Orthotics

ORTHOTICSA report by: Kenneth Pierre M. Lopez

ORTHOTIC BASICS

Orthotics• Derived from the greek worth ORTHO meaning straight,

upright or correct.

• It refers to a static or dynamic device and is preferable to splint or brace which refers only to a static device.

• Three point pressure principle: forms the mechanical basis for orthotic correction; a single force is placed at the area of deformity or angulation; two additional counter forces act in the opposing direction

Functions of Orthotics• Prevent Deformity• Assist function of a weak limb• Maintain proper alignment of joints • Inhibit tone• Protect against injury of a weak joint• Allow for maximal functional independence • Facilitate Motion

Orthotic Consideration• Cost• Energy efficiency• Cosmesis• Temporary versus permanent• Dynamic versus static• Encourage normal Movement

Orthotic Intervention• Ensure continued proper fit• Donning/doffing orthosis• Implement progressive wearing schedule• Patient/caregiver teaching:

• Skin Inspection• Care of orthosis

• Mobility training with orthosis

Orthotic Goals• Maximize functional mobility skills with orthosis• Maximize independence with donning/doffing• Maximize independence with wearing schedule• Maximize independence with skin inspection• Maximize competence with care of orthosis

Alignment• Correct alignment permits effective function

• a. minimizes movement between limb and orthoses (pistoning)• b. minimizes compression on pressure sensitive tissues

LOWER LIMB ORTHOSESComponents/Terminology

SHOESThe foundation for an orthosis; shoes can reduce areas of concentrated pressure on pressure sensitive feet.

Shoes

• A. Traditional leather orthopedic shoes or athletic sneakers can be worn with orthoses; attachments can be external or internal

• B. Blucher opening has vamps (flaps contain the lace stays) that open wide apart from the anterior margin of the shoe for ease of application

• C. Bal (balmoral) opening: has stiched down vamps not suitable for orthotic wear

Shoes

Blucher opening Balmoral opening

FOOT ORTHOSES (FO)A semirigid or rigid insert worn inside a shoe that corrects foot alignment and improves function may also be used to relieve pain. Foot orthotics are custom molded and are often designed for a specific level of functioning

Foot Orthoses (FO)• May be attached to the interior of the shoe (an inserted

pad) or exterior to the shoe (thomas heel)• Soft inserts (viscoelastic plastic or rubber pads or relief cut-

outs) reduce areas of high loading, restrict forces, and protect painful or sensitive areas of the feet.

• Metatarsal pad: located posterior to the metatarsal heads; takes pressure off the metatarsal heads and onto the metatarsal shafts; allows more push off in weak or inflexible feet

• Cushion heel: cushions and absorbs forces at heel contact; used to relieve strain on plantar fascia in plantar fasciitis

• Heel-Spur pad.

Foot Orthoses

Metatarsal Pad: Neuroma Pad

Cushion Heel

placed between the metatarsal shafts to relieve nerve pain ans is most commonly placed between the 3rd and 4th met shafts commonly this is also used with a wider shoe to achieve relief

Heel Spur Pad

LONGITUDINAL ARCH SUPPORTSPrevent depression of the subtalar joint and correct for pes planus (flat foot)

Longitudinal Arch Supports

• UCBL (university of California biomechanics laboratory) insert: a semi rigid plastic molded insert to correct for flexible pes planus

• Scaphoid Pad: used to support the longitudinal arch

• Thomas heel: a wedge with an extended anterior medial border used to support the longitudinal arch and correct for flexible pes valgus (pronated foot)

Longitudinal Arch Supports

Scaphoid Pad Thomas Heel

UCBL Heel

Posting• Rearfoot posting alters the position of the subtalar joint or

rearfoot from heel strike to foot flat. Must be dynamic, control but not eliminate STJ function.• Varus Post (medial wedge): limits or controls eversion of the

calcaneus and internal rotation of the tibia after heelstrike. Reduces calcaneal eversion during running

• Valgus Post (lateral wedge): controls calcaneus and subtalar joint that are excessively inverted and supinated at heelstrike.

