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Orthotics > Orthotics from Orthotists Perspective > Flashcards

Orthotics from Orthotists Perspective Flashcards

1
Q

Goal of ANY Orthotic Treatment

A
  • Limit or assist motion
  • Limit deformity or pain
  • Protect fragile structures –> prevent further progression, reduce stress on a joint
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2
Q

Choosing Appropriate Orthotic Intervention

A
  • Previous Orthotic History
  • Cognition
  • Attitude
  • Outside Support
  • Condition of Extremity
  • Muscle Tone
  • Gait Evaluation
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3
Q

Determinants of Gait

A
  1. Pelvic Rotation
  2. Pelvic Tilt
  3. Knee Flexion at Midstance
  4. Foot and Ankle Motion
  5. Knee Motion
  6. Lateral Pelvic Displacement
    -All influence energy expenditure and the mechanical efficiency of walking
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4
Q

Pelvic Tilt

A
  • At midstance, COG reaches it’s highest point
  • Pelvis tilts down on the swing side 5 degrees
  • Depresses COG 3/16”
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5
Q

4 Questions for an orthotic prescription

A

-What control is needed?
-What are the deficits?
-What assistance is needed?
-What function should remain?

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6
Q

Basic Principles of Orthoses

A
  • Balanced parallel force systems used to control motion
  • 3 points of force application required to control motion in one plane (1 corrective, 2 stabilizing)
  • The larger the corrective force, the larger the surface area required for the force application to stay within soft tissue tolerances for pressure
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7
Q

Metal and Leather Benefits

A
  • Little contact on limb
  • Traps little heat
  • Accommodates fluctuating edema
  • Structurally Sturdy
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8
Q

Metal and Leather Drawbacks

A
  • Heavy
  • High force with less control due to lack of contact areas
  • Limited to one pair of shoes
  • Bulky
  • Requires more maintenance
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9
Q

Plastic Benefits

A
  • Vacuum formed
  • Intimate contact can be customized for more weight bearing with bony prominence relief
  • Allows most biomechanical control
  • Better shoe fit
  • Easily Adjusted
  • Colored/patterned plastics
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10
Q

Plastic Drawbacks

A
  • Can be hot
  • Difficult with fluctuating edema
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11
Q

Benefits of Carbon

A
  • laminated to mold
  • intimate contact can be customized for more weight bearing with bony prominence relief
  • Allows most biomechanical
  • Best shoe fit
  • Lightest weight
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12
Q

drawbacks of carbon

A

not easily adjusted

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13
Q

5 functions of AFOs

A
  1. Block plantarflexion
  2. Block dorsiflexion
  3. Assist dorsiflexion
  4. Control supination (3 point pressure system)
  5. Control pronation (3 point pressure system)
    *** can correct some deviations but might create others
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14
Q

Classes of Orthoses- Off the shelf

A
  • prefabricated
  • requires minimal self-adjustment (can be completed by patient or beneficiary or supplier of device)
  • patient or therapist can obtain without orthotist assistance
  • Generally paid for OOP or billed through hospital/therapy
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15
Q

classification of orthoses - custom fit

A
  • prefabricated
  • requires more than minimal self-adjustment (trimmed, bent, molded)
  • requires expertise of certified orthotist to fit item on the patient
  • orthotist submits to insurance fro coverage/reimbursement, more cost effective than custom fabricated
    ** typically seen spinal
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16
Q

classification of orthoses - custom fabricated

A
  • custom (based on measurements, cast and/or digital model)
  • Provides total contact
    0 more control over final design since fabrication is done via orthotist
  • orthotists submits to insurance for coverage/reimbursement
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17
Q

OTS plastic AFO - Design

A
  • One size fits most
  • Plastic calf band with posterior strut to footplate
  • little contact on skin, decrease risk of skin breakdown
  • stops most PF
  • very flexible, can be too flimsy on larger patients
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18
Q

