Chapter 30: Orthotics

An orthosis is an external appliance worn to restrict or assist motion or to transfer load from one area of the body to another. The older term, brace, is a synonym. A splint connotes an orthosis intended for temporary use. An orthotist is the health care professional who designs, fabricates, and fits orthoses for the limbs and trunk, and a pedorthist is the health care professional who designs, fabricates, and fits only shoes and foot orthoses. The term orthotic is an adjective, although some use the word as a noun. Archaeological evidence indicates that orthoses have been used at least since the fifth Egyptian dynasty (2750 to 2625 BC).¹ The term orthosis appears to have been coined in the mid-20th century.

This chapter presents the most frequently prescribed orthoses for the lower extremity (LE) and the trunk, as well as new developments in the field. Key elements in preparing patients to use orthoses are discussed. Focus is placed on orthotic design characteristics, their biome-chanical rationale, merits of specific materials, and criteria for judging the adequacy of orthotic fit, function, and construction. Although every attempt is made to use evidence-based research to guide clinical practice, the heterogeneity within the population of orthotic users and within orthotic designs confounds this effort.²

Generic terminology is superseding the traditional use of eponyms (surname of developer). Naming orthoses by the joints they encompass and the type of motion control facilitates communication among clinicians and consumers. Thus, foot orthoses (FOs) are appliances applied to the foot and placed inside or outside the shoe, such as metatarsal pads and heel lifts. Ankle-foot orthoses (AFOs) encompass the shoe and terminate below the knee. The knee-ankle-foot orthosis (KAFO) extends from the shoe to the thigh. A hip-knee-ankle-foot orthosis (HKAFO) is a KAFO with a pelvic band that surrounds the lower trunk. A trunk-hip-knee-ankle-foot orthosis (THKAFO) covers part of the thorax as well as the lower extremities (LEs). Knee orthosis (KO) and hip orthosis (HO) are other applications of the same system of nomenclature.

Lower extremity orthoses range from shoes used for clinical purposes to THKAFOs. Characteristics and functions of the principal FOs, AFOs, KAFOs, HKAFOs, and THKAFOs, and trunk orthoses, together with the clinically important attributes of shoes, will be described. Although physical therapists also encounter KOs, HOs, and orthoses for special purposes, such as management of Legg-Calvé-Perthes disease, these orthoses are not included because they are used less frequently than the appliances that do appear in this chapter. Similarly, orthoses for the upper limb are omitted from this chapter because they are less commonly prescribed and in most instances are used only for a brief duration.

Shoes

The shoe is the foundation for most LE orthoses. Each part of the shoe contributes to the efficacy of orthotic management and offers many options for selection. Shoes transfer body weight to the ground and protect the wearer from the terrain and the weather. The ideal shoe should distribute bearing forces so as to provide optimum comfort, function, and appearance of the foot. For the individual with an orthopedic disorder, footwear can serve two additional purposes: (1) it reduces pressure on sensitive deformed structures by redistributing force toward pain-free areas; and (2) it serves as the foundation for AFOs and more extensive bracing. Unless the shoe is correctly fitted and appropriately modified, the alignment of the orthosis will not provide the designed pattern of weight-bearing. The major parts of the shoe are the upper, sole, heel, and reinforcements. These features are found in both the dress leather shoe (Fig. 30.1A) and the athletic shoe (Fig. 30.1B).

Upper

The portion of the shoe over the dorsum of the foot is the upper. It consists of an anterior component called the vamp and the posterior part, the quarter. If the shoe is to be used with an AFO having an insert as its foundation, then the vamp should extend to the proximal portion of the dorsum to secure the shoe and thereby the rest of the orthosis onto the foot. In a laced shoe, the vamp contains the lace stays, which have eyelets for shoelaces (Fig. 30.2). Laces provide more precise adjustment over the entire opening than do strap closures. The latter, however, enable individuals with limited manual dexterity to manage the shoe more easily. For most orthotic purposes, a Blucher lace stay is preferable; it is distinguished by the separation between the anterior margins of the lace stays and the vamp. The alternate design is the Bal, or Balmoral, lace stay, in which the lace stay is continuous with the vamp. The Blucher opening permits substantial adjustability, an important feature for the patient with edema. It also offers a large inlet into the shoe, so that one can determine whether paralyzed toes lie flat within the shoe. An extra-depth shoe is one having an upper contoured with additional vertical space. The shoe is manufactured with a second inner sole that can be removed to accommodate an insert or thick surgical dressing.

Quarter height is another consideration in shoe prescription. The low-quarter terminates below the malleoli and is satisfactory for most clinical purposes. This style does not restrict foot or ankle motion. If the patient will be wearing a plastic orthosis molded about the ankle, it is not necessary to go to the additional expense of providing a high-quarter shoe for ankle support. A high-quarter shoe, covering the malleoli, is indicated to cover the foot having rigid pes equinus. It is also appropriate to augment foot stability in the absence of an AFO. The high-quarter shoe, however, is more difficult to don and more expensive than a comparable low-quarter one.

Sole

The sole is the bottom portion of the shoe. For use with a riveted metal attachment between shoe and orthosis, the sole should have an outer and an inner sole. Between the two lies a metal reinforcement that receives the rivets. This type of shoe, however, is heavier than an athletic shoe with a single sole. Leather soles absorb little impact shock and provide minimal traction as compared to natural or synthetic rubber soles. To absorb shock, the shoe may have a resilient outer sole, inner sole, or insert. Older people should wear shoes with firm, slip-resistant outsoles to reduce the risk of falling.^3,4

Regardless of material, the outer sole should not contact the floor at the distal end; the slight rise of the sole is known as toe spring (see Fig. 30.1), which allows a rocker effect at late stance. If a lift is added to the sole to compensate for leg length discrepancy, the lift should be beveled to achieve toe spring.

Heel

The heel is the portion of the shoe adjacent to the outer sole, under the anatomical heel. A broad, low heel provides greatest stability and distributes force between the back and front of the foot most evenly. For adults, a 1-in (2.5-cm) heel tilts the center of gravity slightly forward to aid transition through stance phase, but does not disturb normal knee and hip alignment significantly. Slight heel lifts increase the contraction of the medial gastrocnemius and the tibialis anterior.⁵ A higher heel places the ankle in greater plantarflexion range and forces the tibia forward. The wearer compensates either by retaining slight knee and hip flexion or by extending the knee and exaggerating lumbar lordosis. The high heel transmits more stress to the metatarsals⁶ and knee.⁷ Nevertheless, transferring load anteriorly may be desirable if the patient has heel pain. The higher heel also reduces tension on the Achilles tendon and other posterior structures and accommodates rigid pes equinus. Although most heels are made of firm material with a rubber plantar surface, a low resilient heel is indicated to permit slight plantarflexion if the ankle cannot move because of orthotic or anatomical limitation.

Reinforcements

Reinforcements located at strategic points preserve the shape of the shoe. Toe boxing in the vamp protects the toes from stubbing and vertical trauma; it should be high enough to accommodate hammer toes or similar deformity. The shank piece is a longitudinal plate that reinforces the sole between the anterior border of the heel and the widest part of the sole at the metatarsal heads. A corrugated steel shank is necessary if an orthotic attachment is to be riveted to the shoe. The counter stiffens the quarter and generally terminates at the anterior border of the heel. The patient with pes valgus, however, should have a shoe with a long medial counter that provides reinforcement along the medial border of the foot to the head of the first metatarsal, thus resisting the tendency of the foot to collapse medially.

Last

The last is the model over which the shoe is made. The last, whether of traditional wood, custom-made plaster, or computer-generated design, remains with the manufacturer; the shoe shape duplicates the last's contour. A given shoe size may be achieved with many lasts, each transmitting different forces to the foot. Consequently, the physical therapist should ascertain that the shoe shape fits the foot satisfactorily, rather than relying on a particular shoe size. The patient with a markedly deformed foot requires a shoe made over a special last, either a factory- or custom-made one.

Foot Orthoses

Foot orthoses are appliances that apply forces to the foot. These may be an insert placed in the shoe, an internal modification affixed inside the shoe, or an external modification attached to the sole or heel of the shoe. They can enhance function by relieving pain. This may be accomplished by transferring weight-bearing stresses to pressure-tolerant sites, protecting painful areas from contact with the shoe, correcting alignment of a flexible segment, or accommodating a fixed deformity. Inserts can also improve the wearer's transition during stance phase, by altering the rollover point in late stance and by equalizing foot and leg lengths on both limbs. In many instances, a particular therapeutic aim can be achieved by a variety of devices.

Internal Modifications

Generally, the closer the modification is to the foot, the more effective it is. Biomechanically, inserts and internal modifications are identical. Both inserts and internal modifications reduce shoe volume, so proper shoe fit must be judged with these components in place. An insert permits the patient to transfer the orthosis from shoe to shoe, if the shoes have the same heel height; otherwise, a rigid insert may rock in the shoe. Most inserts terminate just behind the metatarsal heads; thus, they may slip forward, particularly if the shoe has a relatively high heel. Some inserts extend the full length of the sole, preventing slippage, but occupying the often limited space in the anterior portion of the shoe. Internal modifications are fixed to the shoe's interior, guaranteeing the desired placement, but limiting the patient to the single pair of modified shoes.

Inserts made of resilient materials, such as the rubber, viscoelastic plastics (e.g., Sorbothane and Viscolas), or polyethylene foam, reduce impact shock and shear, thus protecting painful or insensitive feet.⁸ Inserts are also constructed of semirigid or rigid plastics and metal, often with a resilient overlay. A full-length insert tends to reduce gait unsteadiness by improving proprioception from the increased foot contact area.⁹ A heel-spur insert orthosis (Fig. 30.3), for example, may be made of vis-coelastic plastic or rubber.¹⁰ The orthosis slopes anteriorly to reduce load on the painful heel. In addition, the orthosis has a concave relief to minimize pressure on the tender area.

