CBR - Orthotics
CBR - Orthotics
CBR - Orthotics
Orthotics
INTRODUCTION
Modern orthotic devices play a vital role in the field of orthopaedic and
neurological rehabilitation. They are given to improve function, restrict or
enforce motion, or increase support to a part of the body, like the spine or
lower limbs. In India, where several adults suffer from the long term effects
of childhood poliomyelitis, orthotics are an integral part of the life of persons
with disability.
DEFINITION
An orthosis is a mechanical device fitted to the body to maintain it in an
anatomical or functional position.
GENERAL PRINCIPLES OF ORTHOSIS
Use of forces:
Orthoses utilize forces to limit or assist movements, for example
Rigid material spanning a joint prevents motion, e.g. posterior tube
splint.
A spring in a joint is stressed by one motion and then recoils to assist
the opposite desired motion e.g. leaf spring orthosis.
Sensation: An orthotic device often covers skin areas and decreases sensory
feedback. Proprioception should be preserved where possible.
Correcting a mobile deformity: A flexible deformity may be corrected by an
orthosis, like the one given in genu recurvatum or mobile scoliosis. The
corrective force must be balanced by proximal and distal counter forces
(three point force systems).
Fixed deformity: If a fixed deformity is accommodated by an orthosis, it will
prevent the progression of the deformity.
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Figure 7.1: Principle of Jordan to remain stable, the body has to have one point of pressure
opposed by two equal points of counterpressure in such a way that F 1 = F2 + F3
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CLASSIFICATION
According to Function
Supportive: It stabilizes the joints and supports the body in its anatomical
position, e.g. calipers, gaiters.
Functional: It stabilizes the joint and also makes up for a lost function, e.g.
foot drop splint in common peroneal nerve palsy or dynamic cock-up splints
in wrist drop.
Corrective: To correct deformities, e.g. club foot boot in congenital talipes
equinovarus.
Protective: To protect a part of the body during its healing, e.g. rigid four postcollar for fracture cervical vertebrae.
Prevent substitution of function: In a full length caliper, substitution of hip
flexors by abductors or adductors of hip and other similar trick movements
are prevented.
Strengthen certain groups of muscles: Tenodesis splint
Relief of pain: The lumbosacral corset supports the lower back, preventing
painful movement.
Prevent weight bearing: A weight relieving orthosis, prescribed for conditions
like fracture calcaneum will take weight away from the injured site to a
proximal site like the patellar tendon bearing area.
Regional Classification
They are classified according to the anatomical area fitted with the orthosis.
Cervical Orthosis
Head-Cervical Orthosis (HCO)
Head-Cervical-Thoracic Orthosis (HCTO)
Sacral Orthosis
Lumbo-sacral Orthosis (LSO)
Thoraco Lumbo-sacral Orthosis (TLSO)
Upper Extremity Orthosis
Shoulder and Arm Orthosis
Elbow Orthosis
Wrist Orthosis
Hand Orthosis
Lower Extremity Orthosis
Foot Orthoses (FO)
Ankle-Foot Orthoses (AFO)
Knee-Ankle Foot Orthoses (KAFO)
Hip-Knee-Ankle-Foot Orthoses (HKAFO)
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Ulnar nerve injurySplints that maintain the flexion of metacarpophalangeal joints and extension at interphalangeal joint with a lumbrical
bar, e.g. knuckle duster splint.
Median nerve injurySplint is applied to the thumb in an abducted, opposed
position. (Opponens splint).
Orthosis used for inflammation of joints and tendons: Static thumb spica
orthosis with the proximal interphalangeal joint kept free.
Orthosis used for burns: Splinting done to hold the part in neutral position
and this prevents stiffening of the metacarpophalangeal joints.
Orthosis used in rheumatoid arthritis: Static three point proximal
interphalangeal orthosis for Boutonniere deformity.
Orthoses used for stroke and brain injury: In stroke, large arm slings are used
to prevent subluxation of the shoulder.
Contraindications to Orthoses
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Subjective Assessment
Goalswhat the patient hopes to achieve with his caliper
Complaints from the patient about the orthosis on its performance and
appearance, and whether there is pain.
Whether the patient has used an orthosis previously.
ComprehensionUnderstanding of oral and written instructions on how
to use the orthosis.
Economic considerations like the funding of the treatment and the patients
social environment.
MATERIAL AND FABRICATION FOR LOWER LIMB ORTHOSES
A wide variety of materials have been used to fabricate orthotic appliances,
among them metals like steel, aluminium and alloys, rubber, leather and
canvas. Some of them used more often recently are plastics and synthetic
fabrics.
