SARHAD UNIVERSITY OF SCIENCE & INFORMATION TECHNOLOGY,

PESHAWAR
Department: SARHAD INSTITUTE OF ALLIED HEALTH SCIENCES
Program:DPT_________ B

MID TERM Examination-Spring 2021

Course Title: orthotics and prosthetics Semester: Spring 2021

Course Code: Time Duration: 12 Hours
Instructor’s Name: Dr Waleed Khan Total Marks: 30 (30 % weightage)
Exam Date: 27 /May/2021
Student’s Name: Muhammad Ijaz
Registration No: SU-17-01-107-061
Student email: mijaz8156@gmail.com
WhatsApp Contact No: 03479148470

INSTRUCTIONS:
A) Answer all the Questions in the same Question Paper under each question/section subsequently.
B) Before uploading, save the same file in this format MID EXAM_DEPARTMENT_COURSE_Student Name_Reg#.doc
C) Upload it at your SUIT PORTAL before the deadline. Answer Sheet sent through EMAIL will not be accepted.
D) The total size of this file should not exceed 5MB at the time of uploading it at portal.
E) Type the answers under each question, avoid inserting unnecessary images and follow the instructions at SUIT Portal.
Copying, plagiarism, and sharing your answers with other students is strictly prohibited and marks will be deducted.

Attempt All the Questions(with-in 500 - 600 words limit).

Each Question Carries 10 marks.

Q#1:

Discuss the use of orthotic devices for increase in ROM.

What actually is the procedure if we want to improve ROM in postoperative knee with the help of
orthotic devices and what other physiotherapy modalities must be used in this process?

SOLUTION:
PART-A
USE OF ORTHOTIC DEVICES FOR INCREASE ROM:
 Orthotic devices, commonly known as orthoses, are braces that assist in the support of weak
muscles during walking.
 Orthoses are custom-made or prefabricated devices used to optimize body functions and
structures.
 Orthotics devices will treat or prevent abnormal motion, or rolling, of the foot . By redistributing
the pressure on the bottom of foot that reduce discomfort, pain and calluses.
 They also improve comfort and help contractures progress more slowly (tightened muscles or
tendons that become shorter over time). Thus helping an increase in Range of motion. And also
Wearing orthotic devices at any time of day or night is possible which also help the joint to
become and helps in ROM.
 Orthotics devices can help reduce pain caused by medical conditions such as arthritis, bunions,
plantar fasciitis, flat feet, and diabetes. Thus helping in ROM .
 Orthotic devices assist with weak muscles, or to increase passive joint range of motion.
  Examples of articular orthoses include a wrist immobilization orthosis, proximal interphalangeal
(PIP) joint extension mobilization orthosis, and elbow flexion restriction orthosis.

PART-B
 A knee orthosis is a specially designed external medical device constructed of varying lightweight
and durable compositions of metals and high-density materials to provide biomechanical
assistance to stabilize and support an injured knee and its surrounding ligaments, tendons, and
muscles by extending above and below the knee joint to provide healing support for injuries,
diseases, inflammations and post-surgical recovery and rehabilitation of the knee. Thus helps in
increasinpost operative ROM .
 E.g. knee cage orthosis brace is Designed to provide comfortable knee stabilization and Helps to
control the hyperextension of the knee for healing.
 A postoperative knee orthosis is commonly used after a knee arthroplasty. The knee orthosis is
usually designed to allow ROM adjustment in graduating increments, as desired. A soft knee
orthosis is commonly used to address arthritis-related pain and promote knee stability through a
greater kinesthetic awareness.
 A knee orthosis with wraparound closure design is recommended for the elderly patient to
facilitate donning and doffing. Some orthopedists order knee immobilizers postoperatively for
their patients who have had total hip replacements.
 The rationale is that by preventing knee flexion, the operative hip flexion will be reduced, thereby
mitigating the risk of dislocation. This technique should be considered for individual patients only
in the early postoperative period as it does impede mobility and may cause knee stiffness and hip
pain because of the long lever arm
OTHER PHYSIOTHERAPY MODALITIES:
 Quadriceps Sets. Tighten thigh muscle.
 Straight Leg Raises.
 Ankle Pumps.
 Knee Straightening Exercises.
 Bed-Supported Knee Bends.
 Sitting Supported Knee Bends
All the physical therapy devices can be used to increase ROM
Q.2:
What could be the possible areas you need to work on for strength, when advising or using KAFO
with any patient and give reason for each area?
What level of spinal cord injury will go best with KAFO? of pressure difference, also discuss
qtheat
SOLUTION:
 Antigravity muscle should be strengthen while using KAFO because they keep the body upright.
 Hip flexors and abdominal muscles should be strengthen to hold the body in upright position .
 Good trunk strength is necessary to maintain an erect posture in standing position without
excessive weight bearing in the arms. .high level paraplegics without adequate trunk strength must
exert a strong upward force by arms throughout the entire gait cycle to prevent forward collapse
and make forward progression.
 Knee Joint:
 Working on knee joint is the first priority for the stability.k @¹ of knee joint as well as for other
deformity prevention, because the knee joint is the main joint where the person faced main
problem.

