Disability Sport

Development Conference

#PlayParticipateEnjoy

The Management of Neurological, Musculoskeletal and Postural Conditions

within the Sports environment using Dynamic Movement Orthoses’

Dan Severn - Clinical Manager – DM Orthotics Ltd

Dan Severn

• Children’s Physiotherapist & Clinical Manager at DM Orthotics Ltd

• Background – BSc (Hons) Sports Science, BSc (Hons) Physiotherapy

• Currently in third year of MBA (part time)

Session outline –

1. Development and theory behind the DMO

2. Practicality and reasons for use of the DMO range

3. Development of DMO in the sports environment

4. New products and R&D

The development of DMO

1960’s Wrapping athetoid patients with crepe bandage

Dynamic Movement Orthoses (DMO)

• Customised orthoses:

– Truly dynamic

• Base layer and reinforcement panelling comprised of elastomeric fabrics

• Reinforcements enable:

– Selective positioning

– Application of force

Neurological

• Used in the management of a range of paediatric and adult conditions

• Examples:

-CP (Attfield et al 2008)

-MS (Betts 2006)

-Post CVA (Gracies et al 2000)

Musculoskeletal

• Used in in the management of a range of paediatric and adult conditions

• Examples:

– Shoulder subluxation (Matthews et al 2011)

– Scoliosis (reduce Cobb angles)(Matthews et al 2006)

– Pelvic pain in athletes (Sawle et al 2013)

How do they work?

The orthoses are just fabric so why do we get the effects?

• Sensory / proprioceptive input from the tightness of the base material (McNair and Heine 1999)

• Biomechanical positioning from the elastomericpanelling which allows for force application which aids in correcting positioning

• Enhance stability (Matthews et al 2011)

The aim is to:-

– Facilitate more efficient movement and / or positioning

– Improve function / awareness

Why choose a DMO?The use of DMOs compliment therapeutic intervention by:• Positively influencing tone• Reducing muscle imbalance/preventing deformity• Improving posture and postural control• Optimising biomechanical advantage• Providing relevant experience to maximise potential• Not restricting movementSupporting therapy:• Facilitation• Positioning• Support• Active exercise

When have DMO’s been used?

Individually designed orthoses that address specific neurological and functional requirements have been used in the following conditions;

• Cerebral Palsy• CVA• Traumatic Brain Injury• MS• Downs• Muscular Dystrophy• SMA• Charcot Marie Tooth

• ADHD• Retts• Spinal Injury• Hypermobility syndrome• DCD• Parkinsons• Autism

The products

Summary of benefits

• Improved proximal stability

– to aid development of distal function / control

• Improved posture

• Cosmesis

• Normalised tone

• Reduction in swelling

• Reduced involuntary movements

• Improved dynamic function and independence

• Improved breathing leading to improved speech

• Improved self care and social skills• Enhanced handling• Carry over effect

Adult Case studies

Paediatric Case studies

Assessment and Prescription

How to assess for DEFOs

•

–

At the assessment…• What are the objectives?

• Which area of the body are you wanting to control?

– Determine which Key Points of control are needed to facilitate more normal movement or symmetry of posture.

• Does re-positioning improve function?

• Which areas respond to sensory feedback

• How much facilitation is required?

• What is the level of compliance and tolerance?

• What are the daily living needs of the patient?

• Are there any feeding issues?

Considerations/precautions

• Poor compliance

• Low motivation

• Poor temperature regulatory system

• Circulatory disorders

• Skin disorders

• Respiratory disorders

• Skeletal fragility

• Gastrostomy

Reinforcements

Reinforcements

• Layers of Lycra can be added to the garment to exert more pressure on any muscle/muscle group affect muscle imbalance

• Number of layers added depends on how much pressure/facilitation is necessary

• Reinforcement kept away from areas like the axilla, popliteal fossa, etc. to avoid rubbing

How do I know when to reinforce?

• If there is improvement in joint alignment through minimal handling around the trunk then there is no need to reinforce.

