Recovering or improving function is frequently among the rehabilitation goals set for individuals affected by lower extremity impairment. A brace or orthosis may be part of a strategy to reach those goals, and the marketplace offers a range of solutions—from off-the-shelf braces to customized orthotics thoughtfully tailored for specialized needs. To smartly navigate these variations, Physical Therapy Products invited clinicians to sound off about what they value most in the products they select for populations they frequently treat: older adults, pediatrics, and athletic-orthopedic users.
Physionetics therapist Shane Smith, PT, DPT, observes an orthotist evaluating a client for a solid ankle AFO to provide adequate toe clearance in swing phase and proper heel strike in initial stance phase of gait. This AFO also provides more stability to the ankle joint and promotes proper foot alignment upon weight bearing.
OLDER ADULTS
By Niki Varveris, PT, DPT, MSPT, MBA, Owner, Physionetics, Naples, Fla
Though we offer services that are appropriate for a varied population, from general orthopedic injuries and sports injuries to women’s health and work activities, a good number of the clientele who visit Physionetics come from the older adult population. Among those individuals, the majority of conditions for which we recommend application of orthotics tend to have an underlying neurological component. More specifically, foot drop resulting from strokes, multiple sclerosis, spinal stenosis, and peroneal nerve damage is the number one reason for us advocating the use of an orthotic. The goal of that advocacy is to maximize the client’s safety, mobility, and independence.
The most common product in this category used at our clinic is the ankle-foot orthosis (AFO), given the fact that we treat a high volume of neurological conditions that result in foot drop. While matching the client’s stability without the orthotic to the product stability/rigidity is the primary consideration that drives the decision to select a particular product, when making the choice between prefabricated and custom products we also consider the client’s lifestyle needs, mobility challenges, goals, and prognosis. Recently we have added the ToeOFF semi-custom Dynamic Response AFOs from Allard USA Inc, Rockaway, NJ, to our list of favorite products. They’re built with carbon fiber composite materials and designed to provide assistance to varying degrees of weakness. It’s possible to customize the dynamic and stabilizing properties of the ToeOFF by going up or down in size or product type. For pediatric use, Allard also offers the KiddieGAIT and KiddieROCKER.
Traditionally, we have had also had good success with the Freedom Swedish AFO and the Superior C-90, and we use them in many cases with great functional outcomes. These two particular off-the-shelf AFOs are affordable, lightweight yet supportive, and most often are available the next day. In cases where foot drop is accompanied by spasticity, other foot biomechanical issues, or proximal instability, we work very closely with our local orthotist to fabricate the most appropriate brace.
Tiffany Weiser, PT, DPT, C/NDT, ensures a proper fit for an AFO for a patient.
PEDIATRICS
By Tiffany Weiser, PT, DPT, C/NDT, director of physical therapy, All Care Therapies of Georgetown, Georgetown, Tex
All Care Therapies uses orthotics to help children with a wide variety of diagnoses that cause low muscle tone, high muscle tone, and/or spasticity within the lower extremity. Typical diagnoses for which we recommend orthotics for children presenting with low muscle tone are Down syndrome, Spinal Muscular Atrophy, Charcot Marie Tooth, and Spina Bifida, but an orthotic can also be recommended for a child who simply presents with general low muscle tone that has no underlying diagnosis. An orthotic is important for these children to address poor foot and lower extremity positioning due to decreased ability to initiate and sustain muscle contractions. It is necessary to address because it causes decreased sensory input from the foot that will affect the child’s balance and proprioception. In addition, malalignment in the foot will affect bone development as bone development is significantly affected by weight bearing. Another benefit of an orthotic for children with low muscle tone is that it provides additional stability within the lower extremity to allow them to achieve their functional goals. We use similar orthotics for children with high muscle tone and spasticity, but additional components are commonly included in these orthotics, including ankle dorsiflexion assist and a plantarflexion stop to achieve heel contact during the gait cycle and limit unwanted movement.
Physical therapist adjusts the strap on an AFO designed for pediatric use to ensure proper positioning.
