This module for Pediatric Rehabilitation covers orthotics and assistive gait technology in children with disabilities. It was created in 2020, and thanks go to Josh Vova for his technology slides. Orthotics are devices that assist, resist, or stimulate the function of a body part, and they can be made of a huge variety of materials, so it is very important to know your orthotist and know their capabilities. The type of materials may impact a child's or young adult's desire to wear the orthotics, and can impact their comfort and the function of the device. When choosing an orthotic, many factors need to be considered, including the force needed to control the joint and the direction and magnitude of that force, as well as the materials that will be used to produce this, the movement that needs to be controlled, either rotational or translational, and if you want movement to be allowed so that absolute stability is achieved or relative stability. But most importantly, if the patient is not comfortable and cannot don the device without extensive assistance, they will most likely not be compliant with it. Moving from head to toe, the cervical orthoses are in a variety of types, and the halo is the most restrictive, with a soft collar the least restrictive. A halo is typically used post-surgically because there are pins placed in the skull, as well as a body jacket posteriorly and anteriorly, so virtually no movement is allowed. This is uncommon to see in a child. The Somi collar or the Milwaukee brace type orthoses can be utilized to keep the neck stable, but also the trunk post-surgically, and again is not commonly used. The soft cervical orthoses is often utilized to give some head support to a child with a weak neck who is not able to keep their head up to interact with their peers, to ride in the car, or to sit up in a wheelchair all day. If there is a tracheostomy, these can be adapted with a hole in them. Hard collars are a bit more restrictive and a bit more uncomfortable, but can be utilized for these purposes as well. Other cervical supports commonly seen would be the Hensinger collar, which can be washed and easily placed on the child in virtually any environment. The headmaster, which can be utilized if there are issues with access to the neck, and the head pod, which allows a child to move their head in all planes, but will bring them back to the midline when they become fatigued or when they need that little bit of extra support. It can be fastened onto a chair, a wheelchair, and a car, so moved to a variety of different environments. TLSOs come in a variety of types. Typically, they are utilized for a teen or a child that has a curve of over 20 degrees. For idiopathic scoliosis, these need to be worn at least 18 hours a day to make a significant difference, but have clearly been shown to be of benefit and to be well tolerated. They need to control the lateral and rotational components of a curve, and a 3D brace is becoming more and more commonly seen. For neuromuscular curves in young to older children, these are not as amenable to curve correction with bracing, but they can be used as a functional support to allow a child to sit in a chair and see their peers do their schoolwork without constantly having to worry about maintaining their trunk posture. The ability of a teen to don and doff their brace is crucial, because although posterior closing braces encourage compliance, no one can get them off to go to the bathroom independently. Compliance chips are available to put in the brace if that is a huge issue. Boston Soft TLSOs are the most commonly used brace in the United States, but 3D braces made out of different kinds of plastic are becoming more commonly used. The expertise of the orthotist is essential. Here are four slides of braces made for the same person, all by different orthotists who had different ideas. Lower limb orthoses come in a variety of types made out of a variety of materials. The shortest would be the UCB, which is just under the arch of the foot, then the supramalleolar orthosis, which goes above the malleolar bone, and is the first lower limb orthosis that is typically covered by insurance. Then there is the AFO, the KAFO, and the HKFO. In this picture, you will see floor reaction braces, as well as shorter braces that cover the top of the foot, which makes it more difficult for someone who does not have both hands to open up the brace to get their foot in. The materials can greatly impact independence, because if they are too hot, too thick, or too difficult to open, the brace will most typically not be worn. Some braces can provide some energy return, some provide mobility, and some provide only stability. Hip orthoses are used in children after they have VDROs, or varus derotational osteotomies, that require their hips to be in abduction, or may be required if a child has spina bifida or poor hip control. The swash, the sitting, standing, and walking hip orthoses, can provide the ability for a child to keep their legs apart when walking, but then allow them to sit down in a chair for class, and not have to remove the brace. These can be utilized in adults, but toileting requires that they be removed. The types of joints used in the lower extremity bracing can vary significantly, and can impact the ability of the brace to hold the foot in a certain degree of range, or to allow it to be as mobile as possible. A tamarack joint versus a metal joint can make a difference in weight. The plastic materials of the brace itself are also quite variable, and you need to know how comfortable your orthotist is, and how creative in using the different types. Some materials will give a little bit of energy return, while others are more rigid, and might break on a child who is very active. The HK AFO is used typically in a child with spina bifida, or a spinal cord injury, for exercise only, because they are heavy and difficult to functionally walk in. A KAFO can be used for knee instability, but again has high energy expenditure, and is not used typically for long distance walking. AFOs are probably the most common orthotic prescribed for children, and they can be made out of carbon graphite, which is pretty popular with teens, or a variety of plastic materials. They can have an articulation, which allows the foot to dorsiflex, and have a little bit more flexibility when