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Therapeutic Orthotics after Stroke

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Presentation on theme: "Therapeutic Orthotics after Stroke"— Presentation transcript:

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

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