Longitudinal arch supports are intended to prevent depression of the subtalar joint and flattening of the arch (pes planovalgus, pes planus). The orthosis may include a wedge (post) to alter foot alignment. The minimum support is a resilient scaphoid pad (Fig. 30.4) positioned at the medial border of the insole with the apex between the sustentaculum tali and the navicular tuberosity. Flexible flat foot can be realigned with a semirigid plastic University of California Biomechanics Laboratory (UCBL) insert.¹¹ It is molded over a plaster model of the foot, taken with the foot in maximum correction. It controls hindfoot valgus and limits subtalar motion. The insert encompasses the heel and midfoot. Corrective alignment includes a three-point counterpressure system and force couple for control of calcaneal eversion; forefoot abduction is controlled by a second three-point counterpressure system (Fig. 30.5).¹² A full-length insert reduces motion at the first metatarsophalangeal joint, resulting in pain reduction.^13,14 Wearing arch supports is associated with increased activation of the tibialis anterior and peroneus longus.¹⁵ With regard to the effect of inserts on proximal joints, the evidence is equivocal; some investigations show that orthoses alter the onset of erector spinae and gluteus medius activity¹⁶ and support the positive effect of FOs on reducing knee pain,^{17,17,18,19,20,21} whereas others show little or no effect.^22,23 Some adults with plantar fasciitis also respond favorably to foot or-thoses.^{24,25,26,27,28} Children with pes planus may also benefit from wearing longitudinal arch supports, although the evidence is weak.^29,30

Insert orthoses are also used to relieve pain and activity limitation associated with pes cavus.^31,32,33 The metatarsal pad (Fig. 30.6) is a convex component that may be incorporated in an insert or may be a resilient domed piece glued to the inner sole so that its apex is under the metatarsal shafts. The pad transfers stress from the metatarsal heads to the metatarsal shafts and is effective in reducing plantar pressure particularly in patients with diabetic neuropathy.^34,35,36

Occasionally, modifications are sandwiched between the inner and outer soles; for example, the patient with marked arthritic changes in the front of the foot probably will be more comfortable if the shoe has a steel band between the soles to eliminate motion at the painful joints. The same effect can be achieved with a rigid insert.

External Modifications

An external modification ensures that the patient wears the appropriate shoes and does not reduce shoe volume, but will erode as the individual walks and is somewhat conspicuous. In addition, the client is limited to wearing the modified shoe, rather than being able to choose from a wide selection of shoes.

A heel wedge (Fig. 30.7) is a frequently prescribed external modification. It alters alignment of the rearfoot. A medial heel wedge, by applying laterally directed force, can aid in realigning flexible pes valgus or can accommodate rigid pes varus by filling the void between the sole and the floor on the medial side. A medial wedge is incorporated in a Thomas heel, intended for flexible pes valgus (Fig. 30.8 [middle]). The anterior border of the Thomas heel extends forward on the medial side to augment the effect of the medial wedge in supporting the longitudinal arch. A cushion heel is made of resilient material to absorb shock at heel contact. Because it provides slight plantarflexion, the cushion heel is indicated when the patient wears an orthosis with a rigid ankle. Sole wedges alter medial–lateral forefoot alignment. A lateral wedge shifts weight-bearing to the medial side of the front of the foot. It compensates for fixed forefoot valgus, allowing the entire distal foot to contact the floor.

A metatarsal bar (see Fig. 30.8 [left]) is a flat strip of firm material placed posterior to the metatarsal heads. At late stance, the bar transfers stress from the metatar-sophalangeal joints to the metatarsal shafts. A rocker bar (see Fig. 30.8 [middle and right]) is a convex transverse band affixed to the sole proximal to the metatarsal heads. It reduces the distance the wearer must travel during stance phase, improving late stance, as well as shifting load from the metatarsophalangeal joints to the metatarsal shafts.^37,38

The patient with leg length discrepancy of more than 1/2 in (1 cm) will walk better with a shoe lift made of cork or other lightweight material. Approximately 3/8 in (0.8 cm) of the elevation can be accommodated on the insole at the heel of a low-quarter shoe.

Ankle-Foot Orthoses

The AFO is composed of a foundation, ankle control, foot control, and a superstructure.

Foundation

The foundation of the orthosis consists of the shoe and a plastic or metal component.

Insert

A plastic or metal insert or foot plate foundation (Fig. 30.9) has several advantages. Because internal modifications can be incorporated in it, the insert provides good control of the foot. It must be worn with a shoe that closes high on the dorsum of the foot to retain the orthosis. The insert facilitates donning the orthosis because the shoe can be separated from the rest of the brace. The insert also permits interchanging shoes, assuming that all shoes have been made on the same last. Less expensive shoes, such as sneakers, can be worn, because the foundation does not need to be riveted to the shoe. Because the insert is usually made of a thermoplastic material, such as polyethylene or polypropylene, the orthosis with an insert is relatively lightweight. The orthotist creates a plaster model of the patient's leg, then modifies the model, removing plaster in areas where the orthosis is to apply substantial pressure, and adding plaster where pressure relief is required. Thermoplastic is then heated and molded over the modified plaster model.

An insert foundation, however, is inappropriate if the patient cannot be relied on to wear the orthosis with a shoe of proper heel height. If the orthosis is placed in a shoe with too low a heel, the uprights would incline posteriorly, increasing the tendency of the wearer's knee to extend. Conversely, if the orthosis is worn with a higher heeled shoe, the patient might experience knee instability. The insert reduces interior shoe volume, and thus must be used with suitably spacious shoes. Custom-molded foot plates may be more expensive than other types of foundations. If the orthosis is to be used by a very obese or exceptionally active individual, a plastic foot plate may not provide adequate support.

Stirrup

An older foundation for the AFO is the steel stirrup, a U-shaped fixture, the center portion of which is riveted to the shoe through the shank. The arms of the stirrup join the brace uprights at the level of the anatomical ankle, providing congruency between orthotic and anatomical joints. The solid stirrup (Fig. 30.10) is a one-piece attachment that provides maximum stability of the orthosis on the shoe. The split stirrup (Fig. 30.11) has three segments. The central portion has a transverse rectangular opening. Medial and lateral angled side pieces fit into the opening. The split stirrup simplifies donning the orthosis because the wearer can detach the uprights from the shoe. If a central piece is riveted to another shoe, the shoes can be interchanged. The extremely active client may dislodge a side piece from its receptacle unintentionally. The split stirrup is bulkier and heavier than a solid stirrup.

Ankle Control

Most AFOs are prescribed to control ankle motion by limiting plantarflexion and/or dorsiflexion, or by assisting motion. The patient with dorsiflexor weakness or paralysis risks dragging the toe during swing phase. Dorsiflexion assistance can be provided by a posterior leaf spring that arises from a plastic insert (Fig. 30.12). During early stance, as the patient applies force to the braced foot, the upright bends backward slightly. When the patient progresses into swing phase, the plastic recoils forward to lift the foot. Thinner, narrower plastic permits relatively greater motion. Motion assistance can also be achieved with a steel dorsiflexion spring assist (Klenzak joint) (Fig. 30.13) incorporated into each stirrup. The coiled spring compresses in stance and rebounds during swing. The tightness of the coil can be adjusted. An orthosis with a dorsiflexion spring assist is noticeably bulkier than the posterior leaf spring model. Both types of spring assists yield slightly into plantarflexion at heel contact, affording the wearer protection against inadvertent knee flexion. Other AFO designs which control toe drag are presented in Figures 30.14 and 30.15. Healthy subjects wearing a posterior leaf spring AFO exhibited less hip extension and ankle plantarflexion during the transition from stance to swing phase.³⁹ AFOs with flexible ankle control altered the stance phase transition between rear- and forefoot among nondisabled adults.⁴⁰

The alternate approach to prevent toe drag is plan-tarflexion resistance, which stops the ankle from plan-tarflexing so that the patient with weak dorsiflexors will not catch the toes and stumble during swing phase. A joint placed in a plastic hinged AFO (Fig. 30.16) or a steel posterior stop (Fig. 30.17) can be incorporated in the stirrup. The posterior stop also imposes a flexion force at the knee during early stance, preventing the knee from hyperextending. Healthy adults walking with the ankle fixed in plantarflexion consumed more oxygen than when walking with AFOs which kept the foot in neutral position.⁴¹

An anterior ankle stop limits dorsiflexion, aiding the individual with paralysis of the triceps surae to achieve propulsion during late stance.

Limiting all foot and ankle motion can be done with a plastic solid ankle-foot orthosis (Fig. 30.18); its trimlines are anterior to the malleoli. Able-bodied adults fitted with solid ankle AFOs descended stairs more slowly than when walking without orthoses.⁴² The solid ankle orthosis may be divided transversely at the ankle, with the two sections hinged, creating the hinged ankle-foot orthosis (see Fig. 30.16). It permits slight sagittal motion, facilitating progression to the foot-flat position in early stance. The joint at the hinge may be a plastic overlap or a flexible plastic rod. A versatile option is a pair of metal hinges that can be adjusted to alter the excursion of ankle motion. An alternative to the plastic solid ankle AFO is a metal joint that resists both plantarflexion and dorsiflexion, known as a limited motion joint. One type of limited motion joint is a pair of bi-channel adjustable ankle locks (BiCAALs) (Fig. 30.19) that consist of a pair of joints, each of which has an anterior and a posterior spring. The springs may be replaced by metal pegs (or pins), the lengths of which determine the amount of motion provided by the orthosis. To compensate for lack of plantarflexion in early stance, the shoe worn with the solid AFO or the orthosis with a limited motion stop should have a resilient heel. Similarly, to facilitate rollover in late stance, the shoe sole should have a rocker bar. Hinged AFOs reduced frontal plane motion during ramp descent exhibited by subjects who have subtalar osteoarthritis.⁴³

Adults with hemiplegia who wore AFOs demonstrated increased cadence, walking speed, step length, and ankle dorsiflexion,⁴⁴ and the AFO enabled some patients to walk with increased stride length and cadence.^{45,46,47,48,49,50} Other subjects with stroke improved their scores on the Berg Balance Scale when wearing AFOs⁵¹ and improved weight transfer during stance phase.⁵² Balance improvement was also achieved by those wearing an anterior AFO,^53,54 while other subjects demonstrated better function with a posterior leaf spring AFO.⁵⁵ Orthoses may either contribute to improved compensatory functions of the nonparetic limb,⁵⁶ or may be less important during swing phase of the paretic limb as compared with pelvic obliquity.⁵⁷

A hinged AFO with full-length insert and posterior stop improves early stance stability for subjects with hemiplegia.⁵⁸ The alignment of a solid AFO should be individualized to achieve optimal function.⁵⁹

Limited investigation of energy expenditure of adults with hemiplegia wearing AFOs suggests that wearing orthoses results in more efficient gait.^60,61,62

Adults with hemiplegia complicated by plantarflexor contracture walk with less plantarflexion and greater knee flexion when wearing either an AFO with posterior stop or a solid AFO.⁶³

Functional electric stimulation is an alternative to an AFO for some adults with stroke and other central neuropathies. Various commercially available systems all incorporate a cuff on the proximal leg; the interior of the cuff contains a skin electrode over the peroneal nerve. The electrode is stimulated by a self-contained electrical unit. As compared to walking with an AFO, subjects report more positive results, particularly during swing phase.^{64,65,66,67,68}

Children with hemiplegic cerebral palsy improved weight-bearing on the paretic limb while wearing either a posterior leaf spring AFO or a hinged AFO with plan-tarflexion stop.⁶⁹ Other children with similar disability showed slight gait improvement.^70,71,72 Energy expenditure lessened when children wore a hinged AFO.^73,74,75,76 Other investigators found that hinged AFOs were preferable to other designs for level walking^77,78 and stair climbing.⁷⁹

Some young patients with excessive knee flexion achieved better gait when wearing AFOs with anterior band (floor reaction orthosis).^80,81,82 The desirable effect occurred only if the child did not have knee flexion contracture.