Posting• Forefoot posting: suports the forefoot

• Medial wedge prescribed for forefoot varus• Lateral wedge prescribed for forefoot valgus

• Contraindicated for insensitive foot

HEEL LIFTSAka Heel Platform

Heel Lifts• Accommodates for leg length discrepancy; can be placed

inside the shoe (up to 3/8 inch) or attached to the outer sole.

• Accommodates for limitation in ankle joint dorsiflexion

ROCKER BAR & ROCKER BOTTOM

Rocker bar & Rocker bottom• Rocker bar: located proximal to metatarsal heads;

improves weight shift onto metatarsals• Rocket bottom: builds up the sole over the metatarsal

heads and improves push off in weak or inflexible feet. May also be used with insensitive feet

ANKLE-FOOT ORTHOSIS (AFO)Consist of a shoe attachment, ankle control, uprights and a proximal leg band

Shoe attachments & Stirrups• Foot Plate: a molded plastic shoe insert; allows

application of the brace before insertion into the shoe, ease of changing shoes of same heel height.

• Stirrup: a metal attachment riveted to the sole of the shoe; split stirrups allow for shoe interchange solid stirrups are fixed permanently to the shoe and provide maximum stability

Shoe attachments & Stirrups

Foot Plate and Split Stirrups Solid Stirrups

Ankle Controls• Free motion: provides mediolateral stability that allows

free motion in dosiflexion and plantarflexion• Solid ankle: allows no movement indicated with sever pain

or instability• Limited motion: allows motion to be restricted in one or

both directions

Ankle Controls

Free Motion Limited Motion

Solid AFO

Limited Motion Ankle Control• Bichannel adjustable ankle lock (BiCAAL): an ankle joint with the

anterior and posterior channels that can be fit with pins to reduce motion or springs to assist motion

• Anterior Stop (dorsiflexion stop): determines the limits of ankle dorsiflexion. In an AFO, if the stop is set to allow slight dorsiflexion (~5degrees), knee flexion results; can be used to control for knee hyperextension; if the stop is set to allow too much dorsiflexion, knee buckling could result

• Posterior stop (plantarflexion stop): determines the limits of ankle plantar flexion. In an AFO if the stop is set to allow slight plantar flexion (~5degrees), knee extension results; can be used to control for an unstable knee that buckles; if the stop is set to allow too much plantar flexion, recurvatum or knee hyperextension could result

Limited Motion Ankle Control

BiCAAL Anterior Stop

DORSIFLEXION ASSISTANCE

Spring Assist & Posterior Leaf Spring• Spring assist (Klenzak housing): double upright metal

AFO with a single anterior channel for a spring assist to aid dorsiflexion

• Posterior leaf spring (PLS): a plastic AFO that inserts into the shoe; widely used to prevent foot drop.

Dorsiflexion assistance

Spring Assist Posterior Leaf Spring

VARUS OR VALGUS CORRECTION STRAPS (T STRAPS)

T Straps

• Control for varus or valgus forces at the ankle. • Medial strap buckles around the lateral upright and

correct for valgus• Lateral strap buckles around the medial upright and

corrects for varus

UPRIGHTS AND ATTACHMENTS (BANDS OR SHELLS)

Uprights and attachments

• Conventional AFOs have metal uprights (aluminum, carbon graphite or steel) and a hinged ankle joint allowing plantarflexion and dorsiflexion. Provides maximum support if the patients condition is changing (e.g. peripheral edema), conventional metal AFOs may be easier to alter to accommodate changes than molded AFOs.

Uprights and attachments• Double metal uprights extend upwards from the ankle on

both sides of the leg and attach to a calf band.• Conventional AFO, calf band (metal with leather lining or

plastic); provides proximal stabilization on leg; anterior opening and buckle or velcro closure.

