"New Paradigm" replies and a humble apology

Posted By: Kevin Matthews on December 1, 2011

In my attempt to be concise I neglected an important part o
Hello all, In my attempt to be concise I neglected an important part of this dialogue, the person responsible for this line of thought and treatment.  I apologize for the oversight.  I believe anyone that has been exposed to this practice has heard of the infamous Elaine Owens.  She is with the University of Strathclyde in Scottland, and Beverly Cusick did inform us of her groundbreaking work.  My apologies for the error of omission. I received many replies and quite a few inquiries.  I have literature available to those interested.  Send an e-mail and one of these days I'll send you some quite useful, thoughtful and groundbreaking lkiterature.  This is a very thoughtful approach and should not be taken lightly.  I would definitely recommend the always sold out conference featuring Elaine Owen's work at the Rehabilitation Institute of Chicago.  I have not, but will one day, attend an event. Following are a few, many were just inquiries, of the replies.   Hi Kevin, I was not in attendance at the meeting where Beverly Cusick taught and so am not privy to what was said.  However, your description of the client, placing the talocrural joint in PF, inclining the shank and lifting the contralateral side sounds very familiar to the work done by Elaine Owen, a Physio who practices in Wales. She started exploring AFO Footwear Combination with Tuning for her Masters at Strathclyde and worked with Roy Bowers, CO and under the tutelage of Barry Meadows, PhD.  Since 1986 she continued to work with AFOFC in a very large Paediatric Clinic of which she manages.  She started using slow motion video, but presently uses a Vicon Video Lab with force plate to observe Ground Reaction Forces.  This was published last year in Prosthetic Orthotic International http://poi.sagepub.com/content/34/3/254.abstract .  The article includes her Clinical Algorithms for decision making.  It is very important to pay careful attention to the way Elaine has presented this material, she has investigated these ideas very thoroughly. Next week will be the 4th year she will have lectured at our hospital, the Rehabilitation Institute of Chicago.  Beverly Cusick and John Russell were in attendance two years ago.  The 3 day course has been full for two months.  She will be returning in May for an Advanced course - the first of it kind anywhere.  She has lectured extensively in Europe. Elaine, myself, Stefanie Fatone, PhD, and Deborah Gaebler, MD have presented the material at the last two AACPDM meeting in Las Vegas.  I have presented with some of our Tuning Clinic team at the last ACPOC meeting. This is a very exciting technique and I am convinced a paradigm shift.  But there is a learning curve.  It is also very important to recognize these techniques as more than typical orthotic intervention. AFOFC with Tuning will influence Ground Reaction Forces by small changes in the AFOFC which have significant influences upon hip and knee flexion and extension moments.  These influences can have very positive effects on muscle length and activity which often require excellent physical therapy and continued orthotic assessment with the slow motion video.   There is a great deal of information contained in the above article.  I would suggest you read it.  Also Google Elaine and Roy as they have some other interesting items out there. ************************************ Hello Kevin It was good to read your post. I have been advocating (and practising) this approach for many years now, and have considerable experience in this area. I lecture on the subject everywhere I get the opportunity, and routinely teach this to our P&O undergraduates at Strathclyde. It is based on sound biomechanical principles and an understanding of the fact that if an AFO dorsiflexes the foot beyond the angle that can be readily achieved with the knee fully extended, then the orthosis will actually impact negatively on the knee and the hip, preventing full extension of both joints in terminal stance, and thereby possibly contributing to soft tissue contracture. Ensuring that the knee and hip are allowed to fully extend by casting at an appropriate "gastrocnemius length" can create a desirable biomechanical situation at the knee and the hip in TSt and can help maintain muscle length (providing you "tune" the angle of the tibia with wedges, as you did). I have even seen cases where the gastrocnemius has become longer due to good biomechanics using a solid AFO, which is counter-intuitive to some. Careful assessment of the length and tone of the gastrocnemius muscle is the key here. I spoke about this in 2005 at the AAOP meeting in Florida in a session I was fortunate to deliver with my friends Tom DiBello and Bryan Malas (in fact I believe I spoke to Tom and his clinical colleagues  in Houston on the same trip, and to the clinical staff at Shriners there). I have also spoken about the concept at subsequent AAOP meetings. I'll be at the meeting in Atlanta in March - if you are there I would be happy to meet up to discuss. I submitted a case study on this to Academy Today to try to raise awareness of this approach - you can find it at