therapeuticgaittraining

Therapeutic Application and Gait Training Stance control orthoses

E-MAG Active and Free Walk

| Information for orthotists and therapists |

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Preface

Walking freely places a high demand on an orthotic system. The orthosis has to bear the patient’s full body weight for a moment in the stance phase, while also allowing for mobility of the knee joint during the swing phase.

The development of knee joints that are movable during the swing phase has ushered in a new era of leg apparatuses. The Free Walk orthosis is the first intelligent orthotic system that offers a broad range of applications as well as ample experience.

Customized orthotic fitting requires lower leg apparatuses that promote patients’ stance stability and ability and that provide pain relief for arthroses and neuromuscular diseases.

Mary Jerell reported in her survey in 2004 that “20% of post-polio syndrome patients are candidates for stance control orthoses”. The case of this neuromuscular disease shows that fitting patients with orthoses with posteriorly placed Swiss locks or lock rings should no longer be an acceptable practice as these components unnecessarily immobilize the knee joint. Rather, every fifth patient could be fitted with an orthosis allowing the knee joint to move in swing phase, which would demonstrably improve their neuromuscular and muscle-energetic gait pattern.

Patients fitted with swing-phase movable orthoses are shown to expend less energy than patients with rigid apparatuses. Moreover, they will also suffer less damages of the locomotor system and large joints.

E-MAG Active and Free WalkTherapeutic Application and Gait Training

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However, the best intelligent leg orthosis is worthless if professional and qualified explanations and instructions for use are not complied with.

This brochure is not a comprehensive and complete instructions for use manual. Rather, it aims to give impulses and advice for experienced and less experienced therapists for optimally fitting their patients with an intelligent leg orthosis. To counter the "well operated, but poorly mobilized" syndrome, orthotic fitting must comply with requirements and para-meters set by industry, orthotists, therapists and treating physicians.

Our experience with Free Walk over the past three years has shown that patients readily accept the orthosis because of its form and weight. However, the crucial factor for ultimately mobilizing the patient is the therapist’s conviction and qualification. It does not make sense to evaluate and possibly not favour an extensive medical-technical product for reasons of economy, arguing that therapeutic training is poor or non-existent. We recommend patients to test the limits of a swing-phase movable leg orthosis for their daily activities, such as sitting, climbing stairs, sitting down, getting into cars, or doing sports. In that way, they will rea lize the advantages of an intelligent orthosis for their daily life. This test phase, that includes applying, hand ling and walking with the orthosis, is indispensable for all further success.

It is with great pleasure that I present this training brochure. Long overdue, it will benefit the many patients who have already been fitted with the Free Walk and who, due to further developments and changed indications and contra-indications, require the experience of instructing therapists. The brochure will be a valuable reference for both patient and thera pist, assisting them in the transition to independent, daily use once the fitting by the orthotist and physician is completed.

I wish all therapists and patients great success with this brochure. Finally, I also encourage them to assert their legitimate claim for a sufficient number of therapy sessions that are to follow the fitting.

Dr. med. Axel RuetzChief Physician Orthopaedics

Sankt Josef Brüderkrankenhaus Koblenz

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Contents

Preface Page 2

Introduction Page 5

Therapeutic Benefit Page 6

Medical Indications Page 7

Biomechanics of the Normal Gait Page 8

Gait Cyle with the E-MAG Active and Free Walk Page 9

Prerequisites and Targeted Therapy for the Application Page 10

Handling of the Orthosis and First Exercises Page 20

Specific Gait Training with Stance Control Orthoses Page 24

Daily Life Activities Page 30

Frequently Asked Questions Page 33


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Introduction

Stance control orthoses make it possible to walk dynamically and stand securely during the stance phase. The special Otto Bock orthosis systems lock the knee joint during the stance phase and unlock it for the swing phase. The patient thereby achieves a dynamic, almost physiological gait pattern requiring less energy.

With their function, the E-MAG Active and Free Walk orthoses relieve the back, hips, and knee joint. In different ways, because of the individual differences of the orthosis systems, they provide the patient with increased security, stability, and – above all – greater mobility.

The E-MAG Active and Free Walk orthoses differ by their design and functionality. While the E-MAG Active functions electronically and independently from the ankle joint, the Free Walk system is controlled purely mechanically with the ankle joint correlating with the knee joint.

