An orthosis is an externally applied device used to support the body, correct alignment, protect injuries, or assist motion. Occupational therapists play an important role in orthotic intervention by understanding orthotic goals, designs, and fitting to promote function. Common orthoses include those for the foot, ankle, knee, and upper limb to improve mobility and rehabilitation outcomes. Custom orthoses are fitted by orthotists/prosthetists while prefabricated devices may be fitted by other practitioners.

1. Occupational Therapy Orthotic Intervention

2. WHAT IS AN ORTHOSIS?
An orthosis is a mechanical device applied to the body in order to
support a body segment, correct anatomical alignment, protect a body
part, or assist motion to improve body function
An orthosis is the correct term for an externally applied device that is
designed and fitted to the body to achieve one or more of the following
goals:
 Control biomechanical alignment
 Prevent or correct or accommodate deformity
 Protect and support an injury
 Assist rehabilitation
 Reduce pain
 Increase mobility
 Increase independence
 Stabilize, position or immobilize a body part,

3. Orthosis Goal
 Assist weak muscles or substitute for absent muscle power
 Promote healing, or Assist or restore function.
 Focuses on fitting, construction & training to use special devices
that can be applied to substitute for lost function.
 Can be applied to any part of the body
 Designed to promote function when it is compromised by acute
injury, cumulative trauma, disease, surgical intervention,
congenital anomaly or degenerative changes

4.  Orthoses are first divided according to whether or not they
influence articular structures.
 Non-articular orthoses do not influence joint action.
 When named, these orthoses always carry the “non-articular”
designation in their respective scientific names.
 Non-articular orthoses are further subdivided according to the
anatomical segment to which they are fitted
 In contrast, articular orthoses affect joint motion. Because the vast
majority of orthoses are articular, for convenience, the designation
“articular” is dropped from these scientific names.
 Articular orthoses are further ranked according to five hierarchical
sub classifications

5. Four purposes for orthotic application
 1.Immobilization orthoses stop motion at main/primary joints via
external forces.
 2.Mobilization orthoses increase motion at main/primary joints via
external forces.
 3.Restriction orthoses limit normal arc of motion of main/primary
joints via external forces.
 4.Torque transmission orthoses redirect internal forces to
main/primary joints.

6.  Orthoses act as levers; the longer the lever, the more comfortable
and effective the orthosis. Short knee braces require considerable
force to achieve the same turning effect as full length orthoses.
 In assessing potential to correct or achieve alignment, it is
important to consider the force required and the patient's ability to
tolerate this.
 Degree of force will also influence design of orthosis which must
have sufficient rigidity to apply correction and withstand deforming
forces.

7. Orthotics
 Orthoses are passive or powered external devices for the neck,
upper limb, trunk, and lower limb that are designed to guide
motion, bear weight, align body structures, protect joints, or correct
deformities.
 Unlike prostheses that replace a body part, orthoses are designed to
work in cooperation with the intact body, and either control or
assist movement

8. Commonly prescribed orthoses include:
 Foot Orthoses (FOs) - for various foot, leg or postural problems
 Ankle Orthoses (AOs) and Knee Orthoses (KOs) - for joint
protection, pain reduction or support after surgery
 Ankle-Foot Orthoses (AFOs) and Knee-Ankle-Foot Orthoses
(KAFOs) - to improve mobility, support rehabilitation and
biomechanical goals
 Various upper-limb orthoses - to provide positional and functional
support to the upper limb
 Fracture orthoses - the modern alternative to plaster or fiberglass
casts
 Spinal Orthoses - to correct or control spinal deformities and
injuries and to provide immobilization or support to spinal injuries.

9. Common types of lower limb orthosis include
- Foot orthosis (FO) shoe inserts for correcting ankle and foot
deformities
- Ankle−foot orthoses (AFO) for correcting foot drop
- Functional knee orthoses (KO) for athletic injuries
- Hip abduction orthoses for limiting range of motion
- Long leg knee−ankle−foot orthosis (KAFO)
- Full length hip−knee−ankle−foot orthoses (HKAFO) for standing
and gait stability.

