Investigation Of Kinetic And Kinematic Parameters Physical Education Essay

Investigation Of Kinetic And Kinematic Parameters Physical Education Essay This study reviewing the biomechanical effects of the orthosis on human gait pattern and a specific type of ankle foot orthosis (AFO) with rocker bottom was used for the pilot study. Walking gait cycle background theory and related terms definition is explained as the introduction. A complete review on AFO functionality and efficacy on gait correction via laboratory testing is done. The review is mainly expressed from biomechanics approach with the use of kinematics and kinetic knowledge. From the reviewed process, it is no doubt to clarify that AFO enable to prevent and correct pathological gait for better improvement. Motion analysis technique using camera based system to conduct laboratory experiment on human gait is studied too. A sequence of procedures is design for further study, which consist of subject acquirement, rocker AFO fabrication, customization, laboratory experiment testing using Vicon motion analysis system, data collection and analyse. Besides, pilot studys results are included in result and discussion. A healthy woman was used as the subject in the pilot study who undergo 2 types of walking, which are walked barefoot and with AFO condition. As conclusion, the review provides evidence that the influence of AFO in altering human walking gait is significant and further study is necessary to be proceeded for better describe AFO functionality. Acknowledgement The first thank goes to Prof. Dr. Ir. Wan Abu Bakar Wan Abas, my supervisor for this graduation project. His willingness and patient in teaching and guide me either to accomplish the tasks or when I facing problems during the time, were indeed appreciated. My grateful thank goes to Dr Noor Azuan Abu Osman with his enthusiasm of sharing valuable knowledge and all kind of challenges gave by him, were definitely brought me chances to work as an professional biomedical engineer. I express much gratitude to Miss Arezoo Eshraghi too, for her guidance and assistance brought to the smoothness of my thesis study. Nevertheless, I would like to thank for all the hard work done by my faculty, especially to the Coordinator for the Graduation Project, Dr.Belinda Murphy, assistant for the project Miss Khairunnisa Hasikin and all the stuff of Biomedical Engineering Department. Table of Contents List of Figures List of Tables List of Symbols and Abbreviations AFO Ankle Foot Orthosis IC Initial contact LR Loading Response MST Mid Stance TST Terminal Stance TO Toe Off ISW Initial Swing MSW Mid Swing TSW Terminal Swing DF Dorsiflexion PF Plantarflexion KF Knee Flexion KE Knee Extension HF Hip Flexion HE Hip Extension PTB Patellar Tendon Bearing ToA Types of AFO CGC Control Group Condition Introduction Human locomotion defined as movement from one place to another and a numbers of ways could be done to achieve it, walking, use of a bicycle, wheelchair are examples of locomotion (Smidt, 1990). In this study, walking gait is the targeted locomotion. Walking is a cyclic movement interlaced between left and right foot with at least one foot being contact with the ground at all times in a certain periodic pattern (Ounpuu, 1995). A systemic analysis and parameter is required to evaluate walking gait effectively and biomechanics knowledge has been introduced to solve for this. It is a brand new term developed around the year of 1970s which integrating engineering mechanics knowledge into biological system. Biomechanics is actually applied in gait analysis by the ancient scientists few centuries ago (Martin, 1999). Biomechanics study on the gait analysis has been started since the year of 1680 by Aristotle on the gait of animals and in the year of 1890, Christian Wilhelm Braune an anatomist and Otto Fischer were started investigating human gait from biomechanics aspects (Martin, 1999). Scientists enthusiasm toward human gait analysis never shelved, it continue evolutes until today. At present, biomechanics investigation in gait analysis is able to provide profusion information for clinical practitioner to assess patient locomotion effectively. For instances, a pathology gait pattern by patient can be visualized by measuring biomechanical parameters, step length, length, joint angles, forces and etcetera. To evaluate how well the treatment improves patient ambulatory level, biomechanics knowledge applied too. Main interest of this study is not only focus on human walking gait, but also to investigate the manner orthotics alters its users gait pattern from biomechanics aspect. Orthosis is a medical appliance major used in orthopedics field for the purpose to support, alter, and align injured body segments involve in body movement (Edelstein Bruckner, 2001). In this study, the ankle foot orthosis (AFO) with additional rocker sole is chose as the orthosis in this study. Figure 1.1(a) shown a solid AFO and (b) rocker bottom. Figure 1. Solid AFO Rocker AFO is a kind of treatment apply to diabetic patient who has plantar foot ulceration risk and with ankle joint mobility difficulty. From statistical analysis from University Malaya Medical Centre Diabetic Foot Clinics, plantar foot wound treatments on diabetic patient possess the highest number of among other kind of treatment and also footwear is the highest treatment modality among others in 2008 and 2009. This statement has support and encourages the necessity to carry out this study as number of diabetic patient is increase gradually every year. AFO is worn on lower extremity and around foot to support and correct ankle position. Patient having diabetes, experienced bones segment fracture, cerebral palsy, spinal cord injury, tendon dysfunction