Thank you for those of you who are here and also for those of you who are listening later on asynchronously. So Mary Dubon from the Peds Rehab community and super excited to welcome you for the AAPMNR webinar series today to introduce my friend and colleague Jenna, who's going to be speaking us today about a really important topic and that's lower extremity bracing. So I'm talking about which orthotic to choose and when to choose it, which we all know is something that's super complicated. It's also something that Jenna is incredibly skilled at. So Jenna has her own private practice. I refer lots of patients to her here in the Massachusetts area. She also does some work at Spalding as well as seeing some teaching, which she's going to talk to you a little bit more about as well. So without further ado, I'm going to send you over to Jenna and you can keep questions towards the end here, but as you go sticking them in the chat in the Q&A, we'll keep track of them and then Megan will be asking them to Jenna at the end here. So without further ado, I'm going to pass along to Jenna. Thank you very much and thank you, Dr. Dubon, for the very kind introduction. So I think that Dr. Dubon covered the gist of it, but basically, so my name is Jenna Raheb and I'm a physical therapist. I'm a pediatric physical therapist and I'm very fortunate that I've had experience working with the opportunity to work with patients and help them problem solve through their bracing needs in a variety of settings. So I did my PT residency at the Children's Hospital of Philadelphia. I worked with patients in the acute care, inpatient rehab, and outpatient settings that are helping them with bracing. From there, I went on to Spalding Rehab Hospital full-time and as you guys know, inpatient rehab, lots of bracing needs. I was in brace clinic every week, working with my patients and families and orthotists and physicians and other clinicians on bracing needs and I worked on, so my full-time job was on the pediatric unit, but I also did a lot of cross coverage on the adult floors as well. From there, I went to outpatient private practice where I actually started a brace clinic to help meet the needs of the patients coming to that clinic and to try to get more clinicians in the same room when they're coming up with these team decisions. And then from there, I left there and I started my own home care practice and I specialize in working with kids with complex medical needs. So almost all of my patients have bracing needs. So I talk to physicians and orthotists a lot about bracing and I attend a lot of orthotist appointments with my patients and families. So I, slides are being a little slow on my end here. So I want to start by saying I don't have any conflicts of interest to disclose, so I'm going to talk to you guys about a lot of different products that patients can buy. I make no financial gain by, I do not have any, I don't make any extra money by convincing someone to decide on a particular brace or not. So I'm a physical therapist. I work in inpatient home care settings. I'm also a professor, so I teach in the PT programs at Boston University and Massachusetts College of Pharmacy and Health Sciences, and I will also be teaching their bracing and prosthetics course in the fall at MCPHS. So I have no conflicts of interest to disclose. I work for my patients and my families and I teach. So today, I do want to review the different types of lower extremity bracing, the common options. I feel like, you know, 45 minutes to an hour is never enough time to talk about bracing. So I will talk about the most common options that you're going to see. I want to get us on the same page with terminology and I also want to talk about the pros and cons. I also want to talk about the clinical decision making process. I think that's the most important piece. I don't expect any physician or PT or OT to be an expert in bracing decisions. But I want to make sure you guys have a good checklist of questions to ask yourself when you are making bracing decisions. I also want to talk about how bracing can be modified over time. I want to talk about how the team works together in making these decisions and some final patient information that needs to be reviewed with your patients and families. I do want to emphasize that this is such a team effort. This is so, so, so important to make sure that the patient's getting the right brace and that they are using the brace that they get. For lower extremity bracing, the common team players, the orthotists, they're the specialists, they're the ones who are going to help with that final brace prescription and they're going to be fitting the patient or molding the patient for a brace. The caregivers are also part of the team as well. Physicians, physical therapists, occupational therapists work more so with upper extremity bracing, but I still included them here as a common team member because I have consulted with them. They play an important role with dressing and that's also part of bracing, being able to put a brace on and off. So the team does have to work together along with the patient to have a sound bracing decision. Why should we brace? So when bracing is done properly, there are so many benefits to bracing. So I have a few articles here for you guys to show that this is an evidence-based thought process. There's so much literature out there. Whenever I do a literature on bracing, I'm always pleasantly overwhelmed by the number of articles that I find. And, you know, not all of them are the biggest studies, but there is a lot of research out there on the benefits of bracing. So probably the most common reason lower extremity bracing is prescribed is for improved functional mobility. There's so much research that shows all the benefits it can have towards gait mechanics, functional mobility, improving someone's balance, decreasing the energy expenditure of gait. There's so many ways in which a bracing can help with functional mobility. It can also improve positioning. It can improve and or maintain range of motion. It can improve lower extremity weight bearing and allow the use of adaptive equipment. So, for example, right, if you have a patient who is not ambulatory and maybe they are using a stander and they have poor ankle control, well, giving them really good support at the ankles is going to allow them to use equipment. So that way, when their ankle is taking all that weight from their body, that it'll stay in a good position. The ankles will stay in a good position and you'll have some really good injury prevention. Now, when bracing is done improperly, it can do the opposite of all of those things. And when we over brace, we can also weaken the muscles of the surrounding joint. So when we're bracing, not only do we have to think about what type of brace we want to recommend, but we also have to think about how much support we're providing. It is not good to under brace because then you are not