bernie veldman, co certified orthotist -...
TRANSCRIPT
9/1/2015
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Don’t Take That Tone!Bernie Veldman, COCertified Orthotist
Don’t Take That Tone
• Discuss:• Muscle Tone
• Compare and contrast hypertonia and hypotonia• Muscle Strength
• Differences between tone and strength• Determine goals of orthotic management for high vs. low tone• Explore options for orthotic management of
• Lower Extremities• Trunk• Head/Neck
Course Objectives
• A muscle’s resistance to passive stretch– The inherent ability of a muscle to respond to a stretch– Tone is “on” during waking hours and “off” during sleeping hours
• An intrinsic property of the nervous system– Cannot be changed through voluntary control, exercise or diet
Function:– maintain joint integrity and posture
TONE & STRENGTHAre they the same thing?
Muscle Tone
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• Spectrum includes Very Very Low to Very Very High andeverything in between.
TONE & STRENGTHAre they the same thing?
Low High
Normal
What is Hypertonia?• Increased resistance to passive stretch of a muscle• Often associated with:
– Muscle Contractures– Spasticity and/or Dystonia– Bone and Joint abnormalities
• Can be measured:– Ashworth Scale– Modified Ashworth Scale
TONE & STRENGTHAre they the same thing?
Orthotic Management - Hypertonia• Maintain and/or increase ROM• Prevent joint breakdown• Improve alignment of joints• Increase base of support during weight bearing activities• Minimize triggering of spastic responses• Minimize pain secondary to spasticity
TONE & STRENGTHAre they the same thing?
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What is Hypotonia?• Low muscle tone• Little to no resistance against passive stretch• No scale for accurate measurement
TONE & STRENGTHAre they the same thing?
Common Diagnoses Associated With
• Down syndrome• Myasthenia gravis• Cerebellar ataxia, congenital• Prader-Willi Syndrome• Myotonic dystrophy• Riley-Day syndrome• Marfan's syndrome• Muscular Dystrophy• Sepsis
• Congenital hypothyroidism• Krabbe disease• Menkes syndrome• Metachromatic leukodystrophy• Rickets• Spinal muscular atrophy type 1
(Werdnig- Hoffman)• Tay-Sachs disease• Aicardi syndrome
Hypotonia
…is not a specific diagnosis,but can be a part of over 600
genetic disorders….
Hypotonia
TONE & STRENGTHAre they the same thing?
LISI, E. C. and COHN, R. D. (2011), Genetic evaluation of the pediatric patient with hypotonia:perspective from a hypotonia specialty clinic and review of the literature. Developmental
Medicine & Child Neurology, 53: 586–599. doi: 10.1111/j.1469-8749.2011.03918.x
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Hypotonia
• Infants:– Excessive joint mobility– Decreased deep-tendon reflexes– Gross motor skill delay– Difficulty with balance/coordination
TONE & STRENGTHAre they the same thing?
• Impaired mobility• Poor posture• Breathing difficulties• Delayed Speech & Feeding difficulties• Lethargy• Poor Reflexes• Ligament and joint laxity
TONE & STRENGTHAre they the same thing?
Often Seen With Hypotonia:
(Parker and Bronks, 1980).
Low muscle tone, also known ashypotonia, contributes to joint
hypermobility.
Low Muscle ToneHypotonia
Hypermobility
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HYPERMOBILITY COMPONENT• Many scales to measure generalized joint
hypermobility (excessive ROM of joint)• Beighton scale• Brighton criteria• Bulbena criteria• Carter & Wilkinson• Global Joint Mobility Index• Horan Joint Mobility Index• Rotés-Quérol• Villefranche• Lower Limb Assessment Score
TONE & STRENGTHAre they the same?
Strength:• The ability to exert force on physical objects
– Through controlled muscle contraction.• Up to the recruitment and use of all motor units within a
muscle– MAXIMUM CONTRACTION
– Can be increased: Exercise and strengthening– Can be measured: Manual muscle testing
HYPOTONICITY• Peredo & Hannibal (2009):• Need to distinguish weakness from hypotonia• Hypotonia is reduced resistance (tension) to
passive range of motion in joints, whereas,• Weakness is the reduction in the maximum power
that can be generated• Impairment in ability to sustain postural control
and movement against gravity, therefore, “floppyinfants” have poor control of movements, delayedmotor skills and hypotonic movement patterns
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Hypotonia• Martin, et al. (2007):
– Current literature gives only descriptions or vagueattempts to quantify hypotonia
– Survey with a response of 300 pediatric PTs and OTs– Children with hypotonia had the following characteristics:
»decreased strength» hypermobile joints» increased flexibility» rounded shoulder posture» poor attention and motivation» leaning on supports» decreased activity tolerance» delayed motor skill development
Children with Hypotonia:
Does not equate toWeakness
Are in very poor biomechanicalalignment when in closed chainand function in a weak manner.
Have great difficulty in recruitingtheir strength because of theiralignment
Hypotonia(Low Muscle Tone)
Often equated to:
Weakness(Low Muscle Strength)
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Hypotonia…A parent’s perspective.
• My child has low muscle tone, therefore, she isweak.
