Orthoses, an integral part of assistive technology, are specially made splints which are being used to align abnormal joints or muscles. These are never bought from ready made shops. Each and every pediatric orthosis should be made by qualified orthoticians. In selected cases, orthoses should be made after taking a POP cast. In a developing child, the orthoses should be changed after every six to nine months and for older children, the splint should be changed after every 9-15 months. Most of the orthoses require modifications so consult your orthotician after every three months or as recommended. Please note, a faulty orthosis always harm the child.
We at ICD, Delhi provide orthotic support to the following condition whenever there is a need
CTEV (Club Feet)
Cerebral palsy
Spina bifida
Erb’s palsy
Brain injury
Spinal cord injury
Post-polio paralysis
Meningomyelocele
Arthrogryposis
Congenital Hip dislocation
Genu recurvatum / Genu varum / Genu valgum
Flat feet / Hallux valgus / Flexed wrist / thumb in palm, etc
Orthotic aids are an integral part of habilitation / rehabilitation therapy. It helps
• To correct and/or prevent deformity
• To provide a base of support
• To facilitate training in skills
• To improve the efficiency of gait
• To improve function
At ICD New Delhi , we have
• Provision for Orthoses for Lower Limbs
• Provision for Orthoses for neck, spine and trunk
• Provision for Orthoses for Upper Limbs
2.
An orthosis by definition, is "an externally applied
device used to modify the structural and functional
characteristics of the neuromuscular and skeletal
system.
Orthoses
3.
The identified goals were:
To correct and/or prevent deformity
To provide a base of support
To facilitate training in skills
To improve the efficiency of gait
It is important that the interdisciplinary team check the
patient’s functional limitations according to the GMFCS in
order to plan the treatment. The type and design of the
orthosis is decided accordingly and can be changed
periodically depending on the improvement of the patient
condition.
Why to use orthoses in Cerebral Palsy?
5.
Orthoses for Lower Limbs
Orthoses for Trunk and Spine
Orthoses for Upper Limbs
Types /Classifications of Orthoses
6.
Foot Orthoses (FO)
Supramalleolar Orthosis (SMO)
Ankle foot Orthoses (Dynamic, solid, posterior leaf spring,
ground reaction, hinged)- AFO
Knee Orthoses (Immobilisers, Gaiters ,Plastic knee ankle
orthoses)- KO
Hip Orthoses (HO)
Orthoses for Lower Limbs
7.
Foot orthotics do not prevent deformity. They provide a
better contact of the sole of the foot with the ground.
Foot Orthoses (FO)
8.
This orthosis extends to just above the malleoli and
to the toes. Consider in mild dynamic equinus, varus
and valgus instability.
The medial side is higher than the lateral, holds the
calcaneus more firmly, supports the longitudinal
arch. Prescribed for hind and midfoot instability.
Supramalleolar Orthosis (SMO)
10.
The main function of the AFO is to maintain the foot in
a plantigrade position. This provides a stable base of
support that facilitates the function and also reduces
tone in the stance phase of the gait. The AFO supports
the foot and prevents foot drop during swing phase.
AFOs provide a more energy efficient gait. The brace
should be simple, light but strong. It should be easy to
use. Most importantly it should provide and increase
functional independence
Ankle Foot Orthoses (AFO)
11.
Solid AFO
Dynamic AFO (DAFO)
Hinged AFO
Posterior Leaf Spring AFO (PLSO)
Ground Reaction AFO (GRAFO)
Anti-Recurvatum AFO
Ankle Foot Orthoses (AFO)
12.
The solid or rigid AFO allows no ankle motion, it covers the
back of the leg completely and extends from just below the
fibular head to metatarsal heads
The solid AFO enables heel strike in the stance phase and toe
clearance in the swing phase. It can improve knee stability in
ambulatory children. It also provides control of varus/
valgus deformity
Solid AFOs provides ankle stability in the standing frame in
non-ambulatory children
Solid AFO
13.
A solid ankle foot orthosis aims to prevent all movement of
the foot and ankle at the talo-crural, subtalar and midfoot
joints. It is prescribed to children with CP when there is:
Moderate to high tone in the gastrocnemius muscle;
Less than 10 degrees of ankle dorsiflexion with the knee
in maximum extension,
Moderate to severe medio lateral instabilities at the ankle
A requirement to provide proximal control at the knee
and hip joints.
Solid AFO
14.
A Solid AFO may be prescribed
to help reduce the effects of ‘
crouch’ gait, where the hips and
knees are in a flexed position during
mid stance. If the solid AFO does not
resist the dorsiflexion moment during
mid to late stance, the tibial Shank to
Vertical Angle (SVA) is inclined and
the Ground Reaction Force is shifted
posterior at the knee and anterior
to the hip, thereby permitting crouch gait
to occur.
Solid AFO
15.
