ORTHOTHICS

Orthosis- is a device that is externally applied or attached to a

body
segment and that facilitates or improves function by
supporting, correcting
or compensating for skeletal deformity or weakness
 Orthotics - is defined as the specialty relating to orthoses
and their use. The word
‘orthosis’ seems to be derived from a combination of the
words ‘orthopaedic’
and ‘prosthesis’
REGIONS OF THE BODY IN AMERICAN
ACADEMY OF ORTHOPEDIC SURGEONS

(AAOS) nomenclature
Upper limb Lower limb Spine
S – Shoulder H – Hip C – Cervical
E – Elbow K – Knee T – Thoracic
W – Wrist A – Ankle L – Lumbar
H – Hand F – Foot S – Sacroiliac
Thus, FO = foot orthosis, KO = knee orthosis and KAFO = knee–ankle–
foot
orthosis
 Control of designated function
 • F: free motion allowed.
 • A: assist, i.e. application of an external force to increase
range or velocity of a
 desired motion.
 • R: resist movement by external force.
 • S: stop, i.e. static unit to deter motion in one plane.
 • H: hold, i.e. elimination of all motion in prescribed plane.
 • L: lock, i.e. optional lock
 ORTHOSES- The practical ideal orthosis
should aim to have the following characteristics

• Biomechanically effective.
• Lightweight.
• Durable.
• Cosmetically pleasing.
• Easy to put on (don) and take off (doff).
• Rapid provision and replacement.
• Inexpensive.
• Washable.
• Adjustable.
• Comfortable.
• Free of pressure areas
 FUNCTIONAL CHARACTERISTICS OF
ORTHOSES
Provision of support: to prevent weak muscles or ligaments being stretched,
or to support joints by substituting for weakened muscles or ligaments, e.g.
• Limitation of motion: e.g. KO to prevent hyperextension.
• Correction of deformity: to force the affected joint(s) into near-alignment an
redirect growth if possible, e.g. thoracolumbar sacral orthosis (TLSO) to
correct an idiopathic scoliosis, or ankle–foot orthosis (AFO) in cerebral palsy.

• Assistance of motion: e.g. hip–knee–ankle–foot orthosis (HKAFO) to aid

walking in myelomeningocele.
• Miscellaneous: e.g. warmth, placebo effect.
• Combination: many orthoses combine several functions, e.g. KAFO for a leg
afflicted by polio gives support, limits movement at the knee (and perhaps the
ankle), may help to correct a varus ankle and may have a spring to assist ankle
dorsiflexion.
Static (passive): has no moving parts and is used to
immobilize a part of the
body in a particular position.
• Dynamic (active): has moving parts, but movement is
controlled by an energy
store, e.g. an elastic band. An example is a post-operative
outrigger for
mobilizing tendon repairs of the hand.

AN ALTERNATIVE FUNCTIONAL
CLASSIFICATION OF ORTHOSES
COMPRISES TWO MAIN GROUPS:
• all orthoses, at least three points of pressure are needed
for proper control of a joint.

• supportive orthoses of the resting splint type, the joint

must be
maintained in optimum anatomical position during rest
periods. For
corrective
orthoses, the purpose of the orthosis is to impose or control a
set of forces on the
body part.
A basic understanding of biomechanics is essential when prescribing
orthoses.
Newton’s third law of reaction, which states that for every reaction there is
an
equal and opposite reaction, is vital for comprehension of the principle of
ground reaction force (GRF).

BASIC BIOMECHANICAL
CONCEPTS
The GRF is the force exerted by the ground on the body. It is equal in
magnitude, but opposite in direction, to the force exerted on the ground by the
body.

Ground reaction force and its line of action

during (a) mid-stance
and (b) pre-swing.
 BIOMECHANICS OF ORTHOSES

• Orthoses function by application of mechanical forces to the musculoskeletal

system.

• Regardless of whether the body is stationary or moving, it is always subject to a

system of external forces and moments.

• Normally, the effects of the external moments acting on the body are restricted or
controlled by forces generated internally, either in passive tissues such as capsules,
ligaments and articular cartilage, or in active tissues such as muscles.

• Injury or disease of one of these (e.g. ligament rupture, muscle atrophy, spasticity,
contractures) can lead to an inability to produce the appropriate force to resist the
system of external forces.
Control of moments about a joint: this is the most common reason
for prescribing an orthosis. By modifying the moments about a joint,
an orthosis may partially or totally restrict the rotational movement
at the joint
Control of translation forces across a joint: translational instability arises
only when there are significant shear forces acting across the.

