Reciprocating Gait Orthosis (RGO)
Robert R. Madigan, M.D. — Knoxville Orthopedic Clinic, P.A.; 1128 Weisgarber Road Knoxville, Tennessee 37909
Karl D. Fillauer, C.P.O. — Fillauer, Inc. 2710 Amnicola Highway Chattanooga, Tennessee 37406

The Reciprocating Gait Orthosis (RGO) represents the best in design and construction for the paraplegic individual who is unable to stand or walk because of total or partial loss of function of the lower extremities. It demonstrates the high level of achievement realized when allied professionals come together each adding their expertise for the benefit of the patient.

Although many people have been involved in the development of the RGO, three individuals are primarily credited with the concept, development and manufacture. The original concept of coupling hip flexion on one side with contralateral hip extension to produce a more natural reciprocating gait was conceived by Wally Motloch, an orthotist at the Ontario Crippled Children’s Centre in Toronto, Ontario, Canada (1). His original idea was to couple hip flexion on one side with contralateral hip extension on the other by a series of metal gears attached to long-leg braces. This proved unsatisfactory because the excessive force applied to the system resulted in failure as the gear teeth sheared.

Roy Douglas, a colleague of Motloch’s, continued the development at Louisiana State University, substituting a horizontal cable system for the failed gear system to achieve reciprocation(2). The final credit for solving many design problems and creating innovative solutions in its manufacture was given to Carlton Fillauer of Fillauer, Inc., Chattanooga, Tennessee (3). Because of the effort of these men, many children and adults can walk and stand more easily and effectively.

Besides the patient, four other individuals are necessary to achieve results with the RGO. These individuals include an orthopaedic surgeon aware of the many problems associated with paraplegics and their orthotic requirements; a skilled, energetic orthotist responsible for the manufacture and maintenance of the sophisticated device; a physical therapist who is responsible for teaching the individual to use the orthosis properly; and finally, a supportive family unit whose encouragement and efforts in transporting the individual to the physician, orthotist and physical therapist are necessary to ensure success. It is both ideal and beneficial if the orthopaedist, orthotist and therapist have a working knowledge of the other’s area of expertise in order to anticipate and eliminate problems that might adversely effect the patient.

The purpose of this article is to share with the orthotist the concepts and success factors of the RGO system from both an orthopaedic and orthotic viewpoint.

The highlights of the concepts and success factors that have been accumulated over the years are key for achieving lasting results. One area that was neglected for many years was an understanding of the total concepts, parameters, and requirements for obtaining a successful and lasting wearer. Initially we did not adequately set forth a strict and concise evaluation protocol in order to properly select potential candidates that would become successful wearers. As a result many that were fit with R.G.O.s became nonusers which tarnished the reputation of the Reciprocating Gait Orthosis. Even today we occasionally hear comments such as, “many years ago we tried a few R.G.O.’s that the patients did not wear or use.” Today we reflect back and see the flaw in both orthotic design and the lack of an adequate protocol that includes patient evaluation, proper training, and follow up.

The patient, and other individuals are necessary to achieve lasting results with the RGO. These individuals include an orthopaedic surgeon and era physiatrist, an orthotist, a physical therapist and a strong family unit. The physician needs to be aware of the many problems associated with paraplegics and their orthotic requirements. A skilled orthotist is responsible for the manufacture and maintenance of the sophisticated device. The physical therapist is responsible for teaching the individual to use the orthosis properly. A supportive family unit whose encouragement and efforts in transporting the individual to the physician, orthotist and physical therapist are necessary to ensure success. It is both ideal and beneficial if the physician, orthotist and therapist have a working knowledge of the other’s area of expertise in order to anticipate and eliminate problems that might adversely affect the patient.

The purpose of this presentation is to share with you the key factors of the RGO system from both an orthopaedic and orthotic viewpoint. How does the RGO work? The concept of the RGO system is to couple the right and left sides of the orthosis by specially designed hip joints and pelvic section. Hip extension in one joint results in hip flexion on the contralateral side, resulting in a more normal and efficient type (reciprocating) gait. The flexion power of the hip is the ideal “motor” which drives the orthosis. Both hip joints can be unlocked for sitting, and may be abducted bilaterally, which makes sitting more natural and stable. Abduction also permits other procedures such as catheterization, to be performed easier.

