Prosthetics and Orthotics International

December 2007; 31(4): 353 – 361

Gait changes over time in stance control orthosis users

STEVEN E. IRBY, KATHIE A. BERNHARDT, & KENTON R. KAUFMAN

Motion Analysis Laboratory, Division of Orthopedic Research, Mayo Clinic, Rochester, Minnesota, USA

Abstract
This report presents objective motion analysis measurements of 14 stance control orthoses (SCO) users
during a prospective open-enrollment 6-month clinical field trial. Participants were fitted with a
Dynamic Knee Brace System (DKBS) which is a novel electromechanical SCO developed by the
authors. Seven of the 14 subjects that had been prescribed but did not use a KAFO at the time of
enrollment were defined as novice users. Those subjects who at the time of enrollment were using a
locked KAFO for ambulation were defined as experienced users. Results showed that all subjects
significantly increased peak knee flexion from 49.0 + 15.58 to 55.9 + 11.48 between the initial and six
month tests (p ¼ 0.02). They also tended to increase peak hip flexion from 39.6 + 13.48 to 46.0 + 14.58
between the 3 month and 6 month tests (p ¼ 0.09). Novice users significantly increased velocity from
74.7 + 19.4 cm/s to 81.2 + 19.0 cm/sec between the initial and 3-month tests (p ¼ 0.005). These same
users increased stride length from 109 + 15.3 cm to 112 + 16.6 cm over the same time period
(p ¼ 0.008). Experienced KAFO users, however, tended to increase velocity from 68.8 + 20.5 cm/s to
83.2 + 16.8 cm/s at 3 months (p ¼ 0.06). This was combined with a significant increase in cadence from
76.2 + 14.1 steps/min to 83.9 + 8.3 steps/min between the initial and 3 month tests (p ¼ 0.05). Joint
kinetics showed no changes for users over the duration of the testing period. These results indicate that
KAFO users make significant gains in temporodistance measures, while changes in joint kinematics take
longer to develop.

Keywords: Stance control, knee-ankle-foot orthoses, dynamic knee brace system, gait

Introduction
Knee-ankle-foot orthoses (KAFOs) are prescribed for those individuals that have significant
weakness of the knee extensor musculature. The diagnoses of people requiring KAFOs
includes but is not limited to polio, neurovascular pathology and trauma, and neurological
and developmental defects such as spina bifida. In the United States approximately 989,000
people wear KAFOs (Russell et al. 1997). These orthoses are typically fabricated with hinge
joint mechanisms that lock the knee in full extension thus providing unyielding knee stability
to the patient. Oxygen cost of walking is increased however, with the knee immobilized by as
much as 23 – 33% (Waters et al. 1982; Mattsson and Brostrom 1990; Kaufman et al. 1996a).
A stance control orthosis (SCO) is designed to allow swing phase freedom for the knee joint to
minimize the impact on oxygen consumption while automatically providing stance phase

Correspondence: Kenton R. Kaufman, Motion Analysis Laboratory, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA.
Tel: þ1 507 284 2262. Fax: þ1 507 266 2227. E-mail: kaufman.kenton@mayo.edu

ISSN 0309-3646 print/ISSN 1746-1553 online Ó 2007 ISPO

DOI: 10.1080/03093640601076909
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354 S. E. Irby et al.

stability. The desirability of the SCO concept has been appreciated by orthosis designers since
the first half of the last century (Spahn 1913; Taylor 1941). Over 20 patents have been issued
in the US and internationally for SCO devices.
Test reports from several experimental SCO systems have been published since 1978
demonstrating a range of potential benefits (Lehmann and Stonebridge 1978; Malcolm et al.
1980; Kaufman et al. 1996b; Suga et al. 1998; van Leerdam and Kunst 1999; McMillan et al.
2004; Rietman et al. 2004; Irby et al. 2005). All reports include changes in kinematic and
temporodistance measures when comparing locked knee and SCO gait patterns. However,
these reports have all studied subjects shortly after receiving their SCO. With one exception
(van Leerdam 1993), there are no reports in the literature that document the gait changes
over time. Therefore the objective of this report is to document the results of a prospective
6-month open label clinical field trial of a novel SCO. The authors hypothesized that there
would be improvements in gait over time.

