Page 4

(Continued on page 2)

Ankle-foot orthoses of various designs are widely consideredan important aid in managing young patients with spasticcerebral palsy; indeed, they are prescribed for C.P. manage-

ment more than any other orthotic de-vice. Primary goals include contractureprevention, improved function andambulation and tone reduction inproximal muscles to improve functionat higher levels.

The chief role of the AFO in this application is to limit unwantedankle and subtalar movement, primarily ankle plantarflexion, andindirectly to affect knee and hip function. Children with spastic C.P.often acquire a dynamic equinus deformity, which prevents themfrom putting their foot flat and attaining a stable base for stance andwalking. Assuming the ankle can be placed in a neutral position atrest, i.e. the deformityis not fixed, a correc-tion can be appliedthrough one of severalAFO constructions,depending on the capa-bilities of and goals forthe patient.

Reviewing the dif-ferent types of AFOsthat may be appropriatefor C.P. patients:

With a shorter profile

than a full AFO, the supra malleolar orthosis (SMO) maintains adesired ankle position and provides support for the dynamic archesof the foot. Due to its shortened lever-arm, an SMO allows anklemovement, beneficial for ambulation and sit-to-stand transitions.The basic SMO is not very effective for managing equinus, howeverwhen constructed as part of a two-piece AFO with an extendedfootplate, this design can address that deformity as well.

AFOs Bring Unruly Legs Under Control

Orthotists are frequently involved in the management of youngpatients with cerebral palsy. United Cerebral Palsy estimates

that 764,000 children and adults living in the United States mani-fest C.P. symptoms and that some 8000 babies and infants and1100-1500 preschool-age children are newly diagnosed each year.Of these, a majority are affected with spastic diplegia — stiff,permanent contraction of the muscles in both legs.

Bracing for C.P. is primarily employed to stretch hypertonicmuscles and prevent contractures. Ankle foot orthoses (AFOs),the most frequently prescribed devices for C.P. patients, manageabnormal plantar flexion (equinus deformity) by controlling or

eliminating ankle and subtalar motion toprevent contractures and improve gait.

Splints can be employed to forestallelbow, wrist and hand contractures.Spinal braces can help children who arehaving difficulty sitting upright andstraighten the spine in the presence of adeveloping deformity.

This newsletter explores the contribution orthotics can makein the C.P. management milieu. We hope you find the informa-tion worthwhile and welcome your comments and inquiries.

Combination (two-piece) AFOsCourtesy of Orthomerica Products Inc. ©2007

Supra malleolarorthosis (SMO)

Courtesy OrthopericaProducts Inc.

Orthoses for Managing Cerebral Palsy

OrthoticsToday

Note to Our ReadersMention of specific products in our newsletter neither consti-

tutes endorsement nor implies that we will recommend selectionof those particular products for use with any particular patient orapplication. We offer this information to enhance professionaland individual understanding of the orthotic and prosthetic disci-plines and the experience and capabilities of our practice.

We gratefully acknowledge the assistance of the followingresources used in compiling this issue:

Innovative Neurotronics Inc. • Marta Tankersley Orthomerica Products Inc.

Anew therapeutic concept combining the bracing role of theorthotics discipline with the muscle restoration function of

FES (functional electrical stimulation) is now availablefor patients suffering from dropfoot through a productcalled the WalkAide.

Dropfoot, the inability to properly lift the forefootduring ambulation, frequently results from interrup-tion of normal signals from the brain to the peronealnerve, which normally trigger dorsiflexion in swingphase. The condition is a common outcome of multiple sclerosis,cerebral palsy, stroke, traumatic brain injury, and spinal cord injury.

Common manifestations are toe dragging in swing phase and footslap at the beginning of stance phase as the dorsiflexors are unable toovercome the plantarflexion moment created at heelstrike. Patients

with dropfoot often compensate with anexaggerated high-stepping ambulationknown as steppage gait.

