responses to "TBI patient"
Brittany White
Description
Collection
Title:
responses to "TBI patient"
Creator:
Brittany White
Date:
8/16/2012
Text:
Thanks to all who replied to my post a couple weeks ago. We have narrowed
down to two options: the Ultraflexx SafeStep KAFO or the Ottobock
Sensorwalk depending on how he does in diagnostic test brace fitting. I
just wanted to go ahead and post the replies and say thanks for the input!
I will post or reply to anyone interested after we finalize an orthotic
design and fit an orthosis.
Thanks
Brittany White CO
Original Post:
I have a young male patient with a head injury from a motorcycle accident
and strong extensor tone as a result (incidentally an Iraq veteran, but not
injured in service)
He pretty much walks on the ball of his foot, heel never hits the
ground, strong varus thrust at the knee and ankle, knee and hips stay
slightly flexed throughout stance and swing phase. He currently
ambulates with a quad cane, a loner articulated AFO that is way too big,
and PT assistance. Right now his tone is keeping his knee from buckling in
ambulation, but he can't do single limb stance on affected side at all or
stand for more than 3 minutes with weight mostly on good side. No use of
hand on affected side either.
His tone is so high that I cannot passively stretch his knee into full
extension, and the tone of course varies. He is awaiting botox treatment.
He lives at a TBI rehab center now, so has access to plenty of PT.
He currently has an order for an AFO and a KO as well, but they are open to
any orthotic suggestions.
Ideal orthosis would lock his knee in various degrees of extension for
standing stability, allow free swing, resist genu varum, resist equinovarus
at foot. Easy as that.
I immediately thought KAFO to address his knee as well and would love to
make use of stance control technology, but not sure if that is an option
with his tone, lack of heel strike, etc. Therapist is asking if there is a
quick disconnect type option to use the AFO independently of thigh
section or KO over the top of AFO. I've never loved the KO over the AFO
set up, but I'm open to any suggestions.
I've got some ideas rolling around in my head, but would greatly appreciate
any ideas on orthotic design
Responses:
ultra flex makes a quick disconnect
----------
And seeing as how I can no longer practise myself as a result of TBI, MCC
also, I do have direct personal knowledge of what you're facing.
But there is a disconnect option available for a KAFO to convert to AFO,
and if the long term file clerks are correct, check with COD in Cali,
the Isocentric RGO folks, and again going by memory, I believe they are in
Campbell CA, and are part of Filauer.
And you got yourself a project here in that unless and until you can
control the ankle varus, everything else is putting a band aid on and
amputation so to speak.
So AFO design has absolutely got to control the varus first and foremost,
and then with PT, and time, everything else might fall into place.
And I am currently 3 years post and can at least for the most part, on good
days, ambulate with only a single point cane, and lace up boots.
Good luck, and keep me posted if you will.
----------------------
It may not be a truely quick disconnect, but here's an idea. Bend the
metal uprights to the cast, then pull the plastic for AFO and thigh section
over the upright. Then you can attach the uprights with Pam head screws
from the outside, through plastic, into threaded metal. The screws can be
removed and the KAFO becomes an AFO.
----------------------
You patient certainly presents an interesting case. TBI is an unfortunate
injury for sure. As you state, he is awaiting a Botox treatment regime
which should decrease his tone however, that still may leave an unstable
LE. Your young man appears that he may be a candidate for Stance Control.
The Fillauer SPL-2 joint offers not only the ability to lock the a
anatomical knee when the weightline is posterior to the knee but then
unlock with a weight shift anterior to the knee.. the SPL-2 joint
incorporates a 15 degree 'security stop' that (while the patient is
receiving PT and further medical treatment to reduce tone and therapy
modalities) provides stability when the anatomical knee does not come to
full extension but has the possibility to through medical treatment. Here
is a link to a testimonial about the joint;
<URL Redacted> or www.fillauer.com
Should you have further questions, please let me know. The SPL is available
through Fillauer @ 800-251-6398 | 423-624-0946 and can be fabricated by
your lab or the Fillauer C-fab.
-----------------------------
I would put him in a Texas Turbo triplanar control AFO. Set him up with
heel lift under AFO, which can be reduced as he makes gains in rehab. Make
sure you balance pelvis. I doubt you need to cross the knee. A very solid
ankle will stabilize the patient in stance. Feel free to call and
discuss. If you want info on the turbo...
<URL Redacted>
There is also a video on fab of the design at youtube and our website.
Good luck!