10. Upper limb devices include
- Shoulder and elbow slings for weight support during fracture
healing
- Balanced forearm orthoses (BFO) for feeding assist
- Array of wrist, hand, and wrist−hand orthoses to position the joints
or assist in activities of daily living.
The fit of orthoses is critical as they must carry loads without
interfering with normal skin and tissue function.

11.  A prefabricated orthosis is a device which is pre-made and is
subsequently customized to meet the specific needs of the client.
 These orthoses are often prescribed for short term use or in the
case of non-complex clinical presentations.
 A variety of health practitioners are involved in fitting a small
range of prefabricated orthoses, however orthotist/prosthetists are
the only health professionals qualified to fit orthoses to the entire
body.
 It is also important to note that all pre-fabricated orthoses should
be modified and customized to fit the client and ensure the
treatment goals are met and the best functional outcome obtained..

12.  A custom-made orthosis is a highly specialized device that is
manufactured from a cast or mould of the individual client.
 It is not able to be fitted to another person, as it has been designed
and manufactured to meet the specific needs of the individual.
 Whilst selected health practitioners provide custom made orthoses
for either the foot or the upper limb, only orthotist/prosthetists are
qualified to fit custom made orthoses for the entire body.
 Therefore, a clinical assessment and consultation by an
orthotist/prosthetist will ensure that your entire body or limb
segment is assessed and the full range of orthotic treatment options
considered.

13. Why do Occupational Therapists need to understand upper limb
orthotics?
Occupational Therapists are often those who:
 Work most closely with clients with hand dysfunction
 Are depended upon to prescribe orthoses (or recommend changes
to orthotic prescription)
 Are responsible for training/educating clients in the use of
orthoses.

14.  Occupational Therapist involved in the fabrication and application
of orthotic devices need a good understanding of biomechanics and
anatomy as well as the physiologic response to tissue healing.
 They also need technical and creative skills that allow them to
design and fabricate orthotic devices that can win the patient’s
acceptance and satisfy the treatment goals

15. The Wrist
 The wrist will act as the keystone for hand positioning and outlines
the basis for all splinting, except isolated digital splinting.
 The weight of the immobile hand, gravity, and resting muscle
tension tend to pull the wrist into flexion, which increases tension
in the extrinsic extensor tendons, pulling the metacarpophalangeal
(MCP) joints into hyperextension.
 Concurrently, the tension of the extrinsic flexor is maintained
while forcing the interphalangeal (IP) joints (which include the
proximal interphalangeal [PIP] and distal interphalangeal [DIP]
joints) into flexion.
 The metacarpal arch of the hand flattens and the thumb falls into
adduction. This results in a “claw hand” that is not functional.
Prevention of this deformity is one goal of hand splinting.

16. The hand
 The hand is used during functional activities through basic
prehension patterns: to pinch, to grasp, or to hook objects.
 There are two basic types of hand grips: power and precision
(which can be further subdivided).
 In power grip the wrist is held in dorsiflexion with the fingers
wrapped around an object held in the palm (such as holding a
screwdriver with a cylindrical grip).
 The spherical grip is useful for holding a ball. The hook pattern is
useful for carrying heavy objects.
 In precision grip, the thumb is held against the tip of the index and
middle finger.

17. The hand
 Functional hand splinting is typically aimed at improving pinch.
 There are three types of pinch: (1) oppositional pinch (three-jaw
chuck), (2) precision pinch, and (3) lateral key pinch.
 It is best to splint towards oppositional pinch. This allows the best
compromise between fine precision pinch and strong lateral pinch.
 No practical orthosis can substitute for or improve thumb
adduction.
 When making a splint, the therapist should fabricate it in a position
that enhances prehension and does not force the thumb into a
position of extension and radial abduction. This position causes the
rest of the arm to have to compensate for poor thumb positioning

18. The metacarpophalangeal joints (MCP)
 The MCP joint is the key for finger function.
 When MCP joints are hyperextended, the IP joints flex because of
the tension of the flexors and the delicate balance between the
finger extensors and flexors.
 Extension stability of the wrist is important for optimal function of
the hand.
 The wrist should also be placed in slight extension to maintain
flexor tendon length and to improve hand function
 This position will place the MCP collateral ligaments on maximum
stretch, preserve the anatomic arches of the hand and thus oppose
the development of a “claw hand” deformity.