It is still necessary for the individual to use a walker or crutches during ambulation. Therefore, dexterity and strength in both upper extremities is a must for effective RGO use.

There are two significant advantages to the RGO system over conventional orthoses for the paraplegic individual. The first advantage is that, the RGO is energy efficient. The wheelchair offers the advantages of speed and has the energy demands comparable to walking by normal individuals (4, 5). Two point swing-to gait with crutches increases energy requirements 33% over normal walking, and a faster swing-through gait increases the energy consumption to 78% (6). Ambulation with the RGO system has energy demands significantly less than the use of standard HKAFO’s with crutches. Thus, ambulation with the RGO system is energy efficient without sacrificing speed when compared to using HKAFO’s (7).

A second major advantage of the RGQ, especially in the adult paraplegic, is the ability to stand unassisted with security and confidence. In standing, the orthotic device prevents bilateral flexion and extension from occurring simultaneously unless the hip joints are unlocked in preparation for sitting. As one hip tends to flex, as occurs when one falls forward, the other hip automatically extends with the same degree of force, thus preventing the fall. With practice, the paraplegic can learn to stand for long periods of time with no assistance, thus freeing the upper extremities for work or play activities. Therefore, the RGO system offers two distinct advantages over traditional HKAFO’s. First, it enables an energy efficient reciprocating gait, and second, allows the individual to stand comfortably and safely, freeing up the upper extremities for other activities.

ORTHOPAEDIC CONSIDERATIONS
The goal is to have the patients walk with orthotic support in the most efficient manner possible, and to allow the patients to stand without upper extremity support so they may use their upper extremities in work and play related activities.

Knowledge of four orthopaedic principles are necessary to gain a good understanding of why a particular orthosis is selected. These include concepts of ambulation, paralysis, contractures and deformities and the rationale of the orthotic prescription. By having a good understanding of the orthopaedic principles, the orthotrst can become a more constructive and effective member of the team. The orthotist must act in concert with the orthopaedist for the benefit of the patient.

It is necessary for all members of the team to speak a common language if communication is to be clear and precise. Walking ability or ambulation for paraplegics is customarily divided into four groups. These groups define the functional ambulatory status or potential of the paraplegic.

“Community Ambulators” have the ability to walk in the community. This means they can go up and down low curbs, and have the speed to cross the street during normal change of traffic (requiring a velocity of 1.5 miles per hour).

“Household Ambulators” can walk only on level terrain both indoors and outdoors and can transfer with little or no assistance.

“Therapeutic Ambulators” walk only during therapy sessions and walk a few steps during transfers.

“Non Ambulators” are those individuals who use the wheelchair exclusively.

PARAPLEGIA AND THE ORTHOTIC PRESCRIPTION:
The orthopaedic surgeon performs a neurologic evaluation on a repeated basis to determi1ie what muscle groups are functioning. With this knowledge, he/she can predict the long-term ambulatory potential and orthotic needs of the individual. Obviously, this has important implications for the orthotist, and therefore, he/she should have a basic understanding of the concepts of neurosegmental levels when dealing with the paraplegic patient. The neuro segment level is the lowest functional motor level as determined by specific muscle testing and clinical observation, not only does the muscle group need to be present but its power must be sufficient to be of functional use to the patient. In the thoracic level paraplegic, there is complete motor loss in the lower extremities. Because many of these individuals have poor abdominal muscles, unassisted sitting can be a problem, and any orthotic prescription will require stabilizing the torso, pelvis, hips, knees and ankles. Although these individuals do not possess active hip flexors to power the RGO, they can be trained to initiate hip flexion by forward motion of the trunk and can become successful RGO users.

The upper lumbar paraplegics (Lumbar 1 and 2) have strong hip flexor and adductor functions. Their orthotic needs demand stabilizing the lower extremities to the pelvis because they lack abduction and extension to control upright stance. These individuals are ideal candidates for the RGO system because they have powerful hip flexors which can be used to power the RGO system. This results in a faster, more energy efficient reciprocating gait. The alternative orthotic prescription is the HKAFO utilizing the swing-to- and swing-through gait. This has two significant disadvantages in comparing it to the RGO. It is more energy consuming and does not permit independent standing. These individuals will be household ambulators at best, but the use of the RGO system is appealing to them because it will enable them to walk about the house, school and work place, and to stand for long periods at a bench or table.

