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== Introduction ==
== Introduction ==
[[File:AFO brace for foot drop.jpeg|thumb]]
The aim of orthotics is to increase the efficiency of function during acute or long-term injury. This includes soft-tissue and bony injury, as well as changes as a result of [[Spasticity|neurological changes]]. They can be an effective adjunct alongside physiotherapy techniques such as muscle [[Strength Training|strengthening]] and [[Stretching|stretches]], [[Gait Disturbances|gait]] and [[Balance Training|balance retraining]] and reach and grasp strategies.
The aim of orthotics are to increase the efficiency of function during acute or long-term injury. This includes soft-tissue and boney injury, as well as changes as a result of [[Spasticity|neurological changes]]. They can be an effective adjunct alongside physiotherapy techniques such as muscle strengthening and stretches, gait and balance retraining and reach and grasp strategies.


A number of considerations need to be made before deciding on the type of orthotic needed:
A number of considerations need to be made before deciding on the type of orthotic needed:
* What are the patient’s goals?
* What are the patient’s goals?
* What are the specific impairments impacting on their function (thinking of head-to-toe and [[Gait|gait analysis]]).
* What are the specific impairments impacting on their function (thinking of head-to-toe and [[Gait|gait analysis]]).
Line 21: Line 13:
* Can the patient cope with any adjuncts given?
* Can the patient cope with any adjuncts given?


Orthotics can be pre-made or customised, depending on the patient's needs.  
Orthotics can be pre-made or customised, depending on the patient's needs.  


=== "Off the shelf" Orthotics ===
== What is an Orthosis? ==
Many patient's can utilise ready made orthotics, which can often be adjusted to fit their size. These may come in small, medium and large sizes and can often be sized to the patient, e.g. with velcro straps. These are often lighter materials. They can also be good for an assessment, to confirm or deny a theory before a custom orthotic is made.
An orthosis is generally an individually designed or customised device, which is applied to the external part of the body to provide support and protection for that particular area of the body. It uses integrates [[Biomechanics|biomechanical]] principles to realign joints and reduce pain. The design, materials and function of the orthosis are based on a patient assessment, including their medical history, biomechanical principles and the individual needs of the user.  


=== Custom Orthotics ===
Commonly prescribed orthoses include:
Some individuals have more complex injuries / changes to one of multiple joint structures, and therefore require a customised orthosis. This may be particularly true in neurological conditions, such as [[Cerebral Palsy Effects through Lifespan|Cerebral Palsy]] (CP), [[Parkinson's|Parkinson's Disease]] (PD) or after brain injury, such as [[Overview of Traumatic Brain Injury|traumatic brain jury]] (TBI) or stroke. In these cases, spasticity of muscles may have an impact on the patient's function. Orthotics can be used both in resting and during mobility to improve affects of spasticity or reduce risk of contractures. In which case the orthotic will be specifically measured to the individual, and likely to be redone as the individual grows (in paediatrics) or as changes are made to joint structures.


=== Advantages ===
* Foot Orthoses (FOs), for various foot, leg or postural problems; there is significant variety in terms of their design and manufacturing methods<ref>Chapman LS, Redmond AC, Landorf KB, Rome K, Keenan AM, Waxman R, et al. [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6347791/ Foot orthoses for people with rheumatoid arthritis: a survey of prescription habits among podiatrists]. J Foot Ankle Res. 2019;12:7. </ref><ref>Gerrard JM, Bonanno DR, Whittaker GA, Landorf KB. [https://jfootankleres.biomedcentral.com/articles/10.1186/s13047-020-00401-3 Effect of different orthotic materials on plantar pressures: a systematic review]. Journal of foot and ankle research. 2020 Dec;13(1):1-1.</ref>
Lower limb: Influence both swing and stance phase of gait<ref>Condie & Meadows ''Report of a consensus conference on the lower limb orthotic management of cerebral palsy'' International Society for Prosthetics and Orthotics(1995) <nowiki>ISBN 9788789809021</nowiki></ref>.
* Ankle Orthoses (AOs) and Knee Orthoses (KOs), for joint protection, pain reduction or support after [[Surgery and General Anaesthetic|surgery]]
* Prevent or correct deformity and reduce pain during weight bearing
* Ankle-Foot Orthoses ([[Introduction to Ankle Foot Orthoses|AFOs]]) and Knee-Ankle-Foot Orthoses (KAFOs), to improve mobility, support rehabilitation and biomechanical goals
* Improve efficiency of gait and maintain balance
* Various upper-limb orthoses, to provide positional and functional support to the upper limb
* Improve base of support / lateral support
* Fracture orthoses, modern alternative to plaster or fibreglass casts
* Reduce need for compensation of ipsilateral and contralateral limbs and secondary pain
* Spinal Orthoses, to correct or control spinal deformities and injuries and to provide immobilisation or support to spinal injuries<ref>AOPA What is an orthotics? Available:https://www.aopa.org.au/careers/what-are-orthoses-and-prostheses (accessed 4.6.22)</ref>
* To facilitate training in skills
Upper limbs: Can be used after an injury to prevent further injury, or reduced pain by supporting an injured limb.
* Prevent or correct deformity reducing pain and maximising function in reach and grasp tasks.
* In prove efficiency of reach and grasp tasks
* Off load an injured limb to allow healing
* Reduce need for compensation of ipsilateral and contralateral limbs and secondary pain
* Improve role of upper limb in maintaining balance
Spine: Stabalise spinal fractures to allow the patient to return to some normal activies (although they may be restricted) and protect the spinal cord.


