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MANAGING PEDIATRIC GAIT DYSFUNCTION
Functional bracing with Adjustable Dynamic Response™ (ADR™)
Ultra Safe GaitTM - USGTM
The ideal system… “a device that would control the position
of the foot in swing phase, initial contact and loading
esponse, but leave the ankle completely uncumbered during
midstance and terminal stance”
Gage, J.R. The treatment of gait problems in Cerebral Palsy. 17: 273-285.
Mac Keith Press. 2004
ORTHOPEDIE PROTHESE
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Ultraflex® UltraSafeGait™ (USG™)
Optimising gait with ADR™ technology (Adjustable Dynamic Response™)
Adjustable Dynamic Response™ (ADR™) optimizes gait outcomes by addressing the entire gait cycle with:
ü maintaining functional ROM ü an adjustable dynamic stability ü a foot clearance in swing ü a prepositioning of the foot at initial contact
Clinical presentations
crouch gait equinus gait variants of crouch and equinus
Indications
spastic hemiplegic, diplegic, and quadriplegic cerebral palsy (GMFCS Level 1 - 4) post-stroke idiopathic toe walking syndrome spinal cord pathology challenging neurological and developmental conditions spina bifida
Advantages
an increase of muscle force obtained by a more active muscle functioning an improved balance precise adjustments in function of the patients’ muscle deficit and evolution superior stability and comfort
Age groups
Ultraflex® UltraSafeGait™ (USG™) is used for: young children < 25 kg external + UUJ* adolescents < 50 kg internal + external
Ultraflex® UltraSafeStep™ (USS™) is used for: adolescents and adults: >25 < 80 kg external + UUJ* > 80 kg internal + external bilateral
* UUJ: Ultraflex® Universal Joint
Settings
Ankle: ADR™ technology offers the necessary adjustable resistance for stability without limiting mobility:• posterior channel controls dynamically the foot position in dorsiflexion• anterior channel dynamically controls the position of the foot in plantarflexion
Depending of the objectif, flexion stops in dorsiflexion and plantarflexion can be set. The resistance is adjustable independantly and individually in plantar- and dorsiflexion.
Knee : ROM up to 30° in flexion depending on the needs of the patient.
Biomechanical rationale
Ankle :
Adjustable muscle augmentation ADR™ elastomer technology fine-tunes first, second and third rockers. Compression of the posterior channel augments the tibialis anterior at initial contact. Compression of the anterior channel augments the gastroc-soleus in mid to late stance. Changing the restraint levels are accomplished with simple set screw adjustments.
Unrestricted motion Ultraflex® ADR™ restrains motion, does not hold or stop it. Ranges are adjustable from 0 – 40° in both directions (plantar- and dorsiflexion). The plantarflexion or dorsiflexion stop can be used to create a rigid stop when dynamic restraint is not adequate.
Customized stability Stability is achieved by augmenting the resistance dynamically. ADR™ selectively augments and provides support for the tibialis anterior and gastroc-soleus muscles and alters their response to ground reaction forces (GRF) as needed; Up to 15,8 N/m of torque restraint (68 N/m for UltraSafeStep™ for adults) for plantarflexion (at initial contact and just before toe-off in terminal stance) and for dorsiflexion (from mid stance terminal stance) . Dual medial and lateral stirrups support the mid-foot and transfers GRF to the toe lever. The custom interface provides support specific to patient presentation.
Smooth, natural rollover ADR™ allows for improved foot-ankle-knee-hip biomechanics which result in optimized gait: maximized speed at a reduced energy cost.
Clearance in swing ADR™ provides sufficient force to restrain GRF, returns ankle into neutral, and assists foot clearance during swing.
Knee:
The ADR™ knee joint allows an adjustable free swing and shock absorption till 30°. The rachet support prevent knee buckling from sit-to-stand. The sit-to-stand slide lock/safety release is easy to engage and disengage (also without cable)
Comprehensive orthotic management for the growing child with spasticity and/or LOM (loss of motion)
Ultraflex®’s therapeutic line of lower extremity stretching braces complements ADR™-technology orthoses. They provide a precise dynamic stimulus (LLPS - Low Load Prolonged Stretch) and proper posturing to increase muscle length, ROM, muscle strength and decrease spasticity during growth.
