Bedotto RA. 2006. Biomechanical assessment and treatment in lower extremity prosthetics and orthotics: a clinical perspective. Phys Med Rehabil Clin N Am. 17(1): 203-243. ¹[Abstract: Biomechanical treatment is like a jigsaw puzzle with two complex counterparts having many pieces. The physical and mechanical components are equally important and cannot be separated from each other. The patient with a prosthesis or an orthosis represents a biomechanical system; total treatment is essential. All of the pieces to the puzzle must be used to complete the picture. Given the present structure of the educational system, there is a separation of disciplines necessary to provide one truly biomechanical treatment. Physical therapists are educated in the bio aspect of treatment, whereas prosthetists/orthotists are educated in the mechanical aspect. Biomechanical treatment requires the direct interaction and integration of the two disciplines. Physical therapists and prosthetists/orthotists need each other. One without the other can provide only half of the treatment necessary for optimal outcomes. The patient needs both.

Physical therapists need to become more familiar with mechanical treatment and learn how to integrate this into their physical treatment program. Prosthetists/orthotists must become more familiar with the importance of physical treatment and the internal corrective forces necessary for efficient ambulation. The traditional label of orthotics and prosthetics and related technology as products must be replaced with biomechanical treatment that includes orthotics and prosthetics services.

Professionals working with each other is a positive step, but they need to be working together as a team toward a common goal. They need to be in the same place at the same time and work together consistently to provide total treatment. This is more than a multidisciplinary approach. It is one treatment. In this way, each benefits the other as they teach and learn simultaneously. At present, this teaching and learning can be done only on an individual basis. It is the author’s hope that experienced prosthetists/orthotists and physical therapists reading this article will see the need to combine their efforts to provide truly biomechanical treatment. By working together, they can expand their present knowledge and skills.

In this way, treatment and outcomes can improve and serve as the guiding force for a new generation of rehabilitation specialists. This process can be expedited through the educational system by offering advanced clinical degrees specializing in biomechanical treatment specifically designed for clinical practice rather than research, administrative, or academic positions. For this idea to become reality, educational institutions representing the physical and mechanical aspects of biomechanical treatment also must work together; this would expedite the learning curve so that it would not take so long to put the pieces of the puzzle together.] 

Edin BB, Vallbo AB. 1988. Stretch sensitization of human muscle spindles. J Physiol. 400: 101-111. [67] ²Afferents from the finger extensor muscles were consecutively recorded by microneurography. The units were classified as primary (I) or secondary (II) muscle spindle afferents or Golgi tendon organ (GTO) afferents on the basis of their responses to ramp-and-hold stretches, sinusoidals superimposed on ramp-and-hold stretches, maximal twitch contractions and isometric contractions and relaxations. The muscle was repeatedlystretched and then either kept short or long for a few seconds followed by a slow ramp stretch. The responses of the muscle afferents to the slow stretch were compared under the two conditions. 30 of 38 I spindle afferents, 4 of 11 of the II afferents, and none of the 18 GTOs showed an enhanced response to the slow ramp when the muscle had been kept short compared to the response when the muscle had been kept long.

Conclusion: Stretch sensitization does occur in human muscle spindles and, when present, constitutes firm evidence of the afferent originating from a muscle spindle rather than a GTO. 

Ge W, Long CR, Pickar JG. 2005. Vertebral position alters paraspinal muscle spindle responsiveness in the feline spine: effect of positioning duration. J Physiol. 569(Pt 2): 655-665. ³ [Proprioceptive information from paraspinal tissues including muscle contributes to neuromuscular control of the vertebral column. We investigated whether the history of a vertebra’s position can affect signalling from paraspinal muscle spindles.

Single unit recordings were obtained from muscle spindle afferents in the L6 dorsal roots of 30 anaesthetized cats. The L6 vertebra was controlled using a displacement-controlled feedback motor and was held in each of three different conditioning positions for durations of 0, 2, 4, 6 and 8 s. Conditioning positions (1.0-2.2 mm dorsal and ventral relative to an intermediate position) were based upon the displacement that loaded the L6 vertebra to 50-60% of the cat’s body weight. Following conditioning positions that stretched (hold-long) and shortened (hold-short) the spindle, the vertebra was repositioned identically and muscle spindle discharge at rest and to movement was compared with conditioning at the intermediate position. Hold-short conditioning augmented mean resting spindle discharge; however, the duration of hold-short did not significantly affect this increase. The increase was maintained at the beginning of vertebral movement but quickly returned to baseline.

Conversely, hold-long conditioning significantly diminished mean resting spindle discharge. The relationship between conditioning duration and the diminished resting discharge could be described by a quadratic revealing that the effects of positioning history were fully developed within 2 s of conditioning. In addition, 2 s or greater of hold-long conditioning significantly diminished spindle discharge to vertebral movement. These effects of vertebral positioning history may be a mechanism whereby spinal biomechanics interacts with the spine’s proprioceptive system to produce acute effects on neuromuscular control of the vertebral column.]

