PT 634 W4 Day 1 ORTHOTIC PRESCRIPTION AND DECISION MAKING FOR PHYSICAL THERAPISTS

What are the 4 functions of orthodics?

Control motion

Compensate for weakness

Correction of deformity

Improve function and mobility

Control motion description

▪ Limit or Facilitate motion

▪ Stop plantarflexion and/or dorsiflexion

▪ Control supination or pronation

▪ Inhibit Spastic Muscles

Compensate for weakness description

• Assist dorsiflexion

• Compensate for weak plantarflexors or quadriceps

• Increase Stability

• Shock absorption

Correction of deformity description

• Assist dorsiflexion

• Compensate for weak plantarflexors or quadriceps

• Improve alignment and posture

• Improve ROM

• Prevent contracture or further deformity

• Reduce Pain

• Shock absorption

An orthotic is a __________ device applied to an individual’s lower extremity

removable, external, wearable

REVIEW OF CURRENT EVIDENCE: CLINICAL PRACTICE GUIDELINE FOR USE OF ANKLE FOOT ORTHOSES AND FUNCTIONAL ELECTRICAL STIMULATION POST STROK

purpose and consideraitons

Purpose: Provide evidence to guide decision making for the use of AFO or FES as an

intervention for individuals with hemiplegia

 Rehabilitation of individuals with acute and chronic stroke

 Define effects on goals based on compensation and recovery approach

 Define Effects on outcomes across the ICF levels

 DOES NOT recommend specific AFO types and/or FES unit/parameters

Other considerations

 Providing a device without intervention or practice may limit an individual's ability to fully achieve

potential gains

 Clinicians should use outcome measures that are most responsive to the benefits of an AFO/FES

 Periodic assessments are important, as needs may change over time

 Limited evidence in acute stage vs. chronic

SUMMARY OF RECOMMENDATIONS: 8 ACTION STATEMENTS for orthodicts

To improve QOL: Clinicians should provide AFO/FES for individuals with foot drop in chronic hemiplegia: Level II; moderate

 To improve gait speed: Clinicians should provide AFO/FES in acute or chronic hemiplegia: Level I; Strong

 To improve other mobility: Clinicians should provide AFO/FES in acute or chronic hemiplegia: Level I; Strong

 To improve Dynamic Balance: Clinicians should provide AFO/FES in acute or chronic hemiplegia: Level I; Strong

 To improve Walking Endurance: Clinicians may provide AFO/FES in acute hemiplegia: Level II; Moderate

 To improve PF spasticity: Clinicians should not provide AFO/FES in acute or chronic hemiplegia: Level II; Moderate

 To impact muscle activation:

 Clinicians may provide AFO with decreased stiffness to allow activation of TA/GAS/SOL in acute or chronic hemiplegia: Level II; Moderate

 Clinicians should provide FES to improve activation of TA in chronic hemiplegia: Level II; Moderate

 To improve Gait Kinematics: Clinicians may provide AFO/FES to improve ankle DF at initial contact, loading response and swing in acute or chronic hemiplegia:

Level III; Weak

Participation outcomes of 8 action statement

To improve QOL: Clinicians should provide AFO/FES for individuals with foot drop in chronic hemiplegia: Level II; moderate

Activity outcomes of 8 action statement

 To improve gait speed: Clinicians should provide AFO/FES in acute or chronic hemiplegia: Level I; Strong

 To improve other mobility: Clinicians should provide AFO/FES in acute or chronic hemiplegia: Level I; Strong

 To improve Dynamic Balance: Clinicians should provide AFO/FES in acute or chronic hemiplegia: Level I; Strong

 To improve Walking Endurance: Clinicians may provide AFO/FES in acute hemiplegia: Level II; Moderate

body structure & function outcomes of 8 action statement

 To improve PF spasticity: Clinicians should not provide AFO/FES in acute or chronic hemiplegia: Level II; Moderate

 To impact muscle activation:

 Clinicians may provide AFO with decreased stiffness to allow activation of TA/GAS/SOL in acute or chronic hemiplegia: Level II; Moderate

 Clinicians should provide FES to improve activation of TA in chronic hemiplegia: Level II; Moderate

 To improve Gait Kinematics: Clinicians may provide AFO/FES to improve ankle DF at initial contact, loading response and swing in acute or chronic hemiplegia:

Level III; Weak

Types of LE orthoses

FO ‐ Foot Orthosis

AFO ‐ ankle‐foot orthosis

KAFO ‐ knee‐ankle‐foot orthosis

KO – knee orthosis

HKAFO ‐ hip‐knee‐ankle‐foot orthosis

THKAFO ‐ trunk‐hip‐knee‐ankle‐foot orthosis

MOST COMMON TYPES AFOS UTILIZED IN REHABILITATION SETTING

1. Solid AFO

2. Pre-articulated AFO

3. Hinged/Articulated AFO

4. Solid AFO with anterior shell/Ground

Reaction AFO

5. Carbon Fiber AFO

6. Posterior Leaf Spring (PLS) AFO

7. Conventional AFO

Solid AFOs restriction

trimline anterior to mallelous

• DF stop, PF stop

Rigid AFOs restriction

Trimline through apex of malleolus

• DF resist (high), PF stop

Semirigid AFO restriction

trimline just posterior to malleolus

• DF resist (moderate), PF resist (moderate)

