Slings

Question 1

General Rationale for Using Slings and Orthoses

Answer 1

• Positioning (Bed rest -> prevent contractures, Positioning to prevent deformity &/or maintain optimal joint alignment, Potential to inhibit tone (controversial))
• Protection/Healing (Immobilization, Movement control, Ex: Knee brace for ACL)
• Improve balance/function through correction or re-establishment of approprtiate BOS
• Improve function of weak limb
• Feedback (tactile or proprioceptive)

Question 2

General Types of Slings

Answer 2

Question 3

What is an alternative to a sling?

Answer 3

E Stim for Shoulder Subluxation

Question 4

Shoulder abduction and basic sling: Purpose and Pros/Cons

Answer 4

• Goal is to protect and stabilize shoulder and rotator cuff.
• May have added abductor ‘pillow’ and wrist support.

Pros:
* “Off shelf”
* Supports entire forearm

Cons:
* If patient has neglect, arm is hidden.
* Wrist and hand may swell if patient does not use.
* Inhibits trunk rotation with ambulation

Question 5

Hemisling: Purpose and Pros/Cons

Answer 5

• Protect shoulder
• Typically used post stroke or post TBI, though could be used for any population requiring support of the shoulder/forearm/wrist

Pros:
* “Off shelf“
* easy to don/doff
* Wrist can be supported

Cons:
* If patient has neglect, arm is hidden.
* Encourages flexion synergy pattern post stroke/elbow contraction
* Wrist and hand may swell if patient does not use.
* Inhibits trunk rotation with ambulation

TBI and Stroke may result in similar impairments

Question 6

Giv-Mohr Dynamic Hemisling: Purpose and Pros/Cons

Answer 6

• Provides approximation and support to subluxed shoulder

Pros:
* Allows for arm swing and possible trunk rotation during gait.
* Provides approximation of GH joint
* If person has neglect, arm is not ‘hidden’
* Swinging of arm may promote blood flow
* Available ‘off shelf”

Cons:
* Hand dependent and may swell

Question 7

When moving slings ____, when sitting slings ____

Answer 7

• on
• off

Question 8

Splint definition

Answer 8

Some variability, but typically an orthosis intended for temporary use

Question 9

Stiffer othorthotic material =

Answer 9

less mobility but more support

Question 10

What is this?

Answer 10

Spring Leaf Orthosis

Question 11

What is this? What does it do?

Answer 11

• Swedish knee cage
• Stops people from snapping back into extension; weak quads

Question 12

What is this called? What is the purpose?

Answer 12

LEMA strap

Helps with weak dorsiflexion

Question 13

Indications for Ankle Foot Orthosis

Answer 13

• Indicated when assist is required for ankle-knee positioning (proprioception, strength, or coordination deficits) or control during gait

Examples:
* Foot drop (Dorsiflexion weakness)
* Tendency to hyperextend knee secondary to mild-moderate plantar flexor spasticity

Question 14

AFO Requirements

Answer 14

• Strength: Requires 3+/5 knee extension strength or Quad spasticity to stabilize knee during stance phase
• Sensation: Intact proprioception and control of the knee

Question 15

Other important AFO considerations

Answer 15

• Heel cushion or shoe type canbe selected to help the impactofheel strike
• Proximal end of orthosis fit 1” distal to fibular head to prevent pressure on fibularis (peroneal) nerve.

Question 16

Solid AFO: Purpose & Biomechanics

Answer 16

No Hinge at Ankle
Purpose:
* Patient requires maximal stability & static positioning
* Trim Lines:Molded AFO with the trim line cut anterior to the malleoli is the most stable AFO and limits ankle motion
* Maintain ankle ROM and foot position in non-ambulatory patient

Biomechanics
* Provides good support but limited mobility
* Encourages knee extensionmoment at initial contact to mid-stance to correct knee buckling
* Provides medial-lateral ankle stability
* Custom rigid AFOs can be designed to be converted to Hinged AFO as status improves

Get one AFO every 5 years; Except for kids

Question 17

Hinged (Articulating) AFO

Answer 17

Purpose:
* Patient requires assist, but able to control elements of knee-ankle mechanics

Biomechanics:
* Allows some DF/PF movement during gait for more normalized gait pattern, while providing M/L ankle stability and potential to limit knee hyperextension in mid-stance

Question 18

Posterior Leafspring AFO: Indication, Purpose and Pros/Cons

Answer 18

Indications:
* Weakness of ankle DF
* Minimal to no spasticity and sensory deficits
* No medio-lateral instability

Provides:
* Increased ankle motion in stance phase
* Assist for DF for swing phase
* Assist with PF into heel off

Pros:
* Lightweight
* Cost-available ‘Off-shelf’

Cons:
* Heavier patientsmay require a more rigid material
* Lightweight-cannot control moderate-severeplantar flexorspasticity
* May not provide stability for M/L control of ankle

