By Dr. Om Prasad Biswal (P&O)

1. Presenter- Om Prasad Biswal
M.P.O 1st Year, 3rd Batch
Pt. Deendayal Upadhyaya National Institute for
Persons with Physical Disabilities (Divyangjan)

2. What is an orthosis and
Orthotist??
 It’s a Latin word derived from “Orthogan”.
Ortho means to make something straight. So
orthosis is defined as an externally applied
device used to modify and align the structural
and functional characteristic of neuromuscular
and skeletal systems.
 Orthotist is defined as a person who has
completed an approved course of education and
training and is authorized to assess the patient
and design, measure and fit the orthosis.

3. Lower Extremity Orthotic Goals:
 Stabilize weak or paralyzed segments and muscle
groups.
 Support damaged or diseased joints or segments.
 Unload distal segments.
 Control abnormal or spastic or involuntary
movements.
 Limit or augment motion across joints.
 Prevention of mal-alignments and contractures or
correcting deformity

4. Orthotic Evaluation
 Comprehensive team evaluation including PMR
(Physiatrist), Orthopedic surgeons, Prosthetist and
Orthotist, Physiotherapist, Occupational therapist,
Patient and patient’s family.
 Establish the orthotic and rehab goals early.
 Educate the patient.
 Clarify the limitations of the orthosis.
 Order appropriate therapy for the device.
 Follow up with the patient.

5. Orthotic Issues to consider:
 Biomechanics of the device :
o Principle of Jordan
o Control of rotational moments across a joint
o Control of axial forces around a joint
o Control of translational forces around a joint
o Control of line of action of the GRF
 Durability of the materials
 Tissue tolerance to pressure( Total contact or even
pressure distribution)
 Partial weight relieving.

6. Classification
Functional Classification Regional Classification
Supportive Foot Orthoses
Functional Ankle Foot Orthoses
Corrective Knee-Ankle-Foot Orthoses
Protective Knee Orthoses
Preventive Hip-Knee-Ankle-Foot
Orthoses
Hip Orthoses

7. Prescription Criteria
 Patient Evaluation
 Demographic Data
 Chief Complaint
 Medical History
 On Observation
 On Palpation
 On Examination
 Other Assessment

8. Patient Assessment and Evaluation
Demographic Data:
 Patient Name
 Father
 Mother
 Address
 Age
 Sex
 Height
 Weight

9. Cont.…
 Chief Complaint(C/C): A/c to patient’s language or
through direct encounter with the patient; the reason
for presenting the problem.
 History:
a) Patient History
• Diagnosis
• Cause
• Segment and Side Involved
• Period of Occurrence
• Duration

10. Cont.…
b) Family History
• No. of member
• No. of earning member
• Marital Status
• No. of child
c) Education History
• Qualification/education of patient
• % of educated members in the family
d) Occupation History
• Past Job
• Present Job

11. Cont.
e) Environmental History
• Type of environment (rural/urban)
f) Medical History
• Past History
1. Prenatal: Mother age & Immunization
2.Perinatal: Baby wt., cry, type of delivery
3.Postnatal:Immunization and illness
4. Developmental Milestones
5. Trauma: Date & Place of occurrence & treatment
6. Previous aids and appliances
• Present History
Drugs and medications, therapies, surgeries, use of any
aids or appliances etc.

12. Cont.
 On Observation:
• External aid/appliance
• Postural Alignment
• Segment Involved
• Body structure
• Gait
 On Palpation:
• Tenderness
• Pain
• Temperature
• Swelling
• Skin Texture(Smooth/Rough)

13. Cont.
 ON EXAMINATION:
• Manual Muscle Testing:
Right Left
Flexion - -
Hip Extension - -
Abduction - -
Adduction - -
Knee Flexion - -
Extension - -
Ankle Dorsiflexion - -
Plantar
Flexion
- -

15. Cont.
Active RoM Passive RoM
Flexion - 0-120
Hip Extension - 0-30
Adduction - 0-30
Abduction - 0-45
Knee Flexion - 0-135
Extension - 135-0
Ankle Plantar Flexion - 0-50
Dorsiflexion - 0-20
• Range of Motion:

16. Cont.
 Motor Examination:
 Muscles Tone:
• Fast and passive movement
• Hypotonic, Normal, Hypertonic
• Modified Ashworth Scale ( MAS Scale): The scale was
elaborated and applied by Bohannon and Smith in 1987.

