Prefabricated Foot Orthoses

=> The simplest types of prefabricated FOs are in-shoe pads.

=> Felt forefoot pads are available to relieve metatarsal GIA, sesamoiditis, traumatic, Neuroma, and intractable plantar keratoma (Fig 1.1). These adjust pressure by off-loading adjacent areas and increasing pressure on the pad itself. Thus they are often placed near, but not directly under, the area of pain.

Fig 1.1

=> Heel pads are designed to relieve pressure and symptoms associated with plantar heel spur syndrome and plantar heel fat pad atrophy (Fig 1.2). They distribute forces over a larger area, thus decreasing pressure under the heel.

Fig 1.2

=> Flat insoles are used primarily for cushioning the impact during walking and running. These flat, cushioned insoles can also off-load bony prominences and are used to prevent pressure-induced pathologies of the foot – Fig 1.3

Fig 1.3

=> Contoured cushioned prefabricated insoles are also prevalent and have a wide variety of clinical application for relief of plantar foot pressures, dissipation of impact shock, and enhancement of overall foot comfort. These contoured insoles also function as a softer version of a prefabricated arch support – Fig 1.4

Fig 1.4

=> Prefabricated, “biomechanical” semirigid foot orthotics have gained popularity over recent years. These devices made from materials commonly used in the fabrication of more expensive custom functional Fos. Prefabricated biomechanical devices contoured to an average shape of a medical and lateral longitudinal arch. In general, these devices lack any heel cup. Sometimes, posting is provided to enhance the rear foot pronation control.

=> The goal of treatment of these devices is to provide more rigid support and motion control than with softer arch supports.

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Introduction and Types of Orthotics

Introductions of Orthotics

An externally applied used to the device modify the structural or functional characteristics of the neuromusculoskeletal system. Alternative Definition: An apparatus used to support, align, prevent, or correct deformities or to improve the function of movable parts of the body.

During static stance and ambulation, the lower extremities are subjected to external forces and moments. During normal function, these troops and moments are resisted or controlled by internal structures of the body. These structures include skeletal segments, ligamentous connections, and muscle-tendon units.

When internal structures fail, orthoses can modify external forces and moments to allow the body to function in a “normal” manner.

An external device used to support or improve function of the foot and ankle can take many physical forms. This orthotic can be as simple as a felt pad placed under the metatarsals or as sophisticated as a composite brace controlling foot and ankle motions.

Orthotics prescribed for lower extremity pathologies include foot orthoses (Fos), ankle-foot orthoses (AFOs), knee orthosis, and knee-ankle-foot orthoses.

Types of Orthotics

Various types of orthoses commonly prescribed for foot and ankle pathologies. An overview of these orthoses provided in a show at Image 3.1

The primary subcategories are FOs prefabricated and custom. There are clear differences between the manufacture and design of orthoses in each category, yet advantages or benefit of one type of device over another has yet to prove.

Prefabricated devices have the distinct advantage of lower cost compared with custom-fabricated foot orthotics. In addition, prefabricated orthoses can be stocked in the clinic, pediatric facility, or retail setting for immediate dispensing to the patient.

3.1

The disadvantage of prefabricated orthotic devices is their difficulty in application to limb and foot shapes that fall outside the “average” range.

Custom molding and contouring of an orthotic device to a body segment may be the critical feature necessary for a successful treatment outcome. The mechanism by which foot orthotics achieve their treatment effects remains poorly understood, and thus claims of superiority of custom versus prefabricated device remain somewhat speculative.

Prefabricated FOs are available for a broad range of clinical application. In general, these methods are used to off-load specific areas of the foot, cushion the foot from impact, support the medical longitudinal arch, and provide mild biomechanical control of hindfoot movements.

Custom FOs fall into two basic categories: accommodative and functional. Functional orthoses are most often used with flexible feet, and work to alter how the foot meets the floor. Accommodative orthoses used with more rigid deformities. Rather than attempting to change foot alignment, accommodative orthoses work to relieve pressure under bony prominences (make the floor fit the foot better).

