Orthoses for Management of Neuromuscular Impairment: Difference between revisions

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== Introduction ==
== Introduction ==


The neuromuscular system can be called as the biomechanical apparatus through which the CNS executes postural actions<ref>Alghwiri A, Whitney S; Guccione's Geriatric Physical Therapy, (Fourth Edition), Mosby,2020.</ref>.  It includes all the muscles in the body and the nerves serving them. The term ‘neuromuscular disorders' encompasses conditions which affect either the muscles, such as those in the arms and legs or heart and lungs, or the nerves which control the muscles<ref>Potikanond, S., et al. Muscular Dystrophy Model. Adv Exp Med Biol, 2018; 1076: 147-172.</ref>. Common examples may include: [[Cerebral Palsy and Associated Conditions|Cerebral palsy]], [[Stroke]], [[Spinal Cord Injury|Spinal cord injury]], [[Post-Polio Syndrome|Post-polio syndrome]], [[Muscular Dystrophy|Muscular]] dystrophies, [[Spinal Muscular Atrophy (SMA)|Spinal muscular atrophy]],etc.
The neuromuscular system can be called as the biomechanical apparatus through which the CNS executes postural actions<ref>Alghwiri A, Whitney S; Guccione's Geriatric Physical Therapy, (Fourth Edition), Mosby,2020.</ref>.  It includes all the muscles in the body and the nerves serving them.  
 
The term ‘neuromuscular disorders' encompasses conditions which affect either the muscles, such as those in the arms and legs or heart and lungs, or the nerves which control the muscles<ref>Potikanond, S., et al. Muscular Dystrophy Model. Adv Exp Med Biol, 2018; 1076: 147-172.</ref>. Common examples may include: [[Cerebral Palsy and Associated Conditions|Cerebral palsy]], [[Stroke]], [[Spinal Cord Injury|Spinal cord injury]], [[Post-Polio Syndrome|Post-polio syndrome]], [[Muscular Dystrophy|Muscular]] dystrophies, [[Spinal Muscular Atrophy (SMA)|Spinal muscular atrophy]],etc.
 
[[International Classification of Functioning, Disability and Health (ICF)|Impairments]] in these diseases may vary widely by person and condition, in type and severity, and may include:
[[Category:Assistive Technology Content Development Project]]
[[Category:Assistive Technology Content Development Project]]
[[Category:Assistive Technology]]
[[Category:Assistive Technology]]
[[Category:Prosthetics and Orthotics]]
[[Category:Prosthetics and Orthotics]]
[[Category:Neurology]]
[[Category:Neurology]]
[[International Classification of Functioning, Disability and Health (ICF)|Impairments]] in these diseases may vary widely by person and condition, in type and severity, and may include:
* increased or decreased tone,  
* increased or decreased tone,  
* atrophied muscle mass, weakness,  
* atrophied muscle mass, weakness,  
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* balance problems, loss of  postural control
* balance problems, loss of  postural control


 
These impairments often cause mobility problems and affect the quality of life of the individual adversely. They have to rely on assistive devices like [[Orthotics|orthoses]] to improve function and mobility.
These impairments often cause mobility problems and affect the quality of life of the individual adversely. They have to rely on assistive devices like [[Orthotics|orthoses]] to improve function and mobility. The clinician has to identify the impairments and functional limitations, understand the prognosis, take into account the lifestyle and risk factors before selecting the most appropriate treatment method and/or assistive device.


== Types of orthoses ==
== Types of orthoses ==


The main aim of using orthoses for neuromuscular impairments is  
The main aim of using orthoses for neuromuscular impairments is:


* improving the quality of life
* improving the quality of life
* independence
* independence
* maintaining optimal functioning of muscles
* maintaining optimal functioning of muscles
The orthoses should fulfill the following criteria for an individual:
* Optimal Alignment
* Stability
* Prevent contractures


The orthoses used can be divided into:
The orthoses used can be divided into:
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# [[Introduction to Foot Orthoses|shoe inserts]]
# [[Introduction to Foot Orthoses|shoe inserts]]
# [[Introduction to Ankle Foot Orthoses|ankle-foot orthoses]] (AFO)
# [[Introduction to Ankle Foot Orthoses|ankle-foot orthoses]] (AFO): AFOs are the most common and vary greatly in the design and the types of materials used. AFOs may be solid or hinged at the ankle and may have a removable foot plate.
# knee-ankle-foot orthoses (KAFO) and  
# knee-ankle-foot orthoses (KAFO) and
# hip-knee-ankle-foot-orthoses (HKAFO).
# hip-knee-ankle-foot-orthoses (HKAFO).
AFOs are the most common and vary greatly in the design and the types of materials used. AFOs may be solid or hinged at the ankle and may have a removable foot plate. Most AFOs are made of plastic but can also be made from leather, carbon fiber, silicone or metal.


