LE Orthotics LECTURE

Question 1

Who initiates the need for LE orthotics?

Answer 1

The PT!
Have to consider the patient’s structural and functional needs, and patient goals/willingness to utilize the orthotics.
- may need to educate patient on need and impact of orthotic, do a trial ambulation or transfer with and without the orthotic and educate on safety risks without using the orthotic (fall risk)

Question 2

What are some factors to consider when evaluating for LE orthotics?

Answer 2

Patient’s height — will impact the height of orthotic
Patient’s weight — will impact choice of materials
Patient’s DX — static/progressive
Current level of activity
Anticipated level of activity
Degree of deformity — is it fixed or flexible
ROM at ankle, knee, etc
Strength — of entire LE (MMT)
Sensation
Swelling
Ambulation with and without device

Question 3

What does the recommendation for the device look like?

Answer 3

• Justification for device
• Rationale for choice — especially important if primary PT isn’t going to meet with orthotist team
• Team may ambulate very short distances while completing evaluation, but not likely at distance of therapists during treatment

Question 4

What are possible orthotic materials

Answer 4

Plastic
Metal
Hybrid
Carbon Fiber
FES

Question 5

What determines the choice of orthotic materials

Answer 5

Consideration of patient presentation/needs will determine choice of materials

Question 6

What is generally more preferred by patients?

Answer 6

Plastic AFOs or carbon fiber due to the ability to adjust foot wear, and cover it with clothings
— But plastic AFOs have direct contact with the skin throughout the LEs which may be a caution due to sensation or swelling

Question 7

Indications for a metal system orthotic?

Answer 7

Interim management — allows therapist to make changes to the system.
Swelling
Poor sensation — really depends on patient’s ability to perform good skin checks
Poor skin quality — like history of ulcers or easily tears
Severe spasticity?

Question 8

Advantages of metal system orthotics

Answer 8

Easy alignment
Good consistent foot wear
Ability of therapist to adjust
Minimal direct skin contact

Question 9

Disadvantages of metal system orthotics

Answer 9

Weight
Appearance (Cosmesis)
Shoes
Limited control of foot

Question 10

Where should the calf band be on the shank?

Answer 10

1.5 inches distal to the neck of the fibula!!!

Question 11

Where does the anatomical axis of the ankle pass through? What about medial upright?

Answer 11

Anatomical axis — through malleoli
Medial upright — may curve anteriorly to align orthotic ankle axis to anatomical axis

Question 12

What directions of the stirrup moving for the metal ankle joint correspond with osteo kinematics? What about upright moving?

Answer 12

Stirrup moves forward = Dorsiflexion
Stirrup moves backward = plantarflexion
Upright moves forward = tibial progression/knee flexion
Upright moves backward = knee hyperextension

Question 13

What is a T strap

Answer 13

Something you can add to the orthotic to limit hind foot movement in the frontal plane —> control varus/valgus control
- patient could be constantly landing on the outer border off their foot then they aren’t landing flat so have to add the strap to pull the foot in order to get flat foot contact.

Question 14

Where do you place the T strap to control inversion/eversion?

Answer 14

Control inversion — stitched to lateral side of shoe and buckled around medical upright
Control eversion — stitched to medial side of the shoe and buckled around lateral slide

these are not really commonly utilized - general for excessive inversion/eversion when we are worried about ligaments

Question 15

Advantage of plastic AFOs

Answer 15

Light weight
Improved control - especially through the foot
Cosmesis
Patient willingness to wear

Question 16

Disadvantages of plastic AFOs

Answer 16

Intimate fit - directly on skin
Cannot adjust for large volume changes
Therapist cannot make adjustments to the system

Question 17

What is the foot plate length in a plastic system

Answer 17

To sulcus — most common
To end of toes — in cases of spasticity or toe clawing (common with brain injury and peds)

Question 18

What are the options for the ankle joint in a plastic system

Answer 18

Can be articulated or non articulated
choose articulated if the plan is to eventually use the articulated joint because it has to be built into the joint from the beginning

Question 19

The amount of control and type of a non articulated plastic orthotic depends on…

Answer 19

Type of plastic — polypropylene most common
Trimlines of the brace

Question 20

What is a flexible/posterior leaf spring?

Answer 20

Smallest amount of support. The trim lines are very posterior to malleoli, basically covering the Achilles
- Indicated for foot drop only u
- Maintains neutral foot during swing
no control at the knee.

Question 21

What is a semi rigid AFO

Answer 21

More full brace then flexible at shank and foot
Trimlines behind malleoli - cut back behind them
Indicated for foot drop, slightly more control at foot may assist with inversion/eversion

Question 22

What is a rigid AFO

Answer 22

Trimlines bisect the malleoli
Provides PF stop, resists DF
Used to control foot drop and knee hyperextension
since it resists DF its going to prevent tibial progression.

Question 23

What is a solid AFO

Answer 23

Provides DF stop AND PF stop
Trimlines are anterior to malleoli
Used to control knee buckling in stance and drop foot in swing.
highest level of control

Question 24

What is a ground reaction force AFO

Answer 24

A non articulated AFO/solid AFO wiht increased control for the knee.
— Either a single unit where instead of a calf band has a plastic segment up to the patellar tendon. Puts pressure on the patellar tendon so when you land and move into stance the GRF will come all the way up and put even more resistance to tibial progression
OR CAN BE A SOLID AFO WITH A FRONT SHELL — on the tibia up to patellar tendon that will provide increased knee control as well.

