Whitehall Township, PA, United States
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Esquenazi A.,Gait and Motion Analysis Laboratory | Novak I.,The University of Notre Dame Australia | Sheean G.,University of California at San Diego | Singer B.J.,University of Western Australia | Ward A.B.,Staffordshire University
European Journal of Neurology | Year: 2010

Botulinum neurotoxin (BoNT) is most commonly used to reduce focal over-activity in skeletal muscle, although newer indications such as management of drooling, pain and tremor are emerging. Treatment of spasticity incorporating BoNT is usually part of an integrated multidisciplinary rehabilitation programme. Prior to initiating this therapy, specific functional limitations, goals and expected outcomes of treatment should be discussed with the patient/carers. Muscle selection and the order/priority of treatment should be agreed. Treatment goals may involve increasing active or passive function or the avoidance of secondary complications or impairment progression. This paper describes the basic science mechanisms of the action of BoNT and subsequent nerve recovery and introduces a supplement comprising the best available evidence and expert opinion from international panels on questions of assessment, indications, BoNT regimen, adjunctive therapy, expected outcomes and recommended monitoring. Speciality areas reviewed include Paediatric Lower Limb Hypertonicity, Paediatric Upper Limb Hypertonicity, Adult Lower Limb Hypertonicity, Adult Upper Limb Hypertonicity, Cervical Dystonia, Drooling and Pain and Niche Indications. There is good quality scientific evidence to support the efficacy of BoNT to reduce muscle over-activity in the limbs secondary to central nervous system disorders in adults and children, to address primary or secondary cervical dystonia, to reduce saliva flow and to treat some pain syndromes. There is emergent evidence for the efficacy of BoNT to reduce focal tremor, to treat other types of pain including neuropathic pain and also to improve function following treatment of focal muscle over-activity. © 2010 EFNS.


Zeilig G.,Chaim Sheba Medical Center | Zeilig G.,Tel Aviv University | Weingarden H.,Chaim Sheba Medical Center | Weingarden H.,Tel Aviv University | And 6 more authors.
Journal of Spinal Cord Medicine | Year: 2012

Objectives: The objective of the study was to evaluate the safety and tolerance of use of the ReWalk™exoskeleton ambulation system in people with spinal cord injury. Measures of functional ambulation were also assessed and correlated to neurological spinal cord level, age, and duration since injury. Study design: Case series observational study. Setting: A national spinal cord injury centre. Methods: Six volunteer participants were recruited from the follow-up outpatient clinic. Safety was assessed with regard to falls, status of the skin, status of the spine and joints, blood pressure, pulse, and electrocardiography (ECG). Pain and fatigue were graded by the participants using a visual analogue scale pre- and post-training. Participants completed a 10-statement questionnaire regarding safety, comfort, and secondary medical effects. After being able to walk 100 m, timed up and go, distance walked in 6 minutes and 10-m timed walk were measured. Results: There were no adverse safety events. Use of the system was generally well tolerated, with no increase in pain and a moderate level of fatigue after use. Individuals with lower level of spinal cord injury performed walking more efficiently. Conclusion: Volunteer participants were able to ambulate with the ReWalk™ for a distance of 100 m, with no adverse effects during the course of an average of 13-14 training sessions. The participants were generally positive regarding the use of the system. © The Academy of Spinal Cord Injury Professionals, Inc. 2012.


Esquenazi A.,Gait and Motion Analysis Laboratory | Lee S.,Gait and Motion Analysis Laboratory | Packel A.T.,Gait and Motion Analysis Laboratory | Braitman L.,Albert Einstein Healthcare Network
PM and R | Year: 2013

