Stance Control Orthoses (SCO) make both dynamic Offering two alternative systems means that the
walking and secure standing in the stance phase, needs of a number of different patient-groups can
possible. These special orthotic systems from be met by one or other product.
Ottobock lock the knee joint in the stance phase
and release it for the swing phase. As a result, the In general, a knee-ankle-foot orthosis (KAFO) fit-
patient achieves a dynamic, almost physiological ted with the E-MAG is suitable for patients who:
gait pattern requiring less energy than is the case
have strong deviations in the frontal and sagit-
with a locked joint system, for example.
tal planes (of the knee joint and ankle joint)
and/or
At the same time, the E-MAG Active and FreeWalk
have a highly atrophic, bony leg with little soft
orthoses relieve the back, hip, and knee joints.
tissue covering and/or
These two orthosis systems provide the patient
have a considerably shortened leg (over 5 cm)
with increased security, stability and above all
and/or
mobility, in differing ways.
require a dorsal stop in the ankle joint to
achieve knee joint extension
The E-MAG Active and FreeWalk orthoses differ in
have a stiff ankle
terms of their functionality and their construc-
or require a strong dorsiflexion function.
tion. Whereas the E-MAG Active has electronic
components and functions independently from
Patients who are suitable for the FreeWalk ortho-
the ankle joint, the FreeWalk system is controlled
sis are typically those who have lost the control
purely mechanically with the ankle joint being
of their muscles due to trauma, but have not suf-
connected to the knee joint.
fered any severe lesions on the limb (for example,
condition after incomplete paraplegia). This
Another major difference lies in their construction
means patients who:
methods. The knee-ankle-foot orthosis (KAFO)
into which an E-MAG Active is integrated, is cus- have no or only minor deviations in the leg
tom made by the orthotist, from a plaster cast. axis, where
the ankle joint is stable, yet flexible (range of
This is not the case with the FreeWalk which is a motion of at least 10) and
complete system fabricated by the manufacturers who do not require the orthosis to feature large
service fabrication department, from measure- support surfaces.
ments supplied by the orthotist. Here, the ortho-
tist has the responsibility of taking initial meas- For detailed information on different indications,
urements well as for fine-tuning the orthosis on please see page 10 onwards.
the patient.
The E-MAG Active knee joint system and the Free- Stance control orthoses (SCO) can help correct
Walk orthosis were developed for users who, due these non-physiological movements. They provide
to partial paralysis or a complete failure of the the user with safe functionality and enable a
knee extensors, are unable to stabilise their knees largely normal gait.
without compensatory measures.
There are numerous therapeutic benefits for
The knee joint is often stabilised as a result of paralysis patients: contractures and joint damage
hyperextension achieved by compensatory acti- caused by immobilisation are prevented and
vation of the gluteal muscles (in other words, muscle atrophy is reduced. Cardiovascular ability
when the foot touches the ground, hip extension is retained for everyday activities. In the case of
leads to knee extension). disorders affecting the central nervous system,
the resumption of functions by other, unaffected
As a result, severe ligament instabilities and brain regions (motor relearning, cortical reorgan-
arthritic symptoms in the knee joint will develop isation) can also be promoted.
over time. These are some of the areas in which our orthoses
support the patient rehabilitation as well as their
(re-)integration into their social and professional
lives.
The gait cycle is comprised of a stance phase and Following completion of the terminal stance phase,
a swing phase. The stance phase begins when the the swing phase begins with the pre-swing
heel touches the ground and ends with the toe-off phase, with toe-off initiating the actual swing
from the ground. The swing phase begins with phase. In the pre-swing phase, primarily the
the toe-off and ends at the next heel contact. pretibial muscles and the hip flexors are employed.
The stance phase begins as soon as the heel The initial swing phase is controlled by the hip
touches the ground. At heel strike the knee is flexors, the knee extensors and the anterior lower
controlled by the thigh and lower leg muscles. leg muscles. During transition to the mid-swing
When the leg starts to bear weight the knee is sta- phase knee flexion is no longer needed to bring
bilised by the thigh extensors. In the mid-stance the leg with its pendulum mass into the terminal
phase, the thigh and lower leg muscles stabilise swing phase. The terminal swing phase ends
the leg up to the end of transition to the terminal upon initial heel contact, where the entire series
stance phase, with the latter being accomplished of muscles is needed to stabilise the knee joint.
by the lower leg muscles alone.
The swing phase itself is not greatly affected by
The thigh extensors provide significant support knee extensor deficits. This demonstrates that
during the stance phase. If this supporting func- conventional locked orthoses that promote stance
tion is missing or significantly weakened, the phase stabilisation are in fact too immobilising
normal stance phase cycle is disturbed. during the swing phase.
