bernie veldman, co certified orthotist -...

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Don’t Take That Tone!Bernie Veldman, COCertified Orthotist

Don’t Take That Tone

• Discuss:• Muscle Tone

• Compare and contrast hypertonia and hypotonia• Muscle Strength

• Differences between tone and strength• Determine goals of orthotic management for high vs. low tone• Explore options for orthotic management of

• Lower Extremities• Trunk• Head/Neck

Course Objectives

• A muscle’s resistance to passive stretch– The inherent ability of a muscle to respond to a stretch– Tone is “on” during waking hours and “off” during sleeping hours

• An intrinsic property of the nervous system– Cannot be changed through voluntary control, exercise or diet

Function:– maintain joint integrity and posture

TONE & STRENGTHAre they the same thing?

Muscle Tone

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• Spectrum includes Very Very Low to Very Very High andeverything in between.


Low High

Normal

What is Hypertonia?• Increased resistance to passive stretch of a muscle• Often associated with:

– Muscle Contractures– Spasticity and/or Dystonia– Bone and Joint abnormalities

• Can be measured:– Ashworth Scale– Modified Ashworth Scale


Orthotic Management - Hypertonia• Maintain and/or increase ROM• Prevent joint breakdown• Improve alignment of joints• Increase base of support during weight bearing activities• Minimize triggering of spastic responses• Minimize pain secondary to spasticity


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What is Hypotonia?• Low muscle tone• Little to no resistance against passive stretch• No scale for accurate measurement


Common Diagnoses Associated With

• Down syndrome• Myasthenia gravis• Cerebellar ataxia, congenital• Prader-Willi Syndrome• Myotonic dystrophy• Riley-Day syndrome• Marfan's syndrome• Muscular Dystrophy• Sepsis

• Congenital hypothyroidism• Krabbe disease• Menkes syndrome• Metachromatic leukodystrophy• Rickets• Spinal muscular atrophy type 1

(Werdnig- Hoffman)• Tay-Sachs disease• Aicardi syndrome

Hypotonia

…is not a specific diagnosis,but can be a part of over 600

genetic disorders….

Hypotonia


LISI, E. C. and COHN, R. D. (2011), Genetic evaluation of the pediatric patient with hypotonia:perspective from a hypotonia specialty clinic and review of the literature. Developmental

Medicine & Child Neurology, 53: 586–599. doi: 10.1111/j.1469-8749.2011.03918.x

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Hypotonia

• Infants:– Excessive joint mobility– Decreased deep-tendon reflexes– Gross motor skill delay– Difficulty with balance/coordination


• Impaired mobility• Poor posture• Breathing difficulties• Delayed Speech & Feeding difficulties• Lethargy• Poor Reflexes• Ligament and joint laxity


Often Seen With Hypotonia:

(Parker and Bronks, 1980).

Low muscle tone, also known ashypotonia, contributes to joint

hypermobility.

Low Muscle ToneHypotonia

Hypermobility

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HYPERMOBILITY COMPONENT• Many scales to measure generalized joint

hypermobility (excessive ROM of joint)• Beighton scale• Brighton criteria• Bulbena criteria• Carter & Wilkinson• Global Joint Mobility Index• Horan Joint Mobility Index• Rotés-Quérol• Villefranche• Lower Limb Assessment Score

TONE & STRENGTHAre they the same?

Strength:• The ability to exert force on physical objects

– Through controlled muscle contraction.• Up to the recruitment and use of all motor units within a

muscle– MAXIMUM CONTRACTION

– Can be increased: Exercise and strengthening– Can be measured: Manual muscle testing

HYPOTONICITY• Peredo & Hannibal (2009):• Need to distinguish weakness from hypotonia• Hypotonia is reduced resistance (tension) to

passive range of motion in joints, whereas,• Weakness is the reduction in the maximum power

that can be generated• Impairment in ability to sustain postural control

and movement against gravity, therefore, “floppyinfants” have poor control of movements, delayedmotor skills and hypotonic movement patterns

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Hypotonia• Martin, et al. (2007):

– Current literature gives only descriptions or vagueattempts to quantify hypotonia

– Survey with a response of 300 pediatric PTs and OTs– Children with hypotonia had the following characteristics:

»decreased strength» hypermobile joints» increased flexibility» rounded shoulder posture» poor attention and motivation» leaning on supports» decreased activity tolerance» delayed motor skill development

Children with Hypotonia:

Does not equate toWeakness

Are in very poor biomechanicalalignment when in closed chainand function in a weak manner.

