Orthotic Prescription And Decision Making For Physical Therapists

What are the functions of orthotics?

• Control motion (inhibit spastic muscles)

• Compensate for weakness (assist dorsiflexion, compensation for weak muscles, improve stability, shock absorption)

• Correction of deformity (alignment, posture, ROM, prevent contracture, reduce pain)

• Improve function and mobility

What is an orthotic?

Removable, external wearable device applied to an individual’s lower extremity

What is the purpose of a Clinical Practice Guideline for use of Ankle Foot Orthoses and Functional Electric Stimulation Post Stroke?

Provide evidence to guide decision making for the use of AFE or FES as an intervention for individuals with hemiplegia

T/F: Providing a device with intervention or practice may limit an individual’s ability to fully achieve.

False, providing a device without an intervention or practice may limit an individual’s ability to fully achieve

T/F: Clinicians should provide AFO/FES for individuals with foot drop in chronic hemiplegia.

True, it is a level II moderate evidence

What level of evidence is clinicians providing an AFO/FES in acute or chronic hemiplegia to improve gait speed?

Level I Strong

What level of evidence is clinicians providing an AFO/FES in acute or chronic hemiplegia to improve after mobility?

Level I Strong

What level of evidence is clinicians providing an AFO/FES in acute or chronic hemiplegia to improve dynamic balance?

Level I Strong

What level of evidence is clinicians providing an AFO/FES in acute hemiplegia to improve walking endurance?

Level II Moderate

What level of evidence is clinicians not providing an AFO/FES in acute or chronic hemiplegia to improve platarflexion spasticity?

Level II Moderate

What level of evidence is clinicians may provide an AFO w/ decreased stiffness to allow activation of the TA/GAS/SOL in acute or chronic hemiplegia to improve muscle activation?

Level II Moderate

What level of evidence is clinicians may provide an FES to improve activation of TA in chronic hemiplegia?

Level II Moderate

What level of evidence is clinicians may provide AFO/FES to improve ankle dorsiflexion at initial contact, loading response and swing in acute or chronic hemiplegia to improve gait kinematics?

Level III Weak

For the clinical effects of an AFO/FES, what are the 4 types?

• Immediate effect

• Training effect

• Therapeutic effect

• Combined effect

What type of clinical effect is testing without an AFO/FES followed by re-testing immediately after donning an AFO/FES?

Immediate Effect

What type of clinical effect is testing without the AFO/FES, followed by a period of use with the AFO/FES, then re-testing without the AFO/FES?

Therapeutic Effect

What type of clinical effect is cumulative effects of both the immediate and training effects (immediate + training effect = combined effect)?

Combined effect

What type of clinical effect testing with the AFO/FES, followde by a period of use with the AFO/FES, then re-testing with the AFO/FES?

Training Effect

What type of clinical effect tests without AFO/FES and re-tests with AFO/FES?

Immediate Effect

What type of clinical effect is testing and re-test with AFO/FES, but using an AFO/FES for activity?

Therapeutic Effect

What type of clinical effect uses AFO/FES for testing, period of us, and re-testing?

Training effect

What type of clinical effect tests without AFO/FES, but uses AFO/FES for period of use and re-testing?

Combined effect

What type of AFO is trimline anterior to malleolus and stops DF and PF?

Solid

What type of AFO has a trim line through apex of malleolus and resists DF(high), and stops PF?

Rigid

What type of AFO has a trim line posterior to malleolus, resists DF & PF (moderate)?

Semi-rigid

What type of AFO has a trim line posterior to malleolus, DF free, and resists PF (mild)?

Flexible/PLS

What AFO is associated with the following therapist indication: custom fit, weakness in quad/hamstring, increase in tone / PF spasticity, poor knee stability in stance, no active ankle DF, inability to transfer weight onto affected leg, foot abnormality (equinas, valgus/varus, combination), and poor motor control / balance?

Solid AFO

What are the orthotist indications for solid AFO?

• Limitations in DF ROM without breaking down midfoot

• PF weakness / poor tibial control

• Likely to need continued sagittal plan control (can be trimmed to semi-rigid/PLS)

What are the therapist indications for pre-articulated AFO?

• Similar indications as solid

• Good alignment through mid-foot

• Minimal tone

• Potential for recovery

What are the orthotist indications for pre-articulated AFO?

• Likely to need continued medial-lateral stability

• Potential to recover PF strength and quad strength

For solid vs pre-articulated AFO, what AFO will be used for spasticity, slower progression, need for prolonged sagittal plane control?

Solid

For solid vs pre-articulated AFO, what AFO is used for minimal tone, quicker progression, prolonged control in coronal plane, knee recurvatum control (no tone), external factors for articulation (stairs, on the floor)?

Pre-articulated

What are the therapist indications for hinged/articulated AFO?

• Good knee stability in standing and during gait cycle

• Anti-gravity ankle DF

• Minimal tone

• Functional ROM

• Ability to achieve hip/knee extension in terminal stance

What are the orthotist indications for Hinged/articulated AFO?

• Need for medial-lateral stability

• Good quad strength

• DF stop (knee instability toward buckling)

• PF stop (foot drop, knee hyperextension, and toe walking)

What type of AFO is double metal uprights attached to the patient’s shoe?

Conventional AFO

What occurs when there is a PF stop to limit platanrflexion?

• Compensation for weak dorsiflexors

• Limits knee hyperextension

What occurs when there is DF assist for an AFO?

