By: Feryanda Utami, B.

PO
14th March 2019
 OBJECTIVES
At the end of this session, students will be able to:

Explain what is orthotic prescription and the responsibilities of

orthotic Interdisciplinary team

Understand the basic factors to consider in prescription

processes

Apply the prescription principle to develop appropriate

prescription for KAFO
 CONTENTS
What is Orthotic Prescription and Responsibilities of
Orthotic Clinical Team Members
Factors to develop appropriate prescription
1) Clinical Evaluation Protocol
2) Team consensus on the treatment goals
3) Knowledge in components & materials
Prescription Rationale for KAFOs
 Weakness of the muscle controlling the limb
 Spasticity o the muscles controlling the knee
 Loss of structural integrity of the knee or hip joints
and /or lower limbs bones
 Over view
What is an Orthotic Prescription and
Responsibilities of Orthotic Clinic Team??

Rx = a written and signed document of instruction

from a medical doctor which includes:
• Patient’s Name, Age, Gender
• Diagnosis, Medical History
• Orthotic Design, Components & Materials
• Wearing Schedules
• Attached X-ray if necessary
• E.t.c.
Orthotic Clinic Team Members
Orthotic prescription
requires the
collaboration with
other members of
rehabilitation team
because of multiple
need in rehabilitation
care program
Factors to be Considered in Order to Establish
Appropriate Prescription
What is an Orthotic Prescription and
Responsibilities of Orthotic Clinic Team??
 Overview
Example: Patient came to your clinics with Rx from doctor for
KAFO with free knee and ankle joints. What factors to be
considered?

Clinical Assessment and Evaluation Protocols

Interview the patient or Caregiver – to know the chief

complain

Review of medical records – Diagnosis and history of illness,

past and current treatment
 Overview
Perform Physical and Clinical Assessment
 To know the integrity of the muscles, joints and Postural
alignment

Asses about financial status

 Health insurance/ kind of payment?

Emotional issues
 Does the patient/ care giver want your services?
Team consensus on appropiate treatment goals

Discuss the goal of orthotic treatment with

the team –

in order to set priorities on the most

appropriate design
Why Team Consensus is Important During
Rx???
Because Orthotics treatment goals may be different
for each member.
• Patient's goal – "to walk faster "and stable
• Orthotist goal – to prevent deformity by control of
the abnormal joint motion
• Physician's goal – to improve gait efficiency
• Therapist's goal – to facilitate training for improving
muscle strength

Rx = Medical Prescription
Why team consensus for orthotic goals is needed?
= Orthotic intervention designed to solve one goal will likely create
limitation on the limb functions

E.g. orthotic goal to prevent or correct deformities may not improve the
efficiency of gait
>> Due to restrictions of ankle dorsiflexion leading to lack of Foot
Clearance during swing phase

It is important for clinic team member to have agreement on the appropriate

treatment goals during Rx phase
 Knowledge of Orthotic
Components & Materials
Which types of orthotic components you will select?
• Limited, or free motion ankle joints
• Locked, free motion or free swing with safe locking stance knee joint
• Ischial/gluteal bearing
Which materials you will select?
• Thermo plastics/thermo setting
• Pre-impregnated carbon fiber, or
• Conventional aluminum/stainless
Knowledge in Components & Materials
Knowledge in Components & Materials
Summary of What We Have Discussed
1) What is a Prescription
2) What are the orthotic team member and their
responsibility
3) Three important factors needed to develop
appropriate prescription
4) Important of team consensus about the
treatment goals
5) Why clinic team members is important in Orthotic
Prescription
 What is the general KAFO are mainly
indication of KAFO prescribed in order to:
prescription??

KAFO is indicated when an AFO  Provide stability at the knee

or KO are not sufficient to and/or ankle joints
provide stability or control of the  Assists functional ambulation,
knee during static or ambulation exercise or both
Prescription Rationale in KAFOs
What are the benefit of using KAFOs?

 Provide support for lower limbs weakness

 Correct flexible deformities (young children)
 Prevent contractures of the lower limb
 Enhancing body fitness and strengths
 Delaying the development of osteoporosis in adult
 Decreasing the risk for complications, such as deep venous
thrombosis
 Prescription Rationale in KAFOs
What are the common major clinical conditions
indicating the use of KAFOs?

