Transcript ارتز وپروتز - Tehran University of Medical Sciences

‫ارتز وپروتز‬
‫مجتبی کامیاب‬
‫مهر هشتاد و هشت‬
Outlines
• What Orthotics and Prosthetics are
• History of Orthotics and Prosthetics
• Orthotics and Prosthetics in Iran
• What we are going to get on today’s and
tomorrow’s sessions
What Orthotics and Prosthetics are
• Orthotics, Orthosis, and Orthoses
– Brace, Splint
• Eponyms
– Milwaukee Brace
– Miami Brace
– ISO terminology 1989
• Acronyms
– Cervical Orthosis: CO
– Ankle Foot Orthosis: AFO
• Prosthetics, Prosthesis, and Prostheses
– Terminology
History of Orthotics and Prosthetics
• A Persian soldier: 486 B.C.
• A Mummy: 250 B.C.
• A Knight in Germany: 1840
• Pirates
• 1st and 2nd World Wars
• Orthotics and Prosthetics is rapidly
evolving
Orthotics and Prosthetics in Iran
• Establishment process
• Education
• Problems
What we will have in the next 3
sessions
• Spinal orthoses
• Lower limb orthoses
• Upper limb orthoses
Few points on orthotic prescription
Optimal setting:
• Physician, Orthotist, therapist are available
for evaluation as well as follow-ups.
• Prescription:
– Name, DoB, Functional deficit, Reason of
orthosis, Area of coverage, Action on each
joint in each plane, Materials, Concerns, Need
for consultation, and etc.
Different classification styles
• Function
• Area of the body
• Material
• Manufacturing method
• Objectives
Classification based on function
• Prophylactic
• Rehabilitive
• Functional
Classification based on area of the
bady
• Upper limb
• Lower limb
• Foot
• Spine
• Head
Classification based on the used
materials
• High temperature thermoplastics
• Low temperature thermoplastics
• Leather
• Metal
• Electronics? Particularly in sport!
Classification based on
manufacturing method
• Prefabricated
• Custom made
• Prefabricated – custom fitted
Classification based on objectives
• Pain relief
• Deformity correction
• Enhance range of motion
• Immobilisation
• A counterforce
‫ارتز‬
‫وپروتز‪2‬‬
‫مجتبی کامیاب‬
‫مهر هشتاد و هشت‬
Spinal orthoses
• Reasons
– Abdominal support
– Pain management
– Motion/Position control
• Level
– SO
– LSO
– TLSO
• Structure
– Semi rigid
– Rigid
Semi rigid spinal orthoses
• Some degree of immobilisation
• Lordosis reduction lumbo-sacral strain
• Intracavitary pressure reduced axial load
• Management of pain caused by muscle strain
• Long term use Atrophy Increased chance
of reinjury
Semi rigid spinal orthoses (cont.)
• Sacroiliac corset
– Provides assistance to pelvis only
– The main indication is hyper mobility of sacroiliac
joints.