Foot Control

Medial–lateral motion can be controlled with a solid ankle AFO. The rigidity of the orthosis can be increased by using thicker or stiffer plastic, corrugating the plastic, forming the edges with a rolled contour, or embedding carbon fiber reinforcements. A solid ankle AFO (see Fig. 30.18) or a hinged solid ankle AFO (see Fig. 30.16) also controls frontal and transverse plane foot motion of children with cerebral palsy to a limited extent.⁸³ Less effective is a metal and leather orthosis to which a leather valgus (or varus) correction strap is attached. The valgus correction strap (Fig. 30.20) is sewn to the medial portion of the shoe upper near the sole, and buckles around the lateral upright, exerting a laterally directed force to restrain pronation. The varus correction strap has opposite attachments and force application. Either strap, although adjustable, complicates donning.

Superstructure

The proximal portion of the orthosis, the superstructure, consists of one or two uprights, and a shell, band, or brim. Plastic AFOs usually have a single upright or shell. Both the solid ankle and the hinged solid ankle AFOs have a posterior shell extending from the medial to the lateral midline of the leg, thus providing excellent medial-lateral control and a broad surface to minimize pressure. The posterior leaf spring AFO (see Fig. 30.12) has a single posterior upright that does not contribute to frontal or transverse plane control.

The spiral AFO (Fig. 30.21) is a design in which a single upright spirals from the foot plate around the leg, terminating in a proximal band. It may be made of polypropylene, nylon acrylic, or carbon fiber. The spiral orthosis controls, but does not eliminate, motion in all planes. Orthoses with plastic shells or uprights are molded over a cast of the patient's leg and are designed to fit snugly for maximal control and minimal conspicuousness. Such AFOs are contraindicated for the individual whose leg volume fluctuates markedly, because the orthoses cannot be adjusted readily.

Metal and leather orthoses usually have medial and lateral uprights to maximize structural stability. Occasionally, a single side upright will suffice when the patient insists on a less conspicuous orthosis and the person is not expected to exert undue force. Some AFOs shear stress on the calf and Achilles tendon. Aluminum uprights are typically used because they are lighter in weight than steel. Carbon graphite and titanium uprights weigh appreciably less than aluminum and rival the strength of steel; however, orthoses made of these materials are more expensive.

Most orthoses have a posterior calf band made of rigid plastic or leather-upholstered metal. The band has an anterior buckled or pressure closure strap (Fig. 30.22). The farther the band is from the ankle joint, the more effective the leverage of the orthosis; however, the band must not impinge on the peroneal nerve. An anterior band that is part of a solid ankle AFO imposes posteriorly directed force near the knee, enabling the AFO to resist knee flexion. Such an orthosis is known as a floor reaction orthosis (Fig. 30.23). In fact, all LE orthoses are influenced by the floor reaction when the wearer stands or is in the stance phase of gait. If the AFO is to reduce the amount of weight transmitted through the foot, it may have a patellar-tendon-bearing brim (Fig. 30.24), resembling a transtibial (below-knee) prosthetic socket. The plastic brim has a slight indentation over the patellar tendon, and is hinged to facilitate donning. The brim must be used with a plastic solid ankle or a steel limited-motion ankle joint.

Knee-Ankle-Foot Orthoses

Individuals with more extensive paralysis or limb deformity may benefit from KAFOs, which consist of a shoe, foundation, ankle control, knee control, and superstructure. KAFOs often include foot control. The shoe, foundation, ankle control, and foot control of the KAFO may be selected from the components already described. Patients with poliomyelitis who wore carbon-composite KAFOs walked better than with leather/metal or plastic/metal KAFOs.^84,85,86 Donning a plastic and metal KAFO is appreciably faster than putting on a metal and leather orthosis because the shoe can be separated from the rest of the orthosis.

Knee Control

The simplest knee joint is a hinge. Because most KAFOs include a pair of uprights, the orthosis has a pair of knee hinges that provide medial–lateral and hyperextension restriction while permitting knee flexion.

The offset joint (Fig. 30.25 [left and middle]) is a hinge placed posterior to the midline of the leg. When the weight line falls anterior to the offset joint, stabilizing the knee in extension during the early stance phase of gait. The offset joint does not hamper knee flexion during swing or sitting. The joint may, however, flex inadvertently when the wearer walks on ramps.

The most common knee control is the drop ring lock (Fig. 30.25 [right]). When the client stands with the knee fully extended, the ring drops, preventing the uprights from bending. Although both medial and lateral joints should be locked for maximum stability, manipulating a pair of drop ring locks is inconvenient, unless each upright is equipped with a spring-loaded retention button. The button permits the wearer to unlock one upright, then attend to the other one without having the first lock drop. The buttons also enable the physical therapist to give the patient a trial period of walking with the knee joints unlocked.

The pawl lock with bail release (Fig. 30.26) provides simultaneous locking of both uprights. 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. Some people are agile enough to be able to nudge the bail by pressing it against a chair. The bail is bulky and may release the locks unexpectedly if the wearer is jostled against a rigid object.

The offset joint and knee joints with basic drop ring or pawl locks are contraindicated in the presence of knee flexion contracture. If one cannot achieve full passive knee extension, an adjustable knee joint such as the fan lock, serrated lock (Fig. 30.27), or ratchet lock is required. Such joints usually have a drop ring lock for stability in the partially flexed attitude.

Sagittal stability is augmented by a kneecap (Fig. 30.28A) or an anterior band or strap that completes the three-point pressure system necessary for stability. The cap or band applies a posteriorly directed force to complement the anteriorly directed forces from the back of the shoe and the thigh band. The leather knee cap has four straps buckled to both uprights above and below the knee. The knee cap requires the patient to buckle two straps when donning the orthosis. When the straps are tight enough to stabilize the knee, the cap is likely to restrict flexion when the wearer sits. A more practical alternative is a rigid anterior band, either a pretibial band or a suprapatellar band, both of which apply posteriorly directed force, but do not interfere with sitting and are easier to don. The bands generally are molded of plastic and thus not readily adjustable. The prepatellar band rests over the bony proximal portion of the leg and requires careful contouring to be comfortable. The suprapatellar band fits over the fleshy anterodistal thigh. Examples of combined metal and plastic KAFOs are presented in Fig. 30.28 (B and C).

Another means of obtaining sagittal stability involves a KAFO with an electronic stance control mechanism that prevents knee flexion during stance phase and permits knee flexion during swing phase. By moving a lever on the side of the joint, the patient can select the mode of action: (1) stance control that is disengaged during swing phase, (2) no stance control, and (3) lock in full extension. Preliminary investigation indicates that adults with LE paralysis walked faster and more efficiently, with increased cadence and step length, and fewer compensatory trunk movements, as compared with use of a locked KAFO.^{87,88,89,90,91,92,93,94,95} KAFOs with computer-controlled knee joints are also available⁹⁶ (Fig. 30.29). A KAFO with electronic knee control enables some patients with stroke and other neuropathies to walk⁹⁷ (Fig. 30.30).

Frontal plane control may be achieved with plastic calf shells shaped to apply corrective force for genu valgum or genu varum. To reduce genu valgum, the medial portion of the shell extends proximally in order to apply laterally directed force at the knee. The semi-rigid shell is more effective than a valgum correction strap, which is a knee cap with a fifth strap designed to be buckled around the lateral upright. The opposite force application is indicated for the patient who has genu varum. The shell does not require time in donning and applies force over a broad area without impinging on the popliteal fossa.

Superstructure

Thigh bands provide structural stability to the orthosis. If the distal portion of the limb cannot tolerate full weight-bearing, then the proximal thigh band may be shaped to form a weight-bearing brim. To eliminate all weight-bearing through the lower extremity, the orthosis must include a weight-bearing brim, a locked knee joint, and a patten bottom. The patten is a distal extension that keeps the foot on the braced side off the floor (Fig. 30.31). To maintain a level pelvis, the patient must also wear a lift on the opposite shoe; the height of the lift should equal the height of the patten.

Hip-Knee-Ankle-Foot Orthoses

Addition of a pelvic band and hip joints converts the KAFO to an HKAFO.

Hip Joint

The usual hip joint is a metal hinge (Fig. 30.32) that connects the lateral upright of the KAFO to a pelvic band. The joint prevents abduction and adduction, as well as hip rotation. If the patient requires only control of hip rotation, a simpler alternative to the hip joint and pelvic band is a webbing strap. To reduce internal rotation, the strap resembles a Silesian belt on a prosthesis. The center of the strap is riveted to the rear of a waist belt. Each end of the strap is attached to the proximal end of the lateral upright. To reduce external rotation, a strap joins the lateral uprights of the KAFOs, passing anteriorly at the level of the groin. If flexion control is required, a drop ring lock is added to the hip joint. A two-position lock stabilizes the patient in hip extension for standing and walking, and at 90 degrees of hip flexion for sitting.

Pelvic Band

An upholstered metal band (Fig. 30.33) anchors the HKAFO to the trunk. The band is designed to lodge between the greater trochanter and the iliac crest on each side. HKAFOs are not used very often because they are much more awkward to don than KAFOs, and, if the hip joints are locked, they restrict gait to the swing-to or swing-through pattern. The pelvic band may be uncomfortable when the wearer sits.

Trunk-Hip-Knee-Ankle-Foot Orthoses

Patients who require more stability than provided by HKAFOs may be fitted with THKAFOs (Fig. 30.34), which incorporate a lumbosacral orthosis attached to KAFOs. The pelvic band of the trunk orthosis serves as the pelvic band used on HKAFOs. Because the THKAFO is very difficult to don and is heavy and cumbersome, it is seldom worn after the client is discharged from the rehabilitation program. Alternative orthoses providing standing stability, with or without provision for walking, are available for some individuals with paraplegia.

