Orthotics & Prosetics

week 1 - quiz, async

4 functions of gait

• forward progression

• weightbearng stability

• shock absorption

• energy conversation

Requirements to Achieve Gait Functions

Strength – upper and lower extremity, trunk

ROM and accommodative joints

Motor control and coordination

Cardiovascular fitness

Sensory and kinesthetic feedback

Skin integrity to withstand pressure forces

Cognition and safety awareness

ROM needed for Hip, knee, and Ankle, (range)

• hip = 20 ext to 25 flex

• knee = 0 ext to 60 flex

• ankle = 10 DF to 15PF

walking design

Designed to move center of mass forward with minimal vertical and

mediolateral displacement

Advancing foot______ to clear the floor

“just enough”

NBOS is more _____ in ambulation

efficient

Measuring Energy Cost of Walking - Direct measurement

• calorimetry (usually only in lab settings)

Serum lactate (INdirect measurement)

serum CO2 and lactate levels (indicators of anaerobic energy production); usual transition at 55% of VO2max or at 80% VO2max in highly trained athletes.

Oxygen Rate and Oxygen Cost (indirect measure)

VO2 max - highest rate of O2 uptake possible as tested to voluntary exhaustion

Heartrate and Physiologic Cost Index – HR and O2 consumption are highly correlated (indirect measure)

PCI (Physiologic Cost Index) = (HRwalking – HRresting)/Walking speed

Low values: energy-efficient gait

O2 consumption is highest in ______

childhood

d/c in adults

Walking without orthotic is ______ energy expenduture

higher

The cost of walking is ____ when using an orthotic

lower

It is _____ efficient to walk with an orthotic

more

Knee orthotic does what and what is needed to offset it

locks the knee and limits foot clearance, contralateral shoe lift

Energy returning technologies and products

(carbon fiber)

Gait using functional orthoses for a person with SCI have significantly _____ energy expenditures at slower walking speeds

higher

traumatic etiology tend to walk ____ than dysvascular etiology

faster

Preservation of anatomic knee is highly predictive of ___ (and level of independence)

walking speed

evidence that metabolic demands for young adults with traumatic transtibial amputation were _______

close to controls without amputation

Walking with prosthetic is more efficient than walking with assistive device without the prosthetic: true or false

true

what indicates stance phase stability

CTL step length

Limiting ankle dorsiflexion (stance/stability)

too much DF causes:

• collapse of foot

• collapse of knee flexion

• buckling of knee in stance

causes of too much DF:

weak quads or gastroc

Limiting ankle plantarflexion (for foot clearance)

too much PF causes:

• knee hyperext.

causes of too much PF:

weak TA, weak hamstring

limiting PF:

*changes terminal stance and toe off

shortens stance length

Limiting knee flexion (stance control/weightbearing)

too much knee flexion:

• buckling

• lack of terminal knee ext.

causes of excessive knee:

• weak quads/tight hamstrings

limiting knee flexion

• cause circumduction - ineffient

Biomechanics dictated by _____, ____, and proximal

control

• floor reaction forces

• contralateral

____ ____ do not offer any power to substitute for muscle function

Standard prosthetics

Prosthetic User Deviations (Intrinsic)

Weakness

ROM limitations

Lack of confidence/habit

Pain/avoidance

Fear of falling

Prosthetic Issues (Extrinsic)

Prosthetic too long/too short

Poor suspension

Poor selection of components –

function/component mismatch

Misalignment

Component wear

“foot drop” causes, acute/chronic, compensatory strategies, and int. goals

 peroneal n injury

 nerve root injury (spinal)

 spinal cord injury

 multiple sclerosis (MS)

 amyotrophic lateral sclerosis (ALS)

acute or chronic

in chronic

• Foot slap as precursor to foot drop

• Accompanied by foot intrinsic weakness

• Steppage gait as compensatory strategy – increased energy expenditure i/c hip flx

• flaccid paralysis - responds to orthotic for weak muscles, spastic does not.