• My child has flat feet due to her low muscletone or weakness.
• What can my child really achieve?
Hypotonia…A parent’s perspective.
• My child has flat feet due to her low muscletone or weakness.• Most children with hypotonia do pronate
• Not flat feet• Not weak children
Hypotonia…A parent’s perspective.
• What can my child really achieve?• THE SKY IS THE LIMIT
• What they are lacking is stability, not strength• Create stability
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Closed ChainLigamentous Laxity = Joint Instability
PRONATIONCalcaneal Valgus
• Primarily coronal/frontal plane movement
• Facilitates improper distal positioning
• Encourages poor proximal function
• Initiates medial translation of weight-line
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Pronation
Tri-planar- 3 ComponentsCalcaneal Valgus
2. Midfootdorsiflexion/eversion
A. Sagittal/Frontal planeB. Downward and Medial
collapse of mediallongitudinal arch
C. Lengthening of medialaspect of the foot
Sagittal Coronal
Medial Longitudinal Arch Elongation
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Medial Longitudinal Arch Elongation
Pronation1. Calcaneal Valgus2. Midfoot Eversion
Tri-Planar – Three Components
3. Forefoot abduction• Transverse, Sagittal and Coronal Planes
• Lengthening of Medial Longitudinal arch, combinedwith medial weight shift at midfoot forces Abduction
of forefoot• Varus in relation to hindfoot
• Dorsiflexed in relation to midfoot
W-Sitting…• W- sitting• Study by KC Chen et al. (2010)
– study of 1,598 children– From 3-6 years of age– central area of Taiwan– 17.3% of preschool children W-sat– significant differences in unilateral and
bilateral flatfoot groups when comparedto the normal foot group
KC Chen et alEuropean Journal of Pediatrics, July 2011, Volume 170, Issue 7, pp 931-936
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SureStep Criss-CrossersAVAILABLE NOW
Calcaneal ValgusMidfoot Eversion
Forefoot abduction
Closed ChainLigamentous Laxity = Joint Instability
Pronation
Orthotic Management
Foot OrthosisUCBL
SMOSupra-Malleolar Orthosis
Traditional means of addressing pronation
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Traditional means of addressing pronation
Alter the position of the foot.Improve positioning.
Subtalar Neutral
Subtalar NeutralDYNAMIC FUNCTION
High Tone Concepts…Low Tone Feet…
*
Traditional means of addressing pronation:Foot Orthoses (FOs)
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Colson JM. An effective orthotic design for controlling the unstable subtalar joint. Orthotics Prosthet. 1979;33:44.
Traditional means of addressing pronation:UCBL
Traditional means of addressing pronation:Supra-Malleolar Orthosis (SMO)
Orthotic Management
Foot OrthosisUCBL
SMOSupra-Malleolar Orthosis
Traditional means of addressing pronation
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SureStep is Different• What Is SureStep?
–Supra-Malleolar AFO. (SMO)–SureStep is Custom Fabricated–SureStep is completely unique:
• Unique in appearance, Function andConcept.
SureStep Dynamics
• Trimlines• Medial trimline
proximal to 1st met-head
• Lateral trimline distalto 5th met-head
*
How SureStep Works• Compression: Ultra-thin, flexible plastic
– Compression creates stability.– Allows normal intrinsic movement– Facilitates improved balance and coordination.– Enables use of intrinsic muscles–SureStep’s focus is on creating stability, not
statically posting the foot into a position.
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Hydrostatic pressure:
Flexibility, combined with SureSteptrimlines allow true dynamic movement
SureStep functions not as a brace,But as an exoskeletal ligament system.
Don’t Take That Tone
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Pronation
Distal
Pronation• Proximally Affects:
• Position
• Function
• Development
PositionWeight line shifts medially causing:
• Change in tibial deflection
• Genu valgum• Global ligamentous laxity
• Hip Adduction
Long Term:• Tight Peroneals• Tight Heel Cords
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• Inefficient joint movements• Joints articulate outside
optimal axis of movement
• Inefficient muscle usage• Muscles work out of optimal
range and angulation.
