ORTHOSIS

1. BIOENGINEERING ORTHOSIS

2. Characteristics of IDEAL ORTHOSIS FUNCTION COMFORT COSMESIS FABRICATION COST

3. FUNCTION Meets the individuals mobility needs ad goals Maximizes stance phase stability Minimizes abnormal alignment Minimally compromises swing clearance Effectively pre-positions the limb for initial contact Is energy efficient with the individual’s preferred assistive device

4. COMFORT Can be worn for long periods without damaging skin or causing pain Can be easily donned and doffed ( eg , considering clothing, footweare , toileting)

5. COSMESIS & COST Meets the individual’s need to fit in with peers Can be made with minimal initial cost, minimal cost for maintainence .

6. FABRICATION Can be made in the shortest period of time Uses a minimally complex design Has some degree of adjustability to enhance initial fitting For children, responds to growth or change over time Is durable: stands up to stress/strain of daily activity

7. PRINCIPLES UNDERLYING ORTHOTIC DESIGN PRESSURE= FORCE/AREA The forces are distributed over large surface areas to minimize pressure on skin and soft tissue. TORQUE = FORCE * DISTANCE The forces applied in such a way that a large moment arm reduces the amount of force needed to control the joint

8. PRINCIPLES Control direction of primary force direction of counter –forces EQUILIBRIUM (SUM OF ALL FORCES)= 0 The sum of primary force and opposing counter-forces of each control system equals zero.

9. TOE-SPREADER TOE-SPREADER WITH HALLUX CORRECTION

10. MEDIAL HEEL WEDGE

11. ANKLE-FOOT ORTHOSES Used to control the lower extremity during each phase of the gait cycle for individuals with neuromuscular or musculoskeletal impairments. Categories Static Dynamic

12. AFO COMPONENTS Foundation- Consists of shoe and plastic/ metal component Ankle control Foot control Superstructure

13. PARTS OF ANKLE- FOOT ORTHOSIS

14. TYPES OF AFO Static AFO Dynamic AFO Supramalleolar Orthosis Tone reducing Orthosis Floor reaction Orthosis Posterior leaf spring Orthosis

15. STATIC ANKLE FOOT ORTHOSIS

16. SAFO ACTIONS Control ankle position throughout stance Provide stance phase Stability via ankle-knee coupling Assist limb clearance in swing Pre-position foot for IC by heel Distal trim line behind metatarsal heads or extended toe-plate INDICATIONS Significant hypertonicity with seriously impaired motor control at ankle and knee. CONTRA-INDICATIONS LMN paralysis ( flaccidity) Hypotonicity as primary problem

17. Dynamic AFO

18. DAFO ACTIONS Stabilize sub- talar and tarsal joints in stance INDICATIONS FLEXIBLE PES PLANUS MILD TO MODERATE SPASTIC DIPLEGIC HEMIPLEGIC CP HYPOTONIC CP CONTRAINDICATIONS RIGID FOOT DEFROMITY

19. KAFO KNEE-ANKLE-FOOT ORTHOSIS PARTS Shoe Foundation Ankle control Knee control Superstructure

20. KAFO Knee, ankle, foot orthosis , custom may include knee joints. Joints may be locking or adjustable in flexion and extension. Indications: Polio, MS, paresis, knee instability/buckling. Contraindications: Morbid obesity, dependent patient with poor cognition and upper extremity weakness combined with poor support system.

21. Knee Control Hinge joint Offset joint Provide medial-lateral and hyperextension restriction while permitting knee flexion Hinge placed posterior to midline of leg. Weight falls anterior to offset joints, stabilizing knee in extension during early stance phase.

22. Drop ring lock Pawl lock with bail release When client sands with full knee extension, the ring drops, preventing knee from bending. Provides simultaneous locking of both uprights. The pawl is a spring-loaded projection that fits into a notched disk. The patient unlocks the brace by pulling upward on the posterior bail.

23. 'Bail Lock' Knee joint. This joint remains locked until the spring-loaded release bar that connect the two mechanical knee joints is lifted. It automatically locks when the user fully extends their limb, i.e., when rising from a chair. Polycentric Knee joint to allow knee flexion with less bunching of the skin behind the knee and to reduce vertical movement of the device when the knee bends. Offset free motion knee joint with ‘Drop locks’ to maintain knee extension

24. BIOMECHANICAL PRINCIPLES APPLIE TO THE DESIGN AND FITTING OF KAFO Mediolateral stability and toe off must be provided during swing phase Knee stability needs to be provided during the stance and simulated push-off Excessive force should not be applied to the knee. Orthosis must be fitted with knee in extension in order to reduce the bending moment at the knee.