moving upstairs, or they can be rigid for someone that has a very spastic foot. Floor reaction AFOs are used for kids that crouch, and that have range of motion at the knees, but some weakness. Side straps can be added to an AFO to allow it to be used as a stretching splint, for someone that can use it at dinner time, during homework, or sometimes to sleep in at night. Shoes are often difficult to fit over AFOs, and there are a variety of companies that have created shoes with extra depth, and extra width in order to accommodate these. Additionally, there are shoes for children that have zippers, so that a hemiplegic child can do this independently, and there are a variety of shoelace fasteners, that are magnets, or twist ties, so that it is easier for the child to become independent. Truncal Support Truncal support can be very important in children that have low tone, and are not able to sit up well. From left to right, the Spio is the first, with the long black sleeves, and is essentially just a lycra, or Spanx-like clothing article, that gives compression, and a little bit of sensory support. This can come in leggings, in a shirt, or in a onesie-type bodysuit. The little girl in the middle is wearing a Dynamic Movement Orthosis, or a DMO. This is like a Jobst garment, that is extremely custom-made, and form-fitting, that can be helpful in children, or adults, that are athetoid, or dystonic. However, they are not able to be easily donned, or doffed, during the day, so they are typically put on in the morning, and there is accommodation for toileting, so that the patient wears them full-time. Next, the little baby is wearing a Theratog, which is Velcro straps that can support different movement patterns of the body. Therapists love these, but parents hate them, because they are very difficult to get on in the right pattern. The boy at the bottom has a Benek Splint-On. This is a soft orthosis, made out of wetsuit material, that is a little bit thicker than a Spio, both this and the Spio can have a cross brace put in them, to give them a little bit more support, and this will also allow them to be paid for by insurance. Knee immobilizers, or elbow immobilizers, such as the bamboo brace shown, can provide extension of the limbs for contracture reduction, stretching, and functional reasons, such as keeping a child's hand out of their mouth. The blue Benek splint over the thumb can be made in almost any variation that you want. It can serve the purpose of holding the wrist in extension, and holding either one or all fingers out, as well as providing an easy, soft, washable brace for the child. Technology has also advanced to allow for external systems to provide extremity support, and while these are not typically utilized in children in an outpatient setting, they are often used in a therapy or inpatient setting. They might include an exoskeleton, a partial body weight supporting truncal device over a treadmill, or programmable stimulators that can be used in therapy to give biofeedback to the child, so they know what muscle the therapist is trying to get them to strengthen. The E-Stim Neuroprosthesis, also known as the Bioness or the WalkAid, are external stimulators that can help with dorsiflexion during gait. Unfortunately, they are extremely expensive, have to be adjusted by the client themselves, and not many children are responsible enough to be able to use them. They are also somewhat fragile, and at their high cost are not something that is typically approved for a child that might break them on the playground. Typically, we prescribe these for teenagers or college students who need to have them for vocational or educational reasons because they are less fatigued. Insurance typically argues that an AFO will do the same thing. Electrical stimulation has also been utilized in young adults for attempted relaxation of spastic muscles, as well as biofeedback, sensory awareness, and firing patterns during gait, which the therapist can trigger. The main drawback for children is that they cannot tolerate that sensation of being stimulated, or that they can't feel the sensation of being stimulated. External robotic systems have been utilized in children to create repetitive gait patterns, either passively or with active assistance, to improve their motor patterning so that after a certain amount of time, they are able to continue their gait patterns. This can be done by using an external robotic system. to improve their motor patterning so that after the device is no longer utilized, they would hopefully have some retention. These are typically only found in large facilities due to their cost, and they are in some robotics programs as not just inpatient, but as an outpatient intense program where the child might go twice a day for a couple of weeks in a row. End effectsor devices provide a stable surface for the foot to be on, and are similar to the partial weight-bearing treadmill trainings that children have used for many years. While robotic devices provide repetition, strengthening, innovation for a bored child who has been in regular therapy for many years, they really can't replace the expertise of individual therapists. A 13-year-old spina bifida patient is having knee pain with long-distance ambulation. You observe reduced strength and a crouch. What orthotic prescription would provide her with optimal function? Floor reaction AFOs are typically used for crouch if there is range of motion at the knee and not a huge degree of spasticity. These can be fabricated out of a variety of materials that are lightweight but provide support and are easy to get on. A 9-year-old boy with spastic quadriplegia has an increasing lumbar-thoracic curve. You are educating the medical student about the type of orthotic that might be needed. What would you choose? A plastic TLSO can help support a child's ability to sit and pay attention and visually interact with their peers. A soft orthosis can do this to some degree but will not impact a neuromuscular curve. Greater than 18 hours of wear is needed for idiopathic curves but as this will not necessarily change the pattern of a neuromuscular curve, any amount of time that the child uses this as a functional support versus as an orthopedic device can still be helpful.

orthotic devices

assistive gait technology

children with disabilities

orthotics

materials used