Curs de Recuperare în

Neurochirurgie

Principale dispozitive asistive de tip ortetic utilizate

in neurorecuperare – Prof. Dr. G. Onose
Curs de perfecționare: ”Noțiuni de bază și
actualități în NeuroRecuperare – adulți”

Cursul 21

Principale dispozitive asistive de tip ortetic utilizate

in neurorecuperare – Prof. Dr. G. Onose
Main orthotic devices, and their use, in
NeuroRehabilitation
- brief synthesis of basics, and practical examples -
Principale dispozitive asistive de tip ortetic utilizate in neurorecuperare

Prof.G.Onose,MD,PhD,MSc

The Teaching Emergency

Hospital ”Bagdasar-Arseni”
(TEHBA) Bucharest
 BACKGROUND. Introductory items
Correct/ recommended related denominations :
- orthotic device(s)
- orthosis(es)
The term(s) derive from the Greek word ”orthos”, that means to make
straight or to correct 1. In literature can be found terms of more specific
restricted coverage too, such as braces – structuri de fixare, stabiliza-
re/ (bandaje), that allow/favor – or splints (atele)/respectively, corsets
(which both, basically rather not allow) related articular movements.
Definition - elaborated by the International Standards Organization
(ISO) and adopted by the International Society for Prosthetics and
Orthotics (ISPO) 1 and also 2 by the American Academy of Orthotists
& Prosthetists (AAOP) and respectively, the American Orthotic &
Prosthetic Association (AOPA):
”any externally applied device used to modify structural and/or
functional characteristics of the neuromuscular skeletal system” 3
1 Patel AT, Graber LM Upper Limb orthotic Devices - in Braddom RL (ed.), et al. Physical Medicine & Rehabilitation (3rd
edition), WB Saunders Company, Philadelphia, USA, 2007
2 Popescu R, Trăistaru R Recuperarea membrului inferior ortezat și protezat. Ed. Med. Univ. Craiova, 2007
3 (cited by): Redford JB, Basmajian JV, Trautman P Orthotics: clinical practice and rehabilitation technology. New York: Churcill
Livingstone, 1995
 BACKGROUND. Introductory items

Accordingly, they have valuable and quite large (often

syncretic: for more than one single purpose)
applicability, including in NeuroRehabilitation.
Because of their related wide usefulness, orthotic
devices hold, aside the situations of many cases with a
more simple neural/muscle-skeletal pathology – a very
important intermediate/key (considering also for
continuity) systematic position within the dynamics of
the – mandatory – intricate/integrative: care and
rehabilitative endeavors, that characterize the complex
approach of patients with severe neurological – and
consequent neuro-myo-arthro-kinetic – impairments.
 BACKGROUND. Introductory items

In this latter respect, utilization of orthoses can be

framed both: within Rehabilitation Nursing (RN) –
which ”center on: life processes, well-being and/
or optimum functioning” 4 - and also,
Respectively, among effectively rehabilitative
programs (when – considering the general
evolution of the patient – they may become
possible 5)

