Biomechanical Response to External Biofeedback During Functional Tasks in Individuals With Chronic Ankle Instability

2021 ◽  
Author(s):  
Danielle M. Torp ◽  
Abbey C. Thomas ◽  
Tricia Hubbard-Turner ◽  
Luke Donovan
Keyword(s):  
Real Time ◽  
Plantar Pressure ◽  
Ankle Instability ◽  
Static Balance ◽  
Eyes Closed ◽  
Visual Biofeedback ◽  
Time Integral ◽  
Pressure Time ◽  
Eyes Open ◽  
Functional Task

Context Altered biomechanics displayed by individuals with chronic ankle instability (CAI) is a possible cause of recurring injuries and posttraumatic osteoarthritis. Current interventions are unable to modify aberrant biomechanics, leading to research efforts to determine if real-time external biofeedback can result in changes. Objective To determine the real-time effects of visual and auditory biofeedback on functional-task biomechanics in individuals with CAI. Design Crossover study. Setting Laboratory. Patients or Other Participants Nineteen physically active adults with CAI (7 men, 12 women; age = 23.95 ± 5.52 years, height = 168.87 ± 6.94 cm, mass = 74.74 ± 15.41 kg). Intervention(s) Participants randomly performed single-limb static balance, step downs, lateral hops, and forward lunges during a baseline and 2 biofeedback conditions. Visual biofeedback was given through a crossline laser secured to the dorsum of the foot. Auditory biofeedback was given through a pressure sensor placed under the lateral foot and connected to a buzzer that elicited a noise when pressure exceeded the set threshold. Cues provided during the biofeedback conditions were used to promote proper biomechanics during each task. Main Outcome Measure(s) We measured the location of center-of-pressure (COP) data points during balance with eyes open and eyes closed for each condition. Plantar pressure in the lateral column of the foot during functional tasks was extracted. Secondary outcomes of interest were COP area and velocity, time to boundary during static balance, and additional plantar-pressure measures. Results Both biofeedback conditions reduced COP in the anterolateral quadrant while increasing COP in the posteromedial quadrant of the foot during eyes-open balance. Visual biofeedback increased lateral heel pressure and the lateral heel and midfoot pressure-time integral during hops. The auditory condition produced similar changes during the eyes-closed trials. Auditory biofeedback increased heel pressure during step downs and decreased the lateral forefoot pressure-time integral during lunges. Conclusions Real-time improvements in balance strategies were observed during both external biofeedback conditions. Visual and auditory biofeedback appeared to effectively moderate different functional-task biomechanics.

scholarly journals Biomechanical Response to External Biofeedback During Functional Tasks in Individuals with Chronic Ankle Instability

2020 ◽  
Author(s):  
Danielle M Torp ◽  
Abbey C Thomas ◽  
Tricia Hubbard-Turner ◽  
Luke Donovan
Keyword(s):  
Real Time ◽  
Plantar Pressure ◽  
Ankle Instability ◽  
Chronic Ankle Instability ◽  
Static Balance ◽  
Visual Biofeedback ◽  
Time Integral ◽  
Pressure Time ◽  
Eyes Open ◽  
Functional Task

Abstract Context: Altered biomechanics displayed by individuals with chronic ankle instability (CAI) is a potential cause for recurring injuries and posttraumatic osteoarthritis. Current interventions are unable to modify aberrant biomechanics leading research efforts to determine if real-time external biofeedback is capable of producing changes. Objective: Determine real-time effects of visual and auditory biofeedback on functional task biomechanics in individuals with CAI Design: Crossover study Setting: Laboratory Patients or Other Participants: Nineteen physically active adults with CAI (23.95±5.52 years; 168.87±6.94 cm; 74.74±15.41 kg, female=12) volunteered. Intervention: Participants randomly performed single-leg static balance, step-downs, lateral-hops, and forward-lunges during a baseline and two biofeedback conditions. Auditory biofeedback was given through a pressure sensor placed under the lateral foot connected to a buzzer eliciting a noise when pressure exceeded the set threshold. Visual biofeedback was given through a cross-line laser secured to the dorsum of the foot. Cues given during the biofeedback conditions were used to promote proper biomechanics during each respective task. Main Outcome Measure(s): Location of center of pressure (COP) data points during balance with eyes-open and closed during each condition. Plantar pressure during functional tasks were extracted in the lateral column of the foot. Secondary outcomes of interested were COP area and velocity, time-to-boundary during static balance, and additional plantar pressure measures. Results: Both biofeedback conditions reduced COP in the anterolateral quadrant while increasing COP in the posteromedial quadrant of the foot during eyes open balance, the auditory condition produced similar changes during eyes closed trials. Auditory biofeedback increased heel pressure during step-downs, while decreasing lateral forefoot pressure-time integral during lunges. Visual biofeedback increased lateral heel pressure and increased lateral heel and midfoot pressure-time integral during hops. Conclusions: Real-time improvements in balance strategies were observed during both external biofeedback conditions. Visual and auditory biofeedback appear to effectively moderate different functional task biomechanics.

