The C-Brace is big news in the progression of Orthotic treatment for neurological conditions. The integration of microprocessor technology into a carbon fibre Knee Ankle Foot Orthosis (KAFO’s) opens up a whole new world of possibilities and mobility for patients dependent on full leg support to stand and walk.
As standard, KAFO users are supplied with locked knee KAFOs. This is where the knee is locked in a straight position throughout their gait cycle, but manually unlocked to allow the user to sit down with their knee flexed. The use of a locked KAFO brings about stability of the knee for users with reduced lower leg muscles strength, when walking on level ground.
However, it also results in the development of multiple gait compensations for the user to progress through the gait cycle with a locked knee. Compensations include; hip hitching on the contralateral side, circumduction during swing phase, and vaulting of the contralateral ankle.
Gait can therefore be slower, require more metabolic energy and increase mechanical stress on the sound leg. Walking on slopes and stairs with a locked knee joint is very difficult and often situations avoided by KAFO users.
An alternative option to the locked KAFO is a Stance Control Orthosis (SCO). In a similar way to the locked KAFO, the knee joint is locked straight during stance phase, but unlocks at terminal stance to allow the knee to flex through swing phase, providing a more natural gait pattern and reduction in compensatory motions to achieve ground clearance.
SCOs require considerable confidence from the user, a consistent step length and are again limited on slopes, stairs and uneven ground. In order to prevent accidental disengagement of the knee lock on challenging surfaces, the user often manually locks the SCO.
Where the C-Brace comes into its own is the significant control available in both stance and swing phase of gait. The system provides stability for the foot and ankle, and stabilises the knee in the sagittal plane with the hydraulic unit replicating the eccentric and isometric muscle contraction of the quadriceps and hamstrings.
It controls both the stance and swing phases of gait with microprocessor sensor technology that can adapt to everyday situations in real time. The technology normalises gait by allowing controlled knee flexion during weight bearing, giving patients the ability to safely navigate quick stops, walk on uneven terrain, and descend slopes, curbs and stairs step over step.
The C-Brace calculates the orientation and movement of the system in space in three dimensions, using this information to control the flexion and extension valves of a hydraulic unit that provide varying levels of resistance to knee flexion. In turn, this allows for physiological knee flexion during loading response, absorbing the shock of weight transfer during heel strike.
In a locked KAFO or SCO, that shock is directly transferred to the pelvis and lumbar spine. Additionally, the C-Brace provides microprocessor swing control that adapts to the varying walking speeds of the patient. It does not require consistent step lengths to function as SCOs do.
Variable step length means a patient can increase or decrease walking speed and length of steps based on the instantaneous activity/mobility needs, making walking safer in unfamiliar or dangerous scenarios like crossing roads.
The C-Brace is also able to provide assistance descending stairs and slopes, allowing step-over-step gait, mimicking the contraction of the quadriceps for lowering the body down a stair or slope. The C-Brace considerably reduces stress to the sound limb in unilateral users, and allows bilateral users to descend stairs and slopes and ambulate on uneven terrain.
Additional features of the C-Brace include:
Stumble recovery: The microprocessor swing control of the C-Brace provides a stumble recovery feature that activates high knee flexion resistance during swing phase extension, in preparation for stance phase, allowing the patient to fully load their orthosis and stabilise the body in case of a stumble.
Intuitive Stance Function: This feature allows the patient to stand in a safe and relaxed manner with a flexed knee without the threat of knee collapse, and automatically switches back in to ambulation mode, turning off the blocked knee flexion when the patient moves. This feature allows the patient to unload the sound leg and rest while securely standing on level or non-level surfaces.
Sitting/Kneeling Function: The C-Brace assists the patient when sitting down and standing up from a chair by providing resistance to flexion or extension.
This adds an extra degree of safety and reduces stress to the upper extremities and the sound limb. The microprocessor automatically detects when the patient begins to sit down, adjusting the hydraulic resistance against bending during the transition to sitting.
Allowing the patient to sit in a controlled manner and at a controlled rate. When standing up from a seated position, the C-Brace blocks knee flexion as soon as the knee reaches a flexion angle of 45° or less, allowing the patient to reposition the foot and load the orthosis, for improved leverage to stand. The kneeling down function allows the patient to kneel down safely with controlled flexion of the knee joint, supported by increased flexion resistance.
