Review of Pathology KAFO

Rheumatoid Arthritis (RA)

Rheumatoid Arthritis (RA) is an inflammatory disease that affects many joints, usually in
a symmetrical pattern. It is thought to be an auto-immune disease, where the immune
system attacks healthy tissues. The affects start in the synovial membrane and
progresses to destroy cartilage and bone. Movement and force cause pain and damage
of the joint. The damaged joint then can become deformed which can lead to further
damage and loss of function.

It can have periods where things get worse, followed by periods of time where nothing
changes.

It most commonly begins in the hands and smaller joints of the body, but can include
large joints like the hip and knee.

Commonly the role of an orthosis in RA is to:

- prevent deformity
- reduce movement, thereby reducing damage and pain
- reduce forces acting on the joint, both weight bearing and muscular.

Osteo Arthritis (OA)

Osteo Arthritis (OA) is a condition where the articular cartilage of a joint is worn away,
leaving bone on bone contact. The bone is easily damaged by normal forces and this
can lead to the pain and loss of function. It is not symmetrical and usually affects large
weight bearing joints.

OA is thought to be a result of either overuse or previous injury of the articular cartilage.

The role of an orthosis in OA is to:

- prevent deformity
- reduce movement, thereby reducing damage and pain
- reduce forces acting on the joint, both weight bearing and muscular.

It should be noted that in cases of arthritis prolonged immobility can lead to the joint
surfaces fusing together. This has the advantage that the pain and damage cease.
However the disadvantages are much worse
- loss of movement
- need for compensatory movements at other joints
- increased forces passing to other body segments

Post Poliomyelitis Paralysis

Polio is an infection caused by a virus. The virus enters the body through the digestive
tract (usually through food or water contaminated by faecal matter containing the virus)
and migrates to the Anterior Horn cells of the spinal cord.
The death of these Lower Motor Neurones leads to flaccid paralysis of muscles.
Sensation is intact as the virus does not damage sensory nerves.

It is thought that less than 1% of all people who are infected by the polio virus suffer
permanent disability.

The damage to the LMN cells is not symmetrical and thus the paralysis can be varied
from limb to limb.
After the acute initial infection there is no progression of symptoms, and some recovery
of movement is possible up to 6-8 months post infection. The muscles most commonly
affected are the larger muscles of the lower limb:
- Tibialis Anterior
- Triceps Surae
- Quadriceps
- Hamstrings
- Hip abductors

Common problems
- Flaccid dropfoot
The ankle dorsiflexors are commonly affected resulting in an inability to lift the
foot against gravity. In some cases the plantarflexors are also paralysed
leading to a completely flaccid ankle, which is unstable.
- Pes cavus
Loss of strength in the ankle dorsiflexors can be partly compensated by
actions of toe extensors. Over time this will pull the foot into a cavus position.
- Knee hyperextension and/or valgus
The knee joint is prone to deformity due to the loss of stability provided by the
muscles. This can result in a number of compensations that over time will
lead to stretching of the knee ligaments and deformity. This is commonly
hyperextension, but valgus may also develop due to an externally rotated hip.
- Leg Length discrepancy
Post Polio Paralysis patients usually were children when infected (adults who
progress to paralysis usually die) and thus have grown up with some
paralysis of muscles. This results in a lesser blood flow to the affected limb,
and lesser forces being placed upon the bone, both of which reduce the
growth of the bone. The non-affected limb grows at a normal pace, leading to
a leg length discrepancy.
Polio patients also often have contractures, which can lead to apparent leg
length shortening and functional deformity.
- Trendelenberg Gait
Weak hip abductor muscles will cause the patient to display lateral trunk
bending and a drop of the unsupported hip in swing phase.
- Hyperlordosis
 If the hip extensors have been affected the patient may take up a lordosed
position to stabilise the hip joints. The patient uses the anterior “Y-ligaments”
of the hip joint to provide stability to the joint. But to maintain a stable body
posture requires increased lordosis of the lumber area.
- Contractures
Due to the asymmetrical paralysis of muscles, it is common to develop
contractures of joints where there is muscle strength imbalance. Additional to
this, Polio patients are often unable to walk and develop contractures due to
prolonged poor positioning.
- Significant atrophy of affected muscles (cosmesis)
As flaccid muscles no longer receive any input from the LMN, they do not
even have “tone”. This lack of activity in the muscle leads to severe atrophy of
the muscle.

The role of an Orthotic device

- Control of the foot, ankle and knee
- Prevent deformity
- Improve stance stability
- Compensate for LLD

Spinal Cord Injury

Damage to the spinal cord, if complete, will result in motor and sensory loss to all
sections below the injury. The effects are usually symmetrical and depending on the
level will display spasticity. The symptoms are non-progressive, but may show some
improvement in the first 6-8 months.
If an Injury is incomplete the symptoms and functional losses are varied.
Injuries in the thoracic spine will lead to poor control of the trunk muscles and these
patients will not be able to use KAFOs. They will usually require a section around the
pelvis and hip joints (HKAFO) or even a spinal orthosis attached to the KAFO. The
energy needed to walk in such devices is very high, and patients usually choose to use
a wheelchair.