Effects of Real-Time Video Feedback on Plantar Pressure Measures in Individuals With Chronic Ankle Instability During Walking

2019 ◽  
Vol 24 (6) ◽  
pp. 229-234
Author(s):  
Anna M. Ifarraguerri ◽  
Danielle M. Torp ◽  
Abbey C. Thomas ◽  
Luke Donovan
Keyword(s):  
Real Time ◽  
Plantar Pressure ◽  
Ankle Instability ◽  
Video Feedback ◽  
Chronic Ankle Instability ◽  
Treadmill Walking ◽  
Gait Retraining ◽  
Pressure System ◽  
Time Integral ◽  
Pressure Time

Individuals with chronic ankle instability (CAI) have been shown to have increased lateral plantar pressure during walking which is thought to contribute to symptoms associated with CAI. The objective of this study was to determine whether real-time video feedback can reduce lateral plantar pressure in individuals with CAI. Twenty-six participants with CAI completed 30 s of treadmill walking while plantar pressure was measured using an in-shoe plantar pressure system (baseline). Next, participants completed an additional 30 s of treadmill walking while receiving video feedback (VID FB). During the VID FB condition, participants had a significant decrease in medial forefoot peak pressure and medial midfoot pressure-time integral; however, both changes were associated with small effect sizes. Real-time video feedback did not reduce lateral plantar pressure in individuals with CAI; therefore, other gait retraining strategies should be considered when treating patients with CAI.

Increased In-Shoe Lateral Plantar Pressures with Chronic Ankle Instability

2011 ◽  
Vol 32 (11) ◽  
pp. 1075-1080 ◽  
Author(s):  
Heather Schmidt ◽  
Lindsay D. Sauer ◽  
Sae Yong Lee ◽  
Susan Saliba ◽  
Jay Hertel
Keyword(s):  
Plantar Pressure ◽  
Peak Pressure ◽  
Ankle Instability ◽  
Chronic Ankle Instability ◽  
Maximum Force ◽  
Pressure System ◽  
Time To Peak ◽  
Time Integral ◽  
Pressure Time ◽  
Force Time

Background: Previous plantar pressure research found increased loads and slower loading response on the lateral aspect of the foot during gait with chronic ankle instability compared to healthy controls. The studies had subjects walking barefoot over a pressure mat and results have not been confirmed with an in-shoe plantar pressure system. Our purpose was to report in-shoe plantar pressure measures for chronic ankle instability subjects compared to healthy controls. Methods: Forty-nine subjects volunteered (25 healthy controls, 24 chronic ankle instability) for this case-control study. Subjects jogged continuously on a treadmill at 2.68 m/s (6.0 mph) while three trials of ten consecutive steps were recorded. Peak pressure, time-to-peak pressure, pressure-time integral, maximum force, time-to-maximum force, and force-time integral were assessed in nine regions of the foot with the Pedar-x in-shoe plantar pressure system (Novel, Munich, Germany). Results: Chronic ankle instability subjects demonstrated a slower loading response in the lateral rearfoot indicated by a longer time-to-peak pressure (16.5% ± 10.1, p = 0.001) and time-to-maximum force (16.8% ± 11.3, p = 0.001) compared to controls (6.5% ± 3.7 and 6.6% ± 5.5, respectively). In the lateral midfoot, ankle instability subjects demonstrated significantly greater maximum force (318.8 N ± 174.5, p = 0.008) and peak pressure (211.4 kPa ± 57.7, p = 0.008) compared to controls (191.6 N ± 74.5 and 161.3 kPa ± 54.7). Additionally, ankle instability subjects demonstrated significantly higher force-time integral (44.1 N/s ± 27.3, p = 0.005) and pressure-time integral (35.0 kPa/s ± 12.0, p = 0.005) compared to controls (23.3 N/s ± 10.9 and 24.5 kPa/s ± 9.5). In the lateral forefoot, ankle instability subjects demonstrated significantly greater maximum force (239.9N ± 81.2, p = 0.004), force-time integral (37.0 N/s ± 14.9, p = 0.003), and time-to-peak pressure (51.1% ± 10.9, p = 0.007) compared to controls (170.6 N ± 49.3, 24.3 N/s ± 7.2 and 43.8% ± 4.3). Conclusion: Using an in-shoe plantar pressure system, chronic ankle instability subjects had greater plantar pressures and forces in the lateral foot compared to controls during jogging. Clinical Relevance: These findings may have implications in the etiology and treatment of chronic ankle instability. Level of Evidence: III, Retrospective Case Control Study