Have great difficulty in recruitingtheir strength because of theiralignment

Hypotonia(Low Muscle Tone)

Often equated to:

Weakness(Low Muscle Strength)

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Hypotonia…A parent’s perspective.

• My child has low muscle tone, therefore, she isweak.

• My child has flat feet due to her low muscletone or weakness.

• What can my child really achieve?


• My child has flat feet due to her low muscletone or weakness.• Most children with hypotonia do pronate

• Not flat feet• Not weak children


• What can my child really achieve?• THE SKY IS THE LIMIT

• What they are lacking is stability, not strength• Create stability

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Closed ChainLigamentous Laxity = Joint Instability

PRONATIONCalcaneal Valgus

• Primarily coronal/frontal plane movement

• Facilitates improper distal positioning

• Encourages poor proximal function

• Initiates medial translation of weight-line

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Pronation

Tri-planar- 3 ComponentsCalcaneal Valgus

2. Midfootdorsiflexion/eversion

A. Sagittal/Frontal planeB. Downward and Medial

collapse of mediallongitudinal arch

C. Lengthening of medialaspect of the foot

Sagittal Coronal

Medial Longitudinal Arch Elongation

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Medial Longitudinal Arch Elongation

Pronation1. Calcaneal Valgus2. Midfoot Eversion

Tri-Planar – Three Components

3. Forefoot abduction• Transverse, Sagittal and Coronal Planes

• Lengthening of Medial Longitudinal arch, combinedwith medial weight shift at midfoot forces Abduction

of forefoot• Varus in relation to hindfoot

• Dorsiflexed in relation to midfoot

W-Sitting…• W- sitting• Study by KC Chen et al. (2010)

– study of 1,598 children– From 3-6 years of age– central area of Taiwan– 17.3% of preschool children W-sat– significant differences in unilateral and

bilateral flatfoot groups when comparedto the normal foot group

KC Chen et alEuropean Journal of Pediatrics, July 2011, Volume 170, Issue 7, pp 931-936

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SureStep Criss-CrossersAVAILABLE NOW

Calcaneal ValgusMidfoot Eversion

Forefoot abduction

Closed ChainLigamentous Laxity = Joint Instability

Pronation

Orthotic Management

Foot OrthosisUCBL

SMOSupra-Malleolar Orthosis

Traditional means of addressing pronation

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Alter the position of the foot.Improve positioning.

Subtalar Neutral

Subtalar NeutralDYNAMIC FUNCTION

High Tone Concepts…Low Tone Feet…

*

Traditional means of addressing pronation:Foot Orthoses (FOs)

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Colson JM. An effective orthotic design for controlling the unstable subtalar joint. Orthotics Prosthet. 1979;33:44.

Traditional means of addressing pronation:UCBL

Traditional means of addressing pronation:Supra-Malleolar Orthosis (SMO)

Orthotic Management

Foot OrthosisUCBL

SMOSupra-Malleolar Orthosis


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SureStep is Different• What Is SureStep?

–Supra-Malleolar AFO. (SMO)–SureStep is Custom Fabricated–SureStep is completely unique:

• Unique in appearance, Function andConcept.

SureStep Dynamics

• Trimlines• Medial trimline

proximal to 1st met-head

• Lateral trimline distalto 5th met-head

*

How SureStep Works• Compression: Ultra-thin, flexible plastic

– Compression creates stability.– Allows normal intrinsic movement– Facilitates improved balance and coordination.– Enables use of intrinsic muscles–SureStep’s focus is on creating stability, not

statically posting the foot into a position.

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Hydrostatic pressure:

Flexibility, combined with SureSteptrimlines allow true dynamic movement

SureStep functions not as a brace,But as an exoskeletal ligament system.