OTS plastic AFO - Indications

A
  • Neurological injuries (return of function is anticipated)
  • Short term use: acute foot drop, inpatient rehab, while waiting for another device
    (good when coming out of TKA or THA when nerve might have been nicked)
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19
Q

OTS (custom fit) carbon AFO - Design

A
  • carbon fiber calf cuff wit posterior strut and attached foot plate (more dynamic/springiness motion through late stance into swing phase)
  • Stops PF
  • very lightweight and strong
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20
Q

OTS (Custom Fit) Carbon AFO - Indications

A
  • foot drop (isolated)
  • mild coronal ankle instability
  • mild spasticity
  • patient with adequate ROM to load the strut
  • Mild/moderate knee buckling
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21
Q

OTS (Custom Fit) Carbon AFO - Contraindications

A

PF contractures/knee hyperextension

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22
Q

OTS (Custom Fit) Carbon AFO with Anterior Panel - Design

A
  • Carbon fiber anterior panel (‘shin guard’) with strut and attached foot plate
  • Provides more knee control to prevent excessive/unwanted knee flexion through stance
    phase
  • Still provides springiness at late stance into swing phase
  • Stops plantarflexion and some
    dorsiflexion
  • Lightweight and stron
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23
Q

OTS (Custom Fit) Carbon AFO with Anterior Panel - Indications

A
  • foot drop
  • mild coronal ankle instability
  • mild spasticity
  • patient with adequate ROM to load the panel/strut
  • moderate knee buckling instability
  • contraindicated: PF contractures/knee hyperextension
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24
Q

Supramalleolar AFOs (SMOs) - Design

A
  • Intimately fitting, low profile wrap around AFO –> Wraps around dorsum of ankle and forefoot
  • Pediatric populations –> Thicker plastic needed to accommodate an adult for weight bearing (less ideal)
  • Several 3 point pressure systems –> Total contact, multiplane control
  • Ends 2-3” proximal to malleoli
  • Can be used as an inner portion of an AF
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25
Q

Population that typically uses SMOs

A

Low tone pronators
Kids with Down syndrome

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26
Q

Supramalleolar AFOs - indications

A
  • Subtalar joint instability (Low tone pronation, Poor balance/coordination, Developmental delay/gross motor skill delay)
  • If talocrural joint is not controlled with FO/UCBL
  • Goal is to add stability without limiting ADLs –> Allows for some PF and DF
  • Contraindicated: high tone
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27
Q

hybrid model

A

better foot control, much more control for supination/ pronation

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28
Q

Arizona / Gauntlet Style AFO Design

A
  • Plastic AFO wrapped in leather with laces/Valcro on dorsal to apply total contact
  • Multiple 3 point pressure systems at play to limit ankle motion
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29
Q

Arizona / Gauntlet Style AFO Indications

A
  • coronal ankle instability
  • when unweighting/offloading ankle joint is warranted (arthritis, failed ankle fusions)
  • Often when we decrease the motion, we decrease the pain
  • Contraindicated for fluctuating edema, dexterity issues to lace up
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30
Q

Charcot Restraint Orthotic Walker (CROW) Design

A
  • Bivalve total contact plastic boot lined with foam padding
  • Designed to treat Charcot deformity and offload bony prominences / wounds
  • Custom made walking boot
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31
Q

Charcot Restraint Orthotic Walker (CROW) Indications

A
  • Charcot
  • Open wounds/sores
  • To offload foot/ankle
  • typically have wounds, pitting edema
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32
Q

Goal:

A
  • Provide 1 decide to last 5+ years
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33
Q

Most common ankle joints

A

tamarack and double action

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34
Q

tamarack ankle joint

A
  • stretchy/gummy, have slight transverse motion
  • also available in dorsiflexion assist (swing
    phase clearance)
  • contraindicated for spasticity, can set off
    clonus (substitute Oklahoma if increased tone)
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35
Q

Double action ankle joint

A
  • most common on metal and leather AFOs
  • Can assist/resist dorsiflexion and plantarflexion
  • Infinite adjustability
  • Bulky/heavy
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36
Q

