Upper and lower limb orthoses and therapeutic footwear

Author(s): Marlis Gonzalez-Fernandez, MD, PhD, David Taftian, MD, Mark Hopkins, PT, CPO

Originally published:09/20/2014

Last updated:09/20/2014

1. OVERVIEW AND DESCRIPTION

Limb orthoses are devices applied to the body to modify or control structure or function. Many limb orthoses use three points of pressure to perform at least one of the following functions: 1) provide support, 2) modify joint motion, or 3) manipulate body tissue. Orthoses are named after the joints/segments they manage, and are classified based on action (static vs. dynamic or accommodative vs. corrective). Application in acute injury tends to focus on maintaining range of motion, preventing contractures, protecting damaged or weakened soft tissue, or providing immobilization. Chronic use aims to prevent or control unwanted motion, enhance motion, decrease abnormal tone, alleviate pain, or maximize function. These interventions apply to all phases of a rehabilitation plan and depend on the patient’s level of impairment.

Upper extremity orthoses with clearly defined therapeutic purposes may offer particular advantages at various stages of a rehabilitation program when managing limb deficits caused by deformity, paralysis, or pain. For long-term patient acceptance and utilization orthoses need to fit precisely and be mechanically efficient while providing mobilization/immobilization to the upper limb.1 General concepts include: support the joints, prevent deformity, and expand functional parameters.

Lower extremity orthoses are to facilitate the rehabilitation of patients with lower extremity impairment. Their versatility and the desire of most people with a disability to stand or walk has made them common devices for patients with neuromuscular impairment.1Intervention typically begins by addressing distal needs and adding proximal components when additional management is needed.

Footwear protects and warms feet, transfers body weight during ambulation, and redistributes weight to reduce foot pressure and pain.Therapeutic footwear and foot orthoses also accommodate deformity, disease, and pathology,1,2 Although not curative, footwear can correct or accommodate a deformity and/or affect foot and lower limb biomechanics.1

Medical conditions which warrant the use of limb orthoses or therapeutic footwear include: trauma, stroke, traumatic brain injury, spinal cord injury, multiple sclerosis, cerebral palsy, peripheral nerve injury, arthritic conditions, burns, and contracture management in both pediatric and adult populations.

Common complications seen with orthotic use include skin breakdown, infections, and contracture development. Thus, it is essential that medical examination pays special attention to dermatologic, neurological and musculoskeletal systems when following these patients.

2. RELEVANCE TO CLINICAL PRACTICE

Upper Limb Orthoses

Hand orthoses are common in patients with intrinsic hand musculature weakness or paralysis with intact wrist extensors. Thumb adduction stop maintains the thumb web space and position of the hand for functional tasks.1MCP extension stops address transverse arch weakness by avoiding MCP hyperextension and are used where recovery of strength is expected.Thumb spica orthoses provide support and positioning to the thumb CMC and MP joints and decrease pain or provide thumb stability. Thumb IP orthoses assist a weak extensor pollicis longus. Proximal interphalangeal joint orthoses (PIPO) are used in Boutonniere or swan neck deformity to block exaggerated displacement using splints and rings.1

Wrist-hand orthoses (WHO) are used in wrist and hand weakness. Resting WHOs preserves wrist and hand architecture by positioning the wrist and hand in a functional position with the thumb abducted and flexed. Wrist action WHOs protect and assist weak wrist extensors by transferring power from active wrist extension into finger flexion by utilizing tenodesis. Dynamic dorsal WHOs for radial nerve injuries position the hand with wrist and MCP extension.1

Elbow orthoses (EO) address functional limitations caused by soft tissue contractures at the elbow and are often custom fabricated. EO are used after surgery or trauma for limb stabilization rather than casting. Functionally, EOs are commonly used for assistance with elbow flexion in patients with weak elbow flexors.1Elbow-wrist-hand orthoses (EWHO) are used for fractures involving the olecranon and distal humerus where radial or ulna nerve injury affects wrist and fingers function.

Shoulder-elbow orthoses (SEO) support a painful shoulder or brachial plexus injury. Shoulder slings are commonly used in acute settings. A mobile arm support (MAS-SEO) is used in severe arm paralysis to improve limb function by supporting the weight of the arm and assisting with shoulder and elbow motion in the horizontal plane while seated in a wheelchair.1

Shoulder-elbow-wrist orthoses (SEWO) are used post-operatively in rotator cuff and anterior-posterior capsular repairs to relieve tension on the deltoid and rotator cuff by externally rotating the glenohumeral joint and stretching the internal rotators. They also protect soft tissue and prevent contractures.1

Tone reduction orthoses are used to reduce flexor tone in patients with significant spasticity and include: bobath splint, cone splint, and the anti-spasticity ball splint.

