orthosis ppt

ORTHOSIS

HIMAKSHI BHATTACHARYA

GUIDED BY: Dr. BHAVANA GADHAVI MAM

OBJECTIVES

1) What is Orthosis Splints and brace ???

2) Classification

3) Splint Design

4) Material use and performance characteristic

5) Prefabricated splint

6) Biomechanical Principle of splinting

7) Upper limb orthosis

8) Lower limb orthosis

9) Spinal Orthosis

10) recent advances

11) ReferencesTextbook of Rehabilitation: S Sunder, Susane O sullivan

Orthosis

A force system designed to control,

correct, or compensate bone deformity,

deforming forces or forces absent from

the body.

Textbook of Rehabilitation: S Sunder, Susane O sullivan

SPLINTING AND BRACING

SPLINT:An orthopedic device use to immobilize and support the body part is

termed as splint.

BRACE:Brace is a device fitted to the body part which is weak and injured to give support.

Eg: Knee brace for OA.


Classification of Orthosis

ORTHOSISARTICULAR NONARTICULAR

LOCATION

DIRECTION

PURPOSE

TYPETextbook of Rehabilitation: S Sunder, Susane O sullivan

SPLINT DESIGN

1) Static Splint

2) Serial Static Splint

3) Drop out Splint

4) Dynamic Splint

5) Static Progressive Splint


Static Splint

FOR STABILIZING AND PROTECTINNG JOINT IN PARTICULAR POSITION


Serial Static Splint

THIS TYPE OF SPLINT HELPS IN REGAINING MOVEMENT REDUCING PAIN WITH NOT OVER STRESSING THE TISSUE.


Drop Out Splint

THIS TYPE OF SPLINT BLOCK ONE MOVEMENT AND ENHANCE OTHER.


DYNAMIC SPLINT

FOR MOBILITY AND ENHANCING

FUNCTION.


Static Progressive Splints

STRESS AND TENSION ADJUSTABLE AND MOVEMENT

ENHANCING SPLINT. USED NOWADAYS TO AVOID SPLINT

COMPLICATION.


MATERIALS USED

1) Low Temperature Thermoplastic material

2) Heated Between 135* & 180* F

3) These materials are such when heated they become pliable and when they

cool down they become rigid

This must be taken in note that the rigidity of orthosis provide its durability.


PERFORMANCE CHARACTERISTIC

1) Conformability: Properly to fit intimately to contoured area. Proper

conformability is required for proper pressure distribution.

2) Flexibility: Circumference splinting requires flexibility for open and removal

3) Durability: Must be thermoplastic material as its durable rubber may get

fragile with time.

4) Rigidity: Rigidity and firmness of splint provide stability to area provide.

5) Perforation: For allowing air circulation.


PREFABRICATED SPLINTS

Prefabricated splints are the splints which are made commercially for various

material and styles.

As the demand is less so they are not made as frequent as alteration in market is

common so these are not made in bulk.

People who approach this type of splints are rare.


BIOMECHANICAL PRINCIPLES

The Biomechanical Principles of splinting are mainly:

1) Three Point Pressure 7) Control Axial Force across the joint

2) Mechanical Advantage 8) Control line of action of Ground react

3) Torque ion force

4) Degree and Duration of Stress

5) Repetitive stress

6) Control Normal force across the joint



1) Three point pressure: (JORDAN’S Principle)

Most splint follow this three point pressure system to affect a joint motion. A

three-point pressure system consists of three individual linear forces in which

middle force is directed in opposite direction to the other two forces.

It is multiple direction force where one force immobilize one joint and mobilize the

other joint.

Example: cockup splint


FORCE SYSTEMTextbook of Rehabilitation: S Sunder, Susane O sullivan


2) Mechanical Advantage:

Splint incorporate lever system, which incorporate forces, resistance, axes of

motion, and movement arm.

Lets understand it with an example:

Volar based wrist cock up splint here for mechanical advantage forearm length is

made longer so splint has better pressure distribution support and comfortability.



3) Direction of stress:

There are three direction of force to act:

1) Tension

2) Compression

3) Shear

Tension occur when forces both are acting on opposite direction.

Compression occur when force acting in same direction

Shear force occurs when parallel forces are applied in equal and opposite direction.



4) Torque:

It is biomechanical principle defined as rotational effect of mechanism. Torque is

the production of the applied force multiplied by perpendicular distance from the

axis of rotation to the line of application. Most important for dynamic splint.



4) Degree and Duration of Stress:

Generally low stress can be tolerated for longer period of time, whereas high stress

over long period of time cause damage.

Therapist must remember the least stress is tolerated is skin. Skin become

ischemic if load increases.

Distribution of stress is most important for long term wearing of orthosis.



5) Repetitive Stress:

If repetitive stress is applied in moderate amount may lead to breakdown and

damage to skin. So to avoid that traction must be release to avoid unnecessary

tension and well distributed pressure.

These are basic principles of orthosis.



6) Control Normal force across the joint:

Now two free body load carrying are shown in figure when are subjected to

ground reaction force are free to rotate the are maintained in extension this is

normal joint is maintained by capsule and ligaments. But in abnormal joint we

require orthosis to correct it. So, here the role is to correct excessive translation

movement. But this rotatory this creates anticlockwise moment now to balance

this also is role of orthosis

Thus a force system from R1 to R4 with rigid framework helps to maintain

translation and balance anticlockwise moment this is four point pressure system.



6) CONTROL AXIAL FORCES ACROSS A JOINT:

In normal healthy individual load is carried through bony structures and layers of

articular cartilage which have immense strength to bear this weight. Now due to

some degenerative change the integrity of this structure is lost which will cause

excessive compression on joint.

So, here come role of orthosis to offload the joint. This process of offloading

depends on two thing:

1) How the orthosis is fitted

2) orthosis and body segment interface



1) The orthosis here is incorporated as rigid orthosis framework and strapping it

at the end of two limb segment which would divide the force into half.

2) The second criteria is the transfer of load across skin and orthosis solely

depend on friction of orthosis and underlying skin.



8)Control of line of action of ground reaction force:

This principle is only applicable to lower limb orthosis. As foot is placed on ground

it experience ground reaction force.

Now as stance phase is from heel strike to toe off the force and pressure applied is

moving from heel to metarsal head that is toe off.

