Introduction to Orthosis PDF

Introduction to Orthosis https://youtu.be/EWKjKbH4r9w  Objectives Demonstrate an understanding of basic and common orthotic terminology Demonstrate an understanding of basic orthotic goals Differentiate between general types of orthoses Be able to select an appropriate type of orthosis giv...

Introduction to Orthosis https://youtu.be/EWKjKbH4r9w  Objectives Demonstrate an understanding of basic and common orthotic terminology Demonstrate an understanding of basic orthotic goals Differentiate between general types of orthoses Be able to select an appropriate type of orthosis given a simple case scenario Orthotist Specializes in the design, fabrication, fitting, alignment adjustment of orthoses. An orthosis is any device added to the body to stabilize or immobilize a body part, prevent deformity, protect against injury, or assist with function. (Taber’s Cyclopedic Medical Dictionary. ©2001, FA Davis) Some Basic Goals of Orthoses Maintenance or correction of body segment alignment Assistance or resistance to joint motion Axial loading of the orthosis & therefore relief of distal weight bearing forces Protection against physical insult Characteristics of an ‘Ideal’ Orthosis Function Meets the individuals mobility needs and goals Maximizes stance phase stability Minimizes abnormal alignment Minimally compromises swing clearance Effectively pre-positions the limb for initial contact Is energy efficient with the individual's preferred assistive device Comfort Can be worn for long periods without damaging skin or causing pain Can be easily donned and doffed (e.g., considering clothing, footwear, toileting) Cosmesis Meets the individual's need to fit in with peers (Lusardi 221) Lusardi, Michelle. Orthotics and Prosthetics in Rehabilitation, 3rd Edition. W.B. Saunders Company, 2013. VitalBook file. Lower Extremity Orthoses: FO foot orthosis AFO ankle foot orthosis KO knee orthosis KAFO knee ankle foot orthosis HKAFO hip knee ankle foot orthosis HO hip orthosis Before we talk more about Orthosis, we need to discuss trimlines/cuts which are analogous to different cuts of jeans… High Rise, Low Rise, Boot Cut, Straight Cut Tight Pants Jean Brand Names: Levi’s, Gap, Wrangler ect… are brands just line Cascade, Powersteps, and Quadrastep are brands of orthotics. Different orthotics have different trimlines or “cuts”  Orthosis Trimlines THE TRIMLINES Location of the trimlines will depend upon the results of the assessment of the patient, thus on the patient's individual needs. The following rules apply in general: The proximal trimline is located approximately 3.8 cm. (1 1/2 in.) distal to the head of the fibula so that it will be clear of the peroneal nerve. The proximal trimline should encircle about 3/4 of the calf. The anterior trimline extends from the bottom of the junction of the Velcro strap and the orthosis to the midpoint of the shank. The anterior trimline should curve posteriorly as it proceeds distally to the midline of the shank The location of the ankle trimline affects the rigidity about the ankle joint more than any other single factor. Obviously, the further anterior that the trimline is located, the more resistance there is to rotation about the ankle. The foot trimline on the medial side extends through or slightly above the apex of the navicular. On the lateral side, the foot trimline extends slightly above the shaft of the fifth metatarsal. The metatarsal, or terminal, trimline lies along the apices of the metatarsal heads. All trimlines should be contoured and blended together smoothly. When a trimline is located slightly below a bony prominence, the area often becomes irritated, but when the trimline is located at the level of or slightly above the apex of a bony prominence, pressure areas do not occur as a rule. http://www.oandplibrary.org/op/1975_04_041.asp  Brands of Orthotics Powersteps, Quadrasteps, and Cascade Brands…just to name a few Summary Tables for most common orthosis created for board review on next three slides Basis Overview of Orthotics for different pathologies and requirements needed to wear them UCBL: Think kids with flat feet and low tone. Think adults with posterior tib dysfunction DAFO: Realize DAFO can be utilized to point us towards child foot orthosis or can be utilized as a overall umbrella term for AFO’s. The “D” stands for dynamic so returns some energy but because of that isn’t stable enough to block up rigid foot deformities. SMO: More than a UCBL but less than a DAFO. Comes up over the ankles. Controls the ankles for better foot/heel correction. Posterior leaf spring is the most common AFO Mildly controls knee hyperextension and mildly/moderately controls foot drop.  