Prothetics, Orthotics. EXAM (POAT)
Describe the 3rd rocker phase of gait
(D) During the third rocker, the ankle plantar flexes over a fixed forefoot (about the metatarsophalangeal joints) ending in toe-off, initiating the swing phase of gait
Your patient comes in with decreased ankle strength,or impaired proprioceptionor ankle PF spacitiy, but NONE of this affects foot placement during standing. This indicates that you should use a orthosis with articulated ankle joint. Now you determine if you need a DF stop: Pt has PF strength <4 in standing or excessive ankle DF or PF. DF strength is >4. What is indicated?
Polyarticulating AFO with DF stop. or Metal AFO with double-adjustable ankle joint and poly footplate with DF stop or Metal AFO with DAAJ, DF stop ***Dont need DF assist since DF is >4/5
Describe the common etiologies of excessive knee and hip flexion with excessive ankle DF
Distal and proximal neuromuscular control inadequacies. Weak ankle PF, hip/trunk and knee extensors Compensation for inadequate hip ROM, hip flexor limited. compensation for lack of knee extension with hamstring contracture or hypertonicity
What are posterior offset axis KAFO knee joints used for?
Relocate the axis of the knee joint in posterior direction, to provide more knee joint stability in stance phase. GRF is now positioned more anterior and reduced knee flexion moment arm
What is the best way to observe the shoe shape?
Remove in-sole and observe
What are some types of heating sources to fabricate an orthotic device?
Heating pans and guns, to allow a therapist to custom mold an orthotic.
Why would moving the joint axis in a posterior direction with a posterior offset axis for the knee joint help reduce the knee flexion moment arm?
Move the GRF in anterior direction. In later stance in TS and PReSw, the GRF is posterior to axis and creates a flexion force for swing phase! pretty cool
What are the 2 main force laws, in regards to orthosis effectiveness and comfort?
Orthotic forces are Distributed over large surface areas to minimize local skin and ST pressures Applied using larger moment arms possible Sum of forces and counterforces should be 0
What is the OPUS?
Orthotics and prothetics user survery. Subjective info about orthotic intervention outcomes.
What are the 4 prerequisites for effective upright standing?
Plantigrade feet Extended knee or slightly hyperextended. Extended hips COM balanced over BOS
What kind of orthosis, would you want to use, if you wanted to stretch a muscle and promote relaxation of the tissue?
Serial static progressive orthosis
Describe why we would use a serial static orthoses for the UE?
Series of static orthotses Low load and long duration of stretch.
What is the clinical application of a halo orthoses?
Shift the COM higher since the brace is top heavy. Functional training requires change in approach to control upper body mass
What are the components of a KAFO?
Shoe Foundation Ankle control Knee control Superstructure
A rigid forefoot valgus malalignment with a STJ supination compensation. How would you use a wedge to fix this?
Support forefoot on lateral plantar surface to bring ground up to foot
A rigid forefoot varus malalignment, with a STJ pronation compensation. How would you use a wedge to fix this?
Support forefoot on medial plantar surface
What are the two types of UCBL devices?
Supramalleolar AFO (SMO) Dynamic AFO (DAFO)
Excessive pressure on the nerves of the UE, can be a major problem with orthotic placment. What areas should we watch out for, that may lead to pain, numbness and tingling?
Suprascapular nerve on spine of scap Axillary nerve Radial groove Cubital tunnel Superficial radial and ulnar nerve on dorsum of forearm Median nerve at wrist Digital nerves
What are some attachments for UE orthotics?
Straps Linings and padding Outrigger systems, hinges Fingertip attachments and slings
How do we calculate stress?
Stress = force / area
Describe the characteristics of conventional KAFO
Strong, durable, easy to adjust Less cosmetic Heavier Must be attached to shoe
What is the concept of traditional foot biomechanics?
Structural foot type --> functional characteristics --> Pathomechanical function and efficient function ***Certain foot types have certain pathological characteristics
What is a Minerva Type Cervical thoracic orthosis?
Substantial stabilization to cervical spine, with halo strap. need training to accomodate for lack of cervical motion
A solid AFO can assist in swing foot clearance. This can substitute for what weakness?
Substitute for weak DF
A solid AFO can assist in promotion of ankle and knee stability in stance. This can substitute for what weakness?
Substitute for weakness of PF or weak inverters/evertors
Describe what a stability shoe is
Subtalar joint medial control for protection of pronation
What is the standardized frame or reference for foot orthoses?
Subtalar joint neutral
What provides a frame of reference in our assessment of the forefoot to the rearfoot alignment?
Subtalar neutral
What are some factors to consider according to our roadmap, in order to order an AFO?
Sufficient ROM in LE joints to align lower extremity segments cognition in tact and desire to meet goals Adequate cardiovascular endurance and adequate UE/Le strength for intended activity
Before ordering an orthoses, what factors should be considered to see if the patient could don an LE orthotic device?
Sufficient ROM in Lower Ex tremity joints to align segments The ability (including cognition) and desire to meet ambulation goals Adequate cardiovascular endurance and adequate Upper Extremity (UE) and Lower Extremity (LE) strength for the intended activity, i.e. ambulation Sufficient strength to advance the limb
What is linear static/dynamic equilibrium?
Sum of the forces and how they are balanced. Resultant forces need to occur with movements
What are considerations of shoe outsole size and friction coefficients for patients with neuro deficits while wearing orthotics? (Footwear Key factor)
Want shoe drop of 3/4 in from heel to ball. Rocker soles to enhance rocker Increased toe spring Heel lifts Grip of outsole
How would you educate a patient about the effects of decreased blood flow, due to excessive compression with an UE orthotics?
Watch out for color changes, temperature changes or excessive throbbing.
What may happen if we have too much pressure or contact in a small area?
We cut off capillary and blood supply and may give nociceptive input which leads to negative outcomes.
Identify specific indications for use of a solid AFO
Weak DF, this will assit in swing foot clearance With foot equinovarus/valgus, to preposition foot for initial contact Weak PF, Inv/Everters to promote knee/ankle stability and hold in STJ neutral
What are some common material properties in Orthosis and Prothetics?
Weight Stiffness to deformation Elasticity Viscoelasticity Plasticity Hysteresis Ductility Brittleness
What is the gait training progression sequence?
Weight shifts side to side Weight shifts in tandem Weight shifting with involved limb Weight shifting with uninvolved limb Weight shifting with univovled limb, back first then forward.
Describe the WIFE principle for long term patient acceptance for orthosis?
Weightless Invisible Free Effortless to utilize
There are studies that suggest that the ground reaction force may increase with a medial knee unloader brace during ambulation. Is this very bad? what may be causing this?
Well the increase may suggest an increase in walking speed, which would naturally generate more force.
What are the basic factors when considering a KAFO prescription?
Whether knee joint is locked in extension during swing phase. Unilateral or Bilateral Degree of spasticity present at joints Strength and ROM of ipsilateral hip joint Sensation and proprioception in affected limb
How do we balance rearfoot and forefoot misalignment with foot orthoses?
Medial and lateral wedgin
What are the characteristics of a Temporary Orthoses?
"Off the Shelf" Non-specific, and usually costs less: Short term use for Healing, Function, Contracture prevention Generic fit Assess functional benefits/systems and practical applications
Describe the 1st rocker phase of gait
(A) During the first rocker, the heel strikes the ground, the foot rotates around this, and the ankle joint axis to come to rest in the flat foot position. Contraction of the anterior compartment muscles* controls this motion. (DF act extrinsically)
What are the 3 rockers of gait?
(A) During the first rocker, the heel strikes the ground, the foot rotates around this, and the ankle joint axis to come to rest in the flat foot position. Contraction of the anterior compartment muscles* controls this motion. (DF's control motion) (B) During the second rocker of gait, the tibia is brought " up and over " the talus, rotating around the ankle joint. The intrinsic muscles of the foot and tibialis posterior fire* to maintain a medial longitudinal arch. (C) The terminal portion of the second rocker signals the powerful triceps surae to fire.* (gastroc-soleus complex (D) During the third rocker, the ankle plantar flexes over a fixed forefoot (about the metatarsophalangeal joints) ending in toe-off, initiating the swing phase of gait
Describe the 2nd rocker phase of gait
(B) During the second rocker of gait, the tibia is brought " up and over " the talus, rotating around the ankle joint. The intrinsic muscles of the foot and tibialis posterior fire* to maintain a medial longitudinal arch. (C) The terminal portion of the second rocker signals the powerful triceps surae to fire.* (triceps surae is gastroc-soleus complex)
When are KAFO provided vs. AFOs?