19. The metacarpophalangeal joints (MCP)
 This position is also referred to as the ”safe” or “intrinsic plus.
 ”This position fosters the weaker intrinsic motions of the MCP
flexion and IP extension that are difficult to obtain.

20.  When increasing joint range of motion with splinting, the angle of
pull needs to be perpendicular to the bony axis that is being
mobilized
 Otherwise the forces on the skin and underlying structures can be
sufficient to cause injury through excessive pressure on the skin
and deforming stresses on the underlying healing structures.
 The improvement in range of motion is directly proportional to the
length of time a joint is held at its end range.
 This is referred to as the TERT principle and is used with static
progressive splinting.

 The load should be low and the application long for effective tissue
deformation. the clinically safe degree of force covers a very
narrow range.

21. Splint is a term commonly used.
 Splint (n): “a thin piece of wood or other rigid material used to
immobilize a fractured or dislocated bone, or to maintain any part
of the body in a fixed position”.
 Splint (v): “to secure, hold in position, or support by means of a
splint or splints, as a fractured bone”
 Splint or splinting considered to have relatively narrow scope &
does not adequately reflect professional training and skill required
for orthotic intervention.

22. Primarily a biomechanical intervention, but is influenced by other
performance components:
Biomechanical
- Stabilize, position, or immobilize body part
- Prevent or attempt to correct deformity
- Protect against injury
- Assist weak muscles or substitute for absent muscle power
Sensory-Motor
- Decrease pain
- Decrease spasticity
- Also decreases sensory input
- Cerebral integration required for coordination

23. Psychosocial
- Improved cosmetic appearance through decreased deformity
- Improved self-esteem & independence through increased function
- May be viewed as “ugly” (poor cosmesis)
- Label of disability
Cognitive Clients need to be aware of:
- How to put orthosis on and take it off
- Care & hygiene
- Wearing regimen
Protect
- Against forces that cause pain, injury or deformity, or stresses that
interfere with healing
Assist
- Weak, paralyzed or spastic muscles to promote functional

24. Correct - Deformity
- A single orthosis may be designed to meet more than one objective,
and more than one orthosis may be required for an individual to
meet all objectives.
Immobilize
- The joint, preventing and motion
Block the motion
- At a certain point, restricting the permitted range of the joint
Prevent Deformity by maintaining joint mobility and alignment.
- Contracture of muscle whose antagonist is paralyzed can be
prevented by placing muscle at its resting length in functional
position & by permitting motion, provided either by orthosis or
passively.

25. - Splint hand in functional position where muscles are said to be
placed in most advantageous position for function.
- Stabilize/support unstable joint or tendon, or fractured bone, or
painful joint.
- May only be necessary temporarily (e.g., when in pain)
- Permits motion of uninvolved or painless musculature (e.g.,
stabilize wrist in arthritis or after injury).
- Protect vulnerable or healing structures to promote healing &
prevent (re)injury.

26. - The non-articular splint provides support to a body part without
crossing any joints, and protects a bone or body part.
- For example, a humeral fracture splint provides circumferential
support to the arm during fracture healing
- The static splint provides static support to hold a joint or joints
stationary.
- For example, a volar wrist splint for acute carpal tunnel syndrome
reduces motion and rests injured tissues
- Static splints can be used to protect healing structures, to decrease
or prevent deformity, and to reduce tone in spastic muscles.