 KAFOs are best for individuals with lesions from L1 to T9. (Thoracic and lumber ).
  In a patient with paraplegia above the level of L3 maximal stability in standing with KAFO is
achieved with the ankle position in neutral or dorsiflexion. Knee lock in extension and the hips
passively position in extension. In this position some time referred to the Para stance.
 In spinal cord patient, the KAFO provide stability at the knee and ankle, that has indirectly effect
the hip stability.
 An extension movement is created at the hips. Which prevent the individual from folding while
hip extension is passively maintained by the anterior capsular ligament of hip.
 However when the patient ambulates the hip transition through flexion and crutches or other
assistive aid are essential for stability

Q.3:
Discuss ponsetti method in detail.

SOLUTION:

Ponsetti method
 It was developed by Dr. Ignacio.V.Ponseti
 The Ponseti Method is a conservative and manipulative method that is utilized to correct clubfoot
or Congenital Talpes Equino Varus (CTEV).
 Ponseti method was developed in response to the complications and poor outcomes which came
with surgical management of clubfoot.
 The Ponseti method consists of 2 equally important phases: the corrective phase and the
maintenance phase and consist of serial manipulation, casting and tenotomy of the Achilles
Tendon.
 This is followed by the use of foot abduction brace to prevent the occurrence of relapse. All these
procedures are divided into two phases;
 Casting Phase which consist of Manipulation, Casting and Tenotomy .
 Maintenance Phase which is the use of Foot Abduction Brace to prevent relapse or recurrence

Goals of Ponseti Method

The goal is to reduce if not eliminate all elements of the clubfoot deformity, hence leaving a
functional / pain- free, normal-looking, plantigrade, mobile foot
 Functional, Pain-free Feet
 Wear Normal Shoes
 Avoid Permanent Disability
Procedure :-
 clubfeet can be corrected in infancy in about six to eight weeks with the proper gentle
manipulations and plaster casts. The treatment is based on a sound understanding of the functional
anatomy of the foot and of the biological response of muscles, ligaments and bone to corrective
position changes gradually obtained by manipulation and casting.
 Components of the clubfoot deformity must be corrected in the sequence C-A-V-E.
 Cavus, Adductus, Varus, Equinus. Cavus,
 It is corrected by supinating the forefoot in proper alignment with the hindfoot.
 Adductus and Varus are corrected by gradually abducting the midfoot, with movement occurring
in the plane of the sole of the foot.

A)Corrective Phase
 During the corrective phase the position of the foot is gradually corrected using a series of
manipulations and plaster of Paris casts, then finally a small outpatient procedure is performed to
 cut the Achilles Tendon (Tenotomy). The Corrective Phase usually takes 4–8 weeks and the baby
is seen weekly for the treatment.
 the treatment should begin in the first weeks or two of life because of elasticity of the tissues
forming the ligaments joint capsules and tendons.
 A plaster cast is applied after each weekly session to retain the degree of correction obtained and
to soften the ligaments. Thereby, the displaced bones are gradually brought into the correct
alignment.

