A Physiologic Rationale for Orthotic Prescription in Paraplegia

A difficult clinical decision to be made when treating a paraplegic patient is deciding if walking is a realistic goal, if orthoses should be prescribed, and what the functional outcome will be. It has been demonstrated that the en­ ergy expenditure for paraplegics, utilizing a crutch assisted swing-through gait pattern, is markedly elevated. Many patients have learned to walk with crutches and orthoses, but discon­ tinued their use after discharge from a rehabili­ tation center. , , 4 Studies of other forms of bracing also reveal elevated energy expendi­ ture. 1 2 In this review, we will describe the indica­ tions for prescribing ankle-foot orthoses and knee-ankle-foot orthoses. We will then outline the criteria used at Rancho Los Amigos Med­ ical Center to determine whether or not a para­ plegic is a candidate for ambulation. These cri­ teria are based on the results of energy expen­ diture measurements of 150 patients with traumatic paraplegia. Further investigation of the data collected revealed that the propriocep­ tion level or pattern seemed a reliable indicator of which patients would achieve ambulation, while muscle function seemed to determine the quality of their ambulation. These results have helped us to develop guidelines for projecting the functional outcome of ambulation of para­ plegics.