Rancho ROADMAP questions

[Harriet Hill]

Hey Chrissy! I am working through the module 12 lecture and I have a couple of questions.

First, I am curious about this <3+/5 quad strength rule for long leg vs. AFO braces. I have never ordered or seen used a long leg brace for an individual post stroke in cases where they have <3+/5 quad strength. Is this a thing? I had never heard of the ROADMAP before studying for the NCS, and most of it makes sense in theory. However, in practice I have never seen this so I’m just curious. Is this where the first footnote in the bottom right corner of page 2 comes in? Or is this a clinical judgement situation as described in the disclaimer in the bottom left? Or something else?

I’m also wondering about the completion criteria for long leg braces. In the instance of your case 2 SCI patient, is this completion criteria done without braces? As in, they have to walk through the // bars independently and walk with an AD 20 steps with supervision only, but no braces? That’s what it seems like, but I just wanted to check since it seems like the whole point of braces would be to allow them to walk.

Thanks in advance for your help!

[Chrissy Durrough Lugge]

Hi Harriet,

I think the key here is that the ROADMAP recommends KAFOs for individuals with <3+/5 quad strength *bilaterally*. So, this recommendation pertains more for someone with SCI than CVA.

The completion criteria on the ROADMAP is WITH KAFOs. They recommend completing a trial with sample braces to ensure the patient will be able to learn how to successfully use KAFOs before ordering them for a specific patient.

For my case quiz and the question I think you are referring to, the patient is walking without braces and you are being asked to score him on the WISCI. It's not an orthosis/ROADMAP question.

I wrote this recently in response to another question and it holds up here: Orthoses are tricky and it’s difficult to find hard and fast rules (likely because they don’t really exist). I work with lots of orthotists and there are exceptions to every rule. I used the Rancho ROADMAP to provide evidence-based justification for my orthoses questions (though, admittedly, you could make a strong case for deviations from this algorithm for specific patients). As long as you can justify your reasoning, I think you will find you are in great shape for the NCS and clinical practice. Obviously, you can’t make your case on the NCS exam, but there won’t be enough orthoses questions for them to make or break whether you pass – and being able to defend your answer means it wasn’t a wild guess and that increases your chances of being correct.

Hope this helps!

Chrissy

[Harriet Hill]

Hi Chrissy! Thanks so much for your explanations. It is always helpful to talk it through with someone! I’m reviewing the Rancho ROADMAP again, and I have another quick question about part of the long leg algorithm and determining if a DF stop is indicated. I just want to make sure my general understanding of this is on track. It says a DF stop is indicated if PF strength </=4 and/or there is excessive DF/KF or PF/KE. Here is my understanding of why:
-PF weakness: reduced eccentric control of PFors during tibial advancement may cause excessive DF and result in buckling, so a DF stop would block this excessive tibial advancement and prevent buckling.
-Excessive DF: a DF stop would block this excessive tibial advancement and prevent buckling.
-Excessive PF: I would have thought excessive PF would indicate a PF stop, however I’m thinking maybe here excessive PF is a compensation d/t poor stance control (where excessive PF would results in knee hyperextension, as a compensation to prevent buckling). In this line of reasoning, providing the pt with a DF stop would prevent buckling and help them not have to compensate as much.
Just wondering if I’m on the right track with this reasoning, or if I’m missing something!

[Harriet Hill]

Oops – just realized I meant this question to be referencing the AFO algorithm on page 3, NOT the long leg orthoses on page 2. Sorry about that!

[Chrissy Durrough Lugge]

Hi Harriet! I couldn’t have explained it better myself! Spot on! 🙂

[Author]

Posts