Professional articles

Lower Limb Orthoses in Rehabilitation of a Neurologically Impaired Patient

Case report
Summary Patients with severe brain injury frequently present with cognitive and behavioural problems, limiting engagement in physical rehabilitation. Contractures developed during the acute phase of illness may need months of intensive treatment and require an integrated multi-disciplinary approach. We describe the case of a young woman with complex disabilities following acute demyelinating encephalomyelitis. She presented with severe lower limb contractures and hypertonus, preventing weight bearing. Cognitive and behavioural problems restricted progress and the team adopted a functional weight bearing programme using traditional metal and leather orthoses to facilitate gait. By the end of her admission this patient was able to walk with an aid and under supervision and she has progressed further following discharge. The rationale and factors contributing to the successful outcome in this complex case are discussed.
Introduction Patients with severe neurological disability frequently present with cognitive and behavioural problems which limit functional improvement (Kaplan and Corrigan, 1994; Alderman, 2001). Jackson et al (2000) identified that these patients took longer to walk. Lower limb contractures are a recognised problem (Wheeler et al, 1995) that can have a negative effect on the rehabilitation of standing and gait (Carter and Edwards, 2002; Shumway-Cook and Woollacott, 2001). Some authors refer to the use of lower limb orthotics in this client group (Edwards and Charlton, 2002; Brodnansky et al, 1997; Tyson and Thornton, 2001). This case report aims to illustrate their use when managing contractures and reeducating gait in a patient with severe neurological disability. The issues related to this management approach are discussed.

359 Key Words Orthosis, contracture, cognitive deficit, neurological impairment, muscle hypertonia, rehabilitation. by Patricia Watts Lisa Knight Paul Charlton

Watts, P, Knight, L and Charlton, P (2003). Lower limb orthoses in rehabilitation of a neurologically impaired patient: Case report, Physiotherapy, 89, 6, 359-364.

Case Presentation Kathleen was a 25-year-old housewife with two children who developed acute demyelinating encephalomyelitis. She initially presented with quadraparesis, impaired swallowing and marked cognitive impairment. CT and MRI scans showed diffuse cerebral swelling and extensive white matter lesions, including the brain stem. She was admitted to an intensive care unit and intubated and ventilated for four weeks. Kathleen was then transferred to a neurosciences unit for post-acute care. During this five-month phase muscle hypertonus, particularly flexor tone in the right lower limb, was problematic. Treatment centred on casting combined with botulinum toxin and periods of standing using the tilt table. She was on a small dose of oral baclofen. A combination of crying and hitting out, swearing and drowsiness had hampered rehabilitation. Cognitive impairments including distractibility, poor safety awareness and disorientation had also limited progress. Kathleen was admitted to the Regional Rehabilitation Unit at Northwick Park Hospital six months after onset, where she remained an inpatient for eight months. Thereafter she became an outpatient at a general hospital, attending regular orthotic reviews at the Regional Rehabilitation Unit. On admission, Kathleen presented with a mixture of hypertonus and hypotonus. She had low muscle tone around the trunk, resulting in a flexed posture and inability to sit unsupported. She had mildly increased tone in the left upper limb with poor selective movement. Tone and movement were now normal in the right upper limb. She had increased flexor and adductor tone and weakness of the extensor muscles in both lower
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Table 1: Contractures on admission and discharge

Admission Right hip Right knee Left ankle Flexion contracture of 15 * No abduction beyond neutral Flexion contracture of 40 20 off plantargrade Discharge Flexion contracture of 10 10 of abduction Flexion contracture of 5 10 off plantargrade

*All contractures measured from the anatomical position in supine using a hand-held goniometer. The axis of the goniometer was placed over the greater trochanter for measuring hip flexion, at the lateral femoral condyle for knee flexion and at the lateral malleolus for plantarflexion.

limbs, particularly on the right, with contractures (table 1). The mixture of tonus and drowsiness led to the decision to discontinue baclofen. Kathleens cognitive and behavioural problems were still apparent. She had no ability to remember new information and was disorientated to person, time and place. Kathleen was non-ambulant and dependent for all activities (table 2). Outcome Measures The Functional Ambulatory Category is an outcome measure used at the Regional Rehabilitation Unit to evaluate progress towards independent gait. It is an ordinal measure with established reliability and validity in rehabilitation settings (Wade, 1992), which provides information on the physical support needed by patients while walking. It consists of six categories ranging from 0 (patient cannot walk, requires help of two or more people) to 5 (patient can walk independently anywhere). Kathleens admission score was 0. FIM + FAM A global measure of disability, incorporating the Functional Independence Measure (Wade 1992), but with additional sections, particularly reflecting cognitive function. It has been shown to be a reliable and sensitive tool in postacute rehabilitation (Turner-Stokes et al, 1999). Each of the 30 sections is scored from 1 (total dependence) to 7 (complete independence). The scores can be represented visually as in figure 1. Kathleen scored 24 out of a possible 112 for the motor sub-scales and 37 out of 98 for the cognitive, psychosocial sub-scales. The shaded area indicates the amount of change during admission to the Regional Rehabilitation Unit. The mobility chart (table 2) is not a recognised outcome measure, but is used routinely at the Northwick Park Regional Rehabilitation Unit to show functional abilities on admission and discharge. All contractures were measured from the anatomical position in supine using a hand-held goniometer. The axis of the goniometer was placed over the greater trochanter for measuring hip flexion, at the lateral femoral condyle for knee flexion and at the lateral malleolus for plantarflexion. A consistent technique