Function
HYPOTONICITY• Peredo & Hannibal (2009):• Need to distinguish weakness from hypotonia• Hypotonia is reduced resistance (tension) to
passive range of motion in joints, whereas,• Weakness is the reduction in the maximum power
that can be generated• Impairment in ability to sustain postural control
and movement against gravity, therefore, “floppyinfants” have poor control of movements, delayedmotor skills and hypotonic movement patterns
In some kids,it is quickly obvious
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Poor Balance
Poor Coordination
Wide Base
In some kids it is not.Functional deficits often seen with hypotonia
Poor Balance
Poor Coordination
Wide Base
High Guard
Excessive WeightShiftIncreased Fatigue
In some kids it is not.Functional deficits often seen with hypotonia
Typical Pediatric Gait Development:
• Age 9 Months Pull to Stand• Age 10 Months Cruise
4 Steps HH• Age 11 Months Independent standing
SteppingWalking 1 HHIndependent walking
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Typical Pediatric Gait Development:
• Age 12 Months 130 Steps/minHigh GuardExternal Rotation of HipsMore Knee FlexionWider Base of Support
• Age 18 Months Heel-Toe Gait (most)Reciprocal Arm Swing (most)Narrowed Base of Support
Typical Pediatric Gait Development:
• Age 24 Months Less Hip FlexionReduced Pelvic TiltReduced Hip AbductionReduced External RotationSignificant knee flexion
(more than adults)Decreasing Base of SupportSingle Leg Stance 34%
Typical Pediatric Gait Development:
Age 36 Months reciprocal arm swing (90%)Base of Support(proportional to an adult)Typical joint anglesSingle Leg Stance 35%
Age 7 years Refining continues as long bonegrowth continues throughoutSingle Leg Stance 39%
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Hypotonia Studies
• Outcomes of infants with idiopathic hypotonia (Strubhar, et.al.2007)– Survey of 105 parents of children diagnosed with hypotonia– Transient impairment group (10.5%) reported no issues– Minimal impairment group (32.4%) mild issues (learning
disability, language delay) but no major developmental issues– Globally impaired group (40.9%) had mental retardation or
recognizable genetic or developmental diagnosis
Hypotonia Studies
• Outcomes of infants with idiopathic hypotonia (Strubhar, et.al.2007)–Greater than 50% of minimal impairment group had poor
coordination, language delay and learning difficulty
–Mean walking age of minimal group was 22 months*Developmental Delay*
Pull-To-StandThe Waiting Game
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Weight ShiftThe Waiting Game
CruisingThe Waiting Game
Independent StandingThe Waiting Game
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Independent StepsThe Waiting Game
Independent WalkingThe Waiting Game
6 weeksNo OrthoticIntervention
Independent AmbulationThe Waiting Game
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Independent AmbulationThe Waiting Game
6 monthsNo OrthoticIntervention
Independent AmbulationThe Waiting Game
6 monthsNo OrthoticIntervention
Independent AmbulationThe Waiting Game
6 monthsNo OrthoticIntervention
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RunningThe Waiting Game
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Earlier is better!
BRADEN• 19 months old• DX: Developmental Delay, Hypotonia,
Pronation• Cruising 5 months• No independent standing or ambulation
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Winning The“Waiting Game”
True Dynamic Bracing forTrue Dynamic Function…
CORA• 17 months old• DX: Developmental Delay, Hypotonia,
Pronation• Cruising 4 months• No standing or ambulation
Winning The“Waiting Game”
True Dynamic Bracing forTrue Dynamic Function…
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CHANCE• 21 months old• DX: Pierre Robin Syndrome, Developmental
Delay, Hypotonia, Pronation• Independently ambulatory 4 months
Winning The“Waiting Game”
True Dynamic Bracing forTrue Dynamic Function…
Megan Smith, COCertified OrthotistSureStep Director of Clinical Research
Gross Motor Skill Changes ofChildren Wearing SureStep SMOs
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COLIN
• 16 MONTHS OLD AT START OF STUDY• DX: DEV DELAY, PRONATION, HYPOTONIA,
SIGNIFICANT LIGAMENTOUS LAXITY• WAS PULLING TO STAND FOR A COUPLE OF
WEEKS. NOT YET TAKING INDEPENDENT STEPS• RECEIVED PHYSICAL THERAPY 1X/WEEK FOR
DURATION OF STUDY
DAY 1 – BAREFOOT DAY 1 – SMOS
WEEK 16 – BAREFOOT
GAIT ANALYSIS• Day 1: Not walking• Month 1: Walking with 2 hands held; very
unstable• Month 2: Walking with 1 hand held. Extended
gait pattern – for stability and consistency. HighBOS, externally rotated, high guard. Startingindependent steps.
• Month 3: Stable with no hands held. Wide base• Month 4: Stable in grass/uneven surfaces and
transitioning surfaces. Narrow BOS and lowguard.
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PARENT QUESTIONAIRRE• Was this your child’s first set of orthoses? YES• Wear Schedule: Hours/Day 12 Days/Week 7• How does your child respond to wearing the SureStep SMOs? LIKES• How satisfied are you with the SureStep SMOs (1 = Not at all; 10 = Very Satisfied)? 10• Rate your child’s activity level without SureStep SMOs (1 = Not at all; 10 = Very Active): 8• Rate your child’s activity level with SureStep SMOs (1 = Not at all; 10 = Very Active): 10• Rate your child’s coordination when active without SureStep SMOs (1 = Not at all; 10 = Very
Coordinated): 6• Rate your child’s coordination when active with SureStep SMOs (1 = Not at all; 10 = Very
Coordinated): 9• Rate your child’s endurance without SureStep SMOs (1 = Not at all; 10 = Very High): 8• Rate your child’s endurance with SureStep SMOs (1 = Not at all; 10 = Very High): 8• Rate the difficulty in donning and working with the SureStep SMOs (1 = Very Difficult; 10 = Very
Easy): 10• Comments: Love the SMOs. They have made a world of a difference in our kiddo’s walking
NORMAL – RATE OF CHANGE = 0.51PATIENT – RATE OF CHANGE = 0.27
DEVELOPMENTAL DELAY AT BEGINNING = 6 MONTHSDEVELOPMENTAL DELAY AT END (16 WEEKS) = 2 MONTHS*WE GAINED 4 MONTHS IN 16 WEEKS
• TYPICAL CHILD TAKE 8-9 MONTHS TO PROGRESSFROM PULLING TO STAND TO WALKING FAST.
