orthosisseminar-170910081137 (1).pdf

ORTHOSIS
HIMAKSHI BHATTACHARYA
GUIDED BY: Dr. BHAVANA GADHAVI MAM

OBJECTIVES
1) What is Orthosis Splints and brace ???
2) Classification
3) Splint Design
4) Material use and performance characteristic
5) Prefabricated splint
6) Biomechanical Principle of splinting
7) Upper limb orthosis
8) Lower limb orthosis
9) Spinal Orthosis
10) recent advances
11) References
Textbook of Rehabilitation: S Sunder, Susane O sullivan

Orthosis
A force system designed to control,
correct, or compensate bone deformity,
deforming forces or forces absent from
the body.

SPLINTING AND BRACING
SPLINT:
An orthopedic device use to immobilize and support the body part is
termed as splint.
BRACE:
Brace is a device fitted to the body part which is weak and injured to give support.
Eg: Knee brace for OA.

Classification of Orthosis
ORTHOSIS
ARTICULAR NONARTICULAR
LOCATION
DIRECTION
PURPOSE
TYPE

SPLINT DESIGN
1) Static Splint
2) Serial Static Splint
3) Drop out Splint
4) Dynamic Splint
5) Static Progressive Splint

Static Splint
FOR STABILIZING AND PROTECTINNG JOINT IN PARTICULAR POSITION

Serial Static Splint
THIS TYPE OF SPLINT HELPS IN REGAINING MOVEMENT REDUCING PAIN WITH NOT OVER
STRESSING THE TISSUE.

Drop Out Splint
THIS TYPE OF SPLINT BLOCK ONE MOVEMENT AND ENHANCE OTHER.

DYNAMIC SPLINT
FOR MOBILITY
AND ENHANCING
FUNCTION.

Static Progressive Splints
STRESS AND TENSION
ADJUSTABLE AND MOVEMENT
ENHANCING SPLINT. USED
NOWADAYS TO AVOID SPLINT
COMPLICATION.

MATERIALS USED
1) Low Temperature Thermoplastic material
2) Heated Between 135* & 180* F
3) These materials are such when heated they become pliable and when they
cool down they become rigid
 This must be taken in note that the rigidity of orthosis provide its durability.

PERFORMANCE CHARACTERISTIC
1) Conformability: Properly to fit intimately to contoured area. Proper
conformability is required for proper pressure distribution.
2) Flexibility: Circumference splinting requires flexibility for open and removal
3) Durability: Must be thermoplastic material as its durable rubber may get
fragile with time.
4) Rigidity: Rigidity and firmness of splint provide stability to area provide.
5) Perforation: For allowing air circulation.

PREFABRICATED SPLINTS
Prefabricated splints are the splints which are made commercially for various
material and styles.
As the demand is less so they are not made as frequent as alteration in market is
common so these are not made in bulk.
People who approach this type of splints are rare.

BIOMECHANICAL PRINCIPLES
The Biomechanical Principles of splinting are mainly:
1) Three Point Pressure 7) Control Axial Force across the joint
2) Mechanical Advantage 8) Control line of action of Ground react
3) Torque ion force
4) Degree and Duration of Stress
5) Repetitive stress
6) Control Normal force across the joint

1) Three point pressure: (JORDAN’S Principle)
Most splint follow this three point pressure system to affect a joint motion. A
three-point pressure system consists of three individual linear forces in which
middle force is directed in opposite direction to the other two forces.
It is multiple direction force where one force immobilize one joint and mobilize the
other joint.
Example: cockup splint

FORCE SYSTEM

2) Mechanical Advantage:
Splint incorporate lever system, which incorporate forces, resistance, axes of
motion, and movement arm.
Lets understand it with an example:
Volar based wrist cock up splint here for mechanical advantage forearm length is
made longer so splint has better pressure distribution support and comfortability.

3) Direction of stress:
There are three direction of force to act:
1) Tension
2) Compression
3) Shear
Tension occur when forces both are acting on opposite direction.
Compression occur when force acting in same direction
Shear force occurs when parallel forces are applied in equal and opposite direction.

4) Torque:
It is biomechanical principle defined as rotational effect of mechanism. Torque is
the production of the applied force multiplied by perpendicular distance from the
axis of rotation to the line of application. Most important for dynamic splint.

4) Degree and Duration of Stress:
Generally low stress can be tolerated for longer period of time, whereas high stress
over long period of time cause damage.
Therapist must remember the least stress is tolerated is skin. Skin become
ischemic if load increases.
Distribution of stress is most important for long term wearing of orthosis.

5) Repetitive Stress:
If repetitive stress is applied in moderate amount may lead to breakdown and
damage to skin. So to avoid that traction must be release to avoid unnecessary
tension and well distributed pressure.
These are basic principles of orthosis.

6) Control Normal force across the joint:
Now two free body load carrying are shown in figure when are subjected to
ground reaction force are free to rotate the are maintained in extension this is
normal joint is maintained by capsule and ligaments. But in abnormal joint we
require orthosis to correct it. So, here the role is to correct excessive translation
movement. But this rotatory this creates anticlockwise moment now to balance
this also is role of orthosis
Thus a force system from R1 to R4 with rigid framework helps to maintain
translation and balance anticlockwise moment this is four point pressure system.

6) CONTROL AXIAL FORCES ACROSS A JOINT:
In normal healthy individual load is carried through bony structures and layers of
articular cartilage which have immense strength to bear this weight. Now due to
some degenerative change the integrity of this structure is lost which will cause
excessive compression on joint.
So, here come role of orthosis to offload the joint. This process of offloading
depends on two thing:
1) How the orthosis is fitted
2) orthosis and body segment interface

1) The orthosis here is incorporated as rigid orthosis framework and strapping it
at the end of two limb segment which would divide the force into half.
2) The second criteria is the transfer of load across skin and orthosis solely
depend on friction of orthosis and underlying skin.

8)Control of line of action of ground reaction force:
This principle is only applicable to lower limb orthosis. As foot is placed on ground
it experience ground reaction force.
Now as stance phase is from heel strike to toe off the force and pressure applied is
moving from heel to metarsal head that is toe off.
So, now in normal joint line of gravity passes from front of Hip, back of knee, front
of ankle. Now due to some asymmetric movement the this pattern of GRF is
altered so we need a orthosis for its allingment

So, in this case orthosis management would be moving the line of gravity to center
that is close to joint line. Which can be achieved by modifying the limb movement
during gait.
This is done in two way:
1) By altering angular relationship with plantar surface of foot and floor
2) By altering the angular relationship with most distal joint.