Uprights and attachments• Molded AFOs are made of molded plastic and are lighter

in weight and cosmetically more appealing; contraindicated for individuals with changing leg volume.• Posterior leaf spring (PLS): has a flexible narrow posterior shell;

functions as dorsiflexion assist; holds foot at 90degree angle during swing; displaced during stance; provides no medial-lateral stability.

• Modified AFO: has a wider posterior shell with trimlines just posterior to malleoli; foot plate includes more medial-lateral stability (control of calcaneal and forefoot inversion and eversion)

• Solid AFO: has widest posterior shell with trimlines extending forward to malleoli; controls (prevents) dorsiflexion, plantarflexion, inversion and eversion.

• Spiral AFO: a molded plastic AFO that winds (spirals) around the calf; provides limited control of motion in all planes

AFO

Conventional Molded

SPECIALIZED AFOS

Specialized AFOs• Patellar-tendon-bearing brim: allows for weight distribution

on the patellar shelf similar to patellar-tendon-bearing prosthetic socket; reduces weight bearing forces through the foot

• Tone-reducing orthosis: molded plastic AFO that applies constant pressure on spastic or hypertonic muscles (plantarflexors and invertors); snug fit is essential to achieve the benefits of reciprocal inhibition

Specialized AFOs

PTB Tone Reducing Orthosis

KNEE-ANKLE-FOOT ORTHOSIS (KAFO)Consists of a shoe attachment, ankle control, uprights, knee control, and bands or shells for the calf and thigh

Knee-ankle-foot orthosis (KAFO)• Knee Controls

• Hinge joint: provides mediolateral and hyperextension control while allowing for flexion and extension.• Offset: the hinge is placed posterior to the weight bearing line

(trochanter-knee-ankle TKA line); assists extension, stabilizes knee during early stance patients may have difficulty on ramps where knee may flex inadvertently

• Locks• Drop ring lock: rings drops over joint when knee is in full extension

to provide maximum stability; a retention button may be added to hold the ring lock up, permit gait training with the knee unlocked

• Pawl lock with bail release: the pawl is a spring loaded posterior projection that allows the patient to unlock the knee by pulling up or hooking the pawl on the back of a chair and pushing it up adds bulk and may unlock inadvertently with posterior knee pressure

Types of Orthotic Knee Joints

Knee-ankle-foot orthosis (KAFO)• Knee stability

• Sagittal stability achieved by bands or straps used to provide a posteriorly directed force.• Anterior band or strap (knee cap): attaches by four buckles to metal

uprights; may restrict sitting, increases difficulty in putting on KAFO• Anterior bands: pretibial or suprapatellar or both

• Frontal plane controls: for control of genu varum or valgum• Posterior plastic shell• Older braces utilize valgum (medial) or varum (lateral) correction straps

which buckle around the opposite metal upright; less effective as controls than plastic shell

Knee-ankle-foot orthosis (KAFO)• Thigh bands

• Proximal thigh band• Quadrilateral or ischeal weight bearing brim: reduces weight

bearing through the limb• Pattern bottom: a distal attachment added to keep the foot off the floorl

provides 100% unweighting of the limb; a life is required on the opposite leg.

• Specialized KAFOs• Craig-Scott KAFO: commonly used appliance for individuals with

paraplegia; consists of shoe attachments with reinforced foot plates BiCAAL ankle joints set in slight dorsiflexion, pretibial band, pawl knee locks with bail release, and single thigh bands

• Oregon orthotic system: a combination of plastic and metal components allows for triplanar control in three plans of motion(sagittal, frontal, and transverse)

KAFO

Scott-Craig Oregon Orthotic System

Knee-ankle-foot orthosis (KAFO)• Fracture braces: a KAFO device with a calf or thigh shell that

encompasses the fracture site and provides support.• Functional electrical stimulation (FES) orthosis: orthotic use and

functional ambulation is facilitated by the addition of electrical stimulation to specific muscles; the pattern and sequence of muscle activation by portable stimulators is controlled by an externally worn miniaturized computer pack; requires full passive range of motion good functional

