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Physical Rehabilitation


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Define Orthotics
the study/practice of design and fabrication of ortheses
Define Orthosis(es)
a device e.g. an appliance or brace, designed to protect, provide support or improve function of a specified body part
Define Othotist
A member of the rehab team who designs and fits orthoses. Works at the direction of a physician
Who is credited to bringing a humanistic view to the fields of disability and orthotics?
What are the indications for orthoses?
Provide stability, relief of pain, immobilizes and protects, prevents and corrects deformity, assists and improves function in a weak limb(AFO), Allows for maximal functional independance in function.
How does the orthotic provide stability and support?
It supports weakened structes by improving jt. alignment and stability. (ie knee bracing)
How does an orthotic relieve pain?
by limiting joint motion
How does an orthotic prevent and correct deformity?
It provides good feedback and it provides kinestetic feedback to the client.
What are the cuases or conditions that necessitate an orthotic?
Congenital, Accidents, Pathologies, and muscle imbalance.
What are common congenital conditons that necessitate and orthotic?
CP, spina bifida, clubfoot
What are common accidents conditons that necessitate and orthotic?
ACL injuries, fractures, soft tissue inj, and burns
What are common pathologic conditons that necessitate and orthotic?
CVA, artritis, multiple sclerosis
What are the roles of Physical Therapy with orthotics?
1. Maximize functional mobility of orthotic
2. Promote compentence in donning and doffing
3. Promote compentence in care of orthotic
4.Ensure patient compliance with skin inspection
5.Ensure proper fit and alignment
6.Devl'p functional tolerance of orthotic and it's wearing time.
7.Remember that an orthosis is an adjunct to therapy and that the use of an orthosis does not eliminate the need for dynamic activity.
What are some convential materials used in the making of an orthotic?
Leather cuffs, straps, and ties with heavy metal uprights.
What are the problems of conventional materials in making orthotics?
They are heavy and use a lot of enrgy to take them on and off.
What are contemporary materials used to make orthotics?
1.semi rigid or flexible plastic
2 Joints are constucted of metal
3. Rigid plastic
What are the adv/dis of semi rigid plastic?
1. decresed cost
2. quick delivery time
3. custom fit
4. have some give in them and have compacity to act as compressive springs as the person's body weight stratches the plastic material during loading phase of stance

disadvantages- deofrmable under increased or prolonged forces.
2. decreased ability to control jt instability
What are the adv/dis of rigid plastic?
1. signifigantly increased ability to control forces/alignment
2. lighter in weight
3. custom fit w/ ability for modifications
4. do not give with stresses
(#$ is an adv if this is a goal)
How are materials for an orthotic choses for a patient?
based on static vs dynamic needs of client for improved function
What are the biomechanical principals of orthotics?
1.Three point system
2.The larger the area in relationship to the force applied, the smaller the pressure will be. Therefore if you have a large corrective force, a larger surface area is required for the forcr application.
3.If an orthoses has a joint, the joint must be positioned close to the anatomical joint.
4. Rigid vs plastic problem:accomodation
Biomechanical principals of orthotic-
What is the Three point system?
1. One point of pressure is applied at the apex of the curve, or the point of instability. Reffered as the corrective force
2. Two points of pressure are applied in opposite directions above and below the apex of the curve or point of instability.
These are reffered to as stabilizing forces.
What is a jewiit brace used for?
correction of lordosis
Where is the corrective force and stabilixing forces applied on a jewitt brace?
Corrective is applied to the ASIS; the stabilizing forces are applied at the ball of the footand the posterior thigh.
Where are the forces applied on a KAFO?
How is an orthosis named?
It is named after the joint it crosses
Name the lower-limb orthoses.
There are 5
Foot orthosis, or FO
Ankle orthosis or AFO
knee-ankle orthosis KAFO
hip-knee0ankle-foot orthosis HKAFO
knee only- KO
Name the upper limb orthoses
There are 5 (6)
Hand orthoses, or HO
Wrist-Hand orthoses, or WHO
Elbow wrist hand, or EWHO
Shoulder-elbow-wrist-hand, or SEWHO
Elbow orthoses, EO
Wrist orthoses WO
The spine is considered 4 joint complexes which are not subdivided.
Name them.
Cervical, C
Thoracic, T
Lumbar, or T
Sacroiliac, or SI
Spinal Orthoses may also include?
There are 4
1. Cervical-thoracic-lumbo-sacral, or CTLSO
2. Thoracic-lumbo-sacral orthoses, or TLSO
3. Lumbo-sacral orthoses or LSO
Sacroiliac orthosis, or SIO
(when only sacroilliac is involved, SI is used to avoid confusion with S for shoulder.)
Why are AFO's usually indicated?
To control ankle motion by limiting plantar and.or dorsiflexion.

