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INTRODUCTION
This is the project about the HKAFO with spine support, this appliance given to the paraplegic patient. This report contains about the appliance, its various designs and the biomechanics of the appliance.

PARAPLEGIA:Only a small proportion of cases of spinal injuries are complicated by injury to the neural structures within the vertebral column. In the cervical spine, it may lead to paralysis of all four limbs (quadriplegia). In thoracic and thoraco-lumbar spine, it may result in paralysis of the trunk and both lower limbs (paraplegia). The terms quadriparesis and Para paresis are sometimes used for incompletes paralysis of all four limbs or the limbs respectively. The commonest spinal injury to be associated with paraplegia is a fracturedislocation (flexion-rotation injury) of the dorso lumbar spine. Quadriplegia most commonly results from fracture-dislocation at the C5C6 junction. Only severely displaced lumbar spine injuries below L1 level produce cauda equine type of paralysis.

Bilateral HKAFO with spine support (hybrid) orthosis mainly prescribed for paraplegic patient who are unable to walk even unable to stand. In this report I discussed about the paraplegia, its causes, pathology, clinical examination, investigation and various thing about paraplegia. Then I discussed about the appliance, its design and biomechanics of the appliances.

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PARAPLEGIA

WHAT IS PARAPLEGIA?

Paralysis is a general term used to describe the loss of movements and/or sensation following damage to the nervous system. Knowing the precise level of the injury is helpful in predicting which parts of the body will be affected by paralysis and loss of function. Paraplegia describes complete or incomplete paralysis affecting the legs and possibly also the trunk, but not the arms. The extent to which the trunk is affected depends on the level of spinal cord injury. Paraplegia is the result of damage to the cord at T1 and below. Injuries at the thoracic level and below result in paraplegia, with the hands not affected. At T-1 to T-8 there is most often control of the hands, but poor trunk control as the result of lack of abdominal muscle control. Lower T-injuries (T-9 to T-12) allow good truck control and good abdominal muscle control. Sitting balance is very good. Lumbar and Sacral injuries yield decreasing control of the hip flexors and legs. Besides a loss of sensation or motor functioning, people with SCI also experience other changes. For example, they may experience dysfunction of the bowel and bladder,. Sexual functioning is frequently impaired or lost with SCI. Men may have their fertility affected, while a women's fertility is generally not affected. Other effects of SCI may include low blood pressure, inability to regulate blood pressure effectively, reduced control of body temperature, inability to sweat below the level of injury, and chronic pain.

T-1 injuries are the first level with normal hand function. They can perform all motor functions of a non-injured person, with the exception of standing and walking. As thoracic levels precede caudally, intercostals and abdominal musculature recovery is present, and there is improved respiratory function and trunk balance as a result. Some complete lower injuries have partial trunk movement and may be able to stand, with long leg braces and a walker, and may be able to walk short distances using this equipment, with assistance. T6-12 patients also have partial abdominal muscle strength, and may be able to walk independently for short distances with long leg braces and a walker or crutches (The working abdominal muscles are used to throw the paralyzed legs forward whilst the body weight is taken on a frame or crutches).

-3Attempting this form of walking is normally a decision taking in a medical environment. It takes a lot of determination and strength to achieve any success with this sort of walking. It isn't for everyone; indeed many complete paraplegics won't even want to try it.

ETIOLOGY:DIVIDED INTO TWO TYPES DUE TO UPPER MOTOR NEURON LESION. DUE TO LOWER MOTOR NEURON LESION.

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UMN LESIONS
SPINAL LESIONS (COMMON) Spinal cord compression ( potts disease, disc prolapsed, fracture, tumors, epidural abscess, cervical spondylosis etc) VASCULAR Hemorrhage, infarction SYSTEMATIC DEGENERATION OF TRACTS Multiple sclerosis, MND, sub acute combined degeneration of cord. INFECTION Transverse myelitis, neurosyphilis.

CEREBRAL LESIONS (UNCOMMON)

Thrombosis of superior saggital sinus Tumor of flax cerebi Hydrocephalus

LMN LESIONS
ANTERIOR HORN CELLS Poliomyelitis, motor neuron disease. PERIPHERAL NERVE Peripheral neuro pathy NEUROMUSCULAR JUNCTION Myasthenia gravis MUSCLES Muscular dystrophy

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Spinal cord compression

It may be acute with trauma, metastasis or arterial occlusion or it may be slow developing over week as in Potts disease and cervical spondylosis etc.

Pott s disease

TB of spine often involves two or more adjacent vertebral bodies. Lower thoracic and upper lumbar are also involved, intervertebral disc are also destroyed. With advanced Para vertebral cold abscess, gibbous formation and PARAPLEGIA occur.

TRANSVERSE MYELITIS

Its an acute and sub acute inflammation of spinal cord occurring after infection and recent vaccination. Many agents like influenza, measles, CMV, EBV, and mycoplasma have been implicated.

