Orthotics for the Neuro Population Flashcards
4 Factors in Decision Making for Orthoses
Advantages or Positive Outcomes
-How it iwll improve mobility & gait, influence tone, or protect a limb
Disadvantegs or Concessions
-How it complicates daily activity, mobility, or preferred activities. Energy cost and expnse
Indications that it’ll be Useful
-Match between the person’s caharaceristics and needs and what it provides
Circumstances/Characterstics of the Individual that make the device detrimental or contraindicated
Characteristics of an Ideal Orthosis
Maximizes stance phase stability
Minimizes abnormal alignment
Minimally compromises clearance
Maintains/reduce joint contractures
Meet individual’s mobility needs
Effectively positions for initial contact
Energy efficient
Orthotics:
Abnormal Joint Position
Orthotic will assist the ligamentous support and prevent unwanted movement from previous joint damage
Orthotics:
Limb Length
Orthotic will add a heel lift to help with unequal leg length
Orthotics:
Motor Control
Orthotic will prevent unwanted motion and assist the integumentary system
Orthotics:
Muscle performance
Orthotic will assist with endurance and weakness of the muscles
Orthotics:
Muscle Posture (Spasticity)
Orthotic will reduce Equinus/PF
Orthotics:
Sensory Loss
Orthotic will enhance stability due to loss of sensation
Requirements for Gait:
Range of Motion
Neutral DF and PF
Ideal 5 degrees of DF
Full Knee Extension passively
Requirements for Gait:
Synergistic vs. Muscular
Strong synergies require orthotist
Support for the swing & stance phases
Requirements for Gait:
Sensation
Tactile: inform orthotist
Proprioception: ankle (increased M/L support - trimlines)
Skin Protection:
Sock Wear
Athletic socks that covers the entire area of the orthotic
Keeps skin dry
No wrinkles!
Skin Protection:
Brace Checking
Check brace 20 min after 1st wear
1. Medial and Lateral Malleolus
2. First Ray
3. Calcaneus
4. Edges of the Orthotic
If any redness appears, request that the person does not wear the orthotic and seek assistance
What must you see after applying an Orthotic?
An immediate change in an individual’s gait or alignment (Stance or Swing phase)
Team Members for Orthoses:
Orthotist
Offers orthotic possibilities based on the patient, MD, PT
Team Members for Orthoses:
MD
Medications for spasticity
Considerations for E-Stim
Long Term Prognosis
Team Members for Orthoses:
PT
Gait Mechanics
Greatest Need/Problems
Stability vs Mobility
Joint Integrity
3 Needs for an Orthotic:
1st Need
- Gait Deviation
Swing Phase: drop foot gets an AFO, consider Leaf Spring vs DF assist
Stance Phase: Ankle instaiblity gets a Solid AFO / Hinged AFO
Ankle PF weakness or NM function gets a Solid AFO
(Can even help with knee hyperextension)
3 Needs for an Orthotic:
2nd Need
- Protection from Injury
Decubitus Ulcer
Joint protection from instability
3 Needs for an orthotic:
3rd Need
- Muscular Adaptations
Maintain ROM
Increase ROM
Ankle Foot Orthosis (AFO):
Description and Prescription
Adaptations of the trimline for more or less control
Prescribed for:
Weakness
Stroke / CP
Head Injury
Peripheral Neuropathy
Alignment Issue
Spinal Cord Injury
Progressive Disease
Orthosis:
Force Principles
3 Points with Force Principles
1. CF Posterior
2. F Primary
3. CF Plantar
Orthosis:
Comfort
An orthosis is most comfortable & effective when:
- Pressure = Force/Area
- Control direction of primary force and direction of counterforces
Knee Ankle Foot Orthotics KAFO Materials
- Leather and Metal (Initial)
Heavy and less malleable - Thermoplastic (Middle)
Easily molded and stronger - Carbon Fiber (NOW)
-Lightweight and durable
Uses for KAFOs
Spinal Cord Injury
Muscular Dystrophy
Pediatric Spina Bifida
Polio
Designed for limited community or household ambulation
Orthotics:
Considerations in Decision Making
Body Structure
Function
Participation
Stable Disease, improving or degenerative (MS, ALS)
Orthotic Priorities for Function: Gait training
PT ensures adequate fit and gait mechanics
(Uneven surfaces, soft ground)
Orthotic Priorities for Function: Sit to Stand
PT increases GRF through limb but an AFO will decrease DF
(Chair height will assist)
Orthotic Priorities for Function: Floor to Stand
Decrease in DF, inability to maneuver orthotic limb
(Tall object to assist transfer)
Orthotic Priorities for Function: Balance
Reduced joint mobility: does the orthotic increase falls?