1) Weakness of the muscles controlling the knee

2) Spasticity of the muscles controlling the knee
3) Loss of structural integrity of the knee or hip joints and /or lower
limbs bones
 Weakness of the muscles controlling the knee

It may result from:

Nerve Injury as a result of trauma or spinal cord Injury
Neuromuscular disease such as
Post polio syndrome
Spinal bifida and
Duchene muscular dystrophy
 Weakness of the muscles controlling the knee

Example: Paraplegic patient with trunk and upper limb

strength, and some hip flexor muscle strength

Prescription consideration of Bilateral KAFOs:

 to provide ankle and knee stability for patient
and aid in ambulation
 to provide stability at the Hip joint the weight line
should passes behind the hip joint axis.
 Weakness of the muscles controlling the knee

 The patient may tend to lean posteriorly, increasing

lumbar lordosis, so as to increase stability of the hip joint by
placing the COG behind the hip joint axis

Ambulation can be achieved by the use of forearm

crutches
*However patient will use more energy during
ambulation
 Weakness of the muscles controlling the knee
Orthotic design

KAFOs with locking knee joints and limited range of ankle

dorsiflexion motion
Locking knee joints - to stabilize the knee
Limited range of ankle dorsiflexion (5-7 degrees) to
help in reducing the energy expenditure for paraplegic
patient when ambulating with bilateral KAFO and
crutches

Free ankle motion or dorsiflexion assist should be avoided.

(David at el., 1993)
 Weakness of the muscles controlling the knee

Paraplegic patients with loss of trunk and upper limb

strength are not indicated for KAFOs
• To ambulate with KAFOs needed upper body
strength with ambulation aids (walkers or crutches)

Orthotic Prescription Consideration

• THKAFO, standing frame device, parapodium, or
swivel walker are generally appropriate prescription
 Weakness of the muscles controlling the knee

Example: Patient with Knee Extensor weakness

Patient may adopt compensatory gait deviations to
prevent the external knee moment tending to flex
the knee

 Flexion of the trunk, causing GRF to pass anterior

of the knee axis to create extension moment
 Alternatively the patient may resist flexion by
manually pushing the thigh posterior

However, these maneuvers result in a highly energy

consuming and unsightly gait pattern
 Weakness of the muscles controlling the knee

Example: Mild Knee Extensor Weakness

Prescription Consideration:
In case of mild knee extensor weakness with absence of a knee
flexion contracture, a GRAFO or KO may be sufficient to provide
knee stability during stance
Weakness of the muscles controlling the knee

Example: Severe Knee Extensor Weakness

Prescription Consideration:
In case of severe knee extensor weakness with/ out
knee flexion contracture

 KAFO that provide knee control during

stance phase will be appropriate to permit
more safe and more stable walking pattern

**KO may not be sufficient to resist large flexion

moment due to its shorter lever arms**
Weakness of the muscles controlling the knee

 Example: Severe Knee Extensor Weakness

 Orthotic Design: Control of the knee joint, it can be achieved by
various design of Orthotic knee mechanism joints such as:

• Manually locked knee joints system

• Posterior off set free motion knee joints
• Advanced orthotic knee joints system
Weakness of the muscles controlling the knee

 Orthotic Design: KAFO with locked knee joints

It Keep the knee joint in a position of full extension
throughout the gait cycle (Drop locks)

 Common Problem: Difficult to do clearance from

the ground during swing phase
 More energy expenditure
 Gait deviations (circumduction and hip hiking)

 Solutions: Removal of 0.5 to 1.5 cm heel lift may

provide swing clearance but pelvic obliquity must
be considered
Weakness of the Muscles Controlling the Knee
 Orthotic Design:
KAFO with Posterior Off Set Free Knee Joints

Enhanced knee stability during stance

phase via GRF without interfering with swing
phase flexion

**Not recommended for Poor hip muscle and for patient

walking on uneven terrain or declining slopes
= GRF to move posterior to knee joint axis causing knee flexion
during loading response
Weakness of the Muscles Controlling the Knee
 Orthotic Design:
KAFO with Advanced Orthotic Knee Joints

Creates a more natural gait cycle by automatically

assist knee extension during stance phase and allowing
free flexion during swing phase
 Spasticity of The Muscles Controlling The Knee
Spasticity of the muscles controlling the knee results from UMN
diseases or spinal cord injuries

Upper motor neuron lesions pathologies leading in Spasticity of

the muscles controlling the lower limbs such as:
Traumatic head injuries
Cerebrovascular accident (stroke)
Cerebral palsy

The functional loss resulted from UMNL includes:

Loss of the normal control of the lower limb muscle
Absent of sensation and proprioception
Spasticity of the Muscles Controlling the Knee

Example: Patient with UML leading to

spasticity of the muscles controlling the knee

Patient may achieve knee stance stability by:

Ankle Plantarflexion, Subtalar Joint Supination,
and Knee Extension

to move the GRF anterior to the anatomical

knee joint
= Resulting in large knee extension moment
Weakness of the Muscles Controlling the Knee
Prescription Consideration:
KAFO is prescribed for a spastic hemiplegic with
quadriceps weakness to control genu-recurvatum when
an AFO offers insufficient control
KAFO is intended for short term use
Due to difficult of achieving a better gait

