O - Orthotics for NM Conditions Flashcards
(107 cards)
1
Q
what is an orthosis
A
externally applied device designed to modify structural and functional characteristics of NM/MSK systems
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
3
Q
what is orthotics
A
specialty w/i field of medicine which describes design, fabrication, and application of orthoses
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
5
Q
what are the 5 functional goals of an orthosis
A
- substitute for weak ms by providing external support
- limit motion to minimize pain
- dec risk of developing bony deformity or contracture
- offload forces during WBing to promote healing and preent injury
- position limb segments for optimal alignment
6
Q
what joints do orthoses directly and indirectly impact
A
directly - joints crossed
indirectly - next proximal joint
7
Q
what are the 3 orthotic design principles
same physics principles as w prosthetics
A
- pressure = force/ area
inc SA = more comfortable and effective - torque = force x distance
larger moment arms dec amt of force needed to control a joint - sum of forces = 0
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
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
10
Q
what is the purpose of the flexible inner boot
A
control FF
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
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
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
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
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
- initial weakness
- spasticity, hypertonicity, hyperreflexia
- dec motor control (speed, accuracy, coordination, fluidity)
ex: CVA, TBI, MS
16
Q
what characteristic of UMN damage is often what triggers the referral to brace clinic
A
dec motor control (speed, accuracy, coordination, fluidity)
17
Q
what is likely the biggest pt population utilizing AFOs
A
stroke pts
18
Q
8 clinical presentation characteristics in CVA pts
A
- changes in resting tone (initial hypotonus)
- spasticity
- weakness / paralysis - stiff knee gait
- postural issues
- loss of proprioception
- sensory deficit
- neglect of affected side
- cog, emotional, intellectual impairment
19
Q
how will the clinical presentation of weakness or paralysis in CVA pts translate into abnormal gait
A
stiff knee gait
20
Q
3 clinical presentation characteristics in TBI pts
A
- difficulty w speech or communication
- hypertonicity
- balance challenges
21
Q
what is a TBI
A
non-degenerative, external trauma to the brain
22
Q
what is the prognosis w a TBI
A
may or may not recover
23
Q
4 clinical presentation characteristics in MS pts
A
- usually BL
- poor balance
- lack of coordination
- sensory challenges (temp sensitive)
24
Q
what characteristic of MS is often what triggers the referral to brace clinic
A
poor balance and lack of coordination
25
what ambulation compensations are seen in MS
wide BOS
small step lengths
26
how should an orthotic intervention be handled in MS
should be "delicate"
* more effective early on in dz
* MS is progressive
27
4 clinical presentation characteristics in SCI pts
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
28
# RGO
what is it
what are cons
when would you use it today
* reciprocal gait orthosis
* cumbersome, hard to put on
* might use to get pt upright for few hours a day
29
# SCI
T12 intact: what orthotic?
RGO/HKAFO
30
# SCI
L1 intact: what orthotic?
KAFO
31
# SCI
L3 intact: what orthotic?
KAFO/AFO
32
# SCI
L4 intact: what orthotic?
AFO
33
# LMN pathologies
what is an LMN?
what are 3 characteristics of LMN damage?
what are examples of LMN conditions?
