Overview and Description
Terminology: An orthosis describes an externally applied device used to modify structural and functional characteristics of the neuromuscular skeletal system, as defined by the International Standards Organization of the International Society for Prosthetics and Orthotics.1 The term orthotics refers to the science and practice of patient assessment, fabrication, fit, and adjustment of an orthosis.
An orthosis or orthotic device is applied to the body to modify or control skeletal structure or function. A basic principle for limb orthoses is to use three points of pressure to perform at least one of the following functions: 1) stabilize or immobilize a body part; 2) improve alignment; 3) prevent deformities; 4) protect against injury; 5) assist with motion; 6) off load a joint or body part; or 7) improve function. Orthoses are named for the joints/segments they manage according to the International Organization for Standardization (ISO) and are classified based on action (e.g., static versus dynamic).
Other terminology useful to consider in orthoses includes understanding the differences between custom versus off-the-shelf orthoses as well as dynamic versus static orthoses. “Off-the-shelf” orthoses are prefabricated, mass-manufactured orthotic devices that are available in various designs, sizes, and materials and require minimal adjustments. Custom-fabricated orthoses refer to those made specifically for individual patients. Meanwhile, custom fitted orthoses include devices that are already fabricated and are adjusted by a therapist to fit a patient by trimming, molding, or bending the orthosis.
A static orthosis has no motion across the joint or segment involved. A dynamic orthosis indicates that there is motion across the joint, and often incorporate strings, springs, pulleys, or other mechanical additions to promote function. A tone-reducing orthosis works to inhibit reflexes and provide prolonged stretch to decrease tone.2 A static progressive orthosis is a type of adjustable tone-reducing orthosis that applies force to a joint and holds it in its end range position to improve passive joint range of motion.3
Orthoses in acute injury tend to focus on maintaining range of motion, preventing contractures, managing pain, protecting damaged or weakened soft tissue, or providing immobilization. Chronic orthosis use aims to prevent or control unwanted motion, enhance desired 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.
Some medical conditions which warrant the use of limb orthoses may include trauma, stroke, brain injury, spinal cord injury, multiple sclerosis, cerebral palsy, peripheral nerve injury, peripheral neuropathy, arthritic conditions, burns, hypotonia, hypermobility, neuromuscular disorders, and contracture management in both pediatric and adult populations.
Common complications that can be seen with orthotic management include pressure injuries or skin breakdown, infection, and pain. Thus, it is essential that special attention is given to examine the skin, neurological function, vascular status, and musculoskeletal system in patients who will be using an orthosis.
Relevance to Clinical Practice
Upper Limb Orthoses
Upper limb orthoses differ in scope and purpose from lower extremity orthoses due to the functional difference between fine motor control in upper extremity and gross motor control and weight-bearing in the lower extremity.3 Along the same lines, the upper extremity has less soft tissue, decreased force requirements, increased sensory requirements, and more precision of movement compared to the lower extremity.1 Upper limb orthoses often focus on achieving a functional range of motion rather than seeking to achieve a normal range of motion. The examples of upper extremity orthoses listed in this section include various commonly utilized orthoses, however this list is not exhaustive.
Thumb, Finger, and Hand Orthoses:
- Thumb and finger orthoses are often utilized to stabilize bony and soft tissue structures as well as prevent contracture.
- Hand orthoses are commonly used for intrinsic hand musculature weakness or paralysis with intact wrist extensors.3
| Type of Orthosis | Action | Goals/Indications |
| Static finger orthosis | Inhibit motion at the proximal interphalangeal (PIP) and distal interphalangeal (DIP) joints of a finger | Promote healing (e.g., phalanx fracture) and prevent flexion contracture (e.g., burns) |
| Proximal interphalangeal orthosis | Decrease exaggerated displacement of PIP joint | Prevent contracture formation (e.g., blocking excessive PIP flexion in Boutonniere deformity or obstructing PIP hyperextension in swan neck deformity) |
| Metacarpophalangeal extension stop orthosis | Stop metacarpophalangeal (MCP) joint hyperextension with lumbrical bar while allowing MCP flexion | Support transverse arch weakness, prevent claw hand deformity, maintain functional hand position |
| Thumb interphalangeal (IP) orthosis | Maintain neutral position of thumb IP joint | Support weak extensor pollicis longus |
| Short opponens orthosis | Immobilize the first MCP and reduce movement of the carpometacarpal (CMC) joint while allowing wrist movement | Protect and promote healing (e.g., ulnar collateral ligament injury) as well as decrease pain and provide thumb stability |
| Long opponens orthosis (e.g., thumb spica) | Immobilize the first MCP and CMC joints and often crosses the wrist joint to restrict wrist and thumb movement | Provide stability, promote healing, decrease pain (e.g. arthritis of the wrist and thumb, De Quervain’s tenosynovitis) |
Wrist-hand orthoses (WHOs):
- Static resting WHOs preserve wrist and hand architecture generally by positioning the wrist and hand in functional alignment, including wrist in neutral to slight extension, MCPs partially flexed, and thumb abducted.
