Orthotic Management of Charcot Marie Tooth

Mr Simon B Dickinson MSc (Hons) MBAPO SRpros/orth

Orthotic Clinical Lead & Clinical Specialist-Nottingham University Hospitals

Professional Affairs Chairman- British Association Of Prosthetists and Orthotists (BAPO)

Orthotists are registered healthcare professionals who specialise in the assessment of the whole body for biomechanical problems and if appropriate may prescribe, measure, fit, or review, an orthosis.

An orthosis is an externally applied device.

It may also be called a „brace‟, „splint‟ or „orthotic‟.

The purpose and design of an orthosis may change over time along with the changing needs of the patient.

An orthosis can: improve function, reduce pain, prevent deformity.

Centre of Excellence In-house service On site

manufacturing 3 sites 3rd Largest Orthotics

department in England

The Team 7 Orthotists 6 Administrators 4 Technicians

Neurologist

Orthopaedic Surgeon

Orthotist

Physiotherapist

Podiatrist?

Named in 1886

Common inherited Neurological disorder

Affects 1:2500 people

Affects peripheral sensory and motor nerves

Mainly affects feet and hands

Slowly Progressive

Impaired Balance

Recurrent Ankle Sprains/fractures

Changing foot shape (high arch, flat foot

Drop-Foot

Reduced hand function

Motor nerve degeneration

Typically weakening Peroneal muscles (ankle evertors) causing muscle imbalance

Repeated sprains weaken lateral ankle structures

Weakness in Peroneal Muscles

Initially ankle feels unstable

Made worse on uneven ground

Frequency of sprains increases

Weakness of pre-tibial muscles

Initially causes increased tripping

Foot Slap

Compensation by bending knee and hip excessively to help swing leg through

Patient History/Diagnosis

Biomechanical Assessment

Gait/Pressure/Force Analysis

Establish Biomechanical Deficit/Objective

Design Orthosis

Measurement/Casting

Fitting Stage

Is Biomechanical Objective Being Achieved?

Yes No

Follow Up Return To Beginning

Review

Manufacture

This must include:

Weight Bearing and Non-Weight Bearing Exam

Static and Dynamic Assessment

Proprioception

Physical Examination

For every patient and EVERY Joint

Ask about discomfort/pain in segment

R.O.M (Range of Motion)

Muscle Strength

Limitations/compensations

Soft tissue

“Neutral”

Supination Pronation

Protect against excessive ankle inversion

Function is to evert ankle and forefoot

Mm

d D

For Rotation Equilibrium to occur the net turning moment must be zero

M x d= m x D

GRF

MF

2D D

GRF x 2D = MF x D

Improve Balance

Improve Stability

Improve Walking Pattern

Prevent deformity

Reduce Pain

Supplement function of weakened muscles

Reduce need for Surgery

Every patient is different

Every Patient should be thoroughly assessed

Orthosis designed in conjunction with patient and clinical team

Orthosis should be designed to meet patients needs

Orthosis should be as comfortable and cosmetic as possible

Insoles (foot orthoses) Ankle Braces Supra Malleolar

Orthoses (SMO‟s) Ankle Foot Orthoses

(AFO‟s) Silicon Ankle Foot

Orthoses (SAFO‟s) Footwear and

footwear adaptions Conventional calipers Surgery?

Orthopaedic footwear controls foot deformities

Insoles (foot orthoses) correct feet to neutral and make them work normally

All AFO‟s should be at 90 degrees

The hindfoot and forefoot should be held neutral in an AFO

Aim to improve stability and reduce pain

Rarely pre-made

“Gold standard” is custom made

Wedges added to improve alignment and stability

DESIGN ESSENTIALS

Should conform to shape of foot

Fairly rigid

Durable materials

Wedges to replace function of weakened peroneal muscles-lateral forefoot wedges

Accommodate fixed deformities

Should be comfortable

FUNCTION

Reduce heel inversion

Improve ankle stability

Can assist very mild drop foot

Caution

Ankle braces can improve stability but can make ankles weaker when brace removed

Push Aequi.

Correct drop foot

Increase ankle stability

Improve balance

Prevent contractures

Can be bulky and cause problems with footwear

Should be comfortable

Strong durable devices

Should conform to shape of leg and foot

Should correct poor foot alignment

Accommodate fixed deformities

Wedges to replace function of weakened peroneal muscles-lateral forefoot wedges

Ankle straps to control ankle position

Highly cosmetic

Appropriate for very mild instability and easily correctable drop foot

Difficult to apply/remove

Tolerance?

Unsuitable for moderate to severe ankle instability

Unsuitable for any patient with reduced ankle movements

Required to accomodate fixed deformities

Must have custom made insole inside boot/shoe

Can be reinforced for increased support

Footwear adaption: Heel raises, wedges, floats/flares

Used to provide increased forces

Must be used in conjunction with appropriate footwear

Must be used in conjunction with foot orthosis

Orthotic treatment for patients must be designed to meet their individual needs

Orthoses must be appropriately designed and made

All patients must be regularly reviewed

More investment must be made to improve orthotic treatment options to meet the needs of patients