Good outcome for young woman with Spinal Cord Injury by combining the use of two unique active dynamic orthoses

A little while ago I was called by the clinical team at a regional Spinal Injuries Centre to help evaluate a patient. This was a 25-year-old woman with spinal cord injury (SCI) 6 years earlier, that left her with significant left-sided weakness in her lower limb (LL). Her main problem was a 15-degree hyperextension that had been difficult to correct, as well as foot-drop on the left side.

This lady had previously tried various orthoses to correct her knee hyperextension, including a knee-ankle-foot-orthosis (KAFO) with a drop-lock mechanism (which locks the knee joints in 0° extension when the user is walking). Unfortunately, she could not tolerate the resulting gait pattern with the compensations required to achieve ground clearance and the high energy cost. She had also previously tried various ankle-foot-orthoses (AFOs) to reduce foot-drop, but they either exacerbated her knee hyperextension, or made her unstable.

Physical examination showed that her left quads were 3 on the Oxford Scale, knee flexors were 4, dorsiflexors were 3, plantarflexors were 2 and foot invertors/ evertors were 1. She complained of knee pain and wanted to improve her mobility, but also protect her knee joint long-term. Her usual gait pattern (without orthoses) is shown in the first video below.

The clinical team decided to try a “Controlled Dynamic Stretch” (CDS) knee extension brace at the first instance. The reasoning behind this was that the extension assist would supplement the function of her weak quadriceps (which originally resulted in the knee hyperextension) to provide knee stability, while also limiting the hyperextension to protect her joint. The CDS knee brace offers the ability to allow an adjustable degree of hyperextension (0°-15°, in 1° increments) which was thought to be important, since this lady had been walking with the hyperextension for a few years, and might have had trouble adjusting to 0° extension.

The aluminium shells of the CDS brace were adjusted in shape and position to fit this lady. A moderate amount of extension assist was trialled and the brace was set to allow 5° of hyperextension. This was soon reduced to 2° and then 0°, as the patient felt confident and did not experience any knee instability. Adjusting the extension assist allowed her to benefit from knee stability in (early to mid-) stance phase, while allowing knee flexion to occur in early swing phase (which improved ground clearance). The gait pattern with the CDS brace applied is shown in the second video below.

When the hyperextension and knee stability issues had been addressed, the next stage was to correct the foot-drop. It was decided to try an active-dynamic Step-On AFO for three main reasons: (1) the adjustable dorsiflexion (DF) assistance would further assist in tibial/LL advancement during stance phase (and reduction of the knee extension moment), (2) the 22° DF ROM was expected to improve heel initial contact and ground clearance in swing phase significantly, and (3) active dynamic AFOs with adjustable DF assistance have been shown to improve loading response, providing a more normal gait pattern. A Step-On 100MH AFO was fitted with the tibial shell applied over the CDS knee brace. The lady was pleased with the improvement in her gait pattern and the reduction in the knee hyperextension, and also felt more confident. Since this was the first time she was using both braces, her therapist advised her to use her crutches. The resulting gait pattern with both the Step-On and CDS braces is shown in the third video below. This combination of active dynamic knee and ankle-foot orthoses can also be used as a very good assessment tool before committing to a lightweight composite KAFO with active assist joints.

If you would like to hear more about Brace Orthopaedic’s range of Step-On and CDS active dynamic orthoses or indeed arrange a product demonstration then please call Customer Services on 0191 258 8944 where Cathryn or Iain would be delighted to help. Alternatively, please visit our website at www.braceorthopaedic.co.uk