Saturday, October 1, 2011

Contextual Perspective on Orthotics, Splints, and Braces

The recent post by Leonid Blyum “Analytical Review: Cerebral Palsy and Forceful Devices-Orthoses, Splints, Braces” raised a number of fundamental important points regarding the use of “devices of external support”. One particular comment prompted some significant questions which then lead to some more evaluation and thought. Without going into detail about the actual thought process, I will simply get right to the point.
There seems to be a great deal of consensus regarding the benefits of the implementation of orthotics, braces, and splints. In fact, it is without question a “staple” protocol for almost every issue of mild to severe distortions of the feet. It goes without question that some form of AFO, KFO, lift, etc will be implemented as part of the rehabilitation plan. It isn’t my intention to debate “do they work or don’t they”…this question is far too simplistic and, quite honestly, a naïve way of approaching the topic. My intention is simply to take a step (or two) backwards and attempt to gain some perspective on the more fundamental question: “are these devices doing what I intend them to do?” To be precise, are they “fixing the feet”…are they preventing any further distortion…and are they creating a more “harmonious” environment for the user? These types of questions are either never asked or simply assumed to be yes, yes, and yes. Therefore, I would like to propose that the implementation of these devices be put into proper CONTEXT. By definition, my opinion as to their “therapeutic value” is completely dependent on the context they are being prescribed. The proper context is clearly explained in the video, therefore I won’t go into detail but I will expand on a very interesting analogy that was brought up that will offer some useful insight into what I have called “Contextual Perspective”.
Let us first consider a simple construct or continuum. Everything regarding biological systems can be classified as either “simple” or “complex”. For example, movement patterns can be considered simple or complex (in reality nothing is truly simple, but you get my idea). Let’s probe a little further and consider biological joints. You can argue that a hinge joint is a relatively simple joint…and a hip joint is relatively complex. You can also postulate that a single-jointed movement is simple and a multi-jointed movement is complex….there is an infinite amount of ways to organize this concept, but it should be relatively straight-forward.

If you accept this concept, then you must also accept that achieving biotensegral equilibrium in a simple joint is far simpler than achieving biotensegral equilibrium in a complex joint. If we look at an x-ray of a horses foot, we can easily see that the complexity of the horse’s “foot” (or hoof, to be precise) is relatively simpler than that of the human foot.

Although it is classified as “simple”, it most certainly is effective in performing it’s intended function.
If we move along this continuum a little more, we will move from the hoof to the more complex “paw”.

The paw (canine, feline for example) essentially contains the same general elements that the human hand and foot do, however it is organized in a very specific way which is clearly illustrated in the above image showing what could be considered metacarpals (purple bones) more or less fused together. However, there are more joints within it and therefore it’s organizational and proprioceptive demands are more involved. It can be assumed that the more complex paw can also perform more complex functions that are inherent in the feline and canine family (tigers, wolves, etc). These animals are extremely fast AND agile…the horse, although being fast, has a significantly poorer agility rating (if you have ever been around horses as much as I have, you will agree that horses trip a lot and are extremely uncomfortable on unstable and/or slippery footing).
Now we get to the human foot. When put into perspective, it is an absolute marvel of engineering. The human foot has 28 bones in it, therefore it has 84 separate potential planes of movement. This would most certainly deserve the classification of “complex”.

It’s complexity can be explained by evolution…we are biped and therefore have “two less points of contact with the ground”. Our horse, canine, and feline friends have the advantage of having four…therefore our 2 feet must be highly adaptable, sensitive, and capable of not only providing a stable platform , but allowing for multiple micro levels of movement that ultimately define our high level of agility.
What does all this mean and where does it fit into the issue of orthotics, splints, and braces??! If you’ve managed to get this far, then you are definitely worthy of some clarity! Given the obvious complexity of the human foot, it is somewhat naïve to assume that ANY adjustment at one SINGLE point of movement will produce any significant “improvement” in the condition of the foot. It is analogous to winning the lottery…yes, you may be extremely lucky and get the singular point of conflict that resolves all of your problems. However, the reality is that this is highly unlikely. Therefore my professional opinion as to the use of orthotics to “reduce distortion and improve the condition of the foot” currently remains highly skeptical at best. However, there is definitely a rationale for their use in improving comfort and reducing risk of further injury.

This statement can be explained as such: When braces are placed on the human foot, you essentially “block” the majority of the freedom within and “downgrade” the foot to a hoof. Obviously having a functional “hoof” is more productive than a distorted and painful foot. This is precisely what I mean by CONTEXTUAL PERSPECTIVE. It is also important not to stop there in this “contextual thinking”. The rest of the human body is designed with the idea that a “complex foot” is underneath…therefore, if we switch out a foot for a simpler “hoof”, there is a significant change in the force transmission to the knee and hip. Essentially, a significant amount of stress that was previously absorbed and distributed through the foot now bypasses it completely and impacts the knee and hip further up…keep this in mind when designing your treatment plan!!
This most certainly qualifies as a “rant”…so I will end with a very warm thank you for reading!!


  1. Dear Gavin,
    This DEFINITELY does not qualify as a rant.
    Rather, it is a well thought out professional opinion,
    and an erudite, and accessible explanation for your
    thoughts. A great addendum to Leonid's post.
    Thanks so much.
    Maribeth (of Team Adam, of course!)
    Cheers back to YOU!!

  2. Based on experience with our son (quad CP) splints, AFOs etc are useful for standing stability and short-term comfort with sitting, helping stabilise the foot on footplate or floor (the hoof theory). They are useless for supported walking or therapeutic input for the reasons outlined above. The compromise is an in-shoe orthotic which broadens the load-bearing spread but doesn't push force and tension up to the pelvis the way AFOs seem to do. But I'm never satisfied with compromises ...

    1. I think your formulation has some good under-pinnings...and comes with some obvious thought behind it. The main message is that external support devices are quite primitive and therefore require some extensive evaluation before implementing them...instead of dispensing them in some mass "generic" form. It seems like you have taken the next step and have done some careful evaluation with respect to your own specific set of considerations and other words, some steps towards intelligent "customization". This is indeed refreshing to hear! Thanks for the comment and I hope to hear from you again soon!

      If you havent already been to the Facebook page, I invite you to go have a look...there is a more diverse group of topics there and I would also invite you to post / comment on it as much as you like.

      All the bestto you!

  3. Well I do not agree with Meb, Sorry to say but I don't feel so Meb..