Overview

An orthosis is an external device that produces a force that biomechanically affects the body to correct, support, or stabilize the trunk, the head, and/or an extremity. The goals in patient care with orthotic use vary from temporary application to permanent usage to maintain improvement. Orthoses are named by the sections of the body to which they are applied. For example, an orthosis that controls and covers the ankle and foot is called an ankle-foot orthosis (AFO). The abbreviations for the device are used by professionals in clinical documentation. Many factors enter into the decision regarding use and type of orthosis, and these will be discussed later. It is essential that the least complicated and most cost-effective orthosis be applied to the patient. The rehabilitation team must build a priority list of desired outcomes and accept that sometimes all of the items on the list may not be achieved by either the orthosis or the patient-team combination. At the very least, care must be attempted in stages because the patient’s condition changes or other medical concerns may arise. For example, an excessive number of custom-made and custom-fit plastic AFOs have been issued because they are “more cosmetic and lighter” than AFOs made of metal and leather material. There are times when all higher-priority goals can be achieved so that down the list the goals of cosmesis and light weight can be considered (Table 34-1). However, in the case of neuropathy of the foot, significant risk would be incurred by providing a total contact AFO made of plastic to keep it lightweight. A double-upright metal AFO with a well-fitting extra-depth shoe with a custom accommodative insert would fit the patient’s needs and take into consideration the sensory and motor changes within the lower extremity. Effective coordination and communication between health professionals in development of patient goals is essential during the evaluation process. For example, a design criteria omission as simple as placing a loop closure on the side that the patient cannot reach will prohibit the use of the orthotic device. A sound understanding of biomechanical and orthotic principles as well as skilled patient management techniques must be used to be successful with patients who require orthoses.

There are similarities in orthotic management of orthopedic and neurologically impaired patients; however, the neurological population presents additional factors that challenge prescription criteria and outcomes for the rehabilitation team. Lack of proprioception, impairments in sensation, and spasticity are some of these special considerations. Concurrent medical issues, problems with communication, and caregivers may complicate patient management.

The advancements in and access to medical technology have had a profound effect in the field of orthotics. The evolution of plastic, composite, and metals fabrication technology has dramatically improved the ability to control, support, and protect all areas of the human body. Today, patients are fit for custom and prefabricated orthotic devices that provide a variety of functions in both a timely and cost-effective manner. These factors have led physicians to routinely prescribe orthoses for a wide range of medical conditions, whereas in prior decades lack of availability and shortage of experienced orthotists restricted patient access and narrowed the use of orthoses.¹ Orthoses are important options for postoperative management, acute fracture management, and adjunct treatment, in addition to more traditional uses. For many, the proliferation of the prefabricated orthosis signaled a dilution of quality orthotic care, but in reality it has had the opposite effect. These readily available, cost-effective orthoses have not taken orthoses out of the hands of the orthotist but rather have moved them into the minds of treating professionals. There has been continued growth of new and improved orthoses and expansion into other areas of treatment previously lacking in orthotic management. For example, positional and corrective orthoses can be used for premature and newborn infants, and a wide range of sizes of orthoses that previously were made only in adult sizes have become available for pediatric patients. As with any new technological advancement, there has been incorrect application and use. It is not that many of these prefabricated orthoses are difficult to apply; rather, there has been lack of a clear understanding of the indications, contraindications, and limitations these devices present to the orthotist and other health professionals such as occupational and physical therapists.

Advancements in technology have allowed the use of lighter, stronger materials in the fabrication of lower-extremity orthotics. Specifically, the substance called preimpregnated carbon is a graphite fabric with an exact amount of resin and catalyst already incorporated into the material. With the fibers properly directed over a model, it can be formed with heat. Graphite in other forms has been used in both prosthetics and orthotics for years. However, it had limited acceptance in orthotics because it did not significantly reduce the weight of the orthosis compared with other materials. It also lacked the properties to enable modification of the orthosis after the lamination process. The preimpregnated graphite has a dramatically reduced weight, still maintains its strength, and gives the orthotist the opportunity to use the dynamics of loading and response during the gait cycle. This allows for assistance in both the swing and stance phases of gait (Figure 34-1). A clinical example at the end of this chapter demonstrates this need in patient management.

Another significant advancement in component technology has been the introduction of weight-activated orthotic knee joints. Although available in prosthetics for decades, the development of a lightweight, compact knee joint that would allow a patient to have knee stability during stance² and clearance during swing phase has been elusive until recently. Before this, the available knee joints for knee-ankle-foot orthoses (KAFOs) involved some type of locking mechanism that remained locked throughout the gait cycle. The joint provided stabilization of the weak quadriceps musculature during stance but kept the knee in a fully extended position, making advancement of the limb in swing more difficult for the patient. There are specific indications and contraindications for stance control KAFOs, but early results are promising. This feature can significantly reduce energy output,³ as it is not necessary to raise the center of gravity to clear the locked knee during swing phase. This improves patient safety when walking on uneven surfaces. New technology for externally powered knee orthoses has just entered the market. These “bionic legs” are robotic aids worn during therapy sessions for gait training. They assist and augment the strength of the patient’s muscle and are most typically used in post–cerebrovascular accident (CVA) rehabilitation. Once the patient has achieved functional improvements, the use of the orthosis is discontinued.

