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Orthosis

An orthosis is an external device that is applied to the body to improve function, provide support, reduce pain, correct deformities, and prevent progression of fixed deformities. Lower limb orthoses include foot orthoses, ankle-foot orthoses, knee orthoses, knee-ankle-foot orthoses, and hip-knee-ankle-foot orthoses. The goals of lower limb orthoses are to maintain or correct body segment alignment, assist or resist joint motion, provide axial loading and relieve distal weight bearing forces, and protect against injury. Orthoses can be static devices that hold body parts in position or dynamic devices that facilitate motion.

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LOWER LIMB ORTHOSIS
• An orthosis is an external device applied or attached to a body segment to:  improve function by controlling motion Providing support through stabilising gait Reducing pain through transferring load to another area Correcting flexible deformities And prevent progression of fixed deformities.
Some basic goals of orthosis • Maintenance or correction of body segment alignment • Assistance or resistance to joint motion • Axial loading of the orthosis & therefore relief of distal weight bearing forces • Protection against physical insult
Locomotion and gait • The total mass of the body can be considered concentrated at one point, called the center of gravity. • The center of mass is located in the midline, just anterior to the second sacral vertebra while the individual is standing and walking. • The center of mass changes with the configuration and function of the body.
• The line of gravity is a line passing through the center of gravity to the center of the earth. • This line (1) arises from the supporting surface between the ball and heel of the foot, then (2) passes in front of the ankle and knee joints and slightly behind the hip joint to the center of gravity, then (3) passes through the lumbosacral junction and behind the lumbar vertebral bodies to intersect the spine at the thoracolumbar junction, then (4) continues in front of the thoracic vertebral bodies and through the cervicothoracic junction, and, lastly, (5) travels behind the cervical vertebral bodies to the occipitocervical junction. • When the center of gravity does not fall through the area of support, it is unstable at that moment.
• The average total displacement of the center of gravity in the vertical and lateral directions is less than 2 inches in normal gait. The increase in displacement of the center of gravity increases the amount of energy for walking. • The purpose of using an orthosis is to enhance normal movement and to decrease abnormal posture and tone. Lower extremity orthoses can be used to correct abnormal gait patterns and to increase the efficiency of walking.
• An orthosis is classified as a static or dynamic device. A static orthosis is rigid and is used to support the weakened or paralyzed body parts in a particular position. A dynamic orthosis is used to facilitate body motion to allow optimal function. In all orthotic devices, 3 points of pressure are needed for proper control of a joint
• A lower limb orthosis should be used only for specific management of a selected disorder. The orthotic joints should be aligned at the approximate anatomic joints. Most orthoses use a 3-point system to ensure proper positioning of the lower limb inside the orthosis. • The orthosis selected should be simple, lightweight, strong, durable, and cosmetically acceptable. Considerations for orthotic prescription should include the 3-point pressure control system, static or dynamic stabilization, flexible material, and tissue tolerance to compression and shear force
Lower limb orthoses • FO foot orthosis • AFO ankle foot orthosis • KO knee orthosis • KAFO knee ankle foot orthosis • HKAFO hip knee ankle foot orthosis • HO hip orthosis
Foot orthosis • When foot cannot attain neutral, FO may shim the gap to that fixed position- Accommodative FO • May help the foot attain a neutral position- Corrective FO • Either may unload compromised tissue; or may provide total contact • May be full custom or Off The Shelf (OTS)
UCBL • University of California Biomechanics Laboratory (UCBL) • Rigid plastic total contact design • Hind foot / mid foot correction • Heel cup extends proximal to inframalleolar area and distally to the metatarsal heads
AFO Most common orthosis 1. Metal bars 2. Total Contact 3. Floor reaction 4. Unweighting 5. Immobilizing ▫ Most AFO’s can be articulating or non- articulating • STABILIZES ANKLE IN STANCE • HELPS CLEAR TOE IN SWING • GIVES SOME PUSH OFF IN LATE STANCE TO SAVE ENERGY
SMO • Supra Maleolar Orthosis • Low profile design that crosses the ankle • Less invasive trim lines than a standard AFO
Metal bars • Commonly used in specific scenarios ▫ i.e. Post-Polio, Neuropathic feet
Total Contact AFO’s • provide sleek, intimate fit with total contact to provide better control • Subtypes are thermoplastic and thermosetting • higher patient acceptance possibly due to light weight & concealment (150-200gms); • more common today
Floor reaction AFO • Uses floor reaction force through toe aspect of foot plate to prevent forward tibial progression & subsequent knee collapse; • May be articulated
Unweighing AFO • May be patella tendon bearing (PTB), specific weight bearing or total surface bearing, TSB (inverted cone with lace closure) to unweight the ankle foot using prosthetic principles
Immobilising AFO Commonly used with a lower extremity deficiency when ankle immobilization is desired ▫ distal tibia/ fibula fracture ▫ foot bone fractures ▫ tendocalcaneus rupture ▫ Diabetic Foot (Charcot Foot) Crow Walker CAM Walker AFO for Fracture Management.
