Case Study | Keeping Up with Therapy Goals & Innovative Bracing Plans for Crouching
Early History
This is the story of Kristin. She was born in April, 1999, a full-term baby without any complications. By the time she was nine months old, her mother realized something was wrong. She immediately enrolled Kristin in a birth-to-three program, and a massive amount of testing was begun to discover her diagnosis. Originally, she was given the diagnosis of global developmental delay with hypotonia. At the same time, the doctors were looking for a genetic cause to her symptoms. After numerous tests and MRIs, the only recognizable abnormality was some scarring in the thalamic region of the brain.
At two years of age, Kristin still had difficulty with head control and fine motor skills. She was receiving speech, occupational, and physical therapy. Once she transitioned out of the birth-to-three program, her parents enrolled her into private PT, OT, and speech therapy, which she continues today as well as receiving therapy at school.
Kristin’s Current Status
Kristin is now 10 years old. She is very lean at 42 lbs. and a petite 46 in. tall. She currently uses a wheelchair as her primary means of mobility in school and community. When at home, Kristin bunny hops on her knees and uses a four-point crawl when she wants to get somewhere quickly. Kristin is non-verbal and was recently introduced to a DynaVox® communication board (www.dynavoxtech.com). She now has a DynaVox attached to her wheelchair and loves to communicate and interact with others. She is in 4th grade and very social with others in her class.
Kristin was also recently fit with a Pacer Gait Trainer walker (www.rifton.com), which she’s been using at school since September, 2008. She is still learning how to use it. She is very good at going forward, but turning the Pacer on her own is difficult for her. Kristin currently uses the walker for 15- to 30-minute sessions in the classroom and in her physical education class. For PE as well as other classes, she is integrated with the rest of her 4th grade.
Kristin is motivated to walk and loves to walk with her family with assistance if her trunk is being supported. In weight bearing, Kristin pronates significantly bilaterally, with collapsed medial longitudinal arches and prominent naviculars. She has bilateral knee tightness: flexion contracture of the right knee at 23 degrees and of the left at 12 degrees. Kristin tends to crouch in weight bearing with her knees flexed at 30 degrees bilaterally. She has good passive range of motion of her feet, full bilateral correction of her hindfoot and forefoot, and good dorsiflexion. The limitations of her range are primarily in her knees, which contribute to the crouched posture.
Bracing History
Kristin has worn DAFO braces since she was two years old. When she first began using a prone stander, she presented with significant pronation and crouching. Over the years, her brace styles have changed as her needs and therapy goals have evolved. When Kristin was two, the primary focus was to stabilize and control her severe pronation by controlling the hindfoot and supporting the longitudinal arch. She was fit with the DAFO 4. At that time, Kristin was doing a lot of floor activities and needed to have her ankles free to bunny hop and crawl.
As she got older and began weight bearing with assistance and trunk support, Kristin needed braces that would limit her knee flexion as well as control the severe pronation. Her therapeutic goals were shifting, and the need to provide a corresponding higher level of stability was becoming necessary. Since Kristin has always been small and lean for her age, her feet have always been very boney. We shifted her from the SMOs (DAFO 4) to the DAFO 3.5 SoftyTM brace. The taller posterior strut had the advantage of controlling pronation and resisting the excessive dorsiflexion which occurred during weight bearing. The DAFO 3.5 Softy, with a moderately flexible posterior upright, gave her adequate knee extension by resisting dorsiflexion.
During that time, Kristin was weak in her quadriceps and had tight knee flexors, but no contractures were present. The Softy version of the brace provided a comfortable solution to her boney feet. As the years rolled by and Kristin continued to grow in height, the DAFO 3.5 Softys became too flexible: she overpowered them with her long legs.
When Kristin came in for a reevaluation in October, 2008, she was in need of braces that could resist her strong tendency to collapse into a crouched posture, yet have some flexibility. Her therapeutic goals were changing again, as there was much more emphasis on ambulating with her Pacer Gait Trainer. There was consensus among mother, PT, and myself to address the right knee flexion contracture this time around.
Kristin’s parents had a stretching program for her that resulted in limited success. The family dynamics had changed: Kristin’s father accepted a new job which required regular out-of-state travel. This left Kristin’s mother to assume the daily challenges of caring for a special needs child, running the family, and juggling a job. I thought that managing the knee flexion contracture might be easier for the family with a night stretching knee orthosis.
Physical Therapy Goals and Bracing Strategy
The PT’s long-term goal for Kristin has always been to stretch out the right knee flexion contracture and continue to work on strengthening her quadriceps, hip extensors, and plantarflexors so she can ambulate in a more erect posture. Kristin was measured for a custom K2 HoundDog knee brace to provide a static progressive stretch on the gastrocnemius and hamstrings through a three-point pressure system.
In choosing a brace design this go-round for Kristin, I was considering an orthosis that would provide comfortable control of her strong pronation plus resistance to dorsiflexion due to the tightness in the gastrocnemius and hamstrings.