SAFO: If DAFO’s are dynamic then SAFO’s are rigid. Able to control hypertonicity or severe low tone i.e. flaccidity. Creates extension moment at the knee TONE-Inhibiting AFO is not a type of AFO as much as it is the goal of the AFO. This would include Anterior floor reaction AFO but would also include rigidly built SAFO, or clamshell designed AFO with strapping Anterior Floor Reaction: Instead of blocking behind the leg they block in front of the knee. Crouch gait Crouch gait Weight relieving AFO is basically the walking boot we see many people in after a significant ankle/plantar fascia injury  FO (foot orthosis) When foot cannot attain neutral, FO may shim the gap to that fixed position-Accommodative FO May help the foot attain a neutral position- Corrective FO Either may unload compromised tissue; or may provide total contact May be full custom or Off The Shelf (OTS) Heel wedges or post for foot orthosis Pronated Feet with heel post orthotic  JOSPT Robert Kingman et al 1997 The mean change in medial patellar glide displacement was found to be 1.08 mm with the placement of a semirigid rearfoot posting. The study proposed that this was evidence for the utilization of orthotics in treatment of patients with PFPS with excessive rearfoot pronation. A total of seven studies were included in the final review. The review found limited evidence that prefabricated foot orthoses may reduce the range of transverse plane knee rotation and provide greater short-term improvements in individuals with PFPS compared with flat inserts. Findings also indicated that combining physiotherapy with prefabricated foot orthoses may be superior to prefabricated  SACH heel Medical Engineering Physics. 2004 Oct;26(8):639-46 The effects of rocker sole and SACH heel on kinematics in gait. Wu WL1, Rosenbaum D, Su FC. Author information Abstract The rocker sole and solid-ankle cushion-heel (SACH) heels are the most commonly prescribed external shoe modification. Only a limited number of scientific evidence exists to support these interventions in clinical practice. The objective of this study was to determine the effects of rocker soles and SACH heels on kinematics during gait. In this study, we investigated the gait parameters during level walking, stair climbing and stair descending in healthy volunteers and assessed the effects of the modified shoes on the motion of the forefoot and hindfoot compared with the traditional shoes. Eleven normal subjects participated in this study. A six-camera motion analysis system was used to capture motion trajectories. The three-dimensional (3D) coordinates of the markers were used to calculate the angles of flexion-extension, valgus-varus, and internal-external rotation at the hindfoot and forefoot joints in a gait cycle by the custom software for foot kinematic analysis. The results showed that the rocker soles offer several advantages from the viewpoint of gait kinematics. The forefoot joint excursion in sagittal plane while wearing rocker shoes was significantly less than that while wearing traditional shoes during level walking, stair climbing and stair descending. It means that they could mimic the action of the forefoot joint, aid in roll off, and simulate forefoot dorsiflexion. Since the bony structures mechanically link the forefoot joint and hindfoot joint to a triplanar axis of motion, they could be used whenever there is minimal or no motion at the forefoot joint or hindfoot joint, because of, for example, fusion, fracture, cast immobilization, orthosis design, pain, or arthritis.  Metatarsal bars flat surface placed behind the metatarsal head, that are used to relieve pressure from the metatarsal heads. All met bars are designed to help metatarsalgia and relieve plantar pressure by adding a wedge of firm material across the sole of the shoe just proximal to the met heads. This unloads the pressure from the met heads, allowing for rapid transfer from the shafts of the metatarsals to the distal end of the toes, with limited extension of the digits. Met bars are typically ¼" in vertical height, which can make them a tripping hazard. They can be made using firm crepe or leather. Unlike rockers, met bars have a much flatter plantar surface, providing a broader area of contact with the ground. Plantar Fascia Splint Principles underlying the plantarflexion control system acting during swing phase in a rigid/solid ankle-foot orthosis (SAFO). The large primary force (FPrimary) is applied in a posterior-inferior direction over a large surface area (stippled area) anterior to the axis of the ankle joint, usually by the shoe's closure or reinforced by webbing across the anterior ankle. The two counterforces, applied in an upward (CFPlantar) and anterior (CFPosterior) direction, also over a large surface area, far from the axis of the ankle joint, create an effective moment arm so that less force is required to achieve the desired stabilization. The sum of the primary (large arrow) and two opposing counterforces (small arrows) is zero in a well-balanced orthosis. (Lusardi 222) Lusardi, Michelle. Orthotics and Prosthetics in Rehabilitation, 3rd Edition. W.B. Saunders Company, 2013. VitalBook file.  