I appreciate everyone’s input on my original posting. It was requested that I post a summary of responses.
I tend to have great success with dynamic orthoses such as the Ultralfex AFO with a molded inner boot for midfoot support and to help anchor the foot in the AFO. I like the Ultraflex because it is very user friendly and allows the parent, patient or caretaker to simply click a button and allow the orthosis to take over. No need to worry about having to set it at a certain position.
If he improved with serial casting and day bracing isn’t holding him then nocturnal bracing is the way to go. If he has great length already you cld make a static afo that is lined and put a small non-skid base on it for him to get to theBathroom. I have also had good results with ultraflex (custom needed for a neuro case) with a lockout mech.
I believe that our Ankle Dorsiflexion Dynasplint Sytem (avail in peds) could help your patient. The protocol is for overnight wear, but can be used in several bouts while resting if sleep is difficult. Have a look!
short answer is yes!
the brace/design you chose depends on the patient – I like the following options
1. He could try his existing AFO”s to bed – however it sounds like his achilles is fairly tight . . . he will probably plantar flex strongly when prone & skin problems will arise quickly
2. Orthomerica’s UFO – comes in pedi sizes & colors – allows for progressive stretch & you can allow some plantar flexion to start with – liners are removable & washable – this is an in expensive concept to try – there is no LT / RT so you could try one – sometimes alternating legs at night helps with tolerance/acclimation
3. If his foot needs to be managed more than the generic UFO allows, & if coverage is not an issue, the rolls royce (in my humble opinion) would be a hinged/articulated AFO set in some plantar flexion, with a molded inner boot (SMO trims with full dorsal wrap) and dynamic dorsi assist joints – Tamarack variable assist/ Ultraflex – I usually start with one side to see if this extravagant approach is going to be effective
obviously I have not answered your question – hopefully I have given you some options to ponder – best of luck
We have a good protocol for heelcord tightness with hinged AFO’s after serial casting. They pretty much wear 23 hours per day for 3-6 months and then transition to just nighttime use when the physician feels it’s time.
Hi John,
The key to maintaining range of motion is to hold the achieved end range from the serial casting. It is my opinion that a custom is needed. If you use an OTS design you won’t really hold neutral foot positioning and sagittal plane goals as the patients tend to just compensate within the device, thus causing recurring contractures / loss of range. If there’s a strong spastic tone then you’ll have to be creative with your design to have the ability to offset anticipated pressure. Even with you best design and fit there are patients that may need annual or even biannual serial casting to maintain range.
Hope this helps
You can make night time braces or just set up removable elastic straps from the mets to the calf to act like dynamic flexion braces to give a little stretch at night. Look into Botox also.
Night use of ankle foot orthoses such as the PRAFO do work. I have used them on a number of patients over the years for exactly the same problem. It is imperative that the people who will be caring for the patient are well versed in the proper application of the orthosis. In addition I have found that if they wear the orthosis at night they have a much easier time getting into their orthosis that they will use for standing and ambulation. Skin care is always an issue and the PRAFO has not been a problem. Other orthoses like the HeelPro or the Multipodus work well also. The less expensive models do not hold up and the closure is usually not as secure or controlling as the above mentioned orthoses.
I never have a patient wear his orthoses to bed unless I make custom orthoses with custom liners and protection for the heels. It is also important that the PRAFO is properly adjusted for the best control by making sure that the height of the posterior portion is set to give the best lever control and that the foot plate is set at the proper length and the straps are secure and not loose. The biggest problem with any night splinting is getting care givers to apply them properly.
OTS night splints work and work even better in combination with knee immobilizers. This will allow you to put a stretch on the gastrocnemius as well. Make sure parents are aware of the adjustment straps and how they work. Sometimes custom NT are necessary if the patients ankle cannot be controlled with OTS.
I have tried the off the shelf products with limited success. I am not a fan of dynasplints for 2 reasons 1) no rigid cuffs to keep anything lined up with the joint it should be stretching 2) we give away a referral to someone who is none certified.
