Upper limb orthosis


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Upper limb orthosis

  2. 2. Contents:  Introduction  Objectives of upper limb orthosis  Nomenclature  Classification  Biomechanics of orthosis  General principles  Special principles  Assessment of upper limb orthosis  Description of upper limb orthosis  Recent advances
  3. 3. Introduction  Mechanical device- anatomical and functional position  Orthos – to correct or maintain straight  Any externally device used to modify structural and functional characteristics of the neuromuscular skeletal system  Physiotherapist + orthotist
  4. 4.  Categorized : - Upper limb orthosis - Trunk orthosis - Lower limb orthosis
  5. 5.  Objectives of upper limb orthosis: 1) Protection : - stabilization - Dynamic control 2) Correction 3) Assistance
  6. 6.  To immobilize a body part to promote tissue healing  Prevent contractures  Increase ROM  Correct deformities  Strengthen muscles  Reduce tone  Reduce pain  Restrict motion to prevent harmful postures
  7. 7. Nomenclature :  On basis of - joint they cover - the function they provide - condition they treat - by appearance - name of the person who designed them
  8. 8.  Mainly three systems: 1) International Organization for Standards(ISO) which gives anatomic region wise names 2) 1992, American Society of HandTherapists published ASHT splint classification system (SCS) which gives function and body part wise. In that, numbering system – ‘type’ 3) McKee and Morgan
  9. 9. Common name ASHT splint classification system IOS McKee and Morgan Humeral fracture brace Non articular splints- humerus Not applicable Circumferential non-articular humerus stabilizing Tennis elbow splints or brace 45 degree elbow flexion immobilization type 1[1] Shoulder- elbow – wrist – hand orthosis Circumferential non-articular proximal forearm strap Duran splint, post operative flexor tendon splint Wrist and finger flexion immobilization; type 0[4] WHO Dorsal forearm based static MCP- IP protective flexion and MCP extension blocking orthosis Thumb spica splint Thumb MCP extension immobilization type 2[3] WHFO Volar forearm- based static wrist thumb orthosis
  10. 10. Classification :  On basis of anatomical regions: - Shoulder and arm orthosis - Elbow orthosis - Wrist orthosis - Hand orthosis
  11. 11.  Based on function: - Supportive - Functional - Corrective - Protective - Prevent substitution of function - Prevent weight bearing - Relief of pain
  12. 12.  Based on design: - non-articular - Static - Serial static - Static motion-blocking - Static progressive - Dynamic - Dynamic motion-blocking - Dynamic traction splints - Tenodesis - Continuous passive motion orthoses - Adaptive or functional usage
  13. 13.  Non-articular splint – gel shell splint
  14. 14.  Static – wrist splint for carpal tunnel syndrome, with the wrist position 0-5 degree of extension, distal palmar crease free to allow MCP motion
  15. 15.  Static motion – blocking – swan neck splint
  16. 16.  Static progressive – forearm based splint with both static line pull and MERIT component for increasing MCP flexion
  17. 17.  Dynamic – capener splint for increasing joint extension in the proximal IP joint of the finger
  18. 18.  Dynamic motion-blocking – Kleinert post operative splint for flexor tendon repairs
  19. 19.  Dynamic traction splints- schenck splint for intraarticular fracture
  20. 20.  Tenodesis – Rehabilitation Institute of Chicago tenodesis splint to achieve functional pinch
  21. 21. Biomechanics of orthosis  External force + moments on body  Internal forces  Mainly 4 biomechanical principles: 1) Control of moment across a joint 2) Control of normal forces across a joint 3) Control of axial forces across a joint 4) Control of action of ground reaction force
  22. 22. General principles: 1) Uses of force 2) Limitation of movements- pain 3) Correcting the mobile deformities 4) Fixed deformity 5) Adjustability 6) Pressure reduction 7) Heat
  23. 23. 8)Weight 9) Maintenance and cleaning 10) Application 11) Sensation 12) Gravity 13) Comfort 14) Cosmesis
  24. 24. Special principles: 1) Principle of Jordan 2) May assist with residual motor power or substitute for absent motor power 3) Prehension force must be adequate 4) Only one action 5) Operation of electrically powered orthosis 6) Tactile sensation
  25. 25. Assessment :  Subjective assessment: - Comprehension - Complaints – pain, performance, appearance - Previous orthotic experiences - Gadget tolerance - The goals - Economic consideration
  26. 26.  Objective assessment: - Type of paralysis and prognosis - Limb alignment - Joint range - Muscle power - Coordination and spasticity - Sensory status - Skin - Manual dexterity - Vision - Other disabilities
  27. 27. Description of orthoses: 1) Calvicular orthoses:  Regional name: shoulder orthosis  Common names: figure of four harness, clavicular brace/ harness
  28. 28. Functions Indications - Restrict motion to promote tissue healing Clavicular fractures - Improve posture - Forward shoulder posture - TOS - Reduced scapular myofascial pain - Cumulative trauma disorder - Increase/maintain PROM - Pectoral contractures
  29. 29.  Placement : - Material goes over clavicles, under arms and crosses over high thoracic spinous processes.  Biomechanical efficacy: - Restrict movement of the clavicle and to some extent inhibit scapular protraction while allowing free movement at the GH joint.  Materials : -Webbing straps - Padding and velcro - Prefabricated orthoses often used.
