INTRODUCTION TO

ORTHOTICS
KAMRAN YOUSUF SIDDIQUI
HOD/SENIOR LECTURER
PROSTHETICS AND ORTHOTICS
ORTHOTICS CATEGORISATION

 "Off the shelf" Orthotics

Many patients can utilize 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.
CUSTOMIZED ORTHOTICS

 Some individuals have more complex injuries / changes to one of the multiple
joint structures and therefore require a customized 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.
Where can an Orthosis be used?

 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.
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. 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.
3 Steps to Create an Orthosis

 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. This can be a complex process and a problem-solving exercise.
All orthotists need to be good at problem-solving.

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

 1. Assessment
 Medical/Physical
 Biomechanical
 ROM/Muscle Power
 Proprioception
 Sensation
Continue

 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
 BASIC TERMINOLOGY
 Orthosis: derives from Greek expression making straight
 Definition :An Orthosis is an orthopedic appliance used to support ,align, prevent ,or
correct deformities of a body part or to improve the function of moveable parts of the body
 Brace: is the synonymous with orthosis.
 Splint; is a temporary orthosis used to prevent deformity and maintain correction.
 ORTHOTIST: An Orthotist is the healthcare professional who designs , fabricates, and fits
patients with orthosis.
 Orthotics: Orthotics refers to the field of Knowledge relating to orthoses and their use.
 HISTORICAL BACKGROUND
 To understand evolution of contemporary orthoses & to appreciate differences in orthotic
practice, it is useful to highlight the history of orthoses Additionally , some current
orthoses are known by the name of developer.
 The origin of orthotic and prosthetic practice is traceable back to ancient times. The first
orthotic craftsmen applied leather, textiles and the metals at their disposal to splint-making
and bone-setting.
 The study of orthotics began with the ancient art of splint and brace making . Bonesetters
and brace makers eventually developed into what we now call orthopedic surgeons and
orthotists. The study of prosthetics has been closely associated with amputation surgery
performed as a lifesaving measure from the aftermath of battle.
 FACTORS IN PRESCRIPTION

Determining the most appropriate orthosis for a given patient at a particular point in the
individuals treatment should take into account many considerations. These include:
 Persons present status such as evaluated by various members of multidisciplinary rehab
team;
 the anticipated duration of orthotic;
 and patients environment;
 financial resources and psycho-social concerns.
 CLINIC TEAM
 The main purpose of clinic team is to formulate a prescription for an orthosis evaluate its
fit, and assess the wearer function while wearing its (static and dynamic alignment of the
body)
 The larger objective is to manage the patients rehabilitation, which usually encompasses
the training with orthosis and may include services of a
 Surgeon
 Physiatrist
 Rehab nurse
 Orthotist/ Prosthetist
 Physical therapist
 Team

 Occupational Therapist
 Psychologist
 Speech therapist
 Social worker
 Patient
 Team

 The clinic team meets on a regular basis to review candidates for orthoses.
 Prior the meeting the members of the team should evaluated the patient so that those
pertinent findings can be shared with the entire group.
 As each patient is presented, team members provide key information that may affect
prescription , then consider the array of possible designs and materials.
 The final prescription should represent the considered judgment of entire team.
 The team also meets when orthosis is delivered to ascertain whether it fits and functions
properly .
 TEAM
 Selection of most appropriate orthosis for a given individual is a major responsibility.
 Ideally, prescription is a shared endeavor by the patient and the professional staff closely
associated with orthotic use.
 PRESCRIPTION GOALS
 A reasonable starting point for prescription is when clinic team establishes rational goals
for orthotic use.
 The team may need to set priorities for the patient who has multiple needs, for example
person with hemiplegia needs to stand to prevent contractures and disuse osteoporosis, to
transfer from bed to chair and to move safely in the community, although an orthosis may
aid the patient in maintaining a stable standing position and transfer from bed to chair.
 PHYSICAL EXAMINATION

 Examination and evaluation should identify the patho-mechanical disorders that disturb
the individuals function.
 TYPES OF ASSESSMENTS
 Subjective assessment
 Objective assessment
 The assessment of the patient and/or the patient-prosthesis/ orthosis interaction in order to
provide treatment plan to the patient.
 Subjective assessment