Methods
The Dynamic Knee Brace System (DKBS) used in this study is a novel stance control
orthosis. It is comprised of a custom designed wrap spring clutch (Irby and Kaufman 2002),
an electromechanical release, and sensors at the knee and footplate, all fit to a conventional
KAFO (Figure 1) (Irby 1994; Irby et al. 1999a, 1999b). The wrap spring clutch is designed to
provide 113 Nm of braking capability about the joint axis while withstanding 100 Nm of
varus/valgus loading and/or 7 Nm of transverse (i.e., axial) moments. The clutch along with
the electromechanical release mechanism measures 2261065 cm. The control circuitry is
housed in a case measuring 116862 cm and is typically mounted on the lateral border of the

Figure 1. The Dynamic Knee Brace System (DKBS) is a stance control orthosis (SCO) and consists of a standard
knee-ankle-foot-orthosis with the lateral hinge replaced with a novel wrap spring clutch designed for this application.
The electromechanical release system includes a rechargeable battery pack, control electronics and a footswitch. The
battery is carried by the user in a waist pack.

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 Gait changes over time in SCO users 355

thigh shell of the KAFO. A typical DKBS KAFO weighs approximately 3.1 kg, with about
one-third of the weight attributed to the clutch, electromechanical release, and electronics
circuitry. The remainder of the weight is due to that of a typical KAFO with thermoplastic
thigh and shank sections, stainless steel uprights, and medial-side stainless steel hinge. The
lateral hinge is replaced by the wrap spring clutch assembly. A rechargeable battery pack
providing approximately two full days of use measures 136762 cm, weighs 0.37 kg, and is
carried by the user in a waist pack. Two sensors provide input to the control circuit. One at
the knee joint provides knee angle information. The second at the foot provides foot-floor
contact information.
Research participants were recruited based upon the inclusion and exclusion criteria shown
in Table I. The testing protocol and consent forms were approved by the local institutional
review board prior to subject enrollment. Written consent was obtained from each participant
prior to initiation of the laboratory testing. KAFOs were fabricated by certified professional
orthotists. Proper fit was carefully evaluated and modifications made as needed to eliminate
problems with orthosis alignment and fit. Testing was conducted using a single DKBS even
though in some cases patients had bilateral involvement. In those cases the weaker limb was
fitted with the DKBS.
Objective gait measurements were acquired with a computerized video motion analysis
system utilizing ten infrared cameras (EvaRT 4.0, Motion Analysis Corporation, Santa Rosa,
CA). Motion measurement markers were placed at bony prominences for establishing
anatomic coordinate systems for the pelvis, thigh, shank, and foot (Kadaba et al. 1989).
Where orthosis componentry interfered with placement of markers directly on the skin, offsets
were recorded and joint centre locations were corrected in subsequent post-processing. One
set of data corresponding to the standing position (static data) were recorded in order to
calculate the location of the joint centres. After a brief orientation session, the subject was
instructed to walk on the laboratory walkway. Participants were allowed to choose walking
aids befitting their ambulatory status and confidence. Floor reaction forces were recorded
using two AMTI force plates (Advanced Mechanical Technology, Inc., Watertown, MA;
model BP2416) and two Kistler force plates (Kistler Instrument Corp., Amherst, NY; model
9281B) embedded in the floor in the centre of the calibration volume. The 3D marker
coordinates and force plate data were used as input to a commercial software program,
OrthoTrak 5.0 (Motion Analysis Corp., Santa Rosa, CA), to calculate the joint kinematics
and kinetics. Joint moments reported are internal moments normalized by body mass (kg).
Temporal-distance factors such as stride, cadence, and velocity were calculated from the
kinematic data. Gait cycle periods were selected by heel-strike to heel-strike events. All gait
events were expressed as a percentage of the gait cycle, irrespective of the actual time for a
stride, to yield a normalized gait cycle. Testing was conducted in a permanent motion analysis
laboratory environment with a level vinyl tiled floor. Data were collected with the DKBS

Table I. Criteria for research subject enrollment.