Effect of Orthotic Therapy on Claw Toe Loading

2004 ◽  
Vol 94 (3) ◽  
pp. 246-254 ◽  
Author(s):  
Penny J. Claisse ◽  
Jodi Binning ◽  
Julia Potter
Keyword(s):  
Pressure Measurement ◽  
Plantar Pressure ◽  
Metatarsal Head ◽  
Plantar Surface ◽  
Time Integral ◽  
Pressure Time ◽  
Second Metatarsal ◽  
Plantar Pressure Measurement ◽  
Access To Data ◽  
Toe Deformity

This study demonstrates the effect of orthotic therapy for toe deformity on toe and metatarsal head pressures using a new analysis method facilitated by an in-shoe pressure-measurement system’s ability to export detailed data. Plantar pressure–time integrals in 11 individuals (22 feet) with claw deformity of the lesser toes were measured with and without toe props. Differences in pressure–time integrals at every individual sensor unit were then calculated for the two conditions, and significance was tested using the paired t-test. Plantar surface charts with contours of equal significant pressure–time integral change showed significant reduction under 17 second toes (77%), 22 third toes (100%), 15 fourth toes (68%), 13 second metatarsal heads (59%), 16 third metatarsal heads (73%), and 16 fourth metatarsal heads (73%). All 22 feet showed increases under the prop in the area of the third toe sulcus. This innovative approach to plantar pressure analysis could improve access to data that show significant pressure–time integral changes and, therefore, could advance the clinical application of plantar pressure measurement. (J Am Podiatr Med Assoc 94(3): 246–254, 2004)

scholarly journals Static Balance of Visually Impaired Athletes in Open and Closed Skill Sports

2017 ◽  
Vol 24 (1) ◽  
pp. 10-14 ◽  
Author(s):  
Grzegorz Bednarczuk ◽  
Ida Wiszomirska ◽  
Jolanta Marszałek ◽  
Izabela Rutkowska ◽  
Waldemar Skowroński
Keyword(s):  
Physical Activity ◽  
Visually Impaired ◽  
Body Posture ◽  
Posture Control ◽  
Static Balance ◽  
Motor Abilities ◽  
Eyes Closed ◽  
Unstable Surface ◽  
Eyes Open ◽  
Left And Right

AbstractIntroduction. In elite sport, athletes are required to maintain appropriate body posture control despite a number of destabilising factors. The functions of body posture control are monitored by the central nervous system that constantly receives information from the vestibular and somatosensory systems as well as from the visual analyser. Visual impairment may contribute to a decrease in the level of motor abilities and skills; however, it does not prevent visually impaired individuals from taking up physical activity. Therefore, this study sought to assess the static balance of visually impaired goalball players and shooters. Material and methods. The study included 37 goalball players and 20 shooters. A force platform was used to assess static balance. The study participants performed tests: standing on both feet with eyes open (BFEO) and closed (BFEC) (30 s), single left- and right-leg stance with eyes open (SLEO and SREO) as well as single left- and right-leg stance with eyes closed (SLEC and SREC). Statistical analyses were carried out using the following parameters: centre of pressure (CoP) path length [cm], CoP velocity [m/s], and the surface area of the stabilogram [cm2]. Results. No significant differences were found between goalball players and shooters in static balance levels. However, such differences were observed after taking into account the number of athletes who were capable of performing particular tests. Conclusions. The findings indirectly confirm that there is a correlation between the type of physical activity and balance levels in visually impaired individuals. Further research ought to include tests performed on an unstable surface.