Other advancements in orthotic technology include the development of neuroprosthetic devices. These devices act through circuitry and programming to substitute for a deficit in the neural system. Functional electrical stimulation (FES) is a method of applying low-level electrical currents to motor nerves to restore function. In the 1960s the application of FES for foot drop was demonstrated by using a simple single channel to stimulate the common peroneal nerve to activate the ankle dorsiflexors. FES has widespread applications in many other neuroprosthetic devices such as cardiac pacemakers, cochlear stimulators, bladder stimulators, and phrenic nerve stimulators. Until recently, FES devices to provide ambulation assistance were large, unreliable, complex, and restricted to use in a therapy setting. The FES used in neurological rehabilitation attempts to unmask existing voluntary control (if any) and/or initiate dormant activity of the nerves and muscles. For FES to be used, the patient must have an upper motor neuron lesion. This means the nerve-to-muscle pathway is intact and the reflex arc is undamaged. Goals of FES address many rehabilitative outcomes. FES can reduce spasticity, synergy patterns, swelling, and blood clot formation as well as maintaining range of motion (ROM). FES used in gait can improve overall walking abilities by dorsiflexing the foot during swing to provide foot clearance, control initial contact, increase safety, decrease energy expenditure, and retrain muscles. FES has some application in the upper extremity as well, although at this time it is purely in a therapeutic setting. Currently, there are several FES units for foot drop on the market. These devices are used by patients in their daily lives and are not limited to the rehabilitation setting. The WalkAide from Innovative Neurotronics (Figure 34-2) and NESS L300 from Bioness (Figure 34-3) both function to provide dorsiflexion during the swing phase by stimulating the peroneal nerve. An ideal candidate for these devices must have an upper motor neuron lesion, good control of the knee joint, and drop foot. Common neurological conditions in which these devices are used are CVA and multiple sclerosis (MS). Both devices involve some sort of sensor to determine when the patient is initializing the swing phase of the gait cycle and send an electrical stimulus to the nerve to dorsiflex the foot. Advantages of functional FES over traditional orthotic management for foot drop are that it shifts an orthotic device from being a passive support to providing active assistance. FES stimulates the patient’s muscles to lift the foot, rather than acting as a passive splint to hold the foot.

Future developments in the field of orthotics will provide external power and support for patients lacking muscular control. There are already prototypes of systems that can be applied to a patient with paraplegia to allow him or her to stand and walk. “Bionic” orthotics will incorporate microchips and computer programming to provide a degree of artificial intelligence to devices. This will allow the orthosis to change its setting according to the patient’s input or position during the specific task or part of the gait cycle. In more traditional types of orthotics, the materials used will continue to become lighter, stronger, and more versatile.

No discussion of the delivery of health care services within the United States would be complete or accurate without acknowledging the effects of governmental and private regulations. The earlier discussion regarding a dramatic increase in usage has raised the medical justification debate about the use of orthotic intervention.

Governmental regulations have dramatically changed the course of the orthotic profession, beginning with the Medicare program, to diagnosis-related groups (DRGs), managed care, and, soon, qualified providers. Medicare was the first national program to cover the cost of both orthotic and prosthetic devices. Before that time only a special few had access to “braces and limbs.” DRGs put the responsibility of paying for prescribed orthoses into the hands of the local hospital. Once a specific diagnosis was made, the government would pay a specified amount as reimbursement, leaving the decision of how to manage the patient’s care with the physician and hospital. This policy change created many new innovations. Hospitals, interested in reducing the length of hospital stays, challenged physicians to change the way they treated their patients. Patients are no longer immobilized for long periods in hospital beds and are sent home sooner, or sent to a less acute setting or a skilled nursing facility. The use of orthotic devices to expedite care and for precautionary care during hospitalization has increased dramatically. The use of halo fixation systems, thoracolumbosacral orthoses (TLSOs), fracture orthoses, and contracture-preventing orthoses are a few examples of orthotic care that is helping to reduce length of stay. Another significant effect of the DRG decade on orthotics was the need to reduce delivery times and be as cost-effective as possible. Orthoses needed to be delivered in hours, not days. Careful evaluation developed to determine whether a prefabricated, custom-fit, or custom-made orthosis was most appropriate. A prefabricated orthosis is one that is available in “off-the-shelf ” sizing and is intended for temporary use. Commonly used prefabricated items are commonly kept in stock by the orthotic provider. Custom-fit orthoses are customizable devices that can be modified to optimize the fit to each individual patient. These devices are intended for use on a more definitive basis, and are often appropriate when the patient has adequate sensation and normal anatomy. Custom-made orthoses require very specific measurements or models of the patient to be obtained for the most specific fit and to accommodate any deformity. These devices are time and labor intensive and are worn definitively when the patient’s condition is permanent or when his or her condition or anatomy does not facilitate fitting of a more basic device. Challenges to improve traditional methods of fabrication, better materials, and higher usage spawned the rapid growth of a wide range of orthoses for patient care. There is no reason to believe that this trend will slow as the population ages.

