Functional Top Down Approach to
Bracing
•
•
•
•
•
RGOs (Reciprocal Gait Orthoses)
HKAFOs (Hip Knee Ankle Foot Orthoses)
KAFOs (Knee Ankle Foot Orthoses)
AFOs (Ankle Foot Orthoses)
FOs (Foot Orthoses)
DISCLAIMER
• The upcoming algorithm should be used for
the adult/pediatric population with
neuromuscular impairments who are looking
to ambulate as a means for functional
mobility.
Lower extremity Bracing algorithm
Is your patient a candidate for
restorative, locomotor
therapy?
Yes
Proceed to the
Locomotor
Therapy section
No
Is your patient a candidate for
functional electrical stimulation?
Yes
No
Proceed to FES
section
Proceed to the
bracing algorithm
Algorithm Overview
Is trunk support required to maintain
standing?
Yes
No
Able to advance lower
extremity with full step?
Able to maintain frontal/sagittal plane pelvic
stability without therapist assistance during gait
cycle?
No
Yes
Yes
No
Is a reciprocal gait
pattern desired?
HKAFO
algorithm
Able to maintain knee stability in
stance phase of gait during
contralateral step?
HKAFO
algorithm
No
Yes
Yes
No
Hip Guidance Orthosis, TLSO with
HKAFO or parawalker
RGO
algorithm
Able to clear foot
through swing phase
of gait?
KAFO algorithm
Yes
No
FO algorithm
AFO algorithm
Reciprocal Gait Orthosis (RGOs)
Is trunk support
required to
maintain standing?
Yes
No
Is patient able to advance
involved LE with maximum
assist below hip?
HKAFO algorithm
No
Yes
Is a reciprocal gait
pattern desired?
HKAFO
algorithm
Yes
No
Hip Guidance Orthosis, TLSO
with HKAFO or parawalker
Does patient
weigh…?
Up to
55
pounds
?
Up to 85
pounds?
Up to 132
pounds?
Horizontal
cable RGO
Horizontal
cable RGO
ARGO 25
Up to 175
pounds?
Fillauer
Rocker Bar
ARGO
60
Up to 200
pounds?
Greater than 175
pounds?
COD
IRGO
Fillauer
Rocker
Bar
Horziontal
cable RGO
Aluminu
m Rocker
Bar
COD
HD
welded
ARGO 90
Hip Knee Ankle Foot Orthosis (HKAFO)
Is trunk support required to
maintain standing?
Yes
No
RGO
algorithm
With assistance at hips, is
patient able to advance lower
extremity with a full step?
No
RGO algorithm
Yes
With assistance at hips is patient able to
maintain upright trunk control and
frontal/sagittal alignment at hips during gait
cycle?
Yes
No
KAFO algorithm
With assistance at hips is patient able to
maintain upright trunk control and
frontal/sagittal alignment at hips during
gait?
No
Yes
KAFO with locked joint-refer to
technical sheet
Free motion HKAFO in sagittal
plane
KAFO algorithm for knee
and ankle joints
Refer to KAFO to determine
knee and ankle joints
Knee Ankle Foot Orthosis (KAFO)
Without assistance at hips is patient able to
maintain upright trunk and frontal/sagittal
alignment at hips during gait cycle?
No
Yes
HKAFO
algorithm
Is patient able to maintain knee stability (frontal and/or
sagittal plane) in stance phase of gait during contralateral
step?
Yes
No
AFO algorithm
Does patient present with knee stability (frontal
and/or sagittal plane) without ankle
involvement)
Yes
No
Knee orthosis
technical sheet
In staggered stance, is patient able to initiate
swing phase while maintaining frontal and/or
sagittal pelvic/trunk stability to position limb
for weight acceptance?
Yes
No
Stance Control
KAFO
Locked knee KAFO
Ankle Foot Orthosis (AFO)
*1-knee flexion
and/or
hyperextension
*2-instability defined
as decreased control
of movement
Is patient able to maintain knee stability (frontal and/or sagittal plane*1)
with assistance provided at ankle in stance phase of gait during
contralateral step?
Yes
No
Does patient present with significant sagittal ankle instability *2,
medial/lateral instability *3 and/or knee instability that requires
control of the ankle and/or tibia during gait?
KAFO
algorithm
No
Yes
Swing Clearance Assist
(isolated foot drop)
Does patient have medial/lateral ankle
instability without sagittal ankle instability or
knee stability?
“Dorsiflexion
maintainence” *4-AFO
with posterior trimline,
semi-solid or posterior
leaf spring design
(including carbon fiber)
*4 Static
hold/positioning into
ankle dorsiflexion or
neutral position
*3-instability defined as
subtalar,
forefoot/hindfoot,
excessive movement and
or alignment
“Dorsiflexion
assist” *5-dual
action ankle joint
or anterior spring
channel or FES
*5 Dynamic
movement into ankle
dorsiflexion
Yes
No
Does patient have
moderate to severe
medial/lateral instability
*6 present?
Proceed to
next slide
No
FO algorithm
Yes
Free
Motion
AFO
*6 Consider
alignment/movement up the
kinetic chain causing
medial/lateral ankle
instability (ie knee
varus/valgus, femoral
anteversion/retroversion,
leg length discreptancy
Ankle Foot Orthosis continued..
Does patient have medial/lateral ankle instability without sagittal
ankle instability or knee instability?
Yes
No
Does patient demonstrate a gait
pattern of excessive knee
hyperextension with/without
excessive ankle
plantarflexion/tibial recline?
Refer to
previous
slide
Yes
If patient is assisted into
decreased ankle
plantarflexion or tibial
incline, are they able to
maintain stance stability
without significant knee
hyperextension?
No
Does patient demonstrate a gait
pattern of excessive knee flexion
with ankle dorsiflexion during
stance?
No
Yes
If patient is assisted into decreased
ankle dorsiflexion, is patient able to
maintain knee position/stability during
contralateral step?
Yes
No
AFO with
plantarflexion
Proceed to control or use of
heel wedging
KAFO
algorithm
No
Yes
KAFO
algorithm
Dorsiflexion
control
See
next
slide
Anterior floor
reaction
Solid with
pre-tibial
shell
Articulated with
dorsiflexion stop
Ankle Foot Orthosis continued..
Does patient demonstrate a gait pattern of
excessive knee flexion with ankle
dorsiflexion during stance?
Yes
See previous
slide
No
Does patient demonstrate
decreased ankle push off that
impairs advancement of limb and
decreases velocity?
No
Plantarflexion
assist and 3rd
rocker simulation
Does patient demonstrate
decreased control of ankle
plantarflexion during initial
stance?
No
FO algorithm
Yes
Plantarflexion
control or
stop
Yes
Articulated
joint with
plantarflexion
control
Posterior leaf
spring
Footwear