50 Review The range of orthotic devices Types of Orthoses: named by the joint they encompass and the type of motion. Lower Limb orthoses: 1. Shoes: the foundation for the most lower-limb orthoses. a. Reduces pressure on sensitive deformed structures by redistributing weight toward pain free areas. b. Major parts of the shoe: upper, sole, heel reinforcements & the last. 2. Foot orthoses: are appliances that apply forces to the foot. a. They may be: i. insert or internal modifications: 1. longitudinal arch supports- prevent depression of the subtalar jt & flattening of the arch (pes planus) 2. scaphoid pad- support the longitudinal arch 3. Metatarsal pad-transfers stress from metatarsal heads to metatarsal shafts. ii. external modifications: 1. Heel wedge: alters alignment of the calcaneus. Can aid realigning flexible pes valgus or rigid pes varus. 3. Ankle-foot orthoses (AFOs): composed of a foundation, ankle control, foot control and a superstructure. Most AFOs control ankle motion by limiting PF &/or DF. Primary candidates: those with peripheral neuropathy (peroneal lesions & hemiplegia). Foundations: i. Foot plate: provides best control of the foot. ii. Stirrup: steel U-shaped shoe attachment that connects the upright to the shoe Ankle Control: iii. Posterior Leaf Spring: assists DF. iv. Plastic Solid AFO: limits all foot and ankle motions. v. Anterior stop - limits dorsiflexion vi. Posterior stop - limits plantar flexion. Pts with foot drag. Superstructure: vii. Floor reaction orthosis: resists knee flexion. viii. Tone reducing: for reducing spasticity in adults with spastic hemiplegia and children with cerebral palsy. Designed to modify hypertonicity by applying constant pressure to plantar flexors and invertors. 4. Knee-ankle-foot orthoses (KAFOs): for individuals with more extensive paralysis or limb deformity. Consists of the shoe, foundation, ankle control, knee control & superstructure. a. Knee control: i. Drop Lock release with hands ii. Pawl Lock can release pressing against chair 5. Hip-knee-ankle-foot orthoses (HKAFO): addition of a pelvic band and a hip jts converts the KAFO to an HKAFO. They restrict gait to swing-to or swing-through.
a. Hip Jt: prevents abd/add & hip rotation. b. Pelvic band: designed to lodge b/w the greater trochanter & the iliac crest. 6. Trunk-hip-knee-ankle-foot-orthoses (THKAFO): incorporates lumbrosacral orthosis attached to a KAFO. Very difficult to don. 7. Reciprocating Gait orthosis (RGO): For pts with paraplegia. Is a THKAFO were the hips are joined by one or two metal cables. 8. Trunk orthoses: may be used to reduce the disability caused by low-back pain, neck sprain, scoliosis, or other skeletal or neuromuscular disorders. For pts with SCI: a. The orthoses impart control of motion of the lumbar region b. They compress the abdomen to improve respiration. Types: 1. Corset- primary effect is to increase intra-abdominal pressure, reducing stress on posterior spinal musculature, thus diminishing the load on the intervertebral disks. 2. Rigid orthoses- distinguished by the presence of horizontal vertical and rigid plastic or metal components. Motion limitation by 3 point pressure systems. a. Knight spinal orthosis: lumbrosacral flexion, extension, lateral control. b. Taylor brace: thoracolumbosacral flexion, extension control orthosis 9. Cervical Orthoses: a. Collars- minimal motion control b. Four-post orthosis- moderate control. Two anterior adjustable posts attached to sternal & mandibular plates & two posterior attached to thoracic & occipital plates. c. Minerva or halo orthosis maximum orthotic control. Consists of a rigid posterior section from the head to the thorax & anterior section from mandible to thorax. Has a circular band of metal fixed to the skull. 10. Scoliosis Orthoses: forces to realign the vertebral column & thoracic cage. a. Milwaukee orthosis b. Boston orthosis c. Wilmington orthosis d. Charleston Bending brace used at night PT role prescription assessment: 1. Joint mobility: goal is to achieve comfortable contact of entire plantar surface of the foot on the inner sole of the shoe. 2. Limb length: therapist should ascertain whether there is a discrepancy in leg length 3. Motor function: assessment of functional activities to determine what substitutions the pt is able to accomplish standing & walking. 4. Sensation: record the extent of any sensory loss. 5. Upper limbs: determine mobility & power of UEs. 6. Psychological status: prescription of orthotics requires ascertain that pt is willing to wear the device.
Orthotic assessment: 1. Limb orthotic static assessment: The wearer stands & sits. Skin & construction of the orthosis are checked with orthosis off. The calf band should terminate at the fibular head to avoid impingement of the peroneal N. Mechanical knee jt should be congruent with anatomical knee. KAFO: should provide sufficient seat for ischial tuberosities. When the brace is off the therapist should inspect the pts skin to detect any irritations. 2. Dynamic assessment: Foot slap, striking with toes inability to restrain PF or failure to support foot & ankle Excessive media or lateral contact - orthosis does not track the way the pts limb does. Knee hyperextension or excessive flexion not applying adequate control. Anterior or posterior trunk bending pt attempting to control weak knee or hip Hip hiking weak hip flexors Donning Orthoses Pt should wear clean, properly fitting hose AFO with shoe insert apply orthosis to foot & leg prior to placing on shoe. KAFOs pt may find donning easier if the brace is applied while lying on bed. HKAFOs & THKAFOs pt should lie on mat, rolling to one side pt should be able to pull brace under legs. Corsets & rigid orthoses should be donned while in supine to achieve maximum compression of abdomen References 1) OSullivan SB, Schmitz TJ. Physical Rehabilitation: Assessment and Treatment. 4th edition. Philadelphia (Pa): F.A. Davis Company; 2001
2) OSullivan SB, Siegelman RP. National Physical Therapy Examination Review and Study Guide. 2007 Version. Evanston (IL): International Educational Resources; 2007.