Inclusion criteria Exclusion criteria

Requires a locked KAFO Impaired cognitive powers

May use either one or two KAFOs for ambulation Poor balance
Able to walk 100 m Painful condition of the back or limbs
Must have sufficient hip flexor strength to advance the limb Contractures at the hip4158
4108 at the knee or
458 dorsiflexion at the ankle

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356 S. E. Irby et al.

activated, providing automated stance phase control. Gait data were collected at 0, 3, and
6 months.
Gait data for the hip, knee, and ankle were analyzed for differences between users’
experience level and across time in the field. Peak values for pelvic obliquity, hip flexion, hip
extension, and hip abduction were evaluated. These parameters were selected because they
would reflect compensatory effects for a stiff-knee gait. Kinetic data analysis included peak
contralateral hip abduction in swing and ipsilateral extension moments during stance, average
knee extensor moments during stance, knee moment at foot-off, and peak contralateral ankle
plantarflexion moment during stance. Statistical analyses were performed using a commercial
analysis package (JMP 6.0 and SAS 8.2, SAS Institute Inc., Cary NC). Data were lumped
together as well as stratified according to the subjects’ current KAFO status. The
‘experienced’ group routinely used a locked KAFO for ambulation. The ‘novice’ group
had been prescribed but did not regularly use a locked KAFO for ambulation. A two-way
Analysis of Variance with repeated measures was used to compare between experienced,
novice, and aggregate groups at time points of 0, 3, and 6 months. Statistical significance was
set at p ¼ 0.05.

Results
Fourteen research participants (11 males: 3 females) were enrolled (Table II). Of these, 11
returned at 3 months and all 14 returned for the 6-month testing. Average age was 51 + 17
years ranging from 11 – 76 years. Body weight was 84 + 22 kg ranging from 51 – 127 kg. Body
Mass Index (BMI) for this group was 28.6 + 6.4 ranging from 19.2 – 38.4. Nine research
participants had polio while the balance of the patients had other pathologies or trauma
including neuropathies, incomplete spinal cord injuries, spina bifida, multiple sclerosis, and
muscular dystrophy. Seven subjects currently used a locked KAFO and were designated
‘experienced’ users. Of these, 3 had rigid and 4 had articulated or ‘free’ orthotic ankle joints.
The remaining 7 ‘novice’ users in this study had chosen to manage their ambulatory needs up

Table II. Participant demographics.

KAFO experience KAFO

ID# Gender Age (yrs) Height (m) BMI Diagnosis (Yrs) Ankle

1 M 60 1.79 29.9 Polio No recent use Free

2 M 70 1.71 24.7 Polio/MS No recent use Rigid
3 F 51 1.59 34.0 Polio No recent use Free
4 M 68 1.72 20.6 Polio 20 Rigid
5 M 56 1.72 27.1 Polio No recent use Free
6 M 76 1.68 26.1 Polio No recent use Free
7 M 11 1.68 36.1 Polio 6 Rigid
8 M 46 1.85 31.8 Industrial accident/ 10 Free
peripheral
neuropathy
9 M 39 1.63 19.2 Polio 37 Free
10 F 55 1.65 22.8 Polio 18 Rigid
11 M 33 1.70 25.2 Incomplete SCI 14 Free
12 M 54 1.80 29.7 Polio 50 Free
13 F 47 1.61 38.4 MS No recent use, Free
wears sport orthosis
14 M 63 1.83 38.0 Limb girdle disease No recent use Free
(muscular dystrophy)

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 Gait changes over time in SCO users 357

