Orthosis Decision Making

Considerations for orthodic prescription

pt’s diagnosis/prognosis, pt assessment/gait, medical condition and fitness level, vocational and leisure activities, preferences and goals

key principles for orthodic prescription

1. safety first→ must stabilize/control target joints

2. Less is more→ satisfy #1 w/ the least amount of bracing

3. Always have clear and defined problem or problems

What tools can be used to help make orthotic prescription decisions

old braces, ballard braces (adjustable, dual channel)

steps in the orthotic prescription process

identify the problem→ determine level→ choose type→ select specifics

Key examination components for orthotic prescription

gait assessment, strength, sensation/proprioception, spasticity, ROM/deformity, joint laxity

Key points needed for every brace prescription

clear problem you are trying to solve and an identified way to measure improvement in the problem

What is needed to prevent knee buckling in stance?

eccentric control from PFs, quad strength, hip extensor strength

potential causes for recurvatum in stance

weak quads, spasticity, lack of proprioception

why may weak quads be a cause of recurvatum in stance

compensation that moves GRF anterior therefore giving the knee a larger extension moment

possible causes of stiff knee gait during swing

weak hip flexion, spasticity

possible causes of knee valgus/varus deformity

OA, genetics, proximal or distal deformity/weakness

Patient’s knee forcefully thrusts into extension during the loading resonse

knee recurvatum

The patients knee is uncontrolled or poorly controlled into flexion

knee buckling

Considerations when deciding AFO vs. KAFO

Is the knee involved? Will an AFO correct the problem? Consider gait/physical assessment and trial braces

When will an AFO typically correct the problem

knee not involved, knee instability w/ quad/PF strength >3/5 and intact proprioception

When is a KAFO typically needed to correct the problem?

medial/lateral knee instability, uncontrolled knee flexion or recurvatum

Always opt for a ______ if it addresses the problem

AFO

How can knee flexion instability be corrected with an AFO

DF stop or rigid/solid AFO

How can knee hyperextension instability be corrected with an AFO

PF stop or rigid/solid AFO positioned in neutral or slight DF

when is metal KAFO best?

impaired sensation, fluctuating edema, impaired skin, severe tone, hip flexor strength > 3+/5

when is plastic KAFO best?

intact sensation or good judgement, stable edema, intact skin, no severe tone, hip flexor strength </= 3+/5

best knee joint choice to address medial/lateral instability

single axis joint w/o lock

best knee joint choice to address severe knee flexion instability or recurvatum

locked joint

best knee joint choice to address moderate knee flexion instability

offset knee joint

best knee joint choice to address mild/moderate knee hyperextension instability due to weak quads or PF contracture/tone

offset knee joint w/ PF stop

when are weight bearing brims used?

when trying to unweight the distal limb or joints

how are pads and straps used

to add additional support or to control motion