Fw: Fw: summary - polio stance control

Fw: Fw: summary - polio stance control

Diane E Conuel

3/5/2006

Summary of responses I received to the interesting polio case I saw. I
waited to summarize until I had fit the patient. Original post is first.
Then a list of responses separated with ***. There was a WIDE range of
suggestions!! I summarized my outcome at the end of this email. Thank
you for all your responses!
Presenting a 77 yo man who had polio affecting R LE at age 3. He is
6'2, 190#. He reports he briefly wore a brace, but has not for at
least 70 years. He has zero quad strength. All other muscle groups are
virtually unaffected (dorsiflexion, hip flexion are 4/5. hip extension,
plantar flexion are 5/5 (and therefore he has good calf definition)).
Over the years, the patient has been very active (even downhill skiing!),
and learned to always keep his weightline anterior to knee center when
weightbearing on R. He uses R knee flexion in swing to clear floor
nicely; knee snaps back as he comes into single limb support. Patient
does report a few incidences over the 70 years where he has inadvertently
stepped on a rise with his R heel and buckled, with nasty falls.
Today, his complaint is PAIN due to recurvatum at R knee. He is also
concerned of the occasional fall, as he knows that at his age it could
easily result in a hip fx or the like. Pt is still very active with
walking 4-5 miles and easy hiking. ROM at all joints is normal, except
for the 20 degrees of recurvatum at R knee in weightbearing.
I have many ideas for this patient, but am very interested in the list's
input. He is an engineer and is very interested in the BEST design for
him -- he is in no hurry, and wants to carefully consider the options --
he is not sure he will be able to tolerate a brace.

Your thoughts on 1) KO vs KAFO (patient very concerned about ankle
flexibility for driving)?
        2) Stance control brace that also controls recurvatum?
        3) Is stance control really better for him, or is posterior
offset knee joints and recurvatum control simpler/more effective?
        3) Lightweight, least cumbersome design for this very active,
never worn a brace guy?
Diane Tormey CO
***
I have fit a patient in a similar situation with a Townsend KAFO. I like
the anterior shell design. I had the knee extension assist added. I
choose the adjustable ankle to limit dorsiflexion to 10 degrees,
providing some ground reaction resistance if the knee was to buckle. As
cosmetic and low profile as I think you can get. I saw the patient
yesterday for follow-up and he is doing very well.
***
This patient's clinical presentation is not unlike a group of younger
patients that fit into a femoral mononeuropathy etiology i.e., no quad
control. Usually the younger patients have had an iatrogenic injury to
the femoral nerve. We have generally fit these patients with a UTX-Swing
KAFO. This is a stance control KAFO that does offer positive locking in
stance phase. The weight of this tubular steel KAFO is under 2 lbs.
These younger patients usually do not present with any recurvatum. We
have fit a number of post polio patients with the UTX specifically for
recurvatum control. Some of these patients, like yours, either wore no
previous Ox or had a KAFO with a posterior offset knee joint. Most cases
that I have been involved with did not have the muscle control that your
patient has and converted to a SCO-KAFO without a protracted
accommodation period. Safety is a concern with these patients and I feel
that today's stance control systems due offer uninhibited gate stability
with the positive stance phase locking capability.
If you would like to discuss the case in more detail, please feel free
to call me.
Regards,
Gary G. Bedard, CO, FAAOP
Clinical Marketing Manager
Becker Orthopedic Company
***
I didn't see whether you plan to post responses so if you could forward
them to me I would appreciate it as this seems like a very curious case.
I am only a student right now getting ready to graduate and would like to
learn from this case. I do think KAFO would maximize the lever arm that
would resist the movement into hyperextension since he will be putting
large forces through the knee with his weight. How is funding? Will it
be possible to get a stance control?
Shane Wurdeman
Georgia Institute of Technology
***
Why not start out simple by trying an off shelf KO with recurvatum
control (Camp Check or hinged Swedish knee cage) in the office to gage
his reaction. With some designs they allow for adjustment of knee
alignment to help him or you control his comfort level and not
eliminate all of
the advantage he is obviously gaining from the recurvatum. It sounds
like he has nearly perfected a habit pattern with the knee flexion
compensation for toe clearance and he may only accept recurvatum control
initially.
***
Goals are important to establish. For instance, I WOULD NOT define your
orthotic goals in this case as STOPPING hyperextension or ELIMINATING
possibility of knee flexing throughout stance (and Pt. falling). Both of
these goals could be accomplished with a KAFO. Sounds like you have 2
more appropriately defined goals: reduce pain and reduce propensity to
fall. If you and Pt. can live with some degree of residual
hyperextension and only REDUCING possibility of fall an articulated AFO
should be considered: dorsiflexion stop set at apprx. 90 degrees to
resist knee flexion from mid-to-late stance AND plantar-flexion stop
(with springs) set in few degrees of plantar-flexion to resist knee
extension. You would allow a few degrees of resisted plantarflexion to
avoid creating excessive knee flexion force at heel strike. Important
to note he would require/benefit from gait training with AFO for him to
learn/develop proprioceptive feedback on how it works. Given his 65 year
gait pattern we can assume this design will IN NO WAY stop hyperextension
but may reduce terminal velocity of thrust and/or degree
of hyperextension enough to reduce pain. This design will also NOT
eliminate the possibility of knee buckling but may reduce propensity
sufficiently to permit most ADL's with increased safety. Advantages
include nothing to cross knee, reduced weight/bulk/cost versus KAFO
design, no issues of distal migration as with K.O.'s., easier to don,
etc. Majority of active persons function very well with restricted ankle
motion including driving, negotiating stairs, etc. Other option is
Fillauers' Stance control joints in custom K.O.: other than cost,
durability/reliability, distal migration, not sure why this wouldn't be
viable option. KAFO would be last choice only if both other options
fail. Please post responses.
***
I had a patient with this type of issue. She went through townsend and
innovative braces and I think CTI as well. But they always broke. I
have a brace that I made KO. I used Otto Bock modular polycentric knee
joints and fabricated a pre-preg carbon upper and lower shell both
anterior. I had a criss-cross posterior strap that controled the
hyper-extension. I choose to make it my self b/c if the other brace
companies couldn't make it last more than a year then if sent again it
would have the same effect. So I fabricated it myself with pre-preg
which can be bought through Euro International and there course is
strongly reccommended if you prepare your model and take their course you
can fabricate it with them at their Tampa location. It is well worth it.
Extra light and extra stong. No metal bending at all. You just add
straps. I have pictures but I have to look for them. If you need
assistance or need someone to fabricate it let me know
Sincerely
Ferhan
***
Over my 50 years experience I have fitted and fabricated many orthoses to
prevent recurvatum of the knee.