Orthotic Options for Patients with Paraplegia

Orthoses are often prescribed for patients with spina bi-fida, spinal cord injury, or other disorders that result in paraplegia. The functional goals for such people include standing to maintain skeletal, renal, respiratory, circulatory, and gastrointestinal function and some form of ambulation. Upright posture also affords the individual important psychological benefits.

Mass-Produced Orthoses

Several appliances are marketed for children who have spina bifida or other disorders resulting in paraplegia. The mass-produced orthoses provide the youngster with considerable function and are less expensive and easier to don than many custom-made devices. The stabilizing points on these orthoses are the same, namely a means of securing the shoes to the base, an anterior knee band, posterior dorsolumbar band, and an anterior chest band. The orthoses permit the wearer to stand without crutch support, freeing the hands for play or vocational activities.

Standing Frame and Swivel Walker

The standing frame (Fig. 30.35) consists of a broad base, posterior nonarticulated uprights extending from a flat base to a midtorso chest band, and a posterior thoracolumbar band. Anterior leg bands contribute to stability. A similar orthosis is the swivel walker, which is made in both child and adult sizes. The major difference is the base. The swivel walker has two distal plates that rock slightly to enable a swiveling gait. Standing frames offering a variety of features are commercially available (Fig. 30.36).

Parapodium

The parapodium (Fig. 30.37) is manufactured in child sizes, and permits the wearer to sit. The base is flat. One version of parapodium has a provision for keeping the knees locked while the child unlocks the hips in order to lean forward to pick up objects from the floor. With some of these devices, the child can move from place to place by rotating the upper torso to shift weight, causing the frame to rock and rotate alternately on one edge then the other. For walking longer distances, the youngster uses crutches or a walker in the swing-to or swing-through pattern. The appliances are worn on the outside of clothing, which school-age children eventually find cosmetically objectionable.

Custom-Made Orthoses

Although the mass-produced devices afford considerable function to their users, many individuals seek more streamlined orthoses. Custom-made AFOs, KAFOs, and THKAFOs provide sufficient rigidity, either by metal joints or orthotic alignment, to enable selected individuals to stand. Ambulation requires crutches or similar aids, together with well-coordinated use of the trunk and upper limbs. Some patients may not realize the extent of the physical conditioning program required to prepare them for ambulation. Consequently, a trial period is advisable using mass-produced, adjustable, temporary orthoses.

Stabilizing Boots

AFOs designed for adults with paraplegia include a pair of stabilizing boots molded to conform to the patient's legs and feet (Fig. 30.38). The foot plate is angled at approximately 15° plantarflexion to shift the wearer's center of gravity anterior to the ankles. The plastic component is inserted into leather boots which have flat soles. The legs are thus inclined posteriorly to keep the knees extended. The patient maintains standing stability by leaning backward, with the iliofemoral ligaments resisting a backward fall. A pair of crutches or a walker is needed for two- or four-point gait. Ambulation requires shifting the upper torso diagonally forward to allow one leg to swing ahead. The orthoses are easy to don and do not restrict sitting. The candidate must not have any hip or knee flexion contractures, and must be able to extend the hips and lumbar spine by trunk motion.

Craig-Scott KAFOS

A pair of Craig-Scott KAFOs (Fig. 30.39) may be prescribed for adults with paraplegia. Each orthosis includes either a shoe reinforced with transverse and longitudinal plates and BiCAAL ankle joints set in slight dorsiflexion or a plastic solid ankle section, as well as a pretibial band, a pawl knee lock with bail release, and a single thigh band. The orthoses enable the patient to stand with sufficient backward lean so as to prevent untoward hip or trunk flexion. The gait pattern usually is swing-to or swing-through, with the aid of crutches or a walker. Although the orthoses do not restrict hip motion, the patient with thoracic spinal injury cannot control the hips, and the orthosis has no mechanism to aid single-leg progression. Some individuals perform a two- or four-point gait by shifting the trunk enough to allow the leg to swing forward in a pendular manner.

The Walkabout orthosis consists of a pair of KAFOs with a hinge mechanism joining the medial uprights of the two orthoses. The mechanism permits hip flexion and extension, but restricts hip abduction, adduction, and rotation.

Reciprocating Gait Orthoses

Children and adults can be fitted with a reciprocating gait orthosis (RGO) (Figs. 30.40 and 30.41). The RGO is a THKAFO in which the orthotic hip joints are connected by one or two metal cables or rods. The knees are stabilized with knee locks, and the feet are encased in solid ankle orthoses. To walk, the wearer follows a four-stage procedure: (1) shift weight to the right leg, (2) tuck the pelvis by extending the upper thorax, (3) press on the crutches, and (4) allow the left leg to swing through. For the next step, one shifts to the left leg, tucks, presses, and then allows the right leg to swing. The steel cable(s) or rods prevent inadvertent hip flexion on the supporting leg. Reciprocal four- or two-point gait is stable, because one foot is always on the floor, but the pace is slow. For sitting, the wearer releases the cable(s) to enable both hips to flex. RGOs require substantial energy expenditure on the part of the wearer.^{98,99,100,101}

Alternatives for patients with thoracic level spinal cord injury are the ParaWalker and the ParaStep. The ParaWalker is a THKAFO with massive hip joints. The clinician can limit the flexion and extension excursion of the hip joints. Gait is similar to that with an RGO. Subjects who wore the ParaWalker had fewer pressure sores and no fractures.¹⁰² The ParaStep is a system combining AFOs with skin electrodes over the quadriceps and glutei maximus. Energy expenditure with either device is very high.¹⁰³

Trunk orthoses may be used in association with LE orthoses or may be worn to reduce disabilities caused by low-back pain, neck sprain, scoliosis, or other skeletal or neuromuscular disorders. By supporting the trunk, the orthosis assists in controlling spinal motion; however, forces that the orthosis exerts are modified by the skin, subcutaneous tissue, and musculature that surround the vertebral column, and, in the case of higher orthoses, by the thoracic cage. Patients with spinal cord injury benefit from trunk orthoses in two ways: (1) the orthoses control motion of the lumbar region, with or without thoracic control, and (2) they compress the abdomen to improve respiration. Individuals with cervical lesions may need to wear an orthosis that restrains neck motion until stability is achieved by surgery or other means. A special group of trunk orthoses is intended for children and adolescents with scoliosis.

Corsets

If abdominal compression is the sole goal, a corset (Fig. 30.42) will suffice. It is a fabric orthosis that has no horizontal rigid structures, although many have vertical rigid reinforcements. The corset may cover only the lumbar and sacral regions, or may extend superiorly as a thoracolumbosacral corset. The primary effect of a corset is to increase intraabdominal pressure, although the orthosis does reduce frontal movement.¹⁰⁴

Some individuals with low back disorders find that corsets relieve pain.¹⁰⁵ The efficacy of orthotic intervention to reduce or prevent low back pain remains controversial.¹⁰⁶ The increase in intraabdominal pressure reduces stress on posterior spinal musculature, thus diminishing the load on the lumbar intervertebral disks. Although temporary reduction of abdominal and erector spinae muscular activity is therapeutic, long-term reliance on a corset can promote muscular atrophy^107,108,109 and contracture, as well as psychological dependence on the appliance.

Rigid Orthoses

Most lumbosacral and thoracolumbosacral orthoses include a corset or a fabric abdominal front to compress the abdomen. Rigid orthoses are distinguished by the presence of horizontal, as well as vertical, rigid plastic or metal components. Motion limitation is accomplished by a series of three-point pressure systems, in which force in one direction is counteracted by two forces in the opposite direction.

Lumbosacral Flexion, Extension, Lateral Control Orthoses

A typical example of a rigid trunk orthosis is the lumbosacral flexion, extension, lateral control (LS FEL) orthosis (Fig. 30.43), also known as a Knight spinal orthosis. This appliance includes a pelvic band, which should provide firm anchorage over the midsection of the buttocks, and a thoracic band, intended to lie horizontally over the lower thorax without impinging on the scapulae. The bands, which may be foam-lined rigid plastic or leather-upholstered metal, are joined by a pair of posterior uprights on either side of the vertebral spines, and a pair of lateral uprights placed at the right and left lateral midlines of the torso. A corset or abdominal front completes the LS FEL orthosis. The orthosis restrains flexion by a three-point system consisting of posteriorly directed force from the top and bottom of the abdominal front or corset and an anteriorly directed force from the posterior midportion of the orthosis. Extension is controlled by posteriorly directed force from the midsection of the abdominal front or corset and anteriorly directed force from the upper and lower posterior segments. The lateral aspects resist lateral flexion. Other rigid lumbosacral (LS) orthosis are made entirely of polyethylene with removable replaceable liners (Fig. 30.44).

Thoracolumbosacral Flexion, Extension Control Orthoses

Also called a Taylor brace, the thoracolumbosacral flexion, extension control (TLS FE) orthosis consists of a pelvic band, posterior uprights terminating at midscapular level, an abdominal front or corset, and axillary straps attached to an interscapular band. This orthosis reduces flexion by a three-point system consisting of posteriorly directed force from the axillary straps and the bottom of the abdominal front or corset, and anteriorly directed force from the midportion of the posterior uprights. Extension resistance is provided by posteriorly directed force from the midsection of the abdominal front or corset and anteriorly directed force from the pelvic and interscapular bands. Addition of lateral uprights converts the orthosis to a TLS FEL Knight Taylor orthosis (Fig. 30.45). Although TLSOs reduce segmental and gross spinal movements, the amount of movement reduction varies greatly from one person to another.¹¹⁰ Trunk movement restriction is evident when the wearer walks.¹¹¹ A plastic thoracolumbosacral jacket limits trunk motion in the frontal, sagittal, and transverse planes providing maximum support.

