As clinicians, when we consider our orthotic treatment options for users with neurological conditions, we should not be blinkered in our thinking and limit our treatment to a solid ankle foot orthosis (AFO).
Biomechanically we understand the theory and practical success of solid AFOs, however, focusing all of our clinical aims and attention on these principles can be doing our orthotic users an injustice.
In the same way that no two people are truly the same, no two neurological conditions are the same. Treating a child with hemiplegic cerebral palsy should be considered and managed very differently from an adult user with secondary progressive multiple sclerosis.
As clinicians, we often draw on our knowledge of one condition to support our decision making in treatment of another condition, but treating all patients with, (for use of a generic term ‘foot drop’) using the same prescription is not considering each patient as an individual.
In time and cost pressured clinical environments, it is easy to settle on a treatment plan by using our previously acquired experience or theoretical knowledge and not focus on what else is out there to help meet our end users functional goals.
The subject of individual treatment brings us nicely onto the use of ankle joints in custom made AFOs. The use of an ankle joint can be considered from the acute stages of a condition through to the long-term management of both stable and progressive neurological conditions. For a user with ankle range of motion (ROM), or even those with very restricted ROM, an ankle joint may help to improve multiple aspects of their daily lives; getting in and out of a car, increase their walking speed and improve the number of footwear options available to them.
From a clinician’s perspective, an ankle joint can help to encourage equal weight bearing, ease sit to stand, improved tibial progression, maintain or re-establish the rockers of the foot and ankle, to name just a small number of the many benefits.
The Nexgear Tango is an ankle joint with multiple functional options. Initially it could be used in rehabilitation with ROM stops, acting as a solid AFO and as a user’s stability and proximal strength improves, the mechanical ROM at the ankle can be increased, to allow the muscles to work through either a part of or their full ROM.
The Nexgear Tango allows a clinician to manipulate the ground reaction force (GRF), which is the force exerted by the ground as an opposite reaction to the patients weight and acceleration. An anterior stop, which limits dorsiflexion in weight bearing, can be used to create a plantar flexed position of the foot and ankle and in turn offers increased stability to a knee joint affected by quadriceps weakness.
A posterior reaction module can support propulsion into swing phase and compensate for week knee or hip flexors aiding ground clearance during swing phase.
Depending on the modular set up of the Nexgear Tango, the joint can offer restriction to ROM, active assistance to dorsiflexion in swing phase and active assistance or resistance to dorsiflexion and plantarflexion throughout the stance phase of gait. In practical terms, this might be to provide bilateral knee extension to a user with crouched gait due to diplegic cerebral palsy, or propulsion into swing phase and improved ground clearance for user with spina bifida presenting with triceps surae weakness. The options for set up and use are multiple and can be adapted throughout the long-term treatment process.
In many clinical instances, the Nexgear Tango is drawn upon after repeated failures of solid AFOs or less supportive and adaptable ankle joints have not provided the resolution to an active AFO user’s orthotic wear and tear. Clinical experience suggests the joint should be one of the first thoughts on a clinicians mind when looking to optimise a patient’s gait cycle and manufacture a robust and practical AFO. In the long-term treatment plan, the Nexgear Tango may save both time and money by preventing the need for repeated orthotic manufacture to accommodate changes in prescriptions and in turn reduce the number of clinical appointments. It will also provide the patient with an AFO that works to reliably support their functional goals.
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