stance control (responses)

stance control (responses)

chris huff

8/29/2008

WOW!! You guys and gals are great!! Thank you so much for the help to all that responded. This list serve is very helpful and I appreciate everyone's help.
 
I did not give an evaluation of the patient as I was not looking to see if I had the right patient model, but rather looking for everyones experience with stance control kafo's. This is a personal friend who had a T11 kink, has grade 3 hip flexors, grade 1 hip extensors. Grade 2 quads and hamstrings and flaccid ankles. I am donating my services and spent a lot of money with little success. I recast and laminated carbon afos with 5 degree dorsiflexion and thigh shells, then swapped SPL knee joints over from plastic system. Patient can walk on treadmill supporting his upper body with the bars. He is very strong and flexible at 170lbs. When on ground with crutches the system does not work that well. He has a harder time moving, locks don't function and now the joint just broke and these are almost new. I was thinking of making carbon kafo's with posterior offset knee joints and an extension assist. I would use a double action ankle joint for proper functional postitioning. I would love to get away from a locked knee, but may need a drop or lever lock just in case. Patient is comfortable in dorsiflextion with hips anterior to midline for balance. He cannot recover if he starts to fall backward. He is very determined to walk and without a doubt I believe he will with the right system. Again, Thank you for all the great responses! I will have to read through and decide what I want to try next. Everyone have a great holiday!
 
Chris Huff CO
Advanced O&P
Albany, NY
 
You are right. The SPL stance control are not the most impressive. I have only used them a couple of times. My luck was good, but the selection of the right patient is critical and the fine tuning is time consuming. Durability is definately a factor and I do not know how long my patients actually wore the KAFO. The best bet for a long term is a conventional orthosis.
I have fit all but the Horton SCO, 40+ over the last 3 years in total. They all have durability issues compared to standard thermoplastic KAFO's when used on community ambulators, especially bilateral applications. I have found the SPL to be the most reliable and durable for bilateral application or when you have a very active patient. I had 1 problem with the SPL on a young 240 lb. 6' 2 that beat the H out of them which led to having the distal joint head replaced $$$ due to a malfunction. Otherwise, I have had an overall good experience with the SPL system other than the inherent weight and bulk. UTX in my experience has not worked on active community male ambulators weighing 210 lbs. +, had stirrups break on both patients along with wire that releases knee locking mechanism breaking. Otherwise UTX works well and light weight for all other patients. Otto Bock's free walk - bulky padding covering metal anterior bands, only used once. have not fit newer Otto Bosk SCO's. Becker safety stride worked very well but does have an audible clicking noise from locking mechanism.
 
I have become very selective, primarily to get optimal results as the fitting and follow up care can become tedious. I have resorted to more traditional designs when not using the SCO design. Traditional design consists of a thermoplastic design with offset knee joints, stirrup with footplate having DAAJ's with anterior pins and posterior springs
 
Hope this helps!
 
Chris --- doesn't one need hip extensors to pull the leg back to unlock the knee ? I have not done any of the SC KAFO's from the start of a patient - so I am going by what I remember. Anyway - is your T11 a complete para - therefore without hip extensors ?That might be the problem. But it is good of you to try to get him to be the most functional . I would also be careful of someone without sensation and proprioception if you are doing a bilateral. Just my thoughts -- but as I said - I haven't done any.
 
