Prosthetic management of symes and partial foot amputationSmita Nayak
prosthetic management of partial foot and syme's amputation is a very challenging task. Now a days the availability of advanced technology some how fulfilling the need of the amputee but not the fully.
Orthotic Knee joints. consists data about various orthotic knee joints still used for KAFO, KO, and AFO. it consists of both concentric and eccentric orthotic knee joints.
This presentation is very beneficial for those who are in the field of prosthetics & orthotics. I have covered the basics of prosthetic foot, its mechanisms & its types. I have mentioned advanced prosthetic foot also. Hope this will help you all.
Prosthetic management of symes and partial foot amputationSmita Nayak
prosthetic management of partial foot and syme's amputation is a very challenging task. Now a days the availability of advanced technology some how fulfilling the need of the amputee but not the fully.
Orthotic Knee joints. consists data about various orthotic knee joints still used for KAFO, KO, and AFO. it consists of both concentric and eccentric orthotic knee joints.
This presentation is very beneficial for those who are in the field of prosthetics & orthotics. I have covered the basics of prosthetic foot, its mechanisms & its types. I have mentioned advanced prosthetic foot also. Hope this will help you all.
In this ppt, there is various types of hip orthoses were disscussed according to various types of hip pathologies like developmental dysplasia of hip, legg calve perthes disease, spina bifida, cerebral palsy, lower extremity weakness and paralysis, torsional deformities.
also various types hip orthoses with HKAFOS were discussed from the conventional design to most advanced design like post operative hip orthoses for hip reconstruction surgery etc.
Over the past decade, technology and research have greatly expanded the functionality and aesthetics of prosthetic feet. Today, amputees have a wide array of feet from which to choose. Various models are designed for activities ranging from walking, dancing and running to cycling, golfing, swimming and even snow skiing.
Prosthetic management of different levels of amputationAamirSiddiqui56
In this presentation, i have covered all the basics about levels of amputation. I have mentioned the different levels of amputation and their prosthetic management. Beneficial for those who are in the field of P & O.
1- Why isn't Jamie allowed unlimited use of aspirin for pain- 2- Why d.docxKevinjrHWatsono
1. Why isn't Jamie allowed unlimited use of aspirin for pain? 2. Why does Jamie's pain subside after a period of inactivity? 3. Why is Sever disease more likely to occur in a child who is active than in one who is sedentary? 4. Why does Sever disease occur in children rather than adults? 5. Describe the pattern of pain appearance and remission that can be expected if Jamie uses heel pads only intermittently. 6. Why are Jamie's X rays normal? If Jamie had calcaneal spurs, how would the X rays have differed? 7. In craniosynostosis, why would premature closure of the sagittal suture restrict the lateral growth of the skull? 8. If you were a pediatrician, what measurements of the skull would you take to distinguish different forms of craniosynostossis from each other? 9. About 50% of children with cranioynostossi exhibit mental retardation. Explain the probable connection between the skeletal deformity and the neurological effect. 10. Explain why Paget disease could cause abnormal pressure on a spinal nerve. Objectives In this chapter we will study - foor developmental disorders of the skull-microcephaly, macrocephaly, acrania, and craniosynostosis; - two developmental disorders of the face and jaw-cleft palate and mandible disorders: - developmental disorders of the vertebral column, incloding spina bifida and aboormal spine curvatures; - some of the causes of lower back pain later in life; and - two disorders of the pelvis-rachitic pelvis and pelvis asyametry. - three disorders of the legs - congenital short fenur, genu varum, and genu valgum: - skeletal disorders of the foet, specifically foot deformities and heel pain. Diagnosing Skeletal Disorders Craniosymosiosis This chapter focuses on disonders of some of the groups of booes Normal human babies are born with unfused e that compose the skeletoa, and examines skeletal problems at the able to shift enough to allow their heads to organ and system level as opposed to the tissue level treated in canal. The cranial booes become rigidly joi the previous chapter. You may find it helpfal to refer to a buman 2 years after birth. Craniosynostonis oecurs asatomy textbook to review the skeleton. The methods used to di- of the cranial sutures fuses prematurely durin agnose the disorders diseussed in this chapter are largely the same months of life. It occurs in about 5 out of 100 as those deseribed in the previous chapter. twice as often in males as in females. Developmental Disorders of the Skull Premature closure of a suture results in I Developmental defects that occur daring the formation of the tures that remain open. For example, if the o bones of the skull can be so minor that they have little or no effect prematurely, the head cannot grow normally or so major that they cause death. This discussion focuses ce two direction but shows excessive promth in a la defects of the skull: acrania and crasiosynostosis. pendicular to the sagittal suture. As a result, Acrania mally wide (left to right) and sh.
In this ppt, there is various types of hip orthoses were disscussed according to various types of hip pathologies like developmental dysplasia of hip, legg calve perthes disease, spina bifida, cerebral palsy, lower extremity weakness and paralysis, torsional deformities.
also various types hip orthoses with HKAFOS were discussed from the conventional design to most advanced design like post operative hip orthoses for hip reconstruction surgery etc.
