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Them: S, M, L, XL, XXL... An AFO by any other name? You know what you get with Orthomerica. We provide a complete range of lower extremity orthotic solutions — as individual as the patients who wear them. Custom-made for the ultimate in performance. Precision-crafted for superior comfort. Rigorously designed to be the acknowledged industry standard. Ask your Orthotist about Orthomerica’s Products and Services! Us: The TC Flex Plantar Blocker is a prime example of how superior, comfortable fit leads to better results. Visit us at Orthomerica.com/ tcflex for more information about our TC Flex collection — 100% custom. 100% of the time! The other AFO guys. ADVANCE for Physical Therapy & Rehab Medicine 15
[Foot DRoP] Positive steps Understanding the mechanics of foot drop conditions guides the way to more effective treatment By Toni Patt, dPT Foot drop refers to the downward point of toes from a plantar-flexed ankle, resulting from weakness or contracture around the ankle joint. In the language of the ICD it is an impairment of body structure that influences activities and participation. Causes of foot drop include a spinal cord injury, cerebral palsy, an acquired brain injury such as a traumatic brain injury or stroke, injury to tendons or muscles, or a peripheral nerve injury. The dropped foot results from weakness of the tibialis anterior. Often the extensor digitorum longus and extensor hallucis longus are involved. Involvement of the invertors and evertors results in an equus appearance of the foot. The consequence is difficulty clearing the involved foot during swing phase. In normal gait, the swing foot moves away from the floor following push off and clears the floor as the hip and knee move into extension. The foot moves into full dorsiflexion and the hip flexes forward. It remains in dorsiflexion as the heel moves toward the floor for heel strike. In the contralateral limb, the forefoot lowers to the ground following heel contact. The tibia moves forward over the stationary foot via 16 ADVANCE for Physical Therapy & Rehab Medicine The author demonstrates a treatment technique for a patient with foot drop. the heel rocker. As the foot continues to move forward, the heel rises off the floor while the ankle plantar flexes and the toes extend for push off. When the foot remains in a plantarflexed position, gait mechanics are affected. The most noticeable changes are a shortened stride length, decreased gait velocity, decreased stability and decreased shock absorption at the knee. Compensatory Movement With drop foot, forefoot or toe contact occurs instead of heel strike. Following contact the foot immediately goes into flat foot, causing the knee to hyperextend. This prevents the rocker system of the foot to function as the tibia moves forward. Instead of a smooth motion, the tibia is only able to move through available passive range of motion (ROM). Limb advancement is abridged, resulting in shortened stance duration. Heel off occurs once tibial movement halts. The foot is able to move into position for push off, but weak or absent toe extensors limit the amount of force generated. Sometimes forward trunk lean occurs to assist with moving the leg forward over the foot. When the limb is in swing phase, toe clearance is impaired. In mild cases the toes may clear the floor but with little or no room to spare. In severe cases the toes and forefoot can drag along the floor. In order to compensate, gait deviations develop to assist with clearance of the foot. Compensations at the hip include exaggerated flexion or circumduction. The trunk will lean laterally away from the affected leg and may be accompanied by hip vaulting. The purpose of these deviations is to increase the amount of space between the foot and the toes. A secondary effect of foot drop is increased energy expenditure for gait. Normal gait follows a pendulum pattern in which energy is transferred from limb to limb at heel strike. Combined with effective use of gravity, minimal energy is exerted to walk. When gait mechanics are altered, there is increased muscular activity. Instead of relying on the transference of energy, the body must generate the energy necessary to move forward and control balance. The increased energy demand can limit endurance and increase the potential for falls. Management of foot drop focuses on minimizing further loss of ROM, limiting the impact on gait, and preventing damage to the bones and soft tissue of the foot. A secondary goal is decreasing the risk of falls. Depending on the cause, this is accomplished by development of an exercise program and orthotics. Functional electrical stimulation (FES) and neuroprotheses have also been effective. In cases where foot drop is the result of a peripheral nerve injury, a solid plastic anklefoot orthosis (AFO) is used. The purpose is to prevent damage to the foot and maintain ROM while the nerve regenerates. No movement is permitted at the ankle. Strengthening exercises are begun once muscle function returns. Sometimes surgery is required to repair or relocate damaged nerves. Treatment following a neuromuscular or acquired brain injury is more complex. In this case, both the underlying body impairment and the functional loss must be addressed. An AFO is used to position the foot in either neutral or slight dorsiflexion to assist with toe clearance. A built-up medial wall can be used to control an equus deformity. In order to facilitate normal movement and positioning during transfers, an AFO with a hinge is used. The hinge allows the ankle to dorsiflex so the foot can be positioned beneath the patient. It also creates a more normal gait pattern. Dorsiflexion assist can be added if active dorsiflexion is present. Use of AFOs The use of an AFO can be temporary or permanent. If the patient develops activity ankle control, the AFO may eventually be discarded once the muscles are strong enough to function independently. One of the secondary consequences of foot drop is shortening of the Achilles tendon. Use of an AFO along with resting splints can reduce the risk of contracture. FES can be used separately or as part of the AFO. It is applied to the dorsiflexors to facilitate activation during swing. Depending on the patient’s cognition and functional level, it can be applied as part of an exercise program CouRTESy JEREmy STEwART/ToNi PATT
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Page 5 and 6: contents ADVANCE FoR PHYsICAl tHERA
Page 7 and 8: [MORe ARTiCleS] 9 Management Focus:
Page 9 and 10: [EDiToR’S ViEw] 8National Rehabil
Page 11 and 12: [MANAgEMENt FoCus] sticky notes wit
Page 13 and 14: [CoVER stoRY] ruNNiNg righT how To
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Page 19 and 20: [Foot DRoP] for strengthening or us
Page 21 and 22: [lAsER tHERAPY] laser and living ti
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Page 25 and 26: [BACK PAIN] Pain Epidemic Physical
Page 27 and 28: [INFECtIoN CoNtRol] soft-surface Co
Page 29 and 30: [AquAtIC tHERAPY] Confidence gain W
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Page 33 and 34: [CoVER stoRY] running continued fro
Page 35 and 36: [CE DIRECTORY] • • Summer Webin
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