Orthotic Devices

The strength and stability of a person’s body is of paramount concern for individuals with Cerebral Palsy; the more stable a body is, the better a person can ambulate and complete tasks both big and small. Orthotic devices worn on the body help build stability while increasing strength, comfort and independence.

Orthotic devices pave the road towards strength, balance, comfort and independence

Most parents of a child with Cerebral Palsy will tell others that ensuring a child’s mobility and independence is about compensating for physical functions that don’t exist, and enhancing the capabilities a child is born with.

That, in essence, is the concept behind orthotics, which uses devices and instruments to help a child maintain his or her level of mobility, or correct physical issues that are preventing the child from being fully-ambulatory.

Developed in the early part of the 20th Century, orthotic treatment consists of a series of inserts and braces that are fitted to address a child’s specific needs. As a parent learns more about orthotics and their potential role in the life of their child, they will come to know that orthotics can be a valuable resource for improving a child’s overall physical health and emotional well-being.

Finding the right set of orthotics occurs only after a child has undergone a physical assessment. And like so many other facets of having a child with a disability, improvement and adjustment comes over time, in stages. Sometimes, orthotic devices are temporary; other times, a child will need the orthotics for a lifetime. But in all scenarios, orthotic devices have the potential to bring the stability and alignment to young people that is required to grow, move, and be active participants in their own lives.

What are orthotic devices?

A simple way to describe what an orthotic device is that they are braces that are worn externally by a child or adult. In actuality, the braces are complex tools that address a person’s specific physical condition. What materials a device is comprised of, how it fits, and the role it’s expected to play in a child’s development will be dictated by a child’s structural and functional needs.

In many cases, devices are prefabricated to the child’s physical characteristics. Others are manufactured in specific sizes. As a child grows and his or her body changes, orthotic devices will need to be modified and replaced.

Orthotic devices are designed to relieve several conditions, including:

• Knee or hip subluxation, dislocation
• Spastic movement
• Correct, limit or prevent deformities
• Low-tone pronation (fallen arches, outward-turned foot due to muscle weakness)
• High-tone pronation (high arch, outward-turned foot due to increased muscle tone)
• Swing-phase inconsistency (erratic movements in the foot)
• Drop-foot (drop of the front of the foot due to weakness)
• Eversion (outward turn)
• Inversion (inward turn)

Orthotic device textures can be:

• Rigid
• Semi-soft
• Soft

Orthotic devices are made from several materials, including:

• Metal
• Carbon fibers
• Leather
• Metals
• Plastic
• Plastic polymers
• Rubber

What is the goal of orthotic treatment?

According to estimates, about two-thirds of children with Cerebral Palsy have the ability to walk and ambulate. But because of the nature of Cerebral Palsy – and its effect on the muscles, joints, and patterns of motion – establishing a gait that is meaningful can be a challenge. When an orthotic device is a successful part of treatment, it should help children establish normal patterns of joint and muscle motion.

Orthotics can help remedy this situation by:

• Providing a stable base for movement
• Establishing an efficient gait
• Minimizing the effects of spasticity in limbs
• Creating an environment in which a child can take repeatable steps
• Reducing excessive energy used to move
• Aiding the transition between sitting and standing
• Reducing, or eliminating, hip and knee hyperextension, missteps
• Reducing the potential for accidents
• Increasing a child’s ability to function physically, and mentally
• Strengthening weak muscles
• Controling muscular imbalances
• Correcting poor skeletal alignment
• Preventing deformity
• Providing stable base of support

In terms of mobility, lower limb orthotic devices can be used separately, or together, to help a child maintain the stability. This is achieved by limiting certain movements that are irregular so that a child can develop and re-learn how to stand, and take steps.

Additionally, bringing affected limbs into proper alignment helps correct flexible deformities, stops the progression of fixed deformities, and helps transfer a person’s body weight to prevent an unwanted load on affected joints and muscles.

For children with Cerebral Palsy, mobile joint deformities caused by unbalanced muscle tone is a vexing problem that can be treated using orthotics. One common condition is the tendency for children with Cerebral Palsy to walk on the tips of their toes, as opposed to their feet – this can be treated over time by using foot-ankle devices that help stabilize, and strengthen, the muscles and joints of the foot and ankle.

Because 80 percent of children with Cerebral Palsy have spasticity, orthotic intervention can have a major effect on a child’s body mechanics. Once the child has a stable basis for movement, he or she can develop higher levels of functioning, including:

• Increased range of motion
• Strengthened muscles
• Improved endurance
• Increased coordination, cadence
• Increased step length
• Improvedcontrol over spastic movements

From a practical standpoint, the goal of orthotics is to enhance the quality of life for children with Cerebral Palsy. Some ways orthotics can help children with disabilities include:

• Improve independence by enhancing mobility
• Reduce stress and fatigue
• Reduce the likelihood of a fall, or an injury
• Take the focus off of rquired mobilzation and onto family time, play time, building relationships and pursuing interests

What devices are on the market that assist mobility?

Orthotic devices are broken down into categories based on the area of the body they are intended to support. Depending on a child’s physical needs, he or she may need more than one.

