Can everybody hear me? Yeah. Thanks, Lisa. So quick intro, thanks everybody for sticking around here, our last session, and a real pleasure to have Dr. Lisa Prasso, who's joined us, also another trained upstate New York from SUNY Buffalo, and had worked as a travel physical therapist across a whole host of states here before settling at Walter Reed National Military Medical Center, where she's working with the IDEO brace, as we now know. So Lisa, thank you for your time and expertise, sharing with us here today. Of course. I am going to go forward, hopefully this works. Let me know if you see everything. Yeah, it looks great. All right, guys. I'm Lisa. I've been at Walter Reed for around seven years now, which is kind of crazy to think about. So I've worked with Jeff pretty much almost the entire time that I've been here. I started off with in our outpatient section, which was a little bit more limb salvage back in the day, and now it's kind of transitioned to true outpatient. But then I transitioned over into the MATC, which is the Military Advanced Training Center. And now we just do amputees, polytraumas, limb salvage, anybody that's a little bit more complex and injury. So with that being said, so my disclosures, these are my opinions on the government's and I have no financial disclosures. So like what Jeff said, so I'll touch on this stuff, but I mean, Jeff just covered a lot of this stuff for you. So the brace was developed in the CFI down at Brook Army Medical. The initial use was to reduce elective amputations, really try to preserve a limb, right? Because once you cut a limb off, that's the end of it. So really would like to kind of keep those limbs if possible. A lot of our limbs were, you know, limb salvage were due to high energy blasts, open fractures, gunshot wounds, and crush injuries. So when they first started this, they really spent some time developing a four-week immersive return to run program, and then transitioned that program into a study to prove its utilization. So who could benefit from this brace? As Jeff said, you saw kind of very similar in nature, right? Hind and midfoot injuries, ankle injuries, distal tibia injuries, anything complicated by soft tissue injuries, atopic bone, some of our guys have contaminations from the blast. So all that stuff kind of fits into this category. Also, you know, loss of range of motion, especially dorsiflexion, loss of push-off strength, any kind of nerve injury affecting the lower extremity, and pain. Pain is, it's been interesting to see, you know, going from combat wounded to then, you know, everyday outpatient, we've seen a lot of benefits with this brace and pain. So the brace itself, right? So you guys can probably see here, right? It's kind of hard, but I figured I'd get you a little close-up on the actual PowerPoint. So that proximal cuff, you see there's three components, right? The proximal cuff, the posterior strut, and then the custom foot plate. So that being said, how do these affect physical therapy? How do these affect your practice, and what can you do to really help these patients understand it? Oops, sorry. There we go. So the custom foot plate, and Jeff went into this, same kind of things, right? So it's rigid for minimal motion, and that minimal motion has really helped keep guys a little bit more pain-free. The ankle is set in dorsiflexion. So the dorsiflexion allows for increased deflection and energy storage as the tibia progresses forward, so from the middle, from mid to terminal stance, and it allows for that really kind of strong, powerful plantar flexion moment. As Jeff said, that heel cushion is super important. I've had guys show up to PT, and I get super confused because I'm like, why does your knee look like this? And I'm like, can you take the brace out? And they're missing that heel cushion. So that is super, super duper important. But that being said, with that heel cushion, and then you add the brace to it, things that you want to look at as a physical therapist are their leg length. So you really want to make sure that they do have equal leg length from side to side. Unfortunately, you do have to build up that opposite side, because there's such a, that could be almost like a one-inch difference sometimes. So this custom foot plate also, rocker design, easier to roll over. It also allows for loading of the posterior strut to simulate that plantar flexion motion. And a couple other key components, watch out for pressure points. This is where you can see a lot of rubbing, especially in sensate people, nerve injuries, even vascular injuries. So we really want these guys to be checking. And that's where that test socket kind of comes into, or test brace comes into play too. Jeff can really find those hotspots before they become truly an issue as we move forward. So Jeff can also build up the bottom of that, like below the foot plate. So sometimes what happens is, you know, they'll be either, it