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== Introduction ==
== Introduction ==
[[File:AFO brace for foot drop.jpeg|thumb]]
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.
The aim of orthotics are to increase the efficiency of function during acute or long-term injury. This includes soft-tissue and boney injury, as well as changes as a result of [[Spasticity|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:
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 patient’s goals?
* What are the specific impairments impacting on their function (thinking of head-to-toe and [[Gait|gait analysis]]).
* What are the specific impairments impacting on their function (thinking of head-to-toe and [[Gait|gait analysis]]).
Line 21: Line 13:
* Can the patient cope with any adjuncts given?
* Can the patient cope with any adjuncts given?


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


=== "Off the shelf" Orthotics ===
== What is an Orthosis? ==
Many patient's 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.
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.  


=== Custom Orthotics ===
Commonly prescribed orthoses include:
Some individuals have more complex injuries / changes to one of 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 affects of spasticity or reduce 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.


=== Advantages ===
* 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>
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) <nowiki>ISBN 9788789809021</nowiki></ref>.
* Ankle Orthoses (AOs) and Knee Orthoses (KOs), for joint protection, pain reduction or support after [[Surgery and General Anaesthetic|surgery]]
* Prevent or correct deformity and reduce pain during weight bearing
* Ankle-Foot Orthoses ([[Introduction to Ankle Foot Orthoses|AFOs]]) and Knee-Ankle-Foot Orthoses (KAFOs), to improve mobility, support rehabilitation and biomechanical goals
* Improve efficiency of gait and maintain balance
* Various upper-limb orthoses, to provide positional and functional support to the upper limb
* Improve base of support / lateral support
* Fracture orthoses, modern alternative to plaster or fibreglass casts
* Reduce need for compensation of ipsilateral and contralateral limbs and secondary pain
* 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>
* To facilitate training in skills
Upper limbs: Can be used after an injury to prevent further injury, or reduced pain by supporting an injured limb.
* Prevent or correct deformity reducing pain and maximising function in reach and grasp tasks.
* In prove efficiency of reach and grasp tasks
* Off load an injured limb to allow healing
* Reduce need for compensation of ipsilateral and contralateral limbs and secondary pain
* Improve role of upper limb in maintaining balance
Spine: Stabalise spinal fractures to allow the patient to return to some normal activies (although they may be restricted) and protect the spinal cord.


=== Possible Complications ===
=== "Off the shelf" Orthotics ===
* Loss of [[sensation]] (check skin regularly- risk of [[Pressure Ulcers|pressure areas]])
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.
* 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<ref>Karakas & Hoy (2002)</ref>, increased knee flexion in stance<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 contractors<ref name=":0" />
* Loss of sensory feedback and [[proprioception]] loss
* Ristricted 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 moblise within set restrictions, depending on the severity of their injury. Non-adherence to guidance may result in [[Spinal Cord Injury|spinal cord injury]].''' 


Also, success depends on patient's acceptance. Consider:
=== Custom Orthotics ===
* Cosmesis
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.
* Footwear
* Weight/rigidity
* Ability to Don Doff
* Compensations preferred
* Compensations required


=== Types of Orthotics ===
== Why is an Orthosis used? ==
=== Upper Limb ===
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.  
==== Healing ====
* Hinge-elbow brace: May be used to restrict elbow movement post fracture or surgery. Allows early mobilisation without damage to the healing tissue <ref>Fusaro I, Orsini S, Sforza T, Rotini R, Benedetti MG. The use of braces in the rehabilitation treatment of the post-traumatic elbow. ''Joints''. 2014;2(2):81-86. Published 2014 Jul 8. doi:10.11138/jts/2014.2.2.081</ref>.
[[File:Hinge elbow brace.jpg|center|frame|Hinge elbow brace: To restrict movement beyond a set degrees into flexion or extension to protect a healing injury / surgical site.]]
* Slings: Can be used after upper limb injury or surgery to protect the injury site. They can be used to restrict movements in particular directions to prevent further disruption to the injury (for example displacement of a fracture/ fixated bone). 
{{#ev:youtube|h3A_AhqkucY|width}}


* Splints: Hand or wrist splints are often customised for individuals based on their specific impairment. This often achieved using thermoplastics. These can be both resting and functional.  
== Where can an Orthosis be used? ==
[[File:Resting hand split.jpg|center|frame|Resting hand splint: Often customised to fit a patient to maintain range of movement in the hand for skin care and function. ]]
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>


==== Functional ====
== 3 Steps to Create an Orthosis ==
* Wrist splint (e.g. fuctural splint)
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>
{{#ev:youtube|GfQMyo7cGe0|width}}
* Elbow clasp: May be used, alongside exercises, especially if function is affected <ref>NICE ''Management of Tennis Elbow'' NICE Guidelines (2017) <Available online: https://cks.nice.org.uk/topics/tennis-elbow/management/management/> [Accessed: 3/10/20]</ref>
{{#ev:youtube|txnYr4dwjvM|width}}


* Neuromuscular [[Electrical Stimulation - Its role in upper limb recovery post-stroke|Electrical stimulation]] (NMES):
The three main steps to follow are assessment, design and manufacture, and fitting and evaluation.
{{#ev:youtube|qvbMUja6P8Q|width}}


=== Lower Limb ===
=== 1. Assessment ===
Orthotics can be used to optimise the alignment of the lower limb. This can be used to stabilise a joint to allow it to heal, or to facilitate ease of function. It can also be used to prevent or correct deformity in the lower limb, increasing efficiency.


