Orthoses in Cerebral Palsy.pptx

Orthoses, an integral part of assistive technology, are specially made splints which are being used to align abnormal joints or muscles. These are never bought from ready made shops. Each and every pediatric orthosis should be made by qualified orthoticians. In selected cases, orthoses should be made after taking a POP cast. In a developing child, the orthoses should be changed after every six to nine months and for older children, the splint should be changed after every 9-15 months. Most of the orthoses require modifications so consult your orthotician after every three months or as recommended. Please note, a faulty orthosis always harm the child.

We at ICD, Delhi provide orthotic support to the following condition whenever there is a need
CTEV (Club Feet)
Cerebral palsy
Spina bifida
Erb’s palsy
Brain injury
Spinal cord injury
Post-polio paralysis
Meningomyelocele
Arthrogryposis
Congenital Hip dislocation
Genu recurvatum / Genu varum / Genu valgum
Flat feet / Hallux valgus / Flexed wrist / thumb in palm, etc
Orthotic aids are an integral part of habilitation / rehabilitation therapy. It helps
• To correct and/or prevent deformity
• To provide a base of support
• To facilitate training in skills
• To improve the efficiency of gait
• To improve function

At ICD New Delhi , we have
• Provision for Orthoses for Lower Limbs
• Provision for Orthoses for neck, spine and trunk
• Provision for Orthoses for Upper Limbs

1. Orthoses in Cerebral Palsy Dr. Mansoor Alam Consultant Developmental Specialist Institute for Child Development New Delhi

2. An orthosis by definition, is "an externally applied device used to modify the structural and functional characteristics of the neuromuscular and skeletal system. Orthoses

3. The identified goals were: To correct and/or prevent deformity To provide a base of support To facilitate training in skills To improve the efficiency of gait It is important that the interdisciplinary team check the patient’s functional limitations according to the GMFCS in order to plan the treatment. The type and design of the orthosis is decided accordingly and can be changed periodically depending on the improvement of the patient condition. Why to use orthoses in Cerebral Palsy ?

4. GMFCS

5. Orthoses for Lower Limbs Orthoses for Trunk and Spine Orthoses for Upper Limbs Types /Classifications of Orthoses

6. Foot Orthoses (FO) Supramalleolar Orthosis (SMO) Ankle foot Orthoses (Dynamic, solid, posterior leaf spring, ground reaction, hinged )- AFO Knee Orthoses (Immobilisers, Gaiters ,Plastic knee ankle orthoses )- KO Hip Orthoses (HO) Orthoses for Lower Limbs

7. Foot orthotics do not prevent deformity. They provide a better contact of the sole of the foot with the ground. Foot Orthoses (FO)

8. This orthosis extends to just above the malleoli and to the toes. Consider in mild dynamic equinus , varus and valgus instability . The medial side is higher than the lateral, holds the calcaneus more firmly, supports the longitudinal arch. Prescribed for hind and midfoot instability. Supramalleolar Orthosis (SMO)

9. Supramalleolar Orthosis (SMO)

10. The main function of the AFO is to maintain the foot in a plantigrade position. This provides a stable base of support that facilitates the function and also reduces tone in the stance phase of the   gait . The AFO supports the foot and prevents foot drop during swing phase. AFOs provide a more energy efficient gait. The brace should be simple, light but strong. It should be easy to use. Most importantly it should provide and increase functional independence Ankle Foot Orthoses (AFO)

11. Solid AFO Dynamic AFO (DAFO) Hinged AFO Posterior Leaf Spring AFO (PLSO) Ground Reaction AFO (GRAFO) Anti-Recurvatum AFO Ankle Foot Orthoses (AFO)

12. The solid or rigid AFO allows no  ankle  motion, it covers the back of the leg completely and extends from just below the fibular head to metatarsal heads The solid AFO enables heel strike in the stance phase and toe clearance in the swing phase. It can improve knee stability in ambulatory children. It also provides control of varus / valgus deformity Solid AFOs provides ankle stability in the standing frame in non-ambulatory children Solid AFO

13. A solid ankle foot orthosis aims to prevent all movement of the foot and ankle at the talo-crural , subtalar and midfoot joints. It is prescribed to children with CP when there is: Moderate to high tone in the gastrocnemius muscle; Less than 10 degrees of ankle dorsiflexion with the knee in maximum extension, Moderate to severe medio lateral instabilities at the ankle A requirement to provide proximal control at the knee and hip joints. Solid AFO

14. A Solid AFO may be prescribed to help reduce the effects of ‘ crouch ’ gait, where the hips and knees are in a flexed position during mid stance. If the solid AFO does not resist the dorsiflexion moment during mid to late stance, the tibial Shank to Vertical Angle (SVA) is inclined and the Ground Reaction Force is shifted posterior at the knee and anterior to the hip, thereby permitting crouch gait to occur . Solid AFO