Over the past decade, technology and research have greatly expanded the functionality and aesthetics of prosthetic feet. Today, amputees have a wide array of feet from which to choose. Various models are designed for activities ranging from walking, dancing and running to cycling, golfing, swimming and even snow skiing.
Prosthetic management of different levels of amputationAamirSiddiqui56
In this presentation, i have covered all the basics about levels of amputation. I have mentioned the different levels of amputation and their prosthetic management. Beneficial for those who are in the field of P & O.
1- Why isn't Jamie allowed unlimited use of aspirin for pain- 2- Why d.docxKevinjrHWatsono
1. Why isn't Jamie allowed unlimited use of aspirin for pain? 2. Why does Jamie's pain subside after a period of inactivity? 3. Why is Sever disease more likely to occur in a child who is active than in one who is sedentary? 4. Why does Sever disease occur in children rather than adults? 5. Describe the pattern of pain appearance and remission that can be expected if Jamie uses heel pads only intermittently. 6. Why are Jamie's X rays normal? If Jamie had calcaneal spurs, how would the X rays have differed? 7. In craniosynostosis, why would premature closure of the sagittal suture restrict the lateral growth of the skull? 8. If you were a pediatrician, what measurements of the skull would you take to distinguish different forms of craniosynostossis from each other? 9. About 50% of children with cranioynostossi exhibit mental retardation. Explain the probable connection between the skeletal deformity and the neurological effect. 10. Explain why Paget disease could cause abnormal pressure on a spinal nerve. Objectives In this chapter we will study - foor developmental disorders of the skull-microcephaly, macrocephaly, acrania, and craniosynostosis; - two developmental disorders of the face and jaw-cleft palate and mandible disorders: - developmental disorders of the vertebral column, incloding spina bifida and aboormal spine curvatures; - some of the causes of lower back pain later in life; and - two disorders of the pelvis-rachitic pelvis and pelvis asyametry. - three disorders of the legs - congenital short fenur, genu varum, and genu valgum: - skeletal disorders of the foet, specifically foot deformities and heel pain. Diagnosing Skeletal Disorders Craniosymosiosis This chapter focuses on disonders of some of the groups of booes Normal human babies are born with unfused e that compose the skeletoa, and examines skeletal problems at the able to shift enough to allow their heads to organ and system level as opposed to the tissue level treated in canal. The cranial booes become rigidly joi the previous chapter. You may find it helpfal to refer to a buman 2 years after birth. Craniosynostonis oecurs asatomy textbook to review the skeleton. The methods used to di- of the cranial sutures fuses prematurely durin agnose the disorders diseussed in this chapter are largely the same months of life. It occurs in about 5 out of 100 as those deseribed in the previous chapter. twice as often in males as in females. Developmental Disorders of the Skull Premature closure of a suture results in I Developmental defects that occur daring the formation of the tures that remain open. For example, if the o bones of the skull can be so minor that they have little or no effect prematurely, the head cannot grow normally or so major that they cause death. This discussion focuses ce two direction but shows excessive promth in a la defects of the skull: acrania and crasiosynostosis. pendicular to the sagittal suture. As a result, Acrania mally wide (left to right) and sh.
Growth and development /certified fixed orthodontic courses by Indian dental...Indian dental academy
The Indian Dental Academy is the Leader in continuing dental education , training dentists in all aspects of dentistry and offering a wide range of dental certified courses in different formats.
Indian dental academy provides dental crown & Bridge,rotary endodontics,fixed orthodontics,
Dental implants courses.for details pls visit www.indiandentalacademy.com ,or call
00919248678078
Growth &development of cranial vault & base /fixed orthodontic coursesIndian dental academy
The Indian Dental Academy is the Leader in continuing dental education , training dentists in all aspects of dentistry and offering a wide range of dental certified courses in different formats.
Indian dental academy provides dental crown & Bridge,rotary endodontics,fixed orthodontics,
Dental implants courses.for details pls visit www.indiandentalacademy.com ,or call
00919248678078
Orthotic management of Elbow joint, Wrist Joint.pptxPOLY GHOSH
Elbow joints and wrist joints are most common joints in upper extremity effected by sports related injury. This injuries can be prevented and treated with different orthosis.
Hand splinting in common orthopedic & neurological condition 1POLY GHOSH
This Presentation is about role of splinting in orthopedic condition and neurological condition. This presentation can be benefitted for Orthotist, Occupational therapist, phyiotherapist and Physical medicine and rehabilitation specialist.
An electric wheelchair offer mobility and the freedom to get around. A motorized wheelchair, powerchair, electric wheelchair or electric-powered wheelchair (EPW) is a wheelchair that is propelled by means of an electric motor rather than manual power. Motorized wheelchairs are useful for those unable to propel a manual wheelchair or who may need to use a wheelchair for distances or over terrain which would be fatiguing in a manual wheelchair. They may also be used not just by people with 'traditional' mobility impairments, but also by people with cardiovascular and fatigue-based conditions.The electric-powered wheelchair was invented by George Klein who worked for the National Research Council of Canada, to assist injured veterans after World War II.[1]
Biomechanical principle of hand spliningPOLY GHOSH
Hand splinting are provided to people who need protection and support for painful, swollen or weak joints and their surrounding structures. Their designs make sure you position your wrist and hands correctly. There are two types of hand or wrist splint: splints used for resting joints of the wrist and hand.
