Orthotics (Greek: Ορθός, ortho, "to straighten" or "align") is a specialty within the medical field concerned with the design, manufacture and application of orthoses. An orthosis (plural: orthoses) is an orthopedic device that supports or corrects the function of a limb or the torso. An orthopaedic brace, "appliance", or simply brace is an orthopaedic device used to:
It combines disciplines of study within the health and physical sciences; mathematics and materials engineering, gait analysis, anatomy and physiology, pathophysiology, biomechanics and psychology contribute to the work of orthotists (professionals in the field of orthotics). Patients benefiting from an orthosis have sustained a physical impairment such as a stroke, spinal cord injury or a congenital abnormality like spina bifida or cerebral palsy. Corrective shoe inserts are popularly known as orthotics. Certified pedorthic practitioners (known as pedorthists) are specialists in foot orthotics (pedorthics).
An orthosis is intended to mechanically compensate for a pathological condition. In the 1970s, an effort was put forth to classify orthoses by their function and acronyms describing the joints that are encumbered by the orthoses were proposed by a group of American professionals involved in the field of orthotics- from this effort sprung the current nomenclature : AFO- ankle foot orthosis, TLSO-thoracolumbosacral orthosis, WHO- wrist hand orthosis, etc. The nomenclature caught on, but the more tedious effort to describe the function of the orthosis; assist dorsiflexion at ankle, limit wrist flexion to 10 degrees, resist thoracolumbar rotation did not get as much mileage due perhaps to its semantic difficulty in prescription formulation.
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A Certified Orthotist (or CO(c)) is an orthotist who has met the highest standards set by the Canadian Board for Certification of Prosthetists and Orthotists (CBCPO) and maintains certification through mandatory continuing education programs and adherence to the CBCPO's Code of Ethics.[1]
A Certified Pedorthist, or C. Ped(C) (Canadian Certified Pedorthists), specializes in foot orthotics and footwear. Pedorthists are specially trained in the assessment of lower-limb anatomy and biomechanics. With specialized education and training in the design, manufacture, fit and modification of foot orthotics and footwear pedorthists help to alleviate pain, abnormalities and debilitating conditions of the lower limbs and feet that (if left untreated) could result in limited mobility.
In Canada, to become certified as a pedorthist a bachelors degree in kinesiology is generally required, followed by a postgraduate degree (a diploma in pedorthics from the University of Western Ontario). This is followed by a rigorous internship program and a two-part clinical and practical examination. The clinician's duties include gait analysis, casting, measuring, fabricating and fitting orthotic devices.[2][3]
UK orthotists design and fit orthoses for all parts of the body, and are registered with the Health Professions Council . The training is a Bsc.(Hons) in Prosthetics and Orthotics at either the University of Salford or University of Strathclyde. New graduates are therefore eligible to work as an orthotist and/or prosthetist.
A licensed orthotist is an orthotist who is recognized by the particular state in which s/he is licensed to have met basic standards of proficiency, as determined by examination and experience to adequately and safely contribute to the health of the residents of that state. An "ABC" or American Board of Certification certified orthotist has met certain standards; these include a degree in orthotics, completion of a one-year residency at an approved clinical site, and passing a rigorous three-part exam.[4] A Certified Orthotist (CO) is an orthotist who has passed the certification standards of the American Board of Certification in Orthotics & Prosthetics.
Orthoses were traditionally made by following a tracing of the extremity with measurements to assist in creating a well fitted device. Later the advent of plastics as a material of choice for construction necessitated the idea of creating a plaster of Paris mold of the body part in question. This method extensively is still used throughout the industry. Later changes were introduced and CAD/CAM played its part in manufacturing.
Braces are made from various types of materials—plastic, elastic, metal, or a combination of similar materials. Some designs may be purchased at a local retailer; others are more specific and require a prescription from a physician, who will fit the brace according to the patient's requirements. Over-the-counter braces are basic and available in multiple sizes. They are generally slid on or strapped on with Velcro, and are held tightly in place. The purpose of these braces is injury protection.[5]
Upper-limb (extremity) orthoses are devices applied externally to restore or improve functional and structural characteristics of the musculoskeletal and nervous systems. In general, musculoskeletal problems include those resulting from trauma, sports, and work-related injuries.[6]
A lower-limb orthosis is an external device applied (or attached) to a lower-body segment to improve function by controlling motion, providing support through stabilizing gait, reducing pain through transferring load to another area, correcting flexible deformities, and preventing progression of fixed deformities.[7]
Orthotics—comprising a specially fitted insert for the insole or footbed, and providing support for the foot only—are often used, especially by athletes.[8]
An ankle-foot orthosis (AFO) is an orthosis or brace (usually plastic) that surrounds the ankle and at least part of the foot. AFOs are externally applied and intended to control position and motion of the ankle, compensate for weakness, or correct deformities.[9] They control the ankle directly, and can be designed to control the knee joint indirectly as well.[9] AFOs are commonly used in the treatment of disorders affecting muscle function such as stroke, spinal cord injury, muscular dystrophy, cerebral palsy, polio, multiple sclerosis and peripheral neuropathy. AFOs can be used to support wasted limbs, or to position a limb with contracted muscles into a more normal position. They are also used to immobilize the ankle and lower leg in the presence of arthritis or fracture, and to correct foot drop; an AFO is also known as a foot-drop brace.
