Orthotics

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For the branch of medicine dealing with artificial body parts, see Prosthetics.
An ankle foot orthosis (AFO) brace is a type of orthotic. Here it is being used to support the foot due to foot drop, caused by multiple sclerosis.

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Orthotics (Greek: Ορθός, ortho, "to straighten" or "align") is a specialty within the medical field concerned with the design, manufacture and application of orthoses. An orthosis (plural: orthoses) is "an externally applied device used to modify the structural and functional characteristics of the neuromuscular and skeletal system".[1] An orthotist is the primary medical clinician responsible for the prescription, manufacture and management of orthoses. An orthosis may be used to:

  • Control, guide, limit and/or immobilize an extremity, joint or body segment for a particular reason
  • To restrict movement in a given direction
  • To assist movement generally
  • To reduce weight bearing forces for a particular purpose
  • To aid rehabilitation from fractures after the removal of a cast
  • To otherwise correct the shape and/or function of the body, to provide easier movement capability or reduce pain

Orthotics combines knowledge of anatomy and physiology, pathophysiology, biomechanics and engineering. Patients who benefit from an orthosis may have a condition such as spina bifida or cerebral palsy, or have experienced a spinal cord injury or stroke. Equally, orthoses are sometimes used prophylactically or to optimise performance in sport.

Manufacture and materials

Orthoses were traditionally made by following a tracing of the extremity with measurements to assist in creating a well-fitted device. Subsequently, the advent of plastics as a material of choice for construction necessitated the idea of creating a plaster of Paris mold of the body part in question. This method is still extensively used throughout the industry. Currently, CAD/CAM, CNC machines and 3D printing[2] are involved in orthotic manufacture.

Orthoses are made from various types of materials including thermoplastics, carbon fibre, metals, elastic, EVA, fabric or a combination of similar materials. Some designs may be purchased at a local retailer; others are more specific and require a prescription from a physician, who will fit the orthosis according to the patient's requirements. Over-the-counter braces are basic and available in multiple sizes. They are generally slid on or strapped on with Velcro, and are held tightly in place. One of the purposes of these braces is injury protection.[3]

Classification

Under the International Standard terminology, orthoses are classified by an acronym describing the anatomical joints which they contain.[4] For example, an ankle foot orthosis ('AFO') is applied to the foot and ankle, a thoracolumbosacral orthosis ('TLSO') affects the thoracic, lumbar and sacral regions of the spine. It is also useful to describe the function of the orthosis. Use of the International Standard is promoted to reduce the widespread variation in description of orthoses, which is often a barrier to interpretation of research studies.[5]

Upper-limb orthoses

Upper-limb (or upper extremity) orthoses are mechanical or electromechanical devices applied externally to the arm or segments thereof in order to restore or improve function, or structural characteristics of the arm segments encumbered by the device. In general, musculoskeletal problems that may be alleviated by the use of upper limb orthoses include those resulting from trauma[6] or disease (arthritis for example). They may also be beneficial in aiding individuals who have suffered a neurological impairment such as stroke, spinal cord injury, or peripheral neuropathy.

Types of upper-limb orthoses

  • Upper-limb orthoses
    • Clavicular and shoulder orthoses
    • Arm orthoses
    • Functional arm orthoses
    • Elbow orthoses
  • Forearm-wrist orthoses
  • Forearm-wrist-thumb orthoses
  • Forearm-wrist-hand orthoses
  • Hand orthoses
  • Upper-extremity orthoses (with special functions)

Lower-limb orthoses

A lower-limb orthosis is an external device applied to a lower-body segment to improve function by controlling motion, providing support through stabilizing gait, reducing pain through transferring load to another area, correcting flexible deformities, and preventing progression of fixed deformities.[7]

Foot orthoses

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Main article: Shoe insert

Foot orthoses comprise a custom made insert or footbed fitted into a shoe. Commonly referred to as "orthotics" these orthoses provide support for the foot by redistributing ground reaction forces as well as realigning foot joints while standing, walking or running. A great body of information exists within the orthotic literature describing the sciences that might be used to aid people with foot problems as well as the impact "orthotics" can have on foot, knee, hip, and spine deformities. They are used by everyone from athletes to the elderly to accommodate biomechanical deformities and a variety of soft tissue inflammatory conditions such as plantar fasciitis.[8] They may also be used in conjunction with properly fitted orthopaedic footwear in the prevention of foot ulcers in the at-risk diabetic foot.

Ankle-foot orthosis

An AFO worn on the left foot with ankle hinge
Schematic ankle-foot orthosis

An ankle-foot orthosis (AFO) is an orthosis or brace that encumbers the ankle and foot. AFOs are externally applied and intended to control position and motion of the ankle, compensate for weakness, or correct deformities. AFOs can be used to support weak limbs, or to position a limb with contracted muscles into a more normal position. They are also used to immobilize the ankle and lower leg in the presence of arthritis or fracture, and to correct foot drop; an AFO is also known as a foot-drop brace. Ankle-foot orthoses are the most commonly used orthoses, making up about 26% of all orthoses provided in the United States.[9] According to a review of Medicare payment data from 2001 to 2006, the base cost of an AFO was about $500 to $700.[10] An AFO is generally constructed of lightweight polypropylene-based plastic in the shape of an "L", with the upright portion behind the calf and the lower portion running under the foot. They are attached to the calf with a strap, and are made to fit inside accommodative shoes. The unbroken "L" shape of some designs provides rigidity, while other designs (with a jointed ankle) provide different types of control.