Due to these differences there is the possibility of fitting different patient groups.

Generally described, the knee-ankle-foot orthosis (KAFO), into which the E-MAG Active is integrated, is the fitting that comes into question for patients who:

1. have strong deviations in the frontal and sagittal plane (knee joint and ankle joint); and/or

2. have a very atrophic, bony leg with little soft tissue covering; and/or

3. have a considerably reduced leg (more than 5 cm); and/or

4. require a dorsal stop in the ankle joint to get into knee joint extension;

5. have a stiff ankle;6. or require a strong dorsiflexion function.

Typical patients who can be fitted with a Free Walk orthosis are patients who lost the control of their muscles caused by traumatic influence, but who have not suffered from other stronger lesions on the extremity (e.g. condition after incomplete paraplegia). These are patients who:

1. have no or only minor deviations in the leg axis; and

2. have a stable yet flexible ankle joint (range of motion of at least 10°); and

3. do not require large support surfaces in the orthosis.

For detailed differentiation regarding the indication, please see the information on pages 10.

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The E-MAG Active and Free Walk orthoses were developed for patients who, due to a partial paralysis or a complete failure of the knee extensors, are unable to stabilize their knee without compensatory measures.

For example, knee joints are often stabilized through hyperextension achieved by compensatory movement of the gluteal muscles (when the foot touches the ground, the hip extension leads to a knee extension).

As a result, severe ligament instabilities and arthrotic symptoms in the knee joint will develop over time.

The orthoses can help correct these unphysiological movements, allowing patients to regain a natural gait as much as possible.

The orthoses also offer many therapeutic benefits for paralyzed patients: Prevention of contractures and immobilization-related joint damage. Reduction of muscular atrophy. Maintenance of cardiovascular efficiency for daily activities. With diseases affecting the central nervous system, the orthoses also stimulate unaffected areas of the brain to take over functions (motor relearning, cortical reorganization). That is, in a nutshell, how the orthoses support the social and professional (re-) integration of the patient.

Therapeutic Benefit


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Medical Indications for Consideration

Treatment with stance control orthoses is indicated for pareses or paralyses of muscles and muscle groups of the lower extremities. These may develop within the scope of the following basic diseases:

Central nervous system disorders

• Condition following a stroke• Condition following brain tumours• Condition following encephalitis/brain abscesses • Condition following serious craniocerebral

trauma (CCT)• Multiple sclerosis• Ataxia in the context of diseases involving the

cerebellum (sporadic delayed atrophy of the cerebellar cortex, inherited cerebellar ataxia)

Spinal cord diseases

• Condition after spinal cord injury (e.g., incomplete paraplegia)

• Incomplete hemispinal cord syndrome (Brown-Séquard Syndrome)

• Condition following spinal cord tumours and spinal meninges tumours

• Condition following transverse myelitis, abscesses

• Progressive spastic spinal paralysis (Erb-Charcot-Strümpell)

• Myatrophic lateral sclerosis• Progressive spinal muscular atrophy• Condition following acute poliomyelitis• Post-polio syndrome• Degenerative diseases

(e.g., spinal canal stenosis, stenosis of the intervertebral foramina, spondylolisthesis)

• Abnormalities of the spinal cord (e.g., vertebral arch damage with spondylolisthesis, spina bifida aperta, meningocele, myelomeningocele)

• Funicular myelosis• Syringomyelia• Neural muscular atrophy• Anterior spinal artery syndrome

Muscle diseases and conditions (myopathies)

• Progressive muscular dystrophy• Condition following polymyositis/dermatomyositis• Other myopathies (also in the context of other basic

diseases such as Cushing’s myopathy)

Diseases affecting the peripheral nervous system

• Radicular syndromes (e.g., condition following hernia of the intervertebral disk, radiculitis and poly(neuro)radiculitis, Guillain-Barré Syndrome)

• Condition following lesions of the lumbar and sacral plexuses

• Peripheral nerve lesions (e.g., femoral nerve, sciatic nerve, tibial nerve, obturator nerve, superior and inferior gluteal nerves)

• Polyneuropathy (e.g., asymmetrical diabetic polyneuropathy, alcoholic neuropathy, parainfectious and paraneoplastic polyneuropathy)

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The gait cycle is comprised of a stance phase and a swing phase. The stance phase begins when the heel touches the ground and ends with the toe-off from the ground. The swing phase begins from the toe-off and ends at the next heel contact.

