Orthotic principles and practice have a clear role to play
As an adjunct to therapy - for gait evaluation, and for short or longer term application
Ideally customised and applied on time
Spectrum of Dynamic Outcomes
Outcome
Well Maintained
Spontaneous RecoveryEnhanced Recovery
Poorly Maintained
Death
AcutePhase
DynamicSuccess
Failure
StaticSuccess
+
-
time
Outcome
Well Maintained
Spontaneous RecoveryEnhanced Recovery
Poorly Maintained
Death
AcutePhase
DynamicSuccess
Failure
StaticSuccess
+
-
Timing and Nature of Orthotic Intervention
Outcome
Well Maintained
Spontaneous RecoveryEnhanced Recovery
Poorly Maintained
Death
AcutePhase
DynamicSuccess
Failure
StaticSuccess
+
-
Timing and Nature of Orthotic Intervention
Outcome
Well Maintained
Spontaneous RecoveryEnhanced Recovery
Poorly Maintained
Death
AcutePhase
DynamicSuccess
Failure
StaticSuccess
+
-
Timing and Nature of Orthotic Intervention
All of the true things I am about to tell you
Are actually shameless lies..
But they are Useful Lies
History
• Pre 1940’s - “How can I train this person to use their unaffected body parts to compensate for the affected parts - and how can I prevent deformity”
• Emphasis - orthopaedic intervention - surgery, bracing, strengthening exercises
And then..A New Paradigm Emerges
Paradigm - a new set of experiences, beliefs and values that affect the way individuals perceive reality and respond to that perception
History
• 1940 Onward - Neurological approach - Bobath, Motor Relearning and many others
• Emphasis - Patients with neurological impairment have the potential for functional recovery of their affected body parts
Bobath Approach
• One of the most used and accepted approaches in the UK
• Little written about it in recent years
• No robust evidence for its efficacy†
• But has value..
†Davidson & Waters (2000) - Physiotherapists working
with Stroke Patients - A National Survey.Physiotherapy 86:69-80
0
25
50
75
100
Bobath Other
England NIWales Scotland
Cerebral CortexMotor Areas
Brain Stem
Thalamus
Cerebellum
BasalGanglia
Sensory Receptors
Spinal CordMuscle
Contraction & Movement
Kandel, et al 1991“Principles of Neural Science”
p 539, Publ: Elsevier, Amsterdam
MotorNeurons
Muscle & Tendon
SensingInterpreting
Effecting
Bone & Joint
-
+
Multiple Feedback Pathways
Error
DesiredState
ActualState
http://www.annekaringlass.com/05171-Reaching-Deep-copy.jpg
The CNS• Interaction between the
Central & Peripheral components
• Early ideas - CNS controls movement by REACTING to sensory input
• CNS operates in a TASK ORIENTED way
• Activity in brain BEFORE movement begins - FEED-FORWARD process
• Effect of Innate and ongoing influences
• Sensory information vital for fine tuning
DistinctionTheory & Practice
Is it possible that an overemphasis on the neural control of movement has led to
neglect of the practical importance of muscle strength, force
production and movement kinetics?
Recently..• Neurorehabilitation - interest in different
models of CNS function, skill acquisition and training.
• + Growing interest in the biomechanical requirements of a task
• Acceptance that patient must compensate for the damaged nervous system
†Carr & Shepard (1998) “Neurological rehabilitation -
Optimising motor performance” Butterworth-Heinemann
http://www.dalailama.com/images/pgallery/printable1.jpg
Neuroplasticitythe power of the mind to
change the brain......
The brain can change its structure and function in response to experience
Requires a valid “EXPERIENCE”
andATTENTION..
†How thinking can change the brainhttp://www.dalailama.com/news.112.htm
Emerging Implications• Anyone can achieve expert performance in athletics or
academic pursuits
• The effects of media and technology on our thoughts and emotions - images of violence literally rewire our brain;
• Estimate the specific effects of stress on brain functions;
• Formulating new "brain-based" approaches to depression, ADHD and OCD
• Developing ways to enhance our sensory capacities.
Nervous and Musculoskeletal Systems Cannot be Separated
They interact with each other to meetdemands of the internal and external environment
The nervous system is proactive and not simply reactive in response to sensory feedback
Gait Initiation & Termination ✓Balance & Posture ✓Shock Absorption ✓
Energy Conservation ✓Foot & Knee Control ✓
Stability in Stance Freedom in Swing
Restoration of Gait - Mechanistic Paradigm
Do Something!
ActualOutcome
Measurement
DesiredOutcome
Analysis
Learning Happens Best When We Act Quickly
Conclusion• Orthotic and Neurological
approaches are Not Exclusive Choices - they are complementary
• Work with therapists and others to develop a new paradigm
• Orthoses need to be adjustable, fit well, and be easily applied - and what else?
• Aim for consensus & evidence - this means do more not less.
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