Chapter 32: Orthoses for persons with postpolio sequelae Flashcards
What is postpolio sequelae?
A combination of Postpolio paralysis (PPP)
and Postpolio syndrome (PPS) results in overlaping complicated factors as a results of acute postpolio.
The term poliomyelitis is derived from what greek words?
Polio: Gray
Myelitis: infectious process of the spinal cord.
So infection occurs exclusively in the gray matter of the spinal cord.
How many types of polio virus are there?
3
How is the polio virus transmitted to humans?
Through contact with infected air droplets or ingestion of ocntaminated water or other liquids.
What vaccines are used for the polio virus?
Salk vaccine
Sabin vaccine
What percent of polio survivors get postpolio syndrome?
25-70%
What often causes patient to seek orthotic management of their postpolio symptoms?
Development of pain and weakness in the contralateral or “strong” side”
Patient with postpolio sequelae have heightened what?
Sensation and may have difficulty accepting the feel of the brace.
What is a frequent gait compensation in patients with postpolio?
Excessive hip flexion during limb advancement
What are some disadvantages of the carbon fiber KAFO?
Skin irritation
excessive sweating
The need for exact fit
Inability to change the device after initial fabrication
No way to accomodate weight gain or swelling
Greater manufacturing time.
Greater expense.
In the lock mode of a KAFO what degree of flexion is the knee in?
6 degrees
With a stance-phase lock, what are the degrees of flexion seen?
17 degrees flexion and progressed to 55 degrees.
Stance control knee joint decreased what?
Transverse plane pelvic rotation by 6 degrees and overall excursion through the entire gait cycle by 6 degrees.
What questions should be asked to determine the appropriate orthotic treatment for patients with postpolio sequelae?
Past orthotic management Surgical interventions Existing painful joints Vocation and nonvocation activities Falls Patient's posture Gait analysis
What are the goals of AFOs?
Stabilize and protect the joints of the foot and ankle and provide swing phase clearance and stance phase stability as well as affect knee kinematics.
What are the common AFOs used for postpolio sequelae?
Posterior leaf spring AFO Solid ankle AFO Articualted plastic AFO Ground reaction AFO Articulated rear entry ground reaction AFO Metal double upright AFO
What does a posterior leaf spring AFO do?
Provides clearance of the foot through swing phase.
It has little impact during stance phase, so it requires a patient to have good stance phase stability.
It permits smooth advancement from initial contact to loading response and eliminates foot slap.
What does a solid ankle AFO do?
Provid a high degree of control to the ankle-foot complex during stance. It provides good control of dorsiflexion, plantaflexion, inversion, and eversion.
It can control movement in the transverse plane.
This is good for patient’s with fused ankles
What is often added when a patient gets a solid ankle AFO?
A rocker to the shoe.
When should a rocker not be added to a shoe?
Patients with weak quads and feel unstable with the rocker.
What does the articulated plastic AFO do?
Allows movement fore and aft, premitting the anatomical ankle to move through a specific ROM.
What should be considered with choosing the ankle joints of an articulated plastic AFO?
All but the DAAJ cannot control the high loads to control dorsiflexion. So they should be limited to lightweight or limited ambulation patients.
What does a ground reaction AFO do?
Provides a poeterioly directed force to the knee in stance by blocking the forward tibial advancement. It can accept the entire weight of the patient and protects the painful ankle.
How should the ground reaction AFo be set?
In a few degrees of forward tilt when sitting in the shoe.
What does the articulated rear entry ground reaction AFO do?
It resists the deforming forces that occur in stance phase without reinforcement.
The dorsiflexion stop can be made adjustable.
It typically allows for 5 degrees of plantaflexion and 5-10 degrees of dorsiflexion, to permit swing phase clearance and good stance pahse control without disruption of early or late stance phase rockers.
This will decrease imbalance and energy expenditure.
When is a metal double upright AFO considered?
Patients with fluctuating edema or those who have worn a metal device for years and are unwilling to consider changing.
What does the anterior compartment of a DAAJ do with a pin?
controls anterior tibial advancement in stance and creates a knee extension moment at heel off.
Would a spring work in the anterior compartment?
NO. it is unable to efffectibely resist dorsiflexion as the patient’s body weight is transferred to the stance side.
Should a dorsiflexion assist be used in a DAAJ?
Cautiously, in isolation and only in individuals who have strong plantarflexors, or else it can totally dimenish the already weakened plantarflexors.
When should a KAFO be considered?
When buckling or hyperextension of the knee occurs.
It can also partially deweight the limb
When would a quadrilateral or ischial containment KAFO design be used?
Patients currently wearing KAFOs and whose chief complaint is contralateral side pain, fatigue or increased weakness.
What are the different types of knee joints?
Posterior offset Drop (ring) lock Bail and lever lock Adjustable flexion and extension ring lock knee joints Stance control knee joints
Posterior offset knee joints can be used effectively when patients present with what?
Unilateral hyperextension of the knee.
The knee is not corrected to 180 but is set in a number of degrees of hyperextension that permits the patient to feel secure and safe in transferring his or her weight over the involved side.
What does the posterior offset knee joint do?
It reduces the stress on the posterior capsule of the knee.
