BIOENGINEERING

ORTHOSIS
Characteristics of IDEAL ORTHOSIS
• FUNCTION
• COMFORT
• COSMESIS
• FABRICATION
• COST
 FUNCTION
• Meets the individuals mobility needs ad goals
• Maximizes stance phase stability
• Minimizes abnormal alignment
• Minimally compromises swing clearance
• Effectively pre-positions the limb for initial
contact
• Is energy efficient with the individual’s
preferred assistive device
 COMFORT
• Can be worn for long periods without
damaging skin or causing pain
• Can be easily donned and doffed (eg,
considering clothing, footweare, toileting)
 COSMESIS & COST
• Meets the individual’s need to fit in with peers
• Can be made with minimal initial cost,
minimal cost for maintainence.
 FABRICATION
• Can be made in the shortest period of time
• Uses a minimally complex design
• Has some degree of adjustability to enhance
initial fitting
• For children, responds to growth or change
over time
• Is durable: stands up to stress/strain of daily
activity
 PRINCIPLES UNDERLYING ORTHOTIC
DESIGN
• PRESSURE= FORCE/AREA
The forces are distributed over large surface
areas to minimize pressure on skin and soft
tissue.
• TORQUE = FORCE * DISTANCE
The forces applied in such a way that a large
moment arm reduces the amount of force
needed to control the joint
 PRINCIPLES
• Control direction of primary force direction of
counter –forces
• EQUILIBRIUM
(SUM OF ALL FORCES)= 0
The sum of primary force and opposing counter-
forces of each control system equals zero.
TOE-SPREADER

TOE-SPREADER WITH
HALLUX CORRECTION
MEDIAL HEEL WEDGE
 ANKLE-FOOT ORTHOSES
• Used to control the lower extremity during
each phase of the gait cycle for individuals
with neuromuscular or musculoskeletal
impairments.
• Categories
1. Static
2. Dynamic
 AFO
COMPONENTS
• Foundation- Consists of shoe and plastic/
metal component
• Ankle control
• Foot control
• Superstructure
PARTS OF ANKLE-
FOOT ORTHOSIS
 TYPES OF AFO
• Static AFO
• Dynamic AFO
• Supramalleolar Orthosis
• Tone reducing Orthosis
• Floor reaction Orthosis
• Posterior leaf spring Orthosis
STATIC ANKLE FOOT ORTHOSIS
 ACTIONS
SAFO • Control ankle position
INDICATIONS
throughout stance
Significant hypertonicity • Provide stance phase
with seriously impaired Stability via ankle-knee
motor control at ankle and
knee.
coupling
• Assist limb clearance in swing
CONTRA-INDICATIONS • Pre-position foot for IC by
LMN paralysis ( flaccidity)
Hypotonicity as primary
heel
problem • Distal trim line behind
metatarsal heads or
extended toe-plate
Dynamic
AFO
 ACTIONS
DAFO • Stabilize sub-talar and
INDICATIONS tarsal joints in stance
•FLEXIBLE PES PLANUS
•MILD TO MODERATE
SPASTIC DIPLEGIC
•HEMIPLEGIC CP
•HYPOTONIC CP

CONTRAINDICATIONS
•RIGID FOOT DEFROMITY
 KAFO
KNEE-ANKLE-FOOT ORTHOSIS
PARTS
• Shoe
• Foundation
• Ankle control
• Knee control
• Superstructure
KAFO
Knee, ankle, foot orthosis,
custom may include knee
joints. Joints may be
locking or adjustable in
flexion and extension.
Indications:
Polio, MS, paresis, knee
instability/buckling.
Contraindications:
Morbid obesity, dependent
patient with poor cognition
and upper extremity
weakness combined with
poor support system.
 Knee Control
• Hinge joint • Provide medial-lateral
and hyperextension
restriction while
permitting knee flexion
• Hinge placed posterior
• Offset joint to midline of leg.
Weight falls anterior to
offset joints, stabilizing
knee in extension
during early stance
phase.
