Orthotic Managementand Stroke

BAPO 2007

Derek JonesWilliam MunroRichard Sealy

Orthotic principles and practice have a clear role to play

As an adjunct to therapy - for gait evaluation, and for short or longer term application

Ideally customised and applied on time

RequirementThe clinical benefits of Custom fit

with the convenience of Off-the-Shelf provision

Spectrum of Dynamic Outcomes

Outcome

Well Maintained

Spontaneous RecoveryEnhanced Recovery

Poorly Maintained

Death

AcutePhase

DynamicSuccess

Failure

StaticSuccess

+

-

time

Outcome

Well Maintained

Spontaneous RecoveryEnhanced Recovery

Poorly Maintained

Death

AcutePhase

DynamicSuccess

Failure

StaticSuccess

+

-

Timing and Nature of Orthotic Intervention

Outcome

Well Maintained

Spontaneous RecoveryEnhanced Recovery

Poorly Maintained

Death

AcutePhase

DynamicSuccess

Failure

StaticSuccess

+

-

Timing and Nature of Orthotic Intervention

Outcome

Well Maintained

Spontaneous RecoveryEnhanced Recovery

Poorly Maintained

Death

AcutePhase

DynamicSuccess

Failure

StaticSuccess

+

-

Timing and Nature of Orthotic Intervention

What Stops Us?Orthotic technology

Consensus & EvidenceProcess for Improvement

Attitudes and Beliefs

All of the true things I am about to tell you

Are actually shameless lies..

But they are Useful Lies

History

• Pre 1940’s - “How can I train this person to use their unaffected body parts to compensate for the affected parts - and how can I prevent deformity”

• Emphasis - orthopaedic intervention - surgery, bracing, strengthening exercises

And then..A New Paradigm Emerges

Paradigm - a new set of experiences, beliefs and values that affect the way individuals perceive reality and respond to that perception

History

• 1940 Onward - Neurological approach - Bobath, Motor Relearning and many others

• Emphasis - Patients with neurological impairment have the potential for functional recovery of their affected body parts

Bobath Approach

• One of the most used and accepted approaches in the UK

• Little written about it in recent years

• No robust evidence for its efficacy†

• But has value..

†Davidson & Waters (2000) - Physiotherapists working

with Stroke Patients - A National Survey.Physiotherapy 86:69-80

0

25

50

75

100

Bobath Other

England NIWales Scotland

Cerebral CortexMotor Areas

Brain Stem

Thalamus

Cerebellum

BasalGanglia

Sensory Receptors

Spinal CordMuscle

Contraction & Movement

Kandel, et al 1991“Principles of Neural Science”

p 539, Publ: Elsevier, Amsterdam

MotorNeurons

Muscle & Tendon

SensingInterpreting

Effecting

Bone & Joint

-

+

Multiple Feedback Pathways

Error

DesiredState

ActualState

http://www.annekaringlass.com/05171-Reaching-Deep-copy.jpg

The CNS• Interaction between the

Central & Peripheral components

• Early ideas - CNS controls movement by REACTING to sensory input

• CNS operates in a TASK ORIENTED way

• Activity in brain BEFORE movement begins - FEED-FORWARD process

• Effect of Innate and ongoing influences

• Sensory information vital for fine tuning

DistinctionTheory & Practice

Is it possible that an overemphasis on the neural control of movement has led to

neglect of the practical importance of muscle strength, force

production and movement kinetics?

Recently..• Neurorehabilitation - interest in different

models of CNS function, skill acquisition and training.

• + Growing interest in the biomechanical requirements of a task

• Acceptance that patient must compensate for the damaged nervous system

†Carr & Shepard (1998) “Neurological rehabilitation -

Optimising motor performance” Butterworth-Heinemann

1992

Can the mind shape brain matter?

Can pure thought change brain activity and its STRUCTURE?

http://www.dalailama.com/images/pgallery/printable1.jpg

Neuroplasticitythe power of the mind to

change the brain......

The brain can change its structure and function in response to experience

Requires a valid “EXPERIENCE”

andATTENTION..

†How thinking can change the brainhttp://www.dalailama.com/news.112.htm

Emerging Implications• Anyone can achieve expert performance in athletics or

academic pursuits

• The effects of media and technology on our thoughts and emotions - images of violence literally rewire our brain;

• Estimate the specific effects of stress on brain functions;

• Formulating new "brain-based" approaches to depression, ADHD and OCD

• Developing ways to enhance our sensory capacities.

Nervous and Musculoskeletal Systems Cannot be Separated

They interact with each other to meetdemands of the internal and external environment

The nervous system is proactive and not simply reactive in response to sensory feedback

Gait Initiation & Termination ✓Balance & Posture ✓Shock Absorption ✓

Energy Conservation ✓Foot & Knee Control ✓

Stability in Stance Freedom in Swing

Restoration of Gait - Mechanistic Paradigm

Do Something!

ActualOutcome

Measurement

DesiredOutcome

Analysis

Learning Happens Best When We Act Quickly

NASA2 years$20 millionOutput - the Space Pen

USSR0 years$0Output - the Pencil

The Space Pen Lesson

Conclusion• Orthotic and Neurological

approaches are Not Exclusive Choices - they are complementary

• Work with therapists and others to develop a new paradigm

• Orthoses need to be adjustable, fit well, and be easily applied - and what else?

• Aim for consensus & evidence - this means do more not less.