The stance phase begins as soon as the heel touches the ground. At heel strike, the knee is controlled by the thigh and lower leg muscles. When the leg starts to bear weight, the knee is stabilized by the extensor muscles of the thigh. In the mid-stance phase, the thigh and lower leg muscles stabilize the leg up to the end-stance phase. During this last phase, the gait cycle is brought to a completion exclusively by the lower leg muscles.In the normal gait, the thigh extensor muscles have an important supporting function during the stance phase. If this supporting function is missing or significantly weakened, the normal stance phase is disturbed.

Biomechanics of the Normal Gait

Initial stance phase — Heel strike of the

right foot

Mid-stance phase — The standing leg bears the weight

Mid-stance phase Terminal stance phase of the

right leg — Heel strike of the left

foot

Pre-swing phase — The leg is unloaded, transition to swing

phase

Swing phase of the right leg

After the terminal stance phase, the lifting of the toes from the ground—the pre-swing phase—initiates the swing phase. This pre-swing phase utilizes primarily the pretibial muscles and hip flexors. The initial swing phase is controlled by the hip flexors, the knee extensors and the anterior lower leg muscles. During transition to the mid-swing phase, knee flexion is no longer needed to bring the leg with its pendulum mass into the terminal swing phase. The terminal swing phase ends directly at initial heel contact, where the entire chain of muscles is needed to stabilize the knee joint. The swing phase as such is not very much affected by knee extensor deficits. Consequently, conventional orthoses that promote stance phase stabilization, and that are therefore locked, are too immobilizing during the swing phase.


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Gait Cycle with Stance Control Knee Joint Systems

Heel strike with locked knee joint

The leg fitted with the Free Walk orthosis assumes weight bearing, the knee joint is locked

Mid-stance phase with locked knee joint

Heel strike of the left foot

The body moves before the foot, complete extension of the knee joint when the toes are lifted from the ground (dorsiflexion), released lock

Pre-swing phase — the leg is unloaded, the leg fitted with the Free Walk orthosis can swing through with released lock

Heel strike with locked knee joint

The leg fitted with the E-MAG Active orthosis assumes weight bearing, the knee joint is locked

Mid-stance phase with locked knee joint

Heel strike of the left foot

The body moves before the foot, complete extension of the knee joint when the toes are lifted from the ground, released lock

Pre-swing phase — the leg is unloaded, the leg fitted with the orthosis with E-MAG Active can swing through with released lock

In contrast to the gait cycle of a healthy person, the knee joint of patients with lacking function of the knee stabilizing muscles must be stabilized by an orthosis.

The stance control knee joint systems from Otto Bock provide stability only in the phase where it is needed. The swing phase is not compromised.

Between heel contact and toe-off, i.e. when the foot bears weight on the ground, the joints secure the knee joint and support the knee stabilizing muscles.

During the entire stance phase, the orthoses remain locked.

The orthotic joint is then released between the terminal stance phase and the pre-swing phase, allowing the patient’s knee joint to move freely during the swing phase.

This provides the patient a degree of mobility that is nearly comparable with the gait of a healthy person.

Studies have shown that, in comparison with a locked orthosis, the E-MAG Active and Free Walk orthoses offer considerable advantages with regard to energy expenditure, walking speed and reduction of the strain on the contralateral side.Gait cycle with E-MAG Active

Gait cycle with Free Walk

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Prerequisites for the Application and Differentiation of the KAFO with E-MAG Active and the Free Walk Orthosis

Muscle strength required:Muscle strength of the hip or knee extensors is required to initiate the active knee joint extension that releases the orthosis in the terminal stance phase and leads it into pre-swing phase. If neither hip nor knee extensor strength are present, a passive hyperextension of the knee joint may also suffice. At the end of the stance phase, an active hip or knee flexor function is also required to launch the swing phase.

Before the initial heel contact, the knee joint extension must be actively initiated to cause the orthotic knee joint to lock automatically. If this is not possible, a compensatory hip movement can fulfil the task. The pendulum effect caused by the hip movement may suffice to fully extend the knee joint. For assessment of a patient’s suitability and for selection and differentiation of the joint systems, the patient’s muscle strength and mobility of movement are measured.