UPPER LIMB ORTHOSIS
shoulder
Textbook of Rehabilitation: S Sunder, Susane O
sullivan

FIGURE OF EIGHT AXILLA WRAP
Common name: Axilla Wraps, clavicle strap brace
Objectives: To retract the scapulae
To apply pressure to the axilla to prevent or correct hypertrophic scar.
To maintain and restore shoulder mobility
To stretch contracted tissue around anterior chest
To prevent and correct Kyphotic Posture.

FIGURE OF EIGHT AXILLA WRAP
– Indication:
1.) Axilla Burns or skin grafting
2.) Shoulder Adduction Contracture
3.) Kyphotic Posture
4.) Clavicle Fracture

GUNSLINGER SPLINT
2.) Lateral Trunk Based Static Shoulder- Elbow-Wrist Orthosis
Common Name: Shoulder/Gunslinger Splint
Objectives:
1) To fully immobilize the shoulder and sometimes Elbow to
promote healing
2) The elbow and wrist are immobilize to maintain full
control on shoulder.

Ulnar functional brace
Objectives :
1) To stabilize ulnar fracture
2) To promote healing without immobilizing any joint
3) To protect fragile bone from fracture
Indications:
1) Midshafts Ulnar Fracture

GUNSLINGER SPLINT
Indications:
1) In Posterior Glenohumeral Instability.
2) Partial Brachial Plexus injury and brachial neuritis
3) Rotator cuff repair

AIRPLANE SPLINT
Common Name: Axilla/ Airplane splint/Conformer
Objectives:
1) To elevate hand and prevent edema
2) To prevent and reduce an axilla contracture
3) To maintain and restore Shoulder Mobility
4) To immobilize upper extremity after skin grafting
5) To apply pressure to prevent or reduce hypertrophic scaring

AIRPLANE SPLINT
Indication:
1) Brachial plexus injury
2) Shoulder Adduction Contractures
3) Complete supraspinatus tear
4) Axilla burns or skin grafting
4) Static Shoulder Elbow Wrist Sling
Common Name: Hemi arm sling

HEMI ARM SLING
Objectives:
1) To immobilize Shoulder and Elbow
2) To support the weight of the upper extremity across the contralateral
shoulder, without stress on neck and back
3) To prevent Brachial Plexus Traction
4) To prevent pain and shoulder subluxation

HEMI ARM SLING
1) Shoulder subluxation caused by flaccid hemiplegia
2) Brachial plexus injury
3) Rotator Cuff injury
4) Upper Extremity Trauma
5) Shoulder surgery
4) Circumferential Nonarticular Humerus-Stabilizing Orthosis
Common Name: Humeral Fracture/ Function Brace
Objectives: To stabilize Fracture to promote healing without immobilizing any joint
Indications: Humeral Shaft Fracture

Sarmiento Brace
Common Name: Humeral Fracture/ Functional Brace/ Sarmiento Brace
Objectives: To stabilize Fracture to promote healing without immobilizing any joint
Indications: Humeral Shaft Fracture

SPLINTS USED FOR
ELBOW
sullivan

POSTERIOR ELBOW SPLINT
Common Name: (Posterior) elbow splint
Objectives:
1) To support and rest elbow to relieve pain
2) To immobilize elbow to relieve pain
3) To block Elbow Extension
Indications:
1) Rheumatoid Arthritis
2) Elbow surgeries
Like Ulnar Nerve Transposition , Tendon Transplant, Nerve Repairs

ANTERIOR STATIC ELBOW SPLINT
Objectives:
1) To prevent or correct elbow flexion contractures
2) To block elbow Flexion
Indications:
1) Burns
2) Ulnar Nerve Entrapment
3) capsular Tightness
4) Elbow surgeries like:
Triceps rupture
Tumor resection
Total Elbow Arthroplasty.

ELBOW FLEXION HARNESS
Common Name: Elbow Flexion Splint
It is static progressive in nature.
Objectives:
1) To increase elbow flexion ROM
2) To maintain surgically obtain elbow range
Indications:
1) Intra-articular fracture
2) Multiple trauma
3) Capsular tightness

ELBOW FLEXION HARNESS
4) Supracondylar fracture
5)Radial head fracture

TENNIS ELBOW STRAP
Objectives:
1) To reduce pain and inflammation
Indications:
Inflammation of common Tendon origin

Spiral Thumb Abduction Supination
Splint
Objectives:
1) To abduct thumb
2) To facilitate supination or pronation as required
3) To reduce tone of muscles
4) To assist weak muscles
5) To promote functional use of hand

Spiral Thumb Abduction Supination
Splint
Indications:
1) Head injury
2) Multiple Sclerosis
3) Cerebral Palsy
4) Cerebrovascular accident

COCKUP SPLINT
It is static in nature.
Common Name:
1) Volar/Palmar Wrist splint 7) Work Splint
2) Volar Wrist Cock up splint 8) Ulnar Gutter Splint
3) Wrist Immobilization Splint 9) Radial Gutter Splint
4) Drop Wrist Splint
5) Carpal Tunnel Splint
6) Wrist Extension Immobilization Splint

Cockup splint
Objectives:
1) To reduce Pain and Inflammation
2) To protect against joint damage
3) To promote hand function
4) To prevent or correct contractures
5) To provide base for Outriggers
Indications:
1) Tendinitis/Tenosynovitis of wrist tendons

Cockup splint
2) Joint Inflammation such as Rheumatoid Arthritis
3) Skin Graft
4) Unstable Wrist Joint
5) Wrist Sprain
6) Weak/Paralyzed Wrist Extensor
7) Congenital Hand Deformity
8) Volar style for flexion outriggers
9) Dorsal style for extension Outriggers

GAUNLET IMMOBILIZATIONSPLINT
Common Name: Circumferential working Splint
Objectives:
1) Greater wrist stability
Indications:
1) An evaluation tool before wrist arthrodesis
2) To immobilize and stabilize a fracture of radius or base of Metacarpal