When AFOs are not sufficient to provide gait or standing stability
Briefly describe the proximal radioulnar joint?
Articulation of the radial head to the radial notch of the ulna. Pivot joint to permit radius to pivot around ulna for supination/pronation
A rigid forefoot varus deformity would lead to what during MS and terminal stance? How would you fix this?
Compensatory STJ pronation. Medial forefoot posting
How would the rearfoot compensate for a rigid plantarflexed first ray?
Compensatory STJ supination
What type of shoe provides support to the Medial and lateral subtalar joint and midtarsal joint stability
Motion control shoe
How do we apply the lever system to orthotics?
Deliver therapeutic stress to target structure in most efficient manner Length of resistance and effort arms influence mechanical advantage of force production
Why is thickness a consideration for an UE orthotic.
1/16 to 3/16 of an inch. 1/16 inch or Smaller is better for hand orthotic 1/8th inch is recommended for upper arm and forearm and wrist. Choose thinnest possible
What should the length be from the space from the end of the longest toe to the tip of the shoe?
1/2 inch for ability to extend toe
Describe a 1st class lever
1st class lever: Fulcrum in center. Mechanical advantage is greater than or equal to 1
What are the 3 classes of lever systems?
1st class lever: Fulcrum in center. Mechanical advantage is greater than or equal to 1 2nd class lever: Fulcrum on outside with the load in the center. mechanical advantage greater than 1 3rd class lever: Effort arm shorter than resistance force. Force of load at most distal point. Mechanical advantage is <1
Describe a 2nd class lever
2nd class lever: Fulcrum on outside with the load in the center. mechanical advantage greater than 1
In regards to forces in orthotic design, each plane and direction of motion under orthotic control MUST have at-least one what?
3-point loading system
Describe the 3rd class lever
3rd class lever: Effort arm shorter than resistance force. Force of load at most distal point. Mechanical advantage is <1
What are the significant challenges for immobilization of cervical spine via cervical orthoses?
Extremely mobile joint complexes and planes Little body surface available for skin contact
What is normal thoracic motion?
6-9 degrees of lateral bending and rotation at each segment
An angle of what degrees is ideal oreinetation for a lever of an orthotics?
90 degrees (with perpendicular direction there are no other forces that would decrease the torque)
What is the effect of a short lever + small contact areas?
= increased local skin pressures
What main thing is required for indication of KAFO, to help advance swing limb?
>2/5 hip flexion
What is force?
Addressing action or influence that stops or produces change in a moving object
What is necessary for the success of a stance control KAFO?
Adequate quad strength Intact proprioception and kinesthesia Minimal LE spasticity Adequate hip and knee extension ROM. Adequate cognition
What are the characteristics of a Thermoplastic AFO?
Harder to adjust Lighter weight Transferable Poor tolerance to heat and fluid volume changes More cosmetic Energy return
What are the 5 prerequisites for safe and energy efficient walking?
Adequate: Lower limb stability to accept and support body weight Foot position at IC and LR. Foot clearance of swing phases of gait Motor control and motion at foot, ankle, knee, hip and pelvis Balance of limb segment kinetics
What is the KEY benefit for a metal upright articulating AFO?
Adjust ability. Especially for edema
What is a shore durometer?
A measurement of a matierial's hardness or ability to resist permanent indentation Range 35-60 durometer
In general, your patient has significant gait deviations, LE weakness and impaired proprioception at the knee or ankle. The patient has >3+/5 quadriceps strength. Should you use a Long leg orthoses, or ankle foot orthosis
Ankle foot orthosis
How can a solid AFO be positioned in relation to the ground reaction force?
AFO aligned in 5 degree PF or slight DF. PF positions tibia to incline posterior DF positions tibia in anterior incline position
What is bonding in relationship to an UE orthotic?
Ability for material to change with heating. Used for attachments or reinforcements of a specific spot.
What characterizes ideal normal gait?
Able to progress the BCOM through space with stability and minimal energy output
What are the 3 different anatomical columns of the spine?>
Anterior Middle Posterior ***Determines overall stability of spine and changes how spine functions depend on column of trauma
Solid AFO's fundamentally limit the function of what?
All 3 rockers
What motion is C3-C7 spinal segments involved with?
All planes of motion
When are posterior leaf spring AFOs used for?
Allow DF (2nd rocker) Supports forefoot during swing Control PF from initial to loading response (1st rocker) Position foot sagittally in initial contact
How does perforations effect an UE orthotic?
Allow for better airflow for decreased skin issues and weight. But reduces RIGIDITY... which could effect recovery and function of brace
Why would we use articulating thermoplastic AFO's?
Allow progression through 1st rocker. Control knee hyperextension in midstance with PF stop. Control knee flexion during TS, with DF stop Provide medial lateral stability at ankle and STJ
What are high memory materials used for? (ability for brace to return to original shape)
Allow therapist to remold a brace, when tissue changes during healing process
What are high conformability low resistance to stress braces used for?
Allows more room for modification and control. Other type is low conformability, high resistance to stress
What are the 3 ways that an orthotic can assist in postural change in a jointu?
Altered Joint moments Altered Joint shearing forces Altered joint axial forces **most orthoses alter joints directly, but can also effect joints above and below
What is the main consideration when making a forearm orthoses?
Amount of muscle bulk created during rotation and fit of orthoses in all periods of motion. Must insure enough space
Define Orthosis?
An external applied device applied to a part of the body to correct deformity, improve function or relieve symptoms of disease
What is the history of spinal orthoses?
Ancient Egyptians used splints to stabilize joints in spine. Middle aged armorers were used as splints. Metal corset by Ambrois Pere. Halo brace made by Heister in 17th century!
How does angle of application effect force of an orthotic?
Angle of 90 degrees oriented to lever is ideal. total force influencing segment are in same direction
Briefly describe the carpometacarpal joint of the thumb
Articulation between trapezium and first ray. Saddle joint
What is the mechanical goal of orthotic intervention?
Apply forces of specific magnitude at specific points on a limb/trunk segment to achieve desired control
The following are reasons why we use what type of AFO? Allow progression through 1st rocker. Control knee hyperextension in midstance with PF stop. Control knee flexion during TS, with DF stop Provide medial lateral stability at ankle and STJ
Articulating or Thermoplastic AFO's
What is the relationship between stress and force?
As force increases , stress increases
What are the main types of involvement with PTs and Orthoses?
Assessment for identified purposes Evaluation of fit Education in orthotic fit and training in use Assessment and quantification of functional benefits and uses
What can solid AFO's do?
Assist in swing foot clearnce Preposition foot for initial contact Promote ankle and knee stability in stance
What can conventional metal upright AFO's be used for?
Assist swing foot clearance Assist in smoother transition from initial contact to loading response
Describe how we could help someone with equinovarus spasticity
Assist with foot clearance in swing phase and improve foot/ankle position at initial contact Improve the BCOM progression left IC to LR Reduce premature calf activation left from end of loading response to midstance Improve terminal stance ankle position Increase knee flexion in pre-swing.
Where do manufactures actually list foot width?
At the in-sole at the largest space, which is usually at metatarsal heads
What are key aspects of midstance?
Can tibia move forward over foot with eccentric calf muscle function from LR to TS? How well is person positioning knee in sagittal plane as BCOM forward over knee joint?> How well is person positioning hip and pelvis in front plane during Single limb stance?
What are the types of negative effects of spinal orthoses?
Axial muscle atrophy due to reduced movement Immobilization cause contractures pressure/irritation on skin breakdown Psychological dependency on device
A rigid forefoot valgus deformity would lead to what during MS and terminal stance? How would you fix this?
Compensatory STJ supination in all phases of gait. Lateral forefoot posting, to get lateral boarder of foot to ground during phases
When would a rocker bottom be used for with a foot impairment?