going to get the benefit that you're looking for. But it's also not good to over brace and provide too much support because that's also going to impede their functional mobility. Potentially weaken some muscles. So how much should we brace? So this is a very tough question to, I think, a lot of the patients that we work with. But a common guideline I follow is least restrictive bracing. So just like when you prescribe an assisted device, like a walker or a cane, right? You always want to prescribe the least restrictive device. You want to help them, but you don't want to give them too much support. So same thing when it comes to bracing. So it's kind of about finding that happy medium. So what are our options? So I'm going to run through what the common options are. I'm going to start with the least amount of support you can offer someone and end with the more supportive options. So orthotics. In the PM&R world, I feel like this is probably the least likely thing that you guys are going to prescribe. I see these a lot more in the outpatient orthopedic realm. But I do need to include it because it is part of the orthotic and bracing family. So these are orthotics, and pretty much all they're going to do is right in the arch, they're going to give arch support. They're not going to give a ton of arch support, but they can give a decent amount of arch support. You can get them with some cushioning material that helps with a little bit of shock absorption in the heel and the arch. But typically, these are meant for pain relief. The next more supportive is the UCBL or the UCB. So these are named after the lab that they were created in, University of California Berkeley Laboratories. And this is the next step up from that basic orthotic, where the orthotic basically comes up around the heel and it cups the heel. So it gives arch support, but it also helps to hold the heel in a more neutral inversion-inversion position. Now, a lot of these bracing, the bracing options I'm going to show you, there's off-the-shelf options and there's custom options. So that off-the-shelf option is something that you can usually literally offer off the shelf or online. It's prefabricated. You order a particular size, and there isn't really much room for modification. Then there's custom, where a mold is actually taken from a patient's limb, and the brace is made very custom to that patient. So UCBLs can be custom or they can be off-the-shelf. Now, your next supportive is your supramalleoorthosis, or I will be referring to them for the rest of the presentation. These are much more commonly found in pediatrics. They may pop up in the adult world as well, but they're much more common in pediatrics. Also, disclaimer. So whenever you are prescribing bracing like this, an SMO or an AFO or an orthotic, they should be used with a shoe, with a good shoe that fits the brace and the foot very well. I feel like I'm giving a conflicting message by showing you a bunch of pictures of feet with bracing and no shoe. But I'm strategically doing that because if I show you a brace and a shoe, you can't see the brace. I really want you guys to see on all these braces where exactly it falls on the foot. So all these pictures are going to be without shoes. But no, if you are prescribing bracing for standing and walking, a shoe should be used. So for the SMO. So the SMO is the next level up when it comes to the amount of support it can provide. It's going to give really good arch support. It's going to help maintain that neutral heel position. But it also is going to provide really, really good medial lateral support of the ankle. It's going to go around the entire ankle and it's going to go up above the medial and lateral malleoli. And so this is going to give really good ankle support, but it's also going to improve standing balance. And it can improve walking because you're providing the person with a more stable base as they're moving if they need it. So, for example, this is very commonly seen in kids with low muscle tone. So, for example, kids with Down syndrome very commonly have SMOs. They have low muscle tone, commonly have weak ankles and have very excessive overpronation in their ankles. So we want to give them some more ankle support and get them in a better position, but also provide some more stability. So they have more of a stable base to stand and walk on. Next, we've got the posterior leaf spring or more commonly referred to as a PLS. So the PLS is going to go under the foot and behind the calf. And it's made of kind of the SMO and PLS are made of kind of like this plasticky feeling kind of material. And the PLS is going to give very little medial and lateral control of the ankle. It's going to give some. It's not really what it's meant for. You can get them. So these two pictures, the one on the right is an off the shelf one. The one on the left, this is a custom molded PLS of one of my patients. And, you know, you can definitely make them, as you can see here where this was made. So this does give some decent arch support and a little bit of medial lateral control, but not a ton. This bracing is more so prescribed to help maintain dorsiflexion during the swing phase. So it helps. So if you've got foot drop, it helps with foot clearance and swing phase. And it also helps a person get a heel strike at initial contact. Now, when you start bracing, so whenever whenever you think about bracing, it's not just about the feet. Right. Even if even if the goal is to improve walking, it's to help the entire chain. And so, like I was saying, with the SMO, if you can give someone more stability right below, it can help with their walking and their standing balance. So with the posterior leaf spring, it can also help improve standing balance as well. And because whenever you get bracing, too, that goes above the ankle up to below the knee. Now you can actually help with knee control. So disclaimer, I am a physical therapist. I have I have no art skills. So so bear with me as I try to use this visual that I just created. So this is a this is a picture of someone with a PLS and typically a PLS would go up a little bit higher. I would critique and say that this brace is actually kind of a little bit too low. But that being said, the foot is going to be in a fairly fixed position in a PLS. There is some flexibility in a PLS. But what I did was I drew some lines and I marked where, you know, a PT would like the landmarks a PT would use to measure dorsiflexion. Right. So you've got, you know, your your tibia here and then you've got this bottom line lined up with the foot. And this brace here actually looks like you look at this angle like it's set in almost a little bit of plantar flexion. OK, now, if we close this angle here and we make it smaller. Right. So we what would happen is this top part of the brace would then come forward. And now by doing that, you actually drive the knee forward. OK, so by doing that, you can help with knee position. Right. So