Muscle strength assessment:0= no visible and/or palpable muscle contraction1= visible and/or palpable muscle contraction2= distinct muscle contraction, complete movement under best possible bearing of own weight is fully possible3= complete movement in the range within which the muscle works against gravity4= maintaining of test position against low to medium pressure5= maintaining of test position against maximum pressure

Testing Muscle Strength

Knee extension The patient supports her/himself on the edge of the bench and tries to extend the to be tested leg as much as possible. The tester fixes the patient’s thigh with her/his proximal hand while, with the other hand, pressing the tip of the extended lower leg in the direction of the flexion. Test below muscle strength grade 3 with the patient lying on her/his side in order to equalize gravity.

Knee extension strength


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Hip extension The patient tries to lift her/his flexed leg off the bench. With her/his proximal hand, the tester palpates the muscle contraction in the gluteal area and, with her/his distal hand, exerts pressure in the flexion direction on the rear side of the thigh. Test below muscle strength grade 3 with the patient lying on her/his side in order to equalize gravity.

Knee flexion The patient tries to flex the heel towards the buttocks. The tester exerts pressure in the extension direction on the flexed leg. Test below muscle strength grade 3 with the patient lying on her/his side in order to equalize gravity.

Hip flexion The patient is asked to lift her/his thigh with the knee flexed towards her/his shoulder on the same side. At the end of the movement, the tester exerts pressure in the extension direction on the ventral side of the thigh. Test below muscle strength grade 3 with the patient lying on her/his side in order to equalize gravity.

Hip extension strength

Knee flexion strength

Hip flexion strength

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Dorsal extension The patient is asked to pull the back of her/his foot up and inwards (dorsal extension and supination). At the end of the movement, the tester exerts pressure in the plantar flexion direction.Dorsal extension muscle strength testTest below muscle strength grade 3 with the patient lying on her/his side in order to equalize gravity.

The tester checks the maximum passive extension ability of the knee joint.

Dorsal extension muscle strength test

Knee joint hyperextension test

The following muscle strengths are required for the indication of stance control systems:

• Muscle strength of hip extensors 3-5, or• Muscle strength of knee extensors 3-5, or• Passive hyperextension in the knee joint• Muscle strength of hip flexors 3-5, or• Compensatory hip movements


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To be able to optimally use the E-MAG Active or Free Walk orthosis, certain conditions in terms of mobility must also be met. Should a patient not meet these conditions, the therapist or physician can assess whether the patient could possibly meet the prerequisites upon completion of a therapy.

E-MAG Active Free Walk

• Knee joint extension, no flexion contracture above 15° (may be influenceable by dorsal stop) in the ankle joint

•••

Mobility of the ankle joint, at least 10°Knee joint extension, no flexion contracture above 10°Valgus/varus deviations in the ankle joint max. 10°

• No hip flexion contracture (not shown)• Also without ankle motion • Valgus/varus deviations in the knee joint max.10°• No uncontrollable spasms • No hip flexion contracture

• Sufficient support from the contralateral leg• Leg length discrepancy max. 7cm (only with stable ankle

joint)• No uncontrollable spasms

Ankle joint mobility

Test for hip flexion contracture

Flexion contracture in the knee joint

Valgus/varus deviations in the knee joint

Required Mobility

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If the prerequisites described above are not entirely met, certain weaknesses can be improved with a therapy for increasing strength and mobility. Use of a stance control orthosis is then possible at a later point in time. Ideally, testers should provide patients with a home programme to complement the therapeutic measures.

Increasing Muscle Strength

Leg length discrepancy

Strengthening the knee joint extensors

Recommended exercises are so-called uni- or bilateral leg patterns from the PNF technique (Proprioceptive Neuromuscular Facilitation), shown here in sitting position.


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Strengthening the hip extensors und hip flexors

To facilitate hip extension and abduction, the leg patterns can also be realized with the patient lying on her/his side with extended or flexed knee joint as well as in quadruped position.

Increasing Mobility

To improve mobility, physiotherapeutic techniques of manual therapy are suitable (here: passive joint mobilization or muscle stretching techniques, depending on the diagnostic findings).If muscle contractures are the cause of a hypomobility, muscle stretching techniques are recommended to increase the range of motion (Fig. 1 - 4).

Increasing muscle mobility in the knee, ankle and foot joints.

