Indications and decision making in prescription of Orthoses in lower limb conditions

Saumen Gupta

An orthoses is defined as an externally applied device used to modify structural and functional characteristics of the neuro musculoskeletal system
( International Standards Organization )

Orthoses is a device applied directly and externally to the patients body with the object of supporting, correcting or compensating for an anatomical deformity or weakness, however caused, it may be applied with the additional object of assisting, allowing or restricting movement of the body
( Department of Health and Social Services (U.S.)

Orthotic intervention in LL

Orthotic intervention for common maladies of foot

Improve safety and functionality during ambulation

Orthotic prescription
Decisions best made by interdisciplinary team framework

Physician
Pat. with impairment PT, OT

Caregiver

Orthotist

Team approach
Allows Consideration of various influences on the eventual outcome of orthotic intervention
Pat. diagnosis Preferred life style , leisure activities

Recommendations for orthotic options

Understanding
Musculo -skeletal

Diagnosis
Neuro- muscular

Status constant

Prognosis
Status progressive

Function Declined Function improved

Recommendations for orthotic options

Understanding
3.

General medical condition

4.

Levels of fitness

Recommendations for orthotic options

Thorough assessment of
- Gait, - Muscle function, - Motor control, - ROM ,and - Alignment of the limb

Acceptance & use of Orthoses

-

Pat . specific needs Convenience Pat. lifestyle Pre-conception/ expectation about outcome Impact on function / mobility / energy cost

So the primary goal of orthotic intervention is to select the device and components that will best improve the function of the patient

Indications and prescription of orthosis in lower limb musculoskeletal conditions

Prescription Foot orthoses

Alteration of foot function and alignment can be accomplished by

Custom molded shoes Accommodative molded orthosis Shoe modifications

Indicated:

Transfer of forces from sensitive to pressure tolerant areas

Needed to reduce friction, shock and shear forces ,

To modify weight transfer patterns ,

To correct flexible foot deformities , To accommodate for fixed foot deformities To limit motion in painful, inflamed or unstable joints

Types
1. 2. 3.

Moldable leathers Custom molded shoes Plastazote shoe or sandal

Moldable leather
Used to protect feet that are vulnerable due to 1. Vascular insufficiency, 2. Neuropathy or 3. Deformity

Can be heat molded directly to foot

Custom- molded shoe

Foot wear molded directly over plaster reproduction of foot Special modifications can be added while manufacturing

Plastazote shoe or sandal

Used in patients with insensitive or ulcerated foot Temporary protective foot wear

SHOE MODIFICATIONS

To address functional and anatomical deformities of foot and leg

Lifts for leg length discrepancy

-

LLD =/> 3/8 inches external lift mounted on sole of shoe of shorter limb

LLD < 3/8 inches discrepancy accom. with orthotic heel wedge lift

Common indications
-

Hip fracture Congenital anomaly

Biomechanical imbalances
1. Pelvic rotation 2. Hip ante - version / retroversion 3. Unilateral foot pronation

Heel wedging

Wedging used to alter lines of stress to facilitate a normal gait pattern

Effective wedges range from 1/8 1/4 Inches

Useful for children with rotational problems e.g. tibial torsion In adults wedging is used to accommodate conditions such as fixed valgus deformity of calcaneus

Wedging - Goals

To obtain subtalar neutral position during stance position of gait

Med. Heel wedge flexible valgus of calcaneus Lat. Heel wedge flexible varus of calcaneus Full heel wedge fixed or functional equinus deformity

Sole wedging

To modify mid foot and forefoot position

# Medial sole wedge produces inversion effect on forefoot

-

Positioned along medial aspect of footwear ( just proximal to MT head)

# lateral sole wedge creates eversion effect on forefoot

-

Placed proximal to 5th MT head

Bartons wedge
Extends along the medial side of foot to midtarsal joint and tapers laterally just anterior to cuboid bone Supports navicular bone and inverts calcaneus

Control of mid foot is the goal in severe flexible pronation deformity - pes planus

Used when necessary to shift body wt laterally e.g. OA

Metatarsal bars & rocker bottoms

Attached to the sole of the shoe just proximal to the MT heads

Significantly reduces pressure at the MT heads during Push Off Phase of gait cycle

Facilitates Push Off by simulating forward propulsion in absence of MT flexibility

Indicated

Commonly in shoes worn by

1.