We work closely with our orthotists and the child’s family to determine the optimal brace, and after an evaluation the orthotist casts or measures the child for a custom fitted orthotic. For children with low muscle tone, a simple supramalleolar (SMO) brace may be appropriate to provide correct calcaneal positioning and arch support. Some children, however, may require additional support to provide the correct foot position and distal stability to allow them to achieve their functional goals. Distal stability can be achieved using a solid ankle foot orthotic (AFO) for children who have fair proximal stability. A knee ankle foot orthotic (KAFO) or hip knee ankle foot orthotic (HKAFO) is used for children with low muscle tone and significantly decreased ability to initiate and sustain muscle activity within the entire lower extremities and pelvis to allow them to achieve standing weight bearing goals. For children with high muscle tone and spasticity within their lower extremities, we often use an articulated AFO with dorsiflexion assist and a plantarflexion stop to assist with gait kinematics. Children with high and low muscle tone also battle contractures in their lower extremities, and we have seen good results using a low load prolonged dynamic stretching system to increase range and or limit soft tissue ROM restrictions.
We work with our orthotists as a team when determining the right orthotic, so most of our braces are custom made by our orthotists’ companies. I emphasize weighing the pros and cons of each brace and am cautious to not overbrace. As much as braces can cause significant improvement, they can also limit muscle development and create muscle atrophy within the child’s foot and leg due to all of the support and stability the brace can offer. An extremely important feature in choosing a brace or an orthotic company to fabricate a brace is pliability of the plastic used to create the brace. A brace that offers the necessary support and remains dynamic is best because it allows the child’s muscles to continue to be activated and work while the brace is worn. As a consequence of plastic that is too firm, I have seen children’s muscles become weak in an already weak foot and essentially become a useless appendage without the brace. With my children I often use an SMO from Surestep, South Bend, Ind, because they are dynamic and provide the necessary support. For children with contractures, a low load prolonged dynamic stretching orthosis may allow for improved ROM.
A brace will have no value or benefit if the patient cannot don the orthotic device independently or with minimal self-adjustment.
ATHLETIC-ORTHOPEDIC
By Charles Thigpen PhD, PT, ACT, clinical research scientist at ATI Physical Therapy, Greenville, SC
[sidebar float=”right” width=”250]Product Resources
These companies offer a variety of devices useful for lower extremity rehab:
Active Innovations, a Division of Active Ankle
www.activeankle.com
Allard USA
www.allardusa.com
Bioness
www.bioness.com
DM Systems Inc
www.heelift.com
Elite Seat
www.eliteseat.com
Foot Management Inc
www.footmanagement.com
Ottobock
www.ottobockus.com
Pro-Tec Athletics
www.pro-tecathletics.com
Silicon Dynamic Orthotic (SDO)
www.sdo-orthotics.com
Superfeet
www.superfeet.com
Swede-O Inc
www.swedeo.com
Restorative Care of America
www.rcai.com[/sidebar]
Conditions we most commonly see for bracing at our clinics are ankle sprains, knee sprains and osteoarthritis, and foot sprains or stress fractures, as well as most all orthopedic postoperative bracing. For more common ankle sprains or tendonitis, a tall walking boot is recommended to help control ankle inversion and eversion for walking. A short walking boot works well with foot sprains or stress fractures. In general, knee braces for sprains control ROM and support the ligament that was sprained. Ankle and foot boots unload the involved extremity to decrease pain and allow a positive healing environment.
The OA knee brace or “unloader” serves to control varus/valgus forces on the affected knee compartment during weight bearing. Postoperative braces are used to limit ROM and unload the extremity or joint following surgery.
For ACL-related injuries, an ACL functional brace is a common practice, especially after ACL reconstruction. ACL braces improve proprioceptive control during cutting and jumping sports, and provide the athlete more confidence during the first year returning to their sport.
The most convenient and common practice for most all bracing is off-the-shelf options. These bracing options provide in-office solutions with adjustable features to offer some level of customization and best fit. Common off-the-shelf products include braces from DJO Global, Vista, Calif, the functional ACL/OA knee orthosis from Breg, Carlsbad, Calif, and Aircast pneumatic walking boots. Össur, Foothill Ranch, Calif, also offers OA knee braces and Air Walking boots. Postoperative braces include DJO and Breg shoulder, hip, and knee ROM braces.
Ease of application for the physical therapist, ATC, and nurse are the top reasons one model may be preferred over another. The patient must also be taken into account—how easy is it for that person to take on and off when healthcare professionals are not available to assist? Other factors are the physician’s preference, the patient’s out-of-pocket costs, testimonials from other patients, and the type of customer service we receive from the manufacturer’s representative.
It is important to properly educate the patient about the use, purpose, and application of the device. It is likewise important for the clinician to become knowledgeable about the spectrum of orthotics you can use to treat a patient. At the end of the day, the brace will have no value or benefit if the patient cannot don the orthotic device independently or with minimal self-adjustment during ADLs. PTP