Cervical Orthoses

Cervical orthoses are classified according to design characteristics. Minimal motion control is provided by collars (Fig. 30.46) that encircle the neck with fabric, resilient foam, or rigid plastic. The therapeutic benefit of collars remains controversial.^112,113 The Philadelphia collar (Fig. 30.47) has mandibular and occipital extensions and a rigid anterior strut; it is sometimes used for upper cervical injuries.^{114,115,116,117} For moderate control, a four-post orthosis (Fig. 30.48) is used. Usually it has two anterior adjustable posts joining a sternal plate to a mandibular plate and two posterior uprights connecting a thoracic plate to an occipital plate. The sternal plate is strapped to the thoracic plate and the occipital plate is strapped to the mandibular plate. If the cervical orthosis does not fit properly, motion restriction is compromised.¹¹⁸

Maximum orthotic control of the neck may be achieved either with a Minerva or a halo orthosis (Fig. 30.49). The Minerva orthosis is a noninvasive appliance that has a rigid plastic posterior section extending from the head to the midtrunk; the superior posterior portion is held in place by a forehead band. The halo orthosis has a circular band of metal that is fixed to the skull by four tiny screws. Uprights connect the halo to a thoracic vest. Recent investigations confirm that the halo vest allowed cervical fractures to heal,^119,120 par ticularly fractures of the second cervical vertebra.^121,122,123 By limiting upper trunk motion, this orthosis reduces stride length,¹²⁴ and results in temporary atrophy of neck muscles.¹²⁵

Scoliosis Orthoses

Children and adolescents with kyphoses or thoracic, thoracolumbar, or lumbar scolioses may be fitted with a TLSO that applies distraction, derotation, and bending forces to realign the vertebral column and thoracic cage.^126,127,128 Brace effectiveness depends on the flexibility of the patient's torso¹²⁹ and snugness of contact with the wearer's trunk.¹³⁰ Although substantial improvement is evident when the orthosis is worn, long-term follow-up indicates that the major achievement is that the orthosis prevents the curve from increasing beyond its original contour. Bracing diminishes the likelihood of surgical correction of scoliosis.^131,132 Orthotic management is most effective for curves less than 35° Cobb angle.¹³³ Scoliosis orthoses are most effective on patients who have curves in the midthoracic or more inferior portions of the trunk. Although part-time wearing is better tolerated by adolescents, the classic protocol, which requires the youngster to wear the orthosis snugly 23 hours each day, is associated with more favorable results. Patients with larger curves achieve some curve reduction from bracing.^134,135 Braces do not impair standing balance.¹³⁶ Psychological factors, rather than the type or duration of brace wear, appear to be more important in self-reported quality of life among those for whom scoliosis braces are prescribed.^137,138 Adults with scoliosis do not benefit from orthoses.¹³⁹

The Milwaukee orthosis (Fig. 30.50), the oldest of contemporary scoliosis orthoses, is still prescribed. It consists of a frame composed of a pelvic girdle, two posterior uprights, an anterior upright, and a superior ring that can be hidden by clothing. Various pads are strapped to the frame to apply corrective forces. The Boston orthosis (Fig. 30.51) usually does not extend as high as the Milwaukee orthosis; its foundation is a mass-produced plastic module that the orthotist alters to fit the individual patient. Effectiveness is enhanced by snugly strapping the interior pads to the torso.¹⁴⁰ Long-term results are favorable,¹⁴¹ with patients preferring it to surgery.¹⁴² The Wilmington orthosis is another option; it is a custom-made thoracolum-bosacral jacket intended to guide the trunk to straighter alignment.

Night bracing is an alternate approach to scoliosis management. When the patient is in bed the effects of gravity are minimized allowing substantial corrective forces to be applied.¹⁴³ Nevertheless there is a higher risk of progression.¹⁴⁴ Both the Charleston bending brace and the Providence brace provide overcorrection of the spinal curve on the recumbent patient.^145,146 Scoliosis orthoses are also used for adolescents with hyperkyphosis.¹⁴⁷

To obtain the best service from orthoses, the patient should observe basic routine inspection and care procedures. Written instructions help reinforce the recommendations of the orthotist and therapist.

Shoes

Whether or not the shoe is attached directly to the orthosis, it is important that footwear be kept in good condition, with replacement of the sole and heel as soon as moderate wear is evident. The replacements should include whatever wedges, bars, or elevations were originally prescribed. The patient who tends to strike on the toe may need metal toe plates to preserve the sole. Shoes that are outgrown or distorted will not afford the wearer optimal function from the orthosis. If a stirrup is attached to the shoe, the patient should inspect the rivets to make certain that none has separated; if so, the shoe should be returned to the orthotist for repair.

Clean hose without holes or mends should be worn. In addition, long hosiery or cotton leggings shield the leg from pressure at the edges of the brace uprights, bands, and shells.

Shells, Bands, and Straps

Plastic bands and shells should be wiped with a damp cloth to remove any surface soil. It is inadvisable to try to hasten drying by using a hair dryer or other heat source that might soften the plastic. The patient should check the plastic periodically for any cracking; if any is noted, the orthosis should be brought to the orthotist for immediate repair. Hook-and-pile straps eventually become infiltrated with lint, which interferes with the hook-and-loop closing action; the straps should be inspected to determine if they should be replaced. Leather bands require periodic cleaning and can be washed with mild saddle soap. If the original leather deteriorates to the point that portions of the underlying metal are exposed, new leatherwork is required. Leather straps eventually become brittle and may break. A loss of flexibility indicates that it is time to replace the straps, before they break.

Uprights

In a plastic and metal KAFO for a child, the metal upright is screwed or riveted to the plastic shell. The orthosis can be lengthened by removing the fasteners and inserting them in new holes drilled farther up on the calf shell and farther down on the thigh shell. In a metal and leather AFO or KAFO for a child, the uprights are overlapped and secured with screws. The orthosis is lengthened by removing all screws, setting the uprights at the appropriate distance, and reinserting the screws.

Joints and Locks

Metal components should be kept away from sand, liquids, and similar substances. If the joints do not move smoothly or become noisy or if the locks do not engage properly, cleaning and lubrication may remedy the problem. Otherwise, professional attention is required.

Physical therapists participate in management of the wearer of an orthosis (1) before orthotic prescription, (2) at orthotic prescription, (3) on delivery of the orthosis, and (4) during training to facilitate proper use and care of the orthosis. In the ideal situation, the therapist is a member of an orthotic clinic team, working directly with the physician and orthotist to develop the orthotic prescription and examine the patient and orthosis before and after training. The physical therapist is also responsible for training the patient. Whether or not the hospital or rehabilitation center has a clinic team, the physical therapist is expected to accomplish the following.

Preorthotic Examination

The purposes of the preorthotic examination are to:

• Contribute to the orthotic prescription (analyze potential of orthotic components to remediate impairment, activity limitations, or disability).

• Examine the prescribed orthosis through analysis of (1) effects and benefits in terms of improved function, (2) movement while patient wears the device, (3) practicality and ease of use, (4) alignment and fit, and (5) safety during use of device.

• Facilitate orthotic acceptance.

• Train the patient to don, use, and maintain the orthosis.

Matching the patient's biomechanical requirements to the appropriate orthosis requires careful examination.

Joint Mobility

A thorough goniometric examination, including both active and passive range of motion, is a prerequisite to orthotic prescription. If the patient has a fixed foot deformity, either the shoe will have to be modified to accommodate the foot, or an insert will have to be fabricated. In either instance, the goal is to achieve comfortable contact of the entire plantar surface of the foot on the inner sole of the shoe. Knee flexion contracture necessitates prescription of accommodative joints, because the regular drop ring and pawl locks can be used only with a knee that can be brought to the fully extended position. Hip flexion contracture precludes the prescription of orthoses that depend on alignment for stability, such as the offset knee joint, stabilizing boots, or Craig-Scott KAFOs.

Limb Length

The therapist should ascertain whether leg lengths are equal. If the patient can stand, one can check the pelvis to determine if it is level. For the recumbent individual, one can measure each LE from the anterior superior iliac spine to the medial malleolus. A difference of more than 1/2 in (1 cm) should be compensated by a shoe elevation. For the patient with weakness in one limb, a 1/2-in (1 cm) lift on the contralateral shoe will aid clearance of the involved LE during swing phase.

Muscle Function

The manual muscle test (MMT) should be augmented by an examination of functional activities to determine what substitutions the patient makes to accomplish standing and walking. Although the muscle test may reveal marked weakness, if the patient can manage without an orthosis, it is unlikely that it will be accepted. For example, the person with dorsiflexor weakness who can ambulate by exaggerating hip flexion during swing phase may not agree to an AFO with a posterior stop. An important consideration in examination of muscle function is that traditional MMTs may be inappropriate in the presence of marked spasticity. In such instances, functional tests of motor performance are essential.

Sensation

The clinician should record the extent of any sensory loss. Intimately fitted plastic orthoses are satisfactory for individuals with sensory loss if the edges of the orthosis are smooth and the orthosis does not pinch the patient's flesh. Proprioceptive loss may indicate the need for orthotic stabilization, such as a solid ankle AFO to control a Charcot neuropathic ankle. Patients should be taught to inspect the skin (including presence of volume changes) regularly and instructed to bring any changes to the attention of the physical therapist.

Upper Limbs

Although the patient is being considered as a candidate for LE or trunk orthoses, the therapist must determine the mobility and muscle power of the upper limbs. Significant weakness, stiffness, or deformity will interfere with donning the orthosis. Substitution of hook-and-loop closures for leather buckles may suffice. If the individual cannot ambulate without canes or crutches, the therapist should determine whether standard aids will be satisfactory or whether modification of the hand pieces is required. If the upper limbs are very weak, the patient will not be able to use the LE orthoses for walking. Alternate standing arrangements may be preferable, such as the use of a standing frame, standing table, or standing wheelchair to provide weight-bearing stress.

Psychological Status

Realistic orthotic prescription requires ascertaining that the patient is willing to wear the orthosis. The patient with a recent spinal cord injury may still deny the permanence of paralysis and thus oppose wearing orthoses that are visible reminders of disability. The adolescent with spina bifida may prefer to sit unbraced in a wheelchair rather than struggle with donning orthoses and walking slowly, in a manner very different from the individual's peers. The patient with spinal cord injury must be prepared to work vigorously to increase upper limb and trunk strength and aerobic capacity. The person who has sustained a cerebral vascular accident resulting in severe perceptual deficits may not be able to walk, even with orthotic assistance, because the environment now seems unfamiliar. An orthosis for prevention of contractures may be prescribed, rather than one that is designed to aid gait.

The therapist should determine the extent to which the patient is likely to comply with instructions pertaining to orthotic use and care. For example, if it is doubtful that the individual will wear appropriate shoes with an insert orthosis, then the prescription should specify stirrup attachment to suitable shoes.

Orthotic Prescription

Lower extremity orthoses benefit individuals with a wide variety of musculoskeletal and neurological disorders. The particular diagnosis is less important in formulating the prescription than consideration of the patient's impairments and activity limitations. Prognosis also influences prescription. The person who is likely to recover partial or full function should have an orthosis that can be adjusted to accommodate the changing status. An individual with recent hemiplegia, for example, may exhibit marked spasticity, indicating a need for limiting motion at the ankle. As the person regains voluntary control and spasticity decreases, the orthotic ankle joint can be adjusted to permit more movement.

