Whether for temporary application or use over a lifetime, braces and orthoses can be an essential component of rehabilitation programs directed at treating the lower extremities for adults and children. The evolved technology behind today’s bracing and orthotic products are characterized by lightweight support as well as options in materials that offer tailored sizing and customized fit. Construction components made of carbon fiber, rubber, plastic polymers, metal, and leather mean therapists and users may take advantage of devices that are soft, rigid, or semi-soft in structure. As clinicians who assess gait and are often stakeholders in the care of individuals affected by lower extremity impairment, therapists must have a wide grasp of technologies available for this product category.
To provide an update about technologies for lower extremity braces and orthoses for treating the pediatric population as well as the general orthopedic and neurological population, Rehab Management interviewed therapists who practice in these settings. Read this Q&A to find out what these therapists look for in the technologies they recommend, and how their functional properties help maintain mobility and correct physical issues that can affect walking.
Whitney Frisard, PT, DPT, fits an articulating AFO on a patient prior to initiating ambulation and standing at Children’s Hospital of New Orleans.
Small Patients, Big Impact
by Whitney Frisard, PT, DPT, and Laura Matthew, PTA, Children’s Hospital of New Orleans, New Orleans, La
Q. What types of lower extremity impairment do you most often see among pediatric patients that require braces/orthoses?
A. We see multiple diagnoses among our patients that require orthotic intervention, but some of the most common are cerebral palsy, traumatic brain injury, and Down Syndrome. We find it easiest to categorize them as having high or low tone. With the high tone patients, we see equinas deformity with decreased dorsiflexion in both AROM and PROM. As the child ages, we see splaying of the forefoot/digits sometimes causing increased deformities of the foot and ankle. However, with low tone patients, medial/lateral instability collapsing into pronation is the most frequent impairment we see. These are just a few types of impairments with the diagnoses mentioned above, but we see many other neurological and orthopedic issues among our patients.
Q. What problems do those impairments create for walking?
A. Patients with high tone often display toe walking demonstrating a lack of heel contact during the gait phase, causing abnormal stresses through the hips and knees. As the child ages, this could result in an antalgic gait pattern. Patients with high tone typically have poor coordination and motor control, resulting in decreased balance. The patients with low tone often demonstrate a wider base of support, decrease balance, knee hyperextension during stance phase, and upper extremity guarding. Both situations require an increased effort by the child for walking and result in many muscle imbalances.
Q. What types of braces/orthoses can help overcome those impairments and achieve more normal gait?
A. Children’s Hospital has an in-house orthotist who is readily available to help consult on bracing for our patients, which is a significant benefit to our patients. For patients with high tone, we mostly recommend a solid AFO with or without a molded inner boot. The molded inner boot is beneficial for those with significantly high tone for additional positioning. We also utilize articulating AFO’s with a plantar flexion stop to facilitate active dorsiflexion in order to obtain a heel-toe gait pattern. With patients with low tone, it depends on the severity. We would typically utilize a supramalleolar orthotic (SMO) to address the medial lateral instability. However, for those with significant hypotonia, we prefer an articulating AFO to promote a normal gait pattern.
Whitney Frisard, PT, DPT, graduated from LSUHSC in New Orleans in 2012. She has been with Children’s Hospital of New Orleans since 2012. Children’s Hospital is a 247-bed, not-for-profit pediatric medical center offering a complete range of healthcare services for children from birth to 21 years.
Laura Matthew, PTA, graduated from Delgado Community College in 1998. She has been with Children’s Hospital of New Orleans since 1998. For more information, contact [email protected].
Tiffany Weiser, PT, DPT, C/NDT, assists in fitting AFOs for an adult client at All Care Therapies of Georgetown.