Generally, there are two categories of orthotics:

• Functional Orthotics – designed to support abnormal biomechanics, correct various foot deformities and support function.
• Accommodative Orthotics – generally considered over-the-counter orthotics – braces, splints, casts, gait plates, night bars and heel/arch supports – that are used by the general public to relieve foot pain, relieve sensitive areas, reduce pressure, redistribute weight and address minor foot problems.

Orthotics can be both functional and accommodative.

There are several types of orthotics, including:

• Foot orthotics – These are more commonly referred to as inserts that are placed in shoes to shift the weight of the feet and legs and bring balance, relieve shock, and minimize stress. They can be rigid or soft, and they can be custom-made or fitted. Also, the orthotic device can come in the form of an actual shoe.
• Ankle-Foot Orthotics – Sometimes referred to as AFOs or foot drop braces, these semi-rigid L-shaped braces stabilize both the foot and ankle to bring muscles and joints into alignment. The braces extend up the calf, and are typically made of metal or hard plastic; they have straps that can connect together to hold the device in place, and bring stability to foot, ankle and lower leg by immobilizing it. These are also used to correct foot drop. AFOs account for 26 percent of all orthotics used in the United States. AFOs include anti-Talus AFOs, Rigid AFOs, Tamarack Flexure Joint AFOs, Solid AFOs, Spiral AFOs, Hemispiral AFOs, Hinged AFOs, Tone-Reducing AFOs, and Posterior Leaf Spring AFOs.
• Hip-Knee-Ankle-Foot Orthotics – Called HKAFOs, these devices use bands, belts, pelvic girdles and knee-ankle orthotics to help position a person upright while centering the knee joint.
• Knee-Ankle Orthotics – Called KAFOs, these devices stabilize the knee, ankle and foot, allowing for proper function and movement. KAFOs are equipped with mechanically- or electrically-controlled hinges. They are useful when a child has limited movement in his or her legs so they can help when learning to walk.
• Knee Orthotics – A brace that is worn to support and align the knee; it extends from above the knee to below it.
• Spinal Orthotics – If a child needs additional support or alignment in his or her upper torso, a spinal orthotic device can help a child sit up or stand; it is particularly useful if a child has limited trunk control.
• Trunk-Hip-Knee-Ankle-Foot Orthotics – Sometimes called THKAFOs, are HKAFOs with spinal orthosis for control over trunk motion and spine alignment, most often used by individuals with paraplegia.
• Prophylactic Braces – This brace is rigid and has knee hinges; it is used mostly for people who have knee injuries.

In addition, some shoes and supports are designed for orthotic support. These include:

• Orthopedic shoes
• Shoe modifications
• Arch supports
• Heel modifications
  • Cushioned heels
  • Extended heel
  • Heel elevation
  • Heel flares
  • Heel wedges
  • Inner sole excavation
  • Metatarsal bars
  • Metatarsal pads
  • Rocket bar
  • Scapehold pads
  • Sole flare
  • Sole wedges
  • Steel bar
  • Toe Crests

Please note, there are other forms of orthotics for use in the upper body that are not mentioned in this article which primarily focuses on orthotics for mobility.

For children with Cerebral Palsy, wearing a brace can be a difficult experience if they have deformities or other issues that can cause pain. If a child’s muscles are already under pressure, he or she may have tolerance issues. Follow instructions for proper cleanliness and wear to minimize problems with comfort. Report skin tenderness, blisters or other disturbances to the doctor.

What happens during a child’s assessment for orthotics?

A pediatric orthopedic surgeon, or an orthopedic surgeon that specializes in developmental disabilities, will diagnose, care and treat children with Cerebral Palsy that have disorders of the bones, joints, muscles, ligaments, tendons, nerves and skin. They provide medical, physical, rehabilitative, and surgical solutions to optimize a child’s ability to be mobile. At some point, they may refer a child to an orthotist for evaluation for orthotic devices.

When a child sees an orthotist for the first time, his or her parents have likely discussed the prospect of using orthotic devices with an orthopedic physician. During an initial assessment, the orthotist will ask several questions about a child’s overall health, and take into account pertinent medical history.

From there, he or she will conduct an examination. During this examination, the orthotist will look for:

• Bone deformities
• Increased or decreased muscle tone
• Pain or discomfort
• Associated conditions and interventions
• Movement
• Physical functioning

Once an orthotist knows more about a child’s specific challenges, he or she will develop a long-range plan of treatment coordinated with the orthopedic surgeon and the child’s primary care physician.

After taking measurements or creating a casting, an orthotist will recommend devices, some of which can be provided that day, and others that might need to be ordered, custom-designed, or modified. Fabrication times are dependent upon the manufacturer and insurance authorization process.

When the orthotist receives the device, they will schedule a fitting. Bring the child’s socks and shoes. The shoes should have a little extra room in their fit. In some circumstances, an orthotist may recommend the type of shoe and insurance may cover the cost if prescribed by the doctor. He or she will fit the devices to make sure that there is as little discomfort as possible, and to teach a child and parents how to remove, and put on, the devices.