Lifestyle has a bearing on orthotic selection. A very active patient requires an orthosis made of exceptionally sturdy materials. Split stirrups, for example, may not be appropriate because they can spring loose from the receptacle on the shoe if excessive medial–lateral or rotational stress is applied. The patient's concern with appearance is another practical consideration; it may dictate use of a shoe insert so that reasonably fashionable shoes may be worn. Similarly, plastic shells are less bulky than metal uprights and calf bands, and do not present a shiny metal appearance. Although most people want the orthosis to be as inconspicuous as possible, some children and adults opt for bright colors, which can be achieved with various plastics.

Ankle-Foot Orthoses

The primary candidates for AFOs are those with peripheral neuropathy, especially peroneal lesions, and hemiplegia. Those with foot drag can be fitted with an AFO with a posterior stop; this design, however, tends to cause the knee to flex excessively in early stance when controlled plantarflexion is normally achieved. In the absence of plantarflexion, the patient may flex the knee to effect a foot-flat position. The alternative is a resilient shoe heel, or an AFO with a plastic posterior leaf spring or a metal dorsiflexion spring assist, both of which permit controlled plantarflexion early in stance to reduce knee stress.

Orthotic management of a patient with hemiplegia depends on the extent of spasticity and paralysis. If the motor loss is confined to poor dorsiflexion, the posterior leaf spring AFO suffices. An even simpler and less expensive option is a 1/2-in (1-cm) lift on the heel and sole of the contralateral shoe to provide clearance for the paretic limb during swing phase. Those with medial–lateral and sagittal plane instability require an AFO with limited-motion ankle joints or a plastic spiral AFO. With pain or severe instability, a solid ankle AFO is required. In the presence of severe spasticity, a spring assist for joint motion is contraindicated because the spring action may serve to increase spasticity.

Knee-Ankle-Foot and Other Lower Extremity Orthoses

A KAFO may be used to compensate for paralysis of the entire LE. The physical therapist should allow the patient the use a temporary orthosis in order to proceed more confidently with prescription of an expensive, custom-made orthosis. Several versions of temporary orthoses are manufactured and prove exceedingly useful in demonstrating whether the patient is likely to benefit from orthotic knee control.

Stabilizing AFOs, Craig-Scott KAFOs, HKAFOs, and the reciprocating gait orthosis are some options for patients with paraplegia. For the child, the orthotic program should start with a simple standing frame and progress to the parapodium before involving the child in the greater expense and donning difficulty of formfitting bracing. Older children and adults may begin with a swivel walker or lightweight modular frames.

Trunk Orthoses

A corset may be adequate to increase intraabdominal pressure and thereby may reduce the discomfort of low back pain. Where greater motion restriction is indicated, such as for the individual with trunk paralysis, the LS FEL, TLS FE, or TLS FEL orthosis provides substantial support. Plastic lumbosacral or thoracolumbosacral jackets offer maximum support. Cervical orthoses, whether collars or post devices, restrain motion and remind the wearer not to move the head in an abrupt manner. Collars also retain body heat, which may prove therapeutic. For maximum neck control, a halo orthosis is required.

Many orthoses are available for management of patients with scoliosis. These include the Milwaukee orthosis, which covers the greatest body area, as well as the Boston and Wilmington orthoses. The Providence and Charleston braces are designed for nighttime use only.

Orthotic Examination

Examination is an essential element of orthotic management. The physical therapist should be certain that the orthosis fits and functions properly before attempting to train the patient to use it. Analysis may be conducted under the aegis of a formal orthotic clinic team. If so, when the orthosis is delivered, the team should determine the adequacy of the orthosis as pass, provisional pass, or fail. Pass indicates that the orthosis is altogether satisfactory and the patient is ready for training. Provisional pass means that minor faults exist, generally having to do with the cosmetic finishing of the appliance; the patient can wear the orthosis in the training program without harmful effect. Failure signifies that the orthosis has a major defect that would interfere with training; for example, shoes that are too tight for the patient. The problem must be resolved before training can begin. If the orthosis is not prescribed by a clinic team, the physical therapist should use the evaluation procedure to ensure that the orthosis meets the patient's needs. Final evaluation is performed at the conclusion of training to judge the fit and function of the orthosis and the patient's skill in using it.

Lower Extremity Orthotic Examination

Orthotic examination includes both static and dynamic elements. The static component examines the orthosis on the patient while standing and sitting, as well as examination of the device off the individual. The dynamic component of the examination addresses analysis of the wearer's gait. An LE orthotic examination form is provided in Appendix 30.A, and a trunk orthotic examination form is provided in Appendix 30.B.

Static Examination

The orthosis is inspected as the wearer stands and sits. The patient's skin and the construction of the orthosis are checked with the orthosis off the patient. The orthosis should be compared with the prescription. Departures from the original specifications must be approved by the individual who approved the prescription.

The patient should stand in parallel bars, or other secure environment, and should attempt to bear equal weight on both feet. The shoe should fit satisfactorily, particularly in length, width, and snugness of the counter. Whether or not wedges or lifts have been added to the shoe, the sole and heel should rest flat on the floor, except for the distal portion, which should curve upward slightly to aid in late stance. The orthotic ankle joint should be at the distal tip of the medial malleolus to be congruent with the anatomical ankle and avoid vertical motion of the orthosis on the leg during gait.

The calf band should terminate below the fibular head to avoid impingement on the peroneal nerve. If a patellar-tendon-bearing brim is used, it should have a concave relief to limit pressure on the fibular head. This component does not eliminate distal weight-bearing; however, one should judge to see that the shoe heel is somewhat unloaded. This can be estimated by placing a ribbon in the shoe before the patient dons the shoe. One end of the ribbon hangs out the back of the shoe. When the patient stands with the shoe and orthosis on, the therapist should be able to pull the ribbon out of the shoe. The calf shell, band, or patellar-tendon-bearing brim should not intrude on the popliteal fossa; if so, the patient would have difficulty flexing the knee when sitting. Donning ease is affected by the type of closure of both the shoe and band.

The mechanical knee joints should be congruent with the anatomical knee; for the adult, the usual placement is approximately 3/4 in (2 cm) above the medial tibial plateau. The knee lock should function properly, because use of a lock is often the major reason for wearing a KAFO. The medial upright should terminate approximately 1.5 in (4 cm) below the perineum. The calf and distal thigh shells or bands should be equidistant so that when the orthosis is flexed, as in sitting, the plastic or metal parts will contact one another, rather than pinch the back of the wearer's leg.

If the KAFO has a quadrilateral brim to reduce weight-bearing through the skeleton, the brim should have adequate relief for the sensitive adductor longus tendon and should provide a sufficient seat for the ischial tuberosity.

The hip joint is set slightly above and anterior to the greater trochanter to compensate for the usual angulation of the femoral neck; setting the joint anterior to the trochanter takes into account the medial rotation of the femur. The pelvic band should conform to the contours of the wearer's torso, without edge pressure.

When the brace is off, the therapist should inspect the patient's skin to detect any irritations attributable to the orthosis. One should move the orthotic joints slowly to check range of motion. Binding refers to tilting of the distal portion of the joint in relation to the proximal member so as to interfere with movement. If the medial and lateral stops do not contact their respective stops at the same time, the stop that contacts first will erode more rapidly and may contribute to twisting of the orthosis.

Dynamic Examination

The gait pattern exhibited by the person who wears an orthosis reflects both the contribution of the wearer's general health status and orthotic motion control and assistance. Table 30.1 relates orthotic and anatomical causes of the most commonly observed gait deviations.

During early stance, the patient may exhibit foot slap, striking with toes first, or flat-foot contact, indicating inability to restrain plantarflexion or failure of the or-thosis to support the foot and ankle. Excessive medial or lateral contact may indicate that the orthosis does not track the way the patient's limb does. Knee hyperextension or excessive flexion indicates that the orthosis is not applying adequate control. A posterior stop on the AFO should prevent the lax knee from hyperextending. If the patient wears a KAFO and has knee hyperextension, the stops in the knee joint are set improperly or have eroded, or the calf and thigh shells or bands are too deep. Anterior and posterior trunk bending are seen at early stance when the patient attempts to control a weak knee or hip. If the quadriceps are weak, the patient will bend forward. The person who fears that the knee may collapse may benefit from an AFO with a solid ankle and an anterior band, or a KAFO with a knee lock. If the gluteus max-imus is weak, the individual is apt to lean backward. Lordosis indicates hip flexion contracture or a KAFO that does not fit properly. Lateral trunk bending in early stance phase may result from hip abductor weakness or hip instability; however, uncompensated shortness of the limb will also give rise to this problem, as will a medial upright on a KAFO that is too high, or an abducted pelvic joint on an HKAFO. A wide walking base may be the patient's compensation for a medial upright or shell that impinges into the perineum.

The client may have difficulty during late stance either delaying weight transfer or being unable to transfer weight over the affected foot. The problem can be mitigated with an anterior stop and a rocker bar. One should be certain that the trimlines of the solid ankle AFO or the stops on the stirrup function properly.

During swing phase, the patient must be able to clear the floor with the braced leg. Hip hiking (pelvic elevation) occurs when the hip flexors are weak, as well as when the limb is functionally longer than the contralateral limb. Increased length may be produced by a faulty posterior stop that no longer limits plantarflexion, or by a locked knee joint. The problem should be anticipated and, for the unilateral KAFO wearer, can be prevented by adding a 1/2 in (1 cm) lift to the contralateral shoe. Internal or external hip rotation may be caused by imbalance between medial and lateral musculature; the orthotic causes relate to malalignment of the brace. Similarly, excessive medial or lateral foot contact may indicate that the orthosis does not track the way the patient's limb does. A walking base that is abnormally wide can be caused by a limb that is longer than that on the opposite side. Vaulting refers to exaggerated plan-tarflexion on the contralateral limb during swing phase of the affected side. Vaulting occurs because the braced leg is functionally too long, possibly because the posterior ankle stop has eroded or a knee lock is used. The less agile patient may obtain foot clearance by hip hiking, that is, elevating the pelvis on the swing side.

Trunk Orthosis Static Examination

Lumbosacral and thoracolumbosacral orthoses usually include thoracic and pelvic bands, which should fit flat against the trunk without edge pressure. Uprights should not press against bony prominences, particularly when the patient sits. The abdominal front should extend from just below the xiphoid process to just above the pubic symphysis. The cervical orthosis should hold the head in the best tolerated position. Rigid components, such as a mandibular plate, occipital plate, sternal plate, or thoracic plate, should be shaped to apply maximum area to the body segment.