4Hoeman SP – Rehabilitiation Nursing. Prevention, Intervention and Outcomes - Mosby Inc., an affiliate of Elsevier Inc., St. Louis,
2008
5Onose G – Rehabilitation nursing - integrative approaches - in post acute SCI patients - European Teaching Course on Neuro-
Rehabilitation, Cluj-Napoca/ Romania, 2011
 BACKGROUND. Introductory items
The indication, prescription and use/ management
of orthotic devices (including their interaction with
the needing patient and his/her case evolution - in or-
der to favorably influence the rehabilitation process)
is complex, entailing aisde solid professional skills
regarding biomechanics and clinical-functional asses-
sment - which is normal for a physician working in this
domain - and also reasonable interdisciplinary/related
technical knowledge; this is necessary for an appro-
priate collaboration, within the (neuro)rehabilitation
team between the physician and the orthotist ...
... BACKGROUND. Introductory items
An orthotist is a professional who has appropriate training
and specific skills related to building up and fit to the pati-
ent(s)s, of orthotic device(s), in collaboration and under the
guidance – regarding medical/rehabilitative goals setting
and clinical (consequent) evolution monitoring – of a
physician specialized in NeuroRehabilitation.
”Certified orthotist (e.g. ABC). In the USA, academic requirements
can be fulfilled by a baccalaureate degree in orthotics or a 4-year
science degree followed by a postbaccalaureate certificate program
in orthotics. A 1-year residency program is required after the acade-
mic program. Extensive training in the proper fit and fabrication of
orthoses is required. After the education and residency is completed,
a national examination for certification can be taken in the USA by the
American Board for Certification (ABC) in Prosthetics and Orthotics” 6
6 Moore DP, Tilley E, Sugg P - Spinal Orthoses in Rehabilitation - in Braddom RL (ed.), et al. Physical Medicine &
Rehabilitation (3rd edition). WB Saunders Company, Philadelphia, USA, 2007
 BACKGROUND. Introductory items
Detailed denominations for different specific orthotic devices
have been/are connected to some main determinants:
- anatomical region to which it is designated for
application
- morph-functional correction aim
- (eventual) pathological condition/therapeutic state
- (commonly, but more and more seldom) the inventor’s
proper name, institution or geographic region of
emergence, etc.
This, combined on one hand, with the complexity and - ine-
vitably - interdisciplinarity, and on the other, with the gene-
ral diversity (which is normal, considering the almost whole
external body surface where they can be applied), of ...
 BACKGROUND. Introductory items
... orthoses, resulted in difficulties towards a generally
accepted terminology (not yet completely achieved).
The term ”orthotics” (”ortetică” ? - nu e în dicționare) refers
to ”the field of study of orthoses and their management” 6 .
Hence, especially in the last about two decades, there
have been made endeavors - by the afore mentioned
professional dedicated organizations/associations 1,7 - to
unify/standardize the related naming.
Consequently, including at present, a very simple/general
and therefore, largely accepted classification and related
naming - that refers only to the approximate big anatomic/
topographic region of application - is the following
(including with the related abbreviations):
7 Cinteză D, Poenaru D Ortezarea în recuperarea medicală. Ed. Vox, București, 2004
Orthotic devices for the upper limb
Shoulder orthosis (SO) Spinal orthotic devices
Shoulder-elbow orthosis (SEO) Cervical orthosis (CO)
Shoulder-elbow-wrist-hand orthosis (SEWH) Cervical-thoracic orthosis (CTO)
