By: Davin Heyd CO

1. ALIGNMENT AND FINE TUNING OF AFO’S UTILIZING THE STRATHCLYDE APPROACH AND THE DYNAMIC RESPONSE ANKLE FOOT ORTHOSIS By: Davin Heyd CO

2. Our industry is on the advent of a Paradigm shift on a couple of fronts Research proven techniques Objective outcomes – pay for performance will be reality

3. Our focus has been wrong! Too much attention on achieving 90 degrees at the ankle Not paying attention to the foot biomechanics and their alignment Not looking at the entire body too much individual segment focus Forcing everything!

4. We must re-assess our approach There is not a supporting body of evidence w regards to our historical approach to LE management In fact, research show that 90 neutral is actually unstable and detrimental if we are forcing that Alignment Owen 2008, Webber 1990/91

5. Now! use what the patient has, Align, relax, control, and balance our patient to the floor. This is a completely new approach

6. Structure • Modeling until bone maturation • infancy-14 years for girls • Infancy-16 years for boys • “Prevent over-stretching of ligaments.” • Deformation of bone modeling

7. Structure • Effective stretch to gastroc-soleus complex occurs when subtalar and midtarsal joints “ARE” properly aligned.

8. Structure • Talus Alignment : the alignment of the talus requires effective mechanical base levers. • Hindfoot alignment (stabilize subtalar jt.) • Forefoot alignment (adduct midtarsal jt., supination/pronation) • Interdependent on each other

9. Initial Contact Fixed DF angle Caused by tight heel chord Rigid Lever Arm

10. Mid-Stance Forward motion and weight dictates end result In this case: destructive collapse at the midfoot Could also see: Knee hyperextension Early heel rise and up on toes ? ?

11. Terminal Stance Wide stance with abducted forefoot and externally rotated leg Why? Shorten the lever arm to bring the foot through COMPENSATION!

12. FORCE NOTHING! Tardieus 1987 • Warned against precipitating painful spasm by over stretching the muscle fibers in the coarse of casting • Excessive elongation, particularly at high rate, can produce soft tissue strains or complete rupture David S. Butler 1991 Nerves become embedded in tonically – recruited muscles so when the muscle is forcefully stretched so is the nerve contributing to the spasms

13. Physical AssessmentDetermining functional ROM Calcaneal Alignment. Determine Forefoot alignment to attain vertical heel Determine first Catch / R1

14. OWEN • 74 Children independent ambulators in AFOs • Prescription tuned on video vector generator gait laboratory • Ankle angle (PF,DF, or Plantar-grade) did not effect end result • All ended up being tuned to an inclined angle – 8-14ْْ • Alignment produced stability in both Normal and Pathological gait • Centers knee joint directly over the middle of the foot • Author suggests starting at 10-12ْ

15. OWEN Shank Angle to Floor Defined : Angle of the shank (tibia) relative to the horizontal surface when standing in AFOs with heels down and weight equally distributed between heel and toe. Inclined = if shank is inclined forward from vertical Reclined = if shank is reclined from vertical Vertical = 0ْْ *Angle of the Ankle, it refers to: Plantar Flexion, Dorsiflexion, and Plantar grade

16. Perry Control of the kinematics of the shank (tibia) relative to the vertical is essential in normal gait Our patients are here

17. OWENGastrocnemius (GN) is a tri-jointed musculotendinous unit (MTU) crossing the knee, ankle and subtalar joint. It reaches its maximal length twice in the gait cycle (GC): • At initial contact, the knee is extended, the ankle plantigrade, the subtalar joint supinated and the MTU has been lengthening passively during terminal swing • At 40% GC in terminal stance (TST), the knee reaches maximal stance extension, the ankle is in some dorsiflexion, the subtalar joint neutral and the MTU is lengthening actively Passive Stretch Active Stretch

18. OWEN Setting the Angle of the Ankle in the AFO (AA-AFO) without regard to the tri-jointed requirements of the GN can result in insufficient length being available to allow knee extension during the GC. In addition, an overstretched GN in TST will reduce the possibility of MTU force production. The lever arm ratio between the ankle and the knee at 40% GC is 3:2, so small changes in the ankle angle are amplified at the knee.