The lower lumbar paraplegic (Lumbar 3, 4 and 5) has strong quadriceps muscles. A normal quadriceps muscle (Lumbar 4 and 5) which extends and stabilized the knee, is the best predictor of effective long-term ambulation. The individual with good, but not normal quadriceps (Lumbar 3) will often need HKAFO’s, or floor reaction AFO’s, and crutches to be a good ambulator. With normal, powerful quadricep muscles (Lumbar 4 and 5), he/she usually can usually function with AFO’s and no crutches. At times, derotational straps may be needed to control malrotation when the patient lacks rotational control of the lower extremities. This group has the potential to achieve and remain community ambulators.

The sacral levels (Sacral 1 and below) have little or no significant motor loss. Ambulation without orthoses depends on the strength of the gastroc soleus muscle group which flexes the ankle and foot. If strong plantar flexion is present, then they can ambulate without an orthosis, but if a weak plantar flexion exists, a calcaneus gait will result without the use of AFO’s to prevent dorsiflexion of the ankle.

If the orthotist is aware of the concepts of neuro segmental level, then he/she can more accurately assist the orthopaedic surgeon in prescribing the proper orthosis for the patient’s needs. From a neuro segmental viewpoint the ideal candidate for an R.G.O. is Li - L2 level because hip flexors can power the orthosis.

CONTRACTURES AND DEFORMITIES:
Contractures imply permanent muscle-tendon shortening which prevents full and functional range of motion to the joint. An example of this would be a knee which is unable to completely extend because of shortening or tightness of the hamstring muscles, e.g., “a knee flexion contracture.”

Deformities imply deviation from the normal shape or size, e.g., scoliosis. Over time, a contracted muscle group can lead to a significant deformity as when tight hip flexors and abductors lead to a dislocation of the hip and pelvic obliquity. The basic rule is that any contracture or deformity of the pelvis and lower extremities that prevent wearing an orthosis must be corrected either by serial casting or surgery. The orthosis will delay or prevent contractures and deformities, but cannot be expected to correct these problems. The orthotist must share with the orthopaedic surgeon what contractures or deformities will be benefited by modification of the orthosis. If the deformities or contracture are too great, then correction should be done before the orthosis is constructed. At times, this can be done non-surgically with physical therapy or serial casting; at other times, surgery will be necessary.

The orthopaedic surgeon will often combine muscle-tendon transfer with contracture release and deformity correction in order to better balance and prevent recurrence. Deformities can often be predicted in advance by careful observation of the neuro segmental level. The basic goal of the contracture and deformity treatment is the placing of the lower extremity in the extension position referred to by Menelous, consisting of extending hips and knees with plantigrade feet (8).

Mild hip flexion contractures can be accommodated by the RGO system. Because hip flexion contractures do not appear to impair ambulatory ability with the RGO, restraint in surgical release of functioning hip flexion contractures should be exercised when use of the RGO is considered. Dislocated hip is not a contraindication for R.G.O.’s. Knee flexion contractures of 10 degrees or less require no treatment for effective orthotic use. Foot deformities are corrected so the foot is plantigrade and the ankle and subtalar joint can be fitted into a molded AFO component.

An excellent discussion on the surgical treatment of patients under consideration for the RGO system has been presented by Richard E. McCall, M.D, (9).

PHYSICAL THERAPIST:
The main role of a physiotherapist is to train the patient for maximum independence, that is, to sit, stand, transfer and ambulate either via orthoses and/or wheelchair. In this role, they function not only as a teacher to the patient but also as instructors to the family, training the family members to do the bulk of the therapy in the home environment. Since they are the only professionals who spend considerable periods of time working with the patients, they assist the orthopedist in establishing realistic goals, the optimum orthosis for the patient, and decisions on the timing for surgery or initiating an ambulation program. The therapist also assists the orthotist by evaluating the orthosis, and suggesting modifications that will maximize benefit. Again, we see the concept of the team approach, all members interacting, but each with their own area of expertise, all working toward the goal of improving function for the paraplegic patient.

PARAPLEGIC CHILD:
Together with the orthopedist and family the therapist helps design a realistic plan for achieving the highest possible function for each child. This is done by repeated neurologic evaluations to determine the neuro segmental level, assessing the family and child’s motivation, and teaching skills to the family to aid the patient.