and limb disorder patient who ankle failed to support their body weight while walking are commonly suggested by orthotist to use an AFO to improve gait routine and to minimise further injury risk (Edelstein Bruckner, 2001). Besides that, rocker sole is a creature use to reduce pressure on the forefoot and use to transmit pressure from high pressure to low pressure area meanwhile off loading the pressure exerted to risky area (Albright Woodhull-Smith, 2009). To be relative to orthosis definition, an AFO with rocker sole should not bring more burdens to patient in increase energy demand or cause any long term side effects. Consequently, investigating AFO biomechanical performance in aiding and influencing wearer locomotion therefore becomes an important study. Three dimensional (3D) gait analysis systems are laboratory equipment involve the use of reflective markers that placed on subjects interest body segments as the landmarks (Davis, Deluca, Ounpuu, 2000). It has been use widely in clinical gait analysis services and research. The video camera based system employ 2 to 7 infrared cameras allocated on the measurement volume to record subject motion or markers trajectories in precise as shown in Figure 1.2 (a) (b). The entire system applies stereophotogrammetric techniques to produce each markers 3D coordinates from the two dimensional (2D) images capture by each of the camera (Davis, et al., 2000). This 3D system digitized subject movement in real time into frames depending on sampling rate set. The frame to frame analysis provides better motion visualization and subsequently from the 3D images generated it makes the possibility to compute a more complete description towards the dynamic gait in terms of biomechanical parameters. Kinemat ic, kinetic, and temporal parameters or some other dynamic gait variables are able to be obtained from this system. During the entire study, Vicon Nexus 1.4 motion analysis system is employ to record and examine subjects walking gait pattern. Kinematic and kinetic parameters are extracting to further illustrate rocker AFO effects on its user gait pattern. Figure 1.2(c) presented a monkey hooping frame image capture using 3D motion analysis systems. http://rehablab.creighton.edu/share/sharedfiles/UserFiles/image/Camera1.jpghttp://www.med.nyu.edu/rehabengineering/images/vicon8cameras.jpg (b) (c) Figure 1. (a) Infrared Camera (b) Overview of Motion Analysis Laboratory (c) Frame Images Capture from Infrared Camera 1.1 Theory Walking gait Normal one complete gait cycle consists of stance phase and swing phase in a proportion of 60% and 40%, respectively. A normal adult will spent approximately 60% of total gait duration for heel strike to toe off (stance phase) and 40% for initial swing to terminal swing (swing phase). Stance phase is the event when foot touch on ground and body passes over the top of it whereas swing phase is when the same foot moves forwards in the air. Figure 1. Stance and Swing Phase Propotion. Stance phase is defined from initial contact, loading response, mid stance and terminal stance (toe off). Swing phase is defined from the instance toe off, initial swing, mid swing and terminal swing (Ounpuu, 1995). Figure 1.4 illustrates the phases of the gait cycle shown with the corresponding position for sagittal plane motion. http://www.ncbi.nlm.nih.gov/bookshelf/picrender.fcgi?book=physmedrehabpart=A8414blobname=ch6f6-2.jpg Figure 1. Gait cycle phases (Carson, M.D. 1995) Stance phase Initial contact(IC) (0% of the gait cycle), it occur when foot contact to ground. Loading response (LR) (0-10% of the gait cycle), during this stage, shock absorption occurred with stability remain and body more forwarded. This is the first double support happened. Mid stance (MST) (10%-30% of the gait cycle), the first single leg support instance, purpose of this phase is to advance body over the stance phase limb while stability is maintained. Terminal stance (TST) (30%-50% of gait cycle), or sometimes called toe off(TF) single support ended when the sound limb contact with floor and in this phase, body still being advanced through the stance foot through the forward fall of the trunk. Toe off (TO) (60% of the gait cycle), when foots toes are about to leave floor. Swing Phase Initial Swing (ISW) (60%-73% of the gait cycle), second single support phase and begins when the foot leaves the ground until it passes opposite the stance limb. Mid swing (MSW) (73%-87%), continue advance the swing limb while providing clearance of stance foot. Terminal swing (TSW) (87%-100%), swing leg already in preparation for the next stance phase. In order for a person to walk normally, the locomotor system must fulfill four requirements. Firstly, stability of foot is essential to ensure each foot capable to withstand body weight with no collapsing. Secondly, during single leg support in stance phase, balance shall sustain for that particular period. Thirdly, swinging leg must be able to move in a sequence reaching the position where it can take over the supporting leg. Lastly, locomotor system must provided substantial power to induce limb movements and to advance the body (Whittle, 1993). Pathological gait produce abnormal walking patterns when it fails to obey any of the four requirements stated above. It can be indentified obviously by visual or using appropriate clinical gait analysis method. This abnormal gait maybe performed unintended by the subject due to the weakness, spasticity or deformity occurred onto them. Besides, sometimes the abnormal gait is also consequences of the compensatory motion by some other problem. Any abnormal gait should be corrected using an orthotics or braces in order to minimize overload harms on muscles, joints and bones. Kinematic and