Flexible/PLS AFO restriction

trimline posterior to malleolus

• DF free, PF resist (mild)

Solid AFO therapist indications

▪ Custom Fit

▪ Weakness in quad/hamstring

▪ Increase in tone/ PF Spasticity

▪ Poor knee stability in stance

▪ No active ankle DF

▪ Inability to transfer weight onto affected leg

▪ Foot abnormality- equinas, valgus/varus, combination

▪ Poor motor control/balance

Solid AFO orthotist indications

▪ Limitations in DF ROM without breaking down midfoot

▪ PF weakness/poor tibial control

▪ Likely to need continued sagittal plan control (can be

trimmed to semi-rigid/PLS)

PRE-ARTICULATED AFO therapist indications

▪Similar indications as solid

▪Good alignment through mid-foot

▪Minimal tone

▪Potential for recovery

PRE-ARTICULATED AFO orthotist indications

▪Likely to need continued medial-lateral

stability

▪Potential to recover PF strength and

quad strength

Solid vs Pre-articulated AFO

Hinged/Articulated AFO therapist indications

▪Good knee stability in standing and

during gait cycle

▪Anti-gravity ankle DF

▪Minimal tone

▪Functional ROM

▪Ability to achieve hip/knee extension in

terminal stance

Hinged/Articulated AFO orthotist indications

▪Need for medial-lateral stability

▪Good quad strength

▪DF stop (i.e. PF weakness)

▪ Knee instability toward buckling

▪PF stop (i.e. DF weakness)

▪ Foot drop

▪ Knee hyperextension

▪ Toe walking

Ankle control for hinged/articulated afo

• PF stop will limit PF

• Compensates for weak dorsiflexors

• Limits knee hyperextension

•DF assist

• Simulated eccentric contraction of tibia to

prevent foot slap

• Allows DF during stance

• Facilitates DF during swing

Hinged/Articulated AFO for increased dorsiflexion

Increased dorsiflexion will provide good toe

clearance but will promote a knee flexion

moment.

Increased dorsiflexion will assist patients with

increased extensor tone and increased

hyperextension of the knee.

Hinged/Articulated AFO for increased plantarflexion

Increased plantarflexion will promote a knee

extension moment but may allow more toe drag.

Increased plantarflexion will assist a patient with

decreased knee extension control but may allow an

unstable knee to go into hyperextension

solid afo with anterior shell/ground reaction afo therapist indications

* Commonly seen in pediatric population at

Shirley Ryan*

Crouched gait

Hypertonicity through

hamstring/adductors/PF

Decreased ROM through hip

flexors/hamstring/PF

Significant weakness through

gluts/quad/hamstring

solid afo with anterior shell/ground reaction afo orthotist indications

Proprioceptive feedback for knee

extension

Often set in slight PF

Commonly used for →

 Spina bifida

 SCI with limited sensation

 Poor knee control but good hip control

Carbon Fiber AFO therapist indiciations

▪Good knee stability

▪Functional strength in kinetic chain

▪DF assist to achieve heel strike

▪Assist in push-off during terminal stance

▪No significant issue with tone

▪No medial-lateral instability

▪No need for orthotic influence on hip/knee

Carbon Fiber AFO orthotist indications

▪No limitations in ankle ROM

▪Good medial-lateral stability

▪Intact sensation

▪Non-fluctuating edema

▪Lightest weight option

▪Cosmetic/patient acceptance*

▪Good alternative if patient already has AFO*

▪Ease of shoe fit

Posterior leaf spring AFO therapist indications

▪Isolated DF weakness

▪Similar requirements with carbon fiber

Posterior leaf spring AFO orthotist indications

▪Lack of sensation

▪Mild medial/lateral instability

▪Extremely tall or short people

▪Ability to provide more support into knee

extension (if needed) compared to carbon fiber

▪Need mid-foot control

- Mid-foot collapse

- Hindfoot valgus

- Etc.

Indications for conventional AFOs?

▪ Decreased Sensation

▪ Diabetes

▪ Volume Changes

▪ Obesity (Stronger materials)

▪ Severe deformities/ton

the conventional AFO consists of double metal uprights attached the patient’s shoes

and parts of a conventional AFO

Functional electrical stimulation (FES) indications

• Activates DF muscles during swing

by stimulation of peroneal nerve

• May improve strength & motor

control

• May enhance recovery &

participation following acute

stroke

• Responsive to walking at variable

gait speeds

• May allow barefoot walking/

variety of shoe ware

• Optional thigh cuff for FES to

quadriceps & hamstrings

• ↑ gait speed

Functional Electrical Stimulation (FES) contraindications

• PF Spasticity (≥MAS 3)

• Knee buckling/ Genu Recurvatum

• Peripheral nerve injury/

neuropathy

• Sensory tolerance

Other options than AFOs

ankle brace/aircast

• provides medial-lateral stability

• does not provide DF/PF control

steady strider

• provides only DF

• no medial/lateral support

foot up

• provides only DF

  • No M/L support

External shoe modifications

▪ Heel modifications

• Heel cushion

• Heel wedge

• Heel elevation

▪ Sole modifications

• Sole wedge

Internal shoe modifications

▪ Heel modifications

• Heel cushion

• Heel wedges

▪ Sole modifications

• Metatarsal pad

  • Scaphoid pad

What is a KAFOS?

