Orthotics Exam Review
Spinal Orthosis Mechanics
End-point control – has top & bottom to semi-immobilize joints/areas
Total contact – whole surface touched…decreases rotation
3-point system – 2 forces on direction, 1 force opposite in middle
Counter-pressures – brace contact doesn’t allow movement in a given direction
Cervical Orthoses
Soft foam – kinesthetic reminder
Rigid plastic – mild control for soft tissue injury…no rotation control
Philadelphia – soft tissue damage up to C4 or stable Fx
2 & 4-poster – adjustable limits…endpoint control
SOMI – endpoint control…don in supine…can’t put into MRI
Minerva CTO – total contact, extra-stable Philadelphia…hot & hard to don
HALO – can do distraction…limits ALL mvmt…invasive
History of Orthotics
Back to 5th Dynasty
Scoliosis bracing early 1900s
Certifying Organizations – ABC or BOC
Perry – Biomechanical abnormalities of Post-Polio patients and the implications for orthotics management
Post-Polio Pts have normal sensation & motor control
Only need orthoses if substitutions are inadequate / cause joint overuse
Most common is drop-foot…substitution taken is excessive hip flexion  use dorsi-assist device
Goals of LE Orthoses
 P! by  forces around joint (try to distribute forces over as great an area as possible
Assist locomotion & stability
Maintain deformity correction
Influence muscle tone
Shoewear
Environmental protection…support…shock absorption
Good shoe needed for many orthoses…and for efficient gait
Poor shoe may  shearing…cause deformity…lead to fall
Sole – welt, outsole, inner sole, shank
Upper – vamp, tongue, rear quarters
Heel – cushioned or beveled
Reinforcements – widen toe box, shank, counter
Lifts for leg length discrepancy of it locked KAFO on one side
Heel wedge for varus/valgus
Rocker bottom for improved rockers
Beveled/cushioned heel for  lever arms for  force on LR
Heel flares for rolling medial or lateral
Metatarsal pad for pressure shifting
Metatarsal bar for  pressure during toe-off
Metal vs. Plastic Considerations
Edema / swelling (use metal)
Heat resistance & environmental temp.
Sensation / skin integrity
Cosmesis (usually prefer plastic)
Weight limit 180lbs for plastic
Shoe choice
Weight of brace for metal
Orthotics Exam Review
KAFOs
3-point system controls excess knee flexion in stance
Use anterior offset joint for genu recurvatum (usually Post-Polio)
Useful in unlocked position for  proprioception or severe medial-lateral instability
Bilaterally… energy cost… velocity (more than wheelchair)… shoulder forces
Drop locks vs. bail locks
AFOs
Ground reaction  knee extension moment during stance
For weakness/spasticity… stability…indirectly stabilize knee
Rigid for…severe PF spasticity/tone…mild gastroc tightness… DF/KF moment… tibial
progression…use cushioned/beveled heel
Articulating to control DF/PF
Dorsi Stop / Dorsi Assist – weak PFs, excess DF stance, excess PF swing,  tibial control
Leaf spring is dorsi assist – correct foot drop, no tibial control, mild calf weak/tight
Polyarticulating for more precise adjustment
Beekman – Effects of a DFstopped AFO on walking in incomplete SCI patients
DFstop AFOs don’t disrupt calf muscle recovery postSCI
DFstop AFOs  gait speed & step length
DF stop AFOs better knee position   stance limb stability
No change in PF or Quad function…but  pretibial function
Lehmann – Gait abnormalities in hemiplegia: correction by AFO
Main AFO benefits:  speed & normalize heel strike via PFstop
Poorly adjusted/locked AFO   difficulty of gait…KF moment  knee instability
Rancho ROADMAP
KAFOs & RGOs (<3+/5 quads &/or  proprioception)
AFO not KAFO if: intact knee proprioception, but <3+/5 quads
Unlocked KAFO if: ipsi <3+/5 quads…w/o proprioception
ipsi <3+/5 & contra >3+/5 quads…knee HE ROM available
Locked KAFO if:
ipsi <3+/5 & contra >3+/5 quads…w/o knee HE ROM
(B) Locked KAFO if: Bilat <3+/5 quads…no contractures, flexible, strong UEs
AFOs (>3+/5 quads &/or intact proprioception)
No AFO if:
ok strength, ok proprioception, no PF spasticity
weak ankle…PF >4/5 or norm DF & PF during gait…DF >4/5
Locked AFO if:
 proprio or PF spasticity/contracture…Berg <43
PFstop AFO if:
 proprio or PF spasticity/contracture…Berg >43
DFstop+ass AFO if: weak ankle…PF <4/5 or excess DF or PF during gait…DF <4/5
DFstop AFO if:
weak ankle…PF <4/5 or excess DF or PF during gait…DF >4/5
DFass AFO if: weak ankle…PF >4/5 or norm DF & PF during gait…DF <4/5
Why Splint?
Prevention – undesired motion or contraction, pain, edema, hematoma
Increase – ROM
Protect – nerve, tissue, function, healing position
Support – joints, tissues
Common Dx: carpal tunnel, spasticity, Jt Arth, contracture, burn, OA/RA, Fx
Key anatomy to preserve
Arches – proximal transvers, distal transverse, longitudinal (palm can flatten & cup)
Web spaces – allow opposition & grasp (tripod & key)
Orthotics Exam Review
Precautions
Pressure areas – epicondyles, olecranon, cubital tunnel, ulnar styloid, axilla, want 2/3 up forearm
Edema  widen splint, widen straps, use kinesiotape under splint
Vascular insufficiency  loosen splint, widen straps, don’t use hot material
Thin tissue  use prefab splint, bubble out area, breathable material
Watch out for cognitive level
Splint types
Static – no moving parts
Limit mvmt, affect all joints they cross
Ex: resting hand, wrist cock-up
Dynamic – rigid base w/ adjustable elastic component
Provide torque, assist w/ ROM program, help gliding
Serial Static / Serial Cast – no moving parts; non-removable & circumferential
Series of static splints to  ROM
Splint Construction
Use 2/3 of forearm
Flare & fold edges…round internal & external corners
Conform to  unequal pressure
 material strength by adding contours
Consider comfort, function, cosmesis, integration into Tx, wearing schedule
Maintaining splint
Wash w/ warm water & soap…not in a machine
Don’t put near heat
Don’t try to modify at home…stick to schedule & note any discomfort
Bring to each PT session
Inspect skin every time it’s removed (if red area >15min, notify PT)
Custom splinting
Heat material to 150-160oF
Stretchy – polyform & aquaplast – finger / wrist / elbow splint; serial cast; resting hand
Mod Stretchy – polyflex & tailor splint – hand / wrist / knee / foot splint; bivalves; equip mod
Not Stretchy – ezeform – elbow splint; spasticity; functional positioning
Patterns – 2/3 forearm & ½ circumference; mark at MCP of 2 & 5; mark at CMC; 1st & 2nd web space