october 2013 aacpdm 67 annual meeting milwaukee, wi 1 · october 2013 aacpdm 67th annual meeting...

Subjective versus Objective evaluations for lower limb orthotic prescription: beliefs vs. evidence and the laboratory versus patient environment

October 2013 AACPDM 67th Annual Meeting Milwaukee, WI 1

beliefs vs. evidence and

patient environment vs. the laboratory

1. Discuss typical alignment and functional goals in orthotic prescription. 2. Review some available literature guiding orthotic prescription. 3. Explore gait analysis data for evidence suggestive of improved function and/or alignment with the application of orthotics. 4. Consider the short-term and long-term goals in orthotic prescription and how patient goals and compliance influence prescription choice.

Why we like orthotics: Improving gait, allow earlier acquisition of

gait

Providing support and balance for weak muscles

Allowing greater efficiency for more proximal muscle groups

Help to maintain ROM and integrity of foot alignment/structures

Why we don’t like orthotics: Worsen gait

Patients may prefer to not have them

They are expensive

They are rapidly outgrown

They may slow kids down, reduce floor mobility, more likely to W-sit, challenge floor to stand and sit to stand skills, reduce stair mobility, limit balance reactions

Inhibit sensory input to the bottom of the foot, makes negotiating uneven surfaces hard

Solid AFO's inhibit force production and push off from the gastroc and contribute to weakness/limit strengthening of the df’s and pf’s

Fit is challenging

How do you choose what orthosis to recommend? What you want for the patient?

What the patient wants?

What the parent wants?

What another care provider recommends?

Goals??

What does the patient want? Family?

To walk

To walk more typically

To maintain ability to walk

Less falls

More mobility

To keep up with peers

To appear more typical

Pain free, more comfortable

Avoid surgery

Lessen surgery

Morris C et al. 2011

Some Guidance



24 academics, research scientists and healthcare professionals with expertise in CP

Reviewed the evidence and considered current thinking re: orthoses management in CP

Aim is to enable culturally appropriate activities and participation by: Promoting efficient movement Limiting deformity Reducing pain Employing cognitive/behavioral strategies

Healthcare team (orthotist, therapist, physician, bioengineer, etc) must collaborate with the family, taking into consideration medical issues and the family’s goals and priorities

Classification of functioning should follow the WHO ICF guidelines, and furthermore for CP the GMFCS and MACS: ie: goals for GMFCS I – III = gait and deformity

goals ie: goals for GMFCS IV – V = improving sitting

posture, upright standing


Swing phase problem?

Stance phase problem? Causing problems at the knee? Hip?

Correction of these problems may improve mobility.


In general AFO’s:

increase velocity of gait …but in diplegics may have little or no

effect

reduce cadence …but in diplegics may have little or no

effect

Increase step length

Increase stride length

Increase duration of single support


AFO’s can improve ankle kinematics

Restrict ankle joint motion reduce power generation and

absorption at the ankle, but…

increase 2nd peak of GRF in propulsive phase

AFO’s can improve knee and hip kinematics and kinetics

GRF is manipulated to affect the knee/hip Hinged vs. Flexible (with fine tuning of

stiffness)

“Tuning” of sagital plane ankle alignment

Tibia with fwd inclination may be beneficial even if ankle must be set in pf to do so


O2 consumption may be decreased by AFO use

Self selected walking speed increases


Stretching to reduce need for achilles lengthenings

(Weakness of gastroc-soleus??)




STS improves with AFO’s on if the wearer is more than one SD below mean speed The use of df is the consistent way to

improve STS

…but use of articulated AFO when there is pf cntrx is controversial (facilitates midfoot breakdown)

Stair function is not impaired

Can improve standing balance

Little effect if at all on sitting and/or UE function

Utility of posture and alignment in standing frames is limited

Effects on gait?


Recommended Data to Gather:

Age

Sex

Type of CP

GMFCS level

Recent surgery

Medication interventions

ROM of all lower limb joints (easy or difficult to attain?)

Rotational deformity

Strength

Spasticity

Description of gait with and without orthoses

AFO description Design (custom/prefab)

Construction (materials, type, straps/fastenings)

Alignment of leg in orthoses (sagital, coronal and transverse planes for ankle)

Alignment of orthoses to ground (sagital plane)

Footwear and its design (heel-sole differential, stiffness of sole)

Dosage (duration of use)

Side effects


Morris C, Bowers R, Ross K, Stevens P, Phillips D. Orthotic management of cerebral palsy: Recommendations from a consensus conference, 2011. Neuro Rehab 28, 37-46.

