indications and decision making in prescription of orthoses
TRANSCRIPT
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Indications and decision making in
prescription of Orthoses in lower
limb conditions
Saumen Gupta
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An orthoses is defined as an externallyapplied device used to modify structural and
functional characteristics of the neuro -musculoskeletal system
( International Standards Organization )
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Orthoses is a device applied directly and
externally to the patients body with theobject of supporting, correcting or
compensating for an anatomical deformity
or weakness, however caused, it may beapplied with the additional object of
assisting, allowing or restricting movement
of the body
( Department of Health and Social Services (U.S.)
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Orthotic intervention in LL
Orthotic intervention for common
maladies of foot
Improve safety and functionality duringambulation
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Orthotic prescription
Decisions best made by interdisciplinary
team framework
Pat. withimpairment
Caregiver
Orthotist
Physician
PT, OT
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Team approach
Allows Consideration of various influences
on the eventual outcome of orthotic
intervention
Pat. diagnosisPreferred life style ,
leisure activities
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Recommendations for orthoticoptions
Understanding
Diagnosis
Prognosis
Musculo -skeletal
Neuro- muscular
Status progressive
Status constant
Function improved
Function Declined
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Recommendations for orthoticoptions
Understanding
3. General medical condition
4. Levels of fitness
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Recommendations for orthotic
options
Thorough assessment of
- Gait,
- Muscle function,- Motor control,
- ROM ,and
- Alignment of the limb
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Acceptance & use of Orthoses
- Pat . specific needs
- Convenience
- Pat. lifestyle
- Pre-conception/ expectation about outcome
- Impact on function / mobility / energy cost
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So the primary goal of orthoticintervention is to select the device and
components that will best improve the
function of the patient
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Indications and prescription oforthosis in lower limb musculo-
skeletal conditions
Prescription Foot orthoses
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Alteration of foot function and alignmentcan be accomplished by
Custom molded shoes
Accommodative molded orthosis
Shoe modifications
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Indicated:-
Transfer of forces from sensitive to pressure
tolerant areas
Needed to reduce friction, shock and shearforces ,
To modify weight transfer patterns ,
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To correct flexible foot deformities ,
To accommodate for fixed foot deformities
To limit motion in painful, inflamed or
unstable joints
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Types
1. Moldable leathers
2. Custom molded shoes
3. Plastazote shoe or sandal
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Moldable leather
Used to protect feetthat are vulnerable due
to1. Vascular insufficiency,
2. Neuropathy or
3. Deformity
Can be heat molded
directly to foot
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Custom- molded shoe
Foot wear molded
directly over plaster
reproduction of foot
Special modifications
can be added whilemanufacturing
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Plastazote shoe or sandal
Used in patients with insensitive or
ulcerated foot
Temporary protective foot wear
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SHOE MODIFICATIONS
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To address functional and anatomicaldeformities of foot and leg
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Lifts for leg length discrepancy
- LLD =/> 3/8 inchesexternal lift
mounted on sole of shoe of shorter limb
- LLD < 3/8 inchesdiscrepancy accom.with orthotic heel wedge lift
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Common indications
- Hip fracture
- Congenital anomaly
- Biomechanical imbalances
1. Pelvic rotation2. Hip ante - version / retroversion
3. Unilateral foot pronation
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Heel wedging
Wedgingused to alter lines of stress to
facilitate a normal gait pattern
Effective wedges range from 1/81/4 Inches
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Useful for children with rotationalproblems e.g. tibial torsion
In adults wedging is used to accommodateconditions such as fixed valgus deformityof calcaneus
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Wedging - Goals
To obtain subtalar neutral position during
stance position of gait
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Med. Heel wedgeflexible valgus ofcalcaneus
Lat. Heel wedgeflexible varus ofcalcaneus
Full heel wedgefixed or functionalequinus deformity
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Sole wedging
To modify mid foot and forefoot position
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# Medial sole wedge produces inversion
effect on forefoot
- Positioned along medial aspect of footwear( just proximal to MT head)
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# lateral sole wedge creates eversion effect
on forefoot
- Placed proximal to 5th MT head
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Bartons wedge
- Extends along the medial side of foot to
midtarsal joint and tapers laterally justanterior to cuboid bone
- Supports navicular bone and invertscalcaneus
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Control of mid foot is the goal in severe
flexible pronation deformity - pes planus
Used when necessary to shift body wtlaterally e.g. OA
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Metatarsal bars & rocker bottoms
Attached to the sole of the shoe just
proximal to the MT heads
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Significantly reduces pressure at the MT
heads during Push Off Phase of gait cycle
Facilitates Push Offby simulating forward
propulsion in absence of MT flexibility
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Indicated -
Commonly in shoes worn by
1. Fixed arthritic deformities
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3. Diabetes ulceration
4. Forefoot deformitieshallux rigidus and
neuromas
5. LE orthosis limiting forward progression
of tibia over foot during late and midstance phases
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Thomas heel -
Designed to improve
foot balance and relieve
excessive foot pressure
- Increases stability during
gait by making subtalarneutral
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- Applied as lat. or med. flare of the heel toprevent inversion or eversion injuries
resp.
