Polio Place

Orthotics
Orthotics is the use of braces and splints (orthoses) to biomechanically assist in supporting and stabilizing parts of the body affected by paralyzed and/or weak muscles (Bunch, 1985). Orthotics, grouped by a description of the area in which they provide support, are usually divided into three categories:  lower extremity, upper extremity, and spinal. For example, in lower extremity orthotics, foot orthoses (FO) support and align the foot. Knee orthoses (KO) protect and support the knee joint. An orthotic device designed to support the whole lower extremity is called a knee-ankle-foot orthosis (KAFO). Upper extremity and spinal orthotics have similar classifications.

Increased pain, tripping, falling, dropping objects, and muscle loss are an alert to problems in the joints and muscles of the extremities (Redford, 1980). Many polio survivors who discarded their braces in earlier years, through therapy and sheer will, are in need of support once again. Bracing of joints and muscle groups can reduce pain; can prevent tripping and falling; may prevent further development of a joint deformity; and may conserve energy by making activities, such as walking, more efficient.

Communication among the polio survivor, the referring physician, and the orthotist is imperative to design the best possible brace. Today’s braces are often constructed of lightweight plastics and metals with fixed (locked) and/or free (movable) joints, not of leather and steel. The referring physician prescribes the general type of orthosis, including core components such as fixed or movable joints, or metal or plastic fabrication. The physician also includes the diagnosis and the functional goals of the orthosis. The orthotist fabricates a design based on the prescription, including information from a gait analysis and information about the individual’s home, work status, and physical activities.

In general, one must have a physician’s prescription to be reimbursed for orthoses by any insurance company, including Medicare and Medicaid. Most states do not have certification laws for practicing orthotists, but many are certified by professional trade organizations after a minimum of two years of study and training.

Having to use a brace should not be viewed as defeat, but as making a lifestyle change that will provide added stability and safer, more efficient, and less painful mobility, thus enhancing continued independence. 

Excerpt from PHI's "Handbook on the Late Effects of Poliomyelitis for Physicians and Survivors." © 1999

The Latest
The latest in bracing for polio survivors after the frequent switch from leather and metal to lighter materials, such as aluminum and various forms of plastic should be a more comprehensive evaluation of the survivor's unique needs and abilities and more emphasis on follow-up and training in the use of the device.  Other new approaches, when appropriate, include 1) a "stance control" knee joint that can lock into full extension when weight is applied to that limb and unlock when weight is not applied to the that leg, eliminating the need to manually unlock the knee joint when one wants to sit down and allows more normal gait, 2) lightweight but strong materials such as carbon fiber composites,3) materials that "store" energy during part of the walking cycle and release it when needed for other parts of gait, 4) electronic joints and stimulators that help the muscle "fire" during certain phases of gait, 5)  rethinking design and using more "ground reaction forces", and 6) a combination of two or more of the above into a single orthosis.

La ortótica 

La ortótica es el uso de aparatos ortopédicos y tablillas (órtesis u órtosis) para asistir biomecánicamente en el soportar y estabilización de partes del cuerpo afectados por músculos paralizados y/o débiles. La ortótica, agrupada por la descripción del área en la cual se provee apoyo, se divide usualmente en tres categorías: Extremidades inferiores, extremidades superiores, y espinal. Por ejemplo, en la ortótica de las extremidades inferiores, las órtesis del pie (FO [por sus siglas en inglés, foot orthoses]) soportan y alinean el pie. Las órtesis de rodilla (KO) protegen y apoyan la articulación de la rodilla. Una órtesis (llamada también aparato ortopédico) diseñada para soportar la totalidad de la extremidad inferior es llamada: órtesis de rodilla-tobillo-pie (KAFO). Las órtesis de las extremidades superiores y de la espina tienen clasificaciones similares.

El incremento de dolores, tropezones y caídas, así como dejar caer objetos y pérdida de músculos son una alerta a problemas en las articulaciones y los músculos de las extremidades. Muchos sobrevivientes de polio, quienes habían descartado sus aparatos ortopédicos a temprana edad debido a la terapia y a su fuerza de voluntad, necesitan soporte nuevamente. El uso de abrazaderas en las articulaciones y grupos musculares puede reducir el dolor; puede prevenir tropiezos y caídas; puede prevenir el futuro desarrollo de deformidades en las articulaciones; y, puede conservar energía, haciendo que actividades, tales como caminar, sean más eficientes.