Initial Contact Load Response Mid Stance Terminal Stance Pre Swing Initial Swing Mid Swing Terminal Swing
Beginning of the Weight transfer, Forward motion Forward motion Preparation of Toe-off and Continued Braking the
stance phase shock absorption of the body over of the body over the swing phase, forward swing of forward swing of forward swing,
with heel contact through knee the stationary the forefoot knee flexion has the leg, achieving the leg, knee preparation for
0 % of the gait flexion, foot, start of knee 31-50 % of the been initiated maximum knee extension the next step
cycle maintenance of extension gait cycle 50-60 % of the flexion 75-87 % of the 87-100 % of the
forward motion 12-31 % of the gait cycle 60-75 % of the gait cycle gait cycle
0-12 % of the gait cycle gait cycle
gait cycle
Compared to a healthy person with a normal gait users with a high level of mobility, comparable to
cycle, a patient with non-functional knee-stabil- that of a healthy person during a normal gait
ising muscles requires an orthosis that stabilises cycle.
the knee joint.
Studies have shown that, compared with a locked
Ottobocks stance control knee joint systems (SCOs) orthosis, stance control orthoses offer consider-
provide stability in each phase, but only where it is able advantages with regard to energy expendi-
needed. The swing phase is not impaired. ture, walking speed and reduction of the strain
on the contralateral side.
Between heel contact and toe-off, as long as the
foot is bearing weight on the ground, the
orthoses secure the knee joint and support the
knee-stabilising muscles. Literature review by B. Zacharias and A. Kannenberg
Both orthoses remain locked during the entire Zum klinischen Nutzen standphasenkontrollierter
stance phase. They only release the knee joint for Orthesensysteme Eine Analyse der wissenschaftlichen
Literatur (On the clinical uses of stance control orthois
the swing phase, between the terminal stance systems an analysis of the scientific literature),
phase and the pre-swing phase. This provides published in Orthopdie Technik 6/2011.
Heel strike with Leg with E-MAG Active Mid-stance The body moves in Pre-swing phase; the leg Mid to terminal swing phase: in the
stabilised knee orthosis takes the load and phase with front of the foot, fitted with the orthosis and pre-swing phase, the knee joint is
joint. the knee joint is stabilised. locked knee joint. complete extension E-MAG Active is unloaded and stabilised at 15 flexion, the knee joint
of the knee joint; the can swing through the is locked in full extension shortly
lock is released at unlocked joint. before heel strike for the stance
toe-off. phase.
Heel strike with Leg with FreeWalk orthosis Mid-stance Heel strike with The body moves in front of Pre-swing phase: the leg is
stabilised knee assumes the load and the knee joint phase with the contralateral the foot with complete unloaded, the leg fitted with
joint. is stabilised. locked knee foot. extension of the knee joint. the FreeWalk orthosis can
joint. The lock is released when swing through with the lock
the toes are lifted from the released.
Therapeutic Application and Gait Training | Ottobock 9
ground (toe-off).
Prerequisites for use and the differences
between knee-ankle-foot orthoses fitted
with the E-MAG Active joint system and
the FreeWalk
Ankle mobility
Correctly assessing functionality in the ankle
joint is crucial for the selection of the right
orthosis. The FreeWalk requires a certain
degree of ankle movement; the E-MAG Active
functions independently of the ankle. If neces-
sary, assess ankle movement with a goniom-
eter using the neutral zero method.
Specific therapy
If the prerequisites described above are not
entirely met, certain weaknesses may be compen- Caution:
sated for by strength and mobility therapy, mak- Please note: therapy should only be carried
ing use of a stance control orthosis an option at out if the physician/therapist has taken
some point in the future. For the purpose of into consideration all contraindications.
improving therapy, a complimentary personal
home exercise programme should be developed
for the patient.
To further improve the body's constitution, the Please note: the exercises shown here serve as a
patient should do follow-up exercises at home to rough guideline only and must be adapted to the
achieve sustainable benefits from the exercises individual patient.
carried out with a therapist.
Stretching of the calf muscles at home, Stretching of the hip flexors and knee
to improve dorsiflexion in the upper extensors to improve hip extension,
ankle joint. also at home.
Caution:
Before standing up, the joint should
be switched to operating mode.
Caution:
Before standing up, the joint should
be switched to operating mode.
D
ynamic lock release
The patient shifts his or her weight forward on to
the contralateral leg. This causes pre-tension of
the orthosis-side knee joint and ankle joint which
are in extension and dorsiflexion respectively.
With a light rocking movement, the patient can
then unlock the knee joint and sit down.
All exercises should be repeated several times
with the assistance of the therapist.
After a few days, these movements should become
routine. Please note that not every FreeWalk
user is suited to the dynamic method, or indeed
is comfortable using this method of sitting down.
Nevertheless, this method offers the advantages
of being safe and gentle on the body.
Before the user takes their first steps, priority The L.A.S.A.R. Posture is the ideal alternative to
should be given to correct weight-distribution on the inevitably inaccurate scales normally used
the orthosis. To prevent abnormal movements for checking for correct weight distribution.
when the first steps are being taken, balancing
exercises should be practised to determine the
best possible weight-distribution on the sup-
ported limb.
If possible, the exercises for the individual step The individual step cycles should be repeated
cycles should be done between the parallel bars. several times independently of each other, until
The parallel bars give patients an increased sense the movements become routine for the user. The
of security, allowing them to better concentrate first exercise teaches the patient to place trust in
on the exercises. the function of the orthosis in the stance phase.
Terminal stance phase (lock release). Practising the pre-swing phase on the
affected side.
