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Assistive Tech > O - Orthotics for NM Conditions > Flashcards

O - Orthotics for NM Conditions Flashcards

1
Q

what is an orthosis

A

externally applied device designed to modify structural and functional characteristics of NM/MSK systems

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2
Q

what in an orthotist

A

board certified clinician who designs, fabricates, delivers, and maintains orthotic devices (orthoses) for pts w NM/ MSK conditions

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3
Q

what is orthotics

A

specialty w/i field of medicine which describes design, fabrication, and application of orthoses

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4
Q

how are orthoses named

A

to describe the joints that are positioned w/i the device

we most commonly see AFOs and KAFOs

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5
Q

what are the 5 functional goals of an orthosis

A
  1. substitute for weak ms by providing external support
  2. limit motion to minimize pain
  3. dec risk of developing bony deformity or contracture
  4. offload forces during WBing to promote healing and preent injury
  5. position limb segments for optimal alignment
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6
Q

what joints do orthoses directly and indirectly impact

A

directly - joints crossed
indirectly - next proximal joint

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7
Q

what are the 3 orthotic design principles

same physics principles as w prosthetics

A
  1. pressure = force/ area
    inc SA = more comfortable and effective
  2. torque = force x distance
    larger moment arms dec amt of force needed to control a joint
  3. sum of forces = 0
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8
Q

what are common orthotic materials

A

metal and leather
thermoplastic
carbon fiber
fiberglass cast tape
foams
dacron strapping

thermoplastic and carbon fiber are the main materials you will see today

for casting - tend to not use plastic anymore, all fiberglass/synthetic materials

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9
Q

when were metal and leather materials primarily used in orthotics and why are they less commonly seen now

A

in 80s

  • they are annoying to make
  • attached physically to one pair of shoes

they are effective

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10
Q

what is the purpose of the flexible inner boot

A

control FF

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11
Q

what is a casting block and why is this important

A

set the foot on a casting block when casting
* matches heel height in shoe
* want calcaneus in neutral

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12
Q

what pt cases is scanning more commonly utilized as a shape acquisition technique and why

A

spinal orthotics
larger surface

can still use scanning on LE
casting is becoming less common as other shape acquisition techniques are inc in popularity

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13
Q

what is often the purpose of modifying a cast/orthosis? in AFOs what is a common location for modifications?

A

accentuate WBing areas and areas w bony prominences

malleoli

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14
Q

in the interdisciplinary team what 3 members have a relationship that is most crucial for orthosis success

A

PT
OT
orthotist

in collaboration w patient

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15
Q

UMN pathologies

what is an UMN?
what are 3 characteristics of UMN damage?
what are examples of UMN conditions?

A

motor neuron which travels from brain to spinal cord

  1. initial weakness
  2. spasticity, hypertonicity, hyperreflexia
  3. dec motor control (speed, accuracy, coordination, fluidity)

ex: CVA, TBI, MS

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16
Q

what characteristic of UMN damage is often what triggers the referral to brace clinic

A

dec motor control (speed, accuracy, coordination, fluidity)

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17
Q

what is likely the biggest pt population utilizing AFOs

A

stroke pts

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18
Q

8 clinical presentation characteristics in CVA pts

A
  1. changes in resting tone (initial hypotonus)
  2. spasticity
  3. weakness / paralysis - stiff knee gait
  4. postural issues
  5. loss of proprioception
  6. sensory deficit
  7. neglect of affected side
  8. cog, emotional, intellectual impairment
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19
Q

how will the clinical presentation of weakness or paralysis in CVA pts translate into abnormal gait

A

stiff knee gait

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20
Q

3 clinical presentation characteristics in TBI pts

A
  1. difficulty w speech or communication
  2. hypertonicity
  3. balance challenges
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21
Q

what is a TBI

A

non-degenerative, external trauma to the brain

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22
Q

what is the prognosis w a TBI

A

may or may not recover

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23
Q

4 clinical presentation characteristics in MS pts

A
  1. usually BL
  2. poor balance
  3. lack of coordination
  4. sensory challenges (temp sensitive)
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24
Q

what characteristic of MS is often what triggers the referral to brace clinic

A

poor balance and lack of coordination

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25
Q

what ambulation compensations are seen in MS

A

wide BOS
small step lengths

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26
Q

how should an orthotic intervention be handled in MS

A

should be “delicate”
* more effective early on in dz
* MS is progressive

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27
Q

4 clinical presentation characteristics in SCI pts

A
  1. mixed UMN and LMN injury
  2. may be incomplete or complete
  3. can have high or low ms tone
  4. may have sensory issues
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28
Q

RGO

what is it
what are cons
when would you use it today

A
  • reciprocal gait orthosis
  • cumbersome, hard to put on
  • might use to get pt upright for few hours a day
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29
Q

SCI

T12 intact: what orthotic?