kinetics of human gait The terms kinematic and kinetics are branches of biomechanics, which are commonly employed in gait assessment. Kinematic describing a body movement without considering its causes for example forces and torque. Camera is a example of kinematic equipment which only used to observe limbs movement without but without providing information of force involved (Whittle, 1993). Meanwhile, kinetic is more in explaining the body motion with it causes like mass and forces exert onto the system. Moment, force, mass, and acceleration are the examples which usually utilize the kinetic of the systems. Example of kinematic equipment in gait analysis is force plate, which measure force exerted by foot but without the position and angle of the leg segment (Whittle, 1993). Kinematic of human gait: Angle Pelvis, hip, knee and ankle angle are the common kinematic parameters used in gait analysis. Each anatomical angle can be observed from sagittal, coronal and transverse plane. During normal gait, most of the motion occurred in sagittal plane meanwhile coronal and transverse plane have greater motion in pathological gait(Ounpuu, 1995). Table 1.1 is a summary on the each segment movement with respect to gait cycles phases. Table 1. Summary of the Major components of gait with respect to the phase of the gait cycle. Phase Joint Movement Ankle Knee IC Neutral Position Fully KE LR PF KF MST DF KE TST DF KE TF PF KF ISW Peak PF then DF rapidly KF rapidly to peak MSW Peak DF Start with peak KF and KE rapidly TSW PF KE PlantarFlexion(PF), DorsiFlexion(DF), Knee Flexion(KF), Knee Extension(KE), Hip Flexion(HF) and Hip Extension (HE) Kinetics of human gait: Ground reaction forces When a person is walking, forces will apply toward ground on each step taken. According to Newtons Third Law, a force will generate that is equal magnitude but in the opposite direction to the force applied by the foot, and it is called ground reaction forces. The vertical component of ground reaction forces is raise from heel strike and shot 112% of body weight during 25% of gait. At the mean time, the opposite leg propels the centre of gravity upward and thus vertical force descends to around 80% of body weight. At the instance of heel off, centre of gravity start to move downward therefore vertical forces raise again to around 115% of body weight at almost 80% of stance phase. Vertical forces descend greatly right after the peak vertical forces as the foot is propel to swing phase. Figure 1.5 shown the overview of vertical forces exert on the stance leg. Figure 1. Ground reaction forces Literature Review Types of AFO AFO is categorized into many types depending on its functionality, design approach and usages. AFOs are generally classified into five main branches: rigid AFOs, hinged AFOs, Patellar Tendon Bearing (PTB) AFOs, posterior leaf spring AFOs and ground reaction AFOs. Each AFOs functionality will be discussed in detail later. Table 2. Summary on Types of AFO and description (Edelstein Bruckner, 2001) Types of AFO Features Solid AFOSolid ankle-foot orthosis (AFO), Plastazote-lined (Photo courtesy of Hersco Orthotic Labs.) Trimmed anterior to malleoli surrounds ankle. Restrict ankle motion without allows any plantarflexion. During loading response, maintain a rigid foot and ankle alignment Hinged AFOhttp://www.appliedbiomechanics.com/Home/Home/Hinged_AFO.gif Add mechanical joint around ankle to permit motion. Degrees of motion are determined by the joint design. Allow dorsiflexion and plantar flexion without restriction. PTB AFOhttp://www.capstoneorthopedic.com/Orthoservicespages/afo/afo_clip_image018.png Cast until patella area as to transfer weight from plantar foot to patella tendon Responsible for off loading effect. Posterior Leaf Spring AFOhttp://www.neuromuscular-orthotics.com.au/images/PLS%20AFO.jpg Trimmed posterior to malleoli, allow plastic to recoil Function as a spring during swing phase off loaded, allow plantar flexion. Ankle motion is permitted by deformation and recoil of the plastic strip. Gait analysis method Reliability of the result obtained from motion analysis is mainly relay on the markers placement (Ferrari, et al., 2008; A. Leardini Benedetti, 1999). Therefore, marker positioning is depending strongly to the objective of the research or study. The inconsistency of marker placement is generally a crucial factor contribute to the data variation because each marker represent different body landmark respectively too. A full body marker set is often applying to investigate whole body posture and gait. A total of 60 markers with 22 on each leg, 5 on pelvis and 11 on trunk are consider as a complete marker set. It has been applied to evaluate treatment gait pattern correction or diseases caused pathological gait for example cerebral palsy and diabetic patient (Radtka, Skinner, Elise Johanson, 2005; Sawacha, et al., 2009). Only lower limb markers set were use more often in gait motion analysis (Abel Juhl, 1998; Fatone, Gard, Malas, 2009; Alberto Leardini, et al., 2007; Yokoyama Sashik a, 2005). There also few study make their focus on gait assessment on AFO user which only applied reflective marker on lower limb as anatomic landmarks for the whole experiment (Abel Juhl, 1998; Fatone, et al., 2009). When come across with gait analysis, researchers putting more interest on the lower limbs kinetic and kinematic parameters rather than upper limb because the locomotion trajectories occurred mainly in leg segments. In analyzing treatment effect for a particular illness or disease, control group or control variable present to serve a better comparison to the tested result. While evaluating the relation of orthosis treatment and gait assessment caused by it, subject under barefoot condition