IDS ::: Orthotics ::: Procedures
Orthotic Practice and Procedures.
Assessment – may need to be considered in three sections:
Static
During this process the orthotist will be assessing physical features such as range of movement, skin condition including callus formation, sensation and joint stability. This list is by no means comprehensive. He or she will also consider any relevant (and available!) data such as records and X-rays.
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Static assessment of the foot |
[Back to Assessment: Top of page]
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Static assessment for knee stability. |
Dynamic
At this stage the orthotist will, when appropriate, examine the patient in motion. As an example, for a patient with a foot or ankle condition the orthotist will examine the patient walking and observe the general gait, how the foot / ankle behaves under load how other joints and /or posture are affected. [Back to Assessment: Top of page]
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Dynamic assessment for knee stability. Genuvarum under weight bearing due to osteoarthritis |
Psycho / Social
The psycho/social assessment will cover cognitive aspects, compliance, mood, environment and social support. All aspects of the assessment are crucially important to correctly identify appropriate targets and to specify the orthoses. At all stages the orthotist must listen to relevant information from the patient and/or carers. It is possible that this element is most likely to be missed in a busy clinic with potential negative results.
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Only after a full assessment has been carried out can the orthosis be specified and the manufacturing process begin.
- Is the patient prepared to wear the suggested orthosis?
- Will he or she be able to understand its function, don it on and off, use it safely at home?
- Failing to consider these areas can be wasteful or even dangerous!
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[Back to Assessment: Top of page]
Specification of the orthoses [Top of page]
Following an assessment it may be decided that the patient does not require or is not suitable for orthotic intervention. He or she may need to be referred on to another health care specialist. If an orthosis is considered to be appropriate, the exact specification needs to be decided upon with reference to the assessment findings and the opinion of the patient and/or family or carers.
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Selecting the colour for the AFO |
Casting – the intention is to obtain a replica of the limb or body section in the best position possible. [Top of page]
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Marking anatomical features on stockinette with an indelible pencil. These marks will transfer onto the inside of the plaster of paris. |
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Applying a cast for a AFO to a small child |
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Trying to maintain the optimum foot and ankle position during casting. |
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Cutting the hardened plaster of paris off. |
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Close up of cutting the hardened plaster of paris off. |
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Preparing for taking a cast for KAFO |
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Taking a cast for a KAFO. |
Measurement – to record the dimensions necessary for the manufacture of the orthosis. All KAFO's require measurements to be taken. Some KAFO's require only measurements with no cast being required. Some measurements may be taken digitally by scanners.
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Measuring for a KAFO, [left and below]. |
Cast rectification [Top of page]
The hollow cast of the patient's residual limb/body section is sealed to prevent leakage and filled with liquid plaster of paris. When this has set the outer layers of PoP bandage are removed leaving a solid cast with a rough surface. Most custom made orthoses are manufactured directly over the cast so it needs to be smoothed. Very importantly it's shape needs to be optimised to achieve good fit and function. The process of achieving a smooth cast of the correct shape is known as cast rectification. [Top of page]
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Filling a hollow cast with liquid Plaster of Paris to create a solid cast. |
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Reduction rectification of a spinal cast. |
Manufacture [Top of page]
Mainly vacuum forming, machining and light engineering assembly. A small number of orthoses are manufactured by lamination or in silicone. [To see more information on lamination and silicone from the Prosthetic section, please click here: lamination and silicone.]
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Vacuum forming. Polypropylene (which has been heated in an oven and become transparent) is draped over the rectified cast of a KAFO.The blue lines indicate the intended trim lines. When the edges of the hot plastic have been trimmed, the edges are squeezed together to form a seal. |
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Once the seal has been made, vacuum is applied to ensure that the plastic is fully in contact with the cast. It is then allowed to cool and stabilise, often for 24 hours or more. |
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Cutting the hardened plastic off the cast |
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Machining an AFO after it was cut from the cast |
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Assembly of orthotic sections and components |
Fitting and Delivery [Top of page]
Not just to check that the orthosis fits correctly but that it also functions correctly!
Before and after photos illustrating bilateral AFO's with torsion cables. Checking that the orthoses are effective in controlling externation rotation. below.
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Fitting bilateral floor reaction AFO's
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Fitting and delivering a silicone AFO |
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Adjusting an AFO at the fitting stage |
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Adjusting a spinal brace at the fitting stage |
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Scliopathic Scoliosis Spinal Brace at fitting stage. [This was designed and fitted by a colleague in Barcelona.]
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Orthotic rehabilitation. [Top of page]
Many orthoses do not require complicated instructions or training in their use. The orthotist will normally give simple instructions and advice both verbally and in writing. However there are circumstances where training, guidance and initial supervision are essential. In these situations this service is normally provided by physiotherapists and/or occupational therapists.
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Learning to use an RGO under the instruction of a Physiotherapist |
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Bilateral AFO's being used in conjunction with a standing frame. |
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A different view of bilateral AFO's being used in conjunction with a standing frame. |
Subsequent review [Top of page]
Many orthoses do not require close monitoring of usage. However certain types, such as corrective scoliosis braces, need to be reviewed at regular intervals. Also, most children who use orthoses need to be reviewed regularly to ensure that the orthoses still fit well. Review appointments may be by other members of the M.D.T. but are frequently carried out by the orthotist.
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Subsequent review |
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