1. Orthotics for ‘beginners’!
Or how not to fail your FRCS questions
In orthotics 

2. What are Orthoses?
An orthosis is a device that is externally applied or attached to a body segment and that facilitates or improves function by supporting, correcting or compensating for skeletal deformities or weakness.
DHSS (1980)

3. NOMENCLATURE
Like orthopaedic surgery many devices named after individuals or places – creates confusion.... 
In the 1960’s American Academy of Orthopaedic surgeons suggested standard reproducible terminology of orthoses.
Described by the joint or region of the body it encompasses.

4. Hence Upper limb: Spine: S = shoulder C = cervical
E = elbow T = thoracic
W = wrist L = lumbar
H = hand S = sacroiliac
Lower limb:
H = hip
K = knee
A =ankle
F = foot

5. Commonly used A.F.O………ankle foot orthosis
K.A.F.O……Knee ankle foot orthosis
T.L.S.O……Thoracic lumbar sacral orthosis
Unfortunately......
D.A.F.O…..’Dynamic’ ankle foot orthosis
S.A.F.O….Silicone ankle foot orthosis
F.F.O….. Functional foot orthosis

6. Ideal characteristics
Effective
Lightweight
Cosmetically acceptable
Easy to put on (don) and take off (doff)
Comfortable

7. Aims of Lower Limb Orthoses
Correct and/or prevent deformity
Provide a base of support
Facilitate training in skills
Improve efficiency in gait
Improve FUNCTION

8. To improve efficiency of gait
“5 prerequisites for efficient gait” – GAGE
Stability of the stance limb.
Clearance of the swinging limb.
Appropriate position at terminal swing.
Achieving adequate step length.
Conservation of energy expenditure.
These are often limited or non existent in neurological conditions

9. To correct and/or prevent deformity
Dependent upon assessment, if the joints are of a flexible nature, then the orthosis will be used to correct/reduce the rate of deformity as the child grows
Whereas fixed deformities can only be accommodated within the orthosis, and require surgical intervention to improve the position of the limb and reduce forces.

10. How do A.F.O.’s work in the lower limb?
Controls or eliminates ankle and sub-talar motion
By controlling distal joints one can alter the g.r.f. and effect more proximal joints (coupling)
Therefore if placed in a slightly dorsiflexed position the g.r.f. moves posterior to knee joint resulting in flexion of the knee
(ski boot)..

11. Coupling Joints rarely act in a solitary fashion But in unison
Concept of affecting one joint by position of another = coupling
Influences stability.
Each level should be assessed, but also in conjunction with joints above and below.

12. Probably best lower limb example of coupling

13. Simple Ground reaction force

14. Mechanics of an AFO
For a fixed ankle AFO

16. ‘Trade – offs’ using A.F.O.’s in C.P.
POSITIVE
Restricts undesirable motion
Improves ability to stand and take steps
Helps toe clearance
NEGATIVE
Can be cumbersome & heavy
May make ramps and stairs harder
May be uncomfortable
Draws attention

17. Types of A.F.O’s
Rigid Ankle
Hinged
Ground Reaction
DAFO

18. Rigid A.F.O.

19. Hinged A.F.O.

20. D.A.F.O’s The debate rages on…………………..
Designed out of a therapy need for increased control with stability…WITH some movement. (Nancy Hilton)
Fabricated from very thin flexible polypropylene.
Controversy still surrounds it’s neurophysical approach due to lack of solid scientific research.

21. DAFO’s and tonic reflexes
1. Four tonic reflex movements of the foot can be elicited in normal infants and in some older children with cerebral palsy.
2. The disappearance of these tonic reflexes with growth appears related to maturation of the central nervous system.
3. These reflexes are of orthopaedic interest in that they may, by their occasional unopposed action, cause deformity.
4. It is suggested that these slow tonic movements represent a summation of many instantaneous reflexes, and that these instantaneous reflexes are distally located trigger mechanisms that initiate balancing reactions.

22. D.A.F.O.’s Cast in neutral, or as near as possible position.
Provides increased foot ‘control’ without excessive control at ankle complex.
Keeps feet in ‘good shape’.
More FUNCTIONAL.
COSMETICALLY acceptable.

23. D.A.F.O construction
Foot plate shaped to provide increased pressure on
Medial Arch
Peroneal Notch
M/T pad area
Extension of the toes

24. Most orthoses impose a posture, therefore this imposition needs to be realistic.
(rule of thumb, is you can only achieve with an orthosis, what you can achieve with your hands.)
Collaboration
Compromise
Communication = COMPLIANCE!

25. Management
“The role of the therapist is to protect patients with cerebral palsy from orthopaedic surgeons” J Gage, Minneapolis

26. Thank you