PRINCIPLES OF ORTHOSIS AND PROSTHESES PRESCRIPTION

1) Patient-Centered Assessment

a. Functional Needs and Goals

The first and most critical step in prescription is to assess the individual's specific needs:

 What activities does the patient wish to perform (e.g., walking, working, self-care)?

 What are the priorities from the patient's perspective?

 What is the person’s lifestyle, occupation, and community setting?

b. Medical and Physical Evaluation

Key elements include:

 Muscle strength, joint range of motion (ROM), limb length

 Skin condition and vascular integrity

 Neurological status (sensation, spasticity, proprioception)

 Level of amputation (for prostheses)

 Deformity type (flexible vs. fixed)

c. Psychosocial Assessment

This includes:

 Acceptance of disability or limb loss

 Coping strategies and psychological resilience

 Family support and community integration

 Cultural beliefs about assistive devices

d. Environmental Assessment

Orthotic/prosthetic design should consider:

 Terrain (e.g., hilly vs. flat)

 Climate (materials must suit hot or humid weather)

 Availability of maintenance services

 Accessibility and affordability

2. Biomechanical Principles

Orthotic and prosthetic devices must be designed and prescribed with fundamental biomechanical
concepts to maximize function and comfort.

-Three-Point Pressure Principle (for Orthoses and prosthoses)

 A primary corrective force is applied at the apex of the deformity.

 Two counterforces act in the opposite direction above and below.

a. Force Distribution

Pressure should be distributed over a larger surface area to:

 Prevent pressure sores

 Enhance comfort

 Increase adherence

b. Alignment and Joint Axis

Correct alignment of the orthosis/prosthesis with the anatomical joint axis is essential to:

 Reduce friction and discomfort

 Prevent compensatory movements

 Improve efficiency in gait and function

c. Energy Conservation

Design should aim for:

 Reducing the energy cost of walking or movement

 Enhancing biomechanical efficiency (e.g., spring-like action in prosthetic feet)

3. Material Selection

Choosing appropriate materials is vital for functionality, durability, and user satisfaction.

a. Orthoses

 Metal: Durable, good for heavy-duty use, but heavier

 Plastic (thermoplastics like polypropylene): Lightweight, moldable, used for custom-molded

 Composite materials: Carbon fiber provides strength with low weight

b. Prostheses

 Endoskeletal designs (modular components): Lightweight and adjustable

 Exoskeletal designs (solid shell): Durable but heavier

 Socket materials: Must be skin-friendly and shock-absorbing

c. Cost and Availability

In community settings, especially low-resource areas:

 Affordability influences adherence

4. Classification and Functionality

a. Orthotic Classification

Orthoses are categorized based on the body part supported:

 Lower limb orthoses: Ankle-Foot Orthosis (AFO), Knee-Ankle-Foot Orthosis (KAFO)

 Upper limb orthoses: Wrist-Hand Orthosis (WHO), Elbow Orthosis

 Spinal orthoses: Thoracolumbosacral Orthosis (TLSO)

Each is designed to:

 Stabilize or mobilize joints

 Prevent or correct deformities

 Relieve pain

 Support weakened muscles

b. Prosthetic Components

Prostheses consist of:

 Socket: Interface between residual limb and prosthesis

 Suspension system: Holds prosthesis in place (e.g., suction, straps)

 Knee unit (in transfemoral prostheses): May be mechanical or microprocessor-controlled

 Foot/ankle unit: From basic solid ankle cushion heel (SACH) to dynamic response feet

The prescription is tailored to:

 Amputation level

 Functional goals

 User’s activity level

5. Training and Rehabilitation

Prescription is not complete without comprehensive training.

a. Orthotic Training

Includes:

 Donning and doffing techniques

 Skin care education

 Maintenance and cleaning

b. Prosthetic Training

Involves:

 Stump care and hygiene

 Gait re-education

 Use of assistive devices if needed

 Psychological adjustment support

Rehabilitation must be goal-oriented, functional, and context-specific.

6. Patient Education and Empowerment

Empowering the user is key to long-term success:

 Teaching proper usage and maintenance

 Identifying signs of pressure ulcers or poor fit

 Encouraging self-efficacy and confidence

 Training family members where necessary

7. Cultural and Social Considerations

Prescriptions must align with:

 Cultural norms (e.g., preference for concealed devices)

 Social expectations and stigma

 Clothing styles and religious practices

For example, prostheses may need to allow for squatting or sitting cross-legged in Asian or Middle
Eastern cultures. Devices must not prevent participation in daily prayers or traditional occupations.

8. Adaptability and Modularity

Especially in community settings, devices should be:

 Modular: Allowing for adjustments as the user grows or conditions change

 Replaceable components: To reduce cost of full replacement

 Low-maintenance: Given limited access to repair facilities

 Pediatric patients (growth adaptation)

 Progressive neurological conditions (changing needs)

 Rural communities (low service access)

9. Multidisciplinary and Collaborative Approach

Orthotic and prosthetic prescription involves input from:

 Physiotherapists: Functional and biomechanical assessment

 Occupational therapists: ADL training

 Prosthetists/Orthotists: Device fabrication and fitting

 Doctors: Diagnosis and medical management

 Community health workers: Monitoring and follow-up

In community physiotherapy, task-sharing with trained local workers helps ensure long-term support.

10. Follow-Up and Outcome Evaluation

Prescription is an ongoing process. Follow-up ensures:

 Fit and function remain optimal

 User satisfaction is high

 Device is being used correctly

 Early detection of complications

Tools for Evaluation:

 Functional Independence Measure (FIM)

 Gait analysis

 User satisfaction surveys

 Community integration assessment

11. Sustainability and Accessibility

To ensure equity in community settings:

 Devices must be low-cost or subsidized

 Local fabrication centers should be promoted

 Community participation in the service planning

Sustainability also involves:

 Training local personnel

 Using recyclable and locally sourced materials

 Establishing community repair units