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CAUSES:Paraplegia is most often a result of a traumatic injury to the spinal cord nervous tissue or the resulting inflammation and swelling that occurs around the point of injury. Paraplegia can also be caused by non-traumatic and congenital factors such as spinal tumors, scoliosis, or spinal bifida. Scoliosis is an abnormal curving of the bones that make up the structure surrounding the spinal cord. Spina bifida is a birth defect in which parts of bones that make up the structure surrounding the spinal cord do not come together properly. Spinal cord injuries resulting in paraplegia are known as either "complete" or "incomplete". For a "complete" injury, no level of feeling or function exists for the patient below the point of injury. An "incomplete" injury results in the patient retaining some level or feeling or function below the point of injury. Injury to the nervous system is the most common cause of paraplegia. Common injuries and other causes include:

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Broken neck Broken back Stroke Spinal cord injury Genetic disorder (hereditary spastic paraplegia) Congenital (present at birth) Infection Autoimmune diseases Tumor (either within the spinal cord or compressing the spinal cord) Syrinx (a spinal cord disorder)

DISABILITY:While some people with paraplegia can walk to a degree, many are dependent on wheelchairs or other supportive measures. Impotence and various degrees of urinary and fecal incontinence are very common in those affected. Many use catheters or a bowel management program (often involving suppositories, enemas, or digital stimulation of the bowels) to address these problems. With successful bladder and bowel management, paraplegics can prevent virtually all accidental urinary or bowel discharges. Some paraplegics prefer the use of diapers as an alternative.

COMPLICATIONS:Due to the decrease or loss of feeling or function in the lower extremities, paraplegia can contribute to a number of medical complications to include pressure sores (decubitus), thrombosis and pneumonia. Physiotherapy and various assistive technologies, such as a standing frame, as well as vigilant self observation and care may aid in helping to prevent future and mitigate existing complications. As paraplegia is most often the result of a traumatic injury to the spinal cord tissue and the resulting inflammation, other nerve related complications can and do occur. Cases of chronic nerve pain in the areas surrounding the point of injury are not uncommon. There is speculation that the "phantom pains" experienced by individuals suffering from paralysis could be a direct result of these collateral nerve injuries misinterpreted by the brain.

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PATHOLOGY:The displaced vertebra may either damage the cord (very unlikely), the cord along with the nerve roots lying by its side or the roots alone. Pathologically, damage to the neural structures may be a cord concussion, cord transaction or root transaction.

CORD CONCUSSION: in this type, the disturbance is one of functional loss without a demonstrable anatomical lesion. Motor paralysis (flaccid), sensory loss and visceral paralysis occur below the level of the affected cord segment. Recovery begins within 8 hours, and eventually the patient recovers fully.

CORD TRANSECTION: in this type, the cord and its surrounding tissues are transected. The injury is anatomical and irreparable. Initially, the motor paralysis is flaccid because the cord below the level of injury is in a state of spinal shock. After some time, however, the cord recovers from shock and acts as a independent structure, without any control from the higher centers. In this state though the cord manifests reflex activity at spinal level, there is no voluntary control over the body parts below the level of injury. There is total loss of sensation and autonomic functions below the level of injury. The appearance of signs suggestive of reflex cord activity i.e., bulbous cavernous reflex, anal reflex and plantar reflex, without of motor power or sensation is an indicator of cord transaction. These reflexes usually appear with 24 hours of injury, in a few days or weeks, the flaccid paralysis (due to spinal shock) becomes spastic, with exaggerated tendon reflexes and clonus. Involuntary flexors spasms at different joints and spasticity leads to contractures. Sensations and autonomic functions never return.

ROOT TRANSECTION:- spinal may be damaged alone in injuries of the lumbar spine, or in addition to cord injury in injuries of the dorso-lumbar spine. Neurological damage in nerve root injury is similar to cord transaction except that in the former residual motor paralysis remains permanently flaccid. A discrepancy between the neurological and skeletal levels may occur in spinal injuries below D10 level because the roots descending from the segments higher than the affected cord level may also be transected, thereby producing higher neurological than expected.

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Incomplete lesions: occasionally the neurological lesion may be

incomplete lesions i.e. affecting only a portion of cord. In these cases of evidence of neurological sparing distal to the injury (perianal sensation sparing is common). Such sparing is an indication of a favorable prognosis. The incomplete lesions may be of the following types.

a) Central cord lesions: this is the commonest incomplete lesion. There is initial flaccid weakness followed by allowed motor neuron type of paralysis of the upper limbs and upper motor neuron (spastic) paralysis of the lower limbs, with the preservation of bladder control and perianal sensations (sacral sparing).

b) Anterior cord lesion: there is complete paralysis and anesthesia but deep pressure and position sense are retained in the lower limbs (dorsal column sparing).

c) Posterior cord lesion: it is a very rare lesion. Only deep pressure and proprioception are lost.

d) Cord hemi-section (browm-sequard syndrome): there is ipsilateral paralysis and contra lateral loss of pain sensation.

