Orthosis Book Pdf

[Heidi Hall]

Orthoticdevices are classified into four areas of the body according to the international classification system (ICS):[2] orthotics of the lower extremities, orthotics of the upper extremities, orthotics for the trunk, and orthotics for the head. Orthoses are also classified by function: paralysis orthoses and relief orthoses.[3]

Under the International Standard terminology, orthoses are classified by an acronym describing the anatomical joints they support.[2] Some examples include KAFO, or knee-ankle-foot orthoses, which span the knee, ankle, and foot; TLSO, or thoracic-lumbar-sacral orthoses, supporting the thoracic, lumbar and sacral regions of the spine. The use of the International Standard is promoted to reduce the widespread variation in the description of orthoses, which is often a barrier to interpreting research studies.[4]

The transition from an orthosis to a prosthesis can be fluid. An example is compensating for a leg length discrepancy, equivalent to replacing a missing part of a limb. Another example is the replacement of the forefoot after a forefoot amputation. This treatment is often made from a combination of a prosthesis to replace the forefoot and an orthosis to replace the lost muscular function (ortho prosthesis).[citation needed]

In the United States, while orthotists require a prescription from a licensed healthcare provider, physical therapists are not legally authorized to prescribe orthoses. In the U.K., orthotists will often accept referrals from doctors or other healthcare professionals for orthotic assessment without requiring a prescription.[7]

Both custom-fabricated products and semi-finished products are used in long-term care and are manufactured or adapted by the orthotist or by trained orthopedic technicians according to the prescription. In many countries the physician or clinician defines the functional deviations in his prescription, e.g. paralysis (paresis) of the calf muscles (M. Triceps Surae) and derives the indication from this, e.g. orthotic to restore safety when standing and walking after a stroke. The orthotist creates another detailed physical examination and compares it with the prescription from the physician. The orthotist describes the configuration of the orthosis, which shows which orthotic functions are required to compensate for the functional deviation of the neuromuscular or skeletal system and which functional elements must be integrated into the orthosis for this. Ideally, the necessary orthotic functions and the functional elements to be integrated are discussed in an interdisciplinary team between physician, physical therapist, orthotist and patient.

Paralysis orthoses are used for partial or complete paralysis, as well as complete functional failure of muscles or muscle groups, or incomplete paralysis (paresis). They are intended to correct or improve functional limitations or to replace functions that have been lost as a result of the paralysis. Functional leg length differences caused by paralysis can be compensated for by using orthosis.[8]

For the quality and function of a paralysis orthosis, it is important that the orthotic shell is in total-contact with the patient's leg to create an optimal fit, which is why a custom-made orthotic is often preferred. As reducing the weight of an orthosis significantly lessens the energy needed to walk with it, the use of light weight and highly resilient materials such as carbon fiber, titanium and aluminum is indispensable for the manufacture of a custom-made orthosis.[9]

The production of a custom-made orthotic also allows the integration of orthotic joints, which means the dynamics of the orthotic can be matched exactly with the pivot points of the patient's anatomical joints. As a result, the dynamics of the orthosis take place exactly where dictated by the patient's anatomy. Since the dynamics of the orthosis are executed via the orthotic joints, it is possible to manufacture the orthotic shells as stable and torsion-resistant, which is necessary for the quality and function of the orthosis. The orthosis thus offers the necessary stability to regain the security that has been lost due to paralysis when standing and walking.[10]

In addition, an orthosis can be individually configured through the use of orthosis joints. In this way, the combination of the orthotic joints and the adjustability of the functional elements can be adjusted to compensate for any existing functional deviations that have resulted from the muscle weakness.[11][12][13][14][15][16] The goal of a high-quality orthotic fitting is to adjust the functional elements so precisely that the orthosis provides the necessary support while restricting the dynamics of the lower extremities as little as possible to preserve the remaining functionality of the muscles.[10]

In the case of paralysis due to disease or injury to the spinal/peripheral nervous system, a physical examination is needed to determine the strength levels of the affected leg's six major muscle groups and the orthosis's necessary functions.