Different types of electric terminal devices used for transradial and transhumeral, shoulder disarticutaion prosthesis used for external powered prosthesis.
CHAPTER 1 SEMESTER V - ROLE OF PEADIATRIC NURSE.pdfSachin Sharma
Pediatric nurses play a vital role in the health and well-being of children. Their responsibilities are wide-ranging, and their objectives can be categorized into several key areas:
1. Direct Patient Care:
Objective: Provide comprehensive and compassionate care to infants, children, and adolescents in various healthcare settings (hospitals, clinics, etc.).
This includes tasks like:
Monitoring vital signs and physical condition.
Administering medications and treatments.
Performing procedures as directed by doctors.
Assisting with daily living activities (bathing, feeding).
Providing emotional support and pain management.
2. Health Promotion and Education:
Objective: Promote healthy behaviors and educate children, families, and communities about preventive healthcare.
This includes tasks like:
Administering vaccinations.
Providing education on nutrition, hygiene, and development.
Offering breastfeeding and childbirth support.
Counseling families on safety and injury prevention.
3. Collaboration and Advocacy:
Objective: Collaborate effectively with doctors, social workers, therapists, and other healthcare professionals to ensure coordinated care for children.
Objective: Advocate for the rights and best interests of their patients, especially when children cannot speak for themselves.
This includes tasks like:
Communicating effectively with healthcare teams.
Identifying and addressing potential risks to child welfare.
Educating families about their child's condition and treatment options.
4. Professional Development and Research:
Objective: Stay up-to-date on the latest advancements in pediatric healthcare through continuing education and research.
Objective: Contribute to improving the quality of care for children by participating in research initiatives.
This includes tasks like:
Attending workshops and conferences on pediatric nursing.
Participating in clinical trials related to child health.
Implementing evidence-based practices into their daily routines.
By fulfilling these objectives, pediatric nurses play a crucial role in ensuring the optimal health and well-being of children throughout all stages of their development.
Navigating Challenges: Mental Health, Legislation, and the Prison System in B...Guillermo Rivera
This conference will delve into the intricate intersections between mental health, legal frameworks, and the prison system in Bolivia. It aims to provide a comprehensive overview of the current challenges faced by mental health professionals working within the legislative and correctional landscapes. Topics of discussion will include the prevalence and impact of mental health issues among the incarcerated population, the effectiveness of existing mental health policies and legislation, and potential reforms to enhance the mental health support system within prisons.
Global launch of the Healthy Ageing and Prevention Index 2nd wave – alongside...ILC- UK
The Healthy Ageing and Prevention Index is an online tool created by ILC that ranks countries on six metrics including, life span, health span, work span, income, environmental performance, and happiness. The Index helps us understand how well countries have adapted to longevity and inform decision makers on what must be done to maximise the economic benefits that comes with living well for longer.
Alongside the 77th World Health Assembly in Geneva on 28 May 2024, we launched the second version of our Index, allowing us to track progress and give new insights into what needs to be done to keep populations healthier for longer.
The speakers included:
Professor Orazio Schillaci, Minister of Health, Italy
Dr Hans Groth, Chairman of the Board, World Demographic & Ageing Forum
Professor Ilona Kickbusch, Founder and Chair, Global Health Centre, Geneva Graduate Institute and co-chair, World Health Summit Council
Dr Natasha Azzopardi Muscat, Director, Country Health Policies and Systems Division, World Health Organisation EURO
Dr Marta Lomazzi, Executive Manager, World Federation of Public Health Associations
Dr Shyam Bishen, Head, Centre for Health and Healthcare and Member of the Executive Committee, World Economic Forum
Dr Karin Tegmark Wisell, Director General, Public Health Agency of Sweden
The dimensions of healthcare quality refer to various attributes or aspects that define the standard of healthcare services. These dimensions are used to evaluate, measure, and improve the quality of care provided to patients. A comprehensive understanding of these dimensions ensures that healthcare systems can address various aspects of patient care effectively and holistically. Dimensions of Healthcare Quality and Performance of care include the following; Appropriateness, Availability, Competence, Continuity, Effectiveness, Efficiency, Efficacy, Prevention, Respect and Care, Safety as well as Timeliness.
India Clinical Trials Market: Industry Size and Growth Trends [2030] Analyzed...Kumar Satyam
According to TechSci Research report, "India Clinical Trials Market- By Region, Competition, Forecast & Opportunities, 2030F," the India Clinical Trials Market was valued at USD 2.05 billion in 2024 and is projected to grow at a compound annual growth rate (CAGR) of 8.64% through 2030. The market is driven by a variety of factors, making India an attractive destination for pharmaceutical companies and researchers. India's vast and diverse patient population, cost-effective operational environment, and a large pool of skilled medical professionals contribute significantly to the market's growth. Additionally, increasing government support in streamlining regulations and the growing prevalence of lifestyle diseases further propel the clinical trials market.
Growing Prevalence of Lifestyle Diseases
The rising incidence of lifestyle diseases such as diabetes, cardiovascular diseases, and cancer is a major trend driving the clinical trials market in India. These conditions necessitate the development and testing of new treatment methods, creating a robust demand for clinical trials. The increasing burden of these diseases highlights the need for innovative therapies and underscores the importance of India as a key player in global clinical research.