• Standing frames• Allows standing without crutch support may be stationary or

attached to a wheeled mobility base

• Parapodium• allows for standing without crutch support; also allows for ease in

sitting with the addition of hip and knee joints that can be unlocked can be used on children with myelodysplasia

KAFO

Fracture Brace FES KAFO

KAFO

Parapodium Standing Frame

SPECIALIZED KNEE ORTHOSES (KO)

Specialized Knee Orthoses (KO)• Articulated KOs: control knee motion and provide added

stability.• Post surgery KO protects repaired ligaments from overload• Functional KO is worn long-term in lieu of surgery or during

selected activities• Examples include: Lenox Hill, Pro-Am, Can-Am, Don Joy

• Swedish knee cage• provides mild control for excessive hyperextension of the knee

• Patellar stabilizing braces• Improve patellar tracking; maintain alignment• Lateral buttress or strap positions patella medially• A Central Patellar cutout may help positioning and minimizes

compression

KO

Lenox HIll Donjoy

KO

Swedish Knee Cage Patellar Stabilizing

Specialized Knee Orthoses (KO)• Neoprene sleeves

• Nylon coated rubber material• Provide compression, protection

and proprioceptive feedback• Provide little stabilization unless

metal or plastic hinges are added

• Retains body heat which may increase local circulation

• A central cutout minimizes patellar compression

• Can be used in other areas of the body such as the elbow and thigh etc

HIP-KNEE-ANKLE-FOOT ORTHOSES (HKAFO)Contain a hip joint and pelvic band added to a KAFO

Hip-Knee-Ankle-Foot orthoses• Hip joint: typically a metal hinge

joint• Controls for abduction, adduction

and rotation• Controls for hip flexion when

locked, typically with a drop ring lock; a locked hip restricts gait pattern to either a swing to or swing through gait

• Pelvic attachments• A leather covered, metal pelvic

band; attaches the HKAFO to the pelvis between the greater trochanter and iliac crest; adds to difficulty in donning and doffing; adds weight and increases overall energy expenditure during ambulation.

SPECIALIZED THKAFOContains a trunk band added to a HKAFO

Specialized THKAFO• Reciprocating gait orthosis

(RGO): • utilizes plastic molded solid ankle

orthoses with locked knees, plastic thigh shell, a hip joint with pelvic and trunk bands; the hips are connected by steel cables which allow for a reciprocal gait pattern (either 4point or 2point); when the patient leans on the supporting hip, it forces it into extension while the opposite leg is pushed into flexion allowing limb advancement

SPECIALIZED LOWER LIMB DEVICES

Specialized lower limb devices• Denis Browne splint: a bar that connects two shoes that

can swivel; used for correction of club foot or pes equinovarus in young children

• Frejka pillow: keeps hips abducted used for hip dysplasia or other conditions with tight adductors in young children

• Toronto hip abduction orthosis: abducts the hip; used in treating LCPD

Specialized lower limb devices

Denis Browne Splint Frejka Pillow

SPINAL (TRUNK) ORTHOSES:COMPONENTS/TERMINOLOGY

Spinal (trunk) orthoses:Components/Terminology• Corset

• Provides abdominal compression, increases intraabdominal pressure; assists in respiration in individuals with SCI; relieves pain in low back disorders; sacroiliac support

• Lumbosacral orthoses (LSO): control or limit lumbosacral motions• Lumbosacral flexion, extension, lateral control orthes (LS FEL)

(Knight Spinal): includes pelvic and thoracic bands to anchor the orthosis with two posterior uprights, two lateral uprights and an anterior corset

• Plastic lumbosacral jacket: provides maximum support by spreading the forces over a larger areal more cosmetic but hotter

Spinal (trunk) orthoses:Components/Terminology• Thoracolumbosacral orthoses (TLSO): control or limit

thoracic and lumbosacral motions• Thoracolumbosacral flexion, extension control orthoses (TLS FE)

(Taylor brace): includes components of a LS FEL with the addition of axillary shoulder straps to limit upper trunk flexion

