UPPER AND LOWER LIMB ORTHOSES
6.2 Continued
ORTHOSIS COMMON NAME FUNCTION (REF.) LIMITATIONS
Anterior floor reaction or ground reaction ankle foot orthosis
GRAFO Limits a “crouch” posture (stance posture with hip flexion, knee flexion, and ankle dorsiflexion). At heel strike, it encourages a force up through the anterior cuff of this orthosis, giving the knee an extension torque. Knee extension is maintained throughout stance.
A child with significant hamstring or hindfoot tightness or tone will not benefit from this orthosis
Rear-entry hinged floor- reaction AFO
Dorsiflexion stop limits a “crouch”
posture while allowing for plantarflexion during the loading phase of stance and at push-off
Active dorsiflexion is required to restrict foot drag during swing
Posterior leaf spring PLS The trimlines of this solid AFO are posterior to the malleoli. The slender posterior portion of this AFO gives it flexibility to allow for some dorsiflexion in stance and plantarflexion at push-off.
Does not allow full motion into dorsiflexion or plantarflexion. For medial-lateral ankle stability and arch control, another orthosis may be more appropriate. Does not control foot deformity or extensor tone. Excessive torque on spring may cause skin problems.
Dynamic ankle foot orthosis
DAFO A supramalleolar orthosis that uses
a footboard to support the arches of the foot. Provides medial-lateral ankle stability with control for pronation/
supination. Allows some ankle dorsiflexion/plantarflexion.
Difficult to fit into shoes. Difficult for self-donning. Child may quickly outgrow this splint, since it is finely contoured to the foot.
Knee hyperextension splint
Maintains neutral knee and limits knee hyperextension. Uses three points of pressure: superior-anterior surface of the knee, inferior-anterior surface of the knee, and posterior to the knee joint (6,11).
Controls only the knee. Does not control extensor posturing well. It is bulky under clothes and difficult to sit with.
Swedish knee cage KO Controls genu recurvatum with the
same three points of pressure a knee hyperextension splint and works the same. Uses metal uprights and straps instead of plastic material (7).
Controls only the knee. It is difficult to fit to smaller children, and it is difficult to maintain correct positioning.
Knee ankle foot orthosis KAFO Molded plastic upper and lower leg components, usually with a locked or unlocked hinged knee joint. Four most common knee locks are free, drop lock, bail lock, and dial lock. Free knee allows full motion at the knee axis. Knee axis may be straight or offset. Offset axis has an increased extensor moment at the knee joint. The drop lock is a metal collar that slides into place to maintain the knee in extension. The bail lock is a spring- loaded lock that has a trip mechanism to unlock the knee. The dial lock is a lock that may be set in varying degrees of flexion, used to accommodate or decrease a knee flexion contracture (13).
It is bulky and difficult to don/doff.
Free knee at times allows too much motion. Drop lock requires fine motor control to lock and unlock. The child must be able to get the knee fully extended to engage the drop lock.
Bail locks at times become easily disengaged. Dial locks do not allow free movement through the available range.
Continued
6.2
ContinuedORTHOSIS COMMON NAME FUNCTION (REF.) LIMITATIONS
Hip knee ankle foot orthosis
HKAFO Hip belt and joint. Hip and knee joints may be locked or unlocked. Able to progress child to an increasing number of free joints at a time.
Bulky, difficult to don/doff. Difficult to manage clothing for toileting.
Reciprocating gait orthosis
RGO HKAFOs that are connected by a
cable system that links hip flexion on one side with hip extension on the other. This device assists children with active hip flexion and no hip extension to advance legs with a more normalized gait. Allows the child to ambulate with a reciprocal or swing-through gait (13).
Bulky, expensive. Difficult to don/doff.
Not appropriate for a child with hip and/
or knee flexion contractures. Difficult to manage clothing for toileting.
