Orthosis of hand ppt

orthosis description and types

1. ORTHOSIS OF HAND SUBMITTED TO : Dr. SHABNAM JOSHI SUBMITTED BY : MANOJ PUROHIT 170171720001

2. ORTHOSIS A force system designed to control, correct or compensate bone deformity, deforming forces or forces absent from the body. Derived from the Greek word ORTHO meaning straight, upright or correct. Orthoses are devices applied externally to restore or improve functional and structural characteristics of the musculoskeletal and nervous systems.

3. General Classification Orthosis Type • Static • Dynamic • Hybrid Regional Classification • Volar or Dorsal • Joints crossed Finger / thumb splint Wrist Splint Wrist Hand Orthosis

4. Functional Corrective Supportive Protective Orthosis which strengthen certain group of muscle E.g. Tenodesis Splint Relief of pain Prevent weight bearing Facilitate Motion

5. BIOMECHANICAL PRINCIPLES 1) Three Point Pressure 2) Mechanical Advantage 3) Torque 4) Degree and Duration of Stress 5) Repetitive stress 6) Control Normal force across the joint 7) Control Axial Force across the joint 8) Control line of action of Ground reaction force

6. 1) THREE POINT PRESSURE: (JORDAN’S Principle) A three-point pressure system consists of three individual linear forces in which middle force is directed in opposite direction to the other two forces. It is multiple direction force where one force immobilize one joint and mobilize the other joint. Example: cock-up splint

7. 2) MECHANICAL ADVANTAGE: Splint incorporate lever system, which incorporate forces, resistance, axes of motion and movement arm. Example: Volar based wrist cock-up splint for mechanical advantage forearm length is made longer so that splint has better pressure distribution support and comfortability .

8. 3) DIRECTION OF STRESS: There are three direction of force to act: Tension Compression Shear

9. 4) TORQUE: It is biomechanical principle defined as rotational effect of mechanism. Torque is the production of the applied force multiplied by perpendicular distance from the axis of rotation to the line of application. Most important for dynamic splint.

10. 4) DEGREE AND DURATION OF STRESS : Generally low stress can be tolerated for longer period of time, whereas high stress over long period of time cause damage. Therapist must remember the least stress is tolerated by the skin. Skin become ischemic if load increases. Distribution of stress is most important for long term wearing of orthosis .

11. 5) REPETITIVE STRESS: If repetitive stress is applied in moderate amount may lead to breakdown and damage to skin. So to avoid that traction must be release to avoid unnecessary tension and well distributed pressure. 6) CONTROL NORMAL FORCE ACROSS THE JOINT: Now two free, body load carrying bones when subjected to ground reaction force are free to rotate that are maintained in extension this is normal joint is maintained by capsule and ligaments. But in abnormal joint we require orthosis to correct it.

12. 7) CONTROL AXIAL FORCES ACROSS A JOINT: In normal healthy individual load is carried through bony structures and layers of articular cartilage which have immense strength to bear this weight. Now due to some degenerative change the integrity of this structure is lost which will cause excessive compression on joint. So, orthosis is used to offload the joint. This process of offloading depends on two thing: How the orthosis is fitted Orthosis and body segment interface

13. 1) The orthosis here is incorporated as rigid orthosis framework and strapping it at the end of two limb segment which would divide the force into half.

14. 2) The second criteria is the transfer of load across skin and orthosis solely depend on friction of orthosis and underlying skin.

15. 8) CONTROLS ACTION OF GROUND REACTION FORCE : This principle is only applicable to lower limb orthosis . In normal joint line of gravity passes from front of Hip, back of knee, front of ankle. Now due to some asymmetric movement for this pattern, GRF is altered so we need a orthosis for its correct alignments. In this case orthosis management would be moving the line of gravity to center that is close to joint line. Which can be achieved by modifying the limb movement during gait.