• If you need to exert more pressure over a specific area to achieve correction then consider reinforcing

• To alter COG and forces on a joint

• To increase somatosensory stimulation of specific musculature and increase activity

• If there is a fixed deformity then there is probably not much point in reinforcing unless it is to prevent further deterioration but rigid splinting may be required for this

Trunk side flexion

• Side flexion / postural scoliosis

– Short abdominals on opposite side, Iliocostalis and Spinalis short same side

– Multifidus weak

• Use TCP

– Side panel reinforcement to reinforce the opposite side to way of leaning

Shoulder Protraction

• If less control over shoulder protraction is needed

• Use TOS with TVN

– Large over the shoulder reinforcement with V neck line

DMO Development into Sport

Development into Sports

• MSK development for use in rehab

• Cross over into CP Sport

• Disability sport

Sophia Warner – Athlete 2012 Olympics

• Individuals have different challenges and test our orthoses in hard environments

• We are driven to improve our orthoses and are pushed by individual users and clinicians.

“I got through about three different types of carbon fibre splints, but because I was so active, I kept breaking them. They just didn’t last, or weren’t flexible

enough to allow me to do the things I wanted to do.”Tom Watts

CP England U19’s

• DMO user accessed DMO via the NHS

DMO - Sports Development

The following have been developed fromresearch in conjunction with Universities andor Sports Organisations.

REPS PRO Shorts - Incorporating the Results into a DMO

REPS Pro Double Shoulder Support - Bilateral Shoulder Orthosis

REPS Pro Plantar Fasciitis Sock

REPS Pro Diving Glove

The future for DMO

Sam

“I can definitely walk better and further because taking steps is a lot smoother. Instead of my foot curling around after each step I can take one step after another more naturally.”

Sam’s Mum

“The conversion to FES and the DMO e-step has really made a difference to

his walking pattern. It’s really improved his confidence – as his

mum, it’s great to see.”

References and Research

• Arumugam, A., Milosavljevic, S., Woodley, S., & Sole, G. (2012). Can application of a pelvic belt change injured hamstring muscle activity? Med Hypotheses, 78(2), 277-282. doi: 10.1016/j.mehy.2011.10.045

• Attfield, S. F., Nicholson, J., & Morton, R. E. (2008). Evaluation of stability of Lycra soft orthoses using 3-D kinematic analysis. Orthopadie-TechnikQuarterly, English Edition, IV, 7.

• Bayley, I. (2014). Instability Classification (Stanmore). Retrieved from Shoulder Doc website: http://www.shoulderdoc.co.uk/article.asp?article=647&section=515#staticlink

• Betts, L. (2006). Lycra orthoses and their use in MS. Way Ahead, 10(4), 2.

• Borghuis, J., Hof, A. L., & Lemmink, K. A. (2008). The importance of sensory-motor control in providing core stability: implications for measurement and training. Sports Med, 38(11), 893-916. doi: 10.2165/00007256-200838110-00002

• Crawford, F., & Thompson, C. E. (2003). Interventions for treating plantar heel pain. Cochrane Database Syst Rev(3), Art. No.: CD000416. doi: 10.1002/14651858.CD000416

• Ficek, K., Rzepka, R., Orawczyk, T., & Zotnierczyk, Z. (2008). Groin pain in athletes - clinical experience. Journal of Human Kinetics, 19, 141-148.

• Gracies, J. M., Marosszeky, J. E., Renton, R., Sandanam, J., Gandevia, S. C., & Burke, D. (2000). Short-term effects of dynamic lycra splints on upper limb in hemiplegic patients. Archives of Physical and Medical Rehabilitation, 81.

• Holmich, P., Uhrskou, P., Ulnits, L., Kanstrup, I., Bachmann Nielsen, M., Munch Bjerg, A., & Krogsgaard, K. (1999). Effectiveness of active physical training as treatment for longstanding adductor-related groin pain in athletes: randomized trial. Lancet, 353, 439-443.

• Ide, J. M., S.; Yamaga, M.; Morisaw, K.; Takagi, K. (2003). Shoulder-strengthening exercise with an orthosis for multidirectional shoulder instability: Quantitative evaluation of rotational shoulder strength before and after the exercise program. Journal of Shoulder and Elbow Surgery, 12(4), 4.

