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Checkout Principles of lower Checkout Principles of lower limb Orthoseslimb Orthoses

Kunal Y. Chandra Kunal Y. Chandra

MPOMPO

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Checkout (evaluation)Checkout (evaluation)

Checkout may be defined as a systematic Checkout may be defined as a systematic examination of the patient with the orthosis examination of the patient with the orthosis as a biomechanical entity.as a biomechanical entity.

The checkout procedure provides for the The checkout procedure provides for the systematic evaluation of an orthosis. The systematic evaluation of an orthosis. The purpose of checkout is to ascertain that the purpose of checkout is to ascertain that the orthosis is satisfactory and to call attention orthosis is satisfactory and to call attention to any modifications or adjustments that to any modifications or adjustments that may be requiered.may be requiered.

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Initial checkoutInitial checkout

Initial checkout is accomplished before the Initial checkout is accomplished before the initiation of training. It is generally performed with initiation of training. It is generally performed with the appliance in the unfinished state so that minor the appliance in the unfinished state so that minor improvements may be introduced at minimum improvements may be introduced at minimum cost. It is important for two reasons- 1. to provide cost. It is important for two reasons- 1. to provide assurance that the prescription has been followed assurance that the prescription has been followed precisely. 2. to evaluate the biomechanical precisely. 2. to evaluate the biomechanical adequacy of the device.adequacy of the device.

if the orthosis is found satisfactory at Initial if the orthosis is found satisfactory at Initial checkout, orthotic training is started.checkout, orthotic training is started.

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Final checkoutFinal checkout

Final checkout is done after completion of orthotic Final checkout is done after completion of orthotic training.training.

It assures the clinic that the patient is not in It assures the clinic that the patient is not in immediate need of any further orthotic, medical, or immediate need of any further orthotic, medical, or surgical attention.surgical attention.

In Final checkout, the biomechanical adequacy is In Final checkout, the biomechanical adequacy is reviewed, and evaluation is made of the extent reviewed, and evaluation is made of the extent and effectiveness of the patient`s use of the and effectiveness of the patient`s use of the orthosis, as well as his physical and psychological orthosis, as well as his physical and psychological status.status.

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At the initial checkout, attention will be directed to At the initial checkout, attention will be directed to comfort, stability and the fit of the appliance.comfort, stability and the fit of the appliance.

At final checkout, in addition to these items, the At final checkout, in addition to these items, the patient`s ability to use the orthosis effectively patient`s ability to use the orthosis effectively should be carefully evaluated.should be carefully evaluated.

Checkout is designed to ensure that the orthosis Checkout is designed to ensure that the orthosis fits appropriately and wearer has adequate fits appropriately and wearer has adequate stability, and is satisfied with the device.stability, and is satisfied with the device.

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Checkout of lower limb Orthoses involves a static Checkout of lower limb Orthoses involves a static and a dynamic examination.and a dynamic examination.

Static evaluation consists of obeserving the Static evaluation consists of obeserving the orthosis on the patient as the individuals stands orthosis on the patient as the individuals stands and sits, as well as examining the device of the and sits, as well as examining the device of the patient. patient.

Dynamic evaluation is performed while the patient Dynamic evaluation is performed while the patient walks.walks.

Generally, checkout clinic team members includes Generally, checkout clinic team members includes orthotist, physical therapist and physian.orthotist, physical therapist and physian.

Checkout of lower limb OrthosesCheckout of lower limb Orthoses

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Static evaluationStatic evaluation

Conformance with prescription- prior to static Conformance with prescription- prior to static evaluation, examiner should ascertain that the evaluation, examiner should ascertain that the plan developed in the prescription has been plan developed in the prescription has been carried out.carried out.

Construction of the orthosis- the clinic team should Construction of the orthosis- the clinic team should examine the construction of the device, paying examine the construction of the device, paying particular attention to smoothness of the edges particular attention to smoothness of the edges and enterior and exterior.and enterior and exterior.

Donning and doffing of the orthosis- patient/ Donning and doffing of the orthosis- patient/ caregiver should apply and remove orthosis easily caregiver should apply and remove orthosis easily and correctly.and correctly.