Neurological deficit and spinal injuries

Cervical spine: in these injuries, the segmental level of the cord transaction nearly always corresponds to the level of bony damage.

A high cervical cord transaction (above c5) is fatal because all the respiratory muscles (thoracic and diaphragmatic) are paralyzed. Transaction at the c5 segment results in paralysis of the muscles of the upper limbs, thorax, trunk and lower limbs, with the loss of sensation and visceral functions.

- 11 With transaction at level below the c5 segment, some muscles of the upper limbs are spared, resulting in characteristics deformities, depending upon the level.

Thoracic lesion (between t1 and t10): in cord transaction from t1 and t10 trunk and lower limb muscles are paralysed. At the tenth thoracic vertebra, the corresponding cord segment is l1 so that in injuries at this level, only the lower limbs are affected. Dorsolumbar lesions (between d11 and l1): between 11th dorsal and 1st lumbar vertebrae lie all the lumbar and sacral segments along with their

Nerve roots, hence, injuries at this level cause cord transaction with or without involvement of nerve roots.

This is the cause of difference in neurological deficit in fractures and fracture- dislocations with apparently similar X-ray appearances.

In injuries of the cord with nerve root transaction, paralysis in the lower limbs is mixed (UMN+LMN type).

Lesions below l1: this area of the canal has only bunch of nerve roots which subsequently emerge at successive levels of the lumbar-sacral spine. Thus, injury in this area results in root damage, resulting flaccid paralysis, sensory loss and autonomic disturbances in the distribution of the affected roots.

Symptoms
Symptoms will depend on how much of the spinal cord is involved. Symptoms include:

Loss of movement or muscle control in the legs, feet, toes, or trunk Loss of sensation in the legs, feet, toes, or trunk Tingling in the legs, feet, toes, or trunk Loss of bowel and bladder control Sexual dysfunction

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CLINICAL EXAMINATION
A neurological deficit following trauma to the spine is difficult to miss. More important is to perform a thorough neurological examination to evaluate the following :( i) the level of the neurological deficit :( ii) any evidence of an incomplete lesion; and (iii) any indication of complete cord transection.

INVESTIGATION
Radiological examination: Often there is no correlation between the severity of the injury on the X-rays and the degree of neurological deficit. C.T. and M.R.I. scan: This may be indicated in cases with incomplete paralysis, particularly if it is increasing. It is also indicated in cases where no bony lesions are visible on plain X-rays. M.R.I. has become the imaging modality of choice for these cases.

TREATMENT
A patient with traumatic paraplegia, whenever possible, should be admitted to specialized units where the necessary facilities for management of these cases are available. In developing countries, these cases are still managed in general hospitals. Phase I: Emergency care at the scene of accident and in the emergency department Phase II: Definitive care on in-patient basis Phase III: Rehabilitation

PHASE I- EMERGENCY CARE

The care in phase I is along the lines already discussed in treatment of spinal injuries

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PHASE II-DEFINITIVE CARE

Care in phase II consists of: (i) clinical assessment of the neurological deficit ;(ii) radiological and special investigation to understand the type of vertebral lesion, and to detect the possibility of persistent cord compression by a bone fragment in the vertebral canal; and (iii)care of paraplegic in the ward.

Ward care of a paraplegic: Ward care of a traumatic paraplegic or

quadriplegic consists of: (i) management of the fracture; (ii) nursing care; (iii) care of the bladder and bowel; and (iv) physiotherapy.

Management of the fracture: The treatment of the fracture or

fracture-dislocation per se is the same as that for spinal injury at that level without neurological lesion. The role of operative treatment is controversial. This consists of stabilization of the spine by internally fixing it. This ensures better nursing care of the patient but offers no security about the recovery of neurological function. The generally accepted indication for operating in developing countries, with limited expertise. Can be considered as follow: a) An incomplete paralysis, particularly if it is increasing and a C.T. scan shows fragments of bone encroaching upon the spinal canal. b) A patient with multiple injuries, in whom it is desirable to stabilise the spine for overall optimum care of the patient

Nursing care: Specialized nursing care has dramatically changed the

prognosis of a traumatic paraplegic. It can be considered under the following heads: Positioning in bed: The patient is nursed flat on a hard bed with a mattress. The limbs are positioned with pillows so that contractures do not develop; also pressure points are adequately padded. b) Care of the back: Frequent turning in bed in vital so that the patient lies for equal periods on his back and on either side. The bed is kept dry and free of wrinkles. Special beds are available which provide an ease of turning the patient periodically (Stryker frame ), and constantly changing pressure- point (water-bed, alpha-bed). c) Personal hygiene: From tip to toe, all personal hygiene of the patient is to be looked after. This includes combing hair, cleaning teeth, mouth wash, care of the skin and nails etc.
a)

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Care of the bladder: intermittent catheterization is the best but for

convenience an indwelling catheter is used. The catheter is changed once a week, and the patient is kept on prophylactic antiseptic drugs. A urine culture is done once every two weeks. As the becomes haemodynamically stable, the catheter is periodically clamped so that the bladder capacity is maintained. In most cases of cord transaction, satisfactory automatic emptying is established within one to three months of the injury (automatic bladder). In a case, where the sacral segments are irrecoverably damaged, as in a cauda equine lesion, reflex emptying does not occur. In such cases micturition will have to be started of aided by other mechanisms like abdominal straining or manual compression etc. (autonomous bladder).

