LE Orthotics Flashcards
Who is often the person who initiates the need for LE orthotic?
PT
Things to consider for Pre-Orthotic Evaluation
- Patients structural and functional needs
- Patient’s goals/willingness to utilize orthotic
Consideration of patient’s goals/willingness to utilize orthotic
- 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
More Factors to consider for pre-orthotic evaluation/prescription
- 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
Degree of Deformity
- Flexible Deformity- Correct
- Fixed Deforming- Accommodate
*** for PF contracture, they need to be able to get to at least neutral
Ambulation with and without a device
May not be safe to ambulate without device, especially if require high level of assist to ambulate
Recommendation for device
- 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
Orthotic Materials
- Plastic
- Metal
- Hybrid
- Carbon Fiber
- FES
Conventional Metal Orthotic
- Metal Uprights
- Leather Cuff
- Attaches to shoe
- Space between leg and upright accommodates edema
**total contact
Molded plastic Orthotic
- plastic one-piece shell
- no moving parts
- total contact
- fits into shoe (can change shoes but heel height needs to stay the same)
Articulating hybrid
- plastic molded calf shell and shoe inset
- articulating ankle joint
- can change shoes
what will determine choice of orthotic material
consideration of patient’s presentation needs
Which material and is typically preferred by patients and why
Generally plastic AFOs or carbon fiber due to ability to adjust foot wear, covered by clothing
Why are plastic AFOs a caution for sensation or swelling
they have direct contact with skin throughout LEs
Difference of weight from metal and plastic
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
indications for metal systems
- 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 (?)
Metal System Advantages
- Easy alignment
- Good consistent footwear
- Ability of therapist to management/adjust
- Minimal direct skin contact
Metal System Disadvantages
- Weight
- Appearance (Cosmesis)
- Shoes
- Limited control of foot
Where should the calf band lie?
1.5 inches distal to neck of fibula
Where does the shank of a metal system extend into?
body of shoe
Axes of Metal System
- Anatomical axis at the ankle passes through malleoli
- Medial upright may curve anteriorly to align orthotic ankle axis to anatomical axis
Double Action Ankle Joint/Bichannel Ankle Joint
- Manipulate anterior and posterior channels through ball bearing, peg (or spring) and screw
- Amount of closure of screw dictates amount of motion at ankle
See typical shoe for metal AFO slide 15
T Strap to control varus/valgus control
- 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
Where does proximal trimline and calf band lie on a plastic AFO?
1.5 inches distal to fibular head
Plastic AFOs Advantages
- Light weight
- Improved control, especially though foot
- Cosmesis
- Patient willingness to wear
Plastic AFOs Disadvantages
- Intimate fit: directly on skin –> issues with sensation/skin
- Cannot adjust for large volume changes
- Therapist can not make adjustments to system
Plastic System- Custom fitted to calf
If patient needs specific components, will be wearing AFO for longer period of time, custom is indicated
Plastic System - Foot plate length
- To sulcus- usually utilized
- To end of toes- in cases of spasticity or toe clawing
Plastic System - Ankle Joints
- Articulated- if plan is to eventually use articulated need to build joint in from
the beginning - Non-articulated
If plastic system is non-articulated, what might it require?
- strengthening of ankle joints by incorporating carbon fiber composite reinforcement
Non-articulated Plastic System - Control of motion/Type is dependent on:
- Type of plastic- polypropylene is most common
- Trimlines of brace
Non-articulated plastic system - flexible/posterior leaf spring
- Trimlines very posterior to malleoli, essentially just cover Achilles
- Indicated for foot drop only
- Maintains neutral foot during swing
Non-articulated plastic system - semi rigid AFO
- 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
Non articulated plastic system - Rigid AFOs
- Trimlines bisect the malleoli
- Provides plantarflexion stop, resists dorsiflexion
- Used to control drop foot, knee hyperextension
Non articulated plastic system - Solid AFO
- Provides dorsiflexion stop
- Provides plantarflexion stop
- Trimlines anterior to malleoli
- Used to control knee buckling in stance phase,
and drop foot in swing phase
Ground reaction force AFO
- 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
Considerations for training with non articulated plastic system
- 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
Articulated AFOs - Motion Control
- 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
Way to advance non articulated AFO to articulated
Can start as solid AFO with joint included, then get cut to articulated AFO once patient is ready
types of ankle joint systems for articulated AFOs
- Multiple options for ankle joints
- Made of various materials
- Different biomechanical functions
- Different abilities to adjust
- Cosmetic differences
- Orthotist usually makes recommendation
Two ways to get dorsiflexion assist
- carbon fiber AFO
- Spring use in posterior channel
DF Assist - Carbon Fiber AFO
Properties of Carbon Fiber during rocker of stance phase, compression provides bounce back to provide dorsiflexion assist during swing
DF Assist - Spring in Posterior Channel
Can set up channels to have spring
instead of pin, compression of spring in stance phase provides DF assist once lifted in swing
With what patient population are KAFOs typically utilized
SCI
- May be utilized with patient with peripheral nerve injury to femoral nerve
What patient population are KAFOs NOT used with?
CVA and TBI
- Not able to get to stand/manipulated knee in constant extension
KAFO UE strength
- 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
Benefits of KAFOs
decreased contractures, maintain UE strength, decrease instances of osteoporosis, patient mental health
KAFO - Knee alignement Considerations
- Need to consider knee alignment/function/range * Consideration of contractures
KAFO knee alignment in sagittal plane
control flexion and extension of the knee joint and
dorsiflexion/plantarflexion of the ankle joint
KAFO knee alignment in frontal plane
can control mild genu varus/valgum
KAFO Three point control system
- Sagittal Plane- Controls knee flexion/extension
- Frontal Plane- restrains tibia abduction/addition to prevent unwanted varus/valgus at knee
Locked Knee KAFO Advantages
Stability at knee
Locked Knee KAFO Disadvantages
- 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
Drop Lock
- By far most common lock for AFO seen
- Released by manually lifting metal ring up
- Locked by manually sliding ring down over joint
Bail Lock
- 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
Posterior Offset Knee Joint
- 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
Scott Craig KAFO
- 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
Spreader Bar
- Attached between legs
- Keeps legs parallel and in line with one another
- Allows for swing through gait with legs operating as unit
Footwear for metal orthotics
Get footwear with orthotic, educate patient on
monitoring wear/tear of shoe- will need orthotist if need new shoe
Footwear for Plastic Orthotics
- 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)
Socks
- 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
Areas of Concern - Skin Inspection
- Malleoli
- Navicular Bone
- Calcaneus
- Base of 5th metatarsal
- Head of 1st and 5th metatarsal
- Calf Band
- Check locations of all trimlines
Wear Time
- 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
Patient Education
- 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
Patient/Family Education
- 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
Check out
- 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
FES Systems
- 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
Things about FES Systems
- 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
