Physiotherapy June 2003/vol 89/no 6

Professional articles

IntroductionPatients with severe neurological disabilityfrequently present with cognitive andbehavioural problems which limitfunctional improvement (Kaplan andCorrigan, 1994; Alderman, 2001). Jacksonet al (2000) identified that these patientstook longer to walk. Lower limb con-tractures are a recognised problem(Wheeler et al, 1995) that can have anegative effect on the rehabilitation ofstanding and gait (Carter and Edwards,2002; Shumway-Cook and Woollacott,2001).

Some authors refer to the use of lower limb orthotics in this client group (Edwards and Charlton, 2002;Brodnansky et al, 1997; Tyson andThornton, 2001).

This case report aims to illustrate theiruse when managing contractures and re-educating gait in a patient with severeneurological disability. The issues relatedto this management approach arediscussed.

Case PresentationKathleen was a 25-year-old housewife withtwo children who developed acutedemyelinating encephalomyelitis. Sheinitially presented with quadraparesis,impaired swallowing and marked cog-nitive impairment. CT and MRI scansshowed diffuse cerebral swelling andextensive white matter lesions, includingthe brain stem. She was admitted to anintensive care unit and intubated andventilated for four weeks.

Kathleen was then transferred to aneurosciences unit for post-acute care.During this five-month phase musclehypertonus, particularly flexor tone in theright lower limb, was problematic.Treatment centred on casting combinedwith botulinum toxin and periods ofstanding using the tilt table. She was on a small dose of oral baclofen.

A combination of crying and hittingout, swearing and drowsiness had ham-pered rehabilitation. Cognitive impair-ments including distractibility, poor safetyawareness and disorientation had alsolimited progress.

Kathleen was admitted to the RegionalRehabilitation Unit at Northwick ParkHospital six months after onset, where sheremained an inpatient for eight months.Thereafter she became an outpatient at a general hospital, attending regularorthotic reviews at the Regional Rehab-ilitation Unit.

On admission, Kathleen presented witha mixture of hypertonus and hypotonus.She had low muscle tone around thetrunk, resulting in a flexed posture andinability to sit unsupported. She hadmildly increased tone in the left upperlimb with poor selective movement. Toneand movement were now normal in theright upper limb. She had increasedflexor and adductor tone and weakness of the extensor muscles in both lower

Lower Limb Orthoses inRehabilitation of aNeurologically ImpairedPatient Case report

Summary Patients with severe brain injury frequently present with cognitive and behavioural problems, limiting engagement in physical rehabilitation. Contractures developed during the acute phase of illness may need months of intensive treatment and require an integrated multi-disciplinary approach.

We describe the case of a young woman with complexdisabilities following acute demyelinating encephalomyelitis.She presented with severe lower limb contractures andhypertonus, preventing weight bearing.

Cognitive and behavioural problems restricted progress andthe team adopted a functional weight bearing programmeusing traditional metal and leather orthoses to facilitate gait.

By the end of her admission this patient was able to walkwith an aid and under supervision and she has progressedfurther following discharge.

The rationale and factors contributing to the successfuloutcome in this complex case are discussed.

Key WordsOrthosis, contracture,cognitive deficit, neurological impairment,muscle hypertonia,rehabilitation.

by Patricia WattsLisa KnightPaul Charlton

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Watts, P, Knight, Land Charlton, P(2003). ‘Lower limborthoses inrehabilitation of aneurologicallyimpaired patient:Case report’,Physiotherapy, 89, 6,359-364.

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limbs, particularly on the right, withcontractures (table 1).

The mixture of tonus and drowsinessled to the decision to discontinue bac-lofen.

Kathleen’s cognitive and behaviouralproblems were still apparent. She had noability to remember new information andwas disorientated to person, time andplace.

Kathleen was non-ambulant anddependent for all activities (table 2).

Outcome MeasuresThe Functional Ambulatory Category isan outcome measure used at the RegionalRehabilitation Unit to evaluate progresstowards independent gait. It is an ordinalmeasure with established reliability andvalidity in rehabilitation settings (Wade,1992), which provides information on thephysical support needed by patients whilewalking. It consists of six categoriesranging from 0 (patient cannot walk,requires help of two or more people) to 5 (patient can walk independently any-where). Kathleen’s admission score was 0.

