patients.

O diabetes mellitus continua sendo uma doença de incidência crescente em todo o mundo, tomando proporções epidêmicas em nossos dias. Tal fato é acompanhado pelo aumento da prevalência de complicações relacionadas à doença, das quais as relativas aos pés apresentam os maiores índices de morbimortalidade. A perda da sensibilidade protetora é um fator preponderante no surgimento das úlceras em pés de pacientes diabéticos, desta forma, os métodos de diagnóstico devem apresentar alta sensibilidade e reprodutibilidade, além de serem capazes de quantificar o grau de alteração, para que medidas específicas sejam proporcionadas. Foi realizado em estudo do tipo corte-transversal, com o objetivo de determinar os limiares de sensibilidade cutânea em pacientes diabéticos portadores de úlcera em apenas um dos membros inferiores, provenientes do ambulatório de feridas complexas do Hospital das Clínicas da FMUSP, comparando os valores encontrados no pé com úlcera e no pé sem úlcera do mesmo paciente. Para avaliação da sensibilidade, utilizou-se o monofilamento de Semmes-Weinstein, o teste de discriminação de dois pontos com o disk-criminator(TM) e o PSSD - Dispositivo Específico de Sensibilidade de Pressão. O PSSD é um aparelho computadorizado, capaz de determinar de forma quantitativa, em g/mm2, a exata pressão na qual o paciente consegue identificar um estímulo de toque sobre a sua pele, bem como a pressão na qual o paciente consegue diferenciar a presença de dois pontos distinguindo-os de um ponto. O PSSD foi aplicado em quatro áreas dos membros inferiores dos pacientes: hálux, dorso do pé, calcanhar e perna. Em todas as regiões, o teste foi realizado com um ponto de forma estática e dinâmica e com dois pontos, também de forma estática e dinâmica. Foram incluídos 20 pacientes, com idade média de 61,6 anos e tempo médio de diabetes de 12,4 anos. Todos os pacientes do grupo apresentaram sensibilidade positiva, quando avaliados pelo Teste do Monofilamento de Semmes-Weinstein. Os pacientes apresentaram médias das medidas da discriminação de dois pontos superiores nos pés com úlcera, embora os dados tenham sido estatisticamente significantes apenas nas regiões do hálux e perna. Todos os pacientes apresentaram limiares de pressão avaliados pelo PSSD mais elevados no pé com úlcera do que no pé são, tanto nos testes estáticos como dinâmicos, resultando em valores estatisticamente significativos nas quatro regiões avaliadas. Concluiu-se que o PSSD foi capaz de diferenciar os limiares de sensibilidade cutânea entre os pés com úlcera e os pés sem úlcera em pacientes diabéticos. / The diabetes mellitus remains a problem with increasing incidence in the entire world, getting epidemic proportions in present time. This fact is followed by the increase in complications. The foot complications in these patients represent the highest morbimortality levels. The loss of protective sensibility is a preponderant factor in the appearing of foot ulcers in diabetic patients. Thus, the diagnostic methods must have elevated sensitivity, reproducibility and must quantify the disease stage, so specific procedures can be established. The author did a cross-sectional study, with the objective to determine the cutaneous sensibility thresholds in diabetic patients recruited from Hospital das Clinicas, Faculty of Medicine, University of São Paulo, with ulcer in only one of the lower extremities, comparing the thresholds of the member with ulcer with the member without ulcer. The sensibility was evaluated using the Semmes-Weinstein monofilament, the two points discrimination test with the disk-criminator(TM) and the PSSD (Pressure-Specified Sensory Device(TM)). An instrument capable to determine in a quantitative manner, reporting results in g/mm2, the exact pressure at which the individual can feel a touch in their skin, and to measure the pressure at which two points can be distinguished from one point touching the skin. The PSSD was used in four areas in patient\'s lower extremities: great toe pulp, dorsal feet, medial heel and lateral calf. The test was realized in four manners 1 point static, 1 point dynamic, 2 points static and 2 points dynamic. A total of 20 patients were included in the study, average age 61,6 years, average diabetic time 12,4 years. All the patients reported positively with the Semmes-Weinstein monofilament test. The mean of 2 point discrimination test was higher in the feet with ulcer, thus the results had statistic significance only in the hallux and lateral calf. All the patients reported cutaneous pressure thresholds higher in the feet with ulcer when comparing with the feet without ulcer, in both static and dynamic tests, with statistic significance in the four areas measured. As the conclusion, the PSSD was capable to differentiate the cutaneous thresholds among the extremity with ulcer and the extremity without ulcer in diabetic patients.