Be good for forefoot rocker function of the subtalar joint
How does a rigid forefoot varus change the alignment of the foot during normal gait?
Because of excessive varus position of the heel, during WA, you will excessive STJ pronation to bring medial heel to floor. Creates a compensation
To be effective CO's must control what?
Both gross and intersegmental movements of head and neck
Briefly describe the glenohumeral joint?
Ball and socket joint in glenoid fossa and head of humerus. Allows for multiple planes of motions, at the expense of stability in arm
Briefly describe the midcarpal joint
Between proximal carpal joints and distal carpal row. Lunate, scaphoid, trapezius and pisiform to the trapezium, trapezoid, capitate and hamate bones. Allows for flexion, extension and radial/ulnar deviation.
Briefly describe the radiocarapal joint
Between the Distal humerus and the scaphoid and lunate bone. condyloid joint
The prescription of a KAFO is primarily based on what 6 factors?
Biomechanical function to be provided that will address patient's unique structural deficits Weight of orthosis Ease of donning and doffing Safety functional reliability COST
Why does a mismatch of joint axes prevent a common clinical challange with orthoses?
Biomechanical motion is multiplanar. Difficult to match ANY orthosis mechanical axis with normal dynamic multiplanar anatomical axis. May see deformation of joint reactive forces Increases in friction irritation Increases in pistoning with orthotic device
What is the most important consideration for UE orthosis placement?
Bony prominence and pt education on pain, redness and skin issues
What provides the main blood supply to the arm?
Brachial artery
What ROM restrictions are noted with cervical orthoses?
Flexion/Ext- 65% Rotation- 60% decrease SB- 35% restriction
A rigid plantarflexed first ray deformity would lead to what during MS and terminal stance? How would you fix this?
Compensatory STJ supination. What they should do it remove material under first ray, to make it even with the other rays
Your patient has <3+/5 quadriceps in only the test side and >3+/5 strength in the contralateral limb. A unilateral KAFO is indicated on the test side at this point. The patient DOES have knee hyperextension ROM. What does this indicate for type of KAFO?
Can use unlocked KAFO on test side. ***Offset knee joint, with knee axis anterior to joint line or ***Free knee long leg orthosis
When would you generally use a solid AFO?
Cannot control posture or normal movement of the ankle.
What are the key components of Preswing to midswing?
Can person do swing limb shoretening for toe clearance? Adequate DF and knee flexion and hip flexion What factors are compromising ability to relatively shorten the swing limb and continue forward COM progression
What are some common etiologies with limited BCOM progression?
Compensation for inadequate knee and hip extensor capacity Compensation for inadequate plantarflexor capacity Loss of adequate ankle and forefoot rocker functions. ROM impairments and PF spasticity
What is rearfoot valgus?
Calcaneal eversion
What is rearfoot varus?
Calcaneal inversion
What are key aspects of loading response?
Can individual effectively LOAD limb and allow efficient forward movement Can person accomplish shock absorption via eccentric knee and hip extensors along with STJ prontation How does pt accomplish controlled lowering of foot via eccentric DF. How well is positioning of hip and pelvis in frontal plane during Loading response?
What are key components of Terminal swing to pre-swing?
Can individual roll over the 1st met head and 2nd and 3rd met heads to accomplish 3rd rockers? Can individual transfer weight towards the opposite limb that is going into LR? Is there adequate knee flexion to transition into pre-swing?
What is a fixed Deformity?
Can not be passively corrected
What are the key aspects of terminal stance?
Can person convert foot from mobile adapter to rigid level Is there continued forward progression of pelvis with apparent hip extension to prepare for swing phase? What is trailing limb posture?
What are the several sections of joints in the hand?
Carpo-metacarpal joint
What are the 5 types of spinal orthoses?
Cervical Cerviocthoracic Thoracolumbosacral lumbosacral sacral
What types of cervical orthoses are least restrictive of ROM?
Cervical collar soft
What is a Four Poster orthoses?
Cervical thoracic orthoses Mandibular/occipital support and excellent limitation of flexion/extension. Only allows 10-28% normal motion
The key benefit for a metal upright articulating AFO is adjustability. When would it be very beneficial for a patient to use this?
Chronic limb edema, can accommodate to limb volume.
How would the rearfoot compensate for a forefoot varus position?
Compensatory STJ pronation
When considering UE orthotics we must consider Bony prominence and pt education on pain, redness and skin issues. What bony prominences should we worry about?
Clavicle Spine of scapula Acromion Olecranon Medial/lateral epicondyle Radial/ulnar styloid process Base of 1st met Pisiform PIP/DIP joints
A wrist orthoses must clear what two creases to allow normal movement?
Clear distal and palmar crease
What is standard alignment of a solid AFO?
Close to neutral of subtalar or foot positioning
How does coating effects an UE orthotic?
Coating will improve hygiene and protect from bacteria
What is the COMPLETION criteria, for the indication of bilateral KAFO use, with quad strength less than 3+ bilaterally?
Come to stand with AD independently (3 times) Stand and walk through parallel bars with open hands, indepedently (1 time) Walk with AD 20 continuous steps with supervision only (2 times)
What is the shoe, heel counter rigidity test?
Compressing the heel counter to test ankle support and support to frontal plane movements
How does surface area relate to compression?
Compression is inversely proportional to surface area. Increasing surface area, will increase mechanical advantage and decrease compression stress
What type of joints are the MCP jonits?>
Condyloid joints and allow for all motions
What are some handling characteristics of an UE orthotic?
Conformability and stretch resistance (low conformability has more control) Memory Rigidity Bonding Heating and working times
Briefly describe the humeroradial joint
Connects the capitulum of distal humerus to head of radius. Hinge joint and only allows for flexion and extension
What are considerations of shoe weight for patients with neuro deficits while wearing orthotics? (Footwear Key factor)
Consider lightest shoe with the required stability needed
What are the 3 main orthotic design purposes?
Control Movement Assist Movement Combination of both. **Should be able to control in 1 plane and assist in another**
What is the biomechanical approach to foot orthotics and intervention?
Control abnormal motion --> Enhance normal motion --> Optimize tissue stress **All connected together
Describe a locking knee joint KAFO and what it's used for
Control knee buckling
Describe a Stance control knee joint KAFO and what it's used for
Control of knee buckling Assistance of knee extension ***Prevent flexion during stance, but allow it during swing
What are the 6 main mechanical goals of functional foot orthoses?
Control pronation and supination kinematics Control forces and loads on specific foot structures Redistribute of plantar pressures within foot Support of abnormal foot postures when normal anatomy cannot Facilitate sagittal plane progresion of BCOM over foot during WA through Single limb support control of shock absorbing functions of foot/ankle
What are single axis knee joint KAFO used for?
Control unwanted flexion and extension Often used to control knee hyperextension Can lock and stabilize knee.
Describe the biomechanics of SAFO?
Control varus of foot and control PF and DF of ankle in rearfoot and midfoot. 3 point control system in sagittal and frontal plane.
What are the 4 main objectives of a spinal orthoses?
Controlling spinal position by external forces Apply corrective forces to abnormal curvatures Provide spinal stabilization when soft tissues are inadequate Restrict spinal segment movements after trauma
Carbon fiber thermoplastic or conventional KAFO? Strong, durable, easy to adjust Less cosmetic Heavier Must be attached to shoe
Conventional KAFO
The following are reasons we would use what type of AFO? Assist swing foot clearance Assist in smoother transition from initial contact to loading response
Conventional metal upright AFO
What are the 3 types of knee joints incorporated into KAFOs?
Conventional non-locking locking Stance control
If the AFO is aligned in 5 degrees of plantar flexion, what happens to the tibia?
Creates posterior incline of tibia in standing. Positions GRF in more anterior position for greater stability of the knee joint
What are the 3 different types of shoe shapes?
Curved- Forfoot adduction 25 degrees Semi-curved- Forefoot adduction 10 degrees Straight
Describe what a neutral shoe generally is
Cushioning/shock absorption, but not designed to control
What are some orthotic tools to help make an orthotic?
Cutting devices Pliers Hole punches- to make straps loops or rings Hand drills and benders, to fit needs of patients
Describe the 5 effects of the GRF system of control?