scholarly journals Static Balance in Patients with Vestibular Impairments: A Preliminary Study

Scientifica ◽  
2016 ◽  
Vol 2016 ◽  
pp. 1-4 ◽  
Author(s):  
Hossein Talebi ◽  
Mohammad Taghi Karimi ◽  
Seyed Hamid Reza Abtahi ◽  
Niloofar Fereshtenejad
Keyword(s):  
Path Length ◽  
Center Of Pressure ◽  
Balance Control ◽  
Force Plate ◽  
Static Balance ◽  
Eyes Closed ◽  
Significant Difference ◽  
Eyes Open ◽  
Age Limits ◽  
The Difference

Aims. Vestibular system is indicated as one of the most important sensors responsible for static and dynamic postural control. In this study, we evaluated static balance in patients with unilateral vestibular impairments.Materials and Methods. We compared static balance control using Kistler force plate platform between 10 patients with unilateral vestibular impairments and 20 normal counterparts in the same sex ratio and age limits (50±7). We evaluated excursion and velocity of center of pressure (COP) and path length in anteroposterior (AP) and mediolateral (ML) planes with eyes open and with eyes closed.Results. There was no significant difference between COP excursions in ML and AP planes between both groups with eyes open and eyes closed (pvalue > 0.05). In contrast, the difference between velocity and path length of COP in the mentioned planes was significant between both groups with eyes open and eyes closed (pvalue < 0.05).Conclusions. The present study showed the static instability and balance of patients with vestibular impairments indicated by the abnormal characteristics of body balance.

scholarly journals Association between the levels of physical activity and plantar pressure in 6-14-year-old children

PeerJ ◽  
2020 ◽  
Vol 8 ◽  
pp. e8551 ◽  
Author(s):  
Lovro Štefan ◽  
Mario Kasović ◽  
Martin Zvonar
Keyword(s):  
Physical Activity ◽  
Plantar Pressure ◽  
Contact Time ◽  
Cross Sectional Study ◽  
Linear Regression Models ◽  
Older Children ◽  
Cross Sectional ◽  
Time Integral ◽  
Pressure Time ◽  
The Right

Background The main purpose of the study was to determine whether lower levels of physical activity were associated with higher plantar pressure generated under each foot. Methods In this cross-sectional study, we recruited 641 children aged 6–14 years (agemean ± SD = 9.7  ± 2.4 years; heightmean ± SD = 143.6  ± 15.3 cm, weightmean ± SD = 37.6  ± 13.4 kg; body-mass indexmean ± SD = 17.6  ± 3.2 kg/m2; 44.2% girls). We used EMED –XL pressure platform to measure force time integral, pressure-time integral, contact-time and contact area, peak plantar pressure and mean plantar pressure of the right and the left foot during the gait analysis. The level of physical activity was measured by using The Physical Activity Questionnaire for Older Children (PAQ–C). The associations were calculated by using generalized estimating equations with linear regression models. Results Lower levels of physical activity were associated with higher force- and pressure-time integrals, longer contact time and higher peak and mean plantar pressures in both feet. Conclusion Our study shows that the level of physical activity is strongly and inversely associated with plantar pressure in a sample of 6–14 year olds.

scholarly journals Validity and reliability of smartphone-based application for chronic ankle instability

2021 ◽  
Vol 28 (9) ◽  
pp. 1-10
Author(s):  
Taelim Yoon ◽  
Jihyun Lee
Keyword(s):  
Medical Device ◽  
Correlation Coefficient ◽  
Intraclass Correlation Coefficient ◽  
Ankle Instability ◽  
Intraclass Correlation ◽  
Validity And Reliability ◽  
Rater Reliability ◽  
Eyes Closed ◽  
Eyes Open ◽  
Cumberland Ankle Instability Tool