• THIS PATIENT TOOK 5 MONTHS TO MAKE THE SAMECHANGES
OUR KIDS OURCATCHING UP THETHEIR PEERS ANDMAKINGCHANGESFASTER THAN ATYPICAL CHILD!!
8
10
12
14
16
18
20
TYPICAL
COLIN
ANIYAH
• 15 MONTHS OLD AT START OF STUDY• DX: DEV DELAY, PRONATION, HYPOTONIA, 3
MONTHS PREMATURE• WAS PULLING TO STAND FOR A COUPLE OF
WEEKS. NOT YET TAKING INDEPENDENT STEPS• RECEIVED PHYSICAL THERAPY 1X/WEEK FOR
DURATION OF STUDY
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DAY 1 – BAREFOOT DAY 1 – SMOS
WEEK 16 – BAREFOOT
GAIT ANALYSIS
• Day 1: Very unstable. Cruising. Taking some stepswith hands held. Very wide BOS.
• Month 1: Taking independent steps. Very wideBOS. Very unstable in independent steps. Highguard.
• Month 2: Steadier, low guard, narrower BOS.• Month 3: Narrow BOS. Low guard. Much steadier.
Carrying objects well.• Month 4: Very steady. Arms down and swinging.
Trying to run. Still very unsteady without SMOs.
PARENT QUESTIONAIRRE• Was this your child’s first set of orthoses? YES• Wear Schedule: Hours/Day 12 Days/Week 6• How does your child respond to wearing the SureStep SMOs? LIKES• How satisfied are you with the SureStep SMOs (1 = Not at all; 10 = Very Satisfied)? 10• Rate your child’s activity level without SureStep SMOs (1 = Not at all; 10 = Very Active): 4• Rate your child’s activity level with SureStep SMOs (1 = Not at all; 10 = Very Active): 10• Rate your child’s coordination when active without SureStep SMOs (1 = Not at all; 10 = Very Coordinated): 3• Rate your child’s coordination when active with SureStep SMOs (1 = Not at all; 10 = Very Coordinated): 10
• Rate your child’s endurance without SureStep SMOs (1 = Not at all; 10 = Very High): 3• Rate your child’s endurance with SureStep SMOs (1 = Not at all; 10 = Very High): 10• Rate the difficulty in donning and working with the SureStep SMOs (1 = Very Difficult; 10 = Very Easy): 3• Comments: Aniyah is running now! We are all excited about her SMO's. I was very excited when she received
them! Her feet were sideways and I was very concerned about her coordination in the beginning, and the PT,Miranda pointed that out to us. Thank you everyone for her care!
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PT QUESTIONAIRRE• How satisfied are you with the SureStep SMOs (1 = Not at all; 10 = Very
Satisfied)? 10• Rate your child’s activity level without SureStep SMOs (1 = Not at all; 10 =
Very Active): 7• Rate your child’s activity level with SureStep SMOs (1 = Not at all; 10 =
Very Active): 8• Rate your child’s coordination when active without SureStep SMOs (1 =
Not at all; 10 = Very Coordinated): 6• Rate your child’s coordination when active with SureStep SMOs (1 = Not at
all; 10 = Very Coordinated): 7• Rate your child’s endurance without SureStep SMOs (1 = Not at all; 10 =
Very High): 9• Rate your child’s endurance with SureStep SMOs (1 = Not at all; 10 = Very
High): 9• Rate the difficulty in donning and working with the SureStep SMOs (1 =
Very Difficult; 10 = Very Easy): 10• Additional comments: The SureSteps really gave Aniyah the support and
alignment necessary to progress with her gross motor skills.
NORMAL – RATE OF CHANGE = 0.51PATIENT – RATE OF CHANGE = 0.25**RATE OF CHANGE WAS TWICE AS FAST!!**PASSED A “TYPICAL CHILD”
• TYPICAL CHILD TAKE 8-9 MONTHS TO PROGRESSFROM PULLING TO STAND TO WALKING FAST.
• THIS PATIENT TOOK 5 MONTHS TO MAKE THE SAMECHANGES
OUR KIDS OURCATCHING UP THETHEIR PEERS ANDMAKINGCHANGESFASTER THAN ATYPICAL CHILD!!
8
10
12
14
16
18
20
TYPICAL
ANIYAH
DEVELOPMENTAL DELAY ATBEGINNING = 3 MONTHSDEVELOPMENTAL DELAY AT END(16 WEEKS) = -1 MONTHS*WE GAINED 4 MONTHS IN 16WEEKS
CORWIN
• 16 MONTHS OLD AT START OF STUDY• DX: DEV DELAY, HYPOTONIA, PRONATION• WAS PULLING TO STAND FOR ~1 MONTH. NOT YET TAKING
INDEPENDENT STEPS• RECEIVED PHYSICAL THERAPY 1X/WEEK FOR DURATION OF
STUDY
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DAY 1 – BAREFOOT DAY 1 – SMOS
WEEK 16 – BAREFOOT
GAIT ANALYSIS• Day 1: Not walking
• Month 1: Medium base of support; medium guard. Parent reports he is walkingeverywhere - not crawling anymore
• Month 2: Narrowed BOS; arms dropped to side. Doing great in the grass/onuneven surfaces
• Month 3: Carrying large objects with narrow BOS, starting to pick up velocity
• Month 4: Picks up velocity (almost running), very steady.