• Drop ring lock • When client sands with
full knee extension, the
ring drops, preventing
knee from bending.
• Provides simultaneous
• Pawl lock with bail locking of both uprights.
release The pawl is a spring-
loaded projection that fits
into a notched disk. The
patient unlocks the brace
by pulling upward on the
posterior bail.
'Bail Lock' Knee joint. This joint remains locked until the spring-loaded release bar
that connect the two mechanical knee joints is lifted. It automatically locks when
the user fully extends their limb, i.e., when rising from a chair.
Offset free motion knee joint with ‘Drop locks’ to maintain knee extension
Polycentric Knee joint to allow knee flexion with less bunching of the skin behind
the knee and to reduce vertical movement of the device when the knee bends.
 BIOMECHANICAL PRINCIPLES APPLIE TO
THE DESIGN AND FITTING OF KAFO
• Mediolateral stability and toe off must be
provided during swing phase
• Knee stability needs to be provided during the
stance and simulated push-off
• Excessive force should not be applied to the
knee.
• Orthosis must be fitted with knee in extension
in order to reduce the bending moment at the
knee.
 Contd…
• Rigid ankle joint provides more stability
• Posterior thigh strap is necessary to restrain orthosis
from sliding off the leg while sitting
• Dorsiflexion stop with sole plate extended to the
metatarsal head area facilitates push off and reduce
energy consumption.
• Major portion of total knee stabilizing force should
be applied below the knee in order to reduce the
shear forces on the knee ligaments
 Contd…
• Straps should distribute force over large and
tolerant area i.e. patella tendon and supra
patellar area
• Stabilizing straps should be applied as close to
the knee joint as possible to reduce the force
require to counterbalance a bending moment
 Craig-Scot KAFO

PARTS
• Shoe reinforced with
transverse an longitudinal
plates
• BiCAAL ankle joints set in 10
degree dorsiflexion
• Pretibial band
• Pawl lock with bail release
• Single thigh band
 CRAIG SCOTT KAFO
INDICATIONS ADVANTAGES
• Paraplegics • Medio-lateral foot stability
•Thoracic spinal cord injury provided by metatarsal bar
GAIT PATTERN • Enable a patient to stand
with sufficient backward
• Swing-to or swing-through
lean so as to prevent
with aid of crutches or a
untoward hip or trunk
walker
flexion.
• Functional
• Easy to don and doff
• Light weight as compared to
standard KAFO
HKAFO
 HKAFO
Indications
• Weak hip musculature
• Hip instability
Parts
• Pelvic band
• Hip joint
 • Bilateral HKAFO
PRINCIPLE- ipsilateral hip flexion leads
RGO to contra lateral hip extension and
vice versa. It consists of hip joints
that transfer forces from one hip to
other by Bowden cables
INDICATIONS
• Active hip flexion but no hip
extension
• Paraplegic L1 level
DISADVANTAGES
• High energy cost requirement
• Slow speed
 THKAFO
PARAPODIUM
 CERVICAL ORTHOSIS
Immobilizing cervical spine is difficult because
• Most mobile part in spine
• Has small body surface
• Limited pressure tolerant areas like chin, occiput
• Different types of predominant movement at different levels
Functions
• Positions the head
• Limits movement in flexion, extension, rotation and lateral
rotation
• Unload the cervical spine by bearing part of weight of the
skull
 CERVICAL ORTHOSIS
Classification Commonly used
• Cervical collars • Soft and semi-rigid
• Poster appliances cervical collars
• Cervicothoracic orthosis • Philadelphia orthosis
• Halo devices • SOMI brace
• Poster orthosis
• Minerva body jacket
• Halo jacket or vest
SOFT CERVICAL COLLAR
• Made of foam and rubber
covered by stockinet
ADVANTAGES
• low cost
• easy to fabricate
• tolerated by patient
• provides warmth and
psychological comfort
DISADVANTAGES
• Does not restrict cervical
motion in any plane.