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Footwears for common foot
deformities and foot problems
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Metatarsalgia-
Compression of planter digital nerve between
MT heads
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Objectives in prescribing foot wear
- Transfer pressure from painful, sensitive
areas to more pressure tolerant areas
- Reduce friction by stabilizing MT joints
- Stabilize mid and rear foot to reducepressure on MTH
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Foot wear indicated
Cushion sole to absorb shock
High toe box to allow forefoot flexion and
extension
Long medial counter to stabilize rear foot
Low heel to minimize pressure at MTH
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Shoe modification
Transverse MT bar - redistribute pressure
from MTH to MT shaft and shorten stride
Rocker sole to reduce motion of painfuljoints
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Sesamoiditis
Inflammation around the sesamoid bonesunder 1st MTH
Loss of tissue padding under the 1st MTHand from toe deformities such as halluxvalgus and hallux rigidus
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Objectives
Redistribute wt- bearing forces from 1st MT
and sesamoids to long medial arch and shaft
of lesser MTtransverse MT bar
Rocker sole to reduce motion
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Mortons syndrome
Irritation of digital planter nerve between 1st
and 2nd MTH
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Modifications include -
- High, wide toe box to reduce compression
forces along transverse MT arch
- Thomas heel wedge to support the mediallongitudinal arch
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Hallux rigidus
Goalslimit motion of hallux at 1st MTJ
Steel shank from heel to phalanx of thehallux and rigid rocker sole with elevatedheel
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Hallux valgus (bunions)
Lateral deviation of hallux and form foot
pronation
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Objectives-
1. Reduce friction and pressure at 1st MTP
2. Eliminate abnormal pressure from narrowfitting shoes
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3. Reduce pronation of foot from IC tomidstance
4. Correct eversion
5. Relieve post. tibial tendon and lig. strain
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Hammer toes, claw toes, mallet toes
Footwear goals are
- To reduce pressure on MTHMT bars
- Accommodate roll over fixed deformities
rocker bottoms
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Problems in mid foot
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Pes planus
Failure of foot to supinate in mid-stance
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Goals for intervention in pes planus
- Reduce pronation from heel strike to mid -
stance
- Correct eversion
- Relieve tension over tibialis posterior
- Relieve ligamentous strain
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- A long medial heel counter
- Thomas heel (med extension)
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Planter fasciitis
Goals of intervention-
- Transferring wt. bearing pressure to tolerantareas
- Reduce tension on planter fascia andAchilles tendon
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- Control pronation from heel strike to mid
stance
- Maintain subtalar joint in neutral position
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To limit heel valgus- log med. Heel
counter
To reduce tension on planter fasciahighheel
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Problems in rear foot
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Arthrodesis
Motion of ankle in all planes restricted
Alters progression through stance phase ofgait
Compromises limb clearance in swing phase
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Objectives
Provide effective shock absorption
Controlled lowering of forefoot at loadingresponse
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Improve efficiency of push off
Accommodate any shortening or residualequinus
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Footwear-
Stability provided by medial and lateral flaredheel
Application ofcushioned heel to absorbshock and simulate planter flexion after heelstrike
Rocker sole to mimic dorsiflexion needed in
late stance phase
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Diagnosis related considerations
in shoe prescriptions
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Rheumatoid arthritis
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The talo navicular joint is the most commonlyaffected
Subtalar joint involvement shows a similarpattern, with an increase of 25% between 5and 10 yr of duration
Deformity of the tarsal joints and forefoot
also occurs with disease progression
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Advise accommodative shoes of moldableleather,
Rocker bottom to aid the rocker motion ofankle
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Effectiveness of foot orthoses in themanagement of plantar pressure and pain in
subjects with rheumatoid arthritis was
investigated , The custom moulded orthosis
with metatarsal dome was the most effective
orthoses for reducing subjective ratings ofpain
( Clin Biomech (Bristol, Avon). 1999 Oct;14(8):567-75)
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A critical review of foot orthoses in
the rheumatoid arthritic foot
H. Clark, K. Rome, M. Plant
Rheumatology 2006;45:139145
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Both hard and soft FO decreased forefootpain, and
Hard FO decreased rear foot pain in the
patient with early-onset RA
Hard FO also decreased levels of foot
deformity in RA patients with hallux valgus,
but did not improve pain levels
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Wearing time appears to be a crucialfactor in the effectiveness of FO as in all
available studies
Gait parameters improve with the use ofFO: average stride and step length
increased
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GOUT
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Treatment objective
Preventing or limiting motion of painful andinflamed joint
Accommodating foot deformities
Cushioning the impact of loading of
involved joints
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Shoe modifications
- Reinforced counter to limit subtalarmotion
- High top design to limit over all anklemotion
- Extra depth shoe of thermoldable leatherfor acc. of foot deformities
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A rocker bottom to assist push off
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DIABETES
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Patient with neuropathy requires aconsistent follow-up schedule relating to
level of insensitivity,
f ?
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Who requires follow up?
- Patient with loss of protective sensation
(10 g of force) and
- no history of ulceration requires less
frequent follow-up than does the patient
with a chronic breakdown history
T f h h f
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Treatment of the neuropathic foot
- Accommodation,
- Relief of pressure/shear forces,
- Shock absorption
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The combination of materials must becompressible by one half of the original
thickness to accommodate for pressure
relief through the gait cycle
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Plastazote has a limited effective period of
about 2 days; Poron (PPT) remainseffective for 6 to 9 months
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Thermold leather shoe with shockabsorbing material is used for insensitive
feet
PTB AFO can be used for insensitive foot
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Some of the orthotics which can beadvised to patients in community
Rh id h i i
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Rheumatoid arthritis
1. Resting splints for ankle
Use of PVC pipes cut into half
To maintain foot in neutral
2 M l d
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2.Metatarsal pads
To maintain transverse arch
Longitudinal arch support to prevent
navicular drop
3 T d
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3. Toe spreaders
To prevent overriding of toes
B i li
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Bunion splint
Splints and simple orthoses used
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Splints and simple orthoses usedin neuromotor conditions
C t t ti
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Contracture prevention
1 A kl f t th
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1. Ankle foot orthoses
To prevent TA contracture
Can be made by PVC pipes
2
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2
3 M t l b
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3. Metal brace
Adductor bar
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Adductor bar
To prevent scissoring of legs in supine so
that the legs can be kept in abduction
Standing frames
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Standing frames
Walking brace
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Walking brace
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Ankle
Sagittal
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Gait cycle
hip
knee
Whole
Ankle
Regional
coronal
Scheme of presentation for orthotic prescription
Pathological variations in Gait
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Pathological variations in Gaitcycle
Pathological mechanisms
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There is a long list of diseases that impairpatients ability to walk
Differ markedly in primary pathology
The abnormalities imposed on mechanics of
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walking fall into 4 functional categories
Deformity
Muscle weakness
Impaired control
Pain
Sensory loss
Deformity
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Insufficient passive mobility to attain normalposture & ROM
Contracture is the most common cause
Elastic - Mobility appears normal or
slightly delayed
Rigid - Consistent throughout stride
length
Deformity
E g
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E.g.