- A frequent functional focus for WHOs involves facilitating prehension, or the ability to hold or grasp. An example of this concept includes dynamic WHOs that protect and assist weak wrist extensors by transferring power from active wrist extension into finger flexion through tenodesis.
- Dynamic dorsal WHOs for radial nerve injuries position the hand with wrist in extension.3
| Type of Orthosis | Action | Goals/Indications |
| Thenar web space stabilizer orthosis (e.g., C-bar orthosis) | Maintains the thumb web space and functional position of the hand | Prevent web space contractures and increase the ability to perform functional tasks with thumb in abducted position |
| Wrist cock up orthosis | Stabilizes functional position of the wrist and hand while allowing MCP flexion | Decrease pain, provide stability and function, protect structures from excessive movement to promote healing (e.g., carpal tunnel syndrome, arthritis, radial neuropathy) |
| Wrist-driven prehension orthosis | Facilitate finger flexion through active wrist extension | Promote prehension through tenodesis action (e.g., cervical spinal cord injury, commonly C6 or C7)3 |
Elbow orthoses (EOs):
- EOs, including elbow immobilizers, can address functional limitations caused by soft tissue contractures at the elbow.
- EOs are used after surgery or trauma for limb stabilization instead of casting. These can be static or dynamic.
- Functionally, dynamic EOs are commonly used for assistance with elbow flexion in patients with weak elbow flexors. They can also assist in elbow extension.3
- Static elbow-wrist-hand orthoses (EWHOs) are used for fractures such as those involving the radius/olecranon and distal humerus.
Shoulder-elbow orthoses (SEO):
- SEOs support the shoulder to reduce pain and/or provide position due to muscle weakness, e.g., brachial plexus injuries or shoulder subluxation after stroke.
- A mobile arm support SEO (MAS-SEO) is used in severe arm paralysis to improve limb function through assisting shoulder and elbow motion by supporting the weight of the arm and reducing the effects of gravity. These devices are commonly used in a seated position (often in a wheelchair).3
Shoulder-elbow-wrist orthoses (SEWO):
- SEWOs are used post-operatively in rotator cuff and anterior-posterior capsular repairs to relieve tension on the deltoid and rotator cuff. SEWOs externally rotate the glenohumeral joint and stretch the shoulder internal rotators while protecting soft tissue and preventing contractures.3
Other upper limb orthoses:
- Typically, tone reduction orthoses are used to reduce flexor tone in patients with significant spasticity. One example is a Bobath finger spreader orthosis that uses digit abduction to decrease finger flexor tone
- A balanced forearm orthosis (BFO) is a type of shoulder-elbow-wrist-hand orthosis (SEWHO) that supports the weight of the arm, allowing for gravity-eliminated movement of the arm in a transverse plane. This type of orthosis is often utilized for self-feeding, for example, by facilitating horizontal arm movement like elbow flexion and extension in a patient with high cervical spinal cord injury.
- A dynamic movement orthosis (DMO) glove provides compression and enhanced sensory input to allow guided movement, which can be useful for orthotic management of dystonia.
