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&nbsp;Orthotics
<div class="editorbox"> '''Original Editor '''- [[User:Carin Hunter|Carin Hunter]] based on the course by [https://members.physio-pedia.com/course_tutor/donna-fisher// Donna Fisher]<br>'''Top Contributors''' - {{Special:Contributors/{{FULLPAGENAME}}}}</div>
== Introduction ==
The aim of orthotics is to increase the efficiency of function during acute or long-term injury. This includes soft-tissue and bony injury, as well as changes as a result of [[Spasticity|neurological changes]]. They can be an effective adjunct alongside physiotherapy techniques such as muscle [[Strength Training|strengthening]] and [[Stretching|stretches]], [[Gait Disturbances|gait]] and [[Balance Training|balance retraining]] and reach and grasp strategies.


What Are Custom Orthotics?<br>Custom orthotics are devices that are made specifically one person’s feet in order order to optimize the alignment of your lower limb starting at the foot and translating to the ankle, shin, upper leg and pelvis. With improved alignment, custom-made orthotics help to improve efficiency and minimize shock absorption through the lower extremity, pelvis and spine. These corrective devices are placed in an individual’s footwear similar to insoles. They can help to realign the many bones within the foot, and to control excessive mobility or excessive rigidity of these bones and connective tissues. Ultimately they maintain a neutral foot alignment during upright activities. Custom-made orthotics reduce the stress and strain on the body maintaining the most optimal foot position throughout the full gait cycle. This is critical because the feet are the first point of contact between a person and the environment. Faulty placement of the feet will result in increased energy required to balance, weight bear and move forward through weight transfer. This significantly increases the risk of injury.
A number of considerations need to be made before deciding on the type of orthotic needed:


<br>How Are Custom Orthotics Made? <br>Even a very small abnormality in the alignment or function the feet can have a significant impact on the joints and soft tissue function above. Custom orthotics are specifically designed to correct foot issues and improve alignment all the way up the lower limb and even through the spine. A trained health practitioner will complete a detailed assessment of an individual’s gait and foot position in both a static and a dynamic state. The health professional will be looking for asymmetries and abnormalities in the feet and lower extremity. This information will be combined with a precise imprint of the feet on a foam cast. This will be sent off to a lab where the orthotics will be fabricated and created. Some facilities will also use a gait scan machine in order to analyse where the majority of your weight is dispersed while you heel strike and push off during the gait cycle. The foot specialist may request that the lab add special features to the orthotics based on the patient’s area of pain, the wear patterns in the patient’s shoes and the skin changes on their feet. The orthotics can be made to fit into your running shoes, dress shoes, flats, high heels or a combination of different shoes.
* What are the patient’s goals?
* What are the specific impairments impacting on their function (thinking of head-to-toe and [[Gait|gait analysis]]).
* Are impairments the result of soft-tissue changes? Can they be changed with therapy input?
* Is a [[Walking Aids|walking aid]] needed?
* Does the injury need to be protected from particular movements?
* Can an orthotic improve the efficiency of an activity?
* Can the patient cope with any adjuncts given?


<br>Who Needs Custom Orthotics? <br>Not everyone will benefit from custom orthotics. It is important that a proper assessment is conducted before a decision to get custom orthotics is reached. Custom orthotics work best and will have the largest impact if the feet are “driving” the condition being treated. Failed load transfer through your feet due to poor alignment can influence many joints above such as your knees, hips, pelvis, low back and spine however this is not an absolute unidirectional relationship. There are many situations when other body regions can influence foot alignment. If weak hip musculature is causing poor foot control during gait, then wearing custom orthotics to control the feet will be pointless. However, if the increased mobility in the feet is “driving” or causing the hip muscle weakness, then controlling feet with orthotic can improve hip strength and resolve the underlying condition. It seems logical to think that pain in the foot region links directly to dysfunction in the foot region and that orthotics are the intervention of choice. Unfortunately, it is not always that straightforward. Once again, it is important to determine what is “driving” the pain in the foot. Perhaps a low back condition is causing a limp in the gait cycle and placing excessive load through the right lower limb which is irritating the plantar fascia on the plantar aspect of the right foot. If this is the case, it is important to the intervention strategy to lumbar spine and wait to see if orthotics are really necessary.  
Orthotics can be pre-made or customised, depending on the patient's needs.  


