Therapeutic Orthotics after Stroke

Richard SealyPrincipal Physiotherapist in NeuroRehabilitationThe Wolfson Neuro Rehabilitation CentreSt Georges NHS TrustEmail: richard.sealy@blueyonder.co.uk

Aims

• Post stroke gait

• Therapeutic adjunct

• Clinical reasoning

• The potential role of orthoses

Patient Goal

• ‘I want to walk’

Examples of Post Stroke Gait

The Influence of Alignment and Stability

Therapist’s - Clinical Reasoning

• Observation• Where in gait• Why – Problem solving approach

• How am I going to treat this ?

Understanding of the Gait Cycle

• Biomechanics at the foot/ankle– Dorsiflexion / Plantarflexion– Pronation / Supination

• Initial Contact• Terminal Stance

Pronation Supination

Subtalar Joint Biomechanics (Right)

Neutral

Adapted from Mcpoil et al 1985

Acceptable Pronation?

Creating a Base: The Importance of Alignment – Distal to Proximal Influences

Orthotic Management of Pronation following Stroke

Orthotic Management of Excessive Pronation

Biomechanics of Standing

Ground Reaction Force

Biomechanics of Gait

Ground Reaction Force Vector

Biomechanics of Gait

m

Clinical Reasoning / Gait Analysis

Where ?

Why ?

Clinically Reasoning

• Where is it going wrong

• Why is it going wrong

• How can I change this

Improve Motor Control

Motor Control Theories

• Client Centred – Goal settingVan Den Broek (2005)

• Active problem solver – Procedural learning

• Practice, skilled learning results in structure change at 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

Orthotics

An Orthosis:• An external device used to modify the structural or

functional characteristics of the neuromuscular system (International Standards Organisation)

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

• FO, AFO, KAFO

AFO’s 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 consumption’

Meadows (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

Orthotic Management

Clinical Reasoning

Patient Example

Increased Tone

Fixed PF contracture

Normal

Significant compensation strategies

How to manage this?

Midstance

Terminal Stance

AFO’s 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 following stro

ke

• SWIFT Cast Trial – Early intervention cast walking

Summary

• Importance of biomechanical -neurophysiological principles

• Use of orthoses as an adjunct

Condie (2004) Consensus Conference Report

NHS Quality Improvement Scotland (2009)

Thank You For Listening