Stander use is beneficial for promoting good posture and skeletal alignment as well as decreasing spasticity. Orthotic intervention is also frequently done with these same objectives in mind. Because even the best standers are not able to provide the full trunk and distal extremity support some individuals may require, orthotics are a valuable and often essential adjunct to supported standing programs. Bony alignment develops as a result of the forces placed upon the body, so achieving a desirable standing position is especially important for growing children and adolescents.
If you are beginning a standing program with a child and are unsure whether lower extremity orthotics are necessary, I recommend placing the child in the stander in his or her bare feet. If foot pronation or supination is significant and intrinsic muscle motion is minimal or absent, discussing a referral for consultation with an orthotist with the child’s physician is likely in order. In the case of progressive neurological disorders a child may initially maintain a desirable position, but should be re-checked on occasion.
Most orthotics or braces are named according to the joints or body parts they control, and are frequently abbreviated using the first letter of each of those parts strung together.
Most orthotics or braces are named according to the joints or body parts they control, and are frequently abbreviated using the first letter of each of those parts strung together.
TLSO (Thoracolumbosacral Orthosis)
A TLSO is most commonly used in the pediatric population as an intervention for scoliosis. It generally appears as a body shell or corset that stabilizes the body from the chest down to the hips. It is commonly used in children with very high muscle tone, such as in spastic cerebral palsy, and in children with very low muscle tone, as in spinal muscular atrophy. A 2000 study in Developmental Medicine & Child Neurology found progression of spinal curvature of less than one degree per year with TLSO use in children with spastic quadriplegic cerebral palsy. The Concensus Statement for Standard of Care in Spinal Muscular Atrophy indicates the importance of spinal orthoses for postural support, but not for the prevention of curve progression. A TLSO may also be used to limit motion and protect the spinal column after surgery.
AFO – Ankle Foot Orthosis
The AFO is typically made of thin but firm plastic that provides support for the leg behind the calf and ankle as well as under the foot. These are most frequently custom made for an exact fit of the child’s foot. AFOs can be used to prevent knee hyperextension, ankle plantar flexion or tip-toe position, and foot pronation or standing on the arches. Tone or spacticity can also be decreased through the lower legs by an AFO that supports the arch and extends the toes. For children with cerebral palsy, this can help relax the muscles through the legs and moves weight toward the middle or outside of the foot, helping to decrease the “knock kneed” alignment frequently present with spasticity in the legs. A 1995 article in Connective Tissue Research reported increased mobility and earlier standing and walking in children with osteogenesis imperfecta following bracing combined with standing frame use.
KAFO – Knee Ankle Foot Orthosis, Knee Immobilizer
The KAFO extends from the thigh down to the bottom of the foot for increased control of leg position and alignment. These are also custom fit braces made of thin, firm plastic. These provide maximal stability, but minimal mobility for the leg. Knee immobilizers extend from the thigh to the ankle and act to keep the knee from bending. These are important for individuals beginning post-operative weight bearing or those who have a predisposition to fractures or joint injury.
Foot Orthoses
These are more often appropriate for children who are ambulatory and are not meant to prevent deformity or decrease muscle tone. The SMO, or supramalleolar orthosis, supports above the ankle and beneath the foot. The UCBL, or University of California Biomechanics Laboratory orthosis, sits below the ankle bones and provides positioning for the heel bone as well as significant arch support. A heel cup provides stability to keep the calcaneus in a neutral position.
Upper Extremity Braces
While these do not relate directly to standing, they may facilitate function that an individual is working to achieve while in a supported standing position. A wrist hand or wrist thumb orthosis helps to keep the hand open in a near neutral position with the thumb and forefinger creating a “C” shape. It may facilitate maintenance of range of motion and skin integrity for those who have spasticity that causes the hand to squeeze into a fist. A tenodesis splint is used for individuals with wrist control, but minimal use of their hands, usually in the case of spinal cord injury. It allows grasping with the fingers by extending the wrist upward and then releasing by flexing the wrist downward. Elbow immobilizers keep the elbow in a straight or nearly straight position. They are most often used to protect the joint, protect an IV site, or keep children’s hands from their faces, mouths, or tracheostomy sites when there is risk for self harm.