<br>Orthotics Can Help With: <br>Any of the following conditions as long as the feet have been shown to be the “driver” of the pain syndrome:<br>• Metatarsalgia or other foot pain<br>• Plantar fasciitis [[]]<br>• Morton’s Neuroma<br>• Flat feet<br>• High arches<br>• Knee pain<br>• Hip pain<br>• Low back pain<br>• SIJ dysfunction<br>• Degenerative Disc Disease<br>• Scoliosis<br>• Osteoarthritis in the knees, hips, pelvis or low back<br>• Patellofemoral pain syndrome<br>• Femoral acetabular impingment<br>• Iliotibial band friction syndrome<br>• Bursitis in the ankle, knee or hip<br>• Chronic ankle sprains<br>• Piriformis syndrome<br>• Achilles tendonopathy<br>• Patellar tendonopathy<br>• Snapping Psoas <br>• Gluteal tendonopathy<br>• Hamstring tendonopathy<br>• Recurrent Calf Strains<br>• And More...  
== What is an Orthosis? ==
An orthosis is generally an individually designed or customised device, which is applied to the external part of the body to provide support and protection for that particular area of the body. It uses integrates [[Biomechanics|biomechanical]] principles to realign joints and reduce pain. The design, materials and function of the orthosis are based on a patient assessment, including their medical history, biomechanical principles and the individual needs of the user.  


<br>
Commonly prescribed orthoses include:


References:  
* Foot Orthoses (FOs), for various foot, leg or postural problems; there is significant variety in terms of their design and manufacturing methods<ref>Chapman LS, Redmond AC, Landorf KB, Rome K, Keenan AM, Waxman R, et al. [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6347791/ Foot orthoses for people with rheumatoid arthritis: a survey of prescription habits among podiatrists]. J Foot Ankle Res. 2019;12:7. </ref><ref>Gerrard JM, Bonanno DR, Whittaker GA, Landorf KB. [https://jfootankleres.biomedcentral.com/articles/10.1186/s13047-020-00401-3 Effect of different orthotic materials on plantar pressures: a systematic review]. Journal of foot and ankle research. 2020 Dec;13(1):1-1.</ref>
* Ankle Orthoses (AOs) and Knee Orthoses (KOs), for joint protection, pain reduction or support after [[Surgery and General Anaesthetic|surgery]]
* Ankle-Foot Orthoses ([[Introduction to Ankle Foot Orthoses|AFOs]]) and Knee-Ankle-Foot Orthoses (KAFOs), to improve mobility, support rehabilitation and biomechanical goals
* Various upper-limb orthoses, to provide positional and functional support to the upper limb
* Fracture orthoses, modern alternative to plaster or fibreglass casts
* Spinal Orthoses, to correct or control spinal deformities and injuries and to provide immobilisation or support to spinal injuries<ref>AOPA What is an orthotics? Available:https://www.aopa.org.au/careers/what-are-orthoses-and-prostheses (accessed 4.6.22)</ref>


1. The Orthotic Group. Orthotic FAQ. Available from: http://www.theorthoticgroup.com/patientsite/OrthoticFAQ.aspx [last accessed 10/12/14]
=== "Off the shelf" Orthotics ===
Many patients can utilise ready-made orthotics, which can often be adjusted to fit their size. These may come in small, medium and large sizes and can often be sized to the patient, e.g. with velcro straps. These are often lighter materials. They can also be good for an assessment, to confirm or deny a theory before a custom orthotic is made.