Fixed arthritic deformities

3. 4.

Diabetes ulceration Forefoot deformities hallux rigidus and neuromas LE orthosis limiting forward progression of tibia over foot during late and mid stance phases

5.

Thomas heel

Designed to improve foot balance and relieve excessive foot pressure Increases stability during gait by making subtalar neutral

Applied as lat. or med. flare of the heel to prevent inversion or eversion injuries resp.

Footwears for common foot deformities and foot problems

Metatarsalgia

Compression of planter digital nerve between MT heads

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 reduce pressure on MTH

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

Shoe modification

Transverse MT bar - redistribute pressure from MTH to MT shaft and shorten stride

Rocker sole to reduce motion of painful joints

Sesamoiditis

Inflammation around the sesamoid bones under 1st MTH Loss of tissue padding under the 1st MTH and from toe deformities such as hallux valgus and hallux rigidus

Objectives

Redistribute wt- bearing forces from 1st MT and sesamoids to long medial arch and shaft of lesser MT transverse MT bar Rocker sole to reduce motion

Mortons syndrome

Irritation of digital planter nerve between 1st and 2nd MTH

Modifications include -

High, wide toe box to reduce compression forces along transverse MT arch

Thomas heel wedge to support the medial longitudinal arch

Hallux rigidus

Goals limit motion of hallux at 1st MTJ Steel shank from heel to phalanx of the hallux and rigid rocker sole with elevated heel

Hallux valgus (bunions)

Lateral deviation of hallux and form foot pronation

ObjectivesReduce friction and pressure at 1st MTP

1.

2.

Eliminate abnormal pressure from narrow fitting shoes

3.

Reduce pronation of foot from IC to midstance Correct eversion Relieve post. tibial tendon and lig. strain

4. 5.

Hammer toes, claw toes, mallet toes

-

Footwear goals are To reduce pressure on MTH MT bars Accommodate roll over fixed deformities rocker bottoms

Problems in mid foot

Pes planus

Failure of foot to supinate in mid-stance

Goals for intervention in pes planus

-

Reduce pronation from heel strike to mid stance

Correct eversion Relieve tension over tibialis posterior Relieve ligamentous strain

A long medial heel counter Thomas heel (med extension)

Planter fasciitis
-

Goals of interventionTransferring wt. bearing pressure to tolerant areas Reduce tension on planter fascia and Achilles tendon

Control pronation from heel strike to mid stance

Maintain subtalar joint in neutral position

To limit heel valgus- log med. Heel counter

To reduce tension on planter fascia high heel

Problems in rear foot

Arthrodesis

Motion of ankle in all planes restricted Alters progression through stance phase of gait Compromises limb clearance in swing phase

Objectives

Provide effective shock absorption Controlled lowering of forefoot at loading response

Improve efficiency of push off Accommodate any shortening or residual equinus

Footwear

Stability provided by medial and lateral flared heel Application of cushioned heel to absorb shock and simulate planter flexion after heel strike Rocker sole to mimic dorsiflexion needed in late stance phase

Diagnosis related considerations in shoe prescriptions

Rheumatoid arthritis

The talo navicular joint is the most commonly affected Subtalar joint involvement shows a similar pattern, with an increase of 25% between 5 and 10 yr of duration Deformity of the tarsal joints and forefoot also occurs with disease progression

Advise accommodative shoes of moldable leather, Rocker bottom to aid the rocker motion of ankle

Effectiveness of foot orthoses in the management 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 of pain
( Clin Biomech (Bristol, Avon). 1999 Oct;14(8):567-75)

A critical review of foot orthoses in the rheumatoid arthritic foot

H. Clark, K. Rome, M. Plant Rheumatology 2006;45:139145

Both hard and soft FO decreased forefoot pain, 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

Wearing time appears to be a crucial factor in the effectiveness of FO as in all available studies

Gait parameters improve with the use of FO: average stride and step length increased

GOUT

Treatment objective

Preventing or limiting motion of painful and inflamed joint Accommodating foot deformities Cushioning the impact of loading of involved joints

Shoe modifications
-

Reinforced counter to limit sub talar motion High top design to limit over all ankle motion Extra depth shoe of thermoldable leather for acc. of foot deformities

A rocker bottom to assist push off

DIABETES

Patient with neuropathy requires a consistent follow-up schedule relating to level of insensitivity,