Facilitating Orthotic Acceptance

Clinic team management is valuable in fostering acceptance of the orthosis by the patient. The team also enables clinicians to join efforts to help the client achieve the maximum benefit from orthotic rehabilitation. Bringing the new wearer of an orthosis in contact with other users in the physical therapy department can help the new patient recognize that orthotic use is not a strange occurrence. Peer support groups for patients and their families are helpful for sharing concerns and anxieties and reaching workable solutions to common problems. Support groups usually are organized for people having particular disabilities, such as paraplegia or hemiplegia; many clients will have orthoses as part of their rehabilitation. The physical therapist can guide some meetings of the group. The therapist works most closely with the patient, usually on a daily basis, and thus is able to identify those individuals whose response to disability is sufficiently aberrant as to require psychological attention. Appendix 30.C provides website-based orthotic resources for clinicians, families, and patients.

Orthotic Instruction and Training

Orthoses are designed to provide the individual with a maximum of function with a minimum of discomfort and effort. No single training program suits every orthosis wearer because of the wide range of disorders for which orthotic management is indicated. To the extent possible, however, the physical therapist should instruct the patient in the correct manner of donning the orthosis, developing standing balance, walking safely, and performing other ambulatory activities.

Optimal performance depends on the favorable interaction of many factors. Foremost is the extent of skeletal and neuromuscular involvement. The mobility, strength, and coordination of all body segments, especially in the LEs and trunk, are important, as are the individual's muscle tone, cardiovascular and pulmonary health, body weight, psychological status, and chronological age. The quality of the orthosis also influences the client's achievements.

Most orthosis wearers have chronic conditions, such as rheumatoid arthritis, or permanent sequelae from trauma, such as paraplegia following spinal cord injury. Orthotic management enhances function without necessarily influencing the underlying pathology. Training people with chronic disorders prepares the patient for lifelong activity with an orthosis. Persons with reversible disorders, such as peroneal nerve injury, often benefit from temporary use of an orthosis. Such individuals should learn proper use of the orthosis to prevent secondary disorders and should receive reexamination so that the orthosis may be altered as the condition changes. Patients with progressive disorders, such as muscular dystrophy and multiple sclerosis, require vigilant reexamination so that the extent of physical deterioration may be reflected in orthotic changes, as well as continual training to cope with altered functional abilities. For all situations, an individually devised exercise and activity program should enable the patient to manage efficiently for maximum independence.

Donning Orthoses

Regardless of type of LE orthosis, the patient should wear clean, properly fitting hose. The AFO with shoe insert is most easily donned by applying the orthosis to the foot and leg, before placing the braced limb in the shoe. If the AFO has a split stirrup, the shoe should be donned first; then the orthosis should be fitted into the box caliper on the shoe. If the AFO has a solid stirrup, the patient will have to insert the foot into the shoe, then fasten the calf band.

The same general procedures are useful with KAFOs. The patient may find donning easier if the brace is applied while lying on a bed or a mat table. If the KAFO is donned while the patient sits, the therapist should check the tightness of the orthotic knee cap, if this component is part of the orthosis. A kneecap that is comfortable for sitting will probably be too loose for effective knee control when the wearer stands. Donning HKAFOs and THKAFOs is much more arduous. The beginner should lie on a mat table alongside the orthosis. By rolling to one side, the patient should be able to pull the brace under the legs so as to permit lying in it. Then the patient sits with knees extended to don shoes and fasten straps.

Lumbosacral and thoracolumbosacral corsets and rigid orthoses should be donned while the patient is supine to achieve maximum compression of the abdomen. The orthosis should be fastened from the bottom upward.

Standing Balance

The problem of standing safely is most difficult for the individual who wears a pair of KAFOs or more extensive bracing. In ordinary standing, all weight passes through the feet, whereas when standing and walking with orthoses and crutches, the patient must learn to distribute weight partly on the hands and partly on the feet. With orthoses, the line of gravity falls within a tripod bounded by the hands and feet. The tripod is a compromise between leaning too far forward on the hands, to increase stability at the price of fatiguing the arms, and leaning too far backward, which reduces arm strain but makes balance precarious. As balance improves, the patient uses the hands only for balance, rather than for substantial weight-bearing.

The person who wears bilateral KAFOs will need crutches or other aids for independent gait. A prerequisite for crutch ambulation is the ability to shift weight. Shifting weight to the heels takes pressure off the hands so they can be moved. Using parallel bars, the beginner shifts all weight to the feet and raises and lowers one hand, then the other hand. The goal is to be able to lift both hands simultaneously, as may be done with crutches when performing a drag-to or similar gait. Once the patient is able to shift weight from the feet to the hands and back to the feet confidently, the same exercise should be done with crutches. Advanced skills, such as moving the hands and eventually the crutches, behind the body, should be practiced. Those who will walk in reciprocal fashion, alternating footsteps, need to practice diagonal weight shifting.

Gait Training

The various crutch gaits differ in the sequence of crutch and footsteps. Patterns vary in speed, safety, and amount of energy required. The patient should learn as many gaits as possible, so as to modify walking in crowds, over long distances, and in situations in which speed is desired. In addition to walking forward, the client needs to be able to walk sideward, turn corners, and maneuver on different surfaces, such as rugs, gravel, grass, and through doors. A repertoire of gaits permits the client to adjust to environmental requirements. Gait selection depends on the individual's functional ability, including the following areas:

• Step ability: Can the patient take steps with either one or both LEs?

• Weight-bearing and balance ability: Can the patient bear weight and remain balanced on one or both LEs?

• Upper-limb power: Can the patient push the body off the floor by pressing down on the hands?

Reciprocal Gaits

The four- and two-point gaits require that one move the LEs alternately by hip flexion or pelvic elevation. The patient shifts weight as each LE is moved. The four-point sequence is (1) right hand, (2) left foot, (3) left hand, and (4) right foot. The two-point sequence requires greater balance and coordination, but is a faster mode of walking: (1) right hand and left leg; (2) left hand and right leg. The patterns also are useful when one is confronted with crowds or slippery surfaces. These gaits are suited to persons who lack the coordination and balance needed for simultaneous gaits.

Simultaneous Gaits

If both LEs are moved simultaneously, the patient places considerable stress on the upper limbs. The series includes the drag-to, swing-to, and swing-through patterns. Although the swing-through gait can be performed rapidly, simultaneous gaits generally are slow and very fatiguing, because the upper limbs are poorly adapted for ambulatory function; a sizable amount of nonfunctioning bodily structure must be controlled by a smaller muscular apparatus. The weight of the orthoses and, in the case of a patient with spinal cord lesion, absence of peripheral sensation aggravate the problem of using a simultaneous gait pattern.

The drag-to gait is the most elementary of the group, but it is very slow. The sequence is (1) advance both hands, then (2) push on the crutches enough to drag the feet forward. The feet do not pass ahead of the hands. The swing-to pattern is more rapid, because the patient swings rather than drags the LEs. Swinging is accomplished by extending the elbows and depressing the shoulder girdle to elevate the trunk and LEs. The swing-through gait is the most advanced pattern, requiring much balance, strength, and coordination of the upper limbs, because the patient swings the LEs beyond the hands, or crutch tips. The sequence is (1) advance both hands, (2) swing both LEs to a point in front of the hands to reverse the basic tripod position, and (3) advance both hands to the starting position. The swing-through gait requires extensive preliminary training, including push-ups to strengthen the arms. The gait is rapid but requires more floor space than the other patterns, to permit alternate swinging of LEs and crutches.

The ultimate test of walking proficiency is the ability to conduct a conversation while ambulating, an activity pattern that indicates some degree of automatic functioning. Practice in the clinical setting should be extended to walking on varied terrain, indoors and outdoors.

Related Activities

The patient should learn as many activities as physical condition permits. Daily life often involves negotiating stairs, curbs, and ramps, as well as transferring from the chair to the upright position, and into an automobile. Instruction in driving a suitably equipped car is an important part of rehabilitation. Not all individuals who wear orthoses achieve the full range of ambulatory activities, yet they benefit from partial independence in accomplishing tasks, at least from the psychological and physiological values attendant to ambulation.

Final Examination and Follow-up Care

Before discharge, the orthosis wearer and the brace should be examined to make certain that fit, function, appearance, and use are acceptable. The patient should return to the hospital or rehabilitation center at regular intervals so that the clinic team can monitor the individual's function and the orthosis, and can spot incipient abrasions or other signs of misfit or disrepair. The followup visit also enables the physical therapist to reinforce skills taught in the intensive program and address any new problems the patient may present.

Functional Capacities

The patient's ambulatory ability and capacity for other physical activities reflect both orthotic and anatomical factors. Energy measurement is a valuable guide to functional capacity. Energy cost is calculated from the amount of oxygen consumed as the subject performs. Consumption may be determined either per unit of distance traversed or per unit of time. Everyone tends to select a walking speed that requires the least energy per unit of distance. If the energy cost is too high, the patient will realize that ambulation is not practical. Sometimes, high energy cost is tolerable for short distances, as in household ambulation. Community ambulation, however, demands sustained effort for longer distances, plus the ability to maneuver over curbs and other irregularities in the walking surface and cross the street within the time allowed by the traffic light. Many energy studies have been conducted with the two largest groups of individuals who wear orthoses, namely those with paraplegia and those with hemiplegia.¹⁴⁸

Paraplegia

The level of spinal cord damage is a critical determinant of functional capacity. Investigators generally conclude that functional ambulation is not feasible for those with lesions above the T11 segment of the spinal cord. Children wearing the reciprocating gait orthosis while performing the swing-through crutch gait have approximately the same energy expenditure as when propelling a wheelchair. Adults with thoracic injuries consume nine times the energy expended by nondisabled individuals per meter, and those with lumbar lesions require triple the normal amount of oxygen when walking at self-selected speeds. Those with high-level paraplegia use three times their own basal oxygen rate ambulating with Craig-Scott KAFOs; they choose a very slow walking pace. Subjects with lesions between T11 and L2 wearing bilateral KAFOs select walking speeds less than half that of nondisabled persons, with oxygen uptake six times normal. Wheelchair propulsion by the same group increases oxygen uptake less than 10% more than normal, at a considerably faster speed. The very high energy cost may be accounted for by the fact that the LE paralysis requires that the individual move by upper limb and thoracic action, usually in a swing- to or swing-through gait. This pattern is extremely strenuous, taxing nondisabled adults by at least 75% more energy than normal walking.

