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Orthotics > LE Orthotics > Flashcards

LE Orthotics Flashcards

1
Q

Who is often the person who initiates the need for LE orthotic?

A

PT

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2
Q

Things to consider for Pre-Orthotic Evaluation

A
  • Patients structural and functional needs
  • Patient’s goals/willingness to utilize orthotic
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3
Q

Consideration of patient’s goals/willingness to utilize orthotic

A
  • May need to provide education to patient on need, impact of orthotic
  • Trial ambulation or transfer with and without orthotic
  • Education on safety risk or risk to impact of LE without use of orthotic
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4
Q

More Factors to consider for pre-orthotic evaluation/prescription

A
  • Patient’s Height- Impact of height of orthotic
  • Patient’s Weight- Impact choice of materials
  • Diagnosis- Is diagnosis/prognosis static/ progressive?, Is function likely to improve/decline in time?
  • Current Level of activity
  • Anticipated Level of activity
  • ROM- Ankle , Knee
  • Strength- Entire LE
  • Sensation
  • Swelling
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5
Q

Degree of Deformity

A
  • Flexible Deformity- Correct
  • Fixed Deforming- Accommodate
    *** for PF contracture, they need to be able to get to at least neutral
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6
Q

Ambulation with and without a device

A

May not be safe to ambulate without device, especially if require high level of assist to ambulate

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7
Q

Recommendation for device

A
  • Justification for device
  • Rationale for choice; especially important if primary PT is not going to meet with orthotist/team
  • Team may ambulate very short distance while completing evaluation, but not likely at distance of therapist during treatment
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8
Q

Orthotic Materials

A
  • Plastic
  • Metal
  • Hybrid
  • Carbon Fiber
  • FES
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9
Q

Conventional Metal Orthotic

A
  • Metal Uprights
  • Leather Cuff
  • Attaches to shoe
  • Space between leg and upright accommodates edema
    **total contact
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10
Q

Molded plastic Orthotic

A
  • plastic one-piece shell
  • no moving parts
  • total contact
  • fits into shoe (can change shoes but heel height needs to stay the same)
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11
Q

Articulating hybrid

A
  • plastic molded calf shell and shoe inset
  • articulating ankle joint
  • can change shoes
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12
Q

what will determine choice of orthotic material

A

consideration of patient’s presentation needs

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13
Q

Which material and is typically preferred by patients and why

A

Generally plastic AFOs or carbon fiber due to ability to adjust foot wear, covered by clothing

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14
Q

Why are plastic AFOs a caution for sensation or swelling

A

they have direct contact with skin throughout LEs

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15
Q

Difference of weight from metal and plastic

A

Weight of metal and shoe is slightly more than plastic AFO and shoe-less than 1 lb difference –> energy consumption should not be impacted by this weight difference

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16
Q

indications for metal systems

A
  • Interim management –> Allows therapist to make changes to system; fixed to limited motion etc
  • Swelling
  • Poor sensation- dependent on patient ability perform skin checks or reliability of caregiver to evaluate skin
  • Poor skin quality- history of ulcers, easily tear
  • Need to get patients shoeware
  • Severe spasticity (?)
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17
Q

Metal System Advantages

A
  • Easy alignment
  • Good consistent footwear
  • Ability of therapist to management/adjust
  • Minimal direct skin contact
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18
Q

Metal System Disadvantages

A
  • Weight
  • Appearance (Cosmesis)
  • Shoes
  • Limited control of foot
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19
Q

Where should the calf band lie?

A

1.5 inches distal to neck of fibula

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20
Q

Where does the shank of a metal system extend into?

A

body of shoe

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21
Q

Axes of Metal System

A
  • Anatomical axis at the ankle passes through malleoli
  • Medial upright may curve anteriorly to align orthotic ankle axis to anatomical axis
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22
Q

Double Action Ankle Joint/Bichannel Ankle Joint

A
  • Manipulate anterior and posterior channels through ball bearing, peg (or spring) and screw
  • Amount of closure of screw dictates amount of motion at ankle
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23
Q

See typical shoe for metal AFO slide 15

A
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24
Q

T Strap to control varus/valgus control

A
  • Added to orthotic to limit hindfoot movement in the frontal plane
  • Control inversion: stitched to lateral side of shoe and buckled around medical upright
  • Control eversion: stitched to medial side of shoe and buckled around lateral upright
  • Not commonly utilized, generally for excessive inversion/eversion
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25
Q

Where does proximal trimline and calf band lie on a plastic AFO?

