GRAFO’s with hypotonia

NZOPA Case Study Template


Unable to upload images and videos


Name:     Kerry Vickers

Phone:   078380606


Date: ­­­­­­­­­03/10/20

Event Number:     KV- 2020-21-23813

(The event number should start with your initials, then the year, then which case study submission this is for you, then an internal job number that will allow you to identify the case in your practice.  E.g. jcs-2009-01/1435b)


All sections below must be filled in for case study to be accepted


Sectin1: Job Details

Start Date:02/10/2020
Finish Date:ongoing



Section 2: Abstract

Summary of case study. Include details of patient, method and outcome

6 year 8 month old female with Bilateral knee hyperextension on weight bearing.

This patient has Megalencephalic Leucoenceophalopath   – Van der Knapp disease

Van der Knapp Disease is a slowly progressive neurodegenerative disorder.

It is characterized by infantile onset macrocephaly, cerebral leukoencephalopathy and mild neurological symptoms.

This leads on to degenerative muscle weakness and decreasing mobility with a shortened lifespan in extreme cases

It is caused by close blood relation reproduction.

Social situation – The grandmother has full time care of the patient and her 3 siblings, one other sibling who has the same condition

to a lesser degree.

The Grandmother also has care of her own 4 dependants.

She is very positive, proactive and has the best interest of the children at heart.

Custom GRAFO’s to be manufactured and enable patient to be able to “walk “ independently using a posterior walker and reduce time in the wheelchair while she is able.





Section3: Initial Assessment

Clinical Presentation


Functions like CP GMFCS level III – IV

She can walk short distances with a posterior walker with increasing knee hyperextension and foot pronation.


Currently fulltime electric wheelchair

Independant use of the chair – able to get in and out of the chair independantly

The patient has used a standing frame but due to social issues this has been lost along with her splints.

Grandmother now has fulltime care and is moving forward to get assistance for patient and her siblings

I have rung the last providers of her splints and she had been fitted with

bilateral Cascade jump start kangaroos in Nov 2019.



Increase safe mobility with use of current aids, the posterior walker, splints and footwear and reduce time spent in the wheel chair. Maintain a level of independence.



Orthotic/Prosthetic Prescription & Aims:

Provide with custom fixed ankle GRAFO splints, footwear and aids to mobilise safely and independantly.

To control bilateral knee hyperextension and allow and improve independent walking







Discussion with Mulidisciplinary Team:

This case was taken to an in house training weekend at Hastings branch to discuss with colleagues and come up with a solution to fit the needs of the patient and her family.

Case presented to group along with videos and progress to date.

At this point the patient had temporary 7.5 wide Leap frog splints fitted that were already in stock  to provide an immediate solution to enable standing and walking once the posterior frame was located.

It was noted that the patient is very keen to progress and the support of the now immediate carers is detrimental to the quality of life the patient can experience.







Section 4: Literature Review

Summary and critical appraisal of literature used in clinical management, and/or in support of clinical management. Add more table rows for more articles.


If you are unsure how to reference and or you require a referencing guide/tool then please use La Trobe University’s referencing tool:

You will need to select the style: APA 6         


If you do not reference the articles you may be suspected of plagiarism, which may come with your membership & accreditation being suspended.


Article 1Obstet Gynecol


. 1979 Feb;53(2):195-9.

Congenital abnormalities in newborns of consanguineous and nonconsanguineous parents.

This study was used to gain patterns and types of abnormalities in an Iranian population

Out of 9526 pregnancies a total of 9623 newborns were produced of these 7621 from nonconsanguineous parents and 2362 (24.5%) babies from consanguineous marriages. Of the total pregnancies, 1.54% resulted in malformed children (1.53% of singleton and 2.1% of multiple gestations). Abnormalities in newborns of nonconsanguineous parents was 1.66% as compared to 4.02% for newborns of the consanguineous group.

The greater the chances of congenital abnormalities the closer the relationship of the parents.


Article 2

Principles of Ankle-Foot Orthosis Prescription in Ambulatory Bilateral Cerebral Palsy

Ankle-foot orthoses (AFOs) can play an important role in normalizing gait function in CP patients.

Common foot deformities and limited range of motion require careful consideration.

Successful AFO prescription is better supported by physical therapy, spasticity and orthopaedic management.

Recognising the impact of plantar flexion contractures and the effects of footwear on AFO alignment is key to effective orthotic management of gait dysfunction in children with CP.

Case Report


Prosthet Orthot Int

. 2019 Aug;43(4):453-458.

doi: 10.1177/0309364619852239. Epub 2019 Jun 4.

Improved motor function in a pre-ambulatory child with spastic bilateral cerebral palsy, using a custom rigid ankle-foot orthosis-footwear combination: A case report

This article supports the concept of the combination of suitable AFO and footwear choice will enhance the ability of mobilising in a child with CP.

This case covered the Orthotic management of the child over 15 months and over that time the child was able to stand and walk independently.

Custom Rigid AFO’s were prescribed.  Gait speed and Edinburgh Visual Gait Score were assessed with and without the splints.