16. COCK-UP SPLINT It is static in nature. Common Name: 1) Volar / Palmar Wrist splint 2) Volar Wrist Cock up splint 3) Wrist Immobilization Splint 4) Drop Wrist Splint 5) Carpal Tunnel Splint 6) Wrist Extension Immobilization Splint Objectives: 1) To reduce Pain and Inflammation 2) To protect against joint damage 3) To promote hand function 4) To prevent or correct contractures 5) To provide base for Outriggers

17. Indications: 1) Tendinitis/ Tenosynovitis of wrist tendons 2) Joint Inflammation such as Rheumatoid Arthritis 3) Skin Graft 4) Unstable Wrist Joint 5) Wrist Sprain 6) Weak/Paralyzed Wrist Extensor 7) Congenital Hand Deformity 8) Volar style for flexion outriggers 9) Dorsal style for extension Outriggers

18. GAUNLET IMMOBILIZATION SPLINT Common Name: Circumferential working Splint Objectives: 1) Greater wrist stability Indications: 1) An evaluation tool before wrist arthrodesis 2) To immobilize and stabilize a fracture of radius or base of Metacarpal

19. DYNAMIC WRIST EXTENSION SPLINT Objectives: 1) To Passively extend the wrist while allowing active wrist flexion 2) To prevent contracture of unopposed innervated wrist flexors Indications: 1) Weak or Paralyzed wrist Extensors (e.g.. Radial Nerve Palsy)

20. STATIC WRIST WRITING/PAINTING ORTHOSIS Common Name: Wrist Splinting Objectives: 1) To enable writing, drawing or painting by positioning wrist in functional extension and providing attachment of pen, pencil , eraser etc. Indications: 1) Spinal Cord Injuries at level C5 or above where wrist extensors Paralyzed

21. RADIAL THUMB GUTTER SPLINT Objectives: 1) To immobilize wrist, thumb CMC, MCP Joints, which are crossed by inflamed tendons 2) To rest and reduce inflammation Indications: 1) De Quervain’s tenosynovitis : Inflammation of tendon of abductor polices longus and extensor polices brevis in their synovial sheath.

22. DYNAMIC MCP FLEXION SPLINT Objectives: 1) To gently stress the MCP collateral ligaments to promote desired growth and increase flexion range Indications: 1) Extension contracture of MCPs caused by shortened collateral ligaments

23. RESTING HAND ORTHOSIS It is Static or Serial Static type of splint. Objectives: 1) To immobilize the wrist, MCPs, and IPs of Finger and thumb 2) To reduce or prevent contractures 3) Reduce pain and inflammation Indications: 1) Scleroderma 2) Dupuytren’s release 3) Boxer’s fracture (Base of 5 MCP fracture) 4) Burns 5) Inflammatory joint disease 7) Crush injury

24. ANTISPASTICITY SPLINT Common Name: dorsal volar hand splint Objectives: 1) To immobilize wrist, MCP, IP 2) To prevent and reduce contracture 3) To reduce tone of hypertonic muscles Indications: 1) Hand Trauma or surgery

25. TENODESIS SPLINT Objectives: 1) To train a tenodesis grasp 2) To promote tripod pinch Indications: 1) Quadriplegia at level of C6 with at least grade 3 strength of the wrist extensors This splint is a functional aid for such patient which uses extensor carpi radialis muscle giving potential grasp by reciprocal wrist extension and finger flexion.

26. KLEINERT SPLINT It allows protective flexion of MCP and IP and Blocks Extension of MCP. Objectives: To position wrist in static flexion and passively flex the MCP and IP while permitting limited active extension of wrist and MCP and full extension of IP. Indications: 1) Flexor Tendon Laceration in zone 2.

27. EXTENSOR TENDON REPAIR SPLINT Objectives: 1) To position wrist in static extension and passively extend the MCP and IP while permitting limited active flexion of MCP. Indications: 1) Extensor tendon Laceration.

28. METACARPAL FRACTURE BRACE Common Name: Metacarpal(fracture) Brace Objective: To stabilize MC fracture to promote healing. Indication: Midshaft fracture of third, fourth or fifth metacarpal.

29. STATIC ULNAR DEVIATION SPLINT Common Name: MCP protection splint, static ulnar drift/deviation splint, metacarpal ulnar deviation orthosis , trigger finger splint, blocking splint 1)Joint Inflammation: To promote restabilization of tendon to restraints at MCPs, To prevent or correct ulnar drift of MCP 2) Trigger Finger: To block MCP Flexion and limit excursion of long finger flexor. By subsiding irritation at A1 pulley and inflammation subside.

30. 3) Surgical release of Dupuytren’s Contracture To maintain surgical gained extension. 4) Intrinsic muscle tightness and extension contracture: To block MP joint so FDP and FDS can actively stretch IP joint and intrinsic muscle. 5) MC head fracture for stabilization.

