Orthotics and Prothetics

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Orthotics and prothetics

• Orthotics and Prothetics

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Orthosis

• An orthosis (orthotic) is a device that is
  applied externally to a part of the body.
• The word is derived from ortho, meaning straight.
  
• Orthoses are sometimes called orthotics
• Brace is a device that corrects irrigularities.
• Splint usually used after surgry and does not
  allow
• for movement.
• The orthotist is the person who designs,
  fabricates and repair the
• orthotic device.

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Indications for recommending orthotic devices

• To relief pain.
• To limit motion,
• immobilization after surgery
• immobilization after traumatic injury
• Compression fracture management
• Kinesthetic reminder to avoid certain
  movements.
• To correct deformity e.g. Scoliosis management
• To relieve symptoms of a disease by supporting or
  assisting the musculo-neuro-skeletal system.
• To reduce axial loading, mechanical unloading
• To improve function in a certain segment of the
  body.

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• Assist and improve movement and function
• Reduce muscle tone.
• Protect against injury.
• Provide proprioceptive feedback.
• Provide rest.

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Design characteristics of an orthotic device

• Most important features include the following
• Weight of the orthosis
• Adjustability
• Functional use
• Cosmoses
• Cost
• Durability
• Material
• Ability to fit various sizes of patients
• Ease of putting on (donning) and taking off
  (doffing)
• Access to tracheostomy site, peg tube, or other
  drains
• Access to surgical sites for wound care
• Aeration to avoid skin maceration from moisture

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Duration of orthotic use

• It is determined by the individual situation.
• In situations where instability is not an issue,
  recommend use of an orthosis until the patient
  can tolerate discomfort without the brace.
• When used for stabilization after surgery or
  acute fractures, allow 6-12 weeks to permit
  ligaments and bones to heal.

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Effects of the orthosis may lead to

• Decrease pain
• Increase strength
• Improve function
• Increase proprioception
• Improve posture
• Correct of spinal curve deformity
• Protect against spinal instability
• Minimize complications
• Assist healing of ligaments and bones

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Associated drawbacks of the use of an orthotic
device

• Discomfort
• Local pain
• Skin breakdown
• Nerve compression
• Muscle atrophy with prolonged use
• Decreased pulmonary capacity
• Increased energy expenditure with ambulation
• Difficulty donning and doffing orthosis
• Difficulty with transfers
• Psychological and physical dependency
• Increased segmental motion at ends of the
  orthosis
• Poor patient compliance

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Benefits of orthosis

• Improve function.
• Save energy.
• Increase endurance.
• The main aim of orthotic intervention is to
  function without dis-function.

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Disadvantages and limitations of orthoses.

• Limit mobility and ROM of the joint.
• Restrict rotation around a joint.
• Movement is usually limited to certain direction.
• Weakness of other muscles in opposite direction.
• The device is exposing to wear and tear.
• It needs maintenance, care, cleaning, repairing,
  and frequent changing of shoes.

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Principles and considration for orthoses

• Orthosis should
• provide support and stability to the hip, knee
  and ankle joints.
• be designed to permit safe and effective
  ambulation by patients.
• Provide the need and requirements of the patient
  to support or to mobilize.
• Correlate to the findings of tests
  measurements.
• Correlate with pateint personality and the impact
  of device upon him.
• Prevent the development of deformity and require
  modifications in design.
• Orthosis is only one component of the treatment
  and is not the whole treatment.
• Conserve the time and energy of the patient.
• The materials used should be light, sturdy and
  resistance to wear.
• It should meet the functional requirements of the
  client.
• So each client should be evaluated
  individually.

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Role of physical therapist

• Identify functional problems of the patient.
• Determine orthotic needs.
• Prescribe the orthoses according to each patient
  problems and requirements.
• Evaluate orthotic adequacy.
• Teach the patient to don and doff the orthoses.
• Train the patient for proper use of the orthoses.

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Maintenance of orthosis

• Orthosis should be simple and durable as
  possible.
• Patient should be taught for
• Cleaning the leather.
• Oiling the joints.
• Wash the orthosis if possible.

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Types of orthoses

• Temporarily orthoses Used for certain time after
  injury or operation.
• Permanent orthoses Used for ever when there is
  muscle weakness, paralysis or deformity cannot be
  corrected.
• Or,
• Static orthosis does not allow movement.
• Dynamic orthosis allows movement.