Knight Taylor is used for what?
AKA thoracolumbosacral flexion, extension control orthoses.

knight spinal is used to control what?

LS flexion, ext, and lateral control

CASH brace is used for what?
Flexion immobilization
Limits flexion and extension from T6-L1

WIlliams flexion is used for?
limits flexion
Jewett Hyperextension brace does what?
maintains extension and immobilizes
What Brace is more commonly used for scoliosis
Boston Brace:
orotist molds it and it is modular
What are the 6 cervical orthosis
philadelphia, soft collar, 2 and 4 post collar, halo, SOMI, and Miami J
A patient has a peripheal nerve injury with paralysis of anterior tibialis muscle (dorsiflexes and inverts the foot). What orthosis will help in gait training?
Hemiplegic with fair return of of L.E. will and moderate spasticity. What orthosis will help with gait?
AFO or possible an FO casted in sub-talar neutral (UCBL)
Infant with congenital hip dislocation. Give an orthotic(S).
KAFO or most likely ABD splint.
Child with Legg-Calf-Perthese disease would use what type of othotic(S)?
KAFO or most likely ABD spint.
infant with talipes equinovarus(club foot)
What kind of orthotic?
Symptoms of Club foot:
1.) Fixed plantar flexion (equinus) of the ankle, characterized by the drawn up position of the heel and inability to bring to foot to a plantigrad
most likely shoe build-up on the opposite leg and FO to support the equinovarus position if it is considered inflexible.

An AFO is considered if it is considered flexible in equinovarus position.
Spinal cord injury involving lesion at T 10. orthotic?
Bilateral KAFO
Craig-Scott KAFO
This may be prescribed for people that are parapelgic.
A craig scott orthoses can enable a patient to stand with sufficient backward lean so as to prevent untoward hip or trunk flexion.
People with thoracic spinal injuries will not be able to voluntaritly flex their hip and the orthosis does not have a mechanism that to aid single-leg progression. Swing-to or swing through gait with orthosis
What orthotic for L4 lesion?
Bilateral AFO
Immobilization of wrist for symptomatic relief of acute tenosynovitis. What orthotic(s)?
wrist hand orthosis(WHO)
in the "functional" position of the hand; a resting pan/hamd splint
Upper trapezius spasm following trauma to the next would probably have what orthotic?
philadelphia or soft collar cervical orthosis.

Book definintion of Phil:
"the philadelphia collar has mandibular and occipital extensions and a rigid anterior strut; it's sometimes used for upper cervical injuries."
Whiplash injury with acute spasm? Orthotic?
CO, cervical soft collar
mid thoracic compression fracture resulting from osteoporosis. orthosis?
Jewett if low fracture, cruiciform anteriorspinal hyperextension (CASH)orthosis or TLO

"Clinicians recommend soft cervical collars to immobilize the cervical spine following trauma" -taken off web
what orthotic is used with a post-lumbar laminectomy?
williams flexion orthotic or TLSO

people "with kyphoses or thoracic, thoracolumbar, or lumbar scoliosis may be fitted with a TLSO that applies force to realign the vertebral column and thoracic cage. Effective on patients who have immature spines and moderate vertebral curves in midthoracic spine or more inferior portions of the trunk.
weak gastroc would need what orthotic?