=== Possible Complications ===
=== "Off the shelf" Orthotics ===
* Loss of [[sensation]] (check skin regularly- risk of [[Pressure Ulcers|pressure areas]])
Many patients can utilise ready-made orthotics, which can often be adjusted to fit their size. These may come in small, medium and large sizes and can often be sized to the patient, e.g. with velcro straps. These are often lighter materials. They can also be good for an assessment, to confirm or deny a theory before a custom orthotic is made.
* Compensations in ipsilateral or contralateral limbs.  
* Impact on spasticity (is the patient utilising spasticity to allow some function in absence of muscle strength?)
* Complications of casting at incorrect angle: Foot deformities<ref>Karakas & Hoy (2002)</ref>, increased knee flexion in stance<ref name=":0">Owen E. ''The Effects of Tuning an Ankle-Foot Orthosis Footwear Combination on Kinematics and Kinetics of the Knee Joint of an Adult with Hemiplegia'' Prosthetics and Orthotics (2014) 34(3): 270-6</ref>, muscle contractors<ref name=":0" />
* Loss of sensory feedback and [[proprioception]] loss
* Ristricted range of motion
* Loss of natural shock absorption and long term joint damage
* '''Spinal orthotics must be put on and taken off within the guidelines of a spinal professional. Patients may be able to moblise within set restrictions, depending on the severity of their injury. Non-adherence to guidance may result in [[Spinal Cord Injury|spinal cord injury]].''' 


Also, success depends on patient's acceptance. Consider:
=== Custom Orthotics ===
* Cosmesis
Some individuals have more complex injuries / changes to one of the multiple joint structures and therefore require a customised orthosis. This may be particularly true in neurological conditions, such as [[Cerebral Palsy Effects through Lifespan|Cerebral Palsy]] (CP), [[Parkinson's|Parkinson's Disease]] (PD) or after brain injury, such as [[Overview of Traumatic Brain Injury|traumatic brain jury]] (TBI) or stroke. In these cases, spasticity of muscles may have an impact on the patient's function. Orthotics can be used both in resting and during mobility to improve the effects of spasticity or reduce the risk of contractures. In which case the orthotic will be specifically measured to the individual, and likely to be redone as the individual grows (in paediatrics) or as changes are made to joint structures.
* Footwear
* Weight/rigidity
* Ability to Don Doff
* Compensations preferred
* Compensations required


=== Types of Orthotics ===
== Why is an Orthosis used? ==
=== Upper Limb ===
An orthosis provides support and protection for joints or parts of the body. It can optimally align a joint into a better functional position, whether it be the position of a hand or an elbow or a knee or a foot.<ref>Webster JB, Murphy DP, editors. Atlas of orthoses and assistive devices. Amsterdam, The Netherlands:: Elsevier; 2019.</ref> It is often used to reduce pain. A good orthosis can also maintain a functional position with the joint and we can use an orthosis either dynamically or statically to achieve this functional position.