PARENT QUESTIONAIRRE• Was this your child’s first set of orthoses? YES• Wear Schedule: Hours/Day 10 Days/Week 7• How does your child respond to wearing the SureStep SMOs? LIKES• How satisfied are you with the SureStep SMOs (1 = Not at all; 10 = Very Satisfied)? 10• Rate your child’s activity level without SureStep SMOs (1 = Not at all; 10 = Very Active): 7• Rate your child’s activity level with SureStep SMOs (1 = Not at all; 10 = Very Active): 8• Rate your child’s coordination when active without SureStep SMOs (1 = Not at all; 10 = Very
Coordinated): 7• Rate your child’s coordination when active with SureStep SMOs (1 = Not at all; 10 = Very
Coordinated): 10• Rate your child’s endurance without SureStep SMOs (1 = Not at all; 10 = Very High): 7• Rate your child’s endurance with SureStep SMOs (1 = Not at all; 10 = Very High): 9• Rate the difficulty in donning and working with the SureStep SMOs (1 = Very Difficult; 10 =
Very Easy): 10
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PT QUESTIONAIRRE• How satisfied are you with the SureStep SMOs (1 = Not at all; 10 = Very Satisfied)?
10• Rate your child’s activity level without SureStep SMOs (1 = Not at all; 10 = Very
Active): 7• Rate your child’s activity level with SureStep SMOs (1 = Not at all; 10 = Very
Active): 10• Rate your child’s coordination when active without SureStep SMOs (1 = Not at all;
10 = Very Coordinated): 6• Rate your child’s coordination when active with SureStep SMOs (1 = Not at all; 10 =
Very Coordinated): 8• Rate your child’s endurance without SureStep SMOs (1 = Not at all; 10 = Very
High): 10• Rate your child’s endurance with SureStep SMOs (1 = Not at all; 10 = Very High): 10• Rate the difficulty in donning and working with the SureStep SMOs (1 = Very
Difficult; 10 = Very Easy): 10• Additional comments: Automatically noticed decreased BOS and ER of left LE and
increased toe grip with SureSteps on. Received SureStep on 2/8/12 and startedindependent stance x a few seconds with increased balance in standing withinone week and taking independent steps by 2/20/12. On 3/5/12 he was able totake 28 steps independently with encouragement
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10
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TYPICAL
CORWIN
NORMAL – RATE OF CHANGE = 0.51PATIENT – RATE OF CHANGE = 0.32
• TYPICAL CHILD TAKE 8-9 MONTHS TO PROGRESSFROM PULLING TO STAND TO WALKING FAST.
• THIS PATIENT TOOK 5 MONTHS TO MAKE THE SAMECHANGES
OUR KIDS OURCATCHING UP THETHEIR PEERS ANDMAKINGCHANGESFASTER THAN ATYPICAL CHILD!!
DEVELOPMENTAL DELAY ATBEGINNING = 6 MONTHSDEVELOPMENTAL DELAY AT END (16WEEKS) = 2 MONTHS*WE GAINED 4 MONTHS IN 16 WEEKS
HAYDEN
• 15 MONTHS OLD AT START OF STUDY• DX: DEV DELAY, PRONATION, HYPOTONIA• WAS PULLING TO STAND FOR A COUPLE OF WEEKS. NOT YET
TAKING INDEPENDENT STEPS• RECEIVED PHYSICAL THERAPY 1X/WEEK FOR DURATION OF
STUDY• VERY HESITANT/CAUTIOUS
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DAY 1 – BAREFOOT DAY 1 – SMOS
WEEK 16 – BAREFOOT
GAIT ANALYSIS• Day 1: Not walking
• Month 1: Very wide BOS, needs 2 hands held; veryunsteady
• Month 2: Faster velocity with walking toy, looks steadier(with one hand held)
• Month 3: Started taking independent steps - very wide baseof support, high guard, unsteady
• Month 4: Narrower base of support, much steadier, low tomedium guard
PARENT QUESTIONAIRRE• Was this your child’s first set of orthoses? YES• Wear Schedule: Hours/Day 12 Days/Week 7• How does your child respond to wearing the SureStep SMOs? LIKES• How satisfied are you with the SureStep SMOs (1 = Not at all; 10 = Very Satisfied)? 10• Rate your child’s activity level without SureStep SMOs (1 = Not at all; 10 = Very Active): 7• Rate your child’s activity level with SureStep SMOs (1 = Not at all; 10 = Very Active): 9• Rate your child’s coordination when active without SureStep SMOs (1 = Not at all; 10 = Very
Coordinated): 4• Rate your child’s coordination when active with SureStep SMOs (1 = Not at all; 10 = Very
Coordinated): 8• Rate your child’s endurance without SureStep SMOs (1 = Not at all; 10 = Very High): 4• Rate your child’s endurance with SureStep SMOs (1 = Not at all; 10 = Very High): 8• Rate the difficulty in donning and working with the SureStep SMOs (1 = Very Difficult; 10 =
Very Easy): 10
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PT QUESTIONAIRRE• How satisfied are you with the SureStep SMOs (1 = Not at all; 10 = Very Satisfied)?