The WalkAide surmounts dorsiflexorweakness or paralysis by stimulating theperoneal nerve at the appropriate point inthe gait cycle to lift the forefoot, assuringground clearance and providing for a nor-mal heel-to-toe rollover. The result is amore natural, smoother, safer, and moreenergy-efficient gait.

In recreating the natural nerve-to-muscle response, the WalkAide not onlycorrects for biomechanical dysfunctionbut may improve circulation, reduce atro-phy and increase joint range of motion.

This technology was under development at various research cen-ters for 10 years before recently receiving FDA approval.

The device consists of a battery-operated electrical stimulator,two electrodes and electrode leads packaged into a small case, whichis held in position by a cuff on the affected leg just below the kneenear the fibula head.

A New Option for Correcting Dropfoot

Photos courtesy Innovative Neurotronics.

The WalkAide is an alternative to the conventional orthotic treat-ment for dropfoot, an ankle-foot orthosis. AFOs have long been an

effective management toolfor this condition, but forsome patients an FES system may provide animproved gait and be morecomfortable to wear andmore cosmetically acceptable.

A programmable tilt sensor built into the system analyzes move-ment of the wearer’s leg and foot and controls stimulation duringgait. The device is initially programmed with dedicated software on alaptop computer. Though a heel sensor is used for programming, it isnot worn during routine use of the system.

Contraindications include lower motor neuron and/or peripheralnerve damage; secondary complications of knee, back or hip surgery;leg trauma; sciatica; peripheral neuropathy; spinal stenosis; post-poliosyndrome and Guillain-Barre. The WalkAide should not be used bythose wearing a pacemaker or who are subject to seizures.

While probably not the ultimate answer to the control of drop-foot, the WalkAide has the potential to improve gait, overall health,and quality of life for appropriate patients. A physician’s prescrip-tion is required.

What’sNew

New Cast Protector for Water ActivitiesWith springtime just around the corner, Orthopedic Appliance

Company is proud to introduce its newest cast protector. TheStay Dry Pro-Pump is a surgical latex sleeve that fits over casts,bandages and prostheses to provide complete waterproof protec-tion. Its patented vacuum seal assures a cast or bandage will staydry, even when submerged in water.

The cast cover is easy to use: Slide the cover over theappendage and pump the air out by squeezing the built-in pump

until the bulb is flattened. The patient can goswimming, bathe, shower and receive hydro-therapy; the cover protects a cast or bandageduring any water activity.

Orthopedic Appliance Company offers avariety of Stay Dry Pro-Pump sizes designedto fit children as young as age two and adultsas tall as 6 feet, 6 inches. For further informa-tion on this product, call us at (828) 254-6305.

Prosthetics • Orthopedic Bracing • Seating & Mobility No. 3

Orthopedic Appliance Co. (OAC)offers quality bed solutions to meet

every patient need. All functions of thefull electric bed, including head and foot

positioning and bed height, are easilycontrolled with an ergonomic hand pen-dant for maximum comfort, convenienceand ease of operation.

Not only does OAC have great beds tochoose from, but we also offer a varietyof mattresses and accessories, such as ouralternating pressure mattress, to choosefrom. The alternating pressure mattress isa great tool for patients in a comprehen-sive wound care program, providing ther-apeutic benefit to patients suffering from

or at risk of developing pressure ulcers. Whatever your patients’ needs,

OAC has the tools and experience to help. For more information, call

828-254-6305.

Quality Bed Solutions for Every Patient Need

Is an ankle-foot orthosis incorporating tone-inhibiting featureseffective in managing patients with spastic cerebral palsy andother upper motor neuron disorders? There is considerable evidence that abnormal tone in proximal

muscle groups can be influencedby joint position and cutaneousstimulation. For cerebral palsymanagement, maintaining a neutral position of the ankle andsubtalar joint and stimulating keyreflexogenous areas of the plantarsurface (see drawing) can inhibitdeforming reflexes and/or stimu-late desirable antagonist reflexes to counter a dynamic equinus deformity, overcome toe grasp, and con-trol foot pronation-supination and inversion-eversion issues, therebyenhancing function.