Care of the bowel: the patient develops bowel incontinence and

constipation. The latter may result in periodic bloating up of the abdomen. A frequent soap-water enema or manual evacuation of the bowel may be required.

Physiotherapy: the aim of physiotherapy in the initial few weeks is to

maintain mobility of the paralysed limbs by moving all the joints through the full range gently, several times a day. Later, in cases where partial recovery occurs, exercises specifically for building up the muscle groups are taught.

PHASE III REHABILITATION

In most cases with traumatic paraplegia and quadriplegia, the deficit is permanent. With concentrated efforts at rehabilitation a majority of these cases can be made reasonably independent and enabled to lead a useful life within the constraints of their disability. Rehabilitation can be considered under the following heads: (i) physical rehabilitation; (ii) social rehabilitation; and (iii) economic rehabilitation.

Physical rehabilitation: it consists of making the patient as independent

in his activities of daily living (ADL) as possible. A patient may be given special appliances like calipers, wheelchair etc. for this.

Social rehabilitation: keeping the morale of a paraplegic high is a great

challenge. The doctor, nursing care, relatives, friends and social organizations have a great role to play in this.

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Economic rehabilitation: This is an important aspect of rehabilitation of

a paraplegic. As soon as he is able to do a worthwhile job, efforts should be made to procure some form of remunerative employment for him. In developed countries, these patients are managed in special spinal injury centers. There are now more and more surgeons in these centers who believe in the operative treatment of most of the cases of paraplegia and quadriplegia. According to them, stabilization of the spine after reduction of the displacement gives the patient: (a) best chance of relieving compression on the cord, if at all; and, (b) helps in better nursing care of the patient.

Emergency Medical Treatment

If you have an injury that causes paraplegia, emergency treatment is needed to prevent further damage to the nervous system. Once an evaluation has been done and the severity of the damage has been determined, the doctor will determine what therapies are needed to prevent additional injury and maximize recovery. Steroids may be used to minimize the swelling of the spinal cord if it has been injured. Surgery may be done to help stabilize the spine. If a tumor is causing compression of the spinal cord, surgery may be needed. Radiation therapy is another possible treatment option.

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Muscle strength testing of paraplegic patient

Muscle strength is graded using the following Medical Research Council (MRC) scale of 0-5:

5 - Normal power 4+ - Sub maximal movement against resistance 4 - Moderate movement against resistance 4- - Slight movement against resistance 3 - Movement against gravity but not against resistance 2 - Movement with gravity eliminated 1 - Flicker of movement 0 - No movement

Muscle strength always should be graded according to the maximum strength attained, no matter how briefly that strength is maintained during the examination. The muscles are tested with the patient supine. The following key muscles are tested in patients with SCI, and the corresponding level of injury is indicated:

C5 - Elbow flexors (biceps, brachial is) C6 - Wrist extensors (extensor Carpi radialis longus and brevis) C7 - Elbow extensors (triceps) C8 - Finger flexors (flexor digitorum profundus) to the middle finger T1 - Small finger abductors (abductor digiti minimi) L2 - Hip flexors (iliopsoas) L3 - Knee extensors (quadriceps) L4 - Ankle dorsiflexors (tibialis anterior) L5 - Long toe extensors (extensors hallucis longus) S1 - Ankle plantar flexors (gastrocnemius, soleus)

Sensory testing is performed at the following levels:

C2 - Occipital protuberance C3 - Supraclavicular fossa C4 - Top of the acromioclavicular joint C5 - Lateral side of antecubital fossa C6 - Thumb C7 - Middle finger C8 - Little finger T1 - Medial side of antecubital fossa

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T2 - Apex of axilla

T3 - Third intercostals space (IS) T4 - Fourth IS at nipple line T5 - Fifth IS (midway between T4 and T6) T6 - Sixth IS at the level of the xiphisternum T7 - Seventh IS (midway between T6 and T8) T8 - Eighth IS (midway between T6 and T10) T9 - Ninth IS (midway between T8 and T10) T10 - 10th IS or umbilicus T11 - 11th IS (midway between T10 and T12) T12 - Midpoint of inguinal ligament L1 - Half the distance between T12 and L2 L2 - Midanterior thigh L3 - Medial femoral condyle L4 - Medial malleolus L5 - Dorsum of the foot at third metatarsophalangeal joint S1 - Lateral heel S2 - Popliteal fossa in the midline S3 - Ischial tuberosity S4-5 - Perianal area (taken as 1 level)