Children with movement and posture disorders benefit from the gains achieved with Ultraflex® therapeutic bracing and so their potential will increase significantly. The combined benefits of increased muscle length and strength from Ultraflex® therapeutic bracing, and motion and stability from Ultraflex® Adjustable Dynamic Response™ (ADR™) bracing work together to promote/facilitate the movement patterns required for functional gait.
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General Guidelines for ADR™ UltraSafeGait™
Common Clinical Presentations** Common Clinical Measurements Common Clinical
Goals Ultraflex® Solution/ Presc ription ADR Component Channel Adjustments Solution/Prescription
Ultraflex®
R1 and R2 ForceFirst (Heel)
Second (Ankle) Third (Toe) Rocker
A) Manage Gait (ADR)
B) Improve Muscle Length (Therapeutic/
Stretching)
Functional /Day Bracing (ADR™ Ult raSafeGait™)
Posterior Elastomer
Posterior Stop
Anterior Elastomer
Anterior Stop
Therapeutic/Stretching Bracing night and/or at rest**
Early childhood Equinus (extension Gait moment)
Soleus spasticity with flexible rear, mid, and/or forefoot deformities
R1: < 10° dorsiflexion
R2 : within normal limits
Weak tibialis anterior and gastroc-soleus
First: mid or forefoot contact
Second: no tibial progression
Third: early heel rise
A) achieve heel first rocker, tibial advance- ment, control knee hyperextension, allow third rocker
Prescription: Ultraflex® custom molded ADR™ -AFO with posterior calf Shell (and SMO
Near to fully compressed
Only if posterior elastomer com-pression alone does not control knee hyperexten-sion
Little to no compression needed
Usually none neededConsider prescription: Custom molded AFO with Ultraflex® therapeutic hinge**
Pate childhood equinus (extension gait moment)
Soleus spasticity with rigid foot Deformities
R1: < 0° dorsiflexion
R2 < 15° dorsiflexion
Weak tibialis anterior and gastroc-soleus
First: mid or forefoot contact
Second: no tibial progression
Third: early heel rise
A) achieve heel first rocker, tibial advance- ment, control knee hyperextension, allow third rocker
B) lengthen soleus **
Prescription: Ultraflex® custom molded ADR™ AFO with posterior calf shell (consider SMO
Near to fully compressed
Only if posterior elastomer com-pression alone does not control knee hyperexten-sion
Little to no compression needed
Usually none neededRecommanded prescription: Custom molded AFO with Ultraflex® therapeutic hinge**
Earlier childhood crouch (flexion gait moment)
Hamstring and gastroc-soleus
Spasticity with flexible rear, mid, and/or forefoot Deformities
R1: popliteal >30° knee flexion;
gastroc < 5° dorsiflexion
R2 : within normal limits
Weak hip extensors, quadriceps, and gastroc-soleus
First: full, mid, or forefoot contact
Second: too much hip flexion, knee flexion and ankle dorsiflexion in mid-stance
Third: no heel rise (crouch with constant heel contact)
A) improve shock absorption at weight acceptance and dynamc balance, create knee extension moment in mid to late stance, allow third rocker
Prescription: Ultraflex® custom molded ADR™ AFO with Anterior proximal Shell (and SMO)
Little to no compression needed
Only if required for swing clear-ance and initial contact with heel
Near to fully compressed
Only if anterior elastomer compression alone does not create sufficient knee extension moment in mid to late stance
Consider prescription: Custom molded KAFO with Ultraflex® therapeutic hinge**
Late childhood crouch (flexion gait moment)
Hamstring and gastroc-soleus
Spasticity with rigid rear, mid, and/or forefoot deformities
R1 : dynamic limitation
R2: popliteal >30° knee flexion;
gastroc-soleus < 5° dorsiflexion
Weak hip extensors, quadriceps, and gastroc-soleus
First: full, mid, or forefoot contact
Second: too much hip flexion, knee flexion, and ankle plantarflexion in mid-stance
Third: early heel rise (crouch with no heel contact)
A) improve shock absorption at weight acceptance and dynamc balance, create knee extension moment in mid to late stance;
