Our discussion forums are available to anyone to read, but you must be a member to reply or start new topics. Log-in or register to get started.

Viewing 1 reply thread
  • Author
    Posts
    • #490073
      Aushem
      Participant

      On the 2nd SCI practice case, the following is given: Observational gait analysis reveals the following: use of front-wheeled walker, increased hip flexion during swing phase bilaterally, decreased knee extension at terminal swing bilaterally, increased ankle plantarflexion during swing phase bilaterally, absent heel strike at initial contact bilaterally, knee hyperextension during mid-stance bilaterally.

      Complete manual muscle testing in the lower extremities is as follows:
      – Hip flexion: 4/5 RLE, 4/5 LLE
      – Hip extension: 0/5 RLE, 0/5 LLE
      – Knee flexion: 0/5 RLE, 0/5 LLE
      – Knee extension: 4/5 RLE, 4/5 LLE
      – Ankle dorsiflexion: 2/5 RLE, 3/5 LLE
      – Long toe extension: 2/5 RLE, 2/5 LLE
      – Ankle plantarflexion: 1/5 RLE, 1/5 LLE

      Spasticity screening is unremarkable with the exception of bilateral knee flexors and ankle plantarflexors graded as 1+ on the Modified Ashworth Scale.

      Range of motion is grossly within functional limits with no contractures noted.

      Sensation screening reveals absent light touch in bilateral lower extremities, absent proprioception in bilateral ankles and great toes, and grossly impaired detection of pain in bilateral lower extremities. What AFO is appropriate?

      The answer is a solid AFO. Where I am confused is in the Shepard NCS practice text and other questions elsewhere, I have seen numerous times that a solid AFO should really only be used to reduce spasticity (which a 1+ has consistently been seen as non-significant in the Shepard questions). With things being inconsistent, what should I look for to know what should be used (ex: when should the SAFO be used, when should the PF stop be used, etc) because it can be frustrating feeling like I am getting a hold on this and then it turns out you are not. Thanks

    • #490085

      Hi Austin!

      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). Following the ROADMAP, this patient qualifies for a solid AFO based on his absent proprioception.

      I’ll add this one to my list to consider revising to give him more spasticity to make that answer a clearer choice.

      If I saw this patient in the clinic, I’d work with my orthotist and consider a solid AFO that could be converted to an articulated AFO with a PF stop. The PF stop will be key because of his ankle PF during swing phase, absent heel strike, and knee hyperextension (ankle PF) during mid-stance. My only concern is that knee hyperextension during stance phase. I would assume it is stemming from his profoundly weak hamstrings rather than his mildly weak quads- but, on the off chance his 4/5 quads are contributing to him seeking that stable position, the knee flexion moment created by a PF stop could lead to knee buckling.

      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

      • #490096
        Aushem
        Participant

        It does help, especially regarding if I can justify my answer then to not overthink it and worry about it. I haven’t gotten to the ROADMAP yet (starting cerebellum now) so will definitely be looking forward to that. Thanks!

Viewing 1 reply thread
  • You must be logged in to reply to this topic.