2. SBI Orthotic Laboratory. Orthotic FAQ. Available from: http://www.sbiorthoticlab.ca/faq_orthotic.html [last accessed 10/13/14].  
=== Custom Orthotics ===
Some individuals have more complex injuries / changes to one of the multiple joint structures and therefore require a customised orthosis. This may be particularly true in neurological conditions, such as [[Cerebral Palsy Effects through Lifespan|Cerebral Palsy]] (CP), [[Parkinson's|Parkinson's Disease]] (PD) or after brain injury, such as [[Overview of Traumatic Brain Injury|traumatic brain jury]] (TBI) or stroke. In these cases, spasticity of muscles may have an impact on the patient's function. Orthotics can be used both in resting and during mobility to improve the effects of spasticity or reduce the risk of contractures. In which case the orthotic will be specifically measured to the individual, and likely to be redone as the individual grows (in paediatrics) or as changes are made to joint structures.


3. Rebalance Sports Medicine. Custom Orthotics. Available from: [http://www.rebalancetoronto.com/sports-medicine-services/orthotics-downtown-toronto/ http://www.rebalancetoronto.com/sports-medicine-services/orthotics-downtown-toronto/] [last accessed 10/13/14].  
== Why is an Orthosis used? ==
An orthosis provides support and protection for joints or parts of the body. It can optimally align a joint into a better functional position, whether it be the position of a hand or an elbow or a knee or a foot.<ref>Webster JB, Murphy DP, editors. Atlas of orthoses and assistive devices. Amsterdam, The Netherlands:: Elsevier; 2019.</ref> It is often used to reduce pain. A good orthosis can also maintain a functional position with the joint and we can use an orthosis either dynamically or statically to achieve this functional position.  


4. Roger, Collier. Orthotics work in mysterious ways. CMAJ-Canadian Medical Association Journal. March 8, 2011. Volume 183:p 416-417. <br>  
== Where can an Orthosis be used? ==
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An orthoses can be fitted to any part of the body from the head, such as helmets, to the feet and toes with insoles and footwear.<ref>Jarvis HL, Nester CJ, Bowden PD, Jones RK. Challenging the foundations of the clinical model of foot function: further evidence that the root model assessments fail to appropriately classify foot function. Journal of foot and ankle research. 2017 Dec;10(1):1-1.</ref>
 
== 3 Steps to Create an Orthosis ==
The position, structure, design and fitting of the orthosis is based on the assessment of the patient and clear goals of what the therapist and patient want to achieve.<ref>Chui KC, Jorge M, Yen SC, Lusardi MM. Orthotics and Prosthetics in Rehabilitation E-Book. Elsevier Health Sciences; 2019 Jul 6.</ref> This can be a complex process and a problem-solving exercise.<ref>Mangai S, Ranganathan R, Pugalendhi A, Gokul Raj N, Deepan Raju S, Dharani T, Durga R. Design And Development Of Ankle Foot Orthosis Using Additive Manufacturing Technique. 2020.</ref> All orthotists need to be good at problem-solving.<ref>Menz HB, Allan JJ, Bonanno DR, Landorf KB, Murley GS. Custom-made foot orthoses: an analysis of prescription characteristics from an Australian commercial orthotic laboratory. Journal of foot and ankle research. 2017 Dec;10(1):1-9.</ref>
 
The three main steps to follow are assessment, design and manufacture, and fitting and evaluation.
 
=== 1. Assessment ===
 
* Medical/Physical
* Biomechanical<ref>Nester CJ, Jarvis HL, Jones RK, Bowden PD, Liu A. Movement of the human foot in 100 pain-free individuals aged 18–45: implications for understanding normal foot function. Journal of foot and ankle research. 2014 Dec;7(1):1-0.</ref>
* ROM/Muscle Power
* [[Proprioception]]
* [[Sensation]]
 
=== 2. Design/manufacture ===
 
* Materials
* Construction
* Suspension/strapping
* Cosmesis
 
=== 3. Fitting and evaluation ===
 
* Good anatomical fit
* Good biomechanical function
* Easy to don/doff
* Comfortable to wear
 
=== Advantages ===
'''Lower limb:''' Influence both swing and stance phase of gait<ref>Condie & Meadows ''Report of a consensus conference on the lower limb orthotic management of cerebral palsy''International Society for Prosthetics and Orthotics(1995) ISBN 9788789809021</ref>.
 