  30. 30. 2) Arm sling  Regional name: shoulder orthosis  Common names:  figure of eight slings  universal sling  Nothern ring sling  Cuff sling  Hemi sling  Orthopaedic sling  Flail arm sling  Homemade Bandanna-Type sling  Glenohumeral support  Hook hemiharness  Rolyan hemi Arm sling(vertical arm sling)
  31. 31. Functions indications - Immobilize to promote tissue healing - AC joint injury - Scapular, humeral fractures - PO shoulder repair/arthroplasty - PO tendon,artery, or nerve repairs - Rotator cuff injury - Bicipital tendinitis - Prevent overstretching of GH musculature/ligaments - Brachial plexus lesion - Decreased shoulder pain related to arm distraction and shoulder- hand syndrome - Upper motor neuron lesion: hemiparesis with subluxation - Keep hand and forearm elevated to reduce oedema
  32. 32.  Placement :  Most slings support the forearm with the elbow flexed, shoulder internally rotated and arm adducted. -The Rolyan hemi arm sling supports the humerus and allows the elbow and forearm to be free by using a humeral cuff with figure of eight suspension. -The hook hemiharness has two humeral cuffs connected by a posterior yoke and abduct each arm slightly while allowing the elbow and forearm to be free.
  33. 33.  Biomechanical efficacy : - Slings may be static or dynamic. - Dynamic slings use elastic straps and are designed to allow some motion of the forearm while supporting the arm. -The wrist should be supported by the sling to prevent wrist drop if there is distal weakness. - Hand should be higher than the elbow to decrease the oedema. - Care must be taken to mobilize the shoulder SOS possible to prevent adhesive capsulitis.
  34. 34.  Materials : - Cloth -Webbing - Elastic - Metal ring/ fastners -Velcro - Prefabricated slings are often used.
  35. 35.  Contraindications: - Slings have fallen over out of favour with a neurodevelopment treatment approach to UMN lesion because they are thought to encourage flexion synergy, increase flexor tone, and promote contractures. -The Rolyan hemi arm slings or the hook hemiharness may not approximate the GH joint in a large patient.
  36. 36. 3) Arm abduction orthosis: - Regional name: shoulder elbow wrist hand orthosis - Common name: airplane splint
  37. 37. Functions Indications - Immobilize to promote tissue healing - Axilary burns - Post operative shoulder fusion - Post operative scar release - Shoulder dislocation - Increase PROM by soft tissue elongation via low load prolonged stretch( serial static splinting) - Burns - contractures
  38. 38.  Placement : - Medial arm and lateral trunk with weight of arm borne primarily on the iliac crest or lateral trunk. - May be one piece or separate waist piece with arm attachment.  Biomechanical efficacy: -The shoulder should be positioned in abduction with the degree determined by pathology. - Care should be taken not to overstretch skin, nerves or vascular structure.  Material : - Casting -Thermoplastic -Metal -Pillow - Padding - Strapping -Velcro
  39. 39. Functional arm orthosis Arm suspension sling – deltoid aid Balanced forearm orthosis- gun slinger Arm supports- wheelchair arm trough
  40. 40. Nonarticular fracture orthosis- humeral fracture brace
  41. 41. 4) Elbow- forearm wrist othosis:  Regional name : elbow wrist hand orthosis  Common name: sugar-tong splint
  42. 42. Functions Indications - Immobilize elbow/forearm/wrist to promote tissue healing - CTD - Forearm fractures - Post operative elbow arthroplasty - Post operative ulnar nerve transposition • Placement : - Circumferential with elbow in 900 of flexion and forearm/wrist in neutral. • Biomechanical efficacy: - Orthosis should totally restrict elbow, wrist and forearm AROM yet should allow full active use of all digits. • Materials : -Thermoplastics - Strapping -Velcro
  43. 43. 5) Elbow or wrist mobilization orthoses:  Regional name: elbow orthoses or wrist orthoses  Common name: - Dynamic elbow -Wrist flexion/extension splint - Dynasplint - Ultraflex splint - Static progressive splint - Phoenix wrist hinge -Turn buckle splint
  44. 44. Functions Indications - Increased PROM by soft tissue elongation via low-load prolonged stretch - Contracture - Post operative scar release - Burns - Fracture (late phase) - Replace or assist weak wrist extensors to enhanceADL - Radial nerve lesion - Spinal cord injury - Brachial plexus lesion - polio Placement : •Dorsal (posterior), volar (anterior) or circumferential