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

Treatment of the neuropathic foot

-

Accommodation,

Relief of pressure/shear forces,

Shock absorption

The combination of materials must be compressible by one half of the original thickness to accommodate for pressure relief through the gait cycle

Plastazote has a limited effective period of about 2 days; Poron (PPT) remains effective for 6 to 9 months

Thermold leather shoe with shock absorbing material is used for insensitive feet

PTB AFO can be used for insensitive foot

Some of the orthotics which can be advised to patients in community

Rheumatoid arthritis
1. Resting splints for ankle

Use of PVC pipes cut into half To maintain foot in neutral

2.Metatarsal pads

To maintain transverse arch Longitudinal arch support to prevent navicular drop

3. Toe spreaders

To prevent overriding of toes

Bunion splint

Splints and simple orthoses used in neuromotor conditions

Contracture prevention

1. Ankle foot orthoses

To prevent TA contracture Can be made by PVC pipes

3. Metal brace

Adductor bar

To prevent scissoring of legs in supine so that the legs can be kept in abduction

Standing frames

Walking brace

Sagittal Ankle coronal Regional knee hip Gait cycle

Whole

Scheme of presentation for orthotic prescription

Pathological variations in Gait cycle

Pathological mechanisms

There is a long list of diseases that impair patients ability to walk Differ markedly in primary pathology

The abnormalities imposed on mechanics of walking fall into 4 functional categories Deformity Muscle weakness

Impaired control
Pain Sensory loss

Deformity
Insufficient passive mobility to attain normal posture & ROM

Contracture is the most common cause Elastic - Mobility appears normal or slightly delayed Rigid - Consistent throughout stride length

E.g.

Ankle PF contracture (Blocks progression) Knee Flexion Contracture (blocks progression) Hip Flexion Contracture

Muscle weakness
Inefficient strength - Postural substitution

Impaired motor control (spasticity)

Obstructs yielding quality of eccentric muscle function during stance

Pain
Induces deformity and muscle weakness

Ankle and Foot gait deviations

Gait

errors in sagittal plane

Gait errors have been identified by 2 descriptors Excessive ankle PF Excessive ankle DF

Excessive ankle PF
Stance phase - Loss of progression

Swing phase Obstruction of limb advancement

Effects of excessive ankle PF

Phasic patterns of excessive ankle Planter flexion

IC LR Y Y Y Y MS Y TS PSw Y ISw Y Y Y MSw Y Y Y TSw

30 deg contracture 15 deg contracture 15 deg elastic contracture Spastic calf Pre - tibial weakness Voluntary

Y Y Y Y Y

Y Y

Y Y Y

Phasic patterns of excessive ankle Planter flexion

IC LR Y Y Y Y MS Y TS PSw Y ISw Y Y Y MSw Y Y Y TSw

30 deg contracture 15 deg contracture 15 deg elastic contracture Spastic calf Pre - tibial weakness Voluntary

Y Y Y Y Y

Y Y

Y Y Y

Phasic patterns of excessive ankle Planter flexion

IC LR Y Y Y Y MS Y TS Y PSw Y Y Y ISw MSw Y Y Y TSw

30 deg contracture 15 deg contracture 15 deg elastic contracture Spastic calf Pre - tibial weakness Voluntary

Y Y Y Y Y

Y Y

Y Y Y

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

Phasic patterns of excessive ankle Planter flexion

IC LR Y Y MS Y Y TS Y PSw Y ISw Y Y Y MSw Y Y Y TSw

30 deg contracture 15 deg contracture 15 deg elastic contracture Spastic calf Pre - tibial weakness Voluntary

Y Y Y

Y Y

Y Y Y

Y foot contact Mixture Fore of ankle equinus & knee flexion (20 deg either jt.) Y

Phasic patterns of excessive ankle Planter flexion

IC LR Y Y MS Y Y TS Y PSw Y ISw Y Y Y MSw Y Y Y TSw

30 deg contracture 15 deg contracture 15 deg elastic contracture Spastic calf Pre - tibial weakness Voluntary

Y Y Y Y Y

Y Y

Y Y Y

Good ankle mobility Foot rapidly drops with tibia in vertical position

Phasic patterns of excessive ankle Planter flexion

IC LR Y Y MS Y Y TS Y PSw Y ISw Y Y Y MSw Y Y Y TSw

30 deg contracture 15 deg contracture 15 deg elastic contracture Spastic calf Pre - tibial weakness Voluntary