So, now in normal joint line of gravity passes from front of Hip, back of knee, front

of ankle. Now due to some asymmetric movement the this pattern of GRF is

altered so we need a orthosis for its allingment



So, in this case orthosis management would be moving the line of gravity to center

that is close to joint line. Which can be achieved by modifying the limb movement

during gait.

This is done in two way:

1) By altering angular relationship with plantar surface of foot and floor

2) By altering the angular relationship with most distal joint.


UPPER LIMB ORTHOSIS

shoulder

Textbook of Rehabilitation: S Sunder, Susane O

sullivan

FIGURE OF EIGHT AXILLA WRAP

Common name: Axilla Wraps, clavicle strap brace

Objectives: To retract the scapulae

To apply pressure to the axilla to prevent or correct hypertrophic scar.

To maintain and restore shoulder mobility

To stretch contracted tissue around anterior chest

To prevent and correct Kyphotic Posture.


FIGURE OF EIGHT AXILLA WRAP

– Indication:

1.) Axilla Burns or skin grafting

2.) Shoulder Adduction Contracture

3.) Kyphotic Posture

4.) Clavicle Fracture


GUNSLINGER SPLINT

2.) Lateral Trunk Based Static Shoulder- Elbow-Wrist Orthosis

Common Name: Shoulder/Gunslinger Splint

Objectives:

1) To fully immobilize the shoulder and sometimes Elbow to promote healing

2) The elbow and wrist are immobilize to maintain full control on shoulder.


Ulnar functional brace

Objectives :

1) To stabilize ulnar fracture

2) To promote healing without immobilizing any joint

3) To protect fragile bone from fracture

Indications:

1) Midshafts Ulnar Fracture


GUNSLINGER SPLINT

Indications:

1) In Posterior Glenohumeral Instability.

2) Partial Brachial Plexus injury and brachial neuritis

3) Rotator cuff repair


AIRPLANE SPLINT

Common Name: Axilla/ Airplane splint/Conformer

Objectives:

1) To elevate hand and prevent edema

2) To prevent and reduce an axilla contracture

3) To maintain and restore Shoulder Mobility

4) To immobilize upper extremity after skin grafting

5) To apply pressure to prevent or reduce hypertrophic scaring


AIRPLANE SPLINT

Indication:

1) Brachial plexus injury

2) Shoulder Adduction Contractures

3) Complete supraspinatus tear

4) Axilla burns or skin grafting

4) Static Shoulder Elbow Wrist Sling

Common Name: Hemi arm sling


HEMI ARM SLING

Objectives:

1) To immobilize Shoulder and Elbow

2) To support the weight of the upper extremity across the contralateral

shoulder, without stress on neck and back

3) To prevent Brachial Plexus Traction

4) To prevent pain and shoulder subluxation


HEMI ARM SLING

1) Shoulder subluxation caused by flaccid hemiplegia

2) Brachial plexus injury

3) Rotator Cuff injury

4) Upper Extremity Trauma

5) Shoulder surgery

4) Circumferential Nonarticular Humerus-Stabilizing Orthosis

Common Name: Humeral Fracture/ Function Brace

Objectives: To stabilize Fracture to promote healing without immobilizing any joint

Indications: Humeral Shaft Fracture


Sarmiento Brace

Common Name: Humeral Fracture/ Functional Brace/ Sarmiento Brace

Objectives: To stabilize Fracture to promote healing without immobilizing any joint

Indications: Humeral Shaft Fracture


SPLINTS USED FOR

ELBOW


sullivan

POSTERIOR ELBOW SPLINT

Common Name: (Posterior) elbow splint

Objectives:

1) To support and rest elbow to relieve pain

2) To immobilize elbow to relieve pain

3) To block Elbow Extension

Indications:

1) Rheumatoid Arthritis

2) Elbow surgeries

Like Ulnar Nerve Transposition , Tendon Transplant, Nerve RepairsTextbook of Rehabilitation: S Sunder, Susane O sullivan

ANTERIOR STATIC ELBOW SPLINT

Objectives:

1) To prevent or correct elbow flexion contractures

2) To block elbow Flexion

Indications:

1) Burns

2) Ulnar Nerve Entrapment

3) capsular Tightness

4) Elbow surgeries like:

Triceps rupture

Tumor resection

Total Elbow Arthroplasty.Textbook of Rehabilitation: S Sunder, Susane O sullivan

ELBOW FLEXION HARNESS

Common Name: Elbow Flexion Splint

It is static progressive in nature.

Objectives:

1) To increase elbow flexion ROM

2) To maintain surgically obtain elbow range

Indications:

1) Intra-articular fracture

2) Multiple trauma

3) Capsular tightness


ELBOW FLEXION HARNESS

4) Supracondylar fracture

5)Radial head fracture


TENNIS ELBOW STRAP

Objectives:

1) To reduce pain and inflammation

Indications:

Inflammation of common Tendon origin


Spiral Thumb Abduction Supination Splint

Objectives:

1) To abduct thumb

2) To facilitate supination or pronation as required

3) To reduce tone of muscles

4) To assist weak muscles

5) To promote functional use of hand


Spiral Thumb Abduction Supination Splint

Indications:

1) Head injury

2) Multiple Sclerosis

3) Cerebral Palsy

4) Cerebrovascular accident


COCKUP SPLINT

It is static in nature.

Common Name:

1) Volar/Palmar Wrist splint 7) Work Splint

2) Volar Wrist Cock up splint 8) Ulnar Gutter Splint

3) Wrist Immobilization Splint 9) Radial Gutter Splint

4) Drop Wrist Splint

5) Carpal Tunnel Splint

6) Wrist Extension Immobilization Splint


Cockup splint

Objectives:

1) To reduce Pain and Inflammation

2) To protect against joint damage

3) To promote hand function

4) To prevent or correct contractures

5) To provide base for Outriggers

Indications:

1) Tendinitis/Tenosynovitis of wrist tendons


Cockup splint

2) Joint Inflammation such as Rheumatoid Arthritis

3) Skin Graft

4) Unstable Wrist Joint

5) Wrist Sprain

6) Weak/Paralyzed Wrist Extensor

7) Congenital Hand Deformity

8) Volar style for flexion outriggers

9) Dorsal style for extension Outriggers


GAUNLET IMMOBILIZATION SPLINT

Common Name: Circumferential working Splint

Objectives:

1) Greater wrist stability

Indications:

1) An evaluation tool before wrist arthrodesis

2) To immobilize and stabilize a fracture of radius or base of Metacarpal


DYNAMIC WRIST EXTENSION SPLINT

Objectives:

1) To Passively extend the wrist while allowing active wrist flexion

2) To prevent contracture of unopposed innervated wrist flexors

Indications:

1) Weak or Paralyzed wrist Extensors (e.g.. Radial Nerve Palsy)


STATIC WRIST WRITING/PAINTING ORTHOSIS

Common Name: Wrist Splinting

Objectives:

1) To enable writing, drawing or painting by positioning wrist in functional

extension and providing attachment of pen, pencil , eraser etc.