Don’t Take That Tone

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Pronation

Distal

Pronation• Proximally Affects:

• Position

• Function

• Development

PositionWeight line shifts medially causing:

• Change in tibial deflection

• Genu valgum• Global ligamentous laxity

• Hip Adduction

Long Term:• Tight Peroneals• Tight Heel Cords

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• Inefficient joint movements• Joints articulate outside

optimal axis of movement

• Inefficient muscle usage• Muscles work out of optimal

range and angulation.

Function

HYPOTONICITY• Peredo & Hannibal (2009):• Need to distinguish weakness from hypotonia• Hypotonia is reduced resistance (tension) to

passive range of motion in joints, whereas,• Weakness is the reduction in the maximum power

that can be generated• Impairment in ability to sustain postural control

and movement against gravity, therefore, “floppyinfants” have poor control of movements, delayedmotor skills and hypotonic movement patterns

In some kids,it is quickly obvious

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Poor Balance

Poor Coordination

Wide Base

In some kids it is not.Functional deficits often seen with hypotonia

Poor Balance

Poor Coordination

Wide Base

High Guard

Excessive WeightShiftIncreased Fatigue

In some kids it is not.Functional deficits often seen with hypotonia

Typical Pediatric Gait Development:

• Age 9 Months Pull to Stand• Age 10 Months Cruise

4 Steps HH• Age 11 Months Independent standing

SteppingWalking 1 HHIndependent walking

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• Age 12 Months 130 Steps/minHigh GuardExternal Rotation of HipsMore Knee FlexionWider Base of Support

• Age 18 Months Heel-Toe Gait (most)Reciprocal Arm Swing (most)Narrowed Base of Support


• Age 24 Months Less Hip FlexionReduced Pelvic TiltReduced Hip AbductionReduced External RotationSignificant knee flexion

(more than adults)Decreasing Base of SupportSingle Leg Stance 34%


Age 36 Months reciprocal arm swing (90%)Base of Support(proportional to an adult)Typical joint anglesSingle Leg Stance 35%

Age 7 years Refining continues as long bonegrowth continues throughoutSingle Leg Stance 39%

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Hypotonia Studies

• Outcomes of infants with idiopathic hypotonia (Strubhar, et.al.2007)– Survey of 105 parents of children diagnosed with hypotonia– Transient impairment group (10.5%) reported no issues– Minimal impairment group (32.4%) mild issues (learning

disability, language delay) but no major developmental issues– Globally impaired group (40.9%) had mental retardation or

recognizable genetic or developmental diagnosis

Hypotonia Studies

• Outcomes of infants with idiopathic hypotonia (Strubhar, et.al.2007)–Greater than 50% of minimal impairment group had poor

coordination, language delay and learning difficulty

–Mean walking age of minimal group was 22 months*Developmental Delay*

Pull-To-StandThe Waiting Game

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Weight ShiftThe Waiting Game

CruisingThe Waiting Game

Independent StandingThe Waiting Game

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Independent StepsThe Waiting Game

Independent WalkingThe Waiting Game

6 weeksNo OrthoticIntervention

Independent AmbulationThe Waiting Game

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6 monthsNo OrthoticIntervention





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RunningThe Waiting Game

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Earlier is better!

BRADEN• 19 months old• DX: Developmental Delay, Hypotonia,

Pronation• Cruising 5 months• No independent standing or ambulation

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Winning The“Waiting Game”

True Dynamic Bracing forTrue Dynamic Function…

CORA• 17 months old• DX: Developmental Delay, Hypotonia,

Pronation• Cruising 4 months• No standing or ambulation



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CHANCE• 21 months old• DX: Pierre Robin Syndrome, Developmental

Delay, Hypotonia, Pronation• Independently ambulatory 4 months



Megan Smith, COCertified OrthotistSureStep Director of Clinical Research

Gross Motor Skill Changes ofChildren Wearing SureStep SMOs

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COLIN

• 16 MONTHS OLD AT START OF STUDY• DX: DEV DELAY, PRONATION, HYPOTONIA,

SIGNIFICANT LIGAMENTOUS LAXITY• WAS PULLING TO STAND FOR A COUPLE OF

WEEKS. NOT YET TAKING INDEPENDENT STEPS• RECEIVED PHYSICAL THERAPY 1X/WEEK FOR

DURATION OF STUDY

DAY 1 – BAREFOOT DAY 1 – SMOS

WEEK 16 – BAREFOOT

GAIT ANALYSIS• Day 1: Not walking• Month 1: Walking with 2 hands held; very

unstable• Month 2: Walking with 1 hand held. Extended

gait pattern – for stability and consistency. HighBOS, externally rotated, high guard. Startingindependent steps.