Activity specific modes/Freeze mode: The C-Brace is programmable for activity specific needs of the patient in addition to ambulation. For instance, resistance can be reduced to a minimum for cycling, or a flexed knee joint position can be fixed for activities such as Yoga. The user, on their personal C-brace App, can control these modes.
So how can you know if the C-Brace might be right for your patient? The first stage is a thorough assessment, considering both the indications and contraindications of the system.
- Flaccid Paralysis or partial paresis of the lower limb
- Quadriceps deficiency leading to poor knee control during stance phase
The patient may present with regular ‘giving way’ of the knee, reporting stumbles or falls when walking on flat, graduated or uneven surfaces. The C-Brace may be appropriate for a number of neurological conditions, including but not limited to:
- Spinal cord injury between L1 and L5
- Multiple sclerosis
- Neuromuscular disease
- Muscular atrophy or Traumatic paresis
Essential requirements for the use of the C-Brace:
- The user must be able to stabilise their trunk and stand without support.
- The muscles strength of the hip extensors and flexors must allow the controlled swing of the affected leg, or this must be possible through compensatory hip/trunk movement.
Contraindications of the C-Brace:
- Swing phase initiation is not possible
- Insufficient trunk stability
- Severe spasticity
- Knee or hip flexion contracture of more than 10°
- Non correctable genu varus/valgus greater than 10°
- Body weight less than 40Kg or greater than 125Kg
- Height <140cm
- Leg length discrepancy >15cm
- Fluctuating Oedema or severe skin irritation that precludes the use of an orthosis
The C-Brace Dynamic Test Orthosis (DTO) is a trial orthosis, which features the C-Brace joint unit. The DTO can be set up to each individual user and programmed to their individual gait requirements, allowing users to test the function of the orthosis within the clinical setting.
The DTO can also provide valuable evidence to the function and benefits of the C-Brace for payers. The DTO can be trialled with support from the Ottobock Orthotic Academy Clinician or through Ottobock’s clinical partner Dorset Orthopaedic.
“I wouldn’t wish it on anyone, but I’m glad my brain tumour happened in a way”
After Helen Bulbeck’s daughter Megan was diagnosed with a brain tumour, the whole family was left isolated with little to no support. Now she is using this experience, plus her own journey with cancer, to help run the UK’s leading brain tumour support charity Brainstrust.
“It was at the time when Rohypnol was doing the rounds in the local pub, so I just thought maybe her drink had been spiked.”
This was Helen Bulbeck’s initial reaction to her daughter, Megan, collapsing after a night out and being omitted to A&E in 2006.
She later realised that it was the start of a lengthy battle, as MRI scans revealed Megan had a brain tumour.
To complicate matters, surgeons opted not to operate unless the tumour showed signs of developing.
And so began Megan’s monthly brain scans, all while she was completing a History of Art degree.
“University was where Megan’s priorities were,” Helen tells NR Times. “The main focus at that point was to get her epileptic episodes under control.
“We weren’t referred to a neurosurgeon until the following January – that’s six months after her first episode.
“We were completely out of our depth; we had no idea what was going on. We had been told in October that she had a brain tumour, but that was it.”
It was the lack of available support that really concerned and surprised Helen.
“There was nothing,” she says, when asked about the help they received after Megan’s diagnosis. “We were just left in a vacuum.
“That’s what I couldn’t understand, because if you’re diagnosed with breast cancer, you’re assigned a clinical nurse specialist. We didn’t have that.
“I spent a long time on the internet trying to find where the support and information was and I desperately needed to talk to somebody about the impact that this diagnosis had, but there was nobody.”
Helen was left on her own in search of a solution for Megan, spending countless hours learning more about brain tumours and possible treatments.
This led her to discover neurosurgeon Peter Black from Boston, who agreed to operate on the tumour after a consultation.
The severity of brain tumours is graded from one to four. Black was the first surgeon to tell Megan she had a grade two tumour, but it could transform into a higher grade within five years, with the consequences being potentially fatal.
With that in mind Megan decided she would have the tumour removed. Because of the risks involved with the surgery, however, the procedure was delayed until after she had finished her studies.
Through all this Helen was fighting her own battle after being told she had head and neck cancer.
