Evolution of foot orthotics--part 1: coherent theory or coherent practice?

OBJECTIVE

To present a critical review of the evolution of foot orthotics theory and clinical practice.

DATA SOURCES

Several classic publications were consulted because of their overwhelming influence. The work of Merton L. Root and his colleagues in the 1970s was carefully examined. Careful evaluations were performed to determine how faithfully Root's central concepts were subsequently followed. Studies attempting to validate this and other orthotic paradigms were also reviewed.

RESULTS

Epidemiologic studies provide strong support for the clinical advantages of orthoses, yet explanations of foot orthotic mechanisms remain elusive. Considerable variability has crept into the literature with respect to Root's core theoretical concepts of how and why to determine the neutral position of the subtalar joint (weight-bearing vs non-weight-bearing, palpation vs range-checking). Numerous studies document poor clinical reliability and validity; indeed, this paradigm appears to favor supination, thereby violating its "neutral" premise. Mechanisms other than those of the classic Root theory must be at work. Accordingly, successes have been achieved with alternate paradigms that use much simpler casting techniques. Although less frequently cited, successes have been gained with various viscoelastic materials that enhance shock-absorption and proprioception, as well as custom-made flexible orthotic designs that emphasize the 3 natural arches of the foot.

CONCLUSIONS

The use of foot orthoses is well documented for the treatment of many maladies, yet clinical successes have been achieved both inside and outside of the classic Root paradigm. Clearly, a more complete theoretical understanding of the mechanisms of foot orthotics awaits discovery.

The influence of orthosis stiffness on paraplegic ambulation and its implications for functional electrical stimulation (FES) walking systems

This study examines the evidence which supports the importance of maintaining relative abduction for effective reciprocal walking in high level paraplegic patients. In comparisons of orthoses, where this can only be achieved mechanically, those with higher lateral rigidity consistently showed greater levels of walking efficiency. The influence on hybrid systems of functional electrical stimulation (FES) of the gluteal muscles, where the primary function is to maintain abduction, also showed reductions in overall energy cost, reductions in upper limb effort, or both. Examination of the effect of increasing lateral rigidity of a purely mechanical orthosis by 10% showed that significant energy cost reductions were achieved (30% reduction in Physiological Cost Index) for patients with thoracic lesions experienced in reciprocal walking. A review of FES research suggested that for the modern healthcare sector the cost effectiveness of purely mechanical systems make them an attractive means of routinely providing the functional and therapeutic benefits of walking for high level paraplegic patients. In the prevailing climate of strict budgetry control a case is made for concentrating more research resources on improving still further walking efficiency, and resolving the outstanding problems of functionality and cosmesis in such systems for reciprocal walking.

The past, present, and future of podiatric biomechanics

The author places the history and development of podiatric biomechanics, as well as current thinking about its underpinnings and future, in the context of a theoretical framework drawn from the philosophy and sociology of science. This analysis sets the stage for an exploration of the possible future directions in which podiatric biomechanics could develop.

Trends and Technologies in Rehabilitation of Foot Drop: A Systematic Review

INTRODUCTION

Foot Drop (FD) is a condition, which is very commonly found in post-stoke patients; however it can also be seen in patients with multiple sclerosis, and cerebral palsy. It is a sign of neuromuscular damage caused by the weakness of the muscles. There are various approaches of FD's rehabilitation, such as physiotherapy, surgery, and the use of technological devices. Recently, researchers have worked on developing various technologies to enhance assisting and rehabilitation of FD.

AREAS COVERED

This review analyzes different types of technologies available for FD. This include devices that are available commercially or still under research. 101 studies published between 2015 and 2020 were identified for the review, many were excluded due to various reasons, e.g., were not robot-based devices, did not include FD as one of the targeted diseases, or was insufficient information. 24 studies that met our inclusion criteria were assessed. These studies were further classified into two different categories: robot-based ankle-foot orthosis (RAFO) and Functional Electrical Stimulation (FES) devices.

EXPERT OPINION

Studies included showed that both RAFO and FES showed considerable improvement in the gait cycle of the patients. Future trends are inclining towards integrating FES with other neuro-concepts such as muscle-synergies for further developments.