==== Healing ====
* Medical/Physical
* Wedge boot: Often used as conservative treatment or after surgery for Achilles tendon rupture to allow gradual stretching of the tendon as it heals. A heel wedge may also be used in patient's with fixed platar flexion deformity to increased base of support and improve balance.
* 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>
{{#ev:youtube| ZEgD-Mn5ftc|width}}
* ROM/Muscle Power
* [[Proprioception]]
* [[Sensation]]


* Aircast boot: Often used after fracture injuries to support and reduce forces through the bone while healing. The air cells can be inflated around the foot and ankle, compressing the injury.
=== 2. Design/manufacture ===
{{#ev:youtube|XnBm68oTDOw|width}}


* Hinge-knee brace: Often used to protect knee surgery, such as meniscal repair<ref>McDermott, Ian (2010) Meniscal Repair [available from:https://sportsortho.co.uk/treatment/meniscal-repair/] <accessed 29/09/20></ref>.
* Materials
{{#ev:youtube|uBRCXY_qRtg|width}}
* Construction
* Suspension/strapping
* Cosmesis


=== 3. Fitting and evaluation ===


* Splints; Patients with increased tone may require a resting splint to maintain optimal positioning of their lower limb and maintain a functional range in affected joints. Positioning and seated and supine positions are very important for these patients
* Good anatomical fit
* Good biomechanical function
* Easy to don/doff
* Comfortable to wear


==== Functional ====
=== Advantages ===
* Ankle- Foot Orthosis (AFO): Correct alignment of the lower foot and ankle, which translates to the alignment of the shin, upper leg and pelvis. AFOs have an influence on both the swing and stance phase of gait<ref>NHS. ''Best Practice Statement: Use of Ankle-Foot Orthoses Following Stroke'' (2009) [online] <available from: http://www.healthcareimprovementscotland.org/previous_resources/best_practice_statement/use_of_ankle-foot_orthoses_fol.aspx?theme=mobile> [Accessed: 4/10/2020]</ref>. Can also be used to reduce risk of trips and falls as a result of foot drop.  
'''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>.


{{#ev:youtube|XdNrOYAFDbA|width}}
* 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


* Lateral support ankle brace: In patient's after ankle injuries, particularly to lateral ligaments, or neuromuscular disorders, a lateral ankle support may be needed. This brace has stiff lateral supports which will prevent excessive pronation or supination at the foot. This reduces the risk of further injury to lower limb structures, or injuries secondary to a fall.
'''Upper limbs:''' Can be used after an injury to prevent further injury, or reduce pain by supporting an injured limb.
[[File:Ankle brace for grade I or II.jpg|Aircast lateral ankle support. To protect against lateral ankle strain and support lower limb in stance phase. |center|frame]]
* [[Functional Electrical Stimulation - Its role in upper limb recovery post-stroke|Functional Electrical Stimulation]] (FES): In patient's with central nervous system disorders / leisions, it may be possible, and safe, to use FES as a dynamic orthosis''<ref>NICE ''Functional Electrical Stimulation for Foot Drop of Central Neurological Origin'' (2009)[Online] <available from: https://www.nice.org.uk/guidance/ipg278> [Accessed 4/10/20]</ref>''. <ref>RCP Stroke guidelines , 2016</ref>Can be used on a number of muscle groups to simulate electrical impulses in peripheral nerves. It is often used to reduced impact of foot drop or knee hyperextension as a result of muscle weakness. There is also some evidence that it may contribute to strengthening of muscles<ref>Glinsky, J et al. Efficacy of Electrical Stimulation to increase muscle strength in people with neurological conditions: A systematic review. Physiotherapy Reseach Int. 12(3): 175-194 (2007)</ref>. In this way, FES may reduce the patient's risk of falls <ref>Esnouf, J.E. (2010) Impact Activities of Daily Living Using a Functional Stimulator (FES) device to Improve Dropped foot in people with Multiple Sclerosis, measured by the Canadian Occupational Performance Measure. Mult Scler. Sept: 1141-1147</ref> and has been shown to improve quality of life scores <ref>Juckes, F., Marceniuk, G., Seary, C., & Stevenson, V. (2019). A cohort study of functional electrical stimulation in people with multiple sclerosis demonstrating improvements in quality of life and cost-effectiveness. ''Clinical Rehabilitation'', ''33''(7), 1163–1170.</ref>   
[[File:Functional Electrical Stimulation Therapy for walking.jpg|center|frame|Functional Electrical Stimulation for lower limb function [illustration from wikimedia]]]
* Foot Orthotics<ref>The Orthotic Group. Orthotic FAQ. Available from: http://www.theorthoticgroup.com/patientsite/OrthoticFAQ.aspx [last accessed 10/12/14]</ref> <ref>SBI Orthotic Laboratory. Orthotic FAQ. Available from: http://www.sbiorthoticlab.ca/faq_orthotic.html [last accessed 10/13/14].</ref>: Custom orthotics can improve foot alignment by affecting muscle activity <ref>Roger, Collier. Orthotics work in mysterious ways. CMAJ-Canadian Medical Association Journal. March 8, 2011. Volume 183:p 416-417. </ref>. Therefore, they improve efficieny in gait and balance, and minimise shock absorption through the lower limb, pelvis and spine<ref>Rebalance Sports Medicine. Custom Orthotics. Available from: http://www.rebalancetoronto.com/sports-medicine-services/orthotics-downtown-toronto/ [last accessed 10/13/14].</ref>. These corrective devices are placed in an individual’s footwear similar to insoles.
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 to identify asymmetries. 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|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.