Hip spica/hip abduction splint
An orthosis made of thermoplastic material and Velcro to position a newborn’s legs in abduction and flexion. This splint is used to maintain the femoral head in the acetabulum to mimic normal hip formation. Use of this splint helps to avoid hip subluxation and dislocation. Used from birth up to a year.
Requires frequent repositioning. May need frequent adjustments for growth.
Difficult for caregivers to maintain appropriate fit.
Pavlick harness A soft splint used for children with
the diagnosis of congenital hip dislocation. This splint is generally used in the first 9 months of age.
Bilateral lower limbs are positioned with hips abducted and flexed to 90 degrees in an attempt to maintain the hips in a reduced position.
Careful positioning required. Caregivers must be vigilant in checking splint positioning.
Parapodium or Variety Village Stander
This device allows the child to stand without upper extremity support, freeing bilateral arms to do activities. Walking with this device and crutches can be quicker than with the Parapodium with a swivel device (13).
More energy expenditure than with the swivel device. Children are unable to independently don/doff or to independently transfer supine to stand and stand to supine. Device is heavy.
Parapodium with ORLAU swivel modification
This orthosis allows the child to walk without use of a gait aid and to use the arms for other activities.
Less energy expenditure than with a Parapodium and crutches (14,16).
Same as above. Slower than walking with Parapodium and crutches.
Twister cables Cables are attached to a pelvic
band and traverse the lower limbs to attach on shoes or AFOs. These cables provide control for increased internal rotation. Work well with children with normal to floppy tone to control internal rotation (13).
Do not work well with children with extensor spasticity. They may need to be frequently readjusted as the child grows.
the child with bed mobility skills and positioning changes. The position is individually set and can be altered as needed. Typically, trapeze bars assist with supine to sitting transfers and initiating rolling side to side. They are often appropriate for use initially, but are soon removed after the child’s strength and bed mobility skills improve.
Standers
Numerous passive standing devices are available. These devices offer many potential benefits for the child, including the provision of a sustained muscular stretch, maintenance of trunk and lower limb passive range of motion, facilitation of co-contraction of muscles, decreas- ing tone, and improvement in trunk and head control.
Standers should be used a couple of times a day for up to one hour total. The child should progressively work to increase tolerance in the standing position. However, passive standing should not take the place of the child exploring his or her environment and body.
Three types of standers will be discussed here:
supine, prone, and upright. Supine standers go from a horizontal position to approximately 90 degrees upright, depending on the model chosen. Laterals, kneepads, adduction/abduction supports, and head supports all assist to maintain the child’s posture while in this stander. Bilateral upper extremity strengthening can be performed in this position, with or without a tray.
with performing safe transfers for children. The Trans- Aid and Hoyer lift are two examples of patient care lifts. They are designed to transfer children from bed to wheelchair, off the floor, onto a toilet, into a car, and through an 18-inch doorway. Slings are available with heavy-duty support options to further minimize the effort of the caregiver while maximizing safety during the transfer. There are also institutional lifters avail- able, which offer a 400-pound and 600-pound weight capacity, as well as portable home-care lifts, which are lightweight, portable, and designed for home doorways and narrow halls.
Powered overhead transfer lift systems provide families with a unique transfer method. This system enables users to transfer from bed to wheelchair, toi- let, or bath using a motorized lift and either manual or motorized lateral movement along a permanent ceiling-mounted track or a free-standing semiperma- nent rack. However, this transfer system is expensive and usually not covered by insurance.
In addition to patient lifts, there are other smaller devices that can assist children with ease of transfers.