Considerations while Selecting the Material
Strength
Durability
Flexibility
Weight
Should accommodate a simple and inconspicuous design
Comfort
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Cosmesis
Distribution of forces over sufficiently large surface area
Material which can be accurately contoured and padded to the body.
Metal: Traditional orthotic devices are made of metal while leather is used
for straps.
Plastics: They are lighter and close fitting and provide a fairly broader
distribution of forces than the metal orthosis. They are usually lined internally
with thin padding.
They are of two types:
Thermo setting
Thermo plastics
Thermo Setting: Plastics designed to be set after heating will not return to fit
their original consistency if reheated, but they will soften.
Thermo Plastics: Thermo plastics are plastics that are heated and moulded
to the patient. They have a capacity to return to their original shape when
dipped again in hot water. Polypropylene is more commonly used than thermo
setting plastics to make orthosis, sometimes combined with other plastics. Its
unique advantage is that it provides a close fit by heating and moulding to
the part of the patients body that needs orthotic fitting.
Combination of Plastic and Metal: Usually aluminium and stainless steel
uprights may be needed for heavy individuals. Lighter combinations of plastic
and metal are used for those with medium build to reduce the weight of the
orthosis.
Carbon Graphite: It offers strength and low weight with increased durability.
CALIPERS
Calipers are orthosis fitted to the lower limb. They may be
Foot orthosis (FO)
Ankle Foot orthosis (AFO)
Knee Ankle Foot orthosis (KAFO)
Hip Knee Ankle Foot orthosis (HKAFO).
Considerations While Prescribing Calipers
Orthoses need to be prescribed, just like drugs. The specifications would
include the nature and number of joints, the positioning of the straps and
suspensions and accessory attachments to the shoe or boot. The reason for
prescribing it must be explained to the patient, else there will be rejection. It
would be good to check out the following, before delivering the orthoses.
The stability of the hip and knee should be good before deciding how high
the caliper should be. This can only be done after doing a muscle power
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grading, paying special attention to the hip abductors extensors and knee
extensors. Alignment is checked whether the ankle joint is over the medial
malleoli, the knee joint over the prominence of medial femoral condyle and
the hip joint permits a patient to sit upright at 90. The caliper should be
functional throughout all phases of gait and the static and dynamic alignment.
FOOT ORTHOSES (FO)
The essential difference between a shoe and a boot is that a boot covers the
malleoli, while a shoe does not. The foot orthoses is nothing but a boot that
has components like supports and wedges to manage different foot symptoms
and deformities. These modifications are made of various materials like rubber,
foam or leather.
The FO can be divided into a lower part and an upper part (Fig. 7.3).
Components of the Lower Part
Sole: It is the part of the shoe in contact with the ground. The inner part of
the sole against which the foot rests is the insole. Bars straps and wedges,
which are common attachments to the foot orthoses get their leverage and
attachments through the sole and exert their forces (Fig 7.4).
Ball: Widest part of the sole that is located in the region of the metatarsal heads.
Shank: Is the narrowest part of the sole between the heel and ball. The uprights
of the AFO attach themselves to a stirrup at the shank region.
Toe Spring: It is the space between the outer sole and the floor, which helps
to produce a rocker effect during toe off phase of the gait cycle.
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Heel: is the posterior part of the sole, which corresponds to the heel of the
foot. Since it is the portion where most of the body weight is taken it needs
to be resilient and thicker so that it can prevent shoe components from wearing
out and shift weight to the fore foot.
Upper Part (Also Called Shoe Upper) Components
Quarter: This is the posterior portion of the shoe upper. A high quarter is
referred as a high top and is used by runners and footballers for greater
sensory feedback, and to prevent retrocalcaneal pain.
Heel counter: In sports shoes there is a reinforcement of the quarter posteriorly
called a heel counter which provides posterior stability to the shoe and
supports the calcaneus.
Vamp: Vamp is the anterior portion of the upper and is often reinforced with
a toe box anteriorly. In front is the tongue which protects the upper fore foot
behind the lace stays. Extra-depth shoes allow more room inside the shoe for
orthotic intervention.
Throat: This is the opening of the shoe located at base of the tongue, through
which the foot is inserted.
Toe box: It prevents the toes from suffering trauma when the person kicks as
in football. Even normally it is provided in the shoe to avoid stubbing of the
toes.
Tongue: This is the part of the vamp which extends down in front of the throat.