PHILADELPHIA COLLAR
PARTS
• Anterior and psoterior struts,
with molded mandilbular and
occipital support. Extends to uper
thoracic region anteriorly and
posteriorly
ADVANTAGES
• Restricts flx/ext due to chin and
occiput support and thoracic
extension
DISADVANTAGES
• Ineffective in controlling rotation
and lateral bending
• Pressure over clavicle
 SOMI BRACE
(Sternal Occipito Mandibular Immobilization)
PARTS
• Sternal plate
• One anterio stripr to hold chin
• Two rigid metal rods from
anterior to posterior to occiput
support.
ADVANTAGES
• No posterior post, can be used it
supine
• Light weight for donning and
doffing
• Controls flexion effectively at C1–
C3
 SOMI BRACE
Indications:
•Atlantoaxial instability caused by rheumatoid
arthritis
•Neural arch fractures of C2, because flexion causes
instability
Contraindications:
The SOMI controls extension less effectively than do
other orthoses.
Flexion and extension control at C3-T1: better served
with a Minerva
HALO DEVICE
• Rigid metal/graphite ring
attached to skull by four
fixation pins
• 4 posters which are
attached to ringproximally-
2 anteriorly, 2 posteriorly
and distally to
polypropylene vest.
Polyethylene vest
• Half vest- level of nipples
• Short- level of 12h rib
• Full vest- level of iliac crest
 Halo orthosis
INDICATIONS:
• Dens type I, II, or III fractures of C2
• C1 fractures with rupture of the transverse ligament
• Atlantoaxial instability from rheumatoid arthritis, with
ligamentous disruption and erosion of the dens
• C2 neural arch fractures and disc disruption between C2 and C3.
• Bony, single-column cervical fractures
• Cervical arthrodesis – Postoperative
• Cervical tumor resection in an unstable spine – Postoperative
• Debridement and drainage of infection in an unstable spine –
Postoperative
• Spinal cord injury (SCI)
• The halo is the best orthosis for use in controlling rotation and
lateral bending at C1-C3.
 Halo orthosis
• Complications: Contraindications:
• Neck pain or stiffness – 80%
• Pin loosening – 60% 1. Concomitant skull fracture
• Pin site infection – 22%
• Scarring – 30% with cervical injury
• Pain at pin sites – 18%
• Pressure sores – 11% 2. Damaged or infected skin
• Redislocation – 10% over pin insertion sites
• Restricted ventilation – 8%
• Dysphagia – 2% 3. Cervical instability with 2-
• Nerve injury – 2% or 3-column injury
• Dural puncture – 1%
• Neurological deterioration – 1% 4. Cervical instability with
• Avascular necrosis of the dens
• Ring migration rotational injury involving
• Inadequate bony healing facet joints
• Inadequate ligamentous healing
Minerva Body Jacket
• Motion restriction at C5-C7
• Anterior and posterior
chest plates connected by
shoulder straps
• Chin plate
• Occipital piece that connect
to anterior and posterior
struts.
• The brace has poor control
of flexion, extension,
rotation, and lateral
bending at C1-C2.
 MINERVA JACKET
Indications Contraindications:
• Minimally unstable •Flexion control at C1-C5:
fractures from C3-T2 Better served with a SOMI
• Internal fixation from C3-T2
Motion restrictions:
•Limitation of flexion and
extension from C3-T2.
 TLSO (thoraco-lumbar-sacral)
• For fractures between T6 and L3.
• Provide support and immobilization of the
thoracic and lumbar regions following various
surgical procedures/ traumatic injuries
• Help in treatment of post-operative
thoracic/lumbar fusion, laminectomy or
discectomy, compression fractures, degenerative
disc disease, osteoporosis, single column spinal
instability immobilization, and facet syndrome.
JEWETT BRACE
• The Jewett orthosis uses a
3-point pressure system
to control flexion
• PARTS-1 posterior and 2
anterior pads.
• The anterior pads place
pressure over the
sternum and pubic
symphysis.
• The posterior pad places
opposing pressure in the
midthoracic region.