Ankle PF contracture (Blocks progression)
Knee Flexion Contracture (blocksprogression)
Hip Flexion Contracture
Muscle weakness
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Inefficient strength - Postural substitution
Muscle weakness
Impaired motor control (spasticity)
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Obstructs yielding quality of eccentric musclefunction during stance
Impaired motor control (spasticity)
Pain
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Induces deformity and muscle weakness
Pain
Ankle and Foot gait deviations
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Ankle and Foot gait deviations
Gait errors in sagittal plane
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Gait errors have been identified by 2descriptors
- Excessive ankle PF
- Excessive ankle DF
Excessive ankle PF
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Stance phase - Loss of progression
Swing phaseObstruction of limb advancement
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Effects of excessive ankle PF
Phasic patterns of excessive ankle Planter flexion
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IC LR MS TS PSw ISw MSw TSw
30 deg
contracture
Y Y Y Y Y Y Y
15 deg
contracture
Y Y Y Y
15 deg elastic
contracture
Y Y
Spastic calf Y Y Y Y Y
Pre - tibial
weakness
Y Y Y Y
Voluntary Y Y Y
Phasic patterns of excessive ankle Planter flexion
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IC LR MS TS PSw ISw MSw TSw
30 deg
contracture
Y Y Y Y Y Y Y
15 deg
contracture
Y Y Y Y
15 deg elastic
contracture
Y Y
Spastic calf Y Y Y Y Y
Pre - tibial
weakness
Y Y Y Y
Voluntary Y Y Y
Phasic patterns of excessive ankle Planter flexion
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IC LR MS TS PSw ISw MSw TSw
30 deg
contracture
Y Y Y Y Y Y Y
15 deg
contracture
Y Y Y Y
15 deg elastic
contracture
Y Y
Spastic calf Y Y Y Y Y
Pre - tibial
weakness
Y Y Y Y
Voluntary Y Y Y
Low heel contact - Footstrikes floor with 15o PF &knee fully extended
Phasic patterns of excessive ankle Planter flexion
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IC LR MS TS PSw ISw MSw TSw
30 deg
contracture
Y Y Y Y Y Y Y
15 deg
contracture
Y Y Y Y
15 deg elastic
contracture
Y Y
Spastic calf Y Y Y Y Y
Pre - tibial
weakness
Y Y Y Y
Voluntary Y Y Y
Fore foot contact Mixtureof ankle equinus & kneeflexion (20 deg either jt.)
Phasic patterns of excessive ankle Planter flexion
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IC LR MS TS PSw ISw MSw TSw
30 deg
contracture
Y Y Y Y Y Y Y
15 deg
contracture
Y Y Y Y
15 deg elastic
contracture
Y Y
Spastic calf Y Y Y Y Y
Pre - tibial
weakness
Y Y Y Y
Voluntary Y Y Y
Good ankle mobilityFoot rapidly drops withtibia in vertical position
Phasic patterns of excessive ankle Planter flexion
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IC LR MS TS PSw ISw MSw TSw
30 deg
contracture
Y Y Y Y Y Y Y
15 deg
contracture
Y Y Y Y
15 deg elastic
contracture
Y Y
Spastic calf Y Y Y Y Y
Pre - tibial
weakness
Y Y Y Y
Voluntary Y Y Y
Excessive PF in MSwimmediate effect is toe
drag on the floor
Conditions
DF weakness
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Conditions DF weakness
Primary problem is weakness of DF
- Peroneal nerve palsy
- Charcot marie tooth disease
- Polio
- Various other peripheral neuropathies
Preferred
orthosis
dynamic AFO
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Preferred orthosis dynamic AFO
PLS AFO
Conventional DF assist AFO
Posterior leaf spring AFO
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Posterior leaf spring AFO
- In 1st rocker - Substitutes for eccentric
contraction of weak muscles
- 2nd rocker allows DF necessary for tibialadvancement
- Once the swing phase begins PLS holds
ankle at 90 o
Conventional DF AFO
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Conventional DF AFO
The amount of DF assist provided iscontrolled by adjustment of screw placed
in joint
Contra
indications
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Contra indications
May not be effective in controlling Medio-lateral foot position
May not be appro. For patients with flexible
foot deformities at rear feet, mid feet and for
feet
Not to be used in patients with hypertonicity
and neuromotor equinovarus
Phasic patterns of excessive ankle Planter flexion
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IC LR MS TS PSw ISw MSw TSw
30 deg
contracture
Y Y Y Y Y Y Y
15 deg
contracture
Y Y Y Y
15 deg elastic
contracture
Y Y
Spastic calf Y Y Y Y Y
Pre - tibial
weakness
Y Y Y Y
Voluntary Y Y Y
Rigid PF Heel off posturemay continue
Rigid PF Tibia drivenbackwards as heel drops
to floor
Phasic patterns of excessive ankle Planter flexion
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IC LR MS TS PSw ISw MSw TSw
30 deg
contracture
Y Y Y Y Y Y Y
15 deg
contracture
Y Y Y Y
15 deg elastic
contracture
Y Y
Spastic calf Y Y Y Y Y
Pre - tibial
weakness
Y Y Y Y
Voluntary Y Y Y
Premature heel riseused by vigorouswalkers with no
disability
Knee hyperextension- foot flat with post.