Table 2: Mobility chart Function Independent with/ without aid Minimum Moderate help help Total help/ unable

Lying roll on to left side D Lying roll on to right side D Get up from lying through D left side Get up from lying through D right side Unsupported sitting static D for 2 minutes Sitting without arm support D for 2 minutes Stand up to free standing Stand for 2 minutes Transfer bed to chair to left side Transfer bed to chair to right side Walk 2 steps Walk indoors Lying hold arm in elevated A/D position left Lying hold arm in elevated A/D position right Put left hand to face A/D Put right hand to face A/D Grasp and release A - limited left hand release/D Grasp and release A/D right hand Walk outdoors Flight of stairs

A A A A A A D D D D D D A A A A A A

A/D A/D

Minimum help = subject performs 75% of activity Moderate help = subject performs 50% of activity A = On admission 6 months post injury D = On discharge 13 months post injury

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and position was used to maximise reliability as suggested in the literature (Norkin and White, 1995). However, it is recognised that measurement of contracture is subject to significant error, not only due to positioning and observer error, but also to variations in tone. The results should be interpreted with due caution. Management The initial aims of treatment were to: Increase range of right knee extension. Increase range of left ankle dorsiflexion. Mobilise trunk and pelvis from a flexed position. Increase independence in transfers and standing. Serial casting was started early after admission to minimise contractures of the right knee and left ankle, in accordance with current guidelines (Ashburn et al, 1998). After several casts, replaced at inter vals of 5-7 days, the right knee contracture improved to 15 flexion.

Maintaining this with overnight resting splints was problematic, due to poor patient compliance and increased flexor tone. The right knee contracture stabilised at 20 flexion. There was no significant improvement in the range of movement in the left ankle initially, despite casting and the injection of botulinum toxin A into the gastrocnemius/soleus (Dysport 500 mouse units). Later in the admission, as Kathleen spent more time standing in therapy, the left ankle contracture improved to 15 plantarflexion. Mobilisation of the trunk and pelvis was attempted in supine and sitting, but therapeutic handling was poorly tolerated. Supported standing became a high priority for promoting trunk extension. In the first three months of admission Kathleen could only stand using the tilt table, or with help of four people. As her trunk control and activity of the left leg improved, she progressed to standing with help from three people, as well as in a standing frame.

FAM SUB SCALES 1-7 Self care 30. Safety awareness 8-9 Sphincter control 29. Concentration 10-13 Mobility transfer 14-16 Locomotion 28. Orientation 17-21 Communication 22-25 Psycho-social adjustment 27. Memory 26-30 Cognitive function
26. Problem solving

1. Feeding 7 6 5 4

2. Grooming 3. Bathing

Discharge

Admission

4. Dressing upper body 5. Dressing lower body

6. Toileting 3

25. Leisure activities

7. Swallowing

24. Adjustment to limitations

1 0

8. Bladder management

23. Emotional status

9. Bowel management

22. Social interaction

10. Bed, chair, wheelchair transfer

21. Speech intelligibility

11. Toilet transfer 12. Tub, Shower transfer 13. Car transfer 14. Locomotion - Wheelchair 15. Stairs

20. Writing 19. Reading

FIM/FAM SCORES 7 Complete independence 6 Modified independence 3-5 Modified dependence 1-2 Complete dependence

18. Expression 17. Comprehension 16. Community mobility

Fig 1: Change in Kathleens FIM+FAM. Scores are shown along the spokes from 1 (totally dependent) to 7 (totally independent) and the shaded area shows the amount of change during admission to the regional rehabilitation unit

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Authors Patricia Watts BSc MCSP is a senior physiotherapist at the Royal Free Hospital, London. Lisa Knight GradDipPhys MCSP is a clinical specialist in physiotherapy at Northwick Park Hospital regional rehabilitation unit. Paul Charlton MBAPO DipOTC is a senior orthotist with Peacocks Medical Group, Newcastle upon Tyne. This article was received on March 15, 2002, and accepted on March 14, 2003. Address for Correspondence Patricia Watts, Royal Free Hospital, Physiotherapy Department, Lower Ground Floor, Pond Street, London NW3 2QG.

