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Dear Colleagues
I am hoping some one can provide me with some advice regarding materials with proven proprioceptive enhancing qualities. My current post requires me to work in a brain injury unit, where I am involved in gait rehabilitation. I work along with a team of physiotherapists.
I am keen to develop the orthotic therapy currently employed within the unit. I feel that introducing an initial base layer of possibly "textured" material will stimulate a response which hopefully will facilitate the introduction of contours,posts etc in due course. I have found in the past that some orthotic therapy has not been well tolerated. Consequently patients have lost faith in the process.
I have contacted some suppliers of covering materials but to date they have not been able to satisfy my queries.
I would value any advice regarding your experience with orthotic therapy in the field of brain injury patients.

Many Thanks

Regards

Rory

Rory, W.R. Duncan has done work on tone reducing insoles. These incorporate various sinks and pads to help reduce spasticity. Sorry don't have the references to hand but try googling: Duncan tone reducing insoles.

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Also:
http://www.japmaonline.org/cgi/content/abstract/90/1/24

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Simon
Thanks for the reference re: tone reducing insoles. Any thoughts on the more flaccid foot?. Some of my patients present with hypersensitive feet whilst others present with low tone feet.The latter type are the ones that I feel may respond to some type of stimulating insole

Regards

Rory

Rory:

I see patients with many types of neurological disorders. Many of these patients suffer from gait instability. Over the past 25 years of treating these patients, I have observed that the simplest solution that is quite effective for most of these patients is to place a reverse Morton's extension (1/8" adhesive felt padding plantar to 2nd to 5th metatarsal head) on either their shoe insole/sockliner or on an over-the-counter arch support. If using it in a relatively flat shoe insole, I will also add in a small medial cobra pad (slight varus heel wedge combined with small medial longitudinal arch pad) to the insole along with the reverse Morton's extension (i.e. forefoot valgus wedge).

The results of this simple in-shoe wedging is nearly always very helpful for these patients with neurologically-induced gait instability. These in-shoe wedges will generally create an increase in walking speed, a decrease in base of gait, and a subjective increase in "feeling more stable".

My theory is that the effectiveness of this valgus forefoot wedge comes from the valgus wedge shifting the center of pressure (CoP) more laterally on the forefoot which then increases the lateral distance from the CoP to the center of mass (CoM) of the patient. By moving the CoP more laterally on the foot, the patient then can use their gastrocnemius-soleus-Achilles tendon complex more forcefully during late midstance and propulsion without causing an unbalanced subtalar joint supination moment that may create inversion instability of the foot [which these patients try to avoid at all costs-hence the wide base of gait-due to their decrease in neurological function] during the latter half of stance phase of walking gait.

I have never formally published or written up this treatment technique or gait theory and thought it may be worthwhile if those of you who treat similar patients could see if similar types of forefoot valgus insole modifications also give you similar results with your patients.

Now, our flight is about ready to take off to the Dominican Republic to lecture to the Canadians.....

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Sincerely,

Kevin

**************************************************
Kevin A. Kirby, DPM
Adjunct Associate Professor
Department of Applied Biomechanics
California School of Podiatric Medicine at Samuel Merritt College

e-mail: kevinakirby@comcast.net

Private Practice:
107 Scripps Drive, Suite 200
Sacramento, CA 95825 USA
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Voice: (916) 925-8111 Fax: (916) 925-8136
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Related threads:
Other thread tagged with neurophysiological

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Rory

I have worked at Chaley Heritage and spinal units in Glasgow and Edinburgh and found sd plastazote (3 -6mm) as a cover for FO and AFO most staisfactory. The material insulates the skin (keeps it at a constant temperature) great where there is PVD ; and because of the isotactic effect and thermoplastic properties of the material this dynamically adjusts to meet the contours of the foot. The resulting waterbed effect dampens peak pressures which is a good way to manage pre-ulcerated areas.