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Comfort of the orthosisComfort of the orthosis

Regardless of its purpose, the orthosis must Regardless of its purpose, the orthosis must be comfortable, otherwise, the patient is be comfortable, otherwise, the patient is unlikely to wear it.unlikely to wear it.

A major element in ensuring comfort is A major element in ensuring comfort is minimizing pressure by maximizing the area minimizing pressure by maximizing the area covered by the orthosis. Another way to covered by the orthosis. Another way to improve comfort is to proviode sufficient improve comfort is to proviode sufficient leverage through which the longitudinal leverage through which the longitudinal segments of the orthosis apply force.segments of the orthosis apply force.

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Checking with the patient standingChecking with the patient standing

Fitting of the shoe- regardless of its purpose, the Fitting of the shoe- regardless of its purpose, the shoe should fit properly after all modification are shoe should fit properly after all modification are complete and any insert is installed. Each foot complete and any insert is installed. Each foot should be checked separately.should be checked separately.

Fitting and alignment of the orthosis- it includes Fitting and alignment of the orthosis- it includes conformity to contour, free from pressure points conformity to contour, free from pressure points and irritation, correct width and depth of metal and irritation, correct width and depth of metal bands and plastic shell, correct positioned bands and plastic shell, correct positioned mechanical joints, correct location of straps and mechanical joints, correct location of straps and metal bands, stability of the patient.metal bands, stability of the patient.

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Fitting of the shoesFitting of the shoes

Every shoe should be judged for proper fit. Every shoe should be judged for proper fit. The final determination of fit is made on the The final determination of fit is made on the wt. bearing foot after all internal shoe wt. bearing foot after all internal shoe modification have been completed.modification have been completed.

The shoe should be at least ½ inch longer The shoe should be at least ½ inch longer than the longest toe, in order to facilitate toe than the longest toe, in order to facilitate toe off action. off action.

Shoe is snug from the heel to the ball of the Shoe is snug from the heel to the ball of the foot.foot.

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Evaluation of shoe modification and Evaluation of shoe modification and foot orthosesfoot orthoses

At the initial examination, the placement and At the initial examination, the placement and dimensions of the shoe modification should dimensions of the shoe modification should be checked with fitting if shoe.be checked with fitting if shoe.

At initial and follow up examinations, a gait At initial and follow up examinations, a gait analysis should be performed and causes of analysis should be performed and causes of any gait deviations are identified.any gait deviations are identified.

In examining the foot, any signs of irritation In examining the foot, any signs of irritation should be noted.should be noted.

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Fitting and alignment of the orthosisFitting and alignment of the orthosis

Objectives-Objectives-

1.Flat heel and sole contact of the shoe with 1.Flat heel and sole contact of the shoe with the ground.the ground.

2.Anatomical –mechanical joints congruency.2.Anatomical –mechanical joints congruency.

3.Horizontal orientation of the joint axis3.Horizontal orientation of the joint axis

4.Conformity to anatomical contours and land 4.Conformity to anatomical contours and land marks.marks.

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Alignment of hip, knee, and ankle Alignment of hip, knee, and ankle orthotic jointorthotic joint

planeplane hiphip kneeknee ankleankle

frontalfrontal Horizontal Horizontal &perpendicular &perpendicular to sagittal lineto sagittal line

Horizontal Horizontal &perpendicul&perpendicular to sagittal ar to sagittal lineline

Horizontal Horizontal &perpendicul&perpendicular to sagittal ar to sagittal lineline

sagittalsagittal 1 inch sup. and 1 inch sup. and ½ inch ant. to ½ inch ant. to G.T G.T

¾ inch ¾ inch proximal to proximal to tibial plateau tibial plateau and ½ the and ½ the A.P.dia.of A.P.dia.of kneeknee

Distal tip of Distal tip of medial medial malleolusmalleolus

centre centre

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Alignment of hip, knee, and ankle Alignment of hip, knee, and ankle orthotic jointorthotic joint

planeplane hiphip kneeknee ankleankletranceversetranceverse Parellel to

axis of the knee joint

Perpendicular to the plane of motion of the shank: Approximately parallel to plane of popliteal area when knee is flexed 90

Rotated in accord with measured amount of torsion: Usually 20 - 30˚ of external rotation in relation to knee axis.