Improvement in trunk activity and posture allowed Kathleen to transfer in the ward using a sliding board with help from one person. Standing transfers still proved difficult, as she was unable to recruit sufficient extension at the hips and knees. Over the following month Kathleen demonstrated the ability to take steps, although weight bearing through plantarflexed inverted feet, with increased flexion through the trunk and right lower limb. A plaster back slab was needed to maximise right knee extension. These issues were discussed with our orthotist. The team considered that if orthoses could maintain right hip and knee extension, maximise left dorsiflexion and correct inversion, Kathleen would be able to walk with an aid and supervision. A knee ankle foot orthosis in the form of a full leg caliper for the right lower limb and a below-knee orthosis for the left leg (fig 2) were suggested. The orthoses were made of metal and leather as opposed to thermoplastic. The knee ankle foot orthosis had manually operated knee joints to allow flexion in sitting.

Fig 2: Kathleen wearing bilateral lower limb orthoses

Accommodating heel raises were required, as plantarflexion of the left ankle was not fully correctable. Bilateral heel raises were used to maintain symmetry of the pelvis. Once the orthoses arrived, adjustments were needed and Kathleen had to build up tolerance to wearing them. Time was spent educating nursing staff and carers on how to apply them. Treatment then included hydrotherapy, positioning and continued re-education of normal movement. Other members of the multi-disciplinary team were able to build on the increase in Kathleens physical abilities to work on self-care activities. Her family helped Kathleen with exercises and stretches. Six months after admission Kathleen was able to walk with a wheeled frame and the help of two people and stood with one person. She spent a further two months on the Regional Rehabilitation Unit incorporating these abilities into functional activities. On discharge Kathleen still demonstrated low tone centrally, but was able to recruit some trunk extension. She had increased speed and dexterity in left arm movement. She had moderate increased flexor tone of the lower limbs, particularly on the right, but improved voluntary activity of abductor and extensor muscle groups. Her lower limb contractures had reduced (table 1). She could concentrate on a task for up to 15 minutes. Kathleen still needed close supervision at all times, but no longer displayed verbal or physical aggression. She was orientated and was able to use some memory strategies such as a diary, with help. She was more independent in activities (table 2). This included transferring through standing with the help of one person and walking indoors with a wheeled frame and close supervision (Functional Ambulatory Category 2). Her scores on the FIM+FAM had improved to 65/112 on the motor sub-scales, and 59/98 on the cognitive/psychosocial subscales. Kathleen was discharged to her parents house with her two children, with social services support. An orthotic review was requested two months after discharge. At this time Kathleen was walking with the frame and supervision only and could perform such

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activities as getting up from the floor independently. She had full range of right knee extension. There were still contractures at the ankles. It was decided to progress to bilateral metal ankle foot orthoses. Three years post insult Kathleen is able to walk independently indoors and outdoors with bilateral heel raises and two sticks. The current multi-disciplinary team is working towards more independent community living. Discussion The authors believe that a key component in Kathleens rehabilitation was the timely orthotic intervention. The preliminary treatment techniques of serial casting, mobilisation of soft tissues and facilitation of normal movement had partly achieved the aims, but cognitive and behavioural impairments affecting compliance were limiting factors. Weight bearing in standing required more than one therapist to achieve appropriate alignment and could not be used functionally. The orthoses allowed extended periods of standing which helped to increase range of movement in soft tissues and facilitate activation of extensor musculature. Standing appeared to reduce flexor tone in the lower limbs and increase extensor activity. Some authors (Edwards and Charlton, 2002) state that mechanical support should be used with caution when dealing with patients with severe flexor spasticity, as forcing the leg into extension may exacerbate the spasticity. They state that mobilisation of the trunk and pelvis and gentle stretching of the affected muscle groups may prove effective in enabling a patient to accommodate to orthoses. The idea of preparing the patient for the orthoses and using them as an adjunct to, not a replacement for physiotherapy, was incorporated into Kathleens management. The orthoses reduced the number of therapists required for standing. As Kathleen often became distressed when being handled by therapists and responded best to familiar, functional activities, this improved tolerance allowed

