Mayra Gelacio is a 20-year-old female student attending Burbank High School in San Antonio. Gelacio has been at Burbank for the last 2 school years. She is currently enrolled in the Assisted Business Learning Experience (ABLE) program at Burbank, which is a sheltered group workshop for adult students with disabilities. Her main job in this program is shredding papers. Prior to this, she attended the Texas School for the Blind in Austin.

Gelacio is diagnosed with traumatic brain injury with resulting left hemiplegia. She had subdural hematoma at age 2, causing left-sided weakness, cortical visual impairment, and mild optic nerve atrophy. She has a functioning shunt and a history of seizures and drug allergies.

OUTCOME MEASUREMENT TOOL

The School Function Assessment (SFA) was used to track Gelacio's progress. Although the SFA is currently used for K-6th grade, it also can be used for older students. The SFA rates a student's skills as they relate to how the student performs functional skills in an educational environment. The criterion scores range from 0 to 100, with a score of 100 indicating the highest functional skill. Two major areas of the SFA - Travel and Manipulation with Movement - were assessed.

The Travel portion of the SFA assesses a student's ability to navigate the school environment, and the Manipulation with Movement portion assesses a student's ability to hold, carry, or manipulate objects while moving. In order to assess true progress, the SFA's feature of using confidence intervals (CI) was used to determine true progress based on changes in the criterion score.

PRIOR LEVEL OF FUNCTION BEFORE TOEOFF BRACE USE

In the Travel portion of the SFA, Gelacio obtained a criterion score of 52/100. This indicated that her skills were below what is expected from her peers at her age. She was able to ambulate inside the classroom independently without any assistive device with staff supervision for safety. When walking outside the classroom, Gelacio began to hold on to a staff member using her right hand for support. She was able to walk all throughout the campus but was highly dependent on the staff for physical support. She was able to ambulate on uneven surfaces such as unpaved ground with physical support (handheld assistance) from the staff member. The staff had reported that they try to avoid crowded hallways to make classroom transitions easier for Gelacio. Her walking pace was slower compared to other students, and she took longer to transition between classes.

Gelacio required one-on-one supervision while moving around the campus due to a combination of physical, cognitive, and visual problems. She had some awareness of her location in the campus and was able to tell staff members if she needed to go left or right once they reached the end of a hallway as they traveled to and from her classroom. Her gait pattern consisted of hip hiking and circumduction of the left lower extremity in a position of external rotation. Her left lower extremity exhibited left knee hyperextension with stance phase of gait. There was no heel strike due to the weakness of her left ankle dorsiflexors (foot drop). Her left upper extremity was in a flexion pattern position. She required handheld assistance getting on/off the curb and in getting in and out of the school bus. She was not using the stairs in the campus at this time.

In the Manipulation with Movement section, Gelacio obtained a criterion score of 42/100. Her score indicated a significant amount of difficulty with these types of tasks. Tasks assessed in this section included the ability to carry things, walk through the cafeteria line while carrying food, and open doors-all these tasks require a student to use the upper extremity while moving the body at the same time. Prior to wearing the ToeOFF brace by Allard Inc, Rockaway, NJ, she was unable to open doors independently. Doing such a task threw off her balance as she used her strong right hand for support. Using the right hand to open a door meant that she would be holding on to a moving object and not a stationary support. She would frequently wait for a school staff member to open and hold the school building doors for her when transitioning between her portable classroom and the main school building.

Gelacio was also unable to go through the lunch line and pick up and carry her food independently. She used a cart on which to place food and to push around. However, she needed assistance with this task as well, as she was unable to keep the cart going straight because she only used her right hand. As she went through the lunch line, a teacher would ask her what she wanted to eat and would place it on her cart while guiding the cart as Gelacio pushed it. She also took longer to go through the lunch line because her gait was so slow.

Analysis of Gelacio's scores-no overlapping of confidence intervals-indicated that the change in scores from before and after are true improvement of mobility skills and not due to errors of measurement.