DYNAMIC WRIST EXTENSIONSPLINT
Objectives:
1) To Passively extend the wrist while allowing active wrist flexion
2) To prevent contracture of unopposed innervated wrist flexors
Indications:
1) Weak or Paralyzed wrist Extensors (e.g.. Radial Nerve Palsy)

STATIC WRIST WRITING/PAINTINGORTHOSIS
Common Name: Wrist Splinting
Objectives:
1) To enable writing, drawing or painting by positioning wrist in functional
extension and providing attachment of pen, pencil , eraser etc.
Indications:
1) Spinal Cord Injuries at level C5 or above where wrist extensors Paralyzed

Radial thumb gutter splint
Common Name:
1) De Quervain’s static splint
2) Wrist and thumb static splint
3) Long thumb CMC immobilization splint
4) Long opponens splint
5) Radial-thumb gutter splint
6) Wrist Thumb Orthosis

Radial thumb gutter splint
Objectives:
1) To immobilize wrist, thumb CMC, MCP Joints, which are crossed by inflamed
tendons
2) To rest and reduce inflammation
Indications:
1) De Quervain’s tenosynovitis: Inflammation of tendon of abductor polices longus
and extensor polices brevis in their synovial sheath

Scaphoid fracture splint
Objectives:
1) To immobilize the wrist, thumb, CMC and MCP Joints
2) To rest hand to reduce inflammation
Indications:
1) De Quervain’s tenosynovitis
2) Instability of joints
3) Scaphoids fracture
4) Bennett’s fracture (fracture of base first MC joint)

Wrist stabilizing splint
Objectives:
1) To immobilize the wrist and Finger MCPs
2) To relieve pain and inflammation
3) To prevent and correct deformities
4) To correct joint instability
Indications:
1) Joint Inflammation

RADIAL NERVE SPLINT
Common Name: MCP extension-assist splint, MCP Arthroplasty splints
Objectives:
1) To immobilize the wrist in functional position and passively extend MCPs to 0*
while permitting full extension unrestricted motion
Indications:
1) When the extensors of the wrist, fingers MCPs and thumb is paralyzed or
weak.
2) MCP arthroplasty-angle the wires to pull the MCPs radially

MCP ARTHOPLASTY

DYNAMIC MCP FLEXIONSPLINT
Objectives:
1) To gently stress the MCP collateral ligaments to promote desired growth and
increase flexion range
Indications:
1) Extension contracture of MCPs caused by shortened collateral ligaments

Resting hand splint
It is Static or Serial Static type of splint.
Objectives:
1) To immobilize the wrist, MCPs, and IPs of Finger and thumb
2) To reduce or prevent contractures
3) Reduce pain and inflammation

Resting hand splint
1) Scleroderma
2) Dupuytren’s release
3) Boxer’s fracture (Base of 5 MCP fracture)
4) Burns
5) Inflammatory joint disease
7) Crush injury

ANTISPASTICITY SPLINT
Common Name: dorsal volar hand splint
Objectives:
1) To immobilize wrist, MCP, IP
2) To prevent and reduce contracture
3) To reduce tone of hypertonic muscles
Indications:
1) Hand Trauma or surgery

Antispasticity splint
2) High tone Associated with:
 Head Injury
 Cerebral Palsy
 Multiple Sclerosis
 Cerebrovascular Accident

Antispasticity cone splint
Objectives:
1) To prevent flexion contractures
2) To reduce tone of hypertonic muscles
Indications:
1) High tone Associated with:
 Head Injury
 Cerebral Palsy
 Multiple Sclerosis
 Cerebrovascular Accident

Rehabilitation institute of Chicago
Tenodesis(training) splint
Objectives:
1) To train a tenodesis grasp
2) To promote tripod pinch
Indications:
1) Quadriplegia at level of C6 with at least grade 3 strength of the wrist extensors
This splint is a functional aid for such patient which uses extensor carpi radialis
muscle giving potential grasp by reciprocal wrist extension and finger flexion.

FLEXOR AND EXTENSOR
TENDON LACERATION

KLEINERT SPLINT
It allows protective flexion of MCP and IP and Blocks Extension of MCP.
Objectives:
1) To position wrist in static flexion and passively flex the MCP and IP while
permitting limited active extension of wrist and MCP and full extension of IP
Indications:
1) Flexor Tendon Laceration in zone 2

EXTENSOR TENDON REPAIR SPLINT
Objectives:
1) To position wrist in static extension and passively extend the MCP and IP while
permitting limited active flexion of MCP
Indications:
1) Extensor tendon Laceration

Hand Finger Thumb Based Orthosis
sullivan

METACARPAL FRACTURE BRACE
Common Name: Metacarpal(fracture) Brace
Objective: To stabilize MC fracture to promote healing.
Indication: Midshaft fracture of third, fourth or fifth metacarpal

STATIC ULNAR DEVIATION SPLINT
Common Name: MCP protection splint, static ulnar drift/deviation
splint, metacarpal ulnar deviation orthosis, trigger finger splint,
blocking splint
1)Joint Inflammation: To promote restabilization of tendon to restraints
at MCPs
To prevent or correct ulnar drift of MCP
2) Trigger Finger: To block MCP Flexion and limit excursion of long
finger flexor. By subsiding irritation at A1 pulley and inflammation
subside.

ULNAR DEVIATION SPLINT
3) Surgical release of Dupuytren’s Contracture
To maintain surgical gained extension.
4) Intrinsic muscle tightness and extension contracture: To block MP joint so FDP
and FDS can actively stretch IP joint and intrinsic muscle.
5) MC head fracture for stabilization.