Same here. The knee load on the hinge didn't allow the hinge to unlockor react properly to the motion required for swing. I am working with the freewalk from Otto bock right now. So far it'spretty good but needs lots of training. Have you used the Scott-Craig Paraplegic style KAFO's. They areconventional style KAFO's but were designed specifically for para's and haveeffectively been utilized for them since the 1960's. They are extremelystrong, durable and functional for this population. If interested I couldfind some of the old articles on them and forward them to you. The FreeWalk. I've fit 12 to 15 stance phase KAFOs of this design. The Free Walk has been my best experience so far. It's crucial to use Otto Bocks' selection sheet which helps ensure good candidates and the proper design. The starter kit enables you to make many of your own adjustments rather than having to return the brace to a company at $50 for each shipping (not to mention the time wasted). Otto Bock support was timely and helpful during my learning phase. I send in casts for fabrication and have had quite good fits with minimal adjustments. The most usual adjustments would be to tweak the thigh band ML on larger patients. This is easy with the tools provided. Patients tend to walk much better right away. Follow-up appointments for adjustments or repairs are minimal to none. Diagnoses have been CVA, post Polio, MS and non-spastic SCI, Three patients received bilateral but I wouldn't try that unless you have some good experience with this kind of bracing. Bilateral works well because there are no medial bars to catch together. Otto Bock provides a good manual to give to PTs so they can provide the necessary training and strengthening for best results. With a post Polio patient in particular I advise PT (it also helps progress them through that discomfort with brace design change - if they had a brace previously). Some patients will need PT to help problem solve stairs, ramps and sitting but these usually aren't big problems. When you fit the brace don't explain anything about how to walk in it. I put it on them then tell them to walk a little so I can check the alignment - anything to keep them from TRYING TO WALK RIGHT in it. I found that comments such as try to push you knee back just before you start to swing the leg through is sure to change their gait from normal which is all it takes to not work. I really encourage you to try this brace. After 25+ years of working with locked knee KAFOs and all of the residual problems, putting a patient in a stance phase is a trip. When I called my last two patients for one month follow-up they both said to effect that they usually forget they even have it on. SOME ADDITIONAL THOUGHTS, CHRIS: Does the patient have adequate strength proximal to the brace? Also, I see the SPL is double upright - The FreeWalk is a single lateral upright (but very strong) The FreeWalk ankle is very flexible so it only provides the DFA of a thin posterior leafspring but on the positive side the flexibility allows the wearer to position the feet and legs better for standing up and sitting down. I think all of these braces involve more of a learning curve than the manufacturers let on in their inservices. But there's a learning curve for standard KAFOs too.
 I've used the Becker UTX stance phase KAFO with good success. Aslong as the patient doesn't have any moderate to severe knee instability inthe M-L plane. If the patient is active they make a stainless steel versionthat I strongly recommend. I initially had a problem with the aluminumupright stretching at the joint. They added a clamp to prevent any furtherstretching. The cable inside does require adjustments initially. Afterabout six months the cable reaches its stretching point and I haven't had tohave it adjusted anymore. Patient has been wearing it for 3 years now and isa young 23 year old. Hope this helps. If you want to contact me feel free.
Talk to Gary Bedard from Becker...he's an expert on the stance control orthoses and will not do the salesman for Becker stuff thing if it's not appropriate.
I have used just about all of the Stance Locking Free Swinging joints for ko's and kafo's, and they all have their roles. I have found the Fillauer Spl to work very well in a KO configuration with ONLY quad weakness (the client accepts it as a ko vs. a kafo. and the set screw/ pendulum set up is only just adequate), other then that its role is limited. With poor abdominal, hip flexors and extensor that a t11 may exhibit: I would think that a Horton, e-knee, Becker's new version of the Full Stride, with flexion lock and the with extension assist would be good choices. They all have the ability to ratchet from flexion to extension if the client does not make it to full extension. ......We currently have a young man in kafo's with the Up and Around GSO design that we are looking into stance phase joints for. I am not sure if you wanted to use Kafo's, and link them to the Up an Around, or if an RGO would make more sence. I am currently conflicted with my client as well. My thoughts at this point is that an RGO with minimal trim lines is the most functional option. This would replace the antigravity groups, and also provide a much better platform to mount to. The tip bar replacing hip flexors just conceptually seems to be the right idea....... The Horton has been used in this capacity before, but may not be warateed from the manufacturer in this application- Google Horton RGO and find some motivation from the results. I like the horton knee and have used many in the past. It has been revised and is now a better system. Still i think it will need many tune ups over its life span to keep the unlocking mechanism in tip top shape. The E-Knee form Becker is very excessive, and heavy, but may be my choice. The set up is quite easy, and the foot plate/ pressure sensor is very easy to modify. The battery life seem quite good as well. The thing i really like about it is the pressure switch: you can run sensors all the way to the end of the toes or you can block some and only have them for heel strike thew mid stance. As the client goes to heel off, the pressure sensors are disengaged and you have free swing. The down side to this system (and most other systems) is that the knee must find extension before it is allowed to unlock. The Becker full stride can be had with the g-knee extension assist which i have used in cases of mild quad weakness and fell in love with. For our application this would be a great option. I hope this helps.... Also keep in mind all the clients I have fit have had decent hip extensor. For the right patient, carefully selected they are a good option. It takes a lot more precise fabrication and then much more clinical time to fine tune the whole mechanism and patience, patience and more patience on the part of the client to make it work well. The Fillauer joint is one of the best and also the simplest to use. I feel your pain and agree, the last thing you need is a sales pitch! I usedthose SPL on a unilateral Polio patient. They worked, but the real problemis the pair of joints only has an extension stop on the lateral joint. Fitthese to any patient with recurvatum or that needs hyperextension tostabilize the knee joint and watch out, they break. Funny thing is, mostpatients with a unstable knee, position themselves this way, so this designis actually for very few patients. The more robust unit would be the design from Becker that utilizes,conventional joints with a cable that attached to the footplate. The jointdesign is proven/durable and you have two extension stops so joint alignmentis not hypercritical. I only used them with high activity patient singlesided, with excellent results. Remember that these patients need to stand with their pelvis forward,hanging on the Y alignments of the hip, feet in dorsiflexion. So non ofthese designs are really perfect from them. The stance control knee works like the Total prosthetic knee. You have to hyper extend in standing to unlock the knee. With you case your patient does not have this mobility. I would use RGO's,
 
