Posts Tagged orthoses

[WEB SITE] Q&A: Lower Extremity Rehab.

Published on February 7, 2017

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.

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, contactRehabEditor@allied360.com.

Tiffany Weiser, PT, DPT, C/NDT, assists in fitting AFOs for a an adult client at All Care  Therapies of Georgetown.

Tiffany Weiser, PT, DPT, C/NDT, assists in fitting AFOs for a 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, contactRehabEditor@allied360.com.

Source: Q&A: Lower Extremity Rehab – Rehab Managment

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[REVIEW] Mobility and the Lower Extremity | EBRSR – Evidence-Based Review of Stroke Rehabilitation – Full Text PDF

Chapter 9

Mobility and the Lower Extremity

Rehabilitation techniques of sensorimotor complications post stroke fall loosely into one of two categories; the compensatory approach or the restorative approach. While some overlap exists, the underlying philosophies of care are what set them apart. The goal of the compensatory approach towards treatment is not necessarily on improving motor recovery or reducing impairments but rather on teaching patients a new skill, even if it only involves pragmatically using the non-involved side (Gresham et al. 1995). The restorative approach focuses on traditional physical therapy exercises and neuromuscular facilitation, which involves sensorimotor stimulation, exercises and resistance training, designed to enhance motor recovery and maximize brain recovery of the neurological impairment (Gresham et al. 1995).In this review, rehabilitation of mobility and lower extremity complications is assessed. An overview of literature pertaining to the compensatory approach and the restorative approach is provided. Treatment targets discussed include balance retraining, gait retraining, strength training, cardiovascular conditioning and treatment of contractures in the lower extremities. Technologies used to aid rehabilitation include assistive devices, electrical stimulation, and splints.

For evidence tables, please click here.

Source: Mobility and the Lower Extremity | EBRSR – Evidence-Based Review of Stroke Rehabilitation

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[WEB SITE] Foot Drop Rehabilitation: We’ve Come a Long Way, Baby

Mary Free Bed patient John P. Smith works with the Neuroeducator 4 surface EMG biofeedback to help him get maximal volitional signal from the anterior tibialis while stepping forward.

Nearly 50 years ago, “Grandpa Ray,” who had diabetic peripheral neuropathy, had three options for controlling his foot drop: a high-steppage gaitpattern, double metal upright ankle-foot orthotics (AFOs) attached to what he affectionately referred to as his “Herman Munster shoes,” or what he ultimately resorted to—cowboy boots. Today, there is a great variety of options to address the foot drop symptom that occurs with many different disorders and diseases. The difficulty now is being knowledgeable about the plethora of products available to find the best options for each patient.

Identifying the extent and cause of foot drop is the first step in determining the best treatment options. Symptoms can vary in severity, from a patient having a heel strike but then abruptly plantarflexing (PF) into a foot slap pattern to dragging of the toes during swing phase. Foot drop sufferers may also present with high steppage or hip circumduction compensatory gait patterns. Upper motor neuron (UMN) injury etiologies include stroke, brain injury, spinal cord injury, or multiple sclerosis. Lower motor neuron (LMN) injury causes include trauma, surgery, drug toxicity, or metabolic disease. Muscular-level etiologies of foot drop include muscular dystrophy, Charcot-Marie-Tooth disease, and post-polio syndrome.

Musculoskeletal Deficits

Musculoskeletal deficits may be addressed by physical therapy treatment, and home program instruction to improve flexibility and strength into dorsiflexing (DF). Strength and range of motion training tools common to most physical therapy clinics include cuff weights such as those provided by Bolingbrook, Ill-based Advantage Medical, TheraBand resistance bands, available through The Hygenic Corporation/Performance Health, Akron, Ohio, and the BAPS board, marketed by AliMed, Dedham, Mass.

For more significant PF contractures, serial casting and static and dynamic day and nighttime splints can provide a low load prolonged stretch. Many types of these devices are manufactured. For example, on the AliMed Inc website there are 24 products in this category. The products differ in sizing, adaptability, materials used, weight-bearing capabilities (including ability to off-load areas of the foot where there may be wounds or wound susceptibility), and ability to control other rotational moments. Dynasplint Systems, Severna Park, Md, and Össur, Reykjavik, Iceland, also manufacture these types of orthoses. It can be overwhelming to sort out the products in this category, so reliance on a trusted certified orthotist to help match patient needs with products can be invaluable.

Neuromuscular electrical stimulation (NMES) devices such as the Empi Continuum by Empi, a DJO Global company, Vista, Calif, or the Zynex Nexwave from Zynex Medical, Lone Tree, Colo, can be used in cases where a muscle can be stimulated to contract. Clinicians can use these handheld units in the clinic, as well as set them up for patient home use. These AC current devices, of course, will not work in a LMN injury unless substantial neural recovery has occurred. NMES can help retard atrophy and assist patients in relearning to contract the anterior tibialis muscle.

Retraining patients to contract the anterior tibialis can be enhanced with the use of surface EMG biofeedback (BFB) units that provide audio and visual feedback correlating with the degree of volitional activation. The NeuroEDUCATOR 4 system available through Therapeutic Alliance Inc, in Fairborn, Ohio, has four channels available to monitor unilateral, bilateral, agonist, and/or antagonist muscles for obtaining maximal volitional signal in a coordinated manner. The addition of monitoring motor activation while choosing home program exercises provides assurance to both patient and physical therapist that the chosen activities are indeed producing effective motor activation even when there is lack of visual motion. There are also combination NMES and BFB systems such as the MyoTrac from Thought Technology Ltd, Montreal West, Quebec, Canada, with which patients can initiate NMES to heighten contraction of the muscle after they reach a target volitional contraction guided by the BFB visual and audio display.