Of less significance in determining functional capacity is the type of orthosis. Restraining both plantarflexion and dorsiflexion, as provided by Craig-Scott KAFOs, reduces energy demand very slightly. Ankle restraint, however, makes no appreciable difference in the energy required to negotiate stairs and ramps. Performance is somewhat more efficient with molded plastic KAFOs, which weigh slightly less than traditional metal and leather braces. Most subjects fitted with a reciprocating gait orthosis preferred it primarily because of its appearance and perception of stability.

One should not lose sight of the principal purpose of ambulation, namely to get from one place to another, rather than to execute an exhausting physical stunt. The nearly universal abandonment of orthoses by individuals with thoracic spinal cord injury after discharge from the rehabilitation center attests to the fact that most decide that accomplishing vocational and recreational tasks is more important than struggling with brace donning and energy-costly ambulation.

Hemiplegia

Although the increased energy demand occasioned by hemiplegic ambulation is not nearly as dramatic as that for paraplegic gait, the cost should be considered in planning reasonable goals. Energy cost rises in proportion to the amount of spasticity. The increase ranges from no appreciable difference for persons with hemiplegia to a 100% increase for relatively inexperienced walkers. On average, comfortable gait is approximately half the speed of that for nondisabled individuals.

The type of orthosis does not appear to make much difference in functional capacity, although patients with hemiplegia perform more efficiently with some form of AFO than without any bracing. Investigation of the factors that influence energy expenditure, especially physical status, helps the clinician plan the most appropriate rehabilitation program and forecast long-term performance.

This chapter has focused on lower extremity and trunk orthoses. The most frequently prescribed orthoses and orthotic components have been presented. In addition, the responsibilities of the physical therapist in orthotic management have been emphasized.

Ideally, an orthosis is prescribed by an orthotic clinic team composed of a physician, physical therapist, and orthotist. The prescription should be based on a thorough examination, with particular attention to the specific factors discussed in this chapter. Input from the patient and all team members during the decision making process is critical. This approach will ensure an optimum match between the patient's biomechanical and psychological requirements and an appropriate orthosis capable of performing its intended function. Once the orthosis has been prescribed, it should be evaluated to ensure satisfactory fit, function, and construction, and the patient should have the benefit of a suitable training program for donning the orthosis and using it effectively.

Questions for Review

1. Discuss the purpose of a correctly fitted shoe in orthotic management.

2. Describe the purpose (function) of the following external shoe modifications: heel wedge, sole wedge, metatarsal bar, and rocker bar.

3. What are the advantages of a plastic orthotic shoe insert as compared with the solid stirrup?

4. For the patient with dorsiflexor weakness or paralysis, explain how a posterior leaf spring AFO imparts its function during early stance and swing phases of gait.

5. What is the function of the proximal anterior band on a floor reaction AFO?

6. How do tone-inhibiting AFOs improve the patient's function?

7. Indicate the clinical use of an AFO with a patellar-tendon-bearing brim.

8. What strategies can be used to increase the rigidity of plastic orthoses?

9. What is the function of an offset knee joint on a knee-ankle-foot orthosis (KAFO)?

10. Describe the three-point system in a lumbosacral flexion, extension, control orthosis.

11. What data should be gathered before formulating an orthotic prescription?

12. Compare and contrast the orthotic options for a patient with hemiplegia.

13. What are the purposes of the preorthotic examination?

14. What features of the AFO are considered during the static evaluation?

15. What are the anatomical and orthotic causes of vaulting?

PATIENT HISTORY AND CURRENT PROBLEM

The patient is a 65-year-old woman who had poliomyelitis at age 3. She sustained complete paralysis of the right LE and left foot and ankle. During childhood she wore bilateral knee-ankle-foot (KAFO) orthoses and ambulated with a four-point gait with the aid of a pair of axillary crutches. When she was 18, she had a left ankle and subtalar fusion. She was fitted with a right KAFO, which included a stirrup foundation, posterior ankle stop, drop ring knee lock, knee pad, and leather-covered calf and thigh bands. For the next 40 years, she wore the same brace, and had the leather and shoe replaced whenever they became worn. She used a cane in the left hand when she walked outdoors. She returned to the rehabilitation department today complaining of pain in the right knee and fatigue. She also said that her brace tears her stockings at the knee. She is curious about new orthotic developments.

PAST MEDICAL HISTORY

Except for poliomyelitis, she enjoyed good health although her endurance was always less than that of her friends.

SOCIAL HISTORY

The patient is a reference librarian who lives with her husband. She enjoys visiting her grandchildren, attending the theater, and participating in political campaigns.

PHYSICAL THERAPY EXAMINATION FINDINGS

• Cognitive status: Alert, oriented, memory intact

• Endurance: Limited, primarily restricted by discomfort in her right knee. She can walk for three city blocks before having to rest.

• Vision: Intact with corrective lens

• Blood pressure: 136/74

• Respiratory rate: Within functional limits (WFL)

Range of Motion Examination

Sensation

• All modalities WFL bilaterally in both limbs

• Sensation in both upper limbs WFL

Strength: Manual Muscle Test (MMT) Grades

Orthotic Examination

Uprights malaligned permitting 20° knee hyperextension. Posterior ankle stop worn, permitting 10° plantarflexion. Leather on calf and thigh bands is worn.

Balance

Standing

• Static: Good; able to maintain static position for unlimited period.

• Dynamic: Good on level surface. Not tested on ramp; patient reports that balance on ramps is precarious.

Sitting

• WFL

Gait

Patient walks slowly with a right KAFO with considerable trunk bending to the right. Bending reduces when she uses a cane in the left hand. She reports that she has great difficulty ascending and descending ramps. Additional findings include the following:

• Overall decrease in speed of movement

• Broad walking base

• Circumducts right leg

• Right knee hyperextends within the orthosis

• Right ankle plantarflexion limited by orthosis

• Left foot and ankle immobile

Functional Status

• Independent in transfers: sit-to-stand; floor-to-stand transfer

• Independent in all basic activities of daily living (BADL)

• Independent in approximately 85% of instrumental activities of daily living (IADL) (limitations imposed by pain, fatigue, and low ambulatory tolerance)

PATIENT-DESIRED OUTCOME AND GOALS

• Walk without knee pain.

• Improve endurance.

• Improve appearance.

• Reduce frequency of torn stockings in the vicinity of the knee.

1. Formulate a clinical problem list.

2. Formulate a patient asset list.

3. Establish anticipated goals and expected outcomes of physical therapy.

4. Formulate a physical therapy plan of care.

1. Is the orthosis as prescribed?

2. Can the client don the orthosis easily?

Standing

• 3. Is the shoe satisfactory and does it fit properly?

• 4. Are the sole and heel of the shoe flat on the floor?

• 5. If a shoe insert is used, is there minimal rocking between insert and shoe?

Ankle

• 6. Do the mechanical ankle joints coincide with the anatomical ankle (anatomical ankle joint axis is approximated by a horizontal line between the malleoli at level of the distal tip of the medial malleolus)?

• 7. Is there adequate clearance between the anatomical ankle and the mechanical ankle joints?

• 8. Does the valgus or varus correction strap control the foot position?

Knee

• 9. Does the mechanical knee joint(s) coincide with the anatomical knee (0.5–0.75 in [1.2–1.9 cm]) above medial tibial plateau?

• 10. Is there adequate clearance between the anatomical knee and the mechanical knee joint?

• 11. Is the knee lock secure and easy to operate?

Shells, Bands, Cuffs, and Uprights

• 12. Do the shells, bands, cuffs, and uprights conform to the contours of the leg and thigh?

• 13. Is there adequate clearance between the top of the calf shell or band and the head of the fibula?

• 14. Is there adequate clearance between the orthosis and the perineum?

• 15. Is the orthosis below the greater trochanter but at least 1 in (2.5 cm) higher than the medial shell or upright?

• 16. Are the uprights at the midline of the leg and thigh?

• 17. Do the shells, bands, and cuffs conform to the contours of the leg and thigh?

• 18. Is any flesh roll above the shell or band minimal?

• 19. Are the bottom of the thigh shell or distal thigh band and the top of the calf shell or band equidistant from the knee?

• 20. In a child's orthosis, is there adequate provision for lengthening the orthosis?

Weight-Relieving Components

• 21. In a patellar-tendon-bearing brim, is there adequate relief for the head of the fibula?

• 22. With a quadrilateral brim, is the client free from excessive pressure in the anteromedial and medial aspect of the brim?

• 23. With a quadrilateral brim, does the ischial tuberosity rest on the ischial seat?

• 24. With a patellar-tendon-bearing brim, is there adequate reduction in weight-bearing through the orthosis?

Hip

• 25. Is the center of the pelvic joint slightly above and ahead of greater trochanter?

• 26. Is the hip lock secure and easy to operate?

• 27. Does the pelvic band fit the torso accurately?

Stability

• 28. Does the orthosis provide adequate stability to the client?

Sitting

• 29. Can the patient sit comfortably with hips and knees flexed 90°?

• 30. Can the patient lean forward to touch the shoes?

Walking

• 31. Is the patient's performance in level walking satisfactory?

• 32. Is the patient's performance on stairs and ramps satisfactory?

• 33. Is the orthosis sufficiently rigid?

• 34. Does the varus or valgus correction strap provide adequate support?

• 35. Does the orthosis operate quietly?

• 36. Does the patient consider the orthosis satisfactory as to comfort, function, and appearance?

Orthosis Off the Patient

• 37. Is the skin free of abrasions or other discolorations attributable to the orthosis?

• 38. Is the construction satisfactory?

• 39. Do all components function satisfactorily?

1. Is the orthosis as prescribed?

2. Can the client don the orthosis easily?

Standing

Pelvic Band

• 3. Does the pelvic band lie flat on the trunk below the posterior superior iliac spines?

• 4. Does the pelvic band pass between the trochanters and iliac crests?

Thoracic Band

• 5. Does the thoracic band lie flat on the trunk below the scapulae?

• 6. Does the thoracic band lie horizontally on the trunk?

Uprights

• 7. Do the posterior uprights avoid pressure on bony prominences, such as the vertebral spines or scapulae?

• 8. Do the lateral uprights extend along the lateral mid-lines of the trunk?

Abdominal Front

• 9. Is the abdominal front of adequate size?

Cervical Orthosis

• 10. Is the head in the prescribed position?

• 11. Do all rigid components fit properly?

Sitting

• 12. Can the patient sit comfortably with the hips and knees flexed 90°?

• 13. Does the patient consider the orthosis satisfactory as to comfort, function, and appearance?

Orthosis Off the Patient

• 14. Is the skin free of abrasions or other discolorations attributable to the orthosis?

• 15. Is the construction satisfactory?

• 16. Do all components function satisfactorily?