Q. What is an AFO and what does it do?
Ankle Foot Orthosis (AFO): An AFO is a device worn on the lower part of the leg to provide direct control of motion and alignment of the ankle and foot.
Category: Physical rehabilitation
Walking on the ward (continued)
Q. Alan is to commence walking on the ward. What needs to be considered now? Select the crosses next to the labels to find out more.
He starts walking with supervision of a nurse to and from meals and requires a stick and an AFO. Alan is aware of the technique to use and the safety issues.
Walking on the ward
Alan is keen to walk on the ward. The key worker takes Alan’s request to the MDT meeting.
Go through the slides to see each of the team members and view their discussion.
Concern 2 – Alan’s walking
Alan can stand unaided but tends to lose his balance when reaching for objects and has active movement in his hip and knee but his leg is generally weak. He has flickers of movement at his ankle but is unable to pull his foot up. When walking Alan presents with a dropped foot. This means that he can’t lift his foot clear of the ground when swinging his leg through and is at risk of falling. Additionally when standing on his leg his knee tends to flick back into hyperextension (sudden uncontrollable straightening of the knee beyond normal – see photograph below) which could cause long term damage to his knee joint. Alan has been provided with a custom made ankle foot orthosis (AFO) to help with these issues and is currently walking in therapy with the help of a therapist.
Photograph showing a hyperextended knee
Alan approaches you and says that he wishes to walk on the ward. How should you manage this?
Outcome of concern 1
Alan has had Botulinum Toxin to his finger and wrist flexors and stretches and exercises to improve the motor control. This has helped his hand and has improved the functional use of his arm. He can now clean his hand and has flickers of active movement at his wrist and fingers. Following education in stretches and application of the splint, Alan feels that he is competent to apply it. He is happy with the management of his hand and is less distressed about the appearance of his hand.
Hand splinting
Why would splinting be used?
- May reduce pain (by providing support to joints)
- May reduce deterioration from spasticity
- May prevent contracture
- May increase range of movement
- May block unwanted movement
- May improve function
- May improve hand hygiene
Caution: Hand splinting alone will not improve upper limb function or reduce tone. It is a valuable adjunct to other management interventions such as physiotherapy, spasticity management etc. It is therefore important that there is careful consideration for the rationale for selecting this intervention.
Alan has been provided with a custom made hand splint by the therapist. Splint application can be effective if there is good team working. Drag the possible solutions to match the potential issues that may occur.
Spasticity management
Alan’s spasticity management goals are to:
- Improve his hand hygiene
- Improve his body image
- Increase the functional use of his arm
The main aim is to optimise the outcome of his upper limb rehabilitation
As part of his spasticity management Alan attends a spasticity management clinic for assessment and treatment options. As as result of this assessment he has had Botulinum Toxin injections into his wrist and finger flexors. In order to maximise the benefit of this he now needs to follow an appropriate management plan including:
- Stretches (to maintain and increase muscle and soft tissue length)
- Splinting (to provide a good position and optimise the muscle and soft tissue length)
- Exercises (to facilitate activity and strength in the opposing muscle groups)
- Patient education (of stretches, exercises, splint application and to encourage long term self management)
- Upper limb functional tasks (to encourage self practice and overall upper limb function and activity)
For a description of what a spasticity clinic is see additional information.
Link: Spasticity in adults: management using botulinum toxin National guidelines (2nd edition).RCP March 2018 (PDF).
External factors which may affect spasticity
Q. Which external factors may influence the severity of spasticity? Select Yes or No for each question below.
Why consider managing spasticity?
Q. Why consider managing spasticity? Select the crosses next to the labels to find out the possible the benefits of spasticity management.
Considerations in the management of spasticity
- Side effects from medications (medications may impact on patients known risk factors and may cause distressing side effects)
- Tone may be used to allow function (if you reduce the patient’s overall tone then this may reduce their functional ability, as they may use the tone in other muscle groups to achieve tasks e.g. standing to transfer)
- Spasticity may not be an issue to the patient (the patient may not identify it as a problem and may not wish intervention)
Options for managing Alan’s tone
There are a number of options which you could now consider for managing Alan’s tone.