== Where can an Orthosis be used? ==
An orthoses can be fitted to any part of the body from the head, such as helmets, to the feet and toes with insoles and footwear.<ref>Jarvis HL, Nester CJ, Bowden PD, Jones RK. Challenging the foundations of the clinical model of foot function: further evidence that the root model assessments fail to appropriately classify foot function. Journal of foot and ankle research. 2017 Dec;10(1):1-1.</ref>


Useful resources:
== 3 Steps to Create an Orthosis ==
The position, structure, design and fitting of the orthosis is based on the assessment of the patient and clear goals of what the therapist and patient want to achieve.<ref>Chui KC, Jorge M, Yen SC, Lusardi MM. Orthotics and Prosthetics in Rehabilitation E-Book. Elsevier Health Sciences; 2019 Jul 6.</ref> This can be a complex process and a problem-solving exercise.<ref>Mangai S, Ranganathan R, Pugalendhi A, Gokul Raj N, Deepan Raju S, Dharani T, Durga R. Design And Development Of Ankle Foot Orthosis Using Additive Manufacturing Technique. 2020.</ref> All orthotists need to be good at problem-solving.<ref>Menz HB, Allan JJ, Bonanno DR, Landorf KB, Murley GS. Custom-made foot orthoses: an analysis of prescription characteristics from an Australian commercial orthotic laboratory. Journal of foot and ankle research. 2017 Dec;10(1):1-9.</ref>


* [[Introduction to Upper Limb Orthoses]]
The three main steps to follow are assessment, design and manufacture, and fitting and evaluation.
* [[Orthoses for Management of Hand Dysfunction]]


==== Lower Limb ====
=== 1. Assessment ===
Orthotics can be used to optimise the alignment of the lower limb. This can be used to stabilise a joint to allow it to heal, or to facilitate ease of function. It can also be used to prevent or correct deformity in the lower limb, increasing efficiency.


Useful resources:
* Medical/Physical
* Biomechanical<ref>Nester CJ, Jarvis HL, Jones RK, Bowden PD, Liu A. Movement of the human foot in 100 pain-free individuals aged 18–45: implications for understanding normal foot function. Journal of foot and ankle research. 2014 Dec;7(1):1-0.</ref>
* ROM/Muscle Power
* [[Proprioception]]
* [[Sensation]]


* [[Introduction to Foot Orthoses|Introduction to Foot orthoses]]
=== 2. Design/manufacture ===
* [[Introduction to Ankle Foot Orthoses]]
* [[Introduction to Knee Ankle Foot Orthoses]]
* [[Introduction to Hip Knee Ankle Foot Orthoses]]


*  
* Materials
* Construction
* Suspension/strapping
* Cosmesis


* [[Functional Electrical Stimulation - Its role in upper limb recovery post-stroke|Functional Electrical Stimulation]] (FES): In patient's with central nervous system disorders / leisions, it may be possible, and safe, to use FES as a dynamic orthotic''<ref>NICE ''Functional Electrical Stimulation for Foot Drop of Central Neurological Origin'' (2009)[Online] <available from: https://www.nice.org.uk/guidance/ipg278> [Accessed 4/10/20]</ref>''. <ref>RCP Stroke guidelines , 2016</ref>Can be used on a number of muscle groups to simulate electrical impulses in peripheral nerves. It is often used to reduced impact of foot drop or knee hyperextension as a result of muscle weakness. There is also some evidence that it may contribute to strengthening of muscles<ref>Glinsky, J et al. Efficacy of Electrical Stimulation to increase muscle strength in people with neurological conditions: A systematic review. Physiotherapy Reseach Int. 12(3): 175-194 (2007)</ref>. In this way, FES may reduce the patient's risk of falls <ref>Esnouf, J.E. (2010) Impact Activities of Daily Living Using a Functional Stimulator (FES) device to Improve Dropped foot in people with Multiple Sclerosis, measured by the Canadian Occupational Performance Measure. Mult Scler. Sept: 1141-1147</ref> and has been shown to improve quality of life scores <ref>Juckes, F., Marceniuk, G., Seary, C., & Stevenson, V. (2019). A cohort study of functional electrical stimulation in people with multiple sclerosis demonstrating improvements in quality of life and cost-effectiveness. ''Clinical Rehabilitation'', ''33''(7), 1163–1170.</ref>   
=== 3. Fitting and evaluation ===


=== Spinal  Orthotics ===
* Good anatomical fit
Spinal orthotics can be used to give support to a [[Spinal Injury|spinal fracture]]. It is important to have clear instructions about the position that the patient should be in to put the brace on and off. This will be based on spinal scans and an multidisciplinary discussion of the stability of the spinal fracture.
* Good biomechanical function
* Easy to don/doff
* Comfortable to wear


Useful Resources:
=== Advantages ===
'''Lower limb:''' Influence both swing and stance phase of gait<ref>Condie & Meadows ''Report of a consensus conference on the lower limb orthotic management of cerebral palsy''International Society for Prosthetics and Orthotics(1995) ISBN 9788789809021</ref>.


