Therapeutic Orthotics after Stroke Richard Sealy Principal Physiotherapist in NeuroRehabilitation...
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Transcript of Therapeutic Orthotics after Stroke Richard Sealy Principal Physiotherapist in NeuroRehabilitation...
Therapeutic Orthotics after Stroke
Richard SealyPrincipal Physiotherapist in NeuroRehabilitationThe Wolfson Neuro Rehabilitation CentreSt Georges NHS TrustEmail: [email protected]
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
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 settingVan 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?
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 stro
ke
• 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)