Evolution of foot orthotics--part 2: research reshapes long-standing theory

OBJECTIVE

To challenge casual understanding of the causal mechanisms of foot orthotics. Although the classic orthotic paradigm of Merton L. Root and his colleagues is often acknowledged, the research attempting to explain and validate these mechanisms is far less clear in its appraisal.

DATA SOURCES

Studies evaluating the relationship of foot type (medial arch height) and use of foot orthoses to the motions of the foot and ankle were compared and contrasted. A search was conducted to evaluate other possible mechanisms of orthotic intervention.

RESULTS

Although Root's methods of foot evaluation (subtalar neutral position) and casting (non-weight-bearing) are well referenced, these methods have poor reliability, unproven validity, and are, in fact, seldom strictly followed. We challenge 2 widely held concepts: that excessive foot eversion leads to excessive pronation and that orthotics provide beneficial effects by controlling rearfoot inversion/eversion. Numerous studies show that patterns of rearfoot inversion/eversion cannot be characterized either by foot type or by orthotics use. Rather, subtle control of internal/external tibial rotation appears to be the most significant factor in maintaining proper supination/pronation mechanics. Recent evidence also suggests that proprioceptive influences play a large, and perhaps largely unexplored, role.

CONCLUSIONS

Considerable evidence supports the exploration of new theories and paradigms of orthotics use. Investigations of flexible orthotic designs, proprioceptive influences, and the 3-dimensional effects of subtalar joint motion on the entire kinetic chain are areas of research that show great promise.

A review of assistive devices for arm balancing

Due to neuromuscular disorders (e.g., Duchenne Muscular Dystrophy) people often loose muscle strength and become wheelchair bound. It is important to use muscles as much as possible. To allow this, and to increase independency of patients, an arm orthosis can be used to perform activities of daily life. The orthosis compensates for the gravity force of the arm, allowing people to perform movements with smaller muscle forces. For patients, the aesthetics of the orthosis is one of the critical issues. This paper presents the state-of-the-art in passive and wearable active arm orthoses, and investigates how to proceed towards a suitable structure for a wearable passive arm orthosis, that is able to balance the arm within its natural range of motion and is inconspicuous; in the ideal case it fits underneath the clothes. Existing devices were investigated with respect to the body interface, the volume, and the workspace. According to these evaluation metrics it is investigated to what extent the devices are wearable and inconspicuous. Furthermore, the balancing principle of the devices, the architecture, force transmission through the devices, and alignment with the body joints are investigated. It appears that there is only one wearable passive orthosis presented in literature. This orthosis can perform throughout the natural workspace of the arm, but is still too bulky to be inconspicuous. The other passive orthoses were conspicuous and mounted to the wheelchair. Except one, the wearable active orthoses were all conspicuous and heavy due to a large backpack to enclose the actuators. They also could not achieve the entire natural workspace of the human arm. A future design of an inconspicuous, wearable, passive arm orthoses should stay close to the body, be comfortable to wear, and supports pronation and supination.

Influence of orthopaedic-technical aid on the kinematics and kinetics of the knee joint of patients with neuro-orthopaedic diseases

In our gait laboratory, the gait pattern of 18 youths with neurogenic foot deformities as a result of spina bifida or cerebral palsy was examined. The influence of technical orthopaedic devices for the foot and ankle on kinematics and kinetics of the gait and especially of the knee joint were analyzed. Kinematic data were derived from 3D-video analysis, kinetic data from force plates and pressure distribution plates. Muscle activities were measured with eight-channel EMG. The data were examined to see if there were differences when using the technical devices. All patients had already been supported externally with the different devices like orthopaedic shoes, insoles, Nancy Hilton orthoses and orthoses for the lower leg extremity. The devices restricted to the foot and the ankle joint improved the feeling of gait stability of the patients. In this investigation, the different supports had various but little effects on the kinematics and kinetics of the knee joint, depending on the type of orthoses used and the kind of handicap of the youths. Because of the great expenditure, the data obtained in this study were taken from a small number of patients. Therefore, they are individual findings and are of restricted general significance.

