مجتبی کامیاب مهر هشتاد و هشت ارتز وپروتز مجتبی کامیاب مهر هشتاد و هشت

Outlines What Orthotics and Prosthetics are History of Orthotics and Prosthetics Orthotics and Prosthetics in Iran What we are going to get on today’s and tomorrow’s sessions

What Orthotics and Prosthetics are Orthotics, Orthosis, and Orthoses Brace, Splint Eponyms Milwaukee Brace Miami Brace ISO terminology 1989 Acronyms Cervical Orthosis: CO Ankle Foot Orthosis: AFO Prosthetics, Prosthesis, and Prostheses Terminology

History of Orthotics and Prosthetics A Persian soldier: 486 B.C. A Mummy: 250 B.C. A Knight in Germany: 1840 Pirates 1st and 2nd World Wars Orthotics and Prosthetics is rapidly evolving

Orthotics and Prosthetics in Iran Establishment process Education Problems

What we will have in the next 3 sessions Spinal orthoses Lower limb orthoses Upper limb orthoses

Few points on orthotic prescription Optimal setting: Physician, Orthotist, therapist are available for evaluation as well as follow-ups. Prescription: Name, DoB, Functional deficit, Reason of orthosis, Area of coverage, Action on each joint in each plane, Materials, Concerns, Need for consultation, and etc.

Different classification styles Function Area of the body Material Manufacturing method Objectives

Classification based on function Prophylactic Rehabilitive Functional

Classification based on area of the bady Upper limb Lower limb Foot Spine Head

Classification based on the used materials High temperature thermoplastics Low temperature thermoplastics Leather Metal Electronics? Particularly in sport!

Classification based on manufacturing method Prefabricated Custom made Prefabricated – custom fitted

Classification based on objectives Pain relief Deformity correction Enhance range of motion Immobilisation A counterforce

مجتبی کامیاب مهر هشتاد و هشت ارتز وپروتز2 مجتبی کامیاب مهر هشتاد و هشت

Spinal orthoses Reasons Level Structure Abdominal support Pain management Motion/Position control Level SO LSO TLSO Structure Semi rigid Rigid

Semi rigid spinal orthoses Some degree of immobilisation Lordosis reduction lumbo-sacral strain Intracavitary pressure reduced axial load Management of pain caused by muscle strain Long term use Atrophy Increased chance of reinjury

Semi rigid spinal orthoses (cont.) Sacroiliac corset Provides assistance to pelvis only The main indication is hyper mobility of sacroiliac joints. Slight increase to abdominal pressure Lumbosacral corset Increases abdominal pressure Acute back pain Thoracolumbar corset Shoulder straps provide a posteriorly directed force Kinesthetic reminder

Rigid spinal orthoses Prescription considerations: Categories Patient gadget tolerance Donning and doffing Categories Conventional or Metal Contemporary equivalents

LSO Chairback style Knight style (Knight, 1884) Williams style Reduction of gross motion in sagittal plane Knight style (Knight, 1884) Sagittal-coronal control Williams style Extension-coronal control Dynamic orthosis By Willimas in 1937 for spondylolisthesis

TLSO Jewett style Taylor style Knight taylor Cowhorn style Flexion control (hyper extension orthosis) Jewett 1937 Taylor style Sagittal control (equivalent to chairback) Knight taylor Sagittal-coronal control (equivalent to knight) Cowhorn style Triplanar control

Contemporary spinal orthosis LSO TLSO Custom molded body jacket Maximum control The bivalve design  patients with variable volume

Jewett brace Indications: Symptomatic relief of compression fractures not caused by osteoporosis Immobilization after surgical stabilization of thoracolumbar fractures  Motion restrictions: Limits flexion between T6-L1 Ineffective in limiting lateral bending and rotation of the upper lumbar spine Contraindications: Three-column spinal fractures involving anterior, middle, and posterior spinal structures Compression fractures above T6, because segmental motion increases above the sternal pad Compression fractures caused by osteoporosis

Cervical orthoses Reasons Level Structure Pain management Motion/Position control Level CO CTO Structure Semi rigid Rigid

Cervical orthoses Foam collars Semi rigid collars Kinesthetic reminder Semi rigid collars Philadelphia collar Little control of lateral bending and rotation Poster style orthoses

Cervicothoracic orthoses Sternal Occipital Mandibular Immobiliser (SOMI) More effective in control of flexion than extension Halo Provides triplanar control Fixed to skull with pins Intersegmental snaking

Indications for the use of a soft collar: Warmth Psychological comfort Head support when acute neck pain occurs Relief from minor muscle spasm associated with spondylolysis Relief from cervical strain The soft collar provides some motion limitations for the patient, including the following: Full flexion and extension are limited by 5-15%. Full lateral bending is limited by 5-10%. Full rotation is limited by 10-17%.

