lecture 8: pediatric ortho problem solving Flashcards
PTG: what does it stand for
Patient first (needs of pt, family)
Task of orthosis (ambulation vs stretch)
Goal for the device
What else does PTG stand for?
Prioritize the goals
When evaluating a patient,
what should you take into account?
age
Dx
Functional level/ability
family needs
previous history also included in one slide
What 4 ROM considerations with the LE when evaluating the patient
- DF with knee flexed or extended
- difference between R1, R2
- midfoot
- knee and hip contractures
What other physical things do you need to take into account with patient evaluation regarding their deformity?
- correct or accommodate
- fixed or flexible
- force to correct
- LLD
- motor control (spasticity, dystonia or ataxia?)
You take ROM of your patient. What else needed?
- strength MMT
- mm length issues
- rotational profile issues
- sensation/pain
- vascular issues/girth
- cognition
- environment/fam/social situation
Besides orthoses, what are other treatment plan considerations
- botox
- serial casting
- surgery (ortho: mm length or transfer, bony intervention or neuro: dorsal rhizotomy)
Your patient is a 8 year old boy with spastic, diplegic CP functioning at GMFCS 3. Trouble walking, wears bilateral solid AFOs.
bright red spot over right heel, left navicular.
what do you want to do?
Probably it is too tight, need new bilateral solid AFOs
what are 5 tasks of an ambulatory AFO?
- stability in stance
- foot clearance in swing
- preposition foot for IC
- adequate step length
- energy conservation
what are 3 tasks of a non ambulatory AFO?
- contracture management
- wound healing, protection, prevention
- positioning
What are examples of orthotic goals
- correct joint alignment
- assist walking, standing
- improve upright stability
- prevent or reduce contractures
non-ambulatory AFO: prolonged LLLD (low load stretch)
Therapeutic benefit of the
force application may be to do what 4 things:
- resist motion
- assist motion
- transfer force
- protect a body part
Patient has quad paralysis:
The KAFO w/ mechanical lock
stabilizes the knee by preventing knee flexion at
IC and limiting knee flexion during LR
what example of force application is this?
resist motion
Pavlick Harness for DHD
hip orthosis for Legg-Calve-Perthes
Cranial Shaping orthosis
wrist-hand orthosis to minimize ulnar deviation
These are examples of orthoses to -____
improve alignment
Orthoses that can provide mechanical assistance of
weak or paralyzed muscles to enable the wearer to
perform a specific function.
These have a force application of ____
assist motion
Peroneal nerve injury- prevent foot drop or toe drag
Gastroc stretch – nighttime orthoses
What force application do these orthoses do?
assist motion
a women with metatarsalgia will be more comfortable with a FO that includes a pad underneath
the metatarsal shafts. The pad does what from the
painful metatarsal heads to the less sensitive shafts.
transfers force
load transfer is often used in FOs
helmet for s/p craniotomy
patient with insensitive/unstable ankle due to neuropathy
burn patient needing shield from secondary trauma to newly grafted skin
What do these orthoses do?
protect body parts, preventing deformity or injury
How can we improve uncomfy AFOs at nighttime?
Let them wear one at night at a time
What are 2 ways of improving comfort of an orthosis design?
- maximize area to min pressure
- longer longitudinal segment for less pressure exerted at end (sufficient leverage through which longitudinal segments apply force)
The most common basic pressure system for most orthoses is a
3 point system
*principle force acting in 1 direction
*2 counterforces acting in opposite direction
The parapodium (THKAFO) exerts a __ system
4 point pressure system
▪elastic sleeve for burn pt.
▪Sure Step SMO
▪Sensory Dynamic Pressure Garment
▪Theratogs – Beverly Cusick
These exert a ____ system
circumferential or total contact pressure
Winters Gait Classification
Group 1
- foot drop during swing
- flat foot/forefoot contact in IC
- excessive hip and knee flexion during swing
- adequate DF during stance
Winters Gait Classification
Group 2
more constant PF throughout gait
Winters Gait Classification
Group 3
progressing to knee hyperextension & increased lumbar
lordosis
Winters Gait Classification
Group 4
most severe pattern, characterized by limited hip movement
and significantly increased lumbar lordosis
Winters Group 0 was discussed in Case 4: hemipolymicrogyria for ____ children
higher functioning children
case study 4 highlights that not addressing atypical mvmt patterns/compensations leads to…
- increased energy expenditure
- MSK deformities
- need for Sx intervention
common compensations in gait of children with hemiplegia include….
