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What's Covered (Quick Reference)

Q1 - LBP Assessment + Differential Diagnosis (30M)

• Full subjective assessment framework (red flags, yellow flags, SIN factors)
• Complete objective examination: AROM, PIVM, neurological exam (nerve root table L2-S1), special tests (SLR, Slump, FABER, SIJ cluster), outcome measures table
• 8 differential diagnoses with clinical reasoning: disc herniation, stenosis, spondylolisthesis, SIJ dysfunction, ankylosing spondylitis, piriformis syndrome, spinal infection, visceral referred pain
• Hypothetico-deductive clinical reasoning framework

Q2 - Lumbar Stenosis Management (10M)

• Classification (central/lateral/foraminal), pathomechanics (Kirkaldy-Willis cascade)
• Full conservative physiotherapy: flexion exercises, aquatic therapy, BWSTT, core stabilization, Nordic walking, manual therapy, TENS, traction
• Interventional and surgical indications
• 4 recent systematic reviews cited (Ammendolia 2022, Temporiti 2022, Urata 2023, Kirker 2023)

Q3 - Groin Soft Tissue Injuries (10M)

• Doha Agreement classification, phased rehabilitation (POLICE → Copenhagen Adductor Exercise → return-to-sport criteria)
• Evidence-based protocols: Holmich's protocol, CAE, criteria-based RTS
• Special conditions: osteitis pubis, athletic pubalgia, iliopsoas tendinopathy

Q4 - NSCLBP Pain Assessment, Modulation & Management (30M)

• Multidimensional pain assessment: VAS, MPQ, BPI, ODI, FABQ, TSK, PCS, CSI, CPM, QST
• Pain neuroscience: peripheral sensitization, central sensitization, descending modulation, gate control, brain neuroplasticity
• Full management: PNE, motor control exercise, graded activity, graded exposure, CBT, ACT, MBSR, tDCS, GMI

Q5 - Neural Tissue Mobilisation (30M)

• Butler's nervous system continuum, Sunderland's nerve injury classification
• Full assessment: SLR with structural differentiation, Slump test, FNST, sympathetic assessment
• Sliding vs. tensioning techniques with specific protocols for supine/seated/prone
• Maitland grading for neural mobilisation, dosage, precautions
• Key evidence: Nee et al. 2022 meta-analysis (SLR reliability), Coppieters & Butler (sliding vs. tensioning biomechanics)

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MPT MUHS Examination Answers - Orthoses and Splints

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ANSWER 1: Role of Orthosis for Spinal Movement Dysfunctions Under Conservative Care (10 Marks - Summer 2022)

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DEFINITION

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AIMS OF SPINAL ORTHOSIS IN CONSERVATIVE CARE

1. Immobilization / Restriction of motion - protect injured structures, allow healing
2. Pain relief - reduce biomechanical load on pain-sensitive structures; warmth effect; proprioceptive input
3. Deformity correction - apply corrective forces (three-point pressure principle) to reduce or halt curve progression
4. Postural control and spinal stabilization - support weak musculature; increase intra-abdominal pressure (IAP) to unload spine
5. Protection post-surgery - maintain surgical correction during healing
6. Proprioceptive feedback / Postural awareness - reminder to avoid extreme positions

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CLASSIFICATION OF SPINAL ORTHOSES

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ROLE IN SPECIFIC SPINAL MOVEMENT DYSFUNCTIONS

1. Low Back Pain (LBP)

• Intra-abdominal pressure (IAP) mechanism: corsets compress the abdomen, increasing IAP which converts the trunk into a rigid cylinder, reducing compressive loads on lumbar discs and facet joints by up to 30% (Morris, Lucas & Bresler, 1961)
• Restriction of lumbar flexion/extension: reduces mechanical provocation of injured discs or facet joints
• Thermal effect: warmth from the orthosis increases local blood flow, reduces muscle spasm
• Proprioceptive feedback: reduces fear-avoidance by providing postural cues

• Soft lumbar corset / support belt: flexible, allows limited motion; used for non-specific LBP, discogenic pain; worn for short periods (prevents abdominal muscle atrophy with prolonged use)
• Rigid LSO (Chairback orthosis / Knight brace): anterior and posterior uprights with lateral panels; restricts lumbar flexion-extension; for lumbar fractures, post-surgical recovery, disc prolapse
• Lumbosacral corset with steel stays: semi-rigid support; for chronic LBP, lumbar instability
• TLSO: for thoracolumbar fractures, spondylolisthesis

• Acute LBP: short-term (2-4 weeks) rigid orthosis for pain relief; corset during acute phase
• Spondylolisthesis: LSO to limit flexion-extension, reducing shear at the isthmic defect; worn 3-6 months
• Post-discectomy/fusion: rigid TLSO/LSO for 6-12 weeks post-surgery
• Caution: prolonged use (>3 months) leads to paraspinal muscle atrophy and psychological dependency

2. Scoliosis (Idiopathic)

• Curve 25-40° (Cobb angle) in a skeletally immature patient (Risser stage 0-2)
• Documented progression of ≥5° or initial curve >25° at presentation

• Milwaukee brace (CTLSO): for thoracic curves with apex above T8; neck ring + pelvic girdle + lateral thoracic pad; applies three-point corrective pressure; uncomfortable, poor compliance (rarely used now)
• Boston TLSO (underarm brace): prefabricated, trimmed to custom fit; curves with apex at T8 or below; most commonly used
• Charleston Nighttime Brace: worn only during sleep; hypercorrected position; compliance is better
• Providence brace: custom nighttime orthosis; overcorrects curve by lateral bending; for single lumbar/thoracolumbar curves
• Chêneau brace / Rigo-Chêneau (3D brace): asymmetric TLSO with expansion chambers and pressure zones for 3D correction; evidence supports curve correction >50% in compliant patients

• Effectiveness is dose-dependent: worn >13 hours/day = 90% efficacy in preventing surgical threshold (Weinstein et al., BRAIST trial, NEJM 2013)
• Miller's Review of Orthopaedics (9th Ed): "Bracing has been shown to be less effective in boys and overweight patients"