Human spinal cord injury: new and emerging approaches to treatment

The World Health Organization together with the Iceland Ministry of Health and Social Security sponsored a conference entitled 'Human Spinal Cord Injury: New and Emerging Approaches to Treatment' held on May 31-June 2, 2001 in Reykjavik, Iceland. To help catalyze the development of new paradigms to address spinal cord injury, the conference's overall goal was to bring in a diversity of perspectives, ranging from state-of-the-art stem cell biology to the ancient wisdom of Eastern Medicine. The purpose of this paper is to summarize the presentations of the conference's 26 speakers.

Further development of hybrid functional electrical stimulation orthoses

In this study two aspects of hybrid functional electrical stimulation (FES) orthoses were investigated: joint motion constraints and FES control strategies. First, the effects of joint motion constraints on the gait of normal subjects were investigated using modern motion analysis systems, including electromyogram (EMG) and heart rate measurements. An orthosis was developed to impose joint motion constraints; the knee and ankle could be fixed or free, and the hip joint could rotate independently or coupled, according to a preset flexion-extension coupling ratio (FECR). Compared with a 1:1 hip FECR, a 2:1 hip FECR was associated with a reduced energy cost and increased speed and step length. The knee flexion during swing significantly reduced energy cost and increased walking speed. Ankle plantar flexion reduced the knee flexing moment during the early stance phase. Second, trials on 3 paraplegic subjects were conducted to implement some of these findings. It appeared that the 2:1 FECR encouraged hip flexion and made leg swing easier. A simple FES strategy increased walking speed and step length and reduced crutch force impulse using fixed orthotic joints.

Designing the future: NBIC technologies and human performance enhancement

Never before has any civilization had the unique opportunity to enhance human performance on the scale that we will face in the near future. The convergence of nanotechnology, biotechnology, information technology, and cognitive science (NBIC) is creating a set of powerful tools that have the potential to significantly enhance human performance as well as transform society, science, economics, and human evolution. As the NBIC convergence becomes more understood, the possibility that we may be able to enhance human performance in the three domains of therapy, augmentation, and designed evolution will become anticipated and even expected. In addition, NBIC convergence represents entirely new challenges for scientists, policymakers, and business leaders who will have, for the first time, vast new and powerful tools to shape markets, societies, and lifestyles. The emergence of NBIC convergence will challenge us in new ways to balance risk and return, threat and opportunity, and social responsibility and competitive advantage as we step into the 21st century.

Orthotic and prosthetic prescriptions for today and tomorrow

The prosthetic and orthotic field is in constant flux, with newer technology and materials being incorporated into everyday practice. Research into the field is increasing as interest in restoring or simulating lost human function becomes more of a reality with advances in computer and microprocessor technology. This article explores the world of braces and artificial limbs, and reviews the inherent challenges encountered during rehabilitation of patients who have these specific orthotic/prosthetic needs. The authors provide quick-reference tables and highlight critical information needed to manage patients. It examines newer technology being developed and gauges how close the field really is to the era of Steve Austin, television's Six-Million Dollar Man.

Novel actuation design of a gait trainer with shadow leg approach

Robotic gait training has developed since the end of the 20(th) century, yet there is much room for improvement in the design of the robots. With the conventional exoskeleton structures, donning of patients in a gait trainer usually is a cumbersome process due to the need of joint alignments and normal walking is often hindered due to obstructed arm swing. Our goal was to design a gait training robots that overcomes these limitations. We propose a novel design in which these drawbacks are reduced to a great amount. By using a parallel structure behind the patient (shadow leg) that is connected to the patient joints with rods, little alignment is needed, the area lateral to the hip is left free, and thus arm swing is not obstructed. The construction is lightweight, because the actuators are mounted on a fixed base and the transmission of power is executed with light weight rods. An end stop in the shadow leg prevents hyper extension of the patient's knee. The relationship between motor displacement and human joint rotations is nonlinear. In this paper we derive the nonlinear relationships between motors and patient joints and verify these. calculations with a measurement. The device has been built, now tests with subjects are required to assess if subjects can indeed walk normally in the robot.

