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Physiotherapy June 2003/vol 89/no 6 Professional articles Introduction Patients with severe neurological disability frequently present with cognitive and behavioural problems which limit functional improvement (Kaplan and Corrigan, 1994; Alderman, 2001). Jackson et al (2000) identified that these patients took longer to walk. Lower limb con- tractures are a recognised problem (Wheeler et al , 1995) that can have a negative effect on the rehabilitation of standing and gait (Carter and Edwards, 2002; Shumway-Cook and Woollacott, 2001). Some authors refer to the use of lower limb orthotics in this client group (Edwards and Charlton, 2002; Brodnansky et al , 1997; Tyson and Thornton, 2001). This case report aims to illustrate their use when managing contractures and re- educating gait in a patient with severe neurological disability. The issues related to this management approach are discussed. Case Presentation Kathleen was a 25-year-old housewife with two children who developed acute demyelinating encephalomyelitis. She initially presented with quadraparesis, impaired swallowing and marked cog- nitive impairment. CT and MRI scans showed diffuse cerebral swelling and extensive white matter lesions, including the brain stem. She was admitted to an intensive care unit and intubated and ventilated for four weeks. Kathleen was then transferred to a neurosciences unit for post-acute care. During this five-month phase muscle hypertonus, particularly flexor tone in the right lower limb, was problematic. Treatment centred on casting combined with botulinum toxin and periods of standing using the tilt table. She was on a small dose of oral baclofen. A combination of crying and hitting out, swearing and drowsiness had ham- pered rehabilitation. Cognitive impair- ments including distractibility, poor safety awareness and disorientation had also limited progress. Kathleen was admitted to the Regional Rehabilitation Unit at Northwick Park Hospital six months after onset, where she remained an inpatient for eight months. Thereafter she became an outpatient at a general hospital, attending regular orthotic reviews at the Regional Rehab- ilitation Unit. On admission, Kathleen presented with a mixture of hypertonus and hypotonus. She had low muscle tone around the trunk, resulting in a flexed posture and inability to sit unsupported. She had mildly increased tone in the left upper limb with poor selective movement. Tone and movement were now normal in the right upper limb. She had increased flexor and adductor tone and weakness of the extensor muscles in both lower Lower Limb Orthoses in Rehabilitation of a Neurologically Impaired Patient Case report Summary Patients with severe brain injury frequently present with cognitive and behavioural problems, limiting engagement in physical rehabilitation. Contractures developed during the acute phase of illness may need months of intensive treatment and require an integrated multi-disciplinary approach. We describe the case of a young woman with complex disabilities following acute demyelinating encephalomyelitis. She presented with severe lower limb contractures and hypertonus, preventing weight bearing. Cognitive and behavioural problems restricted progres s and the team adopted a functional weight bearing programme using traditional metal and leather orthoses to facilitate gait. By the end of her admission this patient was able to walk with an aid and under supervision and she has progressed further following discharge. The rationale and factors contributing to the successful outcome in this complex case are discussed. Key Words Orthosis, contracture, cognitive deficit, neurological impairment, muscle hypertonia, rehabilitation. by Patricia Watts Lisa Knight Paul Charlton 359 Watts, P, Knight, L and Charlton, P (2003). ‘Lower limb orthoses in rehabilitation of a neurologically impaired patient: Case report’, Physiotherapy , 89, 6, 359-364.
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Professional articles
IntroductionPatients with severe neurological disability frequently present with cognitive andbehavioural problems which limit functional improvement (Kaplan andCorrigan, 1994; Alderman, 2001). Jacksonet al (2000) identified that these patientstook longer to walk. Lower limb con-
tractures are a recognised problem(Wheeler et al , 1995) that can have anegative effect on the rehabilitation of standing and gait (Carter and Edwards,2002; Shumway-Cook and Woollacott,2001).
Some authors refer to the use of lower limb orthotics in this client group (Edwards and Charlton, 2002;Brodnansky et al , 1997; Tyson andThornton, 2001).
This case report aims to illustrate their
use when managing contractures and re-educating gait in a patient with severeneurological disability. The issues relatedto this management approach arediscussed.