Sensory scoring is for light touch and pinprick, as follows:

0 - Absent 1 - Impaired or hyperesthesia 2 Intact

A score of zero is given if the patient cannot differentiate between the point of a sharp pin and the dull edge. Motor level - Determined by the most caudal key muscles that have muscle strength of 3 or above while the segment above is normal (= 5) Motor index scoring - Using the 0-5 scoring of each key muscle, with total points being 25 per extremity and with the total possible score being 100 Sensory level - Most caudal dermatome with a normal score

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Orthotic manageme nt of paraplegia

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CASE STUDY OF THE PATIENT:NAME: -

Imran Ahmed. 19yrs/M. Mohall a shivdwara, amrauha traumatic paraplegia

AGE/SEX: ADDRESS: J.P. nahar, U.P. DIAGNOSIS: -

PRESCRIPTION: - Bilateral HKAFO with spinal support.

HISTORY:Patient has the traumatic paraplegia this is certified by the diagnosed of the patient. Patient has traumatic paraplegia because due to gun shot, the spinous process of his spine at D7-D9 level was ruptured before two and the half years ago. He is not able to walk even not able to stand due to paraplegia. The causes and symptoms are same as written above:

Clinical examination:Examine the level of neurological deficit. Examine the ability of patients sitting, standing and walking. Examine the range of motion of joints.

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Examine the level of paralysis. Examine the sensory power of the patient. Examine the movement of the body.

Examine the level of neurological deficit: - patient has the injury at dorsal region of spine. So the patient has the complete cord transaction at the dorsal region up to D7-D9.

Examine the ability of patient sitting, standing and walking: - patient cant move anywhere. He is not able to sit, stand and walk. Without any help aids he is not able to stand.

Examine the range of motion of joints: - patient has not any range of motion in his joints. He is completely unable to move his joints.
L2 - Hip flexors (iliopsoas) L3 - Knee extensors (quadriceps) L4 - Ankle dorsiflexors (tibialis anterior) L5 - Long toe extensors (extensors hallucis longus) S1 - Ankle plantar flexors (gastrocnemius, soleus)

I was examined the graded of these different muscles with their nerve supply. Patient has the GRADE-1 and GRADE-2 in the muscles.

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Grade-2 = movement with gravity eliminated. Grade-1 = flicker movement.

Examine the level of paralysis: - patient has paralysis of both lower limbs. Upper limbs has the strength of movements, they are not completely paralyzed. Examine the sensory power of the patient: - Test the
sensation on the patients trunk with a pin, starting from below and working upwards. Can he recognize movements of his feet or knees? Test his knee and ankle jerks and his plantar responses. Test to find out if his sacral segments have been spared by pricking the skin beside his anus with a pin.

Examine the movement of the body: - patient has no movement in lower limbs but he is having the movement at upper limbs he is able to move his arms.
Type and design of orthosis should be considered according to muscle grading, ROM level of loss of function & stability of joint. HKAFO- If hip flexor/ extensor are weak KAFO- If knee extensors/extensor affected AFO-If quadriceps weakness with genu recurvatum Rigid AFO- If tibialis anterior and triceps surae weakness In case of AFO- If muscle grading is 3- , Solid AFO If muscle grading is 3+, AFO with Ankle joint In case of KAFO- If knee flexor is 3-, Knee extensor is

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3+, KAFO with drop lock knee joint If knee flexor is 3+, Knee extensor is 3-, KAFO with free lock For Spine: Spinal orthosis TLSO The main objective of orthosis is to rest the inflamed joint, so that the inflammation reduced. The joint needs to be immobilized in proper position, so that the alignment of joint will not be disturbed due to arthritis. Variety of orthosis is prescribed according to location and severity of arthritis.

INVESTIGATIONS:During investigation check the patients X-ray, M.R.I and C.T. scan.

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Radiological examination: Often there is no correlation between the severity of the injury on the X-rays and the degree of neurological deficit. C.T. and M.R.I. scan: This may be indicated in cases with incomplete paralysis, particularly if it is increasing. It is also indicated in cases where no bony lesions are visible on plain Xrays. M.R.I. has become the imaging modality of choice for these cases.

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Orthotic design

BILATERAL HKAFO WITH SPINE SUPPORT

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BILATERAL HKAFO
HKAFO's are effectively KAFO's (Knee ankle foot orthoses) with extensions to include the pelvic area. They are used in situations where an addition to conditions which would require KAFO's, hip joint stability and/or power is also reduced or absent.

Very rarely they may have any articulation at the hip as normally a hip joint is incorporated into the design. The joint may be designed to be free, allowing flexion and extension within limits, or to be lockable. The latter type can generally be locked at 90 and 0 degree of flexion.

The pelvic area can be included by a belt or strap but a more rigid pelvic section or band is more common. These can be made from plastic or leather and metal.

