Ask the Therapist.
Q Dear Ginny:
My 11-year-old daughter, Amanda, has severe spastic quadriplegic cerebral palsy and periventricular leukomalacia. She is fed via g-tube and uses a communicator. She is completely non-ambulatory and weighs about 70 lbs. She can bear some weight on her feet but needs a lot of assistance. She is working on helping with transfers. Her steps would be on her tip toes if she did not have her ankle-foot orthotics (AFOs, braces for the foot) on and if I wasn't supporting her under her arms. I only make Amanda wear her AFOs at school. She doesn't like them, I'm probably too much of a softy for her own good.
How important is it to use the Velcro[R] toe strap that wraps around the big toe on the AFO? It looks so uncomfortable that I frequently don't use it, but the therapist seems to feel it is a critical part of the orthotic. She does not curl up her toes without the toe strap on the AFOs (in my opinion). I think her foot just tries to point inward a little bit. Why stick a piece of Velcro between your toes when you have winter socks on? What's the point? Thanks for your insight.
Francie -- mom to Amanda and Christine, 22, a graduate student.
A Dear Francie:
I had these same questions not so long ago. It seemed like every professional I met had a different term and opinion for the different braces, strapping systems, and even the materials used. Since your letter, I've done some investigating and spoken to some experts (Beverly Cusick, PT, Sue Uglietta, MPT, and Cascade DAFO, Inc.)
Most therapists and orthotists agree that the key to an excellent orthotic is the footplate and the cast. The footplate is what gives the bottom of the brace its contour and shape. If the bottom of the brace (the inside part where the bottom of the foot sits) is flat, the wearer will not get optimal control of the foot.
The footplate also supports the structure of the rest of the AFO and is made just prior to casting. Some orthotists and therapists will make AFOs on the specifications of the physician using pre-made foot plates, and others customize. The footplate adds the "bumps" and support in just the right places. Bumps under the arch and/or under the metatarsal heads (where the toes connect to the foot) help support the bones so that the muscles, ligaments, and tendons are in an optimal position and ready to work. After the footplate is fabricated, then it is time to make the cast for the AFO. The footplate is placed on the bottom of the user's foot and is incorporated into the cast.
In answer to your question about the need for a toe strap, it could be that a good footplate might be the answer. The footplate would decrease pronation (flatfeet or fallen arches) and decrease forefoot compensations (in your daughter's case, toe pointing inward) and the need for a toe strap.
Look inside your daughter's brace and then at your daughter's foot. See if it looks like the foot is supported well, or allowed to collapse. If you want to get rid of the toe strap, you may want to try a new AFO that is made from a cast with a good footplate.
The key to a good brace is that it keeps the foot supported and in the right place (biomechanical alignment). The foot is perpendicular to the leg with the heel (subtalar neutral), mid-foot and forefoot all maintained as straight as possible. When the foot is kept in biomechanical alignment, it may prevent deformity, keep the muscle in the best position for movement and improve your daughter's ability to stand, transfer, or take steps in a gait trainer. Most therapists believe that maintaining bones and limbs in biomechanical alignment leads to better quality of movement, less muscle contractures, and less joint pain as the person ages.
The right kind of brace is important. Too little or too much support can lead to sub-optimal walking. Here's a simple guide to the kinds of orthotics I usually recommend. There are other types that have been developed or adapted, but these are the types most commonly used.
I hope this explanation and chart helps you understand the reasons for using foot braces and the wide range of choices available.
Types of Ankle Foot Orthotics
Rigid AFO (with toe strap)
A solid ankle brace provides excellent foot and ankle control for children with severe spasticity, but does not allow any ankle movement. If my client cannot walk at all, but is in a stander and/or assists with transfers, this is the brace I choose. Some orthotists use this type for children who walk and have a lot of extensor tone (too much pushing from the ankle) or for children who collapse forward over the ankle (crouch gait).
Shorter than a traditional AFO, dynamic AFOs provide dorsiflexion assistance (help in turning the foot or toes upward) for children with hypotonia (low muscle tone) and/or weakness. This brace will not resist strong plantarflexion (walking on the toes). High side support on the foot keeps the foot in good position during standing and the part of gait when the leg is fully weight bearing (stance phase). Mild spring provides more consistent toe pickup, but does not block normal ankle motion during gait. The special part or "trick" about this brace is that there is no tibial strap. This allows the lower leg to move forward over the foot (dorsiflexion)
This type of brace has a hinge at the ankle, which allows free dorsiflexion (toe part of the foot comes up) but limited plantarflexion (toe part of the foot goes down). This encourages a more normal gait pattern in children who have at least 5 [degrees] of dorsiflexion range of motion at the ankle The hinge can also be adjusted to limit amount of dorsiflexion.
Floor reaction AFO
This AFO is solid in the front. The child puts on this brace by slipping the foot in from the back of the brace. The design of this brace forces the knee into extension when the foot is flat on the ground. It is specifically for children with a "crouch gait" (too much knee bending) because of hamstring spasticity or quadriceps weakness. To successfully use this brace, the child must have full range of motion at the knee.
Supramalleolar ankle foot orthosis (SMO)
SMOs cover the bottom of the foot and extend up to just below the ankle. They are used to help control ankle pronation (eversion, or rolling in) and hindfoot valgus (rolling out) position. It is often used in children with mild to moderate spasticity who are just beginning to walk.
Dynamic splint/stretching AFO
Dynamic splinting provides an adjustable springloaded tension. This "push" gives a low dynamic stretch to the muscle, which can help increase range of motion. It is also effective as a nighttime splint to increase ankle range of motion.
Inserts, Arches, Cookies, etc
These minimally supportive options provide foot control for a child with hypotonia (low muscle tone) who is walking and/or standing. These braces may also work for a child with mild diplegia or hemiplegia who has slightly high muscle tone and/or a mild flat foot (minimal biomechanical issues). They work as a compromise for children who do not want to wear their AFOs regularly, or for special occasions when a child wants to wear fancy shoes that cannot accommodate a bigger brace.
This month's guest columnist, Ginny Paleg, MS, PT, is a pediatric physical therapist at the Hospital for Sick Children in Washington, DC. She can be reached by phone at (800) 226-4444, or via e-mail at email@example.com.
Ask the Doctor addresses issues of concern to our readers and is usually coordinated on a monthly basis by David Hirsch, M.D., a pediatrician and member of EXCEPTIONAL PARENT'S Editorial Advisory Board. Dr. Hirsch is a partner in Phoenix Pediatrics, Ltd., in Phoenix, Arizona, and specializes in treating children who have developmental disabilities and chronic illnesses. Parents should review any suggestions made in this column with the appropriate professionals. Mention of specific products or medications illustrate suggestions and are not endorsements of Any specific products. Send questions to: Ask the Doctor, EXCEPTIONAL PARENT, 555 Kinderkamack Road, Oradell, NJ 07649-1517, or fax, (201) 634-6570.
Images provided by Cascade DAFO, Inc. (800) 848-7332.
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|Title Annotation:||Answering Questions About Pediatric Braces and Strapping Systems|
|Publication:||The Exceptional Parent|
|Article Type:||Letter to the Editor|
|Date:||Dec 1, 2000|
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