Professional articles

Lower Limb Orthoses in Rehabilitation of a Neurologically Impaired Patient
Case report
Summary Patients with severe brain injury frequently present with cognitive and behavioural problems, limiting engagement in physical rehabilitation. Contractures developed during the acute phase of illness may need months of intensive treatment and require an integrated multi-disciplinary approach. We describe the case of a young woman with complex disabilities following acute demyelinating encephalomyelitis. She presented with severe lower limb contractures and hypertonus, preventing weight bearing. Cognitive and behavioural problems restricted progress and the team adopted a functional weight bearing programme using traditional metal and leather orthoses to facilitate gait. By the end of her admission this patient was able to walk with an aid and under supervision and she has progressed further following discharge. The rationale and factors contributing to the successful outcome in this complex case are discussed.
Introduction Patients with severe neurological disability frequently present with cognitive and behavioural problems which limit functional improvement (Kaplan and Corrigan, 1994; Alderman, 2001). Jackson et al (2000) identified that these patients took longer to walk. Lower limb contractures are a recognised problem (Wheeler et al, 1995) that can have a negative effect on the rehabilitation of standing and gait (Carter and Edwards, 2002; Shumway-Cook and Woollacott, 2001). Some authors refer to the use of lower limb orthotics in this client group (Edwards and Charlton, 2002; Brodnansky et al, 1997; Tyson and Thornton, 2001). This case report aims to illustrate their use when managing contractures and reeducating gait in a patient with severe neurological disability. The issues related to this management approach are discussed.

359 Key Words Orthosis, contracture, cognitive deficit, neurological impairment, muscle hypertonia, rehabilitation. by Patricia Watts Lisa Knight Paul Charlton

Watts, P, Knight, L and Charlton, P (2003). ‘Lower limb orthoses in rehabilitation of a neurologically impaired patient: Case report’, Physiotherapy, 89, 6, 359-364.

Case Presentation Kathleen was a 25-year-old housewife with two children who developed acute demyelinating encephalomyelitis. She initially presented with quadraparesis, impaired swallowing and marked cognitive impairment. CT and MRI scans showed diffuse cerebral swelling and extensive white matter lesions, including the brain stem. She was admitted to an intensive care unit and intubated and ventilated for four weeks. Kathleen was then transferred to a neurosciences unit for post-acute care. During this five-month phase muscle hypertonus, particularly flexor tone in the right lower limb, was problematic. Treatment centred on casting combined with botulinum toxin and periods of standing using the tilt table. She was on a small dose of oral baclofen. A combination of crying and hitting out, swearing and drowsiness had hampered rehabilitation. Cognitive impairments including distractibility, poor safety awareness and disorientation had also limited progress. Kathleen was admitted to the Regional Rehabilitation Unit at Northwick Park Hospital six months after onset, where she remained an inpatient for eight months. Thereafter she became an outpatient at a general hospital, attending regular orthotic reviews at the Regional Rehabilitation Unit. On admission, Kathleen presented with a mixture of hypertonus and hypotonus. She had low muscle tone around the trunk, resulting in a flexed posture and inability to sit unsupported. She had mildly increased tone in the left upper limb with poor selective movement. Tone and movement were now normal in the right upper limb. She had increased flexor and adductor tone and weakness of the extensor muscles in both lower
Physiotherapy June 2003/vol 89/no 6