3. Cervical Spine Dysfunctions

• Acute whiplash: soft collar (reminder device + proprioceptive input) for 1-2 weeks; longer immobilization NOT recommended (active treatment superior - WAD guidelines)
• Cervical disc prolapse / radiculopathy: soft/semi-rigid collar for 2-4 weeks for pain relief; reduces cervical compressive load; combined with traction and exercise
• Cervical spondylotic myelopathy (CSM): rigid collar post-operatively; stabilizes during neural tissue healing
• Post-surgical: Philadelphia/Miami J for 6-12 weeks post-ACDF

4. Thoracic Spine (Kyphosis)

• Milwaukee brace / CTLSO: Scheuermann's kyphosis in adolescents; three-point pressure over thoracic kyphosis apex
• Jewett hyperextension orthosis (TLS): three anterior pads (sternal, pubic, upper thoracic) + posterior lumbar pad; restricts flexion and facilitates extension; used for stable thoracic/thoracolumbar compression fractures; does not control rotation
• Taylor brace (TLSO): two posterior uprights, abdominal support; for mid-thoracic lesions; restricts flexion
• Knight-Taylor brace: combines Knight (LSO) + Taylor (TLSO); controls all planes including rotation in the thoracolumbar junction

5. Spondylolisthesis / Lumbar Instability

• Rigid LSO with anti-lordosis padding: reduces anterior shear at slipped level
• Lumbosacral fusion orthosis post-operatively

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PRINCIPLES OF APPLICATION (Conservative Management)

1. Prescription: by physiotherapist/orthopaedist based on diagnosis, segment involved, deformity type
2. Fitting: orthotist fabricates/fits; physiotherapist supervises; skin inspection for pressure areas
3. Wearing schedule: gradual increase; typically worn during activity, removed for sleep (unless nighttime brace)
4. Skin care: inspect for pressure sores over bony prominences; wear cotton undergarment
5. Exercises: must accompany orthosis use; prevent muscle atrophy (core strengthening, postural exercises)
6. Weaning: gradual reduction in wearing time as symptoms improve; avoid sudden discontinuation
7. Reassessment: 4-6 weekly; X-ray to assess correction (scoliosis); functional reassessment (LBP)

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• Rockwood and Green's Fractures in Adults, 10th Ed 2025 (Cervical Orthoses, p.3144-3154)
• Miller's Review of Orthopaedics, 9th Ed (Bracing for Scoliosis)
• Bradley and Daroff's Neurology in Clinical Practice (Orthotists and Bracing)
• Lusardi MM, Jorge M, Nielsen CC - Orthotics and Prosthetics in Rehabilitation, 3rd Ed

• Weinstein SL et al. (BRAIST Trial, NEJM 2013): bracing significantly decreases progression to surgical threshold in adolescent idiopathic scoliosis (success rate 72% brace vs. 48% observation)
• NICE guidelines (2016): lumbar supports recommended short-term for acute LBP; not for prevention of LBP in healthy workers

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ANSWER 2: Knee Assessment for Prescription of Orthosis in Functional Valgus + Description of Orthosis (10 Marks - Winter 2022)

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PART A: KNEE ASSESSMENT FOR FUNCTIONAL VALGUS

Definition

• Medial compartment knee OA with varus malalignment (valgus-producing unloader brace)
• Medial collateral ligament (MCL) insufficiency causing valgus instability
• Dynamic valgus collapse causing patellofemoral pain syndrome (PFPS)
• Post-ACL reconstruction with valgus instability
• Genu valgum in children (corrective orthosis)

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Assessment Framework for Orthosis Prescription

• Pain location: medial/lateral/peripatellar/diffuse
• Mechanism: activity-related, landing from heights, cutting sports
• Duration, aggravating/relieving factors
• Functional limitations: stair climbing, squatting, running
• Previous orthoses, braces tried
• Outcome measures: KOOS (Knee injury and Osteoarthritis Outcome Score), WOMAC, NPRS

1. Tibiofemoral angle (Q angle of lower limb): measured in standing; >7° = pathological valgus
2. Q angle: ASIS to patella center to tibial tuberosity; normal 15-18° (females) / 10-15° (males); elevated in functional valgus/PFPS
3. Navicular drop test: assesses foot pronation (associated with functional valgus)
4. Genu valgum measure: intermalleolar distance when knees touching; >10 cm = significant valgus
5. Medial joint line gapping: X-ray weight-bearing AP view; Kellgren-Lawrence grading of OA; joint space narrowing pattern (medial = varus; lateral = valgus)
6. Mechanical axis: measured on long-leg standing radiograph (hip-knee-ankle); normal = passes through knee center; displaced medially = valgus

1. Valgus stress test (MCL):
   • Patient: supine, knee at 0° and 30° flexion
   • Apply valgus force; assess medial gapping
   • 0°: tests posteromedial capsule + MCL
   • 30°: isolated MCL test
   • Grading: Grade I (<5 mm), Grade II (5-10 mm), Grade III (>10 mm) medial gapping
2. Dial test: tibial external rotation at 30° and 90° to rule out posterolateral corner injury (associated with valgus instability)
3. Posterior/Anterior drawer, Lachman: assess cruciate integrity (functional valgus can occur with ACL laxity)

• Patient: single-leg squat to 60° knee flexion
• Observe: knee-over-toe angle, hip adduction, contralateral pelvic drop (Trendelenburg)
• Positive for functional valgus: ipsilateral knee collapses medially (IPEAK criteria: Ip/IP angle)
• Rating: Good/Moderate/Poor alignment (Ireland 2003)

• Patient: drop from 30 cm box, land on both feet, immediately jump vertically
• Record with 2D video from front: measure knee valgus angle at landing
• Positive: >10° valgus on landing = dynamic valgus (high ACL injury risk predictor - Hewett et al. 2005)
• Also observe: peak knee valgus moment (PKVm) - strongest predictor of ACL injury

• Both arms elevated, squat to parallel
• Identifies: knee caving (functional valgus), foot pronation, trunk lean

• Scores 0-3; score of 1 or asymmetry indicates movement dysfunction contributing to valgus