Shoulder supports revisited: a Canadian follow-up survey

This paper investigates the use of shoulder supports with stroke patients in Canada and compares the results of two survey questionnaires carried out in 1984 and 1994. It describes which shoulder supports therapists are using with stroke patients and which goals they hope to achieve with specific supports. The Lapboard, Cuff Type Sling, and Arm Trough Support were the most frequently used supports at both time periods. The most frequent goal chosen for each of these three most frequently chosen supports was the same at both time periods but were chosen significantly less frequently in 1994. There was a significant decrease in the use of the Bobath Axial Roll over the ten-year period. This follow up questionnaire documents the limited changes which have occurred in the last ten years in the management of the shoulder following stroke, raises some questions about this area of practice, and outlines some solutions including the need to base occupational therapy practice on more evidence.

Orthotic management for children with osteogenesis imperfecta

Fitting children and infants who have osteogenesis imperfecta (OI) with braces has posed substantial problems of implementation and patient management For the past twelve years bracing has been an important component of a patient research and management program conducted at the National Institutes of Health. By using the smallest manufactured parts and developing a wealth of experience, functional and well-fitting braces have been provided to a number of tiny and small children. Bracing allows these children to stand and walk earlier than would have otherwise been possible. Braces are used in conjunction with standing frames and parapodiums to increase a child's mobility. Less involved children have become good household and short distance ambulators with the use of braces.

The potential of technological innovations for the disabled

Technical innovations have enormous potential for enhancing the lives of people with disabilities, often providing means for substantial independence and contributing to their dignity. This paper uses a framework related to the personal needs of individuals throughout the hours of waking and rest. Examples of various potentialities are provided and discussed.

The influence of staff training and education on prosthetic and orthotic service quality: A scoping review

BACKGROUND

Education and training in prosthetics and orthotics typically comply with International Society for Prosthetics and Orthotics standards based on three categories of prosthetic and orthotic professionals.

OBJECTIVE

This scoping study sought to describe the evidence base available to answer the question, How are prosthetic and orthotic services influenced by the training of staff providing them?

STUDY DESIGN

Scoping review.

METHODS

A structured search of the peer-reviewed literature catalogued in major electronic databases yielded 3039 papers. Following review of title and abstract, 93 articles were considered relevant. Full-text review reduced this number to 25.

RESULTS

Only two articles were identified as providing direct evidence of the effects of training and education on service provision. While both suggested that there was an impact, it is difficult to see how the more specific conclusions of either could be generalised. The other 23 articles provide a useful background to a range of issues including the specification of competencies that training programmes should deliver (3 articles), descriptions of a range of training programmes and the effects of training and education on student knowledge and skills.

CONCLUSION

Although it is considered axiomatic, the service quality is dependent on practitioner education and training. There is insufficient evidence to establish whether levels of training and education in prosthetics and orthotics have an effect on the quality of prosthetic and orthotic services. Clinical relevance There is very little evidence about the effects of training and education of prosthetists and orthotists on service quality. While this is a somewhat negative finding, we feel that it is important to bring this to the attention of the prosthetics and orthotics community.

Prosthetics and orthotics in developing countries

Principles of orthoses and prostheses in developing countries are discussed. Appropriate technological adaptations to suit cultural needs in developing countries have been identified and illustrative examples have been given. In view of the importance of the problem of leprosy in many developing countries, a separate description to cover prosthetic and orthotic appliances including footwear has been attempted. The material is a summary of the excellent publication from Alert in Addis Ababa.

Trends in Spinal Orthosis Utilization Among Patients Insured Through Medicare Part B

STUDY DESIGN

Retrospective population-based database analysis from the Physician/Supplier Procedure Summary Medicare/Medicaid Data Set.

OBJECTIVE

To provide a comprehensive analysis of trends in spinal orthosis utilization over a 12-year period.

SUMMARY OF BACKGROUND DATA

Widespread prescription of spinal orthosis persists, despite evidence suggesting equivocal efficacy in many spinal conditions. The utilization of spinal orthosis on a national level, including prescribing specialty data, has not been previously analyzed.