Objectives: (1) To compare the effects of robotic-assisted treadmill training (RATT) and manually assisted treadmill training (MATT) in participants with traumatic brain injury (TBI) and (2) to determine the potential impact on the symmetry of temporal walking parameters, 6-minute walk test, and the mobility domain of the Stroke Impact Scale, version 3.0 (SIS). Design: Randomized prospective study. Subjects: A total of 16 participants with TBI and a baseline over ground walking self-selected velocity (SSV) of ≥0.2 m/s to 0.6 m/s randomly assigned to either the RATT or MATT group. Intervention: Gait training for 45 minutes, 3 times a week with either RATT or MATT for a total of 18 training sessions. Outcome Measures: Primary: Overground walking SSV, maximal velocity. Secondary: Spatiotemporal symmetry, 6-minute walk test, and SIS. Results: Between-group differences were not statistically significant for any measure. However, from pretraining to post-training, the average SSV increased by 49.8% for the RATT group (P = .01) and by 31% for MATT group (P = .06). The average maximal velocity increased by 14.9% for the RATT group (P = .06) and by 30.8% for the MATT group (P = .01). Less staffing and effort was needed for RATT in this study. Step-length asymmetry ratio improved during SSV by 33.1% for the RATT group (P = .01) and by 9.1% for the MATT group (P = .73). The distance walked increased by 11.7% for the robotic group (P = .21) and by 19.3% for manual group (P = .03). A statistically significant improvement in the mobility domain of the SIS was found for both groups (P ≤ .03). Conclusions: The results of this study demonstrate greater improvement in symmetry of gait (step length) for RATT and no significant differences between RATT and MATT with regard to improvement in gait velocity, endurance, and SIS. Our study provides evidence that participants with a chronic TBI can experience improvements in gait parameters with gait training with either MATT or RATT. © 2013 American Academy of Physical Medicine and Rehabilitation.


Massaad A.,Gait and Motion analysis Laboratory | Assi A.,Gait and Motion analysis Laboratory | Assi A.,Saint - Joseph University | Assi A.,Arts et Metiers ParisTech | And 3 more authors.
Gait and Posture | Year: 2014

The Gait Deviation Index (GDI) is a dimensionless parameter that evaluates the deviation of kinematic gait from a control database. The GDI can be used to stratify gait pathology in children with cerebral palsy (CP). In this paper the repeatability and uncertainty of the GDI were evaluated. The Correlation between the GDI and the Gross Motor Function Classification System (GMFCS) was studied for different groups of children with CP (hemiplegia, diplegia, triplegia and quadriplegia). Forty-nine, typically developing children (TD) formed our database. A retrospective study was conducted on our 3D gait data and clinical exams and 134 spastic children were included. Sixteen TD children completed the gait analysis twice to evaluate the repeatability of the GDI (test-retest evaluation). Monte Carlo simulations were applied for all groups (TD and children with CP) in order to evaluate the propagation of errors stemming from kinematics. The repeatability coefficient (2SD of test-retest differences), obtained on the GDI for the 16 TD children (32 lower limbs) was ±10. Monte Carlo simulations showed an uncertainty ranging between 0.8 and 1.3 for TD children and all groups with CP. The Spearman Rank correlation showed a moderate correlation between the GDI and the GMFCS (r= -0.44, p< 0.0001). © 2013 Elsevier B.V.


Talaty M.,Pennsylvania State University | Patel S.,New Jersey Institute of Technology | Esquenazi A.,Gait and Motion Analysis Laboratory
Journal of Foot and Ankle Surgery | Year: 2016