• Hip abductors (gluteus medius) - key driver of functional valgus; measured with HHD; deficit >15% side-to-side predicts valgus collapse
• Hip external rotators - weakness allows femoral internal rotation (increases valgus moment)
• Quadriceps: VMO:VL ratio by EMG or clinical assessment; VMO weakness associated with PFPS
• Foot intrinsics and plantarflexors: foot pronation control

• Patellar mobility: medial-lateral glide, tilt, rotation
• Clarke's test / Patellar grind test
• J-sign: patellar lateral maltracking with extension

• Assess for peripheral vascular disease (orthosis contraindicated in severe PVD)
• Skin integrity: edema, wounds, bony prominences

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PART B: ORTHOSES FOR FUNCTIONAL VALGUS

1. Valgus-Producing (Unloading) Knee Orthosis (for medial compartment OA with varus malalignment)

• Three-point pressure system: one pad on the medial femoral condyle + one on the lateral proximal tibia + one counter-force on lateral distal femur
• This creates a valgus moment at the knee
• Examples: OA Adjuster 3 (Össur), GII Unloader (Breg), Unloader One (Össur), DonJoy OA Adjuster
• Materials: lightweight carbon fiber frame, soft textile interface, condylar pads
• Dynamic hinge allows flexion-extension while maintaining valgus correction

• Alfatafta et al. (2021, BMC Musculoskelet Disord, PMID 34384421): Systematic review - valgus knee brace significantly reduces pain and improves activity in medial compartment knee OA at 3-month and 6-month intervals
• Hall M et al. (2022, PMID 35657960): RCT - valgus brace reduces medial tibiofemoral joint contact force in varus-malaligned knees
• Stam M et al. (2025, Acta Orthop, PMID 39832288): RCT - unloader brace comparable to high tibial osteotomy in younger patients with medial knee OA at 2-year follow-up

2. MCL Support Orthosis (for valgus instability from MCL injury)

• Hinged knee brace with medial buttress
• Dual-axis polycentric hinge; adjustable range of motion stop
• Medial upright reinforced; lateral pad provides valgus counter-force
• Examples: DonJoy Armor Fource Point, Bledsoe Axiom, Townsend Rebel
• Custom vs. off-the-shelf (custom preferred for Grade III MCL)

3. Patellofemoral Orthosis (for dynamic valgus causing PFPS)

• Patellar sleeve/strap: neoprene sleeve with patellar cutout + medial patellar pad; recenters patella; reduces peripatellar pain by 40% (Powers et al.)
• Counterforce strap (Cho-Pat): infrapatellar strap; reduces patellar tendon tension
• McConnell taping (not an orthosis but functional equivalent): medial glide + tilt correction of patella; provides proprioceptive input; used during rehabilitation exercises

4. Foot Orthosis for Functional Valgus

• Medial arch support / anti-pronation orthosis: corrects subtalar pronation which drives tibial internal rotation and functional knee valgus
• Custom semi-rigid insole with medial wedge (pronation correction)
• Evidence: Eng & Pierrynowski (1993) - foot orthoses reduce frontal plane knee kinematics in PFPS

5. KAFO (Knee-Ankle-Foot Orthosis) for Fixed Genu Valgum

• For structural valgum in children (ages 2-3 years with progressive deformity)
• Controls tibiofemoral alignment, prevents further valgus progression
• Campbell's Operative Orthopaedics (15th Ed): "observation or bracing with a knee-ankle-foot orthosis may be indicated for children between ages 2 and 3 years, but progressive deformity in children older than 3 years warrants surgical intervention"

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• Miller's Review of Orthopaedics, 9th Ed (Orthosis table; KAFO)
• Campbell's Operative Orthopaedics, 15th Ed 2026 (KAFO for valgus)
• Bradley and Daroff's Neurology in Clinical Practice (Orthotists and Bracing)
• Lusardi MM - Orthotics and Prosthetics in Rehabilitation, 3rd Ed

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ANSWER 3: Spinal Orthosis for Lumbar Spine (10 Marks - Summer 2021)

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INTRODUCTION

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BIOMECHANICAL EFFECTS OF LUMBAR ORTHOSES

1. Restriction of motion: flexion (primary), extension (secondary), lateral bending; rotation least controlled
2. Increase intra-abdominal pressure (IAP): compresses abdominal wall, transforming trunk into a rigid cylinder; unloads lumbar disc and facet joints by up to 30-40%
3. Reduction of paraspinal muscle activity: EMG studies show reduction in erector spinae activity with rigid braces (mechanism: reduction of load-bearing demand)
4. Thermal effect: warmth from brace material increases local circulation, reduces muscle spasm
5. Proprioceptive facilitation: sensorimotor feedback from brace to trunk; helps normalize motor control

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CLASSIFICATION AND TYPES OF LUMBAR ORTHOSES

A. Flexible Lumbar Orthoses (Corsets / Support Belts)

• Fabric (canvas/elastic) with posterior steel stays
• Extends from lower thorax to sacrum
• Controls flexion and lateral bending (not rotation)
• Indications: non-specific chronic LBP, discogenic pain, muscle strain, post-partum low back pain, occupational use
• Limitations: minimal immobilization; provides support and proprioceptive feedback mainly

• Narrow belt worn over iliac crests and greater trochanters
• Compresses SIJ, reduces anterior pelvic rotation and pubic symphysis gap
• Indications: SIJ dysfunction, peripartum pelvic girdle pain, pubic symphysis instability
• Evidence: Wu et al. (2008) - SIJ belt significantly reduces posterior pelvic pain provocation test pain in pregnancy

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B. Semi-rigid Lumbar Orthoses

• Two rigid posterior uprights + two lateral uprights + abdominal apron
• Controls flexion and extension in mid-lumbar region
• Indications: lumbar disc herniation, lumbar instability, acute LBP with nerve root involvement
• Contact points: posterior uprights on paraspinals; lateral uprights on iliac crests; abdominal apron increases IAP

• Restricts lumbar extension, allows flexion
• Lateral uprights connected posteriorly but open anteriorly
• Indications: lumbar stenosis (extension-aggravated); facetogenic LBP; spondylolysis (restricts extension which opens pars defect)

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C. Rigid Lumbar Orthoses (TLSO)