According to Vladimir Janda, a muscle function test is carried out to determine strength levels.[17] The degree of paralysis is given for each muscle group on a scale from 0 to 5, with the value 0 indicating complete paralysis (0%) and the value 5 indicating normal strength (100%). The values between 0 and 5 indicate a percentage reduction in muscle function. All strength levels below five are called muscle weakness.

The combination of strength levels of the muscle groups determines the type of orthosis (AFO or KAFO) and the functional elements necessary to compensate for restrictions caused by the reduced muscular strength levels.[medical citation needed]

Paralysis may be caused by injury to the spinal or peripheral nervous system after spinal cord injury, or by diseases such as spina bifida, poliomyelitis and Charcot-Marie-Tooth disease. In these patients, knowledge of the strength levels of the large muscle groups is necessary to configure the orthotic for the necessary functions.[medical citation needed]

Paralysis caused by diseases or injuries to the central nervous system (e.g. cerebral palsy, traumatic brain injury, stroke, and multiple sclerosis) can cause incorrect motor impulses that often result in clearly visible deviations in gait.[18][19] The usefulness of muscle strength tests is therefore limited, as even with high degrees of strength, disturbances to the gait pattern can occur due to the incorrect control of the central nervous system.

In ambulatory patients with paralysis due to cerebral palsy or traumatic brain injury, the gait pattern is analysed as part of the physical examination in order to determine the necessary functions of an orthosis.[20][21]

One way of classifying gait is according to the "Amsterdam Gait Classification", which describes five gait types. To assess the gait pattern, the patient is viewed directly, or via a video recording, from the side of the leg being assessed. At the point when the leg is mid-stance the knee angle and the contact of the foot with the ground are assessed.[20] The five gait types are:

Patients with paralysis due to cerebral palsy or traumatic brain injury are usually treated with an ankle-foot orthosis (AFO). Although in these patients the muscles are not paralyzed but being sent the wrong impulses from the brain, the functional elements used in the orthotics are the same for both groups. The compensatory gait is an unconscious reaction to the lack of security when standing or walking that usually worsens with increasing age;[19] if the right functional elements are integrated into the orthosis to counter this, and maintain physiological mobility, the right motor impulses are sent to create new cerebral connections.[22] The goal of an orthotic is the best possible approximation of the physiological gait pattern.[23]

In the case of paralysis after a stroke, rapid care with an orthosis is necessary. Often areas of the brain are affected that contain "programs" for controlling the musculoskeletal system.[24][25][26] With the help of an orthosis, physiological standing and walking can be relearned, preventing long term health consequences caused by an abnormal gait pattern.[27] According to Vladimir Janda, when configuring the orthotic it is important to understand that the muscle groups are not paralyzed, but are controlled by the brain with wrong impulses, and this is why a muscle function test can lead to incorrect results when assessing the ability to stand and walk.[citation needed]

An important basic requirement for regaining the ability to walk is that the patient trains early on to stand on both legs safely and well balanced. An orthosis with functional elements to support balance and safety when standing and walking can be integrated into physical therapy from the first standing exercises, and this makes the work of mobilizing the patient at an early stage easier. With the right functional elements that maintain physiological mobility and provide security when standing and walking, the necessary motor impulses to create new cerebral connections can occur.[22] Clinical studies confirm the importance of orthoses in stroke rehabilitation.[28]

Patients with paralysis after a stroke are often treated with an ankle-foot orthosis (AFO), as after a stroke stumbling can occur if only the dorsiflexors are supplied with incorrect impulses from the central nervous system. This can lead to insufficient foot lifting during swing phase of walking, and in these cases, an orthosis that only has functional elements to support the dorsiflexors can be helpful. Such an orthosis is also called drop foot orthosis. When configuring a foot lifter orthosis, adjustable functional elements for setting the resistance can be included, which make it possible to adapt the passive lowering of the forefoot (plantar flexion) to the eccentric work of the dorsal flexors during loading response.[11][12]

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