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Differences between the Biomechanical And Neurophysiological approaches to orthosis

Discuss about the Pediatrics Physical Therapy for Biomechanical and Neurophysiological?

A foot orthosis (prescribed) is considered as an “in-shoe brace” that is designed in order to correct abnormal foot as well as lower extremity function. The lower extremity may include the knee, leg, foot, hip and thigh. There are two types of approaches to the orthosis, such as neurophysiological approach and biomechanical approach. According to Kotwicki & Grivas, (2012) the neurophysiological Ankle-Foot Orthosis (NP-AFO) is considered as a polypropylene device, which is vacuum-formed over a “plaster model” of the patients’ affected feet as well as lower extremity. On the other hand, Bar-On et al., (2013) suggested that there are different types of biomechanical Ankle-Foot Orthosis (AFO), such as Teufel AFO, the TIRR AFO etc. the Teufel posterior “leaf-spring orthosis” was prepared by Ortholen, which is a high density polyethylene. The Hartshill AFO was especially developed for the “drop foot”. However, it is also discovered that in most of the cases the neurophysiological approaches and biomechnical approaches are overlapped with each other. A neurophysiological force is used to inhibit the “toe group reflex” (gastroc-nemius-soleus and toe flexus). This step is performed by unweighting the metatarsal heads by using metatarsal arch. A neurophysiological force, in the context of plantar surface of the foot is useful to facilitate the “eversion refex”. It is also helpful to recruit more control for heep and knee stability asdiscussed by (Kotwicki & Grivas, 2012). On the other hand, biomechanical approaches are through the flexibility of ankle and foot due to the configuration and timeliness of the neurophysiological Ankle-Foot Orthosis (NP-AFO).

According to Bousie, (2013) there are three types of orthotic postings, which affect in different manner in first MTP (metatarsophakangeal) joint kinematics. Posting in the aspects of orthosis is used to refer the process of angling or tilting in the context of an orthotic shell, shoe or insole in order to alter motion or the joint forces. The posting can be used to the forefoot or the rearfoot of a device. However according to Tang et al., (2015) it is observed that the determination of the application of posting that is how much and where to apply posting is considered as a very critical choice. However, the main purpose of posting is to manage supination or pronation of the foot. However, Mulligan, (2011) challenged in their article that the effect of posting in the aspect of the functional control is found as influential for the foot in the period of gait. The three types of postings are Rearfoot Posting, Forefoot Posting and Arch Fill. However, it is also found that posting can be extrinsic or intrinsic. The intrinsic are on positive cast while the extrinsic are on shell. According to (Bousie, 2013) it is also observed that the clinician can use a combination of extrinsic and intrinsic posting at the rearfoot and forefoot in order to manage the supination or pronation of the foot. In rearfoot posting the contact phase is early midstance or heel strike. The Arch Fill is Stance phase midstance. On the other hand, the contact phase of forefoot posting is propulsion phase, Toe Off/ FF load.

The primary purpose of posting

After studying supramalleolar orthosis (SMO) it can be said that SMO could be used to normalize excessive subtalar eversion as well as midtarsal dorsiflexion throughout the stance phase of gait associated with distal hypotonia.

According to AAA SMO (supramalleolar orthosis), like other orthosis is named after the body part for which the SMO (supramalleolar orthosis) encompasses. The SMO is used to support the part of the leg, which is just above the malleoli or anklebones. On the other hand, Carmick, (2012), opined that SMO could be recognized as the shortest of the AFOs (Ankle Foot Orthoses). From researches, it is found that SMO is designed in order to maintain a neutral heel or a vertical heel. In the mean time, SMO is helpful to support three arches of the feet. Therefore, it can be said that the use of SMO could be used to normalize excessive subtalar eversion as well as midtarsal dorsiflexion. However, it is also found from the studies that SMOs are mainly given to the children to help them from excessive subtalar eversion (Looper & Ulrich, 2010). The flat foot is known in different terms such as pes planus, pronated foot, hyper-pronated feet, hyper-pronated feet and pes plano-valgus. Although the midtarsal dorsiflexion can occur in the adult people, doctors mostly prescribe SMO for the children. According to the researchers, SMO is helpful to distribute the pressure points in the contact period, therefore significantly helpful for the subtalar, mid-foot and forefoot instability. However, SMO is not recommended for extension instability or knee flexion.

After studying all four devices, such as SMO (supramalleolar orthosis), CCO (crouch control orthosis), SAFO (solid ankle-foot orthosis) and AAFO (articulated ankle-foot orthosis), it can be said that CCO (crouch control orthosis) is the best device, which theoretically offers the highest degree of subtalar.