Ries, Andy, Rozumalski, Adam, and Schwartz, Michael. “Do Ankle Foot Orthoses Improve Gait for Individuals with Cerebral Palsy?” Gillette Children’s Specialty Healthcare, St. Paul, United States; University of Minnesota- Twin Cities, Minneapolis, United States.

Owen E. The importance of being earnest about shank and thigh kinematics especially when using ankle-foot orthoses, 2010. Prosthetics and Orthotics International 34(3): 254-269.

Aaron Rasmussen, C. P. O.

Gillette Children’s Specialty Healthcare

St. Paul, MN

Role of Orthoses Alignment Indications Quantifying AFO

stiffness

All orthoses must do one of the following:

Control of motion

Correction of deformity

Compensation for weakness

Carlson, “Orthotic management of the Lower Limb of Children with Cerebral Palsy.”



A specific treatment goal

Helps to “personalize” the purpose for the orthosis

Will increase the likelihood of success

Alignment issues which can be improved with orthoses

Available ROM & muscle power

Stability in stance

Clearance in swing

Prepositioning of the foot in terminal swing

Adequate step length

Energy conservation

Be aware of how ankle angle, shoe heel height, toe plate flexibility, and other factors affect gait

Patients activity level/types of activities Goals of patient/parent/ physician/PT/OT

Unfortunately, we can not always achieve all orthotic goals with a single orthotic design

Foot orthoses are the foundation for lower limb management… each and every more proximal orthosis is first and foremost an FO”

("Atlas of Orthoses and Assistive Devices" 209-224)



3 point pressure system for talipes varus

3 point pressure system for talipes valgus

In children with neuromuscular disorders, pes valgus is the 2nd most common foot deformity

Equinus is the most common “position“ we deal with in this group

Carlson and Berglund, “An Effective Orthotic Design for Controlling the Unstable Subtalar Joint.” Carlson and Berglund, “An Effective Orthotic Design for Controlling the Unstable Subtalar Joint.”

A patient with forefoot varus may display hindfoot valgus (eversion) during weight bearing as a method of compensation for the forefoot deformity



Brief discussion of materials used in fabrication

Review of some common lower extremity orthoses and their indications

Thermoplastics Copolymer vs.

polypropylene

Carbon fiber

Provides improved midfoot and forefoot control, primarily through plantar surface forces

Improved midfoot and forefoot control can affect rearfoot position

Effective in controlling flexible deformities of the subtalar and midtarsal joints:

calcaneal eversion/inversion

midfoot instability

forefoot adduction/

abduction

Provides improved heel, midfoot, and forefoot alignment Provides improved

medial-lateral ankle stability Standard trimlines

allow normal 1st, 2nd, and 3rd rocker

Provides clearance during swing, pre-positions the foot for initial contact

Controls lowering of the foot toward the ground

Allows dorsiflexion necessary for tibial advancement over the foot

Flexibility can be fine-tuned for a variety of treatment goals



Provides m-l stability

Plantar flexion stop can affect genu recurvatum in stance and foot clearance in swing

Typically allows free dorsiflexion

Adjustable ankle joints can be used, but have limitations (bulk, durability)

Must have adequate ROM

Dorsiflexion is obtained through the midtarsal joint, not the ankle joint aka the “little ankle” Anatomical motion

does not occur at mechanical ankle joint, thus causing pressure and fit issues with the orthosis

Provides maximum stability in frontal and sagittal planes Provides tri-planar

immobilization of the ankle-foot complex Ankle angle affects

knee and hip motion

Properties and indications are similar to solid AFO. Floor reaction AFO has an anterior proximal tibial shell which promotes knee extension in mid through terminal stance Note foot progression

angle

BRUCE measures the

angle of the ankle when

bending the AFO and the

force it produces

Finds a relationship

between ankle

angle/force

Gait lab can separate

the force provided by an

AFO and the force provided by the patient

BR

UC

EBRUCE

Current practice = Stiff to Flexible

Cannot reverse

Short Term: Is there an ideal stiffness for a pls AFO?

Long Term: By using a specific patients' gait lab data can we predict (and provide) the optimal stiffness of AFO?



Thank You! Atlas of Orthoses and Assistive Devices. 3rd. 1. St. Louis: Mosby, 1997. 209-224. Print.

Carlson, J. Martin, and Gene Berglund. "An Effective Orthotic Design for Controlling the Unstable Subtalar Joint ." Orthotics and Prosthetics. 33.1 (1979): 39-49. Print.