Defecation
Normal defecation begins with movement in the left colon, moving stool toward the anus. When stool reaches the rectum, the distention causes relaxation of the internal sphincter and an awareness of the need to defecate. At the time of defecation, the external sphincter relaxes, and abdominal muscles contract, increasing intrarectal pressure and forcing the stool out
The Valsalva maneuver exerts pressure to expel faeces through a voluntary contraction of the abdominal muscles while maintaining forced expiration against a closed airway. Patients with cardiovascular disease, glaucoma, increased intracranial pressure, or a new surgical wound are at greater risk for cardiac dysrhythmias and elevated blood pressure with the Valsalva maneuver and need to avoid straining to pass the stool.
Normal defecation is painless, resulting in passage of soft, formed stool
CONSTIPATION
Constipation is a symptom, not a disease. Improper diet, reduced fluid intake, lack of exercise, and certain medications can cause constipation. For example, patients receiving opiates for pain after surgery often require a stool softener or laxative to prevent constipation. The signs of constipation include infrequent bowel movements (less than every 3 days), difficulty passing stools, excessive straining, inability to defecate at will, and hard feaces
IMPACTION
Fecal impaction results from unrelieved constipation. It is a collection of hardened feces wedged in the rectum that a person cannot expel. In cases of severe impaction the mass extends up into the sigmoid colon.
DIARRHEA
Diarrhea is an increase in the number of stools and the passage of liquid, unformed feces. It is associated with disorders affecting digestion, absorption, and secretion in the GI tract. Intestinal contents pass through the small and large intestine too quickly to allow for the usual absorption of fluid and nutrients. Irritation within the colon results in increased mucus secretion. As a result, feces become watery, and the patient is unable to control the urge to defecate. Normally an anal bag is safe and effective in long-term treatment of patients with fecal incontinence at home, in hospice, or in the hospital. Fecal incontinence is expensive and a potentially dangerous condition in terms of contamination and risk of skin ulceration
HEMORRHOIDS
Hemorrhoids are dilated, engorged veins in the lining of the rectum. They are either external or internal.
FLATULENCE
As gas accumulates in the lumen of the intestines, the bowel wall stretches and distends (flatulence). It is a common cause of abdominal fullness, pain, and cramping. Normally intestinal gas escapes through the mouth (belching) or the anus (passing of flatus)
FECAL INCONTINENCE
Fecal incontinence is the inability to control passage of feces and gas from the anus. Incontinence harms a patient’s body image
PREPARATION AND GIVING OF LAXATIVESACCORDING TO POTTER AND PERRY,
An enema is the instillation of a solution into the rectum and sig
Antibiotic Stewardship by Anushri Srivastava.pptxAnushriSrivastav
Stewardship is the act of taking good care of something.
Antimicrobial stewardship is a coordinated program that promotes the appropriate use of antimicrobials (including antibiotics), improves patient outcomes, reduces microbial resistance, and decreases the spread of infections caused by multidrug-resistant organisms.
WHO launched the Global Antimicrobial Resistance and Use Surveillance System (GLASS) in 2015 to fill knowledge gaps and inform strategies at all levels.
ACCORDING TO apic.org,
Antimicrobial stewardship is a coordinated program that promotes the appropriate use of antimicrobials (including antibiotics), improves patient outcomes, reduces microbial resistance, and decreases the spread of infections caused by multidrug-resistant organisms.
ACCORDING TO pewtrusts.org,
Antibiotic stewardship refers to efforts in doctors’ offices, hospitals, long term care facilities, and other health care settings to ensure that antibiotics are used only when necessary and appropriate
According to WHO,
Antimicrobial stewardship is a systematic approach to educate and support health care professionals to follow evidence-based guidelines for prescribing and administering antimicrobials
In 1996, John McGowan and Dale Gerding first applied the term antimicrobial stewardship, where they suggested a causal association between antimicrobial agent use and resistance. They also focused on the urgency of large-scale controlled trials of antimicrobial-use regulation employing sophisticated epidemiologic methods, molecular typing, and precise resistance mechanism analysis.
Antimicrobial Stewardship(AMS) refers to the optimal selection, dosing, and duration of antimicrobial treatment resulting in the best clinical outcome with minimal side effects to the patients and minimal impact on subsequent resistance.
According to the 2019 report, in the US, more than 2.8 million antibiotic-resistant infections occur each year, and more than 35000 people die. In addition to this, it also mentioned that 223,900 cases of Clostridoides difficile occurred in 2017, of which 12800 people died. The report did not include viruses or parasites
VISION
Being proactive
Supporting optimal animal and human health
Exploring ways to reduce overall use of antimicrobials
Using the drugs that prevent and treat disease by killing microscopic organisms in a responsible way
GOAL
to prevent the generation and spread of antimicrobial resistance (AMR). Doing so will preserve the effectiveness of these drugs in animals and humans for years to come.
being to preserve human and animal health and the effectiveness of antimicrobial medications.
to implement a multidisciplinary approach in assembling a stewardship team to include an infectious disease physician, a clinical pharmacist with infectious diseases training, infection preventionist, and a close collaboration with the staff in the clinical microbiology laboratory
to prevent antimicrobial overuse, misuse and abuse.
to minimize the developme
2. INTRODUCTION
The term plagiocephaly derives from the Greek plagios meaning oblique and
cephalo referencing the head.