Indications:

1) Spinal Cord Injuries at level C5 or above where wrist extensors Paralyzed


Radial thumb gutter splint

Common Name:

1) De Quervain’s static splint

2) Wrist and thumb static splint

3) Long thumb CMC immobilization splint

4) Long opponens splint

5) Radial-thumb gutter splint

6) Wrist Thumb Orthosis


Radial thumb gutter splint

Objectives:

1) To immobilize wrist, thumb CMC, MCP Joints, which are crossed by inflamed

tendons

2) To rest and reduce inflammation

Indications:

1) De Quervain’s tenosynovitis: Inflammation of tendon of abductor polices longus

and extensor polices brevis in their synovial sheath


Scaphoid fracture splint

Objectives:

1) To immobilize the wrist, thumb, CMC and MCP Joints

2) To rest hand to reduce inflammation

Indications:

1) De Quervain’s tenosynovitis

2) Instability of joints

3) Scaphoids fracture

4) Bennett’s fracture (fracture of base first MC joint)


Wrist stabilizing splint

Objectives:

1) To immobilize the wrist and Finger MCPs

2) To relieve pain and inflammation

3) To prevent and correct deformities

4) To correct joint instability

Indications:

1) Joint Inflammation


RADIAL NERVE SPLINT

Common Name: MCP extension-assist splint, MCP Arthroplasty splints

Objectives:

1) To immobilize the wrist in functional position and passively extend MCPs to 0* while permitting full extension unrestricted motion

Indications:

1) When the extensors of the wrist, fingers MCPs and thumb is paralyzed or weak.

2) MCP arthroplasty-angle the wires to pull the MCPs radially


MCP ARTHOPLASTY


DYNAMIC MCP FLEXION SPLINT

Objectives:

1) To gently stress the MCP collateral ligaments to promote desired growth and

increase flexion range

Indications:

1) Extension contracture of MCPs caused by shortened collateral ligaments


Resting hand splint

It is Static or Serial Static type of splint.

Objectives:

1) To immobilize the wrist, MCPs, and IPs of Finger and thumb

2) To reduce or prevent contractures

3) Reduce pain and inflammation


Resting hand splint

1) Scleroderma

2) Dupuytren’s release

3) Boxer’s fracture (Base of 5 MCP fracture)

4) Burns

5) Inflammatory joint disease

7) Crush injury


ANTISPASTICITY SPLINT

Common Name: dorsal volar hand splint

Objectives:

1) To immobilize wrist, MCP, IP

2) To prevent and reduce contracture

3) To reduce tone of hypertonic muscles

Indications:

1) Hand Trauma or surgery


Antispasticity splint

2) High tone Associated with:

Head Injury

Cerebral Palsy

Multiple Sclerosis

Cerebrovascular Accident


Antispasticity cone splint

Objectives:

1) To prevent flexion contractures

2) To reduce tone of hypertonic muscles

Indications:

1) High tone Associated with:

Head Injury

Cerebral Palsy

Multiple Sclerosis

Cerebrovascular Accident


Rehabilitation institute of Chicago

Tenodesis(training) splint

Objectives:

1) To train a tenodesis grasp

2) To promote tripod pinch

Indications:

1) Quadriplegia at level of C6 with at least grade 3 strength of the wrist extensors

This splint is a functional aid for such patient which uses extensor carpi radialis

muscle giving potential grasp by reciprocal wrist extension and finger flexion.


FLEXOR AND EXTENSOR

TENDON LACERATION


KLEINERT SPLINT

It allows protective flexion of MCP and IP and Blocks Extension of MCP.

Objectives:

1) To position wrist in static flexion and passively flex the MCP and IP while

permitting limited active extension of wrist and MCP and full extension of IP

Indications:

1) Flexor Tendon Laceration in zone 2


EXTENSOR TENDON REPAIR SPLINT

Objectives:

1) To position wrist in static extension and passively extend the MCP and IP while

permitting limited active flexion of MCP

Indications:

1) Extensor tendon Laceration


Hand Finger Thumb Based Orthosis


sullivan

METACARPAL FRACTURE BRACE

Common Name: Metacarpal(fracture) Brace

Objective: To stabilize MC fracture to promote healing.

Indication: Midshaft fracture of third, fourth or fifth metacarpal


STATIC ULNAR DEVIATION SPLINT

Common Name: MCP protection splint, static ulnar drift/deviation

splint, metacarpal ulnar deviation orthosis, trigger finger splint,

blocking splint

1)Joint Inflammation: To promote restabilization of tendon to restraints

at MCPs

To prevent or correct ulnar drift of MCP

2) Trigger Finger: To block MCP Flexion and limit excursion of long

finger flexor. By subsiding irritation at A1 pulley and inflammation

subside.


ULNAR DEVIATION SPLINT

3) Surgical release of Dupuytren’s Contracture

To maintain surgical gained extension.

4) Intrinsic muscle tightness and extension contracture: To block MP joint so FDP

and FDS can actively stretch IP joint and intrinsic muscle.

5) MC head fracture for stabilization.


ANTIULNAR DEVIATION WORKING SPLINT

3) Circumferential hand Based Dynamic Traction D2-5 MCP Corrective Radial

Deviation Orthosis:

Common Name: Ulnar drift splint, Ulnar Deviation Splint, soft metacarpal ulnar

deviation orthosis, antiulnar deviation working splint

Objectives: To prevent and correct ulnar MCP drift

To promote restabilization of restrain tendon at MCP

To improve Hand Function

Indication: Joint Inflammation


Dynamic mcp extension splint

Objectives: To passively extend MCP to 0* extension and allow active flexion

movement and IP movement.