• Absorb floor reaction impact on heel strike

• Foot clearance

• Issue is primarily stride control – stance control is not needed.

hemiplegia: what occurs on the involved side and int.

involved side:

• Decreased dorsiflexion for adequate stride clearance

• Decreased eccentric plantar flexion through stance, late stance

• Decreased stance stability

• Decreased lateral shift over involved stance extremity

• Synergistic extension at stride causing circumduction and internal rotation

intervention

• Need for control isolated to foot/ankle

• Need to influence stance control (knee wobble in stance)

• Need to control stance (≤ 3/5 quad strength)

• Influence of spasticity on gait

cerebral palsy - spastic dipledgia

compensation and what occurs

Spastic diplegia

• Significant LE spasticity

• LE weakness

• Scissoring

• Couched gait pattern – weak gastric soleus

stability

• hyperext.

• excessive knee flx (weak soleus)

spina bidifa

what occurs

• Partial or complete paralysis at/below the level of involvement

• Typically, flaccid paralysis with associated sensory deficits

L5 – S1

• Gluteus max, hip abductors, triceps surae

L3-L4

• Hamstring, hip extension, knee flexion, PF and DF lost

 Develop compensatory lordosis due to hip weakness

crutches

Spinal Orthoses – Purposes + indications

Limit motion of spinal region

Decrease load of spinal region

• Unstable fracture that requires prevention of loading

• Support needed for healing

• Symptoms require support or restriction of motion

• Psychologic reminder to restrict motion

3- point pressure

Single force applied to area of correction + Two additional counter forces in opposing directions above and below the

primary area of correction.

The sum of the primary and two opposing counterforces is zero in a well-balanced orthosis.

Halo Vest - Cervical collar

indications, purpose

• Need for FULL stabilization of occipitocervical spine –

rotational control

• 6-8 transcranial pins attached to thorax vest

• Provides immobilization and a degree of traction/distraction

• Used for high cervical fractures/dislocations

• The halo is lighter weight than it looks but can cause change to COM and limits view of floor/feet. Often

• an assistive device is needed for safe mobility.

soft collar

advantages, use/indications

• Most comfortable, tolerated cervical collar, but minimal stability offered

• Not indicated when cervical immobilization is desired.

• Can serve as a reminder to limit exaggerated neck movements – minor whiplash, cervical spondylosis, or postoperatively on a stable spine

aspen collar

post op

immobilzation

removable pads

Philadelphia collar

• Lacks the removable interior padding of the Aspen and Miami J collar

• Usually used for more short-term use

• post op

maimi j

• removable pads

• Commonly used for cervical injuries, conservative management or post-operative immobilization

headmaster collar

• for head drop

• Indicated for conditions that cause neck muscle

  weakness and postural fatigue; head drop

• Not intended to restrict motion – especially extension or lateral rotation

• not used post op!!!!!!!!!!!!!!!!!!!!

Extended Miami J and Minerva – CTO

• Cervical immobilization with uprights or

  circumferential supports to thoracic region

• Minerva shown to be the most effective in

  immobilizing C1-C2'

• Minerva is brace of choice for upper thoracic

  immobilization.

• 
  

SOMI - Sternal Occipital Mandibular Immobilizer

• lower cerv. spine

• Used for conditions that extend as far caudally as T5

• More commonly used for nonsurgical management of T-spine conditions*************

Jewett Brace, Cash Brace

• Strategy is to limit anterior flexion, unload the anterior column.

• Indicated for fractures T8-L2.

• Prefabricated, 3-point pressure design

• Goal of slight hyperextension (as posture allows)

TLSO

• Used for fracture T6-L4; may be used for conservative, non-surgical management or post-operative fracture management.

• Immobilization achieved through total contact; compression to unload vertebral bodies

Lumbar corset

• function is to reduce gross trunk motion and increase intracavitary pressure in

  the abdomen by transmitting a three-point pressure system to the lumbar spine.

