Case of the Week 27/4/99: What people said...

Hi, after reviewing the enclosed video and kinematics we are drawing these
conclusions:

1. ATNR appears to be inhibiting his gait especially to the Left. The head
reflex is causing his left leg to extend and rotate in mid stance.
2. He is hyperextending his knee in terminal stance . Does he have any AFOs?
His ankle kinematics shows very little movement overall in terms of flexion
and extension but an AFO may place his knee in more flexion and inhibit his
ATNR.
3. His ATNR will not go away and his gait is not likely to improve unless
his ATNR is modified with either orthotic use or tendon lengthening
(achilles) How about Botox into his gastrocnemius or his sternomastoid???

Richard D. Beauchamp, M.D., FRCSC <rbeauchamp@cw.bc.ca>
Department of Orthopaedics,
University of British Columbia,
Vancouver, B.C., Canada V6H 3V4

Medical Director, Shriners Gait Lab,
Sunny Hill Health Centre for Children,
Vancouver, B.C., Canada


I am not a learned viewer of gait.  However I am a Certified Orthotist.
My observation on the right side is that there may be extensive extensor
tone in swing.  Is that correct? Am I reading the stick figure
accurately?  If so, I will tell you that traditional plastic AFOs will
not help that rotary deformity.  Even the traditional metal, double
action AFOs are ineffective in controlling rotation.  The key is to
control rotation viewed in the transverse plane.  There are few systems
that address that problem.  Ironically, virtually all neurological
deficits have a rotary component!
The only system I know that deals with rotational anomolies is the
Oregon Orthotic system.  You may want to contact these folks in Albany
OR. to discuss rotational control in orthotic management.
Again, I may not be reading your analysis correctly.  For that I
appologize.  If I am, my guess is that traditional AFOs are not going to
appreciably aid this patient's gait.

Sincerely,
Gilbert L. Gulbrandson, C.O. <ggulbrandson@ameritech.net>


Just got the chance to look at the case.

I admit I could not figure out his main cause of his problem from the video.  How
did he behave?

Can he turn his head to left and right voluntary? If so, in lying/ sititng position,
how does the head turning affect the limb movement?  I want look see the video in
slow play mode, so as to see which action occurs first: the neck turn or the leg
extent?  Did he recived Botox injection into CSF? or locally in muscle?

Dora Poon
Dept. of Rehabilitation Sciences
The Hong Kong Polytechnic University
Hong Kong
Special Administrative Region of The People's Republic of China


Dear all,
 
Just want to caution you that whenever the head is turned, there are visual
and vestibular mediated reflexes in addition to neck reflexes.  For more
exclusive testing of the neck reflexes, the assessor should move "the body
on the head" rather than "the head on the body". This observation is based
on the work of the vestibular (and neck) physiologists.  This is also the
way I have been teahing my students in McGill.

Christina

Prof. Christina Hui-Chan
Dept. of Rehabilitation Sciences
The Hong Kong Polytechnic University
Hong Kong
Special Administrative Region of The People's Republic of China

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