Ankle-foot orthoses are the most commonly-used orthoses, making up about 26% of all orthoses provided in the United States.[10] According to a review of Medicare payment data from 2001 to 2006, the base cost of an AFO was about $500 to $700.[11] An AFO is generally constructed of lightweight polypropylene-based plastic in the shape of an "L", with the upright portion behind the calf and the lower portion running under the foot. They are attached to the calf with a strap, and are made to fit inside accommodative shoes. The unbroken "L" shape of some designs provides rigidity, while other designs (with a jointed ankle) provide different types of control.
Obtaining a good fit with an AFO involves one of two approaches:
The International Red Cross evidently believes there are four major types of AFOs:
| Flexible AFOs | Anti-Talus AFOs | Rigid AFOs | Tamarack Flexure Joint |
|---|---|---|---|
| may provide dorsiflexion assistance, but give poor stabilization of the subtalar joint. | block ankle motion, especially dorsiflexion; do not provide good stabilization for the subtalar joint. | block ankle movements and stabilize the subtalar joint; may also help control adduction and abduction of the forefoot. | provide subtalar stabilization while allowing free ankle dorsiflexion and free or restricted plantar flexion, depending upon the design; may provide dorsiflexion assistance to correct foot drop.[12] |
The International Committee of the Red Cross published its manufacturing guidelines for ankle-foot orthoses in 2006.[12] Its intent is to provide standardized procedures for the manufacture of high-quality modern, durable and economical devices to people with disabilities throughout the world.
A knee-ankle-foot orthosis (KAFO) is an orthosis that encumbers the knee, ankle and foot. Motion at all three of these lower limb areas is affected by a KAFO and can include stopping motion, limiting motion, or assisting motion in any or all of the 3 planes of motion in a human joint: saggital, coronal, and axial. Mechanical hinges, as well as electrically controlled hinges have been used. Various materials for fabrication of a KAFO include but are not limited to metals, plastics, fabrics, and leather. Conditions that might benefit from the use of a KAFO include paralysis, joint laxity or arthritis, fracture, and others. Altho not as widely used as knee orthoses, KAFOs and HKAFOs can make a real difference in the life of a paralyzed person, helping them to walk therapeutically or, in the case of polio patients on a community level. These devices are expensive and require maintenance. Some research is being done to enhance the design, even NASA helped spearhead the development of a special knee joint for KAFOs
A knee orthosis (KO) or knee brace is a brace worn to strengthen the knee. It is worn around the knee, and works by relieving pressure from the part of the knee joint affected by diseases such as arthritis or osteoarthritis. It also supports the knee, and provides the stability needed to perform daily activities. Knee braces may also help to properly align the knee to help reduce osteoarthritis pain.[13] If pain or instability is experienced, a knee brace may be appropriate. It is not meant to treat arthritis, injury or osteoarthritis on its own, but is used as a component of treatment along with drugs and physical therapy. It is beneficial in several ways; when used properly, a knee brace may help an athlete to stay in training. Knee braces may also help by improving symmetry, enhancing the position and movement of the knee while reducing pain so a person may remain active.
Individuals who cannot undergo surgery may also consider a knee brace to help them deal with acute or chronic pain. Although a knee brace is not a substitute for orthopedic surgery, it may be effective for young people. It is also effective where only one side of the knee is experiencing pain. This condition may develop if a person's alignment is incorrect, and weight is being placed on one side of the knee more than the other. A general knee-rehabilitation program (including strengthening and flexibility exercises, aerobic conditioning, technique refinement and proprioceptive retraining) is the most important factor in improving knee function and stability.
Prophylactic braces are used primarily by athletes participating in contact sports. While it is possible that this type of brace will alter the force on the knee and become problematic, when worn properly it decreases the rate of injury. The majority of these braces are made of neoprene. It acts as a sleeve, providing support to the structure of the knee and reducing the knee's ability to rotate.[14]
Functional braces are designed for use by people who have already experienced a knee injury and need support to recover from it. They are also indicated to help people who are suffering from pain associated with arthritis. They are intended to reduce the rotation of the knee and support stability. They reduce the chance of hyperextension, and increase the agility and strength of the knee. The majority of these are made of elastic. They are the least expensive of all braces and are easily found in a variety of sizes.
Rehabilitation braces are used to limit the movement of the knee in both medial and lateral directions. They are primarily used after injury or surgery to immobilize the leg. They are larger in size than other braces, due to their function.
The unloader brace was developed by a Canadian company, Generation II. Originally, the knee orthosis design that became the custom unloader brace was a functional knee brace for use by athletes. Their single upright design lent itself well to use by individuals with unicompartmental arthritic knee pain. The idea was that the brace could shift the weight bearing vector when walking off of the painful intercondylar area onto the other intercondylar area. The company enjoyed success with their design, even trademarking the term "unloader" brace. The company sold to Ossur of Iceland, but the market they created is vigorous with multiple competitors.
There are a number of spinal orthotic designs common to assist individuals with pathologies of the neck and back. The term TLSO has come to indicate a plastic body jacket to immobilize the thoracolumbar spine, although that term describes any type of orthosis that encumbers the trunk, ranging from soft corsets to metal braces to strap and pad designs that affect pathologies ranging from back pain to scoliosis to fracture. The condition known as scoliosis, a curvature of the spine, is treated with spinal orthoses, such as the Milwaukee brace, the Boston brace, and Charleston bending brace. Generally, this condition is found in adolescent females who have great concern about the appearance and restriction the various orthoses prescribed to address the condition present. The halo brace (also known as a halo ring, halo vest or halo crown) is a cervical thoracic orthosis brace used to immobilize the cervical spine, usually following fracture. The halo brace allows the least cervical motion of all cervical braces currently in use, it was first developed by Dr. Vernon L. Nickel at Rancho Los Amigos National Rehabilitation Center in 1955.
Halo Brace