From the study, it is found that the application of the CCO includes active functions. CCOs are considered as the lower leg orthosis, which is a solid as well as articulating device. The device is especially designed to discourage, prevent or resist the excessive, knee flexion, hip flexion and dorsiflexion of crouch gait (Mulligan, 2011). Therefore, it is considered as the specialized for the “active function.” It is also found that solid CCO is showed satisfactory solution in most of the cases related to the children. According to the Jastifer et al., (2015), CCO is a modified device, which is better than the AAFOs or SAFOs. The CCOs have a long and rigid foot lever, which prolongs the usual “midstance knee extension moment” and helpful to prevent metatarsophalangeal extension. Although the reduction of the foot lever may cause alleviation of few problems but proved as extensively helpful in order to compromise the “ground reaction capability” of the device. It is also found that CCOblock the dorsiflexion mechanically at the TCJ in a significant degree. Secondly, it is also recognized that rigid and long foot and shank sections are useful to magnify the normal knee extension during midstance. This facility is not available in the other devices.

The use of supramalleolar orthosis (SMO)

Prescription of AAFO with free, assisted dorsiflexion and restricted plantar flexion would seem most appropriate in order to facilitate gradual improvement in dorsiflexion range among children with spasticity and mild fixed equines contracture.

From researches it is found that, the various functions of the AAFOs (Articulated Ankle-Foot Orthosis) include active function as well as active deformity management. The ankle articulation is generally used as more “functional alternative” than the basic SAFO design. The AAFO (Articulated Ankle-Foot Orthosis) provide a high level of forefoot joint control as well as the control of TCJ, STJ and MTJ. According to Yamamoto et al., (2011), the AAFO is designed to promote the normalize motion by using three ankle rockers. Although it is also recognized that a greater strength as well as muscle control are also needed from the patient who is using AAFO (Articulated Ankle-Foot Orthosis) than other solid devices. According to researchers, it also found that in order to deformity management in “night splints” the AAFO is designed in a better way, which is now commercially available in the market. This commercially available AAFO (Articulated Ankle-Foot Orthosis) device incorporates a “basic hinge” at the ankle (Dubin, 2014). This device also offers a band-connecting shaft, which is stretchable as well as foot sections. According to the clinicians, this commercially available designed AAFO (Articulated Ankle-Foot Orthosis) is very effective for the patients with dorsiflexion, especially the children. This device is especially designed with dorsiflexion-assist articulation, which is consists of 100 planter flexion stop as well as unrestricted dorsiflexion.

From different researches, it is found that the clinicians mostly prescribe ankle-foot orthosis for the children, who are suffering from cerebral palsy. The patients who are recommended for AFOs foud to walk with severe ankle dorsiflexion as well as suffering from vigorous knee flexion in the period of the stance phase of gait. The AFO is used as more “functional alternative” than the basic SAFO design. The AFO provide a high level of forefoot joint control as well as the control of TCJ, STJ and MTJ. Therefore, AFOs are helpful to use for the children with spastic diplegic cerebral palsy.

Rogozinski et al., (2009) showed in their research the efficacy of the Floor-Reaction AFO (Ankle-Foot Orthosis) in the children who are suffering from Cerebral Palsy. In this research, the reaserchers assessed all the children who are diagnosed for cerebral palsy in two conditions, such as braced walking and bare footed. In addition, they also examined the minimum “sagittal knee moment” in midstance for those who walked without “assistive devices.” After analyzing the result the researchers managed to conclude that “the floor-reaction ankle-foot orthosis” is effective in the aspect of restricting plane ankle motion for the gait patient, who are diagnose for cerebral palsy in the time of stance phase (Rogozinski et al., 2009). According to the findings, hip as well as knee flexion contractures of ≥15° were considered as the limit of orthosis efficacy in the context of controlling knee extension during midstance (Rogozinski et al., 2009). It is also found that the researchers level of evidences of their research as Therapeutic level III.

Selection of the device, which theoretically offers the highest degree of subtalar control

One of the most common drug in the treatment of spasticity among the children is Botulinum  A (BOTOX). According to the researchers, BOTOX is generally injected in the muscle to block the connection between muscles and nerves (Hoare et al., 2010). The effect of BOTOX (one dose) lasts for 3-6 months in case of treating muscle spasms. However, it is also found that the researchers are not sure that the use of BOTOX is as safe as to treat spasticity in upper-limb muscles than those in fingers, elbow or lower-limb. In addition, another drawback of using BOTOX is, if it spread in other limbs other than with spasticity, it may cause severe side effects.

An ITB (intrathecal baclofen) is considered as the drug delivery system in order to muscle spasticity. ITB is directly administrated (injected) in the spinal fluid (intrathecally). Therefore, it is observed that lower dose of ITB can work better than other drugs, which are used to treat muscle spasticity (Borowski et al. 2010). On the other hand, the benefit of using ITB is its use of smaller dose also decreases the risk of side effects like drowsiness. ITB may be helpful to reduce dystonia and muscle spasticity but it is not helpful to reduce other problems, which are associated with cerebral palsy.