ANTIULNAR DEVIATION WORKING SPLINT
3) Circumferential hand Based Dynamic Traction D2-5 MCP Corrective Radial
Deviation Orthosis:
Common Name: Ulnar drift splint, Ulnar Deviation Splint, soft metacarpal ulnar
deviation orthosis, antiulnar deviation working splint
Objectives: To prevent and correct ulnar MCP drift
To promote restabilization of restrain tendon at MCP
To improve Hand Function
Indication: Joint Inflammation

Dynamic mcp extension splint
Objectives: To passively extend MCP to 0* extension and allow active flexion
movement and IP movement.
Indication: Radial nerve injury when reinnervation reach to wrist
Repair of extensor tendon rupture, extensor contracture

Static anticlaw deformity splint
Common: Static Anticlaw deformity splint, static ulnar nerve splint
Objective: To stabilize the fourth and fifth MCPs in flexion.
To correct fourth and fifth MCPs hyperextension
To prevent shortening of MCP Collateral Ligament
To promote active IP Extension
Indication: Ulnar Nerve Lesion

WYNN PERRY SPLINT
Common Name: Dynamic Anticlaw deformity splint, dynamic ulnar nerve splint,
Wynn Perry Splint
Objective: To passively flex the MCP of fourth and fifth finger and to allow active
extension.
To correct Hyperextension
To prevent shortening of MCP
TO promote active IP Extension

DYNAMIC MEDIAN-ULNAR NERVE SPLINT
Common Name: Dynamic anticlaw deformity splint, dynamic median/ulnar nerve
splint, spring wire knuckle bender:
Objectives: To passively flex the MCP of fourth and fifth finger and to allow active
extension.
To correct Hyperextension
To prevent shortening of MCP
TO promote active IP Extension

DYNAMIC MEDIAN-ULNAR
NERVE SPLINT
Indication: Combined median and ulnar nerve lesion at level of wrist

FLEXION BLOCKING SPLINT
Common Name: Blocking Splint
Objective: To Block MCP and PIP so that the flexor digitorium profundus can
actively stretch DIP to increase the flexion range of motion
Indication: Extension contracture of DIP Joint

FINAL FLEXION SPLINT
Common Name: Final Flexion Splint
Objectives: To progressively flexion MCPs IPs in composite flexion applying gentle
prolonged stretch to contracted tissue.
Indication: Contracture of extrinsic Extension Tendon, IP Extension Contracture

Short dorsal outriggers
Objective: To apply gentle prolonged stretch to the contracted PIP capsule and
ligaments to promote growth of the shortened tissues and restore extension ROM.
Indication: Flexion Contracture Of PIP joint

Proximal phalanx fracture brace
Objectives and Indication: To stabilize phalangeal fracture to promote healing,
without immobilizing any joint
For a stable fracture that requires screw fixation apply 3-5 day postoperative

Extension blocking buddy orthosis
Objective: To block MCP extension to promote active PIP Extension
Indication: PIP Flexion lag with flexible or stiff PIP of D3 or D4

trapper
Common Name: Buddy splint, trapper
Objectives: To strap affected finger to an unaffected finger at proximal middle
phalanges
To stabilize finger
To provide passive movement of affected joint by moving unaffected finger
Indication: PIP Collateral ligament injury
flexor tendon reconstruction and PIP flexion

Pip extension splint
It is a extension blocking static splint.
Common Name: Swan Neck Deformity splint, PIP hyperextension splint, Fiqure of
eight splint
Objective: Index finger PIP extension restriction
Indication: Swan Neck Deformity, (caused by: RA, Trauma, intrinsic muscle
tightness, Dorsal migration of extension mechanism,)
Trigger finger

CAPENER SPLINT
Objective: Index finger pip extension mobilization
Indication: PIP flexion contracture, PIP dislocation, Volar plate injury, flexor tendon
repair partial or complete tear of collateral ligament, Boutonniere Deformity

SHORT OPPONENCE ORTHOSIS
Objective: To relieve CMC pain
to immobilize CMC and MCP
To position the thumb in functional opposition
to correct first web space
Indication: Inflammation of CMC or injury
CMC Arthroplasty, Median nerve injury, Quadriplegia

CMC ARTHOPLASTY

DYNAMIC THUMB OPPOSITION STRAP
18) Circumferential Wrist based Dynamic Thumb Opposition Strap:
Common Name: Dynamic Thumb opposition splint, Thumb abduction splint
Indication and Objectives:
Weakness and paralysis of
thenar muscle
position Thumb in palmar
abduction, to facilitate
opposition
Adducted thumb position
associated with high tone
To place thumb in radial
abduction to breakup flexor
spasticity pattern

DYNAMIC THUMB
OPPOSITION STRAP

RECENT ADVANCES
1) Umit Urgulu et all . In their study shows use of dynamic orthosis over static
orthosis it provides definite amount of function to the limb as well as support
where as static orthosis provide support but function ignored.
2) Mike S Macgrath et all. In their study shows that use of static progressive splint
is increasing now a days using a static splint for whole day give rise to other
complication where as these splints help to improve restricted motion, provide
support, enhance mobility with minimizing stress.
3) Use of upper limb exoskeleton over dynamic splints help to enhance body
function of individual in targeted form without adding complication of
splinting.

Recent Advancement
4) Mozghan Nazaffi et all. use of spiral splint instead of traditional splint use in
tennis elbow reduce pain improves grasp and functional abilities.
5) Lee Anee Chazen et all. In their study shows use of splint for spasticity of upper
limb may help to reduce tone it is even helps to rest the hand.

LOWER LIMB ORTHOSIS
sullivan

Function & comfort of Lower Limb Orthosis
 To meet individuals mobility needs
 Maximum stance phase stability
 Minimizes Abnormal alignment
 Minimally compromises swing clearance
 Effectively preposition limb for initial contact
COMFORT:
 Can be worn for long periods
 Can be donned and doffed easily

CONSIDERATION IN GAIT
EARLY STANCE Anatomical cause
Foot slaps ( Fore foot slaps the ground) Weak Dorsiflexors
Toes First (Toes may not be maintained) Short LE, Pes Equinovarus, Extensor
spasticity Heel pain
Flat foot contact Poor balance , Pes calcaneus
Excessive lateral or medial foot contact Weak invertors (evertors), genu
valgum(Varum) pes valgum ( varum)
Excessive knee flexion Weak quadricepps, contralateral short LE,
knee or hip flexion contracture, knee pain
Hyperextended knee Weak Quadriceps, lax knee ligaments,
contralateral hipp knee contractures and
contralateral short LE
Anterior trunk bending Weak quadriceps, Hip and knee flexion
contracture
Posterior Trunk Bending Weak Gluteus Maximus
Lateral Trunk Bending Weak Gluteus Medius, abduction
Contracture, dislocated Hip, Hip pain
Internal or external Rotation Rotators of hip spastic, rotators may be