Stance control when properly applied can be an amazing thing, but of all the systems out there the SPL seems to be the most problematic. Especialy with bilateral patients! We make as many SCO orthoses as any one in the country and have had a lot of succesfull cases, so don't give up on the concept, just try a less cantancerous system. The Horton is big and bulky, and it works so well almost no one seems to care, they have a great track record of function and reliabilty.We also do a groing number of the full stride and safty stride from Becker Ortho. both units have done really well with no maintenance issues so far. Both are easy to tune and easy to repair if they break, the Becker joints are smaller and less expensive but the Hortons lock ROCK SOLID in any flexion angle. Hope this helps, good luck in your quest.
I am sorry you have been having trouble with the SPL, but you really need to have hip flexors to make that joint work. At very least the patient needs to ballistically position the leg with an inverted Y strap with abdominal control. Is that T11 paraplegia complete? I would think a bilateral T11 with paraplegia would be indicated for RGO's for ambulation, but even at that level hip flexors may not be present. If there are no hip extensors to help out, you will only have frustrations. Hip extensors are critical for the proper use of these so called stance control systems. I think T11 could be above truly capable bounds of use for stance control without some type of microprocessor control. I have been using becker fullstride on polio and cva successfully. I have not had a T11, but based on the last 6 patients I have fit, there certainly seems to be a need for some minimal control around the waist or hip. Sensation of the joint releasing seems to be a huge help as well in ambulating. Hope this helps you. The issue I had with the Fillauer was that the lock is activated by the swing and angle of the knee, and not load bearing (similar to a seat belt). The load bearing locking mechanisms seem to be a better choice in many cases. You really need to evaluate your patient on where the lock needs to be established, as well as their strength and ROM.
I have used them twice, and aside from the durability, thehyperextension moment must be strong and constant to release the lock.The cable system is somewhat frail and if you take the proximal cablelocking system apart, keep a watchful eye on flying parts, it is abastard to put back together. I would keep the spl for low dutyusers(moderate recurvatum or higher) and lighter weight bodies.
 
 
 
 
 
 
 
 
 
 
 
 
 
 
                          ********************
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.