According to the researchers, use of Selective Dorsal Rhizotomy (SDR) is the best way to treat muscle spasticity, which is even proved as better than orthopedic surgery (Kwon et al., 2012). In SDR procedure, the neurosurgeons, remove the lamina from 5-7 vertebrae. This technique is vastly used on the children with spastic cerebral palsy. This technique is useful to the reduction of hip flexor spasticity and the risk of developing spinal deformities. However, the process is complicated have risks in surgery.

According to the researchers, these types of muscles get rigid due to muscle spasticity (Schwartz et al., 2013). The surgery is needed to various reasons, such as to help child with “dislocation heap”, helping child facing trouble with walking due to “scissoring” and thirdly lengthening the muscles so that the child can spread legs apart. The surgery involves the gracilis muscles and adductor longus, which are located at the groin. In this treatment, doctors cut down these muscles completely and allow retracting the muscles. If the contracture is excessive then it is observed that the adductor brevis is also lengthened. The sergeants also cut the obturator nerve partially (anterior branches) to weaken these muscles (Hage et al., 2010). After surgery the child experience immense pain, though pain killer is administrated. The doctors do not apply casting, which help the child to move limbs. However, the child needs physical therapy. The parents also went through mental torment but need to have patience.

Prescription of an AAFO with free, assisted dorsiflexion and restricted plantar flexion is helpful to facilitate-

References

Bar-On, L., Aertbeliën, E., Wambacq, H., Severijns, D., Lambrecht, K., Dan, B., ... & Jaspers, E. (2013). A clinical measurement to quantify spasticity in children with cerebral palsy by integration of multidimensional signals. Gait & posture, 38(1), 141-147.

Borowski, A., Littleton, A. G., Borkhuu, B., Presedo, A., Shah, S., Dabney, K. W., ... & Miller, F. (2010). Complications of intrathecal baclofen pump therapy in pediatric patients. Journal of Pediatric Orthopaedics, 30(1), 76-81.

Bousie, J. (2013). Foot-orthosis-shoe interactions in cycling.

Carmick, J. (2012). Importance of orthotic subtalar alignment for development and gait of children with cerebral palsy. Pediatric Physical Therapy, 24(4), 302-307.

Dubin, A. (2014). Gait: the role of the ankle and foot in walking. Medical Clinics of North America, 98(2), 205-211.

El Hage, S., Rachkidi, R., Noun, Z., Haidar, R., Dagher, F., Kharrat, K., & Ghanem, I. (2010). Is percutaneous adductor tenotomy as effective and safe as the open procedure?. Journal of Pediatric Orthopaedics, 30(5), 485-488.

Hoare, B. J., Wallen, M. A., Imms, C., Villanueva, E., Rawicki, H. B., & Carey, L. (2010). Botulinum toxin A as an adjunct to treatment in the management of the upper limb in children with spastic cerebral palsy (UPDATE)(Review). Cochrane Database Syst, 1, CD003469.

Jastifer, J. R., Alrafeek, S., Howard, P., Gustafson, P. A., & Coughlin, M. J. (2015). Biomechanical Evaluation of Strength and Stiffness of Subtalar Joint Arthrodesis Screw Constructs. Foot & ankle international, 1071100715619680.

Kotwicki, T., & Grivas, T. B. (2012). Research Into Spinal Deformities 8 (Vol. 176). Ios Press.

Kwon, D. R., Park, G. Y., Lee, S. U., & Chung, I. (2012). Spastic cerebral palsy in children: dynamic sonoelastographic findings of medial gastrocnemius. Radiology, 263(3), 794-801.

Looper, J., & Ulrich, D. A. (2010). Effect of treadmill training and supramalleolar orthosis use on motor skill development in infants with Down syndrome: a randomized clinical trial. Physical therapy, 90(3), 382-390.

Mulligan, E. P. (2011). Evaluation and management of ankle syndesmosis injuries. Physical Therapy in Sport, 12(2), 57-69.

Rogozinski, B. M., Davids, J. R., Davis, R. B., Jameson, G. G., & Blackhurst, D. W. (2009). The efficacy of the floor-reaction ankle-foot orthosis in children with cerebral palsy. J Bone Joint Surg Am, 91(10), 2440-2447.

Schwartz, M. H., Rozumalski, A., Truong, W., & Novacheck, T. F. (2013). Predicting the outcome of intramuscular psoas lengthening in children with cerebral palsy using preoperative gait data and the random forest algorithm.Gait & posture, 37(4), 473-479.

Tang, S. F. T., Chen, C. H., Wu, C. K., Hong, W. H., Chen, K. J., & Chen, C. K. (2015). The effects of total contact insole with forefoot medial posting on rearfoot movement and foot pressure distributions in patients with flexible flatfoot. Clinical neurology and neurosurgery, 129, S8-S11.

Yamamoto, S., Fuchi, M., & Yasui, T. (2011). Change of rocker function in the gait of stroke patients using an ankle foot orthosis with an oil damper: immediate changes and the short-term effects. Prosthetics and orthotics international, 35(4), 350-359.

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