Lower Limb Orthoses

Ankle foot orthoses (AFO) are commonly prescribed for weakness or paralysis of ankle dorsiflexion, plantar flexion, inversion, and eversion. AFOs aim to stabilize the foot and ankle while weight-bearing and lifting the toes during gait.1,3 Greater muscle tone requires a more rigid design. Metal AFOs are recommended for patients with insensate feet, fluctuating edema, or at risk for skin breakdown. Regardless, AFOs increase functional mobility, walking, and some aspects of balance.Posterior leaf spring AFOs are the most flexible. Semi-rigid plastic AFOs are used in patients with extensor tone and or ankle instability. Rigid plastic AFOs are used for patients who have the highest level of tone/spasticity, and those requiring immobilization. Articulated/hinged AFOs can be set to the desired range of ankle dorsiflexion or plantar flexion. Knee ankle foot orthoses (KAFO) extend the AFO to provide proximal control and stability at the knee. Quadriceps weakness or paralysis is reason for use of a KAFO. They are also used when an AFO fails to prevent knee hyperextension (recurvatum).1

Knee orthoses (KO) provide support or control of the knee joint. Depending on the type of KO, motion may be limited in the sagittal, axial, or coronal planes. Generally KOs are prescribed to prevent genu recurvatum and provide mediolateral stability.Flexible KOs are made from elastic or rubber, and provide comfort, proprioceptive feedback, mechanical support and may stabilize patellar tracking. A Swedish knee cage KO controls knee hyperextension while permitting full flexion. Lenox-Hill derotation orthoses are often used post-ACL injuries to control knee axial rotation. Rigid knee orthoses are commonly prescribed in cases of osteoarthritis to provide a frontal plane thrust and “unload” the affected compartment, medial or lateral.

Hip orthoses (HO) are indicated for isolated acetabular region problems, common uses include post-operative care, dysplasia, and injury.1

Hip-knee-ankle-foot orthoses (HKAFO) are typically used in the pediatric and adult spinal cord injury population to allow for stabilization of the hips and pelvis during standing and walking with assistive devices. Reciprocal gait orthoses (RGOs) are a type of bilateral HKAFO. The aim of the device is to couple flexion of one hip with extension of the other. This allows for a reciprocal step-over-step gait. A set of cables or a rocker bar are used to link the legs together and couple hip flexion with hip extension on opposite side.1

Foot Orthoses and Therapeutic Footwear

Foot orthoses (FO) are generally considered the foundation for all other lower limb orthoses. FOs aim to align and support the foot, prevent, correct, or accommodate foot deformity, or improve the overall function of the foot. These are made up of shoe inserts which can provide arch support, calcaneal support, or accommodate a deformity. FOs are commonly used with therapeutic shoes which should be properly fitted and have adequate room for the foot to expand during weight bearing.1

Both internal and external shoe modifications can be made. Heel and internal sole excavation aim to relieve pain, typically over bony prominences. Pad placement provides arch support or relieves pressure; heel wedges promote appropriate foot positioning or alignment. Bars can be placed to assist with weakness, relieve pressure and transfer load. Flares widen the base and support. Differences in heel material can provide cushioning, stability, positioning, and arch support.1

3. CUTTING EDGE/UNIQUE CONCEPTS/EMERGING ISSUES

Functional electric stimulation (FES) devices have been used as an alternative to traditional orthoses. These devices generate an electrical current that stimulates a nerve, causing muscle contraction in a predictable movement pattern. The most common FES devices for the lower limb are FES-AFOs that function by stimulating the peroneal nerve around the fibular head to produce ankle dorsiflexion and eversion. Accelerometers or heel pressure sensors are used to signal the device to activate based on the phase of gait (swing phase). These devices have shown moderate gait improvements when compared to traditional AFOs.5Recent improvements to traditional lower limb orthoses include stance control orthotic knee joints to provide stance-phase stability, while allowing swing-phase flexion. These should allow for a more normal gait pattern by eliminating some of the motion restrictions of other orthoses.Advances in materials, 3-D printing, and robotic exoskeletons are dramatically changing the durability, fabrication time, overall function and level of assistance provided by orthotic devices.

