In my attempt to be concise I neglected an important part o
Hello all,
In my attempt to be concise I neglected an important part of this dialogue, the person responsible for this line of thought and treatment. I apologize for the oversight. I believe anyone that has been exposed to this practice has heard of the infamous Elaine Owens. She is with the University of Strathclyde in Scottland, and Beverly Cusick did inform us of her groundbreaking work. My apologies for the error of omission.
I received many replies and quite a few inquiries. I have literature available to those interested. Send an e-mail and one of these days I’ll send you some quite useful, thoughtful and groundbreaking lkiterature. This is a very thoughtful approach and should not be taken lightly. I would definitely recommend the always sold out conference featuring Elaine Owen’s work at the Rehabilitation Institute of Chicago. I have not, but will one day, attend an event.
Following are a few, many were just inquiries, of the replies.
Hi Kevin,
I was not in attendance at the meeting where Beverly Cusick taught and so am not privy to what was said. However, your description of the
client, placing the talocrural joint in PF, inclining the shank and
lifting the contralateral side sounds very familiar to the work done by
Elaine Owen, a Physio who practices in Wales. She started exploring AFO Footwear Combination with Tuning for her Masters at Strathclyde and worked with Roy Bowers, CO and under the tutelage of Barry Meadows, PhD. Since 1986 she continued to work with AFOFC in a very large
Paediatric Clinic of which she manages. She started using slow motion
video, but presently uses a Vicon Video Lab with force plate to observe
Ground Reaction Forces. This was published last year in Prosthetic Orthotic International http://poi.sagepub.com/content/34/3/254.abstract. The article includes her Clinical Algorithms for decision making. It is very important to pay careful attention to the way Elaine has
presented this material, she has investigated these ideas very
thoroughly.
Next week will be the 4th year she will have lectured at our hospital, the Rehabilitation Institute of Chicago. Beverly Cusick and John Russell were in attendance two years ago. The 3 day course has been full for two months. She will be returning in
May for an Advanced course – the first of it kind anywhere. She has
lectured extensively in Europe. Elaine, myself, Stefanie Fatone, PhD, and Deborah Gaebler, MD have presented the material at the last two AACPDM meeting in Las Vegas. I have presented with some of our Tuning Clinic team at the last ACPOC meeting.
This is a very exciting technique and I am convinced a paradigm shift. But
there is a learning curve. It is also very important to recognize these techniques as more than typical orthotic intervention. AFOFC with
Tuning will influence Ground Reaction Forces by small changes in the
AFOFC which have significant influences upon hip and knee flexion and
extension moments. These influences can have very positive effects on
muscle length and activity which often require excellent physical
therapy and continued orthotic assessment with the slow motion video.
There is a great deal of information contained in the above article. I would suggest you read it. Also Google Elaine and Roy as they have some
other interesting items out there.
************************************
Hello Kevin
It was good to read your post.
I have been advocating
(and practising) this approach for many years now, and have considerable
experience in this area. I lecture on the subject everywhere I get the
opportunity, and routinely teach this to our P&O undergraduates at Strathclyde.
It
is based on sound biomechanical principles and an understanding of the
fact that if an AFO dorsiflexes the foot beyond the angle that can be
readily achieved with the knee fully extended, then the orthosis will
actually impact negatively on the knee and the hip, preventing full
extension of both joints in terminal stance, and thereby possibly
contributing to soft tissue contracture. Ensuring that the knee and hip
are allowed to fully extend by casting at an appropriate “gastrocnemius
length” can create a desirable biomechanical situation at the knee and
the hip in TSt and can help maintain muscle length (providing you “tune”
the angle of the tibia with wedges, as you did). I have even seen cases
where the gastrocnemius has become longer due to good biomechanics
using a solid AFO, which is counter-intuitive to some. Careful
assessment of the length and tone of the gastrocnemius muscle is the key
here.
I spoke about this in 2005 at the AAOP meeting in Florida in a session I was fortunate to deliver with my friends Tom DiBello and Bryan Malas (in fact I believe I spoke to Tom and his clinical
colleagues in Houston on the same trip, and to the clinical staff at Shriners there). I have
also spoken about the concept at subsequent AAOP meetings. I’ll be at
the meeting in Atlanta in March – if you are there I would be happy to meet up to discuss.