The term deformational plagiocephaly, deformational Brachiocephaly and
deformational Scaphocephaly refer to cranial deformities.
Cranial deformity features:-
• deviations in proportion and/or symmetry of
the neurocranium(i.e skull)
• Accompanied by misalignment of the bones
of the viscerocranium(i.e face).
3. Cont…
Cranial remoulding orhoses are usually in the shape of an adjustable helmet
or band that progressively molds the shape of the infants cranium by
applying corrective forces to prominences while leaving room for growth in
adjacent flattened areas.
A Cranial remoulding orthoses may be requested for the treatment of
positional or postsurgical synostosis in paediatric patient.
An asymmetrically shaped head may be synostotic(craniosynostosis) or
nonsynostotic(deformational).
Positional cranial deformity also known as deformational or nonsynostosis
cranial deformity. The nonsynostosis or deformational cranial deformity
refer to cranial deformities that are recognized in infancy and develop from
both prenatal and postnatal factors.
4. Synostosis defined as premature closures of the sutures of the cranium, may
result in functional deficits secondary to increasing intracranial pressure in
an abnormally or asymmetrically shaped cranium.
The type and degree of craniofascial deformity depends on the type of
synostosis.
Cranial deformity may be plagiocephaly ,brachiocephaly and scapho
cephaly.
5. Clinical anatomy of skull
• The shape and structure of the skull bones
are affected by genetic, metabolic, and
mechanical factors because deformation or
misalignment of one unit affects the
alignment and shape of adjoining structures
• The skull of the infant has nine bones of
the neurocranium
• The viscerocranium consists of 14 facial
bones.
• Alignment and orientation of viserocranium
structures are interdependent with the
alignment and orientation of the
neurocranium.
6. Pathophysiology
Causes:-
1. Abnormalities in brain shape or development- includes microcephaly,
macrocephaly and in uterocerebrovascular accident.
2. Abnormalities in bone or suture development- craniosyntosis, apert
syndrome, crouzon syndrome
3. Prenatal and postnatal deforming forces.
7. Common head deformities:-
Plagiocephaly
Most common cranial anomaly
Asymmetry of rt and lt side of skull
Asymmtery of the neurocranium and
viscerocranium
Unilateral occipital flattening
Ipsilateral anterior ear progression
Ipsilateral forehead bossing
Contralateral forehead depression
contralateral occipital bossing
Fascial asymmetry
Congenital muscular torticollis
Altered alignment of eyes, cheeks, nose,
,mouth and chin
8. Brachiocephaly
Less common
Present with primary disruption in cranial proportion
Disproportion of the neurocranium and viscerocranium
B/L occipital flattening
B/L forehead bossing
Increased height of cranial vault
Associated weakness of neck musculature
Increased cranial width
Decreased cranial length
Increased cranial vault height
9. Scaphocephaly
Disproportion of the neurocranium and viscerocranium
B/L parietal flattening
Anterior forehead bossing
Posterior occipital bossing
Associated weakness of neck
musculature
Increased cranial length
Decreased cranial width
11. Factors for creating cranial deformities
Prenatal factors-
Deforming forces in utero- Restrictive in utero environments
Fetal constraints
Sustained abnormal positioning
Deforming forces during birth process- Vaginal deliveries
Cesarean deliveries
Postnatal factors-
Premature infants due to increased plasticity of the underdeveloped cranial structure
1. Sustained supine positioning in compliance with the AAP Back to sleep program
2. Sustained supine positioning in neonatal intensive care units
3. Sustained supine positioning during normal daily infant/caregiver routines
4. Congenital muscular torticollis
5. Neck muscle asymmetry
6. Unilateral neck involvement
7. Cranial hemivertebrae
12. Evaluation of cranial deformities
Degree of asymmetry
Degree of disproportion
Plasticity of bony structure
Amount of translation of bony plates
Cellular disruption and alterations in suture development
Soft tissue involvement and/or contributions from neck musculature
Genetic predisposition
Effect of neurocranial structure and alterations on adjacent viscerocranial
structure
13. Historical perspective
Intentional cranial deformation
Different cultures applied a variety of measures to alter the shape of infants
skull
Boards, vines, cloth bandages and even weight of stones were applied to
the head of the infants to create a culturally desired shape.
Early and sustained application of intentional and specific force would
produce long standing changes in cranial shape.
In 1979, clarren et al, reported that many infants were treated for many
different congenital or hereditory disorders of the brain, bone or sutures.
Cranial remolding orthoses were being used postoperatively and infants
diagnosed with nonsynostosis deformity treated with cranial orthosis and
treatment concept was based on intentional cranial deformation.
14. Cont…
In early to mid 1990 – significant increase in the no. of infants with
asymmetrical and disproportional skull deformities coincided with AAP
back to sleep program.