Rocker bottom shoes have recently gained considerable popularity, likely in part because of the many purported benefits, including reducing joint loading and toning muscles. Scientific inquiry about these benefits has not kept pace with the increased usage of this shoe type. A fundamental premise of rocker bottom shoes is that they transform hard, flat, level surfaces into more uneven ones. Published studies have described a variety of such shoes-all having a somewhat rounded bottom and a cut heel region or a cut forefoot region, or both (double rocker). Despite the fundamentally similar shoe geometries, the reported effects of rocker bottom shoes on gait biomechanics have varied considerably. Ten healthy subjects agreed to participate in the present study and were given appropriately sized Masai Barefoot Technology (St. Louis, MO), Skechers™ (Manhattan Beach, CA), and New Balance (Boston, MA) conventional walking shoes. After a 12-day accommodation period, the subjects walked wearing each shoe while 3-dimensional motion and force data were collected in the gait laboratory. The key findings included (1) increased trunk flexion, decreased ankle plantarflexion range, and reduced plantarflexion moment in the early stance; (2) increased ankle dorsiflexion and knee flexor moment in the midstance; (3) decreased peak ankle plantarflexion in the late stance; and (4) decreased ankle plantarflexion and decreased hip flexor and knee extensor moments in the pre-swing and into swing phase. The walking speed was unconstrained and was maintained across all shoe types. A biomechanical explanation is suggested for the observed changes. Suggestions for cautions are provided for using rocker bottom shoes in patients with neuromuscular insufficiency. © 2016 American College of Foot and Ankle Surgeons.


Talaty M.,Gait and Motion Analysis Laboratory | Esquenazi A.,Gait and Motion Analysis Laboratory | Briceno J.E.,Simon Bolivar University of Venezuela
IEEE International Conference on Rehabilitation Robotics | Year: 2013

The ReWalkTM powered exoskeleton assists thoracic level motor complete spinal cord injury patients who are paralyzed to walk again with an independent, functional, upright, reciprocating gait. We completed an evaluation of twelve such individuals with promising results. All subjects met basic criteria to be able to use the ReWalkTM - including items such as sufficient bone mineral density, leg passive range of motion, strength, body size and weight limits. All subjects received approximately the same number of training sessions. However there was a wide distribution in walking ability. Walking velocities ranged from under 0.1m/s to approximately 0.5m/s. This variability was not completely explained by injury level The remaining sources of that variability are not clear at present. This paper reports our preliminary analysis into how the walking kinematics differed across the subjects - as a first step to understand the possible contribution to the velocity range and determine if the subjects who did not walk as well could be taught to improve by mimicking the better walkers. © 2013 IEEE.


Talaty M.,Gait and Motion Analysis Laboratory | Esquenazi A.,Gait and Motion Analysis Laboratory
Journal of Prosthetics and Orthotics | Year: 2013

Objective techniques for determining proper configuration (alignment) of lower limb prostheses can help standardize and improve the functional outcomes for amputees. We propose that a dynamic forceline visualization system can assist in the development of such techniques. The forceline is a tool that allows the visualization of the ground reaction force in real time and in a spatially accurate manner relative to the image of the person as he/she walks. We evaluated a simplified version of an alignment protocol based on the forceline and using three novice clinicians and four amputee test subjects. The goal was to determine how easily the novice clinicians could learn the technique and how well they could apply it. All three clinicians were given a group training lasting about 1.5 hrs in which they were familiarized with the forceline visualization tool and were shown how to use it for determining prosthetic alignment on subjects with lower limb amputation. Then, each clinician evaluated the same four amputees both with and without the use of the forceline. The clinicians were able to learn and incorporate the simple alignment methodology using the forceline easily-each demonstrating basic understanding and skill in applying the method on the first amputee that each one evaluated. In 36% of the cases, using the line helped to standardize the clinicians' alignments to the target alignment (the laboratory "nominal"). In 14% of the cases, using the forceline actually moved the clinicians away from the laboratory nominal. The alignment technique presented can assist clinical thinking by removing some of the guesswork and uncertainty involved during the alignment process. No objective or widely accepted standard exists for the definition of an optimal prosthetic alignment. A technique, such as that presented here, may help in defining and also subsequently in obtaining an optimal alignment. © 2012 American Academy of Orthotists and Prosthetists.