1999). The shaded area indicates the amount of change during admission to the Regional Rehabilitation Unit. Kathleen scored 24 out of a possible 112 for the motor sub-scales and 37 out of 98 for the cognitive. She had no ability to remember new information and was disorientated to person.360 Table 1: Contractures on admission and discharge Admission Right hip Right knee Left ankle Flexion contracture of 15º * No abduction beyond neutral Flexion contracture of 40º 20º off plantargrade Discharge Flexion contracture of 10º 10º of abduction Flexion contracture of 5º 10º off plantargrade *All contractures measured from the anatomical position in supine using a hand-held goniometer. psychosocial sub-scales. which provides information on the physical support needed by patients while walking. particularly on the right. FIM + FAM A global measure of disability. 1992). The axis of the goniometer was placed over the greater trochanter for measuring hip flexion. Each of the 30 sections is scored from 1 (total dependence) to 7 (complete independence).limited left hand release/D Grasp and release A/D right hand Walk outdoors Flight of stairs A A A A A A D D D D D D A A A A A A A/D A/D Minimum help = subject performs 75% of activity Moderate help = subject performs 50% of activity A = On admission 6 months post injury D = On discharge 13 months post injury Physiotherapy June 2003/vol 89/no 6 . at the lateral femoral condyle for knee flexion and at the lateral malleolus for plantarflexion. incorporating the Functional Independence Measure (Wade 1992). limbs. time and place. The axis of the goniometer was placed over the greater trochanter for measuring hip flexion. The scores can be represented visually as in figure 1. but with additional sections. Kathleen was non-ambulant and dependent for all activities (table 2). The mixture of tonus and drowsiness led to the decision to discontinue baclofen. It is an ordinal measure with established reliability and validity in rehabilitation settings (Wade. A consistent technique Table 2: Mobility chart Function Independent with/ without aid Minimum Moderate help help Total help/ unable Lying roll on to left side D Lying roll on to right side D Get up from lying through D left side Get up from lying through D right side Unsupported sitting static D for 2 minutes Sitting without arm support D for 2 minutes Stand up to free standing Stand for 2 minutes Transfer bed to chair to left side Transfer bed to chair to right side Walk 2 steps Walk indoors Lying hold arm in elevated A/D position left Lying hold arm in elevated A/D position right Put left hand to face A/D Put right hand to face A/D Grasp and release A . but is used routinely at the Northwick Park Regional Rehabilitation Unit to show functional abilities on admission and discharge. with contractures (table 1). at the lateral femoral condyle for knee flexion and at the lateral malleolus for plantarflexion. requires help of two or more people) to 5 (patient can walk independently anywhere). It has been shown to be a reliable and sensitive tool in postacute rehabilitation (Turner-Stokes et al. Kathleen’s admission score was 0. Kathleen’s cognitive and behavioural problems were still apparent. It consists of six categories ranging from 0 (patient cannot walk. The mobility chart (table 2) is not a recognised outcome measure. Outcome Measures The Functional Ambulatory Category is an outcome measure used at the Regional Rehabilitation Unit to evaluate progress towards independent gait. All contractures were measured from the anatomical position in supine using a hand-held goniometer. particularly reflecting cognitive function.

Wheelchair 15. as Kathleen spent more time standing in therapy. Dressing upper body 5. Dressing lower body 6. she progressed to standing with help from three people. Swallowing 24. Speech intelligibility 11. As her trunk control and activity of the left leg improved. as well as in a standing frame. There was no significant improvement in the range of movement in the left ankle initially. Reading FIM/FAM SCORES 7 Complete independence 6 Modified independence 3-5 Modified dependence 1-2 Complete dependence 18. Maintaining this with overnight resting splints was problematic.Case report 361 and position was used to maximise reliability as suggested in the literature (Norkin and White. In the first three months of admission Kathleen could only stand using the tilt table. Emotional status 9. in accordance with current guidelines (Ashburn et al. Problem solving 1. Tub. Safety awareness 8-9 Sphincter control 29. Later in the admission. The right knee contracture stabilised at 20˚ flexion. Scores are shown along the spokes from 1 (totally dependent) to 7 (totally independent) and the shaded area shows the amount of change during admission to the regional rehabilitation unit Physiotherapy June 2003/vol 89/no 6 . Car transfer 14. Leisure activities 2 7. ■ Increase range of left ankle dorsiflexion. despite casting and the injection of botulinum toxin A into the gastrocnemius/soleus (Dysport 500 mouse units). Management The initial aims of treatment were to: ■ Increase range of right knee extension. due to poor patient compliance and increased flexor tone. ■ Increase independence in transfers and standing. 1995). Stairs 20. Grooming 3. After several casts. Locomotion . Bladder management 23. Orientation 17-21 Communication 22-25 Psycho-social adjustment 27. Toileting 3 25. Concentration 10-13 Mobility transfer 14-16 Locomotion 28. Bowel management 22. FAM SUB SCALES 1-7 Self care 30. Social interaction 10. Expression 17. 1998). Supported standing became a high priority for promoting trunk extension. However. Serial casting was started early after admission to minimise contractures of the right knee and left ankle. Comprehension 16. replaced at inter vals of 5-7 days. Mobilisation of the trunk and pelvis was attempted in supine and sitting. The results should be interpreted with due caution. not only due to positioning and observer error. Memory 26-30 Cognitive function 26. Shower transfer 13. ■ Mobilise trunk and pelvis from a flexed position. Community mobility Fig 1: Change in Kathleen’s FIM+FAM. Bed. it is recognised that measurement of contracture is subject to significant error. Bathing Discharge Admission 4. chair. the left ankle contracture improved to 15˚ plantarflexion. Writing 19. or with help of four people. but also to variations in tone. the right knee contracture improved to 15˚ flexion. Feeding 7 6 5 4 2. Adjustment to limitations 1 0 8. Toilet transfer 12. wheelchair transfer 21. but therapeutic handling was poorly tolerated.