The Dynamic Ankle Foot Orthosis generally refers to a
custom made Supra-Malleolar Orthosis fabricated from
thin thermoplastic material. It fits the foot intimately and
the use of the flexible and thin thermoplastic means that
the DAFO can provide circumferential control of the rear
and fore foot to maintain a neutral alignment
To effectively control sagittal plane deformities such as a
plantar flexed ankle, a long lever arm is required that
involves extending the trim lines up to the proximal calf.
Therefore, DAFOs should only be used where there is
coronal or transverse plane deformities of the foot and
ankle that can be passively corrected with minimal force.
Dynamic AFO (DAFO)
17.
Hinged AFOs have a mechanical ankle joint usually
preventing plantar flexion, but allowing relatively full
dorsiflexion during the stance phase of gait. They provide
a more normal gait because they permit dorsiflexion in
stance phase of the gait, thus making it easier to walk on
uneven surfaces and stairs. This is the best AFO for most
ambulatory patients.
The hinged AFO is contraindicated in children who do
not have passive dorsiflexion of the ankle because it may
force the midfoot joints into dorsiflexion and cause
midfoot break deformity.
Hinged AFO
18.
. Knee flexion contractures and triceps weakness are other
contraindications where a hinged AFO may increase
crouch gait. The AFO may be fitted with a hinge that
allows 10 degrees passive dorsiflexion while preventing
plantar flexion. This creates a more natural gait.
This design of AFO should only be considered if there is
sufficient gastrocnemius length that permits 10 degrees of
dorsiflexion with the knee in full extension and where
there is no spastic catch or resistance in range of the
gastrocnemius due to increased muscle tone.
Hinged AFO
20.
Limited Motion Hinged AFO
It is the advance version of
Hinged AFO which allows
only 10-15 degree of dorsiflexion
which is quite sufficient to walk
efficiently
21.
A Posterior Leaf Spring AFO is a rigid AFO trimmed
behind the malleoli’s to provide flexibility at the ankle
and allows passive ankle dorsiflexion during the stance
phase.
Varus-valgus control is also poor because it is repeatedly
deformed during weight bearing.
A PLSO is an ideal choice in mild spastic equinus. Do not
use it with patients who have crouch gait and pes valgus.
The orthotic treatment goal of the PLS AFO is to maintain
the foot and ankle in a plantigrade position during swing
to permit foot clearance, but permit ankle plantarflexion
and dorsiflexion during stance phase.
Posterior Leaf Spring AFO (PLSO)
23.
This AFO is made with a solid ankle, the upper
portion wraps around the anterior part of the tibia
proximally with a solid front over the tibia. The rigid
front provide strong ground reaction support for
patients with weak triceps surae. The foot plate
extends to the toes. The ankle may be set in slight
plantar flexion of (2-3 degrees) if more corrective
force at the knee is necessary
Ground Reaction AFO (GRAFO)
25.
Use the GRAFO in patients with quadriceps weakness or
crouch gait. It is an excellent brace for patients with weak
triceps surae following hamstrings lengthening. Children
with static or dynamic knee flexion contractures (more
than 15 degrees) do not get benefit out of it and do not
tolerate the GRAFO.
As with the solid AFO it is imperative the GRAFO is
sufficiently stiff to resist the dorsiflexion moment during
mid-late stance phase to ensure it can help influence the
position of the Ground Reaction Force in relation to the
knee and hip joints.
Ground Reaction AFO (GRAFO)
26.
This special AFO is molded in slight dorsiflexion or
has the heel built up slightly to push the tibia
forward to prevent hyperextension during stance
phase.
Consider prescribing this AFO for the treatment of
genu recurvatum in hemiplegic or diplegic children.
Anti-recurvatum AFOs may be solid or hinged
depending on the child’s tolerance.
Anti-Recurvatum AFO
28.
Points to be remembered while prescribing an AFO
Solid AFOs are always better than all other forms of AFO.
Avoid using hinged AFO as far as possible. Unless and
until it is technically required
Don’t use rubber pad beneath the sole of the AFO, may
do more harm than benefits.
Always try to check the alignment of the knees before you
select an AFO. Genu recurvatum requires specialized
recurvatum AFO with adjustable hinged joint
What’s new
29.
Points to be remembered while prescribing an AFO
Always check the three “C” before you ask the child to
wear the AFO
First C represents “Correction”
Second C represents “Comfort”
Third C represents “Cosmetic”
Never prescribe Hinged AFO in case of Crouch Posture
SMO can help valgus but not equinus
Hallux Valgus requires extra modification / straps
What’s new
30.
Knee orthoses are used as resting splints in the early
postoperative period and during therapeutic ambulation.
There are two types of knee orthoses,
The knee immobilizer
The plastic knee-ankle foot orthosis (KAFO).
The use of such splints protects the knee joint, prevents
deformity recurrence after multilevel lengthening and
enables a safer start to weight bearing and ambulation after
surgery.
Knee Orthoses
31.
Knee immobilizers are made of soft elastic material and
hold only the knee joint in extension, leaving the ankle
joint free.
