Rehabilitation medicine curriculum standards (adult)
Knowledge guides
LG 22: Orthotics and footwear
Associated knowledge guides
KG3 – Neurological conditions KG4 – Spinal cord dysfunction KG6 – Musculoskeletal conditions KG8 – Adults with disabilities arising in childhood KG10 – Rehabilitation of other specific conditions
Key presentations and conditions
Advanced Trainees will have a comprehensive depth of knowledge of these presentations and conditions.
Less common or more complex presentations and conditions
Advanced Trainees will understand these presentations and conditions.
Advanced Trainees will understand the resources that should be used to help manage patients with these presentations and conditions.
Epidemiology, pathophysiology, and clinical sciences
Advanced Trainees will describe the principles of the foundational sciences.
Investigations, procedures, and clinical assessment tools
Advanced Trainees will know the indications for and how to interpret the results of these investigations, procedures, and clinical assessments tools.
Advanced Trainees will know how to explain the investigation, procedure, or clinical assessment tool to patients, families, and carers.
Important specific issues
Advanced Trainees will identify important specialty-specific issues and the impact of these on diagnosis and management.
Presentations
- Foot orthoses
- Footwear
- Neurologincal lower limb orthoses
- Orthoses for burns care
- Orthoses for knee dysfunction
- Orthoses for spinal dysfunction
- Orthoses in the management of hand dysfunction
For each presentation and condition, Advanced Trainees will know how to:
Synthesise
- recognise the clinical presentation
- identify relevant epidemiology, prevalence, pathophysiology, and clinical science
- take a comprehensive clinical history
- conduct an appropriate examination
- establish a differential diagnosis
- plan and arrange appropriate investigations
- consider the impact of illness and disease on patients and their quality of life when developing a management plan
Manage
- provide evidence-based management
- prescribe therapies tailored to patients' needs and conditions
- recognise potential complications of disease and its management, and initiate preventative strategies
- involve multidisciplinary teams
Consider other factors
- identify individual and social factors and the impact of these on diagnosis and management
Conditions
- Charcot neuroarthropathy
- High risk feet
For each presentation and condition, Advanced Trainees will know how to:
Synthesise
- recognise the clinical presentation
- identify relevant epidemiology, prevalence, pathophysiology, and clinical science
- take a comprehensive clinical history
- conduct an appropriate examination
- establish a differential diagnosis
- plan and arrange appropriate investigations
- consider the impact of illness and disease on patients and their quality of life when developing a management plan
Manage
- provide evidence-based management
- prescribe therapies tailored to patients' needs and conditions
- recognise potential complications of disease and its management, and initiate preventative strategies
- involve multidisciplinary teams
Consider other factors
- identify individual and social factors and the impact of these on diagnosis and management
- Biomechanical principles of joint motion control
- Biomechanics and phases of the gait cycle (to assist in differentiating normal from pathological patterns)
- Components of appropriate footwear
- Functional anatomy
- Identification of musculoskeletal and neuromuscular pathology, including contracture, joint deformity, joint instability, muscle weakness, and spasticity
- Normal limb and vertebral anatomy and neurophysiology
- Three rockers in stance phase
- Vertebral fracture classifications and relevant orthotic range of motion restriction requirements
Joint assessment
- Use of goniometer for lower and upper limb joint assessments
Lower limb
- Clinical gait assessment
- Footwear examination
- Role of gait laboratory assessments referral
- Targeted physical examination including:
- lower limb vascular examination
- musculoskeletal joint examinations
- neurological limb examination
- Understanding of gait analysis reports for the management of patients
- Wound (pressure area) assessment
Upper limb
- Musculoskeletal joint examinations
- Neurological limb examination
General principles
General principles
- Awareness of causes for poor compliance
- Awareness of footwear modification options to accommodate foot deformity/problems
- Awareness of orthotic use complications
- Indications and contraindications
- Multidisciplinary approach, especially working with occupational therapists, orthotists, podiatrists, and physiotherapists
- Orthoses for individuals with burns, musculoskeletal dysfunction, neurological impairments, and vertebral fractures
- Prescription of prefabricated versus custom-made orthoses
- Prescription of static versus dynamic orthoses
- Role of micro-processing orthoses, e.g. C-brace
- Role of robotic exoskeletal orthoses
- Utilisation of prefabricated, modified, or custom-made footwear
- Utilisation of various materials and components – semi-rigid, e.g. carbon fibre, ethylene vinyl acetates (EVA), joints, metal uprights, thermoplastic
- Wound healing, off-loading (including total contact casting), orthotic and footwear management in the high-risk foot
Biomechanical and functional advantages
Lower limbs
- Ankle-foot orthosis (AFO):
- alteration of knee biomechanics, e.g. GRAFO
- correct/prevent deformity
- improve efficiency of gait
- redistribution of weight bearing forces, e.g. PTB-AFO
- reduce need for compensation of ipsilateral and contralateral limbs and secondary pain
- stance phase stability
- swing phase clearance
- terminal swing foot prepositioning for stance
- Foot orthosis:
- anatomical support to prevent or correct deformity and reduce pain during weight bearing
- off-loading pressure relief
- Knee-ankle-foot orthosis (KAFO):
- facilitate swing phase clearance
- stability in stance
Spine
- Protect the spinal cord
- Stabilise spinal fractures reducing range of motion to facilitate healing
Types of orthotics
- Lower limb
- ankle-foot orthosis (AFO)
- foot orthosis
- hip-knee-ankle-foot-orthosis (HKAFO)
- knee-ankle-foot orthosis (KAFO)
- Prefabricated orthotics:
- single joint prefabricated orthoses (e.g. knee, ankle, wrist) for musculoskeletal conditions
- Spinal
- cervical orthosis
- cervicothoracic orthosis (CTO)
- lumbar orthosis
- thoracolumbar orthosis (TLO)
- thoracolumbosacral orthosis (TLSOs)
- Upper limb
- dynamic orthoses, including Lycra style, e.g. Second Skin
- elbow orthosis, e.g. dynamic for burns contractures
- finger/thumb orthoses
- shoulder orthosis, including for brachial plexus injuries
- spinal cord injury (SCI) orthoses (appropriate to level of injury) universal cuffs with functional attachments
- wrist-hand orthosis, e.g. resting orthoses and dynamic orthoses
Upper limbs
- Dynamic versus passive orthoses
- In the tetraplegic hand, consider positioning and functional orthoses at each cervical level of injury
- Maximising function in reach and grasp tasks
- Off-load an injured limb to allow healing
- Pain reduction
- Prevent or correct deformity
- Reduce need for compensation of ipsilateral and contralateral limbs and secondary pain
- Substitution of weak or absent muscle function