PF Stops

A
  • Plastic on posterior ankle of articulated AFO can stop PF
  • Adjustable stops (DF can be increased within AFO to improve foot clearance)
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37
Q

2nd Flange (Sabolich Extension)

A
  • Distal to the calf, proximal to malleoli
  • adds coronal / rotation control to tibia
  • Medial flange stops medial rotation (stops pronation)
  • Lateral flange stops lateral rotation (stops supination)
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38
Q

Inner Boots

A
  • SMO that fits into larger AFO
  • increases frontal / triplanar control
  • easier to donn larger AFO if tone is present
  • can have foam ‘softy’ version for AFO
  • Modular system for kids, use SMO independently of AFO for therapy settings
39
Q

Anterior Panel

A
  • increases control on foot and ankle
  • can turn a solid AFO into a GRAFO (increased proximal knee control)
  • easy to take off when strength improves
  • Good option for patients who lack spatial skills do donn GRAFO
40
Q

Slot Straps

A
  • increases coronal / oblique control of hind foot
  • redirects the tension/angle of pull more posteriorly
  • medial strap reduces pronation within AFO
  • lateral slot strap reduces supination within AFO
  • can use both medial and lateral (figure of 8) over the ankle to lock heel inside AFO (fleshy kiddos)
41
Q

Medial T Strap

A

reduces pronation within AFO

42
Q

lateral slot T strap

A

reduces supination within AFO

43
Q

DF Stretching Straps

A
  • Must be on an articulated AFO
  • Increases dorsiflexion
  • Frequently used for nighttime stretching
  • Impractical to use for daily use while ambulating
  • Highly adjustable, the tighter the tension, the more dorsiflexion
44
Q

DF Stop Strap

A
  • Limits tibial progression through late stance
  • Can be added to articulated AFO after the fact
  • Velcro can be adjusted to allow some tibial progression before hitting end range
45
Q

Rules of AFOs

A
  • AFO is only effective if the patient can ambulate with the center of gravity over their base of support
  • whenever motion is blocked, there is a compensatory deviation created
  • this creates a ‘trade off’, and must be carefully balanced to result in a benefit to the patient
46
Q

Foot Drop

A

Ankle is plantarflexed in swing phase
Deviations:
* Hip hiking
* Circumduction
* Vaulting

47
Q

To correct Foot Drop

A
  • Flexible and articulated with dorsiflexion assist joints, or plantarflexion stop
  • An AFO that blocks PF will cause excessive knee flexion at loading response
48
Q

Genu Recurvatum

A
  • Knee is hyperextended at mid stance –> Shortens limb during stance phase
  • Can be painful and can lead to early degeneration of knee joint
  • No AFOs will correct without negative side effects
49
Q

To correct genu recurvatum

A

we must block PF
* least invasive are semi rigid AFO or
articulated
* PF stop and free dorsiflexion

50
Q

Knee Buckling

A
  • knee buckles at mid stance, or later
  • due to weak quads or pain in the knee
  • No AFOs correct this without negative side effects
51
Q

To correct knee buckling

A

we must stop dorsiflexion
* blocking dorsiflexion will stop knee flexion at
terminal stance
* least invasive have DFstop with free plantar
flexion (double action ankle joint)
* GRAFO

52
Q

Knee buckling and hyperextension

A
  • this instability can create excessive knee flexion at loading response and lack of knee flexion at terminal stance
  • DF and PF must be blocked
  • Looking at a solid ankle AFO
53
Q

Supination

A
  • Triplanar motion
  • Lengthens limb, disturbs swing and creates a poor and unstable weight bearing structure
54
Q

How is supination controlled

A
  • Maintaining a neutral ankle with 2 three point pressure systems
  • One at proximal medial calf, distal lateral fibula and medial calcaneus
  • One at medial calcaneus, lateral midfoot and
    medial forefoot
55
Q

Supination AFO

A
  • AFO must provide ML coverage to be effective
    (no flexible styles)
  • Must also assist dorsiflexion or block plantarflexion
56
Q

Pronation

A
  • Triplanar motion
  • Does NOT disturb swing but creates a poor and unstable weight bearing structure
57
Q

How is pronation controlled?