HKAFO's are rarely used for adults. They are most commonly used as bilateral HKAFO's for children who suffer from neuromuscular disorders such as spina bifida and cerebral palsy. In these situations, the hip and knee joints are almost always locked in stance and ankle joints would rarely be used. Because the hip joints are locked and the pelvic section is relatively rigid, reciprocating gait is normally not possible and progression is made by a swiveling and rocking motion across smooth surfaces with the aid of a walking frame.

This is not always the case however. If the child has some hip flexor power and good trunk control, the pelvic section can be made flexible enough to allow reciprocating gait, even with locked hip joints. This can be possible even in the absence of hip extensor power.

Although HKAFO's would seem to be a lot of hardware to use there are benefits to achieving stance. Physiologically it may be good for the abdominal organs. Psychosocially it may be of

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benefit with regard to increased independence and being on a level with peers. Because HKAFO's are difficult to don, doff and use but mainly for biomechanical reasons, their use is often terminated before or around the mid teens.

Indications
Hip flexion/extension instability Hip adduction/abduction weakness Hip internal rotation/external rotation instability

Components of HKAFO: Molded AFO (ankle foot orthosis). Uprights. Calf bands. Knee joints. Thigh bands. Hip joints. Pelvic band.

Molded AFO:An ankle-foot orthosis (AFO) is commonly prescribed for weakness or paralysis of ankle dorsiflexion, plantar flexion, inversion, and eversion. AFOs are used to prevent or correct deformities and reduce weight bearing The position of the ankle indirectly affects the stability of the knee with ankle plantar flexion providing a knee extension force and ankle dorsiflexion providing a knee flexion force. An AFO has been shown to reduce the energy cost of ambulation in a wide variety of conditions, such as spastic diplegia due to cerebral palsy, lower motor neuron weakness of poliomyelitis, and spastic hemiplegic in cerebral infarction.4,5 Thermoplastic AFOs - These devices are plastic molded AFOs, consisting of the following 3 parts: (1) a shoe insert, (2) a calf shell, and (3) a calf strap

- 31 attached proximally. The rigidity depends on the thickness and composition of the plastic, as well as the trim line and shape. Thermoplastic AFOs are contraindicated in cases of fluctuating edema and in sensation.

Ankle joints - The mechanical ankle joints can control or assist

ankle dorsiflexion or plantar flexion by means of stops (pins) or assists (springs). The mechanical ankle joint also controls mediolateral stability. Knee extension moment is promoted by ankle plantar flexion, and knee flexion moment is promoted by ankle dorsiflexion. o Free motion ankle joint - The stirrup has a completely circular top, which allows free ankle motion and provides only mediolateral stability. o Plantar flexion ankle joint stop - This ankle joint stop is produced by a pin inserted in the posterior channel of the ankle joint or by flattening the posterior lip of the stirrup's circular stop. The plantar flexion stop has posterior angulations at the top of the stirrup that restricts plantar flexion but allows unlimited dorsiflexion and promotes knee flexion moment. This design is used in patients with weakness of dorsiflexion during swing phase and flexible pes equines. o Dorsiflexion ankle joint stop - The stirrup has a pin inserted in the anterior channel of the ankle joint or by flattening the anterior lip of the stirrup's circular stop. The dorsiflexion stop has anterior angulations at the top of the stirrup that restricts dorsiflexion but allows unlimited plantar flexion and promotes a knee extension moment in the meantime. This design is used in patients with weakness of plantar flexion during late stance.

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Limited motion ankle joint stop - This ankle joint stop has anterior and posterior angulations at the top of the stirrup with restricted dorsiflexion and plantar flexion ankle motion. The limited motion ankle joint stop has a pin in the anterior and the posterior channel, and it is used in ankle weakness affecting all muscle groups. Dorsiflexion assist spring joint - This joint has a coil spring in the posterior channel and helps to aid dorsiflexion during swing phase. Varus or valgus correction straps (T-straps) - A T-strap attached medially and circling the ankle until buckling on the outside of the lateral upright is used for valgus correction. A Tstrap attached laterally and buckling around the medial upright is used for varus correction.

Uprights:o

An AFO with 2 metal uprights extending proximally to the thigh to control knee motion and alignment. This orthosis consists of a mechanical knee joint and 1 thigh band between 2 uprights.

Knee joints - The mechanical knee joint can be polycentric or

single axis. Polycentric is used for significant knee motion, and a single axis is more common and is used for knee stabilization. Single axis knee joints include the following: o Free motion knee joint - This joint has unrestricted knee flexion and extension with a stop to prevent hyperextension. The free motion knee joint is used for patients with recurvatum but good strength of the quadriceps to control knee motion.

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Offset knee joint - The hinge is located posterior to the knee joint and ground reaction force; thus, it extends the knee and provides great stability during early stance phase of the gait cycle. This joint flexes the knee freely during swing phase and is contraindicated with knee or hip flexion contracture and ankle plantar flexion stop.