Dependent on contact with ground with stance phase Dependent on shoe interface/structure Influence control over joints within orthosis Offer less stability depending on slope Generally may be energy efficient
How does color effect an UE orthotic?
Darker material shows less dirt. Good color will decrease compliance
Describe why we would use a dynamic orthoses for the UE?
Designed to mobilize joint and elongate tissues. Have a static base, but uses elastic material to provide force for joint mobilization. Stresses tissue to stress limit
What is the purpose of an orthosis?
Device which support or assists the musculo-neuro-skeletal system
Describe the characteristics of dynamic AFO's
Dynamic AFO's are articulating, flexible, and have either posterior leaf spring or metal single or double upright position. Allow certain motion and disallow other motions Floor reaction forces
What kind of orthoses would you use for tight muscles to elongate the tissue and provide force for joint moiblity?
Dynamic orthoses
How would you fix a rearfoot varus position?
Medial heel wedge to make sure calcaneus is level at all positions
When considering an elbow orthoses, what must you consider?
Elbow angle In males, it is 5 degrees In femals it is 10-15 degrees
What is the ankle rocker phase of gait? What muscles are in eccentric control in this phase?
End of loading response. Ankle is 10 deg PF through midstance when tibia passes vertical and ankle is in DF. Gastroc/soleus work eccentrically
What is the goal of the biomechanical approach to foot orthotics and intervention?
Enhance normal motion and optimize tissue stresses
Articulated AFO's are used to permit sagittal plane motion, while restricting transverse and frontal plane motion. Identify indications for use of an articulated AFO, for specific impairments
Excessive knee hyperextension, with 5 degree PF stop Excessive knee flexion during midstance and terminal stance with DF stop to limit forward tibial translation, to limit excessive DF with weak PF Provide medial and lateral stability to ankle and STJ
Why in the world, would someone require a PF stop?
Excessive knee hyperextension. PF stop will stop tibia from excessive forward translation, and maintain tibia in posterior direction. Weak quads
True or False: Individuals with significant lumbar and thoracic ligamentous injury leading to segmental instability will most likely benefit more from orthotic devices interventions verses surgical interventions alone
FALSE: With ligamentous injury leading to instability, they will more likely benefit from surgical intervention than bracing alone
Know the following terminology: FO AFO KO HO KAFO HKAFO THKAFO
FO- Foot orthosis AFO- Ankle foot orthosis KO- Knee orthosis HO- Hip orthosis KAFO- Knee ankle foot orthosis HKAFO- Hip-knee-ankle-foot orthosis THKAFO- Trunk-hip-knee-ankle-foot orthosis
True or False: Orthoses typically achieve total or near total cervical spine immobility
False They DO NOT achieve total cervical spine immobility
True or False: The thoracic spine presents greater challenges for providing spinal immobilization through orthotic interventions compared to the lumbar spine
False: Lumbar spine presents the greatest challenges
What special joint function does the thumb MCP have, which would be important for orthoses fitting?
Few degrees of rotation which improves precision, hinge function.
What part of the UE is MOST intricate to fit for orthoses due to relationship of tendons and ligamentous structures?
Fingers
Force systems with orthoses generally act, in effect like what type of system? 1st/2nd or 3rd class levers?
First class lever system. ***Counter force, must be equal to initial force***
What are considerations of shoe fit for patients with neuro deficits while wearing orthotics? (Footwear Key factor)
Fit shoes toward end of day when foot is largers. Fit larger of two feet fit to any brace Match shape of shoe to shape of foot
What is the difference between Fixed deformities vs. Dynamic Deformities?
Fixed Deformity: Can not be passively corrected Dynamic deformity: Result from over-activity of muscle tendon groups but when at rest are passively correctable *Can also develop in adjacent joints in response to coupling effects of defomities above and below
When would you use a supramalleolar AFO?
Flexible in sagital plane and biomechanically assists transverse and frontal plane motions
What are posterior leaf spring AFOs?
Flexible thermoplasticis Trimlines posterior malleoli Usually set in DF
What is the ABSOLUTE FOUNDATION or groundwork for any LE prothesis and Orthosis?
Footwear
When would you want to avoid using a PF stop?
For a pt with excessive knee flexion. You want to promote anterior tibial translation to promote knee extension
When would you recommend a floor reaction AFO?
For people with crouched gait. Pushes tibia back, doesn't not allow knee flexion and promotes extension, by pushing tibia tack into extension.
What is torque?
Force x distance (moment arm)
What is pressure?
Force/Area
How well a spinal orthoses is effective depends on what 5 factors?
Force/pressure application Direction and magnitude of forces TIGHTNESS OF DEVICE Body habits of individiual wearing it Type of trauma and instability produced
What are the 3 main area of mechanics for prosthetic intervention?
Forces and Moments Tissue Pressure tolerances Joint axes Alignment
What is shear stress?
Forces parallel to surface
What is tensile stress?
Forces pulling away from each other. Like a distraction or stretch
What is compression stress?
Forces pushing toward each other. similar to pressure. Force and compression in perpendicular direction
How does a rigid forefoot valgus malaligment change the position of the foot during gait?
Forefoot is in everted position, relative to STJ in neutral. During stance, the lateral forefoot would have difficulty meeting the ground. STJ goes in supination to compensate. Alters normal pronatory function
What would a rigid rearfoot varus lead too?
Forefoot valgus to compensate leading to abnormalities
What are some common alterations in weight acceptance seen with patient with neurological involvement?
Forefoot-first initial contact, which would create mechanical effects that restrict tibial advancement. Does not allow tibia to flex, and this stops forward momentum. Excessive knee and hip flexion
What are the types of cervical thoracic orthoses?
Four poster: Allows 10-28% normal motion of flexion/extension Malibu collar with thoracic extension.
What are the parts of the lever systm?
Fulcrum Effort arm Resistance arm
Describe the fulcrum, effort arm and resistance arm in relationship to the elbow joint.
Fulcrum: elbow joint, with load of elbow is dumbell in hand Resistance arm: Forearm Effort arm: Biceps
What are the different types of foot orthoses?
Functional foot orthoses Accommodative foot orthoses
Describe the 5 effects of the 3 point force system of control?
Functions continuously effective in all conditions Not as dependent on shoe structure/interface Controls motion of joints Controlled joints are stable on all terrain May reduce gait and energy efficiency through joint restrictions
Compare and contrast the differences between GRF and 3 point force, systems of control
GRF: dependent on contact with ground 3 point: functions in both swing and stance GRF: Dependent on shoe structure 3 point: not dependent GRF: Influence over joints within orthosis and proximal 3 point: only joints within orthosis GRF: Less stability on different terrain 3 point: stable on all terrain GRF: More energy efficient 3 point: less energy efficient
What is normal lumbar motion
Greatest flexion and extension with least motion at bending and rotation
What are the Corrective control systems utilized by LE orthoses:
Ground Reaction Forces control systems Or 3 point-pressure control systems
What is the toe rocker phase of gait? What muscles control this phase?
Heel rises off ground through push-off in terminal stance. Gastroc/soleus work concentric
Due to the little body surface available for contact with cervical orthoses, what occurs as a result?
High incidence of skin breakdown on occiput and chin High pressure related pain in clavicles and chin Hygiene issues limit comfort for shaving
What kind of footwear style is key for neurologically involved patients with orthotics? (Footwear Key factor)
Higher the counter the more control. (High-top shoes) Yet they are harder to don and doff and are heavier
What type of joints are the DIP and PIP?
Hinge joints and only allow flexion/extension. MOST intricate to fit for orthoses due to relationship of tendons and ligamentous structures.
What kind of knee orthosis control single or multiplanar hypermobility?
Hinged swedish knee cage
Describe solid AFO's?
Hold ankle in fixed position and immmbolize in 3 planes. Close to neutral ankle, 90 degrees of subtalar or foot position
What joints compose of the elbow?
Humeroradial joint Humeroulnar joint Proximal radioulnar joint
A factor facilitating excessive knee flexion in midstance is what? Soleus muscle weakness Popliteus muscle weakness hyperactivitiy of ankle PF hip flexor weakness
Hyperactivity of ankle PF
Describe the characteristics of a thermoplastic carbon fiber KAFO
Interchangeability of shoes Better cosmesis Lightweight Can be hot Hard to adjust
Why does cosmetics affect AFO use?
