Orthotics,+Prosthetics,+and+Adaptive+Equipment

Physical therapists are often involved in making decisions about orthotics, prosthetics, and adaptive equipment for children with special needs. Please use this page to post files, links, and resources related to orthotics, prosthetics, and adaptive equipment for children. Each group member must contribute at least two unique items to this wiki by 5 pm November 18. The discussion board tab is optional, but may be used to discuss issues surrounding standardized gross motor testing in pediatric physical therapy. You may want to consider some of the following questions as you build this page:
 * What level of expertise is a PT expected to have in these areas?
 * What is the PT's role on the adaptive equipment team?
 * How do we make the best possible decisions about orthotics, prosthetics, and adaptive equipment for the children we serve?
 * What do families need to understand about orthotics, prosthetics, and adaptive equipment?

__Resources to order Orthotics, Prosthetics__
I'll start by posting a link to the [|Cascade Dafo] website. On the left side of this website, there is a tab called DAFO guide to brace selection. When you click on it, it takes you to a page where there are several descriptions of patient presentations. You can then click on the type of patient presentation that you are interested in, and it gives you different selections of braces based off of the severity of the problem that the child is having. This is an excellent web site that allows Physical Therapists to at least have an idea of what is available to help children with certain sets of symptoms. Another company that can offer types of orthotics and prosthetics is Hanger on their web site they have pages for pediatric orthotics, and for pediatric prosthetics for the upper and lower extremities. It is important for the therapist and the family to know what is available for the child to use. The Therapeutic Ambulatory Orthotic System (TAOS) is a thoracic to foot orthosis that the child wears and can then be attached to a base to help support the child. This device is not meant for all children but It can be very beneficial for independent ambulation of some children. The Physical Therapist maybe the first person to have the opportunity to suggest a new piece of adaptive equipment. This is one option for a novel piece of equipment. I personally learned about this at an in-service that was brought to a clinic I was working at. Here is a picture of this very involved assistive device.

__Role of the Family__
The family first needs to understand the importance of wearing the device that their child has been prescribed to wear. Sometimes orthotics are uncomfortable to wear but the family needs to make sure that the child is compliant in wearing them, especially during specified activities that the therapist may state. Another area of concern for parents is child safety, the parent or care giver must check the child's skin daily for irritation, redness, rubbing, or blisters. If any of these signs are noted then the parent/caregiver needs to make an appointment with the orthotisist or prosthetist. With children this may be very likely to happen because they grow and move around so much. Parents must have a good relationship with open communication with their child's therapist and orthotist or prosthetist.

__**Education of the Family**__ Going along with the above statement the parents/caregivers must be educated about the importance of proper fitting of the orthotic or prosthetic. How important it is to make sure that the device is still performing the function it was meant to for stabilization, support and correction of an alignment problem. Educating them on what the device is correcting for or supposed to be doing will ensure that the child is wearing it correctly and the device is performing its job. Along these lines the family must be aware of their insurance coverage for different types of orthotics or prosthetics. If their child is needing a new custom foot orthotic and they are having to pay out of pocket for these, they need to know how often to replace them and what the indications for new orthotics are. I think giving the parents some of the resources listed on this page so that they can order their own orthotics without having to pay extra would be a great benefit for the families.

__**Resource for the Family**__
I am attaching the handout from class about residual limb care, prosthetic care, wear schedule, and contracture prevention. I think this is a great list of do's and don'ts for families as well as clinicians. Since this wiki will be up after our class is over it could also be a place for us to find it after graduation.

__**Pointers on PT & Prosthetics**__
The overall goal of PT for a child with an amputation or a limb deficiency is relatively the same as for any other child requiring physical therapy services (Campbell, 2006).
 * GOAL: Promote normalized development and prevent/minimize development of body function impairments, activity limitations, and participation restrictions
 * Prevent joint contracture formation and skin breakdown
 * Minimize muscle imbalances and strength losses
 * Promote independence with mobility and self-care skills

The Child Amputee Prosthetics Project-Functional Status Inventory (CAPP-FSI) is an outcome measure that was developed and tested by Pruitt et al. (1996) as a way to functionally assess children ages 8-17 with limb deficiencies. The CAPP-FSI can be utilized for children with upper and/or lower limb deficiencies and is completed via parent reporting on the child's performance of 40 everyday activities. The child's performance is rated on two 5-point scales: (1) "Does the Activity" - i.e. how many times the child independently performs the activity, and (2) "Uses a Prosthesis" - i.e. how many times the child uses a prosthesis to perform the activity. Two summary scores are yielded: a higher score on the first scale indicates greater independence with activity, a higher score on the second scale indicates greater use of a prosthesis to complete activities.