– Slight increase to abdominal pressure
• Lumbosacral corset
– Increases abdominal pressure
– Acute back pain
• Thoracolumbar corset
– Shoulder straps provide a posteriorly directed force
– Kinesthetic reminder
Rigid spinal orthoses
• Prescription considerations:
– Patient gadget tolerance
– Donning and doffing
• Categories
– Conventional or Metal
– Contemporary equivalents
LSO
• Chairback style
– Reduction of gross motion in sagittal plane
• Knight style (Knight, 1884)
– Sagittal-coronal control
• Williams style
– Extension-coronal control
– Dynamic orthosis
– By Willimas in 1937 for spondylolisthesis
TLSO
• Jewett style
– Flexion control (hyper extension orthosis)
– Jewett 1937
• Taylor style
– Sagittal control (equivalent to chairback)
• Knight taylor
– Sagittal-coronal control (equivalent to knight)
• Cowhorn style
– Triplanar control
Contemporary spinal orthosis
• LSO
• TLSO
• Custom molded body jacket
– Maximum control
– The bivalve design  patients with variable
volume
Jewett brace
• Indications:
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– Symptomatic relief of compression fractures
not caused by osteoporosis
– Immobilization after surgical stabilization of
thoracolumbar fractures
Motion restrictions:
– Limits flexion between T6-L1
– Ineffective in limiting lateral bending and
rotation of the upper lumbar spine
Contraindications:
– Three-column spinal fractures involving
anterior, middle, and posterior spinal
structures
– Compression fractures above T6, because
segmental motion increases above the sternal
pad
– Compression fractures caused by osteoporosis
Cervical orthoses
• Reasons
– Pain management
– Motion/Position control
• Level
– CO
– CTO
• Structure
– Semi rigid
– Rigid
Cervical orthoses
• Foam collars
– Kinesthetic reminder
• Semi rigid collars
– Philadelphia collar
• Little control of lateral bending and rotation
• Poster style orthoses
Cervicothoracic orthoses
• Sternal Occipital Mandibular Immobiliser
(SOMI)
– More effective in control of flexion than
extension
• Halo
– Provides triplanar control
– Fixed to skull with pins
• Intersegmental snaking
Indications for the use of a soft
collar:
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Warmth
Psychological comfort
Head support when acute neck pain occurs
Relief from minor muscle spasm associated with
spondylolysis
– Relief from cervical strain
• The soft collar provides some motion limitations for the
patient, including the following:
– Full flexion and extension are limited by 5-15%.
– Full lateral bending is limited by 5-10%.
– Full rotation is limited by 10-17%.
Indications for the use of a semi
rigid collar:
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Head support when acute neck pain occurs
Relief of minor muscle spasm associated with spondylosis
Psychological comfort
Interim stability and protection during halo application
• Motion restrictions associated with the hard collar include
the following:
– Full flexion and extension are limited by 20-25%.
– The hard collar is less effective in restricting rotation and
lateral bending.
– It is better than a soft collar in motion restriction.
Indications of Philadelphia
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Anterior cervical fusion
Halo removal
Dens type I cervical fractures of C2
Anterior diskectomy
Suspected cervical trauma in unconscious
patients
Teardrop fracture of the vertebral body
(Note: Some teardrop fractures require
anterior decompression and fusion.)
Cervical strain
Indications for immobilization with
the SOMI
– Atlantoaxial instability caused by rheumatoid arthritis
(Note that ligamentous disruption in rheumatoid
arthritis affects flexion more than extension, because
extension is held in check by the intact dens.)
– Neural arch fractures of C2, because flexion causes
instability
• Motion restrictions associated with the SOMI include the
following:
– Cervical flexion and extension are limited by 70%-75%
– Lateral bending is limited by 35%
– Rotation is limited by 60-65%
Indications for immobilization
with a halo device:
– Dens type I, II, or III fractures of C2 (Note: Dens type III
fractures of C2 are treated more successfully with surgery.)
– 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.
(Note: Some patients may need surgery for stabilization.)
– 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)
• Contraindications for the use of a halo device include the
following:
– Concomitant skull fracture with cervical injury
– Damaged or infected skin over pin insertion sites
Orthoses for spinal deformity
• Milwaukee brace CTLSO
• TLSO
– Boston
• Prefabricated, custom fitted
– Miami
• One piece, posterior opening, custom molded
– Wilmington
• Risser frame
– Charleston Bending brace
• Night time use
Main features of an spinal orthosis
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Weight
Adjustability
Functional use
Cosmesis
Cost
Durability
Material
Ability to fit patients of various sizes
Ease with which the device can be put on (donned) and
taken off (doffed)
Provision of access to a tracheostomy site, peg tube, or
other drains
Provision of access to surgical sites for wound care
Provision of aeration in order to avoid skin maceration
from moisture
Indications for recommending the
use of orthoses
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Pain relief
Mechanical unloading
Scoliosis management
Spinal immobilization after surgery
Spinal immobilization after traumatic
injury
Compression fracture management
Kinesthetic reminder to avoid certain
movements
Duration of orthosis use
• Where spinal instability is not an
issue, until he/she can tolerate
discomfort without the brace.