Professional relationships between physical and occupational therapy and orthotics are critical as the evolution of managed care continues. Identifying patient functional goals and a variety of evidence-based care is critical for patient care and clinical outcomes. Orthotic use must be based on proven evidence-based care specific to the profession. In that spirit, a broad overview of the evaluation, prognosis, and intervention of orthotics in neurological rehabilitation is presented.

Alignment of the extremities and spine is a common function in orthotic prescription. The orthosis can provide either temporary or permanent function. A TLSO may be prescribed for stabilizing alignment after spinal fusion in the case of an unstable spinal cord injury (refer to Chapter 16). A supramalleolar orthosis (SMO) is commonly prescribed to hold the foot in proper alignment. When the goal of orthotic intervention is to correct alignment to a position well tolerated by the overlying soft tissue and/or the malalignment is a result of a muscle weakness, the new position should stabilize the joint. Clinicians need to remember that aligning one joint may result in the proximal or distal joint being placed in malalignment. An example of this is a genu valgum knee, which may seem easily corrected. However, changes in alignment result in adjustments by the other joints up and down the kinetic chain. Questions such as “Does the subtalar joint have the mobility to pronate?” must be asked and answered.

Evaluation

The examination and evaluation of the neurologically impaired patient must be comprehensive. One must not read a diagnosis and assume a total clinical picture. The diagnosis should alert the evaluator to movement patterns associated with the impairment, and these should be used to confirm potential findings. Complete patient evaluations do not end with determination of ROM, muscle testing findings, assessment of proprioception, skin sensitivity evaluation, or assessment of the integrity of the affected limb or spine. The individual ordering an orthotic device must assess the total picture to determine what limitations orthotic care may impose on other important functions, activities, and patient participation in life. The evaluation must include a patient management assessment. What is the patient’s or family’s motivation? How much equipment can the patient tolerate, and with how much can he or she function? What chance of success does the patient or family have once they have left the clinical setting? How significant are the risks associated with orthotic intervention? As stated, the total evaluation of the patient and the patient’s environment is important in developing the treatment plan, as is the communication among the physical therapist, occupational therapist, and orthotist. Whether done together or (more realistically) at separate sites, the details of the treatment plan must be discussed. The patient with neurological impairment often presents a series of complex issues: biomechanical, communication, visualization, and so on. Incomplete information or a lack of effort at communication among these professionals will not lead to a comprehensive treatment plan and ultimate outcome optimization.

During evaluation, review of the diagnosis and gathering of patient history are extremely valuable. A complete medical diagnosis will indicate important information to the team. For example, if a patient with poliomyelitis is to be seen, the orthotist is aware that it is a lower motor neuron lesion and that proprioception is intact (see Chapters 17 and 35). These patients have the benefit of skeletal balance in standing and ambulation and therefore require durable orthotic construction. Compare this with a similar result in muscle testing and ROM assessment for an individual with T12 level paraplegia. Assuming this is a complete lesion, patients with this upper motor neuron lesion lack proprioception. They require other means to get feedback about standing balance and require a lightweight orthosis, as they rarely use orthoses as a major means of locomotion. Although gathering patient history is a vital part of the evaluation, it is, more importantly, an opportunity to establish a productive patient management environment. Patients and family members have important information regarding the initial injury, previous medical care, reasons they sought additional care, and desired outcomes of new treatment. Most of this information can be gathered efficiently as either the therapist or the orthotist begins other professional evaluations. These are important patient and family management skills. One must hear from the patient or family why they came to see the health care professional and their expectations of care. The therapist should not assume the family’s goals without asking, as often patient and family goals are higher than the clinicians’ expectations. Communicating at a level that is understandable both is vital and demonstrates to the patient and family that the therapist is a concerned professional, thereby engendering trust and confidence. Complete and timely documentation of these findings is becoming increasingly vital to the evaluation and treatment plan. Whether communicating with others on the rehabilitation team, insurance carriers, or legal professionals, documentation and building medical justification are essential in treating all patients.