if you set it in more plantar flexion, you're driving the knee back. But if you're sending it, if you're setting it in a little bit more dorsiflexion, you're driving the knee forward. Next time you work with a patient with the brace, I encourage you to take a look at the brace without the foot in it and just hold it up in front of you and look at the angle that it's set in. I bet you it's probably set in a little bit of dorsiflexion. It's very common that they're set in at least a little bit of dorsiflexion to help with knee control. So the common that I think the most common time I see this, this. The most common time I see this strategy of increasing the amount of dorsiflexion in the brace to help a patient is the patient example where you have and I'm sure you've all seen this, right? The patient who say they have, say they're a right hemiparesis and they've got really, really weak quads and they've got poor knee control and they've got a little bit of foot drop. Right. And so when they hit the ground, initial contact, they don't get heel strike. Maybe they get four foot first, maybe they get foot flat. And then when they bear weight on the leg, then he snaps back into hyperextension. Well, if you put them in a brace like a PLS, it's going to help them with improved dorsiflexion and swing phase and get some heel strike. But also being set in a little dorsiflexion and driving the knee forward is going to limit the amount of knee snapping into hyperextension. So that's why we commonly set our bracing in a little bit of dorsiflexion. And you can also increase the dorsiflexion too if you feel like someone's trying a brace and a PLS and there isn't enough. It's something that you can oftentimes, you can go back to the orthotist and they can oftentimes, not always, but set the brace a little bit more dorsiflexion. So I have a patient case of mine as an example of someone who has bilateral PLSs that are custom made. And so this is a patient who is, she's about 12 years old and she had an AVM rupture. And she is about a year and two or three months out, a little over a year out from her stroke. And she's a really good example of how a PLS can help not only with gait mechanics, but also balance and stability and everything up the chain. So this video, so you watch her walk, you can see that she's got some pretty uneven cadence. There's a lot of movement in her spine. She's pretty off balance. She's kind of holding her arms kind of high guard and towards her trunk to help with some of that control. As you can see, she's lost her balance and she needed help to get back up into standing. And then, so you can take a look at that again. So she's pretty off balance, you know. She can definitely take some steps without assist, but she frequently does lose her balance when walking barefoot. And then this is her from side view. So you can see when she's stepping on the right, she's actually hitting the ground forefoot first. Her knee snaps back a little bit in hyperextension on the right. I will say for her, this has improved quite a bit over time. If you watch her walk outside on uneven ground, that right knee snaps back even more. On flat ground, it's much better. Now, this is her. Her cadence is improved. There's less movement in her spine. Her arms are actually now more relaxed. So she's actually now starting to initiate a little bit of arm swing and trunk rotation. She didn't need any help this time to do this walk. She's got more even cadence. Watch that one more time. They're short videos. And then this next video you can see on the right, her knee controls a little bit better, and she's actually hitting the ground with a little bit of strike. I'll play that one again for you. So my point being that PLSs can do a really good job with helping with gait mechanics, but they can also help balance. They can also help up the chain. It's not just about what's happening at the feet. Another option is the carbon toe-off. So which is another kind of PLS. So these also can assist with dorsiflexion during swing phase of gait and increase, and help with heel strike at initial contact. They can assist with knee control as well. So this, like this shell right here. So if it's in the front of the leg, it can help early during stance phase to help with extension during, knee extension during stance phase. But if it comes behind the leg, it can help drive the knee forward during stance phase. So it just depends on what your patient needs. It can also assist with push-off because there's a little bit of a spring in the material. What I find is kids are oftentimes not heavy enough to really utilize that spring and push-off. Not all the time, but sometimes. And another thing too is to think about when it comes to carbon toe-offs is they really don't provide arch support or ankle support. You can add an SMO to this, but if you just use the carbon toe-off itself, you're not getting arch support. The foot plate that goes underneath the foot is pretty, pretty flat, which could be exactly what your patient needs. I'm not trying to refer to that as being a con. That could be a pro for your patient. This is off the shelf. There's no custom option, but you can typically trial these in advance. I love when I can trial stuff in advance. Sometimes when it comes to more of the custom stuff, sometimes I can get some like loaner options, and you can trial some off the shelf stuff, but the custom stuff, you can't really trial in advance. This is an option that you can trial in advance. So your next more supportive option is the AFO, the ankle foot orthosis. There's a hinged option and a solid option. So this is still made of that same like plastic kind of material that SMO and the PLS is made of. Now this brace is very, very, very supportive in all plans because the way it supports the ankle, right? If you look at the height of the brace, it goes up to below the knee. So just like the PLS, this can also assist with knee control. So all those rules apply with the AFO. This can assist with shock absorption as well. Now this one here, so if you see right here, there's a hinge, this is why it's called the hinged AFO because there's a hinge in the brace. So you can have free dorsiflexion plantar flexion, but you can also limit this. So I very commonly seen AFOs where they'll limit the amount of plantar flexion. So they can't go past, you know, a couple of degrees of dorsiflexion to help with knee control. You can also add a dorsiflexion assist. So you can add a feature in it that when, you know, a patient picks up their foot, that it helps them move their foot into more dorsiflexion during the spin phase. Again, this can improve standing balance. It can also increase lower extremity weight bearing. So another type of AFO is the solid AFO. So it's basically the same thing, but there's no hinge to it. It's just a, it's a solid AFO, and it's also gonna provide support in all planes. This is going to be really good at assisting with knee