• When employed for stabilisation
after surgery or acute fractures, 6-12
weeks of use should be allowed to
permit ligaments and bones to heal
The use of an orthosis is associated
with several drawbacks
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Discomfort
Local pain
Osteopenia
Skin breakdown
Nerve compression
Ingrown facial hair in men
Muscle atrophy with prolonged use
Decreased pulmonary capacity
Increased energy expenditure with ambulation
Difficulty in donning and doffing the orthosis
Difficulty with transfers
Psychological and physical dependency
Increased segmental motion at the ends of the orthosis
Unsightly appearance
Poor patient compliance
The successful use of an orthosis
may lead to:
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Decreased pain
Increased strength
Improved function
Increased proprioception
Improved posture
Correction of spinal curve deformity
Protection against spinal instability
Minimized complications
Healing of ligaments and bones
‫ارتز‬
‫وپروتز‪3‬‬
‫مجتبی کامیاب‬
‫مهر هشتاد و هشت‬
Lower limb orthoses
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•
FO is a foot orthosis.
AFO is an ankle-foot orthosis.
KO is a knee orthosis.
KAFO is a knee-ankle-foot orthosis.
HO is a hip orthosis.
HKAFO is a hip-knee-ankle-foot orthosis.
THKAFO is a trunk-hip-knee-ankle-foot orthosis.
Shoe Modifications
• Heel modifications
– A cushioned heel: A wedge of compressible
rubber is inserted into the heel to absorb
impact at heel strike. Often with a rigid ankle
– A heel wedge: A medial wedge is used to
promote inversion, and a lateral wedge is
used to promote eversion.
Other heel modifications
– A heel flare:
• A medial flare is used to resist eversion.
• A lateral flare is used to resist inversion.
• Both flares are used to provide heel stability.
– Extended heel: The Thomas heel projects
anteriorly on the medial side to provide
support to the medial longitudinal arch.
– Heel elevation: A shoe lift is used to
compensate for fixed equinus deformity.
Sole modifications
• A rocker bar is a convex structure placed
•
•
posterior to the metatarsal head. The rocker bar
is used to shift the rollover point from
metatarsal head to metatarsal shaft to avoid
irritation of ulcers along the metatarsal head in
patients with diabetes mellitus.
A metatarsal bar is a bar with a flat surface
placed posterior to the metatarsal head. The
metatarsal bar is used to relieve the pressure
from the metatarsal heads.
A sole wedge: A medial wedge is used to
promote supination, and a lateral wedge is used
to provide pronation.
Foot orthosis
• UCBL (University of California at Berkeley
•
Laboratory) insert: This insert is made of rigid
plastic fabricated over a cast of the foot held in
maximal manual correction. The UCBL
encompasses the heel and midfoot, and it has
rigid medial, lateral, and posterior walls.
