LAND DER PALMEN UND BLUMEN Blumenriviera – Côte d'Azur Die Côte d'Azur – wie die französische Riviera genannt wird – ist wohl das schönste Stück Erde in Europa. Das azurblaue Meer, die roten und gelben Felsen, die sich im klaren Wasser spiegeln, die subtropischen Pflanzen wie Palmen, Zitronen- und Orangenbäume, das pulsierende Leben in den
Sitting Walking And Standing Hip orthosis
Fitting and Customization TABLE OF CONTENTS SWASH® Components Product Selection Product size & Upright selection Initial Application Initial Adjustments Initial Function, Evaluation & Customization The Professional Finish Prerequisite reading:
For a successful fitting, read the following sections included
in the SWASH® Clinical Manual (available separately):
• Biomechanics of SWASH®
• Indications & Contraindications
• Candidate Selection
• Pre and Post Fitting Functional Evaluation
• Protocols and Proper Fit Guidelines
Primary development goals of the SWASH®
1. Increase abduction and stretch hip adductors to
improve and maintain hip alignment2. Prevent excessive adduction during sitting and walking3. Optimize sitting and standing posture4. Achieve the above goals with an automatic transition from neutral (walking, standing) to abduction (sitting) SWASH® COMPONENTS 28801 Leg Bars 115o 28802 Leg Bars 123o 28803 Thigh Cuffs w/padding 28804 Pelvic Padding 28805 Joint Set (1) 28806 Boss Cover (2) 28807 Clamp Ring for Leg Bars (2) 28809 Brass Bushings for Thigh Cuff (10) 28810 Slide buckle for waistband 28811 Waistband screw set 28812 Waistband webbing with snap (1) 28813 Rubber Stoppers, Size 1 (set of 2) H Size 2-4 (set of 10) IMPORTANT: Specify needed for Classic 28814 Thigh Cuff Padding (2) 28815 Buckle with snap for Thigh Cuff (1) V 28820 Allen key, set of 4 Low Profile II
Pelvic Padding with Abdominal Pad 1, 2 Thigh Cuffs w/padding Thigh Cuff padding (2) 28846/47 Abdominal Pad Buckle with snap for Thigh Cuff (2) 5 Rubber stoppers (set of 10) IMPORTANT: Specify needed for Low Profile Allen Key, set of 4 This product should only be fitted by a certified professional.
SWASH® COMPONENTS Upright lengths
Pelvic Section - Distance Between Joint Centers
Measurements are taken on flat plate before bending.
PRODUCT SELECTION Before you begin
If it is not possible to meet with the rest of the "team" working with this patient, at least call
the referral source, therapist, and caregiver to discuss primary and secondary goals for this
orthosis. This will affect whether you select SWASH® Classic or SWASH® Low Profile II,
115 or 123 degree upright, plus the adjustment you make to the orthosis. The Pre-Fitting
Evaluation (see SWASH® Clinical Manual) is key to success and, combined with the Post-
Fitting (see SWASH® Clinical Manual) serves as a means for you to document outcomes.
SWASH® Low Profile II
The original design of SWASH® uses a plastic anterior over- SWASH® LP II uses a metal pelvic band with padded iliac lap pelvic band to secure the orthosis around the waist and extensions that are to be shaped and positioned between maintain its position, resting over the ASIS, just below the the crest of the ilium and the ASIS. The double strap front navel. In the back, the pelvic section extends from L2/L3 to closure allows for symmetrical application. In the back, the distal margin of the sacrum, providing maximum pelvic the padded metal posterior frame extends from approx- support. Children with low trunk tone and/or very limited imately L2/L3 to S1/S2. The metal offers positive non-slip trunk control strength may benefit from the increased contact for the abduction control joints, and includes clear posterior and lateral support this design offers. The thigh markings to monitor abduction settings. The joints are cuff closure is a double-lock strapping system to reduce tapered downward to accommodate most walker styles. chances of unwanted removal by children. Pelvic band and The thigh cuff closure is a simple double Velcro fold-back thigh cuff padding are removable for laundering. closure for easy donning and doffing. The pelvic band cover and thigh cuff padding are removable for laundering. The uprights are 6mm (size1) and 7mm (sizes 2-4) diameter. The uprights for all sizes are 8mm diameter. This increase The smaller diameter uprights on the size 1 allow more in diameter offers added strength to manage very high "spring", permitting less restriction of movement. This is tone, plus it allows cuffs to be completely interchangeable often desirable for the developing infant.
between all sizes.
