Orthoses for Cerebral Palsy PDF

Orthoses for Cerebral Palsy Sahra Şirvan Tongar PT, MSc., PhD(c) Lecturer Cerebral Palsy Lesion in the immature brain à Not progressive Problems in the MS system à Progressive Children with CP are at increased risk of developing secondary complications such as muscle contractures, skele...

Orthoses for Cerebral Palsy Sahra Şirvan Tongar PT, MSc., PhD(c) Lecturer Cerebral Palsy Lesion in the immature brain à Not progressive Problems in the MS system à Progressive Children with CP are at increased risk of developing secondary complications such as muscle contractures, skeletal deformities, hip dislocation, and scoliosis. 2/3 of children with CP walk with or without walking aids. However, children with CP usually start to walk later than their peers without CP, walk at a slower speed, and with a higher energy cost. Musculoskeletal Problems vProgressive joint contractures vExcessive shortness of the muscles vTorsional deformities of the hip and foot vTransfer and ambulation problems vInability to generate force vBalance disorder Limitation of vDecrease in walking speed participation in vDecrease in stride length ADL vIncrease in energy consumption vDynamic imbalance between the extrinsic muscles of the calf that control foot and ankle alignment. vTypically, the ankle plantar flexor muscles are overactive and the ankle dorsiflexor muscles are ineffective. vVariable imbalance patterns may be seen between the foot and ankle supination and pronation muscle groups. vThese motor imbalances result in three common coupled foot and ankle segmental malalignment patterns in children with spastic type CP. ØEquinus ØEquinoplanovalgus ØEquinocavovarus  Wolff’s Law If loading on a particular bone increases, the bone will remodel itself over time to become stronger to resist that sort of loading.  Normal Bone Growth vTypical developmental stresses vWeight transfer No movement variation CP No load on the bone Bone and joint deformities  Foot-Ankle Problems vEquinus deformity vVarus deformity vPlanovalgus deformity vHyperdorsiflexion deformity vIn-toeing or Out-toeing v Tone abnormalities vFinger problems v Muscle imbalance v Soft tissue contractures Gait disorders or v Bone torsions inability to walk v Joint instability Factors causing gait disorders Weak muscles Spastic muscles Tibialis anterior Plantar flexors Plantar flexors Hip adductors Hip extensors Quadriceps Hip flexors Hamstrings Hip abductors  Equinus deformity The most common foot deformity in patients with CP. Plantar flexion malalignment of the hindfoot relative to the ankle, with normal midfoot and forefoot alignment. Result from tight calf muscles or Achilles tendons  At 18-24 months : Walking with equinus Until 4-5 years of age : Equinus walking without fixed contracture At 6-7 years of age : Fixed contracture begins to develop. vSometimes, although the cases are hemiparetic, vBilateral tiptoe walking can also be preferred to adapt the other side. Equinoplanovalgus deformity Second most common foot deformity in patients with CP. Equinus deformity of the hindfoot Pronation deformities of the midfoot and forefoot Equinocavovarus deformity Equinus deformity of the hindfoot Supination deformities of the midfoot and forefoot Silfverskiold Test vSpecifically to differentiate accompanying muscle tensions and to determine the cause of ankle dorsiflexion limitation. vAnkle DF is evaluated in knee extension and flexion.  Silfverskiold Test vIf dorsiflexion increases when the knee is flexed: This indicates tightness in the gastrocnemius muscle. The gastrocnemius muscle is affected by the knee position, so it can stretch more in flexion. vIf dorsiflexion does not change despite changing knee position: The problem is probably due to tightness in deep structures such as the soleus muscle or the joint capsule.  Crouch Gait vWeakness in the extensor muscles of the lower extremities. vWeakness in plantar flexors vKnee extension deficit vTight or spastic hamstrings vHip flexion contracture vIatrogenic: Due to surgeries  Purpose of The Orthosis vTo prevent deformity and contractures vTo control muscle stiffness vTo control hypotonia vTo prevent/delay surgery vTo support surgery vTo provide functionality  Tardieu et al. 1988 Contractures can be prevented with a minimum of 6 hours of stretching. We don't have that much time… We can use orthoses as a tool  Texture Rigid: prepared individually with rehearsal made of polyethylene, carbon, lamination, and metals. Semi-rigid Soft: in standard sizes, prepared by series production. made of Fabric, Elastic fabric, Neoprene etc.  