Indications and Decision Making in Prescription of Orthoses

7/29/2019 Indications and Decision Making in Prescription of Orthoses

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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



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30 deg

contracture

Y Y Y Y Y Y Y

15 deg

contracture

Y Y Y Y

15 deg elastic

contracture

Y Y


Pre - tibial

weakness

Y Y Y Y

Voluntary Y Y Y



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30 deg

contracture

Y Y Y Y Y Y Y

15 deg

contracture

Y Y Y Y

15 deg elastic

contracture

Y Y


Pre - tibial

weakness

Y Y Y Y

Voluntary Y Y Y

Low heel contact - Footstrikes floor with 15o PF &knee fully extended



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30 deg

contracture

Y Y Y Y Y Y Y

15 deg

contracture

Y Y Y Y

15 deg elastic

contracture

Y Y


Pre - tibial

weakness

Y Y Y Y

Voluntary Y Y Y

Fore foot contact Mixtureof ankle equinus & kneeflexion (20 deg either jt.)



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30 deg

contracture

Y Y Y Y Y Y Y

15 deg

contracture

Y Y Y Y

15 deg elastic

contracture

Y Y


Pre - tibial

weakness

Y Y Y Y

Voluntary Y Y Y

Good ankle mobilityFoot rapidly drops withtibia in vertical position



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30 deg

contracture

Y Y Y Y Y Y Y

15 deg

contracture

Y Y Y Y

15 deg elastic

contracture

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



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30 deg

contracture

Y Y Y Y Y Y Y

15 deg

contracture

Y Y Y Y

15 deg elastic

contracture

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



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30 deg

contracture

Y Y Y Y Y Y Y

15 deg

contracture

Y Y Y Y

15 deg elastic

contracture

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



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30 deg

contracture

Y Y Y Y Y Y Y

15 deg

contracture

Y Y Y Y

15 deg elastic

contracture

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 )



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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



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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


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


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


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


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


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


Inadequateextension


Excessiveextension

Flexion Y Y


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contracture

IT bandcontracture

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


Inadequateextension


Excessiveextension

Flexion Y Y


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contracture

IT bandcontracture

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


228/252

crouch gait

Children < 25 kg (8-10 yrs of age )wideant calf strap with AFO


229/252

Children > 25 kgFRO ,rear entry in calf

Requisites for FRO in CP

Neutral DF with Knee in full extension


230/252

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


231/252

Pre- requisites are

- normal foot alignment

Half Height AFO

Solid ankle AFO usually without ant ankle


232/252

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


234/252

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


242/252

Disabil Rehabil. 2002 May 10;24(7):345-7

Dursun E, Dursun N, Alican D

Purpose:

To evaluate the effectiveness of (AFOs) on


243/252

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


245/252

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-


246/252

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


247/252

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


250/252

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


252/252

Documents

Indications and Decision Making in Prescription of Orthoses