ORTHOTICS Flashcards
1
Q
Stress Equation
A
Physical Stress = force/area
2
Q
Factors that Affect the level of physical stress on tissues or the adaptive responses to tissues to physical stress
A
- movement and alignment factors
- extrinsic factors (orthotics)
- psychological factors
- physiological factors
3
Q
The effect of physical stress on tissue adaptation
A
4
Q
The Effects of Prolonged Low Stress Lowers Thresholds for Subsequent Adaptation and Injury
A
5
Q
The Effect of Prolonged Low Stress Lowers Thresholds for subsequent adaptation and Injury
A
6
Q
Physical Stress level is composite of what 3 primary values?
A
- Magnitiude (of pressure)
- Time: duration, repitition rate
- direction: tension, compression, shearing, torsion
7
Q
2 Primary questions to ask in an evaluation and treatment
A
- What are the factors that appear to be contributing to the excessive stress on the injured tissue?
- How can these contirbuting factors be modified to reduce stress on the tissue and allow the tissue to heal?
8
Q
Brief History of o&p
A
- major advances due to WWI , WWII, and vietnam, Iraq
- Post WWII research - PTB, TT, TF
- AFter vietnam = myoelectric and modular prostheses
- most advances in orthotics with Polio epidemic
9
Q
What makes for an ideal orthosis?
A
- Control - stabilization and motor control
- Comfort - device meets pts needs
- Cosmesis - will the pt wear it
- Cost - monetory, insurance, energy required
10
Q
Primary functions of Orthoses
A
- Correct or prevent deformity
- protect weakened ms segment
- unload a limb or joint
- rest/immobilize
- assist with motion
- enhance gait
- alleviate pain
11
Q
5 Prerequisites of functional gait
A
- stability in stance
- clearance during swing
- swing phase pre-positioning (adequate loading)
- adaquate step length - timed activity or prox ms and pendulum effect of lower limb below knee)
- energy conservation
12
Q
3 Rockers of STANCE phase in gait
A
- Heel Rocker: initial contact to foot flat during loading response - deceleration of foot towrad floow (eccentric PF by DF)
- Ankle Rocker: ankle advacnes over the ankle foot complex - DF as talocrural joint rolls over stable foot (need 10deg DF)
- Toe Rocker: begins as heel rises and body weight rolls over MTP through push off in terminal stance - extension of MTPs
13
Q
Anatomical Assistive Devices
ANKLE
A
- Stirrup: M/L support, tolerated well, wraps around calcaneus
- Lace up: fxns like ankle tape, contains rear foot
- Active Ankle: allows PF/DF, discourages inversion
- Prophylactic: longer effect than taping
- CAM walker: (controlled ankle motion) adjustable ROM, rocker boot, post surgical, fxs, severe sprains, unloading of wounds etc
14
Q
Anatomical Assistive Devices
KNEE
A
- Prophylactic: decrease M/L damage to knee, conflicting evidence regarding efficacy (no change in injury rate, increased foot injuries)
- Post Operative: protected and controlled motion - can lock ROM to limit flex/ext
- Functional: attempt to control ML stability, anterior tibial translation and recurvatum 0 return to activity - prefab or custom
- PF: correct patellar position, mixed research, valgus control
- Unloading: decrease stress in OA knees, designed to distract joint surface at M or L knee, more effective than neoprene sleeves, condylar separation seen
15
Q
Anatomical Assitive Devices
HIP
A
- Hip Compression shorts: soft tissue injuries
- Post Dislocation:
- Congenital = Pavlik harness
- adults = hip ADD orthosis - both keep femoral head in acetabulum
16
Q
Leg Calve-Pertheses Disease
A
- AVN = loss of blood supply to femoral head
- Scottish - Rite Brace = keeps hips in ABD while still allowing for ambulation
- Toronto Orthosis
17
Q
Shoe Modifications for Neurological Conditions
A
- lifts
- metatarsal bars (shift pressure behind MT)
- last modifications (solid form around shoe)
- wedges
- depth changes
- rocker bottom
18
Q
FO = Foot Orthosis
Neurological Conditions
A
- Plastic foot - orthoses and supramalleolar orthoses (SMO) for excessive tone
- Diabetes shoes, arthritis
- modify weight transfer
- Accomodate deformities
*
19
Q
AFO = Ankle Foot Orthosis
indications, contra indications
A
- General indications
- flexible deformity
- weakness of foot and ankle
- need for stability
- Contraindications
- fixed deformity
- open wound