Rehabilitative Care for a Community
by Tiffany Weiser, PT, DPT, C/NDT, All Care Therapies of Georgetown, Georgetown, Texas
Q. What types of lower extremity impairment do you most often see among your patient population?
A. Nothing can prepare a person for life-altering moments caused by a stroke or any type of insult to the brain or spinal cord, which leads to a neurological change within their body. These insults cause patients to lose function and their ability to participate in activities that bring joy, entertainment, exercise, or simply the ability to complete activities of daily living. Overcoming them requires patience, energy, strength, and courage, from the patient and their support system, which includes physical therapists. Therapists must continually perform assessments and be adaptive to evolve patient-specific, need-based treatments.
The variability of impairments that result from an injury to the brain or spinal cord range significantly depending on the location of the insult. Upper motor neuron impairments include hypertonia, spasticity, and clonus, while lower motor neuron impairments cause low muscle tone and flaccid weakness. It is important to note how these upper and lower motor neuron impairments affect each one of the body systems while conducting a patient’s assessment. Assessments should encompass single body systems to identify associated common impairments including muscular tightness and endurance, postural asymmetries in the extremities and trunk, proprioceptive input, and abilities to isolate movement. Evaluating assessment results develops an understanding of how these single system impairments, when combined, affect the patient’s anticipatory control, balance, and movement strategies.
Q. What problems do those impairments create for walking?
A. The aforementioned impairments affect the patient’s functional activities, including walking—considered critical to quality of life. Common gait abnormalities seen with patients that present with increased tone and spasticity after injury include a steppage pattern to compensate for foot drop. This pattern can include an exaggerated thigh lift, excessive hip and knee flexion, and possibly external rotation of the lower extremity to clear the toe during swing phase. Spasticity seen within the gastrocnemius often results in uncontrolled knee hyperextension during stance phase. Typical gait abnormalities seen with patients that have hypotonia and flaccid paralysis after injury include a slap gait pattern due to decreased eccentric control of the ankle dorsiflexors upon initial contact in the gait cycle, knee buckling resulting from quadriceps weakness, insufficient step length due to hip extensor weakness, a crouched gait due to poor ability to initiate and sustain muscle activation primarily in the plantarflexors, and ankle pronation, genu valgum and genu recruvatum during the stance phase due to generalized weakness. In both scenarios, the patient often has decreased proprioceptive input due to malalignment, an increased fall risk due to the gait abnormalities, and requires increased muscle energy expenditure if not appropriately addressed. Additionally, malalignment in the foot can degrade bone health as it is significantly impacted by standing weight bearing.
Q. What types of braces/orthoses can help overcome those impairments and achieve more normal gait?
A. An ankle foot orthotic (AFO) is the most common type of orthotic used to address those patients with neurological impairments because an AFO provides correct calcaneal positioning and arch support at the foot. Components and design of the AFO at the ankle joint and lower leg will be selected based on the patient’s clinical presentation. Patients that present with hypertonia and spasticity typically benefit from an articulated AFO with dorsiflexion assist and a plantarflexion stop to help achieve heel strike at initial contact and reduce knee hyperextension in stance phase. Additional benefits from using this type of AFO include decreased oxygen and energy consumption and improved walking speed, stride length, and single leg support time. Patients who present with low muscle tone and flaccid paralysis often require an AFO that offers sufficient support that provides distal stability due to a patient’s inability to initiate and/or sustain muscle contraction to achieve their ambulation goals.
Distal stability can be achieved using a solid AFO, which also allows the patient to focus their attention on gaining proximal stability. Once reaching proximal stability, the AFO can be hinged, as desired, to allow controlled ankle dorsiflexion and plantarflexion, progressing their goals. A ground reaction AFO is an alternative brace that has shown to be beneficial for patients with low muscle. The solid anterior component of a ground reaction AFO encourages knee extension through the floor reaction at heel contact that improves stance phase. If this brace is considered, the patient must have available range of motion at the knee and hip. RM
Tiffany Weiser, PT, DPT, C/NDT, is director of physical therapy at All Care Therapies of Georgetown, Georgetown, Texas. She attended Duquesne University in Pittsburgh, where she earned her Doctorate of Physical Therapy in 2010. Weiser became certified in Neurodevelopmental Treatment (NDT) in 2014. For more information, contact [email protected].