http://www.oandp.org/AcademyTODAY/2007Apr/4.asp - I hope it may be of some interest. I would be more than happy to discuss this further with you, and would contribute to your discussion group if I could - sadly I am in Scotland.... Keep trying this - you will not be disappointed ************************************************ Kevin: This technique has been around and used successfully for several years. Originally introduce by the University at Strathclyde, known as the Strathclyde Technique. It is now taught nationwide by a therapist whose name escapes me now, but I have her course materials. I have used this technique for about 7 years myself with excellent results but I would add that I now use motion at the ankles because it is far superior to locking them up. The joint I use is made by Ultraflex Systems and is call the USS Ankle (Ultra Safe Step Ankle Joint). I would love to participate in your discussion and know Beverly from many years back through her interaction with Sharon Vanderbilt and I in Chattanooga. Say hello for me. ********************************************* Kevin, I am in Canada, and very interested in Beverly's methods.   cannot attend your session.  We treat many spastic CP kids in our clinic, and I'd love to get more information. Thanks in advance, ....Lots like this **************************************************** Kevin, It is worth the time. The largest obstacle I have found is the MD's willing to get on board, they all reply "this is plantar flexed, make it at 90 degrees" I don't know how much Beverly went into the shoe mods, but I really don't think the shoe designs that Elaine uses would fly in the U.S. as well as getting the shoes paid for. ***************************************************** Hi Kevin I have to say that I have used your approach on a number of occasions. I don't see a significant number of serial casting patients mainly due to the fact that I am in private practice and the billing isn't covered as it is in public facilities. Regardless, what you say has been my experience. While tone is much different than simply mechanical alignment challenges, I also use the plantarflexed ipsilateral, external elevation contralateral approach. My most recent case is a young adult male, spina bifida who was tx'd w bil rigid afos. His chief compaint was a "sore arch". On assessment he had a significant callus following ulceration and multiple paddings at the medial aspect of his more affected foot. The previous orthotist strived to maintain a stable alignment which simply wasn't achievable in a plantar grade position. I plantarflexed his foot and supinated his forefoot which made a very stable aligment. It needed about a one inch wedge on the outside of the afo and equal elevation on the opposite shoe. Once done he walk very well, liked his afos for the first time, had no navicular pressure and "was taller" which was a huge benefit according to him. Sometimes I think we try to get to a magical angle or alignment putting patient ambulation needs in a compromised position. In your case, fighting tone isn't really going to win; working with it will. Good job! ************************************************** This is something we used in Houston.  I worked with Tom DiBello at Dynamic O and P (now I'm in Omaha).  The key seems to be paying attention to where the first catch of spasticity is (R1).  This is the starting point for where you cast.  Many times you can dorsiflex them past that R1 a little, but it really depends on the degree of spasticity.  What also seems to be a good addition is to use SACH foam for your heel wedge.  It dampens the knee flexion moment at loading response. Attached is some research by Elaine Owen that we really explains the whole concept.  I too am working on getting therapists behind that methodology so please let me know if you find an approach that really works well with these therapists. ************************************************ Hi Kevin,   I must have missed this posting, but a colleague of mine sent it to me.  I did not attend this lecture, but it sounds like she is presenting the work of Elaine Owen out of University of Strathclyde, who has examined the effect of ankle angle within the AFO as well as tibial inclination with respect to the floor.  The latter may be altered through footwear modifications, which she refers to as the AFOFC (AFO footwear combination).  I've attached the O&P Intl. article that was published last year.  I know that some orthotists at Rehab. Institute of Chicago (RIC), Children's Memorial (Chicago), and myself, among others are following this approach to varying degrees, but with good success.    Elaine Owen usually has a course at the RIC in December each year where you learn this technique.  I found it fascinating and well worth the trip to Chicago.  I've cc'd Walter Afable, who works within the O&P department at the RIC; please email him if you would like information about the course.  ****************************************************** There were more, but mostly requesting info.   Thanks to all that took time.  Merry Christmas all!!!    Kevin C. Matthews, CO/LO Advanced Orthopedic Designs 12315 Judson Rd. #206 San Antonio, Texas 78233 210-657-8100 210-657-8105 fax

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