looks like their knee is going to varus or valgus just from the angle of the foot plate. So Jeff can really build up the bottom and really help out and change that moment. So that way it's truly an axial load. So the posterior strut, this is super important is obviously all three components are important. This one is the importance of the posterior strut in your practice is just remember it does flex and to store the energy to assist with that push off. The strut categories are, they range from one being less rigid and then seven being more rigid. And then we, you know, Jeff does a really good job here of being able to tell what category they should sit in. But sometimes when they start getting a little bit more comfortable and they're pushing through that brace more, it's kind of my, you know, it's our job to say, Hey Jeff, like maybe they need a lower or higher category. It's based off of weight, strength, activity level, range of motion and pain. But patients can over and underutilize the struts. In this picture, I don't know if you could really see, kind of have to look closely. It's actually a broken strut. So he was overpowering that strut. And when those struts snap, it literally sounds like a gunshot went off. So it was pretty intense. So we all, I think the whole clinic stopped for a second and we're just like, what just happened? So just be mindful of that. So the proximal cuff, it is used to load the device through a pressure tolerated area, right? So it's circumferential and that BOA system helps with that. It's similar to kind of like a BK socket where it gives that pressure point right below the tibial plateau. So that BOA system is actually pretty amazing. I know Jeff's talked about how it used to be a clamshell. He did a really good job changing it over to the BOA system and that's really helped with comfort with our patients. So that being said, so those are all the kind of the components of the brace itself. And now it's kind of into the nitty gritty, right? So the return to run program was broken into five components, the linear day, a lateral movement and plyometric drill day, or not day, but component, acceleration training, and then two days of strength. So this is part of the study and this is, you know, and we've modified from there. So it used to be four weeks. Now we've kind of shortened it down to two weeks just because it's a lot easier for guys to come up here for only two weeks at a time to really get this training in. We do try to get their information prior so we can send them a pre IDEO home program that they can work on, which is focusing on some strength, you know, some strength training that's going to be essential for their success with this program. With this program, we're hoping to, you know, return patients to running sport and hopefully deployment is our goal here in the military. The one nice thing about this return to run program, when it initially started, it built in a support group. There were so many guys doing the same thing. And that was an amazing predictor of just good outcomes. And, you know, these guys were really killing it back in the day. So it's been a little weird. And what we tried to really do here, just because we have, we do have a lot of people that we can pull from. We tried to ask guys if they're okay with sharing information so that way they can talk to each other and they can figure out, you know, is this idea of race good? Like, do we think this is gonna be beneficial or do you think I will later on become an amputee? What kind of shoes do you wear? You know, what's the biggest component? How do you put them in dress shoes and stuff like that? So this is a linear day. I'm sure these exercises are going to look similar to what you guys usually do on a daily basis for hip and lower extremity strengthening. But this is how we kind of break it down. Obviously, this is all modified per the patient. This is just the generic when they were doing the study. So they wanted to keep it as exact as possible. So, you know, monster walks for glute strengthening, donkey kicks, swings for loosening up the hip, hurdles for mobility, lunges for strengthening. Again, some ladder drills, right? So working on that agility component, learning that sweet spot of the brace, same for the hurdle runs and the hills and the step ups. And one thing that we do use is a pose run belt, and we'll get into that a little later. And then bridges, you know, core strengthening, all the nitty gritty of PT. The lateral day and plyometric day, same thing, just working on a different plane of motion. So looking into sidestepping, kind of lateral hurdles, quick feet, then we start working on towel slides or, you know, lunges. We do a lot of wall drills. So like the wall acceleration drills at two counts and three counts, and then doing a crossover to really kind of get that learning to get that drive force through the brace. And then obviously the agility