The four force systems in a molded thermoplastic solid-ankle ankle-foot orthosis design. A, Plantarflexion is controlled during swing phase by a proximal force (F p) at the posterior calf band and a distal force at the metatarsal heads (Fd) that counter a centrally located stabilizing force (Fc) applied at the ankle by shoe closure. B, For control of dorsiflexion during stance phase (i.e., forward progression of the tibia over the foot), Fp is applied at the proximal tibia by the anterior closure, Fd at the ventral metatarsal heads by the toe box of the shoe, and counterforce Fc at the heel, snugly fit in the orthosis. (Lusardi 228) Lusardi, Michelle. Orthotics and Prosthetics in Rehabilitation, C, The force system for eversion (valgus) locates Fd along the fifth metatarsal, Fp at the proximal lateral calf band, and Fc on either side of the malleolus. D, To control inversion (varus) of the foot and ankle, Fd is applied by the distal medial wall of the orthosis against the first metatarsal, Fp at the proximal medial calf band, and Fc at the distal lateral tibia and calcaneus/talus on either side of the lateral malleolus.  UCBL University of California Biomechanics Laboratory (UCBL) Rigid plastic total contact design Hind foot / mid foot correction Heel cup extends proximal to inframalleolar area and distally to the metatarsal heads Typically extends all the way to the end of the foot An orthotic intervention for subtalar joint instability. The UCBL controls flexible calcaneal deformities (rearfoot valgus or varus) as well as transverse plane deformities of the midtarsal joints (forefoot abduction or adduction) by “grabbing” the calcaneus and supporting the midfoot with high medial and lateral trim lines; it realigns the calcaneus, improving the angle of pull of the Achilles tendon, providing a more stable foundation for the articular surfaces of the talus, navicular, and cuboid bones. The UCBL is also used to improve functional alignment of children and adolescents with flexible pes planus, a longitudinal arch deformity. (Lusardi 231) Lusardi, Michelle. Orthotics and Prosthetics in Rehabilitation, 3rd Edition. www.towerortho.com  UCBL University of California Biomechanics Laboratory (UCBL) Controls Mid foot and Hind foot (subtalar and tarsal joints) Indications: Pronation control, flexible pes planus, OA of the hindfoot, posterior tib dysfunction, tarsal coalition, rearfoot valgus/varus, Contraindications: Toe walker, mod-high tone, ankle arthritis (rigid foot deformities) www.towerortho.com UCBL  Another Summary slide AFO (ankle foot orthosis) Most common orthosis 1. Dynamic AFO=DAFO (flexible) 2. Metal bars=Bilateral metal upright 3. Solid Ankle Foot Orthosis: not moveable like a DAFO. Rigid to control motion. The most extreme version would be Total Contact i.e. like a plastic cast 4. Floor reaction: in the front of the leg 5. Unweighting 6. Immobilizing  AFO (ankle foot orthosis) Most common orthosis 1. Dynamic AFO= also called DAFOs SMO’s, posterior leaf springs, Spiral, etc. Dynamic AFO can be articulating or non-articular 2. Static/Solid AFO= (non articulating limited to no energy return) Solid ankle Foot, Floor reaction, immobilizing AF0’s, total contact Restrict ankle motion and foot motion in all three planes AFO NAMING CLASSIFICATIONS REVIEW 1. It’s material: Metal vs plastic vs carbon/graphic 2. Does it touch the skin? (total contact vs metal uprights) 3. Does it have a joint/movement/dynamic (articulated vs non- articulated) or is it solid/static? 