A

RGO/HKAFO

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30
Q

SCI

L1 intact: what orthotic?

A

KAFO

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31
Q

SCI

L3 intact: what orthotic?

A

KAFO/AFO

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32
Q

SCI

L4 intact: what orthotic?

A

AFO

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33
Q

LMN pathologies

what is an LMN?
what are 3 characteristics of LMN damage?
what are examples of LMN conditions?

A

motor neuron which travels from SC to ms

  1. weakness
  2. hypotonicity, hyporeflexia, flaccidity
  3. fasciculations (involluntary ms twitches)

ex: GBS, polio, PPS, CMT

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34
Q

what is muscle tone and how does this impact compliance to orthoses

A

ms tone = interplay b/w compliance and stiffness of ms, as influenced by CNS

low tone = low stiffness, high compliance
optimal tone = mod stiff, mod compl
high tone = high stiff, low compliance

higher tone can make it difficult for orthotist to obtain a decent cast, harder for pt to be compliant and keep control

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35
Q

what is hypertonicity

A

ms that are too stiff (aka high tone)

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36
Q

what is spasticity

A

velocity-dependent hypertonicity (stiffness that occurs w rapid passive elongation of a ms)

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37
Q

what is rigidity

A

bidirectional, co-contracting hypertonicity and resistance to passive mvmt of both agonistic and antagonist ms groups

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38
Q

what is hypotonicity

A

dec ms stiffness (aka low tone)

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39
Q

what is flaccidity

A

ms cannot be activated bc of interruption of transmission or connection b/w LMN and ms (aka no tone)

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40
Q

what is athetosis

A

when underlying ms tone fluctuates unpredictably

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41
Q

why would an orthotist break down the functional tasks of gait

A

break down gait to see where interventions will be most effective and needed

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42
Q

what are 5 factors that influence gait and which 2 can we have the biggest impact with

A

1. stance phase stability
2. clearance in swing
3. swing phase pre-positioning
4. adequate step length
5. energy conservation

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43
Q

what type of orthosis is considering the rockers important for

A

AFOs

44
Q

what are the 3 rockers in gait

A

heel
ankle
toe

45
Q

heel rocker

what is its function (2)
what 2 ms are activated and why

A
  1. controlled lowering of foot
  2. body weight acceptance

eccentric control of quads and ant tib
* prevents foot slap and protects knee

46
Q

ankle rocker

what is its function
what ms is activated and why

A

tibia progresses over WBing foot during mid to terminal stance

eccentric control of PFs
* limits forward mvmt of shank

47
Q

toe rocker

what is its function (2)

A
  1. FF becomes rigid lever in pre-swing
  2. heel rise off ground for push off in late stance thru DF of MTP joints
48
Q

how would disruption of the forward progress facilitated by the rockers negatively impact gait (3)

A

step length
cadence
SLS

49
Q

what roll should orthosis play with rockers in gait

A

provides external support to ensure forward progression and mobility
* use least amt of external support possible

50
Q

prefab orthoses

5 advantages vs 4 disadvantages

A

advantages:
* available in variety sizes/ materials
* can use as eval tool on where to go
* less expensive
* good short-term solution
* quicker off the shelf (not go thru whole casting process)

disadvantages:
* less control of pt’s limb
* less durable -> meant for temporary use
* not adjustable/customized -> not appropriate for complex presentations
* can cause skin breakdown d/t “generic” fit

51
Q

prefab orthotics

5 indications vs 4 contraindications

A

indications:
* foot drop (CVA, TBI, SCI, MS)
* mild ankle instability
* mild spasticity
* adequate ROM
* mild/mod knee flex instability

contraindications:
* neuropathy/ulcers (concern for skin breakdown)
* severe spasticity
* contracture that can’t be accommodated
* excessive knee flex / hyperext in midstance

52
Q

are prefab or custom molded orthoses more commonly used

A

custom molded

53
Q

custom molded

4 advantages vs 5 disadvantages

A

advantages:
* optimal control of limb
* intimate/custom fit
* more durable
* more of brace present

disadvantages:
* more time consuming to fabricate
* more expensive
* difficult to fit into shoes
* may be hot to wear
* ongoing process of getting adjustments

54
Q

custom molded

indications vs contraindications

A

indications:
* impaired sensation
* hypertonicity
* risk of progressive deformity

contraindications:
* only short-term devices use is needed
* large fluctuations in volume (will need to use conventional design)

if large fluctuations in limb volume w swelling, prefab may be better option bc less material to it

55
Q

footwear

what qualities do you look for?
what type of footwear work best?