extension and standing when the patient is lacking quad strength. So I commonly use these for, I use these a lot in patient rehab when I was there full time, I would get solid AFOs for more of my low level functioning patients who maybe either weren't ambulatory, or maybe they were expected to be ambulatory, but they weren't quite ambulatory yet, or they were just starting day training, and they really needed that support for knee extension and standing, and needed really good ankle support as well. This is also great for positioning and adaptive equipment, like I had mentioned earlier, when I was talking about providing patients with more support and adaptive equipment. This can also be used to increase weight bearing through lower extremities. So again, for example, right, your patient who maybe has a lot of plantar flexor inversion muscle tone, and you can't quite get their foot flat, and they need a lot of support to get their foot in a neutral position for sitting and standing, this is a great option. If you do use this for ambulation, keep in mind that it is not going to allow for tibial progression, right? So when you're standing on that foot, and your tibia is supposed to move forward during stance phase, this is going to limit that, and can cause hyperextension. So when you're doing ambulation, if you can provide a little bit more of that ankle motion, you do want to. Now, another option for a solid AFO is the ground reaction foot orthosis. Because now, so far, right, I've been talking a lot about that patient who's got poor quad control, that knee's snapping into hyperextension, you've got excessive plantar flexion. Now, what happens when you have the opposite problem? So for example, if you've got your patient with maybe diplegic CP, maybe they've got crouched gait, maybe they've got really weak gastroxolias and really weak quads, and so they've got excessive dorsiflexion and excessive knee flexion during ambulation. The ground reaction foot orthosis, it's like the solid AFO, but the AFO at the top, rather than going behind the calf, goes in front of the leg. And then there's a strap behind. And the idea behind this is that it pushes the knees into more extension, right? It's supposed to help with more knee extension and hip extension. Now, keep in mind, if you do recommend a brace like this, your patient has to have the range for it. So if someone's got crouched gait pattern and you want to recommend a ground reaction foot orthosis, they need to have the range of motion to be able to use this. And don't get me wrong, this is not the only way that you can improve crouched gait. There are other ways that you can improve crouched gait. I'm just giving you one example of a reason behind using the ground reaction foot orthosis. You can also start bracing up higher, right? So, so far we've talked about foot and ankle bracing, but we can also brace in a way that crosses the knees and crosses the hips. So the KAFO, or CAFO, oftentimes it's called, the knee ankle foot orthosis, is your AFO, but now you add a knee joint on top. So it usually goes around the thigh. There's usually these bars at the side, they're typically made of metal. And I should have zoomed in, I'm realizing now as I'm explaining this, but I don't know if you guys can see this little, like this little square piece right here, where that's a lock. So if you move that lock up, then the knee is a free swing. And then if you move it down, it locks the knee joint and it locks it in extension. These bracings typically, even if there's the free hinge, if it's unlocked, it usually stops that extension, so you're not encouraging hyperextension and stance knees. So the idea behind this is now you're helping to support the knee, okay? So this is typically used for kids who are very, very weak, and maybe they don't have any, or very much quad or hamstring activity, and it's gonna give them a little bit more support around the knee. Now, something to keep in mind, as you add joints to your brace, you're going to make your brace heavier. But the patients who were bracing higher and higher, they're usually really weak. So you really want to think hard and work with your team when it comes to determining how high do you go when you brace. You really wanna be thinking about what your end goal is. For this boy here, so he is a little older than two years old. He had a spinal cord injury, and he's someone who recently has been getting some more hip return, and we wanted to work on some more pre-gait kind of activities in standing, and give him some alternative ways in standing, alternative ways to stand. So he has some bracing that goes up above the knee. We will give him some support, but now, it's as light as weight as possible, but giving him support above the knee so we can still activate his hip muscles. And when supporting him in standing, it takes less work from a caregiver to support him in standing. Now, sometimes we'll brace even higher, right? So you can also brace past the hip. So you can use your hip, knee, ankle, foot orthosis, or oftenly referred to as HKFO. So sometimes they'll just kind of go up around the waist. This example here, this actually goes up past the trunk. This example right here, this picture is actually a reciprocating gait orthosis, where the two legs are actually connected. So that way, so you can unlock the hip joint, you can unlock the knee joint so the person can sit, but then you can also lock everything out. So you can lock the knees in extension, lock the hips in extension. And as you bear away on one leg, the brace actually helps you swing the other leg forward. So it can help with some walking. Now, if walking is the goal and someone can use an assisted device appropriately to be able to support them with using this, this could be a very appropriate option. Usually takes a lot of practice, but here, this is the point where I say you really, really need to work with your team. If you are thinking about bracing up past the knee or bracing up past the hip or bracing from ankle to top of the torso, really work with a physical therapist. And you also want to consider what device your patient's going to be using, because typically, right, if you're bracing this high up and your goal is, whether it's static standing, whether it's recreational walking, functional walking, there's typically going to be a device involved. And then you have to think about, okay, well, what's going to be appropriate for that patient? Now, there's certain diagnoses where I think that there's more of, you know, more of a standard prescription as to what's used. So for example, with spina bifida, I feel like there's very common prescriptions that are used, right, with how high they are braced so that they can utilize a swing-through pattern where you give them wall-strand crutches and they can bring both crutches forward at the same time and they can, you know, swing both their feet through at the same time and have a really, really