Y Y Y Y Y

Y Y

Y Y Y

Excessive PF in MSw immediate effect is toe drag on the floor

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

PLS AFO Conventional DF assist AFO

Posterior leaf spring AFO

-

In 1st rocker - Substitutes for eccentric contraction of weak muscles

2nd rocker allows DF necessary for tibial advancement

Once the swing phase begins PLS holds ankle at 90 o

Conventional DF AFO

The amount of DF assist provided is controlled by adjustment of screw placed in joint

Contra indications

May not be effective in controlling Mediolateral 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 equino varus

Phasic patterns of excessive ankle Planter flexion

IC LR Y Y MS Y Y TS Y PSw Y ISw Y Y Y MSw Y Y Y TSw

30 deg contracture 15 deg contracture 15 deg elastic contracture Spastic calf Pre - tibial weakness Voluntary

Y Y Y Y Y

Y Y

Y Y Y

Rigid Tibia Rigid PF PF Heel offdriven posture backwards as heel drops may continue to floor

Phasic patterns of excessive ankle Planter flexion

IC LR Y Y Y Y MS Y TS PSw Y ISw Y Y Y MSw Y Y Y TSw

30 deg contracture 15 deg contracture 15 deg elastic contracture Spastic calf Pre - tibial weakness Voluntary

Y Y Y Y Y

Y Y Y

Forward trunk Premature heel lean rise Y Knee hyperextension with ant. Tilt used by vigorous - foot flat with post. maintain balance walkers with no Restrained tibia over PF foot disability

Phasic patterns of excessive ankle Planter flexion

IC LR Y Y Y Y MS Y TS PSw Y ISw Y Y Y MSw Y Y Y TSw

30 deg contracture 15 deg contracture 15 deg elastic contracture Spastic calf Pre - tibial weakness Voluntary

Y Y Y Y Y

Y Y

Y Y Y

Excessive PF in with MS Substitution immediatehip effect toe increased andis knee drag on flexion the floor

Conditions - with Excessive PF

- Stroke
-

Spinal cord injury (incomplete) Cerebral palsy Foot drop (chronic )

Prolonged immobilization

Selection of orthoses

Yes

Pat has decreased ankle strength / impaired or absent proprioception at the knee or ankle / ankle PF spasticity

No

Spasticity, PF contracture, or absent proprioception affects foot placement during standing or gait
Yes No

No orthoses required

Berg Balance Score < 43, or severe spasticity, or absent proprioception

Yes

Orthoses with art. ankle joint, PF stop indicated

Polyart. AFO w (PF) stop / Metal AFO w DAAJ & poly footplate,PF stop / Metal AFO w DAAJ, PF stop

Orthoses with locked joint and undercut or cushioned heel is indicated

Rigid polypropylene AFO / Metal AFO with (DAAJ) poly footplate, locked / Metal AFO with AJ, locked.

Preferred orthoses

AFO

- For children with cerebral palsy foot plate can be extended to reduce the likelihood of abnormal toe grasp reflex

AFOs in Hemiplegia

Effects of ankle-foot orthoses on hemiparetic gait

Gk H, Kkdeveci A, Altinkaynak H Clin Rehabil. 2003 Mar; 17(2):137-9

Objective:

Study evaluated mechanical effects of metallic and plastic AFOs on severely hemiparetic stroke patients

Results

The two types of orthoses generally had similar positive effects on hemiplegic gait parameters

Increased cadence,
Increased walking speed, Increased single and double step length

Increased ankle DF angle at heel strike and swing.

The metallic AFO was better at increasing the ankle dorsiflexion angle than the plastic AFO

Conclusion

Hemiplegic gait was improved by both orthoses However, metallic AFOs provided better stabilization of the ankle, allowing improved heel strike and push-off

Implications for using static AFO

Deleterious impact on the rockers of the gait
-

Prevents controlled lowering of foot towards floor 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
-

Pat. shoe - cushion heel to stimulate 1st rocker

Rocker bottom sole - substitution for forward progression of tibia in 2nd rocker and impaired rollover in 3rd rocker

Excessive ankle dorsiflexion

Second gait error seen in ankle joint

Dorsi flexion beyond neutral is an abnormal event in all the phases of gait cycles except mid stance and terminal stance Has more functional significance in stance than swing