Indications for the use of a semi rigid collar: Head support when acute neck pain occurs Relief of minor muscle spasm associated with spondylosis Psychological comfort Interim stability and protection during halo application Motion restrictions associated with the hard collar include the following: Full flexion and extension are limited by 20-25%. The hard collar is less effective in restricting rotation and lateral bending. It is better than a soft collar in motion restriction.

Indications of Philadelphia Anterior cervical fusion Halo removal Dens type I cervical fractures of C2 Anterior diskectomy Suspected cervical trauma in unconscious patients Teardrop fracture of the vertebral body (Note: Some teardrop fractures require anterior decompression and fusion.) Cervical strain

Indications for immobilization with the SOMI Atlantoaxial instability caused by rheumatoid arthritis (Note that ligamentous disruption in rheumatoid arthritis affects flexion more than extension, because extension is held in check by the intact dens.) Neural arch fractures of C2, because flexion causes instability Motion restrictions associated with the SOMI include the following: Cervical flexion and extension are limited by 70%-75% Lateral bending is limited by 35% Rotation is limited by 60-65%

Indications for immobilization with a halo device: Dens type I, II, or III fractures of C2 (Note: Dens type III fractures of C2 are treated more successfully with surgery.) C1 fractures with rupture of the transverse ligament Atlantoaxial instability from rheumatoid arthritis, with ligamentous disruption and erosion of the dens C2 neural arch fractures and disc disruption between C2 and C3. (Note: Some patients may need surgery for stabilization.) Bony, single-column cervical fractures Cervical arthrodesis - Postoperative Cervical tumor resection in an unstable spine - Postoperative Debridement and drainage of infection in an unstable spine - Postoperative Spinal cord injury (SCI) Contraindications for the use of a halo device include the following: Concomitant skull fracture with cervical injury Damaged or infected skin over pin insertion sites

Orthoses for spinal deformity Milwaukee brace CTLSO TLSO Boston Prefabricated, custom fitted Miami One piece, posterior opening, custom molded Wilmington Risser frame Charleston Bending brace Night time use

Main features of an spinal orthosis Weight Adjustability Functional use Cosmesis Cost Durability Material Ability to fit patients of various sizes Ease with which the device can be put on (donned) and taken off (doffed) Provision of access to a tracheostomy site, peg tube, or other drains Provision of access to surgical sites for wound care Provision of aeration in order to avoid skin maceration from moisture

Indications for recommending the use of orthoses Pain relief Mechanical unloading Scoliosis management Spinal immobilization after surgery Spinal immobilization after traumatic injury Compression fracture management Kinesthetic reminder to avoid certain movements

Duration of orthosis use Where spinal instability is not an issue, until he/she can tolerate discomfort without the brace. When employed for stabilisation after surgery or acute fractures, 6-12 weeks of use should be allowed to permit ligaments and bones to heal

The use of an orthosis is associated with several drawbacks Discomfort Local pain Osteopenia Skin breakdown Nerve compression Ingrown facial hair in men Muscle atrophy with prolonged use Decreased pulmonary capacity Increased energy expenditure with ambulation Difficulty in donning and doffing the orthosis Difficulty with transfers Psychological and physical dependency Increased segmental motion at the ends of the orthosis Unsightly appearance Poor patient compliance

The successful use of an orthosis may lead to: Decreased pain Increased strength Improved function Increased proprioception Improved posture Correction of spinal curve deformity Protection against spinal instability Minimized complications Healing of ligaments and bones

مجتبی کامیاب مهر هشتاد و هشت ارتز وپروتز3 مجتبی کامیاب مهر هشتاد و هشت

Lower limb orthoses FO is a foot orthosis. AFO is an ankle-foot orthosis. KO is a knee orthosis. KAFO is a knee-ankle-foot orthosis. HO is a hip orthosis. HKAFO is a hip-knee-ankle-foot orthosis. THKAFO is a trunk-hip-knee-ankle-foot orthosis.