• Month 3: Stable with no hands held. Wide base• Month 4: Stable in grass/uneven surfaces and

transitioning surfaces. Narrow BOS and lowguard.

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PARENT QUESTIONAIRRE• Was this your child’s first set of orthoses? YES• Wear Schedule: Hours/Day 12 Days/Week 7• How does your child respond to wearing the SureStep SMOs? LIKES• How satisfied are you with the SureStep SMOs (1 = Not at all; 10 = Very Satisfied)? 10• Rate your child’s activity level without SureStep SMOs (1 = Not at all; 10 = Very Active): 8• Rate your child’s activity level with SureStep SMOs (1 = Not at all; 10 = Very Active): 10• Rate your child’s coordination when active without SureStep SMOs (1 = Not at all; 10 = Very

Coordinated): 6• Rate your child’s coordination when active with SureStep SMOs (1 = Not at all; 10 = Very

Coordinated): 9• Rate your child’s endurance without SureStep SMOs (1 = Not at all; 10 = Very High): 8• Rate your child’s endurance with SureStep SMOs (1 = Not at all; 10 = Very High): 8• Rate the difficulty in donning and working with the SureStep SMOs (1 = Very Difficult; 10 = Very

Easy): 10• Comments: Love the SMOs. They have made a world of a difference in our kiddo’s walking

NORMAL – RATE OF CHANGE = 0.51PATIENT – RATE OF CHANGE = 0.27

DEVELOPMENTAL DELAY AT BEGINNING = 6 MONTHSDEVELOPMENTAL DELAY AT END (16 WEEKS) = 2 MONTHS*WE GAINED 4 MONTHS IN 16 WEEKS

• TYPICAL CHILD TAKE 8-9 MONTHS TO PROGRESSFROM PULLING TO STAND TO WALKING FAST.

• THIS PATIENT TOOK 5 MONTHS TO MAKE THE SAMECHANGES

OUR KIDS OURCATCHING UP THETHEIR PEERS ANDMAKINGCHANGESFASTER THAN ATYPICAL CHILD!!

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TYPICAL

COLIN

ANIYAH

• 15 MONTHS OLD AT START OF STUDY• DX: DEV DELAY, PRONATION, HYPOTONIA, 3

MONTHS PREMATURE• WAS PULLING TO STAND FOR A COUPLE OF


DURATION OF STUDY

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GAIT ANALYSIS

• Day 1: Very unstable. Cruising. Taking some stepswith hands held. Very wide BOS.

• Month 1: Taking independent steps. Very wideBOS. Very unstable in independent steps. Highguard.

• Month 2: Steadier, low guard, narrower BOS.• Month 3: Narrow BOS. Low guard. Much steadier.

Carrying objects well.• Month 4: Very steady. Arms down and swinging.

Trying to run. Still very unsteady without SMOs.

PARENT QUESTIONAIRRE• Was this your child’s first set of orthoses? YES• Wear Schedule: Hours/Day 12 Days/Week 6• How does your child respond to wearing the SureStep SMOs? LIKES• How satisfied are you with the SureStep SMOs (1 = Not at all; 10 = Very Satisfied)? 10• Rate your child’s activity level without SureStep SMOs (1 = Not at all; 10 = Very Active): 4• Rate your child’s activity level with SureStep SMOs (1 = Not at all; 10 = Very Active): 10• Rate your child’s coordination when active without SureStep SMOs (1 = Not at all; 10 = Very Coordinated): 3• Rate your child’s coordination when active with SureStep SMOs (1 = Not at all; 10 = Very Coordinated): 10

• Rate your child’s endurance without SureStep SMOs (1 = Not at all; 10 = Very High): 3• Rate your child’s endurance with SureStep SMOs (1 = Not at all; 10 = Very High): 10• Rate the difficulty in donning and working with the SureStep SMOs (1 = Very Difficult; 10 = Very Easy): 3• Comments: Aniyah is running now! We are all excited about her SMO's. I was very excited when she received

them! Her feet were sideways and I was very concerned about her coordination in the beginning, and the PT,Miranda pointed that out to us. Thank you everyone for her care!