Haung et al, outlined specific anatomy of deformational plagiocephaly
versus unilateral lambdoid synostosis.
Asymmetry and unilteral occipital flattening in both condition
Parallelogram head shape in plagiocephaly and trapezoid shape in lambdoid
syndrome.
Anterior ear progression in plagicephaly and posterior ear progression in
lamdoid synostosis
With the increasing no. of infants with these deformities orthotics
management with cranial remolding orthosis was developed and refined.
15. Management
Cranial distortion in newborn is common and generally dissolved within the
first 12 weeks of life.
Early identification of cranial deformities creates the opportunity for
altering external forces.
Treatment recommendations-
1. Repositioning
2. Therapeutic efforts
3. Orthosis- a cranial deformity is considered for orthotic intervention when
the infants abnormal skull proportion remains or fails to improve despite
early intervention of repositioning and therapeutic efforts during the first
3 months after birth
16. Repositioning technique
Goal- better distribution of external forces acting on the developing skull.
Time- first 3months of life
Techniques =
Tummy time
Strategic positioning during diapering, feeding, carrying and handling
Limitation on time spent in car seats, carriers and swings
Positioning of nursery furniture relative to bright areas
17. Anthropometic evaluation
Anthrometric skull measurements establish a baseline for clinical
documentation of improvement or progression of the skull deformity.
Common clinical measurements-
1. Cranial circumference
2. Cranial base
3. Cranial width
4. Cranial length
5. Cranial vault
6. Orbitotragial depth
7. Cranial base measurements.
8. Cranial vault asymmetry
9. Orbitotragial depth asymmetry(OTDA)
10. CVAI
11. Cephalic index(CI)
12. Cranial base asymmetry(CBA)
18. Cranial circumference and cranial width measurements
Taken at the equator
Euryon to euryon(EU- EU)
23. Normative values of cranial development
2cm of circumferential growth/ month in the first 3 months
1 cm of circumferential growth/ month between 4 and 6 months
Approx 0.5 cm of circumferential growth/ month between 6 and 12 months
After 12 months cranial growth slows significantly
24. Therapy technique
Continued cranial deformation
Developmental delay
Weakness and tightness of neck musculature
Hypotonicity
Asymmetry of nuchal fold
Persistent positional preference
Limitations in active and passive neck ROM
25. Orthotic management
Indication- moderate to severe deformities
Disruption in cranial symmetry and/or proportion result from the application
external forces acting on developing cranial structure.
Deformation of the infant skull occurs in response to the amount , direction,
mode and frequency of the forces applied.
Temporomandibular jt. Or orbital alignment may be affected.
Function-
1. Presumes growth
2. Balance the static and dyanamic forces acting on the developing structure
to ensure functional competence of both the neurocranium and
viscerocranium.
26. Goal
Achieve maximum correction of the deformity,
Establish symmetry and/or proportion of the skull,
Provide stimulus to cranium growth,
Encourage passive expansion of the cranium.
27. General consideration for orthosis in pediatric population
1. Time of onset of condition
2. Duration of deforming forces
3. Degree of severity
4. Degree of correctability
5. Diagnosis/etiology
6. Remaining growth of physiological structures
7. Overall health of physiological structures
8. Developmental level
28. Examination
Patient history:-
Prenatal and postnatal factors
Birth history:-
Gestational age, Weight , Length, Fetal positioning, Delivery
Associated medical conditions:-
Skin sensivity, head shape at birth and age when head deformity was first
noted.
Developmental observation:- preferred sleeping postion, repositioning
efforts by caregivers, acquisition of developmental milestone
29. Cont….
Physical examination of the infants skull
and face
1. Visual observation from all angles
2. Manual palpation of cranial structure
Documentation of Asymmetrical and
displaced skull and fascial features
Nonvertical orientation of the head relative
to the trunk
Neck musculature
ROM
Digital photographs and anthrometric
measurements
30. Discussion with caregivers
An overview of orthotic treatment program
Determination of treatment goals and expectatations
Importance of supervised prone position
Casting or scanning process
Fitting and follow up schedule
Orthotic cleaning regimen
Wearing schedule
Signs indicating the need for adjustments
Situations requiring removal of the cranial remolding orthosis
31. Fabrication of cranial remolding orthosis
Step -1
Measurement procedure:-
Goal- to obtain an accurate model with identifiable anatomical landmarks
necessary for rectification and fabrication of custom CRO.
1. Casting- produce an accurate negetive model of infants head
2. Scanning- produce digital representation of infants head.
33. Step -2
Rectification-
Goal- to create a new model with greater symmetry and/ or proportion
than currently exists.
Modification- areas of flattening are expanded to allow for planned
growth and Areas of bossing are maintained to resist growth.
Various orthosis use slightly different rectification technique but basic
theory is same.
34. Cranial mapping instrument
Adapted from a bremer pediatric halo crown
Was developed to measure deformational head shapes.
The instrument measures
1. The position and amount of depression or flatness,
2. The amount of displacement,
3. The orientation of head shape within the instrument.
4. Allows the orthotist to create a blueprint and establish the predicted shape
of the skull after orthotic treatment.
35. Creating the blueprint
After a plaster impression of the infant's head is made, it is essential to
critique the positive model for quality and biomechanical accuracy.
