Therapeutic Orthotics after Stroke

Richard Sealy
Principal Physiotherapist in NeuroRehabilitation The Wolfson Neuro Rehabilitation Centre St Georges NHS Trust
Email: 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

Therapists - 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

Subtalar Joint Biomechanics (Right)

Pronation Neutral Supination

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

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 setting
Van 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

AFOs and Alignment

Condie (2004) Consensus Conference Report Alignment of the orthosis at terminal stance/preswing 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

Significant compensation strategies

Normal How to manage this?

Midstance

Terminal Stance

AFOs 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 stroke

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