The swing phase is the most important element in During transition from the terminal stance phase
the use of the FreeWalk orthosis. In order to guar- to the pre-swing phase, the orthosis is released
antee secure functioning, the free swing phase for the free swing phase. This can only take place
must also be well mastered and understood by the if the knee joint lock is unloaded and the orthotic
patient. This is key to increasing the patients ankle joint exhibits sufficient dorsiflexion.
mobility.
The knee joint lock is unloaded through knee
If the patient moves incorrectly, the orthosis can- joint extension, which is achieved either through
not function properly. During initiation of the sufficient muscle strength of the hip or knee
pre-swing phase as well as at initial heel contact, extensors or through knee joint hyperextension.
the correct movements must be made in order for
the orthosis to function properly. Sufficient dorsiflexion can be achieved by a suffi-
ciently large step.
Initiation of the swing phase is also of fundamen- Dorsiflexion in the ankle joint is not required.
tal importance for the E-MAG Active. Safety and Knee joint extension can be influenced by the
the proper operation of the orthosis depend upon step length as well as by the design (for example,
the design and fit of the orthosis, but also on the the adjustable dorsal stop).
patients understanding of it. He or she must
understand its functionality and must be physi-
ologically able to control the orthosis.
Different exercises can be used for training in When walking sideways, the patient should be
walking backwards and sideways. It is important sure to place the fitted leg slightly in front of the
that the patient does not unlock the knee joint contralateral leg to ensure that she/he can always
when walking backwards. When the patient step safely with the loaded knee joint.
steps backwards with the fitted leg, the knee joint
is extended concurrently with dorsiflexion of the
ankle joint, or the knee joint is unlocked by the
step backwards.
A trained patient can make effective use of spe- Depending on the angle of the incline or decline,
cific benefits of the orthoses when negotiating relatively large steps may need to be taken to
inclines or declines. The orthosis is easily allow the joints to unlock. For safety reasons, the
unlocked, even more so when negotiating patient should support her- or himself when
inclines, allowing the patient to swing her or his walking on an incline or decline.
leg through freely and step on it again safely.
Climbing and descending stairs However, not every patient will be able to do this.
with a bilateral fitting Therefore, patients who do not have this muscle
Patients fitted bilaterally with SCO orthoses can control must climb and descend stairs sideways,
manage stairs like patients with a unilateral fitting step by step.
only in certain cases. These patients generally still
have enough control of one of their legs to manage
Note to the orthotist:
stairs step over step, with one leg orthosis
Some users of stance control orthoses can go
unlocked and with the joint opened mechanically. up and down stairs using the free swing phase.
Please note that this depends on the individual
Patients with bilateral orthoses must use more patient. In case of doubt or if the patient feels
unsure, the joint should always be in the locked
physical strength or use their remaining muscle position.
function.
A trained user of such orthoses will have no prob- patient. Cycling on an exercise bike is a particu-
lem taking up low-activity sporting and leisure larly good way to improve the patients fitness
activities. level. Other sports such as golf may also be suit-
able for patients if they are approved by the phy-
Uniform movements in particular, such as those sician.
involved in cycling, can easily be learned by the
Why does the orthosis sometimes fail to When should the orthosis be inspected?
unlock? The orthosis should be checked for wear by the
Check that: orthotist at least every 6months.
the knee is extended fully before toe-off occurs All working parts such as plastic bearings, PU
the patient is able to reach the knee extension dorsiflexion assist rings, cables, pads, and fas-
stop on the orthosis teners can be replaced.
the orthotic knee joint is behind the load line
the ankle joint has sufficient stability
the pull-release cable has moved or is broken. Why has the foot stirrup on the FreeWalk
orthosis broken?
At the initial fitting with the FreeWalk orthosis, it
Why does the orthosis fail to lock? has often been observed that patients need a rela-
Check that: tively hard dorsal stop to be able to feel the switch
the patient reaches the extension stop on the threshold of the FreeWalk orthosis. However, this
orthotic knee joint before initial heel contact changes very quickly: a high dorsal force at the
the patient has sufficient muscle strength or a ankle is no longer necessary as patients develop an
sufficient hip movement to swing the leg into automatic feel for when unlocking occurs. It is
extension. therefore crucial that if the insole extends beyond
the ball of the foot or as far as the toes, it is perhaps
too stiff to cause a dorsal stop. If the force is per-
Are some parts wearing out too quickly? sistently too high, then the foot stirrup, or in the
If the guide loops tear, check that: worst-case scenario the ankle joint, will break. For
the support tubes are correctly positioned, this reason, the orthosis design and functionality
for example, for patients with hyperextension of should be assessed, and necessary changes made,
the knee the lower support tubes are mounted (for example, switching to a softer forefoot) no later
posteriorly. than two weeks after patients initial fitting.
How should the three-phase switch be In the event of any further concerns, please do not
operated in order to make the joint freely hesitate to contact your Ottobock representative.
movable (such as for riding bicycle)?
In contrast to locking the joint, where you press
the switch down in the extended position, the
joint must be in a flexed position to be released.
Then press the switch down to make the joint
freely movable.