A

1.5 inches distal to fibular head

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26
Q

Plastic AFOs Advantages

A
  • Light weight
  • Improved control, especially though foot
  • Cosmesis
  • Patient willingness to wear
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27
Q

Plastic AFOs Disadvantages

A
  • Intimate fit: directly on skin –> issues with sensation/skin
  • Cannot adjust for large volume changes
  • Therapist can not make adjustments to system
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28
Q

Plastic System- Custom fitted to calf

A

If patient needs specific components, will be wearing AFO for longer period of time, custom is indicated

29
Q

Plastic System - Foot plate length

A
  • To sulcus- usually utilized
  • To end of toes- in cases of spasticity or toe clawing
30
Q

Plastic System - Ankle Joints

A
  • Articulated- if plan is to eventually use articulated need to build joint in from
    the beginning
  • Non-articulated
31
Q

If plastic system is non-articulated, what might it require?

A
  • strengthening of ankle joints by incorporating carbon fiber composite reinforcement
32
Q

Non-articulated Plastic System - Control of motion/Type is dependent on:

A
  • Type of plastic- polypropylene is most common
  • Trimlines of brace
33
Q

Non-articulated plastic system - flexible/posterior leaf spring

A
  • Trimlines very posterior to malleoli, essentially just cover Achilles
  • Indicated for foot drop only
  • Maintains neutral foot during swing
34
Q

Non-articulated plastic system - semi rigid AFO

A
  • More full brace then flexible at shank and foot
  • Trimlines behind malleoli, cut back behind malleoli
  • Indicated for foot drop, slightly more control at foot may assist inversion/eversion
35
Q

Non articulated plastic system - Rigid AFOs

A
  • Trimlines bisect the malleoli
  • Provides plantarflexion stop, resists dorsiflexion
  • Used to control drop foot, knee hyperextension
36
Q

Non articulated plastic system - Solid AFO

A
  • Provides dorsiflexion stop
  • Provides plantarflexion stop
  • Trimlines anterior to malleoli
  • Used to control knee buckling in stance phase,
    and drop foot in swing phase
37
Q

Ground reaction force AFO

A
  • Non articulated AFO
  • Solid AFO with increased control for knee
  • Either single unit where instead of calf band has plastic segment up to patellar tendon
  • OR Solid AFO with front shell on front of tibia up to patellar tendon
  • Provides increased knee control
38
Q

Considerations for training with non articulated plastic system

A
  • Fixed Ankle AFOs limit plantarflexion and dorsiflexion on purpose
  • Has impact on functional abilities of patient
  • Significant consideration/training for: Sit to stand, Up/down stairs, Ramps/Inclines, Grass/uneven flooring
39
Q

Articulated AFOs - Motion Control

A
  • Provides free dorsiflexion
  • Plantarflexion resistance/stop
  • Dorsiflexion assist possible
  • Possible to adjust angle or amount of limited
    motion
  • Used to control foot drop and dependent on
    plantarflexion resistance/stop may impact knee hyperextension
40
Q

Way to advance non articulated AFO to articulated

A

Can start as solid AFO with joint included, then get cut to articulated AFO once patient is ready

41
Q

types of ankle joint systems for articulated AFOs

A
  • Multiple options for ankle joints
  • Made of various materials
  • Different biomechanical functions
  • Different abilities to adjust
  • Cosmetic differences
  • Orthotist usually makes recommendation
42
Q

Two ways to get dorsiflexion assist

A
  • carbon fiber AFO
  • Spring use in posterior channel
43
Q

DF Assist - Carbon Fiber AFO

A

Properties of Carbon Fiber during rocker of stance phase, compression provides bounce back to provide dorsiflexion assist during swing

44
Q

DF Assist - Spring in Posterior Channel

A

Can set up channels to have spring
instead of pin, compression of spring in stance phase provides DF assist once lifted in swing

45
Q

With what patient population are KAFOs typically utilized

A

SCI
- May be utilized with patient with peripheral nerve injury to femoral nerve

46
Q

What patient population are KAFOs NOT used with?

A

CVA and TBI
- Not able to get to stand/manipulated knee in constant extension

47
Q

KAFO UE strength

A
  • Significant high demand on UE strength, ability to control hips by trunk position
  • Effort significantly high, use low –> Most programs have specific requirements of UE strength and control to even initiate paragait training
48
Q

Benefits of KAFOs

A

decreased contractures, maintain UE strength, decrease instances of osteoporosis, patient mental health

49
Q

KAFO - Knee alignement Considerations

A
  • Need to consider knee alignment/function/range * Consideration of contractures
50
Q

KAFO knee alignment in sagittal plane

A

control flexion and extension of the knee joint and
dorsiflexion/plantarflexion of the ankle joint