Should the knee be locked in a KAFO with a posterior offset knee joint?
NO. It forces the patient to hike the hp and circumduct the leg, which increases energy expenditure.
How can one determine how much hyperextension should be present in a kAFO with a posterior offset knee joint?
Patient holds a walker in front of them. Place the back and popliteal fossa of the involved knee against the wall. Assist the patient to slowly move his or her back closer to the wall, forcing the patient to straighten the knee. Simultaneously ask the patient if th eknee feels like it’s about to buckle. Once the patient feels like the knee is too unstable, reverse the movement until the patient feels secure again and note the angle of the knee. The orthosis should be built at this angle plus 5 degrees of hyperextension.
When are drop (ring) locks used?
When patients have lower extremity weakness including weak quads.
What is the drop lock designed to do?
Keep the knee locked anytime the patient is standing.
What can be added in a drop lock that can assist the patient in unlocking the knee? What is more difficult when this is added?
Ball retainers
It may increase difficulty of the sit-to-stand transition because the patient must bend down to lock both sides.
What is the bail and lever locks designed to do?
Permit simultaneous locking and unlocking of both the medial and lateral knee joints. It mimics the drop locks, but is easier to wear.
What is the drawback of the bail and lever locks?
It can be inadvertently disengaged when bumped, causing sudden unlocking of the knee and a possible fall.
What was made to resolve the problem of bail and lever locks from getting bumped?
The cable locking system
What is the advantage of the cable locking system in a bail and lever lock knee joint?
it eliminates the need to bend forward to unlock the knee joints. This benefits patients with poor muscle strength or poor balance.
What are adjustable flexion and extension rock lock knee joints designed to do?
Accommodate individuals with knee flexion contracture and can be adjusted to match the flexion of the patient’s knee. The ring lock will drop when the desired angle is achieved.
What are stance control knee joints designed to do?
Provide the patient with a stable knee during stance phae and an automatically free knee during swing phase
What is the advantage of the stance control knee joint over the locked knee?
Reduction in hip hiking and circumduction in swing and lower energy consumption.
How do stance control knee joints operate?
A variety of mechanisms ranging from electronic switch activation with a microprocessor control to a simple mechanical switch.
Stance control knee joints are good for what population?
Polio survivors with unilateral involvment that perviously would have required a locking knee.
No contractures and have the ability and motivation to work through a training period.
The standard thigh section, is only useful for which patients?
Patients who are limited ambulators or when wearing bilateral KAFOs.
What are the benefits of the quadrilateral and ischial containment thigh sections?
The transfer of weight to the involved side, extending the stance side period on the involved side and provides more effective balance to the patient’s gait and reducing stress and strain on the stronger of the patient’s legs.
What’s a disadvantage of the metal and leather KAFO?
Limmited contact of the rigid bands with the limb. This reduces the amount of control possible with the device, particularly in the transverse plane.
It can also result in limb deformation within the orthosis.
What muscles must be present to use a KAFo stance control knee joint?
Some hip flexor and quad strength exist.
Sufficent balance must also exist.
What muscles are severely weak o suggest a dro plock knee joint disease?
Severe quad and gluteus maximus wekaness, with not hyperextension, but has severe knee buckling.
What are the possible orthotic options for a patient who discontinued orthosis wear in childhood or adolescence. Their stronger leg is becoming fatigued more quickly or painful, or patient is tripping and falling more often.
AFO: Ground reaction, articulated with dorsi stop, dorsiflexion assist, and plantarflexion stop.
KAFO: on weaker side with ischial or quad style thigh section with drop lock or posterior offset knee joint, depending if there is hyperextension or not.
It will have a DAAJ with pin anteriorly and spring posteriorly.
Consider a stance control knee joint when the patient has fair-to-good hip flexors, poor-to-fair quads and sufficient balance.
What possible orthoses should be given to a patient with unilateral painful knee with hyperextension greater than 15 degrees?
KAFO: Posteriorly offset knee joint, with a rigid anterior thigh section and a posterior leaf spring type AFO
What orthoses should be given to a patient with long-term unilateral orthosis wear with a painful knee, hip or sacroiliac joint on the stronger contralateral side.
AFO: Ground reaction, articulated with dorsiflexion stop, dorsiflexion assist, and plantarflexion stop.
KAFO: ischial containment or quad style thigh section and locked knee.
Stance control for fair-to-good hip flexors, poor-to fair quads. and good balance.
What orthoses should be given to a patient with a painful knee on the stronger side secondary to overuse syndrome, with grade three or higher muscle strength above and below the knee and a contralateral limb that is significantly weaker?
AFO: Ground reaction design with dorsiflexion stop, dorsiflexion assist, and plantarflexion stop.
KAFO: Ischial containment or quad thigh section, drop lock knee joints
KAFO: stance control knee joints and DAAJ ankle joints with springs in the posterior channel and pins in the anterior channel.
What orthotic suggestions should be given to a long-term bilateral orthosis wearer. Possible painful joints within or above orthosis, labored gait with increased tripping and falls, and increased fatigue, pressure, and or pain from orthosis itself?
Suggest an improved design where deficiencies in function, components, weight, and or cosmesis exist.
Recommend more aggressive bracing when appropriate.