15. The Dynamic Ankle Foot Orthosis generally refers to a custom made Supra- Malleolar Orthosis fabricated from thin thermoplastic material. It fits the foot intimately and the use of the flexible and thin thermoplastic means that the DAFO can provide circumferential control of the rear and fore foot to maintain a neutral alignment To effectively control sagittal plane deformities such as a plantar flexed ankle, a long lever arm is required that involves extending the trim lines up to the proximal calf. Therefore, DAFOs should only be used where there is coronal or transverse plane deformities of the foot and ankle that can be passively corrected with minimal force. Dynamic AFO (DAFO)

16. Dynamic AFO (DAFO)

17. Hinged AFOs have a mechanical ankle joint usually preventing plantar flexion, but allowing relatively full dorsiflexion during the stance phase of gait. They provide a more normal gait because they permit dorsiflexion in stance phase of the gait, thus making it easier to walk on uneven surfaces and stairs. This is the best AFO for most ambulatory patients. The hinged AFO is contraindicated in children who do not have passive dorsiflexion of the ankle because it may force the midfoot joints into dorsiflexion and cause midfoot break deformity. Hinged AFO

18. . Knee flexion contractures and triceps weakness are other contraindications where a hinged AFO may increase crouch gait. The AFO may be fitted with a hinge that allows 10 degrees passive dorsiflexion while preventing plantar flexion. This creates a more natural gait. This design of AFO should only be considered if there is sufficient gastrocnemius length that permits 10 degrees of dorsiflexion with the knee in full extension and where there is no spastic catch or resistance in range of the gastrocnemius due to increased muscle tone. Hinged AFO

19. Hinged AFO

20. Limited Motion Hinged AFO It is the advance version of Hinged AFO which allows only 10-15 degree of dorsiflexion which is quite sufficient to walk efficiently

21. A Posterior Leaf Spring AFO is a rigid AFO trimmed behind the malleoli’s to provide flexibility at the ankle and allows passive ankle dorsiflexion during the stance phase. Varus -valgus control is also poor because it is repeatedly deformed during weight bearing . A PLSO is an ideal choice in mild spastic equinus . Do not use it with patients who have crouch gait and pes valgus . The orthotic treatment goal of the PLS AFO is to maintain the foot and ankle in a plantigrade position during swing to permit foot clearance, but permit ankle plantarflexion and dorsiflexion during stance phase. Posterior Leaf Spring AFO (PLSO)

22. Posterior Leaf Spring AFO (PLSO)

23. This AFO is made with a solid ankle, the upper portion wraps around the anterior part of the tibia proximally with a solid front over the tibia. The rigid front provide strong ground reaction support for patients with weak  triceps surae . The foot plate extends to the toes. The ankle may be set in slight plantar flexion of (2-3 degrees) if more corrective force at the knee is necessary Ground Reaction AFO (GRAFO)

24. Ground Reaction AFO (GRAFO)

25. Use the GRAFO in patients with  quadriceps  weakness or crouch gait. It is an excellent brace for patients with weak triceps surae following  hamstrings  lengthening. Children with static or dynamic knee flexion contractures (more than 15 degrees) do not get benefit out of it and do not tolerate the GRAFO . As with the solid AFO it is imperative the GRAFO is sufficiently stiff to resist the dorsiflexion moment during mid-late stance phase to ensure it can help influence the position of the Ground Reaction Force in relation to the knee and hip joints. Ground Reaction AFO (GRAFO)

26. This special AFO is molded in slight dorsiflexion or has the heel built up slightly to push the tibia forward to prevent hyperextension during stance phase. Consider prescribing this AFO for the treatment of genu recurvatum in hemiplegic or diplegic children. Anti- recurvatum AFOs may be solid or hinged depending on the child’s tolerance. Anti-Recurvatum AFO

27. Anti-Recurvatum AFO

28. Points to be remembered while prescribing an AFO Solid AFOs are always better than all other forms of AFO. Avoid using hinged AFO as far as possible. Unless and until it is technically required Don’t use rubber pad beneath the sole of the AFO, may do more harm than benefits. Always try to check the alignment of the knees before you select an AFO. Genu recurvatum requires specialized recurvatum AFO with adjustable hinged joint What’s new

29. Points to be remembered while prescribing an AFO Always check the three “C” before you ask the child to wear the AFO First C represents “Correction” Second C represents “Comfort” Third C represents “Cosmetic” Never prescribe Hinged AFO in case of Crouch Posture SMO can help valgus but not equinus Hallux Valgus requires extra modification / straps What’s new

30. Knee orthoses are used as resting splints in the early postoperative period and during therapeutic ambulation. There are two types of knee orthoses, The knee immobilizer The plastic knee-ankle foot orthosis (KAFO). The use of such splints protects the knee joint, prevents deformity recurrence after multilevel lengthening and enables a safer start to weight bearing and ambulation after surgery. Knee Orthoses

