orthotic in 862

peds considerations

• Growth for Life of the orthosis and Nightsplinting

• Development or Recovery of Function

• Ease of use and independence of donning

• Brace materials

foot orthoses for peds

• Shoe Insert and UCBL

• Off-the-shelf vs. Custom

potential indactions for foot orthosis

• Low tone feet

• Pronation with/without excessive eversion

precautions with foot orthosis

• Sensory defensiveness

• Level of evidence

Supramalleolar Orthoses

Above the ankle, controls medial-lateral instability, but does not assist with dorsiflexion in swing

indications for SMO

• Pronation

• Ligamentous laxity, even in setting of mild

• Mild gastrocnemius spasticity and secondary laxitypr

precautions for SMO

• Persistent toe walking

• Plantarflexor contracture

toe-off indications

• Foot drop (dorsiflexion assist)

• Mild crouch?

precautions for toe-off

• Insufficient ankle PROM (need 5o DF)

• Quadriceps spasticity

• Knee hyperextension

• Insufficient medial-lateral control

indications for spring leaf

Foot drop (dorsiflexion assist)

• Poor pushoff? (Ounpuu et al, 2006)

• Hemiplegic CP and insufficient power

precautions for PLS

• Trimline with insufficient medial-lateral control

• Significant gastrocnemius spasticity

indications for AFO

• Insufficient DF in swing

• Gastrocnemius spasticity

• Active DF is present

• Idiopathic toe walking

precautions for articulating AFO

• Plantarflexor contracture – address the contracture first

• Severe proximal weakness – alignment may be compromised (ex. Muscular dystrophy)

indications for Articulating – Free DF with PF block

• Toe-heel gait

• Early heel rise

• Gastrocnemius tone

• Knee hyperextension

precations for Articulating – Free DF with PF block

• Persistent toe walking gait pattern

• Gastrocnemius contractu

indications for solid AFO

• Poor foot alignment in standing program

• Plantarflexor spasticity and ankle weakness

• Risk of further PF contracture

• Plantarflexor paralysis (ex. Spina bifida)

• Can control hyperextension at the knee

precautions for solid AFO

• Independent ambulation without assistive device

• Potential for recovery/independent ambulation

• May make transfers from floor difficult

• Floor mobility is difficult in crawlers

indications for Floor Reaction AFO/Ground Reaction AFO

• Crouched gait

• Significant PF weakness

• Hamstring spasticity

precautions for Floor Reaction AFO/Ground Reaction AFO

• Toe walking

• Set angle to accommodate knee contracture/functional standing position

indications for KAFO

• Inability to maintain knee extension in standing

• Weakness/Paralysis

precautions for KAFO

Align like a prosthetic for A/P weight line

indications and considerations for HKAFOS or RGO

• Inability to maintain knee extension in standing

• Weakness/Paralysis

• Energy efficiency

precuations for HKAFO or RGO

• Patients with spasticity

• Alignment and adjustments to correct weight line

indication for Parapodium

• High level spina bifida

• Weakness/Paralysis

precaution for parspodium

Sensation/skin checks

considerations for parapodium

• Weightbearing vs. Floor Mobility and independence with transfers

• Robotics in the future – size limitations at present

indications for cranial molding helmets

• Deformational plagiocephaly

• Brachycephaly: flat head

• Scaphocephaly: skinny

precaution for molding helmets

> 1 year of age

consideration for molding helmets

• Cost

• Perspiration

• Sleeping patterns

• Remove about an hour a day, perform exercises/PROM/AROM during

this time

• Remove for bathing and swimming

Nightsplinting

• Plantarflexors

• Plantarflexors and hamstrings

• Hamstrings alone (decreased popliteal angle, knee flexion contracture without bony block)

• Plantarflexors, hamstrings, and hip adductors

• Elbow flexion or elbow extension

improving tolerance for nightsplinting

• Prepare the family

• Skin checks first few days, using after school or during weekend day hours (1-2 hours)

• May need to alternate legs with overall goal of wearing bilaterally all night

• Sleep is also important, can consider a 4 hour window after school if unable to sleep

• May need serial casting or intervention (ex. Botox), then better nightsplinting outcomes

pressure

P = force/area

equilibrium

• 3 points are needed for equilibrium on a moveable joint

• static alignment occurs when all forces are equal

• can be M → L or A → P

lever arm principle

the further away the point of force, the less force that is needed for control

• thus the longer the brace, the less force needed for control

moments

• angular force

• force x perpendicular distance

goals of KAFO

• Stability of the knee

• Prevention of deformity or progression of deformity

• Protection (temporary)