Root level Muscles Available Functional

Movement Capabilities
T4 – T6 - Top half of Intercostals Weak control of trunk, Sitting balance is fair.
- Long muscles of back mostly of upper trunk Can use standing frame
HKAFO attached to LSO
T9 – T12 - All intercostals Good control of trunk Walking with KAFOs /
- Lower abdominals HKAFOs and crutches
(high energy)
L2 – L4 - Gracilis - Hip Flexion Functional walking with
- Iliopsoas - Hip adduction KAFOs and crutches.
- Quadradus Lumborum - Knee extension
- Sartorius
L4 – L5 - Extensor Digitorum - Normal trunk control Functional walking with
- Low back muscles - Strong hip flexion AFOs and crutches.
- Medial hamstrings - Strong knee extension
(weak) - Weak knee flexion
- Posterior Tibialis
 - Quadriceps
- Tibialis anterior

Many patients and families will hope that they can walk once more, and that the use of
KAFOs will fulfil that hope. However it must be explained to the patient and family that
the energy demands of such walking are very high, and it is often much easier to use a
wheelchair. Patients will always require the use of crutches.

The health benefits of standing are significant:

- reduce osteoporotic changes in unloaded bones
- improve digestive tract function
- improve respiration
- improve urinary function
- reduce pressure sores from prolonged sitting
- psychological benefits

Role of an orthosis:
- Control of the foot, ankle and knee
- Prevent deformity
- Improve stance stability
- Allow standing

*Patients will have a loss of sensation and will not feel when a device is causing
damage. Devices must be well fitting and / or padded.

Peripheral nerve injury

Damage to a Peripheral nerve, will result in motor and sensory loss to all sections
innervated by the nerve below the injury. The loss will depend on if the injury is
complete or incomplete. Refer to the table below for possible injuries and affects:
Insert table

Ligament laxity / damage

In some pathologies the compensations made by the patient may cause damage to the
ligaments of the knee. This will then produce instability and damage to other structures.

However the most common form of damage to the knee ligaments comes from trauma.
This may be due to motor vehicle accident, falls from height, or sporting activity.
Patients in this case might not need a full KAFO, but simply a Knee Orthosis (KO).

Role of an orthosis:
- prevent deformity
- correct deformity
- allow movement in desired activities
Trauma
As mentioned above trauma of the knee joint complex can lead to injury to the
ligaments, in turn, requiring orthotic intervention. However, other damage to the lower
limb can also lead to the need for a KAFO.

The most common injury is a fracture of the long bones of the lower limb (tibia and
femur). The “traditional” treatment would be to place the patient in a Plaster-of-Paris
cast from the hip to the toes and to avoid weight bearing until the bones are well healed.
However this takes at least 6-8 weeks and the patient can lose a great deal of muscle
condition and joint ROM (ankle, knee and hip) in that time.

Fractures to the main weight bearing structures of the limb can take a long time to heal
and it is advisable to maintain as much function as possible. An alternative is the use of
an orthosis once primary healing has occurred. The advantages of this approach are
that the patient can begin rehabilitation and exercises earlier and prevent contractures /
loss of condition. It has also been noted that muscle activity and partial weight bearing
promote the healing process.

Role of an orthosis
- Prevent deformity / damage to healing tissues
- Promote healing
- Provide partial weight bearing

Genu varum (Bowleg)

In this condition the legs are not straight and appear to be bending out. This is
especially visible at the knee, when the ankles are placed together. This is a normal
posture up to about 3 years of age. However after this time it would be considered
unusual and investigations of the cause should be undertaken. Common causes are
Vitamin D deficiency, Rickets, osteochondritis or damage to the epiphyseal plate.

Common problems
Over time this posture of the legs will lead to damage of the collateral ligaments and
excessive pressure on the medial aspect of tibia and femur. If this is occurring in a
growing child it will cause the growing bone to be deformed, which will exaggerate the
problem.

Orthotic role
- prevent further deformity
- provide corrective forces

Genu valgum (Knock knees)

In this condition the legs appear to be bending in toward each other at the knee. When
the knees are placed together the ankles are widely spread. This is considered normal
from age 2-6. (This is a common posture when learning to stand and walk.) If it is in
excess of 30° or lasts past 6 years of age further investigations should be done.
Common problems
Over time this posture of the legs will lead to damage of the collateral ligaments and
excessive pressure on the lateral aspect of tibia and femur. If this is occurring in a
growing child it will cause the growing bone to be deformed, which will exaggerate the
problem.

Orthotic role
- prevent further deformity
- provide corrective forces