25. Contd … Rigid ankle joint provides more stability Posterior thigh strap is necessary to restrain orthosis from sliding off the leg while sitting Dorsiflexion stop with sole plate extended to the metatarsal head area facilitates push off and reduce energy consumption. Major portion of total knee stabilizing force should be applied below the knee in order to reduce the shear forces on the knee ligaments

26. Contd … Straps should distribute force over large and tolerant area i.e. patella tendon and supra patellar area Stabilizing straps should be applied as close to the knee joint as possible to reduce the force require to counterbalance a bending moment

27. Craig-Scot KAFO PARTS Shoe reinforced with transverse an longitudinal plates BiCAAL ankle joints set in 10 degree dorsiflexion Pretibial band Pawl lock with bail release Single thigh band

28. CRAIG SCOTT KAFO INDICATIONS Paraplegics Thoracic spinal cord injury GAIT PATTERN Swing-to or swing-through with aid of crutches or a walker ADVANTAGES Medio -lateral foot stability provided by metatarsal bar Enable a patient to stand with sufficient backward lean so as to prevent untoward hip or trunk flexion. Functional Easy to don and doff Light weight as compared to standard KAFO

29. HKAFO

30. HKAFO Indications Weak hip musculature Hip instability Parts Pelvic band Hip joint

31. RGO Bilateral HKAFO PRINCIPLE - ipsilateral hip flexion leads to contra lateral hip extension and vice versa. It consists of hip joints that transfer forces from one hip to other by Bowden cables INDICATIONS Active hip flexion but no hip extension Paraplegic L1 level DISADVANTAGES High energy cost requirement Slow speed

32. THKAFO PARAPODIUM

33. CERVICAL ORTHOSIS Immobilizing cervical spine is difficult because Most mobile part in spine Has small body surface Limited pressure tolerant areas like chin, occiput Different types of predominant movement at different levels Functions Positions the head Limits movement in flexion, extension, rotation and lateral rotation Unload the cervical spine by bearing part of weight of the skull

34. CERVICAL ORTHOSIS Classification Cervical collars Poster appliances Cervicothoracic orthosis Halo devices Commonly used Soft and semi-rigid cervical collars Philadelphia orthosis SOMI brace Poster orthosis Minerva body jacket Halo jacket or vest

35. SOFT CERVICAL COLLAR Made of foam and rubber covered by stockinet ADVANTAGES low cost easy to fabricate tolerated by patient provides warmth and psychological comfort DISADVANTAGES Does not restrict cervical motion in any plane.

36. PHILADELPHIA COLLAR PARTS Anterior and psoterior struts, with molded mandilbular and occipital support. Extends to uper thoracic region anteriorly and posteriorly ADVANTAGES Restricts flx /ext due to chin and occiput support and thoracic extension DISADVANTAGES Ineffective in controlling rotation and lateral bending Pressure over clavicle

37. SOMI BRACE ( Sternal Occipito Mandibular Immobilization) PARTS Sternal plate One anterio stripr to hold chin Two rigid metal rods from anterior to posterior to occiput support. ADVANTAGES No posterior post, can be used it supine Light weight for donning and doffing Controls flexion effectively at C1–C3

38. SOMI BRACE Indications: •  Atlantoaxial instability caused by rheumatoid arthritis • Neural arch fractures of C2, because flexion causes instability Contraindications: The SOMI controls extension less effectively than do other orthoses . Flexion and extension control at C3-T1: better served with a Minerva

39. HALO DEVICE Rigid metal/graphite ring attached to skull by four fixation pins 4 posters which are attached to ring proximally- 2 anteriorly , 2 posteriorly and distally to polypropylene vest. Polyethylene vest Half vest- level of nipples Short- level of 12h rib Full vest- level of iliac crest

40. Halo orthosis INDICATIONS: Dens type I, II, or III fractures of C2 C1 fractures with rupture of the transverse ligament Atlantoaxial instability from rheumatoid arthritis, with ligamentous disruption and erosion of the dens C2 neural arch fractures and disc disruption between C2 and C3. Bony, single-column cervical fractures Cervical arthrodesis – Postoperative Cervical tumor resection in an unstable spine – Postoperative Debridement and drainage of infection in an unstable spine – Postoperative Spinal cord injury (SCI) The halo is the best orthosis for use in controlling rotation and lateral bending at C1-C3.

41. Halo orthosis Complications: • Neck pain or stiffness – 80% • Pin loosening – 60% • Pin site infection – 22% • Scarring – 30% • Pain at pin sites – 18% • Pressure sores – 11% • Redislocation – 10% • Restricted ventilation – 8% • Dysphagia – 2% • Nerve injury – 2% • Dural puncture – 1% • Neurological deterioration – 1% • Avascular necrosis of the dens • Ring migration • Inadequate bony healing • Inadequate ligamentous healing Contraindications: Concomitant skull fracture with cervical injury Damaged or infected skin over pin insertion sites Cervical instability with 2- or 3-column injury Cervical instability with rotational injury involving facet joints

42. Minerva Body Jacket Motion restriction at C5-C7 Anterior and posterior chest plates connected by shoulder straps Chin plate Occipital piece that connect to anterior and posterior struts. The brace has poor control of flexion, extension, rotation, and lateral bending at C1-C2.