- A universal cuff serves to hold task-specific items, such as a razor or utensil. Similarly, upper limb orthoses can incorporate a variety of task-specific attachments to aid in directed activities, such as writing, grooming, or any number of other functional tasks.3
Cutting Edge/ Unique Concepts/ Emerging Issues
Functional electric stimulation (FES) devices are used as an alternative or adjunct to traditional orthoses. These devices generate an electrical current that stimulating a muscle causing muscle contraction in a predictable movement pattern to create physiological bracing. This concept has been applied for the upper limb to improve wrist extension as well as to prevent shoulder subluxation.4 Prior studies have reflected a trend towards benefit from upper limb FES on ADL outcomes after stroke; however, there remains a need for high quality large-scale randomized controlled trials, as existing studies do not provide substantial quality evidence from which firm conclusions on effectiveness and optimal therapeutic window can be drawn.5
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.6 Incorporation of sensors providing real-time information has allowed for increased efficacy of active orthoses for tremor suppression.7
Gaps in Knowledge/ Evidence Base
The use of static progressive orthoses for the treatment of upper limb joint stiffness or contractures due to an orthopedic cause shows benefits in increased active range of motion, increased grip strength, and reduced need for pain medications during orthotic intervention.8
Despite controversies, orthoses that allow patients to use their paretic limb for functional tasks and a broader range of rehabilitative interventions, generally result in improved limb function and improved quality of life. Patients rely on orthotic intervention as a cost effective and less invasive means to manage common medical conditions, such as wrist bracing for carpal tunnel syndrome.
The cost of orthotic devices varies based on complexity, materials used and fabrication process. 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.1 Incorrectly prescribed orthoses may lead to functional impairment and biomechanical derangement which cause medical complications. To limit these obstacles, a team including orthotists, therapists, and physicians must work in concert to maximize patient benefit.
References
- Cifu DX. Upper Limb Orthotic Devices. In: Braddom’s Physical Medicine and Rehabilitation. 6th ed. Elsevier; 2020. Accessed August 30, 2022. https://www.sciencedirect.com/book/9780323625395/braddoms-physical-medicine-and-rehabilitation
- Cuccurullo S. Prosthetics and Orthotics. In: Physical Medicine and Rehabilitation Board Review. 4th ed. DemosMedical; 2020. Accessed August 30, 2022. https://connect.springerpub.com/content/book/978-0-8261-3457-8/
- Webster JB, Murphy DP. Atlas of Orthoses and Assistive Devices. 5th ed. Elsevier; 2019. Accessed August 30, 2022. https://www.sciencedirect.com/book/9780323483230/atlas-of-orthoses-and-assistive-devices
- Vafadar AK, Côté JN, Archambault PS. Effectiveness of functional electrical stimulation in improving clinical outcomes in the upper arm following stroke: a systematic review and meta-analysis. Biomed Res Int. 2015;2015:729768. doi:10.1155/2015/729768
- Eraifej J, Clark W, France B, Desando S, Moore D. Effectiveness of upper limb functional electrical stimulation after stroke for the improvement of activities of daily living and motor function: a systematic review and meta-analysis. Syst Rev. 2017;6(1):40. doi:10.1186/s13643-017-0435-5
- Ford C, Grotz R, Kope Shamp J. The Neurophysiological Ankle-Foot Orthosis. Clin Prosthes Orthot. 1986;10:15-23.
- Nguyen HS, Luu TP. Tremor-Suppression Orthoses for the Upper Limb: Current Developments and Future Challenges. Front Hum Neurosci. 2021;15:622535. doi:10.3389/fnhum.2021.622535
- Costa CR, McElroy MJ, Johnson AJ, Lamm BM, Mont MA. Use of a static progressive stretch orthosis to treat post-traumatic ankle stiffness. BMC Res Notes. 2012;5:348. doi:10.1186/1756-0500-5-348
Original Version of the Topic
Marlis Gonzalez-Fernandez, MD, PhD, David Taftian, MD, Mark Hopkins, PT, CPO. Upper and lower limb orthoses and therapeutic footwear. 9/20/2014
Previous Revision(s) of the Topic
Mi Ran Shin, MD, Olga Morozova, MD, Jeffery Rubin, DO. Upper and lower limb orthoses and therapeutic footwear. 2/26/2019
Author Disclosure
Mi Ran Shin, MD, MPH
Nothing to Disclose
Annie Abraham, MD
Nothing to Disclose
Olga Morozova, MD
Nothing to Disclose