She quickly underwent radiotherapy and surgery, knowing she needed to stay strong for her daughter.
“I was just focused on getting fit so that I could go with Meg to America for the surgery.”
Helen was able to make a full recovery, but then faced the challenge of funding Megan’s £30,000 surgery.
Megan’s group of friends were desperate to help and agreed to do some fundraising, eventually smashing their target and generating £70,000.
After this, things finally started to run smoothly. Megan was able to finish her degree and successfully underwent surgery in 2007 which saw her tumour removed.
“We had such a good story and we’d learned so much,” Helen says. “We thought we’ve got one of two options; we can either go back to our lives as they were and donate what we’ve got left to another charity. Or we can use those funds to set up a charity which was going to close the gap in the marketplace.
“Who do you turn to the day you’re told you have a brain tumour? There’s nobody out there and we didn’t want people to feel as lost as we did.”
From this Brainstrust was born.
Starting off simply as a helpline, the charity has evolved into a support trust with UK-wide reach, developing communities to reduce isolation, build resilience and enable people to live the life they want.
It focuses on providing evidence based information around brain tumours and its support specialists can point people to the correct resources, without forcing anything upon them.
“The only other charities that existed at that time were all to do with lab-based research, there was no charity out there where you could pick up the phone and ask for help.
“Because we have that experience, we knew what the information was that people would want to hear.
“Meg and I knew what it meant to be both a patient and a caregiver, so we used that 360 degree perspective to support others.”
Since then Brainstrust has gone on to support thousands of patients and their families.
The vast majority (93 per cent) of those that contacted the charity reported a positive outcome, with nearly 1,000 new patients engaging with it in 2019.
Since its founding in 2006, care around brain tumours has drastically improved.
It is the most common form of cancer that affects those under 40 and it is one that is rising at the fastest rate in over 65s.
Discussing how attitudes to brain tumours have changed, Helen says that new technologies can lead the way to better outcomes.
“Your first line treatment with a brain tumour should always be, where possible, neurosurgery. That was what saved our daughter’s life.
“I think the technology is absolutely key and probably until the last five years, that’s been hugely ignored, but it is catching up.
“In terms of the actual therapies, I think with radiotherapy we’ve made huge advances.”
Despite this progress, Helen says there are still huge differences between the treatment of brain tumour patients and those with other cancers and conditions.
She draws on the example of post-stroke rehab and the general care stroke survivors receive.
“Stroke patients get a wonderful wraparound reablement service and I’d love to see brain cancer having a parity.
“I find that some of the attitudes are a bit nihilistic, as in if you’re diagnosed with a glioblastoma people tend to see this as life limiting with a poor prognosis so it’s not worth investing in. I think it absolutely is.
“That’s the one thing I would love to be able to transform, the day somebody has a brain tumour,
they immediately get that same wraparound care.”
Megan is currently living a happy and healthy life since her surgery, being able to get married and gifting Helen with two granddaughters.
She still undergoes regular brain scans and, after becoming a qualified coach with Brainstrust, she is now training to become a psychodynamic psychotherapist (a discipline involving the interpretation of mental and emotional processes rather than focusing on behaviour).
Reflecting on her journey Helen describes her pride in the work they had done so far, but admits there is still much work to be done.
“It’s been a highly emotional rollercoaster at times, we get very tired but it’s not a job it’s a vocation.
“It’s important not to forget that before we’re patients, we’re people and I think the more we can get clinicians to recognise that sitting in front of them is a person not a patient, then that person is going to be much more resilient.
“Just hearing the testimonials of the impact that our work has had is what keeps us going.
“I will always remember Meg saying to me ‘I would never wish a brain tumour on anybody, but in a way I’m glad this has happened because of what we’ve achieved.’”
Loneliness in lockdown – how have survivors been impacted?
Loneliness in lockdown among brain injury survivors is the subject of a new research study which hopes to shine a light on the ongoing issue of isolation.
While loneliness for the wider population was something rarely previously experienced prior to the COVID-19 pandemic, for those living with a brain injury, the everyday reality is often very different.
And through this new study, researchers hope to discover the true effect the pandemic and its necessity for survivors to stay at home – and in some instances shield for several months – has had and how their protective factors have impacted on that.
The project, by the University of Sunderland in conjunction with Headway, is currently gathering participants for its pioneering research, which will compare the experiences of people living with brain injury to those without.