As stated earlier, the ideal candidate for the RGO is a high lumbar level (Lumbar 1 and 2) who demonstrates strong hip flexors necessary to power the orthosis. Although this is the ideal candidate, many thoracic paraplegics who demonstrate no hip fiexion can also be trained to use the RGO by utilizing their trunk muscles to initiate flexion of the hip. Once the decision is made to use the RGO system, a specific RGO PT program is implemented to prepare the child for its use.

In the infant, a home therapy program is instituted using parents as the therapist to maintain range of motion to the joints, diminish contractures and deformities by proper exercise positioning and bracing. As the child’s balance mechanisms begin to appear, sitting is encouraged and supported. These children are always slower in relation to their normal peers, and as a rough rule of thumb, they are twice as old when they achieve developmental levels, for example, a normal child is ready to walk at a year while the paralyzed meningocele child will be ready at approximately two years. During the first year or two, significant deformities or contractures are corrected in anticipation of future orthotic needs.

Once the child begins to sit well and demonstrates a desire to pull to the upright position and stand, a standing frame or parapodium is used to introduce the child to the upright position. This learning process can take considerable time in a rapidly growing child, and these less sophisticated and cost efficient orthoses can be utilized to teach upright stance and improve balance. At the same time, the upper extremity strength and coordination training begins in anticipation of the need to use a walker or crutches in conjunction with the RGO.

When the child has adjusted to the upright posture, and has good upper extremity strength and dexterity, the RGO is fabricated and fit. The average time spent in the standing frame or parapodium before fitting the RGO is nine to 12 months.

The therapist begins to train the child and the family in the use of the RGO. This includes the activity of daily living skills, such as applying, locking, unlocking and removal of the orthosis. The child is instructed in proper sitting balance on the floor with the kr1ees extended and in a chair with the knees flexed. The therapist shows the patient how to go from sitting to standing and standing to sitting. Utilizing the walker and upper extremity strength, standing first with support and later with no support is a key skill for maximizing the unique potentials of the RGO. Finally, learning to walk utilizing the more natural and energy saving reciprocating movement. Without a skilled and enthusiastic therapist, the child cannot be a successful RGO user.

ADULT PARAPLEGICS:
Although the child and adult paraplegic share the obvious problem of paralysis of the lower extremities, it is not as simple as employing a larger version of the RGO and expecting the same results. It is more difficult for the RGO’s to be used by the adult and these patients have a higher rate of failure. However, when successful, the individual experiences a significantly higher level of function and independence.

Whereas, energy efficient ambulation is the most obvious advantage for the child, the advantage for the adults is the ability to stand for long periods of time without needing the upper extremities to prevent falling. Realistically, they use the wheelchair for most of their ambulation that occurs outside the home or work place. They use the R.G.O. to permit household ambulation, allowing them to walk from place to place within the home and work environment, permitting them to stand at counter, bench, table, etc. and to perform the occupational and recreational activities of daily living, so important to functioning in the real world.

The three key ingredients for successful adult RGO use is motivation, upper extremity strength and proper fit. The therapist is the key figure in evaluating and developing proper motivation, and should begin upper extremity strength training as soon as possible. It is obvious without motivation, the patient will never achieve the levels of strength necessary for RGO success. The patient starts on a program of weight modification if they are overweight. Upper extremity strength training and goals are set and periodically evaluated. This is a very demanding program requiring a significant commitment from the patient. If the goals are not met, the patient will not be considered a candidate for the RGO. It is estimated that approximately 60% of the individuals who are initial candidates fail to meet these goals and are eliminated from the program.

Once the patient has demonstrated the necessary determination, and has developed sufficient upper extremity strength, the RGO is constructed. Training continues with maximum emphasis on unassisted standing. For the highly motivated individual, the success rate is much higher, and the majority of these patients will be successful RGO users. Again, the therapist is the key individual in the early stage of the rehabilitation program for assisting in the selection of those patients who have the proper levels of motivation and dedication, and who have the potential to develop sufficient upper extremity strength. Once these individuals are selected, they undergo a vigorous training program.

IDEAL CANDIDATE FOR RGO:

THE ORTHOTIST:
The successful functional fit of a Reciprocating Gait Orthosis is dependent upon many factors. The R.G.Q. manual reviews the basic protocol for measurements, fabrication, fit, and training (3).