1. articulated AFO has moveable joint ankle, while non-articulated doesn’t 2. Solid/static AFO don’t allow for ankle movement 4. Does it stop particular movements (PF/DF stops/bumpers) 5. Does it assist motion (PF/DF assist)  SMO Supra Malleolar Orthosis: shortest type of DAFO Low profile design that crosses the ankle (extends more proximal than UCBL) Less invasive trim lines than a standard AFO, better M-L control than UCBL Designed to Control pes planus Rounded cut at the superior aspect of the SMO tells you it’s an SMO and typically they only go the metarsals. Allows toe off at terminal stance Surestep SMO’s Need to be worn tightly Surestep SMO Lateral distal trim line to 5th met head Medial distal trim line proximal to 1st met head to allow for great toe depression. Full length shank cascade SMO or SMAFO Supra Maleolar Orthosis Low profile design that crosses the ankle Less invasive trim lines than a standard AFO Rounded cut at the superior aspect of the SMO tells you it’s an SMO Need to be worn tightly Controls hind foot and mid foot Indications: Severe Pes Planus, Mild ankle instability, low (hypo) tone, Intermittent toe walkers, mild to moderate CP, tarsal coalition, post tib dysfunction Contraindications: high tone (hypertonicity) , sagittal plane, weakness deformity (drop foot) , dominate toe walkers, equinovarus/valgus  Superwrap can be used with SMO Neuromuscular facilitator similar to an ACE wrap that is used similar to kinesiotape only stronger. Different types of pediatric orthosis: Cascade brand  AFO’s vs DAFO’s It’s confusing…I’m sorry Ankle Foot Orthosis (AFO): is the large umbrella term/name for any orthotic that encompasses the ankle/foot. Dynamic Ankle Foot Orthosis are different from a traditional AFO in that a DAFO is characteristically thin, flexible and wraps around the patient’s entire foot in order to provide improved sensation and alignment. The concept for the original DAFO was developed in 1985 as collaboration between Don Buethorn, CPO, and Nancy M. Hylton, PT, LO. The two worked together to meet the needs of pediatric patients with neurodevelopment challenges and the result was the creation of a Washington state-based company, Cascade Dafo, Inc. At this point AFO’s the pediatric settings are almost always called DAFO’s even though some of them aren’t always dynamic (such as solid/rigid AFO’s). DAFO=Dynamic ankle foot orthosis Previously DAFO’s referred to pediatric AFO’s but now this term is sometimes being used synonymously with the AFO. A custom-molded orthosis that has evolved from the UCBL shoe insert to better address sagittal plane control of the ankle and foot during stance and to facilitate foot clearance in swing. Its proximal trim lines are superior to the ankle joint, and its distal trim lines encase more of the forefoot than the UCBL. By limiting movement of the mid-foot and forefoot and by holding the foot in functional position, the DAFO provides a stable base for more effective motor performance and postural control during standing and ambulation. The DAFO is designed for mild to moderate diplegic cerebral palsy. Free motion/articulated/hinge AFO More of an orthopedic brace than a neuro brace Allows sagittal plane motion free DF and PF Limits coronal plane instabilities Indications: Posterior tib tendon dysfunction Subtalar or talar joint instabilities Contraindications: Weak Quads, Sagittal plane ankle weakness, drop foot, knee genu recurvatum High impact sports ***ONLY FREE IN THE A-P direction Air-Stirrup Ankle Brace Dorsiflexion assist AFO Assist in clearance of the toes while allowing for some PF Variable DF Assist Allows for controlled foot flat stance phase Indication for DF weakness (i.e., drop foot) Contraindicated in moderate to severe tone levels or in individuals with altered knee control DF Assist AFO’s have a characteristic forward leaning positioning with an aggressive spring assist (tilts forward)  Posterior Leaf Spring: Most common AFO/DAFO Functions to limit PF but has no dynamic assist for DF Limits plantar flexion to assist limb clearance in swing. Patient has to have adequate knee, hip, and ankle plantar flexor strength Indications: Mild –Moderate Foot drop (LMN flaccid paralysis of dorsiflexors) and knee hyperextension Contraindications: moderate to severe spasticity, coronal plane ankle instability, ankle dorsiflexion limitations/fused joint, severe knee instability Spiral AFO’s Spiral has an unwinding effect. Indications: Ankle dorsiflexion weakness and/or plantar flexors ALONG with mild-moderate medial-lateral instability Contraindications: Inadequate hip strength, moderate to severe spasticity, severe medial lateral ankle instability, fluctuating edema. leaf-spring ankle plantar flexion and dorsiflexion resistant DAFO with straps around shell Posterior Stops/Bumpers in AFO Immobilize ankle in swing and stance phase Indications: Structural collapse of the ankle foot, severe spasticity, Contraindications: inadequate hip strength, absent quads, fluctuating edema, fixed/contracted spastic gastrocs If you only have a PF stop and DF is free then it facilitates knee flexion in early stance DF stop/Free Plantar flexion Facilitates knee