David Stiffler: One Step at a Time

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By Jane Albritton
Dustin Stockdill (right) stabilizes David Stiffler as Sam Calabrace, CPO (left), evaluates Stiffler's gait. Photograph by Chad Means. Originally published in Our Town community newspaper, Johnstown, Pennsylvania.

David Stiffler's health crashed suddenly and precipitously on Christmas Day 2008. Stiffler, a resident of Windber, Pennsylvania, suffered a massive heart attack, followed by pneumonia and an aggressive staph infection. To stabilize him and to give his body a chance to heal in a fully quiescent state, doctors put Stiffler in a medically induced coma for two months.

But while the stillness helped Stiffler to heal internally, when he woke up in April, his leg muscles had atrophied, leaving him unable to walk as he began his recuperation at Laurelwood Care Center in May 2009.

"It was scary seeing him lying there unable to move," says his sister, Ann Moyer. "Before his heart attack, he walked in the woods all the time, played golf, and had these great calves."

With the help of physical therapy, Stiffler was able to make some progress on regaining his upper-body strength. He went from not being able to lift a piece of paper to lifting dumbbells.

"I couldn't do anything at first. Then I could at least move my arms," he says. "But I still couldn't walk."

While it was clear that Stiffler was getting better, after a month of physical therapy, both his legs remained too weak to hold him up.

"He was so deconditioned that even attempting ambulation was impractical," said physical therapist assistant Dustin Stockdill, who works with Stiffler daily. "He couldn't even maintain a standing position, so we couldn't make any progress."

It was at that point that Sam Calabrace, CPO, of Svetz Orthotics & Prosthetics, Greensburg, Pennsylvania, was called in to assess Stiffler's needs.

"Until you are able to walk, you can't get your leg strength back," Calabrace says. "Weak quads can't hold the knee in place and keep the knee from buckling at heel strike. Stance control is impossible to achieve until the muscles get stronger. Since the muscles in both of David's legs had atrophied, he was dependent on a wheelchair or a walker and full leg braces to get around."

Calabrace points out that there are two problems with the full leg brace and walker combination as a means to regaining mobility.

"Full braces are exhausting to use because they require the patient to hip hike and swing the leg forward to ambulate," he says. "That activity required strength that David didn't have."

Calabrace adds that traditional KAFOs lock the knee in full extension, which provides stability, but they also cause patients to ambulate with a gait deviation that can lead to overuse injuries caused by the compensatory hip-hike and circumduction.

In contrast, a stance-control orthosis (SCO) allows the knee to bend during the swing phase of gait and blocks knee flexion for stability during the stance phase. By allowing the knee to bend during swing phase, SCOs allow a more normal gait, which may reduce secondary complications from gait compensations and allow the patient to walk with less effort.

In Stiffler's case, until his heart regained significant capacity, any therapy involving unnecessarily strenuous physical exertion made no sense.

The second problem with traditional KAFOs involves the use of space. As the leg swings, it hits the walker, further impeding forward motion. To address both impediments to gaining leg strength, Calabrace worked with Stockdill to create a coordinated evaluation.

"We determined what we were trying to achieve and established goals," Calabrace says. "We looked at his medical history to understand what was possible."

Based on the evaluation, Calabrace and Stockdill agreed that Stiffler was a good candidate for bilateral SCOs and decided to fit him with Otto Bock HealthCare's E-MAG Active, an electronic stance-control KAFO, which had just become available in December 2008. When Calabrace made his assessment, only five patients had been fitted with the braces nationally, and none were bilateral users.

"This technology allows the knee to bend during swing and then to lock when standing," says Adam McPherson, U.S. market manager for Otto Bock. "The gyroscope in this device 'understands' where the leg is in the gait cycle. Othotists like it because it is so easy to calibrate."

Photograph of the E-MAG Active courtesy of Otto Bock HealthCare, Minneapolis, Minnesota.

When being fitted with the E-MAG, the patient first walks 15 steps in locking braces to determine gait length. Then, after the patient has been fitted with the E-MAG, he or she uses parallel bars to take a few steps. While the patient is on the parallel bars, the orthotist hits a button to set the angle at heel strike and then another button to set the angle at toe off. That calibration teaches the E-MAG when to lock and when to unlock.

Because of other medical problems associated with Stiffler's heart attack, Calabrace was not able to fit his patient until August 2009. Stiffler began using the braces the following month and was almost immediately able to use both legs to walk short distances.

"Within 15 minutes, David was able to walk around the office," Calabrace says. "To see him stand up and go 40 to 50 feet was amazing."

While walking such distances may not seem like much, for Stiffler it means the difference between depending forever on a wheelchair and being able to get around on his own in an energy-efficient manner.

"The braces gave him the stability to stand and walk," Stockdill says. "Then we could start making some progress. It was the boost he needed."

Calabrace says that Stiffler progressed much faster than he had expected. So fast, in fact, that once the braces gave Stiffler the ability to walk with a natural gait, he quickly graduated from needing them.

"David is now walking over 150 feet without any orthotic at all," Stockdill says. "It was just a matter of getting him up and going. He has had some flare-ups with...edema, but his progress is clear."

The particular array of medical problems that have attended both Stiffler's initial illness and his return to health point to the fact that designing a recovery plan is an art as well as a science, both of which may be enhanced by the thoughtful addition of new technology to the therapeutic mix.

"Before David had the braces, it took three of us just to hold him up in a standing position," Stockdill says. "Once the braces gave him the support and confidence to stand, then we could concentrate on his walking."

Stiffler's recovery will take time, but his fast progression with walking has given him hope. "I know there is going to be lots of work," he says, "but maybe I will play golf again."

Jane Albritton is president of Tiger Enterprises, Writing Consultants. She is a contributing writer for the Northern Colorado Business Report and Edibles Front Range. She is also an editor for a 50th Anniversary collection of Peace Corps stories. She can be reached at www.peacecorpsat50.org