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PT QUESTIONAIRRE• How satisfied are you with the SureStep SMOs (1 = Not at all; 10 = Very

Satisfied)? 10• Rate your child’s activity level without SureStep SMOs (1 = Not at all; 10 =

Very Active): 7• Rate your child’s activity level with SureStep SMOs (1 = Not at all; 10 =

Very Active): 8• Rate your child’s coordination when active without SureStep SMOs (1 =

Not at all; 10 = Very Coordinated): 6• Rate your child’s coordination when active with SureStep SMOs (1 = Not at

all; 10 = Very Coordinated): 7• Rate your child’s endurance without SureStep SMOs (1 = Not at all; 10 =

Very High): 9• Rate your child’s endurance with SureStep SMOs (1 = Not at all; 10 = Very

High): 9• Rate the difficulty in donning and working with the SureStep SMOs (1 =

Very Difficult; 10 = Very Easy): 10• Additional comments: The SureSteps really gave Aniyah the support and

alignment necessary to progress with her gross motor skills.

NORMAL – RATE OF CHANGE = 0.51PATIENT – RATE OF CHANGE = 0.25**RATE OF CHANGE WAS TWICE AS FAST!!**PASSED A “TYPICAL CHILD”




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TYPICAL

ANIYAH

DEVELOPMENTAL DELAY ATBEGINNING = 3 MONTHSDEVELOPMENTAL DELAY AT END(16 WEEKS) = -1 MONTHS*WE GAINED 4 MONTHS IN 16WEEKS

CORWIN

• 16 MONTHS OLD AT START OF STUDY• DX: DEV DELAY, HYPOTONIA, PRONATION• WAS PULLING TO STAND FOR ~1 MONTH. NOT YET TAKING

INDEPENDENT STEPS• RECEIVED PHYSICAL THERAPY 1X/WEEK FOR DURATION OF

STUDY

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GAIT ANALYSIS• Day 1: Not walking

• Month 1: Medium base of support; medium guard. Parent reports he is walkingeverywhere - not crawling anymore

• Month 2: Narrowed BOS; arms dropped to side. Doing great in the grass/onuneven surfaces

• Month 3: Carrying large objects with narrow BOS, starting to pick up velocity

• Month 4: Picks up velocity (almost running), very steady.



Coordinated): 10• Rate your child’s endurance without SureStep SMOs (1 = Not at all; 10 = Very High): 7• Rate your child’s endurance with SureStep SMOs (1 = Not at all; 10 = Very High): 9• Rate the difficulty in donning and working with the SureStep SMOs (1 = Very Difficult; 10 =

Very Easy): 10

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PT QUESTIONAIRRE• How satisfied are you with the SureStep SMOs (1 = Not at all; 10 = Very Satisfied)?

10• Rate your child’s activity level without SureStep SMOs (1 = Not at all; 10 = Very

Active): 7• Rate your child’s activity level with SureStep SMOs (1 = Not at all; 10 = Very

Active): 10• Rate your child’s coordination when active without SureStep SMOs (1 = Not at all;

10 = Very Coordinated): 6• Rate your child’s coordination when active with SureStep SMOs (1 = Not at all; 10 =

Very Coordinated): 8• Rate your child’s endurance without SureStep SMOs (1 = Not at all; 10 = Very

High): 10• Rate your child’s endurance with SureStep SMOs (1 = Not at all; 10 = Very High): 10• Rate the difficulty in donning and working with the SureStep SMOs (1 = Very

Difficult; 10 = Very Easy): 10• Additional comments: Automatically noticed decreased BOS and ER of left LE and

increased toe grip with SureSteps on. Received SureStep on 2/8/12 and startedindependent stance x a few seconds with increased balance in standing withinone week and taking independent steps by 2/20/12. On 3/5/12 he was able totake 28 steps independently with encouragement