Tone-inhibiting features can be built into different AFO designs to accommodate the needs of both children and adults with neuro-muscular deficiencies. An approach particularly suited to young C.P.patients is the dynamic AFO (DAFO), so named because its flexibledesign intentionally permits some degree of ankle motion. This flexi-ble supra malleolar orthosis can be designed with a custom-contouredsoleplate that evokes the desired reflex response.

Key to the effectiveness of the dynamic AFO is its thin wrap-around construction, which is particularly brief over the dorsum of thefoot. In creating a DAFO, an orthotist can incorporate a set degree of

plantarflexion or dorsiflexionas necessary and combinetone-reduction with other fea-tures, such as plantarflexionstops and three-point pressuresystems, to address uniquepatient needs.

A DAFO is sometimesconstructed around an innerboot, usually made of thermo-plastic but sometimes fabricat-ed of very thin foam material.

The boot is formed first over the patient’s mold followed by theremainder of the AFO structure so the two pieces align correctly.

With its lightweight flexible construction, the dynamic AFO is gen-erally well tolerated by young patients. The total-contact, soft plasticdesign largely eliminates skin breakdown, even in children unable totolerate other types of AFOs because of breakdown or pressure sores.

Dynamic AFOs can be worn under any type of clothing and willfit inside shoes with a wide toe box. They can be rendered in brightcolors and finished with popular children’s designs. Assuming thepatient does not grow out of them, DAFOs typically need to bereplaced after about a year of wear.

Note: The terms “dynamic AFO” and “DAFO” are sometimes associatedwith a particular company that fabricates finished orthoses from patient molds.Other providers fabricate these devices as well, sometimes under different prod-uct names. In using the dynamic AFO and DAFO terms, we are referring to theconcept, not a particular company’s product.

of art and science. However, the value of AFOs forimproving gait function in spastic cerebral palsypatients, relative to no orthosis, is well established.Properly prescribed and custom-fabricated AFOshave been shown to increase stride length, reduceenergy expenditure, and give patients a more naturallook while walking.

When prescribing an AFO for a patient with spas-ticity, bear in mind that while AFOs can prevent ordelay development of a deformity, they are not validfor overcoming pre-existing fixed deformities.Therefore, any existing fixed deformities should becorrected by surgery, therapy, serial casting or othermeans if possible beforeorthotic application.

In summary, AFOsserve as a positive tool in

managing spasticity associated with cere-bral palsy. They will delay or preventdevelopment of fixed deformities but notovercome an existing fixed deformity.They can prevent contractures, improvegait parameters, and often give patients a more natural appearance while ambu-lating.

Our orthotic staff is well prepared toassist in the selection and fabrication ofAFOs for C.P. patients. We welcome yourinquiries and referrals.

A leaf-spring AFO helps overcome mild equinus spasticity andcan improve ground clearance during ambulation swing phase. It isnot normally rigid enough to control stance phase equinus, however.Its low profile and thin foot plate allow it to fit in normal shoes, pro-

viding improved cosmesis over someother designs.

The solid-ankle AFO, one of themost commonly used designs for theC.P. population, essentially preventsdorsiflexion and plantarflexion aswell as varus or valgus deviations ofthe ankle and hindfoot. It can bedesigned to hold the ankle in a neu-tral position or at a predetermineddegree of plantarflexion or dorsiflex-ion depending on the needs of thepatient. This design is a primarychoice for controlling equinus in bothstance and swing phase and for con-tracture prevention.

An articulating AFO, which typically incorporates medial and lateral joints to allow plantarflexion-dorsiflexion, can be beneficial forC.P. patients who require increased ankle motion for higher-level bal-ance and functional activities, including walking and sit-to-stand transi-tions. Stops can be incorporated to restrict plantarflexion and/or dorsi-flexion beyond optimal limits. With a plantarflexion stop, for example,the ankle can be maintained in neutral from heelstrike through mid-stance, then allowed to dorsiflex from midstance through toeoff.