• Custom-molded thermoplastic shell
• Maximum lumbar immobilization
• Indications: unstable lumbar fractures (conservative management), post-fusion surgery, spondylolisthesis Grade II+

• Three-point system: sternal pad + pubic pad (anterior) + posterior lumbar pad
• Restricts flexion, allows extension (hyperextension device)
• Indications: stable thoracolumbar compression fractures (anterior wedge fractures); NOT for burst fractures
• Contraindications: posterior element fractures, instability, burst fractures

• Single cross-shaped anterior component with sternal and pubic pads
• Similar function to Jewett but less comfortable; better for lighter patients
• Indications: same as Jewett brace

• Two posterior paraspinal uprights + interscapular strap + axillary slings + abdominal support
• Controls thoracic and lumbar flexion
• Indications: thoracolumbar junction fractures, thoracic kyphosis

• Combines Knight LSO + Taylor TLSO features
• Controls all planes including partial rotation
• Indications: unstable thoracolumbar fractures, post-surgical, polytrauma

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INDICATIONS SUMMARY TABLE

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CONTRAINDICATIONS AND COMPLICATIONS

• Skin conditions, pressure ulcers over contact areas
• Severe respiratory compromise (abdominal compression raises diaphragm)
• Suspected cauda equina syndrome (requires urgent surgery, not conservative bracing)
• Osteoporosis with vertebral fracture requiring surgical stabilization

• Paraspinal muscle atrophy and weakness (dependency)
• Skin pressure sores at bony prominences
• Reduced respiratory function (rigid thoracic components)
• Psychological dependency
• Sweating, skin maceration

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• Rockwood & Green's Fractures in Adults, 10th Ed 2025 (Orthoses section)
• Miller's Review of Orthopaedics, 9th Ed
• Lusardi MM, Orthotics and Prosthetics in Rehabilitation, 3rd Ed (Spinal Orthoses chapter)
• Norkin CC & Levangie PK, Joint Structure and Function, 5th Ed

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ANSWER 4: Principles of Spinal Orthoses (10 Marks - Summer 2021)

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INTRODUCTION

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PRINCIPLE 1: THREE-POINT PRESSURE SYSTEM

• One force (corrective force) is applied at the apex of the deformity or motion segment
• Two counter-forces (reaction forces) are applied on the opposite side at points above and below the corrective force
• This creates a bending moment that opposes the deformity or restricts motion

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PRINCIPLE 2: INTRA-ABDOMINAL PRESSURE (IAP) MECHANISM

• Abdominal compression by the orthosis converts the trunk into a closed hydraulic cylinder
• Increased IAP creates an upward hydraulic force on the diaphragm, resisting spinal compression
• IAP elevation can reduce lumbar disc compressive load by 20-30%
• This mechanism is responsible for the pain-relieving effect of lumbar corsets and supports

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PRINCIPLE 3: PASSIVE STIFFNESS / RESTRICTION OF MOTION

• Rigid spinal orthoses (TLSO, halo vest) provide passive mechanical resistance to motion at spinal segments
• The orthosis acts as an external mechanical interface reducing angular displacement at the motion segment
• Never completely eliminates motion: cervical collars limit 45-75% of motion depending on level; halo vests limit ~90%
• Restriction is greatest at mid-segment; least at terminal segments of the orthosis (end-level phenomenon)

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PRINCIPLE 4: DEFORMITY CORRECTION / ANTI-DEFORMITY FORCES

• Orthosis must exert a corrective force exceeding the deforming force at the apex
• For scoliosis: lateral pressure pads create a transverse corrective force in the frontal plane; derotation pads for the axial component; expansion zones opposite pressure pads allow the spine to move into the corrected position
• Effectiveness is proportional to curve flexibility (flexible curves respond better than rigid)
• For kyphosis: hyperextension orthosis prevents flexion, allowing posterior ligament healing while maintaining correction

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PRINCIPLE 5: IMMOBILIZATION FOR HEALING

• After spinal fracture or surgery, the orthosis maintains the spine in a corrected, stable position while osseous or ligamentous healing occurs
• Time to bony union: 6-12 weeks (fracture); 12-24 weeks (spinal fusion)
• The orthosis supplements internal fixation, not replaces it
• Rigid orthoses allow early mobilization without compromising healing

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PRINCIPLE 6: PROPRIOCEPTION AND NEUROMUSCULAR CONTROL

• Cutaneous mechanoreceptors (Ruffini, Meissner, Pacinian corpuscles) in the skin under the orthosis are stimulated, providing proprioceptive feedback to the CNS
• Improves postural awareness and motor patterns (postural control hypothesis)
• Reduces fear-avoidance and kinesiophobia
• This is the primary mechanism of soft collars and corsets (not mechanical restriction)

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PRINCIPLE 7: UNLOADING / FORCE REDISTRIBUTION

• Spinal orthoses can redirect forces from injured structures to uninjured ones
• Example: Jewett brace transfers load from anterior vertebral body (fractured) to posterior elements via hyperextension positioning
• Unloader braces redistribute joint contact forces from one compartment to another
• Traction-orthosis (cervical traction collar) can distract facet joints, relieving compression

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PRINCIPLE 8: THERMAL EFFECT

• Many orthoses (especially soft corsets, neoprene supports) retain body heat at the spine
• Heat increases local blood flow, reduces muscle spasm, increases tissue extensibility
• Minor contribution; primarily enhances patient comfort and pain reduction

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PRINCIPLES OF PRESCRIPTION (Biomechanical Rules)

1. Define the goal first: immobilization vs. correction vs. support vs. proprioception
2. Identify the segment to be controlled: determines orthosis level (CO, LSO, TLSO etc.)
3. Select the appropriate rigidity: deformity correction and fracture management require rigid; pain management may use flexible
4. Apply three-point pressure correctly: pad placement is critical; improper placement = ineffective orthosis
5. Minimize skin pressure: pressure relief cutouts over bony prominences; padded interfaces
6. Combine with exercise: orthosis alone causes muscle atrophy; must be paired with active strengthening
7. Monitor and reassess: 4-6 weekly clinical and radiological assessment

