Road Map Question

[kaitmurphy25]

Hi,

I was going through some of the practice questions I had gotten wrong and was hoping to clarify one about the orthoses. In the practice questions, it said that had 4/5 knee extensor, 3/5 dorsiflexors and grade 1 ankle plantarflexor spasticity. When following the road map, the presence of spasticity would need a PF stop so long as it’s not severe. Why then is the correct answer for a DF stop? Do you only consider that if the spasticity is a grade 2 or above?

Thanks!

[Plucus]

My study partner and I are wondering the same thing! We are problem looking at the same test question. Cannot figure it out and hoping for someone with great AFO knowledge to explain!

If we are looking at the same question, I’m also not quite understanding how it comes to recommending ground reaction AFO?

[Aushem]

Hello. I believe this is the question you are mentioning: You note a 57-year-old male with right hemiparesis after a stroke demonstrates excessive right ankle dorsiflexion with knee flexion during static stance. During gait, the patient exhibits decreased foot clearance during swing phase and increased knee flexion during stance. Examination findings of the right lower extremity include: 4/5 knee extensor strength, 3/5 ankle dorsiflexor and plantarflexor strength, ankle range of motion grossly within functional limits, and grade 1 ankle plantarflexor spasticity. Which orthosis would be best for this patient?

The minimal spasticity gets rid of the rigid AFO option. The decreased foot clearance necessitates the DF assist (and because of the minimal spasticity we do not have to worry about using an assist) and the increased knee flexion/knee buckling in stance necessitates the DF stop or GRAFO. This leaves us with only 1 option that has both. The PF stop would be better if there was hyperextension in stance or increased PF spasticity. Spasticity that gets to 2 and higher starts to affect whether we can use assist with our AFOs or needing stops with the AFO. Hope this helps

[Chrissy Durrough Lugge]

Great explanation! 🙂

[Plucus]

Thank you Aushem! That explanation is super helpful. Would you mind sharing where you saw the MAS of 2 being considered “severe” spasticity? Or is that just clinical knowledge. I think that’s the part I keep getting confused on the roadmap (or one of rather). Thanks again!

[Chrissy Durrough Lugge]

If you follow the ROADMAP, you’ll see spasticity really comes into play when it “affects foot placement during standing or gait.” For Modified Ashworth grades 2 and under, the affected joints are “easily moved.” Therefore, scores of 3 and 4 are often considered “severe” spasticity for orthosis to the point that foot placement is affected by spasticity.

[Aushem]

I have seen from the Shepherd books/questions having MAS of 2 or higher being when “stop” AFOs should be considered. However, the question information should be used as well, such as if the foot is having trouble with consistent placement or if the spasticity leads to something. I agree with Chrissy above with the 3-4 on the MAS being “severe”. Really just focus on what the patient is having trouble within gait and make sure the answer choice is doing that to the best of its ability while also not being soooo restrictive.

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