Orthotics

AFO brace for foot drop.jpeg

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 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. 

"Off the shelf" Orthotics

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.

Custom Orthotics

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 (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 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

Lower limb: Influence both swing and stance phase of gait[1].

  • Prevent or correct deformity and reduce pain during weight bearing
  • Improve 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 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

  • 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[2], increased knee flexion in stance[3], muscle contractors[3]
  • 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.

Also, success depends on patient's acceptance. Consider:

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

Types of orthotics

Upper limb

Healing

  • Hinge-elbow brace: May be used to restrict elbow movement post fracture or surgery. Allows early mobilisation without damage to the healing tissue [4].
Hinge elbow brace: To restrict movement beyond a set degrees into flexion or extension to protect a healing injury / surgical site.
  • Slings: Can be used after upper limb injury or surgery to protect the injury site. They can be used to restrict movements in particular directions to prevent further disruption to the injury (for example displacement of a fracture/ fixated bone). 
  • Splints: Hand or wrist splints are often customised for individuals based on their specific impairment. This often achieved using thermoplastics. These can be both resting and functional.
Resting hand splint: Often customised to fit a patient to maintain range of movement in the hand for skin care and function.

Functional

  • Wrist splint (e.g. fuctural splint)
  • Elbow clasp: May be used, alongside exercises, especially if function is affected [5]

Lower Limb

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.

Healing

  • Wedge boot: Often used as conservative treatment or after surgery for Achilles tendon rupture to allow gradual stretching of the tendon as it heals. A heel wedge may also be used in patient's with fixed platar flexion deformity to increased base of support and improve balance.
  • Aircast boot: Often used after fracture injuries to support and reduce forces through the bone while healing. The air cells can be inflated around the foot and ankle, compressing the injury.
  • Hinge-knee brace: Often used to protect knee surgery, such as meniscal repair[6].
  • Splints; Patients with increased tone may require a resting splint to maintain optimal positioning of their lower limb and maintain a functional range in affected joints. Positioning and seated and supine positions are very important for these patients

Functional

  • Ankle- Foot Orthosis (AFO): Correct alignment of the lower foot and ankle, which translates to the alignment of the shin, upper leg and pelvis. AFOs have an influence on both the swing and stance phase of gait[7]. Can also be used to reduce risk of trips and falls as a result of foot drop.
  • Lateral support ankle brace: In patient's after ankle injuries, particularly to lateral ligaments, or neuromuscular disorders, a lateral ankle support may be needed. This brace has stiff lateral supports which will prevent excessive pronation or supination at the foot. This reduces the risk of further injury to lower limb structures, or injuries secondary to a fall.
Aircast lateral ankle support. To protect against lateral ankle strain and support lower limb in stance phase.
  • 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 orthosis[8]. [9]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[10]. In this way, FES may reduce the patient's risk of falls [11] and has been shown to improve quality of life scores [12]  
Functional Electrical Stimulation for lower limb function [illustration from wikimedia]
  • Foot orthotics[13] [14]: Custom orthotics can improve foot alignment by affecting muscle activity [15]. Therefore, they improve efficieny in gait and balance, and minimise shock absorption through the lower limb, pelvis and spine[16]. These corrective devices are placed in an individual’s footwear similar to insoles.

A trained health practitioner will complete a detailed assessment of an individual’s gait and foot position in both a static and a dynamic state to identify asymmetries. This information will be combined with a precise imprint of the feet on a foam cast. This will be sent off to a lab where the orthotics will be fabricated and created. Some facilities will also use a gait scan machine in order to analyse where the majority of your weight is dispersed while you heel strike and push off during the gait cycle. The foot specialist may request that the lab add special features to the orthotics based on the patient’s area of pain, the wear patterns in the patient’s shoes and the skin changes on their feet.

Consideration: It seems logical to think that pain in the foot region links directly to dysfunction in the foot region and that orthotics are the intervention of choice. Unfortunately, it is not always that straightforward. For example, could hip weakness or lower back pain be causing disruption to the gait cycle and compensatory strategies that place increased load on foot stuctures? It is important to determine what is “driving” the pain in the foot and to direct treatment to these structures to see if insoles are needed. Also, can the intrinsic muscle of the foot be trained either alongside, or instead of the use of insole orthotics?

Conditions that may require a foot orthosis as an adjunct include:
Plantar fasciitis
• Morton’s Neuroma
Flat feet or high arches
• Knee, hip or low back pain and SIJ dysfunction
Degenerative Disc Disease and scoliosis
Osteoarthritis
Patellofemoral pain syndrome
• Femoral acetabular impingment
• Iliotibial band friction syndrome
Bursitis
• Chronic ankle sprains
Piriformis syndrome
• Achilles, Patellar, hamstring or gluteal tendinopathy and Snapping Psoas
• Recurrent Calf Strains

Spinal  Orthotics

Spinal orthotics can be used to give support to a 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.

Neck collar:

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.

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.


Thoraco-lumbar-sacral orthosis (TLSO):

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:

References

  1. 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
  2. Karakas & Hoy (2002)
  3. 3.0 3.1 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
  4. Fusaro I, Orsini S, Sforza T, Rotini R, Benedetti MG. The use of braces in the rehabilitation treatment of the post-traumatic elbow. Joints. 2014;2(2):81-86. Published 2014 Jul 8. doi:10.11138/jts/2014.2.2.081
  5. NICE Management of Tennis Elbow NICE Guidelines (2017) <Available online: https://cks.nice.org.uk/topics/tennis-elbow/management/management/> [Accessed: 3/10/20]
  6. McDermott, Ian (2010) Meniscal Repair [available from:https://sportsortho.co.uk/treatment/meniscal-repair/] <accessed 29/09/20>
  7. NHS. Best Practice Statement: Use of Ankle-Foot Orthoses Following Stroke (2009) [online] <available from: http://www.healthcareimprovementscotland.org/previous_resources/best_practice_statement/use_of_ankle-foot_orthoses_fol.aspx?theme=mobile> [Accessed: 4/10/2020]
  8. 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]
  9. RCP Stroke guidelines , 2016
  10. 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)
  11. 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
  12. 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.
  13. The Orthotic Group. Orthotic FAQ. Available from: http://www.theorthoticgroup.com/patientsite/OrthoticFAQ.aspx [last accessed 10/12/14]
  14. SBI Orthotic Laboratory. Orthotic FAQ. Available from: http://www.sbiorthoticlab.ca/faq_orthotic.html [last accessed 10/13/14].
  15. Roger, Collier. Orthotics work in mysterious ways. CMAJ-Canadian Medical Association Journal. March 8, 2011. Volume 183:p 416-417. 
  16. Rebalance Sports Medicine. Custom Orthotics. Available from: http://www.rebalancetoronto.com/sports-medicine-services/orthotics-downtown-toronto/ [last accessed 10/13/14].