Stirrup: This is a piece on the outer sole in the shank region just in front of
the heel offering attachment to the metal uprights.
Modifications of the Orthopedic Shoe
The shoe can be modified according to the deformity, disease process or
congenital anatomical configuration of the patient to:
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Clinical condition
Objectives of modifications
Limb shortening
Arthritis, fusion, or
instability of or
instability of subtalar
joints
Pes plano-valgus
Reduce eversion support
longitudinal arch
Pes equinovarus
Pes cavus
Calcaneal spurs,
calluses and corns
Relieve pressure on
painful area
Metatarsalgia
Reduce pressure on MT
heads Support transverse
arch
Reduce pressure on 1st
MTP joint and big toe
Prevent forward foot slide
Hallux valgus
Modifications
For children
High quarter shoe with broad heel,
long medial counter, medial
heelwedge
For adults:
Medial heel wedge
Medial longitudinal arch support
High-quarter shoe
Heel lift & Metatarsal pads or bars
Heel and sole elevation on other shoe
depending on LLD
Modified lace stay for wide opening
Wide open throat open vamp
High-quarter shoe
Long lateral counter
Lateral sole and heel wedges for
flexible deformity
Medial wedges for fixed deformity
High-quarter shoe
High toe box
Lateral heel and sole wedges
Metatarsal pads or bars
Molded inner sole
Medial and lateral longitudinal arch
support
Heel cushion
Inner relief in heel and fill with
soft sponge
Metatarsal pad
Metatarsal or rocker bar
Inner sole relief
Soft vamp with broad ball and toe
Relief in vamp with cut-out
Low heel
Contd...
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Contd...
Clinical condition
Objectives of modifications
Modifications
Hammer toes
Foot fractures
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Indications
The biomechanical indications for the use of KAFOS (and HKAFOs) are
divided into three parts
Muscle Weakness: Weakness of the muscles of the lower limbs, mainly those
controlling the knee and hip joint (more specifically the quadriceps and hip
extensors). This will most commonly result from spinal cord damage or lower
motor neuron disease such as poliomyelitis or injury to a nerve.
Upper Motor Neuron Lesions: Upper motor neuron lesions impair locomotor
function through loss of the normal control of the lower limb muscles. There
is an extensor synergy in the lower limb, which is used by the hemiplegic to
achieve stance stability. The orthotic device must additionally incorporate knee
joints, which limit hyperextension.
Loss of Structural Integrity: This is due to injuries to the main ligaments of
the knee and joint disease, either due to inflammatory (septic arthritis) or
degenerative (osteoarthritis) processes.
Genu Varus/Valgum: Damage to the medial joint compartment with resultant
varus instability, will result in a concentration of the joint force on the
damaged condyle. In addition the increased knee adduction moment will result
in increased tension on the lateral collateral ligament. Conversely there can
be damage to the lateral joint compartment with a concentration of pressure
on that side of the joint, resulting in abduction movement and stress on the
medial collateral ligament.
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138The orthotic device will
need to incorporate knee joints which resist
abduction or adduction but which permit a normal range of flexion-extension.
It is recommended to prescribe a single upright KAFO with free knee and ankle
joints. The upright may be on the medial or lateral side of the leg, depending
on whether it is genu varus/valgum to be controlled.
Problem in Load Bearing: This form of structural impairment may be a
consequence of either a joint or bony defect such as failure of a hip or knee
joint replacement or a delayed or non-union of a femoral fracture. The orthotic
prescription is a weight-relieving knee-ankle-foot orthosis (explained earlier).
Knee Braces: Knee braces are prescribed in severe osteoarthritis of the knee,
to provide stability to the knee joint. They come with bilateral uprights and
knee joints, and usually extend from mid thigh to mid calf.
HIP-KNEE-ANKLE-FOOT ORTHOSIS (HKAFO)
The HKAFO is an extension of the KAFO. In addition to the KAFO there is
an attached hip joint which allows hip flexion and extension only. The
suspension is with a pelvic band, which is a padded rigid steel band extending
posteriorly and laterally, which fits between iliac crest and greater trochanter
and which is used to control rotational movement at the hip joint. In the front
it is fastened with a soft Velcro or buckle strap fastener. On the lateral side
it is connected by a lateral upright, or bar to a normal KAFO and on the medial
side the upright stops short of the ischial region. Movement at the hip is with
an uniaxial hip joint with a drop lock, which is locked during walking. In
conditions where weight relief from the lower part of the body is needed, the
body weight is taken away from the foot or leg and transmitted from ischial
seat through metal uprights to the ground.
