Resource Category: For Professionals

Jeremiah’s SMO Success Story

Addison’s SMO Success Story

Pediatric Hypotonia Info

Effect of Supramalleolar Orthoses on Postural Stability In Children With Down Syndrome

TLSO FAQ

What is the Surestep TLSO?

The Surestep TLSO is a flexible, dynamic solution that works through compression to support the trunk. Circumferential compression helps maintain and regulate intracavitary pressures to improve posture, sensory input, motor skills, gait, speech, and breathing.

How is it different?

Many other TLSOs either only provide compression (garments) or are made of thicker, more rigid plastic.

What are the indications?

The Surestep TLSO is ideal for patients with:

  • Hypotonia or hypertonia
  • Poor trunk/posture control
  • Neuromuscular scoliosis

It can be worn in a stander or seating system. It can also be combined with the Dynamic Cervical Orthosis (DCO) for those patient with poor head control.

It is appropriate for individuals across the gross motor skill spectrum:

  • Sitting: Use the TLSO to free hands to play with toys, work on feeding, speech, and breathing.
  • Walking: Use the TLSO to improve posture, symmetry, arm swing, energy expenditure, speech, and breathing.

What modifications are available?

The Surestep TLSO is custom fabricated with several avilable modifications:

Openings of the TLSO can either be:

  • Anterior
  • Posterior (ideally paired with the abdominal cutout and/or anterior gill modification)

Breathing modifications include:

  • Abdominal Cutout (with or without a Gusset) allow for diaphragmatic breathing. The gusset helps maintain compression on the abdomen. This cutout typically encompasses a g-tube, which allows for easier access.
  • Lateral Gill Modification allows lower rib lateral movement. This allows the ribs and lungs to expand for increased air intake.
  • Anterior Gill Modifications allows for anterior/superior chest translation during breathing.

Accommodations can also be made for Baclophen pumps and G-tubes.

Breathing and Postural Control are Connected

It's important to take breathing into account whenever providing a TLSO. Patterns of breathing include diaphragmatic, lower lateral rib flare, and anterior/superior upper chest rise. It is common for patients with postural deficits and/or neuromuscular scoliosis to also have breathing deficits. Some patients may be primarily belly breathers, while others may be primarily upper chest breathers.

Modifications on TLSOs not only allow a patient to breathe in their primary pattern but can also help enhance the breathing and/or postural work during therapy.

Open Heel FAQ

What is it?

The Open Heel Modification is a modification available on most of Surestep’s lower extremity products. Instead of the standard heel post, the plastic is cut away on the plantar surface of the heel. To reduce the risk of pinching and to maintain compression and calcaneal position, we have added a very thin molded inner boot.

Who is it for?

Children with low or high muscle tone (regardless of underlying diagnosis) who have anterior weight lines, sensory deficits and/or a fast transition from initial contact to footflat (including knee extension moment).

Does it still control the calcaneus, or pronation like the standard version?

Yes! We have compared Standard Surestep SMOs to Surestep SMOs with the open heel modification. There were no significant differences in the calcaneal position – both styles of SMOs controlled pronation. Because of Surestep’s unique plastic and utilization of compression, an SMO with the open heel modification can still correct excessive pronation.

Doesn’t it make the SMO bulkier?

Overall, no. Even though there is an extra layer of material, because it works through compression, the SMOs are nearly identical. We took a series of measurements of both a standard Surestep SMO with a heel post and a Surestep SMO with an open heel. Here’s what we found: At the metatarsals, or ball of the foot, the SMO with open heel was 1/16” wider. There was no difference in width at the malleoli (ankle bones) or in overall foot length. At the instep (measuring diagonal around the heel), the SMO with open heel was ¼” smaller.

Is it harder to get into shoes?

Slightly. There is a trick, though. Do not “push” the heel of the shoe on. Rather, use a big twisting motion to get started and over the “lip” of the plastic. Then, you should be able to push it on the rest of the way.

Does it actually make a difference?

Yes! We are seeing fantastic functional changes in our kiddos wearing Surestep SMOs, Toe Walking SMOs and AFOs with the open heel modification. Kids are now able to shift their weight more posteriorly, can squat more appropriately and are developing heel-toe gait patterns with more extension. We are slowing down the transition from initial contact to footflat, which also helps with posterior balance reactions and improved gait. We have also heard great feedback about the increased sensory input to the heel. Download PDF for examples.

What products does it apply to?

You can ask for the open heel modification on our SMOs, Toe Walking SMOs, Pullover AFOs, Advanced AFOs and Hinged AFOs. You can also ask for it on the SMO portion of any 2-Stage AFO.

Can it be applied to any level of support or control?

No, an Open Heel modification can only be applied to products that provide dynamic stability.