Indication: Radial nerve injury when reinnervation reach to wrist

Repair of extensor tendon rupture, extensor contracture


Static anticlaw deformity splint

Common: Static Anticlaw deformity splint, static ulnar nerve splint

Objective: To stabilize the fourth and fifth MCPs in flexion.

To correct fourth and fifth MCPs hyperextension

To prevent shortening of MCP Collateral Ligament

To promote active IP Extension

Indication: Ulnar Nerve Lesion


WYNN PERRY SPLINT

Common Name: Dynamic Anticlaw deformity splint, dynamic ulnar nerve splint,

Wynn Perry Splint

Objective: To passively flex the MCP of fourth and fifth finger and to allow active

extension.

To correct Hyperextension

To prevent shortening of MCP

TO promote active IP Extension


DYNAMIC MEDIAN-ULNAR NERVE SPLINT

Common Name: Dynamic anticlaw deformity splint, dynamic median/ulnar nerve

splint, spring wire knuckle bender:

Objectives: To passively flex the MCP of fourth and fifth finger and to allow active

extension.

To correct Hyperextension

To prevent shortening of MCP

TO promote active IP Extension


DYNAMIC MEDIAN-ULNAR

NERVE SPLINT

Indication: Combined median and ulnar nerve lesion at level of wrist


FLEXION BLOCKING SPLINT

Common Name: Blocking Splint

Objective: To Block MCP and PIP so that the flexor digitorium profundus can

actively stretch DIP to increase the flexion range of motion

Indication: Extension contracture of DIP Joint


FINAL FLEXION SPLINT

Common Name: Final Flexion Splint

Objectives: To progressively flexion MCPs IPs in composite flexion applying gentle

prolonged stretch to contracted tissue.

Indication: Contracture of extrinsic Extension Tendon, IP Extension Contracture


Short dorsal outriggers

Objective: To apply gentle prolonged stretch to the contracted PIP capsule and

ligaments to promote growth of the shortened tissues and restore extension ROM.

Indication: Flexion Contracture Of PIP joint


Proximal phalanx fracture brace

Objectives and Indication: To stabilize phalangeal fracture to promote healing,

without immobilizing any joint

For a stable fracture that requires screw fixation apply 3-5 day postoperative


Extension blocking buddy orthosis

Objective: To block MCP extension to promote active PIP Extension

Indication: PIP Flexion lag with flexible or stiff PIP of D3 or D4


trapper

Common Name: Buddy splint, trapper

Objectives: To strap affected finger to an unaffected finger at proximal middle

phalanges

To stabilize finger

To provide passive movement of affected joint by moving unaffected finger

Indication: PIP Collateral ligament injury

flexor tendon reconstruction and PIP flexion


Pip extension splint

It is a extension blocking static splint.

Common Name: Swan Neck Deformity splint, PIP hyperextension splint, Fiqure of

eight splint

Objective: Index finger PIP extension restriction

Indication: Swan Neck Deformity, (caused by: RA, Trauma, intrinsic muscle

tightness, Dorsal migration of extension mechanism,)

Trigger finger


CAPENER SPLINT

Objective: Index finger pip extension mobilization

Indication: PIP flexion contracture, PIP dislocation, Volar plate injury, flexor tendon

repair partial or complete tear of collateral ligament, Boutonniere Deformity


SHORT OPPONENCE ORTHOSIS

Objective: To relieve CMC pain

to immobilize CMC and MCP

To position the thumb in functional opposition

to correct first web space

Indication: Inflammation of CMC or injury

CMC Arthroplasty, Median nerve injury, Quadriplegia


CMC ARTHOPLASTY


DYNAMIC THUMB OPPOSITION STRAP

18) Circumferential Wrist based Dynamic Thumb Opposition Strap:

Common Name: Dynamic Thumb opposition splint, Thumb abduction splint

Indication and Objectives:

Weakness and paralysis of thenar muscle

position Thumb in palmar abduction, to facilitate opposition

Adducted thumb position associated with high tone

To place thumb in radial abduction to breakup flexor spasticity patternTextbook of Rehabilitation: S Sunder, Susane O sullivan

DYNAMIC THUMB

OPPOSITION STRAP


RECENT ADVANCES

1) Umit Urgulu et all . In their study shows use of dynamic orthosis over static orthosis it provides definite amount of function to the limb as well as support where as static orthosis provide support but function ignored.

2) Mike S Macgrath et all. In their study shows that use of static progressive splint is increasing now a days using a static splint for whole day give rise to other complication where as these splints help to improve restricted motion, provide support, enhance mobility with minimizing stress.

3) Use of upper limb exoskeleton over dynamic splints help to enhance body function of individual in targeted form without adding complication of splinting.


Recent Advancement

4) Mozghan Nazaffi et all. use of spiral splint instead of traditional splint use in

tennis elbow reduce pain improves grasp and functional abilities.

5) Lee Anee Chazen et all. In their study shows use of splint for spasticity of upper

limb may help to reduce tone it is even helps to rest the hand.


LOWER LIMB ORTHOSIS


sullivan

Function & comfort of Lower Limb Orthosis

To meet individuals mobility needs

Maximum stance phase stability

Minimizes Abnormal alignment

Minimally compromises swing clearance

Effectively preposition limb for initial contact

COMFORT:

Can be worn for long periods

Can be donned and doffed easily


CONSIDERATION IN GAITEARLY STANCE Anatomical cause

Foot slaps ( Fore foot slaps the ground) Weak Dorsiflexors

Toes First (Toes may not be maintained) Short LE, Pes Equinovarus, Extensor spasticity Heel pain

Flat foot contact Poor balance , Pes calcaneus

Excessive lateral or medial foot contact Weak invertors (evertors), genu valgum(Varum) pes valgum ( varum)

Excessive knee flexion Weak quadricepps, contralateral short LE, knee or hip flexion contracture, knee pain

Hyperextended knee Weak Quadriceps, lax knee ligaments, contralateral hipp knee contractures and contralateral short LE