Excessive dorsi flexion

IC Soleus weakness LR MS

Knee extensor weakness

Fixation of ankle at neutral

Accommodating to flexed knee

Soleus weakness fails to At the time heel contact stabilize tibia, quadriceps exaggerated heel rocker cannot extend flexed knee Initial instability present

Excessive dorsi flexion

IC Soleus weakness LR MS

Knee extensor weakness

Fixation of ankle at neutral

Accommodating to flexed knee

Corresponding increase in the quadriceps demand

Conditions -

Over lengthening of soleus Myelomeningocele Myelodysplesia

Soleus weakness in rheumatoid arthritis Myopathy Crouch gait from neuro muscular problems ( If ROM present at knee )

Selection of orthoses
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
Yes

Orthoses w DF stop indicated

Determine if DF assist is required : DF strength is 4

Yes No

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

Selection of orthoses
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
No

Orthoses wo DF stop indicated

Determine if DF assist is required : DF strength is 4

Yes No

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

Preferred orthoses -FR - AFO

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
( Lindseth J Bone Jt Surg. 1974: 56A(3):556553)

Contra- indications
-

Inappropriate for patients with recurvatum Structural instability of knee joint FRO may cause negative impact on balance reactions If worn B/L then assistive device for ambulation is required

Case Study: Improving Knee Extension with Floor-Reaction AFO in a Patient with Myelomeningocele and 20 Knee Flexion Contractures

Donald Freeman, CP
JPO 1999 Vol. 11, Num. 3 , pp. 63-68

Patients with Myelomeningocele, depending on the spinal level, tend to have decreased lowerextremity 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

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 contractions present

It is unlikely the FRAFO will function effectively for every patient with kneeflexion contractures

Therefore, it is essential to evaluate each case individually

Coronal plane deviations

Excessive inversion Excessive eversion

Coronal plane deviations

Excessive sub talar inversion and eversion lead to clinical abnormalities of varus and valgus

Cause abnormal muscular control

Static deformities Varus dominant in spastic foot Valgus in flaccid foot

Preferred orthoses

Solid static AFO

Gait deviations at knee joint

Most common types of dysfunctions occur in sagittal plane

Sagittal plane deviations

Gait errors have been identified by 4 descriptors 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

Inadequate knee flexion

Excessive extension - Extensor thrust - Hyperextension Excessive flexion Inadequate extension Coronal gait deviations - Varus - valgus

Y Y Y Y Y Y Y Y Y Y Y

Y Y

Y Y

Y Y

Phasing of the gait deviations at the knee LR MS TS PSw ISw MSw TSw

Inadequate knee flexion

Excessive extension - Extensor thrust - Hyperextension Excessive flexion Inadequate extension Coronal gait deviations - Varus - valgus

Y Y Y Y Y Y Y Y Y Y Y

Y Y

Y Y

Y Y

Normal shock absorbing flexion is lost

Causes of knee gait deviations Stance cause Inadequate knee flexion Y Y Y Excessive extensor thrust Y Y Y Extension hyperextensio n Y Y Y Excessive flexion Inadequate extension

Quadriceps weakness Ankle PF contracture Ankle PF spasticity Hamstring spasticity Knee flexion contracture Ankle PF weakness

Y Y

Y Y Y

Phasing of the gait deviations at the knee

LR
Inadequate knee flexion Excessive extension - Extensor thrust - Hyperextension Y

MS

TS

Y Y Y

Quadriceps over activity inhibiting loading response Knee hyperextension as Extensor thrust inhibits knee flexion creating dynamic substitution retraction for by weak GM if knee flexion , premature PF hyperextension Range quadriceps is +,available

Causes of knee gait deviations Stance cause Inadequate knee flexion Excessive extensor thrust Extension hyperextension

Quadriceps weakness
Ankle PF contracture Ankle PF spasticity

Quadriceps spasticity

Conditions

Polio Stroke Cerebral palsy

Selection for orthoses

Patient has < 3+/5 quadriceps strength bilaterally

NO

NO

Patient has < 3+/5 quad strength in test side and 3+/5 quad strength in contra lateral limb?
Yes

Yes

Proprioception intact at test knee

NO

KAFO not required, evaluate for AFO on test side

Unilateral KAFO on test side is indicated

Yes

Person has knee Hyperextension ROM?

