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 Relate back to the way this posture in limb and foot wiil block access to somatosensory

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

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 Link to initial stability mobility 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 Inactive foot impact on somatosensory common presentation

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 Discuss 2ndary complications e.g soft tissue shortening

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

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

Orthotic Management

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

Midstance Relate to somatosensory 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 stroke SWIFT Cast Trial – Early intervention cast walking Small scale Difficult due to heterogeneous nature of rehab populations Poor methodology Wide variety of studies

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

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