FIM + FAM A global measure of disability, in-corporating the Functional Independ-ence Measure (Wade 1992), but withadditional sections, particularly reflectingcognitive function. It has been shown tobe a reliable and sensitive tool in post-acute rehabilitation (Turner-Stokes et al,1999). Each of the 30 sections is scoredfrom 1 (total dependence) to 7 (completeindependence). The scores can berepresented visually as in figure 1.Kathleen scored 24 out of a possible 112for the motor sub-scales and 37 out of 98for the cognitive, psychosocial sub-scales.The shaded area indicates the amount ofchange during admission to the RegionalRehabilitation Unit.

The mobility chart (table 2) is not arecognised outcome measure, but is usedroutinely at the Northwick Park RegionalRehabilitation Unit to show functionalabilities on admission and discharge.

All contractures were measured fromthe anatomical position in supine using ahand-held goniometer. The axis of thegoniometer was placed over the greatertrochanter for measuring hip flexion, atthe lateral femoral condyle for kneeflexion and at the lateral malleolus forplantarflexion. A consistent technique

Table 1: Contractures on admission and discharge

Admission Discharge

Right hip Flexion contracture of 15º * Flexion contracture of 10ºNo abduction beyond neutral 10º of abduction

Right knee Flexion contracture of 40º Flexion contracture of 5º

Left ankle 20º off plantargrade 10º off plantargrade

*All contractures measured from the anatomical position in supine using ahand-held goniometer. The axis of the goniometer was placed over thegreater trochanter for measuring hip flexion, at the lateral femoral condylefor knee flexion and at the lateral malleolus for plantarflexion.

Table 2: Mobility chart

Function Independent Minimum Moderate Totalwith/ without help help help/

aid unable

Lying roll on to left side D ALying roll on to right side D AGet up from lying through D Aleft sideGet up from lying through D Aright sideUnsupported sitting static D Afor 2 minutesSitting without arm support D Afor 2 minutesStand up to free standing D AStand for 2 minutes D ATransfer bed to chair to D Aleft sideTransfer bed to chair to D Aright sideWalk 2 steps D AWalk indoors D ALying hold arm in elevated A/Dposition leftLying hold arm in elevated A/Dposition rightPut left hand to face A/DPut right hand to face A/DGrasp and release A - limited left hand release/DGrasp and release A/Dright handWalk outdoors A/DFlight of stairs A/D

Minimum help = subject performs 75% of activityModerate help = subject performs 50% of activityA = On admission 6 months post injuryD = On discharge 13 months post injury

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and position was used to maximisereliability as suggested in the literature(Norkin and White, 1995). However, it isrecognised that measurement of con-tracture is subject to significant error, notonly due to positioning and observererror, but also to variations in tone. Theresults should be interpreted with duecaution.

ManagementThe initial aims of treatment were to:■ Increase range of right knee extension.■ Increase range of left ankle

dorsiflexion.■ Mobilise trunk and pelvis from a flexed

position.■ Increase independence in transfers

and standing.Serial casting was started early after

admission to minimise contractures of theright knee and left ankle, in accordancewith current guidelines (Ashburn et al,1998). After several casts, replaced atintervals of 5-7 days, the right kneecontracture improved to 15˚ flexion.

Maintaining this with overnight restingsplints was problematic, due to poor patient compliance and increasedflexor tone. The right knee contracturestabilised at 20˚ flexion. There was nosignificant improvement in the range ofmovement in the left ankle initially,despite casting and the injection ofbotulinum toxin A into the gastro-cnemius/soleus (Dysport 500 mouseunits).

Later in the admission, as Kathleenspent more time standing in therapy, theleft ankle contracture improved to 15˚plantarflexion.

Mobilisation of the trunk and pelvis wasattempted in supine and sitting, buttherapeutic handling was poorlytolerated. Supported standing became ahigh priority for promoting trunkextension. In the first three months ofadmission Kathleen could only standusing the tilt table, or with help of fourpeople. As her trunk control and activityof the left leg improved, she progressed tostanding with help from three people, aswell as in a standing frame.