Consideration: 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. For example, could hip weakness or lower back pain be causing disruption to the gait cycle and compensatory strategies that place increased load on foot stuctures? It is important to determine what is “driving” the pain in the foot and to direct treatment to these structures to see if insoles are needed. Also, can the intrinsic muscle of the foot be trained either alongside, or instead of the use of insole orthotics? 
* 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


Conditions that may require a foot orthosis as an adjunct include: <br>• [[Plantar Fasciitis|Plantar fasciitis]] <br>• Morton’s Neuroma<br>• [[Foot Anatomy|Flat feet]] or high arches<br>• Knee, hip or low back pain and [[Sacroiliac Joint|SIJ dysfunction]]<br>• [[Degenerative Disc Disease]] and [[scoliosis]]<br>• [[Osteoarthritis]] <br>• [[Anterior Knee Pain|Patellofemoral pain syndrome]]<br>• Femoral acetabular impingment<br>• I[[Iliotibial Band Syndrome|liotibial band]] friction syndrome<br>• [[Bursitis]]<br>• Chronic ankle sprains<br>• [[Piriformis Syndrome|Piriformis syndrome]]<br>• Achilles, Patellar, hamstring or gluteal [[tendinopathy]] and Snapping Psoas <br>• Recurrent Calf Strains
'''Spine:''' Stabilise spinal fractures to allow the patient to return to some normal activities (although they may be restricted) and protect the spinal cord.


=== Spinal  Orthotics ===
=== Possible Complications ===
Spinal orthotics can be used to give support to a [[Spinal Injury|spinal fracture]]. It is important to have clear instructions about the position that the patient should be in to put the brace on and off. This will be based on spinal scans and an multidisciplinary discussion of the stability of the spinal fracture.


Neck Collar:
* Loss of [[sensation]] (check skin regularly- risk of [[Pressure Ulcers|pressure areas]])
{{#ev:youtube|W12DW-o3jfI|width}}
* 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]].'''


A neck collar may be used for some patients where the fracture is stable, to provide comfort by supporting neck muscles and reducing pain. However, the benefits of a collar need to be weighed up against possible impact on the patient's skin, their swallow and ability to feed themselves. 
=== Consider: ===


If a patient is discharged with a neck collar they will require a suitable collar care plan in the community to ensure their neck is cleaned and skin checked regularly. The soft pads of the neck collar will also need to be cleaned regularly. Therefore, spare pads should be provided to the patient. 
* Cosmesis
 
* Footwear
 
* Weight/rigidity
Thoraco-Lumbar-Sacral Orthosis (TLSO): 
* Ability to Don Doff
 
* Compensations preferred
{{#ev:youtube|uHSl2y1dIms|width}}
* Compensations required
 
=== Outcome Measures ===
Use of outcome measures will determine the effectiveness of orthotics. This will be based on the patient's initial impairments, but may include:
* Neutral-0
* [[Range of Motion|Passive range]]
* [[Range of Motion|Active range]]
* [[Berg Balance Scale]]
* [[Tinetti Test|Tinetti]]
* Gait speed
* [[Timed Up and Go Test (TUG)|Timed up and go]] (TUG)
* Timed Unsupported Stand (TUSS)
* [[Functional Gait Assessment|Functional gait assessment]]
* ARM A, B
* [[Action Research Arm Test (ARAT)|Action Reach Arm Test (ARAT)]]
* Reach and grasp
* Modified Ashworth Scale
* Patient perceived outcome measures


== References ==
== References ==
<references />
<references />
[[Category:Assistive Technology]]
[[Category:Course Pages]]
[[Category:Prosthetics and Orthotics]]
[[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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