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Checking with the patient sitting and Checking with the patient sitting and after removal of the orthosisafter removal of the orthosis

Comfortable sittingComfortable sitting Maintaining the alignment and fittingMaintaining the alignment and fitting Limb should be free from signs of irritation Limb should be free from signs of irritation

immediately after removal of the orthosis.immediately after removal of the orthosis. Satisfactory general workmanshipSatisfactory general workmanship Satisfactory appearance or cosmesisSatisfactory appearance or cosmesis Patient`s performance and opinion - The patient Patient`s performance and opinion - The patient

should consider the orthosis satisfactory as to should consider the orthosis satisfactory as to weight, comfort, function and appearance.weight, comfort, function and appearance.

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Checking with the patient walking Checking with the patient walking (Dynamic evaluation)(Dynamic evaluation)

Assuming the orthosis fits well, the team Assuming the orthosis fits well, the team should proceed to the dynamic phase of should proceed to the dynamic phase of evaluation during which the patient walks evaluation during which the patient walks with the orthosis.with the orthosis.

Gait analysis should be related to the Gait analysis should be related to the purpose of which the orthosis was purpose of which the orthosis was prescribed.prescribed.

Any gait deviation and causes shoud be Any gait deviation and causes shoud be noted.noted.

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TrainingTraining

The orthotist educates the patient about donning, The orthotist educates the patient about donning, doffing, caring for and using the orthosis. A doffing, caring for and using the orthosis. A wearing schedule is often provided for the patient wearing schedule is often provided for the patient to gradually grow accustomed to the orthosis. to gradually grow accustomed to the orthosis. Donning and doffing an orthosis can be a Donning and doffing an orthosis can be a challenge at first, especially for children. The challenge at first, especially for children. The orthotist provides specific instructions for donning orthotist provides specific instructions for donning and doffing with the least difficulty. In addition, he and doffing with the least difficulty. In addition, he or she provides instructions regarding the need to or she provides instructions regarding the need to monitor skin for possible breakdown. monitor skin for possible breakdown.

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MaintenanceMaintenanceof orthosesof orthoses

Orthotic maintenance may include resetting joint Orthotic maintenance may include resetting joint angles, which is usually done by an orthotist or a angles, which is usually done by an orthotist or a physical therapist under the direction of an physical therapist under the direction of an orthotist. Screws in joint mechanisms also may orthotist. Screws in joint mechanisms also may loosen occasionally, and tightening can usually be loosen occasionally, and tightening can usually be done by the patient or caregiver at home with done by the patient or caregiver at home with directions from the orthotist. As with operation, directions from the orthotist. As with operation, maintenance may vary depending on the type of maintenance may vary depending on the type of orthosis, and users should follow the instructions orthosis, and users should follow the instructions of their orthotists.of their orthotists.

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At the end of the checkout, team should At the end of the checkout, team should ascertain that patient/ caregiver has ascertain that patient/ caregiver has received oral and written instruction received oral and written instruction regarding: 1. name and contact no. of the regarding: 1. name and contact no. of the orthotist, 2. purpose of the orthosis, orthotist, 2. purpose of the orthosis,

3. wearing shedule, 4. care of the orthosis, 3. wearing shedule, 4. care of the orthosis, 5. special instructions, 6. precautions.5. special instructions, 6. precautions.

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One of the problems of judging the effectiveness One of the problems of judging the effectiveness of orthotic treatment has been the lack of of orthotic treatment has been the lack of evaluation techniques and instrument that can evaluation techniques and instrument that can readily be applied in routine clinical situations. readily be applied in routine clinical situations. Therefore, a simplified and standard method of Therefore, a simplified and standard method of evaluation technique should be developed for evaluation technique should be developed for testing the effectiveness of the orthoses in routine testing the effectiveness of the orthoses in routine clinical practice.clinical practice.

Conclusion Conclusion

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