Evaluation of the upper extremities

Evaluation of the upper extremities requires multiple inputs from health care professionals, patients, family, and teachers because of the wide range of specific functions an individual performs daily. Unique to the upper extremity, multiple functions generally require multiple orthotic devices for activities of daily living (ADLs). Typical functions of orthoses of the upper extremity include maintenance of functional wrist and hand position, reduction of contracture or tone, transfer of force available in one area to another, and support of subluxations resulting from denervation. It is common for the neurologically impaired patient to require several orthoses with different functions for use throughout the day. Strength, ROM, condition of soft tissues, and sensation are all important evaluation factors. In addition, ambulatory status, bilateral or unilateral condition, status of vision, and condition of the spine and head must be factored into the indications and contraindications in assessment of the orthotic needs of the patient. Much more critical muscle tests must be performed in the upper extremity as opposed to the lower extremity, as minor increases or decreases in strength will dramatically alter orthotic need. For example, the C5 quadriplegic has the ability to function with a wrist-hand orthosis by providing enough wrist extension to use the tenodesis effect, which can produce a three-jaw-chuck type of grip. The difference between a functioning and nonfunctioning orthosis is minor, not only because there is limited muscle strength, but also because minor inefficiencies in the tenodesis splint (from friction or malalignment) could reduce function to below acceptable levels. Patients with unilateral involvement have far different needs than the bilaterally involved. The patient with a CVA with unilateral involvement may have an intervention of a positional wrist-hand orthosis to prevent contracture and injury and a supportive shoulder orthosis to prevent shoulder subluxation (Figures 34-4 and 34-5). In these cases the other extremity becomes dominant, and there is little need to fabricate complex orthoses for the use of the affected extremity. The patient with bilateral involvement presents a much different picture. Consideration for grooming, feeding, mobility, and so on must be factored into the desired expectation during evaluation. The case of the patient with neurological impairments who requires orthotic intervention is complex, as this patient typically has involvement in the trunk, head, and lower extremity. These patients require specialized wheelchairs and seating systems. Evaluation is most effective with all rehabilitation team members present to establish a treatment plan. Orthotic treatments maximize what limited muscle strength and ROM the patient may have. Orthoses that are used during the day to maximize function are often replaced with positional orthoses at night to preserve gains and prevent decline in ROM. The occupational therapist provides most of the functional and positional orthoses for the upper extremity. In today’s rehabilitation environment, many occupational therapists work directly with orthopedic hand specialists and trauma physicians. They use low-temperature materials to mold custom devices specifically designed for protecting surgical reconstruction or promoting or maintaining ROM or for use as assistive devices.

Orthotic intervention

Several factors play key roles in the success of orthotic intervention. To improve function without complication or patient risk, the clinician must be sure to address the patient’s major complaint; the reason the patient and family came to see the therapist or orthotist must be clearly established to ensure compliance with orthotic intervention. It is important to establish a baseline of function so that results of intervention are measurable. In some situations the patient benefit is clear and immediate, whereas in others, concentrated instruction, orthotic modification, and time are required before improved function can be observed or measured. The process of donning and doffing the orthosis as independently as possible enhances the overall goal for the patient and family and must be well thought out by the experienced clinician. The clinician must be conservative in setting these expectations. It is important to remember that what happens in the clinical setting may not be easily reproducible in the home situation. The orthotic interventions must be kept as simple as possible: what is the least amount of orthotic intervention that will provide the expected goal? Although an obvious statement, the balance between too much and not enough can challenge the clinician’s skill and experience. The use of trial orthoses can provide valuable information during the evaluation, and these are generally available commercially for short periods. Various types of heat-moldable plastics have been beneficial for many individuals. At times, however, their use adds risk and complication without improvement compared with traditional AFOs fabricated with metal and leather attached to the patient’s shoe. For example, if the patient requires ankle and knee stability yet lacks sensation in the foot and ankle, the double-upright metal orthosis attached to the patient’s shoe creates much less risk for possible skin breakdown than a rigid total contact plastic orthosis (see Table 34-1). With a plastic orthosis, the family must find a shoe big enough to easily fit the orthosis. Technological advancements have led to a number of additions to the arsenal of orthotists. Prefabricated orthoses with better sizing and materials have given the clinician additional tools for evaluation and for devising permanent orthoses. Preimpregnated graphite AFOs are now available in multiple sizes and provide toe pickup during swing phase and some knee-stabilizing characteristics during stance phase. Although very lightweight, these orthoses provide dynamic stance phase control. Introduction of biomechanical forces to the extremities may cause unwanted movements or restrictions, and careful selection of components is essential to keep the focus on the orthotic plan. For example, a patient with a CVA may need more anterior lever force to provide knee stability, so one would plantar flex the orthotic ankle joint. However, this knee-stabilizing effect in stance phase would cause a toe drag during swing phase. A simple fix is to provide the opposite side with a ¼-inch heel and sole lift for additional clearance during swing phase of the affected extremity (Table 34-2).