Background/aims Ankle instability is one of the most common injuries that can occur during everyday life, sports and exercise. Recently, smartphone accelerometers have been used to measure single leg balance associated with ankle instability, because they are easy to use, inexpensive and can be used in small spaces. Thus, the purpose of this study was to introduce and investigate the intra- and inter-rater reliability of the smartphone accelerometer when assessing ankle instability. Methods A total of 26 individuals who had ankle instability were recruited. The single leg stance balance was measured using a smartphone accelerometer (Accelerometer application) and a force platform (I-Balance) for 5 seconds with their eyes open or their eyes closed. Results In the eyes open position, intra-rater reliability of the smartphone accelerometer was excellent for both raters (intraclass correlation coefficient: 0.87–0.90); and the inter-rater reliability was moderate (intraclass correlation coefficient: 0.71). In the eyes closed position, the intra-rater reliability of the smartphone accelerometer was excellent for both raters (intraclass correlation coefficient: 0.90–0.93); the inter-rater reliability was good (intraclass correlation coefficient: 0.82). Additionally, there were fair positive correlations between the smartphone accelerometer and the Cumberland Ankle Instability Tool, and between the smartphone accelerometer and I-Balance (r=0.33, 0.30 respectively). Conclusions The present study demonstrated excellent intra-rater reliabilities of two raters and moderate to good inter-rater reliabilities. The smartphone accelerometer offers several important advantages as a potential portable medical device to assess ankle instability accurately. Although there was a positive correlation, the relationships between the smartphone accelerometer and Cumberland Ankle Instability Tool and that between the smartphone accelerometer and I-Balance were fair. Future studies should investigate the validity of the smartphone accelerometer as a portable medical device for determining ankle instability.

scholarly journals DIFFERENCES IN HIP MUSCLE STRENGTH AND STATIC BALANCE IN PATIENTS WITH TRANSFEMORAL AMPUTATIONS CLASSIFIED AT DIFFERENT K-LEVELS: A PRELIMINARY CROSS-SECTIONAL STUDY

2022 ◽  
Vol 5 (1) ◽  
Author(s):  
Stefanie John ◽  
Katja Orlowski ◽  
Kai-Uwe Mrkor ◽  
Jürgen Edelmann-Nusser ◽  
Kerstin Witte
Keyword(s):  
Muscle Strength ◽  
Cross Sectional Study ◽  
Static Balance ◽  
Residual Limb ◽  
Sectional Study ◽  
Cross Sectional ◽  
Hip Strength ◽  
Eyes Closed ◽  
Hip Muscle ◽  
Eyes Open

BACKGROUND: Following amputation, patients with lower limb amputations (LLA) are classified into different functional mobility levels (K-levels) ranging from K0 (lowest) to K4 (highest). However, K-level classification is often based on subjective criteria. Objective measures that are able to differentiate between K-levels can help to enhance the objectivity of K-level classification. OBJECTIVE(S): The goal of this preliminary cross-sectional study was to investigate whether differences in hip muscle strength and balance parameters exist among patients with transfemoral amputations (TFA) assigned to different K-levels. METHODOLOGY: Twenty-two participants with unilateral TFA were recruited for this study, with four participants assigned to K1 or K2, six assigned to K3 and twelve assigned to K4. Maximum isometric hip strength of the residual limb was assessed in hip flexion, abduction, extension, and adduction using a custom-made diagnostic device. Static balance was investigated in the bipedal stance on a force plate in eyes open (EO) and eyes closed (EC) conditions. Kruskal-Wallis tests were used to evaluate differences between K-level groups. FINDINGS: Statistical analyses revealed no significant differences in the parameters between the three K-level groups (p>0.05). Descriptive analysis showed that all hip strength parameters differed among K-level groups showing an increase in maximum hip torque from K1/2-classified participants to those classified as K4. Group differences were also present in all balance parameters. Increased sway was observed in the K1/2 group compared to the K4 group, especially for the EC condition. CONCLUSION: Although not statistically significant, the magnitude of the differences indicates a distinction between K-level groups. These results suggest that residual limb strength and balance parameters may have the potential to be used as objective measures to assist K-level assignment for patients with TFA. This potential needs to be confirmed in future studies with a larger number of participants. Layman's Abstract Patients with lower limb amputation (LLA) are classified into different mobility levels, so-called K-levels, which are ranging from K0 (lowest) to K4 (highest). K-level classification is relevant for the patients as it determines the type of prosthetic components available. However, K-level can vary greatly based on the clinician or orthopedic technician individual assessment. Objective data from physical performance tests can help to improve K-level classification. Therefore, muscle strength tests of the amputation stump as well as balance tests were performed in this study to determine whether these parameters have the potential to support K-level classification. Twenty-two participants with a thigh amputation participated in the study (four K1/2-, six K3- and twelve K4-participants). Hip muscle strength on the amputation side was assessed as well as static balance in the double leg stance with eyes open and eyes closed. Analysis of the data showed that all hip strength parameters differed between the K-level groups, with maximum strength increasing from the K1/2 group to the K4 group. Group differences were also seen in the balance parameters with greater body sway for the K1/2 group when compared to the K4 group, especially when participants had their eyes closed. These results show that muscle strength tests of the residual limb and static balance tests may serve as additional measures to improve K-level assignment for patients with LLA. This was only an initial study and further studies with a larger number of participants are required to confirm these results. Article PDF Link: https://jps.library.utoronto.ca/index.php/cpoj/article/view/37456/28905 How To Cite: John S, Orlowski K, Mrkor K.U, Edelmann-Nusser J, Witte K. Differences in hip muscle strength and static balance in patients with transfemoral amputations classified at different K-levels: A preliminary cross-sectional study. Canadian Prosthetics & Orthotics Journal. 2022; Volume 5, Issue 1, No.5. https://doi.org/10.33137/cpoj.v5i1.37456 Corresponding Author: Stefanie John,Department of Sports Science, Faculty of Humanities, Otto von Guericke University, Magdeburg, Germany.E-Mail: [email protected] ID: https://orcid.org/0000-0001-6722-7195

