LE and spinal orthoses

Question 1

Why is an orthotic used?

Answer 1

-to address pathological symptoms

-control motion, pain, or deformity

MOTION
-by stopping, limiting, or assisting at a specific joint or position

PAIN
-by limiting or stopping motion, or by reducing stress to a joint through support or through shock-reducing cushion

DEFORMITY
-by supporting an existing deformity and preventing it from progressing
-by altering the position of the deformity to what is considered natural

Question 2

Goals of an orthotic

Answer 2

meets the individual mobility needs and goals

maximizes stance phase stability

minimizes abnormal alignment

minimally compromises the swing phase

pre-positions the limb for initial contact

ensuring the device will work with patient’s preferred assistive device

-can be worn for long periods without damaging the skin or causing pain
-can be easily donned and doffed

Question 3

Basic principles of orthoses

Answer 3

-balanced parallel force system used to control joint motion

-one corrective force and two stabilizing forces (three points of force application)

-the larger the corrective force, the larger SA required for force application

Question 4

Classification of orthoses:

Answer 4

They are named for the joints that they cross

FO
AFO
KAFO
HKAFO
KO
HO

Question 5

Foot orthoses facts

Answer 5

-rigid, semi-rigid, or flexible
-custom fabrication and off-the-shelf

-subtalar joint support (frontal plane)

-fits into shoes/low profile

INDICATIONS
-pes planus (pronation)
-pes cavus (supination)
-plantar fasciitis
-heel spurs
-metatarsalgia
-mild-moderate calcaneal varus/valgus
-mild-moderate midfoot deformity
-laxity
-diabetic neuropathy

OPTIONS
-full length/partial length (consider discrepancy in leg length)
-material: soft vs firm
-reinforcement
-off-loading

Question 6

What is a UCBL orthotic?

Answer 6

TYPE: FO

-thermoplastic
-custom

-controls calcaneus and midfoot
–transverse plane
–frontal plane

**MOST CORRECTIVE FO

INDICATIONS:
-flexible moderate pronation/calcaneal deformity
-moderate deformity
-plastic materials (range of rigid support)
-require larger/wider shoe size

Question 7

SMO facts

Answer 7

Type: FO

-plastic
-custom

-controls calcaneus, midfoot
–transverse plane
–frontal plane

-ankle support
–frontal plane

-allows free DF and PF

-rigid outer surface and a more flexible material inside

INDICATIONS:
-ankle instability (frontal plane)
-flexible calcaneal and midfoot deformity (frontal, transverse)
-moderate-severe deformity
-visible above shoe line

Question 8

Types of AFOs

Answer 8

solid AFO

semi rigid

articulated (joint)

GRAFO - ground reaction

PLS AFO - posterior leaf spring AFO

Arizona

CROW

Richie Brace

Question 9

Universal AFO fitting goals

Answer 9

-increase ankle stability
-improve cadence
-increase balance/step length
-limit foot drop
-increase knee stability
-limit genu recurvatum (hyperextension)
-create heel to toe gat pattern
-guided control in 3 planes

-increase PT confidence and increase endurance and decrease fatigue

Question 10

Metal AFO facts and indications

Answer 10

-aluminum sidebars attached to a standard shoe
-leather or metal calf band

-custom

-articulation at ankle (hinge)
–> free motion
–> limited motion
–> assisted DF and PF

controls ankle motion in sagittal plane

INDICATIONS
-ankle motion management (sagittal plane)
-edema (if there is constant fluctuating volume) –> need to avoid thermoplastic device

CONS
-increased weight
-more time for fabrication
-increased maintenance

Question 11

PLS-AFO facts and indications

Answer 11

posterior leaf spring orthosis

-thermoplastic material
-custom and off the shelf

-posterior plastic strut has material flexibility
–> sagittal plane

-footplate suport
–> transverse plane: midfoot
–> promotes weight acceptance at initial heel contact
–> keeps angle of ankle at 90 degrees

INDICATIONS
-**drop foot
-tib ant. weakness
-DF paralysis
-lightweight
-low profile
-off the shelf options
-minimal foot deformity

Question 12

Dynamic carbon fiber AFO facts and indications

Answer 12

-carbon fiber material

-off the shelf, some custom

-energy storing in sagittal plane

POSTERIOR PANEL VS ANTERIOR PANEL
-anterior for PF weakness
-posterior panel for DF weakness

INDICATIONS
-thin, lightweight
-low profile
-can be used for dropfoot
-DF or PF weakness
–CVA
–MS
–neuropathy

Question 13

SA- AFO facts and indications

Answer 13

“solid ankle foot orthosis”

-thermoplastic or carbon materials

-custom

-trimelines are anterior to malleoli

-fixed ankle for all phases of gait

3 planes of control
-sagittal –> stability
-frontal –> support
-transverse –> support