Guidelines for Product Selection
The following are offered as general guidelines only. When possible, it is recommended to try each style on the patient to best assess which offers optimum function.
SWASH® Low Profile II
• When maximum trunk control is required, i.e., • When the primary goal is to control scissoring gait for the candidate who lacks muscle strength and the posterior joints on the SWASH® Classic interfere or upper body control to sit upright. with posterior walker, and a new walker is not an option.
• When patient is primarily non-ambulatory • When wearer has limited space between the iliac crest and the rib cage. • When a smaller diameter (6mm) uprights on • When maximum upright strength is required to manage the size 1 are desired to permit less restriction adductor tone.
• When candidate and/or caregiver acceptance of • When the greater pelvic coverage area triggers "bracing" is an issue. The Low profile is more more desirable neuro-sensory motor response. cosmetically acceptable to many. PRODUCT SELECTION 115 or 123 Degree Uprights?
SWASH® is available with either 115° or 123° uprights.
This refers only to the fixed angle of the most proximal
visible curve in the uprights – it does NOT refer to the
exact degree of abduction obtained while wearing the
orthosis. Standing and walking functions of both uprights are very similar. Generally the differences between the two are related to sitting function, with the 123° uprights creating greater amounts of abduction and the 115° uprights crea-ting relatively smaller amounts of abduction. NOTE: In sitting, the 123o uprights will have a greater influ-ence towards posterior pelvic rotation, thereby increasing the flexion influence on the trunk.
The selection of the 115 or 123-degree uprights does have an affect on the postural outcome of the fitting. The following are offered as guidelines: 123 Degree - Wide Sitting Base
115 Degree - Narrow Sitting Base
When the greatest amount of adductor The wearer is primarily chair mobile and muscle lengthening in the sitting position the 123° uprights would be too wide in the sitting position for the child to fit in chair or car seat, and a new chair or car When more trunk lumbar flexion influ- seat is not an option.
ence is desired when sitting.
Adductors are too tight and the amount of abduction when sitting in the 123° When more lumbar extension is desired during gait.
uprights would be impossible or painful.
When less trunk flexion influence desired when sitting.
PRODUCT SIzE & UPRIGHT SELECTIOn PELVIC SECTION CIRCUMFERENCE
Pelvic section circumference
At level of the anterior superior iliac spine (ASIS).
Use the table below to select the largest size that will fit the child, based on the measurements, to allow optimum room for growth. Keep the following in mind: Distal thigh, just proximal to the condyles. When fitted, the • The plastic on the cuffs and the pelvic band (SWASH® ends of the thigh cuffs should almost meet (to allow for Classic only) may be trimmed, if necessary. • The pelvic band on SWASH LP II may be shaped to fit slightly larger or smaller pelvic circumference.
Distance from waist to mid-patella with knees extended.
Interchangeability of Components
• For SWASH® Classic: All components on sizes 2, 3, and For SWASH® Classic only, size 1 uses 6mm diameter 4 units are modular and interchangeable. A size 1 thigh uprights and sizes 2, 3, and 4 use 7 mm uprights. All sizes cuff is available for a size 2 upright (size 1A).
SWASH® LP II use 8 mm diameter uprights. Level of func- • For SWASH® L.P II. : Al components are interchangeable tion and tone (not just the size chart) should be evaluated between sizes.
when selecting the proper diameter upright. • SWASH Classic and LP II components cannot be combined.
• The uprights almost always require trimming (after final fitting approval) so that the distal tips are level with the bottom of the cuff padding.
SWASH® SIZING CHART
in mm and inches.