Elbow orthosis (EO) Cervical-thoracic-lumbar-sacral orthosis (CTLSO)
Elbow-wrist-hand orthosis (EWHO) Thoracic orthosis (TO)
Wrist orthosis (WO) Thoracic-lumbar-sacral orthosis (TLSO)
Wrist-hand orthosis (WHO) Lumbar-sacral orthosis (LSO)
Hand orthosis (HO) Sacral orthosis (SO)
Finger orthosis (FO) Sacral-iliac orthosis (SIO)
Thumb orthosis (TO) Romanian formulations for the orthotic
devices’ prescription - examples:
Orthotic devices for the lower limb
”Orteze de încheietura mâinii-mână - a) fixă, b)
Hip orthoses (HO)
dinamică. ...mâinii-mână-deget - fixă/ mobilă.
Hip-knee-ankle-foot orthosis (HKAFO) Orteze de cot - cu atelă/ fără atelă”
Knee orthosis (KO) ”Orteze de genunchi - a) fixă, b) mobliă; c) Balant
Knee-ankle foot orthosis (KAFO) – termen de înlocuire 2 ani
Ankle-foot orthosis (AFO) ”Orteze cervicale - a) colar; b) Philadelphia/
Reciprocating gait orthosis (RGO)/ Minerva; c) Schanz – termen de înlocuire 12 luni”
Advanced RGO (ARGO) ...
Unitary System for orthotic devices naming - adapted by 7, after Gailey RS -
Orthotics in rehabilitaîion, in Technics in musculoskelesi rehabilitation. Prentice WE &
Voight ML., (eds.), McGraw-Hilf Companies, 2001
 BACKGROUND
To this rather largely accepted classification/naming
could be added a quite heterogeneous array of
assistive devices (that are difficult to be classified
within the afore exposed list, but being clinical/
functionally tight complementarily related to the
(neuro)-rehabilitative approaches) such as: the so-
called ”ambulation aids” 8 – a general feature, from
systematic point of view, of such devices, is their
impact level to be at the upper limbs/trunk,yet they
assist lower limbs to stand and walk:
...
8Hennessey WJ, Johnson EW Lower Limb Orthoses - in Braddom RL(ed.) et al. Physical Medicine & Rehabilitation (2nd edition). WB
Saunders Company, Philadelphia, USA, 2000
… BACKGROUND
- canes, crutches (including, especially
nowadays, different types of non-axillary crutches
and respectively, canes/crutches - four-/quad,
three or two-point gaits), walkers (the high/
wheeled ones, too) but also standing frames
(including parapodium devices in children)
and tilt tables or advanced wheelchairs (with
verticalization and/or ”balanced forearm
orthoses” attached to, with a swivel joint –
(articulație pivotantă/cu cârlig) – to enable ADLs
in wheelchair addicted but also with paralized
upper limb/s, patients 1) facilities
...
 Different ambulation aids - from left to right:
canes (”C” type -adjustable and non-adjustabble in length), with
functional grip, three-point, respectively quad - at the right extremity),
non-axillary (Lofstrand type) forearm crutch/orthosis, platform
forearm crutch/orthosis, axillary crutch, walker
(after 8 and 9)
9 Hennessey WJ Lower Limb Orthoses - in Braddom RL(ed.) et al. Physical Medicine & Rehabilitation (3rd edition).
WB Saunders Company, Philadelphia, USA, 2007
 High/ wheeled walker
(TEHBA - P(n-m)RM Clinic Division casuistry)
 Standing frame
(TEHBA - P(n-m)RM Clinic Division casuistry)
Parapodium - left to right: (non-occu-
pied by patient) in upright/ funtional po-
sition (with the artificial hip and knee
joints locked in extension), respectively
in position propensive to install in the
device the assisted child (with the artifi-
cial hip and knee joints unlocked, in fle-
xion); occupied by patient - after Variety
Ability Systems and respectively, Hugh
MacMillan Rehabilitation Center, (both)
inToronto, Canada - cited by 9 and 8
 Tilt table
(TEHBA - P(n-m)RM Clinic Division casuistry)
...
Newer and effective, due to
their (including) related facilities 10
(10 http://www.mobilitycare.net.au/mobility_products/lifestand-helium-
standing-wheelchair.html) - Brochure