scholarly journals The Difference of In-Shoe Plantar Pressure Between Level Walking and Stair Walking

2019 ◽  
Vol 4 (4) ◽  
pp. 2473011419S0026
Author(s):  
Min Gyu Kyung ◽  
Chungho Lee ◽  
Jae Hee Lee ◽  
Yoon Jae Cho ◽  
Cao Linying ◽  
...  
Keyword(s):  
High Pressure ◽  
Plantar Pressure ◽  
Pressure Load ◽  
Stair Ascent ◽  
Time Integral ◽  
Stair Descent ◽  
Level Walking ◽  
Pressure Time ◽  
Stair Walking ◽  
Peak Pressures

Category: Basic Sciences/Biologics Introduction/Purpose: Stair walking is one of common activities of daily living. It is more demanding than level walking and can aggravate discomfort of the foot, such as Morton’s neuroma, plantar fasciitis, Achilles tendinitis, pressure related-ulcer, and etc. Therefore, analysis of increased pressure in specific plantar area at stair walking can be used as a risk assessment of foot discomfort and basic data in the clinical field. The purpose of this study is to analyze plantar pressure distribution and pressure patterns during gait cycle at stair walking compared to level walking. Methods: Fourty healthy male adults were recruited. Radiologic measurements and gait analysis were performed to check participants’ normality, and 35 healthy males with 20-28 years old were included. They performed level walking (18 meters walkway), stair (26 steps stair, height:16.7 cm, depth:29.8 cm) ascending, and descending in same type of running shoes. Measurements of in-shoe plantar pressure including peak pressure, pressure-time integral (PTI) were done by Pedar-X system. Only measurements of right steps were used to exclude the effect of the dominant foot. The sole was masked in 7 segments (hallux, 2nd-5th toes, medial forefoot, central forefoot, lateral forefoot, midfoot, heel region) to analyze properly. Percentages were assigned in relation to the size for each mask segment. Statistical analysis was performed using repeated measure ANOVA, and Bonferroni post hoc test was done. Results: Mean peak pressures in all regions except for the midfoot were higher during level walking than stair walking. During stair descent, mean peak pressures in all the regions except for the midfoot were generally lower than other types of walking, but it was the highest in the midfoot region. Pressure time integral (PTI) in the medial and central forefoot was higher during stair descent than level walking. PTI in the central and lateral forefoot, and the midfoot was higher when stair ascending than level walking. Pressure time integral (PTI) in the heel region was the highest during level walking, followed by stair ascent, stair descent. Conclusion: The risk of aggravation of discomfort in the midfoot area increases when stair descending. The medial region of forefoot bear high pressure load during stair descent, and the lateral region of forefoot and the midfoot region bear high pressure load during stair ascent. This is the first study to show plantar pressure patterns during level and stair walking in the large healthy gender-controlled population. We recommend that patients with pressure related foot lesions in the forefoot or midfoot avoid stair walking.

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