Heel cup: The heel cup is a rigid plastic insert
that covers the plantar surface of the heel and
extends posteriorly, medially, and laterally up
the side of the heel. The heel cup is used to
prevent lateral calcaneal shift in the flexible flat
Orthotic Management
For Athletic Injuries 1
• Turf Toe
– Common in athletes playing on firm, artificial
turf
– Forceful extension of the 1st MTP joint
– Injury to the joint capsule
– Untreated, can lead to Arthritic Joint Changes
• Hallux limitus
• Hallux rigidus
Orthotic Management
For Athletic Injuries 2
• Turf Toe
– Goal of Orthotic Treatment
• Limit Great Toe Extension
• Helping joint capsule to heal
– Carbon Footplates
– Total Contact FO
Orthotic Management
For Athletic Injuries 3
• Heel Pain
• Sever’s disease
• Active adolescents
– Girls 8 to 10 yrs of age
– Boys 10 to 12 yrs of age
• Strong pull of Achilles’ tendon
Orthotic Management
For Athletic Injuries 4
• Heel Pain
– Conservative Treatment for Sever’s Disease
• Rest
• Stretches
• Soft heel cups
• FO with heel cushion
• Walking boot in slight equinus / heel wedge
Orthotic Management
For Athletic Injuries 5
• Heel Pain
– Plantar Fasciitis
– Repetitive strain of the plantar fascia
Orthotic Management
For Athletic Injuries 6
• Plantar Fasciitis Treatment
– Stretches
– Heel Cushions / Gel cups
– Nocturnal dorsiflexion splints
– AFO (custom) Total contact day & night
Orthotic Management
For Athletic Injuries 7
• Ankle Sprains
– Treatment corresponds to degree of instability
• Walking boot
• Ankle lacer, stirrup, sleeve
• Chronic sprains, instability
– Foot orthotics
– Ankle lacer during sport
– Medial or lateral support
Orthotic Management
For Athletic Injuries 8
• Achilles Tendon Injury
– Immobilization
– Custom made AFO
– Floor reaction AFO
– Walking Boot
• Reduce Stress on Injured Site
• Allow Healing
Orthotic Management
For Athletic Injuries 9
• Metatarsal Fractures
– Dancer’s fracture
• Jones fracture
• 5th Metatarsal fracture
– “March Fracture”
• High rate of 2nd and 3rd MT stress
fractures
Orthotic Management
For Athletic Injuries 10
• Metatarsal Fractures
– Orthotic Treatment
• Walking boot
• AFO (custom made)
– Prevention
• Foot orthotics addressing the shock absorbing
and/or functional needs of the individual
Thermoplastic AFOs
• Posterior leaf spring (PLS): For
compensating for weak ankle dorsiflexors
, no mediolateral control.
• Spiral AFO: Allows for rotation in the
transverse plane while controlling ankle
dorsiflexion and plantar flexion, as well
as eversion and inversion.
Thermoplastic AFOs (Continued)
• Solid AFO: Prevents ankle dorsiflexion and
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•
plantar flexion, as well as varus and valgus
deviation.
AFO with flange: This AFO has an extension
(flange) that projects from the calf shell for
valgus, varus control.
Hinged AFO: The adjustable ankle hinges can
be set to the desired range of ankle
dorsiflexion or plantar flexion.
Metal AFO
• Free motion ankle joint: allows free ankle
motion and provides only mediolateral
stability.
• Dorsiflexion assist spring joint: This joint
has a coil spring in the posterior channel
and helps to aid dorsiflexion during swing
phase.
• Varus or valgus correction straps (Tstraps): valgus, varus correction.
Knee Ankle Foot Orthosis
• Free motion knee joint:
– to prevent hyperextension.
– for patients with recurvatum but good strength of the
quadriceps
• Offset knee joint:
–
–
–
–
is located posterior to ground reaction force; thus,
provides great stability
joint flexes the knee freely during swing phase
is contraindicated with knee or hip flexion contracture
and ankle plantar flexion stop.
• Drop ring lock knee joint:
– is the most commonly used knee lock to control knee
flexion.
Knee Ankle Foot Orthosis
• Adjustable knee lock joint (dial lock): It
allows knee locking at different degrees of
flexion. in patients with knee flexion
contractures that are improving gradually
with stretching.
• Ischial weight bearing:
Knee Orthoses
• Knee orthoses for patellofemoral disorder: to control
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•
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tracking of the patella during knee flexion and extension.
Knee orthoses for knee control in the sagittal plane: to
control genu recurvatum with minimal mediolateral
stability.
Knee orthoses with adjustable knee joint fpr flexion
contracture.
Knee orthoses for knee control in the frontal plane: The
knee joint usually is polycentric and closely mimics the
anatomic joint motion.