31. Knee immobilizers are made of soft elastic material and hold only the knee joint in extension, leaving the ankle joint free. Consider using them in the early postoperative period after hamstring surgery and rectus tendon transfers . Popularly they are known as Knee Gaiters. Knee Gaiters can be CORSET or THREE POINTS Corset gaiters are made with iron / aluminum / plastic rode stitched with clothes Three Points Gaiters are made with aluminum / iron rod with knee cap. Three Points gaiters are also used as anti-torsion splint Knee immobilizers

32. Corset Knee Gaiters

33. Also known as 3-points gaiters Made with Aluminum or iron rode with plastic molded thigh and calf support There is a knee cap to straighten and align the knee Can be used with AFO and with out AFO, need based Mostly used as night splints Can be used after botox injection and orthopedic surgery to train the child graded weight bearing Three Points Knee immobilizer

34. 3-Points Gaiters

35. Plastic resting KAFOs extend from below the hips to the toes and stabilize the ankle joint as well as the knee. They are more rigid and provide better support to the ankle and the knee in the early postoperative phase Though KAFOs are still used for ambulation in poliomyelitis and myelomeningocele where there is a need to lock the knee joint, they are not useful for the child with CP because they disturb the gait pattern by locking the knee in extension in the swing phase KAFOs for functional ambulation have disappeared from use in children with CP. Instead, anti recurvatum AFOs or GRAFOs for knee problems in ambulatory children have proved useful. Plastic KAFOs

36. Use the plastic KAFO at night and in the early postoperative period after multi-level surgery to protect the extremity while allowing early mobilization. Plastic KAFOs

37. These days KFOs are not used during day time as it blocks the knee Need based 3-points gaiters or corset gaiters are used during positioning but not in mobility training 3-ponits gaiters can be used as anti-torsion splint just modifying the knee straps. It can control both in-torsion and ex-torsion Corset Gaiters / Pedi-wraps are used till the age of three years only Above 3 years, 3-points gaiters should be used to get better knee extension and alignment What’s New

38. Static Hip Abductor Dynamic Hip Abductor SWASH Hip Aligner Hip Orthoses

39. S.W.A.S.H. orthosis assures a variable abduction during flexion providing sufficient help all day, when sitting, standing, walking or crawling. Functioning : When fitting the orthosis the hip is stabilized preventing any excessive abduction and internal rotation . SWASH

40. SWASH Dislocated hips Fixed hip flexion contracture greater than 20°.There are no finite guidelines for use with non-fixed flexion contracture - this generally is dependent on wearer tolerance. Adductors so strong they overpower the SWASH®uprights (SWASH® Low Profile has larger diameterand therefore stronger uprights.) Adductor length so short it causes discomfort withSWASH ® use in the sitting position If ambulatory, excessive tibial torsion or foot involvement, without physician assessment of impact SWASH® impacts on these conditions.

41. Hip Abductors These days abductor-bars are not used as it created too much discomfort. Very simple plastic made hip abductors are used instead Above all, it can be used w hile walking and resting both

42. Popularly known as HFAFO Rarely used in Cerebral Palsy due to its limitation with mobility HIP-KNEE-ANKLE AND FOOT ORTHOSES

43. There are various types of braces used for spinal deformity. This braces are not prescribed in order to stop the progression of scoliosis but to provide better sitting balance. As most children with scoliosis need spinal surgery to establish and maintain sitting balance in the long run. A thoraco - lumbo -sacral brace helps the child to sit better during the growth spurt period when spinal deformity becomes apparent, progresses fast and the child out grows custom molded seating devices quickly . Children who are not candidates for surgery for different reasons may use spinal braces instead of seating devices for better sitting. Spinal Orthoses

44. Spinal Orthoses

45. Shoulder Splint Elbow Splint Wrist Splint Thumb Splint Fingers Splint Shoulder + Elbow Splint Elbow + Wrist Splint Shoulder + Elbow + Wrist Splint Upper Limb Orthotics

46. The indications of bracing in the shoulder and elbow are very limited. An example of a resting splint is a thermoplastic resting wrist and hand splint which keeps the wrist in 10-20 degrees extension, the metacarpal phalangeal joint(MPJ) in 60 degrees flexion and the interphalangeal joint (IPJ) in extension. This type of splint is used at night and during periods of inactivity with the hope of preventing deformity. Upper Limb Orthotics

47. An example of a functional splint is an opponents splint, which can be used in everyday activities. Hand orthoses may inhibit the active use of the extremity and effect sensation of the hand in a negative way. Use them only in the therapy setting or at school and take them off during other times in the day . Upper Limb Orthotics

48. CIMT band is used in case of CIMT It is better than a cast as it can be removed as and when required Light weighted It is used in the good or better hand to inhibit the usage while CIMT CIMT Band

49. For all queries, doubts and explanations, please contact us @ Institute for Child Development C-27, Malviya Nagar New Delhi-110017 Landline Number: 011-41012124 Mobile Number: 7838809241 Mail: [email protected] Website: www.icddelhi.org Thanks for listening