INDICATIONS
-low tone
-potential or complete paralysis of gastroc or soleus
-mild instability of knee
-deformities of the ankle (varus, valgus)
-contracture/spasticity management
-traumatic LL injury with pain

Question 14

Ground reaction AFO facts and indications

Answer 14

-thermoplastic materials

-custom

-padded anterior tib section

-knee extension moment in stance (pushes tibia back)
–sagittal plane

-ankle support
–frontal plane
–transverse plane

INDICATIONS
-crouch gait
-quad weakness 3-/5
-knee instability
-weak PFs

CONTRAINIDCATIONS
-genu recurvatum
>20 degrees knee flexion contracture

Question 15

Articulated AFO facts and indications

Answer 15

-thermoplastic or carbon

-custom fabrication

-ankle articulation

OPTIONS
-dorsiflexion assist
-PF/DF stop

Three planes of control
-sagittal plane controlled motion
-frontal plane support
-transverse plane support

INDICATED
-drop foot
-need for natural ankle motion
-medial/lateral ankle instability
-varus/valgus deformity
-plantarflexion contracture

CONS:
-allowing motion reduces control;
-ankle joints add bulk and weight
-poor cosmesis

Question 16

AFOs with inner booties facts and indications

Answer 16

• 2 different thermoplastic materials

-custom fabrication

-inner molded soft bootie

-rigid AFO outer plastic

INDICATIONS
-severe ankle deformity
-bony prominences
-sensitive skin, sensory issues
-need for rearfoot or frontal plane control
-pressure distribution of dorsal strap

Question 17

Arizona AFO: leather ankle Gauntlet facts and indications

Answer 17

-leather gauntlet reinforced with plastic, lace up

-custom molded

**designed to immobilize

-frontal plane support
-adjustability for edema management
-low profile increased comfort solid ankle and articulating styles

INDICATIONS
-posterior tibia tendon dysfunction
-tendonitis
-ankle arthritis
-DJD
-chronic sports injuries

Question 18

CROW - charcot restrain orthotic walker

Answer 18

Type: AFO

-thermoplastic with custom soft foam liner and insert
-rocker bottom
-requires shoe lift for CL side

PLANES OF SUPPORT
-sagittal
-frontal
-transverse

** common for diabetic patients

INDICATIONS
-charcot joint - is a syndrome in patients who have peripheral neuropathy, or loss of sensation, in the foot and ankle–> leads to greater risk of fracture
-chronic diabetic ulcers
-ischemic necrosis
-fracture management

Question 19

Richie brace facts and indications

Answer 19

TYPE: AFO

INDICATIONS:
-PTTD (mild to moderate)
-lateral ankle instability
-peroneal tendinopathy
-cavo-varus deformity

FEATURES:
-semi-rigid support
-control of 1st ray, midtarsal, and subtalar joint
-control of ankle inversion/eversion
-unrestricted sagittal ankle motion

Question 20

PRAFO: pressure relief ankle foot orthosis facts and indications

Answer 20

-soft padded fabric/lambswool, plastic reinforcement PLS

-off-the-shelf

SUPPORT:
-sagittal plane support of ankle position
-transverse plane support of the hip position

-no posterior heel contact

-adjustable

INDICATIONS
-supine bedrest
-prevent PF contractures
-maintain neutral hip rotation while supine–>plastic stoppers that prevent internal rotation
**not intended for ambulation

Question 21

KO - knee orthosis, ACL, or unloader facts and indications

Answer 21

MATERIAL: composite, metal, carbon graphite, titanium knee hinges

-can be custom or off-the-shelf

SUPPORT:
-sagittal (flexion/extension stops)
-frontal
-transverse (limited)

-lightweight

INDICATIONS:
-ACL, PCL, MCL, LCL instabilities
-high-intensity athletic activities
-OA, offloading support

Question 22

Post-op knee braces

Answer 22

-fabric reinforced with metal uprights in specific ROM position

-off-the-shelf

SUPPORT –> Limited ROM allowed
-sagittal
-frontal

-immobilizer
-Short-term use

Question 23

KAFO facts and indications

Answer 23

MATERIAL
-thermoplastic with metal, carbon fiber, metal, and leather

SUPPORT:
-sagittal
-frontal
-transverse

Variety of joint types and function
-torsion/contracture management
-stance control
-C-brace (microprocessor)

INDICATIONS
-when stability during stance cannot be provided by AFO
-when hyperextension of the knee impacts joint integrity
-varus/valgum is present
-genu recurvatum
-hamstring/quad weakness or paralysis
-spastic/flaccid paralysis of the lower limb
–> ex: post-polio syndrome