 JEWETT BRACE
Motion restrictions Contraindications:
•Limits flexion and extension •Three-column spinal
between T6-L1 fractures involving anterior,
Indications: middle, and posterior spinal
•Symptomatic relief of structures
compression fractures T6-L1 •Compression fractures above
•Immobilization after surgical T6, because segmental motion
stabilization of thoracolumbar increases above the sternal
fractures pad
•Ineffective in limiting lateral
bending and rotation of the
upper lumbar spine
ANTERIOR SPINAL HYPEREXTENSION
(ASH) BRACE
Anterior Spinal Hyperextension (ASH)
brace features
• Anterior sternal
• Pubic pads
• Posterior pad and
• Strap around the thoracolumbar
region.
• Sternal and pelvic pads attach to
the anterior, metal, cross-shaped
bar.
• The brace is easy to don and doff,
but it is difficult to adjust.
• It provides greater breast and
axillary pressure relief than does
the Jewett hyperextension TLSO.
 ASH BRACE
Motion Restrictions: Contraindications:
•Limits flexion and •Three-column spinal
extension at T6-L1 fractures involving
Indications: anterior, middle, and
•Flexion immobilization posterior spinal structures
to treat thoracic and •Compression fractures
lumbar vertebral body caused by osteoporosis
fractures T6-L1 •Ineffective in limiting
•Reduction of kyphosis in lateral bending and
patients with osteoporosis rotation of the upper
lumbar spine
 CTLSO-MILWAUKEE BRACE
• CTLSO
• Helps maintain postoperative correction in
patients with scoliosis secondary to polio.
• Stimulates corrective forces in the patient.
• Proper fit allows consant usage of trunk
muscles, disuse atrophy does not occur.
• The brace has an open design.
FEATURES
• Plastic pelvic mold
• 2 posterior upright
• 1 anterior upright
• Thoracic pad
• Transverse pad attached
to uprights
• Neck ring
 Features

• Constant force provided by the plastic pelvic mold.

• The pelvic portion - reduces lordosis, derotates the spine,
and corrects frontal deformity.
• The uprights have localized pads that apply transverse
force, which is effective for small curves.
• The thoracic pad, main corrective force, creates a righting
response to an upright posture.
• The uprights are perpendicular to the pelvic section, so any
leg-length discrepancy should be corrected to level the
pelvis.
• The neck ring - gives longitudinal traction. .
 Milwaukee brace
Indications: Duration of use:
• Used for curves in which the • Daily use ranges from 16-23
apex is above T7. hours per day.
•Patients with a Risser score of I- •Treatment should continue until
II, as well as a curve that is the patient is at Risser stage IV or
greater than 20-30° and that V.
progresses by 5° over 1 year •If the curve is greater than 30°,
•Curves of 30-40°, but not curves consider continued use of the
of less than 20°. brace for 1-2 years after maturity,
•Curves of 20-30°, with no year- because a curve of this
over-year progression, require magnitude is at risk of
observation every 4-6 months. progression.
 Milwaukee brace
PROBLEMS WITH BRACE CAUSES OF FAILURE
• Jaw deformity • Poor patient
• Skin breakdown compliance
• Unsightly appearance • Improper fit
• Difficulty with mobility • Curves below T7
• Difficulty with transfers
• Increased energy
expenditure with
ambulation
TLSO- BOSTON BRACE
• TLSO with built-in lumbar
flexion
• can be worn under clothes.
• Lumbar flexion- achieved
through posterior flattening of
the brace and extension of the
mold distally to the buttock.
• Braces with superstructures
have a curve apex above T7.
• Curves with an apex at or
below T7 do not require
superstructures to immobilize
cervical spine movement.
• Height cannot be ajuste.
 BOSTON BRACE
Indications: Complications
• A curve of 20-25° with • Local discomfort
10° progression over 1 • Hip flexion contracture
year • Trunk weakness
• A curve of 25-30° with 5°
progression over 1 year • Increased abdominal
pressure
• Skeletally immature
patients with a curve of • Skin breakdown
30° or greater Causes of failure
• Curve above T7
• Improper fit
• Poor patient compliance