A

w extra depth, removable insoles, detached tongues
shoe closure - help stabilize calcenus w/i orthosis
may need to inc shoe size to accommodate orthosis

oxford style or athletic shoes are best
* billy shoes, new balance, zappos, plae, stride rite

struggle of appropriate footwear vs cute shoes

56
Q

what is a custom foot orthosis

A

custom insert that works to improve foot mechanics during walking

57
Q

what is a UCBL

A

basically a heel cup - keeps calcaneus in neutral
custom insert that addresses subtalar joint instability
* controls flexible calcaneal deformities
* controls transverse plane
* controls midtarsal deformities

UCBL = university of cali berkley

58
Q

what is the primary goal of an AFO

A

provide just enough external support for stability in stance w minimal compromise of forward progression

59
Q

AFO

what are 2 indications

A
  • need direct control of STJ and ankle joint
  • need indirect control of knee joint
60
Q

AFO

static vs dynamic

A

static (solid ankle) - ankle locked in position

dynamic (articulated) - articulation via mechanical joint or allows flex/ext where and when we need it

61
Q

what is the axis of the ankle joint

A

oblique running ant-med to post-lat

62
Q

what ankle motions accompany DF and PF

A

DF:
* talar pron
* talar ABD
* RF valgus

PF:
* talar sup
* talar ADD
* RR varus

63
Q

what is the most supportive/aggressive AFO

A

static

64
Q

static AFOs

why are trimlines and shoe modifications important considerations

A

inc rigidity greatly compromises transitions thru all 3 rockers
* consider trimlines/shoes to maintain forward progression of shank

restricts ankle motion in all 3 planes
might consider shoes with a rocker bottom to help w forward progression

65
Q

what is an indirect role of ground reaction AFOs

A

indirectly controls knee ext

66
Q

static AFO

how are ground reaction AFOs fabricated

A

ankle in slight PF

67
Q

static AFOs

how does PTB-AFOs offload weight from the plantar surface of the foot

PTB = patellar tendon bearing

A

anterior shell modified to accept weight via:
* total contact
* pressure tolerance areas - medial tib and patellar tendon

vertical uprights transfer forces

essentially just loading the patellar tendon

68
Q

static AFOs

why is it hard to get a good result in pts appropriate for the PTB-AFO

A

pt often already has a lot of damage to foot by the time they are referred –> probably would have done better w an earlier referral

69
Q

what are 3 things you need to be considered appropriate for a PTB-AFO

A
  1. normal anatomic structure of knee
  2. adequate MMT/motor control of quads
  3. sufficient skin integrity
70
Q

static AFOs

what is the degree of control influenced by

A

direction of forces/counterforces, trimlines, and intrinsic modifications w/i the device

71
Q

static AFOs

what are the 4 distinct control systems

A
  1. PF (swing)
  2. DF (stance)
  3. eversion / valgus
  4. inversion / varus

want varus/valgus angles to be in neutral and control inv/eve

72
Q

what are 3 types of static AFOs

A

solid AFO
ground reaction AFO
weight relieving AFO (PTB-AFO)

73
Q

what are 4 types of dynamic AFOs

A

articulated AFO
posterior leaf AFO
supramalleolar orthosis
conventional double upright AFO

74
Q

dynamic AFO

in what patient would you consider a conventional double upright AFO

A

pt w fluctuating edema bc lot less contact (only at calf/shoe)

75
Q

what are dynamic AFOs

ie what is their function

A

allow sagittal plane motion at ankle
* usually allow DF during stance and prevent PF during swing

76
Q

dynamic AFOs

who are supramalleolar orthoses commonly used in

A

kids with mild to mod diplegic CP

77
Q

dynamic AFOs

what are 5 functional improvements seen from a supramalleolar orthosis

A
  1. improve upright posture
  2. improve swing limb clearance
  3. stride length
  4. cadence
  5. self selected walking speed (SSWS)
78
Q

dynamic AFOs

what are the 2 main functions of a posterior leaf spring AFO

A

preloads spring during stance, springs. back when you lift heel into swing phase

  1. support wt of foot during swing phase
  2. assist w controlled PF during loading response
79
Q

dynamic AFOs

what is an advantage and disadvantage of posterior leaf spring AFOs

A

advantage - inc flexibility allows functional advantage (esp on slopes, ramps)

disadvantage - not effective at controlling calcaneus (not enough material at trimlines)

80
Q

dynamic AFOs

what are 4 functional benefits of an articulated AFO

A

dec energy expenditure
improve stride length
cadence
SSWS

81
Q

dynamic AFOs

what is an articulated aFO

A

allows sagittal plane motion via mechanical ankle joint
* allows wide ROM
* can modify amt of motion allowed per pt

similar control system to SAFO except for inc sagittal plane motion

82
Q

what are 4 modifications to an AFO that can dec effects of hypertonicity/spasticity