The following PDF file is the article published by Pruitt et al. (1996) that discusses the development and psychometric analysis of the CAPP-FSI: The following two PDF files are subsequent articles published by Pruitt et al. (1998, 1999) that discuss the developments and psychometric analyses of two additional outcome measures that stemmed off of the CAPP-FSI. The CAPP-FSIP was developed for assessment of preschool-aged children (ages 4-7), and the CAPP-FSIT was developed for assessment of toddlers (ages 1-4).

**__"Unofficial" Adaptive Equipment Resources__**
There are a number of "unofficial" resources out there for legitimate companies, including things like Twitter, Facebook, and Youtube. The following is a link to Tadpole Adaptive's You Tube Channel. Here, you can find a ton of information about their equipment and you can hear from their clients and providers. It's a unique way to reach audiences who might prefer these modes of communication. http://www.youtube.com/user/TadpoleAdaptive Here is an example of one of their videos. media type="youtube" key="gstrRU5-K4o" height="315" width="560"

**__Resources for Adaptive Equipment Ordering__**
TherAdapt® is a therapist-owned adaptive equipment distributing company that offers a wide variety of products, including seating and positioning equipment, mobility aids, and recreational therapy products. Link: []

Another equipment provider is Flaghouse. Here is a link to their homepage. They provide free activity guidelines, which describe the equipment, its value, parameters, intended audience, safety concerns, instructions for use, etc. Below is an example for a "Scoot-A-Round."

The equipment categories are cooperative play, fitness, PE activities, special needs activities, and sports and athletics.

__Considerations for the Therapist When Suggesting Adaptive Equipment__
The Physical Therapist needs to identify deficits, compensation patterns, needs, and level of independence for the child. The therapist also needs to know what is available for the child and family to use__.__ Of course, the therapist needs to maintain good communication with the orthotist, prosthetist, clinicians, physicians, teachers and parents to ensure that the child has the most appropriate and effective device.

Equipment must be used properly and safely. The equipment must be suitable for the child and their level of activity and function. Adaptive equipment can cause injury if not used correctly, or if equipment is uncomfortable, increases energy expenditure too much, or is complicated to use. Injuries can increase complications among children. Here is an article that emphasizes the importance of safety, and looks at the prevalence of injuries that occur while trying to use an assistive device. [|Pediatric Mobility Aid- Related Injuries Treated in US Emergency Departments From 1991-2008]

Even if the orthotic, prosthesis, or adaptive equipment doesn't cause injury it is still important to continuously evaluate whether it is achieving the desired result. Here's a New York Times article that has some information on in shoe orthotics such as those we may recommend for orthopedic pediatric injuries. It mentions [|an article]that basically says in shoe orthotics for adults do not actually result in the consistent changes we expect. Adults adapt differently to the new input the orthotic provides. This is likely true of children as well, especially given the wide range of stages of development and even conditions under umbrella diagnoses like cerebral palsy. Therefore, we can't assume that an orthotic or other device will result in the same gait improvement in two different patients with similar conditions.

The following video is of an adorable little boy with his new prosthetic knee from Ossur. The video starts out showing him donning the prosthesis (of which the socket is colorfully decorated with Spiderman in action, might I add) and then proceeds to show how he is able to get down off the exam table by himself, walk and run freely, go up and down stairs, and walk on varying surfaces (clinic floor vs. uneven pavement) without assistance. All in all, this video represents what an appropriately ordered and fitted prosthesis can provide a child who otherwise may not be able to fully and independently participate in many activities due to limb loss. As physical therapists, not only do we play a role in providing rehabilitation services to a child after he or she has acquired a prosthesis, but we also are key members of the prosthetic team because we can provide input on what type of prosthesis would best fit an individual child so as to maximize his or her participation in everyday life. media type="custom" key="11103718"