PATIENT EVALUATION FROM ORTHOTIC VIEWPOINT:
It is important to discuss with the patient, parents of a child, and the spouse of an adult, the requirements needed in order to successfully fit the patient with the R.G.O. system. The physician may have covered many of these questions and statements but the orthotist needs to reiterate and reinforce the importance of the requirements for successful use. Assuming that the patient understands what they are committing to may lead to failure. The orthotist should explain in detail what is to be expected from the patient and the commitment that both they and their family are about to make. Motivation and commitment to finish the task must be confirmed early. If a strong commitment is not evident R.G.O.’s should not be considered. Everyone must understand that successful R.G.O. wear consists of working toward and achieving specific goals and the process is measured in terms of months; not days.

The Orthotist is not just the individual who builds the R.G.O., but more importantly must be part of the team who decides if this individual is a suitable candidate to use an R.G.O. Certain physical attributes make an individual more likely to succeed in using this orthosis. It is crucial for the orthotist to evaluate the patient from the physical perspective.

Weight:
Obese individuals are not good candidates. They are much more difficugt to fit, and in addition the extra weight requires the expenditure of more energy during ambulation. This is especially true in the adult patient who may not have sufficient upper body strength to successfully use the orthosis.

Contracture’s and Deformities:
As mentioned in the earlier section, a certain degree of contracture and/or deformity can be accommodated in orthosis construction. However, the orthotist must decide when these problems are too severe and will need correction prior to fabrication of the brace. Standing balance and normal lower extremity alignment are crucial for success. Paralytic individuals often have spinal deformities. Will scoliosis, gibbous, and excessive lordosis prevent good standing balance or be impossible to accommodate by modifications in fabrication techniques? Unilateral or bilateral dislocation of the hip are not a contra indicator as long as sufficient range of flexion expansion is present for proper stride length. In unilateral dislocation, one can adjust the hip articulation to the level of the normal hip. Hip flexion contractures up to 15 degrees have been compatible with successful use.

Several contractures of the iliotibial bands will prevent the lower extremities to come together for normal stance position and will require surgical correction prior to brace construction. Mild genu valgum, genu varum, or fixed knee flexion can be accommodated if they do not prevent the foot from being level with the floor. Genu recurvatum is controlled by shallow thigh and calf cuffs or elevations of the heel. Foot deformities must be capable of fitting comfortably in the A.F.O., the goal is a plantigrade foot. These individuals lack skin sensation and excessive force to correct deformities and are poorly tolerated. When excessive force is required, or when fixed deformities such as equinus, hindfoot varus or valgus prevent a plantigrade foot surgical correction of these deformities must precede the orthotic construction. Flexible deformities should be corrected during casting and is made easier by use of a casting board which simulates the contour of the patient’s shoe.

OTHER CONSIDERATIONS:
Spasticity:
Many paralytic individuals will exhibit spasticity but in the absence of significant deformities is not a contra indication to R.G.O. use. Well fit thigh, leg and foot sections will lessen stimulation of trigger points and keep the lower extremity in a relaxed position.

Upper Extremity Strength:
Adequate upper extremity strength is an absolute prerequisite. A walker or bilateral crutches must be used to effect ambulation. Patients with the use of only one arm are not candidates for R.G.O.’s. All patients should be placed on a program of improving their upper limb strength.

Components:
The evolution of the R.G.O. has resulted in three pelvic sections and two KAFO designs for the orthosis. The initial design still in use today is the Hooped Cable System. This system utilizes two stainless steel cables to couple the hips to produce reciprocation. One cable attaches hip flexion and contra hip extension, the second cable is the mirror image as hip flexion is powered in the right hip, the cable produces extension in the opposite hip. As hip flexion is initiated with the left hip, the second cable acts to produce extension with the opposite (right) hip. A modification of this original design resulted in the Horizontal Cable System which used tracks in the posterior pelvic section to channel the steel cables significantly improving the appearance and bulk of the original design. A third modification produced the Rocker Bar R.G.O. This design introduces bilateral rocker bars connected by steel bands to couple hip flexion in one hip to hip extension in the opposite. Selection criteria is based on patient cosmetic preferences, the familiarity of the orthotist with the components and initial cost as well as long term maintenance cost. The most cost effective is the Hooped Cable System, then the Horizontal Cable, followed by the Rocker Bar design. The Hooped and Horizontal designs readily adapt to a metal pelvic band which has a smaller A-P dimension than the Rocker Bar, whereas, the Rocker Bar design eliminates the cables for those not wanting them. The plastic pelvic section is best suited for gibbus deformities because it is fabricated from a plaster wrap representing the contour of the patient.