A
  • By maintaining a neutral ankle with 2 three
    point pressure systems
  • one at proximal lateral calf, distal medial tibia and lateral calcaneus
  • one at lateral calcaneus, medial midfoot and lateral forefoot
58
Q

Pronation AFO

A
  • AFO must provide ML coverage to be effective (no flexible styles)
  • If pronation is associated with a tight heel cord, PF should be blocked
  • Try to leave motion whenever possible
59
Q

Function of KAFO’s

A

-KAFOs stabilize the lower limb
-Provide Direct control over the knee
-Can ‘unweight’ the knee, ankle or foot with a gluteal/ischial seat
-Like AFOs, these can correct some deviations, but might create other concerns

60
Q

How can KAFO’s stabilize the lower limb?

A

longer level arm than an AFO

61
Q

Which motions do KAFOs provide control over in the knee

A
  • flexion
  • extension
  • valgus
  • varus
62
Q

KAFO Considerations

A

-When stance stability cannot be obtained in an AFO
-Increased weight of device increases energy expenditure… Is this functional for daily use?
* Many patients utilize KAFOs in therapeutic settings and wheelchair for longer distances (common for bilaterals)

63
Q

Single Upright KAFO

A
  • lighter
  • more cosmetic
  • easily re-aligned for more correction (Blounts, OA)
  • Used on bilateral/RGOs
64
Q

Double Upright KAFO

A
  • Most common
  • Stronger
  • More torsional control
  • More difficult to adjust
65
Q

KAFO locked knee

A
  • Drop locks
  • Bail/lever locks
  • Ratchet lock
66
Q

Knee Joints Unlocked

A
  • Free motion
  • Posterior offset
  • Polycentric
67
Q

Locked - Drop Locks

A
  • Lock falls into place at extension
  • indications: lock automatically at full extension, simple and secure
  • contraindications: need dexterity/balance to unlock
68
Q

Locked - Bail/Lever Locks

A
  • Releases with bail behind knee
    or lever on lateral thigh
  • indications: bilateral patients, people with dexterity/balance concerns. easy to lock/unlock
  • contraindications: bulky, risk for accidental unlocking (active jobs)
69
Q

Locket - Ratchet Locks

A
  • Adjustable ROM
  • Extension in locking increments, unlock by pressing lever
  • indications: knee flexion contractures
  • contraindications: if no contracture management is needed
70
Q

Unlocked - Free Motion Joints

A
  • controls extension and coronal
    control
  • Allows flexion
  • Contraindications: when limited ROM/locked knee is required
71
Q

Unlocked - Posterior Offset Joints

A
  • Indications: provides stance stability while allowing swing flexion
  • Contraindications: hip/knee contractures, or if the patient cannot reach full extension
72
Q

Unlocked - Polycentric Joints

A
  • Better mimics anatomical knee gliding motion by adding more than one center of rotation
  • indications: KOs, patients with increased soft tissue, better approximates knee axis of rotation
  • contraindications: bulkier, heavier
73
Q

check out the indications and contraindications for KAFO knee joint stuff on 81

A
74
Q

Gait deviations with locked knee

A
  • Hip hiking
  • Circumduction
  • Vaulting
75
Q

Stance Control KAFO

A
  • Knee joint locks in response to weight
    bearing
  • Unlocks and is in free swing during swing phase
  • Mechanical driven
  • Cables, switches under heel, or gravity/ pendulum to unlock
  • Microprocessor driven
  • Accelerometers, pressure switches electronically unlock
76
Q

KAFO Additions

A
  • 4 buckle knee pad
  • 5 buckle knee pad
  • Ischial weightbearing brim
  • All AFO additions can be applied to AFO section of KAFO
77
Q