One option is a transfer board, while another is an over- head trapeze bar attached to an over-bed frame. The most commonly used transfer board is constructed of maple wood measuring approximately 8 inches wide by 24 inches long. It is ideal for all types of transfers (bed, car, bath bench, commode, etc.). Trapeze bars may be attached overhead to bed frames to assist
6.3
Trunk OrthosesTRUNK ORTHOSIS COMMON NAME FUNCTION SPECIAL CONSIDERATIONS
STATIC
Trunk Thoracic-lumbosacral
orthoses
This device is used to stabilize the spine after surgery, fractured vertebrae, or used therapeutically to provide the trunk with upright support during static or dynamic activities
Can affect respiratory function Brace will not correct spinal deformity, but may alter the progression of the curve
Can cause pressure along axilliary line, breast bone, or ASIS area Monitor wear time secondary to heat intolerance
Theratogs/Benik This orthotic undergarment and strapping system gives users with sensorimotor impairment tactile positioning cues for improving postural alignment, postural and joint stability and movement, skill and precision
ASIS, anterior superior illiac spine.
Certain standers are available with a hydraulic or man- ual lift, making positioning of the larger child easier.
This stander mimics a normal standing position and permits the child to work on head control and upper extremity strengthening. The seat swings to the side for ease of transfer.
Gait Aids
Gait aids are assistive devices designed to improve func- tional independence and/or expand exercise options through standing and walking. In pediatrics, gait aids assist children to explore and interact with their envi- ronment. Improved balance, decreased energy expen- diture, decreased impact on joints, improved posture, and decreased pain are all potential benefits of gait aid usage. The most common gait aids are canes, crutches, and walkers.
Canes are available in different sizes with a vari- ety of handles and supports (ie, straight cane versus quad cane). A quad cane provides a better base of sup- port, but a normal gait cycle is more easily mimicked using a straight cane. A hemicane is a combination of a cane and a walker. It has a four-point base and the largest base of support of all the canes. It gives the greatest amount of stability among the canes, but also encourages the child to lean laterally when ambulating.
Crutches generally fall into two categories: axil- lary and Lofstrand. Axillary crutches are usually constructed of wood or aluminum and have limited adaptability. Some crutches may be modified to offer a forearm support to decrease weight bearing through wrists and hands. The child and family should be cautioned about possible nerve impingement from sustained axillary pressure with improper use. A
“Kenney” crutch, not often used in the rehabilitation setting, is an axillary crutch without an underarm support. In place of the underarm support is a leather armband that fits around a child’s arm.
Lofstrand crutches are much more flexible.
They have a variety of forearm cuff styles, includ- ing circumferential or half cuff. Functional indepen- dence is increased with the use of Lofstrand crutches because the child is able to reach with his or her hands and the circumferential cuff will stay on the forearm.
Half cuffs require less reliance on the cuff for balance, but they will not stay on the forearm if the handgrip is released. Handles may be wide and flat, pistol, or rounded. Rounded handles are the most commonly prescribed. The flat, wide handles may be helpful with tonal issues as well as with carpal tunnel inflamma- tion. Pistol grips provide grooves for finger placement.
Newer varieties of Lofstrand crutches are lightweight for children who have limited strength or need shock absorption for their joints.
However, it does not provide for any upper extremity weight bearing. A further limitation is that it will not work to improve head and trunk control. This stander is recommended for a child with significant extensor tone and posturing and/or a child with poor or absent head control. It is also preferred over the prone stander for the larger child due to the increased ease in positioning.
Prone standers support the child anteriorly.
Postural support is supplied through trunk laterals, hip guides, abductor blocks, knee blocks, and shoe holders. These standing devices do come with a chin support to aid children who have limited head control or fatigue easily. However, the child should not be per- mitted to “hang” on this support; a supine stander is more appropriate if the child lacks fair head control.
The stander can be used to improve antigravity head control and promote bilateral upper extremity weight bearing. Its tray may serve as a functional surface for stimulation. This stander may not be appropriate for some children with increased extensor tone. In these cases, gravity increases the work required for neck and trunk extension as well as shoulder retraction, thus feeding into primitive posturing.
Upright standers, such as the Evolv by EasyStand (Fig. 6.1) maintain the child in an erect position through supports at the hips, knees, and trunk.
