Upper Limb Orthotics - Dr Sanjay Wadhwa

1. Orthotics – Upper Limb Dr. Sanjay Wadhwa Professor, Department of Physical Medicine and Rehabilitation, AIIMS, New Delhi – 110029. (wadhwadr@gmail.com) PMR Refresher Course 23 Sept. 2017, Jaipur Dr. Sanjay Wadhwa

2. This topic can be covered in more than one ways: • Orthosis centric • Condition centric Orthotics – Upper Limb PMR Refresher Course 23 Sept. 2017, Jaipur Dr. Sanjay Wadhwa

3. • Definition(s) • Objectives • Indications • Classification • Nomenclature • Biomechanical and Anatomical Considerations • Evidence-base… Orthotics – Upper Limb PMR Refresher Course 23 Sept. 2017, Jaipur Dr. Sanjay Wadhwa

4. • Orthosis • Brace • Splint Orthotics – Upper Limb PMR Refresher Course 23 Sept. 2017, Jaipur Dr. Sanjay Wadhwa

5. • Orthosis – An externally applied device used to modify the structural or functional characteristics of the neuro-musculo-skeletal system. (International Standards Organization, 1987) • Orthoses • Orthotics • Orthotist Orthotics – Upper Limb PMR Refresher Course 23 Sept. 2017, Jaipur Dr. Sanjay Wadhwa

6. Objectives: • Support • Prevent • Align • Relieve • Correct Orthotics – Upper Limb PMR Refresher Course 23 Sept. 2017, Jaipur Dr. Sanjay Wadhwa

7. Conditions: • Rheumatoid Arthritis, • Trauma, • Dupuytren’s Contracture, • Carpal Tunnel Syndrome, • Stroke, TBI, • Spinal Cord Injury, • Neuropathy/ Nerve or Plexus Injury, • Burns, • Hansen’s Disease... Orthotics – Upper Limb PMR Refresher Course 23 Sept. 2017, Jaipur Dr. Sanjay Wadhwa

8. Types: • Static • Dynamic • Hybrid Orthotics – Upper Limb PMR Refresher Course 23 Sept. 2017, Jaipur Dr. Sanjay Wadhwa

9. Types: • Assistive or substitutive • Protective, or • Corrective Orthotics – Upper Limb PMR Refresher Course 23 Sept. 2017, Jaipur Dr. Sanjay Wadhwa

10. Complications/ Problems: • Skin damage, • Joint stiffness, • Muscle weakness or atrophy, • Nerve compression, • Vascular compromise, • Psychological dependence… Orthotics – Upper Limb PMR Refresher Course 23 Sept. 2017, Jaipur Dr. Sanjay Wadhwa

11. Features of a Good Orthosis: • Achieves the objectives for which prescribed, • Available, • Affordable, • Acceptable, • Easily applicable, • Aesthetically appealing, • Light weight, • Durable, • Free of complications… Orthotics – Upper Limb PMR Refresher Course 23 Sept. 2017, Jaipur Dr. Sanjay Wadhwa

12. Types (Task force of ISPO): • FO • HO • WO • WHO • EO • SO • SEO • SEWHO Orthotics – Upper Limb PMR Refresher Course 23 Sept. 2017, Jaipur Dr. Sanjay Wadhwa

13. Orthotics – Upper Limb PMR Refresher Course 23 Sept. 2017, Jaipur Dr. Sanjay Wadhwa

14. • Over the past 17 years, there has been a strong effort to name all orthoses by the joints they cross, and then specifying any design features related to those joints. • Better universal terminology would simply include the five common joints of the upper limb including finger, hand, wrist, elbow, and shoulder. Orthotics – Upper Limb PMR Refresher Course 23 Sept. 2017, Jaipur Dr. Sanjay Wadhwa

15. • The options or control features at each joint are then described. • The four common options for a joint include o fixing the joint in one position, o flexion/extension block, o flexion/extension traction, and o flexion/extension assist. Orthotics – Upper Limb PMR Refresher Course 23 Sept. 2017, Jaipur Dr. Sanjay Wadhwa

16. • Block – a limitation in the range of motion of the joint created by the orthosis; • Traction – an external force applied across a joint for the purpose of stretching soft tissues (e.g., contracture) • Assist – an external force applied across a joint to substitute for weak muscles. • This relates to finger, MCP joint, and elbow. Orthotics – Upper Limb PMR Refresher Course 23 Sept. 2017, Jaipur Dr. Sanjay Wadhwa