Clinicians need to set realistic, manageable patient-centered treatment goals. All too often, treatment plans are only in the minds of the clinicians and are either never or too poorly communicated with the patient and family. Clinicians should assume that the patient and family members will expect benefits of the intervention that will far exceed what the therapist knows are possible. The time to address those gaps is certainly before treatment, not when the patient and family realize that expectations regarding functional gains may not be realistic. If failure is the reason a patient recognizes that the intervention was wrong, the therapists have lost the patient’s trust and the potential for future intervention guidance. Discussing realistic achievable goals of treatment, after assessing all factors, the home situation, and individual motivation, with the patient and family in language they understand is critical if successful orthotic intervention is to be achieved. The goal of orthotic care for a patient with CVA is to provide safe standing balance for transfer and minimal ambulation in the home. Patients and their families will realize the major benefit this will have on the home situation. However, without this identified as the goal before orthotic care, they may leave the therapeutic environment wondering why the patient cannot walk normally and participate in life activities that require longer distance ambulation skills.⁴ This clinical error is an all too frequent patient management mistake. Integrating orthoses with physical and occupational therapy motor relearning and neuroplasticity should help optimize functional recovery.

To provide a cost-effective orthosis in a timely manner with today’s vast number of orthotic devices, the orthotist must stay abreast of the wide array of choices at his or her disposal to meet the needs of the patient. The reality of cost containment is not a recent event in the orthotic profession, as funding for these devices has always been challenged. This has necessitated the development of more cost-effective alternatives, such as the prefabricated orthosis. The introduction of heat-moldable plastics into orthotics in the late 1960s and early 1970s on a custom basis replaced, to a large extent, the need to mold leather and/or metal to fabricate an orthosis (see Table 34-1). This improved the total contact fit and dramatically reduced the time and skill level required for manufacturing. Today’s orthotist has a multitude of devices from which to choose to meet the needs of the patient. Options range from custom-made devices using a patient mold to prefabricated custom-fit devices. A thorough understanding of the indications and contraindications for each of these devices is essential in order to meet patient needs. A lack of understanding of biomechanical principles, of the limitations of prefabricated orthoses, and of custom fitting can lead to failure and increase the impairment problems existing within the patient environment. All orthoses produce a force field, some desirable and some undesirable. It requires an experienced clinician to make the most appropriate choices, as too often the failure of treatment is blamed on an orthosis. Usually such failure is the result of an inappropriate initial selection of orthotic components, lack of discernment between custom-made and custom-fit devices, or misidentification of the patient as an orthotic candidate. Prefabricated custom-fit orthoses are cost-effective only if they produce the desired goal over time. As a general rule, one should consider prefabricated custom-fit orthosis for patients who have an anatomically “normal” biomechanical structural environment and who will use the orthosis for only a short time. Custom-made orthoses for extremities or the spine are usually prescribed for patients who have deformity or unusual size or who must use the device indefinitely.

Orthotic intervention for a patient with paraplegia is generally considered for the lower extremities at the T12 level in the complete lesion.⁵ Complete lesions higher in the cord leave the patient without enough trunk stability to use bilateral orthoses effectively. Although a thoracic extension can be added to bilateral KAFOs, this addition greatly increases the difficulty of donning the orthosis independently, and most patients will have great difficulty getting from sitting to standing.

The most appropriate orthoses for a T12 complete paraplegic are bilateral KAFOs. The patient generally uses a swing-to or swing-through gait, and successful use of orthoses requires excellent standing balance. There are three significant design requirements for these KAFOs: shallow thigh and calf bands, bail or French knee locks, and double-adjustable ankle joints. A double-adjustable ankle joint has channels on the anterior and posterior sides of the joint. This allows the orthotist to easily adjust dorsiflexion and plantarflexion position and ROM, or even provide dynamic assistance via a spring added to the channel of the joint (Figure 34-6). The shallow bands force the center of gravity forward, inducing lordosis so the patient can rest on the iliofemoral or Y ligaments of the hip. The knee joint locks are automatic because the patient requires the upper extremities for standing. The bail or French joint will lock as the patient stands and bends over the rigid ankle joint, forcing the knee joints into extension. The lock then can catch on the back of a wheelchair seat or other chair to release the lock and bend at the joint when the patient sits. The foot-ankle complex forms the basis for balance. A few degrees of adjustment at the double-adjustable ankle joint can make the difference between safe standing balance and limited standing balance. The long tongue stirrup extends at least to the heads of the metatarsals and farther if the patient is taller and heavier than normal (see Table 34-2). The use of a strutter bar from the upright of the stirrup extending to a transverse bar at the heads of the metatarsals with a long tongue stirrup (Scott-Craig design, Figure 34-7) ensures that the necessary rigidity is provided. A point between effective standing balance and ambulation is reached after training and ankle adjustment. Patients must have full ROM at the hips, knees, and ankles for use of these devices to be successful.