B) lengthen hamstring and gastroc-soleus **
Prescription: Ultraflex® custom molded ADR™ AFO with posterior calf shell (consider SMO)
Only if required for swing clearance and initial contact with heel
Only if required for swing clear-ance and initial contact with heel
Near to fully compressed
Only if anterior elastomer compression alone does not create sufficient knee extension moment in mid to late stance
Add a custom molded therapeutic KO section with UQR (UltraQuick Release™) to ADR-AFO with posterior calf and pre-tibial shell total day/night crouch solution - see further
Recommended prescription: Custom molded KO with Ultraflex® therapeutic hinge at the knee and ADR-AFO hinge at the ankle with UQR™ **
Severe crouch (flexion gait moment)
Hamstring and gastroc-soleus spas-ticity
Gross LE weakness and instability, prone to knee buckling
R1 : dynamic limitation
R2: Popli-teal – deficit no greater than 10° from normal limits
Weak hip extensors, quadriceps, and gastroc-soleus or lever arm extensor dysfunction
First: full, mid, or forefoot contact
Second: too much hip Flexion, knee flexion, andankle dorsiflexion in mid-stance
Third: early heel rise (crouch with no heel contact)
A) improve standing alignment, stability, and dynamic balance, fine-tune rockers, create knee extension moment in mid to late stance
B) Lengthen hamstring and
Prescription: Custom molded KAFO with Ultraflex® ADR™ knee and ankle hinge (and SMO)
Only if required for swing clearance and initial contact with heel
Only if required for swing clear-ance and initial contact with heel
Near to fully compressed
Only if anterior elastomer compression alone does not create sufficient knee extension moment in mid to late stance
Consider prescription: Custom molded KAFO with Ultraflex® therapeutic hinge**
** In addition to Ultraflex® ADR™ , Ultraflex® offers therapeutic / stretching bracing solutions for lower and upper extremities. Please refer to Ultraflex®’s General Guidelines for herapeutic / stretching bracing solutions.
* This chart is provided as an example only; the final bracing solution will be determined by the prescribing physician and the physician’s rehab team. Allthough there are many variants to equinus and crouch, these guidelines address: 1) weakness plus dynamic spasticity and, 2) weakness, dynamic spasticity and muscle shortening. Ultraflex® solutions can also address weakness alone.
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Common Clinical Presentations** Common Clinical Measurements Common Clinical
Goals Ultraflex® Solution/ Presc ription ADR Component Channel Adjustments Solution/Prescription
Ultraflex®
R1 and R2 ForceFirst (Heel)
Second (Ankle) Third (Toe) Rocker
A) Manage Gait (ADR)
B) Improve Muscle Length (Therapeutic/
Stretching)
Functional /Day Bracing (ADR™ Ult raSafeGait™)
Posterior Elastomer
Posterior Stop
Anterior Elastomer
Anterior Stop
Therapeutic/Stretching Bracing night and/or at rest**
Early childhood Equinus (extension Gait moment)
Soleus spasticity with flexible rear, mid, and/or forefoot deformities
R1: < 10° dorsiflexion
R2 : within normal limits
Weak tibialis anterior and gastroc-soleus
First: mid or forefoot contact
Second: no tibial progression
Third: early heel rise
A) achieve heel first rocker, tibial advance- ment, control knee hyperextension, allow third rocker
Prescription: Ultraflex® custom molded ADR™ -AFO with posterior calf Shell (and SMO
Near to fully compressed
Only if posterior elastomer com-pression alone does not control knee hyperexten-sion
Little to no compression needed
Usually none neededConsider prescription: Custom molded AFO with Ultraflex® therapeutic hinge**
Pate childhood equinus (extension gait moment)
Soleus spasticity with rigid foot Deformities
R1: < 0° dorsiflexion
R2 < 15° dorsiflexion
Weak tibialis anterior and gastroc-soleus
First: mid or forefoot contact
Second: no tibial progression
Third: early heel rise