400-465 15 3/4-18 1/4 210-250 460-550 18-21 3/4 250-290 9 3/4-11 1/2 7 540-630 21 1/4-24 3/4 290-330 11 1/2-13 620-720 24 1/2-28 1/4 330-380 13-15 400-465 15 3/4-18 1/4 210-250 8 1/4-9 3/4 460-550 18-21 3/4 250-290 9 3/4-11 1/2 8 PROFILE II SIZE 3
540-630 21 1/4-24 3/4 290-330 11 1/2-13 620-720 24 1/2-28 1/4 330-380 13-15 800-900 31 1/2-35 1/2 440-500 1. Remove retainer rings from the uprights
The uprights are labeled "Right" and "Left" to correspond
to the extremity on which they are fit. To assemble the
uprights to the pelvic band: Use the Allen Key to loosen the
set screw and slide the retainer ring off from the upright.
2. Insert retainer rings into joint assemblies
Insert the retainer rings into the center of the hip joint
with the hex-screw pointing up.
SWASH® Low Profile II
3. Insert and secure uprights into joint
4. Symmetrical uprights
Repeat with the opposite side, making certain that both Insert the uprights into the hip joint assembly and through uprights are inserted equal distance through the joint 400-465 15 3/4-18 1/4 210-250 the retainer ring. assembly so they are symmetrical.
460-550 18-21 3/4 250-290 9 3/4-11 1/2 7 540-630 21 1/4-24 3/4 290-330 11 1/2-13 Make certain the groove in the upright faces up and is 620-720 24 1/2-28 1/4 330-380 13-15 aligned with the set screw in the retaining ring. Tighten the set screw until it is securely seated into the groove in the 400-465 15 3/4-18 1/4 210-250 8 1/4-9 3/4 460-550 18-21 3/4 250-290 9 3/4-11 1/2 8 540-630 21 1/4-24 3/4 290-330 11 1/2-13 620-720 24 1/2-28 1/4 330-380 13-15 800-900 31 1/2-35 1/2 440-500 INITIAL APPLICATION SWASH® Low profile
SWASH® Low profile
1. Position the orthosis on the patient
2. Adjust the orthosis to fit the patient:
(in supine position):
SWASH® Classic pelvic band The pelvic section should encase the Anterior Superior Iliac Mark appropriate holes for both truss studs in the waist- Spine (ASIS), low enough that the navel is visible in the band. The studs should fit in the center of the slots in the overlap tab. The dual stud design provides intrinsic stability Ideal is to fit the orthosis at mid-pelvic girdle to obtain firm to the pelvic band. grasp and control of the pelvis. Depending on anatomy, final fitting location may vary from just below the waist SWASH® Low Profile pelvic band (navel) to mid-pelvic girdle Position the pelvic band extensions between the crest of the ilium and Check the ASIS relative to the posterior section of pelvic the ASIS. The pelvic band should be band on both sides to ensure symmetry in pelvic height shaped to the contour of the pelvis and that the orthosis is not rotated on the patient.
and extend no more than 5 cm (2 inches) toward anterior midline. SWASH® Low profile
3. Check the fit of the pelvic band:
Slide the fingers of one hand between the padding and the
patient's abdomen with hips alternately flexed and exten-
ded to ensure a snug yet comfortable fit.
4. Thigh cuffs
Initially, position the thigh cuffs as distal as possible wit-
hout creating pressure in the popliteal area and without
interfering with flexion. However, pressure on the thorax,
excessive spinal flexion, or discomfort due to hamstring
tightness, may be relieved by moving the cuffs up 1-3
inches. Mark on the uprights where the cuff should be se-
cured. If the cuffs are too large, mark on the cuff where it
should be trimmed for recommended fit (do not trim until
after initial fitting as it is possible you will find it necessary
to move the cuffs up higher on the thigh to resolve posture
or comfort issues).
5. Mark location for thigh cuffs:
NOTE: The thigh cuff is a cone shape - greater circum-
ference should be at the top. The straps close to the
INITIAL ADJUSTMENTS Remove the orthosis from the child. Make all necessary changes
to the orthosis while it is off the child.
Pelvic band adjustments
SWASH® Low profile
SWASH® Low profile
SWASH® Classic Loosen the large screws in the outer ring of the hip joint Move pelvic band truss studs to marked holes. assemblies. Rotate the joints to set amount of abduction Tighten with Phillips screwdriver.
needed to improve sitting and standing posture, and/or SWASH® Low Profile prevent scissoring during standing and walking, or to meet Remove the cloth cover. Based on your observations post-operative protocols, and then tighten.
during inital fitting - hand shape the metal frame that forms the iliac extension - maintain symmetry.
