Summary of replies: brace for residual polio with weak quad
Sun G. Chung
Description
Collection
Title:
Summary of replies: brace for residual polio with weak quad
Creator:
Sun G. Chung
Date:
9/30/1999
Text:
Dear List members,
Thank you for your kind replies for my previous question as below.
== Previous question ===
I have a patient with residual poliomyelitis, female 30yo.
She seems to have destroyed motor neurons of Lumbar 3 and 4 level,
unilaterally(left). So, she has very weak left hip flexor and knee extensor,
nearly one grade of muscle power by MMT.
She also has valgus deformed left knee. She already uses conventional type
KAFO with valgus controlling strap and ischial weight bearing function. But
she complains the weight of the brace and dull pain after long time use. She
came to me if there would be any solution for her problems including new
types of brace.
===================
The replies can be summarized as below,
1. Change the material to reduce the weight.
Plastic, thermoplast(for lamination) and carbon graphite(for upright)
were recommended.
2. Remove the ischial seat.
3. Use offset knee joint aligned posterior to the anatomical knee axis: for
clearance on swing phase
4. Strong brace is better than light one.
All of the recommendation were very helpful for me. I really appreciate
their kindness.
You may find more information from the replies.
Sincerely,
---------------------------------------------------
Sun G. Chung M.D., Ph.D.
Instructor
Dept Rehab Medicine
Seoul National University, College of Medicine
YeonGeon Dong 28, ChongRo Gu
Seoul Korea
<Email Address Redacted>
(T) 82-2-760-3954, 760-2619
(F) 82-2-743-7473
----------------------------------------------------
===================================================================
I find that an ischial weight bearing KAFO is not needed. One that is high
enough to provide support should be within 2 finger widths of the ischial
tuberosity, but not touching it. The weight bearing line from greater
trochanter, through the knee and then ankle, should be straight- if the
brace
has a locked knee . Have the braced leg at least 1/2 inch shorter then the
contralateral limb with help make swing through clearance easier . I find
that a plastic KAFO, will provide more support for the valgum and is lighter
in weight.
If the patient had some recurvatum and can ambulate with out a brace, for
short distances, I would consider a posteriorly offset knee joint and leave
the knee free for flexion. Letting that leg be 1/2 shorter will still make
it easier for her weak hip flexors. Plastic again is a good choice of
materials. Very important - if you do use a posterior offset knee joint,
when the KAFO is fabricated, it is important that the mechanical knee axis
falls posterior to the anotomical knee axis - not in line with it - but
posteriorly - to provide stability during stance phase.
I hope this is helpful. Stephanie D. Langdon-Bash, CPO, FAAOP.
======================================================================
Dr. Chung,
Depending on her present weight and functionality, a thermoplastic KAFO
with carbon graphite uprights can work. I personally would get rid of the
ischial weight bearing brim, but that is up to you. At the knee you are
able
to have extension assist incorporated to the joints. Depending on the
degree
of her valgus and its correctabilty, correction can be addressed in the
cast.
Otherwise the strapping system or condylar pad (more comfortable) can be
utilized.
Depending on the pt's weight you can use 5/32 or
3/16 copoly plastic, this will cover approx. 3/4 of the pt's thigh. The
plastic should extend about 5 cm past mid line/uprights (length will vary
according to pt size). Anteriorly, I incorporate an 1/8 or 1/16
polyethylene
tongue attached to the lateral aspect of the proximal shell. This aids in
comfort as well as control. The theory behind the ischial brim is to
relieve
weight from the knee and other areas of the lower extremity. Although, this
type of weight bearing was borrowed from prosthetics and does not seem to
works as intended. In many the genu valgum/varum seems to increase. Plus
it
really is an uncomfortable style to wear, it usually hinders more than help.
B.J. Stagner Jr., C.O.
CEO-Stagner Orthotic Services
=======================================================================
Dr. Chung
I believe your patient could benefit from a total contact Laminated
KAFO.The weight of the orthosis can be kept down to 2.5 lbs.. by the use of
carbon graphite/ kevlar w/ honeycomb inner core for the uprights. By using a
total contact technique the negative drop on the limb will be decreased thus
taking away the feeling of dragging the orthosis.
The lamination should encompass the hole thigh. Flaps can be cut in to the
lamination to allow
easy donning. A proper ischial seat with a quad socket to prevent rotation
would help. I suggest that you stay about 1.5 - 2 cm below the Ischial to
floor measurement if she never had a ISCHIAL seat.