4. GAPS IN KNOWLEDGE/EVIDENCE BASE

Despite the widespread use of AFOs after stroke (up to 22% of stroke survivors discharged from inpatient rehabilitation used an AFO7 ), there is controversy about their use. The Bobath concept, which is widely used for stroke therapy in Europe, discourages orthoses, believing that it prevents or delays recovery of normal movement.8

The literature supports the use of AFOs when stroke or cerebral palsy results in lower extremity impairment by demonstrating improved gait, functional mobility, and reduced energy use when AFOs are used.7,9The effects of orthoses on upper limb function varies based on etiology. For example, nightly use of static splinting after non-progressive brain lesions has been shown to have no effect on upper limb function, pain, or spasticity.The use of static progressive orthoses for the treatment of upper extremity joint stiffness or contractures due to an orthopedic cause show benefits in increasing active range of motion, increased grip strength, and a reduced need for pain medications during orthotic intervention.10

Despite controversies, orthoses that allow patients to use their paretic limb for functional tasks allow a broader range of rehabilitative interventions, potentially resulting in improved limb function and improved quality of life.11 Many rely on these interventions as cost effective and less invasive alternatives for common medical problems, a classic example being lateral wedge insoles and valgus knee braces for knee osteoarthritis symptomatic relief instead of surgical interventions.Further, some orthoses can be used as preventive measures to avoid medical complications. Such is the case with custom foot orthoses used to reduce plantar pressure in patients with diabetes.2

The costs of these devices vary wildly based on materials used, fabrication, and complexity. To optimize both patient care and utilization of health care resources, it is paramount to have an in-depth knowledge of the patient’s deficits, as well as an understanding of the environmental and personal factors that will influence a patient’s orthoses use. Typical barriers to device utilization include its appearance, weight, and ability to don and doff the orthoses.7Prescribing incorrect orthoses may lead to functional impairment and biomechanical darangement which can futher medical complications [see 12 for an example]. To limit these obstacles, a team including orthotists, therapists, and physicians must work in concert to maximize patient benefit.

REFERENCES

1. Michael JW, Lunsford TR, Frey C. Atlas of Orthoses and Assistive Devices. 3rd ed. St Louis, MO:Mosby;1997.

2. Healy A, Naemi R, Chockalingam N. The effectiveness of footwear as an intervention to prevent or reduce biomechanical risk factors associated with diabetic foot ulceration: A systemic review.Journal of Diabetes and Its Complications. 2013;27(4):391-400.

3. Tyson SF, Kent RM. Effects of an ankle-foot orthosis on balance and walking after stroke effects: A systematic review and pooled meta-analysis.Arch Phys Med Rehabil.2013;94(7): 1377-1385.

4. Jones RK, Nester CJ, Richards JD, et al. A comparison of the biomechanical effects of valgus knee braces and lateral wedge insoles in patients with knee osteoarthritis.Gait and Posture.2013;37(3):368-372.

5. Edelstein JE, Assistive devices for ambulation.Physical Med Rehabil Clin N Am. 2013;24(2):291-303.

6. Zissimopoulos A, Fatone S, Gard SA. Biomechanical and energetic effects of a stance-control orthotic knee joint.Journal of Rehabilitation Research and Development.2007;44(4):503-513.

7. Chisholm AE, Perry SD. Ankle-foot orthotic management in neuromuscular disorders: recommendations for future research.Disabil Rehabil Assist Technol.2012;7(6):437-49.

8. Bobath B.Adult Hemiplegia: Evaluation and Treatment. 3rd ed. Oxford: Heinemann Medical Books; 1990.

9. Tyson SF, Kent RM. The effect of upper limb orthotics after stroke: A systemic review.NeuroRehabilitation. 2011;28(1):29-36.

10. Schwartz DA. Static progressive orthosis for the upper extremity: A comprehensive literature review.Hand. 2012;7(1):10-17.

11. Hoffman HB, Blakey GL. New design of dynamic orthoses for neurologic conditions.NeuroRehabilitation. 2011;28(1):55-61.

12. Carmick J. Importance of orthotic subtalar alignment for development and gait of children with cerebral palsy.Pediatric Physical Therapy. 2012;24(4):302-307.

Author Disclosure

Marlis Gonzalez-Fernandez, MD, PhD
Nothing to Disclose

David Taftian, MD
Nothing to Disclose

Mark Hopkins, PT, CPO
Nothing to Disclose

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