Slings Flashcards
General Rationale for Using Slings and Orthoses
- Positioning (Bed rest -> prevent contractures, Positioning to prevent deformity &/or maintain optimal joint alignment, Potential to inhibit tone (controversial))
- Protection/Healing (Immobilization, Movement control, Ex: Knee brace for ACL)
- Improve balance/function through correction or re-establishment of approprtiate BOS
- Improve function of weak limb
- Feedback (tactile or proprioceptive)
General Types of Slings
What is an alternative to a sling?
E Stim for Shoulder Subluxation
Shoulder abduction and basic sling: Purpose and Pros/Cons
- Goal is to protect and stabilize shoulder and rotator cuff.
- May have added abductor ‘pillow’ and wrist support.
Pros:
* “Off shelf”
* Supports entire forearm
Cons:
* If patient has neglect, arm is hidden.
* Wrist and hand may swell if patient does not use.
* Inhibits trunk rotation with ambulation
Hemisling: Purpose and Pros/Cons
- Protect shoulder
- Typically used post stroke or post TBI, though could be used for any population requiring support of the shoulder/forearm/wrist
Pros:
* “Off shelf“
* easy to don/doff
* Wrist can be supported
Cons:
* If patient has neglect, arm is hidden.
* Encourages flexion synergy pattern post stroke/elbow contraction
* Wrist and hand may swell if patient does not use.
* Inhibits trunk rotation with ambulation
TBI and Stroke may result in similar impairments
Giv-Mohr Dynamic Hemisling: Purpose and Pros/Cons
- Provides approximation and support to subluxed shoulder
Pros:
* Allows for arm swing and possible trunk rotation during gait.
* Provides approximation of GH joint
* If person has neglect, arm is not ‘hidden’
* Swinging of arm may promote blood flow
* Available ‘off shelf”
Cons:
* Hand dependent and may swell
When moving slings ____, when sitting slings ____
- on
- off
Splint definition
Some variability, but typically an orthosis intended for temporary use
Stiffer othorthotic material =
less mobility but more support
What is this?
Spring Leaf Orthosis
What is this? What does it do?
- Swedish knee cage
- Stops people from snapping back into extension; weak quads
What is this called? What is the purpose?
LEMA strap
Helps with weak dorsiflexion
Indications for Ankle Foot Orthosis
- Indicated when assist is required for ankle-knee positioning (proprioception, strength, or coordination deficits) or control during gait
Examples:
* Foot drop (Dorsiflexion weakness)
* Tendency to hyperextend knee secondary to mild-moderate plantar flexor spasticity
AFO Requirements
- Strength: Requires 3+/5 knee extension strength or Quad spasticity to stabilize knee during stance phase
- Sensation: Intact proprioception and control of the knee
Other important AFO considerations
- Heel cushion or shoe type canbe selected to help the impactofheel strike
- Proximal end of orthosis fit 1” distal to fibular head to prevent pressure on fibularis (peroneal) nerve.
Solid AFO: Purpose & Biomechanics
No Hinge at Ankle
Purpose:
* Patient requires maximal stability & static positioning
* Trim Lines:Molded AFO with the trim line cut anterior to the malleoli is the most stable AFO and limits ankle motion
* Maintain ankle ROM and foot position in non-ambulatory patient
Biomechanics
* Provides good support but limited mobility
* Encourages knee extensionmoment at initial contact to mid-stance to correct knee buckling
* Provides medial-lateral ankle stability
* Custom rigid AFOs can be designed to be converted to Hinged AFO as status improves
Get one AFO every 5 years; Except for kids
Hinged (Articulating) AFO
Purpose:
* Patient requires assist, but able to control elements of knee-ankle mechanics
Biomechanics:
* Allows some DF/PF movement during gait for more normalized gait pattern, while providing M/L ankle stability and potential to limit knee hyperextension in mid-stance
Posterior Leafspring AFO: Indication, Purpose and Pros/Cons
Indications:
* Weakness of ankle DF
* Minimal to no spasticity and sensory deficits
* No medio-lateral instability
Provides:
* Increased ankle motion in stance phase
* Assist for DF for swing phase
* Assist with PF into heel off
Pros:
* Lightweight
* Cost-available ‘Off-shelf’
Cons:
* Heavier patientsmay require a more rigid material
* Lightweight-cannot control moderate-severeplantar flexorspasticity
* May not provide stability for M/L control of ankle
Common childrens shoe for orthotics:
Billyfootwear
Dorsiflexion Assist brace: Purpose and Pros/Cons
Purpose:
* Assists with DF during swing phase
* Allows for ‘normalized’ gait pattern for person with no ankle instability, good proprioception and no PF spasticity
Pros:
* Cost-available ‘off-shelf’
* Normalizes gait pattern
* May be preferred to Posterior Leaf AFO
* Good for peripheral nerve injuries
Cons:
* No ankle stability provided
* May not be appropriate for CNS lesions or heavier patients
* Must be worn with tie shoes
Patient must have at least 3/5 strength in ankle dorsiflexion as this device provides only light assist
Floor (or Ground) Reaction AFO or Carbon Fiber AFO: Purpose and Pros/Cons
- Prevent knee buckling during stance phase (e.g. weak quadriceps muscles without medial-lateral instability)
- Over-lengthened heel cords
- Crouch gait
- DF assist
Pros:
* Encourages knee extension moment to prevent knee forward buckling
* allows clearance in swing phase
* decreases crouch gait
* keeps torso vertical and center of mass in middle of foot
* Some are able to be don/doffed with one hand
Cons:
* Difficult going up hills
* Some are custom and unable to be easily modified
* Limited M/L support
Good for people that buckle or walk in a crouch
Neuro Prothesis FES for Gait
- Used to stimulatedorsiflexorfunction
Prescription:
* Patient must have adequate quadriceps strength to prevent kneebuckling
Brands: WalkAide, Bioness (Very Expensive)
Knee Ankle Foot Orthosis (KAFO)
Purpose:
- <3+/5 Quad Strength; Severe knee hyperextension; M/L instability at the knee/ankle
Biomechanics:
* AFO section provides M/L stability of Foot/Ankle, DF control in swing phase, ground reaction forces on knee, knee joint and thigh extension provide M/L knee support
* locked knee joints provide max sagittal plane support; unlocks for sitting
- Can change type of knee joint and type of ‘locking’ mechanism for knee joint; typically locked into extension during stance and throughout gait
- Ankle joint is usually locked / fixed
Diagnoses that may require KAFOs = MS, Post-Polio, low level SCI
Hip Knee Ankle Foot Orthosis (HKAFO)
- Basically a KAFO with the addition of hip joints and pelvic section
- This provides control to selected hip motions to increase stability with gait in absence of strength
- Mechanism at hip joint can be unlocked for sitting and locked in stance / for gait
- Provides maximum support for lower extremities and lower torso
Spina Bifida; Extremely rare to see these
Reciprocating Gait Orthosis (RGO)
Purpose:
Mid-thoracic to high lumbar parapalegia
Biomechanics:
* RGO is HKAFO with cable system that pairs hip flexion in one leg with hip extension in opposite leg, facilitating swing phase of gait
* The patient must be able to shift their weight away from swing leg
Facilitation of Gait using Exoskeleton
- Looks likeRGO; however, motorized controls to facilitate sit to/from stand transitions and reciprocal gait for patients with limited LE function
May benefit:
* Guillain-Barre
* Multiple Sclerosis
* Spinal Cord Injury
* Stroke
FDA approved for SCI C7 and below (need hand function to manage controls)
Need to be a “good candidate”:
- spasticity may impair ability to utilize
- safety considerations (cognitive ability, fracture potential, skin integrity)
Things to consider when selecting an orthosis
- Does the patient have the ROM needed for this device?
- What do I want the device to accomplish?
– Where is the joint stable/lax?
– What muscles are weak/strong?
– Is the purpose to compensate or promote recovery? (e.g. solid AFO vs FES) - Physical characteristics
– Material and design (e.g. solid AFO is thicker and heavier than posterior leaf spring)
– Shape-rolled edges, reinforced, curved, etc… - Cost
- Patient or patient’s family’s ability to participate in donning/doffing (e.g. will the patient be able to use it)
- Does the patient want the device/will they wear it?
- Cosmetics-it is the right color/look/design for the patient?
Other important clinical decision making factors:
- Dynamic vs static
- Prefabricated (off-shelf) vs. Custom
- Wearing schedule
- Constant vs Progressive vs Weaning
- Patient/caregiver instruction
- POC
- Teaching: Mobility, ADL, Home program, Follow-up
- Goals: Proper fit, maximize function, able to don/doff and wear appropriately, skin inspection, maintenance of assistive technology
Resource for selecting gait device
Ranchos Los Amigos ROAD MAP