motor neuron which travels from SC to ms
1. weakness
2. hypotonicity, hyporeflexia, flaccidity
3. fasciculations (involluntary ms twitches)
ex: GBS, polio, PPS, CMT
34
what is muscle tone and how does this impact compliance to orthoses
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
## Footnote
higher tone can make it difficult for orthotist to obtain a decent cast, harder for pt to be compliant and keep control
35
what is hypertonicity
ms that are too stiff (aka high tone)
36
what is spasticity
velocity-dependent hypertonicity (stiffness that occurs w rapid passive elongation of a ms)
37
what is rigidity
bidirectional, co-contracting hypertonicity and resistance to passive mvmt of both agonistic and antagonist ms groups
38
what is hypotonicity
dec ms stiffness (aka low tone)
39
what is flaccidity
ms cannot be activated bc of interruption of transmission or connection b/w LMN and ms (aka no tone)
40
what is athetosis
when underlying ms tone fluctuates unpredictably
41
why would an orthotist break down the functional tasks of gait
break down gait to see where interventions will be most effective and needed
42
what are 5 factors that influence gait and which 2 can we have the biggest impact with
**1. stance phase stability
2. clearance in swing**
3. swing phase pre-positioning
4. adequate step length
5. energy conservation
43
what type of orthosis is considering the rockers important for
AFOs
44
what are the 3 rockers in gait
heel
ankle
toe
45
# heel rocker
what is its function (2)
what 2 ms are activated and why
1. controlled lowering of foot
2. body weight acceptance
eccentric control of quads and ant tib
* prevents foot slap and protects knee
46
# ankle rocker
what is its function
what ms is activated and why
tibia progresses over WBing foot during mid to terminal stance
eccentric control of PFs
* limits forward mvmt of shank
47
# toe rocker
what is its function (2)
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
how would disruption of the forward progress facilitated by the rockers negatively impact gait (3)
step length
cadence
SLS
49
what roll should orthosis play with rockers in gait
provides external support to ensure forward progression and mobility
* use least amt of external support possible
50
# prefab orthoses
5 advantages vs 4 disadvantages
**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
# prefab orthotics
5 indications vs 4 contraindications
**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
are prefab or custom molded orthoses more commonly used
custom molded
53
# custom molded
4 advantages vs 5 disadvantages
**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
# custom molded
indications vs contraindications
**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)
## Footnote
if large fluctuations in limb volume w swelling, prefab may be better option bc less material to it
55
# footwear
what qualities do you look for?
what type of footwear work best?
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
## Footnote
struggle of appropriate footwear vs cute shoes
56
what is a custom foot orthosis
custom insert that works to improve foot mechanics during walking
57
what is a UCBL
**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
## Footnote
UCBL = university of cali berkley
58
what is the primary goal of an AFO
provide just enough external support for stability in stance w minimal compromise of forward progression
59
# AFO
what are 2 indications
* need direct control of STJ and ankle joint
* need indirect control of knee joint
60
# AFO
static vs dynamic
static (solid ankle) - ankle locked in position
dynamic (articulated) - articulation via mechanical joint or allows flex/ext where and when we need it
61
what is the axis of the ankle joint
oblique running ant-med to post-lat
62
what ankle motions accompany DF and PF
DF:
* talar pron
* talar ABD
* RF valgus
PF:
* talar sup
* talar ADD
* RR varus
63
what is the most supportive/aggressive AFO
static
64
# static AFOs
why are trimlines and shoe modifications important considerations
inc rigidity greatly compromises transitions thru all 3 rockers
* consider trimlines/shoes to maintain forward progression of shank
## Footnote
restricts ankle motion in all 3 planes
might consider shoes with a rocker bottom to help w forward progression
65
what is an indirect role of ground reaction AFOs
indirectly controls knee ext
66
# static AFO
how are ground reaction AFOs fabricated
ankle in slight PF
67
# static AFOs
how does PTB-AFOs offload weight from the plantar surface of the foot
| PTB = patellar tendon bearing
anterior shell modified to accept weight via:
* total contact
* pressure tolerance areas - medial tib and patellar tendon
vertical uprights transfer forces
## Footnote
essentially just loading the patellar tendon
68
# static AFOs
why is it hard to get a good result in pts appropriate for the PTB-AFO
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
what are 3 things you need to be considered appropriate for a PTB-AFO
1. normal anatomic structure of knee
2. adequate MMT/motor control of quads
3. sufficient skin integrity
70
# static AFOs
what is the degree of control influenced by
direction of forces/counterforces, trimlines, and intrinsic modifications w/i the device
71
# static AFOs
what are the 4 distinct control systems
1. PF (swing)