- Types
- Metal and Leather
- Plastic
- Conventional
- Patient Long Term
- hyperextension before/after DAFO
- better initial contact
- limit hyperextension
- better stepping
- low tone pronation
20
Q
Metal and Leather AFOs
A
- conventionial
- provides very good support
- relies on well constructed shoe
- used if:
- plastic cannot support deformity
- flucuating edema
21
Q
Plastic AFOs
Types and Principles
A
- may have contoured foot plate
- dynamic AFO (DAFO)
- support of arch/toes with custom
- tone reduction
- Molded AFO
- no support arch/toes
- wraps around malleoli depending on need
- Solid AFO
- no ankle motion allowed
- Hinged
- DF assist
22
Q
Solid AFO
WebRep
currentVote
noRating
noWeight
A
- no ankle motion allowed
- indications
- no control of DF
- excessive knee extension in WB
- Contraindications
- knee flex contracture
- need for ankle motion in development
- impacts ALL 3 ROCKERS
- heel rocker - impaired loading response, no PF to reach foot flat
- ankle rocker - dont have 20 DF locked at 90
- Toe rocker - stiff toe plate - no exension of toes
WebRep
currentVote
noRating
noWeight
23
Q
Semi-Rigid AFO
A
- trimlines just behind the malleoli will allow for increase of support and provide both DF positioning of the foot and mediolateral stability of the ankle
- much less motion is allowed
- pt cannot easily propel during push off
- most commonly used for pts with some extensor tone and/or with mediolateral instability of the ankle
24
Q
Hinged AFO
A
- allows ankle motion
- amount of motion limited by stop
- usually limits PF
- indications:
- voluntary DF for adequate toe clearance
- limited control of DF and PF
25
DorsiFlexion Assist AFO
* Can be a spring (conventional)
* assists with DF
* Elasticity of plastic
* Indications
* adequate passive ROM \>5deg
* weakness in DF
* some PF strength
* commonly used for flaccid foot drop
26
Conventional Klenax and Double Adjustable
used when primary problem is DF weakness
Peroneal nerve palsy, CMT, PN
27
Floor Reaction or Ground Reaction AFO
* promote knee extension
* limits DF
* contraindications
* fixed knee or ankle contracture (trying to facilitate motion)
28
Knee Ankle Foot Orthosis
KAFO
* Controls and aligns knee/ankle
* indications
* voluntary hip and trunk
* when excessive movement at knee in stance cant be controlled with AFO
* Contraindications
* Unable to meet energy demands
* lack of strength
* open wounds in area of orthosis
29
Craig Scott KAFO
* used with SCI bilaterally
* swing to or swing thru
* designed for balance in stance
* bail lock - locks when walking, unlock to sit
30
Stance Control KAFO
SCKAFO
* prescribed for quad weakness
* knee is locked in ext during during stance
* free knee flexion and extension in swing
* some elbow resisted flexion during initial contact
31
Hip Knee Ankle Foot Orthoses
HKAFO
indications
* full or partial loss of voluntary control of the trunk and lower extremities
* need to stabilize the trunk
Contraindications
* unable to meet energy demands
* inadequate thoracic, cervical, and UE fxn
* hip flexion contracture
Standing HKAFO
* spina bifida, CP, developmental delay
* parapodiums
* standing shells
* good for weight bearing and preventing contractures, ambulation also
32
Standing HKAFO
* Spina Bifida
* CP
* Developmental delay
* parapodiums
* standing shells
33
Reciprocal-Gait Orthosis
RGO
* uses dual cable system to couple flexion of one hip with extension of the other hip
* AFOs and knee joints offset posteriorly with lateral ring locks
* rigid pelvic band
* may have plastic molded TLSO attached
34
Hip Guidance Orthosis
HGO
* Closed fitting rigid body orthosis
* low friction hip joint
* fixed ankle shoe plate with 6 deg of DF
* rocker sole
* designed to reduce energy in walking and some thing has better ground clearance and smoother gait than RGO
35
Important Things to Monitor with Orthoses
* Wearing Schedule
* Skin care
* Orthosis Care
* Clean soap and water
* Problems
* skin/orthosis breakdown
* pain
* swelling/discoloration
36
Foot Function
* adapt to uneven terrain and act as a rigid lever for push off
* absorb rotation of LE
* offer balance
* offer protection
* inability to perform these tasks causes a problem up the kinetic chain
* need foot orthosis bc: support, control, cushion
37