We have used the ultra flex AFO with either one or both sides having a power unit and had good success. We make our own AFO and place there joints on. The challenge is some of the insurances are not recognizing the power unit billing code. Using a custom padded afot with sole material placed on the plantar allows for little ones to get up in the night if they have to.
I prefer the Ultraflex system. I have had fantastic results and there is a lot of evidence & research behind their management of children with TBIs.
Contact the folks at Ultraflex Systems and let them show you how these nocturnal stretching orthoses work. I have used them for 15 years on TBIs and all types of UMN patients with great success. I have completely replaced serial casting with this orthosis.
I often suggest night use to parents. I prefer to use the custom AFO especially if there is any midfoot instability. Be sure there are no pressure areas before trying this and I usually say to the parents every other night as tolerated. If the design has free dorsiflexion hinges, I usually provide an additional “dynamic dorsiflexion strap” – I add pile velcro to the plantar surface of the forefoot section of the AFO – If there is a metbreak then I stick the velcro just at the metheads – if the footplate is rigid I stick the velcro as far under the toes as possible but still perpendicular to the ankle axis. Then I attach 1″ d-rings facing forward at the same attachment as the proximal strap (just under and pointed downward). These additions stay on the device permanently. For the “DDS” I use 1″ dacron, velcro and elastic running from one d-ring, under the foot attached to the footplate velcro and up to the other d-ring. Just like the OTS velcro side pulls but with elastic to prevent over stressing and causing pain. I suggest donning the AFO’s normally and then straighten the knee to apply the “DDS” and just apply it until there is some resistance – not too much otherwise the child may roll over and straighten and receive a very sudden stretch which would wake them up. Basically you don’t have to crank on it to be effective – the AFO is already in a much more appropriate position than nothing. Be careful with extremely spastic kids who sleep in full extension – pressure on the occiput promotes increased extensor tone so they may have excessive pressure on the ball of the foot. The DDS can then be removed for day wear – the only occaisional problem is with the added pile on the forefoot taking up room in the shoe.
I always check with the PT involved to confirm the treatment. Sometimes I just suggest putting the strap on during TV time (and sitting with their knees extended) or after some intensive PT ROM exercises – then you can tighten it up more than if they are sleeping. Back it off for sleeping.
I do a fair amount of serial casting and have found that night time day time, night time AFO’s and PT a must.
With out PT they tend to go back to there past pattern of walking.
Day time AFO is somewhat flex able in design using caution to protect the mid foot so as/if things tighten up they don’t destroy the mid foot.
Night time is 8 hours in a great position, I use a molded foam inner boot with dorsi assist joints and dorsi flexion straps with a walking bottom. Pull straps to comfort if things relax more the dorsi assist joint get the rest. In some cases that they can’t handle the straps I’ve gone to a ultra flex joint.
Remember to keep in mind the gastroc tightness if they sleep all curled up the soleus soaks up much of the force leaving the gastroc to tighten up, in these cases additional soft knee ext brace with the AFO.
At our facility we use either custom moulded full foot length R-wrap style AFOs or Front/Back boot style AFOs for our kids overnight, depending on sensation we may fully line them but generally we don’t. We find the intimate fit of the r-wrap style mimics the full contact of a serial cast. Leg bands / gaiters/ knee immobilisers may also be appropriate to use o/night with the AFOs if tolerable so the stretch is over both 1 and 2 joint calf muscles.
We only use the OTS style night splints if the child is very flaccid
We use a weaning in period where the child wears the AFOs for longer and longer lengths of time during the day and then goes to overnight if there are no issues with day wear.
If a daytime weaning in program is difficult then we still wean in but do it overnight and rely on parents or nursing staff to remove the AFOs after 1 hour and check, then 2hrs and check then 4hrs etc, etc until the child is going overnight with no issues.
hope this is of some use.
I would try a custom made AFO with ultraflex jts for cases with severe tightness. You can use daytime jointed AFOs with a pull strap for more dorsiflexion for milder cases. I do use a molded inner boot to protect the foot. I find the kids pull out of the OTS night splints
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John Boldt, CPO
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