Kolban M. (1999) Variability of the femoral head and neck antetorsion angle in ultrasonographic measurements of healthy children and in selected diseases with hip disorders treated surgically | Ann Acad Med Stetin. Suppl 51: 1-99. [Article is in Polish] ⁴ [Abstract: An increase in antetorsion was observed in 56 joints (77%) in a group of38 children with spastic CP subjected to surgery. Mean angle of antetorsion was 37o (SD +/- 11). The angle returned to its preoperative values within 2-3 years from surgery. In the group of 25 children with Perthes disease, increased antetorsion was found in 11 (44%) joints subjected to surgery and in 8 (32%) normal joints. The angle changed during the observation period, confirming the opinion that the increase is a secondary event in this disease. The angle was much greater than normal for age in the group of 21 children with congenital hip dysplasia. Basing on the results of surgery it is concluded that corrective osteotomy of femoral proximal end in cases of increased antetorsion and valgity of femoral neck is not a sufficient procedure to prevent the angle from reverting to pre-operative values and should be supplemented by osteotomy of the pelvis.

Furthermore, ultrasonography has emerged as the best method currently available for measurement of femoral head and neck antetorsion. The correlation coefficient for USG vs. direct (intraoperative) measurement was 0.9 in all groups, reaching 0.93 in the spastic CP group, in which contractures and limited mobility are responsible for very low coefficients in the case of other methods.

The use of USG for assessment of femoral antetorsion has revealed, particularly afterlonger observation periods, that the angle in the apparently normal contralateral extremity exceeded values normal for age.] 

Pincivero DM, Bachmeier B, Coelho AJ. (2001) The effects of joint angle and reliability on knee proprioception. Med Sci Sports Exerc 33(10):1708-1712. ⁵The detection of passive knee movement, and the subsequent voluntary response, may be dependent on joint angle. Authors suggest a PPC assessment method that should enhance test-retest reliability.

Sahrmann SA. (2002) Diagnosis and treatment of movement impairment syndromes. St. Louis, MO: Mosby. ⁶[NOTE: This is an essential resource. Tough reading at times, but certainly worth it.]

Sanders JE, Goldstein BS, Leotta DF. (1995) Skin breakdown in response to mechanical stress: adaptation rather than breakdown – a review of the literature. J Rehabil Res Dev. 32(3): 214-226. ⁷[Note: This is a good review of skin tissue adaptability and physiology under loads. Applies to orthotic (compression and shear) more than taping (tensile loading) interventions. Excellent list of references.]

Thomas SS, Moore C, Kelp-Lelane C, Norris C (1996) Simulated gait patterns: the resulting effects on gait parameters, dynamic electromyography, joint moments, and physiological cost index. Gait Posture 4: 100-107. ⁸[Abstract: Authors altered gait function and all other variables by taping the ankle into equinus and setting the knee in flexion on nondisabled subjects. EMG patterns were similar to those reported for children with CP.]

van der Heide JC, Hadders-Algra M. 2005. Postural muscle dyscoordination in children with cerebral palsy. Neural Plast. 12(2-3): 197-203; discussion 263-72. ⁹[Abstract: Until now, 3 children with CP functioning at GMFCS level V have been documented. The children totally or partially lacked direction specificity in their postural adjustments and could not sit independently for >3 seconds. Some children functioning at GMFCS level IV have intact direction-specific adjustments, whereas others have problems in generating consistently direction-specific adjustments. Children at GMFCS levels I to III have an intact basic level of control but have difficulties in fine-tuning the degree of postural muscle contraction to the task-specific conditions, a dysfunction more prominently present in children with bilateral spastic CP than in children with spastic hemiplegia. The problems in the adaptation of the degree of muscle contraction might be the reason that children with CP, more often than typically developing children, show an excess of antagonistic coactivation during difficult balancing tasks and a preference for cranial-caudal recruitment during reaching.]

Woollacott MH, Shumway-Cook A. 2005. Postural dysfunction during standing and walking in children with cerebral palsy: what are the underlying problems and what new therapies might improve balance? Neural Plast. 12(2-3): 211-219; discussion 263-72. Review. ¹⁰[Abstract: The efficiency of balance recovery can be improved in children with CP, indicated by both a reduction in the total center of pressure path used during balance recovery and in the time to restabilize balance after training. Changes in muscle response characteristics contributing to improved recovery include reductions in time of contraction onset, improved muscle response organization, and reduced co-contraction of agonists/antagonists. Clinical implications include the suggestion that improvement in the ability to recover balance is possible in school age children with CP.]