The doctor will provide a wear schedule that should include a break-in schedule that will allow the child’s body to adjust to the new device. Adhere to the proper fitting and monitor skin condition, particularly in the first two weeks. Attend to skin conditions as soon as they are discovered.

A follow-up appointment is usually scheduled so the orthotist can determine trouble areas, and treatment outcomes.

When a child returns to physical therapy, the device is usually incorporated in exercises and coordinated with therapy goals. If they do not, a physical therapist will likely recommend that a child return to an orthotist to address issues that occur in therapy.

It’s important to remember that orthotic intervention is a multi-disciplinary approach – it can take a while to identify and implement the best devices for a child. Also, as a child grows, his or her gross motor skills improve, and they participate in sports or activities that require movement, devices may need to be further evaluated, modified, or replaced.

Who conducts an orthotic assessment, and what are his/her qualifications?

Orthotists are health practitioners that specialize in determining what orthotic devices will be most beneficial to a patient. They work in conjunction with other medical professionals, including physicians, therapists, and orthopedic surgeons to coordinate treatment goals and evaluate progress. Orthotists build, construct, design and modify devices to meet a child’s specific treatment needs.

To practice, orthotists are required to pursue an extensive education as well as certification, and in some cases, state licensure.

Coursework required to be an orthotist includes:

• Anatomy
• Physiology
• Pharmacology
• Biology
• Biomechanics
• Engineering
• Psychology

Most orthotists pursue either a bachelor’s degree or a master’s degree in orthotics and/or prosthetics; professionals degreed at a master’s level are likely to have more employment opportunities. As part of the education process, an aspiring orthotist must complete a residency at an approved clinical site as well as earn a degree from an accredited institution.

The International Society for Prosthetics and Orthotics has endorsed both the National Commission on Orthotic and Prosthetic Education, or NCOPE, and the American Board for Certification in Orthotics, Prosthetics & Pedorthics, or ABC, category one recognition, which means the organization has confidence that the guidelines set forth by the organizations help ensure applicants are suitably prepared to practice.

As part of the certification process, an applicant will have to sit for a comprehensive exam, complete a pre-determined number of in-service residency hours, graduate from an approved educational institution, and re-certify periodically.

How can a parent help a child adjust, physically and psychologically, to wearing and orthotic device?

Even if an orthotic device is properly fitted, a child may experience frustration at having to wear one. Sometimes, depending on a child’s treatment plan, he or she may be required to wear the device continually, except for bathing, so it’s understandable that the child may be somewhat uncomfortable.

If a child finds the device uncomfortable they may cooperate less in wearing the device. To increase comfort levels:

• Make sure the orthotics are securely held and not too loose. Loose fitting device rub and cause skin irritation.
• Periodically check the child’s skin quality. If sore, dark red, blistered, callused, or swollen check to make sure it is secured and fits properly. Ask a provider for ideas on how to toughen the skin or whether the device is fitted properly. Sometimes they will prescribe an alcohol rub, cornstarch dusting, creams, lotions or powder to avoid skin breakdowns.
• If the skin is raw or visibly broken down, the brace should not be used until the skin heals.
• Ask the provider what types of clothing should be used between the skin and the brace, some will recommend socks made of Pima or Gard cotton. Monitor so that socks do not apply undue pressure, bunching, binding and tightness. Special attention should be made to avoid inside seams and irritating ridges.
• Ask the provider for instructions on how to gradually build up to the suggested daily wear schedule.
• Toes extending beyond the orthotic device, or complaints of pain or red markings may indicate that your child is outgrowing their orthotics.
• Abide by the device maintenance regimen for proper cleaning, care and storage.
• Periodically inspect device for cracks, tears, or undue wear.
• Look for parts that may need to be replaced.
• Some children experience excessive perspiration in their device. Changing socks once to twice a day and wearing appropriate sock material will help. Some orthotics allow the orthotist to drill ventilation holes in specific areas to assist with excessive perspiration.

The first thing a parent can do is explain to a child how much the device is going to help them over the long haul. But there are other strategies that a parent can take to help a child adjust to orthotic devices. They include:

• Make sure the device is as comfortable as possible
• Comment about how much improvement is taking place
• Pay attention to a child’s skin condition – chafing is a sign the device is improperly fitted

Psychologically, it can also be challenging to wear orthotic devices because they are conspicuous, and children typically don’t want to stand out from their peers. To help a child adjust, it may be necessary to:

• Explain that the devices help them to move and play with others
• Prepare a child with answers, in case other children ask about the device
• Encourage child to not think of the devices as an impediment, but something that makes them stronger, faster and safer. Some parents tell young children they are a “new pair of shoes.”
• Show children pictures of other young people, or adults, that use orthotics
• Complement children on their progress and appearance

Because orthotics are such an important part of a child’s overall treatment, parents should encourage an open dialog about what to expect from the intervention, and how using the devices will affect a child’s physical well-being and self-esteem.

For more information

“Exploring the Potential of AFO Devices,” Podiatry Today »

“Orthosis for Managing Cerebral Palsy »

Brace Design/Selections – Areas of Specialty, Ultraflexsystems»

New Approaches to Orthotic Management »

Research studies on DAFOs »