http://www.allymedicalsupply.net/attachments/Image/foot-on-orthotic_1.jpg?template=generic

Immediate effects of custom foot orthotics with heel lift on gait and balance for boys with Duchenne Muscular Dystrophy

By: Tyler Shelton, SPT

Background

Over the past 3 years, my interest in the application of orthotics in the physical therapy setting has caused me to consider how orthotics may be used in a variety of settings. During my outpatient neuro rotation, I challenged myself to consider how orthotics could be used to manage patients with more severe musculoskeletal asymmetries/deformities, such as patients with stroke who had severe spasticity at the ankle joint. This process has given me the opportunity to apply these considerations to boys with Duchenne Muscular Dystrophy (DMD), whose musculoskeletal deformities diminish both static and dynamic balance.

Melody Tran, SPT and I collaborated on this pilot study, and completed literature reviews detailing the existing literature on orthotic/orthoses management for children with DMD. With help from Dr. Vicki Mercer, PT, PhD and Dr. Jane Fan, MD, we were able to recruit 2 ambulatory children of different ages with DMD, and evaluate data gathered from the North Star Ambulatory Assessment and GAITRite software. Custom orthotics with heel lift were fabricated by Dr. Mike Gross, PT, DPT, FAPTA, after thorough lower quarter assessments of each child. I have enjoyed this opportunity to apply an intervention strategy of personal interest to a patient population that current research has yet to discover a significant method for immediate balance/gait benefits.

 

Overview

A literature review using the databases PubMed, Cochrane, and AMED yielded a variety of articles related to “Duchenne* muscular dystrophy,”” lower extremity bracing OR brace OR bracing OR ankle foot orthoses OR knee ankle foot orthoses,” “static balance OR dynamic balance,” and “gait OR walk* OR ambulat*,” identifying lower extremity bracing as a common intervention in the standard of care for boys with Duchenne Muscular Dystrophy (DMD).

Using night time ankle-foot-orthoses (AFOs) and a stretching regimen is an accepted method to slow plantarflexion contracture formation;^{1, 2, 3} however, the use of daytime AFOs have been shown to have a negative effect on balance and gait.⁴ The use of daytime AFOs diminishes ambulatory balance by blocking ankle plantarflexion and placing excessive demands on knee extensors during loading response phase in a population that has significantly diminished quadriceps strength.²  While night time AFO use is an essential aspect of care for these children to inhibit the progress of ankle plantarflexion contractures, daytime use should be avoided due to the negative effects on dynamic balance.

Bilateral knee-ankle-foot orthoses (KAFOs) have been used in some cases to help prolong independent ambulation in boys with DMD, but have significant drawbacks that make this intervention less realistic for most patients. For example, Achilles tendon lengthening surgeries are often required to fit into the orthoses, risking expense, pain, and possible surgical complications for an intervention that does not truly provide functional walking ability.⁵ Bakker et al explains that the effects of KAFOs are uncertain in the literature due to the failure of several articles to define the word “ambulatory.”⁵

Statement of Need

Current literature does not provide any insight on effective interventions being used to improve the balance and gait of these children. Children with DMD have progressive muscle weakness that begins proximally and moves distally. Due to quadricep insufficiency, these children rely on bilateral ankle equinus to keep the line of gravity anterior to the knees in order to maintain passive knee stability.² This ankle equinus causes a reduction of base of support, and ultimately balance. This pilot study could lay the foundation for future, larger studies that could identify the use of customized orthotics as an effective method of providing patients with DMD with short-term improvements to balance and gait.

 

Products

Click to read our Capstone Report Final Product.

 

Self-Assessment and Reflection

This experience has exposed me to the volatile world of clinical research, and the multitude of adversities that a researcher can face throughout the process. Early on, we experienced some difficulties with the IRB committee, and ultimately received approval very late in the semester. This obstacle caused Melody and me to adjust our schedule that we made prior to beginning this study, and work in much smaller time intervals. After exhausting all efforts to be prepared for subject assessments, we were able to assess two subjects in one day, and obtain a plethora of valuable data. Throughout the process, we maintained constant contact with our committee members: Dr. Vicki Mercer, Dr. Mike Gross, and Cathy Howes, PT, DPT, MS, PCS, in order to assess our capstone and utilize their valuable input to guide our progress. Melody and I also plan to assess our capstone by referring to the Call for Poster and Platform Abstracts for the APTA Combined Sections Meeting in 2018. Depending on the results of our study, Melody and I are interested in possibly submitting a poster presentation for the research report to CSM.

 

Acknowledgements

I would like to take an opportunity to express my deepest appreciation to the members of our research team. The work ethic and inspiring initiative demonstrated by Melody Tran under the adversity of several early obstacles was a motivating force that allowed us to adapt and succeed in all endeavors. Dr. Vicki Mercer was irreplaceable, as she worked tirelessly to provide us with the resources to be successful, and was a constant source of support throughout. In addition to the countless hours of mentorship, support, and learning opportunities that he has provided me over the past 3 years, Dr. Gross has been incredibly helpful during this process, as he provided us with vital learning experiences concerning orthotic fabrication and advanced orthopedic assessment. Cathy Howes has been accessible and supportive throughout, providing us with resources and insight into the muscular dystrophy community. Demi Eckhoff has also been instrumental to this process as she tirelessly strove to provide recruitment assistance by reaching out to the muscular dystrophy community and associated health services, in order to give us the best opportunity to find subjects. Finally, Dr. Jane Fan, MD was incredibly helpful as she also provided invaluable assistance during the recruitment process.

 

References

1. Alemdaroğlu İ, Gür G, Bek N, et al. Is there any relationship between orthotic usage and functional activities in children with neuromuscular disorders? Prosthet Orthot Int. 2014;38(1):27-33. doi:10.1177/0309364613486915.
2. Stevens PM. Lower Limb Orthotic Management of Duchenne Muscular Dystrophy: A Literature Review. Am Acad Orthotists Prosthetists. 2006;18(4):111-119.
3. De Souza MA, Figueiredo MML, De Baptista CRDJA, Aldaves RD, Mattiello-Sverzut AC. Beneficial effects of ankle-foot orthosis daytime use on the gait of Duchenne muscular dystrophy patients. Clin Biomech. 2016;35:102-110. doi:10.1016/j.clinbiomech.2016.04.005.
4. Townsend EL, Tamhane H, Gross KD. Effects of AFO Use on Walking in Boys With Duchenne Muscular Dystrophy: A Pilot Study: A Pilot Study. Pediatr Phys Ther. 2015;27(1):24-29. doi:10.1097/PEP.0000000000000099.
5. Bakker JP, de Groot IJ, Beckerman H, de Jong BA, Lankhorst GJ. The effects of knee-ankle-foot orthoses in the treatment of Duchenne muscular dystrophy: review of the literature. Clin Rehabil. 2000;14(4):343-359. doi:10.1191/0269215500cr319oa.