CASE STUDY 34-1    A. M.

A. M. is a 21-year-old man with incomplete T12-level paraplegia secondary to a gunshot wound. A. M. has normal upper-extremity strength and ROM. He has had surgery for spinal fusion. Trunk strength is 4/5, left hip is 3/5, knee is 2/5, right hip is 1/5, and right knee is 0/5. ROM is full at hips, knees, and ankles. A. M. can transfer independently and has the goal of household ambulation, although he is aware that it “takes a lot of work.” A. M. was fitted with a right KAFO with shallow bands, drop lock knee joints, and double-adjustable ankle joints locked in 5 degrees of dorsiflexion (Figure 34-8). Drop locks were used instead of bail locks because of the use of a unilateral KAFO. A. M. had balance, strength, and a foot orthosis on the left side. The left lower extremity was fitted with an AFO and double-upright and double-adjustable ankle joints adjusted to match the right orthosis. The distal attachment to the shoes was with long tongue stirrups and strutter bars. The patient was able to ambulate with forearm crutches.

Hemiplegia

Patients who have had a CVA can vary widely in their need for orthotic intervention, from a simple AFO to assist toe clearance, to an AFO to stabilize both ankle and knee, to an orthosis used temporarily for training purposes.^6,7 The use of a KAFO in the patient with hemiplegia is rarely indicated. Even though the more affected patient does not have knee stability, he or she rarely ambulates with a heel strike that would destabilize the knee and therefore can use an AFO with an anterior limited-range ankle joint. In addition, patients cannot don the KAFO with the use of only one upper extremity. With hip flexor weakness and knee instability on the affected side, the orthotic intervention may be to assist in transfers rather than to facilitate gait. As a general rule, orthotic intervention for the client with a CVA ranges from a static toe pickup orthosis to a double-adjustable ankle joint with the ankle locked. The use of dynamic components is not effective, because they will initiate spasticity. The lack of ROM into dorsiflexion or even to neutral causes the most significant problems for these patients. An ankle that lacks dorsiflexion ROM prevents advancement of the center of gravity and produces a lever arm that induces genu recurvatum and pain, and either the heel comes out of the shoe or the ankle rolls into varus. Because these patients lack proprioception, this constant force directed posteriorly will, over time, be significant. The patient will develop pain in the knee and not ambulate, the heel cord will shorten more, and the cycle will continue. Heel cords rarely gain length after the patient has been discharged from the rehabilitation setting, and one must consider the family and home situation. Heel buildups on the affected side are used to bring the tibia into 90 degrees. Buildups of 1 to 1½ inches are not uncommon. Remember to balance the opposite shoe. When selecting between different orthotic components, it is best to choose the more stable orthosis. The use of trial orthoses during evaluation is invaluable and helpful initially. As the patient improves, he or she may require less orthotic management or no orthosis at all. A three-point pressure orthosis for the knee, such as a Swedish knee cage (Figure 34-9), is also a valuable training orthosis and, in the case of some post-CVA patients, is used daily when the degree of recurvatum exceeds the patient’s ability to control the posteriorly directed force. The stirrup (the metal attachment to the patient’s shoe) of the AFO must be firm and extend under the sole and heel to the heads of the metatarsals. Although this adds weight to the orthosis, it is necessary to transmit knee-stabilizing forces. Stirrups attached under the heel will only allow undesirable motion and will not provide the required stability.

CASE STUDY 34-2    D. M.

D. M. is a 58-year-old woman who had a left CVA, resulting in a right hemiplegia, almost 2 years ago. She was evaluated at the request of her physician because of increased knee pain and poor standing balance. D. M. was fitted with a plastic AFO fixed at 90 degrees 14 months ago. She was wearing the orthosis, but the heel would not stay in her shoe. Evaluation showed that the patient lacked 15 degrees from getting the foot to neutral (the ankle was therefore in 15 degrees of plantarflexion), had 0/5 dorsiflexion or plantarflexion, and had 3-/5 knee extension and flexion. She also walked with the aid of a quad cane and had 10 degrees of genu recurvatum and slight genu varum at midstance. Her goal was to walk with less pain and to be more stable. D. M. was fitted with bilateral upright, double-adjustable locked ankle joints with long tongue stirrups and a 1½-inch heel buildup (Figure 34-10). The left shoe was built up 1½ inches in the heel and sole to balance the right shoe (Figure 34-11). A Swedish knee orthosis also was used initially to help train the patient and to provide hyperextension control. Although the double-adjustable ankle joint does give total flexibility to change the angle, a 90-degree posterior stop also can be used. Patients who lack this much ROM provide an “anatomical” anterior stop.