CONSIDERATION IN GAIT
STANCE PHASE Anatomical Causes
Inadequate transition Weak plantar flexors, Fore foot pain
SWING PHASE ANATOMICAL CAUSE
Toe drag Weak dorsiflexors, spastic plantar flexors
Circumduction Weak hip flexor, weak dorsiflexors
Hip hiking Short contralateral LE, hip flexion
contracture, hip flexors weakness, weak
dorsiflexors
Vaulting (exagarated plantarflexion of
contralateral LE to enable the limb to
swing forward
Weak hip flexors, short contralateral LE,
weak dorsiflexors

POINTS TO BE ASSESED
1) Joint Mobility
2) Limb Length
3) Muscle Function
4) Sensation
5) Upper limb strength
6) Psychological status
7) special Life style considerations

SHOE IN FOOT ORTHOSIS
COMPONENTS OF LOWER PART OF SHOE:
1) Sole: It is the part of shoe in contact with ground. The inner part of sole
against which the foot rest is called insole. Bars straps and wedges, which
common attachments to the foot orthosis get their leverage and attachment
through the sole and exert their forces
2) Ball: Widest part of the sole that is located in the region of the metatarsal
heads.
3) Shank: Is the narrowest part of the sole between the heal and ball. The
uprights of the AFO attach themselves to a stirrup at the shank region.

4) Toe spring: It is the space between the outer sole and the floor, which helps to
produce a rocker effect during toe off phase of gait cycle.
If a lift is added to sole it compensate LLD.
5) Heel: Is the posterior part of the sole, which corresponds to the heel of the foot.
Since it is the portion wheremost of the body weight is taken it needs to be resilient
and thicker so that it can prevent shoe components from wearing out and shifts weight
to the fore foot.
UPPER PART COMPONENTS:
1)Quarter: This is the posterior portion of the shoe upper. A high quarter is referred as a
“high top” and is used by runners and footballers for greater sensory feed back

2) Heel counter: There is reinforcement of quarter posteriorly called heel counter
for providing posterior stability.
3) Vamp: Vamp is anterior portion of upper which is reinforced by toe box. Which
protects the toes behind the lace.
4) Throat: this is opening of shoes located at base of tongue though which foot is
inserted.
5) Toe Box: it prevents toes from trauma .
6) Tongue: extends in front of toe
7) Stirrup: it provides attachment for metal uprights.
8) Rocker effect: Lift added to sole will reduce stress to metatarsophalangeal head
to shaft and reduce the distance wearer to travel so improve late stance.

Modification of Shoe
CONDITION OBJECTIVES MODIFICATION
Limb shortening Provide symmetric posture Heel and sole elevation
Arthritis, instability of
subtalar joints
Improve gait and support
and limit joint movement
High quarter shoe Reinforced
heel counters Long steel
shank rocker bar
Pes Plano Valgus Reduce eversion support
longitudinal arch
For children, high quarter
shoe with broad heel, long
medial counter medial heel
wedge
Pes equinus Provide heel strike, contain
foot in shoe, reduce pressure
on MT head, equalize leg
length
High-quarter shoe, Heel lift &
Metarsal pads or bars, heel
and sole elevation on other
shoe according to LLD
Pes equinovarus Realign for flexible deformity
and accommodate fix
deformity, Increase medial
and posterior weight bearing
High quarter shoe, high toe
box, lateral sole, heel
wedges, medial wedges for
fix deformity
Calcaneal spurs, corns Relieve pressure on painful
area
Heel cushion, inner relief in
heel
Matatarsalgia Reduce pressure on MT head Soft vamp, low heel

CONDITION OBJECTIVES MODIFICATIONS
Pes Cavas Distribute weight over
entire foot Restore
anteroposterior foot
balance
High quarter shoe, high
toe box, lateral heel and
sole wedges
Hallux valgus Reduce pressure on 1 MTP
joint prevent forward foot
slide
Metarsal pad, metatarsal
or rocker bar, inner sole
relief
Hammer toes Relieve pressure on painful
area support transverse
arch
Soft vamp, extra depth
shoe with high toe box
Foot fractures Improves push off
immobilize fractured part
Long steel shank
longitudinal arch support,
metarsal pad or rocker bar
Modification of Shoe

University of California
Biomechanics Laboratory
FUNCTIONS:
HOLDS HINDFOOT IN CORRECT
POSITION
SUPORTS MIDFOOT BY
CORRECTING AT MAINTAINING
MEDIAL ARCH
SATABILIZING MIDTARSAL
INDICATIONS:
1) Adult Accquired flat
foot
2) Flexible pes planus
3) Plantar fasciitis
4) Calcaneum spur
5) Midfoot fracture

congenital talipes
equinovarus(CTEV)

ANKLE FOOT ORTHOSIS
The AFO is a boot to which an ankle joint is fixed through the stirrup. The metal
uprights are ascending up to the calf region.
COMPONENTS ARE:
1) Proximal calf band with leather straps
2) Medial and lateral bars articulating with ankle lateral and medial ankle joints.
3) medial and lateral support can be give.
There are five types of artificial ankle attached to foot orthosis:
1) Free ankle: Given when ankle power is normal

ANKLE FOOT ORTHOSIS
2) Limited Ankle joint: Is prescribed when the muscle operating ankle jjoint are fliai
or has no power.
3) 90* foot drop stop: Is prescribed when the ankle joint allows dorsiflexion but
stops short at the neutral position that is 90*. So does not provide plantar flexion.
Prescribed in case of foot drop. When plantar flexors are normal but Dorsiflexors
are weak or when plantar flexors are spastic and Dorsiflexors are normal.
4) Reverse 90* Ankle joint: This ankle joint which allows plantar flexion but stops
short at the neutral at 90*. Does no allows dorsiflexion prescribed to prevent
calcaneal deformity.

ANKLE FOOT ORTHOSIS
Fixed Ankle Joint: Sometimes the foot needs to be protected and weight is taken
off injured portions as in fracture calcaneus when in combination with a weight
relieving orthosis it takes the weight off the foot. It is not commonly used.