The traditional approach for a crouching patient would be a rigid orthosis such as the Dafo Turbo or Floor Reaction to block DF. However, I would have had to accommodate Kristin’s 23 degrees of knee flexion contracture by either (1) setting the DF angle of the orthosis at 12 degrees (to maintain foot to ground contact), or (2) setting the DF angle at 3 degrees and wedging the heel (to provide ground contact under the heel which would raise up to accommodate the knee angle). Neither was a great choice for Kristin. Both choices would keep her knee at a 23 degree angle, even if her ROM at the knee improved (see Fig. 1). Option 2 would also require a wedge to be added to either the DAFO and the shoe or the shoe alone, making the project more expensive.
Since Kristin’s ROM at the knee is expected to improve with the use of the HoundDog knee stretching brace, I wanted her ankle to have some flexibility to allow her to use this more extended knee position as soon as it becomes available. So, I chose a third option by fitting Kristin with a DAFO Flexi-Sport, which has enough resistance in DF to give her a knee extension moment but also enough flexibility for her to keep her heels down without overpowering the orthosis. To get the most stability and control of her hindfoot alignment and to reduce the bulk of the foot component, I chose the polyethylene liner.
I planned for relief at the navicular by adding a very small foam circle over the skin at the apex of her boney prominences just before beginning the cast. I cast her in 4 degrees of dorsiflexion and corrected the hindfoot alignment to vertical. As a precaution and to improve overall comfort of the orthoses, I requested extra navicular padding. Nighttime stretching with the HoundDog and daytime wear of the FlexiSport seemed like a winning combination.
Fit Assessment
Kristin returned a few weeks later for the orthosis fitting, along with her grandmother, aunt, and mother. The braces fit beautifully with minor adjustments to the toe plate length. I showed Kristin’s mother how to don the new K2 HoundDog knee brace and gave her instructions on how to adjust tension for static stretch.
With the FlexiSport braces on, Kristin did some preliminary walking with assistance and trunk support. She really enjoyed
walking and was able to stand without assistance by holding onto the parallel bar. Her heels were down, and her knees were as extended as much as they could be with the limitations of the contractures. The braces did exactly what I had expected: they provided a knee extension moment but also gave ankle flexibility so that she would not be forced up on her toes. Kristin took the FlexiSport home so her family could initiate the break-in schedule.
She returned two months later for a followup. Her mother reported that the nighttime K2 HoundDog stretching orthosis for the right knee was difficult to get used to. She reported that Kristin did not care for the K2 brace and the routine of putting it on by the family was poor but improving. From wearing the FlexiSport, Kristin had some slight redness bilaterally over the navicular bone which needed to be addressed with some minor relief to the plastic. She is using the orthoses most of the day from before school until after dinner. Except for the persistent navicular redness which I relieved, Kristin has not had any skin breakdown.
In and Out of the Pacer
Kristin’s mother brought in her Pacer to show me how well she is ambulating with this assistive device. This new walker is giving Kristin independence at school that she hasn’t had before. Kristin was able to show me how proficient she is in going in straight lines, but she does find it more challenging to turn. When she fatigues, she can rest by sitting in the seat.
When I compare her gait using the Pacer walker with walking with hand-held trunk assistance, Kristin appears to walk with a more upright posture with trunk assistance. Her knees are more extended and her step length is even.
When in the Pacer, Kristin has a tendency to want to lean forward with her trunk, which creates hip flexion, knee flexion, and more dorsiflexion. Whether using the Pacer or walking with assistance, Kristin’s foot alignment in the FlexiSport is greatly improved. It makes for a balanced and stable foot position. This in turn makes for a more effective and efficient gait pattern.
— Cindy Diener
Cindy Diener, CPO, graduated in 1994 from the University of Washington with a degree in prosthetics and orthotics. She is on staff at Cascade Prosthetics and Orthotics as senior clinician and lectures at workshops and trade shows nationally and internationally for Cascade Dafo, Inc.
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Kristin, now 10, greatly enjoys her new DynaVox. ;)
Kristin clearly has the range to achieve foot-flat on her more-involved right foot. ;)
Without braces, Kristin does not habitually bring her right heel all the way in contact with the floor. Fig. 1: Bracing Options
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This option leaves no room for the anticipated increase in knee range.
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As knee range increases, the wedge height must be gradually reduced. This option can be quite effective, however, it would require additional office visits and possibly more costly shoe work.
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The DAFO FlexiSport wants to return to the planned 3˚ DF as her knee gains range. This was the option selected for Kristin.
Bracing Strategy
Nighttime stretching with the HoundDog and daytime wear of the FlexiSport seemed like a winning combination.
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K2 HoundDog
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DAFo FlexiSport
A Familiar Face
When she was several years younger, Kristin was our model for the Crouching patient group. It’s wonderful to see her growing, developing lively social skills, and making mobility progress!
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