- "Orthotist", "orthopaedic brace" and "ankle-foot orthotic (AFO)" redirect here, where they are dealt with in their respective sections.
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 externally applied device used to modify the structural and functional characteristics of the neuromuscular and skeletal system". An orthosis may be used to:
- Control, guide, limit and/or immobilize an extremity, joint or body segment for a particular reason
- To restrict movement in a given direction
- To assist movement generally
- To reduce weight bearing forces for a particular purpose
- To aid rehabilitation from fractures after the removal of a cast
- To otherwise correct the shape and/or function of the body, to provide easier movement capability or reduce pain
Orthotics combines knowledge of anatomy and physiology, pathophysiology, biomechanics and engineering. Patients benefiting from an orthosis may have a condition such as spina bifida or cerebral palsy, or have experienced a spinal cord injury or stroke. Equally, orthoses are sometimes used prophylactically or to optimise performance in sport.
Manufacture and materials
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. Currently CAD/CAM, CNC machines and even 3D printing are involved in orthotic manufacture.
Orthoses are made from various types of materials including thermoplastics, carbon fibre, metals, elastic, fabric 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 orthosis 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. One of the purposes of these braces is injury protection.
Orthoses are classified described by an acronym describing the joints which they affect. For example, an ankle foot orthosis ('AFO') affects the foot and ankle, a thoracolumbosacral orthosis ('TLSO') affects the thoracic, lumbar and sacral regions of the spine. It is also necessary to describe the function of the orthosis.
Upper-limb (or upper extremity) orthoses are mechanical or electromechanical devices applied externally to the arm or segments thereof in order to restore or improve function, or structural characteristics of the arm segments encumbered by the device. In general, musculoskeletal problems that may be alleviated by the use of upper limb orthoses include those resulting from trauma or disease (arthritis for example). They may also be beneficial in aiding individuals who have suffered a neurological impairment such as stroke, spinal cord injury, or peripheral neuropathy.
Types of upper-limb orthoses
- Upper-arm orthoses
- Clavicular and shoulder orthoses
- Arm orthoses
- Functional arm orthoses
- Elbow orthoses
- Forearm-wrist orthoses
- Forearm-wrist-thumb orthoses
- Forearm-wrist-hand orthoses
- Hand orthoses
- Upper-extremity orthoses (with special functions)
A lower-limb orthosis is an external device applied 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.
Foot orthoses comprise a specially fitted insert or footbed to a shoe. Also commonly referred to as "Orthotics" these orthoses provide support for the foot by distributing pressure or realigning foot joints while standing, walking or running. A great body of information exists within the podiatry and pedorthotic community describing the sciences that might be used to aid people with foot problems as well as the impact "orthotics" can have on knee, hip, and spine conditions. As such they are often used by athletes to relieve symptoms of a variety of soft tissue inflammatory conditions like plantar fasciitis. They may also be used in conjunction with properly fitted orthopedic footwear in the prevention of foot ulcers in the at-risk diabetic foot.
Ankle-foot orthosis (AFO)
An ankle-foot orthosis (AFO) is an orthosis or brace (usually plastic) that supports the ankle and foot. AFOs are externally applied and intended to control position and motion of the ankle, compensate for weakness, or correct deformities. AFOs can be used to support weak 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. No evidence exists to support the concern that using an orthosis will keep neurologic repair from taking place.
Ankle-foot orthoses are the most commonly used orthoses, making up about 26% of all orthoses provided in the United States. According to a review of Medicare payment data from 2001 to 2006, the base cost of an AFO was about $500 to $700. 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:
- provision of an off-the-shelf or prefabricated AFO matched in size to the end user
- custom manufacture of an individualized AFO from a positive model, obtained from a negative cast or the use of computer-aided imaging, design, and milling. The plastic used to create a durable AFO must be heated to 400°F., making direct molding of the material on the end user impossible
The International Red Cross evidently believes there are four major types of AFOs, ergo the other 357 types would be considered minor:
|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.|
The International Committee of the Red Cross published its manufacturing guidelines for ankle-foot orthoses in 2006. 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.