-------------------
I can't help you with your questions, but sadly, moreIran and Af. vets are
inured and killed on motorcycles here in the states than in combat.
------------------------
The only stance control joint that I know of that may work for this
patient is Otto Bocks electric one. One of my patients took part in the
study of the design at Mayo clinic, he is post polio and has the usual
contractures. The knee unit will release and lock in varying degrees of
flexion. Becker, Fillauer, Ultraflex and I believe Orthomerica all have
quick disconnects.
Good luck and please let me know how everything turns out.
------------------------
Your questions are right on. The knee issues are directly related to the
extension tightness with the leg in full extension. I would manufacture a
solid ankle AFO at the angle of the first catch of patients ankle
(gastrocs) with the leg in maximum knee extension. Cutting and correcting
the angle beyond that angle will make the system not function correctly and
not allow the patient to stay seated in the AFO. I use the DRAFO design
for the ability to get a smoother first rocker of gait due to the cut out
of the rigid outter shell of the brace. You then need to add a lift to
patients shoe on the affected side to set the brace into about 10 degrees
of flexion at the knee when patient is weight bearing. The AFO should have
a full to toe foot plate to give good knee control in 2nd rocker of gait
and the rocker should be set as a load point rocker to allow knee flexion
at the start of 3rd rocker of gait. The other shoe can then be modified to
match pelvis with correct corresponding lift. I am going to attach a
document distributed by the Scottish government about AFO's and tuning of
braces on page 43 of the document.
------------------------------
He may be a good candidate for the Bioness FES system. I have a young
stroke patient who has severe varus thrust and inversion instability and
she has done very well with the Bioness. Since the FES uses the same
reflex arc as the extensor synergy - it inhibits the extension/inversion
tone immediately. Also since the FES is injecting sensory feedback into
the often neglected side the patient can regain voluntary control to a
certain degree.
It would be worthwhile to trial it for a couple of weeks!
Good Luck
------------------------------
Ultraflexx Systems: Please give me a call at (800)220-6670 to discuss this
case. Your patient may be a candidate for one of our adjustable dynamic
response KAFO’s. These can be equipped with Ultraflex’s quick disconnect
system to separate the AFO from the thigh section. I will look forward to
talking to you.
--
Brittany White CO
BioTech Prosthetics and Orthotics
biotechnc.com
919-471-4994
down to two options: the Ultraflexx SafeStep KAFO or the Ottobock
Sensorwalk depending on how he does in diagnostic test brace fitting. I
just wanted to go ahead and post the replies and say thanks for the input!
I will post or reply to anyone interested after we finalize an orthotic
design and fit an orthosis.
Thanks
Brittany White CO
Original Post:
I have a young male patient with a head injury from a motorcycle accident
and strong extensor tone as a result (incidentally an Iraq veteran, but not
injured in service)
He pretty much walks on the ball of his foot, heel never hits the
ground, strong varus thrust at the knee and ankle, knee and hips stay
slightly flexed throughout stance and swing phase. He currently
ambulates with a quad cane, a loner articulated AFO that is way too big,
and PT assistance. Right now his tone is keeping his knee from buckling in
ambulation, but he can't do single limb stance on affected side at all or
stand for more than 3 minutes with weight mostly on good side. No use of
hand on affected side either.
His tone is so high that I cannot passively stretch his knee into full
extension, and the tone of course varies. He is awaiting botox treatment.
He lives at a TBI rehab center now, so has access to plenty of PT.
He currently has an order for an AFO and a KO as well, but they are open to
any orthotic suggestions.
Ideal orthosis would lock his knee in various degrees of extension for
standing stability, allow free swing, resist genu varum, resist equinovarus
at foot. Easy as that.
I immediately thought KAFO to address his knee as well and would love to
make use of stance control technology, but not sure if that is an option
with his tone, lack of heel strike, etc. Therapist is asking if there is a
quick disconnect type option to use the AFO independently of thigh
section or KO over the top of AFO. I've never loved the KO over the AFO
set up, but I'm open to any suggestions.
I've got some ideas rolling around in my head, but would greatly appreciate
any ideas on orthotic design
Responses:
ultra flex makes a quick disconnect
----------
And seeing as how I can no longer practise myself as a result of TBI, MCC
also, I do have direct personal knowledge of what you're facing.
But there is a disconnect option available for a KAFO to convert to AFO,
and if the long term file clerks are correct, check with COD in Cali,
the Isocentric RGO folks, and again going by memory, I believe they are in
Campbell CA, and are part of Filauer.