NO

Can use unlocked KAFO on test side (offset knee jt / free knee)

Locked knee joint is indicated Locks (Drop or Bail) Select type of knee joint and materials and orthotic ankle components

Person may not require a KAFO even with quadriceps strength < 3+/5 if hip extensor muscle strength is 3+/5, and he/she has full knee 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

Conventional KAFO attached to patients shoe by a stirrup Thermoplastic KAFO fits within patients shoe

Conventional KAFO

Thigh band

Knee joint Calf band Metal upright Ankle joint Stirrup

Thermo- plastic KAFO

Ant. Straps Proximal shell

Metal knee joint Metal uprights Distal shell

Comparison of advantage and disadvantage of CKAFO

Advantages

Disadvantage

Strong

Heavy

Most durable
Easily adjusted

Must be attached to
shoe insert

Less cosmetic Fewer contact points to reduce control

Comparison of advantage and disadvantage of TKAFO

Advantages

Disadvantages

Light weight

Can be hot to wear

Interchangeability of shoes
Greater cosmesis

Indications- CKAFO

When maximum strength and durability are needed For individuals with significant obesity Individuals with uncontrolled edema (e.g. CHF, dialysis)

Contra- indications

When issues of energy expenditure make wt. of the Orthoses a factor When control of transverse plane motion is important Less than intimate fit of this Orthoses reduces efficacy of varus / valgus control systems

Metal KAFO to correct genu recurvatum

Stance Control Knee Ankle Foot Orthoses (SCKAFO)

These orthoses are worn by many patients who can walk without them, but who cannot walk safely. Especially designed for quadriceps weakness Unlocks knee at the beginning of 3rd rocker and decreases strategy for hip hiking

Indications

Isolated quadriceps muscle deficit - can usually walk, but will often have episodes of falling or high instability

Femoral mononeuropathy (FMN)

- 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

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:

Significant impairment in the patients cognition and/or motivation.

Significant knee spasticity.

Knee flexion contractures greater than 10. If follow-up, or compliance on the part of the patient is uncertain.

Gait deviations swing phase

Causes of knee gait deviations (SWING PHASE) Swing Cause Quadriceps spasticity Hip flexion weakness Ankle DF weakness Ankle DF spasticity Hamstrings contracture Hamstrings spasticity Primitive pattern Quadriceps weakness Inadequate knee flexion Y Y Y Y Y Y Excessive knee flexion Inadequate extension Excessive extension

Problems encountered in Inadequate knee flexion

- Seen in stroke

Pre - swing

Failure to adequately flex the knee in pre swing makes toe off more difficult

Greater hip flexion and knee flexor force is required to lift foot at onset of initial swing

Initial swing

Lack of adequate knee flexion in initial swing causes toe drag with inability to advance the limb

Mid swing

Inadequate knee flexion does not occur independently

It reflects either a lack of hip flexion or continuation of pathology in initial swing

Problems encountered in excessive knee flexion / inadequate extension

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 Quadriceps spasticity Hip flexion weakness Ankle DF weakness Ankle DF spasticity Hamstrings contracture Hamstrings spasticity Primitive pattern Inadequate knee flexion Y Y Y Y Y Y Excessive knee flexion Inadequate extension

Coronal deviations in knee

Dynamic deviations

In OA the knee yields to persistent medial alignment of body wt vector throughout stance genu varum seen

In RA , knee valgus is seen

Preferred option for genu varum in OA

Lateral heel wedge is the choice Evidence supports the application of a lateral heel wedge (LHW) as a non operative treatment for varum gonarthrosis

By reducing the adduction moment through changes in the placement of the foot during gait
( J. Robert Giffin JPO 1995 Vol. 7, Num. 1 , pp. 23-28 )

Effects of disease severity on response to lateral wedged shoe insole for medial compartment knee osteoarthritis The kinetic and kinematic effects of wearing of lateral wedged insoles were significant in Kellgren-Lawrence grades I and II knee OA. Result show that use of lateral wedged insoles for 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 wedged insole for treatment of knee osteoarthritis The effect of treatment with a lateral-wedge insole for knee OA was neither statistically significant nor clinically important
203) (Arthritis Rheum. 2007 Apr;56(4):1198-

Articulating KAFO can be given , which provides medio lateral stability

Hip gait deviations

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

Inadequate extension Inadequate flexion

Causes of gait deviation at hip

Inadequate extension Flexion contracture IT band contracture Flexor spasticity Excessive flexion Inadequate flexion Y Excessive extension