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TYPICAL

CORWIN





DEVELOPMENTAL DELAY ATBEGINNING = 6 MONTHSDEVELOPMENTAL DELAY AT END (16WEEKS) = 2 MONTHS*WE GAINED 4 MONTHS IN 16 WEEKS

HAYDEN

• 15 MONTHS OLD AT START OF STUDY• DX: DEV DELAY, PRONATION, HYPOTONIA• WAS PULLING TO STAND FOR A COUPLE OF WEEKS. NOT YET

TAKING INDEPENDENT STEPS• RECEIVED PHYSICAL THERAPY 1X/WEEK FOR DURATION OF

STUDY• VERY HESITANT/CAUTIOUS

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GAIT ANALYSIS• Day 1: Not walking

• Month 1: Very wide BOS, needs 2 hands held; veryunsteady

• Month 2: Faster velocity with walking toy, looks steadier(with one hand held)

• Month 3: Started taking independent steps - very wide baseof support, high guard, unsteady

• Month 4: Narrower base of support, much steadier, low tomedium guard



Coordinated): 8• Rate your child’s endurance without SureStep SMOs (1 = Not at all; 10 = Very High): 4• Rate your child’s endurance with SureStep SMOs (1 = Not at all; 10 = Very High): 8• Rate the difficulty in donning and working with the SureStep SMOs (1 = Very Difficult; 10 =

Very Easy): 10

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PT QUESTIONAIRRE• How satisfied are you with the SureStep SMOs (1 = Not at all; 10 = Very Satisfied)?

10• Rate your child’s activity level without SureStep SMOs (1 = Not at all; 10 = Very

Active): 3• Rate your child’s activity level with SureStep SMOs (1 = Not at all; 10 = Very

Active): 8• Rate your child’s coordination when active without SureStep SMOs (1 = Not at all;

10 = Very Coordinated): 2• Rate your child’s coordination when active with SureStep SMOs (1 = Not at all; 10 =

Very Coordinated): 8• Rate your child’s endurance without SureStep SMOs (1 = Not at all; 10 = Very

High): 3• Rate your child’s endurance with SureStep SMOs (1 = Not at all; 10 = Very High): 8• Rate the difficulty in donning and working with the SureStep SMOs (1 = Very

Difficult; 10 = Very Easy): 10• Additional comments: Overall improvement in alignment from foot to head.

Improved truncal/postural control. Improved stability gave confidence to a verycautious little girl. Walking started within 3-4 weeks after receiving SureStepSMOs. Improved overall static standing balance. I love them





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TYPICAL

HAYDEN

DEVELOPMENTAL DELAY ATBEGINNING = 5 MONTHSDEVELOPMENTAL DELAY AT END (16WEEKS) = 1 MONTHS*WE GAINED 4 MONTHS IN 16 WEEKS

JEREMIAH


LIGAMENTOUS LAXITY• WAS PULLING TO STAND FOR A COUPLE OF


DURATION OF STUDY

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GAIT ANALYSIS

• Day 1: Not walking• Month 1: Walking with 2 hands held; unstable

with 1 hand held• Month 2: Wide BOS, externally rotated, high

guard. Starting independent steps.• Month 3: Stable with no hands held. Wide

base• Month 4: Narrow BOS; carrying objects

DAY 1 – BAREFOOT

DAY 1 – SMOS






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TYPICAL

JEREMIAH

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KATE


LIGAMENTOUS LAXITY• WAS PULLING TO STAND AND CRUISING FOR A

MONTH. NOT YET TAKING INDEPENDENTSTEPS

• RECEIVED PHYSICAL THERAPY 1X/WEEK FORDURATION OF STUDY

GAIT ANALYSIS

• Day 1: Not walking• Month 1: Walking with 1 hand held, behind

push toy, starting some independent steps• Month 2: Medium guard, narrowing BOS• Month 3: Stable with no hands held, narrow

base, speed increasing


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TYPICAL

KATE

SAWYER


LIGAMENTOUS LAXITY• WAS PULLING TO STAND FOR A COUPLE OF


DURATION OF STUDY

GAIT ANALYSIS

• Day 1: Not walking• Month 1: Taking some independent steps –

transferring between supports, wide BOS, highguard

• Month 2: Narrowing BOS, lower guard,walking independently

• Month 3: Stable with no hands held, Widebase, speed increasing

• Month 4: Narrow BOS; carrying objects,walking on uneven terrain

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TYPICAL

SAWYER

• Martin (2004) Effects of supramalleolar orthoses onpostural stability in children with Down syndrome– 17 children with Down syndrome– Ages 3 years 6 months to 8 years– 10 week study– Each child his own control– Provided with SureStep orthoses– Tested with the Gross Motor Function Measure (GMFM) using

dimensions D (Standing) and E (Walking, Running and Jumping)

Martin, K. Effects of supramalleolar orthoses on postural stability in children with Down syndrome.Dev Med Child Neurol. 2004;46:406-411.