17. Cont.

18.  Tightness/Contracture/Deformity
 Reflex examination
Radiological Examinations:
• X-Ray
• MRI

19. Other Assessments
 Balancing:
Sitting
Squatting
Standing
 Functional Ability:
Come to sit
Running
Hoping
Single stance
Jumping
Stair Climbing

20.  Vital Sign:
 Body Temperature
 Blood Pressure
 Pulse Rate
 Higher Motor Functions:
 Orientation
 Speech
 Hearing
 Vision
 Memory
 Problems Identified
 Patient’s Expectation
 Orthotics Intervention

21. Specific Tests and Evaluations
for Specific Conditions

22. Cerebral Palsy

23.  Birth History: Prenatal Perinatal Postnatal
ON EXAMINATION:
 MMT Grading
 RoM
 MAS Scale
 Balance
 Higher Motor Functions
 Functional Evaluation

24.  Voluntary Motor Control (VMC):
1+ Gravity eliminated plane with 1/3rd
movement possible
1++ Gravity eliminated plane with 2/3rd
movement possible
1+++ Gravity eliminated plane with full range
of motion
2+ Against Gravity 1/3rd movement possible
2++ Against gravity 2/3rd movement possible
2+++ Against gravity full RoM
3+ Against gravity with resistance 1/3rd
movement possible
3++ Against gravity with resistance 2/3rd
movement possible
3+++ Against gravity with resistance full RoM
4 Skilled movement

25.  Deep Tendon Reflexes (DTR):

26.  Clonus:
It’s a condition that results in involuntary muscle
spasms.

27.  Plantar Reflex: Flexor Type /Extensor Type
(Babinski’s sign) /Indifferent

28.  Sensory Integrity and Integration:
• Superficial- Crude touch and Fine touch
• Deep- Pressure, Kinesthesia, Vibration
• Cortical- Tactile localization and stereo gnosis

29. Common Deformities in CP (In
Lower Extremities)
Hip Flexion, adduction and internal
rotation
Knee Flexion / Hyperextension
Ankle/Foot Plantar flexion, inversion and forefoot
adduction, valgus and collapsed arches

30. Spinal Cord
Injury (SCI)

31.  RoM: Joint Integrity and mobility
 Manual Muscle Testing(MMT)
 Modified Ashworth Scale (MAS):For tone and
reflexes
 DTR
 Voluntary Motor Control (VMC)
 Sensory Integration Tests: Proprioception
 0 – The sensation is absent
 1 – The sensation is present but impaired
 2 – The sensation is normal
 Postural Control and Balance: Postural Assessment
Scale for Stroke (PASS)

34. Spinal Injury!
Complete or Incomplete?
 The injury is complete if there is:
o No voluntary anal contraction
o S4-5 sensory scores = 0
o no anal sensation
 Otherwise, the injury is incomplete.

35. Complications in Lower Extremities
following Stroke:
Pelvis Weak hip extensors, Flexion
contracture
Insufficient forward pelvic rotation
Hip Trendlenburg limp, Scissoring
Spastic quadriceps
Knee Flexion contracture, weak hip and knee
extensors, genu-recurvatum
Spastic quadriceps and spastic
hamstrings
Ankle/Foot Equinus, Varus, Hammer Toe

36. Post Polio Residual
Paralysis (PPRP)

37.  RoM
 MMT
 MAS
 DTR
 Sensory Integration
 Muscle Wasting
 Limb Length Deficiency (LLD)
o True Length
o Apparent Length

38. Common Deformities in PPRP (LE)
 LLD
 Tibial plateau may be deformed and sloped backward
or forward.

39. Congenital
Talipes Equino-
Varus (CTEV)

40. Age of presentation matters:
 Brought during early
infancy
 Brought during early
childhood
 Brought during late
childhood

41. Examination and evaluation
 Foot examination:
o B/L foot deformity in 60% cases
o Size of the foot is small (U/L)
o Equinus, varus , adduction: Inability to bring the foot
in the opposite direction.
o In late presentation: Cavus
o Heel: Small in size, calcaneus can be felt with great
difficulty
o Deep skin creases on the back of the heel and medial
side of the sole.

42. o Bony prominences: On the lateral side of the foot,
head of the talus, medial side of the sole
o The outer side of the foot is gently convex and dimples
may be present over the outer aspect of ankle.
o On attempted correction, one can feel the tight
structures posteriorly(TA) and plantar fascia.

44. Radiological Examination:
o X-ray: Kite angle/Talo-calcaneal angle

45. Treatment Plan
After manipulation and serial corrective plaster casts,
correction is maintained by D.B splint till 1 ½ years.
AFO Splint at night, shoes during day after 1 ½ years
Follow up till 10-12 years

46. Pes Planus/Pes Plano-Valgus

48. Genu Varum/Genu Valgum