- but more expensive - there

can be used, including for
the same aim, wheelchairs
provided with facilities
for verticalization ...
 … BACKGROUND
Additionally, at least for the upper limb orthotic
devices, by the contribution of the American
Society of Hand Therapists (ASHT), it resulted in
1992, in the achievement of the ASHT:
Splint Classification System (SCS).
This completes the afore exposed classification/na-
ming (that refers only to the anatomic/topographic re-
gion of application and adds, in this respect, characte-
ristics such as articular or non-articular), with infor-
mation related to function and furthermore, to immo-
bilization/ restriction of mobilization - including for
(indirect) controlled mobilization possibilities, too ...
1
 ... BACKGROUND
For articular orthotic devices, in the ASHTSCS/
naming, there are also specified the joints targeted
by a certain orthosis:
- primary (joint on which directly acts the device)
- secondary (within the orthosis, in proximity/ adja-
cent to the primary joint - meant to act for immobili-
zation counteracting control, stabilization and/or
positioning; these secondary articular entities are
numbered by the design: ”type”, followed by the figure
designating the number of secondary joints and res-
pectively, between brackets, the total (primary+secon-
dary) number of joints on which the orthosis acts ...
1
...

Table for upper limb orthotic devices - after 1, quoting:

* Surch CM, Pritham CH - International Standards Organizationterminologgy: application to prosthetics and orthotics. J. Prosthet
Orthot, 6(1):29-48, 1994
** McKee P, Morgan L - Orthotics in rehabilitation, splinting the hand and body. Philadelphia: FA Davis, 1998

...
 BACKGROUND
Brief historical and regarding materials, data
Orthotic devices - especially very simple ones, by their construction -
must probably have been used practically since immemorial times.
Some of the oldest related referents originate from the ancient
Egypt - almost 3.000 years BC 11 - and the Roman antiquity too -
mentioned, for instance, by Galen (the II-nd century BC) 6.
Regarding the ”raw” used to make such devices, this has evolved
over the (long) time, from animal bones and/or leather or wood, to
steel, aluminum, titanium, carbon fibers, synthetic fibers, plastics,
including thermoformable ones 2,6,7 and - more and more, at present -
different types of advanced materials and/or alloys, respectively -
able to support very complex assistive – including interactive/
rehabilitative tasks (see further).
Considering, additional to the definition presented in the beginning ...
11 Smith GE and Cantab MA (cited by Fisher SV and Winter RB - in: Spinal Orthoses in Rehabilitation), in Braddom RL(ed.), et al.
Physical Medicine & Rehabilitation (2nd edition). WB Saunders Company, Philadelphia, USA, 2000
 BACKGROUND
...
of this lecture, i.e. ”a device attached or applied to the
external surface of the body to improve function, restrict
or enforce motion, or suport a body segment” (Redford,

,herein below are some specifications about

Basmajian,Trautman, 1995 - cited by 8)

properties that orthotic devices – including related

materials used – need to bring together:
- A) of general kind, regarding overall properties of such
devices, and afferent endeavors to their achievement
and/or management (fitting to the specific medical/
rehabilitative goals, but to the patient’s own input and ex-
pectations, as well - if unworn, any orthosis is useless 12 -; ...
12 Patel AT, Graber LM, Redford JB Upper Limb orthotic Devices - in Braddom RL (ed.), et al. Physical Medicine &