Anterior trunk bending Weak quadriceps, Hip and knee flexion contracture

Posterior Trunk Bending Weak Gluteus Maximus

Lateral Trunk Bending Weak Gluteus Medius, abduction Contracture, dislocated Hip, Hip pain

Internal or external Rotation Rotators of hip spastic, rotators may be weak, anteversion or retroversion


CONSIDERATION IN GAIT

STANCE PHASE Anatomical Causes

Inadequate transition Weak plantar flexors, Fore foot pain

SWING PHASE ANATOMICAL CAUSE

Toe drag Weak dorsiflexors, spastic plantar flexors

Circumduction Weak hip flexor, weak dorsiflexors

Hip hiking Short contralateral LE, hip flexion contracture, hip flexors weakness, weak dorsiflexors

Vaulting (exagarated plantarflexion of contralateral LE to enable the limb to swing forward

Weak hip flexors, short contralateral LE, weak dorsiflexors


POINTS TO BE ASSESED

1) Joint Mobility

2) Limb Length

3) Muscle Function

4) Sensation

5) Upper limb strength

6) Psychological status

7) special Life style considerations


SHOE IN FOOT ORTHOSIS

COMPONENTS OF LOWER PART OF SHOE:

1) Sole: It is the part of shoe in contact with ground. The inner part of sole

against which the foot rest is called insole. Bars straps and wedges, which

common attachments to the foot orthosis get their leverage and attachment

through the sole and exert their forces

2) Ball: Widest part of the sole that is located in the region of the metatarsal

heads.

3) Shank: Is the narrowest part of the sole between the heal and ball. The

uprights of the AFO attach themselves to a stirrup at the shank region.



4) 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 gait cycle.

If a lift is added to sole it compensate LLD.

5) 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 shifts weight to the fore foot.

UPPER PART COMPONENTS:

1)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 feed back



2) Heel counter: There is reinforcement of quarter posteriorly called heel counter

for providing posterior stability.

3) Vamp: Vamp is anterior portion of upper which is reinforced by toe box. Which

protects the toes behind the lace.

4) Throat: this is opening of shoes located at base of tongue though which foot is

inserted.

5) Toe Box: it prevents toes from trauma .

6) Tongue: extends in front of toe

7) Stirrup: it provides attachment for metal uprights.

8) Rocker effect: Lift added to sole will reduce stress to metatarsophalangeal head

to shaft and reduce the distance wearer to travel so improve late stance.Textbook of Rehabilitation: S Sunder, Susane O sullivan

Modification of ShoeCONDITION OBJECTIVES MODIFICATION

Limb shortening Provide symmetric posture Heel and sole elevation

Arthritis, instability of subtalar joints

Improve gait and support and limit joint movement

High quarter shoe Reinforced heel counters Long steel shank rocker bar

Pes Plano Valgus Reduce eversion support longitudinal arch

For children, high quarter shoe with broad heel, long medial counter medial heel wedge

Pes equinus Provide heel strike, contain foot in shoe, reduce pressure on MT head, equalize leg length

High-quarter shoe, Heel lift & Metarsal pads or bars, heel and sole elevation on other shoe according to LLD

Pes equinovarus Realign for flexible deformity and accommodate fix deformity, Increase medial and posterior weight bearing

High quarter shoe, high toe box, lateral sole, heel wedges, medial wedges for fix deformity

Calcaneal spurs, corns Relieve pressure on painful area

Heel cushion, inner relief in heel

Matatarsalgia Reduce pressure on MT head Soft vamp, low heelTextbook of Rehabilitation: S Sunder, Susane O sullivan

CONDITION OBJECTIVES MODIFICATIONS

Pes Cavas Distribute weight over entire foot Restore anteroposterior foot balance

High quarter shoe, high toe box, lateral heel and sole wedges

Hallux valgus Reduce pressure on 1 MTP joint prevent forward foot slide

Metarsal pad, metatarsal or rocker bar, inner sole relief

Hammer toes Relieve pressure on painful area support transverse arch

Soft vamp, extra depth shoe with high toe box

Foot fractures Improves push off immobilize fractured part

Long steel shank longitudinal arch support, metarsal pad or rocker bar

Modification of Shoe


University of California

Biomechanics Laboratory


FUNCTIONS:HOLDS HINDFOOT IN CORRECT

POSITIONSUPORTS MIDFOOT BY

CORRECTING AT MAINTAINING MEDIAL ARCH

SATABILIZING MIDTARSAL

INDICATIONS: 1) Adult Accquired flat

foot2) Flexible pes planus

3) Plantar fasciitis 4) Calcaneum spur5) Midfoot fracture

congenital talipes

equinovarus(CTEV)


ANKLE FOOT ORTHOSIS

The AFO is a boot to which an ankle joint is fixed through the stirrup. The metal

uprights are ascending up to the calf region.

COMPONENTS ARE:

1) Proximal calf band with leather straps

2) Medial and lateral bars articulating with ankle lateral and medial ankle joints.

3) medial and lateral support can be give.

There are five types of artificial ankle attached to foot orthosis:

1) Free ankle: Given when ankle power is normal


ANKLE FOOT ORTHOSIS

2) Limited Ankle joint: Is prescribed when the muscle operating ankle jjoint are fliai

or has no power.

3) 90* foot drop stop: Is prescribed when the ankle joint allows dorsiflexion but

stops short at the neutral position that is 90*. So does not provide plantar flexion.

Prescribed in case of foot drop. When plantar flexors are normal but Dorsiflexors

are weak or when plantar flexors are spastic and Dorsiflexors are normal.

4) Reverse 90* Ankle joint: This ankle joint which allows plantar flexion but stops

short at the neutral at 90*. Does no allows dorsiflexion prescribed to prevent

calcaneal deformity.


ANKLE FOOT ORTHOSIS

Fixed Ankle Joint: Sometimes the foot needs to be protected and weight is taken

off injured portions as in fracture calcaneus when in combination with a weight

relieving orthosis it takes the weight off the foot. It is not commonly used.


AFO BIOMECHAN

ICS


ANKLE FOOT ORTHOSIS

INDICATIONS:

1) Dorsiflexors Muscle Paralysis

AIM: To prevent contracture of the Achilles Tendon , and to assist dorsiflexion assist

dorsiflexion during heel strike a dorsiflexion assist plastic posterior leaf spring AFO can be

prescribed that can be inserted in shoes. For easy foot flat without undue knee flexion.