speedy mobility in that way. But there's some people who have a little bit more complex diagnoses or evolving muscle tone where they're, you know, it might not be so, you know, it might not be as black and white, not to say that bracing in spina bifida is black and white, but it might not be as black and white. So definitely, definitely work with your team to figure out what the best option is going to be and what your goal is going to be because oftentimes, right, the goal is not walking. Sometimes the goal is just standing, right, and standing in a different way or standing in a certain device. And so that impacts the bracing decision as well. I'm not really going to go into range of motion splints, but there is one that I wanted to talk about that I've seen very commonly. So it's the dynamic hinged night splint. So this is a custom, there's some off the shelf in custom options. I see the custom ones more often, at least with my patient population, because they're more tolerated, but it's basically a hinged AFO with these straps. Okay, so it's a free hinge and you can tighten and loosen these straps to allow for more or less dorsiflexion. It allows for a low load, long duration stretch to help with maintenance and increases in dorsiflexion range. And if a patient loses or gains range, you can adjust them with the straps so they can change with the patient. So this is another option if you need to, if your goal is range of motion. Now consider other treatments as well. I'm, you know, I'm taught, this is the bracing lecture. So I'm going to talk about the bracing treatment, right, of lack of range of motion, but there are other treatments as well, right? Like stretching, PT, serial casting. So you definitely want to think about what your other options are if you're going to go this route and your patient needs some increased dorsiflexion range of motion. There's also lots of accessories. I don't know if accessories is the right word to use, but there's so much out there on the market. Another reason why it's so important to really work with an orthotist and when you're making these decisions, because I feel like they really know all the different things that are on the market. So these are just a few examples. So you've got your dorsiflexion check strap, which, so if you've got a free hinge, you can tighten and loosen this strap back here to allow for more or less dorsiflexion. You can add heel lifts or, you know, different things under the heel to allow improved stability. You've got these, you know, kind of like shin shields, so to speak, that help redistribute pressure. So there's so many other things that and other options out there, but I think the important thing is that you're able to communicate with the orthotist where is your patient at functionally? What is the goal? And what are your concerns? You know, and they can help you figure out what accessories can match that. Another thing to think about is functional electrical stimulation. So I feel like this could be a whole nother lecture in itself. And this, when you're thinking about bracing, this isn't something that's gonna work for everybody, but it's definitely something that I want you to keep in the back of your mind as a potential option. And so what it is, is it's using electrical stimulation to stimulate muscles, right, to help with gait. So this can actually replace bracing in some instances. So for example, if you're working with a patient who's got a foot drop, and they just need some stimulation of that anterior tip to help with dorsiflexion and swing phase, and they actually get a response from STEM, this might be something that they could use. So this, so this is the, there's a couple different models out there on the market. This is the Bioness version, and this, so just like you can see in this picture here, it wraps around your patient's leg, and there is a 3D motion sensor in this device. And depending on the position of this 3D sensor, it sends out electrical stimulation to activate the muscles at the right time during gait. So this can actually replace bracing. This also can have, there's some research that shows that this can actually have some long-term therapeutic benefits with strengthening and function. Now, that comes with time, and this is definitely something that you're not gonna get for your patient who's changing. This is an expensive device that takes time and practice to use. So if you think your patient isn't gonna need this in a month or two, this wouldn't be appropriate to get your patient. When I was in inpatient rehab, I didn't have any patients, actually, who I gave this, who I recommended this to because they were all changing so quickly. But there were a few patients who I worked with who I thought, ooh, in the future, this could work for them. So I at least gave them the education. I at least took out the, you know, STEM. I taught them about STEM and what it was and the fact that there was this device, so at least giving the education. So I'm talking about it with my patients, and it's something I'm always thinking about as another option as well. So how do we decide which brace? So I know some of these questions I've already kind of answered, but I wanna run through the list of questions and things you wanna ask yourself when you're trying to figure out which brace to decide. Now, when I am trying to figure out what brace to recommend, I am never saying to a patient, all right, this is absolutely what you need. I'll say, all right, here are my thoughts. You know, I wanna talk to your physician. I wanna talk to the orthotist, right? I always leave it, I make sure I'm explaining it in a way that I am making sure that my patients and families are still open to hearing what the orthotist thinks, what the physician thinks. And I think that it works the same way for orthotists and physicians, right? We wanna make sure that as we're educating and explaining that we're emphasizing that this is a team decision. So the first question, what is your goal of lower extremity bracing? This sounds so obvious, right? But when, I mean, I can't tell you how many times this gets lost, right? Where people kind of get lost in the clinical decision tree, and sometimes you have to take a step back and say, wait, what's the goal? What's the end goal here? And that's gonna help with coming up with the final bracing decision. Another one is, is your patient changing? So if you see someone early after a stroke or a brain injury, right? We know that there's so much potential for progression and change. And I think that's one of the things that makes bracing so hard, especially in the acute care and the inpatient rehab settings. But there are ways that you can progress in regressive brace. So for example, this right here is a solid AFO. Well, you can actually get this pre-hinged. So you can ask to have the hinge gear. So what they can do is they can put the little gear in right here. So that way, when you're ready for the