sometimes appeared as the control variable (Abel Juhl, 1998; Lam, Leong, Li, Hu, Lu, 2005; Romkes Brunner, 2002). However, in some cases, barefoot control does not provide a comparable opportunity and it is not practical as in real life subjects usually walk with foot wear. Besides, as of experimental approach, it has shown that subjects walking with footwear is more relative to evaluate AFO efficacy with contrast to barefoot ((Radtka, et al., 2005)Churchill et al., 2003; Radtka et al., 2005). Two reviewed articles obtained result with subject walking while wore footwear alone (Bleyenheuft Hanson, 2010; Fatone, et al., 2009). There is one of the article used able bodied subject with footwear alone to acqui re control variables (Fatone et al., 2009). Either way of choosing control group is proportion to the research behavior and objectives. Therefore, appropriate consideration should be taken while designing a research methodology. Gait analysis parameters In general, AFO is use as prevention of foot deformity, limit joint movement, position and provide stability. The effect of AFO in serving all these functionality is been studied via various method from simple to more sophisticated gait analysis technique. Majority of the reviewed papers adopted video-camera based system to collect and record data. (Abel Juhl, 1998; Fatone, et al., 2009; Lam, et al., 2005; Radtka, et al., 2005; Romkes Brunner, 2002; Yokoyama Sashika, 2005). Kinematic and temperal parameters are the two common results obtained from ambulation analysis. Temperal parameter Cadance Cadence, defined as number of steps taken in a given period and its unit is steps over minute. In gait analysis, cadence becomes a popular parameter to evaluate AFO efficacy. Researches which have examined subjects gait with dynamic AFO and without dynamic AFO proved that cadence is one variable altered by the manipulation on AFO (Lam, et al., 2004; Romkes et al., 2001; Bleyenheuft et al., 2007). Lam and Romkes studies have shown a decrease of cadence while subject walked with dynamic AFO compare to walk with barefoot. However, in Bleyenheuft study, changes of cadence value are less significant compare to others. In hinged AFO, two papers reported a increase on cadence compare to barefoot ( Romkes et al., 2001; Tyson et al., 1998) and one shown decrease effect (Radtka et al., 2004). Four reviewed papers tested subjects walked with solid AFO reported decrease of cadence compare to without solid AFO (Abel et al., 1998; Radtka et al., 2004; Lam et al., 2004; Bleyenheuft et al., 2007). C adence in a new design AFO which use oil damper resistance to restrict ankle movement also reported a decrease phenomenon on subjects walking gait with against barefoot trials. Dynamic AFO reported to have higher cadence compare to solid AFO in Lam, 2004 and Bleyenheuft, 2007 studies. Meanwhile, between hinged AFO and dynamic AFO, hinged types AFO having higher cadence value ( Romkes et al., 2001). By reviewing this, an instance conclusion can be making that hinged AFO provide a high cadence. Resultant cadence variation is likely due to the design of types of the AFO. Manipulate ankle movement degree certainly influence entire locomotion trajectories, consequently cadence are involved. Velocity Velocity is a resultant product of stride length time cadence. Any changes of these two variables may vary walking velocity. Solid AFO, dynamic AFO, and hinged AFO were all result higher velocities and stride length compare to the condition without AFO on tested walking trials (Abel et al., 1998; Lam et al., 2004; Radtka et al., 2004; Bleyenheuft et al., 2007; Romkes et al., 2001; Fatone et al., 2009). However, a less significant increase observed while analyzes hinged AFO and solid AFO toward barefoot condition in Fatone, 2009 and Lam, 2004 researches, respectively. From these two cases, a common observation found between them is the insignificant of stride lengths alterations. Kinematic of Gait Analysis DF at IC (Stance Phase) Currently, AFO are design to restrict exceed ankle PF, simultaneously improve pre-positioning of the foot during IC f gait cycle. However, DF ability of AFO is strictly relying on the design and trimming pattern of particular AFO (Yokoyama et al., 2005). All types of AFO being study in this section have shown reasonable increase of DF angle compare to barefoot or without AFO condition (Abel et al., 1998; Lam et al., 2004; Radtka et al., 2004; Bleyenheuft et al., 2007; Romkes et al., 2001; Fatone et al., 2009; Yokoyama et al., 2005). This outcome is consistent with the basic functionality and characteristic of AFOs. For hinged and dynamic types, both allows free ankle DF during stance and meanwhile limit PF (Romkes et al., 2001). From review, subjects wore dynamic AFO have noticeable better DF than solid AFO and barefoot (Lam et al., 2004; Bleyenheuft et al, 2007). KF during IC (Stance phase) Knee fully extends just before heel contact and this is named as stance phase flexion. Patient walked with dynamic AFO showed significant increased in KF during initial stance compare to barefoot and there was less significant compared to solid type AFO (Lam et al., 2004; Bleyenheuft et al., 2007). Nevertheless, a slightly decreased on KF during initial contact is observed too. Both dynamic and hinged AFO shown little attenuate of KF angle compare to barefoot in Romkes, 2001 studies. In Radtka, 2005 research, the abnormal KF during barefoot walking remained although subject walk with hinged and solid AFO and this is consistent with Rethlefsen, 1999 findings. PF during TST (stance Phase) At the instance stance foot leave ground and preparing for swinging, plantar foot is flex as to push off body forwarded. Hinged AFO have impressed decreasing of PF