Inhibitory Orthoses & Neurodevelopmental Approach

Orthoses for Inhibition & Neurodevelopmental Approach

• The Bobath Approach (NDT) is a therapeutic handling technique used for clients with CP or CVA.
• NDT can be translated into orthotics, inhibiting abnormal motor patterns and facilitating normal ones.
• There is poor evidence to support the Bobath Approach.

General Considerations for Inhibitory Orthoses

• Inhibitory principles can be incorporated into orthosis design.
• Firm pressure to tendon insertion and prolonged, submaximal slow stretch are inhibitory.
• Neutral warmth is inhibitory while quick-stretch and light touch of fabric are faciliatory.
• Consider the entire person, not just the extremity, when using orthosis to inhibit hypertonicity
• Incorporate and educate: trunk rotation, segmenting the body, inhibitory positioning and range of motion.

Discussion of Literature on Inhibitory Orthoses

• No evidence supports the application of inhibitory principles to various designs, e.g., orthoses alone are ineffective
• Theoretical and anatomical considerations guide design: biomechanical and neurophysiological approaches.
• Reduce tone, inhibit hypertonic musculature, and facilitate hypotonic musculature
• Prevent contracture, preserve skin integrity and prevent chronic problems with seating, posture, and ADL.

Neurophysiological Designs Using RIP (Reflex Inhibiting Positions) - NDT Theory

• Finger and thumb position finger spreader-abduction is inhibitory.
• A hard cone with firm & constant pressure to tendon insertions as inhibitory.
• Adjuncts to intervention with objective of improving hand function.
• A small end radial cone with maximum palmar contact can be used, an alternative to plastic: with dense foam for finger abduction.

Considerations of Materials for Inhibition/Facilitation

• Dynamic strapping, (eg. elastic for quick-stretch) on dorsum can facilitate extensors, thereby inhibiting flexors.
• Soft cloth in palm can facilitate primitive grasp and increase flexor tone.
• Can use resting pan and roll pan into cone, large part of cone to ulnar hand.
• Keep wrist in submaximal available extension.

Design and Terms: Resting Hand/Pan Orthosis

• A forearm trough should be 2/3 the length to ensure proper forearm weight support and pressure dispersion
• A trough that is less than 2/3 the length results in mid-forearm pressure, while a trough that is more than 2/3 can impede elbow flexion.
• The thumb trough should position the thumb in CMC palmar abduction, perpendicular to fingers, and support the thumb.
• The entire orthosis should be 1 1/2 in depth to contains fingers and provide strap contact with body
• The proximal edge should be flared slightly to disperse pressure.
• The pan supports arches and preserves digital flexion.
• The C bar preserves 1st web and open-packed position.

Anatomy to Guide Pattern Making

• Immobilization of joints: wrist, digits, thumb
• Creases guide pattern making
• The Thumb trough is most challenging visually-perceptually.
• Maintaining a safe versus resting position involves the same pattern but a loss of pan gutter length with safe during fabrication.

Reducing Extensor Tone in Lower Extremity

• Modify a traditional foot dorsiflexor to reduce gutter length of the foot portion to just proximal of ball of foot-eliminates positive supporting reaction.
• Entire body positioning for inhibition include trunk rotation

Pneumatic and Neoprene Designs

• Neutral warmth, passive continuous submaximal stretch and adjunct for weight-bearing.
• Neoprene/lycra uses are: Thumb abduction & supination which acts as inhibitory and provides neutral warmth

TheraTogs

• See https://theratogs.com/evidence/m for more information

Serial and Inhibition Casting

• Orthopaedic casting materials involve serial cast changes, increasing ROM, decreasing contractures
• Also positions the affected joint in submaximal range (5-10°), apply prolonged continuous pressure and is bivalve (can be opened).

Orthoses for Children: General Considerations

• It may be necessary to have two orthoses, not one, to support function, prevent contracture and provide alternate wear
• Match orthoses to occupations such as play, school, and self-care.
• Integrate orthosis into the child's context, including family lifestyle, values, culture, day care, home, school, and community.

Comparison of Orthoses for Children vs Adults

• In children, abnormal tone is present since birth and they need to achieve developmental milestones
• Rapid growth in muscles, tendons, and bones necessitates multiple orthosis revisions.
• Children develop Tolerance for orthosis wear and fabrication and adult direction.
• Children also require more attention span and cooperation than adults.