Kathleen would be able to walk with an aid and supervision. with social services support. Standing transfers still proved difficult. Bilateral heel raises were used to maintain symmetry of the pelvis. Her lower limb contractures had reduced (table 1). and accepted on March 14. although weight bearing through plantarflexed inverted feet. maximise left dorsiflexion and correct inversion. Address for Correspondence Patricia Watts. Lisa Knight GradDipPhys MCSP is a clinical specialist in physiotherapy at Northwick Park Hospital regional rehabilitation unit. Paul Charlton MBAPO DipOTC is a senior orthotist with Peacocks Medical Group. These issues were discussed with our orthotist. London NW3 2QG. particularly on the right. Pond Street. 2002. Other members of the multi-disciplinary team were able to build on the increase in Kathleen’s physical abilities to work on self-care activities. A knee ankle foot orthosis in the form of a full leg caliper for the right lower limb and a below-knee orthosis for the left leg (fig 2) were suggested. Her family helped Kathleen with exercises and stretches. An orthotic review was requested two months after discharge. as she was unable to recruit sufficient extension at the hips and knees. Kathleen still needed close supervision at all times. Her scores on the FIM+FAM had improved to 65/112 on the motor sub-scales. Treatment then included hydrotherapy. She spent a further two months on the Regional Rehabilitation Unit incorporating these abilities into functional activities. adjustments were needed and Kathleen had to build up tolerance to wearing them. She had increased speed and dexterity in left arm movement. as plantarflexion of the left ankle was not fully correctable. On discharge Kathleen still demonstrated low tone centrally. Six months after admission Kathleen was able to walk with a wheeled frame and the help of two people and stood with one person. This article was received on March 15. She was more independent in activities (table 2). Once the orthoses arrived. The team considered that if orthoses could maintain right hip and knee extension. This included transferring through standing with the help of one person and walking indoors with a wheeled frame and close supervision (Functional Ambulatory Category 2). with help. but improved voluntary activity of abductor and extensor muscle groups. but no longer displayed verbal or physical aggression. The knee ankle foot orthosis had manually operated knee joints to allow flexion in sitting. Royal Free Hospital. London. She had moderate increased flexor tone of the lower limbs. She was orientated and was able to use some memory strategies such as a diary. Fig 2: Kathleen wearing bilateral lower limb orthoses Accommodating heel raises were required. Lower Ground Floor. but was able to recruit some trunk extension. She could concentrate on a task for up to 15 minutes. A plaster back slab was needed to maximise right knee extension. Physiotherapy Department. positioning and continued re-education of normal movement. 2003. Over the following month Kathleen demonstrated the ability to take steps. Time was spent educating nursing staff and carers on how to apply them. At this time Kathleen was walking with the frame and supervision only and could perform such Physiotherapy June 2003/vol 89/no 6 . with increased flexion through the trunk and right lower limb. Improvement in trunk activity and posture allowed Kathleen to transfer in the ward using a sliding board with help from one person. The orthoses were made of metal and leather as opposed to thermoplastic. Newcastle upon Tyne. and 59/98 on the cognitive/psychosocial subscales. Kathleen was discharged to her parents’ house with her two children.362 Authors Patricia Watts BSc MCSP is a senior physiotherapist at the Royal Free Hospital.