27. Non-Articular Splint

28. Static Splint

29. Hand-based static thumb splint with interphalangeal joint
included for immobilization of a distal phalanx fracture.

30. Assist movement of joints during functional activities when muscles
are weak or paralyzed, which encourages return of function &
facilitates re-education of musculature.
- Place in functional position & provide as near normal ROM as
possible.
- Use hand in coordinated movements to aid in facilitating return to
function.
- Orthosis discourages abnormal substitution patterns.
Substitute for permanently paralyzed musculature.
- Can use external power source

31. Strengthen weak muscles.
- Provide assistive motion first, then decrease &, if indicated
- Provide resistance to increase muscle strength.
- Muscle completes its full available ROM.
- Reduce/control muscle tone of spastic muscles to promote joint
mobility
- Prevent increased muscle imbalance
- Oppose functional or strong muscles with rubber band antagonists
to pull part through full ROM.

32. . Assistive Devices

33. . Soft Splints

34. Corrective Orthoses
- Correct joint contracture (only soft tissue)
- Only possible for soft tissue contractures (i.e., joint stiffness,
muscle contracture, tight tendons) by maintaining ROM gained by
stretching.
- Used prior to surgery to approximate position &/or motions to be
gained by future surgery.

35. Static Orthosis
- No moving parts
- Provides support, stabilization, protection or immobilization
Serial Static Orthosis
- Used to lengthen tissues & regain ROM by using prolonged static
stretch
- Orthosis remolded/adjusted to end of achievable ROM
Static Progressive Orthosis
- Uses non-dynamic components (e.g. Velcro, buckles, etc.) to adjust
amount or angle of traction to regain ROM.
- Can use same orthosis without remolding
- Client can adjust him/herself
- Easily adjusted

36. Static Orthoses

37. Dynamic Orthoses
- Uses moving parts to allow, control or restore movement
- Use elastic, rubber bands, springs
- Apply intermittent gentle force with goal of lengthening tissues to
restore motion
- Can assist weak or paralyzed muscles
- Force must be applied over long time
- Safe force is ~100-300g
- Excessive force results in tissue trauma, inflammation & necrosis
- Line of pull must be 90° to segment being mobilized
- Use high or low profile outrigger to apply correct line of pull

38. Dynamic Orthoses

39. Orthoses Limitations
- Can do NOTHING to help sensory deficits, & may actually
decrease sensory input by covering skin surface.
- CANNOT provide both mobility & stability at same joint.
Must choose what is required.
- Orthotic intervention can ultimately make hand more cosmetically
appealing, but during process, is usually LESS cosmetically
appealing.

40. Before prescribing an orthosis consider
- What is the primary clinical or functional problem?
- What are the indications for, and goals of orthosis use?
- How will the orthosis affect the problem and the client’s overall
function?
- What benefits will the orthosis provide?
- What limitations will the orthosis impose?
- What evidence is available related to the orthosis?

41. Function of Upper Limb Components – Shoulder
Function:
- Allows wide ranges of movement to position the arm in space for
reach
- Provides stability for function;
- Provides background movements for adjustment of reach and
grasp.

42. Function of Upper Limb Components – Shoulder
Minimum criteria for function without equipment:
ROM
- 0º-90º flexion & 0º-90º abduction
- Full internal rotation 0º-20º external rotation
- Functional static shoulder position is 45º flexion/abduction.
Strength
- Fair+ (3+) musculature (i.e., able to function against gravity with
slight resistance.
Motion
- Controlled, isolated motion (i.e., can isolate movement of the arm
from body/head movement; also coordinated movement is
required).

44. Function of Upper Limb Components – Elbow/Forearm
Function:
- Positions hand in space
- Provides stability
- Provides finer background movements for adjustments of reach &
grasp, particularly pronation & supination.
- Forearm positions hand for manipulation of objects.

45. Function of Upper Limb Components – Elbow/Forearm
Minimum criteria for function without equipment:
ROM
- Full flexion range required to reach mouth
- Full extension range required for transfers
- 20º elbow flexion contracture is acceptable for reach
- Full pronation required for function (tabletop activities)
Strength
- F+ musculature
Motion
- Selective & controlled motion required (select specific movement &
use it in coordinated fashion).