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Common injuries, diseases and deformities that
need use of orthoses

• For discussion

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MATERIALS

• An orthosis can be constructed from metal,
  plastic, leather, synthetic fabrics, or any
  combination. Plastic materials, such as
  thermosetting and thermoplastics, are the
  materials most commonly used in the orthotic
  industry.

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• Plastics
• Thermosetting materials can be molded into
  permanent shape after heating. They do not return
  to their original consistency even after being
  reheated. Thermoplastic materials soften when
  heated and harden when cooled.
• Low-temperature thermoplastics can be fabricated
  easily and rapidly with hot water or hot air and
  scissors, but they are used mainly in low stress
  activities.
• High-temperature (polypropylene) thermoplastics
  require higher temperature (150C) to mold, but
  they are ideal for high stress activities.

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• Leather
• such as cattle hide, is used for shoe
  construction because it conducts heat and absorbs
  water well.
• Rubber
• Rubber has tough resiliency and shock-absorbing
  qualities.
• Rubber is used for padding in body jackets and
  limb orthoses.

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• Metal
• Metals, such as stainless steel and aluminum
  alloys, are adjustable, but they are heavy and
  not cosmetically pleasing.
• Metals can be used for joint components, metal
  uprights, sprints, and bearings.

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Selecting the appropriate material
characteristics for fabrication of an orthotis
device requires careful consideration of a number
of factors

• Strength the maximum external load that can be
  sustained by a material.
• Stiffness the amount of bending or compression
  that occurs under stress. e.g. when greater
  support is required, a stiffer material is used
  when a more dynamic orthosis is desired, a more
  flexible material is used.
• Durability (fatigue resistance) the ability of a
  material to withstand repeated cycles of loading
  and unloading.
• ( selection of a material for orthotic
  appliances is based on the ability of the
  material to withstand the day-to-day stresses of
  each individual client.

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• Density the greater the volume or thicker a
  material the more rigid and more durable. (this
  usually increases the over all weight of the
  orthosis.
• Corrosion resistance the material may be
  affected by chemical degradation. Most materials
  will exhibit corrosion over time, metal will rust
  and plastics become brittle. Contact with human
  perspiration and environments such as dirt,
  temperatures and water accelerate the wearing
  effect on the materials. Knowing the clients
  daily environment can assist in material
  selection.
• Ease of fabrication the equipments needed for
  fabrication of orthosis

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Biomechanichal principles of orthotic design

• The biomechanical principles of orthotic design
  assist in promoting control, correction,
  stabilization, or dynamic movement.
• All orthotic design are based on three relatively
  principles

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The pressure principle

• the pressure should be equal to the total force
  per unit area.
• Force
• P ------------------------
• Area of Application
• It means that the greater the area of a pad or
  plastic shell of an orthosis, the less force will
  be placed on the skin.
• Therefore, any material that creates a force
  against the skin should be of dimension to
  minimize the force on the tissue.

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The equilibrium principle

• The sum of the forces and the bending forces
  created must be equal to zero.
• This means that three-point pressure or loading
  system occurs when three forces are applied to a
  segment in such a way that a single primary force
  is applied between two additional counter forces
  with the sum of all three forces equalizing zero.
• The primary force is of a magnitude and located
  at a point where movement is either inhibited or
  facilitated, depending on the functional design
  of the orthosis

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The lever arm principle

• The farther the point of force from the joint the
  greater the moment arm and the smaller the
  magnitude of force required to produce a given
  torque at the joint.
• This why most orthosis are designed with long
  metal bars or plastic shells that are the length
  of adjacent segment.
• The greater the length of the supporting orthotic
  structure, the greater the moment or torque that
  can be placed on the joint or unstable segment.

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These three principles act dependently on each
other

• So when designing or evaluating an orthotic
  devise we should check that
• There is adequate padding covering the greatest
  area possible for comfort.
• The total forces acting on the involved segment
  is equal to zero or there is equal pressure
  throughout the orthosis and no areas of skin
  irritation.
• The length of the orthosis is suitable to provide
  an adequate force to creat the desired effect and
  to avoid increased transmission of shear forces
  against the anatomic tissues

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General othotic considerations

• The forces at the interface between the orthotic
  materials and the skin.
• The degrees of freedom of each joint.
• The number of joint segments.
• The neuromuscular control of a segment, including
  strength and muscle tone.
• The material selected for orthotic fabrication.
• The activity level of the client.
• The goal of orthotic fitting is to meet the
  functional requirements of the client with
  minimal restriction.