Four-point fixation is required to prevent translation. The orthosis can

be hinged to allow rotation. An example is a KO used to prevent translation in
the transverse plane in posterior cruciate ligament (PCL) rupture of the knee.
Control of axial forces across a joint: this is achieved by load sharing
between the anatomical structures and the orthotic exoskeleton and is
particularly useful for reducing pain in arthritic joints.
Control of line of action of GRF: this involves modification of the point of
application and line of action of the GRF during either static or dynamic weight
bearing and is relevant only to the lower limb. It is
particularly useful in modifying abnormally high moments about a joint, but it can
also be used to change the alignment of a joint. An example is the use of a lateral heel
wedge, which can transfer the GRF from the medial aspect of a varus degenerate knee
to the intercondylar eminence or lateral joint line.
 MATERIALS USED IN ORTHOTICS

• Thermosetting plastics: e.g. polyester resins, which can be moulded into

permanent shape after heating and do not return to their original consistency,
even after being reheated. They are formed by pouring liquid plastic resin into
a mould, which is then mixed with catalyst that polymerizes the resin to set
into a rigid form. They are more commonly used in prosthetics than orthotics,
where greater rigidity is required.

• Thermoforming plastics (thermoplastics): these soften when heated

(allowing reshaping by application of pressure) and harden when cooled. They
can be reshaped many times and are subdivided according to their moulding
temperatures:
• high-temperature thermoplastics: require moulding temperatures 120–
190°C. Great skill is required in their manufacture. They are ideal for highstress
activities. These orthoses are made by heating a sheet of polyethylene (e.g. Vitrathene™,
Subortholen™, Ortholen™) or polypropylene (e.g. Vitralene in a hot oven. The final
product is then either vacuum-formed or moulded over a positive plaster of Paris cast.
Plastics differ in molecular weight, tensile strength, fatigue resistance and mouldability.
They are commonly used for making more rigid orthoses such as AFOs and TLSOs;

• moderate-temperature thermoplastics: require moulding temperatures of 100–120°C.

An example is Plastozote™ foam made from polyethylene of closed-cell construction. It
is very lightweight and, after heating in a hot-air oven, it can be moulded directly on the
patient, as it has low heat
conductivity and its surfaces cool rapidly. It is commonly used for making
custom-made cervical collars and pressure-distribution pads;
• low-temperature thermoplastics: require moulding temperatures below
80°C and so can be moulded in a water bath or hot-air oven. Ideal for use in
acute splinting by occupational therapists. They can be moulded directly on
to the patient, with minor modifications made using a heat gun or hair dryer.
As a group, these thermoplastics are less rigid and less durable than other
plastics; however, they are cheaper, because less time, skill and equipment
are required for fabrication. Note that they may also soften in direct sunlight
or near a fire. The common types of polymers in use are transpolyisoprene
(Orthoplast™) and polycaprolactone (Polyform™, Aquaplast™), to which
synthetic rubber may be added (many types of Sansplint™). The plastics
differ in setting times, rigidity, impact strength and transparency.

• Self-generating polyurethane foam: used in Neofract™ corsets and braces,

this freshly prepared foam is poured into a cotton pattern and distributed
evenly with a roller. The filled pattern is allowed to harden directly over the
patient. The custom-made cast is prepared in minutes and is donned and
doffed by using a zip fastener. Polyurethane foam is also used to make
moulded cushions for wheelchairs and can be used as filler in KAFOs and
shoes.
COMMON ORTHOSES
Foot orthoses

• Simple insoles: either off-the-shelf or fabricated without casting. Provide poor

surface area contact and little if any biomechanical control.

• Total contact insoles: made initially by taking an imprint of the patient’s foot
and then casting this imprint with plaster of Paris. A thermoplastic is then
moulded from the positive plaster of Paris cast. These are the most commonly
used foot orthoses.

• Functional/biomechanical orthoses: corrective insoles introduced by Mervon

Root, a podiatrist, in the 1960s. The foot is held in its corrected position when
the cast is taken. The insole obtained therefore acts to correct the underlying
foot deformity when the deformity is flexible. For fixed deformities, an
accommodative insole is used.
Shoes can be modified either externally or internally in order to
reduce pressure on sensitive areas by redistributing weight towards pain-free areas.
For external shoe modifications, heels can be of the following types:

• Cushioned: wedge of compressible rubber used to absorb impact at heel-strike or, with a
rigid ankle, to allow more rapid ankle plantarflexion by reducing the knee flexion
moment.

• Flared: medial to resist eversion and lateral to resist inversion.

• Wedged: medial to promote inversion and lateral to promote eversion.