46. Function of Upper Limb Components – Wrist
Function:
- Good hand function dependent on ability of wrist to position hand
in stable manner.
- Position of wrist changes according to functional task presented to
hand.
- When task requires power + strength, position of wrist is extension
+ radial deviation.
- When task requires fine precision, wrist assumes position of slight
flexion & ulnar deviation.

47. Function of Upper Limb Components – Wrist
Minimum criteria for function without equipment:
ROM:
- 0º - 45º flexion (PROM)
- 0º - 45º extension (PROM)
Strength:
- Minimum of F+ (3+) wrist extension required to counteract action
of finger muscles involved in grasp & pinch.
Motion:
- Controlled & isolated motion required for fine precision.

48. Function of Upper Limb Components – Hand
Thumb
- Main function is to supply stable opposition to fingers in order to
hold objects.
Fingers
- Make up other half of pinch & positioning force needed to
accomplish controlled grasp.
- Primary function is to grasp, hold & release objects.

49. Function of Upper Limb Components – Hand
Minimum criteria for function without equipment:
Thumb
ROM
- 0º - 35º palmar abduction (PROM)
Strength
- Good (4) strength essential for adequate stability if thumb is to
effectively oppose finger flexor force during grasp & pinch.

50. Function of Upper Limb Components – Hand
Minimum criteria for function without equipment:
Fingers
PROM
- 0º - 80º MCP flexion for efficient release & pinch respectively.
- 35º - 90º IP flexion range for power grasp
- Efficient pinch can be managed with IPs stabilized in 35º flexion
Strength
- Good (4) strength required for power grasp
- Fair (3) strength required (in long finger flexors & lumbricals) for
fine pinch
- Fair (3) strength required in finger extensors for adequate release.

53. Function of Upper Limb Components – Wrist
Sensibility of the Hand
- In addition to range, strength & structure, adequate sensation is
essential for normal hand function.

54. Function of Upper Limb Components
Cerebral Integration
- Normal upper limb function is dependent on CNS’s ability to
integrate & direct strength, movement & sensory information about
environment towards functional movement.
When the CNS fails to complete its integrative tasks, upper limb
function will be characterized by:
- Incoordination
- Abnormal movement patterns
- Failure to generate functional movement.

55. Prehension
- Application of functionally effective forces by the hand to an object
for a task, given numerous constraints
- Definition emphasizes the function and task

56. Palmar Prehension
- Natural functional grip.
- Most preferred hold/grip.
- Provides greater gripping surface than other pinches.
- Pads of the fingers used for sensory detection.
- Wide range of chuck-like motion.
- Used 60% of the time in accomplishing every day tasks.
- Requires more coordination than other grips, except fingertip
prehension.
- Also known as tripod or 3-jaw chuck grip.

57. Fingertip Prehension
- Strongly arched digits.
- Used commonly to pick up small objects like pins, nails, & beads, to
fasten buttons and to sew.
- Insecure grip for large objects.
- Requires finest coordination pattern.

58. Lateral Prehension
- Clamping of thumb against side of index finger.
- Requires good stability in both thumb & index finger.
- Used for turning key, winding watch, or carrying a plate.

59. Hook Grips
- Accomplished entirely by fingers, without use of thumb.
- Main action takes place at IPs, which must be able to fully flex.
- Used mainly to carry heavier objects by a handle e.g., bucket,
suitcase, package.

60. Spherical Grip
- Palm acts as an opposition platform with all 5 fingers rotating
around spherical object to be supported.
- Wrist is stabilized in extension.

61. Cylindrical Grip
- Palm serves as opposition platform & fingers close on it or object is
supported by it.
- Most primitive grasp – reflex in infants.
- Used for holding a rail, using a hammer, etc.
- Can be accomplished without thumb but it helps to get object into
palm of hand.
- Wrist is stabilized between neutral & extension.
- Decreased flexion of IPs & MCPs of fingers makes this grip
impossible.