Figure 6.1 EasyStand Evolv.
are attached. The seat is not used to support the entire body weight, but rather to keep the child erect. This gait device has been used to teach a more normal recip- rocal gait pattern. It may function as a stepping stone to walking with a walker or crutches. Some limitations of gait trainers include decreased transportability, dif- ficulty with positioning, and decreased accessibility.
They are wider and longer than traditional walkers are. Gait trainers do have a place in therapeutic reha- bilitation—to provide a child with independent means of ambulation when no other assistive device is appro- priate and as a therapeutic tool toward ambulation with a more accessible assistive device. Accessories available with gait trainers are trays, wheel locks, har- nesses, forearm supports, and differing lower extrem- ity supports.
For facility use, weight bearing and ambulation aids are available. The Lite Gait is a partial weight bearing gait therapy device. It allows the therapist to control the amount of weight bearing by supporting the patient in a harness system over a floor treadmill.
With other therapeutic modalities, this has been shown to improve ambulation and endurance levels (18).
The EVA Walker is a heavy duty walker that has a manual or hydraulic lift that is easily adjustable for a variety of patients. It allows for significant upper extremity weight bearing to assist and improve ambu- lation for more moderately dependent patients.
Wheelchairs and Seating
The degree of limitation in mobility varies across a broad range for people with physical disabilities (4).
Over the years, technology related to wheelchair seat- ing and mobility has enhanced the opportunities for people with disabilities. Many more options exist to match technology with the user than ever before.
In order to begin the process of matching the child’s needs to a particular wheelchair, it is recommended that a thorough evaluation be made. Many factors con- tribute to deciding on a particular seating and mobil- ity system for the pediatric population. These include growth, specific disability, medical interventions, and prognosis of future functional and cognitive abil- ities. Assess the particular needs of the child, collect medical and surgical history, and perform a physical assessment. A multidisciplinary team approach usu- ally works best. Once the assessment is performed, educate the family on various wheelchairs relative to the child’s goals. If possible, simulate the child in as close to the recommended equipment as possible.
Finally, determine the particular seating objectives for the child as well as the type of mobility base (22).
Every child has a unique set of challenges that will dictate how his or her rehabilitation needs will be met. Proper seating provides stability and support, Another adjustable option for all crutches is the
crutch tip. Crutch tips may be constructed with mate- rials of various flexibilities and in different widths to make the crutches more stable. Tips may include a gel, providing some shock-absorbent qualities. In addition, studded cups, which cover crutch tips, are available to make ambulation in rain and snow easier.
Three varieties of walkers are appropriate for the pediatric population: forward, reverse, and gait train- ers. Forward walkers are the traditional type of walker.
They can be purchased with or without wheels.
Children can grip flat handles or use platforms on one or both sides to weight bear through the elbows and forearms. It should be remembered that forward walk- ers promote trunk flexion in many children.
Reverse walkers, also called posture control walk- ers, promote an erect posture. The child has increased extension at the trunk and hips when his or her hands are positioned to the sides or slightly in front. A pel- vic support can be added to assist with lateral pelvic control and to facilitate trunk extension. Platforms can also be attached to allow forearm weight bearing.
These walkers are widely used in the pediatric popu- lation. However, due to increased width, adult-sized children may have difficulty with accessibility. Other accessories available with some walkers are swivel wheels, forearm attachments, hip guides, hand brakes, baskets, and seats.
Gait trainers make ambulation a viable option for children who are unable to ambulate with other aids.
Intensive body weight–supported treadmill training may be an effective intervention for some children with cerebral palsy who are ambulatory (14). A gait trainer is an assistive device that provides signifi- cant trunk and pelvic support (Fig. 6.2). It consists of a metal frame with adjustable-height metal uprights that support the trunk and arms. Adjustable-height seats, which are either slings or a bicycle-type seat,
Figure 6.2 Rifton gait trainer.
positioning components. Evidence supports that chil- dren with cerebral palsy should be fitted for wheel- chairs that place them in a functional sitting position (17). Lateral supports can be used to encourage midline trunk position when trunk control is poor. They may also be used to partially correct or delay the progres- sion of scoliosis. Chest harnesses assist in stabilizing the trunk by anterior support as well as by preventing forward trunk flexion.