  45. 45.  Biomechanical efficacy:  Two distinct methods can be used to stretch soft tissue, thereby encouraging tissue elongation and increased PROM. 1) Serial splinting: -With low temperature thermoplastics (progressive static splinting) or serial casting.  Advantages: good conformity, little shifting  Disadvantage : potential skin breakdown 2)Traction :  (via elastics, coils, or springs) is applied across the joint(often a hinged joint)  Advantage : amount of load can be adjusted  Disadvantage: forces can cause shifting of orthosis such splints are more difficult to fabricate unless prefabrications are used.  Non compliant patients can remove the orthosis.
  46. 46.  Materials: - Casting -Thermoplastics - Elastics - Neoprene - Metal - Strapping -Velcro - Springs  Contraindications: - Dynamic traction put on muscles with high tone may increase tone.
  47. 47. Posterior elbow splint Epicondylar straps Articulated elbow orthosis Dynamic supination/pronation splint
  48. 48. 6) Forearm-wrist orthosis:  Regional name: wrist-hand orthosis  common name: - Thumb whole wrist cock up splint - Wrist extension splint - Static wrist splint - Bunnell dorsal wrist splint - Bunnell spring cock up splint - Serpentine splint - Neoprene or leather prefabricated wrist extension splint - Gutter splint
  49. 49. Dynamic cock up splint Half cock up splint Spring cock up splint
  50. 50. Functions Indications Immobilize to promote tissue healing CTD CTS Flexor/extensor tendinitis Lateral/medial epicondylitis Wrist sprain/contusion Arthritis Forearm/wrist fractures Post operative extensor tendon repair Post operative wrist fusion Post operative skin grafting Substitute for weak wrist extension SCI BPL Prevent overstretching of wrist extensors Stabilize the wrist for maximal grasp and pinch prehension/strength ALS Radial nerve lesion Polio GBS Arthrogryposis UMN lesion: CVA,TBI, CP,MS
  51. 51. Immobilize wrist / forearm to maintain PROM Restrict motion to prevent harmful wrist postures during activities -Burns -Post operative scar release -CTD - arthritis Elongate soft tissue via low-load prolonged stretch( serial static splinting) -Burns - wrist contractures
  52. 52.  Placement: - This orthoses are volar, dorsal, circumferential, or gutter based, extending from the proximal MP to 2/3rd of the distal forearm. - If volar based, palmar material should end 1/4th inch proximal to the distal palmar crease to allow unrestricted MP flexion  Biomechanical efficacy: - The wrist can be positioned in flexion or extension but for optimal hand function, it should be in 15-30 degrees of dorsiflexion. - For CTS, wrist should be neutral.
  53. 53.  Materials: - Rigid: metal, thermoplastics, casting, straping, velcro - Flexible: neoprene leather, plastics, fabric, strapping, velcro
  54. 54. 7) Forearm-wrist- thumb orthosis:  Regional name: wrist-hand-forearm orthosis  Common names: - Long opponens splint - Thumb spica
  55. 55. Functions Indications Immobilize thumb/wrist to promote tissue healing -CMC/MP synovitis/ arthritis -CTD - de Queryain’s disease -Tenosynovitis -Thenar tendinitis -Thumb sprain -CMC/MP collatral ligament injury( gamekeeper’s thumb) -Scaphoid/ thumb fracture -Post operative thumb - ORIF - Surgical CMC/MP fusion - arthroplasty or reconstruction - tendon transfer - tendon/ligament repair - nerve repair - postoperative trapeziumectomy Substitute for weak thumb muscles, stabilize thumb in opposition for three jaw chuck pinch Median/ ulnar nerve lesion UMN lesion:CVA,TBI,CP
  56. 56. Maintain thumb prom burns Restrict motion to prevent harmful thumb positions during activities CTD Arthritis Athletes or performing artists Elongate soft tissues via low-load, prolonged stretch (serial static splinting) -Burns -Thumb contractures • Placement : - The orthotic material usually cover 2/3rd of the distal radial forearm and surrounds the thumb to the IP ( but can extend to tip)
  57. 57.  Biomechanical efficacy: - In most cases, the thumb should be positioned in palmar abduction so that three jaw chuck prehension is easily achieved , unless pathology dictates otherwise. - Material should not restrict motion of digits 2-5.