La comunicación entre el sobreviviente de polio, el médico tratante y el ortesista, es imperativa para diseñar el mejor aparato ortopédico posible. Los aparatos ortopédicos contemporáneos con frecuencia se construyen de plásticos y metales livianos, con articulaciones fijas (con seguro) y/o libres (móviles), y no de cuero y acero [, como era antes la costumbre]. El médico tratante prescribe el tipo general de órtesis, incluyendo los componentes básicos, tales como las articulaciones fijas o móviles, y la fabricación en metal o plástico. El médico también incluye el diagnóstico y las metas funcionales de la órtesis. El órtesista fabrica un diseño basado en la prescripción, incluyendo información proveniente de un análisis de la forma de andar y datos sobre la manera de vivir del individuo que incluye su vivienda, tipo de trabajo y actividad física.

En general, uno debe tener una prescripción médica para que las compañías de seguros reembolsen los costos de las órtesis [si aplica] incluyendo Medicare y Medicaid[2] [y el seguro social, en otros países]. La mayoría de los estados [de la Unión Americana, y otros países], no tienen leyes de certificación para la práctica de los órtesistas, pero muchos de ellos son certificados por organizaciones profesionales comerciales después de un mínimo de dos años de estudio y capacitación.

Tener que usar un aparato ortopédico no debe ser visto como una derrota, sino como realizar un cambio en el estilo de vida que proveerá estabilidad agregada y una movilidad más segura, más eficiente y menos dolorosa, lo que redundará en una independencia continuada.

Excerpt from PHI's "Handbook on the Late Effects of Poliomyelitis for Physicians and Survivors." © 1999

The Utility of Post-Polio Bracing
Patients with post-polio weakness can often benefit by using an appropriate brace.

Braces can 1) provide support, 2) correct a flexible deformity, or 3) relieve pain. Usually it is best to correct a fixed deformity through stretching or surgery before applying the brace. Post-polio patients require special consideration when it comes to bracing. They usually present with both weakness and deformity. They often have post-polio muscular atrophy (so-called "post-polio syndrome") often accompanied by the arthritic changes of advancing age accelerated by joint deformity secondary to their poliomyelitis. Bracing can sometimes avoid the need for surgery. Patients often have worn braces during earlier rehabilitation and they sometimes present in braces. These are often heavy leather and stainless steel calipers. Though cumbersome, patients get used to their weight as they feel "supported." It is sometimes difficult convincing the patient to accept a modern plastic brace which is thinner and lighter, though equally supportive.

Let us now consider some of the special problems in bracing for the post-polio patient.

Lower extremities:
The legs are more frequently in need of bracing than the arms. Where quadriceps (thigh) weakness is modest, a neoprene wrap-around knee sleeve can offer sufficient support, especially if augmented by the use of a cane. With severe weakness and an almost flail limb, support is provided with a thin plastic knee-ankle-foot orthosis (KAFO) with Velcro closures and an eccentrically-placed knee hinge which permits knee flexion during the swing phase of gait, locking in extension on heel strike. Where indicated, an ischial weight-bearing socket can provide hip support. Sometimes elastic strapping can effectively substitute for weak hip extensors.

Knee position can be adjusted in a short-leg brace (ankle-foot orthosis) by adjusting the position of the ankle on stance. Modest quadriceps weakness can be addressed in this way. For instance, an ankle-foot orthosis (AFO) can incorporate slight equinus (plantar flexion) for toe-touch, forcing the knee into extension on toe weight-bearing. Where hyperextension (back knee) is a problem, lowering the heel of the brace can cause the knee to flex (bend) on heel strike.

For the average post-polio patient with calf and thigh weakness, the most satisfactory below-knee brace is hinged and allows free plantar flexion of 15-20° while permitting only 5-10° of ankle dorsiflexion. This provides adequate stability yet permits enough ankle mobility to facilitate stair walking.

Orthotics (arch supports) and shoe modifications can balance the foot. Heel grip arch inserts or supramalleolar orthoses (SMOs) can help position and support the ankle.

The judicious use of a cane or forearm or axillary crutches can stabilize gait. Every five pounds of force transmitted through such an appliance relieves the hips of 25 pounds of pressure. However, a patient requires strong upper extremities to use crutches or a cane, as the arms now become weight-bearing extremities.

Upper extremities:
A variety of neoprene sleeves, with or without stays, can be used for elbow support. Off-the-shelf wrist splints as well as custom dynamic finger splints are available to assist weakened hands. The neoprene or elastic thumb spica will stabilize the thumb, reduce pain and assist pinch.