51
Q

KAFO knee alignment in frontal plane

A

can control mild genu varus/valgum

52
Q

KAFO Three point control system

A
  • Sagittal Plane- Controls knee flexion/extension
  • Frontal Plane- restrains tibia abduction/addition to prevent unwanted varus/valgus at knee
53
Q

Locked Knee KAFO Advantages

A

Stability at knee

54
Q

Locked Knee KAFO Disadvantages

A
  • High energy expenditure= Decreased activity levels
  • Creates gait deviations
  • Uneven stride length or swing to gait required
  • Functionally longer limb
  • Secondary medical considerations long term due to compensatory patterns required at other joints – impact of contralateral limb/hip, trunk
55
Q

Drop Lock

A
  • By far most common lock for AFO seen
  • Released by manually lifting metal ring up
  • Locked by manually sliding ring down over joint
56
Q

Bail Lock

A
  • Bail lock is released when bail is lifted
  • Allows knee flexion
  • Helpful because patient could back up to chair and use chair to lift bail release
  • Not used as much due to unintentional releases
57
Q

Posterior Offset Knee Joint

A
  • Provides knee extension assistance during stance phase
  • Ground Reaction Force Vector remains anterior to the mechanical axis and produces an extension moment at the knee
58
Q

Scott Craig KAFO

A
  • Provides stance phase hip extension moment by manipulating ground reaction force vector posterior to the hip joint
  • PF stop forces the legs to rotate as a whole forward during the loading response
  • Hip is stabilized in slight extension by ground reaction forces and stabilized by anterior iliofemoral ligament in midstance
  • KAFO must by set in 7-10 degrees of dorsiflexion to place legs anterior to hip in stance
  • Ankles locked, knees locked
59
Q

Spreader Bar

A
  • Attached between legs
  • Keeps legs parallel and in line with one another
  • Allows for swing through gait with legs operating as unit
60
Q

Footwear for metal orthotics

A

Get footwear with orthotic, educate patient on
monitoring wear/tear of shoe- will need orthotist if need new shoe

61
Q

Footwear for Plastic Orthotics

A
  • Generally shoes need to be ½ size larger on side requiring AFO
  • Some shoe companies will allow patient to get one shoe in one size, one shoe in a different size
  • Laced and Velcro closures work best, want firm control at foot
  • Heel height is critical- all shoes must have similar heel heights and must be minimal (higher heel- higher demand for patient to control knee)
62
Q

Socks

A
  • Generally provide cushion, absorb perspiration, reduce shear forces
  • Over the calf tube socks, specialty socks, stockinette, compression garments
  • Make sure limb is covered for length of AFOs
  • Don socks without without wrinkles
63
Q

Areas of Concern - Skin Inspection

A
  • Malleoli
  • Navicular Bone
  • Calcaneus
  • Base of 5th metatarsal
  • Head of 1st and 5th metatarsal
  • Calf Band
  • Check locations of all trimlines
64
Q

Wear Time

A
  • Depends on patient presentation, corrections needed, sensation, skin quality
  • Needs to be part of the training to patient and caregiver
  • Start with 1-2 hours of wear time; gradually increase every couple of days
  • Skin checks after each initial use
  • Redness lasting over 15 minutes and over areas of concern, can be a sign of ill-fitting orthotic and needs immediate attention from orthotist/tea
65
Q

Patient Education

A
  • Educate patient on when they need to wear orthotic
  • Training in donning/doffing
  • Training in wear schedule
  • Training in skin inspection
  • Training in maintenance- likely areas to break down first
  • Training in changes that must be made by orthotist
  • Training to not place any additional foam inside brace for comfort
66
Q

Patient/Family Education

A
  • Consideration of impact when orthotic is not in use
  • Big concern is use of bathroom at night- can patient safely get to bathroom at night without putting orthotic on
  • May change assist needs
67
Q

Check out

A
  • Examination of orthotic (off of client)
  • Re-examination of client
  • Static assessment of orthotic on client
  • Examination of orthotic on client during gait/transfers
  • Examination of donning/doffing ability
  • After wear and use for 30-60 minutes- skin check
68
Q

FES Systems

A
  • Electrodes in calf band to stimulate- anterior tibialis
  • Triggered by sensor set up to stimulate at specific angle on tibial inclination
  • Indicated for foot drop only- no control at knee, no control for frontal plane motion
69
Q

Things about FES Systems

A
  • Need to evaluate patient sensation/response to stimulation
  • Need to have significant set-up specific to patient and patient gait cycle
  • Not always covered by insurance
  • Most hospitals/clinics do not have trial options for patients to utilize
  • May be contraindicated in patients with pacemakers, metal implants, history of phlebitis

Orthotics (9 decks)

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