The model must be assessed
1. to ensure that it represents the exact model of the cranium
2. to ensure that all anatomic positions and marks are captured.
The anthropometric data collected during the evaluation must be compared
with the cast
36. Procedure
Clean and remove excess plaster from the model.
Remove all ridges and unnatural bumps using smooth finishing.
The positive model must be free of plaster irregularities.
The indelible pencil marks are transferred and reinforced on the mold
37. Cont…
Mark the following bony prominences and landmarks:
1. Glabella (the center at which the eyebrows meet);
2. Tuberosity of the frontal bone (left and right);
3. Frontozygomatic bone (at the level of the tragus);
4. Pinna beginning from the anterior inferior lobule to the posterior inferior
lobule (called auricle or trumpet);
5. External occipital protuberance;
6. The inferior edge of occipital bone; and
7. Sagittal and coronal lines dividing the mold into quadrants.
38. Establish the trimlines
Mark the glabella and make a horizontal
line around the cast at the level of the
supra orbital margin (eyebrow) extending
to the superior edge of the pinna.
This serves as a primary reference
line for anterior trim lines.
40. Cont….
In the sagittal plane, draw a vertical line 1 cm lateral to the supraorbital
margin and another 1 cm distal to the frontozygomatic bone. These lines
connect to create the anterior trim line. The width of the temporal extension
is maintained with 0.5-cm clearance anterior to tragus. A width
approximately 3 to 3.5 cm seems to be appropriate to distribute any pressure
exerted at the temporal area. Draw another line starting from the
frontozygomatic line following the mark of pinna to the posterior inferior
lobule. The line terminates 12 mm distal to the inferior border of occipital
bone
42. Cont….
The posterior trimline is established by joining two points drawn with the
anatomic curvature to facilitate neck extension without impingement.
43. Length and Width Dimensions
Once the trimlines are established, measure the length and width dimensions
of the cast. Compare these measurements with the anatomic measurements
recorded in the craniometry form.
44. Establishing symmetry
Symmetry is an attribute of a shape, an exact correspondence of form on
opposite sides of a dividing line or plane.
Mild asymmetry is usually found in human craniofacial bones and is present
in both affected and unaffected groups. 2 The left and right side differences
occur in variable degrees and could affect appearance. Absolute symmetry
could be considered when each half of the skull is exactly the same, like in a
mirror image.
45. Establishing proportion (displacement and orientation)
Proportion is the relationship of various parts of the skull to the overall
whole.
Maintaining proportion of the skull is an essential element of cranial
molding therapy. a sense of proportion by using a simple cranial mapping
instrument is developed.
46. Cont….
The anterior and posterior center
pins are placed at marks of
glabella and occipital
protuberance and joined.
the lateral lines are joined at the
midline from the center of the
superior border of the left pinna
to the superior border of the right
pinna.
The geometric center of the
instrument is marked by length
and width lines. Quadrant II is
displaced laterally compared with
the geometric center .
The ear displacement is
measured from the centerline and
documented.
47. Craniometry form
It was developed to document the linear
measurements of the cranium.
The distance is measured from the inner
border of the craniometry mapping instrument
to the outer surface of the positive mold.
amount of asymmetry present in the mold.
Repeat the measurements at the glabella,
lateral one third of the eyebrow, ears, lateral
one third of occipital bone, and occipital
protuberance.
Make further notations regarding the skin
condition, muscle tightness, range of motion,
facial asymmetry, and any other relevant
information.
48.
49. Factors affecting modification specification
AGE OF THE INFANT
The skull expands as the brain grows so that normal head growth is a sign of
healthy brain growth.
The philosophy behind the cranial molding orthosis is that the brain and the
skull grow very quickly during the first year of life.
This growth curve is quite steep in the early months and then starts to level
off after 6 months of age.
The cranial molding orthosis is designed to take advantage of that rapid
growth. Therefore, the sooner the treatment is initiated, the better the result.
50. DEGREE OF SEVERITY
Degree of severity affects potential outcomes and protocols of the orthotic
treatment program. In general, moderate to severe deformities can be treated
satisfactorily with a cranial molding orthosis.
51. HEAD SHAPE
The cranial base forms the platform on which the rest of the skull grows and
attaches, and it provides and protects the crucial foramina through which the
brain connects to the face and the rest of the body.
variations in the shape of the human neurocranium are influenced by
variations in the shape of the neurocranium growth and endocranial
expansion driven by brain growth. During normal growth in humans, the
upper half of the neurocranium enlarges and the cranial growth assumes that
overall shape.
This integrated growth occurs through many processes, like sutural
expansion, deposition, and drift.
Length and width changes of the skull occur through coronally oriented and
sagittally oriented sutures.
52. Types of cranial remoulding orthoses
The design and application of a cranial remolding orthosis does not alter the
magnitude of the intrinsic brain growth but merely its direction.
1. Types- Active or dynamics and passive
2. Rigid or flexible
3. Hinged or circumferential
Most cranial orthoses are passive.
Active part - ongoing growth of the infants brain and skull and the extent to
which orthotist is involved in directing head growth.