component of full ladders, diagonals, the S drill, T drill, and then we do a shadow drill to learn to kind of push off when, you know, when they're not expecting it. And then we, you know, the plyo is still, you know, some people will say, how do you do that? Well, you can do a box jump, obviously they'll be pushing with their dominant leg, but at least they're going to learn how to land on the ideal brace. So just be mindful of that. That can be a little tricky, especially when you have a bilateral in ideos, that's a little tricky. There's going to be no jumping for that one. And if they do, it's pretty impressive. So the acceleration day, again, we start off with a warmup of just, we here at Walter Reed, we call it the Maxi Mile, where we do, we make our guys walk one lap, sidesteps one way, one lap, the other way, monster walks forward, monster walks backwards. We love these guys. So we can, then we give them their fancy band to take home with them. We do a lot of hurdle runs to learn how to clear and quick turnovers, and then lunges obviously at different counts to work on power and acceleration. And then you can see, we do add in some core strengthening. So planks, power presses, active straight lowering, and then our motion to kind of, if they haven't been running in a while, just to retrain the brain a little bit on that quick motion. And then you can see on the block three, we do again, some of the bounding exercises, just learning to absorb, learning to push. And then we start looking at pushup starts to kind of get that speed, and then falling starts to start to bring their body weight forward over that brace to help them understand that rollover. And then these are our strength days. The strength days are nothing too crazy. I don't know who, unfortunately, I was not there when they developed this. I'm guessing it was just to make sure that it was more of a whole body program that they were kind of targeting and not so much just the lower extremities. So strength day, your typical, a lot of pressing, pulling, landmines, or actually, we still do those. Those are phenomenal for just core and learning to kind of push through the lower extremities if you do a nice power drill with those. And then they used to do a cardio kind of hit routine. And then the same thing for strength day number two, looking at that dead lifting, kind of glute strengthening, all that, you know, quad and glute, just trying to fatigue those guys out. And then they did a lot of this eccentric concentric to failure, just trying to fatigue those leg muscles out, get them as strong as possible. You know, that's one of the biggest things is that if your legs aren't strong, this brace will overpower you and you need to overpower the brace kind of. So tips and tricks. Okay. So everyone goes, well, how do you walk in it? We always joke, we're like, just walk. There's unfortunately, there's really no right or wrong to walk, but sometimes we do occasionally say, you know, retrain them for that heel toe rollover pattern. So that if these are guys, some of these guys have been, you know, non-weight bearing for, you know, X amount of timeframe, or they just weren't able to weight bear because of pain. So sometimes you do have to do the, you know, the quick true gait training of just heel toe learning to roll to that terminal stance of gait. So, but you know, walking, you know, usually it's pretty straightforward. Training is what gets exciting. And this is where it takes a little bit of understanding from the patient perspective and, you know, just kind of hearing them a little bit, and then we can modify. So on the left-hand side or left-hand side of your screen, you should see a gravity supported treadmill. Sometimes when there is a pain component and they haven't been running in forever and, you know, everything's going smooth with the agility training and the strength training. But as soon as you start doing true high impact, they start having pain. We'll put them in the gravity treadmill to see if we could kind of really help them just get used to impact forces in a consecutive manner for prolonged periods of time. And then the other one we talked about was that wall acceleration drill. So this guy, I think this is maybe day two or three of him getting his ideal brace. And you can see he's struggling, right? He's trying to figure out that happy medium of where that sweet part, like where that sweet point in the braces to get that return. the other one that we, you know, a couple of ones that we've loved to do are the resisted running drills. So we'll take one of those sport cords, um, and we'll attach it to like a hip belt and we'll have them run into that hip belt, right? Cause that quick, that quick turnover, learning that impact force, uh, giving that resistive force guys really pick up where that, where they need to hit and strike on that brace. The other one that we've used in the past is the, uh, pose running