Knee orthoses for axial rotation control: These orthoses
can provide angular control of flexion-extension and
mediolateral planes, in addition to controlling axial
rotation. This orthosis is used mostly in management of
sports injuries of the knee. This type of KO includes
Hip Knee Ankle Foot Orthoses
• Reciprocating Gait Orthosis
Sport related orthoses
• Prophylactic
– Yes:
• To prevent excessive forces
• To prevent sudden impact
– No:
• It increases energy expenditure
• It can harm others
• Anatomical and mechanical correspondence
‫ارتز‬
‫وپروتز‪3‬‬
‫مجتبی کامیاب‬
‫مهر هشتاد و هشت‬
Lower limb orthoses
•
•
•
•
•
•
•
FO is a foot orthosis.
AFO is an ankle-foot orthosis.
KO is a knee orthosis.
KAFO is a knee-ankle-foot orthosis.
HO is a hip orthosis.
HKAFO is a hip-knee-ankle-foot orthosis.
THKAFO is a trunk-hip-knee-ankle-foot orthosis.
Materials
• Plastics
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•
•
– Low-temperature thermoplastics: Mainly in low stress
activities.
– High-temperature: They are ideal for high stress activities.
Leather: It conducts heat and absorbs water well.
Rubber: Rubber is used for padding in body jackets and limb
orthoses.
Metal
– Metals, such as stainless steel and aluminum alloys can be
used for joint components, metal uprights, sprints, and
bearings.
Shoe Modifications
• Heel modifications
– A cushioned heel: A wedge of compressible
rubber is inserted into the heel to absorb
impact at heel strike. This cushion often is
used with a rigid ankle to reduce the knee
flexion moment by allowing for more rapid
ankle plantar flexion.
– A heel wedge: A medial wedge is used to
promote inversion, and a lateral wedge is
used to promote eversion. The heel counter
should be strong enough to prevent the
Other heel modifications
– A heel flare: A medial flare is used to resist eversion,
and a lateral flare is used to resist inversion. Both
flares are used to provide heel stability.
– Extended heel: The Thomas heel projects anteriorly
on the medial side to provide support to the medial
longitudinal arch. The reverse Thomas heel projects
anteriorly on the lateral side to provide stability to the
lateral longitudinal arch.
– Heel elevation: A shoe lift is used to compensate for
fixed equinus deformity or for any leg-length
discrepancy of more than one centimeter.
Sole modifications
• A rocker bar is a convex structure placed posterior to the metatarsal
•
•
•
•
head. The rocker bar is used to shift the rollover point from
metatarsal head to metatarsal shaft to avoid irritation of ulcers
along the metatarsal head in patients with diabetes mellitus (DM).
A metatarsal bar is a bar with a flat surface placed posterior to the
metatarsal head. The metatarsal bar is used to relieve the pressure
from the metatarsal heads.
A sole wedge: A medial wedge is used to promote supination, and a
lateral wedge is used to provide pronation.
A steel bar: The steel bar is placed between the inner sole and outer
sole. This bar is used to reduce forefoot motion to reduce the stress
from phalanges and metatarsals.
Combination of sole and heel modifications: If heel elevation is
more than one half an inch, a sole elevation should be added to
avoid equinus posture.
Foot orthosis
• UCBL (University of California at Berkeley Laboratory)
•
•
insert: This insert is made of rigid plastic fabricated over
a cast of the foot held in maximal manual correction.
The UCBL encompasses the heel and midfoot, and it has
rigid medial, lateral, and posterior walls.
Heel cup: The heel cup is a rigid plastic insert that
covers the plantar surface of the heel and extends
posteriorly, medially, and laterally up the side of the
heel. The heel cup is used to prevent lateral calcaneal
shift in the flexible flat foot.
Sesamoid insert: This addition to an orthosis is an insert
amounting to three quarters of an inch with an extension
under the hallux to transfer pressure off the short first
metatarsal head and onto its shaft.