* [[Introduction to Spinal Orthoses|Spinal orthoses]]:
* [[Introduction to Spinal Orthoses|Spinal orthoses]]:
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# Wilmington Robotic Exoskeleton (WREX): a functional upper limb orthosis designed to enhance movement for individuals with neuromuscular disabilities.<ref>Rahman T, Sample W, Jayakumar S, King MM, Wee JY, Seliktar R, Alexander M, Scavina M, Clark A. Passive exoskeletons for assisting limb movement. J Rehabil Res Dev. 2006 Aug-Sep;43(5):583-90. doi: 10.1682/jrrd.2005.04.0070. PMID: 17123200.</ref>
# Wilmington Robotic Exoskeleton (WREX): a functional upper limb orthosis designed to enhance movement for individuals with neuromuscular disabilities.<ref>Rahman T, Sample W, Jayakumar S, King MM, Wee JY, Seliktar R, Alexander M, Scavina M, Clark A. Passive exoskeletons for assisting limb movement. J Rehabil Res Dev. 2006 Aug-Sep;43(5):583-90. doi: 10.1682/jrrd.2005.04.0070. PMID: 17123200.</ref>


* Functional electric stimulation (FES) devices: alternative to traditional orthoses. They generate an electrical current stimulating a muscle causing muscle contraction in a predictable movement pattern creating a physiological bracing<ref>Prenton S, Hollands K, Kenney L, Onmanee P. Functional electrical stimulation and ankle foot orthoses provide equivalent therapeutic effects on foot drop: A meta-analysis providing direction for future research. J Rehabil Med. 2018;50(2):129-139. doi:10.2340/16501977-2289</ref>.  
* Functional electric stimulation (FES) devices: alternative to traditional orthoses. They generate an electrical current stimulating a muscle causing muscle contraction in a predictable movement pattern creating a physiological bracing<ref>Prenton S, Hollands K, Kenney L, Onmanee P. Functional electrical stimulation and ankle foot orthoses provide equivalent therapeutic effects on foot drop: A meta-analysis providing direction for future research. J Rehabil Med. 2018;50(2):129-139. doi:10.2340/16501977-2289</ref>.These  have shown gait improvements when compared to traditional AFO.  


== Assessment ==
== Assessment ==


Add your content to this page here!
The clinician has to identify the impairments and functional limitations, understand the prognosis, take into account the lifestyle and risk factors before selecting the most appropriate treatment method and/or assistive device.
 
It is important to assess the body holistically when planning a rehabilitation programme. This may include evaluation of
 
# muscle testing, normal joint movement,
# evaluation of flexibility,
# evaluation of motor and sensory functions, and functional capacities,
# functional posture, and gait analysis
# respiratory functions.
 
Orthotic prescription has to be preceded by a complete [[Biomechanics|biomechanical]] assessment, [[gait]] analysis (for lower limb), functional assessment and patient counselling and education. Each orthosis has to be custom made and proper fitting to avoid complications.
 
=== Fitting and Measurements ===
It is important to consider the fitting of the orthoses for the individual. Weight of the material of the device also has to be taken into account. The measurements of the limb can be taken by:
 
# measuring tape
# plaster cast
# computer scanner
# foam prints/ ink prints
# 3D scanner<ref>Telfer, S., Woodburn, J. The use of 3D surface scanning for the measurement and assessment of the human foot. J Foot Ankle Res 3, 19 (2010). <nowiki>https://doi.org/10.1186/1757-1146-3-19</nowiki></ref>
 
For measuring for an AFO:


== Complications ==
== Complications ==
Common complications that can be seen with orthotic management include pressure injuries, infection, and pain. Thus, it is essential that special attention made to examine the skin, neurological function, vascular status, and musculoskeletal system in patients who will be using an orthosis.
There are some complications can arise with orthotic management:
 
# pressure sores and broken skin<ref>Witherow E, Peiris C. Custom-Made Finger Orthoses Have Fewer Skin Complications Than Prefabricated Finger Orthoses in the Management of Mallet Injury: A Systematic Review and Meta-Analysis; Archives of Physical Medicine and Rehabilitation, 2015; 96(10):1913-1915. <nowiki>https://doi.org/10.1016/j.apmr.2015.04.026</nowiki>.</ref>
# infection, and  
# pain
# inadequate support/stabilization
 
Thus, it is important to evaluate the skin, neurological function, vascular status, and musculoskeletal system in patients who will be using an orthosis.


== Evidence ==
== Evidence ==

Revision as of 10:00, 16 June 2021

Welcome to Assistive Technology in Rehabilitation. Please do not edit unless you are involved in this project, but please come back in the near future to check out new information!! If you would like to get involved in this project and earn accreditation for your contributions, please get in touch!

Original Editors - Rucha Gadgil

Top Contributors - Rucha Gadgil, Naomi O'Reilly and Kim Jackson      

Introduction[edit | edit source]

The neuromuscular system can be called as the biomechanical apparatus through which the CNS executes postural actions[1]. It includes all the muscles in the body and the nerves serving them.

The term ‘neuromuscular disorders' encompasses conditions which affect either the muscles, such as those in the arms and legs or heart and lungs, or the nerves which control the muscles[2]. Common examples may include: Cerebral palsy, Stroke, Spinal cord injury, Post-polio syndrome, Muscular dystrophies, Spinal muscular atrophy,etc.