extension and stiff ankle in late stance. Limits uncontrolled knee flexion/instability Indications: weak PF and weak quads Contraindications: DF weakness knee hyperextension  SAFO=Solid Ankle Foot Orthosis=a non articulated AFO Indications: MORE SEVERE CONDITIONS. Think about these for Extremely HIGH TONE or Extremely LOW TONE neurological patients Ankle instability/weakness in more than one plane Equino varus Moderate-severe pes plano valgus Moderate-severe genu recurvatum Contraindications: not appropriate for more mild dysfunctions like mild drop foot or mild pes planus SAFO=Solid Ankle Foot Orthosis Rigid AFO made of thermoplastic (like a prosthetic socket) which has no recoil or energy return. I.E. it’s not dynamic (DAFO) To resist plantarflexion during swing phase, there is a fulcrum force applied at the anterior ankle (by strapping or by the shoe's laces or Velcro closure) opposed by a distal counterforce upward under the metatarsal heads and a proximal counterforce at the posterior proximal surface of the AFO. To resist dorsiflexion during stance phase, there is an upward and inward compressive force at the posterior heel, opposed by a distal downward counterforce delivered by the shoe, and a proximal force applied by the anterior closure straps just below the knee. It is important to note that the locked ankle created by an AFO generates an extensor moment at the knee during stance. In this way, a SAFO can substitute for impaired motor control or muscle performance of knee extensors for persons with stroke, cerebral palsy, or other neuromotor dysfunction.(Lusardi 227)  SAFO vs Articulated DAFO Solid Ankle Articulated Articulated or Non- articulated May be designed for progressive increases or decreases in sagittal plane ROM and control An articulating option may be available in many designs of AFO’s Non-Articulating (Solid Ankle) Articulating Ground/Floor Reaction AFO Blocks knee flexion/crouch gait by resisting the forward movement of shin over foot. Indications are for crouched gait, Foot drop with knee instability, quadriceps weakness, MS, Spina Bifida patients Contraindications: Genu recurvatum, ACL, Severely ER Feet, patients that do not have adequate trunk control/balance or have flaccid/limited quad strength especially if used bilaterally *** Unique AFO in that it is blocking the front of the leg not the back of the lower leg.  Floor reaction AFO- (FRO) Uses floor reaction force through toe aspect of foot plate to prevent forward tibial progression & subsequent knee collapse. Used for patients with quadriceps weakness and motor control of the knee. CP children with crouch gait, post polio. Often used with Lofstrand crutches or roller walker. NOT APPROPRIATE FOR GENU RECURVATUM OR ACL DEFICIENT KNEES.  Floor Reaction AFO Strap is posterior along the calf Blocks forward progression Designed for high tone vs low tone of CVA Oregon Orthotic System (OOS) another brand of floor reaction AFO. Helios: dynamic ankle ground force reaction A  Quick Clarification: Total Contact AFO’s just means it’s not a bilateral metal upright Typically made of plastic or carbon fiber. Pro’s of non-metal material is that it has higher patient acceptance possibly due to light weight & concealment (150-200gms); Con’s/Contraindications: Edema doesn’t work with total contact AFO’s…see metal uprights on following slides Courtesy of Westcoast Brace & Limb Bilateral Metal Upright (bars) AFO Indications: Foot drop, Post-Polio, Neuropathic feet Poor knee control in sagittal plane Ankle varus/valgus Foot drop with uncontrolled edema Poor skin below the knee Contraindications: Patient’s concerns with bulk/weight Limits shoe wear  Bilateral Metal Upright (bars) Commonly used in specific scenarios i.e. Post-Polio, Neuropathic feet, and CVA Calf Band Stirrup Varus or Valgus Corrective strap (optional Ankle Joint Metal AFO Ankle Joints Free Variable ROM Dorsiflexion Assist Double Action Spring Assist Spring assist comes in two forms 1. Klenzak housing: double upright metal AFO with a single channel for a spring assist to aid dorsiflexion. The Klenzak housing is a single channel spring assist. 