to this point without the aid of a KAFO. Six of the seven novice participants used articulated
or ‘free’ ankle joints while the 7th decided upon a rigid ankle for their orthosis.
Temporodistance measures of velocity, cadence, stride length, and percent single limb
stance were evaluated over time for all participants. Self-selected walking velocity increased
from 72 + 19 cm/sec at the initial test to 82 + 16 cm/sec at 6 months (p ¼ 0.005). Cadence
increased from 78 + 13 steps/min at the initial test to 83 + 8 steps/min) at 6 months
(p ¼ 0.009). Stride length increased from 107 + 18 cm at the initial test to 117 + 15 cm at six
months (p ¼ 0.03). Single limb support time remained unchanged throughout this field trial,
measuring 31 + 5% across all data sets. Dividing the data by KAFO experience provided
further insight. Between the initial and three month tests, novice users showed significant
changes in velocity and stride length (Figure 2).
Velocity increased from 75 + 19 cm/sec to 81 + 19 cm/sec at 3 months (p ¼ 0.005). Stride
length increased from 109 + 15 cm to 112 + 17 cm (p ¼ 0.008) at 3 months. Experienced users
showed significant increases in cadence from 76 + 14 steps/min initially to 84 + 8 steps/min at
three months (p ¼ 0.009). They increased walking velocity from 69 + 21 cm/s to 83 + 17 cm/s
at 3 months, but this change was not statistically significant (p ¼ 0.06). No significant changes
were observed in the 3 – 6 month period for either the novice or experienced groups. Percent
single-limb stance demonstrated no changes across experience group or test session.
Peak hip flexion tended to increase between the 3 month and 6 month tests (40 + 138 to
46 + 158 respectively, p ¼ 0.09). No significant changes over time were observed for pelvic
obliquity, hip abduction or hip extension. Peak knee flexion increased for all users between
the initial and six month tests (49 + 168 and 56 + 118 respectively, p ¼ 0.03) (Figure 3).

Figure 2. (a – d) Changes in temporodistance parameters of velocity, cadence, stride length, and % single limb stance
(braced limb) over the six-month trial. Parameters indicated by an asterisk were significantly different. *p  0.05.

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358 S. E. Irby et al.

Figure 3. Peak SCO knee flexion versus time in the field. Statistically significant increases in peak knee flexion were
observed between the initial and 6-month tests. *p  0.05; **p  0.00.

Experienced KAFO users showed a significant increase in knee flexion between the initial and
six month tests (44 + 128 and 54 + 128 respectively, p ¼ 0.03). Novice users showed no
significant change between the three time points but had greater peak knee flexion during
swing. Average values over the three laboratory sessions were 58 + 148 for novice users and
48 + 128 for experienced users (p ¼ 0.002). Ankle motion plantar flexion and dorsiflexion
maxima did not differ between experience groups or over time. No significant changes were
found in the kinetic data across the 6-month field trial period. Knee extensor moments
during stance averaged 0.14 + 0.11 Nm/kg. Knee extensor moments at foot-off averaged
0.051 + 0.029 Nm/kg across all test periods.

Discussion
Objective laboratory data collected at the initial three- and six-month milestones provide
means to evaluate the functional benefits provided by the SCO. Significant changes were
observed in walking velocity, cadence, stride length, and knee flexion. In general users tended
to increase walking velocity between the initial and three month test point. Previous KAFO
experience had an impact on outcome. Novice KAFO users increased velocity and stride
length over the first 3 months. Experienced KAFO users increased cadence over the same
period with a trend of increased velocity. The flexed knee effectively shortens the swing limb
thereby reducing the natural period of oscillations. Thus a minimum of three months of time
may be required to realize objective kinematic benefits of SCO technology.
Compensations for pathologic stiff knee gait are circumduction, and contralateral ankle
plantar flexion (Sutherland et al. 1990). One may reasonably add increased pelvic obliquity
(rotation in the coronal plane) to the list of compensations that KAFO users could employ to
manage a locked knee joint. The authors expected a diminution of these compensatory
motions as more ‘normal’ gait patterns were developed over time. No statistically signifi-
cant changes were observed however. This outcome may be due to the spectrum of com-
pensations adopted by individuals. Regardless of the original walking style for these subjects,
each individual adopts a unique combination of compensations at the hip, knee, and ankle.
As a result one would expect that the adoption of new compensations for the SCO would
vary from one person to the next without statistically significant changes found in the
aggregated data.

