Bracing For Adults

Although at Cascade a large focus of our work is on helping young children with mobility challenges, we do indeed make braces for and work with many adults. Patients mature and many of them, although larger in size as they grow, still need the support provided by a DAFO brace. Additionally, the onset of many mobility challenges, such as complications from a stroke, can happen later in life.

In addition to pediatric patients with CP or other neurological challenges who are now adults, practitioners often see adult patients with a variety of complaints including plantarfasciitis, stroke (CVA), poor stability from advanced age or heel ulcerations from extended bed rest.

When bracing for adults, we find the overall main challenge is to choose a style that is appropriate for the patient’s size and weight. There is less room for error in identifying a style that is appropriate to the patient’s presentation as underbracing can lead to premature breakdown or ineffectiveness of the device. Another concern is customizing the brace so that it fits well into the patient’s shoe. Adult shoes tend to have less depth to them proportionally than children’s shoes do, although this challenge is diminishing as more specialty products become available that address the issue of depth.

Adults with high tone can have any number of diagnoses such as CP or head injury that exhibit excessive plantar-flexion, poor positioning of the foot and excessive hindfoot varus or valgus. The Turbo would be most beneficial to these patients. The outer shell of the Turbo should be specified to be made with ¼” polypropylene and if more stability is necessary, to add posterior reinforcement. The outer shell should also remain full length at the toe plate to give a knee extension moment in assisting with excessive plantarflexion. The inner boot should also be specified to be made out of a thicker plastic (1/8”) and should have bead reinforcement to help prevent buckling of the instep. Heel stabilization should be eliminated to reduce friction in donning. Anterior strap should always go through a D-ring and an additional strap could be considered for very large patients, or for those patients that will heavily bear weight on these straps. An additional anterior strap added distal to the first will help to distribute pressure. All straps should have plastic reinforcement washers and be attached with copper rivets. The instep strap should be reinforced with Dacron. These specifications should be listed in the “special instructions” box on the bottom right side of the order form.

Geriatric adults that have been prone to heel ulcerations because of extended bed rest would benefit from several brace designs. The braces that would work for this patient group would include the DAFO 8, DAFO 9, Softy 3, 3.5, and Turbo. Giving ample room to the ulcerated area will take pressure off the ulceration and allow it to heal. This can be achieved by adding volume to the foot directly over or around the lesion prior to cast by using foam or moleskin. Alternatively, writing a request for this modification in the special instructions box indicating the specific area on the back of the work order would also be appropriate. Identify the problem area with an indelible pencil or sharpie on the cast. Adding a walking sole on these orthoses will aid in transfers and eliminate the need for a shoe. This is only recommended for non ambulatory or very minimally ambulatory patients. Keep in mind that many of these patients may lack normal ROM, and your casting and instructions should reflect that.

Occasionally components of the DAFO 2 can be overstressed due to size and weight of the patient. Extra features are available to strengthen the brace components. For cases where that may be a concern call Cascade Technical Support to discuss these options.

More straight forward solutions are available for adults with post CVA, hindfoot varus or valgus, and plantarfasciitis. Patients with CVA who exhibit classic symptoms of equinovarus or drop foot and supination fare well with the DAFO 3.5, the DAFO 4.5, and the DAFO Hemi. Hindfoot varus and valgus (as in the case of posterior tibialis tendonitis or rupture) without high tone would benefit from the DAFO 4. Adults with symptoms of plantarfasciitis would benefit from the DAFO 9, which is a custom stretching orthosis to be worn at night. This brace may be preferable to many off-the-shelf versions due to its lower profile.

In all cases of bracing adults, care must be taken to minimize bulk while maintaining the best possible support for the patient. This includes:
1. Trim lines. Alter dorsal trimlines so they are proximal to the metatarsal heads. The toe plate can be trimmed at the toe sulcus. Indicate this on the work order or trim at time of fitting.
2. Strapping. Eliminate the forefoot strap and have a “Y” strap installed instead.
3. Heel stabilizations. Eliminating this reduces friction during shoe donning/doffing, and reduces the overall bulk. Apply on patients with hind foot varus or valgus to control eversion/inversion if necessary.

Practitioners at Cascade P&O who see adults frequently, find it is important to explain thoroughly to adult patients what they are going to do when casting and bracing. Adults are generally interested in looking at a sample brace and having the functionality and benefits of the brace explained in advance. Although these patients are referred by a physician we find it is valuable to ask the patient if they understand what is going on with them and why their doctor has suggested they see a practitioner for a bracing solution.

If you have adults in your practice, or your pediatric patients are growing larger and you would like to discuss DAFO options, please call the Technical Support department and they will be happy to discuss with you the different products available to your patient.