Arthrodesis

Pain

Voluntary

Causes of gait deviation at hip

Inadequate extension Flexion contracture IT band contracture Flexor spasticity Excessive flexion Inadequate flexion Y Excessive extension

Arthrodesis

Pain

Voluntary

Inadequate extension of hip

Lack of hip extension threatens persons wt bearing stabilty It also impedes progression

Mid stance

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 accommodate by spine if its not abnormally stiff

Greator loss of hip extension t axes spine mobiltiy

Knee flexion

Flexing the knee tilts the thigh back And allow pelvis to retain its normal alignment , despite fixed hip flexion Hence crouch posture is seen as means of accommodating to inadequate hip extension This is very inefficent as it requires quadriceps control

Terminal stance
Functional deficits of inadequate hip extension - Anterior pelvic tilt - And trailing thigh

Causes of gait deviation at hip

Inadequate extension Flexion contracture IT band contracture Flexor spasticity Excessive flexion Inadequate flexion Y Excessive extension

Arthrodesis

Pain

Voluntary

Excessive flexion

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 , is common substitution for excessive ankle PF

Causes of gait deviation at hip

Inadequate extension Flexion contracture IT band contracture Flexor spasticity Excessive flexion Inadequate flexion Y Excessive extension

Arthrodesis

Pain

Voluntary

Inadequate hip flexion

-

Initial swing Failure to flex hip 15 deg reduces limb advancement and causes limited knee flexion since thigh momentum is needed ti initiate action is lacking

This inturn contributes to the knee drag and ankle PF Dragging toe can inhibit hip flexion, function of the knee and ankle in other gait phases

AFO in CP

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 should be custom molded

Implications of using AFO in CP

-

Improved stability by use of AFO in children who 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

Prescribed for children at ambulatory stage , between age of 18 and 24 months Provides stability to ankle and foot to give stable base for standing Easy to don for care givers Marginal ambulators and non ambulators solid AFO

As the children get the stability and walk with walker at age 3-4 , ankle hinge can be added 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 gastronemus contracture

The effect of hinged ankle-foot orthosis on gait and energy expenditure in spastic hemiplegic cerebral palsy

Disabil Rehabil. 2007 Jan 30;29(2):139-44 Balaban B, Yasar E

Purpose:

To assess the effectiveness of a hinged anklefoot 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 barefoot condition improved walking speed, stride length and single support time

Double support time was decreased significantly with AFOs and no change in cadance
Ankle dorsiflexion at initial contact, midstance and midswing showed significiant increase

Knee flexion at initial contact was 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 dynamic equinus deformity and reducing the energy expenditure of gait in children with hemiplegic spastic cerebral palsy

Floor reaction AFO- control of crouch gait

Children < 25 kg (8-10 yrs of age ) wide ant calf strap with AFO Children > 25 kg FRO ,rear entry in calf

Requisites for FRO in CP

Neutral DF with Knee in full extension Very little knee flexion contracture

Foot to knee axis should be in normal alignment , < 20 deg of Internal or external tibial torsion
Works for ambulatory children

Art. FRO in CP
-

Hinged FRO to allow PF , restricting DF Pre- requisites are normal foot alignment

Half Height AFO

Solid ankle AFO usually without ant ankle straps are usually cut low to half the normal calf height Indicated in children having mild PF force and mainly needs gentle pressure reminder in swing phase or early stance phase Contra- indicated if strong flexor spasticity is there

Functional Level

Non Ambulator Orthotic used for standing or control foot deformity

Ambulator

Solid Ankle full calf height M-AFO to toe tips

1-3 yr old

3-10 yrs old

>10 yrs old

Miller , Text Book of CP

1-3 yrs Old

Hypotonic, Poor motor control, Weakness

Spasticity, Major Problem

Mild - SMO or IMO to MT heads

Moderate - Art MAFO to MT head

Severe - Solid MAFO to MT heads

Severe Solid MAFO , biomechanical foot plate to toe tips

Passive DF available with knee extension Art. MAFO, BMFP to toe tips

Mild increase in equinus due to tone ( N Passive D F) HH, AFO , BMFP to toe tips

3-10 yrs Old

Hypotonic, Poor motor control, Weakness

Mild - IMO to MT heads or wrap around IMO to toe tips

Moderate Determine specific problem

Severe - Solid MAFO to MT heads

Idiopathic toe walker Art. MAFO to toe tips

Isolated DF weakness with good Gastronemus leaf spring MAFO

Global problem SMO or HH AFO with BMFP

3-10 yrs Old

Spasticity, Major Problem

Mild Spastic PF with adequate DF, PV or EV main problem

Moderate Spastic , good ambulator , mild or moderate PV or EV

Severe- spastic , limited ambulation with PV, EV, no DF

Desire good control of sub talar joint , pat. Requires easy to don orthotic Solid SMO to MT head