belt where you get to attach it to the back of their legs and it helps with that hamstring activation, that quick turnover again, um, making it a more of a mid foot striker, getting rid of that over striding, uh, for running, which is really, um, we definitely need to, that's the, one of the biggest components, you know, trying to get rid of that over striding. And then the one that we've been playing with lately is the metronome running. Uh, we know that, you know, there's a certain, you know, 150 to 170 beats is really typical quote unquote cadence for running. Um, and it really does improve subconsciously that over striding and it helps them turn over faster by staying, uh, on that quick, just nice metronome pace, which has been nice to see. So exercise modifications. What do you guys usually have to modify? And this is the, we always come back to the same thing. It's just squats, right? Squats are unfortunately because of the brace being set in plantar flexion, uh, having that rigid strut, not allowing for true tibial, um, progression, you have to put something underneath the heel to be able to really truly achieve, uh, the depth of a squat, depending on how deep they're trying to go. The other one that we do use, and, um, it was actually, you know, that return to run program brought BFR to our clinic, um, it, you know, we use it because it's such a good way to assist with strength training if done correctly. And our, especially when you have a limb salvage guy who can't push through like, uh, you know, an ankle joint that's been shredded or soft tissue, that's just been annihilated, right? How do we strengthen these guys, give them as much optimization as we can. Um, And really work on some of these muscle bellies. So BFR has been a key component to the success for a lot of these guys, um, which has been really nice to see. So that, uh, you know, always PT outcomes, right? Uh, some of the ones that we look at, um, are the four squares step test. And we use that it's a time-based test, obviously, uh, used for dynamic balance and agility. So there's two, we usually have two. We that's a lower, that's one of the lower end ones. And then the upper end one would be the Illinois agility test to give us an idea of truly how, uh, they compare to the elite athlete, which is pretty neat to see. Um, moving forward for, uh, more of a lower extremity strength, um, strength kind of examination. We do the five times to the sand, which is also a time-based test, uh, and also to see how they do transitional emotions. The higher level tests would be the stair ascent, um, which is also again, for that strength and power where you take them down and you have them as walk up as fast or run up as fast as they can to give us a really good idea. Um, and it really, you can see a lot with these tests. Um, when you start to break it down, do they shift, do they not want to go step over step? Do they need to hold on to something? So it's pretty interesting. So, uh, self-selected date speed and that Jeff was talking about that. Uh, when we do it with the brain or without the brace first, and then you put a brace on them, they clean up tremendously, their walking speed cleans up phenomenally. Uh, so just really looking at their functional mobility and speed with this test and then the higher level tests would be that 30 foot agility run, uh, where they have to start, you start at the line, run down, grab a cone, bring it back, run down and grab the other cone, bring it back. Right. So starting to look at a little bit more, can they, you know, can they return to duty, you know, are, are these, is this brace giving them the ability to return to not just duty, but sport running activities of daily living and then the beat test, the beat test is always fun. Nobody ever wants to do it. Uh, and our guys always yell at me when we think it's cold right now. So they don't have to worry about it. Cause I don't like standing out in the cold doing this test. Uh, so the view, you know, we're looking for here is that VO two max seeing, you know, have we changed anything? Have we made them more efficient with this brace? Can we, does this brace even change efficiency for some of these guys? Um, so it's pretty fun to watch, um, these guys go through these outcome metrics and really improve drastically from, you know, either walking without a brace, walking with just a regular AFO and then going into this higher dynamic brace, so to kind of sum everything up for you guys, uh, just to make it easy. So you can see on the left-hand side, that's our bilateral. And you can kind of see if you look at his left foot, watch that braid, that strut, look how much deformation. So that's the guy that broke that strut. I think it was right after I stopped the video, it popped. Uh, so that would be someone who you would send back to the orthotist and say, Hey, listen, I think he either needs to go up in a strut in a category to make it a little