And you got yourself a project here in that unless and until you can
control the ankle varus, everything else is putting a band aid on and
amputation so to speak.
So AFO design has absolutely got to control the varus first and foremost,
and then with PT, and time, everything else might fall into place.
And I am currently 3 years post and can at least for the most part, on good
days, ambulate with only a single point cane, and lace up boots.
Good luck, and keep me posted if you will.
----------------------
It may not be a truely quick disconnect, but here's an idea. Bend the
metal uprights to the cast, then pull the plastic for AFO and thigh section
over the upright. Then you can attach the uprights with Pam head screws
from the outside, through plastic, into threaded metal. The screws can be
removed and the KAFO becomes an AFO.
----------------------
You patient certainly presents an interesting case. TBI is an unfortunate
injury for sure. As you state, he is awaiting a Botox treatment regime
which should decrease his tone however, that still may leave an unstable
LE. Your young man appears that he may be a candidate for Stance Control.
The Fillauer SPL-2 joint offers not only the ability to lock the a
anatomical knee when the weightline is posterior to the knee but then
unlock with a weight shift anterior to the knee.. the SPL-2 joint
incorporates a 15 degree 'security stop' that (while the patient is
receiving PT and further medical treatment to reduce tone and therapy
modalities) provides stability when the anatomical knee does not come to
full extension but has the possibility to through medical treatment. Here
is a link to a testimonial about the joint;
<URL Redacted> or www.fillauer.com
Should you have further questions, please let me know. The SPL is available
through Fillauer @ 800-251-6398 | 423-624-0946 and can be fabricated by
your lab or the Fillauer C-fab.
-----------------------------
I would put him in a Texas Turbo triplanar control AFO. Set him up with
heel lift under AFO, which can be reduced as he makes gains in rehab. Make
sure you balance pelvis. I doubt you need to cross the knee. A very solid
ankle will stabilize the patient in stance. Feel free to call and
discuss. If you want info on the turbo...
<URL Redacted>
There is also a video on fab of the design at youtube and our website.
Good luck!
-------------------
I can't help you with your questions, but sadly, moreIran and Af. vets are
inured and killed on motorcycles here in the states than in combat.
------------------------
The only stance control joint that I know of that may work for this
patient is Otto Bocks electric one. One of my patients took part in the
study of the design at Mayo clinic, he is post polio and has the usual
contractures. The knee unit will release and lock in varying degrees of
flexion. Becker, Fillauer, Ultraflex and I believe Orthomerica all have
quick disconnects.
Good luck and please let me know how everything turns out.
------------------------
Your questions are right on. The knee issues are directly related to the
extension tightness with the leg in full extension. I would manufacture a
solid ankle AFO at the angle of the first catch of patients ankle
(gastrocs) with the leg in maximum knee extension. Cutting and correcting
the angle beyond that angle will make the system not function correctly and
not allow the patient to stay seated in the AFO. I use the DRAFO design
for the ability to get a smoother first rocker of gait due to the cut out
of the rigid outter shell of the brace. You then need to add a lift to
patients shoe on the affected side to set the brace into about 10 degrees
of flexion at the knee when patient is weight bearing. The AFO should have
a full to toe foot plate to give good knee control in 2nd rocker of gait
and the rocker should be set as a load point rocker to allow knee flexion
at the start of 3rd rocker of gait. The other shoe can then be modified to
match pelvis with correct corresponding lift. I am going to attach a
document distributed by the Scottish government about AFO's and tuning of
braces on page 43 of the document.
------------------------------
He may be a good candidate for the Bioness FES system. I have a young
stroke patient who has severe varus thrust and inversion instability and
she has done very well with the Bioness. Since the FES uses the same
reflex arc as the extensor synergy - it inhibits the extension/inversion
tone immediately. Also since the FES is injecting sensory feedback into
the often neglected side the patient can regain voluntary control to a
certain degree.
It would be worthwhile to trial it for a couple of weeks!
Good Luck
------------------------------
Ultraflexx Systems: Please give me a call at (800)220-6670 to discuss this
case. Your patient may be a candidate for one of our adjustable dynamic
response KAFO’s. These can be equipped with Ultraflex’s quick disconnect
system to separate the AFO from the thigh section. I will look forward to
talking to you.
--
Brittany White CO
BioTech Prosthetics and Orthotics
biotechnc.com
919-471-4994
Citation
Brittany White, “responses to "TBI patient",” Digital Resource Foundation for Orthotics and Prosthetics, accessed November 25, 2024, https://library.drfop.org/items/show/234309.