A
  1. MT bar/dome to change MT head loading
  2. mechanism to encourage toe ext
  3. additional loading on either side of distal point of achilles tendon attachment
  4. ankle held in neutral ST and DF position
83
Q

what is the primary goal of KAFOs

A

provide just enough external support for stability in stance and clearance in swing w minimla compromise of forward progression

84
Q

how do pts feel ab KAFOs

A

they hate them - acceptance rate is low

85
Q

what are 2 indications for KAFOs

A
  1. need direct control of ankle and knee joints
  2. need indirect control of hip joint
86
Q

when should a KAFO be considered (4)

A
  1. excessive recurvatum at knee
  2. excessive varus or valgus at knee
  3. grade 3 or below MMT of quads
  4. impaired proprioception at knee
87
Q

since pts hate KAFOs, what could you try first if they have weak quads

A
  • GRF AFO to see if help w knee ext
  • could cast foot into extra DF to push knee into little more flex and prevent hyper ext
88
Q

what are considerations of a solid vs articulating ankle joint in a KAFO

A

consider how orthotic control of ankle and GRF will impact knee function and forward progression
* if allow ankle motion, can help w overall gait pattern

89
Q

what knee joint would you use to

stabilize flail knee w SOME ability to generate knee ext moment (MMT 2 to 3+)

A

offset unlocked

90
Q

what 2 knee joints would you use to

stabilize flail knee with NO ability to generate knee ext moment (MMT 0 to 2)

A

single axis locked
offset locked

91
Q

what knee joint would you use to

reduce knee flexion contracture

A

variable positioning

92
Q

what 2 knee joints would you use to

control genu valgum/varum

A

single axis unlocked
offset unlocked

93
Q

what is the function of a stance control knee joint

A

allows locks on heel strike in stance but triggers into flex in swing

94
Q

what is a ring/drop lock and what is a con of this

A

automatically locks knee joint into full ext
con: need hand dexterity to unlock the sides in sync to sit

95
Q

what is a lever lock and what is a pro of this

A

locking knee joint with a release mechanism
pro: can unlock and lock both joints simultaneously when go to sit

this is the better version of a ring/drop lock

96
Q

what is a bail lock, what is pro/con

A

metal rod connecting med and lat lever locks for simultaneously unlock

pro: can back up to wc to unlock
con: could accidentally bump, can’t wear under clothes

97
Q

what is a cable/trigger lock and what is a pro of this

A

same as function as lever lock - med and lat lock connected to cable to unlock simultaneously
* less likely to accidentally unlock

98
Q

variable positioning locks

what are they
what is an indication

A

allows locking of knee at various deg of knee flex (via dial lock like ACL brace), fully locked during stance/swing and unlock to sit

indicated in knee flexion contractures

provides stability despite GRF being posterior to anatomical knee center

99
Q

what patient populations are stance control locks indicated in

A

initially developed for PPS

CVA, brain tumor, TBI, incomplete SCI, spinal degen dz, MS, peripheral nerve injury

100
Q

stance control lock during gait

A

locked when weighted
* locked in ext from IC through terminal stance

unlocked when unweighted
* goes into free swing from preswing thru swing phase

101
Q

what are 2 things needed for a stance control lock to be indicated

A
  • must have at least 3/5 MMT at hip ext and hip flex
  • must have full knee ext ROM
102
Q

what are 3 advantages to a stance control lock

A
  1. improved SSWS, cadence, and stride length
  2. improved gait symmetry
  3. reduced compensatory patterns
103
Q

how does an RGO work
who was it designed for
what is a con

A
  • get reciprocal motion as pt shifts weight and ext trunk –> ext leg
  • incomplete SCI
  • not overall effective gait so long term acceptance is low
104
Q

what are 2 indications of HKAFOs/RGOs

A
  1. need direct control of ankle, knee, and hip joints
  2. need indirect control of trunk
105
Q

what are 3 examples of some pathologies that a HKAFO/RGO would be indicated for

A
  1. myelomeningocele
  2. high level SCI
  3. progressive neuro disorders
106
Q

what are 4 disadvantages to HKAFO/RGO

A
  1. heavy
  2. high energy cost
  3. difficult to fabricate
  4. challenge to don/doff
107
Q

what are 3 functions to a HKAFO/RGO

A
  1. limited amb
  2. standing for tasks
  3. standing contributes to bone health, skin integ, digestive/urinary/bowel health, respiratory capacity, CV fitness, and psych health

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