hinge, all they have to do is cut the brace and you've got a hinge. That isn't a feature that can be added later. So you gotta think ahead. Maybe they need a solid now, but you think, oh, what if they need a hinge later? If I don't know, when in doubt, I ask for that pre-hinged brace. So that way I'm prepared to ask for that hinge if slash when the time comes. PLSs, right? You can get a PLS that is a little bit stiffer and then the orthotist can trim it back and make it more flexible and make it less supportive. So there's plenty of ways to progress in regress braces. Are there features that can be added or removed, right? You know, you can ask questions to your orthotist. Like if you're thinking about the dorsiflexion assist option, but you don't want to give them too much support. Well, if they approve, I don't, can it be removed? That's a question I'd want to ask the orthotist. Are there any upcoming procedures or treatments that might change the shape of the patient's extremity? Insurance typically covers about, I mean, depending on your insurance company, about one a year. But if you get a brace in one month now, they're about to get a bony surgery that's going to change the shape of their foot. You're going to be in a bind after the shape of the patient's foot changes and then the brace doesn't fit them very well. What's the patient's diagnosis and prognosis, right? As you're thinking about what's appropriate for function and if they're going to progress or regress, what will your patient's bracing needs be over the year? And not just the brace itself, but any other bracing needs. So even if you're thinking about getting someone a hinged night splint, that can also impact coverage of getting a brace. And I'm not saying that you shouldn't get the hinged night splint, but you need to be thinking about it and having a conversation with the orthotist so that patients and families can be making informed decisions. What is the patient's ability to don and doff the brace? So we want to make sure that the patient can be independent as possible. And if they're relying on the caregiver, we want to make sure that the caregiver can put the brace on and off. What is age appropriate? So the example, so I think this is more of like the question that comes up in the kids' world than the adult world, but it's very common that things are corrected for that shouldn't be corrected for when it comes to bracing. So the example I give is arch of the foot. So the adult-like arch of the foot is formed around seven years old. So a little bit of overpronation in a child under than seven, I'm actually not worried about and I'm actually not trying to correct it. So for example, this is a picture of a, this is an 18 month old boy who is typically developing and he is an independent ambulator. And this, so here we see in the right ankle, the right ankle at this angle of the picture, but on his left foot, you can tell that he actually has some overpronation of his ankle. His heel is in a little bit of an everted position, but at 18 months old, this is actually age appropriate. I would not recommend bracing for him. Now this boy here. So this is a two-year-old who has a history of a brain injury, a little over a year ago, and he has bilateral lower extremity weakness. And he has a history of his right leg being weaker than his left. He has so much overpronation and his heels, I mean, they're so everted that if you see over here, the lateral border of his feet is actually coming off the ground. And when he, I mean, when he walks, sometimes it's almost like he's like on his navicular bone. That is too much overpronation. We want to connect for that. Come for a ride with me. I'm going to take you on a little bit of a tangent with this particular patient case, because I think this show is a really good example of proper bracing and also age appropriate correction of overpronation. So this, so this is the boy in the picture. So in his right ankle, it almost, okay, it almost looks like his right leg is externally rotated. But if you look at his knee, I mean, he's not very externally rotated. That excessive external rotation is actually coming from his right ankle. He's got a wide base of support. He's got almost no single, or I would say no single leg stance time. And he, you know, because of his brain injury, he did have to relearn how to walk, but he is not a new walker in this video. It's him from behind. So now at the time of this video, he had a right PLS that was too small for him. So just putting on shoes and a right PLS that was too small, right? So it doesn't fit him super well. So you can tell he's still got some excessive motion in that right ankle, but his toes are pointed forward and he's starting to get a little bit of single leg stance time. Still kind of slow, still got a wide base of support. Now in these next videos, so this is about, so we got him bilateral custom SMOs. And at the time of this video, he had about a month's worth of practice. So when it comes to bracing, sometimes it takes practice. It's not this instant, oh my gosh, everything is, you know, everything is fixed. Oftentimes it takes a little bit of practice. So this is him with new bilateral custom SMOs with practice. I had a really hard time, disclaimer, I had a really hard time getting a video of him walking because now he wants to run everywhere. And if he'd start walking and I'd try to sneak a video, he'd immediately start running again. A couple of walking steps. So huge difference, right? And I know that they're right. There's a little bit of an element of time and practice that can come with improvement. But I mean, this is, this is a substantial difference. This is because of really good bracing. And the day I took these videos, when I watched him walk barefoot, it looked very similar to the barefoot video. I just, so you can see his, he's got a narrower base of support. He's got some single leg stance time, his ankles and his lower extremities are in more of a neutral. Another one for you. And he's a lot quicker and he can stop and go a lot, a lot easier for most of my videos of him running away from me. So really good, really good example of the benefits of some, you know, really, really good SMOs that fit really well. So back to our list of questions. So another important thing I want to drive home again is working with the team is does the team agree on the final decision? I have seen it happen multiple times where there's one team member who really, really, really believes that one particular brace is the way to go, but no one else on the team agrees. Okay. So I've seen it where, you know, a physician or a PT really want something. And then, you know, the caregiver doesn't agree or the, you know, the PT or OT or a physician doesn't agree. But an orthotist might feel pressured to make whatever brace is very strongly recommended. And then the brace is made and delivered and then it's never used, it's abandoned. So we do have to come