Lower Extremity Bracing Research Articles

QOL-12. LESSONS LEARNED FROM LONGITUDINAL CARE IN POSTERIOR FOSSA SYNDROME

Abstract BACKGROUND Posterior fossa syndrome (PFS) is a constellation of neurobehavioral symptoms occurring in 8–24% of children following surgical resection of posterior fossa tumors. Symptoms may include a combination of mutism or reduced verbal output, emotional lability, hypotonia, dysphagia, ataxia and weakness. Direct surgical injury to the dentato-thalamo-cortical pathway has been the proposed pathological mechanism. The trajectory of recovery and the functional outcomes of PFS are not well described. Khan et al. published a prospective study on children after medulloblastoma resection where they divided PFS into type 1 (complete mutism) and type 2 (diminished speech). They showed that PFS type 1 patients had a worse prognosis and a delayed recovery with 44.4% of children being non-ambulatory at one year. Ricci et al. recently published a more detailed severity grading algorithm which over time will hopefully help with data collection and analysis leading to improved prognostication regarding functional recovery. METHODS We present a unique longitudinal look (range 12 months to 19 years) at 5 pediatric patients with posterior fossa tumors who developed PFS following their tumor resections. RESULTS Tumor diagnoses included ependymoma and medulloblastoma. Rehabilitation interventions consisted of acute inpatient rehabilitation where they received intensive physical, occupational, speech and feeding therapy. Most patients benefited from early utilization of trunk and lower extremity bracing as well as a variety of assistive devices and durable medical equipment. Patients continued their rehabilitation for months to years in an outpatient and school setting. All patients demonstrated significant neurological and functional gains however, none of them had a complete resolution of symptoms. We discuss the anatomy, the time to symptom onset, the trajectory of our patients’ recoveries and the rationale behind the applied rehabilitation strategies. CONCLUSIONS This work gives insights on long term sequalae of PFS and demonstrates current rehabilitation approach for children with this complex condition.

Restoration of walking function in an individual with chronic complete (AIS A) spinal cord injury

The prognosis for further recovery of motor function 2 years after complete spinal cord injury is poor. This case report describes recovery of walking function in an a 33-year old man two years post T7 spinal cord injury American Spinal Injury Association Impairment Scale A following intensive physical therapy and robotic locomotor training. Case report. The subject engaged in an intensive clinic-based physical therapy program and research-based robotic locomotor training study over a 7-month period. Physical therapy was initiated 4 months prior to entry into the research study, and targeted trunk control, upper extremity strength, and upright mobility. On initial entry into the robotic locomotor training study the subject's AIS A classification was substantiated. Initial, interim, and follow-up tests of sensation, strength, sitting balance, spasticity, and mobility were performed. Lower extremity motor scores improved from 0/50 to 4/50, bilateral hip flexors increased from grade 0/5 to 2/5, warranting injury re-classification from American Spinal Injury Association Impairment Scale A to C. Intensive physical therapy combined with robotic locomotor training was associated with restoration of short distance walking function with lower extremity braces and a walker. To our knowledge, this is the first report of an individual with chronic spinal cord injury American Spinal Injury Association Impairment Scale A improving in over-ground walking ability following intensive physical therapy and robotic locomotor training. The presence of a neurophysiologically discomplete lesion probably permitted training of operational neural pathways and enabled the development of useful voluntary movement.

Serial Manual Muscle Testing in Duchenne Muscular Dystrophy

Serial measurements of muscle strength of 34 muscle groups were obtained for up to a seven-year period using manual muscle testing (MMT) in a group of 63 boys (mean age = 11.5 years) with Duchenne muscular dystrophy (DMD) not using lower extremity bracing or corrective surgery for ambulation, in order to define the natural course of strength loss and its relation to anthropometric variables and ambulatory status. When correlating the first MMT assessment of each patient with age, strength was found to decrease linearly (-0.26 +/- 0.30 MMT units/year) with time until approximately age 14 when a marked decrease in progression was noted (-0.06 +/- 0.03 MMT units/year). Analyzing individual patients longitudinally yielded a similar rate of strength loss. The average muscle score was 3.0 MMT units at the point of full-time wheelchair use. The marked decline in MMT deterioration around age 14 may be an important consideration when assessing the efficacy of therapeutic interventions in adolescent boys with DMD.

Functional electrical stimulation and lower extremity bracing for ambulation exercise of the spinal cord injured individual: a medically prescribed system.