Consider using them in the early postoperative period
after hamstring surgery and rectus tendon transfers.
Popularly they are known as Knee Gaiters. Knee Gaiters
can be CORSET or THREE POINTS
Corset gaiters are made with iron / aluminum / plastic
rode stitched with clothes
Three Points Gaiters are made with aluminum / iron rod
with knee cap.
Three Points gaiters are also used as anti-torsion splint
Knee immobilizers
33.
Also known as 3-points gaiters
Made with Aluminum or iron rode with plastic
molded thigh and calf support
There is a knee cap to straighten and align the knee
Can be used with AFO and with out AFO, need
based
Mostly used as night splints
Can be used after botox injection and orthopedic
surgery to train the child graded weight bearing
Three Points Knee immobilizer
35.
Plastic resting KAFOs extend from below the hips to the
toes and stabilize the ankle joint as well as the knee. They
are more rigid and provide better support to the ankle
and the knee in the early postoperative phase
Though KAFOs are still used for ambulation in
poliomyelitis and myelomeningocele where there is a
need to lock the knee joint, they are not useful for the
child with CP because they disturb the gait pattern by
locking the knee in extension in the swing phase
KAFOs for functional ambulation have disappeared from
use in children with CP. Instead, anti recurvatum AFOs
or GRAFOs for knee problems in ambulatory children
have proved useful.
Plastic KAFOs
36.
Use the plastic KAFO at night and in the early
postoperative period after multi-level surgery to
protect the extremity while allowing early
mobilization.
Plastic KAFOs
37.
These days KFOs are not used during day time as it
blocks the knee
Need based 3-points gaiters or corset gaiters are used
during positioning but not in mobility training
3-ponits gaiters can be used as anti-torsion splint just
modifying the knee straps. It can control both in-torsion
and ex-torsion
Corset Gaiters / Pedi-wraps are used till the age of three
years only
Above 3 years, 3-points gaiters should be used to get
better knee extension and alignment
What’s New
38.
Static Hip Abductor
Dynamic Hip Abductor
SWASH
Hip Aligner
Hip Orthoses
39.
S.W.A.S.H. orthosis assures a variable abduction during
flexion providing sufficient help all day, when sitting,
standing, walking or crawling.
Functioning: When fitting the
orthosis the hip is stabilized
preventing any excessive
abduction and internal rotation.
SWASH
40.
SWASH
Dislocated hips
Fixed hip flexion contracture greater than 20°.There are
no finite guidelines for use with non-fixed flexion
contracture - this generally is dependent on wearer
tolerance.
Adductors so strong they overpower the
SWASH®uprights (SWASH® Low Profile has larger
diameterand therefore stronger uprights.)
Adductor length so short it causes discomfort
withSWASH® use in the sitting position
If ambulatory, excessive tibial torsion or
foot involvement, without physician assessment of impact
SWASH® impacts on these conditions.
41.
Hip Abductors
These days abductor-bars are not used as it created
too much discomfort.
Very simple plastic made hip abductors are used
instead
Above all, it can be used
while walking and resting both
42.
Popularly known as HFAFO
Rarely used in Cerebral Palsy due to its limitation
with mobility
HIP-KNEE-ANKLE AND FOOT ORTHOSES
43.
There are various types of braces used for spinal
deformity. This braces are not prescribed in order to stop
the progression of scoliosis but to provide better sitting
balance.
As most children with scoliosis need spinal surgery to
establish and maintain sitting balance in the long run. A
thoraco-lumbo-sacral brace helps the child to sit better
during the growth spurt period when spinal deformity
becomes apparent, progresses fast and the child out
grows custom molded seating devices quickly.
Children who are not candidates for surgery for different
reasons may use spinal braces instead of seating devices
for better sitting.
Spinal Orthoses
46.
The indications of bracing in the shoulder and elbow
are very limited.
An example of a resting splint is a thermoplastic
resting wrist and hand splint which keeps the wrist
in 10-20 degrees extension, the metacarpal
phalangeal joint(MPJ) in 60 degrees flexion and the
interphalangeal joint (IPJ) in extension.
This type of splint is used at night and during
periods of inactivity with the hope of preventing
deformity.
Upper Limb Orthotics
47.
An example of a functional splint is an opponents
splint, which can be used in everyday
activities. Hand orthoses may inhibit
the active use of the extremity and
effect sensation of the hand in a
negative way. Use them only in the
therapy setting or at school and take
them off during other times in the day.
Upper Limb Orthotics
48.
CIMT band is used in case of CIMT
It is better than a cast as it can be removed as and
when required
Light weighted
It is used in the good or better hand to inhibit the
usage while CIMT
CIMT Band
49.
For all queries, doubts and explanations, please contact us @
Institute for Child Development
C-27, Malviya Nagar
New Delhi-110017
Landline Number: 011-41012124
Mobile Number: 7838809241
Mail: helpicd@gmail.com
Website: www.icddelhi.org
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