* Prevent or correct deformity and reduce pain during weight-bearing
* Improve the efficiency of gait and maintain balance
* Improve base of support / lateral support
* Reduce need for compensation of ipsilateral and contralateral limbs and secondary pain
* To facilitate training in skills
 
'''Upper limbs:''' Can be used after an injury to prevent further injury, or reduce pain by supporting an injured limb.
 
* Prevent or correct deformity reducing pain and maximising function in reach and grasp tasks.
* Improve the efficiency of reach and grasp tasks
* Offload an injured limb to allow healing
* Reduce need for compensation of ipsilateral and contralateral limbs and secondary pain
* Improve role of the upper limb in maintaining balance
 
'''Spine:''' Stabilise spinal fractures to allow the patient to return to some normal activities (although they may be restricted) and protect the spinal cord.
 
=== Possible Complications ===
 
* Loss of [[sensation]] (check skin regularly- risk of [[Pressure Ulcers|pressure areas]])
* Compensations in ipsilateral or contralateral limbs.
* Impact on spasticity (is the patient utilising spasticity to allow some function in absence of muscle strength?)
* Complications of casting at incorrect angle: Foot deformities<span class="reference" id="cite_ref-2"></span><ref>Karakas & Hoy (2002)</ref>, increased knee flexion in stan<span class="reference" id="cite_ref-:0_3-0"></span>ce<ref name=":0">Owen E. ''The Effects of Tuning an Ankle-Foot Orthosis Footwear Combination on Kinematics and Kinetics of the Knee Joint of an Adult with Hemiplegia'' Prosthetics and Orthotics (2014) 34(3): 270-6</ref>, muscle contrac<span class="reference" id="cite_ref-:0_3-1"></span>tors<ref name=":0" />
* Loss of sensory feedback and [[proprioception]] loss
* Restricted range of motion
* Loss of natural shock absorption and long term joint damage
* '''Spinal orthotics must be put on and taken off within the guidelines of a spinal professional. Patients may be able to mobilise within set restrictions, depending on the severity of their injury. Non-adherence to guidance may result in [[Spinal Cord Injury|spinal cord injury]].'''
 
=== Consider: ===
 
* Cosmesis
* Footwear
* Weight/rigidity
* Ability to Don Doff
* Compensations preferred
* Compensations required
 
== References ==
<references />
[[Category:Course Pages]]
[[Category:Prosthetics and Orthotics]]
[[Category:ReLAB-HS Course Page]]
[[Category:Rehabilitation]]

Latest revision as of 19:54, 5 January 2023

Original Editor - Carin Hunter based on the course by Donna Fisher
Top Contributors - Rhiannon Clement, Kim Jackson, Naomi O'Reilly, Rucha Gadgil, Alishah Merchant, Amanda Ager, Carin Hunter and Robin Tacchetti

Introduction[edit | edit source]

The aim of orthotics is to increase the efficiency of function during acute or long-term injury. This includes soft-tissue and bony injury, as well as changes as a result of neurological changes. They can be an effective adjunct alongside physiotherapy techniques such as muscle strengthening and stretches, gait and balance retraining and reach and grasp strategies.

A number of considerations need to be made before deciding on the type of orthotic needed:

  • What are the patient’s goals?
  • What are the specific impairments impacting on their function (thinking of head-to-toe and gait analysis).
  • Are impairments the result of soft-tissue changes? Can they be changed with therapy input?
  • Is a walking aid needed?
  • Does the injury need to be protected from particular movements?
  • Can an orthotic improve the efficiency of an activity?
  • Can the patient cope with any adjuncts given?