The child was able to stand and walk using the frame and some mobility without the frame as long as the combination of the footwear and splints was worn.

Walking mobility was not possible without the combination with this child

In conclusion the footwear/AFO combination can aid the mobility of some children with CP.



Article 3

Similar articles

Young J, Jackson S.Prosthet Orthot Int. 2019 Aug;43(4):453-458. doi: 10.1177/0309364619852239. Epub 2019 Jun 4.PMID: 31165679

Eddison N, Chockalingam N.Prosthet Orthot Int. 2013 Apr;37(2):95-107. doi: 10.1177/0309364612450706. Epub 2012 Jul 24.PMID: 22833518 Review.

Aboutorabi A, Arazpour M, Ahmadi Bani M, Saeedi H, Head JS.Ann Phys Rehabil Med. 2017 Nov;60(6):393-402. doi: 10.1016/ Epub 2017 Jul 13.PMID: 28713039 Review.

Choi H, Wren TAL, Steele KM.Prosthet Orthot Int. 2017 Jun;41(3):274-285. doi: 10.1177/0309364616665731. Epub 2016 Sep 9.PMID: 27613590

Rogozinski BM, Davids JR, Davis RB 3rd, Jameson GG, Blackhurst DW.J Bone Joint Surg Am. 2009 Oct;91(10):2440-7. doi: 10.2106/JBJS.H.00965.PMID: 19797580


Further articles read for information gathering to assist in choice of splints for the patient.




Section 5: Consultation details:

Consultation 1 (initial meeting)

Assess patients current situation and physical status and current social situation

Observe mobility, however this was not accurate as the posterior walker was not available at this point.

Patient gets out of her wheelchair and crawls independently but I would like to avoid this practice due to poor development opportunities moving forward.

Once patient has ability to stand she can go to school full time

Currently transitioning into school on a part time basis as the saftey equipment for her to mobilise is not available.

Fitted with 7.5 wide Leap frog splints that were in stock to give immediate assistance to give ankle stability . Knee hyperextension is not addressed at this point.

”Walking”at this point observed by support of gandmother, and leapfrog splints.

Patient is able to correct to neutral at the ankle


Consultation 2

Casts taken for GRAFOS – 2-3 * dorsiflexion

Top strap dee ring

Pattern Little lady bugs

Straps – hot pink

Padding medial arches and malleoli – Pink


Instruction and order sent to Manufacturer


Consultation 3

Fitting of  GRAFO’s into the patients own footwear

The left knee is still hyperextending – the shoes are round at heel so I will put her in Billy shoes to see if heel strike is more accurate and possibly look at adding a small heel raise to increase knee flexion and help aid the hinderance of hyperextension.

Order Billy shoes Unicorn metallic glitter.

Consultation 4

Patient came in for the fitting of her Billy shoes

Today Nan brought in her walker so I could observe mobility and go over the use of it with Nan as the patient had a fall at home using the walker..

The walker was provided by the school but no formal tuition has been given to patient and carer as to the purpose and function.

I have advised Nan to approach patients physio and I would expect patient to become more confident and efficient using the frame with physio support and education.

When checking the GRAFOs I noticed the proximal trimline needed to be adjusted as the top strap was loose. This was due to the depth of the AFO being greater than the circumference of the leg so it wasn’t really holding her knee against the anterior shell.

Following this adjustment the AFO fitted snugly over her legs.

The addition of a 1cm heel raise in both shoes created a small inclination of the tibia anteriorly to help prevent hyperextension of the knee.

Verbal consent gained from care giver to use this case for my personal CPD.





Section 6: Critical Appraisal of Case Study

What have you learned from this case?

Control of the hyperextension is well controlled by GRAFO’s and footwear combination in this case with small adjustments at fitting producing a good result.

The patient will benefit from gait training with a physio and a programme to suppliment this combination.

Mutli disciplinary discussion and intervention is valuable and raises healthy discussion to give good results for the patient and a good learning opportunity for colleagues.

Ongoing interaction with multi disciplinary teams allows up to date progress of the patient and ensures continued improvement in the interest of the patient


What could have been done better?

Time frame of the job could have been shorter but lock down, and social issues played a part in this.

Does this study contribute to prosthetic/orthotic research/evidence?





Section 7 – Photographs & Videos:

Please make sure you have written/verbal consent, that is doccumented, from all involved.









Section 8 – Refernces:

If you are unsure how to reference and or you require a referencing guide/tool then please use La Trobe University’s referencing tool:

You will need to select the style: APA 6         


If you do not reference the articles, and or anybody else’s work you have used in your case study, you may be suspected of plagiarism, which may come with your membership & accreditation being suspended.




Guide to Filling in a Case Study


This guide is to help you fill in the updated case study template. It is advised that you open the document in word and fill in electronically. If on any section you run out of space, just keep writing and the boxes will expand. Otherwise, add extra notes on the final pages of the document.


Section 1 Your Details

Fill in name and contact details for yourself. Please add the event number as detailed on the case study template.