together as a team on this decision. And sometimes that means meeting people halfway. And I find that a lot with parents, especially in pediatrics where, you know, I work with a lot of families who really are opposed to bracing. And sometimes, you know, the orthotist physician and I will really strongly feel that a PLS is needed or an AFO is needed, but we might have to alter some of those decisions. Or maybe instead of PLS, we end up cutting it down a little bit more. So it's not going to help me as much as we'd like to, but we know that's what this family needs in order to get compliance with the brace. You also want to think about what the patient is able to trial. So if the patient is able to trial something, you want them to try it and you want to take information from that to make your final decisions. And we talked a little bit about custom or off the shelf. Also, what can the patient tolerate? There have been times I thought an off the shelf as an off the shelf UCBL, I thought was going to be enough support, but it was a patient who has a lot of issues with footwear and sensory needs. And so we ended up getting something more custom and hope to improve comfort. What is the patient's preference? So don't forget to ask your patient, right? There've been scenarios where, you know, the orthotist and I are like, we're agonizing over do we get the carbon toe off with the anterior shell or the posterior shell? And there's one time, you know, an orthotist stopped and he just looked at the patient and he goes, what do you like better? And the patient had a very, very clear, I like this one better. And the orthotist just looked at me and said, well, I guess that makes a decision, right? So don't forget to ask the patient what their preference is. And then also, like I mentioned before, we want to be including the caregiver as well, especially if there's a child or someone who, or an adult, who's really relying on a caregiver for use of that brace, we need to have their buy-in and their input as well. So I did want to leave some time for questions. Before we do that, I'm just going to speed it through really quickly, the process and some education. But basically the big thing is collaborate with your team. I think it's great when a PT is involved. So therefore they can help over, over time. I don't envy, I don't envy PM&R positions and the position that you're in that when you're seeing someone in outpatient basis, you don't get to see them as frequently. So I can't imagine how hard that must be. I'm so used to seeing my patients, you know, once or twice a week or once a month. And so I'm able to have this regular follow-up and it makes my life so much easier. But I think that that's another reason too, why it can be helpful to have a PT on board. So collaborate with your PT, collaborate with your orthotist. If a PT is involved, you might have to refer directly to the orthotist. If the patient's going through insurance, which is very common with bracing because it's so expensive, a script will be required. And more often, orthotists are asking me for PT documentation to help with insurance coverage. So, you know, if a PT is involved, usually you don't have to worry about this, but if you're going straight to the orthotist, you definitely include in your notes why you're recommending bracing. You don't have to be specific with the type of bracing, but document why bracing is needed. So then your patient will see an orthotist for an evaluation. And then, you know, if it's a custom brace or patient's molded, and then they return at a later date to pick up the brace. If it's off the shelf, sometimes they have it readily available and they can walk home same day with that brace or they can head home same day with that with that brace. If it's not in stock, sometimes it needs to be ordered and there's a little bit of time that goes by and then they have to return for a brace. If you think an off the shelf option is needed and time is of the essence, call the orthotist beforehand. I've been in this situation before where I was working with an international patient who was flying back home in two weeks and we did not have time for the turnaround of a custom PLS. And so I reached out to the orthotist to make sure he had something in stock before I sent the patient. So if that's the case, make sure that you reach out to the orthotist before that appointment. And then finally, some education. So never assume that another team member is providing this education. And even if they've gotten it, it's always good to review. So for a brace for a schedule, I feel like typically when it comes to lower extremity bracing, if it's bracing that's going to be worn often, I usually say start with an hour and every day add an hour. So it's one hour the first day, two hours the second day, three hours the third day. I explained to them that they need to, that their skin needs to be covered. So for things like PLSs and AFOs, very commonly these kind of brace socks are used. This is just one type of brand SmartKnit that's fairly inexpensive that you can get online. You can also use a tube sock as well. It's got to be a smooth sock, no bumps or folds in the sock to prevent skin breakdown. And then always make sure that they're checking the skin. So any redness. So whenever the brace comes off, you always want to check the skin. Any redness that's blanchable, we're not worried about. And any redness that goes away in about 20 to 30 minutes, we're not worried about. It's that redness that's not blanchable. It's the redness that's not going away. That's when we, that's when we need to have a conversation. We need to do something about it, right? Did we, you need to look at things like, you know, did they increase the brace wear time too quickly? Is there an adjustment that needs to be made to the brace? Maybe the brace isn't being worn properly. You know, maybe it's too tight or not tight enough and the foot is in a position it shouldn't be in. But regardless, make sure that there is a team member who can follow up with the above things and then re-evaluate. I really want to stress this, that needs change over time and constant reassessment is required. I never, whenever I start working with a patient who has bracing, I never just assume that the bracing works. I always assess. I assess for fit. I make sure that the bracing is achieving the goal that it should be achieving and that I'm constantly reassessing to make sure that we're, that even as time goes by and needs are changing, that all of the, that the bracing option still works, right? And that those lists of questions that I gave you guys, I still go through those lists of questions in my head to figure out is the current bracing still meeting the needs of the patient? So that's all I have for this presentation. Here's my email address and you guys, you know, feel free to reach out with any questions at any point that you have. I'm more than happy to collaborate and bounce