I submitted a case study on this to Academy Today to try to raise awareness of this approach – you can find it at http://www.oandp.org/AcademyTODAY/2007Apr/4.asp – I hope it may be of some interest.
I
would be more than happy to discuss this further with you, and would
contribute to your discussion group if I could – sadly I am in
Scotland….
Keep trying this – you will not be disappointed
************************************************
Kevin:
This technique has been around and used successfully for several years.
Originally introduce by the University at Strathclyde, known as the
Strathclyde Technique. It is now taught nationwide by a therapist whose name
escapes me now, but I have her course materials.
I have used this technique for about 7 years myself with excellent results
but I would add that I now use motion at the ankles because it is far
superior to locking them up. The joint I use is made by Ultraflex Systems
and is call the USS Ankle (Ultra Safe Step Ankle Joint). I would love to
participate in your discussion and know Beverly from many years back through
her interaction with Sharon Vanderbilt and I in Chattanooga. Say hello for
me.
*********************************************
Kevin, I am in Canada, and very interested in Beverly’s methods. cannot attend your
session. We treat many spastic CP kids in our clinic, and I’d love to
get more information.
Thanks in advance,
….Lots like this
****************************************************
Kevin,
It is worth the time. The largest obstacle I have found is the
MD’s willing to get on board, they all reply “this is plantar flexed,
make it at 90 degrees” I don’t know how much Beverly went into the shoe
mods, but I really don’t think the shoe designs that Elaine uses would
fly in the U.S. as well as getting the shoes paid for.
*****************************************************
Hi Kevin
I have to say that I have used your approach on a number of occasions. I
don’t see a significant number of serial casting patients mainly due to
the fact that I am in private practice and the billing isn’t covered as
it is in public facilities. Regardless, what you say has been my
experience. While tone is much different than simply mechanical alignment
challenges, I also use the plantarflexed ipsilateral, external elevation
contralateral approach. My most recent case is a young adult male, spina
bifida who was tx’d w bil rigid afos. His chief compaint was a “sore
arch”. On assessment he had a significant callus following
ulceration and multiple paddings at the medial aspect of his more
affected foot. The previous orthotist strived to maintain a stable
alignment which simply wasn’t achievable in a plantar grade position. I
plantarflexed his foot and supinated his forefoot which made a very
stable aligment. It needed about a one inch wedge on the outside of the
afo and equal elevation on the opposite shoe. Once done he walk very
well, liked his afos for the first time, had no navicular pressure and
“was taller” which was a huge benefit according to him.
Sometimes I think we try to get to a magical angle or alignment putting
patient ambulation needs in a compromised position. In your case,
fighting tone isn’t really going to win; working with it will.
Good job!
**************************************************
This is something we used in Houston. I worked with Tom DiBello at
Dynamic O and P (now I’m in Omaha). The key seems to be paying
attention to where the first catch of spasticity is (R1). This is the
starting point for where you cast. Many times you can dorsiflex them
past that R1 a little, but it really depends on the degree of
spasticity.
What also seems to be a good addition is to use
SACH foam for your heel wedge. It dampens the knee flexion moment at
loading response.
Attached is some research by Elaine Owen that
we really explains the whole concept. I too am working on getting
therapists behind that methodology so please let me know if you find an
approach that really works well with these therapists.
************************************************
Hi Kevin,
I must have missed this posting, but a colleague of mine sent it to me. I did not attend this lecture, but it sounds like she is presenting the
work of Elaine Owen out of University of Strathclyde, who has examined the effect of ankle angle within the AFO as well as
tibial inclination with respect to the floor. The latter may be altered through footwear modifications, which she refers to as the AFOFC (AFO
footwear combination). I’ve attached the O&P Intl. article that was
published last year. I know that some orthotists at Rehab. Institute of Chicago (RIC), Children’s Memorial (Chicago), and myself, among others are following this approach to varying degrees, but with good success.
Elaine Owen usually has a course at the RIC in December each year where you
learn this technique. I found it fascinating and well worth the trip to Chicago. I’ve cc’d Walter Afable, who works within the O&P department at the RIC; please email him if you would like information about the course.
******************************************************
There were more, but mostly requesting info. Thanks to all that took time. Merry Christmas all!!!
Kevin C. Matthews, CO/LO
Advanced Orthopedic Designs
12315 Judson Rd. #206
San Antonio, Texas 78233
210-657-8100
210-657-8105 fax