Foot Orthoses Better contact of the sole of the foot with the ground Do not provide an effective PF / DF control. Used in planovalgus / planovarus deformities. -inframalleolar -supramalleolar  Inframalleolar Orthoses Does not control sagittal plane movements of ankle Used to control moderate pes planovalgus deformity. University of California Biomechanics Shoe Inserts UCBL Laboratory Orthosis  Supramalleolar Orthoses (SMO) From the toes – to above the malleoli It can control the foot movements in the sagittal plane partially Medio-lateral instability of the subtalar joint Varus-valgus deformity Mild to moderate spasticity  FOOT ORTHOSES INDICATIONS CONTRAINDICATIONS Medio-lateral instability of Lack of voluntary DF the subtalar joint control Midfoot deformity Lack of heel strike resulting in valgus/varus of the forefoot Fix equinus deformity Mild to moderate Moderate to severe spasticity spasticity  AFO: ANKLE FOOT ORTHOSES vAFO is the basic orthosis in CP. vUseful for many children with spastic diplegia. vThe main function of the AFO is to maintain the ankle in a 90 degree neutral position. vPrevents drop foot during swing phase. vEnsuring ROM and facilitating functions. vIt can also be used to stabilize the knee and hip joint indirectly. vThere are various types of the AFO and can be prescribed according to our purpose.  Solid AFO (SAFO) FOR STABILITY IN MIDSTANCE PHASE vDoesn’t allow any ankle movement. vCovers the back of the leg completely vExtends from below the fibular head to metatarsal heads. vPlantar flexor, invertor or evertor muscle spasticity, vDrop Foot, vMild Crouch Gait, vModerate to severe mediolateral instabilities at the ankle vIncrease stability in the midstance phase Solid AFO (SAFO) ONLY THE ANKLE JOINT?  Limitations of Solid AFO Does not allow any ankle movement and therefore limits smooth progression from heel strike to push off.  Articulated AFO MORE FUNCTIONAL ØContains a joint ØChildren with CP, who gain enough stability and reach the level of walking with a walker, begin to use articulated AFO to prevent PF by gaining DF. ØIf the child has selective movement ØIf spasticity is under control  PF spasticity may be the cause of genu recurvatum! knee hyperextension a PF stop in 2–5 degrees of DF may assist to control genu recurvatum. IF POSSIBLE, CONTROL THE KNEE JOINT THROUGH THE ANKLE JOINT AVOID USING KAFO L  WHY? Our aim = Functionality Knee joint unable to flex? The quality of walking decreases RESULT: CIRCUMDUCTION GAIT  Containdications Of Articulated AFO Crouch gait : It does not control “crouched” posture allowing increased DF and knee flexion. Children with strong extensor posture If passive DF does not reach 5 degrees Staying in solid AFO may be more beneficial for children who are immobile. Ground Reaction AFO (GRAFO) ØInarticulate orthosis ØIt is the closed version of AFO from the front. ØPrevents the tibia from shifting forward during stance. ØCreates the extensor momentum that should normally be created by the quadriceps muscle. ØUsually used in CROUCH GAIT. Solid AFO Ground Reaction AFO  Posterior Leaf Spring AFO Reflex AFO Passes posterior to the malleolus Formed by cutting the edges of the solid AFO from the back of the malleoli. Apparently jointless, but has the ability to stretch. Resists the PF. Allows 10 ° passive DF in the stance phase. Prevents drop foot in the swing phase.  Dynamic AFO (DAFO) Often used in CP Made of flexible and thin thermoplastic material Provides medial–lateral ankle stability Control of pronation/supination Allows some ankle dorsiflexion/plantarflexion. It is thought that it reduces abnormal PF movements and inhibits hypertonus.  Orthopedic Boots ØUse instead of orthotics? ØDoes not prevent equinus deformity. Abrasion due to equinus deformity in boots worn for only 1 week  KAFO (Knee – Ankle - Foot Orthoses) Rare. Our first goal=> to control the knee joint through the ankle joint** Purpose of use: 1. Preventing knee hyperextension 2. Providing knee extension 3. Helping standing DOES NOT PROVIDE FUNCTIONALITY!!!  