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Orthotic options for children with Myelomeningocele

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Molly Hill

on 1 May 2016

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Transcript of Orthotic options for children with Myelomeningocele

Orthotic options for patients
with Myelomeningocele

Goals of Orthoses:
Prevent or correct deformity
Contracture management
Stabilize joints for standing or ambulation
Facilitate ambulation
Benefits of Early Ambulation:
Fewer fractures
Fewer pressure sores
More independent
Better able to transfer
Obstacles to Ambulation:
Neurologic level of involvement
Hip deformity
Scoliosis
Foot & ankle deformity
Age
Obesity
Research:
L4-L5 & sacral involvement = Community ambulators
L3 & proximal involvement = Most nonfunctional ambulators

Strength of quads and hamstrings = strong indicator for ambulatory success

Quad strength:
Study of 109 pts
4 or 5
89% Community Amb.
98% Household Amb.
3
89% Household Amb.
2-0
88% Non-Amb.
Sacral
High Sacral
Lack gastroc-soleus function
May require AFO's
Low Sacral
Retain gastroc-soleus function
May ambulate without orthoses
SMO - Supramalleolar Orthosis
Provides M/L ankle support
For patients with:
Ankle instability
Hypermobility at ankle
Pronation
Design options:
Custom made in-house
DAFO 4
SureStep
DAFO Leapfrog - OTS
Thoracic/High Lumbar
Related Complications:
Arnold-Chiari malformation
Hydrocephalus
Scoliosis
Hip dislocation
Contractures of hip/knee
Muscle activity of knee, ankle, hip extensors & abductors </= 2
Hip flexors & adductors </= 3
Community ambulation
Through adolescence
Complicated by:
Energy costs
Spinal deformity
Contractures
Obesity
Standing frames/Parapodiums
Not as common
Can be used as early as 12 months of age
Provide hands-free weight bearing
Allow upright activities - postural control, balance, trunk strength
May be used with AFO's
Parapodium can be used for:
Ambulation with addition of swivel walker
Pt shifts weight by rocking laterally
Allows sitting
HKAFO
Pelvic band attached to bilateral KAFO's
For patients with instability at the hip and musculature distal to the hip
Requires hip flexor strength
Require an assistive device
RGO - Reciprocating Gait Orthosis
Provides reciprocal gait pattern for patients with LE weakness
Indications:
Anatomical/Physical
Active hip flexion - drives orthosis
Upper extremity strength
Knee & Hip Contractures < 30 degrees
No obesity
No significant spinal deformity
Psycho/social
Pt motivation to stand & ambulate
Family support/motivation
Access to PT
Ability of pt or caregiver to don/doff
Ability of family to travel to appts
Fillauer, Reciprocating Gait Orthosis Product Manual
Spinal Considerations
Scoliosis and/or kyphosis
C-shaped with decompensation
Pelvic obliquity
Seating balance compromised
20% congenital vertebral anomalies - reduces load carrying capacity of spine
Goals of Spinal Orthoses:
Delay fusion until skeletal maturity
Prevent progression of curve
Increase pulmonary function
Sitting balance - allow use of UE
Postural positioning
Pictures from: Hsu JD, Michael JW, Fisk JR. (2008) AAOS Atlas of Orthoses and Assistive Devices. 4th Ed. Philadelphia: Mosby Elsevier

Low Lumbar
Motor deficits:
Hip extensors
Hip abductors
Ankle plantarflexors & dorsiflexors
Gait Pattern
Posterior trunk lean
Anterior pelvic tilt
Increased hip & knee flexion, ankle DF
Valgus stress at knee
Hyperpronation at ankle
May require KAFO to stabilize the knee
Prevent hyperextension due to weak quads
Prevent coronal plane deformity that AFO's cannot control
Due to hyperpronation - weak PF
Due to trunk lean - weak hip abductors
Knee joint designs:
Drop Lock
Step Lock or Rachet Lock:
Picture from: http://www.cascade-usa.com/default.aspx?page=category+search+results&CurrentPage=1&OrderByColumn=DESCRIPTION1&OrderByDirection=asc&CatList=6121&Parent=3488&tree=560*Orthotics*0%40%402583*Lower+Extremity+Orthotics*0%40%403453*Knee+Joints*0%40%403479*Drop+Lock+-+Ring+Lock*0%40%403488*Becker+Model+1001+Ring+Lock+Knee+Joint*6121%40%40
Picture from: http://www.ots-corp.com/Products/OrthoticComponents.aspx
Hip or Tibial Rotation:
Twister cables
Can be attached to AFO's or shoes

AFO Designs:
Solid Ankle AFO
Must consider ankle/knee alignment
Floor/Ground Reaction AFO
Utilizes PF/Knee extension moment
Not indicated with knee or ankle contractures
Articulated AFO
Must consider muscle strength
Joint options
PF/DF stop
Picture from: http://www.medicus.ca/en/products/orthotics-prosthetics/orthotics-lower-limb/
Picture from: http://www.allardusa.com/pdf/KiddieGAIT.pdf
AFO Designs:
PLS
Foot orthosis or UCBL
Picture from: http://cpo.biz/posterior-leaf-spring-afo/
Picture from: http://www.orthomedics.us/Pages/ankle.aspx
Picture from: http://www.dafo.com/products/dafo-turbo/
Picture from: http://www.ultraflexsystems.com/uss/ussankle/USSAnkle.htm
Contracture Management
Picture from: http://www.medi-kid.com/index.php?p=product&id=6
Picture from: Picture from: http://www.medi-kid.com/index.php?p=product&id=6
Picture from: http://www.crispinorthotics.com/product/hip-knee-ankle-foot-orthosis/
Pictures from:
Motloch W. The Parapodium: An Orthotic Device for Neuromuscular Disorders, Artificial Limbs, Vol. 15, No. 2, pp. 36-47, Autumn 1971.
Fillauer, Reciprocating Gait Orthosis Product Manual
Picture from: http://www.centerfororthoticsdesign.com/isocentric_rgo/
References:
Hsu JD, Michael JW, Fisk JR. (2008) AAOS Atlas of Orthoses and Assistive Devices. 4th Ed. Philadelphia: Mosby Elsevier
Lusardi MM, Nielsen CC. (2007) Orthotics and Prosthetics in Rehabilitation, 2nd Ed. Philadelphia: Sauders Elsevier.
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