Single-Subject Design Study of 2 Types of Supramalleolar Orthoses for Young Children with Down Syndrome

Breath of Fresh Air

Gross Motor Skill Changes of Children with Developmental Delay, Hypotonia and Pronation Wearing Surestep SMOs

Introduction

The purpose of this study was to analyze the changes in gross motor skills of children with developmental delay, benign hypotonia and significant pronation who wore Surestep SMOs over a 16 week period. This study compared the rate of change of gross motor skill level of the participants relative to their sameage peers. Surestep SMOs are indicated for children with developmental delay, hypotonia and pronation1. The Peabody Developmental Motor Scale 2 (PDMS2)2 was used to assess gross motor skill level of the participants and used as the reference for typically developing children. The PDMS is a norm-based test designed to evaluate a child’s skill level relative to same-age peers3. It has been evaluated for reliability and validity4 and can be used as a global measure of change in motor development5.

Method

Twenty seven children were recruited for this study. Five children had an underlying diagnosis, such as Down syndrome, and did not qualify due to non-benign hypotonia. Four children started the study but did not follow through with data collection. Eighteen children (11 males, 9 females) fully participated in this study. Each child presented with developmental delay, benign hypotonia and significant pronation upon weight bearing. Developmental delay was assessed using the PDMS-2. Benign hypotonia was assessed based on the clinician’s clinical experience and a lack of an underlying diagnosis. Significant pronation was assessed by measuring and comparing the degree of calcaneal valgus of the participant to typical. Typical calcaneal valgus was determined based on Valmassy’s equation6: 7 minus the child’s age. The participants were separated into two groups based on initial gross motor skill level. The first group was pulling to stand and cruising when they were evaluated. The second group was taking independent steps. There were 11 participants in Group 1 (PTS) and 7 participants in Group 2 (Walk). Mean age at initial testing was 15.8 ± 2.1 months and 18.6 ± 2.1 months respectively. Each child was evaluated and fit with Surestep SMOs (Figure 1) by an ABC Certified Orthotist (CO). Video was taken and gross motor skills were assessed for mastery with the PDMS-2 test every 2 weeks for 16 weeks. The age of the participant in months was plotted when a skill was mastered, or when he or she received a score of 2. Item numbers tested included skills from the Locomotion and Object Manipulation subsets. Examples included crawling, standing, walking, squatting, stairs, and kicking. Parent reported data was collected for items that had been mastered prior to the initial evaluation. Data for the participants was compared to the developmental normal, per the PDMS-2, to evaluate the rate of change of gross motor skills mastery for both groups and to compare the participant’s skill level to their same-age peers.

Results

Average age of pull to stand was 13.5 ± 2.2 and 13.4 ± 1.5 for Group 1 and 2 respectively. Average age for independent walking was 17.9 ± 2.1 and 18.1 ± 2.0. Compared to typical, the rate of change for Group 1 was 4 times slower than typical prior to receiving SMOs and was almost 2 times faster than typical after receiving SMOs. The rate of change for Group 2 was almost 2 times slower than typical prior to receiving SMOs and was over 2 times faster than typical after receiving SMOs. The rate of change of gross motor skills gain after receiving SMOs was the same for both groups (0.28 ± 0.1). Figure 2 shows the rate of change for each group pre- and post-SMOs as well as the typical comparisons.

Discussion

This study suggests that the Surestep SMOs improve gross motor skills and aid children with benign hypotonia, developmental delay and significant pronation by helping them attain the same gross motor level as their peers. The data would suggest that these children master gross motor skills at a faster rate than their peers once they receive Surestep SMOs. Rate of skill acquirement increased for all participants after receiving SMOs when compared to pre-SMO rates as well as typical rates, suggesting that the SMOs do not slow children down and actually help them gain skills faster than typically developing children. The participants in Group 2 who had a pre-SMO rate similar to typical developing children had some of the fastest post-SMO rates, suggesting that even if a child is gaining skills close to a typical rate but are significantly pronated and delayed, he or she will benefit from Surestep SMOs. The study participants represent children that are normally “stuck” on one or more gross motor skills and are having issues progressing due to their foot and ankle alignment and stability along with a lack of proper postural control development. It is important that we evaluate and provide Surestep SMOs to children with developmental delay, hypotonia and pronation as soon as they start to pull to stand to help facilitate development of age appropriate gross motor skills and postural control alongside their peers.

References

  1. Surestep: Dynamic Stabilizing System: http://www.surestep.net/about.html
  2. Folio MR, Fewell RR. (1983) Peabody Developmental Motor Scales and Activity Cards.
  3. Wiart L, Darrah J. (2001) Developmental Medicine & Child Neurology; 43, 279-285.
  4. Palisano R. (1986) Concurrent and predictive validities of the Bayley Motor Scale and the Peabody Developmental Motor Scales. Physical Therapy 66(11), 1714-1719.
  5. Palisano RJ, et.al. (1995) Validity of the Peabody Developmental Gross Motor Scale as an Evaluative Measure of Infants Receiving Physical Therapy. Physical Therapy; 75, 939-948.
  6. Valmassy RL. (1996) Clinical Biomechanics of the Lower Extremities. St. Louis, MO: Mosby.

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