Orthotics can be pre-made or customised, depending on the patient's needs.

What is an Orthosis?[edit | edit source]

An orthosis is generally an individually designed or customised device, which is applied to the external part of the body to provide support and protection for that particular area of the body. It uses integrates biomechanical principles to realign joints and reduce pain. The design, materials and function of the orthosis are based on a patient assessment, including their medical history, biomechanical principles and the individual needs of the user.

Commonly prescribed orthoses include:

  • Foot Orthoses (FOs), for various foot, leg or postural problems; there is significant variety in terms of their design and manufacturing methods[1][2]
  • Ankle Orthoses (AOs) and Knee Orthoses (KOs), for joint protection, pain reduction or support after surgery
  • Ankle-Foot Orthoses (AFOs) and Knee-Ankle-Foot Orthoses (KAFOs), to improve mobility, support rehabilitation and biomechanical goals
  • Various upper-limb orthoses, to provide positional and functional support to the upper limb
  • Fracture orthoses, modern alternative to plaster or fibreglass casts
  • Spinal Orthoses, to correct or control spinal deformities and injuries and to provide immobilisation or support to spinal injuries[3]

"Off the shelf" Orthotics[edit | edit source]

Many patients can utilise ready-made orthotics, which can often be adjusted to fit their size. These may come in small, medium and large sizes and can often be sized to the patient, e.g. with velcro straps. These are often lighter materials. They can also be good for an assessment, to confirm or deny a theory before a custom orthotic is made.

Custom Orthotics[edit | edit source]

Some individuals have more complex injuries / changes to one of the multiple joint structures and therefore require a customised orthosis. This may be particularly true in neurological conditions, such as Cerebral Palsy (CP), Parkinson's Disease (PD) or after brain injury, such as traumatic brain jury (TBI) or stroke. In these cases, spasticity of muscles may have an impact on the patient's function. Orthotics can be used both in resting and during mobility to improve the effects of spasticity or reduce the risk of contractures. In which case the orthotic will be specifically measured to the individual, and likely to be redone as the individual grows (in paediatrics) or as changes are made to joint structures.

Why is an Orthosis used?[edit | edit source]

An orthosis provides support and protection for joints or parts of the body. It can optimally align a joint into a better functional position, whether it be the position of a hand or an elbow or a knee or a foot.[4] It is often used to reduce pain. A good orthosis can also maintain a functional position with the joint and we can use an orthosis either dynamically or statically to achieve this functional position.

Where can an Orthosis be used?[edit | edit source]

An orthoses can be fitted to any part of the body from the head, such as helmets, to the feet and toes with insoles and footwear.[5]

3 Steps to Create an Orthosis[edit | edit source]

The position, structure, design and fitting of the orthosis is based on the assessment of the patient and clear goals of what the therapist and patient want to achieve.[6] This can be a complex process and a problem-solving exercise.[7] All orthotists need to be good at problem-solving.[8]

The three main steps to follow are assessment, design and manufacture, and fitting and evaluation.

1. Assessment[edit | edit source]

2. Design/manufacture[edit | edit source]

  • Materials
  • Construction
  • Suspension/strapping
  • Cosmesis

3. Fitting and evaluation[edit | edit source]

  • Good anatomical fit
  • Good biomechanical function
  • Easy to don/doff
  • Comfortable to wear

Advantages[edit | edit source]

Lower limb: Influence both swing and stance phase of gait[10].

  • Prevent or correct deformity and reduce pain during weight-bearing
  • Improve the efficiency of gait and maintain balance
  • Improve base of support / lateral support
  • Reduce need for compensation of ipsilateral and contralateral limbs and secondary pain
  • To facilitate training in skills

Upper limbs: Can be used after an injury to prevent further injury, or reduce pain by supporting an injured limb.