Different design variations include-
1. Variety of plastics and lining materials
2. Trimlines
3. Strapping
4. Construction of the inner liner
53. Postoperative use of cranial orthosis-
Goal- to maintain and enhance surgical procedure.
To allow for reduction of swelling.
To allow initial healing of suture site.
Protective,
preventing inadverent trauma to the skull.
To discourage growth along specific suture lines.
To maintain or improve the corrected head shape.
54.
55. Principle of cranial remoulding orthosis
to resist growth in undesired areas and directions and
promotes growth in desired areas and directions.
56. Factors for improvements in CRO
Effective fit of the orthosis
Treatment provided during periods of cranial growth
Compliance with wearing schedules.
Age
Design appropriate follow up
57. Effective fit
maintaining good suspension with room for growth,
appropriate trims,
no redness after 15 minutes' wear time,
control of rotation.
58. Age at the initiation of treatment
Cranial orthoses are approved for use an infants , aged 3 to 6 months.
Moderate to severe deformities who have not shown improvement after
atleast 6 to 8 weeks of repositioning( less than 6 months of age)
Best results have been observed in infants with 4 to 12 months age as a
result of greater malleability of the skull and rapid brain growth during that
period.
59. Wearing duration
Last from 3 to 6 months
Factors of length and the results of treatment program-
1. Biomechanics of skull growth
2. Neuromuscular maturation
3. Chronological age at initiation of treatment
4. Severity of deformity
5. Type of cranial deformity
6. Presence or absence of congenital muscular torticollis
7. Other neck weakness or asymmetry
8. Cranial growth pattern
60. Effect of torticollis on average of length of treatment
If torticollis is resolved it is unlikely to affect the duration of cranial orthosis
treatment.
If unresolved, then duration of cranial orthosis treatment should be
increased by 2 to 4 weeeks as a prophylactic measures.
61. Wearing schedule
May be immediate or implemented over a short period of time.
Depends on-
1. developmental level
2. Fit of the orthosis
3. Regional medical practices
Termination of treatment- an acceptable of improvements in symmetry
and/or proportion has been obtained.
Average wearing schedule:- 22 to 23 hours per day for 6 weeks to 6 months.
Having a full time schedule captures the redirection of growth to the
fullest.
62. Follow up
To evaluate acceptable cranial growth patterns and dimensions and
documents the maintenance of orthotic outcomes.
To ensure proper fit and function of the orthosis
Document changes in anthropometric measurements
Performs necessary adjustments and modification to the orthosis
Verify compliance and understanding of the treatment program
Provide guidance and support to caregivers
64. Craniosynostosis
The second most common group of infants with plagiocephaly is infants
diagnosed with craniosynostosis presenting as early closure of one or more
cranial sutures.
In any case, infants with asymmetrical head shapes will undergo definitive
diagnostic testing to identify the cause of the deformation.
DIAGNOSIS:-
Physical examination
X-ray
Computed tomography (CT) scan,
magnetic resonance imaging (MRI).
65. Treatment
SURGERY :- Performed between 3 and 9 months of age.
ORTHOSES:- Infants with craniosynostosis are contraindicated for cranial
remolding orthoses until the affected suture(s) have been surgically
addressed.
Orthoses can be used postoperatively for protection of the surgical site
and/or continued remodeling.
66. Treating Torticollis
Torticollis is the third most common musculoskeletal deviation in the
newborn after dislocated hips and clubfeet.
80-85% of all infants with positional plagiocephaly present with some
degree of torticollis caused by an asymmetrical tightness of the
sternocleidomastoid muscle.
The overall management of positional plagiocephaly requires the
coordinated treatment of torticollis
1. to prevent the child from continuing to rest on the same area of posterior
cranial flatness
2. to develop bilateral head, neck, and trunk symmetry.
67. TREATMENT
Provided before, during, and after the orthotic treatment program.
Infants under 3 months of age :-
1. Passive stretch to the sternocleidomastoid, upper trapezius, and ipsilateral
trunk muscles.
2. Specific handling and positioning instructions are provided
3. Supervised "tummy time" is used to provide active and passive stretch to
the neck musculature.
68. CONT…
The child reaches 4 to 6 months of age:-
EXECRCISES:-
1. Stretch and massage to the affected muscle is provided .
2. Encourage age-appropriate developmental exercises.
3. emphasize head and neck mobility,
4. equal weight bearing, and midline activities
ORTHOSES:- the cranial orthosis may be removed during these exercises.
Occasionally, a cervical orthosis may be needed to augment the orthotic
treatment program. Cervical orthoses block lateral flexion to the affected
side and prevent the head from rotating to the opposite shoulder.
Weaning time- Usually the orthosis is worn before orthotic treatment is
initiated or whenever the cranial orthosis is not in place.
69. Current research
A systematic review of literature support the need for orthotic treatment of
moderate and severe skull deformity.
1988, Rekate found that prenatal and postnatal factors contributed in skull
deformities and he also found three primary treatment options – observation
and repositioning, mechanical intervention and surgery.
A review by Lima in 2004 reiterated the lack of consistent terminology and
definitions. Difficulty in establishing the incidence of skull deformities in
young infants remained, although many citations suggested common risk
factors and early intervention.