Casting : When the cast is almost dry the pat. should stand with normal
walking base and toe out.
Cast Modifications should be kept tight.
Vincent DeCataldo
Rinko Orthopedic
25-09 Broadway
Fairlawn , New Jersey 07410 USA
201-796-3121
=========================================================================
There is a better solution to lower limb support and protection with the
polio population than using the standard conventional metal and leather
designs. The keys are joint protection, pressure distribution, and
alignment using materials which allow better contact and contours.
Hopefully, there are orthotists in your area that are trained in these
procedures. If not, please contact me and I will try to provide
additioal information.
Mark Taylor
==========================================================================
Dr. Chung,
Your patient with the weakened quads and a presenting valgum attitude at
the knee is probably exhibiting a position of external rotation at the foot
(or forefoot) and would probably be considered as presenting with an
Internal
Rotary Deformity (IRD).
Because of how the weight-line passes at the knee, the single most difficult
obstacle to overcome with your patient is blending a high degree of strength
with, of course, the lightest weight possible for the orthosis.
If you find yourself in conversation with a local practitioner who is
going to make this patient a suitable orthosis, please do your patient (and
orthotist) a big favor by backing off of the weight concern (relative to
strength). There are ways to reduce the weight , i.e utilizing carbon fiber
where appropriate, etc.
You will find that there are numerous approaches in treating this
patient. It will be interesting to read the replies that you receive, but I
would hope that the majority of responses emphasize the overall strength of
the orthosis as a higher concern than weight.
An orthosis that fits well and is really light does no one any good if
it
fails in six months. Especially when the ability to charge for a stronger
(more appropriate) orthosis would be undermined by the decision originally
to
bill for and build an orthosis that was not up to the task of supporting her
during weight-bearing.
I wish you well and would be glad to discuss the case further, either
through the internet or via telephone. You need only contact me at
<Email Address Redacted> or my office # (717) 393-0511 York, PA
===========================================================================
==
In response to your enquiry on O&P listserv, there are probably three
different ways in which you could reduce the weight of the KAFO in question.
You had mentioned that your patient currently wears a conventional KAFO. In
transfering her into a plastic KAFO with the plastic sections moulded over
the side-steels you can improve the inherent strength of the KAFO and
therefore reduce the gauge of the side steels.
The second solution is probably not as appropriate, Proteor provide carbon
fibre side steels which can dramatically reduce the overall weight of the
KAFO. I understand however that these steels do not cope well with M-L
shaping i.e. to accomodate a valgus knee.
The third solution would be to provide a carbon fibre composite KAFO which
can be provided by Otto Bok, these devices are extremely light and strong
but require specialist attention and make take some time to manufacture.
I hope this is of some help.
Peter
Peter Mclachlan
Lecturer in prosthetics and Orthotics
University of Strathclyde
e-mail: <Email Address Redacted>
===========================================================================
===========
Dear Sun G. Chung M.D., Ph.D.
We believe we have such a KAFO. We have developed a new orthotic system
that
will create a paradigm shift in the future. Only three centers are
presently
fitting these new advanced systems. One is in Las Vegas, Nevada, USA the
second is in Vancouver, BC, Canada and the third is in San Diego,
California.
The new systems can control the leg and body so much better. We guarantee a
structural outcome, no other system can provide this.
Our new systems are based on very complex principles. The outcomes are
clearly showing improvements that most of these people dream about and are
looking for. Our systems can allow for an unlocked knee, even with those
who
have zero quads and are presently wearing a locked system. We are
eliminating or greatly reducing gross body compensations. People can walk
much more efficiently, with less energy.
We also have systems with energy response capabilities, to add a spring or
life back in ones step. Our systems can help most lower extremity needs.
Sincerely,
Marmaduke Loke, C.P.O.
(858) 268-7000
==================================================
.
********************
OANDP-L is a forum for the discussion of topics related to Orthotics and
Prosthetics.
Public commercial postings are forbidden. Responses to inquiries of a
commercial nature should not be sent to the entire oandp-l list. Responses
should be collected and reposted by the person asking the question.
Send a message to the list by sending to: <Email Address Redacted> To unsubscribe,
send a message to: <Email Address Redacted> with the words UNSUB OANDP-L in the body of the
message. All postings related to US-politics must use a subject line
starting with US-Politics:
Any questions should be directed to Paul E. Prusakowski, CPO at
<Email Address Redacted>
Thank you for your kind replies for my previous question as below.