19. Owen “The Shank Angle to Floor (SAF) measure of an AFO-Footwear Combination is the prime determinant of gait rather than the AA-AFO.” -An appropriate SAF for normal gait can be achieved with a dorsiflexed, plantigrade or plantarflexed AA-AFO. -The use of plantarflexion may be essential. -Using a plantarflexed AA-AFO does not necessarily lead to MTU shortening and may increase MTU length.

20. Utilization of Hinged AFO: One or more of the “contraindications” or “conditions making hinged AFOs irrelevant” apply in most children with Neurological conditions, so the use of hinged AFOs is limited - OWEN

21. Contraindications: • Tendency to mid foot instability (Webber 1990/1991) • Insufficient passive ROM of DF with knee extended (GN length) • Risk of excessive DF at mid stance and terminal stance – insufficient control of the shank by calf muscles - (lack of stability and over lengthening of soleus) • Too much tone to allow normal stance phase ankle DF-incline of shank during 2nd rocker will not occur to over come this inclination of the shank needs to be increased making the hinge irrelavant

22. Functions other than gait: • Squating to play or pick things up • Stair climbing • Sitting and standing up from a chair • Traditionally felt that SA AFOs prevent these functions • If the knee joint is aligned over the center of the foot, it is possible to squat and climb stairs with a SAAFO

23. AFO design • An AFO should be designed to provide: • Optimum cutaneous and propreoceptive input through the foot and ankle • Enhance the biomechanics of load bearing joint alignment through the knee and hips during the stance phase of gait, and to thereby • Optimize the postural, weight shift, and movement training process (Owen 2008, Butler PB et al 2007, Major 1995)

24. AFO design The key is to not force alignment, and in the case of an equinous deformity, involves acknowledging and accommodating gastrocnemius hypoextensibility in the AFO and posting the AFO and or shoe as needed to influence the alignment and motion of the load bearing segments in order to optimize the GRF and internal moments at the knee and hip joints Owen 2008, Bowers et al 2008, Meadows et al 2008, Owen 2005

25. The DRAFO System:Designed around a scientifically proven biomechanical analysis process and functional gait

26. DRAFO System • The DRAFO System Mimics gait biomechanics of normal human locomotion – • The 3 foot rockers are incorporated into the orthosis • 2nd rocker achieved by Tibial Alignment • Stabilizes and maintains desired alignment without requiring excessive pressure • Plantar aspect functions like a prosthetic foot

27. 1st Rocker • Calcaneal Wrap • Locks in the Hindfoot • Allows 1st Rocker at heel strike • Achieves Stability at Heel Strike • Sach heel effect de-accelerator • De-rotator • Propreoceptor feedback • 2nd Rocker • Tibial inclination • 3rd Rocker • Forefoot design: • Posting designed to have duel function: • Align forefoot • Manipulate terminal stance • Allows for functional 3rd rocker

28. Standing Alignment Alignment of the center of gravity So that the weight line goes through the center of the knee Which centers over the middle of the foot provides the Optimum balance alignment for both “normal and Pathological” Gait Stable alignment Unstable alignment

30. Validation: How do we know what we are doing really does what we say it is doing? Outcomes Measures WHY??? • Hospital Contracts • Insurance Contracts • Institutional Mandates • Prevent misconceptions • State/Federal Mandates • SPARG • Medicare • Everybody else is doing it

31. Practical Outcome Measures • 7 measures • 10MWT • 6mWT (2mWT)w Heart rate • Standing stability (ABC) • Pediatric Balance test • AOS • Dynamic gait index • Time required • maximum of 15 minutes • Items needed • Stop watch, tape measure, tape Validation for: Patient, Practitioner, and Reimbursement Resources

32. Thank You