Patients with cognitive and behavioural deficits in particular may benefit as they increase the possibilities of undertaking functional. Conclusion This case report suggests that lower limb orthoses. 2001). Discussion The authors believe that a key component in Kathleen’s rehabilitation was the timely orthotic intervention. Three years post insult Kathleen is able to walk independently indoors and outdoors with bilateral heel raises and two sticks. Because of Kathleen’s memory loss. lecturer in physiotherapy.Case report 363 activities as getting up from the floor independently. facilitating a 24-hour approach. this improved tolerance allowed her to stand more frequently. Carers were encouraged to be active participants in the rehabilitation process. Department of Physiotherapy. University of Hertfordshire. compared with close fitting. Professor Lynne Turner-Stokes DM FRCP. Heather Thornton MBA MCSP. director/consultant in rehabilitation. The idea of preparing the patient for the orthoses and using them as an adjunct to. including metal knee ankle foot orthoses. Knee ankle foot orthoses of metal and leather design provide this through the ability to alter the tension of the leather straps. The orthoses reduced the number of therapists required for standing. remain an effective adjunct to treatment for selected neurological patients. but the variability of Kathleen’s tone and therefore the alignment of the left ankle and right knee required some adaptability within the orthoses. as forcing the leg into extension may exacerbate the spasticity. Regional Rehabilitation Unit. Weight bearing in standing required more than one therapist to achieve appropriate alignment and could not be used functionally. Northwick Park Hospital. was incorporated into Kathleen’s management. There were improvements in self-care tasks (fig 1). Kathleen’s improvement in cognitive and physical abilities allowed her to make further functional gains in the community setting. but cognitive and behavioural impairments affecting compliance were limiting factors. not a replacement for physiotherapy. Forces applied via conforming leather straps may resist high biomechanical forces with reduced risk of skin pressure. They state that mobilisation of the trunk and pelvis and gentle stretching of the affected muscle groups may prove effective in enabling a patient to accommodate to orthoses. There were still contractures at the ankles. more rigid thermoplastic materials (Charlton and Ferguson. mobilisation of soft tissues and facilitation of normal movement had partly achieved the aims. 1996). repetition and consistency were important parts of the rehabilitation programme. The orthoses allowed extended periods of standing which helped to increase range of movement in soft tissues and facilitate activation of extensor musculature. The current multi-disciplinary team is working towards more independent community living. Brunel University. As Kathleen often became distressed when being handled by therapists and responded best to familiar. It was decided to progress to bilateral metal ankle foot orthoses. Acknowledgements The authors would like to thank the following colleagues for their advice and encouragement in writing this case report: Elizabeth Bond MSc MCSP. Langhorne et al. meaningful activities. senior lecturer. functional activities. Standing appeared to reduce flexor tone in the lower limbs and increase extensor activity. The preliminary treatment techniques of serial casting. These patients may continue to make functional improvements over an extended period. 1997. She had full range of right knee extension. There is increasing evidence that the intensity and environment of therapy affect outcome (Kwakkel et al. Some authors (Edwards and Charlton. Department of Health Studies. 2002) state that mechanical support should be used with caution when dealing with patients with severe flexor spasticity. where length of stay is largely determined by patient need. Kathleen was in an intensive and specialised multidisciplinary team environment with a high staff:patient ratio. The ability to stand with reduced help increased patient participation in activities of daily living. with the goal of improving both independence and orientation. Thermoplastic materials are more frequently used in modern orthotics. Physiotherapy June 2003/vol 89/no 6 .