PART TIME USE
-stance/ambulation therapy
-contracture management

CONS
-increased weight and bulk

Question 24

Hip orthoses facts and indications

Answer 24

MATERIAL
-thermoplastic pelvis and thigh cuff with metal hip joints, fabric/foam lined

-custom or off-the-shelf
-unilateral or bilateral

SUPPORT PLANES
-frontal plane (abduction/adduction control)
-sagittal plane (hip stops)

INDICATIONS
-Legg-Calve Perthes, developmental dysplasia of the hip, post-surgical, hip dislocation

Question 25

SWASH facts and indications

Answer 25

"sitting, walking, and standing hip orthosis" TYPE: HO Material: Thermoplastic hip and thigh cuffs, metal uprights that allow motion through a specific range -off-the-shelf -pediatric SUPPORT: -maintains hip abduction (frontal plane) -limits adduction while sitting, standing, walking -free flexion-extension ROM of the hip (sagittal plane) INDICATIONS -spastic hemi/di/quadriplegia -hip adduction tone -post botox -risk of hip displacement -gait scissoring -allows motion and ambulation

Question 26

HKAFO/RGO:

Answer 26

RGO: reciprocating gait orthosis MATERIAL -thermoplastic with metal joints nd metal uprights -custom PLANES OF CONTROL (hip knee ankle) -sagittal -frontal -transverse RGO: -reciprocating pelvic attachment allows reciprocal gait pattern --> Need trunk rotation/strength INDICATIONS -part-time use for stance and ambulation (therapy) -myelomeningocele -spina bifida -paraplegia -spinal cord injury (C8-T12) CONS -increased bulk and weight -expensive

Question 27

Cranial remolding orthoses facts and indications

Answer 27

MATERIAL: thermoplastic with foam liner -custom -cranial growth-dependent remodeling INDICATIONS -plagiocephaly - brachycephaly -scaphocephaly -cranial deformation secondary to torticollis -post op craniosynostosis -ages 4-12 months ** good outcomes but poor insurance coverage

Question 28

Fitting goals for spinal orthoses

Answer 28

-substitute/assist axial muscle actions -function as a kinesthetic reminder -protect anatomical structures -prevent/reduce pain -prevent progression of condition -reduce severity of deformity

Question 29

Soft cervical collar facts and indications

Answer 29

-soft foam -off shelf SUPPORT: -sagittal -frontal -easy don/doff, velcro -inexpensive INDICATIONS Soft tissue injuries Hyperextension/flexion injuries Post-surgical Fusion Mild cervical arthritis/nerve pain

Question 30

Philadelphia cervical collar facts and indications

Answer 30

-lightweight foam -off-the-shelf SUPPORT: -moderate C2-C5 -thoracic extension: C6-T2 --> sagittal plane --> frontal plane --> transverse plane *tracheotomy access INDICATIONS -post-surgical application -trauma, fractures -immobilization for cervical metastasis -cervical arthritis -degenerative diseases

Question 31

Miami J cervical collar facts and indications

Answer 31

MATERIAL: plastic, fabric-padded removable liners, two pieces, velcro closure -off shelf SUPPORT: -moderate C2-C5 -thoracic ADDITION: C6-T2 (upper thoracic) --> sagittal plane --> frontal plane --> transverse plane MRI compatible INDICATIONS Post surgical application Stable cervical spine injuries Degenerative diseases Cervical arthritis

Question 32

CTO/Minerva

Answer 32

CTO- cervical thoracic orthoses "Minerva" MATERIAL: Thermoplastic, fabric pad lining, metal uprights -off shelf -can be applied while the patient is in supine in the hospital RIGID IMMOBILIZAITON C3-T2 -sagittal (flexion and extension) -frontal INDICATIONS Stable cervical fractures Post-surgical application Immobilization for cervical metastasis

Question 33

SOMI: sternal occipital mandibular immobiler

Answer 33

MATERIAL: Metal uprights with foam lining, straps -off shelf Rigid immobilization C2-C7 -sagittal (mostly flexion) -frontal plane (mild) -transverse plane INDICATIONS -stable displaced fractures -cervical disc immobilization -post-surgical immobilization

Question 34

HALO

Answer 34

MATERIAL: Thermoplastic vest with fabric liner, metal uprights, titanium skull pins MAX immobilization of C1-C3 -sagittal -frontal -transverse -pinless option available (less infection) INDICATIONS **UNSTABLE C spine fractures -dens type I, II, III of C2 -C1 with rupture of transverse lig -SCI -post-surgical management CONS -risk of infection at pin sites, scarring