If they don't think it looks good they probably will abandon device
When would you use metal vs. plastic for a brace?
If you have a pt with a large change in edema volume you want to use metal with a lot of openings. With a lot of edema, plastic is contraindicated since it puts to much pressure on leg.
Describe why we would use a static orthoses for the UE?
Immobilization of a structure/joint that they cross. Can encourage movement at an adjacent joint Can provide place for attachments
What are the 7 Fundamental purposes of Orthotic prescription?
Improve performance of functional activities Improve/enhance mobility Deformity prevention: primary and secondary Correction of passively modifiable deformity Immobilization/Control/protection Regulating or reducing muscle tone Stabilizing weak or flaccid muscles
What is Merton Roots, contribution to the foot orthosis?
In 1950, introduced subtalar neutral foot position, and published about Normal and Abnormal function of foot. Main methods on presciprtion of orthoses
Indication for a KAFO, include When excessive movement occurs at knee that cannot be effectively controlled with AFO. What specific things may cause this?
Inability to control early stance phase knee flexion Late stance phase excessive genu recurvatum Abnormal knee varus/valgus Excessive hypertonicity that overpowers external moments
What are the 5 main common etiologies for forefoot first initial contact?
Inadequate dynamic knee extension control Inadequate pre-tibial muscle eccentric capacity/control Premature calf muscle activation Plantarflexor contracture Inadequate proprioceptive feedback at knee and ankle
What are the 5 main common etiologies for excessive knee and hip flexion?
Inadequate eccentric knee extension capacity/control Inadequate hip extensor eccentric control Loss of adquate hip extension ROM- hip flexion contracture Hamstring contracture
What may cause toe drag, in relation to a problem at the knee?
Inadequate knee flexion
What are some common alterations with swing limb advancement?
Inadequate knee flexion in Pswing Poor foot clearance. continued Inadequate knee flexion, which may cause toe drag **Improve tibial posture and control***
What are some problems with a locked knee joint KAFO?
Inappropriate knee extension leading to hip hike and circumduction. Abnormal gat
What is a articulating or thermoplastic AFO?
Mechanical ankle joint with single axis or flexible non hinged axis to allow PF and DF
Describe the effects of adequate effort arm length and depth in relationship to orthotics
Increased comfort for patient in brace
Describe the effects of a longer and broader effort arm in relationship to increased force production with a brace
Increased force with longer effort arm, due to increased mechanical advantage
When would you use a neuro-orthoses which is used for drop foot and provide e-stim?
Indicated for MS, CVA, TBA, CP REstorative and compensatory Decrease spasticity Part of rehab services Uses Walk-AIDE and L-300
When would you use Dynamic AFO's?
Indicated for pediatrics for reducing tone and promoting optimal foot position, during standing and gait
When would a knee ankle foot orthosis be used over a knee orthosis?
Indicated when lesser devices are biomechanically insufficient. Provides more stability
If knee flexor spasticity was present, what would happen to the gait cycle?
Ineffective limb advancement and limited terminal swing
What is elastic force?
Influence on motion of object resulting from applied stress. Force = spring x extention of spring. ***stiffer the structure has a larger amount of resistance
A solid AFO can preposition the foot for what phase of gait?
Initial contact. Hold in subtalar neutral
What is the indications for use of a sternooccipitalmandibular immobilizer? (SOMI)
Instability at or above C4
What is the indications for use of a Yale cervicothoracic orthosis?
Instability below C4
What motion is C0-C1 spinal segments involved with?
Involves significant flexion, extension. Little rotation and side bending
What is the moment arm?
Is the distance related to torque production
What is the questions you should ask yourself after viewing a patient's gait cycle?
Is there adequate LE ROM to properly align or posture the limb segments in each phase of gait cycle? Is adequate cognition and motivation? Adequate endurance for gait? Adequate UE, trunk, Le strength, power, motor and posture control. Adequate awareness of LE position. IF YES< THEN PT IS A CANDIDATE.
What is a T-strap? What does a medial T-strap promote, what does a lateral T-strap promote?
Is under foot and wraps around the foot for change of foot position and pronation or supination. Lateral promotes pronation and medial promotes supination
Why is the alignment of the shank of a solid AFO important?
It controls GRF and positions ankle to tibia on anterior or posterior incline. Which would alter dynamics of gait
How does an ACL brace reduce tensile loading on the new anterior cruciate ligament while it heals?
It uses a 4 point control system. Prevents unwanted translatory forces to prevent shearing and protecting ligament
What kind of offset knee joint is used when patient has knee hyperextension ROM and weakness in quads?
Knee axis that is anterior to joint line, to provide extension moment during stance and free motion during swing
What are the types of thoracolumbar orthoses?
Knight-Taylor brace Cash (cruciform anterior spinal hyperextension) brace Jewett Type TLO Custom-molded thermoplastic jackets
What devices stimulate the common peroneal nerve to assist in DF?
L-300, or Walk-aide Use built in accelorameter to note foot position and stimulate DF
What is Cruciform anterior spinal hyperextension brace used for? (Case Brace)
LIMITS FLEXION, and allows hyperextension posture
What are the different types of lumbosacral orthoses? (LSO)
LSO with unilateral thigh extension Thermoplastic LSO Chairback type LSO Anterior corset type LSO *Primarily controls sagittal plane movement
What is a dynamic orthosis?
Orthotic devices with moveable joints Blocking/control selected motions Supporting/substituting for weak ms. Increase motion via traction
Where should you apply three points of control to orthotically reduce the genu varus?
Lateral femoral condyle as the FULCRUM. medial proximal femoral and medial proximal tibia as counterforce.
How would you fix a rearfoot valgus position?
Lateral heel wedge to make sure calcaneus is level at all positions
What makes Dr. Coleman crazy?
Lazy makes him crazy. Now keep quizletting.
Describe the effects of longer resistance arm in relationship to force production and orthotics
Less force required for needed torque production of brace
What is the effect of a short lever + large contact areas?
Less increased local skin pressure
What is the effect of a long level + small contact areas?
Less increased local skin pressures
What are some common alterations in single limb support?
Limited BCOM progression, with limited forward rocker, which reduces contralateral step length. Excessive knee and hip flexion with excessive ankle DF in MS and TS. Pt compensates with lumbar lordosis
If plantarflexion spasticity was present, what would happen to the gait cycle?
Limited fwd progression in MidStance and difficulty with forward propulsion in terminal stance
What is the Jewett type Thoracolumbar orthoses used for?
Limits flexion, but allows hyperextension posture
Why are KAFO's considered by PT's as a last resort option?
Limits initial and long term acceptance rate of devices, due to heaviness, bulkiness and increase in energy expenditure
What is bending and torsion stress? Give a few orthotic examples of this stress
Load to structure is simultaneous with compression, shearing and tensile stresses. Torsion is twisting around the longitudinal axis. **Supination/pronation orthosis ***Elbow flexion mobilization orthosis. Compression on anterior elbow, with tensile stress on posterior elbow.
KAFO, historically did what? Which did not make any sense in regards to proper ambulation
Lock patient in knee extension and disallow flexion. This lead to poor patient acceptance
Your patient has <3+/5 quadriceps in only the test side and >3+/5 strength in the contralateral limb. A unilateral KAFO is indicated on the test side at this point. The patient does not have knee hyperextension ROM. What does this indicate?
Locked knee joint brace. Drop or ball
In general, your patient has significant gait deviations, LE weakness and impaired proprioception at the knee or ankle. The patient has <3+/5 quadriceps strength. Should you use a Long leg orthoses, or ankle foot orthosis
Long leg orthoses
What are the 4 arches in the hand?
Longitudinal arch Proximal/distal transverse arch Transverse arch
Describe what a motion control shoe is
Medial and lateral subtalar joint and midtarsal joint stability
Briefly describe the humeroulnar joint?
Made up of proximal ulna and trochlea. Hinge joint and only allows for flexion and extension
Briefly describe the distal radioulnar joint?
Made up of ulnar notch of radius to head of the ulna. Pivot joints
Long term use of an AFO, requires patient acceptance. What main things can lead to better acceptance?