Question 25

What are the considerations for training with AFOs

Answer 25

- Fixed ankle AFOs limit PF and DF on purpose - Has impact on functional abilities of patient - HAVE TO TRAIN: sit to stand, up/down stairs, ramps/inclines, grass/uneven floors

Question 26

What does an articulated AFO provide

Answer 26

Will have some more motion control These are used to control foot drop and dependent on PF resistance/stop may impact knee hyperextension too.

Question 27

What possible settings can you have with an articulated AFO

Answer 27

Free DF PF resistance/stop DF assist possible Can adjust angle or amount of limited motion

Question 28

What are the types of ankle joint systems

Answer 28

All generally allow orthotist to make recommendations on joint system. (Overlap, gillette, gaffney, Oklahoma, insert stirrup, PF stop)

Question 29

What do carbon fiber AFOs allow

Answer 29

DF assist. Properties of carbon fiber during rocker of stance phase, impression provides a bounce back to provide DF assist during swing.

Question 30

What if yo put a spring use in posterior channel?

Answer 30

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

Question 31

When are KAFOs commonly used?

Answer 31

With patients with SCI. May also be utilized with patients with peripheral nerve injury to the femoral nerve *significant high demand on UE strength, ability to control hips by trunk position.*

Question 32

Benefits of KAFOs

Answer 32

Decreased contracture Maintain UE strength Decrease instances of osteoporosis Patient mental health *effort is significantly high, use low — most programs have specific requirements of UE strength and control to even initiate paragait training

Question 33

What is the three point control system for KAFOs?

Answer 33

Sagittal plane — controls knee flexion/extension Frontal plane — restrains tibia abduction/adduction to prevent unwanted varus/valgus at the knee

Question 34

Advantages of locked knee KAFO

Answer 34

Stability at the knee

Question 35

Disadvantages of locked knee KAFO

Answer 35

High energy expenditure = decreased activity levels Creates gait deviation Uneven stride length or swing to gait required Functionally longer limb Secondary medical considerations long term due to compensatory patterns required at other joint — impacts contra limb/hip and trunk

Question 36

What is a drop lock

Answer 36

Most common lock Released by manually lifting metal ring up Locked by manually sliding ring down over joint - lift up = unlocks = can get flexion - push down = locks = in extension

Question 37

What is a bail lock?

Answer 37

Like a bucket handle thing Bail lock is released when bail is lifted to allow knee flexion Helpful because patients could back up into a chair and use chair to lift bail release. *not used much anymore due to unintentional releases and big fall risk*

Question 38

What is a posterior offset knee joint?

Answer 38

Provides knee extension assistance during stance phase GRF vector remains anterior to the mechanical axis and produces an extension moment at the knee.

Question 39

What is a Scott Craig KAFO

Answer 39

Provides stance phase hip extension moment by manipulating GRF vector posterior to the hip joint. PF stop forces the legs to rotate as a whole forward during loading response. Hip is stabilized in slight extension by GRF and stabilized by anterior iliofemoral ligament in midstance. *KAFO must be set in 7-10 degrees of DF to place legs anterior to hip in stance. Ankles locked and knees locked*

Question 40

What is a spreader bar?

Answer 40

Attached between legs to keep them parallel and in line with one another — Allows for swing throug gait with legs operating as a unit. Need the right angle at the ankles, knees locked and symmetrical to have a nice stance.

Question 41

What kind of footwear can be used with plastic orthoses?

Answer 41

- Generally shoes need to be 1/2 size larger on the side requiring AFO - Laced and Velcro closures work best — want a firm control at foot - Heel height is critical - all shoes must have similar heel heights and must be minimal heel height.

Question 42

What about socks?

Answer 42

- 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 wrinkles

Question 43

What are areas of concern for skin inspections?

Answer 43

*areas that are most likely to rub, have shearing or whatever with the brace they put on* - Malleoli - Navicular bone - Calcaneus - Base of 5th metatarsal - Head of 1st and 5th metatarsal - Calf band - Check locations of all Trimlines

Question 44

What is the wear time for patients?

Answer 44

Depends on patient presentation, corrections needed, sensation, skin quality - Need to be part of the training to patient and caregiver - Start with1-2 hours of wear time. Gradually increase every couple of days - Skin checks after each initial use

Question 45

What is a sign of an ill fitting orthotic and needs immediate attention from the orthotist/team?

Answer 45

Redness lasting over 15 minutes and over areas of concern

Question 46

What is included in patient education?

Answer 46

When they need to wear it Donning/doffing Wear schedule Skin inspection Maintence — likely areas to break down first Changes that must be made by orthotist Training to not place any additional foam inside brace for comfort.

Question 47

What is a big concern for patient/family education?

Answer 47

Big concern is use of bathroom at night - can patient safety get to bathroom at night without putting the orthotic on?

Question 48

What needs to happen for the check out process?

Answer 48

Examination of orthotic off the client Re-exam of client Static assessment of orthotic on client Exam of orthotic on client during gait/transfers Exam of donning/doffing ability After wear and use for 30-60 minutes plus skin check

Question 49

What is an FES system?

Answer 49

Electrodes in calf band to stimulate anterior tib Triggered by sensor set up to stimulate at specific angle on tibial inclination Indicated for FOOT DROP ONLY — no control at the knee and no control for frontal plane motion

Question 50

What must happen with an FES system?

Answer 50

1. Need to evaluate patient sensation/response to stimulation 2. Need to have significant set up specific to patient and patient gait cycle

Question 51

What makes getting an FES system difficult?

Answer 51

Not always covered by insurance Most hospitals and clinics do not have a trial option for patients to use May be contraindicated for patients with pacemakers, metal implants, and history of phlebitis. (NO FES IF KNEE REPLACEMENT)