Case Study

5 years old Spina Bifida patient needs new lower limb orthosis. She has weakness on Left lower limb, presents with Left hip internal rotation, knee hyperextension and varus contracture. She put most of the loading on Right leg and walks with increased inversion Right. She has been using AFO on Left and has not used orthosis on Right. After discussion with physio, we decided to try her with Left KAFO. However the KAFO was good for her knee but didn’t help the hip internal rotation and caused pressure. We could not improve the internal rotation with the available orthoses so decided to change back to AFO. At last, she was fitted with a new Left AFO and an orthosis with deep heel cup for Right.

Subjective:

Patient had lived in Singapore and Australia and had AFO made from these countries. Her current AFO was made in Australia a year ago. It is getting short on back height and foot length. Physio reported that patient’s Left leg is shorter and as it is the weak side most of the loading goes on Right. Right is loading on lateral aspect and increases varus. Patient uses AFO on Left only and has not used orthosis on Right.

Objective:

Left lower limb weakness, hip internal rotation, knee hyperextension, ankle can be corrected to 90 degrees but varus contracture. LLD is 15mm shorter on Left.

Right ankle and hindfoot can be corrected.

To stablised and improve gait

Method/Plan:

Measured and casted Left, to order KAFO.

If Left is more stable and increases weight-bearing with the KAFO, loading and gait pattern on Right might change. So we will decide if Right needs orthosis once Left KAFO is fitted.

Discussed with physio, Left to change from KAFO to AFO, use resting AFO to maintain ROM, and try TAP splint to reduce hip internal rotation.

Ivanyi, B., Schoenmakers, M., Van Veen, N., Maathuis, K., Nollet, F., & Nederhand, M. (2015). The effects of orthoses, footwear, and walking aids on the walking ability of children and adolescents with spina bifida. Prosthetics and Orthotics International, 39(6), 437-443.

Objectives:

To review the literature for evidence of the efficacy of orthotic management, footwear, and walking aids on gait and walking outcomes in ambulant children and adolescents with spina bifida.

Methods:

A systematic literature search was performed to identify studies that evaluated the effect of any type of lower limb orthoses, orthopedic footwear, or walking aids in ambulant children (≤18 years old) with spina bifida. Outcome measures and treatment results for gait parameters, walking capacity, and walking performance were identified using International Classification of Functioning, Disability and Health for Children and Youth (ICF-CY) as the reference framework.

Results:

Six case-crossover studies met the criteria and were included in this systematic review. Four studies provided indications of the efficacy of the ankle–foot orthosis in improving a number of kinematic and kinetic properties of gait, stride characteristics, and the oxygen cost of walking. Two studies indicated that walking with forearm crutches may have a favorable effect on gait. The evidence level of these studies was low, and none of the studies assessed the efficacy of the intervention on walking capacity and walking performance.

Conclusions:

Some data support the efficacy of using ankle–foot orthosis and crutches for gait and walking outcomes at the body functions and structures level of the ICF-CY. Potential benefits at the activities and participation level have not been investigated.

Duffy, C. M., Graham, H. K., & Cosgrove, A. P. (2000). The Influence of Ankle-Foot Orthoses on Gait and Energy Expenditure in Spina Bifida. Journal of Pediatric Orthopaedics, 20(3), 356-361.

Carroll, N. C. (1977). The orthotic management of spina bifida children present status-future goals. Prosthetics and Orthorics International, 1, 39-42.

S: Mum reported patient gets on well with the resting AFO, is using it every night. Physio has tried the TAP splint on patient but was too long.

O: Physio didn’t bring the TAP splint today, can’t check the fitting.

A: Trial Left KAFO, AFO part is tight at ankle and hindfoot, back height of AFO and medial thigh section were too high

P: KAFO will be modified and will give to physio when ready, will see patient again in a month

S: Patient has used the KAFO however it caused blister on Left lateral 5th MPJ and pressure on medial top thigh. Physio has advised to stop wearing the KAFO.

O: The KAFO stops knee hyperextension but no improvement of the hip internal rotation. As patient’s thigh rotates inside the KAFO, it was pinching at the top and caused the pressure.

A: Tried the TAP splint with KAFO and patient’s old AFO, but it doesn’t control the internal rotation. Discussed with physio, to change back to AFO. New cast taken on Left to order AFO.

P: Patient to use her old AFO until new AFO arrived. Physio might try patient with body garment and see if it helps to control the hip internal rotation.

S: Left lateral 5th MPJ blister has healed.

O: No pressure noticed on Left

A: Fitted Left AFO. Right still presents with varus. Measured Right foot and will order foot orthosis with deep heel cup.

P: Patient to use the new AFO on Left. We will see patient when the Right foot orthosis is ready and review Left AFO.

The effect of different orthoses on spina bifida child

The KAFO might work if hip internal rotation is controlled. However we could not get it controlled with the available funded orthoses.

If the KAFO worked, gait analysis and energy consumption studies can be done to compare the difference of AFO and KAFO.