MATERIALS AND METHODS

Health care common procedure coding system codes for cervical (CO), thoracic-lumbar-sacral (TLSO), lumbar (LO), lumbar-sacral (LSO), and cervical-thoracic-lumbar-sacral (CTLSO) orthosis were used to determine spinal orthosis utilization from 2010 to 2021. Provider specialty codes were utilized to compare trends between select specialties. In addition, a neurosurgical CO analysis based on subclassifications of cervical bracing was performed. Linear trendlines were implemented to elucidate and present trends by slope (β).

RESULTS

Among 332,241 claims, decreases in CO (β=-0.3387), TLSO (β=-0.0942), LO (β=-0.3485), and LSO (β=-0.1545) per 100,000 Medicare Part B enrollees and CTLSO (β=-0.052) per 1,000,000 Medicare Part B enrollees were observed. Decreases among neurosurgery (β=-7.9208), family medicine (β=-1.0097), emergency medicine (β=-2.1958), internal medicine (β=-1.1151), interventional pain management (β=-5.0945), and chiropractic medicine (β=-49.012), and increases among orthopedic surgery (β=5.5891), pain management (β=30.416), physical medicine and rehabilitation (β=4.6524), general practice (β=79.111), and osteopathic manipulative medicine (β=45.303) in total spinal orthosis use per 100,000 specialty claims were observed. Analysis of subclassifications of cervical orthosis among neurosurgeons revealed decreases in flexible (β=-1.7641), semirigid (β=-0.6157), and collar bracing (β=-2.7603), and an increase in multipost collar bracing (β=2.2032) per 100 neurosurgical cervical orthosis claims.

CONCLUSIONS

While utilization of spinal orthosis decreased between 2010 and 2021, increased utilization was observed among a subset of specialties. Identifying these specialties allows for focused research and educational efforts to minimize unnecessary durable medical equipment use for effective health care spending.

Use and Cost of Orthosis in Conservative Treatment of Acute Thoracolumbar Fractures: A Survey of European and North American Experts

STUDY DESIGN

Survey study.

OBJECTIVE

Assess practices and opinions of spine specialists from Europe and North America on orthosis use in adult patients with acute thoracolumbar (TL) fractures. Evaluate cost of the devices.

SUMMARY OF BACKGROUND DATA

Although orthosis are traditionally used in conservative treatment of TL fractures, recent systematic reviews showed no benefit in patient's outcomes.

METHODS

A search for contact authors with publications on spine fractures from all European and North American countries was performed. An online questionnaire was sent on demographic data, practice setting, mean number of fractures treated, use of orthosis upon choice for conservative treatment, and average orthosis cost. Data was analyzed based in world regions, economic rank of the country, and health expenditure.

RESULTS

We received 130 answers, from 28 European and five North American countries. Most responders had more than 9 years of practice and worked at a public hospital. 6.2% did not prescribe a brace in any patient with acute TL fractures conservatively treated and 11.5% brace all patients. In a scale from 1 to 5, 21 considered that there is no/low benefit (1) and 14 that bracing is essential (5), with a mean of 3.18. Europeans use orthosis less commonly than North Americans (P < 0.05). Orthosis mean cost was $611.4 ± 716.0, significantly higher in North America compared with Europe and in high income, when compared with upper middle income countries (both P < 0.05). Although hospital costs were not evaluated, orthosis is costlier when it involves admission of the patient (P < 0.05). An increase in orthosis cost associated with higher gross domestic product (GDP) per capita and higher health expenditure was found.

CONCLUSION

More than 90% of spine specialists still use orthosis in conservative treatment of adult patients with acute TL fractures. Orthosis cost vary significantly between continents, and it is influenced by the country's economy.Level of Evidence: 4.

Rehabilitation engineering and the growth of prosthetics/orthotics practice

The development of the professions of orthotics and prosthetics since the Second World War has been marked by a number of steps. These include the involvement of the universities and government in education, research, and provision of devices. The establishment of professional bodies has increased their status, and orthotists and prosthetists are recognized as important members of the rehabilitation team. Rehabilitation engineering is a newly defined discipline which is greatly extending the range of interest of orthotics and prosthetics and the future is one of expanding challenge.