AFO
BIOMECHAN
ICS

ANKLE FOOT ORTHOSIS
INDICATIONS:
1) Dorsiflexors Muscle Paralysis
AIM: To prevent contracture of the Achilles Tendon , and to assist dorsiflexion assist
dorsiflexion during heel strike a dorsiflexion assist plastic posterior leaf spring AFO can be
prescribed that can be inserted in shoes. For easy foot flat without undue knee flexion.
2) Ankle and Foot Paralysis:
This is prescribed to provide stability and reduce gait deviation during the swing and stance
phases. A polypropylene solid ankle foot orthosis to be worn with a shoe prevent foot from
dragging during swing, the brace rigidity prevents ankle dorsiflexion during midstance. AFO
can be used with straps for valgus and Varus deformity.

ANKLE FOOT ORTHOSIS
3) Spasticity:
AFO are used in children with cerebral palsy to stabilize the foot during heel strike
and foot flat phase. It prevents toe drag and plantar flexion during swing phase.
4) Limited Weight Bearing:
This is rare indication of AFO. To reduce loading on the leg and foot in conditions
where foot is need to be protected (e.g. calcaneal fracture) . The socket is provided
at patellar tendon bearing area so weight can be barred and heel can be offloaded.

POSTERIOR STATIC ANKLE FOOT ORTHOSIS
COMMON NAME: Foot drop splint
Objectives: To rest ankle and relieve pain
To immobilize ankle and promote healing
To prevent and correct ankle contractures.
Indications: Mild to moderated spastic hemiparesis
Post repair of Achilles tendon
unconscious patient risk of developing ankle flexion contractures
congenital deformities
Tibia/fibula fractures

POSTERIOR STATIC ANKLE FOOT ORTHOSIS
Acute burns
Cerebral palsy
Flaccid Hameparesis
Foot drop
Plantar Fasciitis Night use
Joint inflamation

Anterior Floor Reaction Ankle
Foot Orthosis

DYNAMIC ANKLE FOOT
ORTHOSIS

AFO ADDING VALGUS
CORRECTION
SPIRAL AFO
This spiral band
does valgus
correction

Posterior leaf spring Orthosis
The Posterior Leaf Spring (PLS) AFO is a dynamic thermoplastic AFO designed to
accomplish two things:
• Support the weight of the foot during swing phase as a means of enhancing
swing limb clearance
• Assist with controlled lowering of the foot during loading response in stance as
part of the first/heel rocker

POSTERIOR LEAF SPRING
AFO
The PLS is one of the group of AFOs that provide dorsiflexion assistance. In
contrast to the SAFO, medial and lateral trim lines are located well posterior to the
midline of both malleoli so that the orthosis is flexible at the anatomical ankle
joint The degree of flexibility is determined by the thickness of the thermoplastic
material used to construct the orthosis and width of the posterior upright in the
distal third of the orthosis. In custom-molded PLS orthosis, the orthotist tailors the
stiffness of the orthosis using the trim line pattern that will best support the
weight of the foot during swing as well as the individual’s needs for stability in
stance.

Carbon Fiber Spring orthosis
(CFO)
The carbon fiber springs inserted posteriorly between the foot and calf
component of this carbon-fiber orthosis. The springs provide dorsiflexion
assistance for clearance in swing and pre-positioning of the foot for initial contract,
as well as preservation of the second and third rockers of stance phase.
The Dual Carbon Fiber Spring orthosis (CFO) designed to provide assistance with
plantarflexion/push-off for the transition from stance to swing for persons with
weakness or paralysis of calf muscles/plantar flexors.

Patellar tendon bearing Orthosis
(weight relieving orthosis)
AS THE NAME SUGGEST THE WEIGHT
IS RELIVED IN MIDDLE AND DISTAL
TIBIA HEEL AND FOOT .

INDICATIONS:
INDICATIONS:
1) UNSTABLE FRACTURE OF PELVIC RING
2) FRACTURE OF ACETABULM WITH
MINIMAL DISPLACE MENT
3) FRACTURE OF FEMUR
4) COMPLICATED FRACTURE
5) COMMUNITED FRACTURE OF TIBIAL
PLATEAU
6) TIBIAL PLATEAU FRACTURE

KAFO

KNEE-ANKLE-FOOT ORTHOSIS (KAFO)
Components are same as AFO. In addition to this there is upright extended from
knee joint to thigh. Thigh band are suspension mechanism to which the uprights
are attached.
Knee Joints Are: This are provided so wearer can sit and can have good gait pattern
to avoid stiff knee gait pattern.
1) Straight set knee joint: Allows free flexion and prevents hyperextension. Upper
segment rotates in single transverse axis. It is used in combination with drop lock
to give stability. It is cheap and easy to repair.

2) The polycentric Knee joint: Use double axis system to stimulate the
flexion/extension movements of femur and tibia at knee joint.
3) Posterior Offset Knee Joint: This is given for patients with minimal quadriceps
weakness, since it keeps the knee extended, though there is not enough stance
control. There must be adequate power of hip flexion and extension and ability to
produce adequate momentum to walk. The placement of joint is just behind the
actual knee joint to provide stability.
4) Stance Control: The ideal joint should have stability during weight bearing and
flexion during the swing phase of gait when it is non weight bearing. This is more
energy efficient, decrease the exaggerated movements of hip when knee is locked.

KNEE LOCKS
1) Drop lock: it locks when knee extends. Use commonly
2) Spring Lock: use with drop lock for patient who loose balance or find it
embrace to unlock joint mechanically.
3) Cam Lock: It provides better stability.
4) The ball lock: Patient who has limited balance and dexterity.
5) A dial lock: may be adjusted every 6* use for better knee flexion control.
6) Plunger type lock: use for people with hand weakness. Cosmetically more
appealing.

Indications:
1) Muscle Weakness: weakness of lower limb controlling hip and knee.
Specifically hip extensors and quadricep. In spinal cord damage. Lower Motor
disease like poliomyelitis or injury to nerves.
2) Upper Motor Lesion: Normal Motor control is lost. So it is provided to achieve
stance stability.
3) Loss of structural Integrity: In inflammatory disease like RA or degenerative
disease like Osteoarthritis.

4) Genu Varum/Valgum: For stability and to protect medial and lateral
compartment.
5) Problem in Load Bearing: Any structural impairment. Use for weight relieving.
6) Knee Braces: Knee Braces are prescribed in severe osteoarthritis of the knee, to
provide stability to knee joint.