bit more stiffer, or there's gotta be something else where, you know, maybe there's, he's not sitting down in the brace enough to really, um, get that true stop at the tibia. So, so make sure proper fit, very, very much essential. And then you'll see on the guy on the right, he's picture perfect. Look at that stride, midfoot, midfoot strike, super important. Right. Not really over striding, bringing that hamstring. So that hamstring strength, that quad strength, no hyperextension at the knee. Uh, so this guy was, uh, he was, it was pretty successful, I would say. So just think if you're going to take anything home from this, right. Midfoot strike. Lower extremity strength training obviously is important. And that strut is definitely important. And then proper fit of the brace. And that's where, you know, having Jeff down the hall for me, uh, is a blessing. I could literally go over there and be like, I need you. Something is not right. Um, so we are spoiled here at Walter Reed. And, you know, that's why a lot of these, it's probably harder for the civilian sector to make these as easily as we can here and have that ability to do this kind of training. But, um, that being said, there are some pitfalls, uh, there are some downfalls to this brace. And if you ask anybody, the first thing they say is it's bulky. It's heavy. It is not heavy, but it's heavier, right. Than a normal AFO. Uh, they tend to have to have two different shoes for, uh, just cause it's so wide and to fit it into, uh, like a true normal size shoe is almost impossible. You do really need the training. Uh, you do need it, you know, so that way these guys can, you know, really understand how the brace works, where they should be hitting with their foot and how to really activate it for proper use. Um, so they could take it home and really get the maximal effort and, uh, maximal, uh, effect out of it. And then the other last one is it can break. Um, you know, not just the strut, but the carbon fiber footplate has been known to break. Um, and you can break at the kind of those weak areas. Uh, some of the areas we've seen. So obviously this guy can break here. Some of the areas we've seen break are along, hopefully you can see that. And then we've seen a breakthrough here too. So it, I mean, you know, as much as it's an amazing race, you know, unfortunately braces have downfalls and those are probably the biggest ones. Uh, I've seen, um, and I've talked to my guys about this for, you know, like, what can we make, how can we make this better? What can we do? You know, we've tried to, you know, I've talked to Jeff at length on, you know, some of the biggest issues that have been brought up to, uh, to us from our, uh, active duty guys here. So I hope that kind of summed up. I know it was really quick. Uh, I figured Jeff kind of went over, but he's got more to say. Um, so if you guys have any questions, um, any, anything that was pressing or, uh, from a PT side of the house, let me know. Um, and we can go through. All right. Thanks, Lisa. And a great talk. Very interesting. I have a few questions, but, um, I'll let anyone else jump in. Maybe I'll wait just a sec. And I can start with just, um, I'm really curious about this sort of push off strength, plantar flexion strength. Obviously the, you know, the, the telltale role of the idea is that it provides that returned spring. So how do you identify? So it seems like one of the indications is weakness. So how do you quantify that? Is there an assessment of a certain amount of weakness that then you see in patients that then you think is a good indicator that they're going to do successfully with it? Is there functional tasks? Is there people who are too strong? And then you think they probably don't need it. How do you find that balance? Yeah. So this is actually, uh, yes. For Jeff, talk about that. Uh, not wanting to take away motion that they have. This is what we fight with a lot. Uh, we have a lot of guys that have true plantar flexion. So why would we want to take that away? But they don't have dorsiflexion. So how do we come up with a brace that solves that problem? That's a really hard, Jeff is working tirelessly to, and we have a couple models that he's put on our guys and they've done amazing, right? Cause why would you want to take away plantar flexion? If you have it, how do you make an articulated brace that does both? Um, but unfortunately, you know, those braces are still in modification, you know, in kind of construction and they're not, um, he's, I don't think he's a hundred percent satisfied with them. So the idea seems to be the way to go. Uh, so from, uh, if you don't have dorsiflexion, but you have plantar flexion, um, we tend to give you, we, what we do is we tend to say, Hey, take the idea, use that for high level impact activities, but we're going to give you just a true off the shelf AFO for those just normal everyday walking. Cause we want you to keep and