Physiotherapy June 2003/vol 89/no 6 . London. P and Ferguson. J (1995). Measurement of Joint Motion: A guide to goniometry. Philadelphia. ■ Lower limb orthoses do not necessarily increase abnormal tone. 14. 643-647. Turner-Stokes. Williams and Wilkins. ‘General principles of treatment’ in: Edwards. Psychology Press. ‘Contractures: An expensive oversight’. Oxford University Press. Cornall. 538-547. N (2001). Jackson. K. J (1997). Norkin. L (1995). S (ed) Neurological Physiotherapy: A problem solving approach. 75. Nyein. 53-58. 277-287. Physical Therapy. A. Koelman. H (2001). 2.364 References Alderman. P (2002). V and Jankoski. Kwakkel. 9. 15. Shumway-Cook. Motor Control Theory and Practical Applications. T (eds) Neurobehavioral Disability and Social Handicap Following Traumatic Brain Injury. Carter. Kaplan. Clinical Rehabilitation. Simpson. Wheeler. 77. S and Turner-Stokes. Wade. Wagenaar. 5. Wageneer. Tyson. 584. 8. J (1994). 178. pages 13-32. G. D. pages 381-383. S and Charlton. Lippincott. 13. F A Davis. P and Edwards. T and Gatehouse. London. ‘The relationship between cognition and functional independence in adults with traumatic brain injury’. pages 175-203. M and Johnson. S (ed) Neurological Physiotherapy: A problem solving approach. C. Langhorne. Baltimore. R (1998). S (2002). G and Koetsier. Churchill Livingstone. ‘Effects of intensity of rehabilitation after stroke’. Thornton. 75-88. C (1996). ■ Patients with severe. C and Corrigan. ‘Managing challenging behavior’ in: Wood. ■ A consistent 24-hour approach provided by the multidisciplinary team and the family was an important factor in enabling this patient to improve her independence. ‘The use of a knee ankle foot orthosis as a gait training tool for the brain injured patient’. D (2001). Measurement in Neurological Rehabilitation. pages 121-153. Stroke. R and McMillan. R and Partridge. L (2000). Cambridge University Press. Churchill Livingstone. Melville. including traditional metal and leather orthoses. ‘Splinting and the use of orthoses in the management of patients with neurological disorders’ in: Edwards. 4th edn. L. M (2001). Charlton. P. G (eds) Upper Motor Syndrome and Spasticity Clinical Management and Neurophysiology. N. Key Messages ■ Lower limb orthoses. A and Woollacott. M and Wright. D (1992). J (1997). M. ‘The UK FIM+FAM: Development and evaluation’. pages 142-165. Archives of Physical Medicine and Rehabilitation. complex neurological disability may have potential to make functional improvements over an extended period of time. Clinical Practice Guidelines on Splinting Adults with Neurological Dysfunction. C (1999). Turner-Stokes. R. S and Thornton. pages 167-168. Clinical Rehabilitation. Edwards. H and Turner-Stokes. ‘Orthoses. ‘The effect of a hinged ankle foot orthosis on hemiplegic gait: Objective measures and users’ opinions’. 2nd edn. Clinical Rehabilitation. 1550-56. Lankhorst. splinting and casting’ in: Barnes. Hove. L. pages 219-253. 28. ‘Physiotherapy after stroke: More is better?’ Physiotherapy Research International. 1. Ansari. Eberly. 2nd edn. Brodnansky. ‘Can young disabled stroke patients regain the ability to walk independently more than three months post stroke?’ Clinical Rehabilitation. Association of Chartered Physiotherapists Interested in Neurology. C and White. T. Ashburn. can be a useful adjunct to physiotherapy in the rehabilitation of selected neurological patients.

Sign up to vote on this title
UsefulNot useful