KNEE HINGE BRACE
Hinged knee braces provide the strongest amount of
stability for the ligaments in the knee. Hinged braces are
ideal for day-to-day activities and all sports for those who
are suffering from mild to moderate ligament injuries or
instabilities, meniscus injuries, sprains or osteoarthritis.
For severe ligament injuries it is important to select one of
the rigid hinged braces. The rigid hinged braces provide
maximum protection and typically do not have a sleeve or
wrap. Soft-hinged braces provide a moderate level of
support and combine hinge support with a knee sleeve or
wrap for compression.

PATELLA KNEE BRACE
Recommended for mild or moderate ligament joint pain,
sprains, strains, meniscus tears, Osgood Schlatter
disease or patellar instabilities.
•Medial/Lateral polycentric aluminum hinges
•Thigh and calf straps provide additional support and
compression
•Sewn-in pad for additional patellar support
•Compressive neoprene support

1) C Brace:
Changing speed and direction is easier when you can put weight on a bent knee. And,
the idea of “orthotronics” means you have the combination of electronic and
mechanical systems working together to support your every step. The C-Brace
orthotronic mobility system is designed to provide the highest level of support for
patient so they can feel confident with every step.
Objectives:
Stumble Control: Sensors recognize uncontrolled knee flexion and create immediate
stability so the patient can recover — and keep a stumble from turning into a fall.
Greater Ease and Less Concentration: The gait cycle is controlled dynamically and in real
time — allowing patients to walk with greater ease and less need for compensatory
movements.

FEATURES OF C BRACE
Stance Extension Damping: Progressive resistance allows natural movement to
occur without uncontrolled and early knee and hip extension at Terminal Stance,
resulting in a more natural movement without abrupt changes to the center of
gravity, lower back and lower limb joints.
Stance Flexion Damping: Controlled, partial knee flexion while weight bearing
allows the patient to exhibit knee control when walking down hills and ramps,
descending stairs step over step, and while sitting down into a chair.

STANCE CONTROL KAFO
– The E-MAG Active is a stance control KAFO that is calibrated to the patient’s
step length. It is also simple to re-calibrate the E-MAG Active if the patient’s
step length changes over time. The stance control function will remain locked
during weight bearing, then unlock for swing phase. It simplifies gait training
and allows for varied cadence to help meet your patient’s specific needs. A
gyroscope built into the KAFO monitors your patient’s step length. During the
fitting process, the E-MAG Active’s calibrating feature allows it to recognize your
patient’s gait pattern.

STANCE CONTROL KAFO
Stance Control helps users achieve a more natural gait compared to locked KAFOs,
thereby reducing compensatory movements that can lead to degenerative
conditions, excess energy expenditure, and noncompliance. · Gyroscope monitors
the orientation of the user’s lower limb (whether it is at initial contact or at
terminal stance). · Extraordinarily simple calibration allows the Orthotist to
customize the unlocking feature during the fitting process. Varied flexion angled
joints can be used to ease locking/ unlocking of the orthotic knee joint or
accommodate knee contractures. · Optional manual locking/unlocking function

CRAIG SCOTT KAFOS
Prescribed for adult paraplegia.
It includes either a shoe reinforced with transverse and longitudinal plates.
Enables to stand patient with sufficient backward lean to provide undue knee
flexion and trunk flexion.

HIP KNEE ANKLE FOOT ORTHOSIS(hkafo)
It is extension to KAFO. Its hip extension is to provide hip flexion and extension.
The suspension with pelvic band which fits between iliac crest and greater
trochanter to control rotational movement. The lateral extension stops at ischial
region. It helps in weight relieving. It helps in improving Postuure, and balance in
standing. Also during walking.
Uses:
Weak muscle controlling hip.
Can be possibly weak knee and ankle.

BIOMECHANICS

TYPES OF HKAFO
1) Bilateral HKAFO
2) Unilateral double upright HKAFO
3) Bilateral double upright HKAFO

RECIPROCATING GAIT ORTHOSIS
These are bilateral hip, knee, ankle, foot orthosis to provide contralateral hip
extension and ipsilateral hip flexion.

MECHANICS OF RGO
1) It shifts weight in both legs. This accompanied by elbow extension of
contralateral arm which slightly elevated the leg for ground clearance.
2) patient exaggerates lordosis by shoulder retraction and back extension
creating movement at hip.
3) dual cable mechanism helps in shifting the torque to execute the swing phase
of gait.

Modification of HKAFO
ANTERIOR
DISLOCATION
POSTERIOR
DISLOCATION

HKAFO IN PEDIATRICS
THE FREJKA PILLOW WAS DESINGED TO
MAINTAIN ABDUCTION THE PILLOW IS SOFT IN
NATURE INFANTS CAN EASILY OVERCOME THE
ABDUCTION PRESSURE.
ITS PLACE LIKE A DIAPER. CLOTH HARNESS AND
STRAPS ARE USED.

HKAFO IN PEDIATRICS
IT HAS TWO STRAP
WHICH CROSS
SHOULDER AT BACK
UPPER STAP WHICH
PASS THROUGH
CHEST FROM AXILLA
TRAVELS BACK TO
SCAPULAR REGION.

SOME NEW TREND IN
HKAFO
sullivan

RESTING ABDUCTION
ORTHOSIS
It is night splint use for children with early subluxation
due to spastic quadriplegia. By maintaining stretch to
adductors and flexors. It position the hip in central
position within the acetabulum the devices ideally
should promote normal acetabular growth.

By providing variable
hip abduction
according to flexion and
extension
It maintains sitting
balance and prevents
scissors while walking

ELECTRONIC ADVANCE
PARAPODIUM

HKAFO INDICATION:
1) Assist Gait
2) decrease weight
3) control movement
4) minimize progression of movement

TWISTER
For controlling the internal external rotation or torsion of lower limb.

FUNCTION ELECTRIC STIMULATION (FES)
A miniature electrical stimulation producing current between 90 and 200 mA, of
pulse duration between 20 and 300 microseconds.
Criteria of patient selection:
1) Who can walk independently 25m/min
2) foot drop not equinus contracture.
3) proprioception must be intact
FES is newer version of technology for better improvement.