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• Rockwood & Green's Fractures in Adults, 10th Ed 2025 (TPP - cervical orthoses)
• Lusardi MM, Orthotics and Prosthetics in Rehabilitation, 3rd Ed
• Miller's Review of Orthopaedics, 9th Ed
• Perry J, Burnfield JM - Gait Analysis: Normal and Pathological Function

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ANSWER 5: Hand Splints (10 Marks - Summer 2017)

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INTRODUCTION

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TERMINOLOGY (ISO 8549 / ASHT Splint Classification System)

• Static splint: holds joint in a fixed position; no moveable parts; used for rest, immobilization
• Dynamic splint: has moveable components (springs, rubber bands, elastic); applies low-load prolonged stretch to improve ROM; for contractures, tendon repairs
• Static progressive splint: incrementally adjusted static position to gain ROM; uses inelastic components
• Serial casting / serial static splinting: progressively corrected positions of casting/splinting

• Wrist orthosis (WO)
• Wrist-hand orthosis (WHO)
• Wrist-hand-finger orthosis (WHFO)
• Finger orthosis (FO)

• Volar (palmar) - supports palmar surface, most common
• Dorsal - pressure-sensitive palmar conditions
• Circumferential - maximum support

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CLASSIFICATION AND DESCRIPTION OF HAND SPLINTS

A. WRIST SPLINTS

• Positions wrist at 10-30° extension (functional position)
• Covers palmar surface from distal forearm to metacarpal heads
• Indications: carpal tunnel syndrome (nocturnal use), wrist sprains, Colles fracture (post-cast), de Quervain's tenosynovitis, wrist tendinitis, radial nerve palsy
• Materials: thermoplastic (Orfit, Aquaplast), prefabricated neoprene
• Evidence for CTS: wrist splinting in 20° extension reduces carpal tunnel pressure (Gelberman); nocturnal splinting reduces night symptoms (Cochrane review 2012)

• Dynamic splint utilizing tenodesis effect; wrist flexion = finger extension; wrist extension = finger flexion
• Indications: C6 tetraplegia (no active hand/finger movement); allows functional grasp using wrist extensor strength

• Positions thumb in palmar abduction and opposition; includes wrist
• Indications: median nerve palsy (low or high), de Quervain's tenosynovitis

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B. THUMB SPLINTS

• Immobilizes CMC and MCP of thumb; wrist free
• Indications: Bennett's fracture (post-reduction), scaphoid fracture, thumb UCL injury (Gamekeeper's/Skier's thumb), CMC joint OA (basal thumb arthritis), de Quervain's
• Design: volar-based thermoplastic extending from thenar eminence to thumb tip

• Immobilizes only the interphalangeal joint of thumb
• Indications: mallet thumb, IP joint sprain, flexor/extensor tendon injuries at IP level

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C. FINGER SPLINTS

• Holds DIP joint in 0-5° hyperextension (full extension)
• Indications: Mallet finger deformity (Zone I extensor tendon rupture/avulsion)
• Protocol: worn continuously for 6-8 weeks; then night use for 4-6 weeks
• Critical: DIP must never be allowed to flex during the initial treatment period - risks re-rupture

• Holds PIP joint in extension using dynamic force (spring coil)
• Indications: PIP flexion contracture, Boutonnière deformity rehabilitation, post-surgical PIP joint
• Mechanism: applies low-load prolonged stretch (LLPS) to contracted palmar capsule/volar plate; promotes tissue remodeling (creep and stress relaxation)

• Static; positions PIP in full extension or slight hyperextension
• Indications: Swan neck deformity correction, pseudo-boutonnière, PIP sprain, middle phalanx fracture

• Not a formal splint; adjacent finger provides dynamic support
• Indications: PIP/DIP sprain (grades I-II), phalangeal fractures (stable, non-displaced)

• Silver or aluminum ring at PIP joint; controls hyperextension while allowing full flexion
• Indications: Rheumatoid arthritis swan neck deformity, hypermobility syndrome
• Prevents hyperextension at PIP joint while preserving functional flexion

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D. WRIST-HAND ORTHOSES (RESTING HAND SPLINTS)

• Positions hand in: wrist 20-30° extension, MCPs 40-60° flexion, IPs 0-10° flexion, thumb in palmar abduction (cone position)
• Covers entire palmar surface from forearm to fingertips
• Indications: rheumatoid arthritis (reduces pain and deformity overnight), spasticity (stroke, CP, TBI - anti-spasticity), burns prevention of contractures, Dupuytren's post-fasciectomy, acute flexor tendon repair
• Materials: thermoplastic low-temperature (Orfit Classic, Aquaplast T)

• Applied dorsally to avoid stimulating palmar spasticity receptors
• Indications: upper limb spasticity (stroke, brain injury, CP)
• Positions: wrist extension, fingers extended, thumb abducted

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E. DYNAMIC SPLINTS

• Post-Zone II flexor tendon repair; dorsal blocking splint with rubber band traction
• Kleinert: wrist 20-30° flexion + MCP 60-70° flexion + rubber band assists finger flexion; patient actively extends fingers to the dorsal hood block
• Duran modified: passive flexion exercise protocol within splint
• Indications: Zone II flexor tendon repair (no man's land) - allows tendon gliding while protecting repair from rupture (4-kg load threshold for zone II repairs)
• Used for 3-4 weeks post-repair

• Wrist extended; MCP extension via outrigger + rubber band slings; IPs free
• Indications: extensor tendon repair (Zones IV-VII); allows active MCP flexion, passive MCP extension

• Dynamic: outrigger directs force perpendicular to proximal phalanx; rubber band or spring provides traction
• Indications: MCP flexion contractures, post-arthroplasty, scarring from burns
• Low-profile: less bulky, better compliance; mechanics requires adjustment as ROM changes

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PRINCIPLES OF HAND SPLINTING