Case Presentation
Kathleen was a 25-year-old housewife withtwo children who developed acutedemyelinating encephalomyelitis. She
initially presented with quadraparesis,impaired swallowing and marked cog-nitive impairment. CT and MRI scansshowed diffuse cerebral swelling andextensive white matter lesions, includingthe brain stem. She was admitted to anintensive care unit and intubated and
ventilated for four weeks.Kathleen was then transferred to a
neurosciences unit for post-acute care.During this five-month phase musclehypertonus, particularly flexor tone in the
right lower limb, was problematic.Treatment centred on casting combined with botulinum toxin and periods of standing using the tilt table. She was ona small dose of oral baclofen.
A combination of crying and hittingout, swearing and drowsiness had ham-pered rehabilitation. Cognitive impair-ments including distractibility, poor safety awareness and disorientation had alsolimited progress.
Kathleen was admitted to the RegionalRehabilitation Unit at Northwick Park
Hospital six months after onset, where sheremained an inpatient for eight months.Thereafter she became an outpatient at a general hospital, attending regularorthotic reviews at the Regional Rehab-ilitation Unit.
On admission, Kathleen presented witha mixture of hypertonus and hypotonus.She had low muscle tone around thetrunk, resulting in a flexed posture andinability to sit unsupported. She hadmildly increased tone in the left upper
limb with poor selective movement. Toneand movement were now normal in theright upper limb. She had increasedflexor and adductor tone and weaknessof the extensor muscles in both lower
Lower Limb Orthoses inRehabilitation of a
Neurologically ImpairedPatientCase report
Summary Patients with severe brain injury frequently
present with cognitive and behavioural problems,
limiting engagement in physical rehabilitation.
Contractures developed during the acute phase
of illness may need months of intensive treatmentand require an integrated multi-disciplinary approach.
We describe the case of a young woman with complex
disabilities following acute demyelinating encephalomyelitis.
She presented with severe lower limb contractures and
hypertonus, preventing weight bearing.
Cognitive and behavioural problems restricted progress and
the team adopted a functional weight bearing programme
using traditional metal and leather orthoses to facilitate gait.
By the end of her admission this patient was able to walk
with an aid and under supervision and she has progressed
further following discharge.The rationale and factors contributing to the successful
outcome in this complex case are discussed.
Key WordsOrthosis, contracture,cognitive deficit,neurological impairment,muscle hypertonia,rehabilitation.
by Patricia WattsLisa Knight Paul Charlton
359
Watts, P, Knight, Land Charlton, P(2003). ‘Lower limborthoses inrehabilitation of a
neurologically impaired patient:Case report’,Physiotherapy , 89, 6,359-364.
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limbs, particularly on the right, withcontractures (table 1).
The mixture of tonus and drowsinessled to the decision to discontinue bac-lofen.
Kathleen’s cognitive and behaviouralproblems were still apparent. She had noability to remember new information and
was disorientated to person, time andplace.
Kathleen was non-ambulant anddependent for all activities (table 2).
Outcome MeasuresThe Functional Ambulatory Category isan outcome measure used at the RegionalRehabilitation Unit to evaluate progress
towards independent gait. It is an ordinalmeasure with established reliability and
validity in rehabilitation settings (Wade,1992), which provides information on thephysical support needed by patients while
walking. It consists of six categoriesranging from 0 (patient cannot walk,requires help of two or more people) to5 (patient can walk independently any-
where). Kathleen’s admission score was 0.
FIM + FAM
A global measure of disability, in-corporating the Functional Independ-ence Measure (Wade 1992), but withadditional sections, particularly reflectingcognitive function. It has been shown tobe a reliable and sensitive tool in post-acute rehabilitation (Turner-Stokes et al ,1999). Each of the 30 sections is scoredfrom 1 (total dependence) to 7 (completeindependence). The scores can berepresented visually as in figure 1.Kathleen scored 24 out of a possible 112for the motor sub-scales and 37 out of 98
for the cognitive, psychosocial sub-scales.The shaded area indicates the amount of change during admission to the RegionalRehabilitation Unit.