== Previous question ===
I have a patient with residual poliomyelitis, female 30yo.
She seems to have destroyed motor neurons of Lumbar 3 and 4 level,
unilaterally(left). So, she has very weak left hip flexor and knee extensor,
nearly one grade of muscle power by MMT.
She also has valgus deformed left knee. She already uses conventional type
KAFO with valgus controlling strap and ischial weight bearing function. But
she complains the weight of the brace and dull pain after long time use. She
came to me if there would be any solution for her problems including new
types of brace.
===================
The replies can be summarized as below,
1. Change the material to reduce the weight.
Plastic, thermoplast(for lamination) and carbon graphite(for upright)
were recommended.
2. Remove the ischial seat.
3. Use offset knee joint aligned posterior to the anatomical knee axis: for
clearance on swing phase
4. Strong brace is better than light one.
All of the recommendation were very helpful for me. I really appreciate
their kindness.
You may find more information from the replies.
Sincerely,
---------------------------------------------------
Sun G. Chung M.D., Ph.D.
Instructor
Dept Rehab Medicine
Seoul National University, College of Medicine
YeonGeon Dong 28, ChongRo Gu
Seoul Korea
<Email Address Redacted>
(T) 82-2-760-3954, 760-2619
(F) 82-2-743-7473
----------------------------------------------------
===================================================================
I find that an ischial weight bearing KAFO is not needed. One that is high
enough to provide support should be within 2 finger widths of the ischial
tuberosity, but not touching it. The weight bearing line from greater
trochanter, through the knee and then ankle, should be straight- if the
brace
has a locked knee . Have the braced leg at least 1/2 inch shorter then the
contralateral limb with help make swing through clearance easier . I find
that a plastic KAFO, will provide more support for the valgum and is lighter
in weight.
If the patient had some recurvatum and can ambulate with out a brace, for
short distances, I would consider a posteriorly offset knee joint and leave
the knee free for flexion. Letting that leg be 1/2 shorter will still make
it easier for her weak hip flexors. Plastic again is a good choice of
materials. Very important - if you do use a posterior offset knee joint,
when the KAFO is fabricated, it is important that the mechanical knee axis
falls posterior to the anotomical knee axis - not in line with it - but
posteriorly - to provide stability during stance phase.
I hope this is helpful. Stephanie D. Langdon-Bash, CPO, FAAOP.
======================================================================
Dr. Chung,
Depending on her present weight and functionality, a thermoplastic KAFO
with carbon graphite uprights can work. I personally would get rid of the
ischial weight bearing brim, but that is up to you. At the knee you are
able
to have extension assist incorporated to the joints. Depending on the
degree
of her valgus and its correctabilty, correction can be addressed in the
cast.
Otherwise the strapping system or condylar pad (more comfortable) can be
utilized.
Depending on the pt's weight you can use 5/32 or
3/16 copoly plastic, this will cover approx. 3/4 of the pt's thigh. The
plastic should extend about 5 cm past mid line/uprights (length will vary
according to pt size). Anteriorly, I incorporate an 1/8 or 1/16
polyethylene
tongue attached to the lateral aspect of the proximal shell. This aids in
comfort as well as control. The theory behind the ischial brim is to
relieve
weight from the knee and other areas of the lower extremity. Although, this
type of weight bearing was borrowed from prosthetics and does not seem to
works as intended. In many the genu valgum/varum seems to increase. Plus
it
really is an uncomfortable style to wear, it usually hinders more than help.
B.J. Stagner Jr., C.O.
CEO-Stagner Orthotic Services
=======================================================================
Dr. Chung
I believe your patient could benefit from a total contact Laminated
KAFO.The weight of the orthosis can be kept down to 2.5 lbs.. by the use of
carbon graphite/ kevlar w/ honeycomb inner core for the uprights. By using a
total contact technique the negative drop on the limb will be decreased thus
taking away the feeling of dragging the orthosis.
The lamination should encompass the hole thigh. Flaps can be cut in to the
lamination to allow
easy donning. A proper ischial seat with a quad socket to prevent rotation
would help. I suggest that you stay about 1.5 - 2 cm below the Ischial to
floor measurement if she never had a ISCHIAL seat.
Casting : When the cast is almost dry the pat. should stand with normal
walking base and toe out.
Cast Modifications should be kept tight.