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 Gait changes over time in SCO users 359

In a similar vein, percent single-limb stance was included in this review as an indicator of
change in right-left symmetry. Again, no significant changes were observed either between
experience groups or across laboratory sessions.
The body-mass indices (BMI) of participants in this study ranged from 19 – 40. According
to the CDC, the group consisted of 4 ‘normal’, 6 ‘overweight’, and 4 ‘obese’ participants
(CDC 2004). Nonetheless, no mechanical failures of the DKBS occurred during the
accumulated 7 years of field use.
As of this writing there are five commercial SCOs in the marketplace. Only two offer
different sizes, both based upon body weight. However, half of the subjects in this trial would
not have qualified for any of the commercial SCOs because they exceeded body weight
restrictions. Knee moment data collected in this project will be useful in the design of future
SCO systems by providing a realistic upper bound on the forces across the orthotic knee joint.
Furthermore, this study documents the knee joint moment at the instant of foot-off; knee
extensor moments at foot-off averaged 0.051 + 0.029 Nm/kg equalling 4.3 + 2.4 Nm in
absolute terms. This net moment would tend to collapse the knee and cause binding of most
locking mechanisms. This highlights an important benefit of the DKBS system and its use of a
wrap spring clutch. During gait the position of the limb just before foot-off (pre-swing) creates
an extrinsic knee flexion moment as confirmed by this laboratory data. The wrap spring clutch
is able to disengage under this load allowing a normal knee flexion pattern. Other self-
engaging mechanisms cannot provide this functionality.
Comments from the research subjects after field trial experience included ‘hard to find
clothes to wear’, ‘fanny pack is too bulky’, ‘walking is easier, but the weight tires me out’, and
‘I like the function, it’s just too bulky’. Spontaneous comments during initial gait training
included ‘walking is easier’, ‘feels lighter when it is turned on’ and ‘I don’t have to think about
my knee or ankle, I can just pick my foot up and go’. These comments highlighted areas for
future DKBS development. The size and weight of all components should be reduced to ease
clothing selection and presumably walking energetics. However, the size and weight concerns
have been shown to be secondary to operation and stability of the DKBS stance control
orthosis (Bernhardt et al. 2006). User comments such as ‘I don’t have to think about my knee
or ankle’ encourages the authors to continue DKBS development and SCO testing.
Limitations of this study were lack of documentation of the actual use in the field and
limited number of subjects enrolled. This study design did not include objective measures
of DKBS use in the field. From interview data we know that use during the six-month field
trial varied markedly from ‘only on Sundays’ to every day, all day (Bernhardt et al. 2006). The
time course of accommodation would logically be linked to actual use in the field. As part of
the remuneration, the custom-made KAFO shell was made available to each subject at the
end of their participation. Overall however, remuneration was low and did not equal the costs
of time away from work, travel, or room and board. For future studies automatic electronic
surveillance of use in the field will be built into the electronics control package. In this way
unbiased data will be available to help correlate changes in kinematics and kinetics with actual
time in the SCO. Additional incentives to encourage completion of future research protocols
need to be considered. These may include increased remuneration to compensate for absence
from work as well as for travel and lodging expenses.

Conclusion
This report is the culmination of a six-month open enrollment field trial of a stance control
orthosis (SCO). The Dynamic Knee Brace System, a wrap spring clutch based SCO was used
exclusively in this project. Fourteen individuals requiring a KAFO were enrolled and fitted

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360 S. E. Irby et al.

with the DKBS. Testing under laboratory conditions was conducted at 0, 3, and 6 months of
SCO use. All users benefited from SCO use, demonstrating significant improvements in
temporodistance factors at 3 months. Gait changes, however, depended upon previous KAFO
use. Experienced users demonstrated a significant increase in peak knee flexion but they did
not ‘‘catch up’’ to the novice users during this six-month trial. Novice users showed increased
velocity and stride length while cadence changed for the experienced users. Kinematic
variables, however, reached significant change levels only at the six-month mark. Therefore,
three months represents the minimum time required for the SCO technology.

Acknowledgements
This project was supported by the National Institutes of Child Health and Human
Development, Grant HD30150, and the Mayo Foundation. The authors wish to thank
Robert Lotz CPO of Prosthetic Orthotic Center, and Richard Miller CO of Prosthetic
Laboratories of Rochester, for their support in KAFO fabrication and patient recruitment.
We also wish to acknowledge the staff of the Motion Analysis Laboratory, and in particular
Diana Hansen, for motion data collection and reduction. David H. Sutherland, MD, is
recognized for his conviction, energy, and generosity that made this project possible.
Kaufman and Irby are the inventors technology used in this research, the technology has been
licensed, and they have received royalties on it.