The mobility chart (table 2) is not arecognised outcome measure, but is usedroutinely at the Northwick Park RegionalRehabilitation Unit to show functionalabilities on admission and discharge.
All contractures were measured fromthe anatomical position in supine using ahand-held goniometer. The axis of the
goniometer was placed over the greatertrochanter for measuring hip flexion, at the lateral femoral condyle for kneeflexion and at the lateral malleolus forplantarflexion. A consistent technique
Table 1: Contractures on admission and discharge
Admission Discharge
Right hip Flexion contracture of 15º * Flexion contracture of 10ºNo abduction beyond neutral 10º of abduction
Right knee Flexion contracture of 40º Flexion contracture of 5º
Left ankle 20º off plantargrade 10º off plantargrade
*All contractures measured from the anatomical position in supine using ahand-held goniometer. The axis of the goniometer was placed over thegreater trochanter for measuring hip flexion, at the lateral femoral condylefor knee flexion and at the lateral malleolus for plantarflexion.
Table 2: Mobility chart
Function Independent Minimum Moderate Total with/ without help help help/
aid unable
Lying roll on to left side D A
Lying roll on to right side D A
Get up from lying through D Aleft side
Get up from lying through D Aright side
Unsupported sitting static D Afor 2 minutes
Sitting without arm support D Afor 2 minutes
Stand up to free standing D AStand for 2 minutes D A
Transfer bed to chair to D Aleft side
Transfer bed to chair to D Aright side
Walk 2 steps D A
Walk indoors D A
Lying hold arm in elevated A/Dposition left
Lying hold arm in elevated A/D
position right
Put left hand to face A/D
Put right hand to face A/D
Grasp and release A - limitedleft hand release/D
Grasp and release A/Dright hand
Walk outdoors A/D
Flight of stairs A/D
Minimum help = subject performs 75% of activityModerate help = subject performs 50% of activityA = On admission 6 months post injuryD = On discharge 13 months post injury
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361Case report
and position was used to maximisereliability as suggested in the literature(Norkin and White, 1995). However, it isrecognised that measurement of con-tracture is subject to significant error, not only due to positioning and observererror, but also to variations in tone. Theresults should be interpreted with duecaution.
ManagementThe initial aims of treatment were to:
■ Increase range of right knee extension.
■ Increase range of left ankledorsiflexion.
■ Mobilise trunk and pelvis from a flexed
position.■ Increase independence in transfers
and standing.Serial casting was started early after
admission to minimise contractures of theright knee and left ankle, in accordance
with current guidelines (Ashburn et al ,1998). After several casts, replaced at intervals of 5-7 days, the right kneecontracture improved to 15˚ flexion.
Maintaining this with overnight restingsplints was problematic, due topoor patient compliance and increasedflexor tone. The right knee contracturestabilised at 20˚ flexion. There was nosignificant improvement in the range of movement in the left ankle initially,despite casting and the injection of botulinum toxin A into the gastro-cnemius/soleus (Dysport 500 mouseunits).
Later in the admission, as Kathleenspent more time standing in therapy, theleft ankle contracture improved to 15˚plantarflexion.
Mobilisation of the trunk and pelvis wasattempted in supine and sitting, but
therapeutic handling was poorly tolerated. Supported standing became ahigh priority for promoting trunkextension. In the first three months of admission Kathleen could only standusing the tilt table, or with help of fourpeople. As her trunk control and activity of the left leg improved, she progressed tostanding with help from three people, as
well as in a standing frame.