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Increasing muscle mobility in the knee joint and hip joint

Increasing Arthrogenous Mobility in the Foot, Knee, and Hip Joints

If joint capsules and/or ligaments impede the required mobility in the extremities, passive joint mobilization techniques are recommended.


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Exercises to Increase Muscle Strength and Mobility at Home

In addition to the exercises carried out with a therapist, the patient should do exercises at home to ensure a lasting effect. The following are some mobility increasing exercises which patients can easily do at home. The more often the patient can do strengthening and mobilizing exercises, the sooner she/he will be able to walk safely and physiologically with a stance control orthosis.

Please note: The measures shown here serve as a rough guideline only and must be adapted to the individual patient.

Strengthening of the knee joint extension using a therapy band. The non-affected leg should support the movement.

ATTENTION:The therapy can only be carried out if the physician/therapist has taken all contra-indications for the physiotherapeutic treatment into consideration!

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Strengthening of the hip extension using a therapy band.

Strengthening of the hip extension and knee joint encompassing muscles (bridging). By changing the knee angle, different muscle groups in the knee joint and hip joint are strained to a different extent.

Strengthening of the hip encompassing muscles (here: abductors).


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Self-stretching of the calf muscles to improve dorsal extension in the upper ankle joint (auto-stretching).

Auto-stretching of the hip flexors and knee ex-tensors to improve hip extension.

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Handling of the Orthosis and First

Exercises

Applying the Free Walk Orthosis

The open shape of the Free Walk orthosis makes it very easy and safe to apply.

It is crucial that the orthosis has the same fitting position on the body at all times. This is ensured by the pre-set closures that can be closed and opened with a quick-lock system.

The open shape of the orthosis with frontal pads in the thigh area allows for a comfortable and safe application while the patient is sitting.

The flexible foot stirrup facilitates the application. It determines the correct fit of the orthosis on the knee pivot point and controls the knee joint lock.

Applying a Knee-Ankle-Foot Orthosis with E-MAG Active Joint System

Due to the different design options, it strongly depends on the patient’s demands and requirements how to apply the orthosis.

Important for the patient is that he can unlock the joint system by pressing the release button (Fig. 2) and that the E-MAG Active can then be flexed.


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Standing up and Locking the E-MAG Active and Free Walk

The first exercises—to take place under the supervision of the therapist or orthotist—are standing up, locking, releasing, and sitting down.

These fundamental exercises serve to develop a feeling for the locking function of the orthosis and will facilitate the release when making the first steps.

1 Standing upSupport yourself with both hands when standing up. Move the contralateral leg more forward to achieve increased stability. Stand up, place the heel of the fitted leg before the standing leg, and move the thigh to the rear to achieve knee joint extension. After the orthosis has locked, try to stand evenly on both legs with the therapist’s assistance.

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2a Sitting down with the Free Walk orthosis Two different ways of sitting down can be practiced in daily life.

A: A button located directly on the knee joint is used to mechanically release the knee joint lock. This method is particularly safe and is appropriate for situations in which the patient has to concentrate on the seat surface. By bending her/his upper body forward, the knee is easily extended. With the arm of the contralateral side, the patient supports her/himself on the armrest (or car door, etc.). With the hand on the side of the orthotic fitting, the patient can then unlock the knee joint by pressing the button on the knee joint.

B: Dynamic release of the knee joint lockThe patient shifts her/his weight forward onto the contralateral leg. This causes pre-tension of the knee joint and ankle joint of the fitted leg that is in extension and dorsal extension. With a light rocking movement, the patient can then unlock the knee joint and sit down.

All exercises should be repeated several times with the therapist’s assistance. A routine of these movements will set in only after a few days. Please note that dynamic sitting down may not be appropriate or desirable for some patients. Nevertheless, these movements have advantages in terms of safety and protection of the body.


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2b Sitting down with E-MAG Active With the E-MAG Active as well, two different ways for sitting down can be practiced.

A: Electro-mechanical release of the lock is possible by pressing the lower button (s. Fig. 1) on the electronic unit of the E-MAG Active. Like with the Free Walk orthosis, this method is appropriate for situations in which the patient has to concentrate on sitting down. Prior to releasing the knee joint, the patient must reach a knee extending position. Some patients are able to achieve a knee extending position in normal stance already, other patients have to generate a knee extending moment with a conscious movement.