• Plastic thoracolumbosacral jacket: provides maximum support and control of all motions; used in individuals recovering from SCI; allows for early mobilization out of bed and functional training

• Jewett (TLSO): limits flexion but encourages hyperextension (lordosis); used for compression fractures of the spine

TRUNK ORTHOSIS

Knight Spinal Taylor Brace

Jewett Brace

Spinal (trunk) orthoses:Components/Terminology• Cervical orthoses (CO): control or limit cervical motion

• Soft Collar: provides minimal levels of control of cervical motions; for cervical pain or whiplash

• Four-poster orthosis: has two plates (occipital and thoracic) with two anterior and two posterior posts to stabilize the head; used for moderate levels of control in individuals with cervical fracture/SCI

• Halo orthosis: attaches to the skull by screws, four uprights connect from the halo to a thoracic band or plastic jacket; provides maximal control for individuals with cervical fracture or SCI; allows for early mobilization out of bed and functional training

• Minerva orthosis: a rigid plastic appliance that provides maximum control of cervical motions; uses a forehead band without screws

Cervical Orthosis

Soft Collar Four Poster

Cervical Orthosis

Halo Minerva

SPECIALIZED TRUNK ORTHOSES

Specialized trunk orthoses• Milwaukee orthosis

• a cervical, thoracic, lumbosacral orthosis (CTLSO) used to control scoliosis; it has a molded plastic pelvic jacket and one anterior and two posterior uprights extended to a superior neck or chest ring; pads and straps are used to apply pressure to the areas of convexity of spinal curves; bulky, less cosmetic and may be used for all kyphotic and scoliotic curves less than 40 degrees

• Boston orthosis (TLSO)• A low profile molded plastic orthosis for scoliosis; more cosmetic,

can be worn under clothing; used for midthoracic or lower scoliosis curves of less than 40degrees; also used to treat spondylolisthesis and conditions of severe trunk weakness

Trunk Orthosis

Milwaukee Boston

UPPER LIMB ORTHOSESCOMPONENTS/TERMINOLOGY

Most UL orthoses are directed toward creating usable prehension, functional and hand position

Upper limb orthoses• Passive (static) positioning devices: generally made out of

a variety of low temperature plastic; ie orthoplast, hexalite• Resting splint (cock-up splint): an anterior or palmar splint that

positions the wris and hand in a functional position• Dorsal splint: frees the palm for feeling and grasping by the use of

grips that curve around over the second and fifth metacarpal heads; allows for the attachment of dorsal devices ie rubber bands to make it a dynamic device

• Airplane splint: positions the patients arm out to the side at 90degrees of abduction the elbow is also flexed to the same degrees; the weight of the outstretched arm is borne on a padded lateral trunk bar and iliac crest band; a strap holds the device across the trunk; used to immobilize the shoulder following fracture of injury when trapping to the chest is not desirable or with burns

Upper limb orthoses

Resting Splint Dorsal Splint

Airplane Splint

Upper limb orthoses• Dynamic devices

• Wrist driven prehension orthosis (flexor hinge orthosis): assists the patient in use of wrist extensors to approximate the thumb and forefingers (grip) in the absence of active finger flexion; eg facilitates tenodesis grasp in the patient with quadriplegia

• Motor driven flexor hinge orthosis: complex control systems that allow for grasp not generally in widespread use

Upper limb orthoses

Wrist Driven Prehension Device Motor Driven Flexor Hinge

PHYSICAL THERAPY INTERVENTIONA physical therapist functions as a member of an orthotic clinic team that includes the physician, orthotis and therapists

Physical Therapy Intervention• Assessment• Pre-orthotic assessment and prescription evaluate:

• Joint mobility• Sensation• Strenth and motor function• Functional level• Psychological status

• Orthotic prescription• Consider the patients abilities and needs

• Level of impairments, functional limitations, disability• Status: consider if the patient’s condition is permanent or changing

Physical Therapy Intervention• Consider level of function, current lifestyle

• Consider if the patient is going to be a community ambulator versus a household ambulator