Obtaining a good fit with an AFO involves one of two approaches:

  1. provision of an off-the-shelf or prefabricated AFO matched in size to the end user
  2. custom manufacture of an individualized AFO from a positive model, obtained from a negative cast or the use of computer-aided imaging, design, and milling. The plastic used to create a durable AFO must be heated to 400 °F., making direct molding of the material on the end user impossible.

The International Red Cross recognizes four major types of AFOs:

Flexible AFOs Anti-Talus AFOs Rigid AFOs Tamarack Flexure Joint
may provide dorsiflexion assistance, but give poor stabilization of the subtalar joint. block ankle motion, especially dorsiflexion; do not provide good stabilization for the subtalar joint. block ankle movements and stabilize the subtalar joint; may also help control adduction and abduction of the forefoot. provide subtalar stabilization while allowing free ankle dorsiflexion and free or restricted plantar flexion. Depending upon the design; may provide dorsiflexion assistance to correct foot drop.[11]

The International Committee of the Red Cross published its manufacturing guidelines for ankle-foot orthoses in 2006.[11] Its intent is to provide standardized procedures for the manufacture of high-quality modern, durable and economical devices to people with disabilities throughout the world.

Knee-ankle-foot orthosis (KAFOs)

A knee-ankle-foot orthosis (KAFO) is an orthosis that encumbers the knee, ankle and foot. Motion at all three of these lower limb areas is affected by a KAFO and can include stopping motion, limiting motion, or assisting motion in any or all of the three planes of motion in a human joint: saggital, coronal, and axial. Mechanical hinges, as well as electrically controlled hinges have been used. Various materials for fabrication of a KAFO include but are not limited to metals, plastics, fabrics, and leather. Conditions that might benefit from the use of a KAFO include paralysis, joint laxity or arthritis, fracture, and others. Although not as widely used as knee orthoses, KAFOs can make a real difference in the life of a paralyzed person, helping them to walk therapeutically or, in the case of polio patients, on a community level. These devices are expensive and require maintenance. Some research is being done to enhance the design; even NASA helped spearhead the development of a special knee joint for KAFOs

Knee orthosis (KO)

A knee orthosis (KO) or knee brace is a brace that extends above and below the knee joint and is generally worn to support or align the knee. In the case of diseases causing neurological or muscular impairment of muscles surrounding the knee, a KO can prevent flexion or extension instability of the knee. In the case of conditions affecting the ligaments or cartilage of the knee, a KO can provide stabilization to the knee by replacing the function of these injured or damaged parts. For instance, knee braces can be used to relieve pressure from the part of the knee joint affected by diseases such as arthritis or osteoarthritis by realigning the knee joint into valgus or varus. In this way a KO may help reduce osteoarthritis pain.[12] However, a knee brace is not meant to treat an injury or disease on its own, but is used as a component of treatment along with drugs, physical therapy and possibly surgery. When used properly, a knee brace may help an individual to stay active by enhancing the position and movement of the knee or reducing pain. Also used for elephants when traumatic amputation has occurred.

Prophylactic, functional and rehabilitation braces

Prophylactic braces are used primarily by athletes participating in contact sports. Evidence about prophylactic knee braces, the ones football lineman wear are often rigid with a knee hinge, indicates they are ineffective in reducing anterior cruciate ligament tears, but may be helpful in resisting medial and lateral collateral ligament tears.[13]

Functional braces are designed for use by people who have already experienced a knee injury and need support to recover from it. They are also indicated to help people who are suffering from pain associated with arthritis. They are intended to reduce the rotation of the knee and support stability. They reduce the chance of hyperextension, and increase the agility and strength of the knee. The majority of these are made of elastic. They are the least expensive of all braces and are easily found in a variety of sizes.

Rehabilitation braces are used to limit the movement of the knee in both medial and lateral directions- these braces often have an adjustable range of motion stop potential for limiting flexion and extension following ACL reconstruction. They are primarily used after injury or surgery to immobilize the leg. They are larger in size than other braces, due to their function.