Shoe Modifications Heel modifications A cushioned heel: A wedge of compressible rubber is inserted into the heel to absorb impact at heel strike. Often with a rigid ankle A heel wedge: A medial wedge is used to promote inversion, and a lateral wedge is used to promote eversion.

Other heel modifications A heel flare: A medial flare is used to resist eversion. A lateral flare is used to resist inversion. Both flares are used to provide heel stability. Extended heel: The Thomas heel projects anteriorly on the medial side to provide support to the medial longitudinal arch. Heel elevation: A shoe lift is used to compensate for fixed equinus deformity.

Sole modifications A rocker bar is a convex structure placed posterior to the metatarsal head. The rocker bar is used to shift the rollover point from metatarsal head to metatarsal shaft to avoid irritation of ulcers along the metatarsal head in patients with diabetes mellitus. A metatarsal bar is a bar with a flat surface placed posterior to the metatarsal head. The metatarsal bar is used to relieve the pressure from the metatarsal heads. A sole wedge: A medial wedge is used to promote supination, and a lateral wedge is used to provide pronation.

Foot orthosis UCBL (University of California at Berkeley Laboratory) insert: This insert is made of rigid plastic fabricated over a cast of the foot held in maximal manual correction. The UCBL encompasses the heel and midfoot, and it has rigid medial, lateral, and posterior walls. Heel cup: The heel cup is a rigid plastic insert that covers the plantar surface of the heel and extends posteriorly, medially, and laterally up the side of the heel. The heel cup is used to prevent lateral calcaneal shift in the flexible flat foot.

Orthotic Management For Athletic Injuries 1 Turf Toe Common in athletes playing on firm, artificial turf Forceful extension of the 1st MTP joint Injury to the joint capsule Untreated, can lead to Arthritic Joint Changes Hallux limitus Hallux rigidus

Orthotic Management For Athletic Injuries 2 Turf Toe Goal of Orthotic Treatment Limit Great Toe Extension Helping joint capsule to heal Carbon Footplates Total Contact FO

Orthotic Management For Athletic Injuries 3 Heel Pain Sever’s disease Active adolescents Girls 8 to 10 yrs of age Boys 10 to 12 yrs of age Strong pull of Achilles’ tendon

Orthotic Management For Athletic Injuries 4 Heel Pain Conservative Treatment for Sever’s Disease Rest Stretches Soft heel cups FO with heel cushion Walking boot in slight equinus / heel wedge

Orthotic Management For Athletic Injuries 5 Heel Pain Plantar Fasciitis Repetitive strain of the plantar fascia

Orthotic Management For Athletic Injuries 6 Plantar Fasciitis Treatment Stretches Heel Cushions / Gel cups Nocturnal dorsiflexion splints AFO (custom) Total contact day & night

Orthotic Management For Athletic Injuries 7 Ankle Sprains Treatment corresponds to degree of instability Walking boot Ankle lacer, stirrup, sleeve Chronic sprains, instability Foot orthotics Ankle lacer during sport Medial or lateral support

Orthotic Management For Athletic Injuries 8 Achilles Tendon Injury Immobilization Custom made AFO Floor reaction AFO Walking Boot Reduce Stress on Injured Site Allow Healing

Orthotic Management For Athletic Injuries 9 Metatarsal Fractures Dancer’s fracture Jones fracture 5th Metatarsal fracture “March Fracture” High rate of 2nd and 3rd MT stress fractures

Orthotic Management For Athletic Injuries 10 Metatarsal Fractures Orthotic Treatment Walking boot AFO (custom made) Prevention Foot orthotics addressing the shock absorbing and/or functional needs of the individual

Thermoplastic AFOs Posterior leaf spring (PLS): For compensating for weak ankle dorsiflexors , no mediolateral control. Spiral AFO: Allows for rotation in the transverse plane while controlling ankle dorsiflexion and plantar flexion, as well as eversion and inversion.

Thermoplastic AFOs (Continued) Solid AFO: Prevents ankle dorsiflexion and plantar flexion, as well as varus and valgus deviation. AFO with flange: This AFO has an extension (flange) that projects from the calf shell for valgus, varus control. Hinged AFO: The adjustable ankle hinges can be set to the desired range of ankle dorsiflexion or plantar flexion.