Thermoplastic AFOs
• Posterior leaf spring (PLS): The PLS is the
•
most common form of AFO with a narrow calf
shell and a narrow ankle trim line behind the
malleoli. The PLS is used for compensating for
weak ankle dorsiflexors by resisting ankle
plantar flexion at heel strike and during swing
phase with no mediolateral control.
Spiral AFO: This AFO consists of a shoe insert,
a spiral that starts medially, passes around the
leg posteriorly, then passes anteriorly to
terminate at the medial tibial flare where a calf
band is attached. The spiral AFO allows for
rotation in the transverse plane while
controlling ankle dorsiflexion and plantar
Thermoplastic AFOs (Continued)
• Solid AFO: The solid AFO has a wider calf shell
•
•
with trim line anterior to the malleoli. This AFO
prevents ankle dorsiflexion and plantar flexion,
as well as varus and valgus deviation.
AFO with flange: This AFO has an extension
(flange) that projects from the calf shell
medially for maximum valgus control and
laterally for maximum varus control.
Hinged AFO: The adjustable ankle hinges can
be set to the desired range of ankle
dorsiflexion or plantar flexion.
Metal AFO
• Free motion ankle joint: The stirrup has a
•
•
completely circular top, which allows free ankle
motion and provides only mediolateral stability.
Dorsiflexion assist spring joint: This joint has a
coil spring in the posterior channel and helps to
aid dorsiflexion during swing phase.
Varus or valgus correction straps (T-straps): A
T-strap attached medially and circling the ankle
until buckling on the outside of the lateral
upright is used for valgus correction. A T-strap
attached laterally and buckling around the
medial upright is used for varus correction.
Knee Ankle Foot Orthosis
• Free motion knee joint:
– to prevent hyperextension.
– for patients with recurvatum but good strength of the
quadriceps
• Offset knee joint:
–
–
–
–
is located posterior to ground reaction force; thus,
provides great stability
joint flexes the knee freely during swing phase
is contraindicated with knee or hip flexion contracture
and ankle plantar flexion stop.
• Drop ring lock knee joint:
– is the most commonly used knee lock to control knee
flexion.
Knee Ankle Foot Orthosis
• Adjustable knee lock joint (dial lock): It
allows knee locking at different degrees of
flexion. in patients with knee flexion
contractures that are improving gradually
with stretching.
• Ischial weight bearing:
Knee Orthoses
• Knee orthoses for patellofemoral disorder: to control
•
•
•
•
tracking of the patella during knee flexion and extension.
Knee orthoses for knee control in the sagittal plane: to
control genu recurvatum with minimal mediolateral
stability.
Knee orthoses with adjustable knee joint fpr flexion
contracture.
Knee orthoses for knee control in the frontal plane: The
knee joint usually is polycentric and closely mimics the
anatomic joint motion.
Knee orthoses for axial rotation control: These orthoses
can provide angular control of flexion-extension and
mediolateral planes, in addition to controlling axial
rotation. This orthosis is used mostly in management of
sports injuries of the knee. This type of KO includes
Hip Knee Ankle Foot Orthoses
•
•
•
•
Hip joints and locks: The hip joint can prevent
abduction and adduction as well as hip rotation.
Single axis hip joint with lock: This joint is the most
common hip joint with flexion and extension. The
single axis hip joint with lock may include an
adjustable stop to control hyperextension.
Two-position lock hip joint: This hip joint can be locked
at full extension and 90° of flexion and is used for hip
spasticity control in a patient who has difficulty
maintaining a seated position.
Double axis hip joint: This hip joint has a flexionextension axis and abduction-adduction axis to control
these motions.
Sport related orthoses
• Prophylactic
– Yes:
• To prevent excessive forces
• To prevent sudden impact
– No:
• It increases energy expenditure
• It can harm others
• Anatomical and mechanical correspondence