Rehabilitation (2nd edition), WB Saunders Company, Philadelphia, USA, 2000

 BACKGROUND
…
this regards, on one hand, the balance between
prescription/ assistive benefits, including in terms of
autonomy and comfort – encompassing: facility to
be worn and/or to don/doff, adequate stockinet
interfacing between tegument and the inner side of
an orthosis for perspiration absorption, osseous
prominences’ padding, cosmesis with related
psychologic acceptance, in terms of self image/
esteem – and risks,
…
 BACKGROUND
…
mainly related to skin and subjacent soft tissues
possible harming – pressure and/or tear wounds
especially above/arround bony superficial
surfaces/edges and/or induced local/regional
edema, as tissue/circulatory disturbance, secon-
dary to an aggressive pressure and/or stretch,
with possibly neuro-vascular bundles’ excessive/
traumatizing, compression/elongation, that may
result also in associated redness or blueness of
the cutis)
…
… Segal NA1, Stockman TJ, Findlay CM, Kern AM, Ohashi K, Anderson DD – The effect of a
realigning brace on tibiofemoral contact stress.*
1University of Kansas, Kansas City, KS.
”Abstract
OBJECTIVE:
To determine the degree to which focally elevated tibio-femoral joint contact stress is
reduced by using a frontal plane realigning brace.
METHODS:
Fifteen volunteers (9 women) with unicompartmental tibiofemoral OA underwent weight-bearing
radiographic imaging at 15-20° and 5-10° of knee flexion with and without an UnloaderOne
knee brace. Discrete element analysis was used to estimate compartment-specific contact
stress distributions. Paired t-tests were used to assess the differences in mean contact stress
and contact stress distributions, comparing the braced and unbraced conditions.
RESULTS:
The mean±SD age was 56.1±6.4 years and BMI was 28.4±4.5kg/m2 . Twelve of 15 participants
were fit with braces set to unload the medial compartment. For the 15-20° condition, the mean
contact stress in the compartment of interest did not significantly change (+0.08±0.35 MPa;
p=0.410). Also at 5-10° flexion, the mean contact stress in the compartment of interest did not
significantly change with use of the brace (+0.24±0.45 MPa; p=0.175).
CONCLUSION:
This is the first study of the effects of a frontal plane realignment brace on in vivo articular
contact stress in native human knees. Using the off-the-shelf brace tested, there were no
changes in compartmental tibio-femoral contact stress distributions at either 15-20° or
5-10° of knee flexion, revealing no redistribution of contact stress away from the
compartment of interest. These findings indicate that the brace that was studied was
ineffective for redistributing tibio-femoral contact stress. Further research is necessary to
determine whether double-upright or customized frontal plane braces are effective in
redistributing compartmental articular contact stress. This article is protected by copyright. All
rights reserved. © 2015 American College of Rheumatology.”
*Arthritis Care Res (Hoboken) 2015 Mar 16. doi: 10.1002/acr.22578. [Epub ahead of print]
(http://www.ncbi.nlm.nih.gov/pubmed/25779857)
 BACKGROUND
- B) of more specialized kind – such as concerning some
principal materials’ (and/or of fabrication and respecti-
vely, of prescription) – characteristics.
To be mentioned, in this respect:
B.1. a. for materials 2,7: hardness (basically as bending res-
ponse to stress applied on it) and related resistance (as
maximal external loading or deformation force that can be
applied on it without bending), lastingness (especially to
repeated/daily use, in common wearing solicitations, on
medium/ long term), density - all classically, dependent on
thickness and weight - advances in this technology field
constantly aim to improve this antagonic paradigm, i.e. to
introduce in fabrication materials which are both, lighter
and more consistent), persistance to corrosion (pro-
duced by chemical/phyiscal - environmental: humidity ...
... BACKGROUND
temperature contrasts, dust - and/or of the bearer’s:
perspiration, sweat)
B.1.b. for fabrication (generally connected, on one hand,
to the toughness of materials used - less resistant mate-
rials can, in principle, be easier manufactured/ processed -
and on the other, to the tooling and technology available,
including with the respective orthotists’s professional skills);
to be specified they can be prefabricated or custom made.
Are worth some brief specifications regarding synthetic
materials 13,2,7, - that, considering different such types and res-
pectively qualities, are actually the most largely used:
- Velcro type straps - to be found in almost all interlocking/
holding in place, parts of orthoses
- plastics (high and low temperature thermoformable) ...
13 [Anonymous] North Coast Medical Company hand therapy catalog, 1998 (Prism Orthoplast, Velcro, and Orift are trademarks of the
North Coast Medical Company - cited by 1,12
... BACKGROUND
The formers, also referred to as ”thermoresistant/plasti-
ficable by heating” (over 150-160°C - and pressure 2,7 (for
which’s molding can be used heat guns 1,12), frequently con-
sist in polyestheric or epoxy resins, polyurethanic foam,
acrylonitril-butadin-styren (ABS), vinil-copolymers,
poly-propilene, etc.;
physically and chemically resistant - including rigid/ stout
(indicated, for instance, in slow stretching - to counteract
muscle hypertonias and/or in order to provide consistent
support - mandatory for most orthoses practiced in lower
limbs) when cooled, but with some flexibility provided, too;
rather uncomfortable, regarding skin perspiration/ overhea-
ting and also because of possibly generating allergies;