31. DYANAMIC MCP EXTENSIION SPLINT Objectives: To passively extend MCP to 0* extension and allow active flexion movement and IP movement. Indication: Radial nerve injury when reinnervation reach to wrist Repair of extensor tendon rupture, extensor contracture

32. STATIC ANTICLAW DEFORMITY SPLINT Common: Static Anticlaw deformity splint, static ulnar nerve splint Objective: To stabilize the fourth and fifth MCPs in flexion. To correct fourth and fifth MCPs hyperextension To prevent shortening of MCP Collateral Ligament To promote active IP Extension Indication: Ulnar Nerve Lesion

33. DYNAMIC MEDIAN-ULNAR NERVE SPLINT Common Name: Dynamic anticlaw deformity splint, dynamic median/ ulnar nerve splint, spring wire knuckle bender. Objectives: To passively flex the MCP of fourth and fifth finger and to allow active extension. To correct Hyperextension To prevent shortening of MCP To promote active IP Extension Indication: Combined median and ulnar nerve lesion at level of wrist.

34. FLEXION BLOCKING SPLINT Common Name: Blocking Splint Objective: To Block MCP and PIP so that the flexor digitorium profundus can actively stretch DIP to increase the flexion range of motion Indication: Extension contracture of DIP Joint

35. FINAL FLEXION SPLINT Common Name: Final Flexion Splint Objectives: To progressively flexion MCPs IPs in composite flexion applying gentle prolonged stretch to contracted tissue. Indication: Contracture of extrinsic Extension Tendon, IP Extension Contracture.

36. SHORT DORSAL OUTRIGGERS Objective: To apply gentle prolonged stretch to the contracted PIP capsule and ligaments to promote growth of the shortened tissues and restore extension ROM. Indication: Flexion Contracture Of PIP joint

37. TRAPPER Common Name: Buddy splint, trapper Objectives: To strap affected finger to an unaffected finger at proximal middle phalanges To stabilize finger To provide passive movement of affected joint by moving unaffected finger Indication: PIP Collateral ligament injury flexor tendon reconstruction and PIP flexion

38. PIP EXTENSION SPLINT It is a extension blocking static splint. Common Name: Swan Neck Deformity splint, PIP hyperextension splint, Fiqure of eight splint Objective: Index finger PIP extension restriction Indication: Swan Neck Deformity, (caused by: RA, Trauma, intrinsic muscle tightness, Dorsal migration of extension mechanism,) Trigger finger

39. CAPENER SPLINT Objective: Index finger pip extension mobilization Indication: PIP flexion contracture, PIP dislocation, Volar plate injury, flexor tendon repair partial or complete tear of collateral ligament, Boutonniere Deformity

40. SHORT OPPONENCE ORTHOSIS Objective: To relieve CMC pain To immobilize CMC and MCP To position the thumb in functional opposition To correct first web space Indication: Inflammation of CMC or injury CMC Arthroplasty , Median nerve injury, Quadriplegia

41. GENERAL PRINCIPLES Use of forces: Orthosis utilises forces to limit or assist movements Rigid material spanning a joint prevents motion, e.g posterior tube splint A spring in a joint is stressed by one motion and then recoils to assist, the opposite desired motion. E.g. leaf spring orthosis Limitation of movement: Limiting motion may reduce pain. Correcting a mobile deformity: a flexible deformity may be corrected by an orthosis . Corrective forces must be balanced according to principle of Jordan.

42. Fixed deformity: if the fixed deformity is accommodated by an orthosis , it will prevent the progression of deformity. Adjustability: orthotic adjustability is indicated for children to accommodate their growth and for patients with progressive or resolving disorders. Maintenance and cleaning: the orthosis should be simple to maintain and clean. Application: the design should be simple for easy donning and doffing. Sensation: An orthotic device does not provide sensation, in fact it often covers skin areas and decreases sensory feedback.

43. Comfort: The Orthosis should be comfortable. Pressure should be distributed over the largest area possible. Utility: the Orthosis must be useful and serve a real purpose. A well functioning opposite extremity is a major deterrent to the use of an upper extremity orthosis as most activities can be performed with the good hand. Gravity: Gravity plays an important role in upper limb orthosis , especially in those joints where the heaviest movement masses are present. Cosmesis : Cosmesis is important especially in hand orthosis . A functional but unsightly orthosis is often rejected if the patient values appearance over function.