plantarflex the ankle
knee flexion (when not weight bearing)
stabilizes ankle & knee when standi
flexible plastic AFO or traditional AFO w/ ANT stop
weak anterior tibialis. orthosis?
flexible, plastic AFO or traditional AFO with posterior stop
recuvatum(hyperextension of the knee)? Orthotic?
plastic AFO molded into slight DF or traditional AFO w/ posterior stop
poor proprioception. orthotic?
flexible plastic AFO, traditional AFO w/ spring asst for DF/PF
oscalis fx (?) orthiotic?
ishial weight bearing HKAFO
What is an HKAFO used for?
(Definition is taken from Handbook p.746)
provides an opportunity for stance and mobility. Patients will adopt a swing through gait using crutches or a walker. Indicated for patients with signifigant neurouscularor muculoskeletal impairments such as CP and SCI
Burn to the axilla area. Orthotic?
molded shoulder ABD orthosis
SCI for tenodesis function would need what orthotics?
A tenodesis splint; dynamic wrist hand orthosis
DF causes knee flex/ext?
PF causes knee flex/ext?
You are working with a client who is wearing a clamshell orthosis. Create a patient brochure to teach your client how to care for the orthoses.
Supine, fasten from bottom upward. Avoid heat wipe w/ cloth; maintain constant body weight. Do not soak.
Name one patient diagnosis that a clamshell would be used for?
Describe how the clamdhell should be fit to the client, i.e., what will you do to verify it fits, not how the clamshell is made?
3 points of pressure
Name one orthosis that the plastic clamshell orthosis might have replaced.

designed to limit flexion and extension of the thoracic and lumbar spine.
You have just been working with a client who is wearing a plastic AFO. The client is resting. You doff the AFO to give the client a redt. What do you want to see as you inspect the skin? What do you not want to see?
signs of abrasions, redness, and swelling
Your client is experiencing some instability about the knee joint during gait. You decided to try to alter the ankle joint in an attempt to change the control at the knee. What are your two main options, and what impact do you expect that each will have?
dorsiflexion. it will cause the knee to flex
Rank the four CO's you have available with regard to the stability they provide
soft, semi rigid (philadelphia), 2,3,4 post, and Halo
Name three diagnoses for which the COs might be appropriate.
mm spasm, dislocation fracture
Given a client who is wearing a soft collar, what signs and symptoms will you look for to determine if the client is ready to reduce his/her wear time of the CO? To discontinue wear time of CO?
Decrease of pain and increase of ROM
Describe the different exercises you will reccommend to the client to augment the wear of the CO
Isometrics all planes
ROM supine when out of the collar
You are working with a client who is wearing a (L) KAFO. Describe different knee locking mechanisms available for the orthosis
Pawl lock w/ bail release(against chair)

Drop ring w/ or spring loaded release

A drop ring lock is the most common. When the client stands fully extended, the ring drops, preventing the uprights from bending.

The pawl lock with bail release provides simultaneous locking of both uprights. The prawl is a springloaded projection that fits into a notched disk. The patient unlocks the brace by pulling upward on a posterior bail.

The offset joint and knee joints with the basic drop ring or pawl locks are contraindicated in the presence of knee flexion contracture.
Your client just donned a KAFO. What will you look for to determine the fit and/or managment problems. Explain the relation of the deviation to the orthosis problems.
hyperextension or recuvatum- the ankle is in too much plantarflexion.
knee buckling- ankle is in too much dorsiflexion
What can you do as the therapist to correct the gait deviations?
call orthosist for an adjustment.
What is a T-Strap used for?
A T-strap attached medially and circling the ankle until buckling on the outside of the lateral upright is used for valgus correction. A T-strap attached laterally and buckling around the medial upright is used for varus correction.
What type of patients would need a KAFO?
KAFO can be used in quadriceps paralysis or weakness to maintain knee stability and control flexible genu valgum or varum. KAFO also is used to limit the weight bearing of the thigh, leg, and foot with quadrilateral or ischial containment brim. A KAFO is more difficult to don and doff than an AFO, so it is not recommended for patients who have moderate-to-severe cognitive dysfunction.
The leading cause of disabled elderly is what?
What are the 4 causes of amputations?
PVD, Tumor, trauma, and congenital
What is the leading cause of cancer in children?
What is the leading cause of amputation in young adults?
What is one congenital etiology of amputations.
What 5 criteria is used to determine the level of amputation?
1. Maintain greatest bone length
2. Save all joints possible
3. The presence/abscense of pulses may help determine the level of the amputation.
4. An amputation may be performed at any level
5. the client's potentioal for successful rehab will affect the level of amputation.
What are the levels of amputation?
Transmetatarsal- through the midsection of all the metatarsals