43. MINERVA JACKET Indications  Minimally unstable fractures from C3-T2 Internal fixation from C3-T2 Motion restrictions: • Limitation of flexion and extension from C3-T2. Contraindications: • Flexion control at C1-C5: Better served with a SOMI

44. TLSO ( thoraco -lumbar-sacral) For fractures between T6 and L3. Provide support and immobilization of the thoracic and lumbar regions following various surgical procedures/ traumatic injuries Help in treatment of post-operative thoracic/lumbar fusion, laminectomy or discectomy, compression fractures, degenerative disc disease, osteoporosis, single column spinal instability immobilization, and facet syndrome.

45. JEWETT BRACE The Jewett orthosis uses a 3-point pressure system to control flexion PARTS-1 posterior and 2 anterior pads. The anterior pads place pressure over the sternum and pubic symphysis. The posterior pad places opposing pressure in the midthoracic region.

46. JEWETT BRACE Motion restrictions • Limits flexion and extension between T6-L1 Indications: • Symptomatic relief of compression fractures T6-L1 • Immobilization after surgical stabilization of thoracolumbar fractures Contraindications: • Three-column spinal fractures involving anterior, middle, and posterior spinal structures • Compression fractures above T6, because segmental motion increases above the sternal pad • Ineffective in limiting lateral bending and rotation of the upper lumbar spine

47. ANTERIOR SPINAL HYPEREXTENSION (ASH) BRACE Anterior Spinal Hyperextension (ASH) brace features Anterior sternal Pubic pads Posterior pad and Strap around the thoracolumbar region. Sternal and pelvic pads attach to the anterior, metal, cross-shaped bar. The brace is easy to don and doff, but it is difficult to adjust. It provides greater breast and axillary pressure relief than does the Jewett hyperextension TLSO.

48. ASH BRACE Motion Restrictions: • Limits flexion and extension at T6-L1 Indications: • Flexion immobilization to treat thoracic and lumbar vertebral body fractures T6-L1 • Reduction of kyphosis in patients with osteoporosis Contraindications: • Three-column spinal fractures involving anterior, middle, and posterior spinal structures • Compression fractures caused by osteoporosis • Ineffective in limiting lateral bending and rotation of the upper lumbar spine

49. CTLSO-MILWAUKEE BRACE CTLSO Helps maintain postoperative correction in patients with scoliosis secondary to polio. Stimulates corrective forces in the patient. Proper fit allows consant usage of trunk muscles, disuse atrophy does not occur. The brace has an open design.

50. FEATURES Plastic pelvic mold 2 posterior upright 1 anterior upright Thoracic pad Transverse pad attached to uprights Neck ring

51. Features Constant force provided by the plastic pelvic mold. The pelvic portion - reduces lordosis , derotates the spine, and corrects frontal deformity. The uprights have localized pads that apply transverse force, which is effective for small curves. The thoracic pad, main corrective force, creates a righting response to an upright posture. The uprights are perpendicular to the pelvic section, so any leg-length discrepancy should be corrected to level the pelvis. The neck ring - gives longitudinal traction. .

52. Milwaukee brace Indications: • Used for curves in which the apex is above T7. • Patients with a Risser score of I-II, as well as a curve that is greater than 20-30° and that progresses by 5° over 1 year • Curves of 30-40°, but not curves of less than 20°. • Curves of 20-30°, with no year-over-year progression, require observation every 4-6 months. Duration of use : • Daily use ranges from 16-23 hours per day. • Treatment should continue until the patient is at Risser stage IV or V. • If the curve is greater than 30°, consider continued use of the brace for 1-2 years after maturity, because a curve of this magnitude is at risk of progression.

53. Milwaukee brace PROBLEMS WITH BRACE Jaw deformity Skin breakdown Unsightly appearance Difficulty with mobility Difficulty with transfers Increased energy expenditure with ambulation CAUSES OF FAILURE Poor patient compliance Improper fit Curves below T7

54. TLSO- BOSTON BRACE TLSO with built-in lumbar flexion can be worn under clothes. Lumbar flexion- achieved through posterior flattening of the brace and extension of the mold distally to the buttock. Braces with superstructures have a curve apex above T7. Curves with an apex at or below T7 do not require superstructures to immobilize cervical spine movement . Height cannot be ajuste .

55. BOSTON BRACE Indications : A curve of 20-25° with 10° progression over 1 year A curve of 25-30° with 5° progression over 1 year Skeletally immature patients with a curve of 30° or greater Complications Local discomfort Hip flexion contracture Trunk weakness Increased abdominal pressure Skin breakdown Causes of failure Curve above T7 Improper fit Poor patient compliance