Question 35

LSO

Answer 35

MATERIAL: Thermoplastic shell, soft foam liner Custom fabrication or off-the-shelf THREE PLANES OF CONTROL: -L1-L5 -sagittal, frontal, transverse -bivalve (two pieces, front and back) Trimlines: * sub scapula * xyphoid process * Sacrum * Contain ASIS for pelvic control INDICATIONS: Post-surgical immobilization Low back pain management Compression fractures Non-surgical disc treatment Obese patients Laborious work -IMMOBILIZATION OF: -flexion/extension -some rotation and side bending

Question 36

BOB- Boston overlap brace anterior overlap LSO

Answer 36

MATERIAL: Thermoplastic, variable flexibility/rigidity, lined or unlined custom fabrication SUPPORT: -sagittal -frontal -transverse -overlap closure anteriorly IMMOBILIZATION: L3-L5 (lower lumbar) through abdominal compression (hydrostatic loading) (hydrostatic load on soft tissue/organs helps to reduce load through axial skeleton Trimlines: * Posterior sub scapula * Xyphoid process * Distal sacrum * Contain ASIS for pelvic stabilization INDICATIONS: Post surgical immobilization Low back pain management Compression fractures L3-L5 Non-surgical disc treatment Disc disease Spondylosis, Spondylolysis, Spondylolisthesis Anti-lordotic posturing

Question 37

CASH- cruciform anterior spinal hyperextension

Answer 37

MATERIAL : -aluminum uprights with foam pads, straps -off shelf -lightweight, anterior design SUPPORT -flexion limited T6-L1 (maintain extension) --> sagittal plane INDICATIONS -anterior compression fractures (anterior column burst fracture) -mild kyphosis -frail patients in need of minimal support -reduction of kyphosis in OA

Question 38

Jewett Hyperextension Brace

Answer 38

MATERIAL -Aluminum uprights with foam pads, straps -off-the-shelf -Lightweight, anterior design, easy donning SUPPORT -flexion limited T6-L1 INDICATIONS Anterior compression fractures T6-L1 Burst fractures Post Surgical Immobilization Mild kyphosis Frail patients in need of minimal support Reduction of kyphosis in osteoporosis

Question 39

Soft TLSO hyperextension corset

Answer 39

-Fabric/elastic with rigid thermoform reinforcement, more comfortable -off the shelf POSTURAL REMINDER- limits thoracic flexion in the sagittal plane -good cosmesis, lightweight INDICATIONS: -Geriatric kyphosis -Stable anterior thoracic compression fractures -Accommodates frail individuals -More comfortable for the elderly

Question 40

Lumbar-sacral corset

Answer 40

-Elastic or neoprene, plastic or metal reinforcement, moldable stays, off-the-shelf -mild-mod support: -- > sagittal (flexion and extension) --> abdominal compression (hydrostatic loading) INDICATIONS: -LBP

Question 41

SI belt

Answer 41

-1.5-2” wide elastic webbing and posterior pad -off the shelf -low profile -pressure on SI joint INDICATIONS -SIJ pain -SIJ subluxations -pregnancy SI support

Question 42

TLSO

Answer 42

MATERIAL: Thermoplastic, many design variations -bivalved (straps on both sides) -lateral opening -anterior/posterior opening -lined/unlined -may have struts -flexible/rigid plastic -intimate, total contact -can have openings for feeding tubes, etc -custom SUPPORT: -sagittal plane -frontal plane -transverse Trimlines: -sternal notch, the spine of the scapula INDICATIONS Post-surgical immobilization Unstable/Stable fracture management T3- L3 Pain management **Can include hip joint & thigh cuff for lower lumbar stabilization ** can also include cervical attachment (CTLSO) Neurologic injuries Custom for atypical shapes *TYPICALLY NEED ASSISTANCE FOR DONNING

Question 43

TLSO for scoliosise

Answer 43

-Thermoplastic with padding, additional padding for corrective forces -custom -design depends on the curve SUPPORT -sagittal -frontal -transverse DOSE: hours per day INDICATIONS: -curves with apex T8 and below -curves > 25 degrees ---> consider age of patient and growth --> consider skeletal immaturity - non-surgical intervention GOALS: -50% correction -prevent progression of curve

Question 44

CTLSO: Milwaukee scoliosis brace

Answer 44

-thermoplastic pelvic section -Anterior & posterior uprights (aluminum) -Neck ring -padding at apex/strapping -custom, time-consuming to produce PLANES: -sagittal, frontal, transverse INDICATIONS: -treatment of curves with apex above T8 CONS: -outdated -low compliance

Question 45

Night-time bending brace for scoliosis

Answer 45

-Thermoplastic, foam lining -Anterior opening -Custom fabrication SUPPORT: -sagittal (curve) -frontal plane (lordosis, kyphosis, rotation) -transverse plane -only worn at night TYPES: Charleston Bending brace, providence brace INDICATIONS -Idiopathic Scoliosis, Single Curves, -Curvature of 25-40 degrees CONS -low compliance