Orthosis For Paraplegia And Hip Disorders

BY: DR.SAIMA ASGHAR

 PARAPLEGIA
  Paraplegia is the word comes from Greek language
para + plēssein. means ‘strike at side’
 Paraplegia is defined as impairment in motor
function of the lower extremities with or without
involvement of sensory system
 It is usually caused by involvement of cerebral
cortex, spinal cord, the nerves supplying the
muscles of lower limbs or due to involvement of
the muscles directly.
 Cont.
 The individual with spinal cord disorder, typically a
child with spina bifida or a man with a spinal
cord injury, who wishes to walk must have a means
of achieving a secure standing position and a way of
moving from place to place in an energy-efficient
manner.
 Orthoses designed for standing apply a four-point
force system to the wearer, namely posteriorly
directed forces at the midchest and midleg and
anteriorly directed forces from the dorsolumbar
region and feet.
 Cont.
 The patient must have sufficient control of the
upper torso, neck, and head in order to stand.
 The standing orthoses must also provide a stable
base. The base may be an orthotic foundation, either
a pair of plastic shoe inserts or steel stirrups each
with an ankle control that restrics mediolateral
and posterior motion, and may also limit anterior
motion.
 Cont.

 Stability is enhanced by the use of a walker,

crutches, parallel bars, or a harness attached
to an overhead rigid frame.
 STANDING FRAMES

 The human body was not designed to sit for long

periods of time and still remain healthy. But what
choice do you have when you're disabled or have
physical challenges and have to live most of your life
from a wheelchair? Standing Frames!
 Cont.

 A standing frame, also known as a standing aid or

stander, is specifically designed for wheelchair users.
This alternative positioning device helps to support
all kinds of physically challenged individuals with
mild to severe disabilities, including paraplegia and
quadriplegia. This act of 'passive' standing helps
these individuals to reap the physical, emotional and
mental health benefits that this movement provides
and to reduce the health risks and dangers often
associated with prolonged sitting.
STANDING FRAME
 “L” Standing Frame

 The simplest standing frame resembles a capital “L”

when viewed from the side.
 It consist of a broad wooden board approximately as
long as the child is tall. A footboard is attached to
the lower end of the main board. Chest and knee
straps complete the frame.
 The “L” frame can be made easily.
“L” Standing Frame
 “A” Standing Frame

 It resembles a capital “A” when viewed from the

back.
 The posterior support consists of two angled
metal uprights with a transverse dorsolumbar
band. The frame has a chest and a knee strap.
 Swivel Walker

 Another version of a standing frame was developed at

the orthotic research and locomotion assessment unit
(ORLAU), England. The posterior section is a curved
aluminum or plastic trough, which facilitates donning.
 Its upper surface has straps designed to secure the
wearer’s shoes. The lower surface has two swiveling
plates, which facilitate ambulation.
 The swivel walker, unlike the other standing frames, is
manufactured in both child and adult sizes. Patients can
ambulate with it only on flat, smooth surface.
.

ORLAU swivel walker

 parapodium

 The parapodium is an articulated version of a standing

frame originated at the ontario crippled children’s
centre.
 The aluminum orthosis has lateral uprights that
terminate superiorly in a dorsolumbar band and
inferiorly in a footplate with springs to secure the
child’s shoes.
 The orthosis has hip and knee joints that the child can
operate by means of levers on each lateral upright. Chest
and knee straps provide posteriorly directed force to
keep the wearer uprights.
PARAPODIUM
ORTHOSES DESIGNED FOR
AMBULATION
.
 ANKLE-FOOT ORTHOSES:
Vannini-Rizzoli Stabilizing Boots

 A different orthotic approach for patients with paraplegia

involves custom-made orthoses. The least encumbering orthoses
are AFOs known as vannini-Rizzoli stabilizing AFOs or boots.
 Vannini-Rizzoli stabilizing boots Designed for spinal cord injury
patients, these boots extend to four centimeters below the knee
to immobilize the ankles and feet in approximately 10 -15
degrees of plantar flexion. The patient controls balance by
holding the head high with shoulders back and hips forward,
effectively locking the knees. Patients learn to walk by shifting
the upper body left or right, causing the center of gravity to shift,
then moving the unweighted foot in a pendulum motion.
 Knee-Ankle-Foot Orthoses
craig-scott orthoses:
 One of the most common orthotic designs for adults with
paraplegia is known as the craig-scott KAFO.
 This design allows a person to stand with a posterior lean of
the trunk.
 Craig-scott KAFOs are somewhat more expensive than other
versions of KAFOs.
craig-scott orthoses:
 Spreader Bar

 Some patients have such severe adductor spasticity

that their balance is precarious. They may find a
steel spreader bar attached to both medial upright
near the ankle to be a useful device.

 The bar prevent any hip adduction or rotation.

Spreader Bar
 Medially Linked KAFOs

 The medial linkage orthosis, also known as the walkabout

orthosis, has a hinge-like joint positioned between the legs.
The joint limits hip flexion and extension but does not
mechanically assist either. Instead, gravity flexes the hip
and moves the unweighted leg forward.
 Hip extension is achieved by leaning the trunk backwards and
extending the lumbar spine, consequently, even slight loss of
passive hip extension can be a problem, increasing patient’s
reliance on their upper limbs to hold the trunk upright.
 Cont.
 The medially-linkage orthoses is aesthetically more appealing
than other types of hip-knee-ankle foot orthoses butt it
provides a slower and more energy-consuming gait.
 As is the case with stabilizing boots, KAFOs are not suited
to patient who have hip or knee flexion contracture,
marked spasticity, or obesity.
Medially Linked KAFOs
 Hip-Knee-Ankle-Foot Orthoses