Carlson, J. Martin. "Orthotic Management of the Lower Limb of Children with Cerebral Palsy." (2001): Print.

Clinical Aspects of Lower Extremity Orthotics. Second Edition. Winnipeg: Canadian Association for Prosthetics and Orthotics, 1993.

Goldberg, Bertram, and John D. Hsu. Atlas of Orthoses and Assistive Devices. Third Edition. St. Louis: Mosby, 1997.

Kroll, G. (2008) Meeting Treatment Objectives Through Proper Orthotic Design & Application [PowerPoint Slides]. Gillette Children’s Specialty Healthcare: Assistive Technology Department.

Sohrweide, S. (2008) Clinical Evaluation of Foot Deformities. [PowerPoint Slides]. Gillette Children’s Specialty Healthcare: Center for Gait and Motion Analysis

Ries, Andy, Rozumalski, Adam, and Schwartz, Michael. “Do Ankle Foot Orthoses Improve Gait for Individuals with Cerebral Palsy?”. Gillette Children’s Specialty Healthcare, St. Paul, United States; University of Minnesota- Twin Cities, Minneapolis, United States.

Data guiding orthoses prescription

Introduce/review gait analysis Elements of a gait analysis

Terms kinematics and kinetics

Gait graphs

Understand role of gait analysis data in orthoses prescription

Knowledgeable participant in presented case studies that utilize gait analysis data to guide orthoses prescription

It provides useful information about the intricacies of an individual’s gait, as well as how far the individual’s walking pattern deviates from normal

Split screen video Augments kinematics/kinetics

Physical exam Provides useful information about many

things that gait analysis does not directly measure (boney torsion, foot deformity, strength, motor control etc.)

Kinematics Quantitative 3-dimensional measurement

of motion

Kinetics Measurement of moment and power

generation

Dynamic EMG On-off signals of individual muscles

Metabolic energy assessment Oxygen consumption

Pedobarography Dynamic foot pressure







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140+ measurements

Ph

ysic

al E

xam

What is needed to optimize effectiveness of an orthoses? Proper skeletal alignment

Absence of contractures

Adequate strength

Adequate motor control



The motions of the segments in space and relative to one another

Utility objective specific joint angular changes

accurate pre and post-treatment measurement

accurate comparison of barefoot vs. braced walking

Limitations only descriptive, can't distinguish cause of

motion disorders

error



PELVIS

HIP

KNEE

ANKLE/ FOOT

FRONTAL SAGITTAL TRANSVERSE

X = GAIT CYCLE

Gray = typical range of motion

Red = left leg

Green = right leg

IC FO

STANCE

SWING

Gait analysis permits evaluation of the specific effect of orthoses (White et al 2002, Bartonek et al 2007)

Motion analysis is routinely performed in and out of orthoses

Allows us to:

Analyze orthotics role in improving/hindering walking

Design more functional orthoses that are best suited to their specific task (Harrington et al 1984, Van Gestel et al 2008)



Left

Right

Barefoot braced

Retrospective study of 686 Gillette patients (1372 limbs) diplegic CP

walking trials collected both barefoot and wearing orthoses (SAFO, PLS, HAFO)

Gait data analyzed for each trial

GDI (Gait Deviation Index) change from barefoot to orthotic was calculated for each limb GDI score is a single number that

represents overall gait pathology

GDI ≥100 indicates normal gait kinematics and each decrement of 10 points is one standard deviation from normal.

GDI change of 5 = 1 level on the FAQ functional walking scale (Schwartz)

Gait changes associated with AFO use among individuals with diplegic CP showed Subjects with poorer kinematics (lower GDI)

derived greater benefit from AFOs than those with milder gait deviations

Small benefit among subjects using assistive devices

Nearly negligible improvement in independent ambulators

AFO design was not a statistically significant factor in predicting changes in GDI among either dependent or independent ambulators

Distribution of GDI changes suggests that while overall response to AFO wear is underwhelming, there are a significant number of good responders (i.e. GDI changes of > 5)

0

5

10

15

20

25

30

35

40

45

50

Freq

uen

cy

Change in GDI [Orth - BF]

GDI Scores

• Average BF GDI 73.8 (SD 10.2) • 60% have positive GDI Change • 25% have +5 or better GDI change • 13% have -5 or worse GDI change • 62% have minimal change (between -5 and +5)

0

10

20

30

40

50

60

Freq

uen

cy

Change in Normalized Walking Speed [Orth - BF]

Change in Normalized Walking Speed [Orth – BF]

• Control ND BF Speed 0.363-0.500 [Schwartz et al. ‘08] • Average ND BF walking speed 0.315 (SD 0.112) • 88% of slow walkers (ND Speed<0.363) have speed increase

• Relative increase of 34% • 12% of slow walkers have speed decrease

• Relative decreased of 10%

Focus on identifying patient characteristics that lead to meaningful positive gait changes with use of AFO’s Random Forest Algorithm predictive model that is essentially a

collection of small decision trees; It takes a bunch of data, sifts through it to find the helpful/important information, and then makes a prediction based on that information.