CASE STUDY 34-3    M. H.

M. H. is a 59-year-old woman with a history of a CVA 1 year ago. She has left hemiplegia. She works as a facilities manager and walks through her office building several times per day. She underwent extensive therapy after the CVA and has good strength; ROM is within normal limits at her hip and knee. At her left ankle, M. H. has 3+/5 plantarflexion strength but 0/5 dorsiflexion or eversion strength, and she has extensor tone into plantarflexion and inversion. She ambulates very cautiously owing to her inability to dorsiflex and evert the foot during the swing phase of gait. She has a high risk of falling because of her ankle instability and has sustained multiple inversion sprains at the ankle.

M. H. was tested using an FES device and had an appropriate response to the stimulus. She was fitted with an FES device for foot drop. This unit consists of a cuff and control unit around her proximal calf, attached to electrodes on her skin near the fibular head. It allows her to ambulate barefoot and/or with various types of footwear, as it is programmed using the angle of her leg to determine the transition from stance to swing phase in gait. The unit is inconspicuous and lightweight. Her walking velocity, safety, and stability are significantly improved with the FES unit. She uses it throughout the day on a daily basis.

Paralytic spine

Many neuropathic diagnoses affect the spinal column. Spinal muscle atrophy, tetraplegia, myelomeningocele, and Duchenne muscular dystrophy can all require orthotic intervention. Although materials, padding versus no padding, trim lines, length of time used, and optional area openings can vary with different conditions, most spinal stabilizing orthoses are TLSOs. Orthoses used for postsurgical stabilization tend to be of more rigid material to support the healing spine. The paralytic spine that is not surgically stabilized can have either a flexible or a rigid curvature. An orthosis for a patient with a rigid curvature is used to avoid further deformity and differs from that used by the patient with a flexible curvature. If the curve is flexible, the orthosis will be used to hold some of the correction that can be obtained. Patients with paralytic spine deformity usually undergo casting for custom orthoses, and although non–weight-bearing supine casts can greatly reduce the curve, many patients will not tolerate the pressure once in the upright sitting position. Orthotic intervention usually has one or more of the following goals: (1) improved sitting balance, (2) support of surgical stabilization, (3) prevention of further spinal deformity, (4) use as an assistive positional device for better use of head and upper extremities, and (5) improved respiratory function. Most TLSOs for these patients are total circumferential designs that use rigid materials (polypropylene) to less rigid materials (polyethylene) or a combination of padding with a rigid or semirigid frame internal to the heat-formable foam. Fabrication and fitting of these orthoses require an experienced orthotist and adherence to detail. Establishing the distal and proximal trim lines of the orthosis will require a fine balancing act between providing enough length to support the spine without breaking down the skin in accomplishing that goal. Several clinic visits are typically necessary to achieve the desired outcome.

CASE STUDY 34-4    S. G.

S. G. is a 13-year-old girl with spastic cerebral palsy with involvement of all four extremities. She is nonambulatory with significant scoliosis. Her hip ROM is from −25 degrees to 135 degrees of flexion. S. G. is fully dependent and lacks upper-extremity use.

The goal of orthotic intervention was to prevent further deformity, maintain the thoracic and lumbar column height for internal organ function, and provide trunk stability for seating balance in her wheelchair. She was fitted with a custom TLSO fabricated from a cast impression (Figure 34-12). It has ¼ inch of padding with a polypropylene outer layer, which has been modified over bony prominences for skin tolerance.

S. G. wears her TLSO not only while seated in her chair, but also in bed. Frequent checks of the skin were made during the first few weeks of use to establish trim lines and window type modifications. She continues to be checked periodically for comfort and control as she grows to ensure that the TLSO’s fit and function are appropriate.

Spastic diplegic cerebral palsy

The goals of orthotic intervention in the patient with cerebral palsy are to control tone, prevent contractures, and provide a secondary support after a surgical procedure.⁸ Orthotic intervention for these individuals varies from region to region. As a general rule, the orthosis used to prevent contracture should be different from the orthosis used for ambulation. Some of the new designs incorporate modules that can key into one another or be used separately. This feature allows flexibility, assists in donning (especially in a patient with spasticity), and meets several treatment objectives. Modular articulating joints with various settings and functions to use with thermoplastic orthoses greatly increase the options that are available today. With the goals of orthotic intervention stated earlier, total contact–type orthoses are generally the desired option. As with any total contact orthosis and hypersensitive or hyposensitive skin, a cautious balance between correction or holding and skin tolerance must be reached. The fitting of and follow-up for these types of orthoses require experience, knowledge, and patience. Combinations of padding, wedging, straps, and heat relief methods are often necessary to enable the patient to wear the orthosis for a significant amount of time on a daily basis. A patient with spastic diplegic cerebral palsy relies heavily on her or his orthosis and wears it out faster than most other orthotic patients. In the case of a child, she or he may grow out of the orthosis before it wears out. This should be considered in the design and fabrication.