1. Feeding2. Grooming

3. Bathing

4. Dressing upper body

5. Dressing lower body

6. Toileting

7. Swallowing

8. Bladder management

9. Bowel management

10. Bed, chair, wheelchair transfer

11. Toilet transfer

12. Tub, Shower transfer

13. Car transfer

14. Locomotion - Wheelchair

17. Comprehension

18. Expression

19. Reading

20. Writing

21. Speech intelligibility

22. Social interaction

23. Emotional status

24. Adjustment to limitations

25. Leisure activities

26. Problem solving

27. Memory

28. Orientation

29. Concentration

30. Safety awareness

15. Stairs16. Community

mobility

7

6

5

4

3

2

1

0

Discharge Admission

Fig 1: Change in Kathleen’s FIM+FAM. Scores are shown along the spokes from 1 (totally dependent) to 7 (totally independent)and the shaded area shows the amount of change during admission to the regional rehabilitation unit

FAM SUB SCALES1-7 Self care8-9 Sphincter control10-13 Mobility transfer14-16 Locomotion17-21 Communication22-25 Psycho-social

adjustment26-30 Cognitive function

FIM/FAM SCORES7 Complete independence6 Modified independence3-5 Modified dependence1-2 Complete dependence

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Improvement in trunk activity andposture allowed Kathleen to transfer inthe ward using a sliding board with helpfrom one person. Standing transfers stillproved difficult, as she was unable torecruit sufficient extension at the hipsand knees.

Over the following month Kathleendemonstrated the ability to take steps,although weight bearing through plan-tarflexed inverted feet, with increasedflexion through the trunk and right lowerlimb. A plaster back slab was needed tomaximise right knee extension.

These issues were discussed with our orthotist. The team considered that if orthoses could maintain right hip and knee extension, maximise leftdorsiflexion and correct inversion,Kathleen would be able to walk with anaid and supervision. A knee ankle footorthosis in the form of a full leg caliperfor the right lower limb and a below-kneeorthosis for the left leg (fig 2) weresuggested. The orthoses were made ofmetal and leather as opposed to thermo-plastic. The knee ankle foot orthosis hadmanually operated knee joints to allowflexion in sitting.

Accommodating heel raises wererequired, as plantarflexion of the leftankle was not fully correctable. Bilateralheel raises were used to maintainsymmetry of the pelvis.

Once the orthoses arrived, adjustmentswere needed and Kathleen had to buildup tolerance to wearing them. Time wasspent educating nursing staff and carerson how to apply them.

Treatment then included hydrotherapy,positioning and continued re-educationof normal movement. Other members ofthe multi-disciplinary team were able tobuild on the increase in Kathleen’sphysical abilities to work on self-careactivities. Her family helped Kathleenwith exercises and stretches.

Six months after admission Kathleenwas able to walk with a wheeled frame and the help of two people and stood withone person. She spent a further twomonths on the Regional RehabilitationUnit incorporating these abilities intofunctional activities.

On discharge Kathleen still demon-strated low tone centrally, but was able to recruit some trunk extension. She hadincreased speed and dexterity in left armmovement. She had moderate increasedflexor tone of the lower limbs, particularlyon the right, but improved voluntaryactivity of abductor and extensor musclegroups. Her lower limb contractures hadreduced (table 1).

She could concentrate on a task for upto 15 minutes.

Kathleen still needed close supervisionat all times, but no longer displayed verbalor physical aggression. She was orientatedand was able to use some memorystrategies such as a diary, with help. She was more independent in activities(table 2). This included transferringthrough standing with the help of oneperson and walking indoors with awheeled frame and close supervision(Functional Ambulatory Category 2). Herscores on the FIM+FAM had improved to65/112 on the motor sub-scales, and59/98 on the cognitive/psychosocial sub-scales.

Kathleen was discharged to her parents’house with her two children, with socialservices support.

An orthotic review was requested twomonths after discharge. At this timeKathleen was walking with the frame andsupervision only and could perform such

Authors

Patricia Watts BScMCSP is a seniorphysiotherapist at theRoyal Free Hospital,London.

Lisa KnightGradDipPhys MCSPis a clinical specialistin physiotherapy atNorthwick ParkHospital regionalrehabilitation unit.

Paul CharltonMBAPO DipOTCis a senior orthotistwith Peacocks MedicalGroup, Newcastleupon Tyne.

This article wasreceived on March 15,2002, and acceptedon March 14, 2003.

Address forCorrespondence

Patricia Watts, Royal Free Hospital,PhysiotherapyDepartment, Lower Ground Floor,Pond Street, London NW3 2QG.