RF data available for the case studies we will be looking at

Barefoot data will be collected and run through the RF to make prediction on orthoses type which would be best for that child

Predicted orthoses will be made and child will use it for 6 weeks, then return to motion lab

Data will be collected in predicted brace, GDI will be calculated and then compared to the actual predicted GDI using the RF.

Analyze the existing prescription algorithm in an effort to improve AFO efficacy BRUCE



Show barefoot video Audience response re: orthoses design

Add physical exam measurements Audience response re: orthoses design

Add barefoot gait data Audience response re: orthoses design

Look at gait data in prescribed orthoses

Discussion

8+4 y/o male

CP spastic quadriplegia

GMFCS III

Surgical history SDR 2009

SEMLS 2011

Bilateral femoral external derotation osteotomy.

Right tibial internal derotation osteotomy.

Bilateral calcaneal lengthening.

Bilateral first metatarsal plantar flexion osteotomy.

Bilateral Baker-type gastrocnemius/soleus lengthening.

Referred for 1 year post ortho surgery gait lab

Family is concerned about patient’s endurance, strength and gait pattern.

Parental goal is for patient to be able to walk independently with his walker or crutches.

Case #1

I would prescribe the following orthoses

1. None

2. UCBL

3. SMO

4. PLS

5. HAFO

6. SAFO

7. GRAFO



Left Right

Hip extension WNL WNL

Anteversion 25° 10°

Tibial torsion (BM) 30° 15°

Knee extension WNL with stretch WNL with stretch

Popliteal angle 30° (from vertical) 40° (from vertical)

Patella alta yes yes

Extensor lag 40° 30°

Ankle dorsiflexion ROM (90/0)

25°/10°

30°/15°

WB foot (RF/MF/FF) val/pla/abd/mild val/pla/abd/mod

Hip ext. strength 2+/5 2+/5

Quad strength 5/5 (in available range) 5/5 (in available range)

AJ DF strength 2+/5 3-/5

AJ PF strength 2/5 2/5

Spasticity absent absent 1 2 3 4 5 6 7 8

0% 0% 0% 0%0%0%0%0%


1. None

2. UCBL

3. SMO

4. PLS

5. HAFO

6. SAFO

7. GRAFO

Sagittal Transverse

L R

*

*

*

*

*

1 2 3 4 5 6 7 8

0% 0% 0% 0%0%0%0%0%


1. None

2. UCBL

3. SMO

4. PLS

5. HAFO

6. SAFO

7. GRAFO

Left BF vs. SAFO Right BF vs. SAFO

*

*

*

*

*

*

*

*

GDI

Walking trial conditions

Left Right Average

Barefoot, walker 67 66 67

B – SAFO, walker 71 75 73 (one of 25% that had +5)

Gait deviation index (GDI) is a scaled measure of gait pathology. A GDI value equal to or greater than 100 equates to a normal gait.



SAFO PLS HAFO SMO UCBL

Left 3.9 (+4) 2.0 .5 -1.0 1.5

Right 3.1 (+9) 1.6 -2.0 -3.1 2.8

Predicted Change in GDI using RF (+ number = improvement)

Linear Parameters

Barefoot video SAFO video

6+8 y/o female

Lumbosacral level mylomeningocele

Referred for initial gait lab

Surgical history

Closure of spinal defect

Shunting

Family concerned about the possible future deterioration of patient’s gait and how this may get to the point that patient will be unable to walk.