Spine:
The torso and spine can be supported by a variety of custom braces. Some are total contact, others use three-point pressure (sternum, pubis, spine) to maintain upright spinal posture.

A weak neck can be supported by a soft myocervical collar. Where a more substantial brace is indicated, a plastic (C-breeze or Aspen type) collar can be prescribed. Lightness as well as support is offered by the Oxford cervical brace.

Summary
The special needs of the post-polio patient provide a unique challenge to his physician and orthotist. However, with careful consideration of the faulty biomechanics involved in each case an appropriate brace can be fabricated that will assist the patient to live as functionally as possible for as long as is feasible.

Irwin M. Siegel, MD

Dr. Siegel is an orthopaedic surgeon at Rush University Medical Center, Chicago, Illinois. He specializes in the orthopaedic and physiatric rehabilitation of patients with neuromuscular disorders including post-polio syndrome.

Using diagrams, More About Braces shows different brace types and photos of children wearing them. The article is from StandProud, a non-profit that provides corrective treatment, locally-crafted leg braces, and accompanying rehabilitative services, at no cost to poor families with children who have been disabled by polio or who have similar disabilities, and promotes the full integration of disabled persons into society. They currently support groups in the Democratic Republic of the Congo. 

BRACE YOURSELF!
Along with wheelchairs, nothing conjures up as much anxiety as the idea of having to use new—or long-ago discarded—splints, braces, canes or crutches. Using supportive devices may seem like sending a beacon to the world that we are disabled. After years of functioning without obvious aids, it seems like stepping backwards.

I know how difficult these transitions are. I had polio in one leg at age nine and functioned relatively well for thirty years. All that time I fooled myself into thinking I was a "passer" and worked very hard not to look disabled. I'm convinced now that the stress of trying to fit into the able-bodied world brought on my post-polio symptoms sooner.

By the age of forty-one I had so much pain and instability in my polio knee that going without bracing was no longer an option. About ten years later I starting using a cane and later a forearm crutch, then a scooter for distance walking. As each new piece of equipment became part of my life, my overwhelming emotion was relief, and I wondered why I hadn't done it sooner. My quality of life improved, and I didn't have to prove anything anymore.

Supportive devices and walking aids offer many advantages, such as compensating for muscle weakness, relieving pain, and supporting unstable joints. All this makes a big difference in our energy level and therefore our functional level.

When muscles are too weak to provide support during walking, such as the quadriceps muscle at the front of the knee, ligaments have to provide the support. This can lead to problems like "back-knee" or medial-lateral instability (sideways shifting), and the joint gradually deteriorates. Once a joint is damaged, it will not regain its former functional level, but a long-leg brace can maintain the knee in an acceptable position.

Weak muscles at the front of the ankle can cause a "foot drop" where you cannot bring your toes upward to allow your heel to hit the ground first. To keep from stubbing your toe and possibly falling, your leg has to lift higher than normal with each step. In this case, a short leg brace is an energy-saver and a safety aid.

Weakness in the wrist or thumb muscles can cause you to compensate by moving your arm in ways which quickly fatigue the whole upper extremity, including the elbow and shoulder muscles. Hand splints such as a wrist or thumb support keep these joints in a functional position. If a brace or splint is fabricated properly and fits well, it should never be uncomfortable, throw you off balance, or compromise your function. Now and then commercial off-the-shelf devices are adequate, but it usually works better when the appliance is custom-made especially for your individual problems. Don't hesitate to return, as many times as needed, to the person who made your device if you experience any problems at all. I've known people who were afraid to be critical so they didn't report difficulties and ended up storing the appliance in the closet. If we want our needs to be met, we must learn to be effective complainers.

© 2008 Grace R. Young

BRACE MAINTENANCE AND CARE GUIDELINES
Brace maintenance and care will improve the function, extend the life and improve the comfort of the brace. The following guidelines are provided for your use. Please feel free to ask any questions.

I. Plastic braces:
Check for discoloration in the plastic on a regular basis. Discoloration indicates that the plastic in those areas is excessively stressed, creating the possibility of breaking and/or plastic failure with the associated incident of falling or injury. Bring this to the attention of your orthotist!!

Cracks-look for cracks in the metal joints-especially around rivets and by any joints. Again, bring this to the attention of your orthotist.

Clean plastic with a damp wash cloth using the same soap that you use on a daily basis. Wipe out well. If no padding is present, the brace can be washed under water. If pads are present, this is not recommended as the water can become trapped between the materials and cause separation.