Restrained tibia
Forward trunk leanwith ant. Tilt
maintain balance
over PF foot
Phasic patterns of excessive ankle Planter flexion
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IC LR MS TS PSw ISw MSw TSw
30 deg
contracture
Y Y Y Y Y Y Y
15 deg
contracture
Y Y Y Y
15 deg elastic
contracture
Y Y
Spastic calf Y Y Y Y Y
Pre - tibial
weakness
Y Y Y Y
Voluntary Y Y Y
Excessive PF in MSimmediate effect is toe
drag on the floor
Substitution withincreased hip and knee
flexion
Conditions
-
with Excessive PF
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- Stroke
- Spinal cord injury (incomplete)
- Cerebral palsy
- Foot drop (chronic )
- Prolonged immobilization
Selection of orthoses
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Pat has decreased anklestrength / impaired or
absent proprioception at
h k kl / kl PF
No
Yes
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the knee or ankle / ankle PFspasticity
No orthosesrequired
Spasticity, PF contracture, or absent
proprioception affects foot
placement during standing or gait
Rigid polypropylene AFO /
Metal AFO with (DAAJ) poly
footplate, locked / Metal AFO
with AJ, locked.
Berg Balance Score < 43,
or severe spasticity, orabsent proprioception
Yes
Orthoses with art.
ankle joint, PF stopindicated
Orthoses with locked joint
and undercut or cushioned
heel is indicated
Polyart. AFO w (PF) stop /Metal AFO w DAAJ & poly
footplate,PF stop / MetalAFO w DAAJ, PF stop
Yes
No
Preferred orthoses
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AFO
- For children with cerebral palsy foot plate
can be extended to reduce the likelihoodof abnormal toe grasp reflex
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AFOs in Hemiplegia
Effects of ankle
-
foot orthoses on
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hemiparetic gait
Gk H, Kkdeveci A, Altinkaynak H
Clin Rehabil. 2003 Mar; 17(2):137-9
Objective:
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j
Study evaluated mechanical effects ofmetallic and plastic AFOs on severely
hemiparetic stroke patients
Results
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The two types of orthoses generally hadsimilar positive effects on hemiplegic gait
parameters
- Increased cadence,
- Increased walking speed,
- Increased single and double step length
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- Increased ankle DF angle at heel strike and
swing.
The metallic AFO was better atincreasing the ankle dorsiflexion angle than
the plastic AFO
Conclusion
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Hemiplegic gait was improved by bothorthoses
However, metallic AFOs provided betterstabilization of the ankle, allowing improvedheel strike and push-off
Implications for using static AFO
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Deleterious impact on the rockers of thegait
- Prevents controlled lowering of foot towardsfloor during loading response
- Flat foot position instead of achieving rapid
knee flexion
- Pat must have at least fair eccentric strength
to control rapid knee flexion
Overcoming limitations
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g
- Pat. shoe - cushion heel to stimulate 1st
rocker
- Rocker bottom sole - substitution forforward progression of tibia in 2nd rocker
and impaired rollover in 3rd
rocker
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Excessive ankle dorsiflexion
Second gait error seen in ankle joint
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Dorsi flexion beyond neutral is an abnormal
event in all the phases of gait cycles exceptmid stance and terminal stance
Has more functional significance in stancethan swing
Excessive dorsi flexion
IC LR MS
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Soleus weakness
Knee extensor
weakness
Fixation of ankle
at neutral
Accommodating
to flexed kneeSoleus weakness fails tostabilize tibia, quadriceps
cannot extend flexed knee
At the time heel contactexaggerated heel rocker
Initial instability present
Excessive dorsi flexion
IC LR MS
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Soleus weakness
Knee extensor
weakness
Fixation of ankle at
neutral
Accommodating to
flexed kneeCorresponding increase in
the quadriceps demand
Conditions
-
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- Over lengthening of soleus
- Myelomeningocele
- Myelodysplesia
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- Soleus weakness in rheumatoid arthritis
- Myopathy
- Crouch gait from neuro muscular problems (
If ROM present at knee )
Selection of orthoses
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Determine if DF stop is indicated:
a) PF strength 4 in standing & /or
b) Excessive ankle DF (knee flexion)
or ankle PF(knee extension) in stance
Orthoses w DFstop indicated
Determine if DF assist is
required : DF strength is 4
1. Polyart. AFO w (DF) stop.
2. Metal AFO w AJ & poly
footplate, DF stop.