Positioning belts are used for pelvic alignment and stabilization. An improperly placed pelvic posi- tioner is more detrimental than no positioner at all.
The standard angulation of a pelvic positioning belt is at a 45-degree angle to the sitting surface (4). Subasis bars are used primarily for high-tone patients. Proper placement and position of the bar is critical to the suc- cess of the product. Improper positioning can poten- tially lead to skin breakdown.
Additional positioners include abductor pads that reduce or prevent increased adduction and assist in providing proper leg alignment. It should be remem- bered that abductors are not to be used to block a child from “sliding” out of the wheelchair. This may cause injury to the perineal area (1). Adductors decrease hip abduction and assist in providing proper leg align- ment. Shoe holders and ankle positioners help control increased extension or spasms in the lower limbs and correct or prevent excessive internal or external foot rotation.
Head position is important for many reasons, includ- ing proper visual input, control of tone, and proper alignment for feeding and swallowing. Headrests pro- vide support and positioning for a patient with poor head control due to low tone, active flexion, or hyper- extension. They provide posterior and, if necessary, decreases the likelihood of postural deformities, and
enhances upper extremity control. Within a wheelchair seating system, maintaining proper body alignment is achieved by using various seating and positioning components (23). Seating systems, including both the seat and the back, can be linear, contoured, or molded.
Of the three, linear seating systems provide adjustabil- ity that allows the seating system to grow as the child grows. Linear seating systems are the least conforming to a person’s body, but they are the easiest to fabricate and most adaptable as the person’s orthopedic needs change. The basic materials consist of plywood for the base, foam (which can vary in density) for comfort and pressure relief, and a covering, usually Lycra, Rubatex or Dartex. Positioners such as laterals, abductors, and adductors are easy to mount on these systems.
Contour systems, in contrast to linear systems, conform closer to the actual shape of one’s body.
When recommending a contour system, close atten- tion should be given to the growth rate and potential medical interventions, as the shape of the contour may not be an appropriate choice. Custom molded systems provide maximal support and should be considered for children with fixed deformities. Molded systems do not change as the child grows, unless remolding is performed, which is potentially time-consuming and costly. Although this system aids in controlling tone and nicely contours to most deformities, it has the reverse effect of limiting the amount of freedom children have in their seating system.
For patients who lack sensation, a variety of cush- ions exist that assist in alleviating pressure, which will decrease the likelihood of skin breakdown. Cushions fall under several categories, including foam, gel, air, and water (Table 6.4). Cushions should provide pres- sure relief under bony prominences, provide a stable support surface for the pelvis and the thighs, and func- tion effectively in different climates. They should be lightweight, especially if a person is transferring inde- pendently or is a self-propeller, and be durable. Each type of cushion has advantages and disadvantages.
Pressure mapping systems are tools used by cli- nicians to measure interface pressures between two surfaces, such as a seated person and the cush- ion he or she is sitting on. (See an example of a pres- sure mapping system by Vista Medical at http://www.
pressuremapping.com/.) A visual output on a computer monitor allows easy viewing and understanding. Using this tool allows clinicians to “diagnose” potential causes of skin ulcers as well as to select a cushion that will pro- vide the most appropriate pressure relief for that patient.
Positioning Components
Within a wheelchair seating system, maintaining proper body alignment is achieved by using various
FOAM GEL AIR
Lightweight Provides a stable base of support Various densities available that can improve pressure- relieving qualities Heavy Conforms to individual shape
Lightweight Provides a stable base of support Various densities available that can improve pressure- relieving qualities Heavy
Conforms to individual shape
Provides extremely good pressure relief Lightweight Can be unstable Requires careful monitoring and maintenance