Wipe pads off in the same manner but do not scrub the pad as it will roughen the surface and cause either friction or further soiling. Alcohol pads can also be used to wipe down the brace/pads.

The brace should be wiped out on a regular basis to reduce the incidence of dermatitis and odor. Using a sock or interface between your skin and the brace is standard- this will reduce the need for cleansing and protect your skin. Socks should be cotton/polyester blend with low-profile semis and no heavy banding, sewn in designs or anti-slip pads. If your leg size precludes you from using standard socks then a section of thermal underwear can be used to cover the calf area.

Check your shoes on a regular basis- remove the brace, the insole and shake out my sand, gravel, animal hair, etc. All these can abrade the bottom of the plastic brace and can be the site of plastic fracturing. Shoes should be leather, full cut, removable insole, Velcro or lace closure. There should not be any significant heel and the width of the sole should be appropriate for the size of your foot and the type of stability you need. Avoid manmade uppers, avoid heavy seams across the forefoot and make sure the shoe holds your foot into the brace securely. The shoe is a functioning part of your brace- it secures the brace to your foot and aligns your foot/ankle to the ground. Replace when the upper becomes stretched and sloppy- you are reducing the function of the brace and in effect, your safety.

DO NOT USE THE FOLLOWING. Febreeze, super glue, solvents, torches, tin snips, dremels, hack saws or band saws. Stay out of the tool shed! If you have a problem with your brace or with the function of your brace- TALK TO YOUR OTHTOTIST OR YOUR DOCTOR! I promise to stay out of your professional field if you promise to stay out of mine.

II. Metal and Leather braces:
Check for cracks in the metal joints on a regular basis especially around the rivers, the knee joints and the ankle joints. Check that any moving parts or aligned hinges are moving freely without any halting, binding or squeaking. If concerns are noted, speak to your orthotist.

Joints need to be cleaned and lubricated on a regular basis. Remove any fiber or debris out of the hinges with a cloth, a toothpick or with a can of compressed air. Use a dry silicone lubricant on the hinges and wipe off any excess. It is best to lubricate the hinges at night, thus permitting any excess to drain out, hopefully avoiding soiling your clothes. Wipe off the hinges again prior to wearing the brace.

If crunching or grinding is heard at any joint, you need to see your orthotist. Parts break, wear out, get out of alignment and get rusty. Most springs or ball bearings can be easily replaced, realignment is a tougher job. A metal hinge requires smooth function in order to move with your leg and to lock/unlock when needed. 

Do not add anything to your hinges unless your orthotist approves. Materials added to protect clothing can impede the secure locking of the hinge and increase the possibility of falling.

III. Straps
Straps hold the brace onto the leg and provide biomechanical alignment between the brace and your body- each strap has a unique function and needs to be secured in order to achieve the outcome the brace was prescribed for.

Always check the rivet/screw that attaches the strap to the brace for signs of failure.

Remove hair, fiber or debris with fork tines, a toothpick or a comb. The exposed surface of each part of the strap is what determines the contact and security of the strap closure- keep them clean so that the straps close securely.

If the Velcro becomes worn, it needs to be replaced. Replacing a strap requires measuring, sewing the new strap, removing the old rivet, attaching the new strap and cleaning up the rivet site. The addition of pads can increase the amount of work required. There is a cost associated with this- a prescription can be provided to cover the cost but there is no guarantee of payment by your insurance company. However, just like the tires on your car, the soles on your shoes or the clothes you are wearing- things wear out and need to be replaced. Maintenance has an associated cost.

Covering the rivet site inside of the brace with a piece of moleskin or bandage will reduce any skin irritating from the metal. Raised edges must be addressed by...your orthotist. Again, please do not hammer, grind, drill or modify your brace in any way. Repairing “repairs" can be costly and sometimes impossible.

Straps can be washed and squeezed dry- use a soft scrub brush if needed and
follow the brace wear/care guidelines for additional help.

VL. Miscellaneous
Hold onto old brace for emergencies!!

Replacement of braces is covered by insurances based on each company’s own protocols. In general, it is once every 3-5 years unless there is a change in function, change in weight, brace breaking or change in physical status. This must be documented by your physician and a certificate of medical necessity provided with the prescription. Again, there is no guarantee of payment by your insurer. We will try our best to verify your coverage, your deductible and your co-payment and will work with you to procure coverage if possible.

Tamara Treanore, CO, ABC
Daniel M. Ryan, MD