Question 19

Common childrens shoe for orthotics:

Answer 19

Billyfootwear

Question 20

Dorsiflexion Assist brace: Purpose and Pros/Cons

Answer 20

Purpose:
* Assists with DF during swing phase
* Allows for ‘normalized’ gait pattern for person with no ankle instability, good proprioception and no PF spasticity

Pros:
* Cost-available ‘off-shelf’
* Normalizes gait pattern
* May be preferred to Posterior Leaf AFO
* Good for peripheral nerve injuries

Cons:
* No ankle stability provided
* May not be appropriate for CNS lesions or heavier patients
* Must be worn with tie shoes

Patient must have at least 3/5 strength in ankle dorsiflexion as this device provides only light assist

Question 21

Floor (or Ground) Reaction AFO or Carbon Fiber AFO: Purpose and Pros/Cons

Answer 21

• Prevent knee buckling during stance phase (e.g. weak quadriceps muscles without medial-lateral instability)
• Over-lengthened heel cords
• Crouch gait
• DF assist

Pros:
* Encourages knee extension moment to prevent knee forward buckling
* allows clearance in swing phase
* decreases crouch gait
* keeps torso vertical and center of mass in middle of foot
* Some are able to be don/doffed with one hand

Cons:
* Difficult going up hills
* Some are custom and unable to be easily modified
* Limited M/L support

Good for people that buckle or walk in a crouch

Question 22

Neuro Prothesis FES for Gait

Answer 22

• Used to stimulatedorsiflexorfunction

Prescription:
* Patient must have adequate quadriceps strength to prevent kneebuckling

Brands: WalkAide, Bioness (Very Expensive)

Question 23

Knee Ankle Foot Orthosis (KAFO)

Answer 23

Purpose:
- <3+/5 Quad Strength; Severe knee hyperextension; M/L instability at the knee/ankle

Biomechanics:
* AFO section provides M/L stability of Foot/Ankle, DF control in swing phase, ground reaction forces on knee, knee joint and thigh extension provide M/L knee support
* locked knee joints provide max sagittal plane support; unlocks for sitting

• Can change type of knee joint and type of ‘locking’ mechanism for knee joint; typically locked into extension during stance and throughout gait
• Ankle joint is usually locked / fixed

Diagnoses that may require KAFOs = MS, Post-Polio, low level SCI

Question 24

Hip Knee Ankle Foot Orthosis (HKAFO)

Answer 24

• Basically a KAFO with the addition of hip joints and pelvic section
• This provides control to selected hip motions to increase stability with gait in absence of strength
• Mechanism at hip joint can be unlocked for sitting and locked in stance / for gait
• Provides maximum support for lower extremities and lower torso

Spina Bifida; Extremely rare to see these

Question 25

Reciprocating Gait Orthosis (RGO)

Answer 25

Purpose: Mid-thoracic to high lumbar parapalegia Biomechanics: * RGO is HKAFO with cable system that pairs hip flexion in one leg with hip extension in opposite leg, facilitating swing phase of gait * **The patient must be able to shift their weight away from swing leg**

Question 26

Facilitation of Gait using Exoskeleton

Answer 26

* Looks like RGO; however, motorized controls to facilitate sit to/from stand transitions and reciprocal gait for patients with limited LE function May benefit: * Guillain-Barre * Multiple Sclerosis * Spinal Cord Injury  * Stroke FDA approved for SCI C7 and below (need hand function to manage controls) Need to be a "good candidate": - spasticity may impair ability to utilize - safety considerations (cognitive ability, fracture potential, skin integrity)

Question 27

Things to consider when selecting an orthosis

Answer 27

* Does the patient have the ROM needed for this device? * What do I want the device to accomplish? -- Where is the joint stable/lax? -- What muscles are weak/strong? -- Is the purpose to compensate or promote recovery? (e.g. solid AFO vs FES) * Physical characteristics -- Material and design (e.g. solid AFO is thicker and heavier than posterior leaf spring) -- Shape-rolled edges, reinforced, curved, etc… * Cost * Patient or patient’s family’s ability to participate in donning/doffing (e.g. will the patient be able to use it) * Does the patient want the device/will they wear it? * Cosmetics-it is the right color/look/design for the patient?

Question 28

Other important clinical decision making factors:

Answer 28

* Dynamic vs static * Prefabricated (off-shelf) vs. Custom * Wearing schedule * Constant vs Progressive vs Weaning * Patient/caregiver instruction * POC * Teaching: Mobility, ADL, Home program, Follow-up * Goals: Proper fit, maximize function, able to don/doff and wear appropriately, skin inspection, maintenance of assistive technology

Question 29

Resource for selecting gait device

Answer 29

Ranchos Los Amigos ROAD MAP