Diabetes can affect the structure and function of the foot, resulting in severe limitation of mobility and reduction of life expectancy. Early warning signs include limited joint mobility (LJM), soft tissue changes, high plantar pressure (HPP), high pressure time integrals (P/TI) and plantar callus. These abnormalities were examined in 216 young people with diabetes and 57 controls. The fingers, toes, ankle subtalar and first metatarsophalangeal joints shows reduced motion and the plantar aponeurosis was thicker in diabetic subjects. Skin thickness was the same for diabetic and control subjects. LJM in the feet was more common in males and older subjects. Subtalar and finger LJM was associated with early sensory nerve changes and finger LJM was associated with retinopathy and higher HbAtc. Thicker plantar aponeurosis was associated with male gander and larger feet. High peak pressure, high P/TI and callus were no more common in diabetic subjects than controls. However, high P/TI and callus were associated with early sensory nerve changes in young people with diabetes. Diabetic subjects with callus were significantly older than those without callus. Those with HPP had higher body mass index and less motion at the first MTP joints than those without HPP. Although plantar callus, HPP and high P/TI were no more common in young people with diabetes these abnormailities may be complicated by diabetes. Cushioning, custom orthoses or both in combination significantly reduced peak pressure and P/TI in diabetic subjects. / Doctor of Philosophy (PhD)

Rocker profiles are one of the most commonly prescribed footwear modifications provided to individuals with impaired rollover. Impaired rollover is caused due to loss of neuromuscular function (i.e. stoke) or orthotic ankle constraint. When rollover is impaired, continued forward progression is interrupted and walking gait becomes less efficient (i.e. increased energy expenditure). Rocker profile footwear modifications are designed to mimic the functions of the anatomical ankle-foot rockers and provide its users with a smooth and efficient rollover. However, while there is theory governing the design of a rocker profile and subjective descriptions of rocker profile function, the extent to which a rocker profile footwear provides rollover has not yet been quantified. The aim of this study was to quantify effective and ineffective rollover and test whether our rocker profile provides effective rollover. We hypothesized that healthy subjects (n=4) walking with orthotic ankle constraint and the rocker profile (STOP) would have no change in rollover and energy expenditure outputs compared to walking with orthotic ankle free and rocker profile (FREE); but that healthy subjects (n=4) walking in STOP would have a change in rollover and energy expenditure outputs compared to walking with orthotic ankle constraint and no rocker profile (STOP-NR). To test this hypothesis, rollover was quantified as stance phase duration, cadence and radius of curvature and energy expenditure was quantified as heart rate and rating of perceived exertion. In addition to these outputs, we analyzed the ground reaction forces and duration of stance in early, middle and late stance period to determine the effects of the rocker profile footwear components. Through the rollover and energy expenditure outputs of the STOP, FREE and STOP-NR conditions, we quantified effective rollover as 0.29 (0.01) radius of curvature with a heart rate of 110.5(6.7) bpm and ineffective rollover as 0.69(0.12) radius of curvature with a heart rate of 131.5 (8.1) bpm. By creating this scale, we were able to determine that our rocker profile provided effective rollover (0.34[0.04] radius of curvature with a heart rate of 111.3[8.3] bpm). However, a future study with a greater sample size is needed to confirm these results.

published_or_final_version / abstract / toc / Orthopaedics and Traumatology / Master / Master of Philosophy