Because I use double sided tape (stuck to the flat plastazote sheet) then moulded to the contoured shell, I can easily replace the plastazote and use a serial orthotic approach which is worthwhile particularly when dealing with discharge and ulceration. Rather than maintain orthoses contaminated with discharge, plastazote is cheap and easy to replace. As an option I preferred to have a supply of different coloured plastazote and could then colour code the serial care. Problems do arise when there is excessive sheer and cement glues are recommend.

AS a general observation many practitioners find the bottoming out effect a limitation of the expanded polyethaline and will discard it whenever it appears. However the way the isotactic material works is the surrounding crosslinkages are pushed to the side and form reinforced walls around the indentation. This makes for very intimate mirroring of the lesion and increases surface contact thereby reducing the overall pressure. So by discarding the intrinsically shaped plastazote at this stage would be the equivolent of throwing the baby out with the bath water.' However plastazote is so cheap (by comparison) replacing the cover would allow dynamic shaping to occur anyway.

One further benefit of serial orthosis is the facility to keep and measure the previous covers. The changing contour of the lesion is measured by the indentation on the material surface.

As to how this would effect propriaceptive feedback I cannot say but insulating the skin, reducing shearing stress and providing a waterbed effect would seem useful material properties.

toeslayer

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Kevin
I had similar thoughts regarding the application of a forefoot valgus some time ago.I tend to employ it quite frequently.The feed back from patients is usually that they feel "more stable" or that their gait is "smoother" or "more fluid". I have found that extending the posting to sulcus (in a less dense material) works for those patients with a very tight gastrosoleus complex.


Toeslayer
I am interested your plastazote approach as an orthotic modification. Although I am still keen to explore the textured theory ,i will certainly give the insulation theory a go.


Thank you both for taking the time to reply

Regards

Rory

The old pin surfaced "massage sandal" could be seen as offering increased sensory return, have you triedanything like that? Some folks with neuro changes I have dealt with have got improved comfort using a slightly tight compressive sock made from an old scratchy cotton towel.
regards Phill Carter.

Thanks Phill,
I will add your idea to my "must try" list. I would really like to get my hands on a material similar to the pimpled surface found on some table tennis bats.

Regards
Rory

You could ring the table tennis companies, the importers sell it for recovering bats, I had not thought of that one, good idea, I play every week, I'll see if I can find some material, I know some guys who do bat rebuilds etc.
regards Phill

Hi! The answer is closer to home than you think. No need for table tennis bats! In our study we used EVA which has a textured surface on it to help with adhesion. Just have it textured side up!

PM me if you want more information. Here is the reference to our study in Gait and Posture.

Wilson et al, (2008) Gait & Posture, Effect of textured foot orthotics on static and dynamic postural stability in middle-aged females, Volume 27, Issue 1, January 2008, Pages 36-42

Marjorie
Thank you for your contribution. I will get in touch.

Phill
Let me know if you have any success with the pimple surfaced covers.

I am open to all suggestions.

Regards

Rory

Where do you get that stuff?
regards Phill

Very interesting. Please do feedback how you go with this. I have often wondered about the same issue, but for paeds - but same thing really, improving proprioceptive feedback to stablise gait.

Back in the mists of time I vaguely recall someone did a study and found that sandpaper / grit paper helped, but the sensory effect was lost faily quickly. Don't think I'd use that for patients with PVD...

Do let us know how the table tennis stuff goes.

Good luck,
Sally

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I have tried a few different techniques for this problem.

I have used and tried with good success what Kevin suggested and still incorporate that. I have also tried proprioceptive rehab. The best I found for low tone patients was a polyprop direct milled with nipples on the dorsal surface then a top cover to help protect the patients skin surface.

The location of the nipples were to locate them in a muscle belly to induce an antagonistic reaction from the ORF and has given very good results of improving tone. Combined with the rehab patients are making go progress

Regards

Dave