• Kraemer, W. J., Bush, J. A., Newton, R. U., Duncan, N. D., Volek, J. S., Denegar, C. R., . . . Sebastianelli, W. J. (1998). Influence of a compression garment on repetitive power output before and after different types of muscle fatigue. Sports Medicine, Training and Rehabilitation, 8(2), 163-184.

• Lafuente Guijosa, A., O'Mullony Munoz, I., de La Fuente, M. E., & Cura-Ituarte, P. (2007). [Plantar fascitis: evidence-based review of treatment]. Reumatol Clin, 3(4), 159-165. doi: 10.1016/s1699-258x(07)73614-8

• Lee, D., & Vleeming, A. (1998, November 19-21). Impaired load transfer through the pelvic girdle. A new model of altered neutral zone function.Paper presented at the Proceedings of the Third interdisciplinary world congress on low back and pelvic pain., Vienna, Austria.

• Mattacola, C. G., & Lloyd, J. W. (1997). Effects of a 6-week strength and proprioception training program on measures of dynamic balance: a single-case design. J Athl Train, 32(2), 127-135.

• Matthews, M., & Crawford, R. (2006). The use of dynamic Lycra orthosis in the treatment of scoliosis: A case study. Prosthetics and Orthotics International, 30(2), 171-174.

• Matthews, M. J., Payne, C., & Watson, M. (2011). The use of a dynamic elastomeric fabric orthosis to manage painful shoulder subluxation: A case study. Journal of Prosthetics and Orthotics, 23(3), 155-158.

• Matthews, M. J., Watson, M., & Richardson, B. (2009). Effects of dynamic elastomeric fabric orthoses on children with cerebral palsy. Prosthetics and Orthotics International, 33(4), 339-347.

• McNair, P. J., & Heine, P. J. (1999). Trunk proprioception: Enhancement through lumbar bracing. Archives of Physical and Medical Rehabilitation, 80, 96-99.

• Mens, J., Inklaar, H., Koes, B. W., & Stam, H. J. (2006). A new view on adduction-related groin pain. Clinical Journal of Sport Medicine., 16(1), 15-19. • Mens, J. M. A., Vleeming, A., Snijders, C. J., Koes, B. W., & Stam, H. J. (2001). Reliability and Validity of the Active Straight Leg Raise Test in Posterior

Pelvic Pain Since Pregnancy. Spine, 26, 1167-1171. • Michael, J. S., Dogramaci, S. N., Steel, K. A., & Graham, K. S. (2013). What is the effect of compression garments on a balance task in female

athletes? Gait Posture. doi: 10.1016/j.gaitpost.2013.11.001• Rathinam, C. B., S.; Spokes, G.; Green, D. (2013). Effects of a lycra body suit orthosis on a child with developmental coordination delay: A case

study. Journal of Prosthetics and Orthotics, 25(1), 4. • Riddle, D. L., Pulisic, M., Pidcoe, P., & Johnson, R. E. (2003). Risk factors for Plantar fasciitis: a matched case-control study. J Bone Joint Surg Am, 85-

a(5), 872-877. • Roxas, M. (2005). Plantar fasciitis: diagnosis and therapeutic considerations. Altern Med Rev, 10(2), 83-93. • Sawle, L., Freeman, J., Matthews, M., & Marsden, J. (2013). The Grumbling Groin: A Novel Approach. SportEx Medicine, 55(January), 20-24. • Ulkar, B. K., B.; Cetin, C.; Guner, R.S. (2004). Effect of positioning and bracing on passive position sense of shoulder joint. British Journal of Sports

Medicine, 38, 4. • Warner, J. J. P., & Caborn, D. N. (1992). Overview of shoulder instability. Crit Rev Phys Rehab Med 4, 145-198. • Yasukawa, A. M., P.; Guilford, A.; Mukherjee, S. (2011). Case study: Use of the dynamic movement orthosis to provide compressive shoulder

support for children with brachial plexus palsy. Journal of Prosthetics and Orthotics, 23(3), 6. • Zazulak, B. T., Hewett, T. E., Reeves, P. N., Goldberg, B., & Cholewicki, J. (2007). The Effects of Core Proprioception on Knee Injury: A Prospective

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