1. Position of safe immobilization (POSI / Edinburgh Position):
   • Wrist: 20-30° extension
   • MCPs: 70-90° flexion (collateral ligaments in maximum tension - prevent shortening)
   • PIPs/DIPs: full extension
   • Thumb: palmar abduction
   • Use for: acute injuries, burns, post-surgery, edema to prevent contracture
2. Functional position: wrist 20-30° ext; MCPs 40-60° flex; IPs 0-10° flex; used for resting splints in RA and neurological conditions
3. Low-load prolonged stretch (LLPS): dynamic splints exert forces below the threshold for pain or circulation compromise (<300g); sustained over long periods (30 min to hours); achieves permanent tissue elongation via creep
4. Pressure distribution: wide, conforming contact distributes pressure; avoid bony prominences; minimum 2/3 circumference for rigid splints
5. Skin and vascular checks: monitor for blanching, pressure marks, numbness

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• Gilanliogullari N & Soyer K (2024, Prosthet Orthot Int, PMID 38775748): Systematic review - dynamic wrist-hand splints in RA improve grip strength, reduce pain, improve functional performance
• Static wrist splints in CTS: superior to no treatment; equivalent to corticosteroid injection at 6 months (Cochrane 2012)

• Fess EE, Gettle KS, Philips CA - Hand and Upper Extremity Splinting: Principles and Methods, 3rd Ed
• Trombly CA - Occupational Therapy for Physical Dysfunction, 7th Ed
• Bradley and Daroff's Neurology in Clinical Practice (Orthotists and Bracing)
• Cooper C - Fundamentals of Hand Therapy

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ANSWER 6: Ankle Foot Orthosis (AFO) (10 Marks - Summer 2021)

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DEFINITION

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BIOMECHANICS OF THE NORMAL ANKLE DURING GAIT

• Initial contact: heel strike; ankle at neutral (0°)
• Loading response: controlled plantarflexion to ~15° (eccentric tibialis anterior)
• Midstance: ankle dorsiflexes to ~10° (tibia advances over foot)
• Terminal stance: heel rise; plantarflexion begins
• Pre-swing: push-off; max plantarflexion ~20°
• Swing phase: dorsiflexion (toe clearance); tibialis anterior concentric activity

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CLASSIFICATION OF AFOs

A. STATIC / RIGID AFOs

• Thin, flexible thermoplastic shell; no ankle joint; trimlines posterior to malleoli
• Allows slight plantarflexion during loading; mild spring-back dorsiflexion in swing
• Indications: mild-moderate foot drop (L4/L5 radiculopathy, mild hemiplegia, Charcot-Marie-Tooth disease, peroneal nerve palsy)
• Materials: polypropylene, 3-5 mm thickness; custom-molded to foot/ankle
• "A custom-made plastic ankle-foot orthosis is necessary to improve gait in the presence of severe foot drop" (Bradley & Daroff's Neurology)

• Rigid; trimlines anterior to malleoli; no ankle movement
• Maximum restriction of plantarflexion and dorsiflexion
• Indications: severe spasticity, severe foot drop with mediolateral instability, severe hemiplegia, flail ankle, severe neuropathic ankle instability
• Can be set at desired ankle angle: 0° (neutral), 5° DF (reduces knee hyperextension), 5° PF (aids knee extension in weak quadriceps)

• Rigid AFO with anterior tibial shell; positioned 5° plantarflexion
• Creates ground reaction force that extends the knee in midstance (floor reaction force)
• Indications: crouch gait (excessive knee flexion) in cerebral palsy, weakness of knee extensors, crouch gait from weak plantarflexors

• Hinged at ankle; allows free dorsiflexion; stops at neutral (blocks plantarflexion)
• Indications: hemiplegia with spastic equinus; genu recurvatum
• Advantage over solid AFO: allows tibial advancement in midstance (more physiological gait)

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B. DYNAMIC / ARTICULATED AFOs

• Metal or plastic ankle joint; free movement in sagittal plane
• Can add plantarflexion stop, dorsiflexion stop, or both
• Indications: hemiparesis with variable spasticity; polyneuropathy; post-polio

• Carbon fiber spring AFO (e.g., IDEO - Intrepid Dynamic Exoskeletal Orthosis)
• Energy return device: stores energy at heel strike, releases at push-off
• Indications: active military personnel with ankle/foot injuries; traumatic nerve injury with foot drop + weak push-off

• Uses flexible polypropylene joint at the ankle; allows plantar/dorsiflexion with resistance
• Better cosmesis and gait biomechanics than solid AFO

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C. PATTERNED (TONE-REDUCING) AFOs

• Molded with toe extensions and medial longitudinal arch support
• Designed to inhibit spasticity through specific foot positioning
• Indications: CP, stroke with significant spasticity and equinovarus deformity

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D. SPECIALTY AFOs

• Transfers weight-bearing from foot to patellar tendon via proximal cuff
• Reduces loading on foot/ankle (calcaneal fractures, Charcot neuroarthropathy)

• Circumferential boot with rocker bottom sole
• Indications: stress fractures, acute ankle sprains, Achilles tendon rupture (conservative management with progressive dorsiflexion), plantar fasciitis

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INDICATIONS FOR AFO PRESCRIPTION

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PHYSIOTHERAPY ROLE IN AFO MANAGEMENT

• Gait analysis: identify deviations AFO aims to correct (foot slap, toe drag, circumduction, hip hiking)
• Muscle strength: tibialis anterior, gastroc-soleus, peroneals
• Spasticity assessment: MAS, clonus, PROM
• Foot alignment: fixed vs. flexible equinovarus deformity

• "Indications for AFO include inadequate dorsiflexion for initial heel contact or toe clearance, excessive hip hiking during swing, mediolateral subtalar instability, tibial instability during stance, and uncontrolled foot placement from sensory loss"
• AFO set in slight PF → promotes knee extension (weak quad); AFO set in DF 5° → reduces knee hyperextension

• Pre-gait exercises: hip hike prevention, weight shift, balance
• Ambulation training: level surfaces → inclines → stairs → community surfaces
• Energy expenditure monitoring: pathological gait is more energy-intensive than AFO-assisted gait

• Choo YJ & Chang MC (2021, Sci Rep, PMID 34354172): Meta-analysis - AFO in stroke patients significantly improves walking speed (SMD 0.50), stride length, and cadence
• Wada Y et al. (2022, PM&R, PMID 34369101): Meta-analysis - AFO improves ankle kinematics (reduces equinus, improves dorsiflexion angle) in stroke patients

