Dynamisk Ankel-Fot Ortos (DAFO) hos Barn med Spastisk Diplegi
- intervju och experimentella studier -
Dynamisk ankel-fot ortos (DAFO) är ett tunt fot- och fotledstöd som ofta används som komplement till övriga behandlingsmetoder för barn med spastisk diplegi. Syftet med ortosen är att underlätta och förbättra motorisk funktion i sittande, stående och gående samt att förhindra kontrakturer. DAFO håller foten i en neutral och funktionell position och anses bidra till att ge återkoppling till nervsystemet för att förbättra balans och hållning. Syftet med de aktuella studierna var att undersöka hur föräldrar till barn med spastisk diplegi upplever att DAFO påverkar barnens funktions- förmåga samt att i laboratoriestudier undersöka effekterna av DAFO i stående. Vidare studerades i stående samspelet mellan handens rörelse framåt-uppåt (armsträckning) i rummet och kroppens justering av balans och hållning. Femton föräldrar, vars barn var i åldrarna 4-18 år och användare av DAFO, intervjuades utifrån en övergripande forskningsfråga ”Hur upplever Du/Ni att DAFO påverkar barnet”? Intervjuerna analyserades med kvalitativ innehållsanalys. I laboratoriestudierna studerades barn i åldrarna 5-12 år, klassificerade i nivå II-IV enligt Gross Motor Function Classification System (GMFCS) samt en kontrollgrupp bestående av motoriskt normalutvecklade barn i samma åldersgrupper. Barnen utförde stående på kraftplattor en viljemässig armsträckning riktad framåt- uppåt mot ett föremål under samtidig registrering av kraft, rörelse och muskelaktivitet. Barn med spastisk diplegi studerades först enbart med skor och därefter med DAFO och skor under experimentet medan barnen i kontrollgruppen använde enbart skor.
Föräldrarna upplevde att ortoserna med sin stabiliserande effekt på fot och fotled kunde möjliggöra en bättre hållning av kroppen, vilket bidrog till bättre fysiska förutsättningar för olika aktiviteter. Känslan av säkerhet, trygghet och frihet ansågs av föräldrarna vara lika viktiga
som de fysiska effekterna. Resultatet av laboratoriemätningarna visade att kroppsvikten var jämnare fördelad över båda fötterna och att sträckning i knäna förbättrades då barnen använde DAFO jämfört med när de enbart hade skor på sig. Vid start av armrörelsen kunde både barnen med spastisk diplegi när de använde DAFO, och barnen i kontrollgruppen justera hållning och balans. Under accelerations- och uppbromsningsfasen av handens rörelse använde sig barnen med spastisk diplegi av kompensatoriska justeringar av hållning och balans, genom samtidig muskelaktivitet i tibialis anterior och laterala gastrocnemius på båda sidor. För barnen i kontrollgruppen karak- täriserades justeringar av hållning och balans under accelerationsfasen av ökad aktivitet i tibialis anterior på den sida där armrörelsen utfördes och under uppbromsningsfasen av ökad aktivitet i laterala gastrocnemius på motsatt sida. För barn med spastisk diplegi framkom att kvalitén i rörelsen och samspelet mellan uppåt- och framåtföring av handen, saknades jämfört med kontrollgruppen.
Enligt föräldrarnas upplevelser kan DAFO ses som en del av behandlingen, som förbättrar stabilitet, balans och funktionella färdig- heter. Barn med spastisk diplegi, som använder DAFO kan, trots varierande behov av stöd i stående, träna med en mer symmetrisk belastning på båda fötterna. Träning av armsträckning i stående med DAFO kan befrämja motorisk inlärning såsom justering av hållning och balans och därmed förbättra möjligheten att använda händerna i vardagsaktiviteter.
Nyckelord: Spastisk Diplegi, Hållning, Stående, Armsträckning, Kinematik, Kraft, Electromyografi.