• Restoration of lost function

common pathologies that use KAFOs

• polio and post polio syndrome

• femoral nerve palsy

• spinal cord injury

• knee instability into valgus or varus

what planes does a KAFO offer stability

all

what knee deformities do KAFO prevent

• Genu recurvatum

• Valgus varus deformity

protection

• for healing tissue structures

• force attenuation via brace structure and restriction of joints

pathologies for protection

• Femoral and tibial function

• Inert tissue damage

what reason would a clinican use a KAFO instead of a cast for a fracture?

a patient could have wounds or swelling

restoring function

• can be active or dynamic or new microprocessor

• assists w/ loss of function or motion

• has rehabilitive components

what are KAFOs characterized by

material and function

materials

• Metal

• Plastic

• Hybrids

• Microprocessors

function

• Passive KAFO

• Dynamic KAFO

• Microprocessors and exoskeletons

metal KAFOs

• Traditional double upright KAFO

• Scott-Craig KAFO

Plastic and Hybrid KAFOs

• Hybrid: plastic/metal

• All plastic: supracondylar shell but rarely used dues tot he forces going through the joint

Microprocessor and Exoskeleton KAFO

uses a microprocessor and computer algorithm for knee control

components of KAFO

• Weight-bearing brim

• Pads and straps and bands

• Knee joints and locks

• Uprights

• Foot and ankle same as AFO

free motion joint

• Single axis

• Free motion into flexion unless a lock is added

• Motion blocked at terminal extension

what is free motion joint best used with

• Valgus varus deformity

• Genu recurvatum (without lock)* not caused by knee flexion instability

• Flexion instability (with lock)

offset knee joint

• Single axis

• Free motion to flexion unless lock added

• Mechanical axis is posterior to knee joint: promotes knee extension (prevents buckling)

offset joint is best used with

• Genu recurvatum with mild quad weakness (without lock)

• Flexion instability (with lock)

Adjustable knee joint

• Single axis with a drop lock

• Distally is an adjustable locking axis

• Ability to place the knee into multiple angles of flexion

• Indicated for changing contracture

• Rarely used at present

Drop lock

• Drops over joint and locks into extension

• Most often used with free motion and offset knee joints

• Manually controlled by user

• Optional spring-loaded ring for easier use

Pawl lock with bail control

• Easier to use when an expected flexion moment is present

• Disadvantage: can unlock by accident when bumped

• Used best with: SCI/demyelinating diseases

Fan lock

• Permits locking in any degree of flexion—similar to an adjustable

• Utilizes drop lock to maintain stability

• Used when functional change is anticipated

Stance control knee joints

• Lock during stance phase

• Release during pre-swing with toe load

• Advantages: more normal gait pattern (11)

• Disadvantages: Expense, Durability, Application

Microprocessors

• Uses transfemoral microprocessor knees technology to control the orthotic knee

• Allows for stance stability, swing flexion, and “eccentric control”

Upright Function

• Redistribute the load from distal components to proximal

• Provide medial-lateral stability

• Connect the parts

• Major structural component

bands and shells

• apply and distribute force

• want a larger surface area for more control and comfort

Weight-Bearing Brims

• Reduces weight-bearing on the distal parts of LE

• Two types

1. Thomas ring

2. Quad brim

• Used to relieve distal weight-bearing issues

knee cap

• Assists in blocking flexion in stance

• Attenuates forces on bands and helps with 3 pps

Varus/valgus straps

Usually added to knee cap to assist in 3 pps

problems with traditional KAFO

• energy expenditure to weight and control

• need proximal functional strength

• has low function

• UE problems for the long-term user

HKAFOs

• Poor motor control of hip and pelvis with use of KAFO

• Gait deviation

• Trendelenburg, hip hyperextension, severe lumbar lordosis

• Often used with pediatric developmental disease; demyelinating disease

types of HKAFOs

• Traditional

• Double upright KAFO with external hip joint

• Can be all plastic, all metal or a hybrid

• Reciprocating gait orthosis (RGO)