 Hip-Knee-Ankle-Foot orthoses are sometimes

prescribed for patients with paraplegia,
particularly children born with spina bifida.
 The pelvic band with hip joints blocks hip
abduction, adduction and rotation.
Hip-Knee-Ankle-Foot Orthoses
 Trunk-Hip-Knee-Ankle-Foot orthoses

 Rigid THKAFO: The most conservative approach

for adults and children with paraplegia is a custom-
made trunk-hip-knee-ankle-foot orthoses (THKAFO)
 The device usually consists of a pair of plastic solid
ankle orthoses and thigh shells with lateral
uprights, which incorporate locking knee joints
and hip joints attached to a trunk orthosis.
 Gait requires the use of parallel bar or crutches.
 Reciprocating Gait Orthoses

 The reciprocating/ responding gait orthosis joins two

knee-ankle-foot orthoses to a trunk corset with
laterally placed joints. A key feature of the reciprocating
gait orthosis is the coupling together of the hip joints,
preventing bilateral hip flexion in stance.
 The hip mechanism was designed so hip extension on
one leg could assist hip flexion on the other leg when
stepping. However, the effectiveness of this mechanism
may be overstated. The hip joint can be unlocked to flex
simultaneously, this is important for sitting.
 Cont.

 Early version of reciprocating gait orthosis coupled

the two hip joints together with cables. The cables
were attached under high tension so that forces from
extension in one leg were transmitted to flexion of
the other.
Reciprocating Gait Orthoses
 ParaWalker

 The parawalker is the version fitted to adults with

paraplegia. Rather than having a cable joining
the hips, the parawalker has exceptionally strudy
hip joints that have an adjustable feature.
 The orthosis has shoe plates with limited ankle
motion joint, it is considerable heavier and more
rigid than the RGO.
 As with other orthoses for paraplegia, the wearer
needs an assistive device for ambulation.
ParaWalker
 FUNCTIONAL ELECTRICAL
STIMULATION
 Some patients are interested in maintaining muscle tone
so that the joint mobility is preserved, these people may
benefit from functional electrical stimulation, which
involves application of a low-volt current to neutral
trigger points.
 An electrical current causes muscular contractions, which
prevent muscle fiber atrophy.
 Stationary bicycles and other exercise equipment have
been adapted for use by patients with paraplegia who use
functional electrical stimulation to achieve leg movement
 Cont.

 Some people have hybrid systems incorporating both

functional electrical stimulation and orthosis. The
systems are expensive and fragile.
 HIP ORTHOSES

 Hip Dislocation: infants with congenital hip

dislocation are often placed in an orthosis that
maintains the femoral head in the acetabulum.
 The most popular of these devices is the pavlik
harness, in the harness the hips are kept abducted,
flexed and externally rotated.
 The harness does not restrict the baby from kicking
and moving about. It is washable.
HIP ORTHOSES
 Legg-Calv’e-Perthes Disease

 The disease is most commonly found in children

between the ages of 4 to 8 but it can occur in
children between the ages of 2 to 15. The main
long-term problem with this condition is that it
can produce a permanent deformity of the femoral
head which increases the risk of developing
osteoarthritis  in adults. It is also commonly
known as Perthes Disease, Legg–Perthes
Disease, or Legg–Calve–Perthes Disease (LCPD).
 Cont.

 The more common approach is to permit weight

bearing through the affected limb while preventing
the hip. Two orthoses fulfill this purpose, namely the
Atlanta (sometimes called scottish Rite) and the
Toronto orthoses.
 The Atlanta hip orthosis (HO) consists of a pelvic
band and thigh cuffs. The cuffs are attached to the
band by means of heavy metal hip joints, which
restrict abduction, adduction, and rotation.
 The orthosis can be worn under clothing.
Atlanta hip orthoses
 Hip Control Orthoses

 Children who have deficient hip control because of

cerebral palsy or septic arthritis may benefit from a
HO that restricts motion in one or more planes.
 The simplest such HO has a pelvic band to which
two leg cuffs are joined by single-axis hinges.
 The HO permits hip flexion and extension but
restricts motion in the frontal and transverse planes.
 CONT.

 For the nonambulatory child with a hip dislocation, a

hip abduction KAFO can hold the joint in place
while healing occurs. A newer design is the standing-
walking-and-sitting-hip (SWASH) ORTHOSIS. its
hinges permit sagittal motion and abduction.
SWASH ORTHOSIS
 Postoperative Orthoses

 Most orthotic manufacturers offer a range of HOs

that limit the excursion of the hip joint in one or
more planes.
 The orthoses typically include a pelvic band and a
thigh cuff.
 The hip joint has an adjustable mechanism, enabling
the clinician to select the appropriate range of
motion and to alter the excursion as necessary. these
HOs are usually intended for adults who have
arthroplasty or similar surgery.
 GUIDELINES FOR PRESCRIPTION

 The following are biomechanical guidelines for prescribing orthoses for

patients who have paraplegia:
 1. To control hip flexion
 a. HKAFO with hip locks

 2. To control hip rotation

 a. KAFOs with rotation-control straps
 b. KAFOs with a spreader bar
 c. HOs with single-axis hinges
 d. SWASH orthosis
 e. HKAFO with or without hip locks
 Cont.

 3. To stabilize paralyzed hips, knees, and ankles

 a. standing frame
 b. parapodium
 c. swivel walker
 d. Vannini-Rizzoli stabilizing AFOs
 e. craig-scott KAFOs
 f. Medially linked KAFOs
 g. Reciprocating gait orthosis
 h. para Walker/hip guidance orthosis