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Therapeutic Orthotics after Stroke

Richard SealyPrincipal Physiotherapist in NeuroRehabilitation

The Wolfson Neuro Rehabilitation Centre

St Georges NHS Trust

Email: richard.sealy@blueyonder.co.uk

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Aims

Post stroke gait

Therapeutic adjunct

Clinical reasoning

The potential role of orthoses

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Patient Goal

I want to walk

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Examples of Post Stroke Gait

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The Influence of Alignment and Stability

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Therapists - Clinical Reasoning

Observation

Where in gait Why Problem solving approach

How am I going to treat this ?

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Understanding of the Gait Cycle

Biomechanics at the foot/ankle

Dorsiflexion / Plantarflexion

Pronation / Supination

Initial Contact

Terminal Stance

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Pronation Supination

Subtalar Joint Biomechanics (Right)

Neutral

Adapted from Mcpoil et al 1985

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Acceptable Pronation?

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Creating a Base: The Importance ofAlignment Distal to Proximal Influences

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Orthotic Management of Pronationfollowing Stroke

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Orthotic Management of Excessive Pronation

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Biomechanics of Standing

Ground Reaction Force

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Biomechanics of Gait

Ground ReactionForce Vector

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Biomechanics of Gait

m

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Clinical Reasoning / Gait Analysis

Where ?

Why ?

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Clinically Reasoning

Where is it going wrong

Why is it going wrong

How can I change this

Improve Motor Control

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Motor Control Theories

Client Centred Goal settingVan Den Broek (2005)

Active problem solver Procedural learning

Practice, skilled learning results in structure changeat a neural level, experience driving reorganisation

Carry Over(Shunway-Cook & Woollacott 2001)

(Van Den Broek 2005)

(Buonomano & Merzenich 1998)

E.g Learning outside the gym MDT role

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Orthotics

An Orthosis:

An external device used to modify the structural orfunctional characteristics of the neuromuscularsystem (International Standards Organisation)

E.g Callipers, braces, splints, supports, casts,insoles.

FO, AFO, KAFO

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AFOs and Alignment

Condie (2004) Consensus Conference Report

Alignment of the orthosis at terminal stance/pre-swing is critical and will influence step length, gait

symmetry, speed and energy consumptionMeadows (1994)

Owen (2004)

Owen (2004) Suggests when aligned in TS,lengthening of gastrocs, hamstrings and hip flexors

Importance of footwear/AFO combination

Walking enables therapeutic lengthening

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Orthotic Management

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Clinical Reasoning

Patient Example

Increased Tone

Fixed PF contracture

Normal

Significant

compensationstrategies

How to manage this?

Midstance

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Midstance

Terminal Stance

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AFOs Related to Stroke Research

Research poorly performed Focus on chronic stroke

Post rehabilitation

Wide variability in studies

Leung & Moseley (2003) (National Clinical Stroke Guidelines RCP ) Improved temporal spatial, gait pattern and efficiency measures

No strong conclusion can be drawn

Condie (2004) Consensus Conference Report Orthoses should be considered in the management of patients with

stroke NHS Quality Improvement Scotland (2009)

Best Practice Statement ~ Use of ankle-foot orthoses followingstroke

SWIFT Cast Trial Early intervention cast walking

http://www.nhshealthquality.org/nhsqis/files/ANKLEFOOT_BPS_AUG09.pdfhttp://www.nhshealthquality.org/nhsqis/files/ANKLEFOOT_BPS_AUG09.pdfhttp://www.nhshealthquality.org/nhsqis/files/ANKLEFOOT_BPS_AUG09.pdfhttp://www.nhshealthquality.org/nhsqis/files/ANKLEFOOT_BPS_AUG09.pdfhttp://www.nhshealthquality.org/nhsqis/files/ANKLEFOOT_BPS_AUG09.pdfhttp://www.nhshealthquality.org/nhsqis/files/ANKLEFOOT_BPS_AUG09.pdfhttp://www.nhshealthquality.org/nhsqis/files/ANKLEFOOT_BPS_AUG09.pdfhttp://www.nhshealthquality.org/nhsqis/files/ANKLEFOOT_BPS_AUG09.pdfhttp://www.nhshealthquality.org/nhsqis/files/ANKLEFOOT_BPS_AUG09.pdf

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Summary

Importance of biomechanical -neurophysiological principles

Use of orthoses as an adjunct

Condie (2004) Consensus Conference Report

NHS Quality Improvement Scotland (2009)

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Thank You For Listening