▪ Consists of an AFO with metal uprights,

a knee joint, and thigh bands.

▪ Used in quadriceps paralysis or

weakness to maintain knee stability.

▪ Precaution – fatigue, weakness, this is

a heavier choice

What is a conventional KAFOS

▪ Double metal upright

▪ Centered knee joint

▪ Pretibial strap

▪ Choice of locks, but usually drop

locks

▪ UCB insert or shoe or plastic

solid AFO

What is a craig-scott KAFOs

▪ Double metal uprights

▪ Offset knee joints

▪ Pretibial band

▪ Rocker bottom shoe

▪ Bail locks

▪ Shoe attached

What are the types of knee controls for KAFO

drop locks and bail locks

What is a knee orthosis KO?

▪ Provides support and control of the knee but not

the foot or ankle

Swedish Knee Cage

▪ The knee joint is centered over the medial femoral

condyle.

▪ Control knee hyperextension with minimal M/L stability

▪ with/without AFO

Contracture management

▪ Patients may present with decreased ROM in one or both

ankles

▪ Left unmanaged →permanent contracture, loss of function,

poor positioning, and pain

▪ Contractures causes: hypertonia/spasticity and capsular

changes from generalized immobility

▪ Evidence traditional stretching for 30 second intervals is not

effective for preventing or maintaining ROM in the

neurological population, including but not limited to CVA,

SCI, and brain injury

▪ Stretch only provided brief short term affects on the joint

mobility, but research does not support long term effects

Functional positioning for stretching has been shown to be more effective in preventing and maintaining ROM

_______ positioning for stretching has been shown to be more effective in preventing and maintaining ROM

Functional

Indiciations for contracture intervention?

 High tone (MAS 2 or higher)

 Time since onset of injury

 Family compliance with any previous

orthotics

 Current ROM and ROM goals

 Potential functional gains or

limitations

 End feel with ROM/tone assessment

 Previous intervention for lower

extremity contractures

 Has there been any?

PRAFO’s are

effective in prevention of ankle contracture

What is serial casting?

 Slow progressive low load stretch over an extended period of

time

 Changed weekly increasing stretch each cast  Indicated in patient with higher risk for permanent contracture

who currently lack ROM

 Indicated for patients with potential for consistent standing

program, ambulation, functional transfers, improvement with

positioning in wheelchair

What is static progressive night splint?

 Designed to maintain current ROM only

 Higher risk for skin breakdown with poor fit or issues with

donning

 Not designed for weight bearing

 Beneficial post serial casting to maintain weight bearing

 Education, education, education!

Other intervention options for contracture management

botox

ultraflex

dynasplit

What are some orthotic evaluation clinical decision depends on

• Diagnosis

• Prognosis

• What are the gait deviations?

• What Control is needed? What Assist?

• What function should remain?

• Used orthosis in the past?

• Cognition, Attitude, Compliance, Outside

support

• Patient Goals and Therapist’s Goals for the

Patient

What are things to look at when prescribing an orthotic?

▪ Isolated muscle strength/Functional muscle strength

▪ Tone

▪ ROM

▪ Postural control

▪ Sensation

▪ Prognosis

▪ Gait

▪ Kinematics: the branch of mechanics concerned with the

motion of the body

▪ Kinetics: the branch of mechanics concerned with the

forces applied to the body (Gage 1995).

▪ Coronal and Sagittal Planes

Other Considerations

▪ Functional mobility

▪ Skin integrity

▪ Cognitive function

▪ Compliance

What are some education points for PT considerations?

▪ AFO Does Not inhibit Muscle Activation

▪ Always indicate purpose

▪ Highlight independence

▪ Long term benefits for joint protection & appropriate

muscle activation

▪ Risk factors without bracing

▪ Wear schedule NOT just in therapy

▪ Skin checks

▪ Don/Doff- OT

▪ Socks and shoes

▪ May need to provide family training

What are some transition of care for PT considerations?

▪ Determine if progression of bracing can wait until the

next level of care

▪ Don’t rush into progression if instability still remains

▪ Hard to go backwards & may require new bracing

▪ Insurance/ Costs

Wearing schedule for orthodics?

▪ First day 1 hour on, check skin, if OK wait 1 hour then wear for

another hour

▪ Second day 2 hours on, check skin

▪ Increase 1 hour daily

▪ If skin is red, it should clear in 20‐30 minutes

▪ If it does not clear, or if there is ANY blistering or skin break down,

call the orthotist and do not have the patient wear the brace

LE orthosis PT interventions

• Sit <‐> stand

• Car Transfers

• Balance

• Gait

• Curbs

• Ramps

• Stairs

with and without the brace