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

2. 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

3. 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

4. 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

5. Orthotics and Prosthetics in Iran
Establishment process
Education
Problems

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

7. 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.

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

9. Classification based on function
Prophylactic
Rehabilitive
Functional

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

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

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

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

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

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

16. 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

17. 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

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

19. 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

20. 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

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

22. 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

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

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

25. 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

26. 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%.

27. 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.

28. 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

29. 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%

30. 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

31. 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

32. 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

33. 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

34. 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

35. 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

36. 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

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

38. 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.

39. 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.

40. 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.

41. 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.

42. 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.

43. 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

44. 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

45. 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

46. 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

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

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

49. 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

50. 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

51. 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

52. 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

53. 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.

54. 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.

55. 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.

56. 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.

57. 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:

58. 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.

59. Hip Knee Ankle Foot Orthoses
Reciprocating Gait Orthosis

60. 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

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

62. 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.

63. 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.

64. 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.

65. 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.

66. 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.

67. 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.

68. 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.

69. 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.

70. 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.

71. 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.

72. 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:

73. 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.

74. 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.

75. 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