Led by Dr Stephen Dunne, who has a long-standing research interest in social factors which affect brain injury and stroke survivors, he hopes it will both raise awareness of the ongoing issue of loneliness many people face, as well as helping to inspire action.
“There is a dual focus to this project – loneliness is something known to the masses now more than ever before; it’s not just something felt by a particular part of the population. For a neurotypical individual, I think it has shown what life can be like to be lonely in ways they may never have known previously.
“An important point of our research is to try and understand how, for people with brain injury, their loneliness and their perceptions of loneliness have been affected during the pandemic – has this been heightened over the past year and been exacerbated by lockdown?
“Or have they actually felt less lonely than neurotypical individuals, as they have had the experience pre-pandemic of adapting to life like this, and already have the support strategies in place?
“But crucially, the future of this project isn’t to define loneliness, understand its impact, then drop it – we want to understand it so that we can facilitate the removal of barriers so we can bring about strategic improvements to the wellbeing of people living with brain injury.”
Dr Dunne and his team are seeking brain injury survivors nationally to take part in the research, which will be done by a survey: https://sunduni.eu.qualtrics.com/jfe/form/SV_czH5B8R5kieDgQR and an optional additional interview with the team remotely via Microsoft Teams.
“We’re at a crucial stage now where we appear to be coming out of restrictions, but the experiences of the past year are still very real for so many people,” adds Dr Dunne.
“We want to do this at the right time, before reintegration into society starts to happen and we are looking retrospectively, so we’re keen to hear the experiences of as many people as possible.
“We want to better understand loneliness and its impact, so we can help to bring about change for the future. Understanding the journey of brain injury survivors over the past year is a key part of us being able to do that.”
For further information about the research study, or to share experiences through an interview with the research team, contact Stephen.Dunne@sunderland.ac.uk
Temporary concussion substitutes ‘must be introduced by June 1’
Temporary concussion substitutes must be included in the current trials underway in the Premier League to safeguard the safety of players, players’ unions said today.
FIFPRO and the PFA have called for the introduction of temporary substitutes no later than June 1, and for the scope of the 18-month trial – which enables a team to replace a player who has sustained concussion, but on a permanent basis – be extended to include parallel trials for temporary substitutions.
In an open letter to IFAB, football’s lawmakers, FIFPRO – which represents over 65,000 professional footballers worldwide – and the PFA highlighted the cases of West Ham United’s Issa Diop and Sheffield United’s George Baldock in making their case.
“Player safety and welfare is paramount, and should be the only priority,” they say in their letter.
While both bodies were supportive of the permanent concussion trials when introduced, such incidents – added to the new FIFPRO poll, which shows 83 per cent of 96 professional football club doctors at top-flight European club believe temporary substitutes should form part of future protocol – have shown that action needs to be taken.
“In England, since the trial began, we are aware of two incidents where a temporary substitution option would have better protected players,” states the letter.
“In each case, the players suffered from a head injury but, following an initial on-field assessment, continued to play. They were subsequently removed when it emerged their head injury was worse than first thought.
“These cases underline our concern that permanent substitutions do not give medical teams the appropriate environment to assess a player with a potentially serious head injury.
“The reality of the in-game situation is loaded with pressure. Medical teams can be presented with a situation where a globally broadcast match is on hold, awaiting their assessment. They have to make a potentially game-altering decision in a multi-billion-pound industry.
“We have no doubt medical teams act in the sole interests of the players. However, the rules do not do enough to support medical personnel. Pressure on them will be amplified with the return of crowds.”
The letter states that the inclusion of temporary concussion substitutions, which they propose should be tested in parallel with the current trial, will:
- Provide medical teams with additional assessment time
- Allow for the assessment to take place in an appropriate environment
- Permit a match to restart with neither side numerically disadvantaged
- Reduce pressure on players and medical staff to make quick decisions.
“In December 2020, we welcomed the decision by IFAB to invite competitions to trial permanent concussion substitutions,” FIFPRO and the PFA state.
“At the same time, we have remained in favour of testing temporary concussion substitutions. This has been our position for many years.
“Since the beginning of IFAB’s permanent concussion substitute trial, we have seen several incidents where the new laws of the game have fallen short of their objective and jeopardised player health and safety.”
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