10• Rate your child’s activity level without SureStep SMOs (1 = Not at all; 10 = Very
Active): 3• Rate your child’s activity level with SureStep SMOs (1 = Not at all; 10 = Very
Active): 8• Rate your child’s coordination when active without SureStep SMOs (1 = Not at all;
10 = Very Coordinated): 2• Rate your child’s coordination when active with SureStep SMOs (1 = Not at all; 10 =
Very Coordinated): 8• Rate your child’s endurance without SureStep SMOs (1 = Not at all; 10 = Very
High): 3• Rate your child’s endurance with SureStep SMOs (1 = Not at all; 10 = Very High): 8• Rate the difficulty in donning and working with the SureStep SMOs (1 = Very
Difficult; 10 = Very Easy): 10• Additional comments: Overall improvement in alignment from foot to head.
Improved truncal/postural control. Improved stability gave confidence to a verycautious little girl. Walking started within 3-4 weeks after receiving SureStepSMOs. Improved overall static standing balance. I love them
NORMAL – RATE OF CHANGE = 0.51PATIENT – RATE OF CHANGE = 0.32
• TYPICAL CHILD TAKE 8-9 MONTHS TO PROGRESSFROM PULLING TO STAND TO WALKING FAST.
• THIS PATIENT TOOK 5 MONTHS TO MAKE THE SAMECHANGES
OUR KIDS OURCATCHING UP THETHEIR PEERS ANDMAKINGCHANGESFASTER THAN ATYPICAL CHILD!!
8
10
12
14
16
18
20
TYPICAL
HAYDEN
DEVELOPMENTAL DELAY ATBEGINNING = 5 MONTHSDEVELOPMENTAL DELAY AT END (16WEEKS) = 1 MONTHS*WE GAINED 4 MONTHS IN 16 WEEKS
JEREMIAH
• 15 MONTHS OLD AT START OF STUDY• DX: DEV DELAY, PRONATION, HYPOTONIA,
LIGAMENTOUS LAXITY• WAS PULLING TO STAND FOR A COUPLE OF
WEEKS. NOT YET TAKING INDEPENDENT STEPS• RECEIVED PHYSICAL THERAPY 1X/WEEK FOR
DURATION OF STUDY
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GAIT ANALYSIS
• Day 1: Not walking• Month 1: Walking with 2 hands held; unstable
with 1 hand held• Month 2: Wide BOS, externally rotated, high
guard. Starting independent steps.• Month 3: Stable with no hands held. Wide
base• Month 4: Narrow BOS; carrying objects
DAY 1 – BAREFOOT
DAY 1 – SMOS
NORMAL – RATE OF CHANGE = 0.51PATIENT – RATE OF CHANGE = 0.34
DEVELOPMENTAL DELAY AT BEGINNING = 6 MONTHSDEVELOPMENTAL DELAY AT END (16 WEEKS) = 1 MONTHS*WE GAINED 5 MONTHS IN 16 WEEKS
• TYPICAL CHILD TAKE 8-9 MONTHS TO PROGRESSFROM PULLING TO STAND TO WALKING FAST.
• THIS PATIENT TOOK 5 MONTHS TO MAKE THE SAMECHANGES
OUR KIDS OURCATCHING UP THETHEIR PEERS ANDMAKINGCHANGESFASTER THAN ATYPICAL CHILD!!
8
10
12
14
16
18
20
22
TYPICAL
JEREMIAH
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KATE
• 17 MONTHS OLD AT START OF STUDY• DX: DEV DELAY, PRONATION, HYPOTONIA,
LIGAMENTOUS LAXITY• WAS PULLING TO STAND AND CRUISING FOR A
MONTH. NOT YET TAKING INDEPENDENTSTEPS
• RECEIVED PHYSICAL THERAPY 1X/WEEK FORDURATION OF STUDY
GAIT ANALYSIS
• Day 1: Not walking• Month 1: Walking with 1 hand held, behind
push toy, starting some independent steps• Month 2: Medium guard, narrowing BOS• Month 3: Stable with no hands held, narrow
base, speed increasing
DAY 1 – BAREFOOT DAY 1 – SMOS
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NORMAL – RATE OF CHANGE = 0.51PATIENT – RATE OF CHANGE = 0.25
DEVELOPMENTAL DELAY AT BEGINNING = 8 MONTHSDEVELOPMENTAL DELAY AT END (16 WEEKS) = 3 MONTHS*WE GAINED 5 MONTHS IN 16 WEEKS
• TYPICAL CHILD TAKE 8-9 MONTHS TO PROGRESSFROM PULLING TO STAND TO WALKING FAST.