2. BiCAAL=Bi-channel adjustable ankle lock Different types of AFO articulating ankle units and other accessories Double action ankle joint Figure 9-17 A, The double-action Ankle joint (DAAJ) can be used in a conventional double-upright, metal ankle-foot orthosis and a thermoplastic- metal hybrid ankle-foot orthosis. Motion is assisted if a spring is compressed within the channel or can be blocked by placement of a steel pin within the channel. B, The internal anatomy of the double adjustable ankle joint. Ankle joint mobility restrictions (e.g., plantarflexion stop) result from the locations of the pins in the anterior and posterior channels of the orthotic joint. A spring may occupy one of the channels, as depicted here, to assist motion (e.g., dorsiflexion assistance). The ball bearings allow the brace uprights to pivot with ease over the brace stirrup. The set screw can be adjusted to change the relative positions of the rods in each of the channels. (Lusardi 236) Board review books speak of this as a BiCAAL=Bichannel adjustable ankle lock  BiCAAL Bichannel adjustable ankle lock (BiCAAL): an ankle joint with the anterior and posterior channels that can be fit with pins to reduce motion or springs to assist motion Anterior Stop (dorsiflexion stop): determines the limits of ankle dorsiflexion. In an AFO, if the stop is set to allow slight dorsiflexion (~5degrees), knee flexion results; can be used to control for knee hyperextension; if the stop is set to allow too much dorsiflexion, knee buckling could result Posterior stop (plantarflexion stop): determines the limits of ankle plantar flexion. In an AFO if the stop is set to allow slight plantar flexion (~5degrees), knee extension results; can be used to control for an unstable knee that buckles; if the stop is set to allow too much plantar flexion, recurvatum or knee hyperextension could result Varus or valgus correction straps (T Straps) Control for varus or valgus forces at the ankle. Medial strap buckles around the lateral upright and correct for valgus Lateral strap buckles around the medial upright and corrects for varus DAFO/SMO for Level II & III SAFO or very restrictive DAFO Resting splints or stretching splints Decision Tree for Orthotic Options Is an ankle-foot orthosis (AFO) Indicated? AFO Decision Tree Continued Rancho LOS Amigos LE Orthoses ROADMAP Recommendation for Orthopedic Assessment, decision-making, and prescription AFO Select orthosis with articulated ankle joint Determine if DF stop is indicated: a) PF strength ≤ 4 in standing and/or b) Excessive ankle dorsiflexion (knee flexion) or ankle plantar flexion (knee extension) in stance These patients may also need a Dorsiflexor Assist built into the orthoses Determine if DF assist is required: DF strength is ≤ 4 Then the patient requires one of the following orthoses 1. Polyarticulating AFO with dorsiflexion (DF) stop. 2. Metal AFO with DAAJ and poly footplate, DF stop. 3. Metal AFO with DAAJ, dorsiflexion stop 4. Polyarticulating AFO with dorsiflexion assist. Select type of joint 5. Metal AFO with DAAJ and poly footplate, DF assist 6. Metal AFO with DAAJ, dorsiflexion assist Articulated ankle without DF stops Patient has decreased ankle strength OR impaired or absent proprioception at the knee/ankle But NO Spasticity, NO PF contracture And Intact proprioception of foot placement during gait/standing DF stop was not indicated because : a) GOOD PF strength in standing and b) Neutral ankle dorsiflexion/ankle plantar flexion in stance 1. Posterior leaf spring AF 2. Polyarticulating AFO with dorsiflexion (DF) assist. 3. Metal AFO with DAAJ and poly footplate, DF assist. 4. Metal AFO with DAAJ, dorsiflexion assist Summary slides for DAFO’s/AFO’s Unusual AFO’s you will rarely see Unweighting AFO May be patella tendon bearing (PTB), specific weight bearing or total surface bearing, TSB Example of a TSB unweighting AFO from http://www.arizonaafo.com/weightbearing.h tml  Immobilizing AFO Commonly used with a lower extremity deficiency when ankle immobilization is desired distal tibia/ fibula fracture foot bone fractures tendocalcaneus rupture Diabetic Foot (Charcot Foot) AFO for Fracture Management. http://www.orthoactive.com/downlo ads/pdf/fractureBracing.pdf CAM Walker Crow Walker= Charcot http://www.orthopedictechreview.co Restraint Orthotic m/issues/octnov99/productivity.htm Walker www.towerortho.com  Functional Neuromuscular Electrical Stimulation For persons with impaired motor control resulting from disease or trauma of the central nervous system, several commercially available, wearable functional electrical stimulation units, also called neuroprostheses, are available (e.g., WalkAide, Hanger Orthopedic Group, Austin, Texas; Odstock Dropped Foot Stimulator, Salisbury, UK; NESS L300 Foot Drop System, Bioness Inc. Valencia, Calif.). The individual wears a cuff that is positioned snugly just below the knee, rather than an orthosis that must fit into the shoe (Figure 9-13). The cuff holds a small stimulator medially with electrodes positioned laterally over motor end points of the peroneal nerve. Depending on the model, appropriate timing of the functional electrical