New concept
1) Murrat Arrac et all in their study in 2016 showed powered limb orthosis can
be the best newer trend which works better in patient with paraplegia or
hemiplegia who cannot achieve sit to stand will enhance in better way.
2) Mukhtar Arzpour et all in their study said that stance control knee brace use
for knee support is better than traditional KAFO.
3) Zhenxiong Shawn Zhang in his article suggested that children using night splint
for CP shows quite improvement in gait

SPINAL ORTHOSIS
sullivan

CORSET
If abdominal compression is the basic goal a corset will suffice. It provide vertical
reinforcement.
It covers Lumbar and sacral areas. The biomechanics of corset is to increase
intraabdominal pressure which will in turn reduce stress on intervertebral disk.
This will does reduce frontal movement.

Lumbosacral Flexion, Extension,
Lateral, Control Orthoses
It is rigid trunk Orthosis. It is also called Knight spinal orthosis.
This include a pelvic band, which provide anchorage over the midsection of the
buttock and a thoracic band intended horizontal over lower thorax without
impingement of scapula.
Biomechanically it follows the THREE POINT PRESSURE SYSTEM. Posterior pressure
is applied from back upper and bottom side and anterior pressure from abdominal
aspect.
Lateral aspect control lateral flexion.

TAYLOR BRACE
It is also called Thorac Lumbar flexion, extension, control.
Indication are:
– Controlling back pain by limiting motion and unloading discs, vertebrae and
other spinal structures by compressing the abdomen.
– Stabilizing weak or injured structures by immobilizing the spine.
– Providing three-point force systems to provide correction or prevent
progression of a deformity.
– Condition like: Osteoporosis, pot's disease

Taylor Brace
Biomechanically it uses THREE POINT PRESSURE posterior force by axillary strap,
the anterior force by midsection of the abdominal front and anterior pressure from
intrascapular region.

JWETT BRACE
A Jewett brace is a hyperextension brace that prevents the patient from bending
forward too much. It is often used to facilitate healing of an anterior
wedge compression fracture involving the T10 to L3 vertebrae.

ANTERIOR SPINE
HYPEREXTENSION BRACE
To limit front bending, a hyperextension brace features a rectangular metal frame
that goes over the front of the body. This frame puts pressure on the chest and
pubic bone. Because a hyperextension brace is primarily used to treat spinal
compression fractures that occur where the upper back meets the low back, this
brace also puts pressure and support on the thoracic spine. This pressure keeps the
spine in an extended position.
A hyperextension brace also features 3 pads that help stabilize the spine and
prevent forward movement. One pad is located along the abdominals, another is
higher up on the chest, and the third pad is on the back and covers the affected
area.

SCOLIOSIS BRACE
sullivan

Charleston Bending Brace
The most commonly-prescribed nighttime brace is the Charleston
bending brace. It is custom-fitted based on a cast taken of the
patient’s torso. After the cast is created, corrective forces are added
to the brace based on readings from the spine’s x-ray.
In addition to applying lateral forces to push the curve closer to the
back’s midline, the Charleston bending brace also applies pressure to
bend and holds the spine in an overcorrected position. While it
would be unrealistic for someone to be bent so far to the side while
trying to go about the day, this extreme position can be held
relatively easily at night while laying down and sleeping.

Providence Brace
Similar to the Charleston brace, the Providence brace applies a hypercorrective
force on the spine that is only feasible while laying down and sleeping at night.
However, instead of bending the spine’s curve in the opposite direction like the
Charleston brace, the Providence brace slightly elevates one shoulder and directly
applies lateral and rotational forces on the curve.

BOSTON BRACE
– The most-commonly prescribed brace for scoliosis today is the Boston brace.
Many people know the Boston brace as a type of thoracic-lumbar-sacral
orthosis (TLSO). Other types of Boston brace models do exist, such as a CTLSO
(TLSO with a neck extension) for a high thoracic curve, though they are not as
common.
– The Boston brace works by applying corrective pressure on the convex (outer)
side of the curve and cutting out corresponding areas of relief on the concave
(inner) side of the curve so the spine can migrate in that direction.

WILMINGTON BRACE
– Another common TLSO is the Wilmington brace.
– This brace goes onto the body similar to a tight jacket and is known as a full
contact TLSO due to its lack of gaps or open spots.

MILWAUKEE BRACE
– The Milwaukee brace, which is the original cervico-thoracic-lumbar-sacral
orthosis (CTLSO) invented in the 1940s, is an older and bulkier brace. Due to the
effectiveness and relative convenience of today’s more modern braces, the
Milwaukee brace is rarely used anymore. However, it is still sometimes used for
curves higher in the thoracic or cervical spine.

RIGO Cheneau brace
GAIL L DAUMIT et
all.
In their study
shows the
scoliosis
correction is
better In this
splint then
boston.

CERVICAL ORTHOSIS
sullivan

SOFT CERVICAL COLLAR
– A cervical collar, also known as a neck brace, is designed to stabilize and
support the cervical spine in a neutral position while limiting head movement to
help immobilize the cervical spine. Used by emergency personnel for traumatic
neck or head injuries, it can also be utilized therapeutically to help relieve pain
by realigning the spinal cord after strains, sprains or whiplash.

1) Collars are soft or semi rigid which provide minimal motion control. Most
common type is Philedelphia Collar which has mandibular and occipital extension
and rigid anterior strut.
Use for: Upper cervical injury and fractures
2) Four-Post cervical Orthosis:
It gives moderate control of motion
It has to anterior and two posterior uprights.
Two anterior upright connects sternal and mandibular plate
Two posterior upright connects thoracic and occipital plate
CERVICAL ORTHOSIS

MINERVA ORTHOSIS
For Maximum control of movement:
1) Minerva orthosis or Halo orthosis:
It is noninvasive appliance that has rigid plastic posterior section extending from
head to midtrunk.
The superior portion is held in place by forehead band.
Is used for cervical fracture for healing.

References
Textbook of Rehabilitation: S Sunder
Physical Rehabilitation: Susan B. O’Sullivan
Orthotics in Rehabilitation: Pat Mckee and Leanne Morgan
Splinting: Brenda M Coppard and Helene Lohman
Orthotics and Prosthetics Rehabilitation: Michelle M Lusardi and Milgros George

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