3. Metal AFO w AJ,DF stop
1. Leaf spring AFO
2. Polyarticulating AFO w DF assist
3. Metal AFO with AJ,DF assist
NoYes
Yes
Selection of orthoses
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Determine if DF stop is indicated:
a) PF strength 4 in standing & /or
b) Excessive ankle DF (knee flexion)
or ankle PF(knee extension) in stance
Orthoses wo DFstop indicated
Determine if DF assist is
required : DF strength is 4
1. Leaf spring AFO
2. Polyarticulating AFO w DF
assist.3. Metal AFO with AJ and
poly footplate, DF assist
4. Metal AFO with DAAJ,DF
assist
No orthoses required
NoYes
No
Preferred orthoses
-
FR
-
AFO
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PF - knee extension couple (PF/KE) to occur,causing a knee-extension moment
(Perry J. Gait Analysis Normal and Pathological
Function , NJ: SLACK; 1992:239-240)
This knee-extension couple helps to support
weak quadriceps and plantar flexor muscles( LindsethJ Bone Jt Surg. 1974: 56A(3):556553)
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Contra
-
indications
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- Inappropriate for patients with recurvatum
- Structural instability of knee joint
FRO may cause negative impact onbalance reactions
If worn B/L then assistive device forambulation is required
Case Study: Improving Knee Extension
i h Fl
R i AFO i P i
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with Floor-Reaction AFO in a Patient
with Myelomeningocele and 20 KneeFlexion Contractures
Donald Freeman, CP
JPO 1999 Vol. 11, Num. 3 , pp. 63-68
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Patients with Myelomeningocele, depending onthe spinal level, tend to have decreased lower-
extremity muscle strength that results in a
crouched-type gait pattern
Adding to this pattern, a knee-flexion
contracture and an efficient gait is difficult to
achieve
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The FRAFO-even set in 10 dorsiflexion-,improved the patients gait by extending
the knees to the maximum and increasing
the external knee-extension moment,
despite the 20 knee-flexion contractionspresent
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It is unlikely the FRAFO will functioneffectively for every patient with knee-
flexion contractures
Therefore, it is essential to evaluate eachcase individually
Coronal plane deviations
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Excessive inversion
Excessive eversion
Coronal plane deviations
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Excessive subtalar inversion and eversionlead to clinical abnormalities of varus and
valgus
Cause
abnormal muscular control
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Static deformities
Varusdominant in spastic foot
Valgus in flaccid foot
Preferred orthoses
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Solid static AFO
G i d i i k j i
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Gait deviations at knee joint
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Most common types of dysfunctionsoccur in sagittal plane
Sagittal plane deviations
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Gait errors have been identified by 4descriptors
- Inadequate knee flexion
- Excessive flexion
- Inadequate knee extension
- Excessive extension
Phasing of the gait deviations at the knee
LR MS TS PSw ISw MSw TSw
I d k fl i Y Y Y Y
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Inadequate knee flexion Y Y Y Y
Excessive extension
- Extensor thrust Y
- Hyperextension Y Y Y
Excessive flexion Y Y Y Y
Inadequate extension Y Y Y
Coronal gait deviations
-Varus Y Y Y
- valgus Y Y Y
Phasing of the gait deviations at the knee
LR MS TS PSw ISw MSw TSw
I d k fl i Y Y Y Y
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Inadequate knee flexion Y Y Y Y
Excessive extension
- Extensor thrust Y
- Hyperextension Y Y Y
Excessive flexion Y Y Y Y
Inadequate extension Y Y Y
Coronal gait deviations
-Varus Y Y Y
- valgus Y Y YNormal shock absorbing flexion is lost
Causes of knee gait deviations
Stance
I d t E i E t i E i I d t
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cause Inadequateknee flexion
Excessiveextensor
thrust
Extensionhyperextensio
n
Excessiveflexion
Inadequateextension
Quadricepsweakness
Y Y Y
Ankle PF
contracture
Y Y Y
Ankle PFspasticity
Y Y Y
Hamstring
spasticity
Y Y
Knee flexioncontracture
Y Y
Ankle PFweakness
Y
Phasing of the gait deviations at the knee
LR MS TS
I d t k fl i Y
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Inadequate knee flexion Y
Excessive extension
- Extensor thrust Y
- Hyperextension Y Y
Extensor thrust inhibitsknee flexion , premature PF
+
Knee hyperextensiondynamic retraction by GM if
Range is available
Knee hyperextension assubstitution for weak
quadriceps
Quadriceps over activityinhibiting loading response
knee flexion creating
hyperextension Causes of knee gait deviations
Stance
cause Inadequate kneefl i
Excessive extensor thrust Extension hyperextension
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flexion
Quadricepsweakness
Y Y Y
Ankle PFcontracture
Y Y Y
Ankle PFspasticity
Y Y Y
Quadricepsspasticity
Y Y Y
Conditions
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Polio
Stroke
Cerebral palsy
Selection for orthoses
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Patient has < 3+/5quadriceps strength
bilaterally
Patient has < 3+/5quad strength in test
side and 3+/5 quad
strength in contralateral limb?
NO
NO
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lateral limb?
Yes
Unilateral KAFO on
test side is indicated
Person has kneeHyperextension ROM?
Locked knee joint is
indicated Locks(Drop or Bail)
Proprioception
intact at test knee
KAFO not required,
evaluate for AFO on
test side
Yes
Can use unlocked
KAFO on test side
(offset knee jt / free
knee)
NO
Select type of knee joint and
materials and orthotic ankle
components
Yes
NO
Person may not require a KAFO even withquadriceps strength < 3+/5 if hip extensor
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quadriceps strength < 3+/5 ifhip extensor
muscle strength is 3+/5, and he/she has fullknee extension ROM, or quadriceps tone, or
proprioception intact
Person with knee pain may require either
locked or unlocked knee joint for KAFO
(RLA R.O.A.D.M.A.P.)