HYPOTONICITY

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• SureStep is provided through local O&P professionals.• SureStep is a patented product

– US Patent #: 6,517,505 B1

• Only fabricated by SureStep• Accept no substitutes, copies, knock-offs, or imitations.

How to Obtain SureStep

Custom Fabricated

• To measurements: NO CASTING REQUIRED!!!• Nine simple measurements.

– 3 Circumference– 2 M-L (Width)– 2 Length– 2 Height

Measuring Videosurestep.net

Clinicians Corner

SureStep Support• Turn around:

– 2 business days (measurements)– 4 business days (Casts)

• 6 business days (Poor Casts)• 8 business Days (Terrible Casts)

• Technical/Clinical Support– Pediatric Specialists

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Other SureStep Products

• 50 lbs. and up.• No weight limit.

Custom Fabricated to Measurements(Less than 3” at #5 measurement)

Custom Fabricated to Cast(3” and up at #5 measurement)

4 Business Day Fabrication

BigShot Lite Version forPatients up to 90 lbs.

BigShot Standard Versionfor Patients over 80 lbs.

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Stance Stability

SureStep Indy 2-Stage

Fully Finished SMO inside AFO

AFO can be:• Solid Ankle• Posterior Leaf• Articulated with double

adjustable hinge.• Dorsiflexion Assist• Plantarflexion Assist

SMO can be used independent of AFO

Custom to measurements (under 2 ½” at #5)Custom to cast. (2 ½” and up at #5)

Indy 2-Stage

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Convertible Design

SureStep Plastic

SureStep Flexibility

AFO to SMO in 10 min.

Great for Pre-standersCustom to measurements (under 2 ½” at #5)Custom to cast. (2 ½” and up at #5)

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Super lightweight; 4-6 oz.

Custom fabricated to measurements

Low profile

Will not impede floor mobility

HEKO OTSPrefabricated HEKO Now Available

Super lightweight; 4-6 oz.

Available in 4 standard sizes

Low profile

Will not impede floor mobility

Can be ordered by Orthotists or PTs

Perfect for children up to 50 lbs

HEKO PreFab

Loaners Available For Test Fittings!!!


De-Rotation Straps

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De-Rotation Straps

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Spinal Management Considerations

• Degree of the deformity• Rib Prominence• Shoulder asymmetry• Pelvic Obliquity• Trunk imbalance• “wind swept” hip deformity• Flexibility• Tone assessment

• Presences of abnormal reflexes– Hyporeflexia and Hyperreflexia

• Assessment of functionalimpairments– Ambulation– Sitting balance

Neuromuscular Scoliosis Impact

• Functional independence• Pain• Pulmonary function• Self-image• Social role• Quality of life

Determine treatment plan

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X-ray examination• Challenge due to patients ability to sit on their own

An eight-year-old girl with a 100° scoliosis curve. X-rays show thecurve before and after spinal fusion surgery.Courtesy of Texas Scottish Rite Hospital for Children

Orthotic Goals; Hypotonia• Improve functional ROM

– Often resulting in decreasing hypermobility– Help muscles work in appropriate

length/tension relationships throughcompression

• Provide optimal alignment– Increases stability though better base of support or

center of balance.– Requires less work for the patient

Dynamic Spinal Management

Dynamic Spinal Management

Can Result in:• Improved Posture, Balance and Proprioception• Enhanced Motor Control• Increased Functional Use of Extremities• Delayed Surgical Intervention• Better Speech and Swallowing

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• Extremely Flexible

• Low Profile

• Custom to Meas.