Adjust uprights for hip clearance
SWASH® Low profile
Adjust equally the distance that the upright passes through More (left photo) or less (right photo) abduction may be the hip joint assembly and tighten. This setting may need to needed depending on the child's hip alignment and functio- be changed after the orthosis is tested on the patient. nal performance.
Note: Loctite® or other adhesives are not generally
necessary to maintain secure settings on the SWASH®.
Maintain symmetry: The orthosis should be set up
to be symmetrical in every aspect. Most children with
cerebral palsy present with both postural and functional
Move thigh cuff to the marked position on uprights, rotate asymmetries. The SWASH® should be set up and used slightly laterally and tighten. Move other thigh cuff to the symmetrically for two to four weeks in an attempt to help same height and rotation.
the child become more symmetrical.
Final product check before fitting
Are all settings symmetrical?
When at all possible, start with all settings symmetrical.
Give the wearer a chance (2-4 weeks) to see if SWASH®
will help the wearer adjust to more symmetrical posture.
Do the uprights move freely and easily?
The uprights should always move freely and easily in a
full ellipse. If they don't, check that the Allen screw in the
retaining ring in the joint center is properly seated into
the groove in the upright.
Are the uprights in correct RIGHT and LEFT posi-
Fitting the patient
Open all closures on the orthosis. Reapply the orthosis to There is an engraving or blue label on the upright that the patient.
identifies left and right. Another way to check is to be certain the long horizontal groove in the proximal end Check for correct pelvic band height and that the orthosis of the upright that slides through the joint assembly should is not rotated on the child.
always be facing up.
SWASH® Low Profile
Are the cuffs on appropriate upright?
The cuffs are a cone shape and the large circumference Secure the pelvic band studs into their slots and snap the should be on top and the straps should close to the lateral circumference strap closed.
side. If this is not the case, remove the cuffs and switch to opposite uprights.
SWASH® Low Profile
Center the abdominal pad on the patient. Grasp each strap
Are the thigh cuffs rotated to appropriate angle?
and pull simultaneously to assure symmetrical application.
The retaining ring that connects the thigh cuff to the upright must not touch the sitting surface when the patient is sitting. Generally, rotating the cuff approximately 10° posterior from mid-line is sufficient.
Does the abduction angle prevent the cuffs from
A good starting point is 1 to 2 inch (2.5 - 5 cm) gap between
the cuffs when you glide the uprights to the standing position.
This angle will generally need to be re-adjusted after the
SWASH® Low Profile
function fitting, depending on the primary goals of the or- Secure the thigh cuffs. Adjust the hook and pile closure thotic intervention and the amount of tone during function. and check for a snug but comfortable fit.
If the patient is ambulatory, one goal for final fitting is to have the cuffs barely touch each other as the patient walks. SWASH® Low Profile
SWASH® Low Profile
1. Check the height and rotation of the orthosis on the 2. Insert at least three fingers of one hand between the child. Make sure that the pelvic section is located below padding and the abdomen to assure a comfortably snug fit the naval and encases the ASIS, and that the patient is not and the patient's comfort.
rotated in the orthosis. SWASH® Low Profile
SWASH® Low Profile
3. Flex the hips to 90° to check the position of the uprights 4. Check both limbs with the knees at 90° that there is no relative to the greater trochanters. The uprights should be impingement on the popliteus or the gastrocnemius. If the as close as possible to the greater trochanters without thigh cuffs are too high or if they are too low and causing impinging on them with the hips flexed. If there is impinge- impingement on the popliteus or the gastroc, mark a more ment or if the distance is too great, remove the orthosis appropriate height on the upright, remove the orthosis, and and adjust the distance of the uprights through the hip joint adjust the cuffs to the new position.
assemblies. Check to be certain that the desired abduction setting has not been altered. Re-apply the orthosis.
SWASH® Low Profile
5. Have the patient sit on a bench. Check that the location of the retaining rings are symmetrical and are not hitting the sitting surface. Check waist band tightness while sitting.
