Therapeutic Orthotics after Stroke

1. 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

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

6. Therapist’s - Clinical Reasoning • Observation • Where in gait • Why – Problem solving approach • How am I going to treat this ?

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 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

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

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

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 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

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

26. Thank You For Listening