Hesperian Health Guides
Evaluating a Child’s Needs for Aids and Procedures
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Step 1: Start by learning what you can through talking with the child and family (see Child’s History). As you do this, watch the child move about. Observe carefully which parts of the body seem strong, and which seem weak. Look for any differences between one side of the body and the other—such as differences in the length or thickness of the legs. Are there any obvious deformities, or joints that do not seem to straighten all the way? If the child walks, what is unusual about the way she does it? Does she dip forward or to one side? Does she help support one leg with her hand? Is one hip lower than the other? Or one shoulder? Does she have a humpback, a swayback, or a sideways curve of the back?
These early observations will help you know what parts of the body you most need to check for strength and range of motion. Often, by watching a child you can begin to get an idea about what kind of aids or assistance may help. For example:
Step 2: This is the physical examination. It should usually include:
- Range-of-motion testing, especially where you think there might be contractures. (See “Physical Examination,”, and “Contractures”.)
- Muscle testing, especially of muscles that you think may be weak. Also test muscles that need to be strong to make up for weak ones (such as arm and shoulder strength for crutch use).
- Check for deformities: contractures; dislocations (hip, knee, foot, shoulder, elbow); difference in leg length; tilt of hips; and curve or abnormal shape of the back.
Step 3: After the physical exam, again observe how the child moves or walks. Try to relate her particular way of moving and walking with your physical findings (such as weakness of certain muscles, contractures, and leg length).
Step 4: Based on your observations and tests, try to figure out what kind of exercises, aids, or assistance might help the child most. Consider the advantages of different possibilities: benefit, cost, comfort, appearance, availability of materials, and whether the child is likely to use the aid you make. Ask the child and parents for their opinions and suggestions.
Step 5: Before making a final brace or aid to fit the child, if possible test to see how well it may work by using a temporary aid or old brace from another child. For example:
|If a child’s ankle bends over to the outside like this. . .||. . . a lift on the outer side of the sole like this, may help to keep the foot straighter.|
|But before nailing
and glueing in the lift,
quickly make a trial
one of cardboard or
something else and
fasten it temporarily
to the sandal or shoe
with tape or string.
Then have the child
Note: For a few children, a lift like this will help. For many it will not.
Ask the child what she thinks.
Step 6: After the child, her parents, and you have decided what kind of brace or aid might work best, take the necessary measurements and make the brace or aid. When making it, once again it is wise to put it together temporarily so that you can make adjustments before you rivet, glue, or nail it into its final form.
|Mari and Chelo making a child's brace|
Step 7: Have the child try the brace or aid for a few days to get used to it and to see how well it works. Ask the child and parents if it seems to help. Does it hurt? Are there any problems? How could it be improved? Is there something that might work better? Make what adjustments are necessary. But remember that no brace or aid is likely to meet the needs of a child perfectly. Do the best you can.
Here is a story of how workers in a small village rehabilitation program figured out what kind of aids a child needed. How many of the steps we have just discussed did they follow? Was each step important?
A BRACE FOR SAUL
One day a mother from a neighboring village arrived at the village center with her 6-year-old son, Saul. Mari and Chelo, 2 of the village rehabilitation workers, welcomed them warmly. Learning that Saul had polio as a baby, they asked him to walk, and then to run, while they watched carefully. Saul limped a lot and one leg looked thinner and shorter. With each step it bent back at the knee.
“He walks quite well, really,” said Mari. “But he has to ‘lock’ his knee back in order to put weight on it. That knee is going to keep stretching back and some day it will give out.”
“A long-leg brace would protect his knee,” suggested Chelo. “Oh, please, no!” said Saul’s mother. “A year ago we took Saul to the city and the doctors had a big metal brace made for him. It cost so much we are still in debt! Saul hated it! He would always take it off and hide it. We tried and tried to get him to use it, but he wouldn’t.”
“That’s not surprising,” said Mari. “Often a child who can walk without a brace will refuse to use one—even if he walks better with it. We could make him a long-leg brace out of plastic. It would be much lighter. What do you say, Saul?” Saul began to cry.
“Don’t worry, Saul. Maybe we can do something simpler,” said Mari. “But first let’s examine you, okay?” Saul nodded.
|On muscle testing Saul, they found he could not straighten his knee at all. But he had fair strength for bending his knee back ...
That's as high as I can go.
|... and his hip forward ...
I touched you!
... and good strength for bending his hip back.
1, 2, 3, 4, 5!
“Okay,” said Saul. “Sounds like fun!”
|“With the hip and thigh strength he has, he should almost be able to stand on that leg without the knee bending back,” said Mari. “Saul, let’s see you try it like this. Pretend you’re a stork!” For a moment Saul could do it. “Good!” said Mari. “Every day stand like that and see how high you can count without letting your knee go back. Every day try to beat your old record! Okay?”
“The stork exercises may help,” said Chelo. “But I still think he needs a brace. At least at first.”
A long-leg brace might weaken the muscles Saul needs to strengthen.
|"We must weigh the advantages against the disadvantages,” said Mari. “A long-leg brace would keep his knee straight. But it could weaken the muscles he needs to strengthen. Since the brace would keep his leg from bending back, he wouldn’t have to use his muscles to do it.|
“On the other hand, we might try a short-leg brace that holds his foot at almost a right angle. Then, to step flat he will have to keep his knee nearly straight. It could help him strengthen his behind-the-thigh muscles.”
“Let’s try it!” Everyone agreed, except Saul.
|Celo brought someone’s old, lower-leg plastic brace and showed it to Saul. “See how it will fit right around your leg. It isn’t heavy at all. Lift it! And no metal joints to get in the way! What do you say? Do you want to try it?"