during terminal stance if compare to walked with barefoot ( Radtka et al., 2005; Romkes et al., 2001). In Romkes, 2001 study, it revealed that hinged AFO has better push off effect compare to dynamic AFO according to their flexing ability. Besides that, in Radtka 2005s study, researchers concluded hinged AFO has better rocker effect as to proceed swing phase compared to solid AFO. DF during MSW (Swing Phase) DF is necessary to prevent foot drop as to provide toe clearance for patient to have better gait performance. In all the reviewed papers, DF were all increased during MSW (Abel et al., 1998; Lam et al., 2004; Radtka et al., 2004; Bleyenheuft et al., 2007; Romkes et al., 2001; Fatone et al., 2009; Yokoyama et al., 2005). Table 2. Summary on Variables Comparison of Types of AFO (ToA) with respect to Control Group Condition (CGC) Author, Year ToA CGC Variables comparison on ToA with respect to CGC Cadence Velocity DF at IC KF at IC PF at TST Abel et al., 1998 Fixed AFO Barefoot Decrease Increase Increase Increase Blenyenheuft et al., 2007 Dynamic AFO Shoe only Not significant Increase Increase Increase prefabricated AFO Shoe only Decrease Increase Increase Decrease Fatone et al., 2009 Hinged AFO Shoe only Not significant Not significant Increase Increase Lam et al., 2004 Solid AFO Barefoot Decrease Not significant Increase Increase Decrease Dynamic AFO Barefoot Decrease Increase Increase Increase Decrease Radtka et al., 2004 Solid AFO Barefoot Decrease Increase Increase Decrease Hinged AFO Barefoot Decrease Increase Increase Not significant Decrease Romkes et al., 2001 Dynamic AFO Barefoot Decrease Increase Increase Decrease Decrease Hinged AFO Barefoot Increase Increase Increase Decrease Decrease Tyson, 1998 Hinged AFO Barefoot Increase Increase Increase Yokoyama et al., 2005 Oil damper resistance AFO Shoe only Increase Increase Increase Increase Decrease Kinetic of human gait: Ground reaction forces and Peak pressure High peak plantar pressure (PPP) on foot is significant in contributing ulceration and callus formation on diabetic patient (Caselli, 2002; Veyes, Murray, Buoulton, 1992). If PPP occurred on the same area for a repeated period it might associated with callus or skin break down on that particular area (Boulton AJ, 1993). Incidence of skin breakdown in the forefoot chance is higher compare to in rear foot (Mueller, Zou, Lott, 2005). It has been prove in few studies that metatarsal head is the most frequent areas having skin injury problem rather than at heel in diabetic patient (Caselli, 2002; Sinacore, 1996). By using rocker sole in diabetic subjects, reviewed papers shown a significant PPP reduction over the high pressure area especially over forefoot and rear foot area (Albright Woodhull-Smith, 2009; Brown Wertsch, 2004; Schaff Cavanagh, 1990). Rocker sole is designed in a way that to redistribute plantar pressure from a conventional pressure distribution to a newly designed pressure map(Brown Wertsch, 2004). Aims and Objectives Examine orthosis efficacy in walking gait is the foremost objective in this study. AFO is prescribing enable to make better alignment of foot on patient with pathological gait. A rocker bottom is claimed to serve better plantar pressure distribution and as treatment to avoid further foot deformity. Basic approach in this study is to investigate the effectiveness of rocker AFO in prevent and utilize better ambulation pattern on diabetic patient from abnormal walking mechanism. Joint mobility caused by rocker AFO believed serve a better gait pattern and harmless to the connected leg segment. Rocker effect on the AFO is tending to reduce ground reaction forces to AFO user foot. Biomechanics and engineering knowledge is applied for better description. To test this hypothesis the following key objectives were undertaken: To study and enhance better gait mechanism knowledge from engineering and medical approach. To quantify and compare joint mobility with and without rocker AFO using lower limb component motion range analysis. To observe the relationship between the rocker bottom to kinetic changing on patient gait. Methodology Introduction Method to conduct this study is structured into few stages from recruiting subjects to conclude the study objectives. In order to keep align with this study objectives, each procedure taken has to be design carefully to reduce the possibility of data confusion and the occurrence of technical errors. Mostly, methodology to investigate orthosis efficacy usually being categorized into subject acquirement, subject assessment, AFO fabrication, AFO customize process, gait analysis laboratory testing, data acquisition and data analyzing ( Fatone et al., 2009). Subject acquirement In this study, AFO with rocker bottom is fixed to be the interest orthosis to investigate for the entire process. From literature, an AFO rocker sole mostly applied for the purpose of offloading on diabetic patient, thus the targeted subject is diabetic patient who possess potential to occur ulceration at plantar foot (Zimmy et al., 2004; Albright et al., 2009). 