stimulation for dorsiflexion activity is determined by a switch worn in the shoe, an inclinometer, or an accelerometer. Most use surface electrodes to deliver the stimulus for muscle contraction although cuffless versions with surgically implantable electrodes are available. Studies evaluating the device have demonstrated improved spatial and temporal characteristics and safety of walking in persons with acute and chronic stroke when worn as an orthosis alone or when integrated with rehabilitation interventions.66–68 Similar findings support its use for persons with traumatic brain injury, multiple sclerosis, and Parkinson's disease. Each of these devices must be adjusted to the individual's typical gait pattern by an orthotist trained to fine-tune The Hanger WalkAide System, as an example of a wearable functional electrical stimulation unit, is used to trigger muscle contraction of dorsiflexors during appropriate points in the gait cycle. Lusardi pg 234 https://www.youtube.com/watch?v=2AnXOJSVoLs Dynamic Stretching Orthosis Cascade Dynamic Orthosis PRAFO: Spinal cord and acute care setting Orthosis  KO (knee orthosis) Useful for malalignment genu varum, valgum, recurvatum, to protect knee structures from undue loading/stress may be preventative or corrective may be permanent treatment for repaired/compromised knee structures Photo of a patient with Genu Recurvatum courtesy of Westcoast Brace & Limb  non-articulated KO- usually for short term use Knee Immobilizer KO difficult to transfer with Swedish knee cage for Genu Recurvatum Several Types of KO’s: Athletic KO- Non-articulated KO- Custom or OTS KO- OA off loading joint Athletic KO- Preventative. Controversial as short lever arms may not be sufficient to diminish realistic damaging forces. Proprioception thought to play a role.  Patellar Femoral Braces Just as evidence to support prophylactic and functional orthoses for tibiofemoral joint instability is inadequate, research support for the efficacy of patellofemoral taping and bracing is lacking. Off-the-Shelf Offers limited control of the KO- knee. Restricts gross motion Dynamic Extension assist KO to prevent contractures http://www.kneebracesonline.com/product.p hp?productid=307&cat=681&page=1 http://www.orthomerica.com/products/ lowext/polaris_2.htm Knee OA off-weighting braces KAFO Indicated for knee, ankle, and foot instability Post polio syndrome (PPS), genu recuvatum, weakness proximal to knee, SCI, CVA, Spina Bifida Quads less than 3+/5 (scores below need brace) Coronal plane instability (genu valgum or genu varum) Transverse plane instability Decision Tree for Orthotic Options Is a knee-ankle-foot orthosis (KAFO) Indicated? Knee Ankle Foot Orthosis (KAFO) Metal KAFO Components: Shoe Stirrup Ankle joints Side bars Calf band Knee joints Distal thigh band Proximal thigh band Knee Ankle Foot Orthosis (KAFO) Metal vs. Plastic Plastic KAFO  KAFO Knee Ankle Foot Orthosis The rehabilitation team considers a knee ankle-foot orthoses (KAFOs) only when stability during stance cannot be effectively provided by one of the AFO options. KAFOs are often prescribed when in addition to impairment of ankle control there is the presence of (1) hyperextension or recurvatum that jeopardize structural integrity of the knee joint, and/or (2) abnormal or excessive varus or valgus angulation that occurs during weight bearing in stance phase. If not recognized and addressed appropriately, both threaten joint function and structure during walking and, with repeated abnormal loading, increase risk of permanent damage to supporting structures within the knee and development of degenerative joint disease. KAFOs can be used unilaterally (e.g., for individuals with polio affecting one limb) or bilaterally (e.g., for those with SCI or myelomeningocele). (Lusardi 239) Single/Double Bar KAFO- Single axis Posterior offset: preferable for knee hyperextension Polycentric: just like the prosthetic knees. Mimics true knee mechanics http://www.ottobockus.com/ Single/Double Bar KAFO- Accommodates volume fluctuation, Cooler than total contact, Highest material strength. Several lock options. Lock for ambulation, unlock for sitting. May incorporate hyperextension stops. Various knee joints are available e.g. Weight activated stance control, locking, polycentric, single axis, extension assist, etc. http://www.ottobockus.com/ Drop Ring locks vs Pawl locks with Bail Release Hooks on the back of a chair to push it up and unlock the knee Figure 9-24 Orthotic knee joints historically used in conventional and thermoplastic knee-ankle-foot orthoses. A, single-axis, or free, knee allows full flexion and extension