Treatment techniques...

[Orthotics]

Thank you very much for the info and the leads on the Kinemedic AFO. I must say I am very interested in learning more about the benefits of the this design over more traditional AFO designs. I tend to think outside the box and am very picky when it comes to the design and trim lines of the finished product. It sounds like you have used this AFO for CVA pateints? Can you describe the benefits of allowing more motion, specifically with the segmeted foot plate? Why not use a plantar flexion stop with patients that have dorsi weakness or hyperextension issues?

I too am a big fan of only treating the patients needs and make special attempts to recommend designs that will not over brace.

I must be honest, most of my practice is made up of pediatric lower extremity orthoses and I am being offered an opportunity to treat Stroke patients at a major hospital.

The interesting thing about the patients thus far is they present with many of the same issues commonly experienced with the pediatric patient. Weakness, spasticity/tone and limitations in ROM.

I'll try not to eat up too much of your time but I have lots of questions about this population and want to be prepared to treat them with the best possible care.

How do you manage ROM issues if you start to see equinus contractures developing. Nighttime bracing possibly? Stretching excersizes?

I thank you for you communications and look forward to more responses.

Sincerely,

Scott

[Gawaine]

Thank you very much for the info and the leads on the Kinemedic AFO. I must say I am very interested in learning more about the benefits of the this design over more traditional AFO designs. I tend to think outside the box and am very picky when it comes to the design and trim lines of the finished product. It sounds like you have used this AFO for CVA pateints? Can you describe the benefits of allowing more motion, specifically with the segmeted foot plate? Why not use a plantar flexion stop with patients that have dorsi weakness or hyperextension issues?

well, you can basically imagine the advantages and disadvantages..... this AFO is pretty good for someone who has some control of the ankle and needs some more flexibility for further advancement of self-control... one of my biggest (and possibly only) complaints about the PRO is that it doesn't have a plantarflexion stop... that to me is one of the main purposes for using an AFO... but if you're creative, you can fabricate your own... if you're really good with tools and stuff, nothing should be stopping you from creating what each specific patient needs...
thing about AFOs in general is that they're a static fix-it orthotic that does not evolve with the patient's function... i would like to see some progressive AFO that could have its resistance decreased as the patient improved their control of DF... however, the electronic AFOs kind of fall into that category... because you can use the most minimal amount of amplitude to attain the desired dorsiflexion, thereby training the patient over time to DF his own foot in swing phase...

i also believe that knee hyperextension is as much a problem of the hip/pelvis as it is at the ankle...

and i NEVER EVER EVER EVER EVER EVER EVER EVER EVER give a stroke patient a fixed-angle AFO... you TOTALLY screw them up in those things....... they don't allow any dorsiflexion and therefore disallow any phase of gait on the hemi side after midstance--- so the patient steps from midstance to heel strike on the hemi leg, and the non-involved leg only steps as far as the hemi leg is on the ground... and those habits become HARD AS HELL to break........

How do you manage ROM issues if you start to see equinus contractures developing. Nighttime bracing possibly? Stretching excersizes?

yes, exactly... progressive stretching (low-load-prolonged stretches) and bracing/orthoses to maintain the acquired range is indicated in those who have limited ROM due to spasticity...
go back to simple mobilization ideologies: if a joint is tight, you need to stretch it... just keep in mind that maintland or whatever's basic joint mobz aren't going to cut it--- you need to keep in mind we're talking about tight joints due to spasticity... so deformations can occur... realigning the tarsals, metatarsals, and maintaining proper alignment of the toes are all important concepts... it's tough though--- you see an outpatient with a stroke for 45 mins 3x/week--- it's not easy to throw 10 or 15 minutes of stretching and mobilization when you've got ambulation, balance, reaching, UE activities, and other functional stuff to work on... but you MUST do it or you won't achieve an increase in function...

i'm writing about a lot of general concepts here... i think the important things to keep in mind are that you must not forget your anatomy and basic biomechanics while preparing, facilitating (as needed) and improving function... strokes are in a world all to themselves... unique and beautiful in their recovery and potentially debilitating in the wrong hands... not to mention apraxia, aphasia, depression, and other cognitive deficits you need to work through...
my next bit of advice is to just take a lot of courses... PNF, NDT, Neuro-IFRAH, and anything else that you see on the menu at places like Rehab Institute of Chicago, Rancho Los Amigos, and kaiser vallejo--- those are courses you need to take... find out who teaches the good stuff and follow them, but don't fall into taking the kool-aid of any one style... i recently had patients who look very, very similar and i decided to use PNF at an earlier stage than i previously have--- and it worked well for one dude and not for the other...... go figure!!


good luck!!

[Orthotics]

I appreciate your continued dialog...I understand that the focus on design should contain the ability to evolve with the patients progress. It would not be a problem for me to fabricate and replicate the PRO AFO with a plantarflexion stop.

Not to toot my own horn but I'm the inventor of Snapstop (adjustable plantarflexion stop) sold and distributed by Otto Bock. If you haven't used it you may want to incorperate it into your AFO's. It sounds like it may be a good functional fit for you CVA patients. The nice thing about this stop is that you can simply adjust it in a clinic setting as the different size bumpers snap in and out. You can dial in you sagittal alignments with this product or simply remove it all together. It can also be used to manage potential contractures by using an additional bumper in the bottom channel to create a dorsiflexion alignment for nighttime use. This allows you to get dual purpose out of your daytime AFO. See attachment.

It is amazing to me that the stoke patients seem to present with the same issues and concerns of the pediatric patients that I see. Tightness with resulting compensated alignments and gait deviations.

Another thing you may want to try if your looking for something in between a solid ankle AFO and free dorsiflexion is to have your orthotist place a Tamarack flexure joint in place of the stop. The joint acts a dynamic tether creating a dorsiflexion limiter as opposed to stop. You'll get about 5 degrees of motion before it locks out creating a little energy. It can have a nice effect on step length for patients who lack third rocker on the involved limb. Again you can just remove or cut the joint and insert Tamarack dorsi assists medially and laterally to stage the AFO and change the entire function. Just some ideas that I use for pediatrics all the time.

I have enjoyed sharing this information and look forward to utilizing this forum as an educational tool and to advance my skills in patient care.

Sincerely,

Scott Hinshon, CO