(Environments that aren’t conducive to an orthotic)
Orthotic Priorities for Function: Inclines/Stairs
PT responsible for safety and training with orthotic
Essential attributes of an Orthotic
Can be worn for long periods w/o damaging skin or pain for 6-8 hrs/day (work up to this)
Easily donned & doffed
Cosemesis
Considerations for job & play
Areas of Critical Importance for Orthotics: Gait Cycle
Midstance (Single Support)
Mid and Terminal Swing
AFO Types
Solid AFO (Anterior Leaf)
Dynamic AFO (Flexibility)
Hinged AFO (Require ROM)
Ground Force AFO
Leaf Spring AFO (Postioer Leaf)
Custom Molded Orthosis: Why are they important?
Provide optimal control of the limb & are important for patients with impaired sensation, hypertonicity, or risk of progressive deformity
Custom Molded Orthosis: How are they made?
Construction around a rectified model of the limb, to ensure pressure relief over vulnerable areas (prominences)
Types of Material for Orthotics
- Thermoplastic
Rigid AFO (Foot Drop/Weak) - Carbon Fiber
Light Weight, Durable - Custom (Adaptable)
Support joints
Off the Shelf Orthoses:
Mass Manufactured
AFOs and Leaf Spring AFOs
Limited in modification which can be a problem for foot deformities or sensory impariments
Leaf Spring AFO
For Drop Foot
Designed to support the weight during swing phase to enhance limb clearance
Assist controlled lowering during Loading response in stance and heel rocker
Dorsiflexion Assist Designs
Prepositions the foot for heel strike at IC due to impairment of the TA (Lack of Control)
Limited Med/Lat stability during stance while allowing forward progression of the Tibia
Contributes to push-off
Solid AFO
Resists PF during Swing Phase with fulcrum at Ant. Ankle Velcro strap
Counterforce distally at MT heads and proximally at top of AFO (prevents Ev/Inv)
Disadvantages of Solid AFO
Interferes with all 3 rockers of gait in stance phase and limits transition into swing phase
(shortens stride length by limiting progression of the tibia)
Hinged AFO
Allows sagittal motion at the ankle w/ orthosis joint
Improves mobility with inclines and stairs
Reduces risks of falls and has less negative impacts on postural control
Hinged AFO:
Plantarflexion Stop
Prevents Spastic Quinus
Permits DF
Prevents Excessive PF
Alternative Styles to Hinged AFO
Increased trim lines for those with limited muscle control
Higher foot counters to control inversion/eversion
Elastic vs. Pin
Hinged AFO
Pin-type has Plantarflexion stop
Elastic has Dorsiflexion check strap
Ground Reaction AFO
(Anteiror Floor Reaction)
Help impaired motor control of the knee and weakness of the quadriceps
Restricts Tibia rolling and stabilizes the knee in stance
Criteria for a Ground Reaction AFO
Poor Ankle suppport in stance
Minimal DF during swing
Knee flexion/collapse in MS
Tone Reducing Dynamic AFO
Stabilizes the Calcaneus and Rearfoot with ankle strap
Posterior Leaf Spring
(Dynamic - Thermoplastic)
Assist limb clearance in swing for IC by heel
Used for DF weakness, impaired control, LMN flaccidity or paralysis
Mod-Severe Hypertonicity
Carbon Graphite AFO
(Dynamic - Custom)
Assist limb clearance in swing for IC by heel
Used for paralysis or impaired Dorsiflexors
Mod-Severe Hypertonicity
Articulating Ankle
(Dynamic - Thermoplastic)
Assist limb clearance in swing for IC by heel
Permit Tibial Advancement (2nd rocker) in stance
LMN Paralysis / Hypotonicity
Tone Inhibiting AFO
(STATIC - Thermoplastic)
Controlled ankle position in stance for stability
Significant hypertonicity w/ impaired control
LMN Paralysis / Hypotonicity
Anterior Floor Static Reaction AFO
(STATIC - Thermoplastic)
Stability in stance through ankle/knee copuling
Weakness/Lack of control at the knee or ankle
Ligamentous insufficiency or Genu Recurvatum
Assessment for an Orthotic
- Alignment in standing w/o shoes
- Calcaneal Flexibility vs Rigidity
- Prone Flexibility (Gastroc/Soleus)
- Subtalar Joint neutral