17. • Additional joint features will need to describe thumb positioning due to its unique function in opposing the other fingers. Orthotics – Upper Limb PMR Refresher Course 23 Sept. 2017, Jaipur Dr. Sanjay Wadhwa

18. Orthotics – Upper Limb PMR Refresher Course 23 Sept. 2017, Jaipur Dr. Sanjay Wadhwa Upper Limb Orthosis Prescription Patient’s Name: Reg. No.: Diagnosis: Prescribing Physiatrist: Material/Padding: Duration of Need: Finger 2 3 4 5 (Circle as needed) DIP Static at Flexion block at Flexion traction Flexion assist at PIP Dynamic Extension block at Extn. traction Extn. assist at Thumb Static in opposition Flexion block at Flexion traction Flexion assist at Dynamic Extension block at Extn. traction Extn. assist at MCP Static at Flexion block at Flexion traction Flexion assist at Dynamic Extension block at Extn. traction Extn. assist at Hand Circumferential Dorsal Volar Wrist Static at Flexion block at Flexion traction Flexion assist at Dynamic Extension block at Extn. traction Extn. assist at Forearm Circumferential Dorsal Volar Elbow Static at Flexion block at Flexion traction Flexion assist at Dynamic Extension block at Extn. traction Extn. assist at Humerus Circumferential Dorsal Volar Shoulder Static at Flexion block at Flexion traction Flexion assist at Dynamic Extension block at Extn. traction Extn. assist at Special design Tenodesis BFO Universal Cuff Signature of Physiatrist………………………………. Date…………………

20. • Very wide range • Finger Orthoses to Airplane splint • Articulated or non-articulated Orthoses Orthotics – Upper Limb PMR Refresher Course 23 Sept. 2017, Jaipur Dr. Sanjay Wadhwa

21. • Tenodesis splint – a dynamic wrist-hand orthosis used in transmitting active wrist extension to achieve finger prehension. • Used for spinal cord injury patients with residual wrist extension capabilities. • The thumb is held in functional position and the first two fingers are moved against it by orthosis. • Relaxing the wrist allows gravity to open the grip. Orthotics – Upper Limb PMR Refresher Course 23 Sept. 2017, Jaipur Dr. Sanjay Wadhwa

22. • Knuckle bender – dynamic hand-finger orthosis, applies a three-point pressure system to aid flexion of the MCP joints. Rubber bands or springs are used to assist flexion. Orthotics – Upper Limb PMR Refresher Course 23 Sept. 2017, Jaipur Dr. Sanjay Wadhwa

23. Orthotics – Upper Limb PMR Refresher Course 23 Sept. 2017, Jaipur Dr. Sanjay Wadhwa Swan neck Splint

24. Orthotics – Upper Limb PMR Refresher Course 23 Sept. 2017, Jaipur Dr. Sanjay Wadhwa Universal Cuff with spoon fitted

25. Orthotics – Upper Limb PMR Refresher Course 23 Sept. 2017, Jaipur Dr. Sanjay Wadhwa Forearm based thumb spica Splint for de Quervain tenosynovitis

26. Orthotics – Upper Limb PMR Refresher Course 23 Sept. 2017, Jaipur Dr. Sanjay Wadhwa Trigger finger Splint

27. Orthotics – Upper Limb PMR Refresher Course 23 Sept. 2017, Jaipur Dr. Sanjay Wadhwa Splint for a patient with lateral epicondylitis

28. Orthotics – Upper Limb PMR Refresher Course 23 Sept. 2017, Jaipur Dr. Sanjay Wadhwa Hinged Elbow Splint for limited ROM after a fracture

29. Orthotics – Upper Limb PMR Refresher Course 23 Sept. 2017, Jaipur Dr. Sanjay Wadhwa Radial nerve palsy Orthosis

30. Orthotics – Upper Limb PMR Refresher Course 23 Sept. 2017, Jaipur Dr. Sanjay Wadhwa Combined median and ulnar nerve palsy Orthosis

31. Orthotics – Upper Limb PMR Refresher Course 23 Sept. 2017, Jaipur Dr. Sanjay Wadhwa Ulnar nerve palsy Orthosis

33. Orthotics – Upper Limb PMR Refresher Course 23 Sept. 2017, Jaipur Dr. Sanjay Wadhwa Wrist Hand Orthosis – compare wrist angle with CTS