Fig 2: Kathleen wearing bilateral lower limborthoses

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activities as getting up from the floorindependently. She had full range of right knee extension. There were stillcontractures at the ankles. It was decidedto progress to bilateral metal ankle footorthoses. Three years post insult Kathleenis able to walk independently indoors andoutdoors with bilateral heel raises and twosticks. The current multi-disciplinary teamis working towards more independentcommunity living.

DiscussionThe authors believe that a key componentin Kathleen’s rehabilitation was the timelyorthotic intervention. The preliminarytreatment techniques of serial casting,mobilisation of soft tissues and facilitationof normal movement had partly achievedthe aims, but cognitive and behaviouralimpairments affecting compliance werelimiting factors. Weight bearing instanding required more than one thera-pist to achieve appropriate alignment andcould not be used functionally.

The orthoses allowed extended periodsof standing which helped to increaserange of movement in soft tissues andfacilitate activation of extensor musc-ulature.

Standing appeared to reduce flexortone in the lower limbs and increaseextensor activity. Some authors (Edwardsand Charlton, 2002) state that mechanicalsupport should be used with cautionwhen dealing with patients with severeflexor spasticity, as forcing the leg intoextension may exacerbate the spasticity.They state that mobilisation of the trunk and pelvis and gentle stretching of the affected muscle groups may prove effective in enabling a patient to accommodate to orthoses. The idea of preparing the patient for the orthosesand using them as an adjunct to, not areplacement for physiotherapy, wasincorporated into Kathleen’s manage-ment.

The orthoses reduced the number oftherapists required for standing. AsKathleen often became distressed whenbeing handled by therapists andresponded best to familiar, functionalactivities, this improved tolerance allowed

her to stand more frequently. The abilityto stand with reduced help increasedpatient participation in activities of daily living, with the goal of improvingboth independence and orientation.There were improvements in self-caretasks (fig 1).

Thermoplastic materials are morefrequently used in modern orthotics, butthe variability of Kathleen’s tone andtherefore the alignment of the left ankleand right knee required some adaptabilitywithin the orthoses. Knee ankle footorthoses of metal and leather designprovide this through the ability to alterthe tension of the leather straps. Forcesapplied via conforming leather straps mayresist high biomechanical forces withreduced risk of skin pressure, comparedwith close fitting, more rigid thermo-plastic materials (Charlton and Ferguson,2001).

Kathleen was in an intensive andspecialised multidisciplinary teamenvironment with a high staff:patientratio, where length of stay is largelydetermined by patient need. Carers wereencouraged to be active participants inthe rehabilitation process, facilitating a 24-hour approach. There is increas-ing evidence that the intensity andenvironment of therapy affect outcome(Kwakkel et al, 1997; Langhorne et al,1996). Because of Kathleen’s memoryloss, repetition and consistency wereimportant parts of the rehabilitationprogramme. Kathleen’s improvement incognitive and physical abilities allowedher to make further functional gains inthe community setting.

Conclusion This case report suggests that lower limborthoses, including metal knee ankle footorthoses, remain an effective adjunct totreatment for selected neurologicalpatients. Patients with cognitive andbehavioural deficits in particular maybenefit as they increase the possibilities ofundertaking functional, meaningfulactivities. These patients may continue tomake functional improvements over anextended period.

Acknowledgements

The authors wouldlike to thank thefollowing colleaguesfor their advice andencouragement inwriting this casereport:

Elizabeth Bond MScMCSP, lecturer inphysiotherapy,Department of HealthStudies, BrunelUniversity.

Heather ThorntonMBA MCSP, seniorlecturer, Departmentof Physiotherapy,University ofHertfordshire.

Professor LynneTurner-Stokes DMFRCP,director/consultantin rehabilitation,RegionalRehabilitation Unit,Northwick ParkHospital.

Case report 363

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Key Messages

■ Lower limb orthoses, includingtraditional metal and leatherorthoses, can be a useful adjunct to physiotherapy in the rehabilitation of selected neurologicalpatients.

■ Lower limb orthoses do notnecessarily increase abnormal tone.

■ A consistent 24-hour approachprovided by the multidisciplinaryteam and the family was an importantfactor in enabling this patient toimprove her independence.

■ Patients with severe, complexneurological disability may havepotential to make functionalimprovements over an extendedperiod of time.

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