• THIS PATIENT TOOK 4 MONTHS TO MAKE THE SAMECHANGES
OUR KIDS OURCATCHING UP THETHEIR PEERS ANDMAKINGCHANGESFASTER THAN ATYPICAL CHILD!!
8
10
12
14
16
18
20
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TYPICAL
KATE
SAWYER
• 18 MONTHS OLD AT START OF STUDY• DX: DEV DELAY, PRONATION, HYPOTONIA,
LIGAMENTOUS LAXITY• WAS PULLING TO STAND FOR A COUPLE OF
WEEKS. NOT YET TAKING INDEPENDENT STEPS• RECEIVED PHYSICAL THERAPY 1X/WEEK FOR
DURATION OF STUDY
GAIT ANALYSIS
• Day 1: Not walking• Month 1: Taking some independent steps –
transferring between supports, wide BOS, highguard
• Month 2: Narrowing BOS, lower guard,walking independently
• Month 3: Stable with no hands held, Widebase, speed increasing
• Month 4: Narrow BOS; carrying objects,walking on uneven terrain
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DAY 1 – BAREFOOT DAY 1 – SMOS
NORMAL – RATE OF CHANGE = 0.51PATIENT – RATE OF CHANGE = 0.28
DEVELOPMENTAL DELAY AT BEGINNING = 8 MONTHSDEVELOPMENTAL DELAY AT END (16 WEEKS) = 4 MONTHS*WE GAINED 4 MONTHS IN 16 WEEKS
• TYPICAL CHILD TAKE 8-9 MONTHS TO PROGRESSFROM PULLING TO STAND TO WALKING FAST.
• THIS PATIENT TOOK 5 MONTHS TO MAKE THE SAMECHANGES
OUR KIDS OURCATCHING UP THETHEIR PEERS ANDMAKINGCHANGESFASTER THAN ATYPICAL CHILD!!
8
10
12
14
16
18
20
22
TYPICAL
SAWYER
• Martin (2004) Effects of supramalleolar orthoses onpostural stability in children with Down syndrome– 17 children with Down syndrome– Ages 3 years 6 months to 8 years– 10 week study– Each child his own control– Provided with SureStep orthoses– Tested with the Gross Motor Function Measure (GMFM) using
dimensions D (Standing) and E (Walking, Running and Jumping)
Martin, K. Effects of supramalleolar orthoses on postural stability in children with Down syndrome.Dev Med Child Neurol. 2004;46:406-411.
HYPOTONICITY
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• SureStep is provided through local O&P professionals.• SureStep is a patented product
– US Patent #: 6,517,505 B1
• Only fabricated by SureStep• Accept no substitutes, copies, knock-offs, or imitations.
How to Obtain SureStep
Custom Fabricated
• To measurements: NO CASTING REQUIRED!!!• Nine simple measurements.
– 3 Circumference– 2 M-L (Width)– 2 Length– 2 Height
Measuring Videosurestep.net
Clinicians Corner
SureStep Support• Turn around:
– 2 business days (measurements)– 4 business days (Casts)
• 6 business days (Poor Casts)• 8 business Days (Terrible Casts)
• Technical/Clinical Support– Pediatric Specialists
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Other SureStep Products
• 50 lbs. and up.• No weight limit.
Custom Fabricated to Measurements(Less than 3” at #5 measurement)
Custom Fabricated to Cast(3” and up at #5 measurement)
4 Business Day Fabrication
BigShot Lite Version forPatients up to 90 lbs.
BigShot Standard Versionfor Patients over 80 lbs.
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Stance Stability
SureStep Indy 2-Stage
Fully Finished SMO inside AFO
AFO can be:• Solid Ankle• Posterior Leaf• Articulated with double
adjustable hinge.• Dorsiflexion Assist• Plantarflexion Assist
SMO can be used independent of AFO
Custom to measurements (under 2 ½” at #5)Custom to cast. (2 ½” and up at #5)
Indy 2-Stage
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Convertible Design
SureStep Plastic
SureStep Flexibility
AFO to SMO in 10 min.
Great for Pre-standersCustom to measurements (under 2 ½” at #5)Custom to cast. (2 ½” and up at #5)
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Super lightweight; 4-6 oz.
Custom fabricated to measurements
Low profile
Will not impede floor mobility
HEKO OTSPrefabricated HEKO Now Available
Super lightweight; 4-6 oz.
Available in 4 standard sizes
Low profile
Will not impede floor mobility
Can be ordered by Orthotists or PTs
Perfect for children up to 50 lbs
HEKO PreFab
Loaners Available For Test Fittings!!!