Section 2 Abstract

An abstract is a brief summary of an article or review, and is used to help the reader ascertain the purpose of the content. In this section you should include brief patient details, methods of treatment, treatment outcome and review.

Example: 5-year-old male idiopathic toe walker presented to the orthotic clinic.  He had previously been issued with SB boots to resist toe walking with minimal success. At the initial re-assessment, he was found to have TA shortening and there was concern that this wasnt going to improve as he was still walking on his toes constantly. Rigid AFOs and night splints were suggested by the orthotist and were discussed with the orthopaedic consultant who oversaw the patients care. The night splints were not tolerated well as they rubbed during the night. The rigid AFOs for walking were very effective and tolerated well, the family also reported a strong carryover of flat foot walking when the AFOs were removed. A good stretch of the gastrocnemius was achieved with the AFOs, and after a few months of wear 10 degrees of dorsiflexion could be achieved with the knee extended. The patient was then recast for some hinged AFOs as he still tended to toe walk occasionally. The plan is to wear these for 6-12 months then wean the patient off AFOs altogether.

Section 3 Initial Assessment

Clinical Presentation: Summarise your subjective and objective findings. Subjective should cover what the patient told you, and objective is what you found from a look/touch/move assessment.

Orthotic / Prosthetic Aims: Detail here the specific aims of the orthosis. E.g. Resist foot drop and knee hyperextension by blocking plantar flexion

Discussion with multidisciplinary team: Usually when a new patient presents to the orthotic/prosthetic clinic there will be some discussion with the referrer or other members of the multidisciplinary team. If this didn’t occur in your case study example, just leave blank.

Orthotic/Prosthetic Prescription: Here detail your orthotic /prosthetic prescription. E.g. Rigid plastic AFO set in 10 degrees plantarflexion with heel raise, or Boston style TLSO with corrective padding positioned at. etc

Method/Plan: Detail your method of shape capture/measurement if applicable, whether fitting or reviews were required or carried out etc.


Section 4 Literature Review

Here is your opportunity to detail the literature used to help to make your clinical decision. If your decision was based on clinical experience, you should attempt to find some literature to support your prescription. It is imperative that orthotists and prosthetists continue to read upcoming research, and this kind of review helps to understand and build the increasing level of evidence. A simple google scholar search of your topic will help to find appropriate articles, and JPO and ISPO are also good places to look.

Please include a journal reference so the reader can locate the article independently. Then provide a summary and critical appraisal of the article & a passage on how the article relates to your case study. This should include the aim of the study, methods used and relevant findings. Your critical appraisal should attempt to identify if the results are reliable.


If you are unsure how to reference and or you require a referencing guide/tool then please use La Trobe University’s referencing tool:

You will need to select the style: APA 6


If you do not reference the articles you may be suspected of plagiarism, which may come with your membership and accreditation being suspended.


This is an example of a good reference, but you will require different types of referencing depending on what you are referencing (see La Trobe University’s referencing tool for more information):

Order: author(s), year of publication, article title (not in italics), journal name (in italics), volume number (in italics), issue number, and the page number range of the article.

E.g. Castles, F. G., Curtin, J. C., & Vowles, J. (2006). Public policy in Australia and New Zealand: The new global context. Australian Journal of Political Science, 41(2), 131–143.

One appraised article will be accepted, but it is recommended that at least 3 are read and detailed in this section.

Section 5 Consultation Details

This should include a summary of your clinical notes of the patient’s appointments. Not all visits need to be filled in if not required, and more rows can be added to the table if there were more than 4 appointments. Use the SOAP note format to ease understanding for the reader.

Subjective – what the patient told you

Objective – what you learned from your assessment

Action – What you did

Plan – What is the plan? E.g. Fitting, review etc



Section 6 – Critical Appraisal of the Study

It is important to reflect on what you have learnt from interesting or difficult cases. Here detail what you feel you have learnt from the case and how you will use this knowledge going forward.

Include anything you feel could have been done better.

As we continue to recognise the need for evidence-based practice it is important to consider ourselves as contributors to the evidence base. In this final section, reflect on whether your case study presents any new orthotic concepts or if it covers an area which is gapping in evidence. Consider how your case study may inform readers.

Section 7 – Photographs & or Videos:


Please make sure you have written/verbal consent, that is doccumented, from all involved.


More often then not photographs and or video phootage can add a lot of value to a Case Study. For the video include a link for the reader to be able to access it.

Consider adding photographs of the prosthesis/orthosis, and if appropriate, of your client before; during and after. For a video one could add footage of gait pre and post intervention.


We understand that photos and or videos are not always possible for every case study, in those cases please give a reason why they have not been included.


Section 8 – Refernces:

If you are unsure how to reference and or you require a referencing guide/tool then please use La Trobe University’s referencing tool:

You will need to select the style: APA 6


If you do not reference the articles, and or anybody else’s work you have used in your case study, you may be suspected of plagiarism, which may come with your membership & accreditation being suspended.


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