Choparts-disartic of the metatarsals from the tarsals

Symes- an ankle disartic w/ attachment of the heel pad to the distal tibia. Possible removal of the malleoli

BK (below the knee)
*long- more than 50% of tibial length perserved
*short-less than 20%
*optimal between 20-50% of tib reserved

Knee Disartic-amputation through the knee jt; the femur remains intatc

AK- Long more than 60% of femoral length preserved
short- less than 35%
Optimal- between 35-60%

Hip Disartic- resection of the lower half of the pelvis
Hemipelvectomy- ressection of the lower half of the pelvis
Hemicorporectomyp removal of both LE's and pelvis below l4-l5
Surgical considerations: skin flaps?
should be equal length midline incision on distal most aspect of the residual limb.

Long posterior flap with resultant anterodistal incision line.
1)increased healing seconsdary to increased blood supply typical of the posterior tissues.
Surgical considerations:caring for the scar
scar should be pliable, painless, and nonadherant
Surgical considerations:neuromas
develops from severing the distal end of a peripheal neve.
Nerve should be retracted in surgery to prevent development; may not be possible in cases of trauma.
Surgical considerations: bone ends
smooth and rounded in AK and BK

beveled in BK
Surgical considerations:muscles
myoplasty-suture muscle to muscle to stabilize after amputation.

myodesis: suture muscles to periosteum stabilize after amputation
Surgical considerations:major vasculature
ligate the arteries and veins affected by the amputation.
What type of suspension is used for an AK prosthesis?
Suction suspension
What type of suspension is used in a BK prothesis?
neop sleeve and corsett
silicone suction suspension
supracondr cuff (strap above patella)
medial wedge (used to keep othtic in place)
supracondlyr rim (has to be at 90)
What is the major difference between the quadrilateral and the newer design socket for the AKA prosthesis?
???? half right
ishial containment socket designed to contain the ishial tuberosity.
list one advantage of a hydraulic controlled knee.
the knee can accommodate to how fast the patient walks by providing friction to prevent excessive knee flexion or abrupt extension.
What is the MAIN advantage of an energy storing foot?
It would be less energy expended for the patient.
True or false SACH foot stands for solid ankle cushion heel
True or false A selision belt is a type of suspension used for BKA's
False, AK
True or false
Endoskeleton shanks are lighter than exoskelton
T or F
The patella bears a sigifigant amount of weight in an AK prothesis.
False. hint:above the knee is AK. no patella
Name three components of the pre-op program that you would provide a client before amputation.
my three on the quiz were
bandaging techniques,

strengthening the contralateral limb,

MMT for comparison post-surgery
Name one advantage of shaping using an ace wrap. Name one disadvatage of shaping with an ace wrap?
Adv: lightweight
Disadv: not effective in controlling edema
If a patient complains of pain in his toes that have been amputated he is most likely experiencing what?
Phantom limb pain
Name one advantage of an elastic dressing in comparison to a rigid dressing.
What are STG in PT? amputee(8)
Promote healing of incisional area and reduce post-op edema

Indep. bed mobility and self-care, incl transfers

Strength the affeted LE

Strengthen all remaining extremities.

prevent development of contractures. (position is key)
What are advantages of Rigid dressings?
quicker shrinking

if used immed. post-op it will greatly limit edema

allows for early ambulation w/ attachment of pylon & foot

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