INITIAL FUNCTION EVALUATION & CUSTOMIZATION Stability during sitting is usually a fairly immediate improve- In initially setting up the orthosis, it is difficult to judge ment with the SWASH®. Sometimes a few minutes of fun the amount of abduction required to eliminate scissoring activities may be required to learn that now they do not during gait. The goal is for the thigh cuffs to come as close have to touch balance to sit comfortably. More time will together as possible, yet offer sufficient abduction to im- al ow them the opportunity to improve reaching and other prove hip alignment, posture and gait control, and prevent upper extremity functional capacities and a more erect Customization
Patient continues to scissor:
If scissoring is still hindering gait, remove the orthosis and
increase the amount of abduction. For minor increases
in abduction, the thigh cuffs may be externally rotated. In
some cases of higher adductor tone, it may be appropriate
to exaggerate the amount of abduction to provide a wider
base during gait just for the first week or two.
Suggest the patient be evaluated for external tibial or femoral
torsion. Sometimes internal hip rotation can disguise tibial
torsion, so even though the patient's feet don't toe-out
without SWASH®, with SWASH® on and internal rotation
minimized, the tibial torsion becomes more apparent.
Residual Internal Rotation
Many children will demonstrate a more erect and stable Even with the SWASH® in use, there may be residual in- standing posture. It may take some time to become ac- ternal rotation of the lower extremities. Very often, unless climated to their new posture and elevation. Cervical there are internal tibial torsion or metatarsus adductus issues, hyperextension and spinal rotation should diminish as the medial hamstrings have been seen to exert this internal pelvic stability increases. Improvements in standing balance rotary influence. A walking program along with specific and stability may be demonstrated after a few hours or days.
medial hamstring stretching has been seen to minimize this residual internal rotation.
Walker, Standing Frame, and/or Crutch Height
Evaluate the height of any external walking aids with the
patient wearing the SWASH®. They will often need to be
raised to accommodate to the new stance height.
INITIAL FUNCTION EVALUATION & CUSTOMIZATION Too much trunk flexion
Interference with Baclofen Pump
When sitting in SWASH®, ADduction of the legs along or Feeding Tubes
with tight hamstrings may produce a posterior rotary influ- This is not usually an issue with the Low Profile model since it has ence on the pelvis, creating a flexion influence on less abdominal coverage, but can be an issue with the SWASH® the trunk. This is more pronounced with the use of Classic. Upon approval from the referring physician, use a heat 123 degree uprights and less pronounced with the gun to "bubble out" the plastic, allowing space for the pump. Or, 115 degree uprights.
cut a hole large enough for relief of the pump and then use a If the condition persists, try one or a combination heat gun to flare out the edges so they are not pressing on the of the following: tissue around the pump.
a) Change position of thigh cuffs from distal femur to distal 2/3 femur. Pressure on the rib cage
b) Set the hip joints for less abduction. This is usually due to thigh cuffs being fit too distally on the thigh. c) Rotate the thigh cuffs laterally, increasing the 10o lateral Move the cuffs up to approximately 2/3 distal on the thigh.
rotation that is generally recommended.
d) Depending on the patient, additional anterior or Cuffs are too large
posterior padding may stimulate a proprioceptive There are two options: The cuffs can be trimmed and straps response to shift into more trunk extension: adjusted accordingly. Or, go to the next smaller size cuff. For 1. Add a longer foam pad to the posterior aspect of SWASH® Classic, cuffs are interchangeable for sizes 2-4. In addi- the pelvic band or add a sitting wedge (thicker part tion, there is a special size 1A cuff that will fit the 7 mm uprights under seat, narrow part under legs). on larger sized units.
2. Insert a thin pillow or foam pad (slightly larger than the abdominal pad) between the abdominal pad and Cuffs are too small
Fit the next larger sized cuff.
Too much trunk extension:
Posterior section of SWASH® Classic is too long
a) Check the style (115 or 123 degree) of the uprights Verify correct sizing. If size is correct, trim posterior section (find this engraved or on a blue label on the upright).
with heavy duty shears.