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Most Common Types of Hip Knee Ankle Foot Orthotic

Hip Knee Ankle Foot Orthotics (HKFO)

Hip Knee Ankle Foot Orthotics is bilateral knee ankle foot orthotics joined with hip joints. The orthotic hip joints can be placed between the legs or connected laterally to a pelvic or lumbar band or a lumbosacral corset. Orthoses which include extensive trunk bracing sometimes referred to as nose -hip-knee-ankle-foot-orthotics.

By joining two knee ankle foot orthotics together, hip-knee-ankle-foot-orthotics substitute for paralysis of the hip abductor muscles and provide mediolateral stability during stance. In addition, they prevent the pelvis from tilting downwards on the unweighted swing leg. Assists this foot clearance during swing and reduces the need for the upper limbs to lift the swing leg.

However, the torques tending to tilt the pelvis downwards during swing are significant, especially in heavy patients to resist these torques, hip-knee-ankle-foot orthotics needs real lateral rigidity. If the orthotics are insufficiently rigid, swing leg clearance involved.

The three most common types of hip-knee-ankle-foot orthotic are the hip guidance orthotics, the reciprocating gait orthotics, and the medical-linkage orthotics. Various types of hip and knee joints can used in all three orthoses. A summary of each given below

Hip Guidance Orthotics

The hip guidance orthotics, also called the ParaWalker, was first introduced for children with spina bifida in the 1970s.

It consists of two knee ankle foot orthotics attached to a rigid body brace with laterally placed hip joints.

The hip joints are low friction and restrict flexion and extension, although they can be released to enable sitting. During the leg flexes like a pendulum, and swing phase of gait.

That is; hip flexion is achieved solely by the effects of gravity on the unweighted leg. Gravity will only act to flex the hip when the leg extended with the mass of the leg behind the hip joint.


Reciprocating Gait Orthotics

The reciprocating gait orthotics joints two knee ankle foot orthotics to a trunk corset with a laterally placed joints. An essential feature of the reciprocating gait orthosis is the coupling together of the hip joints, preventing, bilateral hip flexion instance. The hip mechanism designed so hip extension on one leg could assist hip flexion on the other foot when stepping. However, the effectiveness of this mechanism may be overstated. The hip joints can be unlocked to flex simultaneously, and it's essential for sitting.

Early versions of reciprocating gait orthotics coupled the two hip joints together with cables. The cables were attached under high tension so that forces from extension in one leg transmitted to flexion of the other. In more recent years, a pivot bar has replaced the cables. The pivot bar is positioned centrally and at the back of the corset in the lumber region. Reciprocating gait orthotics incorporating pivot blocks are called eccentric reciprocating gait orthotics. A variation is the advanced reciprocating gait orthotics.

Medical Linkage Orthotics

The medical linkage Orthotics, also known as the Walkabout orthosis, has a hinge-like joint positioned between the legs. The joints limit hip flexion and extension but do 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. The medical-linkage orthotics is aesthetically more appealing than other types of hip-knee-ankle-foot orthotics but it provides a slower and more energy consuming gait.

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Orthotics and Prosthetics In The Twentieth Century

A fundamental concept and the common goal of the professions of orthotics, prosthetics, and rehabilitation is the standard form of restoration and function after injury or disease. To accept this challenge, the fields of orthotics and prosthetics have evolved into uniquely specialized professions. In addition to training in the basic biological and medical sciences, orthotics and prosthetist have an understanding of biomechanics, kinesiology, and the material sciences complemented by highly developed technical skills.

Knowledge of the physical properties of materials and the techniques to manipulate and use them is essential to the design and fabrication of orthoses and prostheses. The topic is presented here as a general overview so that the rehabilitation clinician can develop a basic understanding of current design and fabrication processes used by orthosis and prosthetists.

Orthotics and prosthetics have a rich history of research and development. Many innovative devices have been designed to restore function and provide relief from various medical ailments. Although progress can document throughout human history, the most significant contributions to orthotics and prosthetics were made in the twentieth century, stimulated by the aftermath of the world wars. Injured veterans who returned home from battle with musculoskeletal and neuromuscular impairments or traumatic amputation dramatically demand increased the orthotic and prosthetic services.