 Five to seven plaster casts extending from the toes to the upper thigh with the knees at right angle
should be sufficient to correct the clubfoot deformity. Even the very stiff feet require no more
than 8 or 9 plaster casts to obtain maximum correction.

 Five to seven plaster casts extending from the toes to the upper thigh with the knees at right angle
should be sufficient to correct the clubfoot deformity.
Find the Lateral Head of Talus
 The lateral head of talus is going to be the central point or fulcrum around which the foot moves
as it is corrected, and the place where the manipulator’s thumb needs to apply gentle pressure.
 The Lateral head of Talus in a baby is usually about 1cm anterior to the lateral malleolus
How to Hold the Foot
 Several ways to hold the foot while doing Ponseti manipulations. If it is a right foot as in the
picture below,
 using the left thumb on the lateral head of talus with the left index and middle fingers holding the
medial malleolus but not touching the heel. The right hand’s fingers can then manipulate the
forefoot as needed.
 For a left foot it is recommend using the right thumb on the head of talus and the fingers of the
right hand going round the ankle, with the left hand free to manipulate the forefoot.
Correction of Cavus
 The cavus is corrected by supinating the forefoot, which elevates the first ray, thereby placing the
forefoot in proper alignment with the hindfoot.
 with the aim being to position the forefoot to create a normal looking arch of the foot.Since the
Cavus usually is not a fixed deformity at birth, correction often occurs with the first cast.
Correction of severe cavus in a stiff foot will need 2 or 3 cast changes with the forefoot in
supination.
Correction of Adductus
 Once the cavus is corrected then manipulations to correct the adduction of the forefoot can be
started.
 The plantarflexed foot is slowly abducted while counter-pressure is used on the head of the talus.
Ligaments on the medial side of the foot are stretched. The distal end of the calcaneum disengages
from its position under the head of the talus and allows the calcaneum to abduct.
 While the midfoot is kept in supination and plantarflexion, it is gently abducted under the talus.
The thumb applies pressure to the lateral side of the head of the talus.

 Use gentle continuous pressure for a few seconds. Repeat once or twice more when the baby is
relaxed, and aim for a total of 60 seconds of stretching.

 The aim is to achieve 50-70 degrees of abduction. Once 50–70 degrees of abduction is achieved
the talus is usually fully covered.

Automatic Correction of Varus

 The Varus of the heel and the whole foot does not need to be actively corrected because it corrects
automatically as the forefoot adduction is corrected. While the forefoot is abducted the navicular,
 the cuboid, and the entire foot are displaced laterally in relation to the head of the talus. The
anterior portion of the calcaneum follows, and automatically the heel Varus deformity is
corrected.

Correction of Equinus
 This is the last stage in the correction of the clubfoot deformity. A little correction of equinus
occurs naturally as the foot is abducted but no attempt should be made to actively dorsiflex until:

 The talar head is covered, usually the midfoot contracture score is 0

 The foot is abducted to 50 - 70 degrees
 The heel is in valgus or at least neutral
 These 3 points should have been achieved at this stage and gentle dorsiflexion can be tried.
Casting
 The application of casts is a crucial part of the correction of clubfoot deformity. The cast is
needed to maintain the correction that has been achieved by manipulation. If the cast is badly put
on it can slip and lose correction, it can also cause rubbing and skin breakdown.
Tenotomy
 The tenotomy corrects the rigid equinus. It is a complete cut through of the Achilles Tendon, not a
Tendon Lengthening. It creates a very small incision - it is known as a percutaneous
B) Maintenance Phase
 Following Correction Phase the clubfoot deformity tends to relapse without adequate
management. To prevent relapses, when the last plaster cast is removed a brace must be worn full-
time for two to three months and thereafter at night for 3-4 years.
 The brace, known as a Foot Abduction Brace, consists of a bar (the length of which is the distance
between the baby's shoulders) with open-toed shoes attached at the ends of the bar in about 70
degrees of External Rotation.
 The baby may feel uncomfortable at first when trying to alternatively kick the legs. However, the
baby soon learns to kick both legs simultaneously and feels comfortable. In children with only
one clubfoot, the shoe for the normal foot is fixed on the bar in 40 degrees of external rotation.
During the daytime the children wear regular shoes.