Orthotics for ‘beginners’!

Or how not to fail your FRCS questions

In orthotics 
What are Orthoses?
An orthosis is a device that is externally applied or
attached to a body segment and that facilitates or
improves function by supporting, correcting or
compensating for skeletal deformities or weakness.

DHSS (1980)
NOMENCLATURE
Like orthopaedic surgery many devices named after
individuals or places – creates confusion.... 

In the 1960’s American Academy of Orthopaedic

surgeons suggested standard reproducible terminology of
orthoses.

Described by the joint or region of the body it

encompasses.
Hence

Upper limb: Spine:

S = shoulder C = cervical
E = elbow T = thoracic
W = wrist L = lumbar
H = hand S = sacroiliac

Lower limb:
H = hip
K = knee
A =ankle
F = foot
 Commonly used

A.F.O………ankle foot orthosis

K.A.F.O……Knee ankle foot orthosis

T.L.S.O……Thoracic lumbar sacral orthosis

Unfortunately......

D.A.F.O…..’Dynamic’ ankle foot orthosis

S.A.F.O….Silicone ankle foot orthosis

F.F.O….. Functional foot orthosis
Ideal characteristics
Effective

Lightweight

Cosmetically acceptable

Easy to put on (don) and take off (doff)

Comfortable
Aims of Lower Limb Orthoses


Correct and/or prevent deformity


Provide a base of support


Facilitate training in skills


Improve efficiency in gait


Improve FUNCTION
To improve efficiency of gait

“5 prerequisites for efficient gait” – GAGE


Stability of the stance limb.

Clearance of the swinging limb.

Appropriate position at terminal swing.

Achieving adequate step length.

Conservation of energy expenditure.


These are often limited or non existent in neurological
conditions
To correct and/or prevent deformity

Dependent upon assessment, if the joints are of a
flexible nature, then the orthosis will be used to
correct/reduce the rate of deformity as the child grows


Whereas fixed deformities can only be accommodated
within the orthosis, and require surgical intervention to
improve the position of the limb and reduce forces.
How do A.F.O.’s work
in the lower limb?

Controls or eliminates ankle and sub-talar motion

By controlling distal joints one can alter the g.r.f. and
effect more proximal joints (coupling)

Therefore if placed in a slightly dorsiflexed position
the g.r.f. moves posterior to knee joint resulting in
flexion of the knee

(ski boot)..
Coupling

Joints rarely act in a solitary fashion

But in unison

Concept of affecting one joint by position of another =
coupling

Influences stability.

Each level should be assessed, but also in conjunction
with joints above and below.
Probably best lower limb example of
coupling
Simple Ground reaction force
Mechanics of an AFO
For a fixed ankle AFO
‘Trade – offs’ using A.F.O.’s in C.P.
POSITIVE NEGATIVE
Restricts undesirable Can be cumbersome &
motion heavy
Improves ability to stand May make ramps and
and take steps stairs harder
Helps toe clearance May be uncomfortable
Draws attention
Types of A.F.O’s

Rigid Ankle


Hinged


Ground Reaction


DAFO
Rigid A.F.O.
Hinged A.F.O.
D.A.F.O’s
The debate rages on…………………..

Designed out of a therapy need for increased control

with stability…WITH some movement. (Nancy Hilton)

Fabricated from very thin flexible polypropylene.

Controversy still surrounds it’s neurophysical approach

due to lack of solid scientific research.
DAFO’s and tonic reflexes
1. Four tonic reflex movements of the foot can be elicited in normal infants and in some
older children with cerebral palsy.

2. The disappearance of these tonic reflexes with growth appears related to maturation
of the central nervous system.

3. These reflexes are of orthopaedic interest in that they may, by their occasional
unopposed action, cause deformity.

4. It is suggested that these slow tonic movements represent a summation of many

instantaneous reflexes, and that these instantaneous reflexes are distally located trigger
mechanisms that initiate balancing reactions.
D.A.F.O.’s
Cast in neutral, or as near as possible position.

Provides increased foot ‘control’ without excessive

control at ankle complex.

Keeps feet in ‘good shape’.

More FUNCTIONAL.

COSMETICALLY acceptable.
D.A.F.O construction
Foot plate shaped to provide increased pressure on

Medial Arch
Peroneal Notch
M/T pad area
Extension of the toes
Most orthoses impose a posture, therefore this
imposition needs to be realistic.
(rule of thumb, is you can only achieve with an
orthosis, what you can achieve with your hands.)

• Collaboration
• Compromise
• Communication = COMPLIANCE!
Management
“The role of the therapist is to protect patients with
cerebral palsy from orthopaedic surgeons”

J Gage, Minneapolis
Thank you