There are two options available in hip joint design. The earliest hip joint as initially used in the Hooped Cable design had a J~~erAoJ~1s the joint for standing and unlock the joint for sitting. A newer button control hip joint is available and is compatible with the Horizontal Cable and Rocker Bar designs. An optional two position locking plate may be used with the Horizontal or Rocker Bar designs. It has the advantage of allowing the patient to go from a sitting to standing position with an optional lock at about 15 degrees of flexion. This second position is also beneficial while working over a bench or table or when it is desirable to lean forward slightly. A third niodilication is the “Abduction” hip hinge which has all the above features but in addition permits abduction, in the flexed position, to improve sitting stability and ease of toilet care and catheterization.

Knee Joint Selection:
There are a number of knee joints that can be used with this system. The most commonly used are drop lock, bail lock and offset type joints. In children, the smaller 3/16 X 5/8 and for adults, the more sturdy 1/4 X 3/4 joints are most commonly utilized. When single lateral bar construction is used, we recommend 1/4 x 5/8 in. aluminum bar for children and 3/16 x 3/4 in. stainless steel bar for adolescents and adults.

Once fabrication of the R.G.O. has been completed, two important responsibilities remain for the orthotists. The patient and family must be instructed in donning techniques, and a check out evaluation of the patient in the orthosis must be done in the sitting and standing positions. Donning the orthosis can be performed either in a sitting or supine position. R.G.O.’s constructed with double bar KAFO’s are usually donned in a supine position by rolling the patient into the orthosis. Single bar designs can also be donned in a supine or sitting position. Both methods can be easily learned and the patient and family will choose a technique that is best suited for them. If the patient has contractures secondary to tight muscle-tendons it is best to encourage stretching exercises prior to donning. Keeping in mind that these paralyzed individuals usually have decreased or no sensation in their lower extremities, clothing such as socks must be wrinkle free in order to prevent pressure sores.

The AFO Section:
When fabricating the AFO we use 3/16” to 1/4” polypropylene with the ankle section reinforced with PolyCar-C to prevent dorsiflexion. For children, the AFO is often lined with a Pe-Lite interface. Pe-Lite can also be added for additional protection in preventing skin breakdown in individuals with poor skin sensation. Also an interface may extend the useful life of the AFO used by children, because it may be removed providing space for volume change as the child grows. The foot section may be fabricated using a foot insert design that extends laterally around the hind and mid foot to provide more control of the foot. We recommend initially leaving the plantar surface section the full length of the foot. This provides maximum leverage and it can always be shortened at a later date.

CASTS AND MEASUREMENTS:
The importance of taking accurate measurements and casts cannot be over emphasized. Not that we don’t always strive for perfection, but realistically the fit of an A.F.O. or arch support is not nearly as critical as when we are dealing with a paraplegic who is going to wear Reciprocating Gait Orthoses. We consider the final product as needing to be considered A+ in appearance and fit.

We recommend using our measurement form that will record the necessary information needed to fabricate the orthoses accurately. In addition to filling out this form we obtain a tracing of the patient prior to taking the plaster wraps of the extremities and posterior pelvis. We utilize a M-L gauge to accurately record the medial lateral dimensions of the thigh, knee, calf, and ankle.

When taking the plaster wrap of the lower extremity we consider several important factors. We attempt to correct, to a limited degree, any genu-valgum or varum and any corresponding pes valgus or varus in the foot. Though we are concerned to not overload the condyle mild corrective forces can be exerted at this time. The goal is to have foot firmly and in proper alignment. Because we wish to have the foot firmly seated in the shoe and at a plantigrade angle to the floor we use a casting board which duplicates the heel - sole profile of the patient’s shoes. The boards are available in three standard sizes. When there are tight hamstrings or Achilles tendon we will take the plaster wrap of the foot and leg section before continuing the wrap of the knee and thigh. Another consideration is that we want to narrow the medial-lateral dimension of the thigh. This is done to prevent the bilateral medial uprights from coming in contact during standing and walking.

