Orthotic Management & Stroke

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.