A) achieve heel first rocker, tibial advance- ment, control knee hyperextension, allow third rocker
B) lengthen soleus **
Prescription: Ultraflex® custom molded ADR™ AFO with posterior calf shell (consider SMO
Near to fully compressed
Only if posterior elastomer com-pression alone does not control knee hyperexten-sion
Little to no compression needed
Usually none neededRecommanded prescription: Custom molded AFO with Ultraflex® therapeutic hinge**
Earlier childhood crouch (flexion gait moment)
Hamstring and gastroc-soleus
Spasticity with flexible rear, mid, and/or forefoot Deformities
R1: popliteal >30° knee flexion;
gastroc < 5° dorsiflexion
R2 : within normal limits
Weak hip extensors, quadriceps, and gastroc-soleus
First: full, mid, or forefoot contact
Second: too much hip flexion, knee flexion and ankle dorsiflexion in mid-stance
Third: no heel rise (crouch with constant heel contact)
A) improve shock absorption at weight acceptance and dynamc balance, create knee extension moment in mid to late stance, allow third rocker
Prescription: Ultraflex® custom molded ADR™ AFO with Anterior proximal Shell (and SMO)
Little to no compression needed
Only if required for swing clear-ance and initial contact with heel
Near to fully compressed
Only if anterior elastomer compression alone does not create sufficient knee extension moment in mid to late stance
Consider prescription: Custom molded KAFO with Ultraflex® therapeutic hinge**
Late childhood crouch (flexion gait moment)
Hamstring and gastroc-soleus
Spasticity with rigid rear, mid, and/or forefoot deformities
R1 : dynamic limitation
R2: popliteal >30° knee flexion;
gastroc-soleus < 5° dorsiflexion
Weak hip extensors, quadriceps, and gastroc-soleus
First: full, mid, or forefoot contact
Second: too much hip flexion, knee flexion, and ankle plantarflexion in mid-stance
Third: early heel rise (crouch with no heel contact)
A) improve shock absorption at weight acceptance and dynamc balance, create knee extension moment in mid to late stance;
B) lengthen hamstring and gastroc-soleus **
Prescription: Ultraflex® custom molded ADR™ AFO with posterior calf shell (consider SMO)
Only if required for swing clearance and initial contact with heel
Only if required for swing clear-ance and initial contact with heel
Near to fully compressed
Only if anterior elastomer compression alone does not create sufficient knee extension moment in mid to late stance
Add a custom molded therapeutic KO section with UQR (UltraQuick Release™) to ADR-AFO with posterior calf and pre-tibial shell total day/night crouch solution - see further
Recommended prescription: Custom molded KO with Ultraflex® therapeutic hinge at the knee and ADR-AFO hinge at the ankle with UQR™ **
Severe crouch (flexion gait moment)
Hamstring and gastroc-soleus spas-ticity
Gross LE weakness and instability, prone to knee buckling
R1 : dynamic limitation
R2: Popli-teal – deficit no greater than 10° from normal limits
Weak hip extensors, quadriceps, and gastroc-soleus or lever arm extensor dysfunction
First: full, mid, or forefoot contact
Second: too much hip Flexion, knee flexion, andankle dorsiflexion in mid-stance
Third: early heel rise (crouch with no heel contact)
A) improve standing alignment, stability, and dynamic balance, fine-tune rockers, create knee extension moment in mid to late stance
B) Lengthen hamstring and
Prescription: Custom molded KAFO with Ultraflex® ADR™ knee and ankle hinge (and SMO)
Only if required for swing clearance and initial contact with heel
Only if required for swing clear-ance and initial contact with heel
Near to fully compressed
Only if anterior elastomer compression alone does not create sufficient knee extension moment in mid to late stance
Consider prescription: Custom molded KAFO with Ultraflex® therapeutic hinge**
** In addition to Ultraflex® ADR™ , Ultraflex® offers therapeutic / stretching bracing solutions for lower and upper extremities. Please refer to Ultraflex®’s General Guidelines for herapeutic / stretching bracing solutions.
