Answers for: 3 yo spastic diplegic girl

Answers for: 3 yo spastic diplegic girl

Stride Orthopedics Ltd

5/21/2003

Dear list members:

First let me thank all those of you who have sent an answer.

The original question was:
Looking for some advice with a 3 yo spastic diplegic girl,

Description:
With help and walker she will walk a little, stands in a stander a few
(1-2) hours a day, locks knees when standing or walking, dorsiflexion
range a bit more then 0 ,of course when spasticity is increased she will
push to plantarflextion. We have made a per of AFOs, solid, 90 degrees
with a digit 8 Velcro strap that starts from inside - under the medial
malleolus and is fastened to the lateral part of the AFO, all that as
to hold the foot in well because of strong spasticity.

The problem:
With one foot only! after 20 minutes the foot swells, gets red and
edematous.

The solution we are looking for will keep the calcaneus well in its
place in spite of spastisity.

THE SOLUTION WAS:
After reading the answers I have decided to make a rigid tongue of 3 mm
PP lined with soft Aliplat and one more layer of poron. The pressure was
well distributed and thus gave a very good result.

Michael Alexander
CO
Israel



Here are soom of the answers :

Have you tried a thermoplastic or stiff foam tongue with a strap over
it, similar to that used on the Cascade DAFOs?

Increase the surface area of a figure 8 pad and strap with 3 slots (an
oval hole the width of the strap) in the AFO:

1. Start with inside medial attachment
2. diagonal and lateral to proximal lateral malleoli with inside slot,
3. posterior and medial through a medial slot,
4. diagonal and distal to a lateral slot.

  When I am in this predicament with a person as you describe I have
recasted and fabricated an R-wrap total contact design AFO. It usually
displaces the pressure over the dorsum better and swelling is
eliminated.




   I'm going to assume, though you didn't mention it in your letter,
that you used a tone-reduction footplate for your patient. It sounds,
though, like you decided to use a strap to keep contact with the AFO. If
this is so, is there a reason you didn't try a DAFO instead? This if
modified correctly, might help keep the swelling down, as there's not as
much direct pressure


You may want to try a two piece AFO design. This is a total contact AFO
that we use for patients with spasticity that need ankle/foot support.
The inside piece is Supramalleolar design and the outer piece is a solid
AFO. We usually pull the SMO out of 1/8 modified polyethylene and the
outer AFO out of 1/8 polypropylene. The malleoli are lined with
aliplast in the SMO. Therapists like to use this type
of design because they can have the patient wear the SMO during therapy
sessions ie treadmill training.

I would pull a piece of 1/16 PE over the dorsum of the cast - on the
foot
and ankle area. Then use this tongue under your figure 8 strap. this
will
give you a greater surface area for control against plantarflexion, and
greater area to distribute the pressure of the strap.


Have you considered making a bivalve afo? I have found that this keeps
the heel in place while spreading the posteriorly directed force over a
large area, thereby preventing the redness and swelling that occurs with
the strap. I keep the anterior panel from midfoot to mid tibia and find
that it can fit in shoes, as long as the parents are willing to go up in
size


Sounds like you need a Total Contact or Dorsal Wrap AFO. These are
made of Copolymer or Polypro and wrap around the dorsum and close with
velcro straps. This not only helps keep the foot in the slight
dorsiflexion you need, but also aligns and calcaneus and prevents
pressure over the dorsum. You may want to consider using an inhibitory
foot plate in your casting.

I have used an anterior shell section to spread the pressure of the
figure 8
strap. Mold it to the positive AFO cast. Use 1/8th inch thick
polyethelene and the same thickness padding. Trim to be about 3cm above
and
the same below the bend of the foot. Taper the edges of the shell to
fit
inside the AFO.

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