Prior to taking the plaster wrap for the pelvic section there are several considerations we review. First, accurately positioning the patient in a prone position with the lower extremities supported in a 90 degree angle. We recommend using our casting fixture. It will accommodate both the child and the adult. A common mistake is made at this point when the orthotist does not consider the effects of the knees too low or too high on the knee board. This affects the lordosis in the lumbar spine. When the knees are positioned too low this decreases the desired amount of lordosis, while having too much support exaggerates normal lordosis. Another consideration is properly locating on the plaster the orthotic hip joints location. Usually it will be at some point on a 45 degree line from the corner of the frame. After the patient is properly positioned we take a M-L measurement. The length of the plaster wrap that will be used on the patient is determined by adding 4” to the measurement from the left to the right side of the pelvis. Stockinette is placed on the pelvic section and the location for the orthotic hip joint is marked, using an adjustable template in conjunction with the casting frame that allows accurate positioning of the left and right trochanters. Eight inch wide plaster bandage is cut to calculated length, layered eight or nine sheets in thickness. The plaster splint is now dipped into warm water and placed on the patient. While the plaster is setting pressure is applied to either side of the pelvis forming a ledge with the excess plaster touching the horizontal section of the casting frame. This is done to key mark the plaster wrap to the frame which will be used in checking the accuracy after removal from the patient. When the plaster is set we take the hip joint template that we set prior to the plaster wrap, and again place it on the frame and scribe externally the hip joint location and a horizontal reference line. This is done on both sides. The plaster wrap is removed from the patient and placed on the casting frame for examination. Again we emphasize the need for accuracy in measurements and in the plaster wraps. If the plaster wrap extends too far distal on the thigh or too far superiorly on the torso, it is possible to have a model that will not produce the desired support. Immediately following removal from the patient we recommend that a metal rod be inserted through the hip joint locations. One should check that the rod is in a horizontal position and equal distance from the casting frame.

At this point we have now completed the measurements, a tracing of the lower extremity including the pelvic section, and have taken plaster wraps of the pelvic section and extremities.

FABRICATION:
Fabrication is very important, like the other key success factors in successfully providing a paraplegic with R.G.O.’s. Many of the techniques for fabrication of the various sections of a R.G.O. are covered in the current R.G.O. manual available from Fillauer, Inc. We will not review these procedures in this presentation, but will re-state the importance of an accurate and well fitting orthosis for the success of an R.G.O.

PolyCar-C, a new material, has modified the technique we use for reinforcing the plastic pelvic section and in the ankle section of the A.F.O.’s as described in the manual. PolyCar-C is a thermo bonding carbon reinforcing material that bonds to metal, polypropylene and co-polymer.

DELIVERY:
Alignment of the R.G.O. on the patient is first checked in the supine position. The pelvic section should fit snugly with the orthotic hip joints aligned anatomically. In the sagittal plane, the upper and lower hip joint bars bisect the mid axis of the torso and thigh, in the coronal plane they lie at the level of the top of the greater trochanter. The knee joints should allow easy flexion of the knees for comfortable sitting. The axis of the knee joint is approximately at the center of the patella, and is easily checked with the knee in flexion. The A.F.O. section should fit snugly but not cause pressure on sensitive areas such as the navicular, base of the fifth metatarsal, M.P. joints and the malleoli. Most patients wear high top athletic shoes with a neutral heel and the degree of ankle flexion of the A.F.O. should correspond to the type of shoe normally used.

Keep in mind that unassisted standing is one of the principal advantages of the R.G.O. system. It is therefore essential to check the orthosis in the standing position with the goal to have the patient stand hands free. Fine tuning adjustments to the orthosis must be made in a methodical manner. Example of these adjustments include adjusting the turnbuckle on the pelvic section to alter the flexion - extension angle of the proximal hip joint upright, changing the angle of the lower knee joint upright on the A.F.O., and adding material to the sole or heel of the A.F.O. The difference between a poor and excellent fit will be gauged by failure or success. The patient and family should be instructed in checking all nuts, screws, straps, etc. on a regular basis watching for loose components. Following final alignment, achieved through multiple visits over a two to three week period, the orthosis is converted from its prototype stage, to the definitive orthosis.