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Functional orthotic considirations

• Alignment The correction of a deformity or
  maintenance of a body segment. e.g.
• a) Musculoskeletal disorders
• Milaukee brace for scoliosis.
• Dynamic splint to prevent scar
  shortening in burns.
• b) Neurological disorders
• Tone reducing AFOs in patient with
  cerebral palsy.
• CTLSO to prevent motion of cervical
  region.
• Movement a joint may require assistance with
  motion or resistance to excessive motion
  example.
• Assistance with joint motion.
• a) Muscloskeletal disorders
• AFO with dorsiflexion assist for
  dorsiflexor weakness.
• b) Neurological disorders
• RGO assist with spinal cord injury
  with ambulation.

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• Resistance with joint motion
• a) Muscloskeletal disorders
• Shoe insert for a patient with foot
  deformity.
• Finger splints for arthritic hand.
• b) Neurological disorders
• Arm sling for neurological disorders.
• Swedish knee cage for unstable knee.

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• 3) Weight bearing to reduce axial loading and
  reduce the forces placed on a joint.
• Muscloskeletal disorder
• Shoe insert with metearsal pad for a
  diabetic patient with foot deformity.
• b) Neurological disorders
• Heel wedge for a child with cerebral palsy.
• 4) Protection protect a segment against further
  injury or pain.
• Examples
• a) Muscloskeletal disorders
• Functional knee brace.
• b) Neurological disorders
• Cock-up splints for post spinal cord
  injury.

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Orthoses are named by the joints they encompass
Ankle-foot orthosis Knee-ankle foot orthosis Hip-Knee-ankle foot orthosis Reciprocal Gait orthosis AFO KAFO HKAFO RGO Foot orthosis Knee orthosis Hip orthosis LL orthoses FO KO HO
Cervical-Thoracic orthosis Cervical-Thoracolumbosacral orthosis Thoracolumbosacral orthosis Lumbosacral orthosis AFO KAFO HKAFO RGO Cervical orthosis Thoracic orthosis Sacral orthosis Sacroiliac orthosis Spinal orthoses CO TO SO SIO
Wrist-Hand orthosis Elbow-Wrist-Hand orthosis Shoulder-Elbow orthosis Shoulder-Elbow-Wrist-Hand orthosis WHO EWHO SEO SEWHO Hand orthosis Wrist orthosis Elbow orthosis Shoulder orthosis UL orthoses HdO WO EO SO
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TYPES OF ORTHOSES

• LOWER LIMB
• Insoles - These are used to help cushion the
  feet, reduce high pressure areas or alter the
  biomechanics of the feet are abnormally shaped so
  do not fit ordinary footwear.
• Footwear adaptations - Adaptations are made to
  either compensate for a leg length discrepancy or
  to alter the angles of the feet when walking.

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• Ankle Foot Orthoses - (plastic or conventional
  metal)  These can be supplied to help control or
  stabilise the ankle and foot.  For example, for
  controlling foot drop or stabilising an
  osteoarthritic ankle.
• Knee Ankle Foot Orthoses - (plastic or
  conventional metal)  These are used to help
  control or stabilise the knee, ankle and foot.
• Knee braces - There are various types to help
  control the knee joint.
• Stockings - These are used to help control
  swelling, help improve circulation and help
  prevent ulcers and Deep Vein Thrombosis.

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TRUNK

• Corsets and Abdominal Supports - A fabric support
  to provide some support to the back or stomach.
• Plastic Spinal Supports - Provides firmer support
  than the corset.  They will control movement, as
  well as support the body to prevent surgery, or
  after surgery.
• Collars - Varying types to provide different
  degrees of support and control to the neck.

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UPPER LIMB

• Wrist Splints - To support or control movements
  of the wrist and help reduce pain.
• Some of our supports are stock items but most are
  custom made devices to suit the individual needs
  of the patient.  This is why you are usually
  required to have more than one visit to the
  department.

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FOOTWEAR

• These are supplied to those patients who are
  either diabetic, have a biomechanical need for
  additional control of the foot and ankle or whose
  feet no longer fit into conventional footwear.
• Repairs to this footwear are only carried out
  through the hospital if a war pensioner wears
  them or if the shoes are have adaptations

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