Make sure it is weightless, invisible, free and effortless to use. When gait efficiency and speed increase, they more likely use it
How should a thoracolumbar orthoses be donned?
Make sure to do it in unweighted supine position. NOT sitting or standing
What is Force?
Mass x Acceleration
What joints make up the wrist joint?
Midcarpal joint Radiocarpal joint
What are conventional variable joint axis KAFO use for?
Mimic true knee joint actions with flexion and extension
What is Torque?
Moments of force X Moment arm length
What are thoracolumbar orthoses used for?
More commonly used than cervical orthoses. Stabilize spinal segments Control of motion is poorly studied. Prevention of injuries is NOT, NOT NOT demonstrated
What are the characteristics of a metal AFO?
More easily adjusted for ROM and edema Heavier Attached and fixed to shoe decreased cosmesis (not pretty)
Briefly describe the distal transverse arch of the hand
More mobile arch. Located at level of metacarpal heads and provides hand ability to grasp objects of different objects
When is a thermoplastic jacket most commonly used?
Multi-columnar instability
What is a swing through gait pattern?
Must have hip extension to help stand and be able to swing past crutches. (2 point gait pattern)
What is a static orthosis?
Orthotic devices with no moveable joints incorporated into design. Block motions and alter local pressure
What parameters define a force?
Nature of force as push or pull. Magnitude is amount of force produced Point of application is location of force application
What is the normal amount of DF needed for gait?
Need 5 degrees of "true" ankle DF. Can incorporate 90 degrees PF stop or DF
What is the bail-locking mechanism for a KAFO?
Need a method to unlock in sitting posture. Pressure from back of seat, will release lock and allow knee flexion
What is a Charcot foot?
Neurological disorder, where foot is numb and the midtarsal bones and foot bones, start moving everywhere. Bones become weakened enough to fracture and they start moving around and foot deforms.
What type of shoe provides Cushioning/shock absorption, but not designed to control
Neutral shoe
What is the participation criteria for the use of an ambulation trial for a bilateral KAFO?
No contractures in hip flexors, knee flexors, or ankle plantar flexors SLR from 0-110 degrees Independent in all transfers including w/c to floor Max VO2 is >20 ml/kg/min 50 continuous full dips in parallel bars
Your patient comes in with decreased ankle strength,or impaired proprioceptionor ankle PF spacitiy, but NONE of this affects foot placement during standing. This indicates that you should use a orthosis with articulated ankle joint. Now you determine if you need a DF stop: Pt has PF strength >4 in standing or does NOT have excessive ankle DF or PF. Pt has DF strength >4 What type of AFO is indicated?
No orthosis required
Your patient has >3+/5 quadriceps in the test side and >3+/5 strength in the contralateral limb. The patient also has proprioception intact at the test knee. Does this indicate the use of an AFO?
No, not required. Evaluate for AFO on test side
What is the utility of the cervical orthoses and cervico thoracic orthosis in terms of how long you should wear the brace, and long term outcomes of brace use?
Non-surgical neuro patients require 3+ months with orthosis Need for surgery is unclear if alginment can be achieved. Non-surgery patients have better long term ROM surgical patients require brace for 6 weeks
What are some shoe upper considerations for orthotics? (Footwear Key factor)
Normal opening vs. extended openings. Velcro vs. lacing Padded collars and tongues
Your patient has <3+/5 quad strength bilaterally, and does NOT meets the criteria for ambulation trail with bilateral KAFO. What does this indicate?
Patient will not recieve bilateral KAFO for ambulation. Pt re-evaluated in >3 months
Your patient comes in with decreased ankle strength,or impaired proprioceptionor ankle PF spacitiy, but NONE of this affects foot placement during standing. This indicates that you should use a orthosis with articulated ankle joint. Now you determine if you need a DF stop: Pt has PF strength >4 in standing and does NOT have excessive ankle DF or PF. Pt has <4 DF strength. What type of AFO is indicated?
Orthosis with DF assist. Leaf spring AFO or Polyarticulating AFO with DF assist or Metal AFO with DAAJ and poly footplate with DF assist or Metal AFO with DAAJ, with DF assist
Your patient comes in with decreased ankle strength and a plantar flexion contracture, which affects foot placement during standing or gait. They score 43 or greater on the BERG balance scale and have in tact proprioception. What type of AFO is indicated?
Orthosis with articulated ankle joint. with PF stop ***Polyartiuclating AFO with PF stop or Metal AFO with DAAJ and poly footplate, PF stop or Metal AFO with DAAJ, with PF stop
Your patient comes in with ankle plantar flexion spasticity, which affects foot placement during standing or gait. They score <43 on the BERG balance scale or have decreased proprioception. What is indicated?
Orthosis with locked joint and undercut or cushioned heel. **Rigid polyporpelyne AFO or Metal AFO with double adjustable ankle joint or Metal AFO with DAAJ locked
Your patient comes in with decreased ankle strength and a plantar flexion contracture, which affects foot placement during standing or gait. They score <43 on the BERG balance scale or have decreased proprioception. What is indicated?
Orthosis with locked joint and undercut or cushioned heel. **Rigid polyporpelyne AFO or Metal AFO with double adjustable ankle joint or Metal AFO with DAAJ locked
Your patient comes in with decreased ankle strength,or impaired proprioceptionor ankle PF spacitiy, but NONE of this affects foot placement during standing. This indicates that you should use a orthosis with articulated ankle joint. Now you determine if you need a DF stop: Pt has PF strength >4 in standing or does NOT have excessive ankle DF or PF. What type of AFO is indicated?
Orthosis without DF stop indicated.
What is the effort arm? What is the resistance arm in terms of a lever?
Part that creates the force, between fulcrum and point of force. Resistance arm attempts to resist effort force and creates opposing force around fulcrum
What are some things that lead to marked increase in acceptance for KAFO acceptance?
Patient retains hip flexor and extensor function Gait efficiency and speed increases
What are the characteristics of a Definitive Orthoses?
Permanent benefit is needed Mechanically and Physiologically stable Custom fit Costly
When would you use an articulated or hinged plastic AFO?
Permit full sagital plane ankle motion, but restrict frontal and transverse plane motion
What are the key components of midswing to terminal swing?
Person controls momentum of LE during forward progression of limb into late swing Can knee flexors eccentrically control advancement of tibia Can patient preposition the foot in prep for HS at IC Adequate stance phase stability of opposite limb for an effective stride length of swinging limb
Who wrote the first text on foot deformities for the use of orthosis?
Petrus Camper in 1781
What are the different types of cervical collars?
Philadelphia Aspen Miami J
Briefly describe the acromioclavicular joint?
Planar joint that allows for rotation and anterior.posterior movement of acromion on clavicle
Your patient comes in with decreased ankle strength,or impaired proprioceptionor ankle PF spacitiy, but NONE of this affects foot placement during standing. This indicates that you should use a orthosis with articulated ankle joint. Now you determine if you need a DF stop: Pt has PF strength <4 in standing or excessive ankle DF or PF. DF strength is <4. What is indicated?
Polyarticulating AFO with DF stop. or Metal AFO with double-adjustable ankle joint and poly footplate with DF stop or Metal AFO with DAAJ, DF stop Since DF is so weak you can use a Polyarticulating AFO with DF assist Metal AFO with ADDJ and poly footplate and DF assist Metal AFO with DAAJ with DF assist
How does positioning an AFO in slight PF, help with gait?
Positions GRF in more anterior position for greater stability of the knee joint, with tibia inclined posterior
The following are characteristics of what kind of AFO? Allow DF (2nd rocker) Supports forefoot during swing Control PF from initial to loading response (1st rocker) Position foot sagittally in initial contact
Posterior leaf spring
The following are characteristics of what type of AFO? Flexible thermoplasticis Trimlines posterior malleoli Usually set in DF
Posterior leaf spring AFO
What is the 3 goals of foot orthoses prescription?
Reduce pathological force loading on injured and non-injured structures Optimizing locomotion and standing weight bearing functions of foot Prevent secondary injury
What are the 3 main concepts in Orthotics and Prothetic Rehab process?
Pressure Tolerances Moments and Force transmissions Alignment of Joint Axes
What motion is C1-C2 spinal segments involved with?
Primarily rotation. Little flexion/extension
What is the main mechanical goal of a functional FO?