Rigid AFO is usually prescribed to provide efficient

functional ambulation if ….
Knee stability can be achieved during stance phase
Spasticity of the Muscles Controlling the Knee
 Orthotic Design:
KAFO design which consist of Orthotic knee joint that can:
• Provides knee stability during stance
• Limit knee extension to 175-180°
• Permitting unrestricted range of knee flexion for sitting

• Ankle components can be Rigid plastic ankle or with ankle joints

that control equinovarus during stance
 Loss of Structural Integrity
This problem occur on the lower limb bones OR at knee and hip joints, it may
results from:
o Trauma
o Joints degeneration
o Tumors of the bones
o Congenital abnormalities

Which may lead to loss of axial loading due to:

o Pain during weight bearing
o Damage or deformity due to bone loss
o Non-union of femoral fracture
 Loss of Structural Integrity
Examples:

Injury of the posterior cruciate ligaments may

lead to Genu-recurvatum

Damage to the collateral ligaments of the

knee may result in a Genu varumor Genu
valgum
 Loss of Structural Integrity
Genu-recurvatum

 Prescription Consideration:
KAFO is most preferred over KO in case of severe
deformities due to:
Discomfort and skin breakdown resulting from the
high limb-orthosis contact forces due to shorter
lever arm

 Orthotic Design: Moulded KAFO with

 Free motion knee joints to limit knee extension
to 175-180°while permitting normal range of knee
flexion
 Free motion ankle joint
 Loss of Structural Integrity
Genu Varum/ Valgum

 Prescription Consideration:

 These disorders are commonly treated using

KOs

 KAFOs may be appropriate for patients with

genu varum or valgum exceeding 15°
 Loss of Structural Integrity
Genu Varum/ Valgum

 Orthotic Design:
KAFO design that resist M-L moment by application of
three force system during weight bearing but
permitting a normal range of flexion/extension should
be appropriate
• Proximal and distal forces should be located as
far apart as possible
• Central force located as close as possible to the
knee joint axis
 Loss of Structural Integrity
Loss of Axial Loading

 Prescription Consideration:
KAFO objective for this condition is based on
 Preventing angular displacement and
 Relieving pain during weight bearing

Biomechanical requirements includes:

 Tolerable weight bearing area proximal to the site of skeletal
defect
 Strong orthotic component capable of transmitting the ground
reaction forces
 Loss of Structural Integrity
Loss of Axial Loading

 Orthotic Design:

 Weight relieving KAFO design can be employed to

provide either partial or total relief
 KAFO load relief generally requires a combination of
ischial bearing and hydraulic effect about the thigh
 References:
KAFO Manual from SSPO

Lower Limb Orthotics from NYU

 “
“A person who never made a mistake never tried anything
new.”
Thanks!
Any questions?
Case 1  Diagnosis: Post Polio patient with
correctable genu recurvatum,
more severe on the Right side.

 MMT of the Knee joints

Right →Flex-G-3, Ext-G-0
Left →Flex-G-3, Ext-G-2

 MMT of the Ankle joint

Both R&L →Dor-3, Plt-0

 Free ROM on both sides

 Deformity - pes planus both Left
and Right
 Non LLD
 Steppage gait deviation
 Knee joint instability in ML
(Valgus)
Case 1  Diagnosis: Post Polio patient with
correctable genu recurvatum,
more severe on the Right side.

 MMT of the Knee joints

Right →Flex-G-3, Ext-G-0
What is your Left →Flex-G-3, Ext-G-2

 MMT of the Ankle joint

recommendation? Both R&L →Dor-3, Plt-0

 Free ROM on both sides

 Deformity - pes planus both Left
and Right
 Non LLD
 Steppage gait deviation
 Knee joint instability in ML
(Valgus)
Case 2  Diagnosis: Post Polio (Right side)

 Hip joint
Dislocation
Adductors and Flexors are weak

 Knee joint
Free ROM
Genu Valgum
Extensor G-2
Slightly in contracture

 Ankle joint
Free ROM
Flaccid Drop Foot

 LLD 3.5cm
 Steppage gait deviation
Case 2  Diagnosis: Post Polio (Right side)

 Hip joint
Dislocation
Adductors and Flexors are weak

What is your  Knee joint

Free ROM
recommendation? Genu Valgum
Extensor G-2
Slightly in contracture

 Ankle joint
Free ROM
Flaccid Drop Foot

 LLD 3.5cm
 Steppage gait deviation
Answers
 Reference of Prescription CASE 1

Reference from VIETCOT Guideline for Orthotic Management of

Lower Extremity Disability and Custom Orthotic Seating
 Reference of Prescription CASE 2

Reference from VIETCOT Guideline for Orthotic Management of

Lower Extremity Disability and Custom Orthotic Seating
 Reference of Prescription CASE 2

Reference from VIETCOT Guideline for Orthotic Management of

Lower Extremity Disability and Custom Orthotic Seating