I do not recommend knee orthoses because they rotate and slip down. the
best results can be achieved with a KAFO.

My design is based on the Swedish knee brace. The KAFO is made with an
anterior superior thigh band a posterior distal thigh band, offset knee
joints and an articulated AFO lower section.

Preferably the knee joint to be at 180 degrees or slightly flexed.
Max Lerman C.O.
***
you may be able to get away with an offset knee joint on a KAFO. If you
want to lock the knee for safety at heel strike, try Otto Bock's new
KAFO. Hard to make money, but it will satisfy the patient.
***
pt. will absolutely reject KAFO due to bullk and cosmesis. try a custom
KO using adjustable knee flexion control stops. If you don't want to fab
in house, use Townsend Design. You have a real challenge on your
hands...good luck. I got a bit of experience with polio and post-polio,
e-mail @ <Email Address Redacted> or call Steve Burnett CO @ 407 509 0093
***
I have fit several Post Polio Syndrome patients in this age group and it
seems that a Plastic KO with posterior offset polycentric jts
(Bock has nice ones) would by an ideal recurvatum control option without
hampering this patients lifestyle to much. I think KAFO would
be overkill and he may reject it as too limiting and restrictive.
***
The orthoses that come to mind are in the stance phase control type knee
joint. The knee joint that gives you the most options is the SPL joint
from Fillauer. The offset knee joints are also an option as well as a
Townsend KAFO. The discussion of least cumbersome design is not the issue
its how much control does your patient need and what is he willing to
toleratewhile learning to use his orthosis for daily activities. Gadget
tolerance has a lot to do with the success of this type of orthosis. The
fact that he is an engineer may not make it any easier. I have used a
laminated KAFO with an SPL Fillauer joint on quad minus patients with
great success, they do not buckle and develop great confidence in their
gait, in some cases where they walk better than ever.
Good luck,
Carey Glass CPO FAAOP
***
My name is Kelly Clark. I saw your post on the list serve. I am with
Otto Bock Health Care. As you probably know we have a stance control
brace called the FreeWalk. It is a unilateral system made from tubular
stainless steel. The criteria that you gave about 20 degrees recurvatum
can be addressed. We can’t accommodate that posture, however. The knee
would have to be brought back to neutral to work with the brace. Because
the patient has gone without a brace for all these years and because post
polio usually have such keen proprioception you would need to determine
if the patient could tolerate being held in a neutral posture. I am
attaching a stance control matrix that has all the current stance control
options available today. I put this together in conjunction with all the
manufacturers and it was presented at AOPA in Las Vegas last year. If
you have any further questions don’t hesitate to give me a call or email.

Have a great day
Kelly Clark, CO
Otto Bock Health Care
****
This sound like a perfect guy for an anterior stop afo with dorsi assist
joint. It does not directly control recurvatum but now he can train
himself to move the knee forward and know that there is ant support.
John
***
Knee orthosis with knee set 5 degress posterior to trigger. It sounds as
though the patietn has already told you what he wants and will
wear....least intrusive.
***
Seems like an ideal candidate for the Fillauer/Basko stance control KO.
No way would I cross the ankle with an orthosis if it is not necessary.
Ted A. Trower C.P.O.
A-S-C Orthotics & Prosthetics
Jackson, Michigan, USA
**************************************
ACTUAL RESULTS!!
I went with Mr Trower's suggestion (Fillauer/Basko stance control (SPL)
KO) after discussing all with the patient. This joint works on a
pendulum-type system to engage the lock and no ankle actuation is needed
(see www.fillauer.com/products/spl/index.html). The orthosis was set at
0 degrees knee flexion. He got the orthosis 2 weeks ago and is doing
well. The patient really wanted to avoid ankle involvement with the
orthosis. Suspension hasn't been a problem as the SC area is well
defined due to lack of musculature and a pad there is working well. Pt.
immediately had an improved gait with the recurvatum controlled and seems
to have easily gained trust in the stance lock. We're having some
pressure issues at popliteal trimlines (I kept them tight to KC to try to
control recurvatum) as patient is still in habit of pushing back into
excessive knee extension (perhaps I should have allowed 5 degrees of
recurvatum?). Hopefully, he will continue to adapt to orthosis and it
will continue to be a success.

Again, thanks for your input and I welcome additional comments.
Diane Tormey CO

                          ********************
To unsubscribe, send a message to: <Email Address Redacted> with
the words UNSUB OANDP-L in the body of the
message.

If you have a problem unsubscribing,or have other
questions, send e-mail to the moderator
Paul E. Prusakowski,CPO at <Email Address Redacted>

OANDP-L is a forum for the discussion of topics
related to Orthotics and Prosthetics.

Public commercial postings are forbidden. Responses to inquiries
should not be sent to the entire oandp-l list. Professional credentials
or affiliations should be used in all communications.