Esquenazi A.,Gait and Motion Analysis Laboratory | Talaty M.,Gait and Motion Analysis Laboratory | Packel A.,Gait and Motion Analysis Laboratory | Saulino M.,Gait and Motion Analysis Laboratory
American Journal of Physical Medicine and Rehabilitation | Year: 2012

Esquenazi A, Talaty M, Packel A, Saulino M: The ReWalk powered exoskeleton to restore ambulatory function to individuals with thoracic-level motor-complete spinal cord injury. Am J Phys Med Rehabil 2012;91:911Y921. Objective: The aim of this study was to assess the safety and performance of ReWalk in enabling people with paraplegia due to spinal cord injury to carry out routine ambulatory functions. Design: This was an open, noncomparative, nonrandomized study of the safety and performance of the ReWalk powered exoskeleton. All 12 subjects have completed the active intervention; three remain in long-term follow-up. Results: After training, all subjects were able to independently transfer and walk, without human assistance while using the ReWalk, for at least 50 to 100 m continuously, for a period of at least 5 to 10 mins continuously and with velocities ranging from 0.03 to 0.45 m/sec (mean, 0.25 m/sec). Excluding two subjects with considerably reduced walking abilities, average distances and velocities improved significantly. Some subjects reported improvements in pain, bowel and bladder function, and spasticity during the trial. All subjects had strong positive comments regarding the emotional/psychosocial benefits of the use of ReWalk. Conclusions: ReWalk holds considerable potential as a safe ambulatory powered orthosis for motor-complete thoracic-level spinal cord injury patients. Most subjects achieved a level of walking proficiency close to that needed for limited community ambulation. A high degree of performance variability was observed across individuals. Some of this variability was explained by level of injury, but other factors have not been completely identified. Further development and application of this rehabilitation tool to other diagnoses are expected in the future. © 2012 by Lippincott.


Esquenazi A.,Gait and Motion Analysis Laboratory
Physical Medicine and Rehabilitation Clinics of North America | Year: 2014

Gait analysis combined with sound clinical judgment plays an important role in elucidating the factors involved in the pathologic prosthetic gait and the selection and effects of available interventions to optimize it. Detailed clinical evaluation of walking contributes to the analysis of the prosthetic gait, but evaluation in the gait laboratory using kinetic and kinematic data is often necessary to quantify and identify the particular contributions of the variables impacting the gait with confidence and assess the results of such intervention. The same approach can be considered when selecting prosthetic components and assessing leg length in this patient population. © 2014 Elsevier Inc.


PubMed | Pennsylvania State University, Gait and Motion Analysis Laboratory and New Jersey Institute of Technology
Type: Journal Article | Journal: The Journal of foot and ankle surgery : official publication of the American College of Foot and Ankle Surgeons | Year: 2016

Rocker bottom shoes have recently gained considerable popularity, likely in part because of the many purported benefits, including reducing joint loading and toning muscles. Scientific inquiry about these benefits has not kept pace with the increased usage of this shoe type. A fundamental premise of rocker bottom shoes is that they transform hard, flat, level surfaces into more uneven ones. Published studies have described a variety of such shoes-all having a somewhat rounded bottom and a cut heel region or a cut forefoot region, or both (double rocker). Despite the fundamentally similar shoe geometries, the reported effects of rocker bottom shoes on gait biomechanics have varied considerably. Ten healthy subjects agreed to participate in the present study and were given appropriately sized Masai Barefoot Technology (St. Louis, MO), Skechers() (Manhattan Beach, CA), and New Balance (Boston, MA) conventional walking shoes. After a 12-day accommodation period, the subjects walked wearing each shoe while 3-dimensional motion and force data were collected in the gait laboratory. The key findings included (1) increased trunk flexion, decreased ankle plantarflexion range, and reduced plantarflexion moment in the early stance; (2) increased ankle dorsiflexion and knee flexor moment in the midstance; (3) decreased peak ankle plantarflexion in the late stance; and (4) decreased ankle plantarflexion and decreased hip flexor and knee extensor moments in the pre-swing and into swing phase. The walking speed was unconstrained and was maintained across all shoe types. A biomechanical explanation is suggested for the observed changes. Suggestions for cautions are provided for using rocker bottom shoes in patients with neuromuscular insufficiency.

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