Knee Ankle Foot Orthosis (KAFOs) in Duchenne muscular dystrophy
Although Knee Ankle Foot Orthosis May be used for a number of pathologies affect motor control and stability in the lower limbs of children, the use of these orthoses in those with Duchenne muscular dystrophy has been studied on a larger scale than the others. These relate only to boys, Duchenne muscular disease is the cause progressive weakness, particularly in the proximal muscle. Orthoses are generally considered to extend ambulation when a child shows the need for external assistance, such as when a wall or furniture is essential to maintaining balance while walking. The age at which to stop the run in the absence of treatment is variable, ranging from 6 years, 5 months to 13 years 7 months. 1 Both ankle-foot orthoses (AFOs) and KAFOs may be indicated, based on the strength and the consequent possibility ambulatory patients. Orthoses can also be used in an attempt to help the progressive contractures or in reducing muscle cramps. 2 KAFOs are often used in conjunction with the muscle releases right sagittal plane deformities, especially in the ankle, such as the release of achilles tendon tenotomy. Release 3 of the iliotibial band on the hips, posterior tibial tendon and the transfer to the correct varus of the foot and ankle, is also indicated for some patients. 4 A program of postoperative physical therapy and daily passive stretching in many of the studies evaluating the use of KAFOs in this patient population. One question the validity of pursuing this line of treatment aimed at the renewal of ambulation have expressed doubts about whether this is actually functional ambulation. 5.6 opponents suggest is a more responsible and beneficial for patients and families to enable the use of a wheelchair fully functional ambulation time is no longer possible, that the more practical point-mobility and focus on activities other than walking easier, the second success in life. That said, there is evidence in the literature that the use of KAFOs in those with Duchene muscular dystrophy renewable ambulation usually by at least 2 years, compared with those who use a wheelchair exclusively an independent ambulation without supplies no longer possible. Death by the age of 18 to 19 years or older, often as a result of pulmonary insufficiency, pneumonia, or cardiomyopathy. 4
Bakker et al 3 conducted a systematic review available literature on the use KAFOs in those with Duchene muscular dystrophy. Their goal is to the degree of proof that exists for the use of KAFOs for ambulation in this population. The researchers a new analysis of the literature published in Dutch, English, French, German, or the years 1966 to 1997. In their report published in 2000, 30 articles describing the 35 studies meeting the criteria for inclusion. It is not randomized controlled trials were found and 40 articles are usually excluded because of lack of sufficient data or outcome measures. Study design are categorized as an observational of case studies (n = 8), uncontrolled study group (n = 23), or the study under the control group (n = 4). The identification of a total of 485 patients treated with KAFOs, the age at which started KAFO use in the range of 6 to 17 years. There was considerable differences with the reported results. Most studies reported on ambulation, "but there is often a mali description of the manner in which he described ambulation. One of the better descriptions for various forms of ambulation in this population described KAFOs is used, chronologically, for independent walking (one child can survive without the support and can walk without assistance), walking helps (a child can not maintain balance while standing and walking, but can walk with a ga), attended by walking (can not support or without progress in the walking, without much help), and the state with the support in the table at least 2 hours). 7 The diversity of the outcome measures is difficult to compare with the results of all studies. With the help of studies with sufficient data for review (n = 7), the percentage of success is calculated for those who use KAFOs as a percentage of the patients is not entirely dependent on a wheelchair after a period of 1 to 3 years . Disability dependence is deemed reliable definable point in time, since the last point ambulation of any kind was reported. Together with this definition of success and the use of KAFOs after 1 year of use had success median value of 75.1% (range 58.6% -92.8%) after 2 years of 47.9% (range 22, 7% - 85.7%), and after 3 years of 24.3% (range 4.5% - 29%). The median means for independent walking was 24 months (range 19.2-32.6 months); assisted for a walk, 36.2 months (range 0-90 months) and for standing passengers, 50.5 months (range, 31,5-58, 6 months). With the help of KAFOs in this population was also mentioned as a positive effect on combating contractures, the greater independence of the patients in both the school and the family, without invitation to the aid of a wheelchair or poverty, and other activities of the daily life, as they could play, ga on the board, changing classes, continues in places like they do not get a wheelchair. 4 One study showed that 8 boys who ran after the age of 13 years were significantly less likely to develop rapidly progressive scoliosis during the adolescent growth spurt compared with boys who stopped walking in the younger age.
The potential for bias in many studies. The publication is the possibility of a bias none of the studies that the randomized controlled study design. With only four studies are non-randomized controlled trials and most other studies the case, there are more opportunities to published reports, to take into account only the best results with different forms of treatment. Patient selection bias is also possible in many reviews, which often these patients were reported to those who are probably the most motivated to make the necessary logistical be equipped with KAFOs, not to mention most frequently performed surgery and physiotherapy. Finally, the principle investigator in most reviews is also drug doctor or physiotherapist care added to the topic, which has the potential to prevent certain types of measurement bias. The potential for these systematic errors in reporting only suggest a number of conclusions should be read with caution.
In the review of the literature, more than three decades, as Bakker in the report, which is also important to take into account possible changes in technology. Only three studies described in this study the use of what could be regarded as mildly orthoses 8-10 for the subjects tested. Thorough descriptions of orthotic design that may affect the exercise of ambulatory, as adjustments and / or immobilization joints, were often missing. For example, only one report 9 angular position of the ankle (90 degrees) and decoration of plastic is no more than distal metatarsal head. This is important because all remaining static equinus of hard plastic expansion beyond the toes of the patients can delay the progression of walking during the ipsilateral middle and late-stage attitude trip. This in turn could result in less energy-efficient ongoing pattern, which could ultimately have a negative impact on the renewal of ambulation in a given subject.
Another point worth considering orthotic design is the fact that all KAFOs static locked in the expansion, which require users to compensate with hiking, pelvis or circumducting feet on the ipsilateral side. 11 Ambulating with both knees locked in the enlargement process has shown that there is significantly more energy than it is possible for the bending of the knee while walking in healthy subjects. 12 Although it is a static locked, in the absence of motor control for the various items reviewed by Duchene muscular dystrophy, a number of recent attitude control knee joint design is available today, May orthotic offer alternative is not possible in previous assessments.
The available literature on the date for this population indicates that the use of renewable KAFOs assisted walking and standing, but the functionality of the walk, which is extended, is still uncertain. It also seems that the boys are most likely to benefit are those with relatively low pace of deterioration as a result of illness, are able to work in a sustainable, well-motivated, and have the support of caregivers .