• Simulated eccentric contraction of tibia to prevent foot slap

• Allows DF during stance

• Facilitates DF during swing

What are indications for a conventional AFO?

• Decreased sensation

• Diabetes

• Volume changes

• Obesity (Stronger materials)

• Severe deformities / tone

If a patient is able to increase DF, what are the benefits the patient will experience?

• Good toe clearance

• Promote knee flexion moment

• Assist patients with increased extensor tone

• Increased hyperextension of the knee

If a patient is able to increase PF, what are the benefits the patient will experience?

• Promote a knee extension moment but may allow more toe drage

• Assist a patient with decreased knee extension control but may allow an unstable knee to go innto hyperextension

What are the therapist indications for Solid AFO w/ anterior shell/ground reaction AFO?

• Crouched gait

• Hypertonicity through hamstring / adductors / PF

• Decreased ROM through hip flexors / hamstring / PF

• Significant weakness through flutes / quads / hamstring

What are the orthotist indications for Solid AFO w/ anterior shell/ground reaction AFO?

• Proprioceptive feedback for knee extension

• Often set in slight PF

• Used for spina bifida, SCI with limited sensation, poor knee control but good hip control

What are the therapist indications for carbon fiber AFO?

• Good knee stability

• Functional strength in kinetic chain

• DF assist to achieve heel strike

• Assist in push-off during terminal stance

• No significant issue with tone

• No medial-lateral instability

• No need for orthotic influence on hip/knee

What are the orthotist indications for carbon fiber AFO?

• No limitations in ankle ROM

• Good medial-lateral stability

• Intact sensation

• Non-fluctuating edema

• Lightest weight option

• Cosmetic / patient acceptance

• Good alternative if patient already has AFO

• Ease of shoe fit

What are the therapist indications for posterior leaf spring AFO?

• Isolated DF weakness

• Similar requirements w/ carbon fiber

What are the orthotist indications for posterior leaf spring AFO?

• Lack of sensation

• Mild medial / lateral instability

• Extremely tall or short people

• Ability to provide more support into knee extension (if needed) compared to carbon fiber

• Need mid-foot control (mid-foot collapse, hindfoot valgus, ect…)

What are contraindications for functional electrical stimulation (FES)?

• PF spasticity (MAS 3 or greater)

• Knee buckling / Genu recurvatum

• Peripheral nerve injury / neuropathy

• Sensory tolerance

What are indications for conventional AFOs?

• Decreased sensation

• Diabetes

• Volume changes

• Obesity

• Severe deformities / tone

What are indications for Functional Electrical Stimulation?

• Activates DF muscles during swing by stimulation of peroneal nerve

• May improve strength and motor control

• May enhance recovery and participation following acute stroke

• Responsive to walking at variable gait speeds

• May allow barefoot walking / variety of shoe ware

• Option thigh cuff for FES to quadricep & hamstring

• Increase gait speed

For ankle brace / air case,

A) Does it provide medial-lateral stability?

B) Does it provide DF control?

C) Does it provide PF control?

A) Yes

B) No

C) No

For steady strider,

A) Does it provide medial-lateral stability?

B) Does it provide DF control?

C) Does it provide PF control?

A) No

B) Yes

C) No

For foot-up orthosis,

A) Does it provide medial-lateral stability?

B) Does it provide DF control?

C) Does it provide PF control?

A) No

B) Yes

C) No

What are heel modifications to use for orthosis?

Heel cushion

Heel wedge

Heel elevation

What are the sole modifications for orthosis?

Sole wedge (metatarsal pad, scaphoid pad)

What type of AFO consists of metal uprights, a knee joint, and thigh bands?

KAFOs

What are KAFO’s used for?

Quadricep paralysis or weakness to maintain knee stability

What are the precautions associated with KAFOs?

Fatigue, weakness

T/F: Knee orthosis provides support and control of the knee but not the foot or ankle.

True

Can decreased ROM in one or both ankles may present with contractures?

Yes

What impairments occur when contractures are unmanaged?

• Permanent contracture

• Loss of function

• Poor positioning

• Pain

Is 30 second intervals stretching effective for preventing and maintaining ROM in neurological population?

No

Is functional positioning for stretching more effect than stretching in preventing and maintaining ROM?

yyes

What indications are present for intervention to occur for contracture management?

• High tone (MAS 2 or higher)

• Time since onset of injury

• Family compliance with any previous orthotics

• Current ROM and ROM goals

• Potential functional gains or limitations

• End feel with ROM/tone-assessment

• Previous intervention for lower extremity contractures

What interventions can be used for contracture management?

• Serial casting

• Static progressive night splint

• Botox

• Ultraflex

• Dynasplint

What is serial casting for contracture management?

Low load stretch over an extended period of time

How often is serial casts changed?

Weekly

What population is indicated for using serial casting for contractures?

Higher risk for permanent contracture who currently lack ROM, patients with potential consistent standing program, ambulation, functional transfers, and improvement with positioning in wheelchair

T/F: The goal for static progressive night splint to increase current ROM?

False, it is to maintain current ROM only

What high risk is associated with static progressive night splint?

Skin breakdown with poor fit or issues with donning

What is the first day wearing schedule?

1 hour on, if OK wait 1 hour then, wear another hour

What is the second day wearing schedule?

2 hours on and check skin

How many hours should you increase orthosis wear each day?

1 hour

What should you do if there is blistering or skin break down from the orthosis they are wearing?

Call orthotist and do not have the patient wear the brace