Impairments in these diseases may vary widely by person and condition, in type and severity, and may include:

  • increased or decreased tone,
  • atrophied muscle mass, weakness,
  • muscle twitching, shaking, cramping,
  • stiff or tight muscles (spasticity),
  • walking on the toes,
  • a crouched gait,
  • drop foot, numbness and tingling
  • balance problems, loss of postural control

These impairments often cause mobility problems and affect the quality of life of the individual adversely. They have to rely on assistive devices like orthoses to improve function and mobility.

Types of orthoses[edit | edit source]

The main aim of using orthoses for neuromuscular impairments is:

  • improving the quality of life
  • independence
  • maintaining optimal functioning of muscles

The orthoses should fulfill the following criteria for an individual:

  • Optimal Alignment
  • Stability
  • Prevent contractures

The orthoses used can be divided into:

  • Lower limb orthoses[3]:
  1. shoe inserts
  2. ankle-foot orthoses (AFO): AFOs are the most common and vary greatly in the design and the types of materials used. AFOs may be solid or hinged at the ankle and may have a removable foot plate.
  3. knee-ankle-foot orthoses (KAFO) and
  4. hip-knee-ankle-foot-orthoses (HKAFO).
  1. Thoracolumbosacral orthoses (TLSOs) correct spinal curvatures, scoliosis, and can improve balance and stability as well as control of the extremities, head, neck and trunk.
  2. Cervical orthoses: to assist in positioning head and neck in case of muscle weakness. eg. in ALS patients
  • Upper limb orthoses:
  1. Wilmington Robotic Exoskeleton (WREX): a functional upper limb orthosis designed to enhance movement for individuals with neuromuscular disabilities.[4]
  • Functional electric stimulation (FES) devices: alternative to traditional orthoses. They generate an electrical current stimulating a muscle causing muscle contraction in a predictable movement pattern creating a physiological bracing[5].These have shown gait improvements when compared to traditional AFO.

Assessment[edit | edit source]

The clinician has to identify the impairments and functional limitations, understand the prognosis, take into account the lifestyle and risk factors before selecting the most appropriate treatment method and/or assistive device.

It is important to assess the body holistically when planning a rehabilitation programme. This may include evaluation of

  1. muscle testing, normal joint movement,
  2. evaluation of flexibility,
  3. evaluation of motor and sensory functions, and functional capacities,
  4. functional posture, and gait analysis
  5. respiratory functions.

Orthotic prescription has to be preceded by a complete biomechanical assessment, gait analysis (for lower limb), functional assessment and patient counselling and education. Each orthosis has to be custom made and proper fitting to avoid complications.

Fitting and Measurements[edit | edit source]

It is important to consider the fitting of the orthoses for the individual. Weight of the material of the device also has to be taken into account. The measurements of the limb can be taken by:

  1. measuring tape
  2. plaster cast
  3. computer scanner
  4. foam prints/ ink prints
  5. 3D scanner[6]

For measuring for an AFO:

Complications[edit | edit source]

There are some complications can arise with orthotic management:

  1. pressure sores and broken skin[7]
  2. infection, and
  3. pain
  4. inadequate support/stabilization

Thus, it is important to evaluate the skin, neurological function, vascular status, and musculoskeletal system in patients who will be using an orthosis.

Evidence[edit | edit source]

Add your content to this page here!

Conclusion[edit | edit source]

References [edit | edit source]

  1. ↑ Alghwiri A, Whitney S; Guccione's Geriatric Physical Therapy, (Fourth Edition), Mosby,2020.
  2. ↑ Potikanond, S., et al. Muscular Dystrophy Model. Adv Exp Med Biol, 2018; 1076: 147-172.
  3. ↑ Webster J, Murphy D. Atlas of Orthoses and Assistive Devices. 5th Edition. Elsevier. 2017
  4. ↑ Rahman T, Sample W, Jayakumar S, King MM, Wee JY, Seliktar R, Alexander M, Scavina M, Clark A. Passive exoskeletons for assisting limb movement. J Rehabil Res Dev. 2006 Aug-Sep;43(5):583-90. doi: 10.1682/jrrd.2005.04.0070. PMID: 17123200.
  5. ↑ Prenton S, Hollands K, Kenney L, Onmanee P. Functional electrical stimulation and ankle foot orthoses provide equivalent therapeutic effects on foot drop: A meta-analysis providing direction for future research. J Rehabil Med. 2018;50(2):129-139. doi:10.2340/16501977-2289
  6. ↑ Telfer, S., Woodburn, J. The use of 3D surface scanning for the measurement and assessment of the human foot. J Foot Ankle Res 3, 19 (2010). https://doi.org/10.1186/1757-1146-3-19
  7. ↑ Witherow E, Peiris C. Custom-Made Finger Orthoses Have Fewer Skin Complications Than Prefabricated Finger Orthoses in the Management of Mallet Injury: A Systematic Review and Meta-Analysis; Archives of Physical Medicine and Rehabilitation, 2015; 96(10):1913-1915. https://doi.org/10.1016/j.apmr.2015.04.026.
 
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