34. Orthotics – Upper Limb PMR Refresher Course 23 Sept. 2017, Jaipur Dr. Sanjay Wadhwa Resting hand splint

35. Orthotics – Upper Limb PMR Refresher Course 23 Sept. 2017, Jaipur Dr. Sanjay Wadhwa Antispasticity Orthosis

36. Orthotics – Upper Limb PMR Refresher Course 23 Sept. 2017, Jaipur Dr. Sanjay Wadhwa Figure of 8 sling

37. Orthotics – Upper Limb PMR Refresher Course 23 Sept. 2017, Jaipur Dr. Sanjay Wadhwa Joint Jack – a progressive Splint to increase extension at PIP joint

38. Orthotics – Upper Limb PMR Refresher Course 23 Sept. 2017, Jaipur Dr. Sanjay Wadhwa Postoperative flexor tendon Splint: tenodesis flexion – extension exercises

39. Orthotics – Upper Limb PMR Refresher Course 23 Sept. 2017, Jaipur Dr. Sanjay Wadhwa Postoperative Splint for a patient with extensor pollicis tendon repair

40. Orthotics – Upper Limb PMR Refresher Course 23 Sept. 2017, Jaipur Dr. Sanjay Wadhwa Postoperative Splint for a patient with MTP arthroplasty

43. Orthotics – Upper Limb PMR Refresher Course 23 Sept. 2017, Jaipur Dr. Sanjay Wadhwa Cochrane Database Syst Rev. 2003;(1):CD004018. Splints/orthoses in the treatment of rheumatoid arthritis. Egan M1, Brosseau L, Farmer M, Ouimet MA, Rees S, Wells G, Tugwell P. Author information Abstract BACKGROUND: Splints/orthoses are often recommended to patients with rheumatoid arthritis (RA) to decrease pain, decrease swelling and/or prevent deformity. These orthoses include resting hand splints, wrist supports, and finger splints. OBJECTIVES: To assess the effectiveness of splints/orthoses in relieving pain, decreasing swelling and/or preventing deformity and determine the impact of splints/orthoses on strength, mobility and function in people with RA.

44. Orthotics – Upper Limb PMR Refresher Course 23 Sept. 2017, Jaipur Dr. Sanjay Wadhwa REVIEWER'S CONCLUSIONS: There is insufficient evidence to make firm conclusions about the effectiveness of working wrist splints in decreasing pain or increasing function for people with RA. Potential adverse effects such as decreased range of motion do not seem to be an issue, although some of these splints decrease grip strength and dexterity. Similarly, preliminary evidence suggests that resting hand and wrist splints do not seem to affect range of motion or pain, although patients preferred wearing a resting splint to not wearing one. There is evidence that extra-depth shoes and molded insoles decreases pain on weight- bearing activities such as standing, walking and stair-climbing. Posted insoles may be effective in preventing progression of hallux abductus angle but do not appear to have an impact on pain.

49. Orthotics – Upper Limb PMR Refresher Course 23 Sept. 2017, Jaipur Dr. Sanjay Wadhwa Cochrane Database Syst Rev. 2003;(1):CD004018. Splints/orthoses in the treatment of rheumatoid arthritis. Egan M1, Brosseau L, Farmer M, Ouimet MA, Rees S, Wells G, Tugwell P. Author information Abstract BACKGROUND: Splints/orthoses are often recommended to patients with rheumatoid arthritis (RA) to decrease pain, decrease swelling and/or prevent deformity. These orthoses include resting hand splints, wrist supports, and finger splints. OBJECTIVES: To assess the effectiveness of splints/orthoses in relieving pain, decreasing swelling and/or preventing deformity and determine the impact of splints/orthoses on strength, mobility and function in people with RA.

50. Orthotics – Upper Limb PMR Refresher Course 23 Sept. 2017, Jaipur Dr. Sanjay Wadhwa REVIEWER'S CONCLUSIONS: There is insufficient evidence to make firm conclusions about the effectiveness of working wrist splints in decreasing pain or increasing function for people with RA. Potential adverse effects such as decreased range of motion do not seem to be an issue, although some of these splints decrease grip strength and dexterity. Similarly, preliminary evidence suggests that resting hand and wrist splints do not seem to affect range of motion or pain, although patients preferred wearing a resting splint to not wearing one. There is evidence that extra-depth shoes and molded insoles decreases pain on weight- bearing activities such as standing, walking and stair-climbing. Posted insoles may be effective in preventing progression of hallux abductus angle but do not appear to have an impact on pain.

Upper Limb Orthotics - Dr Sanjay Wadhwa

Upper Limb Orthotics - Dr Sanjay Wadhwa

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Upper Limb Orthotics - Dr Sanjay Wadhwa