Selecting Appropriate and

Effective Equipment: Choosing the right equipment

„ Mobility
„ Purpose
„ Design
„ Painful sitters
„ Difficulty with proper alignment

Orthopedic Issues Optimizing the environment

„ Loss of passive joint mobility „ House
„ Fixed contractures „ School
„ Loss of stability „ Recreation
„ Scoliosis „ Car

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 Important determinants of
Mobility
ambulation potential
„ Energy Expenditure
„ Spasticty
„ Contractures
„ Pain

Ambulation Categories
„ Community
„ Household
„ Exercise
„ Nonamulatory

Community ambulators
„ Pelvic control with at least fair strength in
hip flexors bilaterally and in at least one
knee extensor

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Potential benefits
„ Ability to overcome functional barriers
„ Increased self esteem
„ Cardiopulmonary exercise
Mechanical devices to assist
ambulation
„ Hip-knee- ankle-foot orthosis (e.g.
reciprocating gait brace)
„ Knee-ankle-foot orthosis (e.g. Scott-Craig
brace)
„ Ankle-foot orthosis
Neurologic predictors for
ambulation
„ Level of injury below T11 associated with
increased potential for ambulation
„ Complete tetraplegia do not become
“community” ambulators
„ Chronologic age is not by itself a
prognostic factor
Rehabilitation for ambulation
training
„ Strengthening of the lower and upper
extremities
„ Control of the pelvis and trunk
„ Joint stabilization
Goals
„ Prevent or accommodate orthopedic
deformities
„ Prevent skin break down from pressure
„ Provide trunk stability to enhance arm
function
„ Promote independent mobility
„ Facilitate independence in the activities of
daily living
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Planning a seating system
„ Angle between the seat and the back
surfaces
„ Tilt of the system in space
„ Type of seating surface
The Angle
„ Whatever is needed to
„ maintain the pelvis in an neutral or slights
anterior pelvic tilt
„ achieve the proper lumbar curve
„ provide a base for good spinal alignment

Opening the angle (making it Using head, shoulder, and back

more than 90 degrees) extensors to remain upright
„ At 90 degrees of hip flexion need to be
available
„ Over 90 degrees may reduce spasticity
„ But may also destabilize trunk support
„ May force low back extensors to “fire”
increasing lumbar curve

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 A slight tilt may help sit more
Upright support options
upright against gravity
„ Anterior harnesses or chest straps
„ Upper extremity support like a tray
„ Tilting
„ slight tilt may be enough to sit more upright
against gravity

Tilt-in-space base The Seat

„ Planar
„ Contoured
„ Provides adjustment
for seat tilt while „ Custom molded
holding hip, knee, and
ankles in place

Sitting on flat surfaces may cause Some types of foam will reshape
increased pressure over bony in response to body weight
prominences

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Blocks can be added to the sitting High density foam shapes can be
surface to provide lateral as well placed under more flexible foam
as posterior supports to create a contoured cushion

Seat Surface The pelvis and lower extremities

„ Does the seat provide enough support? „ A firm base of support is needed from
„ Is the seat the proper depth? which to function
„ The base needs to be
„ Does the seat provide enough pressure
„ Stable
relief?
„ Symmetric
„ Supportive
„ The pelvis position should be neutral or
slightly tipped forward

Posterior pelvic tilt affects body

Falling into anterior pelvic tilt
posture
„ Weakness
„ Discomfort „ Very low tone
„ Finding a balance „ Hip flexion
point contractures
„ Shortening of the
hamstring muscles

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 Sitting in a sling seat increases
asymmetries
Back Surface
„ Does the back surface provide enough
support?
„ Is the seat the proper depth?
„ Is the back support high enough?
If the seat is too deep then the
pelvis will tilt back causing the
pelvis to round
Firm sitting surface provides a
good base of support
Support to the back of the pelvis
can help maintain good
alignment
Is the back support high enough?
„ Fair trunk control – should rise to the
middle of the shoulder blade
„ Poor trunk control – should rise to the
shoulder
„ Increase extensor tone – should rise to the
shoulder
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 Positioning belts or bars are used
to prevent the pelvis from
slipping
„ A belt across the
waist will encourage
posterior pelvic tilt

A rigid bar may be needed with Hip guides to control pelvic

excessive trunk extension position

Knee supports Trunk supports

„ A “spacer” may be
needed to keep the
legs in a neutral
position
„ It should start at the
front of the knee and
move 1/3 of the way
up the thigh
„ Leaning to one side
or the other
„ Muscle imbalance
„ Poor postural control
„ Discomfort
„ Perform a functional
task

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 Three point control is needed to
maintain trunk position
Y straps tend to bind against the
side of the neck putting pressure
over neck blood vessels
Standing Frames
Proper position of the straps is
very important
„ The strap should pass
over the shoulder to a
point at or slightly
below the shoulder
line
„ The bottom should be
securely tethered
H straps work well but should not
be tethered to the lap belt
Gait trainers
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Orthopedic surgery: Should we
or shouldn’t we?
Common Clinical Patterns: Lower Limbs
Orthopaedic surgery
„ 3 major goals
„ Remove or diminish muscle imbalance
„ Prevent bony deformity
„ Correct bony deformity
Decisions to treat
„ Based on degree of contracture
„ Whether the joint motion covers a
“functional” range
„ Belief that surgery will improve the natural
history
Physiology of Contractures
„ Mobile tissues usually separated by thin
layers of loose areolar connective tissue
„ Immobility causes reorganization of the
loose connective tissue
„ Once soft tissues are involved - muscle
shortening may follow
Orthopaedic Surgery: Goals
„ Muscle-tendon surgery
„ restore dynamic alignment
„ improve agonist-antagonist balance
„ Osteotomies
„ realigns osseous levers
„ correct torsional deformities
„ Arthrodesis
„ stabilize severely subluxed, painful arthritic joints
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Musculotendinous Procedures
„ Lengthening of the tendon
„ Tendo Achilles lengthening
„ Hip adductor tenotomy
„ Lengthening of the musculotendinous
junction or fascia
„ Strayer, Vulpius, or Baker lengthenings
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Defining the functional problem
„ Joint contracture: loss of passive range of motion
„ muscle-tendon unit
„ dynamic which is braceable
„ fixed which requires surgery
„ ligament or joint capsule
„ Gait deterioration
„ Joint instability or torsional deformity
„ Pain
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