HKAFO provides improved posture, and balance during standing and a
better controlled forward leg swing in patients with weak hip muscles.
However it is difficult wear and remove, and permits only limited step length.
There is also an increase in lumbar spine movements to compensate for limited
hip motion (Figs 7.7 and 7.8).
Uses
The HKAFO is prescribed whenever the muscles controlling the hip and its
stability are strained or weak. Of course muscles controlling the knee and ankle
may also be weak, and there may be tendency to varus or valgus of the ankle
which can be accommodated in the orthosis. The prescription of the HKAFO
must also take into consideration the problems at the knee and ankle.
Hip Rotation Control
Abnormal rotation at the hip, seen in some children with cerebral palsy is
not resolved by a general HKAFO, but by using:
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legs but this restricts the leg from taking a step though each leg prevents the
others rotation. Silesian bands are bands that begin laterally posterior and
superior to the greater trochanter, encircle the pelvis on the normal side
between the greater trochanter and the iliac crest and attach anteriorly to
achieve some hip rotation control. It reduces gait deviation, particularly toeingin that is attributable to faulty hip control. Hip rotation control straps are
prescribed and for preventing internal rotation, the client wears a waist belt.
Tied to the posterior aspect of the belt in the midline are two straps, each
having its distal attachment on each of the uprights of the HKAFO. The
bilateral hip joints control frontal and transverse plane motion.
FUNCTIONAL ELECTRICAL STIMULATION (FES) (FIG. 7.9)
The concept of FES was introduced by Liberson and co-workers to control foot
drop during the swing phase in hemiplegic patients. The theory is based on
the survival of the motor neuron in UMN lesions such as hemiplegia. Such
stimulation is done to obtain a functional movement, such as picking up objects
or walking. Multichannel stimulators are being used for paraplegics in research
laboratories, to simulate walking. The emphasis today is on miniaturization
and portability.
A typical functional stimulator consists of:
Stimulator
Leads
Electrodes which may be superficial or implanted.
A miniature electrical stimulator producing currents between 90 and
200 mA, of pulse duration between 20 and 300 microseconds, and voltage
between 50 to 120 V is fitted to the patient. It must be light in weight and portable.
Figure 7.9: A functional electrical stimulator. The surface electrode is near the common
peroneal nerve and the other stimulating electrode on the motor point of tibialis anterior
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A power pack which powers the stimulator is worn on a waist belt and
in the typical peroneal stimulator, one skin electrode is applied to the common
peroneal nerve below the fibular head on the affected side, while the inactive
electrode is applied to the leg at the motor point of the tibialis anterior. A heel
switch is incorporated in the shoe that turns on the stimulator when the heel
leaves the ground and turns it off on heel strike. Thus at heel off the tibialis
anterior and other dorsiflexors are stimulated, affording clearance, and at heel
strike the stimulation is switched off, allowing the foot to become plantigrade.
Sometimes electrodes are surgically implanted instead of being placed
directly on the skin. This eliminates the need for wires passing all over the
affected site.
When an implanted electrode is used, it must be placed directly on the nerve
with a flexible wire lead connected to a subcutaneously implanted receiver
located over the antero-medial aspect of the thigh. There is an antenna located
over the implanted receiver, responding to signals from a transmitter
incorporated into the shoe. Phasing of the stimulation during the gait cycle
is controlled by the heel switch. The power pack for the stimulator and
transmitter is worn at the waist.
Criteria for Selection of Patients
The selection of patients who can use the FES has to be done very carefully:
Such patients should be able to walk independently at a speed more than
25 m/min without an orthosis, and have good balance and saving
reactions.
The major gait problem should be foot drop, without equinus contracture.
Proprioception should also be intact.
The regular use of a FES system could result in an increase in the strength
of foot dorsiflexors in the long-term, and may improve the gait pattern
through re-education and over a period the patient may reach a stage where
he may no longer need it.
This principle is also used to major hip and thigh muscle groups in patients
with spinal cord injuries for muscle strengthening, maintaining standing
posture and ambulation.
SPINAL ORTHOSIS
The common thoracic or lumbar orthosis consists of a plastic or aluminium
frame, anterior abdominal support, two posterior uprights, and pelvic and
thoracic bands, which are fitted to the spine.
Mechanism
The three point force control system of Jordan is used in these orthoses by
working on the principle of pelvic positioning, which acts as a base of support
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Uses
In the above-mentioned conditions the collar reminds the wearer not to move
abruptly, thus reducing stress on the damaged tissues.