Knee-ankle-foot orthosis (KAFOs)
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. Although not as widely used as knee orthoses, KAFOs 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
Knee orthosis (KO)
A knee orthosis (KO) or knee brace is a brace that extends above and below the knee joint and is generally worn to support or align the knee. In the case of diseases causing neurological or muscular impairment of muscles surrounding the knee, a KO can prevent flexion or extension instability of the knee. In the case of conditions affecting the ligaments or cartilage of the knee, a KO can provide stabilization to the knee by replacing the function of these injured or damaged parts. For instance, knee braces can be used to relieve pressure from the part of the knee joint affected by diseases such as arthritis or osteoarthritis by realigning the knee joint into valgus or varus. In this way a KO may help reduce osteoarthritis pain. However, a knee brace is not meant to treat an injury or disease on its own, but is used as a component of treatment along with drugs, physical therapy and possibly surgery. When used properly, a knee brace may help an individual to stay active by enhancing the position and movement of the knee or reducing pain.
Prophylactic, functional and rehabilitation braces
Prophylactic braces are used primarily by athletes participating in contact sports. Evidence about prophylactic knee braces, the ones football lineman wear are often rigid with a knee hinge, indicates they are ineffective in reducing anterior cruciate ligament tears, but may be helpful in resisting medial and lateral collateral ligament tears.
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- these braces often have an adjustable range of motion stop potential for limiting flexion and extension following ACL reconstruction. They are primarily used after injury or surgery to immobilize the leg. They are larger in size than other braces, due to their function.
Scoliosis, a condition describing an abnormal curvature of the spine, may in certain cases be treated with spinal orthoses, such as the Milwaukee brace, the Boston brace, and Charleston bending brace. As this condition develops most commonly in adolescent females who are undergoing their pubertal growth spurt, compliance with wearing is these orthoses is hampered by the concern these individuals have about changes in appearance and restriction caused by wearing these orthoses.
There are a number of spinal orthotic designs common to assist individuals with pathologies of the neck and back. A thoracolumbar spinal orthosis (TLSO) is 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.
TLSOs may also be used in the treatment of spinal fractures. A Jewett brace, for instance may be used to facilitate healing of an anterior wedge fracture involving the T10 to L3 vertebrae. A clamshell TLSO may be used to stabilize fractures of the spine of either anterior or posterior elements of the spine in the region of T8 to L3. The halo brace is a cervical thoracic orthosis 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.-The halo. A spinal skeletal traction fixation device. Nickel VL, Perry J, Garrett A, Heppenstall M.J Bone Joint Surg Am. 1968 Oct;50(7):1400-9
Orthotists are healthcare professionals that specialize in the provision of orthoses. In most circumstances, orthotists work by prescription from a licensed healthcare provider who has consult and directive authority- often physicians, some times physician assistants or nurse practitioners. Physical therapists, in spite of their professional doctorate, are not legally authorized to prescribe orthoses in the U.S. For details on qualification and training by country, see below. Aside from orthotists, many other healthcare professionals may be involved in the provision of orthoses.
Training: United Kingdom
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.
Training: United States
A licensed orthotist is an orthotist who is recognized by the particular state in which they are 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 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.
A Certified Orthotist (CO) is an orthotist who has passed the certification standards of the American Board of Certification in Orthotics & Prosthetics. Other credentialing bodies who are involved in orthotics include the Board for Orthotic Certification, the pharmaceutical industry, the Professional Footwear Association, and various of the professional associations who work with athletic trainers, physical and occupational therapists, and orthopedic technologists/cast technicians.
- ISO 8549-1:1989
- Braces and Splints for musculoskeletal conditions American Family Physician. 2010-02-09
- ISO 8549-3
- "Upper Limb Orthotics". eMedicine from WebMD. Retrieved 15 September 2010.
- "Lower Limb Orthotics". eMedicine from WebMD. Retrieved 15 September 2010.
- Kolata, Gina (2011-01-17). "Close Look at Orthotics Raises a Welter of Doubts". New York Times. Retrieved 2011-01-18.
- Whiteside, S., et al. Practice analysis of certified practitioners in the disciplines of orthotics and prosthetics. 2007, American Board for Certification in Orthotics and Prosthetics, Inc., Alexandria, Virginia.
- Centers for Medicare and Medicaid Services, PSPS Files 2001-2006.
- ICRC AFO Manufacturing Guidelines
- Mayo Clinic. "knee braces overview" 2010-01-26.
- Am Fam Physician. 2000 Jan 15;61(2):411-418
- www.abcop.org - Certification - Orthotist & Prosthetist