KAFO design options
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Conventional KAFO attached to patientsshoe by a stirrup
Thermoplastic KAFO fits within patientsshoe
Conventional KAFO
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Knee joint
Calf band
Metal upright
Ankle joint
Stirrup
Thigh band
Thermo
-
plastic KAFO
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Ant. Straps
Proximal shell
Metal knee joint
Metal uprights
Distal shell
Comparison of advantage and
disadvantage of CKAFO
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Advantages Disadvantage
Strong
Most durable
Easily adjusted
Heavy
Must be attached to
shoe insert
Less cosmetic
Fewer contact points
to reduce control
Comparison of advantage and
disadvantage of TKAFO
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Advantages
Light weight
Interchangeability ofshoes
Greater cosmesis
Disadvantages
Can be hot to wear
Indications
-
CKAFO
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When maximum strength and durability areneeded
For individuals with significant obesity
Individuals with uncontrolled edema (e.g.
CHF, dialysis)
Contra
-
indications
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When issues of energy expenditure make wt.of the Orthoses a factor
When control of transverse plane motion isimportant
Less than intimate fit of this Orthosesreduces efficacy of varus / valgus control
systems
Metal KAFO to correct
genurecurvatum
-
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Stance Control Knee Ankle Foot
Orthoses (SCKAFO)
-
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These orthoses are worn by many patientswho can walk without them, but who cannot
walk safely.
Especially designed for quadriceps weakness
Unlocks knee at the beginning of 3rdrockerand decreases strategy for hip hiking
Indications
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Isolated quadriceps muscle deficit
- can usually walk, but will often
have episodes of falling or high instability
Femoral mononeuropathy (FMN)
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- Orthosis offers
- A secure stance phase
- Avoid the circumduction and hip hiking
patho-mechanics , common to a static drop
lock KAFO.
- Decreases energy expenditure
Pre
-
requisite for prescription
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Pat in middle yrs present with full cognition
No sec. restrictions in affected limb
And usually have 5/5 muscle strengths for all
other components of the limb
Universal contraindications for all
stance control systems include:
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Significant impairment in the patients cognitionand/or motivation.
Significant knee spasticity.
Knee flexion contractures greater than 10.
If follow-up, or compliance on the part of thepatient is uncertain.
Gait deviations
swing phase
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Causes of knee gait deviations (SWING PHASE)
Swing
Cause Inadequate Excessive knee Inadequate Excessive
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qknee flexion flexion
qextension extension
Quadricepsspasticity
Y
Hip flexionweakness
Y
Ankle DFweakness
Y
Ankle DF spasticity Y
Hamstringscontracture
Y
HamstringsspasticityPrimitive pattern
Y
Quadriceps
weakness
Y
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Problems encountered in Inadequateknee flexion
- Seen in stroke
Pre
-
swing
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Failure to adequately flex the knee in pre
swing makes toe off more difficult
Greater hip flexion and knee flexor forceis required to lift foot at onset of initial
swing
Initial swing
L k f d k fl l
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Lack of adequate knee flexion in initial
swing causes toe drag with inability to
advance the limb
Mid swing
-
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Inadequate knee flexion does not occur
independently
It reflects either a lack of hip flexion orcontinuation of pathology in initial swing
-
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Problems encountered in excessiveknee flexion / inadequate extension
-
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- In mid swing and terminal swing Passive
extension that normally occurs in mid
swing is inhibited
Causes of knee gait deviations (SWING PHASE)
Swing
Cause Inadequate knee Excessive knee Inadequate extension
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Caus a quatflexion
c ss vflexion
a quat t s o
Quadricepsspasticity
Y
Hip flexionweakness
Y
Ankle DFweakness Y
Ankle DF spasticity Y
Hamstrings
contracture
Y
HamstringsspasticityPrimitive pattern
Y
Coronal deviations in knee
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Coronal deviations in knee
Dynamic deviations
I OA h k i ld i
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In OA the knee yields to persistent
medial alignment of body wt vector
throughout stancegenu varum seen
In RA , knee valgus is seen
Preferred option for
genu
varum inOA
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Lateral heel wedge is the choice
Evidence supports the application of alateral heel wedge (LHW) as a non -
operative treatment for varum gonarthrosis
B d i th dd ti t th h
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By reducing the adduction moment through
changes in the placement of the foot during
gait
( J. Robert GiffinJPO 1995 Vol. 7, Num. 1 , pp. 23-28 )
Effects of disease severity on response tolateral wedged shoe insole for medialcompartment knee osteoarthritis
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- The kinetic and kinematic effects of wearing oflateral wedged insoles were significant inKellgren-Lawrence grades I and II knee OA.