Metal AFO Free motion ankle joint: allows free ankle motion and provides only mediolateral stability. Dorsiflexion assist spring joint: This joint has a coil spring in the posterior channel and helps to aid dorsiflexion during swing phase. Varus or valgus correction straps (T-straps): valgus, varus correction.

Knee Ankle Foot Orthosis Free motion knee joint: to prevent hyperextension. for patients with recurvatum but good strength of the quadriceps Offset knee joint: is located posterior to ground reaction force; thus, provides great stability joint flexes the knee freely during swing phase is contraindicated with knee or hip flexion contracture and ankle plantar flexion stop. Drop ring lock knee joint: is the most commonly used knee lock to control knee flexion. gait is stiff without knee motion.

Knee Ankle Foot Orthosis Adjustable knee lock joint (dial lock): It allows knee locking at different degrees of flexion. in patients with knee flexion contractures that are improving gradually with stretching. Ischial weight bearing:

Knee Orthoses Knee orthoses for patellofemoral disorder: to control tracking of the patella during knee flexion and extension. Knee orthoses for knee control in the sagittal plane: to control genu recurvatum with minimal mediolateral stability. Knee orthoses with adjustable knee joint fpr flexion contracture. Knee orthoses for knee control in the frontal plane: The knee joint usually is polycentric and closely mimics the anatomic joint motion. Knee orthoses for axial rotation control: These orthoses can provide angular control of flexion-extension and mediolateral planes, in addition to controlling axial rotation. This orthosis is used mostly in management of sports injuries of the knee. This type of KO includes Lenox-Hill derotation orthosis and Lerman multiligamentous knee control orthosis.

Hip Knee Ankle Foot Orthoses Reciprocating Gait Orthosis

Sport related orthoses Prophylactic Yes: To prevent excessive forces To prevent sudden impact No: It increases energy expenditure It can harm others Anatomical and mechanical correspondence

مجتبی کامیاب مهر هشتاد و هشت ارتز وپروتز3 مجتبی کامیاب مهر هشتاد و هشت

Lower limb orthoses FO is a foot orthosis. AFO is an ankle-foot orthosis. KO is a knee orthosis. KAFO is a knee-ankle-foot orthosis. HO is a hip orthosis. HKAFO is a hip-knee-ankle-foot orthosis. THKAFO is a trunk-hip-knee-ankle-foot orthosis.

Materials Plastics Low-temperature thermoplastics: Mainly in low stress activities. High-temperature: They are ideal for high stress activities. Leather: It conducts heat and absorbs water well. Rubber: Rubber is used for padding in body jackets and limb orthoses. Metal Metals, such as stainless steel and aluminum alloys can be used for joint components, metal uprights, sprints, and bearings.

Shoe Modifications Heel modifications A cushioned heel: A wedge of compressible rubber is inserted into the heel to absorb impact at heel strike. This cushion often is used with a rigid ankle to reduce the knee flexion moment by allowing for more rapid ankle plantar flexion. A heel wedge: A medial wedge is used to promote inversion, and a lateral wedge is used to promote eversion. The heel counter should be strong enough to prevent the hindfoot from sliding down.

Other heel modifications A heel flare: A medial flare is used to resist eversion, and a lateral flare is used to resist inversion. Both flares are used to provide heel stability. Extended heel: The Thomas heel projects anteriorly on the medial side to provide support to the medial longitudinal arch. The reverse Thomas heel projects anteriorly on the lateral side to provide stability to the lateral longitudinal arch. Heel elevation: A shoe lift is used to compensate for fixed equinus deformity or for any leg-length discrepancy of more than one centimeter.

Sole modifications A rocker bar is a convex structure placed posterior to the metatarsal head. The rocker bar is used to shift the rollover point from metatarsal head to metatarsal shaft to avoid irritation of ulcers along the metatarsal head in patients with diabetes mellitus (DM). A metatarsal bar is a bar with a flat surface placed posterior to the metatarsal head. The metatarsal bar is used to relieve the pressure from the metatarsal heads. A sole wedge: A medial wedge is used to promote supination, and a lateral wedge is used to provide pronation. A steel bar: The steel bar is placed between the inner sole and outer sole. This bar is used to reduce forefoot motion to reduce the stress from phalanges and metatarsals. Combination of sole and heel modifications: If heel elevation is more than one half an inch, a sole elevation should be added to avoid equinus posture.