It is recommended that a routine orthotic evaluation and inspection of components be carried out quarterly because of the more sophisticated nature of the R.G.O. Large patients place greater loads on the orthosis, increasing normally expected wear and tear. Children are very active stressing the attachment points and often subject the orthosis to dirt and sand affecting the joint surfaces. Hip and knee joints should be disassembled, cleaned, greased and inspected for wear. Cables and Rocker Bar components are subjected to high torque and tensile loads that weaken them over time. It is essential to inform the patient of maintenance procedures and the need to have rivets, straps, and padding replaced on an as needed basis. Failure to maintain the orthosis will reduce the efficiency of it. Children will grow out of their orthosis and replacement occurs frequently, often yearly in small children. Designs utilizing single bar KAFO’s will tend to show more stress on the uprights and the joints. Look for torque misalignment as well as lateral bending of the uprights and deformation of the plastic A.F.O.

The efficiency of the system is compromised if joints loosen and the cables or rocker bar do not move smoothly. It is beneficial to monitor the amount of time the patient wears the orthosis. The goal is to practice on a daily basis increasing endurance and confidence in the orthosis. R.G.O. wearers should continue the process of improving balance and strengthening muscles. This is accomplished through follow-up visits on a monthly basis until the patient demonstrates consistent routine wearing of the orthosis. You do not want weeks to pass without the patient wearing the orthosis, which may result in the loss of enthusiasm they initially had at delivery. Our concern arises when patients are left to their own motivation without supervision. Experiences have shown this to be a leading warning sign for the eventual rejection of the orthosis.

CONCLUSION:
The Fillauer Reciprocating Gait Orthosis has evolved over many years of development and patient experiences. It is well documented to be an effective means of assisting paraplegics in performing the functions of standing and ambulation. Two year old children through mature adults can be fit with the series of components currently available. Fillauer Inc. offers a selection of designs that complement the preferences, goals and needs of the wearer. R.G.O’s improve the functional ability and quality of life for paraplegics.

BIBLIOGRAPHY:

1. Woolridge, C. Spina bifida orthotics program presented at the Workshop on Bracing of Children with Paraplegia from Spina Bifida and Cerebral Palsy, National Academy of Sciences, University of Virginia, Charlottesville, VA, October 2-4, 1969.
2. Yongue, D.A. Douglas, R., Roberts, J.M., The Reciprocation Gait Orthosis in Myelomeningocele. Journal of Pediatrics, 4.304-310, 1984. Final credit to solving numerous design problems and creating innovative solution in it manufacture is given to Carlton Fillauer of Fillauer, Inc., Chattanooga, TN.
3. Reciprocating Gait Orthosis including the horizontal cable system, a pictorial presentation and application manual. copyright 1993 by Fillauer, Inc., Chattanooga, TN, p.2.
4. Cerney, K., Waters, R., Hyslop, H., Perry, J., Walking and Wheelchair Energentics in Persons with Paraplegia. Physical Therapy, 1980; 60:1133-9.
5. Williams, L.O., Anderson, A.D., Campbell, J., Thomas, L., Feiwell, E., Walker, J.M., Energy cost of Walking and of Wheel Chair Propulsion by Children with Myelodysplasia: Comparison with Normal Children. Dev. Med. Child Neural, 1983; 25:617-24.
6. McBeath, A. A., Balhe, M., Balhe, B., Efficiency of assisted ambulation determined by oxygen consumption measurement. J. Bone Joint Surgery (A.M.) 1974: 56:994-1000.
7. Flandry, F., Burke, S., Robert, J.M., Hall, S., Drouihet, A., Davis, G., and Cook, S., Functional Ambulator in Myelodysplasia: The Effect of Orthotic Selection on Physiologic Performance, J. Pediatric Orthop., Vol. 6, No. 6,1986, p. 661-665.
8. Menelous, M.B., The Orthopaedic management of Spina Bifida Cystica, ed. 2, New York, Churchill-Livingston.
9. McCall, R.E., Douglas, R., Rightor, N., Surgical Treatment in Patients with Myelodysplasia Before Using the L.S.U. Reciprocation-Gait System. Orthopaedics, Vol. 6, No. 7, July, 1983, p. 843 to 848.

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