Drop ring lock knee joint - The drop ring lock is the most

commonly used knee lock to control knee flexion. The rings drop to unlock over the knee joint while the knee is in extension by gravity or manual assistance. This type of joint is stable, but gait is stiff without knee motion. A ball bearing on a spring can be added just above the drop lock to keep it from slipping up as the patient ambulates. Patients over 120 pounds usually feel more secure with medial and lateral drop locks.
o

Pawl lock with bail release knee joint - The semicircular bail attaches to the knee joint posterior, and it can unlock both joints easily by pulling up the bail or backing up to sit down in a chair. A major drawback is the accidental unlocking while the patient is pulling his or her pants up or bumping into a chair. Adjustable knee lock joint (dial lock) - The serrated adjustable knee joint allows knee locking at different degrees of flexion. This type of knee joint is used in patients with knee flexion contractures that are improving gradually with stretching.

Ischial weight bearing - Most individuals in a KAFO sit partially on the upper thigh band unless the cuff is brought up above the ischium. Knee cap and strap - The knee cap can be placed in front of the knee in the orthosis to prevent flexion of the knee. A medial strap is used for genu valgum and a lateral strap is used for genu varum. These buckles wrap around the upright in the same way as ankle straps.
o

- 34 A hip-knee-ankle-foot orthosis (HKAFO) consists of a hip joint and pelvic band in addition to a KAFO. The orthotic hip joint is positioned with the patient sitting upright at 90, while the orthotic knee joint is centered over the medial femoral condyle. Pelvic bands complicate dressing after toileting unless the orthosis is worn under all clothing. Pelvic bands increase the energy demands for ambulation.

Pelvic bands
o

o o

Bilateral pelvic band - This band is used more commonly with its posterior metal ends located anterior to the lateral midline of the pelvis and is interconnected by a flexible belt. Unilateral pelvic band - This band rarely is used because most conditions requiring a HKAFO have bilateral involvement. Pelvic girdle - The pelvic girdle is made of molded thermoplastic materials, providing a maximum degree of control in patients with bilateral involvement. Silesian belt - This belt has no metal or rigid band and offers mild resistance to abduction and rotation of the hip. The Silesian belt attaches to the lateral upright and encircles the pelvis.

Hip joints and locks - The hip joint can prevent abduction and

adduction as well as hip rotation. o Single-axis hip joint with lock - This joint is the most common hip joint with flexion and extension. The single axis hip joint with lock may include an adjustable stop to control hyperextension.

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Two-position lock hip joint - This hip joint can be locked at full extension and 90 of flexion and is used for hip spasticity control in a patient who has difficulty maintaining a seated position. Double-axis hip joint - This hip joint has a flexion-extension axis and abduction-adduction axis to control these motions.

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FABRICATI ON OF THE DESIGN

First assessed the patient in all aspects.

Casting:-

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Casting of AFO:-

Take the casting of the patient for molded AFO and spine support. Take casting of molded AFO at the level from mid calf to the tip of the middle finger of leg. Wrap the POP bandages around the leg. After set the cast fill with the POP powder and then modified the negative mould and then turn into the positive mould. Draping the mould with using HDPE PP sheet. Then trimmed the molded AFO according to the leg contour.

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2.

Casting of spinal support:-

Take the casting of spine support. Wrap the POP bandages around the spine with applying the pressure on the iliac crest and other bony prominences. After set the cast fill with the POP powder and then modified the negative mould and then turn into the positive mould. Draping the mould with using HDPE PP sheet. Then trimmed the spine support according to contour of the body.

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Fabrication of Bilateral HKAFOs: Assemble the uprights. Assemble the knee joints. Give proper contour to the uprights by bending it. Attach the calf band and thigh band according to the measurement of the patient. Attach the hip joints. Attach the pelvic band according to the measurement. Both HKAFOs are ready and then attach the molded spine support to the pelvic band.

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Biomechan ics of spine

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Spine and Associated Muscle Anatomy

To better understand how muscle loads are placed on the spine, we need to know some reference of anatomy. First consider the bony anatomy of the spine as illustrated below:

The major vertebra within the spine is grouped as cervical, thoracic and lumbar. There are soft cartilaginous disks between each vertebra that are named appropriately enough intervertebral disks. A schematic of an intervertebral disk is shown below:

It is typically a problem with the disk that occurs when people complain of low back pain. The disk contains an interior gel, the nucleus pulpous, and an outer layer of laminated concentric rings formed primarily of type I collagen. Typically severe lower back pain associated with numbness occurs when the nucleus pulpous is "squeezed out" through the annulus fibrosus and places pressure on the spinal cord. Excessive loads

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Experimentally can cause disk prolapse; the clinical relationship is much more complex and may involve genetic predispositions as well. Still, it is widely theorized that excessive loads on the disks can cause damage, namely fissures in the disk that over time lead to disk degeneration and prolapsed. Thus, understanding the compressive loads on the spine is of critical importance for understanding the etiology of low back pain. To estimate spinal compression loads, we also need to know something of spinal muscle anatomy.

