The Reciprocal-Gait Orthosis: Its Use in Neurologically Deficient Patients
R. E. McCALL, MD*Shreveport, Louisiana
Part-time ambulation in some fashion is desirable in myelodysplasia, but the degree of rehabilitative efforts to be expended is controversial. Obvious limiting factors include the degree of neurological deficit and the functional inadequacy of existing orthoses.
As the neurologic deficit is immutable, efforts have been directed toward improving the functional capabilities of braces. At Shriners Hospital for Crippled Children, Shreveport Unit, the basis of the ambulatory bracing program has become the reciprocal-gait orthosis. The orthosis consists of bilateral polypropylene knee-ankle-foot orthoses, posteriorly offset knee joints and a rigid pelvic assembly. The key to the system is the cable coupling the limbs; in standing the cable provides hip stability, yet instantly permits unilateral hip flexion during gait.
An important adjunct to the brace program is surgical intervention in order to place the legs in a braceable posture: hip and knee extension, neutral ankles and plantigrade feet. The thrust of the program is early bracing and early surgical intervention. Optimally, bracing begins at 9 to 12 months of age, using the parapodium. With the development of stance balance and adequate parapodium gait, usually 6 to 9 months, bracing with the reciprocalgait orthosis begins. In anticipation of early bracing, surgical modalities need to be accomplished by 9 months of age.
From September 1981 to September 1982, 29 children were placed in the reciprocal-gait orthosis program including myelodysplasia 22, traumatic paraplegia 2, osteogenesis imperfecta 1, congenital myopathy 1, Werdnig-Hoffman 1, Kugelberg-Welander I and cerebral palsy 1. Age range was from I to 16 years with 14 patients being under 4 years of age. Eight patients are presently in the parapodium, one is ambulatory and seven are nonambulatory. Twenty-one patients are in the reciprocal-gait orthosis, 19 ambulatory and three nonambulatory. Of the 22 myelodysplastic patients, nine have T12 lesion level or higher; seven are ambulatory with the reciprocal-gait orthosis and two not yet ambulatory in the parapodium. Twelve myelodyplastic patients have L1 lesion level or lower, of which six are ambulatory with a reciprocal-gait orthosis, one ambulatory with the parapodium and five not ambulatory with the parapodium. The majority of the nonambulators are at an early stage in their respective gait programs.
The reciprocal-gait orthosis offers improved standing and ambulatory potential in neurologically deficient patients, helping with both prevention of deformity and increased patient independence.
*Shriners Hospital for Crippled Children, Shreveport, LA 71103