Thoughts from Don | People Never Forget Stories

I’d like to tell you a story about finding an unusual solution to a patient’s need.

In clinic, I revisited an elderly post-polio patient who walks with a limited gait marked by heavy trendelenburg limp away from his weak left side. Mr. Robard (not his real name) is a consummate gentleman: proud in the best sense, as independent as he can be, careful about his appearance and full of spunk. He has always been most proactive with opinions about his orthosis, how well it’s doing, and his own feedback—a supremely welcome thing, and not uncommon in
adult patients.

He depends on a KAFO with locking knee joints to stabilize his left knee and ankle during ambulation. He uses his brace hard.

His visit to the clinic was to discuss possible “solutions” for his good side, which is becoming weaker and less reliable. (A patient like Mr. Robard, who has spent most of his life in a KAFO and still has a very compromised gait, knows that good braces can help people cope with a problem but are not able to “solve” the underlying issue.)

His better leg has marginal ankle control. His foot has a pes cavus deformity and also an inverted heel. Until recently, the underlying rigidity of the pes cavus deformity provided sufficient stability at his ankle, despite the inverted heel. Now the ankle was tipping him over laterally every once in a while. “I look like a gunny sack of spuds falling off the back of the truck,” Mr. Robard commented.

One thing I’ve seen from helping older post-polio patients is that their gait and resulting function are fragile. Any change is difficult to accommodate. So I needed to find something adding enough stability to his right ankle to prevent the lateral collapse without restricting his sagittal plane movement, especially plantarflexion at heel strike. Further, the device had to sit in his current shoes (ordered specially for the KAFO).
I left the clinic room to get some sample AFOs to support my discussion with Mr. Robard. I was thinking about tamarack hinges. The framework would need to be as light as possible. The trimlines and padding would need to provide lateral containment of the hindfoot. The shoe could control the adduction of the forefoot. Even though this solution is technically correct, I was still thinking that this was a lot of brace and, more, that it wasn’t feeling right to me.

On the way back to the patient room, I passed by the JumpStart production area. I’ve been having a lot of clinical success with JumpStarts in the last few months. Our joke amongst the clinicians here at Cascade is that whatever works well this week will be my first option for every patient I see until I run into problems, at which point I hope to find another starring answer, good for another month or so. I stopped in at the office of Loretta Sheldon, our clinical assistant, to remark in jest to her that maybe we should just use a JumpStart! She found that droll and accompanied me back to see what the result would be.

Funny thing—when we got back to Mr. Robard in the clinic room, he held up a JumpStart from our pediatric samples and said, “This is just what I have in mind!”

After a good laugh all around, we got down to business. To define the distinct pes cavus aspect of his plantar surface, we cast his foot resting on a 1-in. block of foam. I applied corrective force to the hindfoot and forefoot. I had applied the casting material to the foot and ankle with moderate tension. The semi-weight-bearing rest encouraged his met heads to spread out against the compression of the cast.

We fabricated a supra-malleolar orthosis, using the principles of a JumpStart: two layers of very thin, flexible plastic. We extended the proximal ears of both the inner and the outer layer to provide a foundation for the proximal elastic ankle strap added for increased medial and lateral stability.

[Note: Don’s custom work here is considered part of our R&D. This is not something we currently offer.]

Walking trials were very positive. The orthosis fit into Mr. Robard’s current shoe with good comfort. We had to add an instep strap to help contain the lateral aspect of the instep and a small relief at the side of the 5th toe, but otherwise it’s working very well. I think we have a solution that “feels right.” Believe me, I did not deserve that good luck, but I think Mr. Robard did.

As a result, I now have another story to add to the thousands that make up my experience as an orthotist; and Loretta has a story to add to the budding repertoire of her work with adult patients.

Along the same line, I am working hard to bring stories into our workshops, switching to a format that will allow participants to engage in the story of each presented patient. I think it will get everyone involved in considering the different inputs and thus creating and carrying out a bracing plan—all contributing to a successful “story.” The first trial of the new format was at the Ohio School Board OT/PT Institute in early August. I planned to present six patients as the key content, not just as examples of planning details. I presented the patients as if they were in a real clinic, and the decision-making and viewing of results will follow the typical clinical cycle of a DAFO patient.

As you read this, the Ohio talk will be history and I will surely be working hard on refining the presentation based on that experience.

Persistence, in close attention to patient suggestions (especially adult patients, who are more vocal) and in listening to my own intuition, pays off. The key is the continual search for the best solution. This applies to workshops, patients and many other things. And that’s my story!

-- Don Buethorn

Done Buethorn, CPO, is founder-owner of Cascade Dafo, Inc., and Cascade Prothestics and Orthotics.