Made available in DSpace on 2016-12-06T17:06:57Z (GMT). No. of bitstreams: 1 Carolina Neis Machado.pdf: 2019539 bytes, checksum: 551e51b6d116d4ba06d2ac853f60e010 (MD5) Previous issue date: 2013-08-30 / Coordenação de Aperfeiçoamento de Pessoal de Nível Superior / Following exercise programs in vogue in recent years, one can observe the highlight of the Pilates method. Contrary to its popularity, there is a lack of quantitative information for prescription and progression of exercises of the method, which are important subsidies, particularly for rehabilitation. This study aims to characterize the strength of the lower limbs during the execution of an exercise often used in Pilates, the foot work. It is a quasi-experimental study, and a study of technological development. It was conducted in two phases: preliminary phase, corresponding to the construction of the instruments concerning to force measures (extensometric force plates), and application phase, in which occurred the data collection itself. The studied population consisted of 20 healthy adults, between 20 and 35 years old, familiar with the method. Data collection was carried out in a Pilates studio in the city of Florianópolis. For this purpose, the platforms developed for the study were secured to support the Reformer bar in order to enable the participant to perform the exercise without any changes in movement pattern. To collect data and force platforms we used the following instruments: digital scale, and stadiometer tape. Data was acquired and processed with the aid of ADS2002-IP and SAD32 systems. For the characterization of the vertical and horizontal components of force, descriptive statistics were used, identifying the mean and standard deviation. The analysis of the effect of different springs on the peak horizontal force component was performed using the paired Student T test, assuming a value of p <0.05, where a significant difference was found between the averages of peak of the horizontal component of the lower limbs reaction force in both collection situations. By verifying the effect of springs on the asymmetry of force in the right and left leg differences were only statistically significant against the resistance of blue springs. The practice time was an aspect that influenced the bilateral symmetry of the lower limbs. At the end of this work, other uses are visualized for the implementation of instrumented Reformer, as the evaluation of lateral asymmetries of the lower limbs, the diagnosis of bilateral deficit and its application in the context of hemiparetic. / Acompanhando programas de exercício em voga nos últimos anos, observa-se o destaque do método Pilates. Na contramão da sua popularidade, verifica-se falta de informações quantitativas para a prescrição e progressão dos exercícios do método, que são subsídios importantes, em especial, para a reabilitação. Este estudo tem por objetivo caracterizar a força de membros inferiores durante a execução de um exercício bastante utilizado no método Pilates, o foot work. Trata-se de um estudo quasi-experimental, bem como de um estudo de desenvolvimento tecnológico. Foi realizado em duas fases distintas: fase preliminar, correspondente à construção e adaptação dos instrumentos referentes às medidas dinamométricas (plataformas de força extensométricas), e fase de aplicação, em que se deu a coleta de dados propriamente dita. A população deste estudo foi composta por 20 adultos saudáveis, com idade entre 20 e 35 anos, familiarizados com o Pilates. A coleta de dados foi realizada nas dependências de um estúdio de Pilates, na cidade de Florianópolis. Para tal, as plataformas desenvolvidas para o estudo foram fixadas à barra de apoios do Reformer para possibilitar ao participante a execução do exercício sem que houvesse alterações no padrão de movimento. Para a coleta de dados, além das plataformas de força, foram utilizados um estadiômetro, uma balança antropométrica e uma fita métrica. Os dados foram adquiridos e processados com o auxílio dos sistemas ADS2002-IP e SAD32. Para a caracterização das componentes vertical e horizontal da força foi utilizada a estatística descritiva, com a identificação dos valores de média e desvio padrão. A análise do efeito das diferentes molas utilizadas no exercício sobre o pico da componente horizontal da força foi realizada através do teste T de Student para amostras dependentes, admitindo-se um valor de p<0,05, onde foi encontrada diferença significativa entre as médias dos picos da componente horizontal da força de membros inferiores nas duas situações de coleta. Ao verificar o efeito das molas sobre a assimetria da força de membro inferior direito e esquerdo, apenas foram encontradas diferenças estatisticamente significativas contra a resistência das molas azuis. O tempo de prática foi um aspecto que influenciou a simetria bilateral de membros inferiores. Ao fim desse trabalho, outras finalidades são visualizadas para a aplicação do Reformer instrumentado, como a avaliação de assimetrias laterais de membros inferiores, o diagnóstico do déficit bilateral e sua aplicação no contexto de pacientes hemiparéticos.