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• Bradley and Daroff's Neurology in Clinical Practice (Orthotists and Bracing, AFO section)
• Campbell's Operative Orthopaedics, 15th Ed 2026 (AFO table)
• Lusardi MM, Orthotics and Prosthetics in Rehabilitation, 3rd Ed
• Perry J & Burnfield JM - Gait Analysis

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ANSWER 7: Principle of Three-Point Pressure and Its Application in Orthosis (10 Marks - Winter 2020)

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INTRODUCTION

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BASIC PHYSICS OF THREE-POINT PRESSURE

• Bending moment (M) = Force × Perpendicular distance from force to fulcrum
• For correction: M_corrective must equal or exceed M_deforming
• To achieve sufficient corrective moment with less force: increase the distance between reaction force contact points (lever arm) - this allows correction with lower, tissue-safe pressures

• F1: Corrective force - applied at the apex of deformity (greatest single force)
• F2 and F3: Reaction forces - applied on the opposite side above and below F1; each = F1/2 (when symmetrically placed)
• Total equilibrium: F1 = F2 + F3

• Capillary closing pressure (Husain, 1953): ~32 mmHg (~4.3 kPa)
• Forces exceeding this over small areas cause pressure necrosis/ischemia
• Orthosis design: distribute forces over large surface areas to keep interface pressure below 32 mmHg
• Formula: Pressure = Force / Contact Area → Larger area = less pressure per unit

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APPLICATIONS IN ORTHOSES

1. Cervical Orthoses

• F1 (corrective): Posterior cervical pad (restricts extension / supports flexion deformity)
• F2: Anterior mandibular support (above)
• F3: Anterior sternal/clavicular pad (below)

• F1 = anterior chin/occipital pad; F2+F3 = posterior neck pad (mid) + posterior thoracic pad

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2. Thoracolumbar Hyperextension Orthosis (Jewett Brace)

• F1 (corrective): Posterior lumbar pad at fracture level - pushes spine anteriorly (into extension)
• F2: Anterior sternal pad (upper)
• F3: Anterior pubic symphysis pad (lower)

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3. Scoliosis Bracing (Boston TLSO / Chêneau Brace)

• F1 (corrective): Lateral pad at the apex of the convex curve (e.g., right thoracic pad for right thoracic scoliosis)
• F2: Lateral counter-pad on the concave side above the apex (left shoulder region)
• F3: Lateral counter-pad on the concave side below the apex (left pelvis/iliac crest)

• Adds rotational correction via derotation pads
• Expansion zones opposite pressure pads allow active 3D correction (pneumatic-effect)
• This is the basis of principle of 3D brace correction: transverse force (3-point) + sagittal correction + derotation

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4. Milwaukee Brace (CTLSO) for Thoracic Scoliosis

• F1: Lateral thoracic pad at apex (thoracic)
• F2: Lumbar pad (opposite side, below)
• F3: Cervical ring (neck hold, above) - unique feature of Milwaukee brace
• Axillary slings provide additional corrective forces
• Correction also relies on the patient actively "growing away" from the pads (active correction principle)

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5. Lumbosacral Orthosis for Spinal Fractures

• F1: Anterior abdominal pad (pushes lumbar spine into extension, corrects kyphosis)
• F2: Posterior upper thoracic pad
• F3: Posterior sacral pad

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6. Knee Orthosis (Valgus Unloader Brace for Medial OA)

• F1: Lateral femoral condyle pad (pushes knee medially from lateral side)
• F2: Medial proximal tibial pad (pushes up-and-in from below the joint)
• F3: Lateral distal femoral counter-pad (proximal reaction force)
• Net effect: valgus moment at knee → shifts load from medial compartment (OA) to lateral compartment

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7. Wrist Drop Orthosis (Radial Nerve Palsy)

• F1: Dorsal wrist extension pad (holds wrist in extension)
• F2: Palmar distal forearm pad
• F3: Palmar mid-palm pad
• Maintains wrist in functional extension in radial nerve palsy (wrist drop deformity)

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8. Mallet Finger Splint (DIP Extension)

• F1: Dorsal DIP joint pad (pushes DIP into extension)
• F2: Palmar fingertip pad
• F3: Dorsal proximal phalanx pad
• Net effect: DIP maintained in full extension → allows Zone I extensor tendon healing

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DESIGN CONSIDERATIONS FOR EFFICIENT THREE-POINT PRESSURE

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LIMITATIONS OF THE THREE-POINT PRESSURE PRINCIPLE

1. Soft tissue compliance: forces transmitted to bone reduced by compressible soft tissue (subcutaneous fat, muscle)
2. Forces cannot be applied directly to bone (unlike internal fixation)
3. All orthoses reduce motion, not eliminate it (end-level motion, soft tissue creep)
4. Skin pressure tolerance limits maximum corrective force
5. Obese patients: force transmission significantly reduced

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• Rockwood & Green's Fractures in Adults, 10th Ed 2025 (Three-point pressure, Cervical and Spinal Orthoses)
• Lusardi MM, Orthotics and Prosthetics in Rehabilitation, 3rd Ed
• Seymour R - Prosthetics and Orthotics: Lower Limb and Spinal
• Miller's Review of Orthopaedics, 9th Ed

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ANSWER 8: Splints Used for Hand Disorders (10 Marks - Summer 2019)

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CLASSIFICATION BY CLINICAL DISORDER

I. RHEUMATOID ARTHRITIS (RA)

1. Resting Pan Splint (night splint): positions hand in functional position; reduces pain and morning stiffness; prevents contracture progression; worn nocturnally
2. Working wrist splint: stabilizes wrist in 10-15° extension during daily activities; reduces pain, increases grip function
3. Ulnar Deviation Splint: positions MCPs in neutral, prevents further ulnar drift; custom-made for each finger or whole hand
4. Swan Neck Ring Splint (Silver Ring Splint): at PIP level; prevents PIP hyperextension while allowing full flexion; used during activities
5. Boutonnière Splint: static: PIP in extension; serial splinting to reduce PIP flexion contracture; dynamic extension splint (Capener)
6. Thumb CMC Stabilizer: for CMC-I OA in RA; short opponens splint