Floor Reaction Orthosis (FRO) — This solid-ankledesign incorporates a broad, rigid anterior wall, whichapplies a knee extension moment during stance phase.The FRO can be a welcome improvement over a heavyknee-ankle-foot orthosis for addressing C.P. crouch gaitand other sources of knee instability.

Tone-inhibiting characteristics can be built into manyof these designs to address hypertonicity in proximal

muscles. (See accompany-ing article.)

Donning and wearingan AFO can be a chal-lenge for C.P. patientswith deformities, abnor-mally stretched muscles,pressure-sensitive feet andother tolerance issues. Afabrication option that provides relief inappropriate instances is a two-piece orcombination construction featuring aflexible molded inner boot of thin ther-moplastic, which wraps around the footand can be donned separately from,then joined to, the outer AFO. Becausethe two components are custom-fabri-

cated from the same mold, they fit together intimately and are heldsnugly in place by closure straps.

Available research is inconclusive on the relative merits of differ-ent AFO options, so selection of a particular design is a combination

Leaf-spring AFO

Solid-ankle AFO Articulating AFO

Floor reaction orthosis

Page 2 Page 3

Choosing the Right AFO for Cerebral Palsy Patients

Managing children born with cerebral palsy is a challengingbusiness as clinicians strive to address a variety of issues,such as dystonia, hip migration, scissoring gait that inter-

feres with ambulation, and hip adduction that limits independent sitting. The SWASH (Standing, Walking And Sitting Hip) orthosistackles these difficult aspects of ambulating C.P. kids.

Though its primary application hasbeen to benefit C.P. patients, this sys-tem is intended for use by any childwhose adduction and/or internal rota-tion at the hip joint interferes withfunction or induces lateral migration ofthe femoral head. The SWASH bracehas been proven effective for spasticdiplegic and spastic quadriplegic chil-dren, even those with spina bifida.

The orthosis ensures variable abduc-tion during both extension and flexionand therefore can support an activechild in all postures encountered duringan active day: standing, sitting, walking,

All photos appearing in thisarticle are from the

TC-Flex AFO System,Courtesy of Orthomerica

Products Inc. ©2007

crawling, even toileting. It can also be of value atnight to retain hips in an abducted position ormaintain stretch on tight hip adductors.

Though outwardly simple in appearance, theSWASH orthosis is capable of advanced biome-chanical functions. It uses basic geometry to pro-vide wide hip abduction when the wearer is sittingbut narrower abduction when erect.

During ambulation, the brace maintains thelegs virtually parallel, thus preventing scissorgait. By neutralizing destabilizing forces at thehips, this device also may improve overall trunkcontrol and thereby facilitate upper limb function.The orthosis also reportedly encourages some children to learn how to overcome pathological patterns of movementon their own.

How It WorksWhen properly fitted, the SWASH stabilizes the hip and opposes

excessive adduction and internal rotation. As the hip moves into flex-ion, the joint mechanism is guided into abduction, reducing scissoringgait while walking and improving balance while standing. When the

(Continued from page 1)

Tone-Inhibiting Designs Enhance AFO Function

Plantar surface reflexogenousareas: (1) dorsiflexion, (2) toe grasp,(3) inversion, (4) eversion.

child sits, the orthosis provides continuous abduc-tion, resulting in a wider base and potentially abalanced posture without having to use hands forsupport. The wearer may then be able to concen-trate better on other activities.

SWASH components include a padded waistband, connected in front by a pressure pad. Twojoint assemblies attached on the posterior quartersare connected by shaped leg bars to adjustable thighbands, which guide the legs in the desired position.The leg bars are free to rotate within the respectivejoint assemblies.