Articulated or non articulated • May be designed for progressive increases or decreases in sagittal plane ROM and control • An articulating option may be available in many designs of AFO’s
Nonarticulating(solid ankle) Articulating
Knee orthoses • Useful for malalignment ▫ genu varum, ▫ valgum, ▫ recurvatum, • to protect knee structures from undue loading/stress • Extends above and below knee joint. • may be preventative or corrective • may be permanent treatment for repaired/compromised knee structures Photo of a patient with Genu Recurvatum courtesy of Westcoast Brace & Limb
Several types of KOS • Athletic KO- • Non-articulated KO- • Custom or OTS KO-
Athletic ko • Preventative. • Controversial as short lever arms may not be sufficient to diminish realistic damaging forces. • Proprioception thought to play a role.
Off-the–shelf KO • Offers limited control of the knee. • Restricts gross motion Dynamic Extension assist KO to prevent contractures
KAFO • Indicated when lesser devices are biomechanically insufficient; • Combines KO & AFO
Subtypes ▫ Single/Double bar (upright) KAFO- ▫ Total contact KAFO- ▫ Ischial Weight Bearing (unweighting) KAFO-
Single/Double Bar KAFO- ▫ Accommodates volume fluctuation, ▫ Cooler than total contact, ▫ Highest material strength. ▫ Several lock options.  Lock for ambulation, unlock for sitting. ▫ May incorporate hyperextension stops. ▫ Various knee joints are available  e.g. Weight activated stance control, locking, polycentric, single axis, extension assist, etc.
Total contact KAFO • More customizable. • Better load distribution. • Includes Sarmiento Style Fracture Bracing
Ischial Weight Bearing (unweighting) KAFO- • Ischial containment or Quadrilateral style brims with high trimlines. • Generally used with paralytic limbs. • Not as effective with larger or obese individuals.
HKAFO Hip Knee Ankle Foot Orthosis • Very restrictive and laborious to swing-to or through in gait ▫ causing high rejection rates ▫ Includes Reciprocating Gait Orthoses (RGO), total contact, leather and metal upright, postural and others
Specific HKAFO: Reciprocating Gait Orthosis (RGO • Commonly used in cases of spina bifida and spinal cord injury. • Combines flexion of one hip with extension of the opposite hip. • The flexion power of one hip is utilized to extend the opposite hip.
Hip arthroses • Hip Abduction Orthosis • Standing Walking AND Sitting Orthosis (SWASH) • Some Orthoses can intervene at the hip without crossing the hip. Select examples: Dennis Brown Bars A-Frame Orthosis
Hip abduction orthosis • Commonly used post-operatively to position the femoral head optimally within the acetabulum Hip Abduction orthoses can be an HO only or can have a KAFO extension. www.pelsupply.com
Specific Case Hip Orthosis (HO): S.W.A.S.H Orthosis  Standing Walking And Sitting Hip Orthosis  Maintains femoral abduction in standing, walking and sitting
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