2. DF (stance)
3. eversion / valgus
4. inversion / varus
## Footnote
want varus/valgus angles to be in neutral and control inv/eve
72
what are 3 types of static AFOs
solid AFO
ground reaction AFO
weight relieving AFO (PTB-AFO)
73
what are 4 types of dynamic AFOs
articulated AFO
posterior leaf AFO
supramalleolar orthosis
conventional double upright AFO
74
# dynamic AFO
in what patient would you consider a conventional double upright AFO
pt w fluctuating edema bc lot less contact (only at calf/shoe)
75
what are dynamic AFOs
| ie what is their function
allow sagittal plane motion at ankle
* usually allow DF during stance and prevent PF during swing
76
# dynamic AFOs
who are supramalleolar orthoses commonly used in
kids with mild to mod diplegic CP
77
# dynamic AFOs
what are 5 functional improvements seen from a supramalleolar orthosis
1. improve upright posture
2. improve swing limb clearance
3. stride length
4. cadence
5. self selected walking speed (SSWS)
78
# dynamic AFOs
what are the 2 main functions of a posterior leaf spring AFO
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
# dynamic AFOs
what is an advantage and disadvantage of posterior leaf spring AFOs
advantage - inc flexibility allows functional advantage (esp on slopes, ramps)
disadvantage - not effective at controlling calcaneus (not enough material at trimlines)
80
# dynamic AFOs
what are 4 functional benefits of an articulated AFO
dec energy expenditure
improve stride length
cadence
SSWS
81
# dynamic AFOs
what is an articulated aFO
allows sagittal plane motion via mechanical ankle joint
* allows wide ROM
* can modify amt of motion allowed per pt
## Footnote
similar control system to SAFO except for inc sagittal plane motion
82
what are 4 modifications to an AFO that can dec effects of hypertonicity/spasticity
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
what is the primary goal of KAFOs
provide just enough external support for stability in stance and clearance in swing w minimla compromise of forward progression
84
how do pts feel ab KAFOs
they hate them - acceptance rate is low
85
what are 2 indications for KAFOs
1. need direct control of ankle and knee joints
2. need indirect control of hip joint
86
when should a KAFO be considered (4)
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
since pts hate KAFOs, what could you try first if they have weak quads
* 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
what are considerations of a solid vs articulating ankle joint in a KAFO
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
# what knee joint would you use to
stabilize flail knee w SOME ability to generate knee ext moment (MMT 2 to 3+)
offset unlocked
90
# what 2 knee joints would you use to
stabilize flail knee with NO ability to generate knee ext moment (MMT 0 to 2)
single axis locked
offset locked
91
# what knee joint would you use to
reduce knee flexion contracture
variable positioning
92
# what 2 knee joints would you use to
control genu valgum/varum
single axis unlocked
offset unlocked
93
what is the function of a stance control knee joint
allows locks on heel strike in stance but triggers into flex in swing
94
what is a ring/drop lock and what is a con of this
automatically locks knee joint into full ext
**con**: need hand dexterity to unlock the sides in sync to sit
95
what is a lever lock and what is a pro of this
locking knee joint with a release mechanism
**pro**: can unlock and lock both joints simultaneously when go to sit
## Footnote
this is the better version of a ring/drop lock
96
what is a bail lock, what is pro/con
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
what is a cable/trigger lock and what is a pro of this
same as function as lever lock - med and lat lock connected to cable to unlock simultaneously
* less likely to accidentally unlock
98
# variable positioning locks
what are they
what is an indication
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
## Footnote
**provides stability despite GRF being posterior to anatomical knee center**
99
what patient populations are stance control locks indicated in
initially developed for PPS
CVA, brain tumor, TBI, incomplete SCI, spinal degen dz, MS, peripheral nerve injury
100
stance control lock during gait
locked when weighted
* locked in ext from IC through terminal stance
unlocked when unweighted
* goes into free swing from preswing thru swing phase
101
what are 2 things needed for a stance control lock to be indicated
* must have at least 3/5 MMT at hip ext and hip flex
* must have full knee ext ROM
102
what are 3 advantages to a stance control lock
1. improved SSWS, cadence, and stride length
2. improved gait symmetry
3. reduced compensatory patterns
103
how does an RGO work
who was it designed for
what is a con
* 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
what are 2 indications of HKAFOs/RGOs
1. need direct control of ankle, knee, and hip joints
2. need indirect control of trunk
105
what are 3 examples of some pathologies that a HKAFO/RGO would be indicated for
1. myelomeningocele
2. high level SCI
3. progressive neuro disorders
106
what are 4 disadvantages to HKAFO/RGO
1. heavy
2. high energy cost
3. difficult to fabricate
4. challenge to don/doff
107
what are 3 functions to a HKAFO/RGO
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