* [[Introduction to Spinal Orthoses]]
* Prevent or correct deformity and reduce pain during weight-bearing
* [[Orthoses fo Management of Spinal Dysfunction|Orthoses for Management of Spinal Dysfunction]]
* Improve the efficiency of gait and maintain balance
* [[Assistive Devices for Spinal Cord Injury]]
* Improve base of support / lateral support
* Reduce need for compensation of ipsilateral and contralateral limbs and secondary pain
* To facilitate training in skills


Neck Collar:
'''Upper limbs:''' Can be used after an injury to prevent further injury, or reduce pain by supporting an injured limb.
{{#ev:youtube|W12DW-o3jfI|width}}


A neck collar may be used for some patients where the fracture is stable, to provide comfort by supporting neck muscles and reducing pain. However, the benefits of a collar need to be weighed up against possible impact on the patient's skin, their swallow and ability to feed themselves. 
* Prevent or correct deformity reducing pain and maximising function in reach and grasp tasks.
* Improve the efficiency of reach and grasp tasks
* Offload an injured limb to allow healing
* Reduce need for compensation of ipsilateral and contralateral limbs and secondary pain
* Improve role of the upper limb in maintaining balance


If a patient is discharged with a neck collar they will require a suitable collar care plan in the community to ensure their neck is cleaned and skin checked regularly. The soft pads of the neck collar will also need to be cleaned regularly. Therefore, spare pads should be provided to the patient.
'''Spine:''' Stabilise spinal fractures to allow the patient to return to some normal activities (although they may be restricted) and protect the spinal cord.


=== Possible Complications ===


Thoraco-Lumbar-Sacral Orthosis (TLSO):
* Loss of [[sensation]] (check skin regularly- risk of [[Pressure Ulcers|pressure areas]])
* Compensations in ipsilateral or contralateral limbs.
* Impact on spasticity (is the patient utilising spasticity to allow some function in absence of muscle strength?)
* Complications of casting at incorrect angle: Foot deformities<span class="reference" id="cite_ref-2"></span><ref>Karakas & Hoy (2002)</ref>, increased knee flexion in stan<span class="reference" id="cite_ref-:0_3-0"></span>ce<ref name=":0">Owen E. ''The Effects of Tuning an Ankle-Foot Orthosis Footwear Combination on Kinematics and Kinetics of the Knee Joint of an Adult with Hemiplegia'' Prosthetics and Orthotics (2014) 34(3): 270-6</ref>, muscle contrac<span class="reference" id="cite_ref-:0_3-1"></span>tors<ref name=":0" />
* Loss of sensory feedback and [[proprioception]] loss
* Restricted range of motion
* Loss of natural shock absorption and long term joint damage
* '''Spinal orthotics must be put on and taken off within the guidelines of a spinal professional. Patients may be able to mobilise within set restrictions, depending on the severity of their injury. Non-adherence to guidance may result in [[Spinal Cord Injury|spinal cord injury]].'''


{{#ev:youtube|uHSl2y1dIms|width}}
=== Consider: ===


=== Use of Orthotic in Neurology ===
* Cosmesis
 
* Footwear
* [[Orthoses for Management of Neuromuscular Impairment|Orthoses for management of Neuromuscular Impairment]]
* Weight/rigidity
 
* Ability to Don Doff
=== Paediatrics ===
* Compensations preferred
 
* Compensations required
* [[Orthoses for Management of Paediatrics]]
* [[Assistive Devices for Cerebral Palsy|Assistive devices for Cerebral Palsy]]
* [[Orthotics in Cerebral Palsy]]
 
=== Outcome Measures ===
Use of outcome measures will determine the effectiveness of orthotics. This will be based on the patient's initial impairments, but may include:
* Neutral-0
* [[Range of Motion|Passive range]]
* [[Range of Motion|Active range]]
* [[Berg Balance Scale]]
* [[Tinetti Test|Tinetti]]
* Gait speed
* [[Timed Up and Go Test (TUG)|Timed up and go]] (TUG)
* Timed Unsupported Stand (TUSS)
* [[Functional Gait Assessment|Functional gait assessment]]
* ARM A, B
* [[Action Research Arm Test (ARAT)|Action Reach Arm Test (ARAT)]]
* Reach and grasp
* Modified Ashworth Scale
* Patient perceived outcome measures