Promotes sagittal plane progression rather than pronation/supination, to facilitate the shock absorbing and mobile adapter and a functional lever for propulsion **reposition foot alignment
What are UCBL?
Provide comfortable support, but undergo deformation to allow motion. For flexible deformities of STJ and midtarsal joints while allowing rocker function
What are thermoplastic jackets or TLSO used for?
Provide total contact over desired area, to limit motion in all 3 planes. Go from sternum to pubic bone, and contoured around rim of pelvis. (CUSTOM FIT)
Briefly describe the scapulothoracic joint?
Pseudo joint that allows the scapula to glide along the thoracic wall as arm moves
Why might an orthotist recommend setting an AFO in 3 degrees of PF?
Pt has excessive knee flexion. Yet, they also have good knee control from hamstrings in the stance phase.
Why might an orthotist recommend setting an AFO in 5 degrees of DF?
Pt has genu recurvatum, due to weak hamstrings or quads. This will keep tibia in anterior position to promote flexion, and prevent hyperextension
What are some personal/motivational factors before you can order a patient an orthosis?
Pt must acknowledge benefits of orthosis and agree to wear it. Pt must have an institute trail with appropriate temporary orthosis Pt must agree to temporary trail Must discuss with family and patient of benefits or other treatment options than AFO. If any don't occur that orthosis can NOT be ordered
What is a swing too method gait pattern?
Pt that lacks hip extension, they can only swing too the crutches. But they still have hip flexion
A single axis KAFO knee joint, may lock knee into hyperextension in which the individual may do what?
Pt will have to hip hike and use circumduction
What are the goals of a ACCOMMODATIVE foot orthoses?
Redistribute of plantar pressures within foot to decrease areas of excessive vertical/shearing loads Support abnormal foot postures when normal anatomy CANT Reduce skin breakdown Relieve pain through accommodative support of intrinsic/extrinsic tissues
How could you prevent unwanted knee flexion during midstance and terminal stance, when using an hinged AFO?
Put a DF stop, which would limit forward tibial inclination. Assist person who lacks control of unwanted knee flexion.
How could you prevent knee hyperextension, when using an hinged AFO?
Put a stop at 5 degrees of plantar flexion. During midstance, the Tibia is maintained and posterior inclination is NOT allowed to reduce hyperextension.
What makes a foot orthoses accommodative in nature?
Redistributes plantar foot pressure to decrease areas of excessive vertical and shearing loads. Placing foot wedge to increase arch.
Which is a 90 degree angle of pull on a joint the best angle for an orthotic?
Reduces alternative forces acting on a brace.
Describe a conventional non-locking knee joint KAFO and what it's used for
Reduction of knee hyperextension Control of mild to moderate varus/valgus angulations
What is mechanical advantage
Relationship between length of effort arm vs length of resistance arm
What should the normal durometer measurement be for shoes?
Range 35-60 in running shoes
What are the 5 main fixed structural malalignments of the rearfoot and forefoot?
Rearfoot varus Compensated forefoot varus Uncompensated forefoot varus Forefoot valgus Plantarflexed first ray
When would you use an anterior tibial shell for a long leg orthosis?
Required if knee flexion contractures are present
What does it mean to have a 3-point system orthoses?
Requires 3 different points of force to control a specific joint abnormality
What is the main function of spinal orthotic devices?
Restrict or limit motion through application of sternal core system. Relieve pain with motion or posture. Correct or prevent deformity
If hip flexor spasticity was present, what would happen to the gait cycle?
Restrictions at midstance through terminal stance progression
What is a dynamic deformity?
Result from over-activity of muscle tendon groups but when at rest are passively correctable *** These Can also develop in adjacent joints in response to coupling effects of defomities above and below
What type of brace would you use for an instability at or above C4?
Sternooccipitalmandibular immobilizer. Provide much greater restriction in cervical spine compared to cervical collars
Briefly describe the proximal transverse arch hand
Rigid arrangement at level of distal carpal row,
What are the 5 different postural types of feet?
Rigid rearfoot and forefoot Stable rearfoot and forefoot Flat rearfoot and forefoot Flexible rearfoot and forefoot Rigid rearfoot and flexible forefoot
What is the axis of rotation?
Rotation of proximal and distal segments around a joint axis
Briefly describe the longitudinal arch of hand
Runs from carpal level through four digital rays and adapts to meet needs for grasping activities
What is rigidity in relation to an UE orthotic?
Stiffness or strength of material. High rigidity, when brace has a lot of stress on it
Briefly describe the sternoclavicular joint?
Saddle joint that allows motion in several directions
Lumbosacral orthoses primarily control what motion?
Sagittal plane movement
What is the heel rocker phase of gait? What muscles need to be active through this phase?
Same as weight acceptance, and is from heel strike through loading response. Tibialis anterior controls eccentrically foot slap, and quads need to control slow load
What is a specialized TLSO and when are they used?
Scoliosis bracing for transverse and abnormal instabilities or deformities.
Your patient comes in with decreased ankle strength, but does not have any PF contracture, spasticity or absent proprioception. What type of AFO does this indicate?
Select Orthosis with articulated ankle joint.
What are the different types of functional foot orthoses?
Semi-rigid Flexible Shock absorbing Full length graphite shell Specialized modifications
What are some considerations for Orthoses and Prosthses besides force and application?
Sensitivity to skin and underlying tissues Ventilation of skin: perspiration/heat hygiene Device weight/mass distribution
What are some key footwear factors to consider for neurologically involved patients with orthotics?
Shoe style: Want higher counter or ankle support shoe Shoe Upper: Want extended opening, possible velcro, with padding Shoe weight: Want shoe as light as possible. Balance stability and weight Outsole size and friction coefficients: Design assists with biomechanical control. 3/4 inc. pitch from heel to ball. consider grip, heel lift, toe spring and flares for stability Fit: Match shape of shoe to foot, towards end of day when foot is biggest
There are some general considerations in regards to short/long levers with short/large contact areas. Describe the effects of each combination starting with short levers + small contact areas
Short levers + small contact areas = increased local skin pressures Short levers + large contact areas = less increased local skin pressures Long levers + small contact areas = less increased local skin pressure Long levers + large contact areas = smaller local skin pressures
How does the walk-aide and L-300 work within a neuro or myo-orthosis?
Stimulates common peroneal nerve to assist DF
What are the types of KAFO knee joints for the convential device?
Single Axis Variable joint axis Posterior offset axis
What should the rehab process be for individuals with orthotic interventions?
Skill, endurance, strength and power interventions. Postural control and effectiveness of interventions Simultaneous maintenance of ROM BMI stability Donning, doffing and care of orthosis
What cautions are frequently noted with UE orthotic prescription?
Skin breakdown on bony prominence. Pressure on nerves leading to pain, numbness and tingling Excessive compresssion and lack of blood floow
What is the effect of a long lever + large contact areas?
Smaller local skin pressures
What are the 4 joints of the shoulder complex, which need to work properly or it affects the rest of the UE?
Sternoclavicular joint Scapulothoracic joint Acromioclavicular joint Glenohumeral joint
Briefly describe the transverse arch of hand
Space between distal and proximal transverse arches
What type of shoe provides Subtalar joint medial control for protection of pronation
Stability shoe
What type of Orthosis and Prothetics have the longest lifespan?
Stainless steel- indefinite Graphite, Polyproylene- 1-3 years Cork- 9-12 months
What type of KAFO, is used to prevent flexion during stance but allows it during swing?
Stance control knee joint KAFO
What are the 2 common types of AFO's?
Static AFO's Dynamic AFO's
What are the differences between static AFO's and Dynamic AFO's?
Static AFO's hold the ankle in static position and have total contact. Dynamic AFO's are articulating, flexible, and have either posterior leaf spring or metal single or double upright spring. Each have floor reaction
What are the characteristics of AFO's
Static AFO's hold the ankle in static position and have total contact. Restrict motion and hold in static posture. Floor reaction force
What kind of orthoses, would you use to prevent contractures?
Static orthoses
What are the 4 classifications of UE orthoses?
Static orthoses Dynamic orthoses Serial static orthoses Static progressive orthoses
What type of orthoses in the UE depend on the stress relaxation principle?