1. Feeding2. Grooming
3. Bathing
4. Dressing upper body
5. Dressing lower body
6. Toileting
7. Swallowing
8. Bladder management
9. Bowel management
10. Bed, chair, wheelchair transfer
11. Toilet transfer
12. Tub, Shower transfer
13. Car transfer
14. Locomotion - Wheelchair
17. Comprehension
18. Expression
19. Reading
20. Writing
21. Speech intelligibility
22. Social interaction
23. Emotional status
24. Adjustment to limitations
25. Leisure activities
26. Problem solving
27. Memory
28. Orientation
29. Concentration
30. Safety awareness
15. Stairs16. Communitymobility
7
6
5
4
3
2
1
0
Discharge Admission
Fig 1: Change in Kathleen’s FIM+FAM. Scores are shown along the spokes from 1 (totally dependent) to 7 (totally independent)and the shaded area shows the amount of change during admission to the regional rehabilitation unit
FAM SUB SCALES1-7 Self care8-9 Sphincter control10-13 Mobility transfer14-16 Locomotion17-21 Communication22-25 Psycho-social
adjustment26-30 Cognitive function
FIM/FAM SCORES7 Complete independence
6 Modified independence3-5 Modified dependence1-2 Complete dependence
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Improvement in trunk activity andposture allowed Kathleen to transfer inthe ward using a sliding board with helpfrom one person. Standing transfers stillproved difficult, as she was unable torecruit sufficient extension at the hipsand knees.
Over the following month Kathleendemonstrated the ability to take steps,although weight bearing through plan-tarflexed inverted feet, with increasedflexion through the trunk and right lowerlimb. A plaster back slab was needed tomaximise right knee extension.
These issues were discussed withour orthotist. The team consideredthat if orthoses could maintain right
hip and knee extension, maximise left dorsiflexion and correct inversion,Kathleen would be able to walk with anaid and supervision. A knee ankle foot orthosis in the form of a full leg caliperfor the right lower limb and a below-kneeorthosis for the left leg (fig 2) weresuggested. The orthoses were made of metal and leather as opposed to thermo-plastic. The knee ankle foot orthosis hadmanually operated knee joints to allowflexion in sitting.
Accommodating heel raises wererequired, as plantarflexion of the left ankle was not fully correctable. Bilateralheel raises were used to maintainsymmetry of the pelvis.
Once the orthoses arrived, adjustments were needed and Kathleen had to buildup tolerance to wearing them. Time wasspent educating nursing staff and carerson how to apply them.
Treatment then included hydrotherapy,positioning and continued re-educationof normal movement. Other members of the multi-disciplinary team were able tobuild on the increase in Kathleen’sphysical abilities to work on self-careactivities. Her family helped Kathleen
with exercises and stretches.Six months after admission Kathleen
was able to walk with a wheeled frameand the help of two people and stood withone person. She spent a further twomonths on the Regional RehabilitationUnit incorporating these abilities intofunctional activities.
On discharge Kathleen still demon-strated low tone centrally, but was ableto recruit some trunk extension. She hadincreased speed and dexterity in left arm
movement. She had moderate increasedflexor tone of the lower limbs, particularly on the right, but improved voluntary activity of abductor and extensor musclegroups. Her lower limb contractures hadreduced (table 1).
She could concentrate on a task for upto 15 minutes.
Kathleen still needed close supervisionat all times, but no longer displayed verbalor physical aggression. She was orientatedand was able to use some memory strategies such as a diary, with help.
She was more independent in activities(table 2). This included transferringthrough standing with the help of oneperson and walking indoors with a
wheeled frame and close supervision(Functional Ambulatory Category 2). Herscores on the FIM+FAM had improved to65/112 on the motor sub-scales, and59/98 on the cognitive/psychosocial sub-scales.
Kathleen was discharged to her parents’house with her two children, with social
services support. An orthotic review was requested two
months after discharge. At this timeKathleen was walking with the frame andsupervision only and could perform such
Authors
Patricia Watts BScMCSP is a seniorphysiotherapist at theRoyal Free Hospital,
London.
Lisa Knight GradDipPhys MCSPis a clinical specialist in physiotherapy at Northwick ParkHospital regionalrehabilitation unit.
Paul CharltonMBAPO DipOTCis a senior orthotist
with Peacocks MedicalGroup, Newcastleupon Tyne.
This article wasreceived on March 15,2002, and acceptedon March 14, 2003.
Address forCorrespondence
Patricia Watts,Royal Free Hospital,
Physiotherapy Department,Lower Ground Floor,Pond Street,London NW3 2QG.