2) Ankle and Foot Paralysis:

This is prescribed to provide stability and reduce gait deviation during the swing and stance

phases. A polypropylene solid ankle foot orthosis to be worn with a shoe prevent foot from

dragging during swing, the brace rigidity prevents ankle dorsiflexion during midstance. AFO

can be used with straps for valgus and Varus deformity.


ANKLE FOOT ORTHOSIS

3) Spasticity:

AFO are used in children with cerebral palsy to stabilize the foot during heel strike

and foot flat phase. It prevents toe drag and plantar flexion during swing phase.

4) Limited Weight Bearing:

This is rare indication of AFO. To reduce loading on the leg and foot in conditions

where foot is need to be protected (e.g. calcaneal fracture) . The socket is provided

at patellar tendon bearing area so weight can be barred and heel can be offloaded.


POSTERIOR STATIC ANKLE FOOT ORTHOSIS

COMMON NAME: Foot drop splint

Objectives: To rest ankle and relieve pain

To immobilize ankle and promote healing

To prevent and correct ankle contractures.

Indications: Mild to moderated spastic hemiparesis

Post repair of Achilles tendon

unconscious patient risk of developing ankle flexion contractures

congenital deformities

Tibia/fibula fractures


POSTERIOR STATIC ANKLE FOOT ORTHOSIS

Acute burns

Cerebral palsy

Flaccid Hameparesis

Foot drop

Plantar Fasciitis Night use

Joint inflamation


Anterior Floor Reaction Ankle

Foot Orthosis


DYNAMIC ANKLE FOOT

ORTHOSIS


AFO ADDING VALGUS

CORRECTION

SPIRAL AFO

This spiral band does valgus correction


Posterior leaf spring Orthosis

The Posterior Leaf Spring (PLS) AFO is a dynamic thermoplastic AFO designed to

accomplish two things:

• Support the weight of the foot during swing phase as a means of enhancing

swing limb clearance

• Assist with controlled lowering of the foot during loading response in stance as

part of the first/heel rocker


POSTERIOR LEAF SPRING

AFO

The PLS is one of the group of AFOs that provide dorsiflexion assistance. In

contrast to the SAFO, medial and lateral trim lines are located well posterior to the

midline of both malleoli so that the orthosis is flexible at the anatomical ankle

joint The degree of flexibility is determined by the thickness of the thermoplastic

material used to construct the orthosis and width of the posterior upright in the

distal third of the orthosis. In custom-molded PLS orthosis, the orthotist tailors the

stiffness of the orthosis using the trim line pattern that will best support the

weight of the foot during swing as well as the individual’s needs for stability in

stance.


Carbon Fiber Spring orthosis

(CFO)

The carbon fiber springs inserted posteriorly between the foot and calf

component of this carbon-fiber orthosis. The springs provide dorsiflexion

assistance for clearance in swing and pre-positioning of the foot for initial contract,

as well as preservation of the second and third rockers of stance phase.

The Dual Carbon Fiber Spring orthosis (CFO) designed to provide assistance with

plantarflexion/push-off for the transition from stance to swing for persons with

weakness or paralysis of calf muscles/plantar flexors.


Patellar tendon bearing Orthosis

(weight relieving orthosis)

AS THE NAME SUGGEST THE WEIGHT IS RELIVED IN MIDDLE AND DISTAL

TIBIA HEEL AND FOOT .


INDICATIONS:


INDICATIONS:1) UNSTABLE FRACTURE OF PELVIC RING

2) FRACTURE OF ACETABULM WITH MINIMAL DISPLACE MENT

3) FRACTURE OF FEMUR 4) COMPLICATED FRACTURE

5) COMMUNITED FRACTURE OF TIBIAL PLATEAU

6) TIBIAL PLATEAU FRACTURE

KAFO


KNEE-ANKLE-FOOT ORTHOSIS (KAFO)

Components are same as AFO. In addition to this there is upright extended from

knee joint to thigh. Thigh band are suspension mechanism to which the uprights

are attached.

Knee Joints Are: This are provided so wearer can sit and can have good gait pattern

to avoid stiff knee gait pattern.

1) Straight set knee joint: Allows free flexion and prevents hyperextension. Upper

segment rotates in single transverse axis. It is used in combination with drop lock

to give stability. It is cheap and easy to repair.



2) The polycentric Knee joint: Use double axis system to stimulate the flexion/extension movements of femur and tibia at knee joint.

3) Posterior Offset Knee Joint: This is given for patients with minimal quadriceps weakness, since it keeps the knee extended, though there is not enough stance control. There must be adequate power of hip flexion and extension and ability to produce adequate momentum to walk. The placement of joint is just behind the actual knee joint to provide stability.

4) Stance Control: The ideal joint should have stability during weight bearing and flexion during the swing phase of gait when it is non weight bearing. This is more energy efficient, decrease the exaggerated movements of hip when knee is locked.


KNEE LOCKS

1) Drop lock: it locks when knee extends. Use commonly

2) Spring Lock: use with drop lock for patient who loose balance or find it

embrace to unlock joint mechanically.

3) Cam Lock: It provides better stability.

4) The ball lock: Patient who has limited balance and dexterity.

5) A dial lock: may be adjusted every 6* use for better knee flexion control.

6) Plunger type lock: use for people with hand weakness. Cosmetically more

appealing.



Indications:

1) Muscle Weakness: weakness of lower limb controlling hip and knee.

Specifically hip extensors and quadricep. In spinal cord damage. Lower Motor

disease like poliomyelitis or injury to nerves.

2) Upper Motor Lesion: Normal Motor control is lost. So it is provided to achieve

stance stability.

3) Loss of structural Integrity: In inflammatory disease like RA or degenerative

disease like Osteoarthritis.



4) Genu Varum/Valgum: For stability and to protect medial and lateral

compartment.

5) Problem in Load Bearing: Any structural impairment. Use for weight relieving.

6) Knee Braces: Knee Braces are prescribed in severe osteoarthritis of the knee, to

provide stability to knee joint.