B: Dynamic release of the knee joint lockLike with the Free Walk orthosis, the patient must move the contralateral leg more forward to enable the orthosis in a backward position to switch electronically so that the E-MAG Active knee joint releases in a knee extending position.

Like with the Free Walk orthosis, the movement should be practiced with the therapist’s assistance to enable the patient to get accustomed to it.

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Gait Training

Part I Exercise for attaining even weight bearingBefore the patient walks the first steps, priority should be given to correct weight bearing of the orthosis. To prevent atypical movements during the first steps, balancing exercises should be practiced to attain the best possible weight bearing of the supported extremity.

For verification of correct weight bearing, the L.A.S.A.R. Posture is an ideal alternative to the conventional scales with which inaccuracies are unavoidable. With the help of the visual weight bearing line and the hand control device, the therapist or orthotist can give patients precise instructions on how to move in order to find the optimal weight bearing position.

The patient must then practice standing evenly and stably on both legs. For this purpose, different exercises can be practiced.

Stabilizing exercise: The therapist builds up a resistance against the shoulder and/or pelvic girdle to train a stable stance.


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Stabilizing exercises outside the parallel bars

These exercises are to be practiced with the legs in parallel or in step position to engage various muscle groups of the trunk and lower extremities.

The exercises also promote the sense of balance and the weight bearing of the orthosis.

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Part II Practicing initial heel contact up to the stance phase

If possible, the exercises should be done between the parallel bars. The parallel bars give patients an increased sense of security, allowing them to better concentrate on the exercises. The individual step cycles should be repeated several times independently from each other until the patient has attained a certain routine of the movement.

The first exercise teaches patients to place trust in the function of the orthosis in the stance phase. The patient supports her/himself with both hands on the parallel bars (depending on the initial constitution) and swings the leg with locked orthosis from the parallel stance position to the terminal swing phase using either the residual functions of the hip flexors or a tilt movement of the pelvis.

What follows is the initial heel contact with direct transition to weight bearing (Fig. 1). Upon weight bearing, the patient shall try to completely unload the contralateral leg (Fig. 2). Thereafter, the patient practices the transition from the mid-stance phase to the terminal stance phase to unlock the orthosis (Fig. 3).

Initial contact (exercise begins with both legs in parallel position)

Ball contact – transition to weight bearing

Terminal stance phase (lock release)

1 2 3

At the beginning of the exercise, the therapist should guide the affected leg during the swing phase to provide the patient with a feeling for the correct step length (Fig. 4).

Practicing the pre-swing phase of the affected side

4


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Part III Exercise for practicing the lock release function for the swing phase with the Free Walk orthosis

The swing phase is a critical aspect in the use of the Free Walk orthosis. While instrumental for promoting the patient’s mobility and activity, it must also be well mastered and understood by the patient to guarantee a secure functioning.

Wrong movements can cause the orthosis to function improperly. When initiating the pre-swing phase as well as at first heel contact, the right movements must be made so that the orthosis functions properly.

During the transition from the terminal stance phase to the pre-swing phase, the orthosis is released for the swing phase. This can only take place with an unloaded knee joint lock and sufficient dorsal extension in the orthotic ankle joint. The knee joint lock is unloaded through knee joint extension. The latter is achieved either through sufficient muscle strength of the hip or knee extensors or through knee joint hyperextension.

Sufficient dorsal extension is achieved by a sufficiently large step.

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Part III Exercise for practicing the lock release function for the swing phase with a KAFO with E-MAG Active joint system

With the E-MAG Active, initiation of the swing phase as well is of fundamental importance. Safety and proper operation of the orthosis depend on the design and fit of the orthosis, but also on the patient’s understanding. He or she must understand the function and must be physiologically able to control the orthosis.Wrong movements can cause the orthosis to function improperly. During the transition from the terminal stance phase to the swing phase, the orthosis is released for the swing phase. With the E-MAG Active as well, this can only take place with an unloaded knee joint lock, i.e. extension of the orthotic knee joint.

Dorsal extension in the ankle joint is not required. Knee joint extension can be influenced by the step length as well as by the design (e.g. adjustable dorsal stop).


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Part IV Practicing a double step with parallel bars and on a tread mill

After practicing the individual step cycles, the double step is trained between parallel bars. To increase the degree of difficulty, the exercise can be modified by practicing outside the parallel bars, with only one hand supported on a bar and the other hand using a forearm crutch (not shown).

