1. Therapeutic Orthotics after Stroke
Richard Sealy
Principal Physiotherapist in NeuroRehabilitation
The Wolfson Neuro Rehabilitation Centre
St Georges NHS Trust

2. Aims Post stroke gait Therapeutic adjunct Clinical reasoning
The potential role of orthoses

3. Patient Goal
‘I want to walk’

4. Examples of Post Stroke Gait

5. The Influence of Alignment and Stability
Relate back to the way this posture in limb and foot wiil block access to somatosensory

6. Therapist’s - Clinical Reasoning
Observation
Where in gait
Why – Problem solving approach
How am I going to treat this ?
Therapist choices in managing biomechanical changes emphasis to orthotics

7. Understanding of the Gait Cycle
Biomechanics at the foot/ankle
Dorsiflexion / Plantarflexion
Pronation / Supination
Initial Contact
Terminal Stance

8. Subtalar Joint Biomechanics (Right)
Pronation
Neutral
Supination
Link to initial stability mobility
Adapted from Mcpoil et al 1985

9. Acceptable Pronation?

10. Creating a Base: The Importance of Alignment – Distal to Proximal Influences

11. Orthotic Management of Pronation following Stroke
Inactive foot impact on somatosensory common presentation

12. Orthotic Management of Excessive Pronation

13. Biomechanics of Standing
Ground Reaction Force

14. Biomechanics of Gait
Ground Reaction Force Vector

15. Biomechanics of Gait m

16. Clinical Reasoning / Gait Analysis
Where ?
Why ?

17. Clinically Reasoning Where is it going wrong Why is it going wrong
How can I change this
 Improve Motor Control
Discuss 2ndary complications e.g soft tissue shortening

18. 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
It is suggested
Motor Theorists
Individual learns through experience of movement (implicit learning)
Being able to provide the patient the opportunity to experience movement outside the gym setting

19. 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

20. AFO’s and Alignment Condie (2004) Consensus Conference Report
‘Alignment of the orthosis at terminal stance/pre- swing 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

21. Orthotic Management

22. Clinical Reasoning Patient Example Increased Tone Fixed PF contracture
Significant compensation strategies
Normal
How to manage this?

23. Midstance
Relate to somatosensory
Terminal Stance

24. AFO’s 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
Small scale
Difficult due to heterogeneous nature of rehab populations
Poor methodology
Wide variety of studies

25. Summary Importance of biomechanical - neurophysiological principles
Use of orthoses as an adjunct
Condie (2004) Consensus Conference Report
NHS Quality Improvement Scotland (2009)
Suggest earlier use

26. Thank You For Listening