Vincent DeCataldo
Rinko Orthopedic
25-09 Broadway
Fairlawn , New Jersey 07410 USA
201-796-3121
=========================================================================
There is a better solution to lower limb support and protection with the
polio population than using the standard conventional metal and leather
designs. The keys are joint protection, pressure distribution, and
alignment using materials which allow better contact and contours.
Hopefully, there are orthotists in your area that are trained in these
procedures. If not, please contact me and I will try to provide
additioal information.
Mark Taylor
==========================================================================
Dr. Chung,
Your patient with the weakened quads and a presenting valgum attitude at
the knee is probably exhibiting a position of external rotation at the foot
(or forefoot) and would probably be considered as presenting with an
Internal
Rotary Deformity (IRD).
Because of how the weight-line passes at the knee, the single most difficult
obstacle to overcome with your patient is blending a high degree of strength
with, of course, the lightest weight possible for the orthosis.
If you find yourself in conversation with a local practitioner who is
going to make this patient a suitable orthosis, please do your patient (and
orthotist) a big favor by backing off of the weight concern (relative to
strength). There are ways to reduce the weight , i.e utilizing carbon fiber
where appropriate, etc.
You will find that there are numerous approaches in treating this
patient. It will be interesting to read the replies that you receive, but I
would hope that the majority of responses emphasize the overall strength of
the orthosis as a higher concern than weight.
An orthosis that fits well and is really light does no one any good if
it
fails in six months. Especially when the ability to charge for a stronger
(more appropriate) orthosis would be undermined by the decision originally
to
bill for and build an orthosis that was not up to the task of supporting her
during weight-bearing.
I wish you well and would be glad to discuss the case further, either
through the internet or via telephone. You need only contact me at
<Email Address Redacted> or my office # (717) 393-0511 York, PA
===========================================================================
==
In response to your enquiry on O&P listserv, there are probably three
different ways in which you could reduce the weight of the KAFO in question.
You had mentioned that your patient currently wears a conventional KAFO. In
transfering her into a plastic KAFO with the plastic sections moulded over
the side-steels you can improve the inherent strength of the KAFO and
therefore reduce the gauge of the side steels.
The second solution is probably not as appropriate, Proteor provide carbon
fibre side steels which can dramatically reduce the overall weight of the
KAFO. I understand however that these steels do not cope well with M-L
shaping i.e. to accomodate a valgus knee.
The third solution would be to provide a carbon fibre composite KAFO which
can be provided by Otto Bok, these devices are extremely light and strong
but require specialist attention and make take some time to manufacture.
I hope this is of some help.
Peter
Peter Mclachlan
Lecturer in prosthetics and Orthotics
University of Strathclyde
e-mail: <Email Address Redacted>
===========================================================================
===========
Dear Sun G. Chung M.D., Ph.D.
We believe we have such a KAFO. We have developed a new orthotic system
that
will create a paradigm shift in the future. Only three centers are
presently
fitting these new advanced systems. One is in Las Vegas, Nevada, USA the
second is in Vancouver, BC, Canada and the third is in San Diego,
California.
The new systems can control the leg and body so much better. We guarantee a
structural outcome, no other system can provide this.
Our new systems are based on very complex principles. The outcomes are
clearly showing improvements that most of these people dream about and are
looking for. Our systems can allow for an unlocked knee, even with those
who
have zero quads and are presently wearing a locked system. We are
eliminating or greatly reducing gross body compensations. People can walk
much more efficiently, with less energy.
We also have systems with energy response capabilities, to add a spring or
life back in ones step. Our systems can help most lower extremity needs.
Sincerely,
Marmaduke Loke, C.P.O.
(858) 268-7000
==================================================
.
********************
OANDP-L is a forum for the discussion of topics related to Orthotics and
Prosthetics.
Public commercial postings are forbidden. Responses to inquiries of a
commercial nature should not be sent to the entire oandp-l list. Responses
should be collected and reposted by the person asking the question.
Send a message to the list by sending to: <Email Address Redacted> To unsubscribe,
send a message to: <Email Address Redacted> with the words UNSUB OANDP-L in the body of the
message. All postings related to US-politics must use a subject line
starting with US-Politics:
Any questions should be directed to Paul E. Prusakowski, CPO at
<Email Address Redacted>
Citation
Sun G. Chung, “Summary of replies: brace for residual polio with weak quad,” Digital Resource Foundation for Orthotics and Prosthetics, accessed November 26, 2024, https://library.drfop.org/items/show/213181.