ideas off with you guys. And then I figured I'll turn it over for some questions. Yes. Thank you, Jenna. We do have a few questions that came in, one early in the talk. And the question is, can you talk about what physical exam findings usually push you to do SMO rather than UCBL? That's, oh, sorry. I went ahead of my slide. So, sorry. You're talking about SMO versus UCBL? Correct. Yes. Okay. Really, really good question. So that's actually something that went, that I'm often torn in. That's a really good question. The last time I actually sent someone to an orthotist, I was torn between those two options, the UCBL and the SMO. And I basically, I reached out to the orthotist and I verbalized that. I was working with another young patient, right, who had really excessive overpronation and he has had really poor balance. And I was, I thought he needed an SMO, but I was concerned that an SMO might be too much bracing because I thought the primary things that needed to be corrected were just the heel positioning and the arch positioning. But I reached out to the orthotist and the orthotist did think that the SMO was needed. It was a patient who, I mean, he had poor balance and he had weak ankles and he needed the extra support. So what, you know, that's a really tough question and it's one I'm often torn with and that I collaborate with the orthotist. Really the UCBL is more so for arch support and heel neutral positioning. The SMO is going to be really good at helping more so when some more help is needed for balance. So if you're working with a patient who's a little bit more unstable or you're working with a patient who's low muscle tone, those are the kids that might need a little bit more supportive bracing. So I know that that was like a really great answer, but that's my thought process. Thank you. The next question that came in reads, for patients who are not tolerating their hinged night splint, is there a time minimum you think is necessary for them to see a benefit? That is such a good question. I have this conversation with families all the time. So my question would be, you know, what is your goal? When it comes to hinged night splints, I find that tolerance is really, really hard and compliance is really hard and I do warn that with patients and families before they get them. So oftentimes I just start with it, like if they're having a really hard time, I'll just say, you know what, have them have the brace on and don't even worry about getting a stretch. Just get them used to wearing the brace. Then it's, you know, such like, you know, I'll have them tighten the straps just enough that they're, you know, in a dorsiflex position without a stretch, right? Because even if you can't feel that stretch in the beginning over the course of several hours, it'll feel like a stretch. It's so little. As for dosing, when it comes to hinged night splints, it's, I don't have a specific number for you. What I'll often recommend to families is if they're, you know, if our goal is to increase range of motion, I might even say, you know, try to give me at least a half an hour to start. And then each night, add a little bit with the end goal of being able to tolerate at least a few hours. Ultimately, you know, the more the better, but I really don't have a minimum number, especially because so much of it depends on the patient. You know, if you've got a patient who has really high plantar flexor muscle tone and their feet are really in a plantar flex, resting in a plantar flex position, they might need more time than say someone who doesn't have really high plantar flexor muscle tone, but they have limited ankle range of motion. So it really depends. And what I end up doing is it's a lot of trial and error and I'm just constantly reassessing, which again, I think that's another reason too, I think having a PT involved is helpful because, you know, I'll see my patients once a week or once a month. Or, you know, even if my patients are taking a break, it's often, you know, only for, you know, two to three months and then I'm seeing them again. So I'm just, I'm constantly reassessing and remeasuring to figure out over time, best dosage and positioning. Great. Well, we're going to have, we have one more question, which I think we can get in before the end of the hour. Actually, we've got another one that just came in, but is there an age that you do not brace for an over pronated foot because the patient is so used to it? So I don't have a minimum bracing age. You know, I feel like this question would be easier to answer like surrounding a case, right? So, you know, for example, I mean, I've, I've worked with really little kids, like five months old who I've braced, right. But these were kids who, you know, so for example, I braced a four month old once, but he was a four month old after a brain injury and his toes, he had such high plantar flexion muscle tone all the time. I mean, his toes, his ankles were just stuck in plantar flexion. And I knew as he developed, I needed to keep his foot in a neutral position when he was in his crib. So that way that, that his plantar flexor muscles don't get shorter. And I wanted to make sure his foot was resting in more of a neutral position. So that's specific to that case, right? There's also, you know, some situations where, you know, maybe I'm working with a child who is a very early stander and is really pronated. I might say, right, well, you know, there's so much progression that happens over time. So I might want to wait a little bit to see how the patient's arch of the foot develops. But like in the picture I showed you, I mean, that was an 18 month old who had very little overpronation. And if it's just a little bit of overpronation and it's, you know, it seems age appropriate, then I'm not going to brace it. But if it's so much so that it's impacting function, they're excessively overpronated and it's impacting their ability to participate in age appropriate gross motor skill, that's when I start thinking about, about the brace. Please speak up if that didn't, if that didn't answer the question. While I'm giving you an awesome kudos for a fabulous lecture, and I know you've done this three or four times for the Academy, so thank you for that. Oh, my pleasure. If the anonymous attendee who wrote that question wants to ask a follow-up, you've got about 20 seconds to type it in. And also I strategically left, I ended on the slide that has my email and kept it. So if anyone doesn't feel comfortable putting a question in the box, feel free to email me and I'm more than happy to help answer questions. All right, Jenna, thank you so much again for sharing your time and your talent with us. And we will, thanks again. All right. Take good care of everyone. Thank you. Bye-bye.

Jenna Raheb

pediatric physical therapist

lower extremity bracing

choosing the right brace

bracing decisions

benefits of bracing

types of braces

prescribing braces

brace wear and skin care