Spinal orthoses

Two different spinal orthoses used to treat scoliosis

Scoliosis, a condition describing an abnormal curvature of the spine, may in certain cases be treated with spinal orthoses, such as the Milwaukee brace, the Boston brace, and Charleston bending brace. As this condition develops most commonly in adolescent females who are undergoing their pubertal growth spurt, compliance with wearing is these orthoses is hampered by the concern these individuals have about changes in appearance and restriction caused by wearing these orthoses. Spinal orthoses may also be used in the treatment of spinal fractures. A Jewett brace, for instance, may be used to facilitate healing of an anterior wedge fracture involving the T10 to L3 vertebrae. A body jacket may be used to stabilize more involved fractures of the spine. The halo brace is a cervical thoracic orthosis used to immobilize the cervical spine, usually following fracture. The halo brace allows the least cervical motion of all cervical orthoses currently in use; it was first developed by Vernon L. Nickel at Rancho Los Amigos National Rehabilitation Center in 1955.[14]

Orthotists

Orthotists are healthcare professionals who specialize in the provision of orthoses. In the United States, orthotists work by prescription from a licensed healthcare provider. Physical therapists are not legally authorized to prescribe orthoses in the U.S. In the U.K., orthotists will often accept open referrals for orthotic assessment without a specific prescription from doctors or other healthcare professionals.[15]

Training around the world

Canada

In Canada, a Certified Orthotists C.O. (c) provides clinical assessment, patient management, technical design, and fabrication of custom orthoses to maximize patient outcomes. To be awarded certification by the Canadian Board for Certification of Prosthetists and Orthotists (CBCPO) an applicant must meet the following requirements and procedures: must be fluent in French or English, be a Canadian citizen or legal landed immigrant, graduated from a CBCPO approved and officially recognized post-secondary clinical Prosthetic and Orthotic school, completed a minimum 3450 hours of Residency in Orthotics under the direct supervision of a Practitioner that is Canadian certified orthotist, upon completion of the residency the person may apply to sit the national certification exams, pass all the sections of the 3-day national exam that includes written, practical and oral exams, and finally be awarded certification by CBCPO board of directors [16]

United Kingdom

In the UK orthotists assess patients, and where appropriate design and fit orthoses for any part of the body. Registration is with the Health and Care Professions Council . The training is a B.Sc.(Hons) in Prosthetics and Orthotics at either the University of Salford or University of Strathclyde. New graduates are therefore eligible to work as an orthotist and/or prosthetist.

United States

A licensed orthotist is an orthotist who is recognized by the particular state in which they are licensed to have met basic standards of proficiency, as determined by examination and experience to adequately and safely contribute to the health of the residents of that state. An American Board of Certification certified orthotist has met certain standards; these include a degree in orthotics, completion of a one-year residency at an approved clinical site, and passing a rigorous three-part exam.[17]

Codification of Orthotics, drawn by Harry Gouvas

A Certified Orthotist (CO) is an orthotist who has passed the certification standards of the American Board of Certification in Orthotics, Prosthetics and Pedorthics. Other credentialing bodies who are involved in orthotics include the Board for Orthotic Certification, the pharmaceutical industry, the Professional Footwear Association, and various of the professional associations who work with athletic trainers, physical and occupational therapists, and orthopedic technologists/cast technicians.

Iran

Four universities including the Iran University of Medical Science, Isfahan University of Medical Science, University of Social Welfare and Rehabilitation Sciences and Iran Red Crescent University confer bachelor of science in the Prosthetics and Orthotics. Two universities including the Iran University of Medical Science and University of Social Welfare and Rehabilitation Science also confer M.Sc. and Ph.D and the Isfahan University of Medical Science confers M.Sc.. New bachelor graduates are eligible to work as an orthotist and prosthetist after registration in the Medical Council of Iran.

See also

References

  1. ↑ ISO 8549-1:1989
  2. ↑ [1]
  3. ↑ Braces and Splints for musculoskeletal conditions American Family Physician. 2010-02-09
  4. ↑ ISO 8549-3
  5. ↑ A systematic review to determine best practice reporting guidelines for AFO interventions in studies involving children with cerebral palsy. Prosthet Orthot Int. June 2010;34(2):129–45. doi:10.3109/03093641003674288.
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  8. ↑ Lua error in package.lua at line 80: module 'strict' not found.
  9. ↑ Whiteside, S., et al. Practice analysis of certified practitioners in the disciplines of orthotics and prosthetics. 2007, American Board for Certification in Orthotics and Prosthetics, Inc., Alexandria, Virginia.
  10. ↑ Centers for Medicare and Medicaid Services, PSPS Files 2001–2006.
  11. ↑ 11.0 11.1 ICRC AFO Manufacturing Guidelines
  12. ↑ Mayo Clinic. "knee braces overview" 2010-01-26.
  13. ↑ Knee Braces: Current Evidence and Clinical Recommendations for Their Use. Am Fam Physician. 2000 Jan 15;61(2):411–418.
  14. ↑ Nickel VL, Perry J, Garrett A, Heppenstall M. The halo. A spinal skeletal traction fixation device. J Bone Joint Surg Am. 1968 Oct;50(7):1400–9.
  15. ↑ http://www.hpc-uk.org/assets/documents/10000522Standards_of_Proficiency_Prosthetists_and_Orthotists.pdf
  16. ↑ http://www.cbcpo.ca/index.html
  17. ↑ www.abcop.org – Certification – Orthotist & Prosthetist

External links

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