while providing mediolateral and rotational stability to the knee joint. B, drop lock holds the knee in extension in standing, providing stability in all planes. It must be unlocked for knee flexion to occur when returning to sitting position. C, Because the axis of the offset orthotic knee joint is positioned behind the anatomical knee axis, biomechanical stability of the orthosis is enhanced. It is available with and without a locking mechanism. D, variable position, or adjustable, orthotic knee joint permits the orthotist to accommodate for changing range of motion or for fixed contracture at the knee. Stance control KAFO Microprocessor controls from prosthetics being integrated into KAFO technology. Provides stance phase stability while allowing swing phase flexion Weight, position, or ankle activated Indications: knee buckling flaccid paralysis of quads Contraindications: contractures of knee/ankle, insufficient hip musculature, DF ROM  Knee Ankle Foot Orthosis (KAFO) Knee Joints Free Variable ROM Posterior offset Drop lock Bail lock Subtypes: Single/Double bar (upright) KAFO- Total contact KAFO- Ischial Weight Bearing (unweighting) KAFO- Ischial Weight Bearing (unweighting) KAFO- Ischial containment or Quadrilateral style brims with high trimlines. Generally used with paralytic limbs. Not as effective with larger or obese individuals. http://www.beckerorthopedic.com/cenfab/cfp.htm http://leedergroup.com/bulletin s/limited-definition-of-orthotics Total Contact KAFO- More customizable. Better load distribution. http://www.orthomerica.com/produ Courtesy of Westcoast Brace & Limb http://www.pandocare.com/products.html cts/lowext/orlando_kafo.htm Craig Scott Orthosis Also known as a double-bar hip-stabilizing orthosis. A lightweight variation of a traditional KAFO designed for persons with paraplegia after SCI Persons without active hip control are stable in standing with hip hyperextension, exaggerated lumbar lordosis and a backward leaning trunk; stability is augmented by the orthosis’ dorsiflexion-assist ankle joints and offset locking knee joints. With this combination of orthotic design and exaggerated posture, the GRF passes just anterior to the knee and posterior to the hip, so that little or no muscular activity to provide internally generated counterforce is necessary. While a reciprocal gait pattern with Lofstrand crutches typically requires the ability to volitionally activate hip flexions and quadratus lumborum (hip hikers) to initiate a step, persons with thoracic level SCI can use Craig- Scott orthoses and Lofstrand crutches using a two-point swing-through gait pattern.108 (Lusardi 241-242) paraplegic walking in braces with walker - YouTube HKAFO Hip Knee Ankle Foot Orthosis Very restrictive and laborious to swing-to or through in gait causing high rejection rates. Children with myelomeningocele, SCI patients. Includes Reciprocating Gait Orthoses (RGO), total contact, leather and metal upright, postural and others http://leedergroup.com/bulletins/lim ited-definition-of-orthotics Specific HKAFO: Reciprocating Gait Orthosis (RGO) Commonly used in cases of spina bifida and spinal cord injury. Combines flexion of one hip with extension of the opposite hip. The flexion power of one hip is utilized to extend the opposite hip. Courtesy of Westcoast Brace & Limb HGO (Hip Guidance Orthosis) and RGO Reciprocating Gait Orthosis: Spina Bifida Parapodiums, Standing Frames, Swivel Walker https://www.youtube.com/watch?v=YVuXzcA0wtY ARGO: Alternating Reciprocal Gait Orthosis Used with SCI patients and children with neuromuscular conditions (CP, Spina Bifida). Super high energy consumption so they never really have been functional for most SCI patients. ReWalk by Argo - A Life Regained. - YouTube Hip Orthosis (HO) Hip Abduction Orthosis for Leg calve Perthes (AVN) or congenital hip dislocations Standing Walking AND Sitting Orthosis (SWASH) or Toronto Hip Abduction Orthosis Some Orthoses can intervene at the hip without crossing the hip. Select examples: Specific Case Hip Orthosis (HO): S.W.A.S.H Orthosis or a Scottish Rite Orthosis Standing Walking And Sitting Hip Orthosis Maintains femoral abduction in standing, walking and sitting  Pavlik Harness It need to be worn 18-23 hours/day? o Used to treat Leg Calve or hip dysplasia pg 342 Lusardi Hip Abduction Brace Patten bottom attachment Distal attachment to keep foot off the floor. Requires a lift on the opposite foot. Used with Legg-Calve Perthes disease Hip Abduction Orthosis Commonly used post-operatively to position the femoral head optimally within the acetabulum. Hip dislocation patient are often fitted with these orthosis.