The purpose of this study was to determine whether commercially available electrical muscle stimulators could provide functional ambulation exercise for the spinal cord injured individual. Commercially available electrical muscle stimulators were used for functional electrical stimulation and interfaced with reciprocating gait orthoses so that a new system has been developed. Advantages of the system include commercially available subsystems and subsystems for applications such as gait training. The system involves six electrical stimulation units worn on a belt; controlled by remote switches; and interfacing to electrodes placed over the quadriceps femoris, hamstring, and gluteal muscle groups of each leg. Four electrical stimulation units (for quadriceps femoris muscle stimulation) function primarily for stand-up and sit-down activities. Two other units (for stimulation of the hip extensor muscles) function primarily for ambulation. The system is described for use with a C7-level quadriplegic individual. The patient successfully performed over 20 repetitions of stand-up and sit down exercises with the system. An average walking distance of about 0.8 km was routinely traversed at velocities ranging from 1.2 to 2.0 km per hour. It was concluded that muscle fatigue, rather than battery power, was the functionally limiting factor for the quadriplegic patient. A recommendation is that application of the system for walking exercise should be preceded by a physical conditioning program of functional electrical stimulation. Specific medical criteria should be satisfied prior to formally prescribing the system for an individual. Finally, the steps involved in the writing of the walking system prescription are outlined.

Rehabilitation management of children with spastic diplegic cerebral palsy.

Spastic diplegia has been recognized as the type of cerebral palsy most frequently associated with prematurity. Due to constantly improving neonatal care in developed countries, more and smaller premature infants are surviving, and the number of spastic diplegic children can be expected to increase. This paper reviews the incidence, pathophysiology, and associated handicaps of patients with this type of cerebral palsy. The role of the physiatrist and aspects of traditional management are discussed. Recent advances in treatment of spasticity and lower extremity bracing are stressed as they seem to be particularly suitable to spastic diplegic patients.

Spinal cord lesions and lower extremity bracing: an overview and follow-up study.

This study was undertaken to illustrate to what extent spinal cord injury patients used their lower extremity braces upon leaving the rehabilitation setting. A questionnaire was set to 60 people, all of whom had had braces prescribed from the Rehabilitation Institute of Montreal, in the 5-year-period between 1973-77. All had been discharged from the rehabilitation centre for at least 1 year. Thirty-five replies were received. The majority (60 per cent) continued to use their wheelchair as their main means of displacement. Thirty-one per cent did not use their braces at all. Most people tended to use their braces at home only for standing and exercise. The authors therefore believe that more careful study should be given to each individual case before braces are prescribed. Alternatives to bracing should be strongly considered. A review of the literature is included.

Lower extremity bracing in paraplegia--a follow-up study.

This retrospective study of 98 paraplegics was carried out to determine the utilisation of long leg braces prescribed during their rehabilitation training. An analysis of their age, duration of disability and physical status was done. Other factors such as work status, decubiti, bowel and bladder functions were also considered.

Instructional Course Lectures

This volume is a compilation of selected lectures given at the annual meeting of the American Academy of Orthopaedic Surgeons during 1970. The editors are to be congratulated on assembling topics that are timely, as well as practical, in their clinical application. All subjects are covered in satisfactory detail and have a "just right" number of references for those who want to delve deeper. The book, essential for all persons associated with the field of orthopedics, forms the current standard of reference for many entities, such as lower-extremity bracing. While most physicians might find this topic cumbersome and unrewarding, the volume has much to offer in other areas. The orthopedists at the Lahey Clinic thoroughly survey the common problems concerning the shoulder. In this chapter a classification of shoulder pain is offered which is simple and practical. Appropriate attention is paid to the anatomy of the shoulder, as well as

Lower extremity bracing in paraplegics with usage follow-up.

The patient cannot see and probably could care less what goes into the solid shoe-ankle component. From his standpoint it would seem the main advantage of the braces is their simple design. I repeat, the patients have to wear them before they can appreciate their ease of use. I wish I had a control group of paraplegics with floppy ankle bracing only, to answer the foregoing questionnaire, as it is difficult to equate the bias of the answers due to the patients wanting to please their ‘alma mater’ and say the right things. My impression is that the brace used at Craig Rehabilitation Hospital has many advantages over other types. It appears, the proof is in the pudding, as evidenced by the response to the questionnaire.

Modifications in lower extremity bracing for specific disability problems.

Modifications in lower extremity bracing for specific disability problems.

Bracing for Ambulation in Childhood Progressive Muscular Dystrophy

1. Fifteen of seventeen patients with childhood muscular dystrophy who had ceased walking because of muscle weakness were able to walk independently again after correction of contractures and fitting of long lower-extremity braces. 2. The criterion for bracing is recent loss of the ability to walk independently or the ability to walk only with assistance in a patient who stands less than half an hour a day. 3. Contrary to previous opinion, there is enough residual muscle power for walking in braces when muscle weakness prevents independent walking. 4. When braces are needed to continue walking, the patient with muscular dystrophy has lost 60 per cent of his muscle mass. 5. It is usually necessary to correct heel-cord and iliotibial-band contractures surgically before application of braces. 6. The additional energy requirements for walking with braces have not caused any significant cardiovascular complications as far as can be determined through clinical observation aided by serial electrocardiograms and cardiac roentgenograms.