The 123 degree will influence more flexion.
b) Recommend the child always sit in a chair with a back rest; if needed include a hip strap to avoid sliding forward. c) Set the hip joints for slightly more ABduction. This will increase the flexion influence of the orthosis on the trunk. THE PROFESSIONAL FINISH Cut the uprights to proper length
Congratulations! you are now ready for the Post-Fitting Once the team has approved the orthosis, the uprights should be Evaluation (Refer to Clinical Manual). Be sure to docu- trimmed so that the distal tips are at the same level as the bot- ment the Post-Fitting Evaluation so you have a record of tom of the padding on the thigh cuffs. Ensure the ends are roun- functional improvement when compared to the Pre-Fitting ded and polished smooth. Push on the protective rubber tips.
Teach caregiver to apply
Demonstrate and then ask the caregiver to apply and remove the
orthosis to help assure appropriate caregiver compliance.
Protocols and proper fit guidelines
you will find this in the Clinical Manual.
Benefits and outcomes
This is in the Clinical Manual and may help in the preparation of
documents for submission for insurance.
Frequently asked questions
Also in the clinical manual, this contains many of the questions
asked by both referral sources, therapists, patients, and caregivers.
SWASH® Referencelist 1 R. N. Boyd et al., The effect of botulinum toxin type A and a variable hip abduction orthosis on gross motor function: a randomized controlled trial. European Journal of Neurology 2001, 8 (Suppl.5): 109-119.
2 Dianne Russel et al., Canada Child Centre for Childhood Disability Research, Hamilton, Ontario, Canada, AACPDM Conference, Washington, DC, 1999 3 Danielle Truscelli, Philippe Toullet, Philippe Lancert, SWASH Preliminary report published on the French medical publication "la letter de medicine physique & de réadptation" December 1999 4 Report from "The 15th Scientific Meeting of the Japanese Society of Prosthetics and Orthotics", November 27 - 28, 1999, Hiroshima.
5 Dormans, J.P., Pellegrino, L., Caring for Children with Cerebral Palsy, A Team Approach. Baltimore: Paul H. Brookes Publishing Co., 1998.
6 Batshaw, Mark L., Children with Disabilities. Baltimore: Paul H. Brookes Publishing Co., 1997 7 R.n. Boyd, S.G. Manion, Effect of the Variable Hip Orthosis, newcomen Centre, Guy´s Hospital, London, England, Interbor Conferece, Oslo, 1996 8 R.N. Boyd, New Horizons in Cerebral Palsy, ISPO Melvourne Australia 30-31 March 1995 9 Atyer-Acevedo, Jane, Physical Therapy for the Child with Cerebral Palsy. Pediatric.
10 Physical Therapy, Second Edition, Philadelphia: J.B. Lippincott Company, 1994 11 Scherzer, Alfred, Tscharnuter, Ingrid, Early Diagnosis and Therapy in Cerebral Palsy, New york: Marcel Dekker, Inc. 1990 12 Houkam et al., Treatment of Acquired Hip Subluxation in Children with Cerebral Palsy, Journal of Pediatric Orthopedics, Vol. 6, No. 3, New york: Raven Press, 1986 13 Folio R., Fewell R., Peabody Developmental Motor Scales and Activtiy Cards, Chicago: The Riverside Publishing Co., 1983 14 Paul A.R. Meyer, MRCP, A Variable Abduction Brace to Treat Hip Subluxation in Cerebral Palsy, Addenbrooke´s Hospital, Cambridge, England 15 Jan F.A. Smits, A New Approach for Dynamic Hip Orthotic Management of the Child with Cerebral Palsy ALLARD INTERNATIONAL
c/o Camp Scandinavia AB
www.allardint.com Tel +46 42 25 27 00 SE-254 67 Helsingborg SWEDEN Fax +46 42 25 27 25
SUORE MINIME DELL'ADDOLORATAVia C. Tambroni, 13 - 40137 Bologna - Tel. 051 341755-342624 POSTE ITALIANE S.P.A. - SPED. ABB. POST. D.L. 353/2003 (CONV. IN L. 27/02/2004 N. 46)ART. 1, COMMA 2, DCB - BO - ANNO XLVII - PUBB. INF. 50% - STAMPA: DIGI GRAF - BOLOGNA Giornata mondiale della pace Nel Messaggio per la XLVII Giornata Mondiale della pace,