CASE STUDY 34-5    R. B.

R. B. is a 41-year-old woman with spastic diplegic cerebral palsy. She has tight heel cords bilaterally, with −5 degrees from neutral ROM at the ankle. Plantarflexion strength is 3+/5, and dorsiflexion strength is 3/5 bilaterally. The patient has 5 to 7 degrees of varus in the calcaneus. The left lower extremity is asymptomatic. The right side has pain in the midfemur and at the knee. She has a bilateral genu valgum deformity of 5 to 7 degrees (Figure 34-13, A). ROM at the knees is full, and strength of the quadriceps and hamstrings is good. Her hips are normal except for some internal rotation; leg lengths are equal and sensation is good.

Because the right lower extremity was painful at the knee and ankle (Figure 34-13, B), the patient was fitted with an AFO that extended medially and proximally to the medial tibial condyle; ankle joints that had a posterior adjustment to limit plantarflexion; and a medial heel wedge and heel buildup of ⅝ inch. The ankle was fitted with a submalleolar orthosis that fit inside the AFO (Figure 34-13, C and D). The submalleolar orthosis controlled enough pronation of the ankle along with the medial heel wedging and exerted a varus force at the knee (Figure 34-13, E). The heel buildup reduced the posteriorly directed force from midstance to toe off. The patient’s symptoms were reduced, allowing her to be more active (see Table 34-1).

Multiple sclerosis

As MS progresses and further demyelination occurs, increased interruption of normal nerve impulses creates deficiencies in muscle control, vision, balance, sensation, and mental functions. Orthotic considerations for a patient with MS can vary as the patient’s symptoms fade, recur, and change over the years with the disease. Clinical presentation may vary from month to month. Fatigue plays a major role in the symptoms, and the patient’s expectations and willingness to use orthotic devices ebb accordingly. Typical patient reaction is reluctance to use any form of ambulatory aid or orthosis until safety is a major issue. Patients and family usually seek help when falls become more frequent. Lack of toe clearance during swing phase and poor knee stability and push off in stance phase are the most common problems that can benefit from orthotic intervention. Because of the nature of symptom fade and recurrence and the increase with fatigue, the weight and simplicity of orthotic intervention must be major considerations. In many instances the evaluation will indicate the need for a KAFO, but this will be rejected by the patient because of its weight and complexity. The benefit of the KAFO for knee stability and foot and ankle control is counteracted by the patient’s inability to advance the limb during swing phase and control the extremity, as well as a perception that he or she does not need that type of control. Most patients also will reject the use of a double-upright, double-adjustable metal orthosis for the same reason, and although their strength varies from day to day, they will judge need when they are at their strongest rather than their weakest. Traditionally, plastic AFOs are used to control foot drop and provide some medial and lateral ankle control. These orthoses also can provide some knee stability if the plastic is robust enough and if the medial and lateral trim lines are advanced anteriorly past the malleoli. This anterior force stops the center of gravity’s forward progression at midstance, and, again, many patients reject this type of orthosis. The recent development of prefabricated AFOs made of graphite has met the needs of many of these patients (Figure 34-14). This ultralight orthosis fits inside the patient’s shoe. It will provide toe clearance during swing phase and some dynamic knee stability and push off during stance phase.

CASE STUDY 34-6    D. K.

D. K. is a 38-year-old mother of three young boys and works outside the home. She was diagnosed with MS at the age of 30. Until 4 years ago she was managing the symptoms with medication and having minimal ambulatory problems. With the birth of her son, she had to cease use of medication, and the symptoms recurred and weakness increased. At age 36 she was limiting her activity outside the home because of safety issues—she was falling and unstable in standing and walking. She was evaluated at that point and was fitted with a right AFO, as she had foot drop and knee instability and lacked the ability to recover her balance if she caught her toe. A prefabricated graphite AFO was fitted to the patient (see Figure 34-14). D. K. now has toe clearance during swing phase and dynamic knee extension during stance phase. Shortly after beginning to use the orthosis, she was able to walk safely on uneven ground and walk down stairs step over step for the first time in 3 years.

Summary

All orthoses create a force system. It is important to understand and integrate the appropriate force to achieve the desired outcome of intervention. A thorough initial evaluation and knowledge of the multiple orthotic options available are vital to reaching treatment goals. There has been a dramatic improvement in material technology, along with far greater access to orthotics and a much wider range of indications for orthotic intervention. This should challenge the rehabilitation team to establish measurable goals and then to develop new goals leading from the treatment interventions with the most effective outcomes. This evidence-based practice will help provide better service for future patients.