- Result show that use of lateral wedged insolesfor patients with early and mild knee OA is
recommended
- (Arch Phys Med Rehabil. 2006 Nov;87(11):1436-41)
A randomized crossover trial of a
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A randomized crossover trial of awedged insole for treatment of kneeosteoarthritis
- The effect of treatment with a lateral-wedgeinsole for knee OA was neither statisticallysignificant nor clinically important
(Arthritis Rheum. 2007 Apr;56(4):1198-203)
Articulating KAFO can be given which
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Articulating KAFO can be given , which
provides mediolateral stability
Hip gait deviations
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p g
Sensitive to dysfunction in all the three
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Sensitive to dysfunction in all the three
plans
In assessment of walking thigh motion has
to be differentiated from that of pelvis
Gait errors in sagittal plane
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g p
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Inadequate extension
Inadequate flexion
Causes of gait deviation at hipInadequateextension
Excessive flexion Inadequateflexion
Excessiveextension
Flexion Y Y
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contracture
IT bandcontracture
Y Y
Flexor spasticity Y Y
Arthrodesis Y Y Y Y
Pain Y Y
Voluntary Y Y Y
Causes of gait deviation at hip
Inadequateextension
Excessive flexion Inadequateflexion
Excessiveextension
Flexion - Y Y
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contracture
IT bandcontracture
Y Y
Flexor spasticity - Y Y
Arthrodesis Y Y Y Y
Pain Y Y
Voluntary Y Y Y
Inadequate extension of hip
Lack of hip extension threatens persons
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Lack of hip extension threatens person s
wt bearing stabilty
It also impedes progression
Mid
stance
Limited hip extension can modify the
-
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Limited hip extension can modify the
alignments of either the pelvis or thigh
3 postural errors are introduced
- Forward trunk lean
- Lumbar spinal lordosis- Flexed knee
Forward trunk lean
Hip flexion of 15 deg is easily
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Hip flexion of 15 deg is easily
accommodate by spine if its not
abnormally stiff
Greator loss of hip extension t axes spinemobiltiy
Knee flexion
Flexing the knee tilts the thigh back
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Flexing the knee tilts the thigh back
And allow pelvis to retain its normalalignment , despite fixed hip flexion
Hence crouch posture is seen as means ofaccommodating to inadequate hip extension
This is very inefficent as it requiresquadriceps control
Terminal stance
Functional deficits of inadequate hip
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Functional deficits of inadequate hip
extension
- Anterior pelvic tilt
- And trailing thigh
Causes of gait deviation at hip
Inadequateextension
Excessive flexion Inadequateflexion
Excessiveextension
Flexion Y Y
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contracture
IT bandcontracture
Y Y
Flexor spasticity Y Y
Arthrodesis Y Y Y Y
Pain Y Y
Voluntary Y Y Y
Excessive flexion
Gait error seen in pre swing and initial
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Gait error seen in pre swing and initial
swing
Hip flexion for swing is initiated
prematurely
Mid
swing
Excessive elevation in thigh in mid swing
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Excessive elevation in thigh in mid swing ,
is common substitution for excessive
ankle PF
Causes of gait deviation at hip
Inadequateextension
Excessive flexion Inadequateflexion
Excessiveextension
Flexion Y Y
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contracture
IT bandcontracture
Y Y
Flexor spasticity Y Y
Arthrodesis Y Y Y Y
Pain Y Y
Voluntary Y Y Y
Inadequate hip flexion
Initial swing
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Initial swing
- Failure to flex hip 15 deg reduces limb
advancement and causes limited knee
flexion since thigh momentum is needed tiinitiate action is lacking
- This inturn contributes to the knee drag
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This inturn contributes to the knee drag
and ankle PF
- Dragging toe can inhibit hip flexion,
function of the knee and ankle in othergait phases
AFO in CP
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AFO s include many different variations, and
-
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AFO s include many different variations, and
all published studies have confirmed the
effects of these of orthosis
Wide variation in foot size - AFO s shouldbe custom molded
Implications of using AFO in CP
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- Improved stability by use of AFO in childrenwho are coming to stand in pre -ambulatory
stage
- Improved stability in stance phase of gait
- To improve childs balance ability
Solid AFO with anterior ankle Strap
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Prescribed for children at ambulatory stage ,between age of 18 and 24 months
- Provides stability to ankle and foot to givestable base for standing
- Easy to don for care givers
- Marginal ambulators and non ambulatorssolid AFO
As the children get the stability and walk withwalker at age 3-4 , ankle hinge can be added
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to allow DF but limit PF
- Transition to hinged AFO is contraindicated -
severe PV deformity
- Increased knee flexion in stance or crouch
gait pattern
Hinged AFO
Preferred for children with back knee -
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gastronemus contracture
The effect of hinged ankle
-
foot
orthosis on gait and energy
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expenditure in spastic hemiplegiccerebral palsy
Disabil Rehabil. 2007 Jan 30;29(2):139-44
Balaban B, Yasar E
Purpose:
To assess the effectiveness of a hinged ankle-
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g
foot orthoses on gait impairments and
energy expenditure in children with
hemiplegic cerebral palsy (CP) whom
orthoses were indicated to control equines
Results:
AFO application, as compared with the
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pp p
barefoot condition improved walking speed,stride length and single support time
Double support time was decreasedsignificantly with AFOs and no change incadance
Ankle dorsiflexion at initial contact, midstanceand midswing showed significiant increase
Knee flexion at initial contact was
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decreased and no significant change in
maximum knee extension at stance and
maximum knee flexion at swing was
obtained.
The oxygen consumption was significantly
reduced during AFO walking.