Spinal Muscles: The musculature of the spine is complex. The spinal

musculature may be divided into 5 major classifications by location: 1. Posterior Wall Musculature: erector spinae of Para vertebral muscles 2. Respiratory or Intercostals Muscles: between ribs 3. Abdominal Wall Muscles: intertransversus, interior and exterior obliques, rectus abdominus 4. Superficial Trunk Muscles - broad muscles including the rhomboids, latissimus dorsi, pectoralis, and trapezius 5. Lower Trunk Muscles: transversis abdominus A simplified view of muscles affecting the spine is shown below:

Spine Biomechanics Models

- 46 One of the biggest difficulties in estimating compressive forces on the spine is determining which muscles are active and indeed what muscles

to model. This cross section is taken at the level of the L-3 (3rd Lumbar Vertebra) and includes ten muscle groups: 1. 2. 3. 4. 5. Left Left Left Left Left and and and and and Right Right Right Right Right Rectus Abominis Internal Oblique Abdominals External Oblique Abdominals Erector Spinae Latissimus Dorsi

As an approximation to the above, consider the rigid body model shown below:

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If we assume that Wa (weight of the arm) is 60N, Wh (Weight of the head) is 40 N, Wt (weight of the trunk) is 250 N, Q (weight held in the hand) is 50N and the moment arms of the arm, head, trunk, and weight are 20cm, 5cm, 1cm and 40cm respectively, and we denote the spinal compression force as C and the Erector Spinae muscle force as E, and erector spinae moment arm as e, we have the following balance of force in the y direction and balance of moment about the z axis:

Solving the above gives E = 562N and C = 962N. The value for C is about 2.4 x body weight. Again, large internal forces are generated because muscles have short moment arms.

Optimization Approaches The optimization formulations we discussed previously, including the Crowninshield and Brand formulation and the An formulations may be applied to the spinal compression force and spinal muscle models using the same approach as for the elbow joint. Again, we must have information concerning the physiologic cross sectional area of all muscles

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in the model as well as there insertion points to determine the moment arms for each muscle. In addition to these optimization formulations, another formulation geared toward estimating spinal loads was proposed by Bean et al. (Bean, JC, Chaffin, DB, and Schultz, AB (1988) "Biomechanical model calculation of muscle contraction forces: a double linear programming method", J. Biomechanics, 21:59-66). In this model, the following two stage optimization formulation was proposed. The first stage is identical to that proposed by An:

In the first stage, the sums of the muscle forces are minimized with a constraint that equilibrium is satisfied. This gives an upper bound on the spinal muscle forces. In the second stage, the sum of the muscle forces is minimized such that their maximum stress has to be less than that produced by the first stage optimization problem. Since by equilibrium the sum of the muscle forces will be balanced by the spinal compression force, we are in essence minimizing the spinal compression force. The second stage is written as:

SPINAL SUPPORT Provide stability to the spine of paraplegic patient.

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Biomechan ics of orthosis

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Biomechanical principles of prescription, selection of materials, fit, and fabrication. Biomechanics- Application of force and counterforce. principle Three point

Center of gravity (COG)while standing, the COG is in the midline just in front of the second sacral vertebra. Line of gravity (weight line)line passing through the center of gravity to the center of the Earth.

Passes behind the cervical vertebrae, in front of the Hip

o

thoracic vertebrae, and behind the lumbar vertebrae.

Line of gravity is slightly behind (posterior Tends to hyperextend the hip joint Line of gravity is in front of (anterior to) the Hyperextend the knee

to) the hip joint

o

Knee
o

knee joint
o

Ankle

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Line of gravity passes one or two inches anterior to the ankle joint Tends to dorsiflex the ankle; this activity is resisted by the soleus and gastrocnemius muscles

When selecting appropriate materials for orthotic devices, their strength, durability, flexibility, and weight need to be considered carefully The orthotic design should be simple, inconspicuous, comfortable, and as cosmetic as possible

During "quiet" standing, line of gravity (weight line) passes

posterior to hip joint anterior to knee joint and anterior to ankle joint

Paraplegics can ambulate with a fourpoint gait. A walker or walkerette may also be used.

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ALIGNMENT OF ORTHOSIS FOR PARALEGIC SYMBOLS

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1) 2) 3) 4)

Centre of gravity Joint Joint-free movement Joint- fixed

- 56 5) Joint- one side resistant passive 6) Joint- one side resistant active 7) Joint- one side resistant passive as well as lock

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Through limit stability

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RESULT
This project is meant for paraplegic patient, and we are successful, to make him standing position with the crutches. While making this project we taught many great and new technologies. We are familiar to work with different and any condition.

This project is meant for paraplegic patient and we are successful to make him in standing position with the crutches. All work are finished very successfully, the working of tools, availability of materials and many other things which we are required are happened successfully. The design of the orthosis are fitted to the patient is appropriately supportive, protective and corrective and he feels very comfortable with the orthosis

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ABOUT PARAPLEG IA