Presentation on theme: "Therapeutic Orthotics after Stroke Richard Sealy Principal Physiotherapist in NeuroRehabilitation The Wolfson Neuro Rehabilitation Centre St Georges NHS."— Presentation transcript:
Therapeutic Orthotics after Stroke Richard Sealy Principal Physiotherapist in NeuroRehabilitation The Wolfson Neuro Rehabilitation Centre St Georges NHS Trust
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
Therapist’s - 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
Pronation Supination Subtalar Joint Biomechanics (Right) Neutral Adapted from Mcpoil et al 1985
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 m
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
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
Clinical Reasoning Patient Example Increased Tone Fixed PF contracture Normal Significant compensation strategies How to manage this?
Midstance Terminal Stance
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 strokeBest 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)