5 patients with diabetic peripheral neuropathy are recruiting as the subjects. Subject should be free from any other physical abnormality, surgery or injury on the lower limb extremities. To be prior to their participation, informed concern was acquired from all the subjects. Equipment: AFO Fabrication Only unilateral study will be carry out which means rocker AFO will be only fabricate for either leg depends on the foot condition. Each participant will be customizing a rocker AFO which is unique with their ulceration area and foot sizes. Participants are evaluated barefoot and going through anthropometrical measurement on the affected leg by the orthotists. The AFO are custom molded by polypropylene and with a suggested 4.8 mm thick (Lam eta al., 2005). Neutral position of the AFO will be 90Â ° at foot shank ankle. Foot length of the AFO will extended distally under the toes end and trimmed along the mediolateral border of the foot. Upper part of the AFO will trimmed on posterior until about 2.5cm below fibula. Rocker sole apex has to be position according to subject pressure distribution. Usually subject affected areas are location with metatarsal and forefoot area. A consistent rocker sole design is purposed with the apex fall behind of the fifth metatarsal with an angle of 15à ‚ °. Figure 3.1 shown the rocker AFO suggested: Figure 3. Rocker AFO After rocker AFO finishing, subject request to test the fitness of the AFO. If the custom made rocker AFO raises any comfort ability issue, adjustment being done to fix it. Gait analysis laboratory testi

Essay on the Animal

Animal Farm Essay Prompts Respond to ONE of the following prompts in a five-paragraph essay. Your body paragraphs must follow the shaping sheet. 1. Read the passage from Chapter VII that begins with â€Å"’Comrades! ’† cried Squealer,’† and ends â€Å"’Snowball’s secret agents are lurking among us at this moment! ’† Then, in a well-developed and organized essay, analyze how Squealer uses various persuasive techniques to manipulate the animals. 2. Read the passage from Chapter IV that begins at the beginning of the chapter and ends with â€Å"hearing in it a prophecy of their future doom. Then, in a well-developed and organized essay, discuss how the author uses various stylistic devices and selection of detail to comment on both historical events and human nature. 3. Analyze how Leon Trotsky, Joseph Stalin and the working class are satirized through the characters in Animal Farm. 4. Describe how the abuse of power causes three negative effects upon the animals of Animal Farm. 5. Choose three events from the novel and argue that they are representative of events occurring in Russia during its revolution and the reign of Joseph Stalin.Consider the following. †¢ The Rebellion/the Russian Revolution †¢ The failure of the windmill/Stalin’s Five Year Plans †¢ Executions of pigs and chickens/Stalin’s Great Purge †¢ The Battle of the Windmill/Germany’s invasion of Russia †¢ Napoleon’s use of dogs/Stalin’s use of the secret police †¢ Cruel winters on the farm/Soviet famine of the 1920’s ***** You need to use your novel AND one historical source for numbers 3 & 5***** Animal Farm Essay PromptsRespond to ONE of the following prompts in a five-paragraph essay. Your body paragraphs must follow the shaping sheet. 6. Read the passage from Chapter VII that begins with â€Å"’Comrades! ’,† cried Squealer,’† and ends â€Å"‘Snowball’s secret agents are lurking among us at this moment! ’† Then, in a well-developed and organized essay, analyze how Squealer uses various persuasive techniques to manipulate the animals. 7. Read the passage from Chapter IV that begins at the beginning of the chapter and ends with â€Å"hearing in it a prophecy of their future doom. Then, in a well-developed and organized essay, discuss how the author uses various stylistic devices and selection of detail to comment on both historical events and human nature. 8. Analyze how Leon Trotsky, Joseph Stalin and the working class are satirized through the characters in Animal Farm. 9. Describe how the abuse of power causes three negative effects upon the animals of Animal Farm. 10. Choose three events from the novel and argue that they are representative of events occurring in Russia during its revolution and the reign of Joseph Stalin.Consider the following. †¢ The Rebellion/the Russian Revolution †¢ The failure of the windmill/Stalin’s Five Year Plans †¢ Executions of pigs and chickens/Stalin’s Great Purge †¢ The Battle of the Windmill/Germany’s invasion of Russia †¢ Napoleon’s use of dogs/Stalin’s use of the secret police †¢ Cruel winters on the farm/Soviet famine of the 1920’s ***** You need to use your novel AND one historical source for numbers 3 & 5*****

Case Study for Final Exam Essay

Green Cabs is an environmentally friendly taxi company in New Zealand which was founded in late 2007 by Callum Brown and three other partners. Green Cabs now operates a multi-million dollar business in three main centres of New Zealand – Auckland, Wellington and Christchurch. The company is also contemplating expanding into other areas with its distinctive bright green taxis. Callum Brown is the primary inspiration behind Green Cabs. However, you could argue that Al Gore provided the initial spark for Callum to start thinking about being more environmentally conscious personally. Callum is in his 30s and has spent 10 years working in information technology for various government departments and private sector companies as a business analyst. He grew up close to nature and enjoyed activities such as surfing and tramping. All these things kept Callum close to nature. Despite his love affair with nature, Callum was quite sceptical of climate change. He explains: I thought – how can you tell that there is global warming when we’ve only been taking recordings on temperature for the past whatever, how many years. Hence, it could be seen as fairly surprising that Callum founded a green business! This personal awakening was a direct result of watching Al Gore’s documentary, An Inconvenient Truth. Little did he know at this stage that a major business opportunity would come from his new environmental consciousness. The impetus for the business idea came when Callum was at work. He travelled extensively for work and consequently found himself catching a lot of taxis. It was on one such overnight trip to Auckland that he became aware of the huge amount of carbon