• NO CASTING

• Easily Adjusted

• Available in Several Thicknesses.75mm - 1.25mm - 1.75mm - 2mm – 2.25mm

Hydrostatic pressure:

• Flexible Total Contact system• Compression to maintain alignment• Improve functional sitting abilities• Increased compliance with use• Improved outcome for patients with

neuromuscular conditions

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• Ideal for postural instabilities andflexible kyphosis and lordosis

–Can incorporate an accommodation forthe abdomen as well as the GillModification to provide ease ofbreathing.

SureStep TLSO

• From Measurements, Cast or Scans• Turn around is 4 days in house by Measurements or Scan, and

5 Days by Cast– Rush service available

• Plastic thickness variable on size of mold.• Foam liners out of Volara or Puff• Anterior Window cut out if desired• Gill modifications

Breathing Modifications

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Postural control helps to lead toimproved functional movementand decreased reflex reactions toposture.

Seating systems lack dynamicfunction and do not allow forutilization of postural weightbearing. Leading patients to relyon protective reflexKangas K “Hyperextension, obligatory reflexes, or the Opisthotonic Reation ? Facingthe seating challenges of children whose seating systems do not recognize thisposture.”

Plastizote TLSO

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Late to sitting

Duchenne’s Muscular Dystrophy

• Reported incidence vary between 48-93%• In general, ambulatory patients do not develop scoliosis• Most boys whose disease follows the course are WC dependent at

age 10.• Curve is commonly a c-shaped thoracolumbar curve with pelvic

obliquity

Mullender M, Bloom N, De Kleuver M, et al. A Dutch guideline for the treatment of scoliosis in neuromuscular disorders. Scoliosis 2008; 3:14

DMD Case

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Spina Bifida• A neural tube deficit• Varying degree of nerve involvement & paralysis

below the level of injury.• May have associated congenital spinal or

vertebral abnormalities.• Syringomyelia is a concern

6 y/o with Spina Bifida

OOB75⁰

IB47⁰

SureStep TLSO Design compared to Rigid TLSO

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Update - Curve is the same. Improved sitting

In Seating system

Knowing when to Cast

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Casting

DCO – DYNAMIC CERVICAL ORTHOSIS

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Variable tension setting

Head ptosis (drop)

Resulting in: Associated symptoms are:

• Weakness of the neckextensor,

• or increased tone of the flexormuscles.

• It is characterized by markedanterior curvature orangulation of the cervicalspine

• It is associated with variousneuromuscular (table 1) andextrapyramidal disorders.

Head drop and camptocormia: Umapathi U, July 2002)

• Speech,

• Swallowing,

• Up-gaze (eyes upward) deficits

are often associated.

Indications Contra-Indications• Lack of Head Control• Head Ptosis (Head Drop)• Parkinson’s syndrome• Cerebral Palsy• Multiple Sclerosis• Amyotrophic Lateral Sclerosis• Myopathy

• Hyper rigidity of the neckmuscles or stressed tremor

• Fixed or Fused Neck Position

DCO – Dynamic Cervical Orthosis

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Before & After wearing the DCO…

Before AfterDynamic Head ControlPatient with Head Drop

Head Control…BW36

Therapeutic benefit for adult hyperkyphosis?

BW36 Branden Wawrzyniak, 2/16/2015

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SureStep TLSO – DCO Combo

Without TLSOand DCO

Functional upright postureWith TLSO and DCO

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Children’s Footwear

• Additional ventilation keeps feet cool.• Polyethylene insert in counter.• Broad, round Toe-Box allow improved fit.• Solid sole to ease external modifications.• Two 1/8” removable insoles.• Available in Pink or Blue.• Flexible sole.• Affordable : MSRP only $39.99• Available direct to families at:

www.surestep.net

Children’s Footwear

• Built on same Last as SureStepshoes.

• Available in Pink or Black

• Sizes from Toddler 3 to Youth 12.

• Flexible sole.

• Affordable : MSRP only $39.99

• Available direct to families at:www.surestep.net

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Sophia

• 6 Years Old• Idiopathic Toe Walker• Decreased passive and active ROM into Dorsiflexion• Has tried footplates and has overpowered them.

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Barefoot

Left

Right

Cyclogram

KiddieGaitAFOs

Left

Right

Cyclogram

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Example – Shelby

bernie veldman, co certified orthotist -...

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