Conclusion
The hinged AFO is useful in controlling
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g g
dynamic equinus deformity and reducing the
energy expenditure of gait in children with
hemiplegic spastic cerebral palsy
Floor reaction AFO
-
control of
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crouch gait
Children < 25 kg (8-10 yrs of age )wideant calf strap with AFO
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Children > 25 kgFRO ,rear entry in calf
Requisites for FRO in CP
Neutral DF with Knee in full extension
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Very little knee flexion contracture
Foot to knee axis should be in normalalignment , < 20 deg of Internal or externaltibial torsion
Works for ambulatory children
Art. FRO in CP
Hinged FRO to allow PF , restricting DF
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Pre- requisites are
- normal foot alignment
Half Height AFO
Solid ankle AFO usually without ant ankle
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straps are usually cut low to half the normalcalf height
Indicated in children having mild PF force andmainly needs gentle pressure reminder inswing phase or early stance phase
Contra- indicated if strong flexor spasticity isthere
Functional Level
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Non AmbulatorOrthotic used for
standing or control footdeformity
Ambulator
Solid Ankle full calf heightM-AFO to toe tips
1-3 yr old 3-10 yrs old >10 yrs old
Miller , Text Book of CP
1-3 yrs Old
Spasticity, Major ProblemHypotonic, Poor motorcontrol, Weakness
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Mild - SMO orIMO to MT heads
Moderate - ArtMAFO to MT head
Severe - Solid MAFOto MT heads
Mild increase inequinus due to tone
( N Passive D F)
Severe
HH, AFO , BMFP to
toe tips
Passive DF available withknee extension
Art. MAFO, BMFP to toetips
Solid MAFO ,biomechanical foot
plate to toe tips
3-10 yrs Old
Hypotonic, Poor motor control,Weakness
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Mild - IMO to MTheads or wrap around
IMO to toe tips
Moderate
Determine specificproblem
Severe - SolidMAFO to MT heads
Global problem SMO
or HH AFO with BMFP
Isolated DF weakness withgood Gastronemus leaf
spring MAFO
Idiopathic toe walker
Art. MAFO to toe tips
3-10 yrs Old
Spasticity, MajorProblem
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MildSpastic PF withadequate DF, PV or EV
main problem
ModerateSpastic ,good ambulator , mild or
moderate PV or EV
Severe- spastic , limitedambulation with PV, EV,
no DF
Desire good control of
sub talar joint , pat.Requires easy to donorthotic Continued
Solid SMO to MT head
Desire less control of
sub talar joint , pat. Andpat. Can manage diff. todon orthotic
Wrap around SMO
Moderate
Strong PF but with
Weak PF but good DF
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DF present withknee extended
Art. MAFO BMFPto toe tip
Child stands foot flat withknee flexed
HH MAFO BMFP to
toe tip with wraparound style
Child stands foot flatwith knee extended
Art. MAFO with post.Strap , BMFP to toe tips ora solid ankle MAFO to toe
tips
> 10 yrs old
Hypertonic : spasticity isthe major problem
Hypotonic : Poor motorcontrol weakness
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MAFO HH calfBMFP
SMO / IMO (UBCL)
Desire control ofPV or EV
Moderatethe pat. Iscommunity walker
Mild - the pat. is fullcommunity ambulator
Severeprob. with verylimited walking ability
Severe back knee
Leaf spring full calf Ht
with BMFP
Need to controlmild back knee
Good gastronemusbut poor DF Art. AFO full calf
Ht with BMFP
Solid MAFO with BMFP
> 10 yrs old
Hypertonic : spasticity isthe major problem
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Severelimitedcommunity ambulator,always using assistive
device
Moderatecommunityambulator with assistive
device
Mild - community ambulatorwith no device
Control PV / EV
Need to control PV / EV
SMO
Need to control mild PF
Need to control mild PFOr mild back knee
Art. AFO full calf Ht. withor without BMFP
SMO or IMO(UBCL)
MAFO HH calf BMFP
Severelimited communityambulator, always using
assistive device
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Need to control crouch gait(stance phase hip and kneeflexion with ankle DF )
If child uses crutches or walker andcontinues to back knee with AFO
and has increasing kneehyperextension or knee pain
Use KAFO with Ext. Stop kneehinges and add a solid AFO
< 30 Kg. BW
MAFO solid ankleBMFP and wide ant.
Prox tibial strap
Art. AFO with fullcalf Ht. , BMFP to
the toe tips
Need to control backkneeing in stance phase
> 30 Kg. BW
> 30 Kg. BW
No foot deformity, has With PV or EV foot
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normal foot alignment withknee usually post op afterdeformity correction
deformity but with foot& and knee in normalrotational alignment
Solid GRAFO to toe tip
With active DF ?
Yes
Art. GRAFO to toetip flat foot flat
No
Solid GRAFO
Ankle
-
foot orthoses: effect on gait
in children with cerebral palsy
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Disabil Rehabil. 2002 May 10;24(7):345-7
Dursun E, Dursun N, Alican D
Purpose:
To evaluate the effectiveness of (AFOs) on
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gait function in patients with spastic cerebralpalsy for whom orthoses were indicated to
control dynamic equines deformity
Conclusions:
Cerebral palsied children with dynamic
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equines deformities can benefit fromAFOs for ambulation
A comparison of gait with solid,
dynamic, and no ankle
-
foot orthoses
in children with spastic cerebral
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palsy
Phys Ther. 1998 Feb;78(2):220-2
Radtka SA, Skinner SR, Dixon DM,
Johanson ME
Purpose
To compare the effects of dynamic ankle-
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foot orthoses (DAFOs) with a plantar-flexion stop, polypropylene solid ankle-foot
orthoses (AFOs), and no AFOs on the gait
of children with cerebral palsy (CP)
Results:
Both orthoses increased stride length,
d d d d d d
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decreased cadence, and reduced excessiveankle plantar flexion when compared with
no orthoses.
No differences were found for the gait
variables when comparing the two orthoses.
Conclusion and discussion
Both orthoses can be recommended for
h ld h CP d
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children with spastic CP and excessiveankle plantar flexion during stance,
Additional individual factors should beconsidered when selecting either orthosis
Special KAFO design
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Patient has < 3+/5
quadriceps strengthbilaterally
TRIAL IS ENDED
Patient will not receive
bilateral KAFO / RGO for
ambulation. Patient may be
Patient meets Participation
Criteria for Ambulation Trial
i h Bil l KAFO / RGO?
yesNo
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Order bilateral
KAFO or RGO
Patient successfully meets
Completion Criteria (see
Table) for Ambulation Trial
with Bilateral KAFO/RGO?
re-evaluated in > 3 monthswith Bilateral KAFO / RGO?
Locked knee jointis indicated Drop /
bail
Select type ofknee joint
and materials
No
yes
yes
M i l f hi h
Material selection
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Materials for thigh componenta) Metal uprights with leather at knee/thighb) Metal uprights with plastic at knee/thigh
Anterior Tibial Shell-- required if knee flexion contractures are present
Plastic KAFO/RGO-- metal uprights connect plastic thigh and calf portions
conclusion
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