KNEE HINGE BRACE

Hinged knee braces provide the strongest amount of

stability for the ligaments in the knee. Hinged braces are

ideal for day-to-day activities and all sports for those who

are suffering from mild to moderate ligament injuries or

instabilities, meniscus injuries, sprains or osteoarthritis.

For severe ligament injuries it is important to select one of

the rigid hinged braces. The rigid hinged braces provide

maximum protection and typically do not have a sleeve or

wrap. Soft-hinged braces provide a moderate level of

support and combine hinge support with a knee sleeve or

wrap for compression.


PATELLA KNEE BRACE

Recommended for mild or moderate ligament joint pain,

sprains, strains, meniscus tears, Osgood Schlatter

disease or patellar instabilities.

•Medial/Lateral polycentric aluminum hinges

•Thigh and calf straps provide additional support and

compression

•Sewn-in pad for additional patellar support

•Compressive neoprene support



1) C Brace:

Changing speed and direction is easier when you can put weight on a bent knee. And,

the idea of “orthotronics” means you have the combination of electronic and

mechanical systems working together to support your every step. The C-Brace

orthotronic mobility system is designed to provide the highest level of support for

patient so they can feel confident with every step.

Objectives:

Stumble Control: Sensors recognize uncontrolled knee flexion and create immediate

stability so the patient can recover — and keep a stumble from turning into a fall.

Greater Ease and Less Concentration: The gait cycle is controlled dynamically and in real

time — allowing patients to walk with greater ease and less need for compensatory

movements. Textbook of Rehabilitation: S Sunder, Susane O sullivan

FEATURES OF C BRACE

Stance Extension Damping: Progressive resistance allows natural movement to

occur without uncontrolled and early knee and hip extension at Terminal Stance,

resulting in a more natural movement without abrupt changes to the center of

gravity, lower back and lower limb joints.

Stance Flexion Damping: Controlled, partial knee flexion while weight bearing

allows the patient to exhibit knee control when walking down hills and ramps,

descending stairs step over step, and while sitting down into a chair.


STANCE CONTROL KAFO

– The E-MAG Active is a stance control KAFO that is calibrated to the patient’s

step length. It is also simple to re-calibrate the E-MAG Active if the patient’s

step length changes over time. The stance control function will remain locked

during weight bearing, then unlock for swing phase. It simplifies gait training

and allows for varied cadence to help meet your patient’s specific needs. A

gyroscope built into the KAFO monitors your patient’s step length. During the

fitting process, the E-MAG Active’s calibrating feature allows it to recognize your

patient’s gait pattern.


STANCE CONTROL KAFO

Stance Control helps users achieve a more natural gait compared to locked KAFOs,

thereby reducing compensatory movements that can lead to degenerative

conditions, excess energy expenditure, and noncompliance. · Gyroscope monitors

the orientation of the user’s lower limb (whether it is at initial contact or at

terminal stance). · Extraordinarily simple calibration allows the Orthotist to

customize the unlocking feature during the fitting process. Varied flexion angled

joints can be used to ease locking/ unlocking of the orthotic knee joint or

accommodate knee contractures. · Optional manual locking/unlocking function


CRAIG SCOTT KAFOS

Prescribed for adult paraplegia.

It includes either a shoe reinforced with transverse and longitudinal plates.

Enables to stand patient with sufficient backward lean to provide undue knee

flexion and trunk flexion.


HIP KNEE ANKLE FOOT ORTHOSIS(hkafo)

It is extension to KAFO. Its hip extension is to provide hip flexion and extension.

The suspension with pelvic band which fits between iliac crest and greater

trochanter to control rotational movement. The lateral extension stops at ischial

region. It helps in weight relieving. It helps in improving Postuure, and balance in

standing. Also during walking.

Uses:

Weak muscle controlling hip.

Can be possibly weak knee and ankle.


BIOMECHANICS


TYPES OF HKAFO

1) Bilateral HKAFO

2) Unilateral double upright HKAFO

3) Bilateral double upright HKAFO


RECIPROCATING GAIT ORTHOSIS

These are bilateral hip, knee, ankle, foot orthosis to provide contralateral hip

extension and ipsilateral hip flexion.


MECHANICS OF RGO

1) It shifts weight in both legs. This accompanied by elbow extension of

contralateral arm which slightly elevated the leg for ground clearance.

2) patient exaggerates lordosis by shoulder retraction and back extension

creating movement at hip.

3) dual cable mechanism helps in shifting the torque to execute the swing phase

of gait.


Modification of HKAFOANTERIOR DISLOCATION

POSTERIOR DISLOCATION


HKAFO IN PEDIATRICS

THE FREJKA PILLOW WAS DESINGED TO MAINTAIN ABDUCTION THE PILLOW IS SOFT IN NATURE INFANTS CAN EASILY OVERCOME THE

ABDUCTION PRESSURE. ITS PLACE LIKE A DIAPER. CLOTH HARNESS AND

STRAPS ARE USED.


HKAFO IN PEDIATRICS

IT HAS TWO STRAP WHICH CROSS

SHOULDER AT BACK UPPER STAP WHICH

PASS THROUGH CHEST FROM AXILLA

TRAVELS BACK TO SCAPULAR REGION.


SOME NEW TREND IN

HKAFO


sullivan

RESTING ABDUCTION

ORTHOSIS

It is night splint use for children with early subluxation due to spastic quadriplegia. By maintaining stretch to

adductors and flexors. It position the hip in central position within the acetabulum the devices ideally

should promote normal acetabular growth.



By providing variable hip abduction

according to flexion and extension

It maintains sitting balance and prevents scissors while walking

ELECTRONIC ADVANCE

PARAPODIUM


HKAFO INDICATION:

1) Assist Gait

2) decrease weight

3) control movement

4) minimize progression of movement


TWISTER

For controlling the internal external rotation or torsion of lower limb.


FUNCTION ELECTRIC STIMULATION (FES)

A miniature electrical stimulation producing current between 90 and 200 mA, of

pulse duration between 20 and 300 microseconds.

Criteria of patient selection:

1) Who can walk independently 25m/min

2) foot drop not equinus contracture.

3) proprioception must be intact

FES is newer version of technology for better improvement.


New concept

1) Murrat Arrac et all in their study in 2016 showed powered limb orthosis can

be the best newer trend which works better in patient with paraplegia or

hemiplegia who cannot achieve sit to stand will enhance in better way.