Contraindications to SWASH use include hip dislocation (total loss of contact between the fem-

oral head and acetabulum), a hip flexion contracture of greater than 20 degrees, dynamic or fixed, and excessive external tibial torsion orfoot progression.

The SWASH orthosis can be adapted for child growth—four sizesare available, from one for infants (to prevent hip subluxation) throughtwo medium and one large sizes. The orthosis easy to apply and re-move and can be worn over or under clothing as desired.

Tone-inhibiting AFOsCourtesy Marta Tankersley

SWASH Orthosis Solves Multiple C.P. Bracing Needs

SWASH Orthosis

Page 4

(Continued on page 2)

Ankle-foot orthoses of various designs are widely consideredan important aid in managing young patients with spasticcerebral palsy; indeed, they are prescribed for C.P. manage-

ment more than any other orthotic de-vice. Primary goals include contractureprevention, improved function andambulation and tone reduction inproximal muscles to improve functionat higher levels.

The chief role of the AFO in this application is to limit unwantedankle and subtalar movement, primarily ankle plantarflexion, andindirectly to affect knee and hip function. Children with spastic C.P.often acquire a dynamic equinus deformity, which prevents themfrom putting their foot flat and attaining a stable base for stance andwalking. Assuming the ankle can be placed in a neutral position atrest, i.e. the deformityis not fixed, a correc-tion can be appliedthrough one of severalAFO constructions,depending on the capa-bilities of and goals forthe patient.

Reviewing the dif-ferent types of AFOsthat may be appropriatefor C.P. patients:

With a shorter profile

than a full AFO, the supra malleolar orthosis (SMO) maintains adesired ankle position and provides support for the dynamic archesof the foot. Due to its shortened lever-arm, an SMO allows anklemovement, beneficial for ambulation and sit-to-stand transitions.The basic SMO is not very effective for managing equinus, howeverwhen constructed as part of a two-piece AFO with an extendedfootplate, this design can address that deformity as well.

AFOs Bring Unruly Legs Under Control

Orthotists are frequently involved in the management of youngpatients with cerebral palsy. United Cerebral Palsy estimates

that 764,000 children and adults living in the United States mani-fest C.P. symptoms and that some 8000 babies and infants and1100-1500 preschool-age children are newly diagnosed each year.Of these, a majority are affected with spastic diplegia — stiff,permanent contraction of the muscles in both legs.

Bracing for C.P. is primarily employed to stretch hypertonicmuscles and prevent contractures. Ankle foot orthoses (AFOs),the most frequently prescribed devices for C.P. patients, manageabnormal plantar flexion (equinus deformity) by controlling or

eliminating ankle and subtalar motion toprevent contractures and improve gait.

Splints can be employed to forestallelbow, wrist and hand contractures.Spinal braces can help children who arehaving difficulty sitting upright andstraighten the spine in the presence of adeveloping deformity.

This newsletter explores the contribution orthotics can makein the C.P. management milieu. We hope you find the informa-tion worthwhile and welcome your comments and inquiries.

Combination (two-piece) AFOsCourtesy of Orthomerica Products Inc. ©2007

Supra malleolarorthosis (SMO)

Courtesy OrthopericaProducts Inc.

Orthoses for Managing Cerebral Palsy

OrthoticsToday

Note to Our ReadersMention of specific products in our newsletter neither consti-

tutes endorsement nor implies that we will recommend selectionof those particular products for use with any particular patient orapplication. We offer this information to enhance professionaland individual understanding of the orthotic and prosthetic disci-plines and the experience and capabilities of our practice.

We gratefully acknowledge the assistance of the followingresources used in compiling this issue:

Innovative Neurotronics Inc. • Marta Tankersley Orthomerica Products Inc.

Anew therapeutic concept combining the bracing role of theorthotics discipline with the muscle restoration function of

FES (functional electrical stimulation) is now availablefor patients suffering from dropfoot through a productcalled the WalkAide.