 Name May include:

 Height, weight, gender, age, occupation (or specific tasks), allergies, medical history, social history (family
dynamics), previous prosthetic/orthotic history (including compliance), independence level (ADL’s-
Activities of Daily Living), cognitive abilities, language, pain, symptoms onset, frequency, surgeries,
medication, patient well-being/distress/anxiety, weight fluctuations, degree of caregiver involvement,
history of skin tolerance, pressure sores, hyperhidrosis, visual impairments, patient’s mobility status (use
of walking aids and ambulatory status) and any current treatment(s).
 OBJECTIVE ASSESSMENT
 Physical Exam may include; but it is not limited to the following:
 Evaluation of skin condition and integrity including: wound presence, topical skin
pathology, edema, redness, tissue density, scarring, redundant tissue, neuromas or
sensitivities, bony deformities, prominences and landmarks, adhesions, abrasions;
 Vascularization (skin temperature, capillary refill, hair growth and discoloration)
 Proprioception, sensation, muscle(s) strength, joint(s) Range Of Motion (ROM), joint
contracture, joint stability, joint center location, reflexes or trigger points, U/E (upper
extremity) function(s), L/E (lower extremity) function(s), pain, tone, clonus, spasticity,
body weight.
 STATIC FUNCTIONAL EVALUATION
WITHOUT ORTHOSIS
Comparison of affected body segment to non-affected body segment and/or norms, measure
deviation from normal posture, or balance if applicable. May include evaluation of:
 anatomical alignment,
 pathological alignment or rotation(s);
 anatomical relationships and/or joints under static conditions in frontal, sagittal, and
transverse planes;
 balance, limb volume, coordination/symmetry, head control, respiratory function and the
ability to stand or sit.
 DYNAMIC FUNCTIONAL EVALUATION
WITHOUT ORTHOSIS
This can also include assessment of patient’s ability to transfer, fatigue issues and functional
strength.
May include evaluation of:
 Anatomical relationships and/or joints under dynamic conditions, limb volume, dynamic
balance, coordination/symmetry, footwear and use of gait aids, mobility using
observational gait analysis in frontal, sagittal, and transverse planes or demonstration of
activities of daily living (ADL).
 TREATMENT OUTCOME MEASURES
 The evaluation can span the following scales: pain, functional mobility, alignment,
transfers, skin function, upper extremity, ADL, recreation/community or leisure activities,
adaptive technology and distress/patient’s overall well-being.
 The comparison of this rating before and after treatment will reflect an outcome measure.
This is done pre and post treatment.
 TEST
 Range of motion test
Evaluate passive/active range of motion (ROM) of anatomical joints. Compare with normal
standards.
 Manual muscle test
Evaluate muscle strength using standardized manual muscle rating scale.
 PHYSICAL EXAMINATION
Obtain appropriate anthropometric data using simple measurements, digital photography, or
laser imaging. May include measurements such as length, diameter, circumference, weight,
height, leg length discrepancy, and varus/ valgus angulation.
 Joint stability
Evaluate joint stability. Compare with normal standards.
 Wound evaluation
Evaluate wound and classify using preferred scale e.g. Bates Jensen Wound Assessment Tool
(BWAT) Pressure Ulcer Scale for Healing (PUSH) Wagner Scale, Carville scale.
 Edema: Evaluate edema using preferred scale.
 Sensory testing: Evaluate patient for sensory perception using monofilament testing,
vibration testing and dermatome levels.
 Myo/emg testing: Locate and evaluate, using Electromyography (EMG), the quality of
residual limb electrical signal sites to determine potential for treatment using myoelectric
prosthesis/orthosis.
 Activities of Daily Living (ADL): Evaluate patient for level of function in Activities of
Daily Level (ADL) using preferred scale.
 Diagnostic imaging:
Interpreting the reports from x-rays, bone scan, MRI, CT with application to prosthetic and/or
orthotic treatment. Identify underlying anomalies not clinically apparent.
 Neuro testing
Locate and evaluate, using neuro stimulators, the quality electrical signal sites on the limb to
determine potential for treatment using neuro stimulation prostheses/ orthoses.
 Reflexes
Test specific reflex or trigger points.
 Respiratory functions
Test oxygen saturation levels
 GAIT OR MOBILITY
 Gait analysis includes observational gait analysis as well as instrumented gait analysis. This analysis
may be performed with or without a prosthesis/orthosis and can include different kinds of mobility
aids.
 TREATMENT PLAN
The analysis, evaluation and integration of findings to formulate a comprehensive treatment.
Findings are based on the results of:
 patient evaluation and objective analyses
 Treatment goals enhance function and independence through improved stability
 reduced pain and increased comfort
 deformity prevention
 the transfer of forces between body segment and ground
 increased Range Of Motion (ROM) and/or the promotion of healing
The treatment plan may include referral to other health care services, restoration/ improvement of
function in the current prosthetic/orthotic system, and/or the provision of a new prosthesis/orthosis.
 DURATION OF ORTHOSIS
 The patient should be told the duration of orthotic use;
 How long to use in a day;
 Re-evaluation after weeks or months;
 When orthosis is worn for long term use, strong materials and components are essential.
 Places of use
 Orthotic prescription should reflect the places in which patient is most likely to use the
orthosis.
 Whether home is spacious enough to walk with assisted gait program.
 For e.g, crowded apartment has a little opportunity for practicing ambulation.
 In school ,the child primary activity is sitting with relatively brief periods available for
standing and walking.
 FINANCES
 The one potential contraindication to every prescription option is insufficient funds.
 Social service agencies play a critical role in this regard.
 PSYCHO-SOCIAL ISSUES
 An orthosis may be viewed as a device supporting a body segment , the individuals
cognitive , emotional and social status are critical factors in selecting an orthosis that
patient will accept.
 COGNITIVE ABILITIES
 The clinical team should consider patients
 Cognitive abilities
 Persons ability to understand donning and doffing
 Maintaining the orthosis
 ORTHOTIC NOMENCLATURE