TOEOFF BRACE

The ToeOFF orthosis was developed in Sweden during the early 1990s in response to the need for a more functional AFO. It is a carbon composite device that features an engineered footplate leading into a lateral strut that, in turn, leads into an anterior tibial shell. The footplate and strut act as dynamic lever arms that support the dynamic function of the lower quarter during gait. This design allows for an open calcaneous to allow functional closed-chain biomechanics to occur during gait. The pretibial shell provides dynamic support for the knee and hip during gait. As opposed to the traditional AFO devices that immobilize motion and inhibit muscle function, the ToeOFF is seen to allow appropriate motions and biomechanics events while dynamically assisting the function of muscles during closed-chain gait.

PRESENT LEVEL OF FUNCTION AFTER TOEOFF BRACE USE

The SFA results indicated that Gelacio's criterion score in the Travel section after wearing the ToeOFF brace was 70/100. Gelacio was beginning to ambulate with greater speed and independence. She was now able to transition between her classroom and the main school building without holding on to a staff member for support. She now frequently got up from her classroom chair independently to go to the bathroom, whereas before she would limit herself going to the bathroom because it was too laborious for her to even transition from sit to stand.

Gelacio's walking pace improved tremendously after wearing the ToeOFF brace because the dynamic response characteristics of the device were customized to her level of dysfunction, while the anterior shell design provided proximal stability. In fact, her teacher's goal at this time was to make sure she stayed with her class, as she tended to take off and leave her classmates when transitioning to another site in the campus. (Before, she was last in line because of the slower pace of her gait.) She also was able to move in crowded hallways more confidently and with greater initiative during transition periods without needing close supervision from a school staff member.

Wearing the ToeOFF brace allows Mayra Gelacio to open doors independently.

Gelacio also was able to move on uneven surfaces more confidently and independently with improved balance (whereas before, walking on unpaved ground would require her to hold on to a staff member). She was not bumping into furniture, staff, or students anymore when moving inside, or even outside, her classroom. Her stamina had improved to the point that she was now able to go to class community outings without needing to use her wheelchair (whereas before, she had to use it when out in the community). Her parent reported that when they go to department stores, Gelacio was not using her wheelchair.

With regard to Manipulation with Movement, Gelacio obtained a criterion score of 65/100. After wearing the ToeOFF brace for the last 2 1/2 months, Gelacio was now able to open and close all the doors in her school. The proximal support of the ToeOFF's anterior shell design helps provide "bottom up" dynamic stability to the knees, hips, and even pelvis during closed-chain function. By providing needed lower-extremity stability, Gelacio did not need to use her arm for support and instead could use it for functional upper-extremity tasks such as pushing a door. In fact, she was not waiting anymore for someone to open the door for her when transitioning between classes. She initiated opening and pushing the door by herself.

She also was able to go through the lunch line and pick her food using a portable cooler lunchbox that she places around her neck. The ToeOFF brace has given Gelacio much-needed stability-she was now able to pick her own food using her right hand when going through the lunch line instead of using the hand for support. Gelacio was now able to go through the lunch line much faster and within an acceptable time frame, which allowed her to have more time to spend enjoying her lunch and socializing with her friends during this period.

ADDITIONAL BENEFITS

1) Improved stamina, as noted with the increased amount of walking and increased energy to perform various tasks in her current school-based work program. Gelacio reported that she was less tired when using the ToeOFF brace because of the device's dynamic energy reflection during gait.

2) Improved balance, which allowed her to use her strong, right upper extremity for functional tasks as opposed to using it for support.

3) Increased self-esteem, because she was able to perform and accomplish various tasks more independently. This improved her socialization skills among her peers and staff.

4) Improved quality of life, as the brace has allowed Gelacio to have greater access to the community without needing to use a wheelchair.

Raphael Sadiwa, PT, DPT, is a school-based PT working with students with disabilities in San Antonio. His professional interests include using International Classification of Functioning, Disability, and Health-based outcome measurement and low-cost environmental modifications to enhance student participation. He recently presented at the 21st World Congress of Rehabilitation International in Quebec City, Canada. For more information, contact .