Acknowledgements
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Acknowledgements
This dissertation orginates from the Department of Health Science, Division of Physiotherapy, Luleå University of Technology. I would like to express my sincere gratitude to all those who have contributed to this thesis in so many different ways. The following persons have contributed in their own special way:
All the children and parents, who participated in the studies, which made this thesis possible.
Gunnevi Sundelin, my supervisor, co-author, mentor and friend with great warmth and broad scientific knowledge, for your unending enthusiasm, support and encouragement while guiding me through the research process all the way all the time.
Karin Axelsson, my co-supervisor for inspiring research discussions, good advice, support and for trusting me to launch this project.
Helga Hirschfeld, my co-author for introducing me to the topic “motor control” and generously providing me with all kinds of research opportunities at the Motor Control and Physiotherapy Research Laboratory, Karolinska Institutet, Stockholm.
Lennart von Wendt, my former supervisor and co-author, for excellent guidance into the world of science and for believing in my ability and encouraging me to continue with research.
Ingmarie Apel, for friendship, constructive discussions on creative days and empathy on days of sadness, and excellent assistance at the Motor Control and Physiotherapy Research Laboratory, Karolinska Institutet, Stockholm. You have been the best support in the ups and downs during my research journey. I would not have made it without you.
Maare Tamm, my friend and co-author with great intellectual capacity, for valuable talks, advice and challenging discussions.
Acknowledgements
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Ann Kristin Ericsson, my dear friend, co-author and colleague whose clinical experience helped me to link theory with practice and vice- versa and for always being with me on this, now ended journey.
Tina Jesinkey, my friend, co-author and colleague at the Motor Control and Physiotherapy Research Laboratory, Karolinska Institutet, Stockholm, for good companionship during all the time we struggled together.
Lars Nyberg, head at the Division of Physiotherapy, for inspiring discussions, good advice and support.
All my dear colleagues at the Division of Physiotherapy: Solveig, Daina, Christer, Irene, Inger, Anita, Gunvor, Lotta, Sari-Anne, Tommy, Stina, Katarina M, Jenny, Agneta, Katarina A, Peter, Anna, Anna-Karin, Catrine, Anna-Maj, Erik and Lisbeth for cheerful support, creative discussions and friendship. You are worth travelling across the country for.
Monica Edström, for excellent assistance, friendship, support, and for so much warmth and concern in helping me to finish my “thesis book”. Thank you, for always being on hand.
Ulla Myhr and Berit Ekblom, my dear friends, mentors and colleagues who with so much wamth supported and believed in my ability, from the beginning to the end.
Werner Jäger, my colleague and friend, for stimulating discussions about physiotherapy and life, bringing me back to reality.
Ulla Levin, Erika Jonsson and Marketta Henriksson at the Motor Control and Physiotherapy Research Laboratory, Karolinska Institutet, Stockholm, for inspiring discussions and friendship.
Birgit Enberg, my friend and colleague for your warmth and hospitality during my stay in Umeå.
My colleagues and friends at the Division of Physiotherapy, Umeå University, for warm support and concern.
Acknowledgements
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Anders Brännström, Luleå University Library, for skillful help with literature.
Nils-Göran Karlsson, Sunderby Hospital, for skillful tayloring of the DAFOs.
Albert Crenshaw, for your wise language revision in English. My wonderful family:
My beloved mother Jane, and father Åke, for giving me so much love and support throughout my life.
My beloved sister, Gabriella and nephew Ludvig “Nisse” for backing me up and making me forget the scientific world now and then. My husband Per, my daughter Erika and my son Jonas for your end- less love and never ending support.
Gustav, “boy-friend-in-law", for the final touches with the lay out of the thesis.
Financial support for the work of this thesis was gratefully provided by the Department of Health Science, Luleå University of Technology, Norrbacka-Eugeniastiftelsen, FOU Norrbottens Läns Landsting, Folke Bernadotte Stiftelsen and RBUs forsknings-stiftelse.
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