Pediatric Conditions Requiring Orthoses

• CNS dysfunction: abnormal tone
• PNS injury
• Brachial plexus
• Congenital deformity
• Developmental disability
• Indwelling thumb
• Juvenile rheumatoid arthritis (JRA)

Client Factors to Consider for Pediatric Orthoses

• Muscle tone increases with activity, necessitating an inhibitory orthosis to avoid loss of function.
• Tone decreases during sleep, so no orthosis is need.
• With hypotonia, an orthosis is needed to stabilize or support and counteract gravity.
• Assess ROM by: AROM/PROM & comparison to previous measures.
• Observe for compensation (fixation/stabilization of specific joints) and documenting position of child.

Additional Client Factors to Consider for Pediatric Orthoses

• Contractures: On-going orthosis management to prevent contractures due to developmental disabilities or congenital anomalies, etc.
• Critical to avoid loss of function, compromise of skin integrity, and reduced quality of life.
• Early & preventive orthoses are more cheaper.
• Prolonged stretch (LLLD) will be more effective than brief & intermittent PROM.
• Preventing or minimization of contracture is the principle orthosis for kid.

Performance Skills to Consider for Pediatric Orthotics

• Assess hand function and the goal to improve it with orthosis.
• Monitor hand function development as child ages.
• Evaluate proximal stability for distal skill.
• Assess the influence of use of orthosis on Evaluate cognition.
• Note Reaction to sensory stimuli.
• Apply quantitative and qualitative measure of function

Environmental Context for Pediatric Orthoses

• The orthosis design should be simple and allow ease for caregivers to donning and doffing, compliance.
• Consider whether the orthosis is for Home vs school vs. hospital use.
• Make sure in school context that the orthosis must support engagement in classroom, playground, lunchroom, etc.
• Make sure orthosis purpose relates to education (IEP?)-orthosis must be a means to an end
• Consider to avoid over-burdening the family of a child with special needs.

Preparing a Child Prior to Orthosis Fabrication

• Consider developmental stages
• Involve child-play with scraps of mat
• Decorate orthosis?
• Name orthosis?
• Make use of positive reinforcement for wearing orthosis?
• Use Easily replaced strapping (drooling, soiling)

Pediatric Orthosis Wear Schedule

• If the orthosis purpose is to increase function: wear the orthosis during play and other occupations.
• For the purpose in to reduce tone: wear the orthosis prior to play and other occupations.
• To reduce contracture: wear the orthosis during sleep or other non-occupation times.
• Reducing contracture (or gaining tissue length) requires LLLD-total time more important than continuous vs. intermittent wear.
• Critically is to Communicate wear schedule to multiple care-givers: parent, teacher, nurse, etc.

Resting Pan Orthosis for Children

• Similarities to adult design: forearm, finger pan, and thumb trough (gutters)
• Differences compared to adult design: “C” bar connection to thumb gutter
• Rationale: “C” bar for partial thumb radial abduction: elongates opponens; elongation of thenars can be inhibitory to flexor spasticity
• More like mitten compared to adult design, goal should be low load and prolonged stretch
• During fabrication, pre-stretch “C” bar and Additional strapping as needed to "seat” hand and wrist

Weight-Bearing Orthosis for Children

• Serve to position wrist in extension, thumb radial abduction and create Weight-bearing through heel and lateral borders of hand
• Allows child to work on proximal control and frees therapist's hands

Wrist Orthoses for Children

• The main Purpose: is to function to create Submaximal wrist extension to counteract flexor hypertonicity,
• Facilitates grasp and release of objects.
• A Volar design can be more easily fabricated than dorsal design with high tone.
• Can adapt the design with Index finger pointer and Crayon or pencil holder

Thumb Abduction Orthosis Options

• To inhibit thumb adduction which is excessive in tone
• Thermoplastic can feature Can free tip of thumb for prehension
• Neoprene, Velfoam (Joe-cool) and Serpentine

Orthoses for Pediatric Brachial Plexus Palsy

• The brachial plexus can be stretched due to traction out of the birth canal
• Erb's palsy and Klumpke's palsy are common (lower roots of plexus, not common in congenital injuries)
• The Orthosis is for: Increase function, prevent deformity, LLLD and Protection (if surgical repair)

Orthoses for Older Adults: Objectives and Considerations

• Recognize the effect on aging conditions, settings, and roles.
• Compare and contrast appropriate orthosis adaptations for older adults.
• Effective and safe orthoses immobilized only what needs to be immobilized, provide adequate stability, and decrease energy expenditure when worn.
• Effective and safe orthoses should provide safe distribution of force, be comfortable, easy to don/doff, economical, durable, easily modified and cleaned.
• The top Purposes of orthoses is to :Prevent ROM loss, reduce pain, improve occupational performance and Manage contractures
• Also will want to think about: Decrease edema and Protect skin integrity, substitute for loss of sensorimotor function.
• When considering orthoses for the geratric pt, take into account: Medical conditions, Fall risk/balance and Fragile skin.
• Consider:Immobility, Cognition, Frequent night toileting, Use of ambulatory devices and Wear schedule integrated into ADL/IADL. Light-weight materials and Soft vs thermoplastic materials.
• Consider Padding/Strapping, Caregiver education, lots of labels & Splint cleanliness.