HKAFO Componentry

From thigh to foot the same as KAFO

• Pelvic bands

• Hip joint

• KAFO components

Single-axis joint for hip

• Permits free flexion and extension

• Blocks abduction/adduction

• Reduces hip rotation

• Used with rotational and abduction/adduction instability

Double-axis joint

• Allows flexion/extension and abduction or adduction motion

• Still blocks rotational motion

• Limits motion

Pelvic Bands

Generally provides hip control

1. Unilateral: Less hip control

2. Bilateral: Most often used

3. Pelvic girdle: Plastic, total contact

Scott Craig KAFO

• Designed to help paraplegics (up to T4 level) stand and walk

• Paraplegics utilize a swing-through gait using crutches

• Stability in standing by leaning posteriorly on Y-ligaments

• Bilateral KAFOs

• Offset knee joints with bail locks

• Ankle joints locked into 5–10 degrees DF

• Imbedded steel shank footplate in shoes

Reciprocating Gait Orthosis

• Allows for paraplegic ambulation for T or lower

• Bilateral HKAFOs

• Allows for reciprocating LE motion using tensioning cables

• Rigid foot plates

Types of Exoskeletons

Assistive/restorative

• Complete paralysis

• Developed to use in the community

• Rehabilitation

• Tool in the rehabilitation process

• Utilized to promote recovery

• Augmentation

• Industrial and military applications

advantahes of exoskeleton

• Complete paralysis patients are able to walk multiple surfaces

• Achieve limited community ambulation and stairs

• Effort less than KAFO, speed is greater

disadvantes of exoskelton

• Degrees of freedom

• Body interfaces

• Locus of control

• Need for upper extremity support

• Battery life

• Cost

goals for foot orthotics

1. Support or balance the foot to prevent need for compensation

2. Accommodate for deformity

3. Provide shock absorption and redistribute pressures

4. Plantar pressure relief

Clinical Problems Treated With Foot and Ankle Orthoses

• Diabetic foot

• Foot malalignments

• Deformity

• Tendinopathy: posterior tibial dysfunction

• Instability

• Post injury: sprain strain

• Overuse injuries

• Low back pain

how do we categorized foot orthotics

• Physical properties (soft, semi-rigid, or rigid)

• Method of fabrication (molded or non-molded)

• Goal of device (accommodating or corrective)

soft foot orthotics

• Provide cushioning, shock absorption, decrease shear forces or redistribute plantar pressures

• Pain and diabetic foot

• Considered accommodative

• Do not control motions

• Usually non-molded

semi-rigid foot orthotics

• Provides some flexibility and shock absorption

• Mostly used to balance the malaligned foot; usually molded

rigid foot orthotics

• Primary concern is to control abnormal motion

• May have reduced shock attenuation and energy-absorbing qualities

• Usually molded

posting

Balance achieved through posting

• Buildups on the medial or lateral side of orthotic in order to correct malalignment

• Foot theoretically put into talar neutral position

rational for ankle orthotics

• Prevention or correction of deformity

• Support or immobilization of ankle

• Assistance or restoration of mobility

• Prophylaxis or post-injury usage

Types of ankle orthoses

• UCBL and SMO

• Stirrup

• Lace-up

• Elastic supports

• Controlled ankle motion (CAM) walkers

• Positional orthoses

UCBL

University of California Biomechanics Laboratory

• Rigid foot orthoses

• Designed to correct hind foot valgus and limit subtalar motion

• Heel cup

Supramalleolar Orthoses (SMO)

• Limits subtalar motion

• Stabilizes the calcaneus

• Also limits midfoot pronation

• Primarily used in pediatric populations

stirrup

• Rigid plastic on medial and lateral sides

• Resists inversion, some models can limit plantarflexion

• Ankle sprains, strains, and prevention (9)

• Evidence for immobilization only for Grade III

lace-up

• Midfoot, subtalar, and talocrural joints are encapsulated with a front lacing system

• Prevent inversion/eversion less PF/DF

• Most have Velcro straps to help limit inversion

• Metal stay

• Used in posterior tibialis dysfunction, severe ankle instability

elastic supports

• Not effective for limiting motion

• May have inserts for edema control

Controlled ankle motion (CAM) walker

• Rocker bottom boot with medial and lateral hinges that allow for adjustable ROM

• Indications include fracture management, third degree ankle sprains, post-surgical incision protection

Positional orthoses

• To prevent or correct contracture or skin breakdown

• Example: Multi Podus Boot, night splints

Types of Knee Orthoses

• Prophylactic: to prevent injury in healthy athlete

• Postoperative or rehabilitative: during recovery

• Functional: return to activity and to compensation for deficient knee stability

• Unloaders: orthoses for osteoarthritis

• Patellofemoral orthoses

• Dynamic ROM orthoses

Prophylactic Bracing

Bracing to prevent injury in healthy athletes

• No evidence to support this!

Postoperative rehabilitative

• Allow protected and controlled motion of the knee

• May have an adjustable joint (dial joint) or no joints for immobilization

• Evidence is lacking for use after a variety of knee surgeries— meniscus

Dial knee joint

• Single axis

• Ability to preset ROM with flexion and extension stops

• Can also be locked

• Used with a changing functional situation

• Best used with Post-joint/ligament reconstruction and Post-fracture

Polycentric knee joint

• Attempts to follow the normal axis of rotation

• Two gear model follows a fixed path of rotation

• Genucentric model uses two pivots to follow a changing axis

• Used when accurate tracking is critical

Functional knee orthoses

• Worn for return to activity

• Can control medial and lateral stability, anterior tibial translation, and recurvatum

• Example: DonJoy 4titude

Controversies for Functional Knee Orthoses

• the design,

• not enough evidence