Although World War I stimulated some clinical progress in the two disciplines, notable scientific advancements did not occur until World War II. To improve the performance and quality of assistive devices at the end of World War II, particularly for veterans with amputation. U.S government sponsored a series of development and research projects under the auspices of the National Academy of Sciences (NAS) that would forever change the manner in which orthotics and prosthetics would practiced.

Orthotics and prosthetics have played and important historical role in the development of medical and surgical orthopedics and rehabilitation. Orthotics and prosthetics have evolved as sister professions because the technical skills and knowledge base to prescribe, fabricate, and fit the respective mechanical devices are similar. Because of this, material and technological advancements have been shared between these two rehabilitation specialties.

A research effort was initiated by the NAS in late 1945, when a consensus revealed conference that few scientific principles or developments had introduced in prosthetics. Research and educational committees were formed between 1945 and 1976 to advise and work with the research groups.

In summarizing the most notable achievements in prosthetics during this period, Wilson cites the development of the total contact transfemoral socket; the quadrilateral socket design and hydraulic Swing-phase knee control units for the transfemoral prosthesis.

The patellar tendon bearing (PTB) trans-tibial prosthesis; the solid ankle, cushioned-heel prosthetic foot; several new designs for the Syme's Prosthesis; and the Canadian hip disarticulation prosthesis. He also notes the implementation of immediate postsurgical and early fitting as having a significant impact on the rehabilitation process for persons with lower extremity amputation. The most notable improvements in upper extremity prosthetics were the lyre-shaped three-jaw chuck terminal device and more efficient harnessing systems. In addition, modular components and advances in bioengineering have permitted increased use and availability of the myoelectric prosthesis since it first proposed in 1950.

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Introduction to Orthotics

The field of orthotics includes appliances for the loweb limb trunk, neck, and upper limb. This Article outlines key concepts that apply to orthoses, regardless of the body segment on which the device is worn.

What is an orthosis?
Who is involved with orthotic prescrition?
How ancient are orthoses?
What mechanical priniciples govern orthotic design?
What materials are used in orthoses?
How are orthoses constructed?

 

TERMINOLOGY

Foot Orthotic (FO - Shoe Inserts)

Orthosis derives from the Greek expression “making straight.” An orthosis is an orthopedic appliance used to support, align, prevent, or correct deformities of a body part of the body.

Orhesis is synonymous with orthosis. A Splint is temporary orthosis. Some of the other common Terms that denote particular orthotic designs include sling, corset, pressure garment, and cuff. Surgical appliance is the board category that includes orthoses.

Orthotic is the adjective relating to orthoses, but it is sometimes used to designate a foot orthosis. An orthosist is the healthcare practitioner who designs, fabricates, and fits patients with orthoses. Orthotics refers to the field of knowledge relating to orthoses and their use.

HISTORICAL BACKGROUND

To understand the evolution of contemporary orthoses and 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 the developer.

For Example: Paintings from the Fifth Egyptian dynasty, 2750 to 2625 BCE (Before Common Era) depict men wearing orthoses. Various braces and splints for the treatment of fractures, dislocations, and congential deformities have been attributed to Hippocrates, the Greek physican of the 4th century BCE. Galen, who subscribed to hippocratic teachings, wrote about scoliosis orthoses in the 2nd Century CE (Common Era). Amroise Pare, the father of modern surgery, “who first published his works in 1575, made a perforated steel orthosis for the correction of scoliosis and ankle-foot orthosis to correct club foot, among many other orthoses and prostheses.

Hieronymus Fabricius of Hilden, Germany described in 1607 an orthosis to reduce contractures caused by burns. Nicholas Andry, professor of medicine at the University of Paris, wrote in 1740 about correction and prevention of deformities in children, including trunck orthoses. He coined the word “orthopedic, “meaning straight child. Antonio Scarpa, a Venetian surgeon, published an 1803 treatise on congenital foot determines illustrating several club foot orthoses. The English orthopedist Hugh Owen Thomas designed lower-limb orthoses for weight – bearing, which apperared in his 1875 publication. His contemporary, James Knight, an American surgeon, designed a lumbosacral orthosis that bears his name. The German technican Friederich von Hessing advanced the art of brace-making in the latter part of the 19th Century.

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