Other SureStep Products
De-Rotation Straps
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Other SureStep Products
De-Rotation Straps
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Spinal Management Considerations
• Degree of the deformity• Rib Prominence• Shoulder asymmetry• Pelvic Obliquity• Trunk imbalance• “wind swept” hip deformity• Flexibility• Tone assessment
• Presences of abnormal reflexes– Hyporeflexia and Hyperreflexia
• Assessment of functionalimpairments– Ambulation– Sitting balance
Neuromuscular Scoliosis Impact
• Functional independence• Pain• Pulmonary function• Self-image• Social role• Quality of life
Determine treatment plan
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X-ray examination• Challenge due to patients ability to sit on their own
An eight-year-old girl with a 100° scoliosis curve. X-rays show thecurve before and after spinal fusion surgery.Courtesy of Texas Scottish Rite Hospital for Children
Orthotic Goals; Hypotonia• Improve functional ROM
– Often resulting in decreasing hypermobility– Help muscles work in appropriate
length/tension relationships throughcompression
• Provide optimal alignment– Increases stability though better base of support or
center of balance.– Requires less work for the patient
Dynamic Spinal Management
Dynamic Spinal Management
Can Result in:• Improved Posture, Balance and Proprioception• Enhanced Motor Control• Increased Functional Use of Extremities• Delayed Surgical Intervention• Better Speech and Swallowing
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• Extremely Flexible
• Low Profile
• Custom to Meas.
• NO CASTING
• Easily Adjusted
• Available in Several Thicknesses.75mm - 1.25mm - 1.75mm - 2mm – 2.25mm
Hydrostatic pressure:
• Flexible Total Contact system• Compression to maintain alignment• Improve functional sitting abilities• Increased compliance with use• Improved outcome for patients with
neuromuscular conditions
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• Ideal for postural instabilities andflexible kyphosis and lordosis
–Can incorporate an accommodation forthe abdomen as well as the GillModification to provide ease ofbreathing.
SureStep TLSO
• From Measurements, Cast or Scans• Turn around is 4 days in house by Measurements or Scan, and
5 Days by Cast– Rush service available
• Plastic thickness variable on size of mold.• Foam liners out of Volara or Puff• Anterior Window cut out if desired• Gill modifications
Breathing Modifications
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Postural control helps to lead toimproved functional movementand decreased reflex reactions toposture.
Seating systems lack dynamicfunction and do not allow forutilization of postural weightbearing. Leading patients to relyon protective reflexKangas K “Hyperextension, obligatory reflexes, or the Opisthotonic Reation ? Facingthe seating challenges of children whose seating systems do not recognize thisposture.”
Plastizote TLSO
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Late to sitting
Duchenne’s Muscular Dystrophy
• Reported incidence vary between 48-93%• In general, ambulatory patients do not develop scoliosis• Most boys whose disease follows the course are WC dependent at
age 10.• Curve is commonly a c-shaped thoracolumbar curve with pelvic
obliquity
Mullender M, Bloom N, De Kleuver M, et al. A Dutch guideline for the treatment of scoliosis in neuromuscular disorders. Scoliosis 2008; 3:14
DMD Case
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Spina Bifida• A neural tube deficit• Varying degree of nerve involvement & paralysis
below the level of injury.• May have associated congenital spinal or
vertebral abnormalities.• Syringomyelia is a concern
6 y/o with Spina Bifida
OOB75⁰
IB47⁰
SureStep TLSO Design compared to Rigid TLSO
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Update - Curve is the same. Improved sitting
In Seating system
Knowing when to Cast
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Casting
DCO – DYNAMIC CERVICAL ORTHOSIS
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Variable tension setting
Head ptosis (drop)
Resulting in: Associated symptoms are:
• Weakness of the neckextensor,
• or increased tone of the flexormuscles.
• It is characterized by markedanterior curvature orangulation of the cervicalspine
• It is associated with variousneuromuscular (table 1) andextrapyramidal disorders.
Head drop and camptocormia: Umapathi U, July 2002)
• Speech,
• Swallowing,
• Up-gaze (eyes upward) deficits
are often associated.
Indications Contra-Indications• Lack of Head Control• Head Ptosis (Head Drop)• Parkinson’s syndrome• Cerebral Palsy• Multiple Sclerosis• Amyotrophic Lateral Sclerosis• Myopathy
• Hyper rigidity of the neckmuscles or stressed tremor
• Fixed or Fused Neck Position
DCO – Dynamic Cervical Orthosis
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Before & After wearing the DCO…
Before AfterDynamic Head ControlPatient with Head Drop
Head Control…BW36
Therapeutic benefit for adult hyperkyphosis?
Slide 167
BW36 Branden Wawrzyniak, 2/16/2015
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SureStep TLSO – DCO Combo
Without TLSOand DCO
Functional upright postureWith TLSO and DCO
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Children’s Footwear
• Additional ventilation keeps feet cool.• Polyethylene insert in counter.• Broad, round Toe-Box allow improved fit.• Solid sole to ease external modifications.• Two 1/8” removable insoles.• Available in Pink or Blue.• Flexible sole.• Affordable : MSRP only $39.99• Available direct to families at:
www.surestep.net
Children’s Footwear
• Built on same Last as SureStepshoes.
• Available in Pink or Black
• Sizes from Toddler 3 to Youth 12.
• Flexible sole.
• Affordable : MSRP only $39.99
• Available direct to families at:www.surestep.net
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Sophia
• 6 Years Old• Idiopathic Toe Walker• Decreased passive and active ROM into Dorsiflexion• Has tried footplates and has overpowered them.
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Barefoot
Left
Right
Cyclogram
KiddieGaitAFOs
Left
Right
Cyclogram
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Example – Shelby