Orthotic Management and Stroke BAPO 2007 Derek Jones William Munro Richard Sealy
Orthotic principles and practice have a clear role to play As an adjunct to therapy - for gait evaluation, and for short or longer term application Ideally customised and applied on time
Requirement The clinical benefits of Custom fit with the convenience of Off-the-Shelf provision
Spectrum of Dynamic Outcomes Outcome +
Acute Phase
y r e v o c e R d e
c n a h n E y r e v o c e R s u o e Spontan
Well Maintained
Dynamic Success
Static Success
time
Poorly M aintained
-
Death
Failure
Outcome +
Acute Phase
Timing and Nature of Orthotic Intervention y r e v o c e R d e
c n a h n E y r e v o c e R s u o e Spontan
Dynamic Success
Static Success
Well Maintained Poorly M aintained
-
Death
Failure
Outcome +
Acute Phase
Timing and Nature of Orthotic Intervention y r e v o c e R d e
c n a h n E y r e v o c e R s u o e Spontan
Dynamic Success
Static Success
Well Maintained Poorly M aintained
-
Death
Failure
Outcome +
Acute Phase
Timing and Nature of Orthotic Intervention y r e v o c e R d e
c n a h n E y r e v o c e R s u o e Spontan
Dynamic Success
Static Success
Well Maintained Poorly M aintained
-
Death
Failure
What Stops Us? Orthotic technology Consensus & Evidence Process for Improvement Attitudes and Beliefs
All of the true things I am about to tell you Are actually shameless lies.. But they are Useful Lies
History • Pre 1940’s - “How can I train this person to use their unaffected body parts to compensate for the affected parts - and how can I prevent deformity”
• Emphasis - orthopaedic intervention -
surgery, bracing, strengthening exercises
And then.. A New Paradigm Emerges
Paradigm - a new set of experiences, beliefs and values that affect the way individuals perceive reality and respond to that perception
History • 1940 Onward - Neurological approach -
Bobath, Motor Relearning and many others
• Emphasis - Patients with neurological
impairment have the potential for functional recovery of their affected body parts
Bobath Approach • •
One of the most used and accepted approaches in the UK Little written about it in recent years
•
No robust evidence for its efficacy†
•
But has value..
†Davidson & Waters (2000) - Physiotherapists working with Stroke Patients - A National Survey. Physiotherapy 86:69-80
100 75 50 25 0
Bobath
England Wales
Other
NI Scotland
Cerebral Cortex Motor Areas
Thalamus Basal Ganglia Kandel, et al 1991 “Principles of Neural Science� p 539, Publ: Elsevier, Amsterdam
Cerebellum
Brain Stem
Spinal Cord Sensory Receptors
Muscle Contraction & Movement
http://www.annekaringlass.com/05171-Reaching-Deep-copy.jpg
Error
+ Desired State
Actual State Motor Neurons
Muscle & Tendon
Bone & Joint
Sensing Interpreting Effecting
Multiple Feedback Pathways
The CNS •
Interaction between the Central & Peripheral components
•
Early ideas - CNS controls movement by REACTING to sensory input
•
CNS operates in a TASK ORIENTED way
•
Activity in brain BEFORE movement begins - FEEDFORWARD process
•
Effect of Innate and ongoing influences
•
Sensory information vital for fine tuning
Distinction Theory & Practice
Is it possible that an overemphasis on the neural control of movement has led to neglect of the practical importance of muscle strength, force production and movement kinetics?
Recently.. • Neurorehabilitation - interest in different models of CNS function, skill acquisition and training.
• + Growing interest in the biomechanical requirements of a task
• Acceptance that patient must compensate for the damaged nervous system
†Carr & Shepard (1998) “Neurological rehabilitation Optimising motor performance” Butterworth-Heinemann
1992 Can the mind shape brain matter? Can pure thought change brain activity and its STRUCTURE?
Neuroplasticity the power of the mind to change the brain ...... The brain can change its structure and function in response to experience Requires a valid “EXPERIENCE” and ATTENTION..
http://www.dalailama.com/images/pgallery/printable1.jpg
†How thinking can change the brain http://www.dalailama.com/news.112.htm
Emerging Implications • • • • •
Anyone can achieve expert performance in athletics or academic pursuits The effects of media and technology on our thoughts and emotions - images of violence literally rewire our brain; Estimate the specific effects of stress on brain functions; Formulating new "brain-based" approaches to depression, ADHD and OCD Developing ways to enhance our sensory capacities.
Nervous and Musculoskeletal Systems Cannot be Separated They interact with each other to meet demands of the internal and external environment
The nervous system is proactive and not simply reactive in response to sensory feedback
Restoration of Gait - Mechanistic Paradigm Stability in Stance
Freedom in Swing
Gait Initiation & Termination ✓ Balance & Posture ✓ Shock Absorption ✓ Energy Conservation ✓ Foot & Knee Control ✓
Learning Happens Best When We Act Quickly Desired Outcome
Actual Outcome Do Something!
Analysis Measurement
The Space Pen Lesson NASA 2 years $20 million Output - the Space Pen USSR 0 years $0 Output - the Pencil
Conclusion • Orthotic and Neurological
approaches are Not Exclusive Choices - they are complementary
• Work with therapists and others to develop a new paradigm
• Orthoses need to be adjustable, fit well, and be easily applied - and what else?
• Aim for consensus & evidence this means do more not less.