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II. MEDIAN NERVE PALSY

1. Opponens Splint (Short Opponens / Thumb Spica): maintains thumb in palmar abduction and opposition; allows pinch; worn full-time or during activities
2. Long Opponens Splint: includes wrist support; for high median nerve palsy (elbow + hand)
3. Lumbrical Bar: for claw hand of index and middle fingers (prevents hyperextension of MCPs, enables IPs to extend)

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III. ULNAR NERVE PALSY

1. Lumbrical Bar / Anti-Claw Splint: volar metacarpal bar blocking MCP hyperextension; allows IP extension
2. Knuckle Bender: dynamic MCP flexion splint
3. Opponens bar: if combined median-ulnar palsy

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IV. RADIAL NERVE PALSY (WRIST DROP)

1. Wrist Cock-Up Splint: positions wrist in 20-30° extension; frees intrinsics and flexors for functional pinch/grasp
2. Dynamic Tenodesis Splint: uses tenodesis effect; wrist extension activates passive finger flexion; wrist flexion allows finger release
3. Dynamic MCP Extension Splint with outrigger: rubber bands provide passive MCP extension; patient uses flexors actively; allows functional grasp

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V. CARPAL TUNNEL SYNDROME (CTS)

1. Neutral Wrist Splint (0° or 10-15° extension): worn nocturnally; reduces carpal tunnel pressure; first-line conservative treatment
   • Note: historically wrist extension splints (15-20°) used; evidence now favors neutral (0°) position for minimum CTS pressure (Werner et al.)
2. Activity splint: worn during provocative activities (computer use, driving)

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VI. DE QUERVAIN'S TENOSYNOVITIS

1. Thumb Spica Splint: immobilizes first compartment (APL + EPB tendons); extends from thumb IP to forearm; reduces friction at the first extensor compartment
2. Short Opponens Splint: thumb in abduction + extension; thumb CMC/MCP immobilized; wrist free

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VII. TRIGGER FINGER (STENOSING TENOSYNOVITIS)

1. MCP Blocking Splint: holds MCP in 10-15° flexion; prevents triggering (which occurs at full MCP extension); worn full-time for 6 weeks
2. DIP Splint: for triggering localized to DIP flexion

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VIII. DUPUYTREN'S DISEASE (Post-Fasciectomy)

1. Extension Gutter Splint: holds MCP and PIP in full extension; post-operative; worn nocturnally for 3-6 months
2. Dynamic Extension Splint: low-load prolonged stretch for residual contracture
3. Serial Static Splinting: weekly or bi-weekly re-molding to progressively gain extension

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IX. BURNS (HAND AND WRIST)

1. Position of Safe Immobilization (POSI) Splint: wrist 20-30° extension; MCP 70-90° flexion; PIPs/DIPs full extension; thumb abducted; prevents contracture of collateral ligaments and palmar fascia

1. Dynamic Outrigger Splints: restore ROM to scarred/contracted joints
2. Pressure garments + conformer splints: reduce hypertrophic scarring

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X. FLEXOR/EXTENSOR TENDON REPAIRS

1. Kleinert Dorsal Blocking Splint: wrist 20-30° flex + MCP 60-70° flex + rubber band traction for finger flexion; patient actively extends to dorsal hood; allows controlled early motion (3-4 weeks)

• Zone I (mallet finger): Stack/mallet splint - DIP in 0-5° hyperextension × 6-8 weeks
• Zone IV-VII: Dynamic MCP extension splint; wrist 40° extension + MCP extension via outrigger

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• Fess EE et al., Hand and Upper Extremity Splinting, 3rd Ed (Elsevier)
• Cooper C, Fundamentals of Hand Therapy, 2nd Ed
• Trombly CA, Occupational Therapy for Physical Dysfunction
• Weiss S, Falkenstein N - Hand Rehabilitation, 2nd Ed

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ANSWER 9: Spinal Orthosis (10 Marks - Summer 2017)

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DEFINITION

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GENERAL PRINCIPLES (Brief)

1. Three-point pressure mechanism for deformity correction and motion restriction
2. IAP mechanism for lumbar unloading
3. Passive restriction + proprioceptive facilitation
4. Must be combined with exercise to prevent muscle atrophy

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CLASSIFICATION BY REGION

I. Cervical Orthoses (CO)

II. Cervicothoracic Orthoses (CTO)

• SOMI brace: occipital, mandibular, sternal supports; controls C3-C7 better than collar alone; used post-ACDF
• Minerva brace: 79-87% restriction of sagittal motion; viable alternative to halo in compliant patients; no skin pin complications
• Yale brace: CTO with thoracic shell extension

III. Thoracolumbosacral Orthoses (TLSO)

IV. Lumbosacral Orthoses (LSO)

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PHYSIOTHERAPY ROLE IN SPINAL ORTHOSIS MANAGEMENT

1. Assessment: confirm orthosis indication; identify red flags; body measurements
2. Prescription: collaborate with orthotist; specify motion to restrict, correction needed
3. Patient education: wearing schedule, skin care, hygiene
4. Fitting and adjustment: verify proper fit; test for skin pressure marks
5. Exercise prescription: trunk stabilization, postural re-education, breathing exercises (if thoracic brace)
6. Monitoring: serial radiographs (scoliosis: Cobb angle every 4-6 months); functional outcomes (ODI, NPRS for LBP)
7. Weaning: gradual reduction in wearing hours as condition resolves; abrupt discontinuation contraindicated

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COMPLICATIONS OF SPINAL ORTHOSES

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• Rockwood & Green's Fractures in Adults, 10th Ed 2025 (Cervical and Thoracolumbar Orthoses)
• Miller's Review of Orthopaedics, 9th Ed (Bracing for Scoliosis)
• Bradley and Daroff's Neurology in Clinical Practice (Orthotists and Bracing, AFO + KAFO)
• Lusardi MM, Orthotics and Prosthetics in Rehabilitation, 3rd Ed
• Campbell's Operative Orthopaedics, 15th Ed 2026

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MASTER QUICK-REFERENCE TABLE