Replies: AFO dorsi-assist alternatives

Replies: AFO dorsi-assist alternatives

Thanks to all who took time to respond. Below is the original post followed
by the responses.

Problem: Active adult Cerebral Palsy patient in dorsi-assist AFO's in which
tone, for the most part, overrides the springs in the standard Klenzak
joints. Installing pins is not an option, as it disrupts his gait pattern
too much, and inhibits him from driving (using the accelerator). I have used
elastic webbing and Gaffney flexors to help with this problem, but longevity
is short. Is there any other durable, strong dorsi-assist alternative
available? I've heard of using GII KO knee joint bands but have yet to
explore: Has anyone had experience with these?

I will eventually be making a new set of AFO's utilizing Oregon principles
and design. This will hopefully help with the tone. However, for now, I
need to make the best of his existing 3 y/o hybrid metal/polypro AFO's by
attempting to increase the dorsi-assist. Suggestions?

*******
place a rivet prox&dist. sections connect with terminal device Orings [not
rubber bands]just make sure rivet placement will bring elastic o rings in
front of joint
new brace-same as before but on polypro sections use post. spring assist

Have you considered installing the fiberglass rod from a USMC shoe clasp toe
counter brace (with upper guide) to the back of the brace?
It would significantly increase the toe lift performance and the fiberglass
rod should last for years, easily longer than the klenzak springs and it
would not significantly increase the weight of the orthosis.

Try changing out the ankle joint and using the Becker slimline joint . This
joint has better resistance with the use of springs and also still allows the
patient to dorsi and plantar assist and resist for the type of need he seems
to require. I would not suggest the Oregon type of AFO because of my past
experience with them. You can make the setup just as good as do they and a
lot less costly.

If you think the tone inhibiting modification would help when you make
the new orthoses, how about adding some pelite pads to effect the
modifications in the bottom of the existing ones to see if it will make
the difference now and possibly eliminate the need for stronger springs.
Just a thought.

The basic problem here is not so much finding a joint that will overpower
your patient's plantarflexor tone, but rather understanding that the very
action of the spring is causing exacerbations in that tone. In other words
you're increasing his tone by trying to dorsiflex him against his tightness.
This is called the stretch reflex. When you attempt to stretch a tight
hypertonic muscle it rebels and reflexively, without volitional control
from the patient, forcefully plantarflexes.
A better solution might be to try to gain range in the ankle first by serial
casting or botox injections, Baclafin therapy etc. Once you gain the range
he might be a candidate for a limited motion ankle joint with pins set to
allow say five degrees of plantarflexion and some dorsiflexion, but not
enough to set off his tone. Don't fall into the traditional trap of forcing
upper motor neuron patients into inadequate orthoses; get the patient ready
for the best treatment you can offer and enhance your value as a professional
member of the clinic team because you will be successful when the
expectations for functional improvement are low.

 YOu have a difficult problem that I face routinely. That is, patient needing
solid anlke AFO,s yet wanting to have free plantar flexion to drive. I give
the patient my recommendation from a ambulatory stand point , discuss ADL 's
and recommend hand control. The patient makes the decision. I cannot
effectively control any tone with dorsi -assist joints.