- hemi-pelvis retraction
- increased push-off on unaffected side
- early firing of fib longus
What are the 4 PT and orthotic goals for case study 4: hemipolymicrogyria
- improve gait pattern
- minimize gait deviations
- minimize structural impact of atypical WB
- strengthening
What are the 4 outcome measures of case 4: hemipolymicrogyria
- Gait Deviation Index (GDI)
- Salfort Gait Tool (SF-GT)
- Visual Gait Assessment
- GMFM
What is the Surestep SMO
designed for kids with Downs syndrome
wrap around design
shorter toe-plate and trimlines than typical SMOs
promote high level activities (jumping, hopping) by improving subtalar joint alignment
Surestep SMOs address the ____ issue at the STJ level
coronal plane issue
Down Syndrome is a genetic disorder (trisomy 21) characterized by:
- hypotonia
- ligament laxity
- flatfeet
- cognitive limitations
- delayed milestones
Approximately __ % of people with Downs syndrome present with
15%
Atlantoaxial instability
take x-rays between 3-5 years
Patients with Down Syndrome present with what co-morbidities?
AA instability
cardiac issues
thyroid issues
hip issues (DHD, acetabular dysplasia)
What exam signs may be associated with a 15 month old girl with Down Syndrome
- excessive ROM 2ndary hypotonia, ligamentous laxity
- pronation of STJ in standing
An SMO with PLS extension is designed for patients that have
sagittal plane TC joint issues
coronal subtalar joint issues
What clients could benefit from an SMO with PLS extension?
ITW
spastic hemiplegic CP GMFCS level 2
Solid AFOs come with 3 types of trimlines. What are they?
- solid
- semi-solid
- PLS
the 4th type of trimline is what? a lateral/medial flange, which controls hindfoot varus/valgus, known as a
SABOLICH TAB
GFR AFOs were originally designed for patients with what DX
Duchenne’s Muscular Dystrophy
the GFR AFO provides a ___ moment during ambulation
knee extension
▪Most common inherited muscular dystrophy and muscle
disease of childhood
Duchenne MD
Duchenne MD is an x-linked recessive, inherited neuro-MSK disorder with typical life expectancy between _ and _ years
20-30 years
fatal –> progressive weakness of skeletal and respiratory mm
Duchenne’s is an x-linked recessive disease. Do all cases have a family history?
No-1/3 cases arise from new mutation
Duchenne’s is due to an absence of protein ___
dystrophin
**presents normally in skeletal, smooth mm and brain
Boys with DMD are clumsy, may walk on toes, show gross motor REGRESSION.
What will clue you in to it being DMD?
- Patient history (new onset?)
- pseudohypertrophy of calf
- Gower’s sign
What will gait look like for DMD?
- wide BOS
- lumbar lordosis
- knee hyperextension
- toe walking
ambulation usually lost by 12 years old
What can improve mm mass, strength, and function within first 6 months of treatment for DMD?
corticosteroids
*interventions = PT, steroids
scoliosis affects ___ % of non-ambulatory children with DMD.
What can delay scoliosis?
75-90% develop scoliosis
PROLONGED WALKING/STANDING can delay onset of scoliosis
When is surgical intervention considered for a patient with DMD + scoliosis
curve reaches 30 degrees, esp if kid is under 14 yrs
DMD muscular progression
__ to __
proximal to distal
*Gower’s sign!
order of mm involvement for DMD
early: neck flexors, abs
later: pelvic girdle (hip extensors, abductors) and knee extensors
finally: distal mm UE/LE
▪Gene disruption characterized by degeneration of anterior horn cells of the spinal cord, muscle atrophy,
wide spread muscle weakness, and absent deep tendon reflexes
Spinal Muscular atrophy
spinal muscular atrophy is an inherited neuro-MSK disorder that is autosomal ____
recessive
1: 10,000 live births
What are the 3 types of SMA
type 1: most severe
appears before 6 mo, death by 2 yeras
type 2: 7-18 months onset, live into adulthood with pulmonary function/treatment
type 3: mildest: after 18 months, independent walking with AD into early adulthood/adolescence
What are progressive MSK issues associated with SMA
- scoliosis
- hip subluxation
- joint contractures
- talipes equinovarus
All 3 types of SMA are characterized by:
- significant limb, trunk weakness
- mm atrophy proximally and in LEs
- hypotonia
- areflexia
- progressive MSK issues
What is a PRAFO or Multi-podus
pressure relieving AFO, which is lined with furry stuff for comfort and has an opening at heel for pressure injury
What are types of resting or non-ambulatory AFOs?
PRAFO or multi-Podus
Custom nighttime or resting AFO
*they may include a derotational bar for positioning
5 types of ankle joints on an AFO
- overlap
- tamarack
- gaffney
- oklahoma
- insert stirrup