  58. 58.  Materials : - rigid: thermoplastics, metal, strapping, velcro, casting, padding - Flexible: neoprene, elastics, fabric, leather, strapping, velcro
  59. 59. Bunnell knuckle bender Spider splint Radial gutter splints
  60. 60. Dynamic finger flexion splint RIC tenodesis othosis Resting pan splint
  61. 61. Bobath splint Kleinert flexor tendon repair splint Short opponens splint Ulnar deviation correction splint
  62. 62. Partial hand opposition splint Finger orthosis Reverse knuckle bender C-Bar splint web splint
  63. 63. Shock absorbing gloves
  64. 64. 8) Ring orthosis :  Regional name: finger orthosis  Common name: - Silver ring splint - Swan neck splint - Figure eight splint - PIP hyperextension block splint - Murphy ring splint - Boutonnaire splint - Pulley ring - PIP extension stop
  65. 65. Swan neck splint Boutonniere splint
  66. 66. Functions Indications Block PIP/DIP hyperextension but allow normal IP flexion /extension Arthritis Swan neck deformity PIP/DIP volar palte injury Prevent overstretching of PIP/DIP volar plate Prevent further deformity Immobilize PIP in extension (DIP free) arthritis Prevent deformity Boutonniere deformity Prevent bowstring of flexor tendons A2 pulley injury(annular pulley for flexor tendon located on volar surface of proximal phalanx) Protect reconstruction/ allow dynamic motion, without immobilizing finger Post operative pulley repair
  67. 67.  Biomechanical efficacy: - Rings are custom fitted and worn at all time. swan neck splint: - Prevent IP hyperextension via three points of pressure but allows full IP flexion. - Lateral or distal supports may be added for stability. boutonniere splint: - Immobilize the IP in extension via three points of pressure. Needs to remove several times in a day.
  68. 68.  A2 pulley ring: - Fits firmly around the proximal phalanx from the PIP volar crease to the MP volar crease.  Materials : - Metal - thermoplastics
  69. 69. Recent advances: 1) Ibrahim M et al. did study on Efficacy of a static progressive stretch device as an adjunct to physical therapy in treating adhesive capsulitis of the shoulder: a prospective, randomised study  To compare a static progressive stretch device plus traditional therapy with traditional therapy alone for the treatment of adhesive capsulitis of the shoulder
  70. 70.  CONCLUSION:  Use of a static progressive stretch device in combination with traditional therapy appears to have beneficial long-term effects onshoulder range of motion, pain and functional outcomes in patients with adhesive capsulitis of the shoulder. At 12- month follow-up, the experimental group had continued to improve, while the control group had relapsed.  Physiotherapy. 2013 Oct 3. pii: S0031- 9406(13)00085-0.
  71. 71. 2) Merolla G et al.did study on Efficacy, usability and tolerability of a dynamic elbow orthosis after collateral ligament reconstruction: a prospective randomized study.  To assess the efficacy, usability and tolerability of a dynamic orthosis compared with a standard plaster splint after the reconstruction of elbow medial or lateral collateral ligaments (MCL, LCL).
  72. 72.  CONCLUSIONS:  The dynamic orthosis and the plaster splint both provided effective and safe elbow immobilization after MCL or LCL reconstruction.The orthosis provided greater pain reduction, faster recovery of muscle trophism and grip strength, and was better tolerated.  Musculoskelet Surg. 2013 Oct 25.
  73. 73. 3) Garg R et al.did study on A prospective randomized study comparing a forearm strap brace versus a wrist splint for the treatment of lateral epicondylitis.  To compare the clinical outcomes of a wrist splint with that of a counterforce forearm strap for the management of acute lateral epicondylitis.
  74. 74.  CONCLUSION:  The wrist extension splint allows a greater degree of pain relief than does the forearm strap brace for patients with lateral epicondylitis.  J Shoulder Elbow Surg. 2010 Jun;19(4):508- 12.