Sacral orthoses

• the mechanism involved is a compressive or “squeezing” force across the pelvis that is transferred to the SI joints as a stabilizing force to reduce joint laxity, restrict motion, and thereby reduce pain.

Hip spica orthoses

May be used when lower L-spine immobilization is

critical.

 Also used for proximal hip fracture management

(as opposed to a hip spica cast).

 Used for hip dislocation management.

 Usually set 0-30° flexion.

Indications for Scoliosis Bracing - Idiopathic scoliosis

halt progression;

some degree of curve correction should be achieved within the brace (ideally 50% or more)

• bracing has to be done before maturity

risser sign

a medical grading system that measures a child's skeletal maturity and remaining spinal growth by evaluating the hardening (ossification) of the iliac crest bone in the pelvis on an X-ray.

Milwaukee brace

• Neck ring for proximal control

• Full time brace, recommended wearing 23 hours/day

• Most effective for upper thoracic curvature

Boston Thoracolumbosacral Orthosis

• Designed in response to the poor

  compliance/tolerance with the Milwaukee brace

• low-profile and partially open design

• no neck end pt

Charleston Nighttime Brace

• sleeping

• Curvature is maximally corrected while the patient sleeps;

• 25-35 degree range

SpineCor

• bands not rigid

• custom fit

• questionable evidence

Standard nomenclature for orthotics uses acronyms representing:

• A. Correction achieved

• B. Joints involved

• C. Pathology addressed

• D. Muscles supported

• B. Joints involved

In assessing spinal stability, a spinal region would be considered unstable with the following involvement:

• A. Posterior and middle columns

• B. Anterior and posterior columns

• C. Only middle column

• D. Only anterior column

• A. Posterior and middle columns

To achieve 3-point correction of a scoliosis, directional forces would be applied to:

• A. On the side of convexity

• B. Directed at convexity with counters above and below

• C. On the side of concavity

• D. Directed at concavity with counters above and below

• B. Directed at convexity with counters above and below

The cervical orthosis that provides maximum immobilization at the occipital-cervical joint is the:

• A. NecLoc

• B. Miami J

• C. Halo

• D. Aspen

• C. Halo

The primary indication for a thoracic extension brace for osteoporosis-related compression fracture is:

• A. Postural strengthening

• B. Fracture treatment

• C. Spinal stability

• D. Pain management

• D. Pain management

Spinal bracing for correction of scoliosis is most effective:

• A. With nighttime bracing

• B. In biologic females more than biologic males

• C. For curvature greater than 50 degrees

• D. Prior to skeletal maturity

• D. Prior to skeletal maturity

What is the primary purpose of spinal orthotics?

• A. Increase motion to spinal region(s)

• B. Decrease load in spinal region(s)

• C. Decrease motion of distal limb region(s)

• D. Increase load in spinal region(s)

• B. Decrease load in spinal region(s)

Compression fractures that occur as a result of osteoporosis:

• A. Results in posterior instability

• B. Is always considered an unstable fracture

• C. Often occurs in middle-aged men

• D. Can progress from stable to unstable

• D. Can progress from stable to unstable

When working in acute care, you receive a referral to evaluate and treat an individual with a cervical injury. When you enter the patient's room, you observe the patient wearing a halo vest collar. Which of the following statements is most true? For this question, you can assume the patient is medically stable and cleared for activity.

• A. All bed mobility activities should be avoided.

• B. You should include gait and functional mobility in your evaluation and treatment.

• C. The patient is required to use a cardiac/platform walker for sit-to-stand activities.

• D. You should ask the nurse to remove the halo so you can assess cervical range of motion.

• B. You should include gait and functional mobility in your evaluation and treatment.

When treating an individual with idiopathic scoliosis with a curvature of less than 25%, which of the following may not be initially indicated?

• A. Corrective exercises

• B. Surgery

• C. Bracing

• D. Posture education

• B. Surgery