References
Bernhardt KA, Irby SE, Kaufman KR. 2006. Consumer opinions of a stance control knee orthosis. Prosthet Orthot
Int 30:246 – 256.
CDC. 2004. Body Mass Index Calculator. http://www.cdc.gov/nccdphp/dnpa/bmi/calc-bmi.htm: National Center for
Chronic Disease Prevention and Health Promotion.
Irby SE. 1994. A digital logic controlled electromechanical free-knee brace. San Diego: San Diego State University.
Irby SE, Bernhardt KA, Kaufman KR. 2005. Gait of stance control orthosis user: The Dynamic Knee Brace System.
Prosthet Orthot Int 29:269 – 282.
Irby SE, Kaufman KR. 2002. Electromechanical joint control device with wrap spring clutch. US Patent 6500138.
USA, Mayo Foundation.
Irby SE, Kaufman KR, Mathewson JW, Sutherland DH. 1999a. Automatic control design for a dynamic knee brace
system. IEEE Trans Rehabil Eng 7:135 – 139.
Irby SE, Kaufman KR, Wirta RW, Sutherland DH. 1999b. Optimization and application of a wrap spring clutch to a
dynamic knee-ankle-foot orthosis. IEEE Trans Rehabil Eng 7:130 – 134.
Kadaba M, Ramakrishnan H, Wootten M, Gainey J, Gorton G, Cochran G. 1989. Repeatability of kinematic, kinetic,
and electromyographic data in normal adult gait. J Orthop Res 7:849 – 860.
Kaufman KR, Miller LS, Sutherland DH. 1996a. Gait asymmetry in patients with limb-length inequality. J Pediatr
Orthop 16:144 – 150.
Kaufman KR, Irby SE, Mathewson JW, Wirta RW, Sutherland DH. 1996b. Energy efficient knee-ankle-foot orthosis:
A case study. J Prosthet Orthot 8:79 – 85.
Lehmann JF, Stonebridge JB. 1978. Knee lock device for knee ankle orthoses for spinal cord injured patients: An
evaluation. Arch Phys Med Rehabil 59:207 – 211.
Malcolm LL, Sutherland DH, Cooper L, Wyatt, M. 1980. A digital logic-controlled electromechanical orthosis for
free-knee gait in muscular dystrophy children. Orthop Trans 5:90.
Mattsson E, Brostrom LA. 1990. The increase in energy cost of walking with an immobilized knee or an unstable
ankle. Scand J Rehabil Med 22:51 – 53.
McMillan AG, Kendrick K, Michael JW, Aronson J, Horton GW. 2004. Preliminary evidence for effectiveness of a
stance control orthosis. J Prosthet Orthot 16:6 – 13.
Rietman J, Goudsmit J, Meulemans D, Halbertsma JPK, Geertzen JHB. 2004. An automatic hinge system for leg
orthoses. Prosthet Orthot Int 28:64 – 68.
Russell JN, Hendershot GE, LeClere F, Howie LJ. 1997. Trends and differential use of assistive technology devices:
United States, 1994. Advanced data from vital and health statistics; No. 292.

Downloaded from poi.sagepub.com at VIRGINIA COMMONWEALTH UNIV on March 13, 2015

 Gait changes over time in SCO users 361
Spahn E. 1913. Knee and ankle brace. United States.
Suga T, Kameyama O, Ogawa R, Matsuura M, Oka H. 1998. Newly designed computer controlled knee-ankle-foot
orthosis (Intelligent Orthosis). Prosthet Orthot Int 22:230 – 239.
Sutherland DH, Santi M, Abel MF. 1990. Treatment of stiff-knee gait in cerebral palsy: A comparison by gait analysis
of distal rectus femoris transfer versus proximal rectus release. J Pediatr Orthop 10:433 – 441.
Taylor BM. 1941. Support for normal body locomotion. United States.
van Leerdam NGA, Kunst EE. 1999. Die neue Bienorthese UTX-Swing: Normales Gehen, kombiniert mit sicherem
Stehen. OrthopTech 6:506.
Waters RL, Campbell J, Thomas L, Hugos L, Davis P. 1982. Energy costs of walking in lower-extremity plaster casts.
J Bone Joint Surg Am 64:896 – 899.

Downloaded from poi.sagepub.com at VIRGINIA COMMONWEALTH UNIV on March 13, 2015