44. CONTRAINDICATIONS Skin infections. When the muscle power is very much affected by the weight of the orthosis . In case of severe deformity which cannot be accommodated in the orthosis . If it limits the movement at other normal joints. Where the orthosis interferes grossly with clothing or limits other functions. Lack of motivation or other psychological problems Very young or old patients.

45. PHYSICAL THERAPY INTERVANTION • Assessment • Pre-orthotic assessment and prescription evaluate: • Joint mobility • Sensation • Strength and motor function • Functional level • Psychological status • Orthotic prescription • Consider the patients abilities and needs • Level of impairments, functional limitations, disability • Status: consider if the patient’s condition is permanent or changing

46. • Consider level of function, current lifestyle. • Consider if the patient is going to be a community ambulator versus a household ambulator . • Consider recreational and work related needs. • Consider overall weight of orthotic devices, energy capabilities of the patient. Some individuals abandon their orthoses quickly in favor of wheelchairs because of the high energy demands of ambulating with orthosis . • Consider manual dexterity, mental capacity of the individual. The donning and use of devices may be too difficult or complicated for some individuals.

47. Orthotic Assessment check out • Ensure proper fit and function; construction of the orthosis . Static assessment 2. Dynamic assessment • Fit and function during activities of daily living, functional mobility skills. • Fit and function during gait. • Consider the pressure tolerance of the skin and tissues. • Consider use of a temporary orthosis to assess likelihood of functional independence, reduce costs.

48. ORTHOTIC TRAINING • Instruct the patient in procedures for orthotic maintenance: routing skin inspection and care. • Ensure orthotic acceptance • Patients should clearly understand the functions, limitations of an orthosis . • Can use support groups to assist • Teach proper application (donning-doffing) of the orthosis , teach proper use of the orthosis . • Balance, gait and functional activities training. • Reassess function and construction of the orthosis at periodic intervals; assess habitual use of the orthosis .

49. RECENT ADVANCES 1.) Pilot Study Combining Electrical Stimulation and a Dynamic Hand Orthosis for Functional Recovery in Chronic Stroke. Barbara M. Doucet  and  Joni A. Mettler OBJECTIVE.  We investigated the effect of a combined neuromuscular electrical stimulation (ES) and dynamic hand orthosis (DHO) regimen with a group of people with chronic stroke to improve performance on specific daily tasks. METHOD . Four people with chronic stroke participated in an ES–DHO regimen using the affected upper extremity 5×/wk for 6 wk. Outcome measures included grip strength, range of motion (ROM), and analysis of muscle activation–deactivation during release of grasp through electromyography. Ability to perform specific daily living tasks was assessed using the Assessment of Motor and Process Skills (AMPS ).

50. RESULTS. Results suggested that improvements in strength, ROM, and grasp deactivation are possible with the combined ES–DHO regimen. All participants’ AMPS motor scores improved. CONCLUSIONS . An ES–DHO regimen may improve motor skills needed for functional task performance in people with chronic stroke. Results should be interpreted cautiously because of the pilot nature of the study and the small sample size.

51. Introduction: People with Duchenne muscular dystrophy are currently in need of assistive robotics to improve their hand function and have a better quality of life. However, none of the available active hand orthoses is able to address to their specific needs. Methods : In this study, the use of hydraulic technology is proposed in the design of an active hand orthosis . Commercially available components were used to identify where customization is necessary for a new electrohydraulic hand orthosis . 2.) Design of an electrohydraulic hand orthosis for people with Duchenne muscular dystrophy using commercially available components Ronald A. Bos1, Kostas Nizamis2, Dick H. Plettenburg1, Member, IEEE, and Just L. Herder3, Member, IEEE

52. The presented prototype was able to move four finger modules with a single actuator. The finger modules were separable and had a total mass of only 150 g, whereas the valve manifold added another 250 g. Results revealed that the prototype was able to function well with full flexion/extension cycles up to 2 Hz, but with hysteretic losses between 37–81% of the total input energy. Specialized valves and slave cylinders are required to increase efficiency at higher speeds and to obtain more robust sealing performance.

53. REFERENCES Textbook of Rehabilitation: S Sunder Physical Rehabilitation: Susan B. O’Sullivan Orthotics in Rehabilitation: Pat Mckee and Leanne Morgan Splinting: Brenda M Coppard and Helene Lohman Orthotics and Prosthetics Rehabilitation: Michelle M Lusardi and Milgros George DELISA’S physical medicine & rehabilitation PRINCIPLES AND PRACTICE 5th EDITION

54. THANK YOU