• Extended: e.g. a Thomas heel projects anteriorly on the medial side to provide support
to the medial longitudinal arch.

• Elevated: shoe lift to compensate for fixed equinus deformity or leg-length discrepancy
of more than about 0.65 cm.
 FOR EXTERNAL SHOE MODIFICATIONS,
SOLES CAN HAVE THE FOLLOWING:

• Rocker bars: convex structure placed posterior to metatarsal head, shifting

rollover point from head to shaft. Used for ulcers over metatarsal heads in
diabetes mellitus.

• Metatarsal bars: bar with flat surface placed posterior to metatarsal head to
relieve pressure on heads.

• Wedges: medial to promote supination and lateral to promote pronation.

• Flares: medial to resist eversion and lateral to resist inversion.

FOR INTERNAL SHOE MODIFICATIONS,
THE HEELS CAN HAVE THE FOLLOWING:

• Cushion relief: soft pad with excavation placed under painful point of heel.

• Cups: rigid plastic insert covering the plantar surface of heel and extending
posteriorly, medially and laterally to prevent lateral calcaneal shift in the
flexible flat foot.

• University of California at Berkeley Laboratory (UCBL) insert: rigid

plastic insert fabricated over a cast of the foot held in maximum manual
correction and encompassing the heel and midfoot, with rigid posterior, medial
and lateral walls. Used to control hindfoot valgus and midfoot pronation.
For internal shoe modifications, the soles can have the following:

• Metatarsal pads: domed pads designed to reduce stress from metatarsal heads
by transferring load to metatarsal shafts in metatarsalgia.

• Inner sole excavations: soft pad filled with compressible material placed
under metatarsal heads.

• Arch supports: e.g. medial arch support extending from half inch posterior to
first metatarsal head to anterior tubercle of the os calcis.
ANKLE–FOOT ORTHOSES

AFOs are used to prevent or correct deformities and reduce weight bearing. The
position of the ankle indirectly affects the stability of the knee, with ankle
plantarflexion providing a knee extension force and ankle dorsiflexion providing
a knee flexion force.

AFOs have been shown to reduce the energy cost of

ambulation
PLASTIC AFOS CONSIST OF A SHOE INSERT, A CALF
SHELL, A HEEL-RETAINING STRAP AND A
CALF STRAP ATTACHED MORE PROXIMALLY.
• Posterior leaf spring
• Solid AFO
• Ground reaction AFO

• Dynamic AFO (DAFO) or tone-reducing AFO

• Metal and metal–plastic AFOs

KNEE–ANKLE–FOOT ORTHOSES

KAFOs consist of an AFO with metal uprights, a mechanical knee joint and two
thigh bands. They can be used in quadriceps paralysis or weakness to maintain
knee stability and control flexible genu valgum or varum. They can be
manufactured from metal, e.g. double upright metal KAFO (most common) and
Scott–Craig metal KAFO (used for spinal cord injury patients with paraplegia),
or from plastic, e.g. ischial weight-bearing KAFO.
TRUNK–HIP–KNEE–ANKLE–
FOOT ORTHOSES

A THKAFO is indicated in patients with paraplegia and is very difficult

to don and doff. An example is the reciprocating gait orthosis (RGO).
MISCELLANEOUS EXAMPLES

• Weight-bearing orthoses

• Charcot restraint orthotic walker (CROW)

• Fracture orthoses

• Angular and deformity orthoses

• Hip orthoses for pediatric disorders

COMPLICATIONS OF
ORTHOSES
Complications can be psychosocial (related to the use of an orthosis, particularly
any perceived associated stigma) or physical. The following are the more
common physical complications seen:

• Compression phenomena

• Heat and water retention

• Patient–orthosis interfacial effects

 TO DECREASE THE PRESSURE
EFFECTS OF AN ORTHOSIS, THE FOLLOWING CAN BE
ATTEMPTED:
• proper contouring increases contact area and decreases the tendency of the orthosis to
move;

• good mechanical design, e.g. increased lever arm to reduce the amount of force exerted on
the skin;

• forces applied perpendicular to limb segment to reduce shearing;

adequate padding and large contact areas over which the forces can act. Note that a
maximal conforming support area will provide a uniform distribution of pressure. This can
be applied in two ways. First, the support surface, made of a relatively high modulus
material, can be matched in shape to the area of the body it interfaces with, e.g. a spinal
brace. Second, the support surface can be flat but made of relatively soft material, which can
deform under load, e.g. in seating applications.
Figure 28.7 Increased lever arm of orthosis decreases pressure at the
orthosis–
patient interface.
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