 Historically orthoses were often named for the designer e.g Thomas ring
 Place of origin (Milwaukee brace, UCBL orthosis, Boston brace etc.)
 Philadelphia collar
 LOWER LIMB ORTHOSIS
 Foot orthosis (insert worn inside the shoes , internal/external modification to the shoe.
 Ankle foot orthosis (Afo covers some portion of foot and leg )
 Knee orthosis (extends from the distal thigh to proximal leg)
 LOWER LIMB ORTHOSIS
 Knee Ankle foot Orthosis (encompasses the thigh , leg and foot )
 Hip orthosis (surrounds the hip)
 Hip knee ankle foot orthosis (originates on the pelvis and terminates at the foot)
 Trunk Hip knee ankle foot orthosis (encircles the torso, both thighs and legs and ends at
feet
 TRUNK AND CERVICAL ORTHOSIS
 Cervical orthosis
 Lumbo Sacral orthosis
 Thoraco lumbo sacral orthosis
UPPER LIMB ORTHOSIS

 Shoulder orthosis
 Elbow orthosis
 Wrist Hand orthosis
 Finger orthosis
 BIO-MECHANICAL PRINCIPLES

 Resist Motion
 Assist Motion
 Transfer force
 Protect body parts
 Comfort
 Snugly fit
 Leverage
 Principles

 Orthotic effectiveness
 Pressure systems
 MATERIALS
 Orthoses are constructed from varieties of materials
 Plastic
 Metal
 Leather
 Rubber
 Cloth
 The physical and aesthetic properties of each material influence orthotic design ,
durability and cost ,as well as patients acceptance of device
 Materials differ in strength , flexibility , ease of forming , weight & acceptance
 MATERIALS

 Nowadays plastics are more commonly used instead of metal

 Plastics are light in weight and easy to use
 Its malleable , changes shape easily and less time consuming , strong enough, corrosion
resistant and available in many colors and thickness.
 Commonly Poly-propelene and Poly ethylene are used in orthotics .
 Plastics are synthetic organic materials.
 PLASTICS

 High temperature sheets (Temperature 130– 300 degree)e.g, Pp , Pe sheets

 Low temperature sheets (Temperature 70– 100 degree) e.g, aqua-plast water moldable
sheets used for Hand splints)
Main two types:
 Thermo-plastics
 Thermo-setting plastics
 THERMOPLASTICS

 Many orthoses are made from thermoplastics.