== References ==
== References ==
<references />
<references />
[[Category:Assistive Technology]]
[[Category:Course Pages]]
[[Category:Prosthetics and Orthotics]]
[[Category:Prosthetics and Orthotics]]
[[Category:ReLAB-HS Course Page]]
[[Category:Rehabilitation]]

Latest revision as of 19:54, 5 January 2023

Original Editor - Carin Hunter based on the course by Donna Fisher
Top Contributors - Rhiannon Clement, Kim Jackson, Naomi O'Reilly, Rucha Gadgil, Carin Hunter, Robin Tacchetti, Alishah Merchant and Amanda Ager

Introduction[edit | edit source]

The aim of orthotics is to increase the efficiency of function during acute or long-term injury. This includes soft-tissue and bony injury, as well as changes as a result of neurological changes. They can be an effective adjunct alongside physiotherapy techniques such as muscle strengthening and stretches, gait and balance retraining and reach and grasp strategies.

A number of considerations need to be made before deciding on the type of orthotic needed:

  • What are the patient’s goals?
  • What are the specific impairments impacting on their function (thinking of head-to-toe and gait analysis).
  • Are impairments the result of soft-tissue changes? Can they be changed with therapy input?
  • Is a walking aid needed?
  • Does the injury need to be protected from particular movements?
  • Can an orthotic improve the efficiency of an activity?
  • Can the patient cope with any adjuncts given?

Orthotics can be pre-made or customised, depending on the patient's needs.

What is an Orthosis?[edit | edit source]

An orthosis is generally an individually designed or customised device, which is applied to the external part of the body to provide support and protection for that particular area of the body. It uses integrates biomechanical principles to realign joints and reduce pain. The design, materials and function of the orthosis are based on a patient assessment, including their medical history, biomechanical principles and the individual needs of the user.

Commonly prescribed orthoses include:

  • Foot Orthoses (FOs), for various foot, leg or postural problems; there is significant variety in terms of their design and manufacturing methods[1][2]
  • Ankle Orthoses (AOs) and Knee Orthoses (KOs), for joint protection, pain reduction or support after surgery
  • Ankle-Foot Orthoses (AFOs) and Knee-Ankle-Foot Orthoses (KAFOs), to improve mobility, support rehabilitation and biomechanical goals
  • Various upper-limb orthoses, to provide positional and functional support to the upper limb
  • Fracture orthoses, modern alternative to plaster or fibreglass casts
  • Spinal Orthoses, to correct or control spinal deformities and injuries and to provide immobilisation or support to spinal injuries[3]

"Off the shelf" Orthotics[edit | edit source]

Many patients can utilise ready-made orthotics, which can often be adjusted to fit their size. These may come in small, medium and large sizes and can often be sized to the patient, e.g. with velcro straps. These are often lighter materials. They can also be good for an assessment, to confirm or deny a theory before a custom orthotic is made.

Custom Orthotics[edit | edit source]

Some individuals have more complex injuries / changes to one of the multiple joint structures and therefore require a customised orthosis. This may be particularly true in neurological conditions, such as Cerebral Palsy (CP), Parkinson's Disease (PD) or after brain injury, such as traumatic brain jury (TBI) or stroke. In these cases, spasticity of muscles may have an impact on the patient's function. Orthotics can be used both in resting and during mobility to improve the effects of spasticity or reduce the risk of contractures. In which case the orthotic will be specifically measured to the individual, and likely to be redone as the individual grows (in paediatrics) or as changes are made to joint structures.

Why is an Orthosis used?[edit | edit source]

An orthosis provides support and protection for joints or parts of the body. It can optimally align a joint into a better functional position, whether it be the position of a hand or an elbow or a knee or a foot.[4] It is often used to reduce pain. A good orthosis can also maintain a functional position with the joint and we can use an orthosis either dynamically or statically to achieve this functional position.

Where can an Orthosis be used?[edit | edit source]

An orthoses can be fitted to any part of the body from the head, such as helmets, to the feet and toes with insoles and footwear.[5]

3 Steps to Create an Orthosis[edit | edit source]

The position, structure, design and fitting of the orthosis is based on the assessment of the patient and clear goals of what the therapist and patient want to achieve.[6] This can be a complex process and a problem-solving exercise.[7] All orthotists need to be good at problem-solving.[8]

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

1. Assessment[edit | edit source]

2. Design/manufacture[edit | edit source]

  • Materials
  • Construction
  • Suspension/strapping
  • Cosmesis

3. Fitting and evaluation[edit | edit source]

  • Good anatomical fit
  • Good biomechanical function
  • Easy to don/doff
  • Comfortable to wear

Advantages[edit | edit source]

Lower limb: Influence both swing and stance phase of gait[10].