her to stand more frequently. The ability to stand with reduced help increased patient participation in activities of daily living, with the goal of improving both independence and orientation. There were improvements in self-care tasks (fig 1). Thermoplastic materials are more frequently used in modern orthotics, but the variability of Kathleens tone and therefore the alignment of the left ankle and right knee required some adaptability within the orthoses. Knee ankle foot orthoses of metal and leather design provide this through the ability to alter the tension of the leather straps. Forces applied via conforming leather straps may resist high biomechanical forces with reduced risk of skin pressure, compared with close fitting, more rigid thermoplastic materials (Charlton and Ferguson, 2001). Kathleen was in an intensive and specialised multidisciplinary team environment with a high staff:patient ratio, where length of stay is largely determined by patient need. Carers were encouraged to be active participants in the rehabilitation process, facilitating a 24-hour approach. There is increasing evidence that the intensity and environment of therapy affect outcome (Kwakkel et al, 1997; Langhorne et al, 1996). Because of Kathleens memory loss, repetition and consistency were important parts of the rehabilitation programme. Kathleens improvement in cognitive and physical abilities allowed her to make further functional gains in the community setting. Conclusion This case report suggests that lower limb orthoses, including metal knee ankle foot orthoses, remain an effective adjunct to treatment for selected neurological patients. Patients with cognitive and behavioural deficits in particular may benefit as they increase the possibilities of undertaking functional, meaningful activities. These patients may continue to make functional improvements over an extended period.

Acknowledgements The authors would like to thank the following colleagues for their advice and encouragement in writing this case report: Elizabeth Bond MSc MCSP, lecturer in physiotherapy, Department of Health Studies, Brunel University. Heather Thornton MBA MCSP, senior lecturer, Department of Physiotherapy, University of Hertfordshire. Professor Lynne Turner-Stokes DM FRCP, director/consultant in rehabilitation, Regional Rehabilitation Unit, Northwick Park Hospital.

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References Alderman, N (2001). Managing challenging behavior in: Wood, R and McMillan, T (eds) Neurobehavioral Disability and Social Handicap Following Traumatic Brain Injury, Psychology Press, Hove, pages 175-203. Ashburn, A, Cornall, C, Melville, N, Simpson, M and Wright, R (1998). Clinical Practice Guidelines on Splinting Adults with Neurological Dysfunction, Association of Chartered Physiotherapists Interested in Neurology. Brodnansky, M, Eberly, V and Jankoski, J (1997). The use of a knee ankle foot orthosis as a gait training tool for the brain injured patient, Physical Therapy, 77, 5, 584. Carter, P and Edwards, S (2002). General principles of treatment in: Edwards, S (ed) Neurological Physiotherapy: A problem solving approach, Churchill Livingstone, London, pages 121-153. Charlton, P and Ferguson, D (2001). Orthoses, splinting and casting in: Barnes, M and Johnson, G (eds) Upper Motor Syndrome and Spasticity Clinical Management and Neurophysiology, Cambridge University Press, pages 142-165. Edwards, S and Charlton, P (2002). Splinting and the use of orthoses in the management of patients with neurological disorders in: Edwards, S (ed) Neurological Physiotherapy: A problem solving approach, Churchill Livingstone, London, pages 219-253. Jackson, D, Thornton, H and Turner-Stokes, L (2000). Can young disabled stroke patients regain the ability to walk independently more than three months post stroke? Clinical Rehabilitation, 14, 538-547.

Kaplan, C and Corrigan, J (1994). The relationship between cognition and functional independence in adults with traumatic brain injury, Archives of Physical Medicine and Rehabilitation, 75, 643-647. Kwakkel, G, Wageneer, R, Koelman, T, Lankhorst, G and Koetsier, J (1997). Effects of intensity of rehabilitation after stroke, Stroke, 28, 8, 1550-56. Langhorne, P, Wagenaar, R and Partridge, C (1996). Physiotherapy after stroke: More is better? Physiotherapy Research International, 1, 2, 75-88. Norkin, C and White, J (1995). Measurement of Joint Motion: A guide to goniometry, F A Davis, Philadelphia, 2nd edn, pages 13-32. Shumway-Cook, A and Woollacott, M (2001). Motor Control Theory and Practical Applications, Lippincott, Williams and Wilkins, Baltimore, 2nd edn, pages 381-383. Turner-Stokes, L, Nyein, K, Turner-Stokes, T and Gatehouse, C (1999). The UK FIM+FAM: Development and evaluation, Clinical Rehabilitation, 13, 277-287. Tyson, S and Thornton, H (2001). The effect of a hinged ankle foot orthosis on hemiplegic gait: Objective measures and users opinions, Clinical Rehabilitation, 15, 53-58. Wade, D (1992). Measurement in Neurological Rehabilitation, Oxford University Press, 4th edn, pages 167-168. Wheeler, L, Ansari, S and Turner-Stokes, L (1995). Contractures: An expensive oversight, Clinical Rehabilitation, 9, 178.

Key Messages Lower limb orthoses, including traditional metal and leather orthoses, can be a useful adjunct to physiotherapy in the rehabilitation of selected neurological patients. Lower limb orthoses do not necessarily increase abnormal tone.

A consistent 24-hour approach provided by the multidisciplinary team and the family was an important factor in enabling this patient to improve her independence. Patients with severe, complex neurological disability may have potential to make functional improvements over an extended period of time.

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