during walking to clear the ground. The problem is that dorsiflexion is not occurring. The standard response seems to be get them a AFO to lock the foot at 90 degrees. I didn't see any attempt to determine why the dorsiflexion was not occurring.
I can see numerous different reasons and I am not medically trained.
1. The motor cortex area that controlled the Tibialis anterior muscle was damaged and in the penumbra.
2. The motor cortex area that controlled the Tibialis anterior muscle is dead.
3. The pre-motor cortex was in the penumbra.
4. The pre-motor cortex is dead.
5. The executive control was in the penumbra.
6. The executive control area is dead.
I don't know my math very well but I think this leads to 6! 6 factoral or 6* 5* 4 * 3 * 2 * 1 = 720 possible variations as to the cause of dropfoot.
Correction: I asked a PhD friend about this and his reply was;
On your combinatorics question - the 6! = 720 combinations would refer to a situation in which all six items are distinct from each other and for which the order matters. I don't believe that is the case here. It seems to me that you are describing three possible areas for controlling dorsiflexion (motor cortex, pre-motor cortex and executive control) that are always there, and the failure of dorsiflexion happens if at least one of these areas is damaged/dead. So if I call those areas M, P and E and if they are either alright (Y) or damaged (N), then normal control happens for one configuration only:
M P E
Y Y Y
In the second row, there are seven other combinations:
Y Y N Y N Y N Y Y
Y N N N Y N N N Y
N N N
In other words, three areas with are either Y/N leads to 2^3 = 8 total combinations, of which only one is all Y, and the other 7 refer to a dysfunction. Then I would say there are 7 different variations as to the cause of dropfoot.
And we have a one-size-fits-all AFO for this.
The standard seems to be a rigid plastic AFO, sometimes with a built-in hinge.
I received one of these for two reasons, allowing my toes to clear the floor and stop the eversion of my foot.
Currently have quit using the AFO from 1 year ago. The use of it was preventing me from getting a decent heel strike and was not allowing me to build up any muscle strength in my ankle muscles.
I think that there should be a protocol for each underlying diagnosis. In my case I can dosiflex in any position but doing it while walking does not work very well. My diagnosis is that since my pre-motor cortex is dead it was not coordinating the firing of all the muscles of walking. Do not take any of this as medical advice.
Peter Levine has a good description of what you are missing by using an AFO to compensate.
http://recoverfromstroke.blogspot.com/2010/11/make-them-walk-funny-and-look-lousy-in.html
Ever since you and Pete schooled me on the use or rather, the disuse, on my AFO, I put it to rest. My bedroom door has an expensive door stop now. While it is advantageous to use immediately after one has a stroke, I believe continued use of one has detrimental effects. The AFO hinders the return to walking. Since I bailed on my AFO, I'm walking better and strenghtening the muscles in my leg and ankle. At first I was just able to take a few short steps, but now, I'm able to walk without it and I have transitioned to a soft ankle brace exclusively. Thank you Dean and Peter for showing me I can walk without my AFO.
ReplyDeleteActually, if common sense were to prevail, a strokee should have their affected ankle put into a 90 degree splint as soon as they turn up in intensive care. This would surely short circuit the contracted calf which is the major cause of the toe drop. If I could have got my heel to the ground immediately upon getting out of bed and upright, then the drop toe disability would not have become endemic. I wonder if medical personelle actually observe stroke patients, and think about the problems we all end up with, or do they, more likely, just go along with old training, and not bother to try to turn the lights on to try to facilitate a better recovery .
ReplyDeleteYes. When I was in my first day in the rehab hospital, the PT brought along an L-shaped brace that I could use to walk, but he wouldn't leave it with me so that I could walk all day. I should have been given one Day 1. Without it, I couldn't even stand, but with it (and a cane) I could walk. The PT told me I needed a special AFO made precisely for me—and I had to wait for the next "brace clinic" to get fitted, then another 2 weeks to get the brace made. So, I spent 3 weeks in rehab learning to use a wheelchair that I was never going to use again. Then I read "Stronger After Stroke (on Dean's recommendation) and, as soon as I read "once an AFO, always an AFO," I sent of a pissed-off email to Peter telling him he was just WRONG about me. I'd wear my AFO now to walk, then give it up. He suggested I get a Walk-Aid or Bioness L300; I bought the L300 because the Walk-Aid blasted the heck out of my leg, even with the rep setting and resetting everything.
DeleteActually, if common sense were to prevail, a strokee should have their affected ankle put into a 90 degree splint as soon as they turn up in intensive care. This would surely short circuit the contracted calf which is the major cause of the toe drop. If I could have got my heel to the ground immediately upon getting out of bed and upright, then the drop toe disability would not have become endemic. I wonder if medical personelle actually observe stroke patients, and think about the problems we all end up with, or do they, more likely, just go along with old training, and not bother to try to turn the lights on to try to facilitate a better recovery .
ReplyDelete