  • Prevent or correct deformity and reduce pain during weight-bearing
  • Improve the efficiency of gait and maintain balance
  • Improve base of support / lateral support
  • Reduce need for compensation of ipsilateral and contralateral limbs and secondary pain
  • To facilitate training in skills

Upper limbs: Can be used after an injury to prevent further injury, or reduce pain by supporting an injured limb.

  • Prevent or correct deformity reducing pain and maximising function in reach and grasp tasks.
  • Improve the efficiency of reach and grasp tasks
  • Offload an injured limb to allow healing
  • Reduce need for compensation of ipsilateral and contralateral limbs and secondary pain
  • Improve role of the upper limb in maintaining balance

Spine: Stabilise spinal fractures to allow the patient to return to some normal activities (although they may be restricted) and protect the spinal cord.

Possible Complications[edit | edit source]

  • Loss of sensation (check skin regularly- risk of pressure areas)
  • Compensations in ipsilateral or contralateral limbs.
  • Impact on spasticity (is the patient utilising spasticity to allow some function in absence of muscle strength?)
  • Complications of casting at incorrect angle: Foot deformities[11], increased knee flexion in stance[12], muscle contractors[12]
  • Loss of sensory feedback and proprioception loss
  • Restricted range of motion
  • Loss of natural shock absorption and long term joint damage
  • Spinal orthotics must be put on and taken off within the guidelines of a spinal professional. Patients may be able to mobilise within set restrictions, depending on the severity of their injury. Non-adherence to guidance may result in spinal cord injury.

Consider:[edit | edit source]

  • Cosmesis
  • Footwear
  • Weight/rigidity
  • Ability to Don Doff
  • Compensations preferred
  • Compensations required

References[edit | edit source]

  1. ↑ Chapman LS, Redmond AC, Landorf KB, Rome K, Keenan AM, Waxman R, et al. Foot orthoses for people with rheumatoid arthritis: a survey of prescription habits among podiatrists. J Foot Ankle Res. 2019;12:7.
  2. ↑ Gerrard JM, Bonanno DR, Whittaker GA, Landorf KB. Effect of different orthotic materials on plantar pressures: a systematic review. Journal of foot and ankle research. 2020 Dec;13(1):1-1.
  3. ↑ AOPA What is an orthotics? Available:https://www.aopa.org.au/careers/what-are-orthoses-and-prostheses (accessed 4.6.22)
  4. ↑ Webster JB, Murphy DP, editors. Atlas of orthoses and assistive devices. Amsterdam, The Netherlands:: Elsevier; 2019.
  5. ↑ Jarvis HL, Nester CJ, Bowden PD, Jones RK. Challenging the foundations of the clinical model of foot function: further evidence that the root model assessments fail to appropriately classify foot function. Journal of foot and ankle research. 2017 Dec;10(1):1-1.
  6. ↑ Chui KC, Jorge M, Yen SC, Lusardi MM. Orthotics and Prosthetics in Rehabilitation E-Book. Elsevier Health Sciences; 2019 Jul 6.
  7. ↑ Mangai S, Ranganathan R, Pugalendhi A, Gokul Raj N, Deepan Raju S, Dharani T, Durga R. Design And Development Of Ankle Foot Orthosis Using Additive Manufacturing Technique. 2020.
  8. ↑ Menz HB, Allan JJ, Bonanno DR, Landorf KB, Murley GS. Custom-made foot orthoses: an analysis of prescription characteristics from an Australian commercial orthotic laboratory. Journal of foot and ankle research. 2017 Dec;10(1):1-9.
  9. ↑ Nester CJ, Jarvis HL, Jones RK, Bowden PD, Liu A. Movement of the human foot in 100 pain-free individuals aged 18–45: implications for understanding normal foot function. Journal of foot and ankle research. 2014 Dec;7(1):1-0.
  10. ↑ Condie & Meadows Report of a consensus conference on the lower limb orthotic management of cerebral palsyInternational Society for Prosthetics and Orthotics(1995) ISBN 9788789809021
  11. ↑ Karakas & Hoy (2002)
  12. ↑ 12.0 12.1 Owen E. The Effects of Tuning an Ankle-Foot Orthosis Footwear Combination on Kinematics and Kinetics of the Knee Joint of an Adult with Hemiplegia Prosthetics and Orthotics (2014) 34(3): 270-6
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