2 primary types of foot orthoses
1. corrective/functional
2. accomodative - more cushioning
38
Soft Foot Orthoses
* reduce pressure
* tend to be thicker and require a deeper shoe
* PLASTAZOTE = most common material - closed cell polyethylene thermoplastic
* disadvantage = retains heat from foot
39
Semi-Rigid Foot Orthoses
* firmer materials than soft
* incorporate posting techniques
* usually full length
* purpose:
* improve weight transfer
* support and stabilize deformities of the foot and LE
* to relieve pressure
* most frequent used
* NICKLEPLAST = common
* derometer = measure of density
40
Rigid Foot Orthoses
* Advantages
* thin
* 3/4 length (can slide in shoe though)
* useful in dress shoes
* SUBORTHOLENE
* Disadvantages
* limited impact reduction
* increased pressure areas
* highly skilled fabrication
* materials often crack with high forces
* contraindicated for highly active
* may result in stress fx, impingement or neuroma
41
Shell
Can be modified - basic starter for modifcation
42
Post
RF 3-5 degrees normal)
* Medial post to prevent collapsing down
* Internal post - add post to cast
* External post - add to orthotic, more modifiable
* 1/4 in material = 2-3 deg post
43
Flanges
like a wing - widening of the orthotic shell
44
Fore Foot Ext/ Morton's Ext
| (metatarsalgia)
longer where first MTP is
good for turf toe - prevent ext of 1st MTP
45
Scaphoid Pad
increases arch height
46
Met Pad/ Met Bar
| (metatarsalgia)
* unload metatarsal heads
* creates shelf for joints to decrease load
* increase transverse arch
47
Cut out
remove areas of pressure (PF 1st)
48
Basyily
Over the counter customizable - like stickers that you add or remove
49
Foot Orthoses and Gait
* posted non-molded = best at reducing peak RF eversion and tibial IR in non injured
* non-posted molded and posted molded = reduction in loading rate and vertical impact forces when compared to controls and posted non-molded
* neuromuscular control paradigm - inconclusive
50
Effectiveness of Sham, Prefab and Custom
* Sham didnt work
* similar response in prefab and custom
* long term = didnt have any advantage
* think of orthotics as a temporary device
51
Foot Orthoses as an Intervention
Treatment DIrection Test (TDT)
* determine the suitability of an orthosis
* determine the activities that the athlete has difficulty performing or provoke pain
* determine possible harmful or excessive motions and attemp to alter these motions via strapping, taping, or temp felt orthosis
* reasses the painful activity with the modification
* the greater the improvement the more likely orthoses would be beneficial
* using pads and taping to alter asterisk signs
* TDT for excessive pronators:
* low dye taping to control navicular hieght
* prefab OTC inserts
* orthopedic felt temporary orthoses
52
Shoe Recommendation
Under Pronator
* stitch lasted
* curve lasted
* neutral heel cup
* moderate to soft cushioning
* lateral flex in midfoot
53
Shoe Recommendation
Over Pronator
* Board lasted
* straight lasted
* wide forefoot
* moderate to firm cushioning
* sitff midfoot
54
Common Mechanisms of Action
Spinal Orthoses
1. reduce gross spinal motion
2. stabilize individual motion segments
3. apply closed chain force systems to correct or prevent deformity
4. protect surgical constructs by preventing bending and twisting
5. require careful detail and follow up adjustments
55
Effects and Negatives of Spinal Orthoses
Effects:
* trunk support
* motion restriciton
* modification of skeletal alignment
Negatives:
* atrophy, weakness, dependence
* discomfort
* respiratory difficulty
56
Sacroiliac Corsets
* only support SIJ
* emcompass pelvis but not lower trunk
* increase abdominal pressure only slightly
* best for mild SIJ dysfunction
57
Lumbosacral Orthoses
LSO
* most frequently prescribed orthosis for LBP
* fortified with rigid and flexible stays
* limit much but not all lumbar motion
* increase intracavity pressure
* transmit 3 point pressure systems to lumbar spine
* often used for acute LBP
* questionable efficacy for chronic LBP
58
Jewett Hyperextension or
CASH TLSO
* used for patients with compression fractures of low thoracic and lumbar spine
* limits trunk flexion with 3 point pressure system
59
Taylor-Knight TLSO
* Limits spinal motion in both coronal and sagittal planes