Knee Pads 4 buckle for KAFO

A

Sagittal Control
* Holds knee in extension
* 4 straps around KAFO uprights to adjust tension
* Need double upright KAFO

78
Q

Knee Pads 5 buckle

A

Coronal Control
* Holds knee in extension * Acts as a “t strap” for the knee
* Controls varus/valgus with adjustable strap
* Pulls knee into more desirable alignment

79
Q

Ischial Weight Bearing Brim

A
  • Uses principles from above knee prostheses to carry weight through ischium/pelvis –> Thigh cuff looks very similar to prosthetic socket
  • Unweights hip, thigh, knee ankle and foot
  • Metal ischial band or molded plastic brim
80
Q

How to apply all this to patients with knee hyperextension

A
  • Stabilize knee joint
  • Need longer lever arm, cannot always control with AFO alone
  • Knee orthosis often independently will not suspend nor stay in place
  • If deviation is due to quad weakness, we must ensure weight line stays anterior to anatomical knee for stability
81
Q

How to apply all this to pt’s with knee buckling

A
  • Stabilize knee joint through locking knee
  • Need longer lever arm, cannot always control with AFO alone
82
Q

How to apply this to patients with coronal knee instability

A
  • Free motion joint to allow flexion and block hyperextension and improve coronal alignment .
  • Double upright sometimes needed for extra support
83
Q

What is Functional Electrical Stimulation

A
  • Alternative to AFOs
  • Uses electrical currents to activate nerves innervating extremities affected by paralysis
  • Electrodes placed over muscle belly in appropriate location to deliver targeted electrical impulses to neurons to cause contractions
84
Q

Who are the candidates for FES

A
  • Upper motor nerve or CNS disorders
  • MS * CVA * TBI * Incomplete SCI
    (won’t work for peripheral nerve lesions)
85
Q

How does FES work?

A
  • Through stimulating the peroneal nerve, we obtain dorsiflexion in swing phase
  • Isolated foot drop only * Uses accelerometers and inclinometers to approximate legs position through gait cycle
86
Q

FES Brands

A
  • Two main brands
  • WalkAide: 2 electrodes
  • Bioness: 4 electrodes; more precise fitting to detect sideways motion
87
Q

Benefits of FES

A

-Low profile design
-Can wear barefoot
* Beach
* Flip flops
-Enhanced circulation -Increased ROM
-Decrease atrophy

88
Q

Downside of FES

A

-No insurance coverage
* Patient cost: $5500
* Maintenance, trials, will need new electrodes every few months (electrodes ~$35/each)
-Only some UMN patients are candidates

89
Q

Problems to look for with ANY orthotic device

A
  • prolonged redness (>20 mins)
  • Skin irritation (blisters, bruising, abrasions, hotspots)
  • Increased swelling/volume changes
90
Q

Solutions for problems with orthotic device

A
  • Break in schedule
  • Add a sock/cotton barrier against skin (wicks moisture)
  • Send back to orthotist (NO CHARGE FOR ADJUSTMENTS/MODIFICATIONS)
91
Q

Physiological orthotic difficulties

A
  • Awkward
  • Bulky
  • Cumbersome
  • Slows down ability to ambulate/cadence
  • Increased energy expenditure –> Is wheelchair more practical?
  • Medication changes –> Change in volume/swelling
  • Insensate skin less likely to notice problems
92
Q

Psychosocial Orthotic Difficulties

A
  • Cosmesis
  • Others can see the disability
  • KAFO joints are bulky
  • Difficult to hide under clothes
  • Draws more attention to themselves
93
Q

Practicality orthotic difficulties

A

Support team at home:
* Difficult to donn independently
* Too time consuming to donn
Discomfort:
* Groin for KAFOs when sitting
* Bulk under thigh
* Keeping ankle fixed at one angle
Expense

94
Q

When in doubt…

A
  • Call your orthotist –> You spend more time and get to know your patients more than we do
  • We are certified / licensed individuals just like you all working towards the same goal of bettering our patient’s lives

Orthotics (9 decks)

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