When the brace was made, they tested it. Saul said he liked it. At first, when he tried hard, he could walk without bending his knee back. But after a few days, his mother complained that often he would walk, or even stand, with his knee bent way back as before, and his toes in the air, like this.
|"WE THOUGHT IT WOULD WORK LIKE THIS..."||"... BUT IN FACT IT WORKED LIKE THIS."|
“I have an idea,” said Chelo. “Why don’t we let the heel stick out behind the shoe. That way, when he steps, his weight will come well forward of the back of his heel. This should help bring his foot down and his knee forward.”
They tried it, and most of the time (especially when he was reminded) Saul walked without letting his knee bend back much.
|"THIS WORKED BETTER"|
|Heel extended backwards helps prevent back-kneeing.||rounded front of sole to avoid pushing knee back at end of step|
|At home Saul’s mother encouraged him to do his stork exercises. As his muscles grew stronger, he began to walk without bending his knee far back — even in active play!|
“WILL MY CHILD EVER BE ABLE TO WALK?”
This is often one of the first questions asked by the parents of a disabled child. It is an important question. However, we must help parents realize that other things in life can be more important than walking.
If the child whose legs are severely paralyzed by polio is to walk, generally she will need at least 2 things:
fairly strong shoulders and arms for crutch use
- fairly straight legs (hips, knees, and feet). (It is important to correct contractures so that the legs are straight or nearly straight before trying to adapt braces for walking.)
To evaluate a child’s possibility for walking, always test arm and shoulder strength:
Have her try to lift her body weight off the ground with her arms, like this:
|If she can easily lift up and down several limes, she has a GOOD chance of being able to walk using crutches. If her arms and shoulders are so weak she cannot begin to lift herself, her chances for crutch-walking are POOR.|
If her shoulder and arm strength is FAIR, and the child can almost lift herself, daily exercise lifting her weight like this may increase strength enough to make crutch use possible.
|Having the child lift herself while holding a bar like this will also help strengthen her hands and wrists for crutch use.|
|Pushing herself in a wheelchair or wheelboard (trolley) is apractical way to strengthen shoulders, arms, and hands.|
|If the child cannot lift herself because of weak elbows, put simple splints on her arms to see if she can lift herself with these.||If she can lift herself with the elbow splints, maybe she can use crutches that give elbow support.|
|If she is fat, she should lose weight. This will make walking on weak limbs much easier.||
Sorry! No more sweets!
Now check how straight the legs will go.
|If the hips, knees, and feet can be placed in fairly straight positions, chances for walking soon with braces are good (if arm strength is good).||But if the child has much contracture of the hips, knees, or feet, these will need to be straightened before she will be able to walk.|
|For correction of contractures,
see Chapters 8 and Chapter 59.
|Sometimes, if contractures are severe in one leg only, the child can learn to walk on the other leg only, with crutches. But it is best with both legs, whenever
After checking arm strength and leg straightness, the next thing to check is the strength in the ankles, knees, and hips. This will help you decide if the child needs braces, and what kind.
A child with a foot that hangs down (foot drop), or flops to one side may be helped by a below-knee brace of plastic or metal.
|Foot drop: he cannot lift his foot||Foot flops to one side.|
For foot drop, you can make a brace that lifts the foot with a spring or rubber band.
piece of inner tube
The kind of brace you choose will depend on various factors, including cost, available skills and materials, and what seems to work best for the particular child. Advantages and disadvantages of different kinds of braces, and how to make them, are discussed in Chapter 58.
A child with a weak knee may need a long-leg brace of plastic or metal.
weak thigh and lower leg muscles
|Upper-leg braces may be made with or without a knee joint that locks straight for walking and bends for sitting. Different models are discussed in Chapter 58.|
Note: Not all children with no strength to straighten the knee need long-leg braces. A child with strong butt muscles may be able to walk without a brace.
|strong butt muscles||STRONG butt muscles pull the thigh back and keep the knee from bending.|
|A child who has FAIR butt strength and a straight knee may be helped enough by a lower-leg brace that pushes the knee back.||brace pushes knee back|
Slightly downward angle of a stiff brace causes it to push the knee backward when weight bearing.
|A child with weak butt muscles may walk with one hand pushing on the weak thigh.||Or he may walk by bending the knee back to ‘lock’ it for weight bearing.|
If a child has a contracture and cannot walk with his knee straight, correcting the contracture until his knee bends very slightly backward may allow him to walk better.
A child with very weak hip muscles may find his leg flops or twists about too much
with a long-leg brace.
|If muscles are weak here||the child cannot lift like this|
|or if he cannot turn his leg in and out like this,||it may flop and twist with a brace like this|
He may need a brace with a hip band to help stabilize the leg at the hip.
|A hip band that sits on the butt often provides better posture than a higher waistband.
joint for sitting (with a lock if necessary
A plastic hip band is less stable but more flexible and allows better stepping in some children.
|A hip band that passes above the butt often lets the butt stick way out and causes swayback.|
A child with weak body and back muscles, who cannot hold up her body well, may need long-leg braces attached to a body brace or body jacket.
If she has difficulty holding her body up like this ...
... she may need a brace with body support.
Note: Often a child at first may need a hip band or body jacket to help stabilize her for walking.
A few weeks or months later she may no longer need it. Removing it may help the child gain
more strength and control. It is important to re-evaluate the child’s needs for bracing periodically.
Take care to use no more bracing than is needed.
|A child whose backbone is becoming seriously curved may benefit from a body brace (or in severe cases, she may need surgery).
If necessary, the body brace can be attached to long-leg braces as shown above.