Desire less control of sub talar joint , pat. And pat. Can manage diff. to don orthotic Wrap around SMO

Continued

Moderate

Weak PF but good DF

Strong PF but with DF present with knee extended Art. MAFO BMFP to toe tip

Child stands foot flat with knee extended HH MAFO BMFP to toe tip with wrap around style

Child stands foot flat with knee flexed Art. MAFO with post. Strap , BMFP to toe tips or a solid ankle MAFO to toe tips

> 10 yrs old

Hypotonic : Poor motor control weakness Severe prob. with very limited walking ability Solid MAFO with BMFP Moderate the pat. Is community walker

Hypertonic : spasticity is the major problem Mild - the pat. is full community ambulator

Good gastronemus but poor DF Leaf spring full calf Ht with BMFP

Severe back knee Art. AFO full calf Ht with BMFP

Desire control of PV or EV SMO / IMO (UBCL)

Need to control mild back knee MAFO HH calf BMFP

> 10 yrs old Hypertonic : spasticity is the major problem Moderate community ambulator with assistive device Severe limited community ambulator, always using assistive device

Mild - community ambulator with no device

Control PV / EV SMO or IMO (UBCL)

Need to control mild PF MAFO HH calf BMFP

Need to control mild PF Or mild back knee Art. AFO full calf Ht. with or without BMFP

Need to control PV / EV SMO

Severe limited community ambulator, always using assistive device

Need to control crouch gait (stance phase hip and knee flexion with ankle DF ) Art. AFO with full calf Ht. , BMFP to the toe tips

Need to control back kneeing in stance phase

If child uses crutches or walker and continues to back knee with AFO and has increasing knee hyperextension or knee pain Use KAFO with Ext. Stop knee hinges and add a solid AFO

< 30 Kg. BW MAFO solid ankle BMFP and wide ant. Prox tibial strap

> 30 Kg. BW

> 30 Kg. BW

No foot deformity, has normal foot alignment with knee usually post op after deformity correction

With PV or EV foot deformity but with foot & and knee in normal rotational alignment Solid GRAFO to toe tip

With active DF ?

Yes Art. GRAFO to toe tip flat foot flat

No Solid GRAFO

Ankle-foot orthoses: effect on gait in children with cerebral palsy

Disabil Rehabil. 2002 May 10;24(7):345-7 Dursun E, Dursun N, Alican D

Purpose:

To evaluate the effectiveness of (AFOs) on gait function in patients with spastic cerebral palsy for whom orthoses were indicated to control dynamic equines deformity

Conclusions:

Cerebral palsied children with dynamic equines deformities can benefit from AFOs for ambulation

A comparison of gait with solid, dynamic, and no ankle-foot orthoses in children with spastic cerebral palsy

Phys Ther. 1998 Feb;78(2):220-2

Radtka SA, Skinner SR, Dixon DM, Johanson ME

Purpose

To compare the effects of dynamic anklefoot orthoses (DAFOs) with a plantarflexion 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, decreased cadence, and reduced excessive ankle 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 children with spastic CP and excessive ankle plantar flexion during stance,

Additional individual factors should be considered when selecting either orthosis

Special KAFO design

yes

Patient has < 3+/5 quadriceps strength bilaterally Patient meets Participation Criteria for Ambulation Trial with Bilateral KAFO / RGO?

No

TRIAL IS ENDED Patient will not receive bilateral KAFO / RGO for ambulation. Patient may be re-evaluated in > 3 months

yes Patient successfully meets Completion Criteria (see Table) for Ambulation Trial with Bilateral KAFO/RGO? yes Order bilateral KAFO or RGO Locked knee joint is indicated Drop / bail Select type of knee joint and materials No

Material selection
Materials for thigh component a) Metal uprights with leather at knee/thigh b) 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