Family goals are for patient to maintain/improve mobility

Case #2

1 2 3 4 5 6 7 8

0% 0% 0% 0%0%0%0%0%


1. None

2. UCBL

3. SMO

4. PLS

5. HAFO

6. SAFO

7. GRAFO



Left Right

Hip extension 10° (contracture) 10° (contracture)



Knee extension WNL WNL with stretch

Popliteal angle 25° 25°

Patella alta no no

Extensor lag no no


25°/25° 25°/20°

WB foot (RF/MF/FF) typ/typ/typ typ/typ/typ

Hip ext. strength 2+/5 2+/5

Quad strength 5/5 5/5

AJ DF strength 5/5 5/5

AJ PF strength 2-/5 2/5

Spasticity absent absent 1 2 3 4 5 6 7 8

0% 0% 0% 0%0%0%0%0%


1. None

2. UCBL

3. SMO

4. PLS

5. HAFO

6. SAFO

7. GRAFO

Sagittal

Transverse

L R

*

*

*

*

*

1 2 3 4 5 6 7 8

0% 0% 0% 0%0%0%0%0%


1. None

2. UCBL

3. SMO

4. PLS

5. HAFO

6. SAFO

7. GRAFO

Left BF vs. GRAFO Right BF vs. GRAFO

GDI


Left Right Average

Barefoot 82 75 79

B – GRAFO 89 83 86 (+7)




Barefoot video GRAFO video

Left A : B Right A : B

Hip extension 10° : WNL 10° : WNL

Anteversion 50° : 20° 35° : 25°

Tibial torsion (BM) 0° : 20° 15° : 10°

Knee extension WNL : WNL WNL with stretch: WNL

Popliteal angle 25° : 50° 25° : 55°

Patella alta no : no no : no

Extensor lag no : no no : no


25°/25° : 0°/0° 25°/20° : 10°/0°

WB foot (RF/MF/FF) typ³ : val/pla/abd typ³ : val/pla/abd

Hip ext. strength 2+/5 : 3/5 2+/5 : 3-/5

Quad strength 5/5 : 5/5 5/5 : 5/5

AJ DF strength 5/5 : 3-/5 5/5 : 1/5

AJ PF strength 2-/5 : 2+/5 2/5 : 2+/5

Spasticity absent : absent absent : absent

Barefoot video

Barefoot L/R kinematics (sagittal)

GRAFO video

BF vs. GRAFO kinematics (sagittal)

BF vs. GRAFO Kinematics

(transverse)

BF vs. GRAFO Kinetics


GDI


Left Right Average

Barefoot 91 76 83

B – GRAFO 76 69 73 (-10)




Left 1.6 (-15) 8.4 5.3 -2.6 0.9

Right 2.9 (-7) 8.6 5.5 -3.6 -2.1


Linear Data

10+8 y/o male CP spastic diplegia GMFCS II Referred for orthotic recommendations and

repeat gait lab study Surgical history SDR 2004 SEMLS 2003 Bilateral femoral derotational

osteotomies. Right gastrocnemius lengthening. Botulinum toxin type A injections to the

bilateral gastrocsoleus, medial hamstring and hip adductor musculature.

Family is primarily concerned with crouching and improper heel-toe step

Family expectations and goals “No crouching; maintain good gait habits.” Feel better about himself and be able to do

more at home and school. Participate more in recreational activities

and sports. Free from disability or pain as an adult.

1 2 3 4 5 6 7 8

0% 0% 0% 0%0%0%0%0%


1. None

2. UCBL

3. SMO

4. PLS

5. HAFO

6. SAFO

7. GRAFO

Left Right

Hip extension WNL WNL with stretch



Knee extension -5° (hyperextension) -5° (hyperextension)

Popliteal angle 45° 55°

Patella alta no no

Extensor lag no no


10°/0° 10°/5°

WB foot (RF/MF/FF) typ/typ/typ typ/pla/abd/mod

Hip ext. strength 5/5 4+/5

Quad strength 5/5 5/5

AJ DF strength 4+/5 4/5

AJ PF strength 4+/5 4/5

Spasticity absent absent



1 2 3 4 5 6 7 8

0% 0% 0% 0%0%0%0%0%


1. None

2. UCBL

3. SMO

4. PLS

5. HAFO

6. SAFO

7. GRAFO

Sagittal

Transverse

L R

1 2 3 4 5 6 7 8

0% 0% 0% 0%0%0%0%0%


1. None

2. UCBL

3. SMO

4. PLS

5. HAFO

6. SAFO

7. GRAFO

Left BF vs. SAFO vs. SMO Right BF vs. SAFO vs. SMO

GDI


Left Right Average

Barefoot 85 86 85

B – SAFO 84 93 88 (+3)

B - SMO 91 93 92 (+7)



Left 2.8 (+1) 6.4 5.5 -2.3 (+6) 0.5

Right 5.9 (+6) 6.4 8.2 2.2 (+7) 1.5




Linear data Barefoot

SAFO

SMO

october 2013 aacpdm 67 annual meeting milwaukee, wi 1 · october 2013 aacpdm 67th annual meeting...

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