General Strategies for Orthoses in Geriatric Patients

• Label (right vs left, landmarks) and Think about discharge instructions.
• Store orthosis in same location for easy retrieval with Caregiver education (wear, care, precautions)
• Keep orthosis design simple.

Selection of Materials for Geriatric Orthoses

• Consider the pros and cons of rigid vs less rigid thermoplastic
• Perforated vs lighter weight thermoplastic and soft fabrics

Selection of Strapping Materials for Geriatric Orthoses

• Wider straps help disperse the strap pressure.
• "Tails" of strap allows for the ease in prehension
• Must address Edema fluctuations
• Provides good Durability or has a D-ring that provides mechanical leverage to effectively tighten

Selection of Padding Materials for Geriatric Orthoses

• Open-cell foam: Absorbs moisture and is Hard to clean
• Breeding ground for bacteria.
• Closed-cell foam: Nonabsorbent, Easily washed and towel dried E.g, plastazote
• Remember to pad an orthosis prior to fabrication- 6in Velfoam to pad entire orthosis; secure with hook Velcro on inside of orthosis.

Additional Considerations Geriatric Orthoses

• Fabricating and donning an orthosis is not the only part of your intervention.
• Education/training is critical: for both the caregiver and client.
• Implement Memory strategies for wear schedule , Cleaning , Exercises and Caregiver and client "buy-in".

Lower Extremity Orthoses Objectives

• Know the roles for OTs in orthotic care for Lower Extremity
• Apply the characteristics of orthoses designs to pre-fabricated vs a custom made version
• Explain some of the common applications that lead to occupational performance deficits.

"Splint” vs Weight-Bearing Orthotic Comparisons

• A splint is made of a Low temperature thermoplastic and Molded to body part.
• A splint has short a Short life span of: 3-6 mos
• Splints feature Velcro strapping which is adequate and can have hinges
• An orthotic is made of a High temperature thermoplastic and is Rigid, and will be Cast or mold off body
• An orthotic have a Long life span: greater than 6 mos
• Orthotics will feature permanent strapping w leather & hinges

OTs role in Lower Extremity Orthotics

• OTs design, fabricate, fit, and train (seamless delivery of orthotic services) in both LE and UE.
• OTs must Collaborate to solve problems related to occupational performance with UE and LE.
• PTs must Follow-through on use of orthotic and refer to OT for evaluation of need for orthotic, modification, etc.
• Orthotists Design, fabricate, and fit HIGH temperature devices.

Types of LE Orthotics and OTs role

• Foot orthosis (FO): Accommodates, support, corrects, and OT will check skin integrity.
• Ankle/foot orthosis (AFO): Controls ankle, foot, provide stable base of support, safety, and function is articulated is used. Is evaluated by OT with ADL/IADL via driving squatting and kneeling.
• Knee orthosis (KO): Prevent injury and offers controlled ROM post-op & early wt-bearing and allows OTs to provide Post-TKA ADL (CPM, knee immobilizer).
• General: Adapting and hand function are needed (don/doff)

Examples of LE Orthoses

• Knee extension; static gutter; is a BKA which prevents flex Sleep; intermittent awake?
• Corrects the Knee extension: LLDD; static gutter to give elongated ext-serial statical tissue, medical, and sedentary patient. Is required for

Other OT Applications for LE Orthoses

• Plantar fasciitis
• Foot dorsiflexor
• Sleep wear
• Elongate/remodel tissue
• OT can use modality such as manual therapy
• Tissue repair/wound healing: reduce tension on healing structures
• Plantarflexor tone – eliminate pressure to ball of foot
• Burn – dorsiflexor/knee extension for prevention
• Client always assumes comfort (open/ reduced tissue tension)

LE Orthotics and OT's Role

• The KAFO adds the function to control of knee with AFO is to provide stability so it is primary joint of instability in kinetic chain. Ot provides with Wear over/under clothing and manipulation of locks for sit/stand
• HO is all for developmental problems of femoral head/acetabulum. OT needs for ADl, application of UE functioning
• Ot checks if spasticity maintains abduction

Design Considerations for LE Orthoses

• Must provide increased surface area to disperse pressure
• Address bony prominences
• Maximize Mechanical leverage: long lever arms
• Make use of Weight, cost, adjustability, ease of application, appearance, maintenance, training