O diabetes mellitus continua sendo uma doença de incidência crescente em todo o mundo, tomando proporções epidêmicas em nossos dias. Tal fato é acompanhado pelo aumento da prevalência de complicações relacionadas à doença, das quais as relativas aos pés apresentam os maiores índices de morbimortalidade. A perda da sensibilidade protetora é um fator preponderante no surgimento das úlceras em pés de pacientes diabéticos, desta forma, os métodos de diagnóstico devem apresentar alta sensibilidade e reprodutibilidade, além de serem capazes de quantificar o grau de alteração, para que medidas específicas sejam proporcionadas. Foi realizado em estudo do tipo corte-transversal, com o objetivo de determinar os limiares de sensibilidade cutânea em pacientes diabéticos portadores de úlcera em apenas um dos membros inferiores, provenientes do ambulatório de feridas complexas do Hospital das Clínicas da FMUSP, comparando os valores encontrados no pé com úlcera e no pé sem úlcera do mesmo paciente. Para avaliação da sensibilidade, utilizou-se o monofilamento de Semmes-Weinstein, o teste de discriminação de dois pontos com o disk-criminator(TM) e o PSSD - Dispositivo Específico de Sensibilidade de Pressão. O PSSD é um aparelho computadorizado, capaz de determinar de forma quantitativa, em g/mm2, a exata pressão na qual o paciente consegue identificar um estímulo de toque sobre a sua pele, bem como a pressão na qual o paciente consegue diferenciar a presença de dois pontos distinguindo-os de um ponto. O PSSD foi aplicado em quatro áreas dos membros inferiores dos pacientes: hálux, dorso do pé, calcanhar e perna. Em todas as regiões, o teste foi realizado com um ponto de forma estática e dinâmica e com dois pontos, também de forma estática e dinâmica. Foram incluídos 20 pacientes, com idade média de 61,6 anos e tempo médio de diabetes de 12,4 anos. Todos os pacientes do grupo apresentaram sensibilidade positiva, quando avaliados pelo Teste do Monofilamento de Semmes-Weinstein. Os pacientes apresentaram médias das medidas da discriminação de dois pontos superiores nos pés com úlcera, embora os dados tenham sido estatisticamente significantes apenas nas regiões do hálux e perna. Todos os pacientes apresentaram limiares de pressão avaliados pelo PSSD mais elevados no pé com úlcera do que no pé são, tanto nos testes estáticos como dinâmicos, resultando em valores estatisticamente significativos nas quatro regiões avaliadas. Concluiu-se que o PSSD foi capaz de diferenciar os limiares de sensibilidade cutânea entre os pés com úlcera e os pés sem úlcera em pacientes diabéticos. / The diabetes mellitus remains a problem with increasing incidence in the entire world, getting epidemic proportions in present time. This fact is followed by the increase in complications. The foot complications in these patients represent the highest morbimortality levels. The loss of protective sensibility is a preponderant factor in the appearing of foot ulcers in diabetic patients. Thus, the diagnostic methods must have elevated sensitivity, reproducibility and must quantify the disease stage, so specific procedures can be established. The author did a cross-sectional study, with the objective to determine the cutaneous sensibility thresholds in diabetic patients recruited from Hospital das Clinicas, Faculty of Medicine, University of São Paulo, with ulcer in only one of the lower extremities, comparing the thresholds of the member with ulcer with the member without ulcer. The sensibility was evaluated using the Semmes-Weinstein monofilament, the two points discrimination test with the disk-criminator(TM) and the PSSD (Pressure-Specified Sensory Device(TM)). An instrument capable to determine in a quantitative manner, reporting results in g/mm2, the exact pressure at which the individual can feel a touch in their skin, and to measure the pressure at which two points can be distinguished from one point touching the skin. The PSSD was used in four areas in patient\'s lower extremities: great toe pulp, dorsal feet, medial heel and lateral calf. The test was realized in four manners 1 point static, 1 point dynamic, 2 points static and 2 points dynamic. A total of 20 patients were included in the study, average age 61,6 years, average diabetic time 12,4 years. All the patients reported positively with the Semmes-Weinstein monofilament test. The mean of 2 point discrimination test was higher in the feet with ulcer, thus the results had statistic significance only in the hallux and lateral calf. All the patients reported cutaneous pressure thresholds higher in the feet with ulcer when comparing with the feet without ulcer, in both static and dynamic tests, with statistic significance in the four areas measured. As the conclusion, the PSSD was capable to differentiate the cutaneous thresholds among the extremity with ulcer and the extremity without ulcer in diabetic patients.

The Abstract The Title: Effect of Peroneal Nerve Functional Electrical Stimulation on Gait in Post-stroke Patients The Goal: The aim of this work was to compare two different ways of applying functional electrical stimulation of the peroneal nerve as to their impacts on the gait speed and performance and the spastic paresis of lower leg in adult patients suffering from chronic stages of stroke accompanied by foot drop. The Method: An open, randomized, controlled clinical pilot study combining elements of both controlled and pragmatic experiments in comparing two different clinical approaches to peroneal nerve functional electrical stimulation. With the first group of patients (group A, consisting of 14 subjects), the intervention was carried out as an outpatient, strictly controlled and intense training of gait with electrical stimulation over the period of four weeks, five times a week; the B-group patients (13 subjects) were all provided with their own stimulator which they applied continuously throughout all their daily routines at their homes and community over the equal period of time. The Results: The four-week intervention turned out to cause no statistically significant difference in our two groups in terms of its impact on any of the monitored parameters of the gait speed and performance as well as...

Title: Ranges of joint mobility in the hip and ankle joints and evaluation of flat feet on a podoscope when finding hallux valgus in classical ballet dancers Objectives: The aim of this thesis is to evaluate if selected parameters: passive range of motion (ROM) of rotations in hip joints, Q angle, passive range of motion of plantar flexion in ankle joints and the foot index are connected with the finding of hallux valgus (HV) diagnose. These factors will be compared between two groups of ballet dancers, one with HV and one without the HV diagnose. Methods: This observational case control study involved 30 probands between the age of 20-40 years. The experimental group consisted of classical ballet dances with the HV angle (HVA) >15ř at least on one foot (n1 = 19), in the control group were classical ballet dancers with the HVA <15ř bilaterally (n2 = 11). The HVA, ROM of the rotations in the hip joints, ROM of the plantar flexion in the ankle joints and Q angle were measured by a goniometer. The plantogram was captured by a photograph of the foot while standing on a podoscope and then it was evaluated by the Sztriter-Godunov method. Analysis of the data was done in R software by means of a Welch's Two-Sample t-Test and the correlation was given by Pearson's Correlation Coefficient. Results: Contrary...