maintain what you have. Uh, and we don't want you to just always be locked out in a little bit of plantar flexion. That's not the most ideal situation. Um, and our guys do really well with that. Uh, cause it kind of prevents that atrophy from occurring, uh, and allows them to keep the mobility that they have. So that's one of the things for more of that dorsiflexion plantar flexion. Uh, inversion, eversion, you know, Jeff can modify the brilliant, the brace, because we do have guys, obviously that might have like a peroneal, uh, or tibial nerve, um, that that's got been affected, um, and he'll build up the brace a little bit for that, but that doesn't, you know, besides building it up to create a neutral ankle, that one doesn't really affect the idea that much. Um, The quad. So the quad and the hamstring are probably your biggest, I mean, obviously glute too. But if someone has a significant quad weakness, you'll see a hyperextension moment, um, which is. Going to cause havoc with running. Right. So if we truly can't, they really can't push through that quad to overpower. That, that, um, you know, overpower the, like the forward trajectory trajectory, you're not going to have success with the brace. And that's where we've spent time, obviously prior to, if we have the ability prior to giving them the idea, a lot of strength training, uh, in that quad and the hamstrings is also important, right, because we need to make it more of a mid foot strike. Right. So we know typically mid-foot strikers, um, are quicker turnover and they have that hamstring that's kind of a little bit more, um, active and then an O you know, a heel striker, which it's less of a turnover. So that's where the resisted running and the pose belt kind of comes into play. And we'll see a lot of people clean up once they understand that they have to modify their running. Um, and then glute strength, right? So glute strength, we have to, you know, we do a lot of running analysis with the slow-mo thanks. You know, now we have these cool, you know, cameras in our phone that we could literally slow-mo video. I slow-mo video everybody so I could break it down, but if we have any, so biggest thing is watching for like pelvic drop, right? So, and, you know, pelvic drop and drop and hip extension, right? So if we're seeing a lot of just side to side, you know, we got, we got to look at glute strength and see if that glute meat is really able to stabilize them. And if they're not getting into hip extension and they're cutting it short, you know, they're going to have some pain and discomfort. Uh, so we need to make sure we maximize glute meat and glute, you know, pretty much all glute strength. So hopefully that answered that question for you. Yes. Thank you. Anybody else? You, you briefly mentioned with your outcomes, I think it was one of the shuttle runs or six minute walk or one at one of your running agility tests you see efficiency, like VO2 efficiency with the brace compared to other AFOs. I'm wondering what other, what other AFOs, like how much is that? Do you really think what's that efficiency? And do you do a lot of comparisons to other AFOs? So unfortunately, you know, I'm a status quo PT. We don't do a ton of research. We do try to bring those research questions to the table, to our, you know, our research department. Um, but a couple of the braces that we've used to, you know, if, if we feel like they potentially could push off, um, you know, when a couple are like the spry step and then some of the custom ones that Jeff has made, uh, kind of doing a comparison run, um, from that brace to an ideal brace. Cause typically, you know, if they're referring for an idea, like Jeff will see it will sometimes give them both if we think they have enough plantar flexion strength to kind of give that push off. So that's kind of where we see, you'll see a little bit more of, um, efficiency with the ideal brace, right? Cause it gives it a lot more return versus some of these other kind of off the shelf or like slightly customized braces. All right. Well, if no other questions, I guess we won't keep anybody ever any longer, but, uh, you know, thank you very much again, Lisa, and, uh, you know, send it back to, uh, Jeff, obviously it's great to, great to finish on this talk. I think for sure an interest of mine anyway. So, um, and thanks everybody for participating and, uh, and attending. Yeah. Thank you guys for the opportunity. It's great to be able to kind of distribute some of this knowledge. I think, you know, it's nice to, I don't think we have enough, uh, information going out sometimes about the ideal brace cause everyone's so interested in any care. Great. All right. Well, yeah, hopefully, hopefully we see everybody again. And again, thanks for everyone's, uh, participation and attendance. Have a good one. Bye now.

IDEO brace

limb preservation

elective amputations

Brook Army Medical

hind and midfoot injuries

ankle injuries