Dropfoot, the inability to properly lift the forefootduring ambulation, frequently results from interrup-tion of normal signals from the brain to the peronealnerve, which normally trigger dorsiflexion in swingphase. The condition is a common outcome of multiple sclerosis,cerebral palsy, stroke, traumatic brain injury, and spinal cord injury.

Common manifestations are toe dragging in swing phase and footslap at the beginning of stance phase as the dorsiflexors are unable toovercome the plantarflexion moment created at heelstrike. Patients

with dropfoot often compensate with anexaggerated high-stepping ambulationknown as steppage gait.

The WalkAide surmounts dorsiflexorweakness or paralysis by stimulating theperoneal nerve at the appropriate point inthe gait cycle to lift the forefoot, assuringground clearance and providing for a nor-mal heel-to-toe rollover. The result is amore natural, smoother, safer, and moreenergy-efficient gait.

In recreating the natural nerve-to-muscle response, the WalkAide not onlycorrects for biomechanical dysfunctionbut may improve circulation, reduce atro-phy and increase joint range of motion.

This technology was under development at various research cen-ters for 10 years before recently receiving FDA approval.

The device consists of a battery-operated electrical stimulator,two electrodes and electrode leads packaged into a small case, whichis held in position by a cuff on the affected leg just below the kneenear the fibula head.

A New Option for Correcting Dropfoot

Photos courtesy Innovative Neurotronics.

The WalkAide is an alternative to the conventional orthotic treat-ment for dropfoot, an ankle-foot orthosis. AFOs have long been an

effective management toolfor this condition, but forsome patients an FES system may provide animproved gait and be morecomfortable to wear andmore cosmetically acceptable.

A programmable tilt sensor built into the system analyzes move-ment of the wearer’s leg and foot and controls stimulation duringgait. The device is initially programmed with dedicated software on alaptop computer. Though a heel sensor is used for programming, it isnot worn during routine use of the system.

Contraindications include lower motor neuron and/or peripheralnerve damage; secondary complications of knee, back or hip surgery;leg trauma; sciatica; peripheral neuropathy; spinal stenosis; post-poliosyndrome and Guillain-Barre. The WalkAide should not be used bythose wearing a pacemaker or who are subject to seizures.

While probably not the ultimate answer to the control of drop-foot, the WalkAide has the potential to improve gait, overall health,and quality of life for appropriate patients. A physician’s prescrip-tion is required.

What’sNew

New Cast Protector for Water ActivitiesWith springtime just around the corner, Orthopedic Appliance

Company is proud to introduce its newest cast protector. TheStay Dry Pro-Pump is a surgical latex sleeve that fits over casts,bandages and prostheses to provide complete waterproof protec-tion. Its patented vacuum seal assures a cast or bandage will staydry, even when submerged in water.

The cast cover is easy to use: Slide the cover over theappendage and pump the air out by squeezing the built-in pump

until the bulb is flattened. The patient can goswimming, bathe, shower and receive hydro-therapy; the cover protects a cast or bandageduring any water activity.

Orthopedic Appliance Company offers avariety of Stay Dry Pro-Pump sizes designedto fit children as young as age two and adultsas tall as 6 feet, 6 inches. For further informa-tion on this product, call us at (828) 254-6305.

Prosthetics • Orthopedic Bracing • Seating & Mobility No. 3

Orthopedic Appliance Co. (OAC)offers quality bed solutions to meet

every patient need. All functions of thefull electric bed, including head and foot

positioning and bed height, are easilycontrolled with an ergonomic hand pen-dant for maximum comfort, convenienceand ease of operation.

Not only does OAC have great beds tochoose from, but we also offer a varietyof mattresses and accessories, such as ouralternating pressure mattress, to choosefrom. The alternating pressure mattress isa great tool for patients in a comprehen-sive wound care program, providing ther-apeutic benefit to patients suffering from

or at risk of developing pressure ulcers. Whatever your patients’ needs,

OAC has the tools and experience to help. For more information, call

828-254-6305.

Quality Bed Solutions for Every Patient Need