Fig 2: Kathleen wearing bilateral lower limborthoses
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activities as getting up from the floorindependently. She had full range of right knee extension. There were stillcontractures at the ankles. It was decidedto progress to bilateral metal ankle foot orthoses. Three years post insult Kathleenis able to walk independently indoors andoutdoors with bilateral heel raises and twosticks. The current multi-disciplinary teamis working towards more independent community living.
DiscussionThe authors believe that a key component in Kathleen’s rehabilitation was the timely orthotic intervention. The preliminary treatment techniques of serial casting,
mobilisation of soft tissues and facilitationof normal movement had partly achievedthe aims, but cognitive and behaviouralimpairments affecting compliance werelimiting factors. Weight bearing instanding required more than one thera-pist to achieve appropriate alignment andcould not be used functionally.
The orthoses allowed extended periodsof standing which helped to increaserange of movement in soft tissues andfacilitate activation of extensor musc-
ulature.Standing appeared to reduce flexortone in the lower limbs and increaseextensor activity. Some authors (Edwardsand Charlton, 2002) state that mechanicalsupport should be used with caution
when dealing with patients with severeflexor spasticity, as forcing the leg intoextension may exacerbate the spasticity.They state that mobilisation of thetrunk and pelvis and gentle stretchingof the affected muscle groups may prove effective in enabling a patient
to accommodate to orthoses. The ideaof preparing the patient for the orthosesand using them as an adjunct to, not areplacement for physiotherapy, wasincorporated into Kathleen’s manage-ment.
The orthoses reduced the number of therapists required for standing. AsKathleen often became distressed whenbeing handled by therapists andresponded best to familiar, functionalactivities, this improved tolerance allowed
her to stand more frequently. The ability to stand with reduced help increasedpatient participation in activities of daily living, with the goal of improvingboth independence and orientation.There were improvements in self-caretasks (fig 1).
Thermoplastic materials are morefrequently used in modern orthotics, but the variability of Kathleen’s tone andtherefore the alignment of the left ankleand right knee required some adaptability
within the orthoses. Knee ankle foot orthoses of metal and leather designprovide this through the ability to alterthe tension of the leather straps. Forcesapplied via conforming leather straps may
resist high biomechanical forces withreduced risk of skin pressure, compared
with close fitting, more rigid thermo-plastic materials (Charlton and Ferguson,2001).
Kathleen was in an intensive andspecialised multidisciplinary teamenvironment with a high staff:patient ratio, where length of stay is largely determined by patient need. Carers wereencouraged to be active participants inthe rehabilitation process, facilitating
a 24-hour approach. There is increas-ing evidence that the intensity andenvironment of therapy affect outcome(Kwakkel et al , 1997; Langhorne et al ,1996). Because of Kathleen’s memory loss, repetition and consistency wereimportant parts of the rehabilitationprogramme. Kathleen’s improvement incognitive and physical abilities allowedher to make further functional gains inthe community setting.
Conclusion
This case report suggests that lower limborthoses, including metal knee ankle foot orthoses, remain an effective adjunct totreatment for selected neurologicalpatients. Patients with cognitive andbehavioural deficits in particular may benefit as they increase the possibilities of undertaking functional, meaningfulactivities. These patients may continue tomake functional improvements over anextended period.
Acknowledgements
The authors wouldlike to thank thefollowing colleaguesfor their advice and
encouragement in writing this casereport:
Elizabeth Bond MScMCSP, lecturer inphysiotherapy,Department of HealthStudies, BrunelUniversity.
Heather Thornton
MBA MCSP, seniorlecturer, Department of Physiotherapy,University of Hertfordshire.
Professor LynneTurner-Stokes DMFRCP,director/consultant in rehabilitation,Regional
Rehabilitation Unit,Northwick ParkHospital.
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Key Messages
■ Lower limb orthoses, including
traditional metal and leatherorthoses, can be a useful adjunct to physiotherapy in therehabilitation of selected neurologicalpatients.
■ Lower limb orthoses do not necessarily increase abnormaltone.
■ A consistent 24-hour approachprovided by the multidisciplinary
team and the family was an important factor in enabling this patient toimprove her independence.
■ Patients with severe, complexneurological disability may havepotential to make functionalimprovements over an extendedperiod of time.
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