Foot orthosis UCBL (University of California at Berkeley Laboratory) insert: This insert is made of rigid plastic fabricated over a cast of the foot held in maximal manual correction. The UCBL encompasses the heel and midfoot, and it has rigid medial, lateral, and posterior walls. Heel cup: The heel cup is a rigid plastic insert that covers the plantar surface of the heel and extends posteriorly, medially, and laterally up the side of the heel. The heel cup is used to prevent lateral calcaneal shift in the flexible flat foot. Sesamoid insert: This addition to an orthosis is an insert amounting to three quarters of an inch with an extension under the hallux to transfer pressure off the short first metatarsal head and onto its shaft.

Thermoplastic AFOs Posterior leaf spring (PLS): The PLS is the most common form of AFO with a narrow calf shell and a narrow ankle trim line behind the malleoli. The PLS is used for compensating for weak ankle dorsiflexors by resisting ankle plantar flexion at heel strike and during swing phase with no mediolateral control. Spiral AFO: This AFO consists of a shoe insert, a spiral that starts medially, passes around the leg posteriorly, then passes anteriorly to terminate at the medial tibial flare where a calf band is attached. The spiral AFO allows for rotation in the transverse plane while controlling ankle dorsiflexion and plantar flexion, as well as eversion and inversion.

Thermoplastic AFOs (Continued) Solid AFO: The solid AFO has a wider calf shell with trim line anterior to the malleoli. This AFO prevents ankle dorsiflexion and plantar flexion, as well as varus and valgus deviation. AFO with flange: This AFO has an extension (flange) that projects from the calf shell medially for maximum valgus control and laterally for maximum varus control. Hinged AFO: The adjustable ankle hinges can be set to the desired range of ankle dorsiflexion or plantar flexion.

Metal AFO Free motion ankle joint: The stirrup has a completely circular top, which allows free ankle motion and provides only mediolateral stability. Dorsiflexion assist spring joint: This joint has a coil spring in the posterior channel and helps to aid dorsiflexion during swing phase. Varus or valgus correction straps (T-straps): A T-strap attached medially and circling the ankle until buckling on the outside of the lateral upright is used for valgus correction. A T-strap attached laterally and buckling around the medial upright is used for varus correction.

Knee Ankle Foot Orthosis Free motion knee joint: to prevent hyperextension. for patients with recurvatum but good strength of the quadriceps Offset knee joint: is located posterior to ground reaction force; thus, provides great stability joint flexes the knee freely during swing phase is contraindicated with knee or hip flexion contracture and ankle plantar flexion stop. Drop ring lock knee joint: is the most commonly used knee lock to control knee flexion. gait is stiff without knee motion.

Knee Ankle Foot Orthosis Adjustable knee lock joint (dial lock): It allows knee locking at different degrees of flexion. in patients with knee flexion contractures that are improving gradually with stretching. Ischial weight bearing:

Knee Orthoses Knee orthoses for patellofemoral disorder: to control tracking of the patella during knee flexion and extension. Knee orthoses for knee control in the sagittal plane: to control genu recurvatum with minimal mediolateral stability. Knee orthoses with adjustable knee joint fpr flexion contracture. Knee orthoses for knee control in the frontal plane: The knee joint usually is polycentric and closely mimics the anatomic joint motion. Knee orthoses for axial rotation control: These orthoses can provide angular control of flexion-extension and mediolateral planes, in addition to controlling axial rotation. This orthosis is used mostly in management of sports injuries of the knee. This type of KO includes Lenox-Hill derotation orthosis and Lerman multiligamentous knee control orthosis.

Hip Knee Ankle Foot Orthoses Hip joints and locks: The hip joint can prevent abduction and adduction as well as hip rotation. Single axis hip joint with lock: This joint is the most common hip joint with flexion and extension. The single axis hip joint with lock may include an adjustable stop to control hyperextension. Two-position lock hip joint: This hip joint can be locked at full extension and 90° of flexion and is used for hip spasticity control in a patient who has difficulty maintaining a seated position. Double axis hip joint: This hip joint has a flexion-extension axis and abduction-adduction axis to control these motions.

Sport related orthoses Prophylactic Yes: To prevent excessive forces To prevent sudden impact No: It increases energy expenditure It can harm others Anatomical and mechanical correspondence