Functional Top Down Approach to Bracing RGOs Reciprocal

Functional Top Down Approach to Bracing • • • RGOs (Reciprocal Gait Orthoses) HKAFOs (Hip Knee Ankle Foot Orthoses) KAFOs (Knee Ankle Foot Orthoses) AFOs (Ankle Foot Orthoses) FOs (Foot Orthoses)

DISCLAIMER • The upcoming algorithm should be used for the adult/pediatric population with neuromuscular impairments who are looking to ambulate as a means for functional mobility.

Lower extremity Bracing algorithm Is your patient a candidate for restorative, locomotor therapy? Yes Proceed to the Locomotor Therapy section No Is your patient a candidate for functional electrical stimulation? Yes No Proceed to FES section Proceed to the bracing algorithm

Algorithm Overview Is trunk support required to maintain standing? Yes No Able to advance lower extremity with full step? Able to maintain frontal/sagittal plane pelvic stability without therapist assistance during gait cycle? No Yes No Is a reciprocal gait pattern desired? HKAFO algorithm Able to maintain knee stability in stance phase of gait during contralateral step? HKAFO algorithm No Yes No Hip Guidance Orthosis, TLSO with HKAFO or parawalker RGO algorithm Able to clear foot through swing phase of gait? KAFO algorithm Yes No FO algorithm AFO algorithm

Reciprocal Gait Orthosis (RGOs) Is trunk support required to maintain standing? No Yes HKAFO algorithm Is patient able to advance involved LE with maximum assist below hip? No Yes Is a reciprocal gait pattern desired? HKAFO algorithm Yes No Hip Guidance Orthosis, TLSO with HKAFO or parawalker Does patient weigh…? Up to 55 pounds ? Up to 85 pounds? Up to 132 pounds? Horizontal cable RGO ARGO 25 Up to 175 pounds? Fillauer Rocker Bar ARGO 60 Up to 200 pounds? Greater than 175 pounds? COD IRGO Horziontal cable RGO Fillauer Rocker Bar Aluminu m Rocker Bar COD HD welded ARGO 90

Hip Knee Ankle Foot Orthosis (HKAFO) Is trunk support required to maintain standing? Yes No RGO algorithm With assistance at hips, is patient able to advance lower extremity with a full step? No RGO algorithm Yes With assistance at hips is patient able to maintain upright trunk control and frontal/sagittal alignment at hips during gait cycle? Yes No KAFO algorithm With assistance at hips is patient able to maintain upright trunk control and frontal/sagittal alignment at hips during gait? No Yes KAFO with locked joint-refer to technical sheet Free motion HKAFO in sagittal plane KAFO algorithm for knee and ankle joints Refer to KAFO to determine knee and ankle joints

Knee Ankle Foot Orthosis (KAFO) Without assistance at hips is patient able to maintain upright trunk and frontal/sagittal alignment at hips during gait cycle? No Yes HKAFO algorithm Is patient able to maintain knee stability (frontal and/or sagittal plane) in stance phase of gait during contralateral step? Yes No AFO algorithm Does patient present with knee stability (frontal and/or sagittal plane) without ankle involvement) Yes No Knee orthosis technical sheet In staggered stance, is patient able to initiate swing phase while maintaining frontal and/or sagittal pelvic/trunk stability to position limb for weight acceptance? Yes No Stance Control KAFO Locked knee KAFO

Ankle Foot Orthosis (AFO) *1 -knee flexion and/or hyperextension *2 -instability defined as decreased control of movement Is patient able to maintain knee stability (frontal and/or sagittal plane*1) with assistance provided at ankle in stance phase of gait during contralateral step? Yes No Does patient present with significant sagittal ankle instability *2, medial/lateral instability *3 and/or knee instability that requires control of the ankle and/or tibia during gait? KAFO algorithm No Yes Swing Clearance Assist (isolated foot drop) Does patient have medial/lateral ankle instability without sagittal ankle instability or knee stability? “Dorsiflexion maintainence” *4 -AFO with posterior trimline, semi-solid or posterior leaf spring design (including carbon fiber) *4 Static hold/positioning into ankle dorsiflexion or neutral position *3 -instability defined as subtalar, forefoot/hindfoot, excessive movement and or alignment “Dorsiflexion assist” *5 -dual action ankle joint or anterior spring channel or FES *5 Dynamic movement into ankle dorsiflexion Yes No Does patient have moderate to severe medial/lateral instability *6 present? Proceed to next slide No Yes FO algorithm Free Motion AFO *6 Consider alignment/movement up the kinetic chain causing medial/lateral ankle instability (ie knee varus/valgus, femoral anteversion/retroversion, leg length discreptancy

Ankle Foot Orthosis continued. . Does patient have medial/lateral ankle instability without sagittal ankle instability or knee instability? Yes No Does patient demonstrate a gait pattern of excessive knee hyperextension with/without excessive ankle plantarflexion/tibial recline? Refer to previous slide Yes If patient is assisted into decreased ankle plantarflexion or tibial incline, are they able to maintain stance stability without significant knee hyperextension? No Does patient demonstrate a gait pattern of excessive knee flexion with ankle dorsiflexion during stance? No Yes If patient is assisted into decreased ankle dorsiflexion, is patient able to maintain knee position/stability during contralateral step? Yes No AFO with plantarflexion Proceed to control or use of heel wedging KAFO algorithm No Yes KAFO algorithm Dorsiflexion control See next slide Anterior floor reaction Solid with pre-tibial shell Articulated with dorsiflexion stop

Ankle Foot Orthosis continued. . Does patient demonstrate a gait pattern of excessive knee flexion with ankle dorsiflexion during stance? Yes See previous slide No Does patient demonstrate decreased ankle push off that impairs advancement of limb and decreases velocity? No Plantarflexion assist and 3 rd rocker simulation Does patient demonstrate decreased control of ankle plantarflexion during initial stance? No FO algorithm Yes Plantarflexion control or stop Yes Articulated joint with plantarflexion control Posterior leaf spring Footwear