The collar retains body heat, which enhances circulation to the injured
structures.
Immobilization of spine also helps in relieving pain.
Prescription of the collar should only be done if the neck movement causes
severe pain, giddiness or is otherwise injurious to the anatomical structures.
Long term use is to be discouraged except when there is severe giddiness
or instability.
Head Cervical Orthosis (HCO)
The head cervical orthosis incorporates both head and the cervical spine into
the device, thus providing additional support and motion restriction.
Four Poster Cervical Orthosis
It has padded mandibular and occipital supports attached to anterior and
posterior plates by four rigid adjustable uprights. Laterally leather straps
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connect the mandibular and occipital supports. This orthotic device provides
greater restriction of flexion, extension, lateral bending and rotation than the
ordinary collar.
Minerva Jacket
It is a suitable modified jacket, which is applied to the head and trunk.
Anteriorly, the orthosis has a forehead strap that secures the upper posterior
shell and a rigid mandibular plate. The axillae are also covered by a wool
roll.
Uses
This provides excellent motion limitation in all directions.
There is also the facility of selecting the optimal alignment of the head on
the neck.
Head Cervical-Thoracic Orthosis (HCTO)
Halo Orthosis: Better stabilization of the cervical spine is achieved through
external fixation of skull with reference to the chest. Three major components
include the rings and pins, plastic vest, and connecting adjustable uprights.
The pins penetrate the skin and outer table of the skull and are treated to fix
the halo ring assembly on the skull. Aluminium turnbuckles connecting the
jacket and ring are adjustable to provide variable traction, flexion or extension.
The orthosis is uncomfortable and cumbersome during exercises.
Conditions Used
Paralysis with or without fracture of the cervical spine.
Major cervical vertebral fracture with dislocation.
SOMI Brace (Fig. 7.11)
SOMI stands for Sterno Occipito Mandibular Immobilization, named for its
points of attachment, the sternum, occiput and mandible. The orthosis consists
of three parts; a chin cup with adjustable bar, an occipital support attached
to two bars for the anterior section and from which straps arise to attach to
the chin piece, and a sternal plate with straps for the shoulder pieces. SOMI
restricts flexion, extension, rotation and lateral bending.
Conditions Used
Fracture of cervical vertebra (Lower level)
In the case of non-operative or post-operative immobilization of spine.
Thoraco-Lumbar-Sacral Orthosis (TLSO) (Fig. 7.12)
These braces fix the pelvis and shoulder to prevent spinal movements in all
directions. They may be classified according to whether they control flexion,
flexion-extension, flexion-extension-lateral movement and all these including
rotary movements.
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Hyperextension braces like the Jewett and ASH orthosis do not prevent
lateral or rotary movement. Flexion extension control orthosis like the Taylor
brace consist of two spinal uprights posteriorly. These are attached to a pelvic
band inferiorly and a band in the interscapular area above, providing
attachments to axillary straps which are held tight in order to effectively
control flexion extension. In addition an abdominal corset holds the abdominal
muscles bracing them against the spine. An optional plastic body jacket is
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Static Splints
Static splints have no moving parts, prevent motion and are used to rest or
rigidly support the splinted part.
Uses: These are used to stretch joint contractures progressively or align
specified joints after a surgical procedure for optimal healing. A static splint
should never include joints other than those being treated and should be
discontinued the moment its usefulness is over.
Disadvantages: Immobilization causes atrophy and stiffness.
Dynamic Splints
Dynamic splints are moving splints; their parts permit, control, or strengthen
movement. The movement in a dynamic splint may be intrinsically powered
by another body part or by electrical stimulation of the patients muscles.
Extrinsic power may be provided by elastic bands or pulleys.
Uses: Dynamic splints provide prehension and also static positioning of the
hand in a functional position.
General Functions of Splinting
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C-Splint
This splint maintains the thumb in abduction and partial rotation under the
second metacarpal and supports it. It also stretches the first web space.
Indications
Median nerve injury
Contracture
Burns.
OPPONENS SPLINTS (FIGS 7.20 AND 7.21)
Short Opponens Splint
The short opponens splint maintains thumb in abduction and partial rotation
under the second metacarpal. The wrist and other fingers are free.
Functions
Immobilization of the thumb
Improves prehension by providing a stable position against which the
fingers can pinch.
Protects the joint from pain.
Stretches the web space.
Indications
Low median nerve injury.
Opponens transfer (6 weeks after surgery postoperative splint).
Figure 7.21: Wrist hand orthosis with dynamic MCP extension assist
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