__Diagnosis-Specific Adaptive Equipment__
Cerebral Palsy: The following is a resource that would be appropriate for parents of children with cerebral palsy: http://www.about-cerebral-palsy.org/treatment-therapy/adaptive-equipment.html

Here's an article written with orthopedic nurses in mind, but it has good information regarding skin and orthotic care for both physical therapists and parents:

Here's [|a study on supramalleolar orthoses (SMOs)] for flexible flat feet resulting from hypotonia. Basically cadence and step length improved significantly, but the children didn't walk significantly faster. The introduction mentions several other studies on SMOs for other conditions such as Down Syndrome with mixed results generally showing small or no improvement.

__Splints and Casts: Indications and Methods__
Below is a great article from 2009 summarizing various pediatric splints and casts and the indications for both. The authors are MDs and professors of family medicine and pediatric and orthopedic surgery. The article includes comprehensive charts which outline many upper and lower extremity splints/casts as well as detailed pictures of many. The authors also included common uses, applications, and position of function for each orthotic listed. http://www.aafp.org/afp/2009/0901/p491.pdf

__Fact Sheet for PTs and Families__
The APTA has a fact sheet that outlines the fundamentals of pediatric orthotics. This sheet can be used by PTs for a refresher course on orthotics and can also be provided to families to answer basics questions they may have for their child. This reference answers questions such as: What is an Orthosis? Who Designs and Provides Orthoses? Who Is on the Team? What Are the Characteristics of Pediatric Lower-Extremity Orthoses? Can an Orthosis Be Used for Contracture Prevention/Reduction? Also provided is a chart titled Lower-Extremity Orthoses and Indication in the Gait Cycle (pictures included). http://www.pediatricapta.org/consumer-patient-information/pdfs/Orthotics.pdf

I am including the link to the word document sent to us by Nathan Apple about gait analysis and the anatomic or prosthetic cause of gait deviations seen. I know this is a very technical resource for family members to utilize but it is a great quick way to look at some common causes of gait deviations for Physical Therapists and other clinicians.
 * __Gait Analysis for Prosthetics__**

This site provides many sources where you can go to find information. The overall theme that is demonstrated is that it is important to have a basic understanding of body kinematics for knowing what type of device would be most effective and to stay informed about available options. Hope that these sources are helpful for you!

__**Adaptive Sports/Sporting Equipment for Children with Disabilities**__ With as much as we have focused on the importance of basing our PT goals for children on their participation level, I wanted to include some material on this site about sporting opportunities and adaptive equipment for sports for children with disabilities. It is important for us to realize that by giving children the correct adaptive equipment or suggesting an adaptive sporting league/event, we are opening up a world of opportunities and benefits to these kids. Not only will kids reap the physical benefits of getting more exercise, but they will also gain huge amounts of mental and social advantages from participating in sports with their disabled or normally developing peers. Engaging in physical activity with other kids can support friendship, help to develop sportsmanship, enhance self-esteem and promote peer acceptance.

Here is a link to an article written by a pediatric PT specializing in sports and disabled children. This article highlights the importance for participation in sports, opportunities in adaptive sports, and suggestions for items to include in a pediatric sporting evaluation. []

This is a PDF from the **United Spinal Association** listing many of the adaptive sporting opportunities available nation wide to children with SCI, MS, polio, ALS, and spina bifida. It is 37 pages long but a great resource for PTs and families looking for adaptive sports organizations. []


 * Special Olympics** offers sporting opportunities for people with intellectual disabilities.This is the Kansas website which includes how to get involved, a calendar full of events to participate in, and some great quotes and pictures of kids participating in Special Olympic events. []


 * Paralympics** are sporting opportunities for people with physical disabilities. There are many sporting events nation and world wide for paralympians to compete in. A really inspirational website for athletic kids to check out would be the one for the US Paralympic Team. []

The YMCA also offers an adaptive sporting program nationwide known as the **Challenger program**. Its goal is to provide individuals 4-30 years of age with physical, developmental and intellectual disabilities with the opportunity to learn, grow and thrive through recreational and social opportunities. There is a great branch of the program here in Kansas City. []