  75. 75. 4)WooY et al.did study on Kinematics variations after spring-assisted orthosis training in persons with stroke.  To evaluate the efficacy of training using kinematic parameters after a SaeboFlex orthosis training on chronic stroke patients.  CONCLUSION:  The results of this study indicate that a SaeboFlex training is effective in recovering the movement of the hemiparetic upper extremity of patients after stroke.  Prosthet Orthot Int. 2013 Aug;37(4):311-6.
  76. 76. 5) Forogh B et al.did study on The effects of a new designed forearm orthosis in treatment of lateral epicondylitis.  on the design and testing of a new designed forearm orthosis and explores its efficacious in comparison to the standard counterforce orthosis in patients with lateral epicondylitis.
  77. 77.  CONCLUSIONS:  The new-designed orthosis can significantly relieve pain, improve function, increase pain threshold and grip strength after application. This orthosis seemed to be more effective than counterforce orthosis in relieving pain and increasing the pain threshold probably due to the limitation of forearm supination.  Disabil Rehabil AssistTechnol. 2012 Jul;7(4):336-9.
  78. 78. 6) Chang M et al. did study on Comparison ofTask Performance, Hand Power, and Dexterity with and without a Cock-up Splint.  Men's grip power with the cock-up splint was found to be significantly decreased compared to without the splint. Women's grip and palmar pinch strength with the splint decreased significantly compared to without the splint. In the grooved pegboard test, the dexterity of both men and women with the cock-up splint decreased significantly compared to without the splint
  79. 79.  Conclusion:  To assist patients to make wise decisions regarding the use of splints, occupational therapists must have empirical knowledge of the topic as well as an understanding of the theoretical, technical, and related research evidence.  J PhysTher Sci. 2013 Nov;25(11):1429-31
  80. 80. 7)Whelan DB et al did study on External Rotation Immobilization for Primary Shoulder Dislocation: A Randomized ControlledTrial.  To compare the (1) frequency of recurrent instability and (2) disease-specific quality-of- life scores after treatment of first-time shoulder dislocation using either immobilization in external rotation or immobilization in internal rotation in a group of young patients.
  81. 81.  CONCLUSIONS:  Despite previous published findings, our results show immobilization in external rotation did not confer a significant benefit versus sling immobilization in the prevention of recurrent instability after primary anterior shoulder dislocation.  Clin Orthop Relat Res. 2014 Jan 3.
  82. 82. References:  S Sunder;Text book of rehabilitation; second edition ; pg no:103-130  Orthotics: a complete clinical approach SLACK  P. Bowker; biomechanical basis of othotic management; pg no: 27-37  John B. Redford, JohnV. Basmajian, Paul Trautman orthotics: clinical practice and rehabilitation technology; pg no: 103- 130
  83. 83.  Randall L.Braddom ; physical medicine and rehabilitation: third edition; pg no: 325-341  Joel A. Delisa ; rehabilitation medicine principles and practice; third edition; pg no: 635-651  Jan stephen tecklin ; pediatric physical therapy; second edition  )Whelan DB et al. External Rotation Immobilization for Primary Shoulder Dislocation: A Randomized ControlledTrial Clin Orthop Relat Res. 2014 Jan 3
  84. 84.  Ibrahim M et al. ; Efficacy of a static progressive stretch device as an adjunct to physical therapy in treating adhesive capsulitis of the shoulder: a prospective, randomised study ; Physiotherapy. 2013 Oct 3. pii: S0031-9406(13)00085-0.  ) Merolla G et al.; Efficacy, usability and tolerability of a dynamic elbow orthosis after collateral ligament reconstruction: a prospective randomized study; Musculoskelet Surg. 2013 Oct 25.
  85. 85.  Garg R et al.; A prospective randomized study comparing a forearm strap brace versus a wrist splint for the treatment of lateral epicondylitis ; J Shoulder Elbow Surg. 2010 Jun;19(4):508-12.  WooY et al.; Kinematics variations after spring-assisted orthosis training in persons with stroke; Prosthet Orthot Int. 2013 Aug;37(4):311-6.  Forogh B et al.The effects of a new designed forearm orthosis in treatment of lateral epicondylitis; Disabil Rehabil Assist Technol. 2012 Jul;7(4):336-9.
  86. 86.  Chang M et al. ;Comparison ofTask Performance, Hand Power, and Dexterity with and without a Cock-up Splint ; J Phys Ther Sci. 2013 Nov;25(11):1429-31  www.ottobock.com
  87. 87. Thank you