Static progressive orthoses
What kind of orthotic device design would you use for a patient with equinovarus?
Statically hold the foot in talotibial and STJ neutral during stance phase of gait Posture rear and midfoot into neutral as well during swing, by preventing inversion Statically hold foot in neutral by restricting PF and inversion. Use SOLID RIGID ANKLE FOOT ORTHOSIS
Describe the 3 step process for prescribing a LE orthotic device
Step 1: Identify WHERE in the gait cycle abnormal tone or muscle performance is impaired Step 2: Determine what factors could be compromising the particular abnormal phase of the gait cycle Step 3: Identify what specific orthotic interventions would benefit the particular abnormal phase of gait cycle
Each part of what can enhance or interfere with LE orthotic management
THE SHOE
What is the difference between Temporary vs. Definitive Orthoses?
Temporary: "Off the Shelf" Non-specific, short term use for Healing, Function, contracture prevention Generic fit Usually costs less Assess functional benefits/systems and practical applications Definitive: When permanent benefit is needed Mechanically and Physiologically stable Custom fit Costly
When would you use a single metal upright articulating AFO, due to the tension springs, it assist what?
Tension springs assist DF and limit toe drag during swing phase
What is the torsional rigidity test for a shoe?
Test of twisting the shoe around it's long axis in opposite directions, to see resistance shoe provides
What is the flexion stability test for a shoe?
Testing the shoes ability to flex at forefoot, but NOT at forefoot, where we need stability
What is the typical characteristics of an accommodative foot orthoses?
They are usually soft, and purpose to redistribute forces in the foot. Provide shock absorbing effects. Don't correct postural alignment, just redistributes!
What does the evidence state about stance control KAFO?
They have better gait abnormalities than locked knee brace, BUT NEED LONG TERM STUDIES
Foot orthoses should be modular, what does this mean?
They should be modified based on patient impairments
What are some physical characterisitcs of an UE orthotic?
Thickness Perforations Colors Coating
When would you recommend a posterior leaf spring AFO?
When DF is lacking and weak. Allows for DF at 2nd rocker. Support forefoot during swing with weak DF, and foot drop Control PF from initial to loading response, due to weak DF Position foot sagitally in IC
Why are shock absorbing components in shoes not always good for the feet?
They apply soft midsoles, but firmer midsoles are actually better for the foot.
What type of brace would you use for an instability at or below C4?
Yale cervicothoracic orthosis. Provide much greater restriction in cervical spine compared to cervical collars
Carbon fiber thermoplastic or conventional KAFO? Interchangeability of shoes Better cosmesis Lightweight Can be hot Hard to adjust
Thermoplastic carbon fiber KAFO
What is the perscribed orthosis of a multi-segmental instability of the thoracic and lumbar spine?
Thermoplastic jackets or TLSO
What is the Knight-Taylor thoracolumbo brace used for?
Thoracolumbar corset with axillary straps. LIMITS FLEXION/EXTENSION. Controls sagittal and some coronal movements
Orthoses utilize what system for biomechanical effects?
Three-point pressure system
If the AFO is aligned in slight DF , what happens to the tibia?
Tibia is positioned in anterior position Promotes knee flexion and forward shank progression
How does positioning an AFO in slight DF, help with gait?
Tibia is positioned in anterior position which Promotes knee flexion and forward shank progression
Foot orthoses interventions is based on what theory?
Tissue stress theory
Kevin K and Fuller EA, have the present day theories on foot orthoses, which utilizes what theory?
Tissue stress theory
What is the basic framework for prescribing a LE orthotic device?
To increase safety and functionality during ambulation, transfers and standing. Also protection from external forces
Why are scoliosis bracings used?
To only prevent scoliosis from getting worse
What are the types of force?
Torque Lever system Elastic and friction
What are the 3 tests to determine any Shoe's functional stability characteristics?
Torsional rigidity Heel counter stiffness/rigidity Flexion stability
Your patient has <3+/5 quad strength bilaterally, and successfully meets the PARTICIPATION criteria for ambulation trail with bilateral KAFO. But, they DO NOT meet the COMPLETION CRITERIA for ambulation with bilateral KAFO. What does this indicated?
Trail for bilateral KAFO ends and pt will not receive bilateral KAFO. Pt re-evaluated in >3 months
True or False: Rapid mobilization appears to be best achieved with modern surgical approach as compared to orthotic interventions
True
The biomechanical effects of the 3 point-pressure system include what principles?
Trunk/head support Motion control Spinal realignment Partial weight transfer of head to trunk in upright position
The following are characteristics of what kind of device? Provide comfortable support, but undergo deformation to allow motion. For flexible deformities of STJ and midtarsal joints while allowing rocker function
UCBL AFO
What is the basis for orthotic prescription?
Understanding gait cycle
Describe the Anatomy of the athletic shoe.
Upper- holds shoe together and is part of laces, breathability Midsole- padded area that provides comfort, cushining and stability outsole- durable outer surface of sole, for traction Insole- fits inside shoe and provides cushion and arch support Toe box- provides spaces for distal forefoot and toes Heel counter- Rearportion to support rearfoot Achilles tendon- Support Achilles tendon Boots: (shank, which helps support heel in deeper surfaces) Dress shoe: (similar to normal shoe)
How can we utilize palmar creases for orthotic prescription of the hand?
Use creases to establish boundaries and understand not to restrict motions and not create abnormal stresses on the hand
What is a neuro-orthosis or myo-orthoses used for?
Use of E-stim in device to prevent foot drop
What are conventional metal upright AFOs?
Use of double upright metal stirrups. Mechanical axis with spring loaded DF/PF assist. (BICALL --> Bichannel adjustable ankle locking)
When is a heating pan used for an orthotic
Used during initial phase of fabrication to completely mold an orthotic
What is a drag two gait pattern? What muscles does this patient most likely lack?
Used for low level patients, that dragging feet is the only way. 2 point gait pattern with bilateral crutches. Crutches move first and drag feet to crutches. Pt lacks hip flexion and extension...
When would you use a knee orthosis?
Useful for malalignment (varus, valgus, recurvatum) Protect knee structures from undue loading Preventative or corrective Permanent treatment for compromised knee structures
What is the non-weight bearing assessment of the forefoot to rearfoot alignment based on?
Using Subtalar joint neutral as frame of reference
What is bad about padding of an brace?
Usually cannot be washed, which will reduce hygiene. Also may further restrict joint motion
What are energy return AFO?
Usually carbon fiber and lightweight. During ankle rocker, there is elastic strain to help with propulsion, due to potential energy being stored and release back (spring)
What are extrinsic postings?
Usually to rearfoot or forefoot, which is a wedge to control frontal plane movements of foot. Limit excessive varus or valgus rigid position
Describe why we would use a static progressive orthoses for the UE?
Utilizes principle of stress relaxation Tissues are stretched and held at constant length Stretching causes relaxation over time
When would you have to use halo orthoses and drill pins in the periosteium?
When direct stabilization of cervical-occipital region. Needs incorporation of the skull
What are the indications for the use of a KAFO?
When excessive movement occurs at the knee that cannot be effectively controlled by AFO
What is a first ray plantarflexion foot?
When first ray is more inferior than rest of rearfoot and forefoot
When would you recommend a custom orthotic for a neurologic patient?
When pt needs orthotic for permanent benefit. Pt is mechanically and physiologically stable. These are costly braces that should be used for a long time. If they don't comply or their condition changes, then it would be a waster
Your patient has >3+/5 quadriceps in the test side and >3+/5 strength in the contralateral limb. The patient DOES NOT have proprioception intact at the test knee. Does this indicate the use of an AFO?
Yes, use an unlocked KAFO on test side
Your patient has <3+/5 quad strength bilaterally, and successfully meets the PARTICIPATION criteria for ambulation trail with bilateral KAFO. They also meet the COMPLETION CRITERIA for ambulation with bilateral KAFO. What does this indicated?
You can order a bilateral KAFO
How does a knee valgus brace help patients with right knee medial compartment O/A?
Will help reduce ground reaction force on adduction moment arm. Will normalize genu varus alignment
If knee extensor spasticity was present, what would happen to the gait cycle?
limitation of preswing. Initial swing and mid-swing