• Consider recreational and work related needs

• Consider overall weight of orthotic devices, energy capabilities of the patient. Some individuals abandon their orthoses quickly in favor of wheelchairs because of the high energy demands of ambulating with orthosis

• Consider manual dexterity, mental capacity of the individual. The donning and use of devices may be too difficult or complicated for some individuals

• Consider the pressure tolerance of the skin and tissues• Consider use of a temporary orthosis to assess likelihood of

functional independence, reduce costs

Physical Therapy Intervention• Orthotic Assessment check out

• Ensure proper fit and function; construction of the orthosis• Static assessment

• Check alignments for lower limb orthosis:• In midstance foot should be flat on the floor• Orthotic hip joint: 0.8 cm anterior and superior to the greater trochanter• Medial knee joint: ~2 cm above joint space, vertically midway between

medial joint space and adductor tubercle• Ankle joint: at tip of malleolus • Plastic shells or metal uprights, thigh and calf bands conform to

contours of the limb• No undue tissue pressure or restriction of function

Physical Therapy Intervention• Dynamic assessment

• Fit and function during activities of daily living, functional mobility skills• Fit and function during gait

• Orthotic training• Instruct the patient in procedures for orthotic maintenance: routing

skin inspection and care• Ensure orthotic acceptance

• Patients should clearly understand the functions, limitations of an orthosis

• Can use support groups to assist

• Teach proper application (donning-doffing) of the orthosis• Teach proper use of the orthosis

• Balance, gait and functional activities training

• Reasses fitm function and construction of the orthosis at periodic intervals; assess habitual use of the orthosis

SELECTED ORTHOTIC GAIT DEVIATIONS

Selected orthotic gait deviations• Lateral trunk bending: patient leans toward the orthotic

side during stance. Possible causes: KAFO medial upright too high; insufficient shoe lift; hip pain, weak or tight abductors on the orthotic side; short leg; poor balance

• Circumduction during swing, leg swings out to the side in an arc. Possible causes: locked knee; excessive plantar flexion; weak flexors or dorsiflexors. All of these could also cause vaulting

• Anterior trunk bending: patient leans forward during stance. Possible causes: inadequate knee lock; weak quadriceps; hip or knee flexion contracture

Selected orthotic gait deviations• Posterior trunk bending: patient leans backward during

stance. Possible causes: inadequate hip lock; weak gluteus maximus; knee ankylosis

• Hyperextended knee: excessive extension during stance. Possible causes: inadequate plantar flexion stop; inadequate knee lock; poor fit of calf band; weak quadriceps; loose knee ligaments or extensor spasticity; pes equinus

• Knee instability: excessive knee flexion during stance. Possible causes: inadequate dorsiflexion stop, indadequate knee lock, knee and/or hip flexion contracture; weak quadriceps or insufficient knee lock; knee pain

Selected orthotic gait deviations• Foot Slap: foot hits the ground during early stance.

Possible causes: inadequate dorsiflexor assist; inadequate plantarflexor stop; weak dorsiflexors

• Toes first: on toes posture during stance. Possible causes: inadequate dorsiflexor assist; inadequate plantarflexor stop; inadequate heel lift; heel pain, extensor spasticity; pes equinus; short leg

• Flat foot: contact with entire foot. Possible causes: inadequate longitudinal arch support: pes planus

• Pronation: excessive medial foot contact during stance, valgus position of calcaneus. Possible causes: transverse plan malalignment; weak invertors; pes valgus; spasticity; genu valgum

Selected orthotic gait deviations• Supination: excessive lateral foot contact during stance,

varus position of the calcaneus. Possible causes: transverse plan malalignment; weak evertors; pes varus; genu varum

• Excessive stance width: patient stands or walks with a wide base of support. Possible causes: KAFO height of medial upright too high; HKAFO hip joint aligned in excessive abduction; knee is locked; abduction contracture; poor balance; sound limb is too short

Thank You for your Attention!