* has thoracic and pelvic bands connected by paraspinal bars and a set of lateral bars
* originally designed for patient with TB
* now primarily used for LBP
* stable, noncompression fractures of lumbar spine
60
Cervical Orthoses
General
* comfortable to wear
* soft collar-does not restrict motion in any plane
* kinesthetic reminder after whiplash or neck pain
* molded soft collar
* may contrubute to forward head posture
61
Philadelphia Collar
* most recognized reinforcement collar
* low trimlines do not effectively immobilize C-spine nor prevent lateral flexion or rotation
*
62
Aspen 4-Post
* CTO
* higher trimlines for more control
63
Cervical Halo
* For complete control of cervical and upper thoracic spine
* used in 3 ways:
* min movmnt during surg
* control motion after surg
* conservative tx post non displaced upper cervical vertebral fractures
* Rehab considerations
* some may be "top heavy"
* post control strategies needed after removal
* if pt falls w/ halo, check for bleeding at pin sites
64
Scoliosis
Etiology
* idipathic in 65% of cases (infantile, juvenile or adolescent)
* congenital w/ vert /rib abnormalities
* neuromuscular 10% (CP, SB, SMA)
* Myopathic (MD, arthrogryposis)
* indicence:
* 2% has \>/= 10 degrees
* .2% has \> 20 degrees
* .1% has \> 40 degrees
* 50% of curves \> 15 deg do not progress
65
Scoliosis
Anatomical Abnormalities and Clinical Findings
* structural - does not change with position
* functional - changes depending on cause
* frontal plane curvature noted observation -rib hump
* subjective complaints of soft tissue and/or joint pain
* SOB if very severe
diagnositc tests: Xrays with measurement of curve
66
Measuring Cobb Angle
67
Treatment of and Controlling
Scoliosis
Treatment
* medical intervention of NSAID for p!
* 5 deg over 6mo
* 30-45deg = bracing
* \>50 deg = surgery
controlling scoliosis
* exercise - no proven benefit
* e-stim - questionable results with curves\>30 degress
* bracing
* fusion
68
Treatment of Associated P! and Dysfunction with Scoliosis
* p! controlling modalities
* mobilization of appropriate segments as needed, stability of other segments
* restoration of ROM as tolerated
* restoration of muscle flexibility
* restoration of ms strength of periscapular and trunk/hip stabilizers
* patient ed w/ posture, body mechanics and fitness
69
Indications with Scoliosis
* 10-20 deg = observe
* 20-30 deg = observe. possible brace
* 30-40 deg = orthosis
* 40-50 deg = surgery - try to delay spinal fusion until child has as much trunk height as possible
70
Milwaukee Brace
CTLSO
71
Boston Brace TLSO
To be worn Full TIME
72
Charleston Bending Brace
TLSO
* Worn only at night
* places trunk in overcorrected side psition
* not compatible with walking etc
* stabilizing force at trochanter and a laterally directed force at the apex of the curve
* most effective with single curves
73
Providence Scoliosis System
* Worn only at night
* employs over correction in molded plastic appliance
* uses series of corrective pads to apply hyper correction
* fabricated with CAD/CAM technology
* applies to wider range of curves than charleston and double curves
74
Dynamic Scoliosis Brace
SpineCor
* constructed from flexible materials
* dynamic forces to maintain spinal deform
* re-educates body to return to norm posture
* made of a free moving configuration
* wear 20 hrs/day for at least 18 months
* efficacy not as good as rigid orthoses
75
76
Purpose of UE orthoses
* prevent/correct deformity
* support/protect or immobilze the joint
* assist weak mvmnt
* provide rest to joint
* stress relief
* transfer movement from one joint to another
* assist in muscle re-ed
77
Splint Design Principles
* needs and expectations of pt
* position
* areas to be suppoted
* distribution of support
* total contact?
* small area of support?
*
78
Mechanical Considerations
Wrist/Hand Splinting
apply force perpendicular to segment
use leverage
disseminate the applied force
minimize friction
allow full motion at non affected joints
79
Wrist and Hand Splint
Common Pathologies
* post-fracture
* tendonopathies - tennis elbow
* carpal tunnel
* instability of wrist
* arthritis
80
Static Splint
immobilize and protect
allow tissues to rest
81
Dynamic Splinting
control motion
allow motion
substitute for muscle
82