2) Mukhtar Arzpour et all in their study said that stance control knee brace use

for knee support is better than traditional KAFO.

3) Zhenxiong Shawn Zhang in his article suggested that children using night splint

for CP shows quite improvement in gait


SPINAL ORTHOSIS


sullivan

CORSET

If abdominal compression is the basic goal a corset will suffice. It provide vertical

reinforcement.

It covers Lumbar and sacral areas. The biomechanics of corset is to increase

intraabdominal pressure which will in turn reduce stress on intervertebral disk.

This will does reduce frontal movement.


Lumbosacral Flexion, Extension, Lateral, Control Orthoses

It is rigid trunk Orthosis. It is also called Knight spinal orthosis.

This include a pelvic band, which provide anchorage over the midsection of the

buttock and a thoracic band intended horizontal over lower thorax without

impingement of scapula.

Biomechanically it follows the THREE POINT PRESSURE SYSTEM. Posterior pressure

is applied from back upper and bottom side and anterior pressure from abdominal

aspect.

Lateral aspect control lateral flexion.


TAYLOR BRACE

It is also called Thorac Lumbar flexion, extension, control.

Indication are:

– Controlling back pain by limiting motion and unloading discs, vertebrae and

other spinal structures by compressing the abdomen.

– Stabilizing weak or injured structures by immobilizing the spine.

– Providing three-point force systems to provide correction or prevent

progression of a deformity.

– Condition like: Osteoporosis, pot's disease


Taylor Brace

Biomechanically it uses THREE POINT PRESSURE posterior force by axillary strap,

the anterior force by midsection of the abdominal front and anterior pressure from

intrascapular region.


JWETT BRACE

A Jewett brace is a hyperextension brace that prevents the patient from bending

forward too much. It is often used to facilitate healing of an anterior

wedge compression fracture involving the T10 to L3 vertebrae.


ANTERIOR SPINE

HYPEREXTENSION BRACE

To limit front bending, a hyperextension brace features a rectangular metal frame

that goes over the front of the body. This frame puts pressure on the chest and

pubic bone. Because a hyperextension brace is primarily used to treat spinal

compression fractures that occur where the upper back meets the low back, this

brace also puts pressure and support on the thoracic spine. This pressure keeps the

spine in an extended position.

A hyperextension brace also features 3 pads that help stabilize the spine and

prevent forward movement. One pad is located along the abdominals, another is

higher up on the chest, and the third pad is on the back and covers the affected

area.


SCOLIOSIS BRACE


sullivan

Charleston Bending Brace

The most commonly-prescribed nighttime brace is the Charleston

bending brace. It is custom-fitted based on a cast taken of the

patient’s torso. After the cast is created, corrective forces are added

to the brace based on readings from the spine’s x-ray.

In addition to applying lateral forces to push the curve closer to the

back’s midline, the Charleston bending brace also applies pressure to

bend and holds the spine in an overcorrected position. While it

would be unrealistic for someone to be bent so far to the side while

trying to go about the day, this extreme position can be held

relatively easily at night while laying down and sleeping.Textbook of Rehabilitation: S Sunder, Susane O sullivan

Providence Brace

Similar to the Charleston brace, the Providence brace applies a hypercorrective

force on the spine that is only feasible while laying down and sleeping at night.

However, instead of bending the spine’s curve in the opposite direction like the

Charleston brace, the Providence brace slightly elevates one shoulder and directly

applies lateral and rotational forces on the curve.


BOSTON BRACE

– The most-commonly prescribed brace for scoliosis today is the Boston brace.

Many people know the Boston brace as a type of thoracic-lumbar-sacral

orthosis (TLSO). Other types of Boston brace models do exist, such as a CTLSO

(TLSO with a neck extension) for a high thoracic curve, though they are not as

common.

– The Boston brace works by applying corrective pressure on the convex (outer)

side of the curve and cutting out corresponding areas of relief on the concave

(inner) side of the curve so the spine can migrate in that direction.


WILMINGTON BRACE

– Another common TLSO is the Wilmington brace.

– This brace goes onto the body similar to a tight jacket and is known as a full

contact TLSO due to its lack of gaps or open spots.


MILWAUKEE BRACE

– The Milwaukee brace, which is the original cervico-thoracic-lumbar-sacral

orthosis (CTLSO) invented in the 1940s, is an older and bulkier brace. Due to the

effectiveness and relative convenience of today’s more modern braces, the

Milwaukee brace is rarely used anymore. However, it is still sometimes used for

curves higher in the thoracic or cervical spine.


RIGO Cheneau brace

GAIL L DAUMIT et all.

In their study shows the scoliosis

correction is better In this splint then

boston.


BIOMECHANICS


CERVICAL ORTHOSIS


sullivan

SOFT CERVICAL COLLAR

– A cervical collar, also known as a neck brace, is designed to stabilize and

support the cervical spine in a neutral position while limiting head movement to

help immobilize the cervical spine. Used by emergency personnel for traumatic

neck or head injuries, it can also be utilized therapeutically to help relieve pain

by realigning the spinal cord after strains, sprains or whiplash.


1) Collars are soft or semi rigid which provide minimal motion control. Most

common type is Philedelphia Collar which has mandibular and occipital extension

and rigid anterior strut.

Use for: Upper cervical injury and fractures

2) Four-Post cervical Orthosis:

It gives moderate control of motion

It has to anterior and two posterior uprights.

Two anterior upright connects sternal and mandibular plate

Two posterior upright connects thoracic and occipital plate

CERVICAL ORTHOSIS


MINERVA ORTHOSIS

For Maximum control of movement:

1) Minerva orthosis or Halo orthosis:

It is noninvasive appliance that has rigid plastic posterior section extending from

head to midtrunk.

The superior portion is held in place by forehead band.

Is used for cervical fracture for healing.


References

Textbook of Rehabilitation: S Sunder

Physical Rehabilitation: Susan B. O’Sullivan

Orthotics in Rehabilitation: Pat Mckee and Leanne Morgan

Splinting: Brenda M Coppard and Helene Lohman

Orthotics and Prosthetics Rehabilitation: Michelle M Lusardi and Milgros George


orthosis ppt

Healthcare