The distance that can be covered between parallel bars is relatively short as the patient is obliged to turn around repeatedly. It is therefore advisable to use a tread mill as a training device.

On a tread mill, speed and thus step length can be influenced. The patient learns the correct movement with the orthosis through repeated, uninterrupted gait cycles.

The highly repetitive character of tread mill training contributes considerably to automatizing the movements.

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Daily Life Activities with stance control orthoses

To train safe and stable backward and sideward walking, different exercises can be practiced. It is important that the patient does not unlock the knee joint when walking backwards. When the patient steps backwards with the fitted leg, the knee joint will be extended concurrently with a dorsal extension of the ankle joint, or the knee joint will be unlocked by the step backwards.

When walking sidewards, the patient should take care to place the fitted leg slightly before the contralateral leg to ensure that she/he can always step safely with the loaded knee joint.

Uphill/downhill rampsA trained patient can make effective use of specific advantages of the orthoses when walking on ramps. For example, when walking up ramps, the orthosis is more easily unlocked, allowing the patient to swing her/his leg through freely and step on it safely.

Walking down ramps is slightly more difficult for the patient at the beginning, since she/he must fully rely on the orthosis. The patient must lean on the fitted leg with her/his full body weight in order to minimize the required compensatory movements. The therapist should practice this with the patient.


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Walking up and down stepsWalking up and down steps should only be done with a locked orthosis. Always walk up with the contralateral leg first and walk down with the fitted leg first!

Uneven groundWalking on uneven ground is very important in daily life. A path with coarse pebbles is well suited for practicing walking on uneven ground.

It is important here that the patient feels how safely his orthosis works if she/he uses it correctly.

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Light sports activitiesA trained user of such orthoses will have no problem taking up light sports and leisure activities.

Especially uniform movements such as cycling can be easily acquired by the patient. Cycling

on a training device is particularly well suited for improving the patient’s fitness. If approved by the physician, other sports such as golf are also well suited for the patients.


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Frequently Asked Questions Regarding the Function of the Free Walk Orthosis

Why does the orthosis fail to unlock?

• Is knee extension fully achieved at toe-off?

• Is the patient able to reach the knee extension stop of the orthosis?

• Is the orthotic knee joint behind the load line?

• Does the ankle joint have sufficient stability?

• Has the cable shifted or is it broken?

Why does the orthosis fail to lock?

• Does the patient reach the extension stop of the orthotic knee joint before initial heel contact?

• Does the patient have sufficient muscles or sufficient hip movement to swing the leg into extension?

Why are some components wearing out quickly?

• If the plastic loops break: Are the holder tubes correctly positioned? (Lower holder tubes should be mounted posteriorly for patients with hyperextension of the knee joint.)

How often should the orthosis be serviced?

• The orthosis should be examined for wear by the responsible orthotist at least every 12 months.

• All wearing parts such as plastic bearings, dorsiflexion assist rings made of PU, cables, as well as pads and closures can be replaced.

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Frequently Asked Questions Regarding the Function of the KAFO with E-MAG Active Joint System

Why does the orthosis fail to unlock?

• Does the patient achieve full knee extension of the orthotic knee joint prior to toe-off?

• Is the patient able to reach the knee extension stop of the orthosis?

• Is the alignment of the orthosis correct, i.e. does the orthotic knee joint get behind the load line?

• Is the dorsal stop in the ankle joint sufficient?

• If no ankle joint is present: is the alignment of the foot in relation to the lower leg or knee joint correct?

• Is the foot sole too flexible and cannot be used to affect knee extension?

• Are the electronic unit, the knee joint, and the cables in good order?

• Is the battery in good order and charged?

Why does the orthosis fail to lock?

• Does the patient reach the extension stop of the orthotic knee joint before initial heel contact?

• Is the patient able at all to safely get into extension with his/her remaining muscles or through hip movement?

• Is the alignment of the orthosis correct?

Why are some components wearing out quickly?

• In case of early wear of the plastic bearings: are the joints parallel to each other?

• Is the alignment of the orthosis correct?

• In case of humidity or oxidation in the electronic components: have the components been installed correctly?

How often should the orthosis be serviced?

• According to the instructions for use, the orthosis is to be serviced every 6 months following a maintenance schedule.


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Notes on the fitting

USA 800.328.4058 • Fax 800.962.2549 • www.ottobockus.com

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