  • Prevent or correct deformity reducing pain and maximising function in reach and grasp tasks.
  • Improve the efficiency of reach and grasp tasks
  • Offload an injured limb to allow healing
  • Reduce need for compensation of ipsilateral and contralateral limbs and secondary pain
  • Improve role of the upper limb in maintaining balance

Spine: Stabilise spinal fractures to allow the patient to return to some normal activities (although they may be restricted) and protect the spinal cord.

Possible Complications[edit | edit source]

  • Loss of sensation (check skin regularly- risk of pressure areas)
  • Compensations in ipsilateral or contralateral limbs.
  • Impact on spasticity (is the patient utilising spasticity to allow some function in absence of muscle strength?)
  • Complications of casting at incorrect angle: Foot deformities[11], increased knee flexion in stance[12], muscle contractors[12]
  • Loss of sensory feedback and proprioception loss
  • Restricted range of motion
  • Loss of natural shock absorption and long term joint damage
  • Spinal orthotics must be put on and taken off within the guidelines of a spinal professional. Patients may be able to mobilise within set restrictions, depending on the severity of their injury. Non-adherence to guidance may result in spinal cord injury.

Consider:[edit | edit source]

  • Cosmesis
  • Footwear
  • Weight/rigidity
  • Ability to Don Doff
  • Compensations preferred
  • Compensations required

References[edit | edit source]

  1. ↑ Chapman LS, Redmond AC, Landorf KB, Rome K, Keenan AM, Waxman R, et al. Foot orthoses for people with rheumatoid arthritis: a survey of prescription habits among podiatrists. J Foot Ankle Res. 2019;12:7.
  2. ↑ Gerrard JM, Bonanno DR, Whittaker GA, Landorf KB. Effect of different orthotic materials on plantar pressures: a systematic review. Journal of foot and ankle research. 2020 Dec;13(1):1-1.
  3. ↑ AOPA What is an orthotics? Available:https://www.aopa.org.au/careers/what-are-orthoses-and-prostheses (accessed 4.6.22)
  4. ↑ Webster JB, Murphy DP, editors. Atlas of orthoses and assistive devices. Amsterdam, The Netherlands:: Elsevier; 2019.
  5. ↑ Jarvis HL, Nester CJ, Bowden PD, Jones RK. Challenging the foundations of the clinical model of foot function: further evidence that the root model assessments fail to appropriately classify foot function. Journal of foot and ankle research. 2017 Dec;10(1):1-1.
  6. ↑ Chui KC, Jorge M, Yen SC, Lusardi MM. Orthotics and Prosthetics in Rehabilitation E-Book. Elsevier Health Sciences; 2019 Jul 6.
  7. ↑ Mangai S, Ranganathan R, Pugalendhi A, Gokul Raj N, Deepan Raju S, Dharani T, Durga R. Design And Development Of Ankle Foot Orthosis Using Additive Manufacturing Technique. 2020.
  8. ↑ Menz HB, Allan JJ, Bonanno DR, Landorf KB, Murley GS. Custom-made foot orthoses: an analysis of prescription characteristics from an Australian commercial orthotic laboratory. Journal of foot and ankle research. 2017 Dec;10(1):1-9.
  9. ↑ Nester CJ, Jarvis HL, Jones RK, Bowden PD, Liu A. Movement of the human foot in 100 pain-free individuals aged 18–45: implications for understanding normal foot function. Journal of foot and ankle research. 2014 Dec;7(1):1-0.
  10. ↑ Condie & Meadows Report of a consensus conference on the lower limb orthotic management of cerebral palsyInternational Society for Prosthetics and Orthotics(1995) ISBN 9788789809021
  11. ↑ Karakas & Hoy (2002)
  12. ↑ 12.0 12.1 Owen E. The Effects of Tuning an Ankle-Foot Orthosis Footwear Combination on Kinematics and Kinetics of the Knee Joint of an Adult with Hemiplegia Prosthetics and Orthotics (2014) 34(3): 270-6
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