emissions he was generating through travel. He elaborates: I sat there watching all the taxis come and drop people off and thought about the emissions and everything they were producing; there’s got to be a better way than this. Why is there no eco-friendly option and that was the light bulb moment, and saying, ah, why not? Following this light bulb moment, Callum contacted a former colleague who was  also a taxi driver. Together the pair set about establishing an environmentally conscious taxi service with two other partners. They struck the New Zealand taxi industry at what they called a lucky time. The government had just tightened legislation to make it consistent for all operators. The Land and Transport Authority was supportive and helpful in making sure everything the emerging Green Cabs did was in line with the new legislation. The Authority too was excited by what Green Cabs was hoping to achieve. Once started, Green Cabs experienced rapid growth and within six months had approximately 85 cabs and self-employed drivers and employed 15 support staff (mostly in its 24-hour call centre). Callum never had aspirations to become an entrepreneur, nor any experience in business ownership, but his extensive work background as a business analyst made him feel he was well equipped to investigate whether the Green Cabs idea would be successful. In fact, prior to coming up with the business idea Callum felt afraid of the risk involved in having his own business. However, once he had the idea, these risks vanished: I was so passionate about Green Cabs, once I had the idea, there were no perceivable risks for me. That was how strong the drive was to do it . . . It’s like I’ve never doubted for a moment that Green Cabs was going to succeed. It has. Any concerns Callum had about risk were dissipated when he took on a number of business partners to share the risk. These business partners all understood and were sympathetic to the worsening state of the environment and to Callum’s vision for the company. Callum’s vision resulted in a company which entered the taxi industry with the goal of achieving much more than a traditional taxi firm. Green Cabs wanted to force change, to preserve the environment and inform the public about climate change. This meant a whole new way of thinking about business and the principles of the business founders were intertwined with the business model. Green Cabs offers the same basic service as any other taxi company. The key difference is that it is an environmentally conscious company. The main means of the company being environmentally friendly is that its vehicles are hybrids (Toyota Prius). There are substantially fewer ongoing running costs in providing the service. Green Cabs passes these savings onto consumers and is therefore able to offer considerably lower prices than its competitors. It already is forcing change in the taxi industry with many competitors rapidly switching to hybrids  because they can see they will save on emissions a nd fuel costs. The difference between these competitors and Green Cabs is that those changing due to lower running costs do not necessarily have environmental concerns at the forefront of their decision making as does Green Cabs. Indeed, sceptics could argue that the competition is switching because it is losing market share to Green Cabs and is attempting to imitate the service. Therefore, Green Cabs has been successful in changing behaviour in the industry to being more environmentally friendly, but this has come at a cost to the business, as Callum explains: I have had such an impact on the market that I had planned, that they (competitors) are now switching. Now, from an environmental point of view, it’s fantastic that I could have that impact, but from a business point of view it’s not good. However, competitors are still failing to offset their carbon emissions whereas Green Cabs prides itself on being carbon neutral. To achieve this Green Cabs drives only the Toyota Prius, the car it considers to be the best option for lessening the impact on the environment. The remainder of its carbon emissions are ‘paid for’ by providing funding for trees to be planted (predominantly in the developing world). Green Cabs donates to ‘Trees for the Future’, an organisation that has already organised the planting of 50 million trees, which retrieve approximately a million tonnes of carbon from the atmosphere annually (www.greencabs.co.nz). Green Cabs also ‘pays off’ its carbon debt prior to its accrual. That is, it calculates its future carbon footprint (down to the number of squares of toilet paper used) for the next year and funds the planting of sufficient trees to offset this before it emits the carbon. Although this is one of the key environmental strategies Green Cabs carries out, it actually is sceptical of buying carbon credits. This is because this carbon strategy essentially dispatches the problem to someone else; it does not help reduce the carbon in the atmosphere. As such, Green Cabs aims to both reduce carbon and offset before it accumulates. The business model of Green Cabs is based on the premise that the customer has a greater connection with the product or service. By using Green Cabs customers will feel part of a greater commitment to the environment and they will choose Green Cabs product over the competitors. As Callum notes, the  business model is win-win for both consumers and the environment: It is cheaper, it’s eco-friendly, it’s quieter, you’ve got a pleasant driver, we do a whole lot of feel good stuff as well. Give me a reason why you wouldn’t take a Green Cab. Green Cabs target market is the corporate sector and government departments. However, they pay tribute to the ‘grassroots’ support they have received. This is from people who have seen what Green Cabs are doing and even if their company has no agreement with Green Cabs, when they take a taxi they want it to be a Green Cab. Callum has also noted that younger people are more environmentally aware and appreciate the choice they are being offered in Green Cabs. One future development is for Green Cabs to install roof signs on their vehicles to promote the environment. These will not be advertising signs for businesses but to say something individuals can do for the environment. Green Cabs intend to use advertising space on their vehicles to promote the environment, not fizzy drinks or the like! FINDING BALANCE BETWEEN THE ENVIRONMENT AND PROFIT ‘For me anyway, it’s not just about turning a profit.’ – Callum Brown Finding a balance between profit and the environment can be a difficult one. To be successful in Callum’s view, you have to understand and have faith that doing things and sticking closely to the set of values that the company started with is what is going to bring success. Too much compromise for business then you will compromise the overall success of the business. The business might still be profitable but will not captivate the public into changing their behaviour regarding the environment. These environmental values are held firm by Green Cabs and are an underlying part of their distinctive business model. Callum elaborates: If we compromise on those values then that put us at risk of just being like any other taxi company out there and doesn’t set us apart. Following through on their commitment to the environment easy for Green Cabs and they suggest that other should look at the environment differently in their businesses. For example, Callum is frustrated by talk about how much it costs to offset carbon emissions. He suggests people fail to see that the whole process is a cost saving exercise. In becoming sustainable, businesses look at ways of reducing  electricity, travel and so forth. All of these areas can reduce a company’s carbon footprint while also reducing their overall costs. Their commitment to the environment is one side of the equation in Green Cab’s business model. The business must be sustainable and there are investors, franchisees and employees who expect returns from their input into the business. Callum is conscious of this need to make a profit, but he has some boundaries: I want to make some money but at the end of the day, I don’t even need a million dollars a year to live on . . . I really like my life in New Zealand, I like the things that I do and the things that I do don’t cost a lot of money. Callum has found that as the business has grown, more investors (such as potential franchisees) are becoming better aligned with his personal views on the environment. However, that is not necessarily the case for all employees of the company, as Callum notes: I have people working for me who don’t have necessarily the same value set. I mean they’ve got good values and wouldn’t be here if they didn’t but to the degree where mine are – no, they’re not anywhere near there. In April 2009, Green Cabs has grown to 16 employees and 104 drivers. The business has many opportunities to grow their business into other location and other services (e.g. courier services). As the business continues to grow Green Cabs are looking towards carbon neutral certification, and implementing ISO 14001 and 14064 certifications. The ongoing financial success of the company is also attracting more interest from other investors who are not necessarily focused primarily on the environment, but see Green Cabs as a solid investment opportunity.

The Transformation of Chaucer’s Narrator in the Book of...

A dream vision is a widely utilised literary device that provides an author with an avenue to explore the intricacies of the subconscious mind that effectively allows for its narrator to overcome some obstacle that seemed to be insurmountable prior to entering into the dream. In other words, the dream vision acts as an allegoric representation of the subject’s waking life and, in moving through the dream, is able to overcome the hurdle that lay before him previously. As a result, although being faced with a philosophical or moral dilemma, the narrator of a dream vision gains the ability to move on and conquer their ailments. This connotes the idea that there may not only be character development, but also a complete overhaul on their†¦show more content†¦There is overwhelming evidence that the Book of the Duchess was written as a commemorative poem to honour the death of the wife of one of Chaucer’s patrons. As such, the poem was written as an occasional poem, dedicated to the tragic early death of the Blanche of Lancaster, the wife of the duke of Lancaster John of Gaunt, who was left grieving over his loss (Palmer 255). The poem was Chaucer’s poetic response to a problem that confronted him following the death of his patron’s wife. Faced with the task of comforting her grieving husband, yet unable to assume the appearance of superior emotional wisdom, Chaucer worked obliquely by manipulating the narrative style he inherited from French and Spanish dream-vision literature into a suitable memorialisation of Blanche and Gaunt’s love for her (Bahr, 43). This is made apparent by the famous punning lines that identify the subjects of the poem: â€Å"A long castel with walles white, / Be seynt Johan! on a ryche hil† (1318-19). The first line identifies Blanche of Lancaster for Lancaster or â€Å"long castel† was her title which her husband assumed, and the second line suggests John of Richmond or â€Å"ryche hil†, which was Gaunt’s own title (Palmer 255). The idea that the character of the Black Knight and the lady that he mourns are