* This chart is provided as an example only; the final bracing solution will be determined by the prescribing physician and the physician’s rehab team. Allthough there are many variants to equinus and crouch, these guidelines address: 1) weakness plus dynamic spasticity and, 2) weakness, dynamic spasticity and muscle shortening. Ultraflex® solutions can also address weakness alone.
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Total day/night crouch solution
Therapeutic custom molded KO section for lengthen-ing hamstring and gastroc-soleus with a detachable ADR-AFO for improving first rocker and creating knee extension moment
Easily disconnect KO from ADR™-AFO with the Ultra Quick Release feature (UQR™).
Ultraflex® exclusive component technology
Component Features
ADR™-AFO hinge
Recommended for patients up to: - < 25 kg: 1x USG + 1x UUJ (universal joint) - < 50 kg: 2x USG - > 25 < 80 kg: 1x USS + 1x UUJ (universal joint) - > 80 kg: (bilateral) 2 x USS
Adjustable dynamic respons: - plantarflexion and dorsiflexion 0 - 15,8 Nm (USG) - plantarflexion and dorsiflexion: 0 – 68 Nm (USS)
Continuously adjustable: - 0 – 40° in plantarflexion and in dorsiflexion
ADR™-KO hinge
For a safe stance without locking the knee
0-30° ROM for both stance and swing
Rachet support from 0 to 120° in flexion
Sit-to-stand slide safety lock/release, low profile easy to engage/disengage
Depending upon the desired stiffness of Adjust-able Dynamic Response™ élastomer durometer of 85D or 95D
Common problems with existing orthoses
Solid AFO’s or AFO’s that limit equinus but allow dorsiflexion : • no loading response at initial contact • too aggresive knee flexion moment • no propulsion at the end of the stance phase
If the gastroc test shows an equinus and if the ankle movement is limited to 90°: • great risk to stimulate crouch gait • too much knee flexion at the end of swing • bad heel contact • compliance problems
The AFO’s with double action joint : • spring is too weak (2Nm compared to 15,8Nm for USG and 68Nm for USS™) no control of the free ankle movement• limited ROM (10° in both directions compared to 40° for ADR™. ROM is very importantfor those with short gastroc-soleus)
u u
dynamic adjustable resistance
in dorsi- flexion
dynamic adjustable resistance in plantari-flexion
antarflexion stop channel
dorsiflexion stop channel
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Also available at Ultraflex® :Therapeutic bracing with precise dynamic
stimulus and proper posturing for managing muscle deficits caused by spasticity
ü muscle growth ü reduced spasticity (R1 and R2) ü increased ROM ü good compliance and comfort
Treatment specialties Age groups
SPASTICITY
cerebral palsy
child, adolescent/adult
traumatic brain injury (TBI)
CVA – stroke
spinal cord injury
spina Bifida
multiple sclerosis adult
OTHER NEUROLOGICAL AFFECTION
brachial plexus Injury child, adolescents/adult
duchenne muscular dystrophy child, adolescent
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“Children with pathological gait have abnormal shank kinematics. Normalizing shank kinematics
produces the best chance of achieving optimum thigh and trunk kinematics and knee and hip kinetics.”
Owen E (2004) “Tuning of ankle-foot orthosis combinations for children with cerebral palsy, spina bifida and other conditions” Proceedings of European Society of Movement Analysis in Adults and Children (ESMAC) Seminars 2004
The ideal system … “a device that would control the position of the foot in swing phase, initial contact and loading response,
but leave the ankle completely uncumbered during midstance and terminal stance..”
Gage, J.R. The treatment of gait problems in Cerebral Palsy. 17: 273-285. Mac Keith Press. 2004
ORTHOPEDIE PROTHESE
D I R A M E O R T H O NV/SA
Assesteenweg 27/29 / B-1740 Ternat (Brussels) / T + 32 2 582 82 50 / F + 32 2 582 61 12E-mail : [email protected] / www.dirame.com
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