 When heated, the material becomes malleable and can be reshaped easily.
 It also permits orthotists to alter the fitting of the appliance by heating the plastic.
 THERMOSETTING PLASTICS

 Alternate molecular arrangements produce thermosetting plastics such as polyester and

acrylic resins
 Once molded the plastic cannot be reshaped.
 METAL

 A metal is a chemical element that is lustrous , opaque ,fusible & ductile

 Most metals are used in alloys
 Alloys improve strength ,wear resistance and corrosion resistance.
 As a group ,metals are strong , stiff fatigue resistant and impervious to the effects of
environmental heat.
 STEEL

 Steel in orthoses are usually stainless steel ,which is an alloy of iron , nickel and chromium
 Nickel increases corrosion resistance
 Chromium makes the metal more ductile.
 Stainless steel is heavier , stiffer and stronger than most other materials.
 ALUMINUM
 Aluminum is often alloyed with copper , manganese and other elements .
 When compared with steel , aluminum is more malleable .
 Aluminum which is radiolucent , is more subject to fatigue failure than steel.
 These qualities makes aluminum unsuitable for orthotic joints.
 TITANIUM

 Titanium is very light in weight and corrosion resistant, making it desirable for orthotic
joints.
 It is more expensive than steel or aluminum, so it is used less often .
 Titanium is used in orthotic knee joint and is also used in modular components for
amputees.
 LEATHER
 Leather is animal skin that is chemically treated in process known as tanning.
 The specific skin and type of tanning determine flexibility ,durability and appearance of
leather.
 Leather is a porous , does not compress , and can be molded over a model of the body
part.
 If patient is allergic to particular leather, the contact dermatitis may be resolved with
another leather , a fabric interface between leather and patient skin
 Cow leather is exceptionally strong and is widely used for straps and upper portion of
shoes.
 WOOD
 The most common wood used in orthoses is cork.
 The bark of the cork oak tree is exceptionally light weight and resilient and is used
primarily for shoe compensations and arch supports.
 Sometimes cork is ground and mixed with rubber to achieve greater flexibility.
 RUBBER
 The sap of rubber trees is cured to form rubber, which is noted for its elasticity, shock
absorbency and toughness.
 Synthetic rubber such as neoprene , is less expensive and more resistant to corrosion.
 Natural or synthetic rubber provides excellent traction on shoe soles & is a good padding
material .
 Many companies using neoprene in pre fabricated spinal belts , different types of knee
orthosis, shoulders or hip belts.
 ADHESIVES
 In some orthoses , such as foot orthoses ,two materials are attached to one other with
synthetic glue.
 Synthetic resins whether thermoplastics or thermosetting are widely used in orthotics.
 Some adhesives are toxics or flammable and are unsuitable for pediatric orthoses.
 CONSTRUCTION METHODS
 Orthoses are made in various ways . Many are mass produced
 The clinician can select from a vast variety of off the shelf products , such as corsets,
hand splints and choose one appliance that will be best suitable for patient .
 The clinician adjust the mass produced orthosis so that it fits the patient precisely such
customizing can result in relatively inexpensive , readily available orthosis . Shortening
the delay between prescription and delivery of a finished device
 Custom made orthoses can be made by molding plastic sheet directly on the body as its
often done with hand orthoses.
 CONSTRUCTION METHODS
 Other custom made orthoses involve more elaborate methods, the Orthotist wraps the
specific body part with plaster bandages and makes positive models and apply relieve or
pressure where needed and then mold with high temperature sheets and fits the appliance
to the patient.
 Orthoses with metal uprights are usually made from a pattern and metal uprights are bend
according to pattern and attached metal or plastic bands or shells.
 Currently the modern technique is introduced with CAD CAM .(computer aid designing
and computer aid manufacturing)
 The body part is exposed to an electronic sensor device , such as laser scanner which
creates detailed pattern of segment .
 CONSTRUCTION METHODS
 Nowadays, robots are used to fabricate the appliance accurately and with more precision .
 3-D printers are also used for making appliances in Orthotics and Prosthetics.