Orthoses

Whether or not recovery of motor function is in the picture, patients will typically benefit from some type of AFO intervention in the interim of recovery or as a permanent solution when recovery is not likely. The first goal of the brace is to hold up the toe so the patient does not trip during swing phase of the gait cycle. Secondly, using devices that have some flex via the property of the materials used or adding a hinge to the brace can help achieve rollover for a more fluid gait cycle and reduce energy expenditure. Alternatively, providing rigidity at the ankle can help to correct problems up the chain, such as a DF stop to reduce knee buckling or a PF stop to help reduce knee hyperextension. Adding in other kinetic chain corrections such as medial or lateral posts…..

Continue —> Foot Drop Rehabilitation: We’ve Come a Long Way, Baby – Physical Therapy Products

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[ARTICLE] Usability test of a hand exoskeleton for activities of daily living: an example of user-centered design

Usability test of a hand exoskeleton for activities of daily living: an example of user-centered designAbstract

Purpose: (1) To assess a robotic device (Handexos) during the design process with regard to usability, end user satisfaction and safety, (2) to determine whether Handexos can improve the activities of daily living (ADLs) of spinal cord injury (SCI) patients and stroke patients with upper-limb dysfunction.

Methods: During a 2-year development stage of the device, a total of 37 participants (aged 22–68), 28 clinicians (experts) and nine patients with SCI or stroke (end users) were included in a user-centered design process featuring usability tests. They performed five grasps wearing the device. The assessments were obtained at the end of the session by filling out a questionnaire and making suggestions.

Results: The experts’ opinion was that the modified device was an improvement over the preliminary version, although this was not reflected in the scores. Whereas end user scores for comfort, grasp, performance and safety were above the sufficiency threshold, the scores for year 2 were lower than those for year 1.

Conclusions: The findings demonstrate that although Handexos meets the initial functional requirements and underlines the potential for assisting SCI and post-stroke subjects in ADLs, several aspects such as mechanical complexity and low adaptability to different hand sizes need to be further addressed.

Implications for Rehabilitation

Wearable robotics devices could improve the activities of daily living in patients with spinal cord injury or stroke.They could be a tool for rehabilitation of the upper limb.Further usability tests to improve this type of tools are recommended

Source: Taylor & Francis Online

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[ARTICLE] Applications of Shape Memory Alloys for Neurology and Neuromuscular Rehabilitation – Full Text HTML

Abstract

Shape memory alloys (SMAs) are a very promising class of metallic materials that display interesting nonlinear properties, such as pseudoelasticity (PE), shape memory effect (SME) and damping capacity, due to high mechanical hysteresis and internal friction. Our group has applied SMA in the field of neuromuscular rehabilitation, designing some new devices based on the mentioned SMA properties: in particular, a new type of orthosis for spastic limb repositioning, which allows residual voluntary movement of the impaired limb and has no predetermined final target position, but follows and supports muscular elongation in a dynamic and compliant way. Considering patients in the sub-acute phase after a neurological lesion, and possibly bedridden, the paper presents a mobiliser for the ankle joint, which is designed exploiting the SME to provide passive exercise to the paretic lower limb. Two different SMA-based applications in the field of neuroscience are then presented, a guide and a limb mobiliser specially designed to be compatible with diagnostic instrumentations that impose rigid constraints in terms of electromagnetic compatibility and noise distortion. Finally, the paper discusses possible uses of these materials in the treatment of movement disorders, such as dystonia or hyperkinesia, where their dynamic characteristics can be advantageous.

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Full Text HTML —> JFB | Free Full-Text | Applications of Shape Memory Alloys for Neurology and Neuromuscular Rehabilitation | HTML.

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[REVIEW] Mobility and the Lower Extremity | EBRSR – Evidence-Based Review of Stroke Rehabilitation – Full Text PDF

Abstract

Rehabilitation techniques of sensorimotor complications post stroke fall loosely into one of two categories; the compensatory approach or the restorative approach. While some overlap exists, the underlying philosophies of care are what set them apart. The goal of the compensatory approach towards treatment is not necessarily on improving motor recovery or reducing impairments but rather on teaching patients a new skill, even if it only involves pragmatically using the non-involved side (Gresham et al. 1995). The restorative approach focuses on traditional physical therapy exercises and neuromuscular facilitation, which involves sensorimotor stimulation, exercises and resistance training, designed to enhance motor recovery and maximize brain recovery of the neurological impairment (Gresham et al. 1995). In this review, rehabilitation of mobility and lower extremity complications is assessed. An overview of literature pertaining to the compensatory approach and the restorative approach is provided. Treatment targets discussed include balance retraining, gait retraining, strength training, cardiovascular conditioning and treatment of contractures in the lower extremities. Technologies used to aid rehabilitation include assistive devices, electrical stimulation, and splints.

Get Full Text PDF

via Mobility and the Lower Extremity | EBRSR – Evidence-Based Review of Stroke Rehabilitation.

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WEB SITE: Restorative Care of America – RCAI – Rehabilitative Orthoses

More than thirty-five years of innovation, industry leadership, and superior quality have made Restorative Care of America, Incorporated one of the world’s leading manufacturers of restorative care products. RCAI prefabricated orthoses are handcrafted and made at the RCAI manufacturing facility in St. Petersburg, Florida. Developed under the guidance of certified orthotists and tested in leading teaching hospitals, RCAI products address the effects of immobility and neurological conditions associated with traumatic injuries and chronic disease, including joint contracture and pressure sores.

via Restorative Care of America – RCAI – Rehabilitative Orthoses.

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