Immobilizer Resting splint (immobilizer) for knee extension  HKAFO (Hip-Knee-Ankle-Foot Orthoses) Usually for non-ambulatory children Maintaining and increasing hip joint range of motion Positioning the hip against the risk of subluxation and dislocation.  HKAFO (Hip-Knee-Ankle- Foot Orthoses) FOR AMBULATORY CHILDREN; (rare!!!!) ØTo reduce hyperadduction in the hip in children with scissoring gait, ØTo increase the sitting balance. Bulky, difficult to put on and take off Difficult to manage clothing for toileting…  Hyperabduction Device Scissor gait Standing with Sitting without Sitting with without device hyperabduction device hyperabduction device device Hip-abduction orthoses may improve sitting stability by increasing the size of the base of support.  Gait Trainer For children at GMFCS 4-5. To increase activity For participation If there is no severe contracture Gait Trainer  Hart Walker For children at GMFCS 4-5. It is a walking aid that allows the child to walk independently, hands-free. It has 4 wheels Provides external balance Important for participation Hart Walker Hart Walker Hart Walker  Upper Extremity Orthoses Upper extremity orthoses are insufficient to deal with these problems. It can be used to prevent deformity development and progression, contracture formation and to provide rest in the postoperative period. ØThose for stabilization are used mostly at night in order not to limit functionality. ØBut it can also be used during the day to increase functionality. v AVOID USING LARGE ORTHOSES! v Orthoses should not cover the palm and volar part of the fingers. v Because orthoses covering the palmar part prevent tactile and sensory stimulation, which may result in hand neglect.  Spinal Orthoses ØTo support sitting independently. ØThoracolumbosacral type orthoses It was found that they were not effective on scoliosis.  TheraTogs The use of flexible dynamic orthotic garment Ø Improve the ability to stabilize the posture, Ø Correct or prevent deformities Ø Improve functionality https://vimeo.com/414535630 https://vimeo.com/414576482  Symmetrical Approach Even if the child is hemiplegic... Only the weight is transferred to the affected side. The healthy side is used for compensation… Our aim should be equalize the step width and step velocity two sides. BILATERAL ORTHOSES IS RECOMMENDED DO NOT INSIST ON THE NIGHT ORTHOSIS! If the child cannot tolerate, It can also spread throughout the day… Orthosis should be decided not according to the disease/condition but according to the individual needs of the child. CASE -1 A 6-year-old boy with a diagnosis of spastic diplegia was admitted to the pediatric rehabilitation clinic. Foot-Ankle Examination: There is equinus deformity in the right and left feet. Silfverskiold Test: Ankle dorsiflexion is limited when the knee is extended, but dorsiflexion increases when the knee is flexed. CASE -1 Gait Analysis: Toe-walking is observed. Step length is short and walking speed is decreased. There are sideways deviations due to dynamic imbalance. Muscle Strength and Tone: Tibialis anterior is weak. Spasticity is present in gastrocnemius muscle. ** Which orthosis would be appropriate in this case? CASE -2 A 7-year-old girl diagnosed with spastic diplegia presented to the pediatric rehabilitation clinic. Her family reported that her knees were hyperflexed and she often got tired when walking. Thechildhaddifficultywalking,especiallyforlong distances, and she had imbalance when standing. CASE -2 Posture and Gait Analysis: Child walks with crouch gait: Knees are constantly flexed, Increased dorsiflexion in ankles, Hip are slightly flexed. Muscle Tone: Spasticity is present in the hamstrings muscle. Weakness in the quadriceps muscle CASE -2 Other Findings: Stability is impaired due to the forward displacement of the tibia, which increases energy consumption during walking. ** Which orthosis would be appropriate in this case? Summary Correct evaluation => correct treatment. Orthosis selection should be aimed not only at the deformity but also at increasing the child's participation in daily life activities. Orthosis planning involves a collaborative process between the physiotherapist, orthotist, physician and family. Orthosis use should be monitored regularly to assess effectiveness and make adjustments if necessary.