generally meant for long-term and unique use, i.e.
not suitable for re-fabrication 2,7 ...
 BACKGROUND
...
Yet, some of such kind of materials may have so-called
shape ”memory”: regainig, by re(over)heating, their initial
structure/configuration - thus prone, including, to be re-
availed and hence, more cost effective (useful to reduce
the economic burden when - especially for longer
periods - serial static orthoses need to be applied 1,12).
The latters - also referred to as ”thermomaleable” - are
easy to be conformed according to orthotic tasks, by low
temperature heating (below 80°C - thereby needing, for
being processed, usually, just hot water baths); in
most of the cases they are, easy/patient directly customized;
light, soft, partially re-fabricable (by simply re-heating) thus
to be of choice, for instance in temporary/intermediate splints,
applied in upper limbs, if no marked toughness is required
 ... BACKGROUND
C) of prescription related kind, entailing specific medical
diagnosis and therapeutic/ rehabilitative aims (realistic,
taking into account consequent morph-functional expected
improvements/ efficiency 1,2,7), within an appropriate
indications’ framing.
These two basic prescription items underpin on a complete,
clinical and functional/ disability, evaluation - considering
also the respective case particularities, such as: co-morbidi-
ties/ complications of the needing for neurorehabilitation
main condition, personal psychological compliance - inclu-
ding depression/ negativism and/or low self esteem/ motiva-
tion -, economic affordability, remaining self care autonomy
and social-professional state, connected also to the posibility
of ortosis(es) wearing schedule and/or maintenance, keeping;
...
 BACKGROUND
...
the afore mentioned case particularities of not fitting (most
important being those of pathological type: skin constraints
such as troubles related to sensitivity (anesthetic regions,
pain) and/or lesions (mainly, but not exclusively, pressure so-
res), therapeutic stomas (for drainage or breathing, feeding,
respectively for urine or stool evacuation, catheters); compre-
sion on skin/subcutaneous structures generate related tissue
trophy matters and/or respiratory, respectively swallowing,
restrictions; extra-large sized, severely obese, patients; all
represent possible (supplementary) general contraindica-
tions for orthosis(es) prescription ...
 BACKGROUND
Aside, there has to be emphasized a related global/main (ra-
ther non- than contra-) indication for orthosis(es)’prescription:
it can not provide (as stability - immobilization/ posturing
and/or support aid, and/or respectively, as controled mobility
assistance) the necessary/ expected morph-functional
correction/ improvement, i.e. making the patient less
funtional than without the respective orthosis(es) bearing.
Basic, general indications/ goals and reasons for
orthosis prescribing 2,7 :
- postural correction/ limitation of unbalanced (bio)me-
chanical forces that may action, in pathological situations, on
one or more muscle-skeletal segments (and - nuances) …
… BACKGROUND
- joint stabilization/ immobilization, including where
necessary, positioning and counteract action(s), provide
- (segmental) muscle tone control
- pain reduction (by limitation/ elimination of abnormal
movements in certain skeletal zone/s) and/or
sensory stimulation
- assisted active movements/ motor performance
promotion
- compensation(s) of (temporary or permanently) lost
neuro-myo-arthro-kinetic actions (possibly including ADLs
aid) for maximization of segmental related functionality(es)
…
 BACKGROUND
The afore mentioned items are grouped in literature 12,1
(didac-
dactically) into 3 principal pathways by which generally, an
orthotic device may therapeutically/ rehabilitative, act:
1) correction and/or 2) protection (the first 4/6 exposed
orthotic functions, i.e. modulation/ correction of muscle tone
- spasticity and/or contractures -; segmental, including of
joint/s, corrective posturing by stabilization - thus abnormal
mobility and/or related subluxations, deformities limitation/
elimination - through applied controlled compresive for-
ces and also - by traction forces - reducing of mechanical
burden on bones, cartilages and/or entheses - addequate
evaluation and related padding indication for the interaction/s
between the skin and the inner site of the orthosis, see
further -; thus including with overall pain reduction), and
 BACKGROUND
Basic principles and mechanisms of action
...These 3 pathways/objectives are underpinned on the 5
following basic physical mechanisms and respectively,
biomechanical action principles:
- three-point action (Loke, 2000 - cited by 9) or ”equilibrum” principle -
for instance to treat/ correct an elbow flexum or
respectively, a hyperextended/ ”back knee” (above and be-
low the joint, same bearing application of forces and - at the
joint level - a converse one: all by the device and equal in
between, their resultant force being = 0 7)
- (rather) uniform pression exertion on the skin surface in
contact with the orthosis, thereby the force with which it ac-
tions on the tegument must be inverse proportional to the
whole device’s contact surface (i.e. the pression ratio exer-
...
... BACKGROUND. Basic principles and mechanisms of action
ted by the orthosis on a certain segment should be
equal to the total – mean – force,
applied on the surface unit 7)
- the arm of (pârghie) heaver’s principle (i.e. ”the distance
from the joint on which an orthosis acts, to its pression point
of application on the respective segment, is directly corre-
lated to the arm of heaver’s moment and inverse proportio-
nal with the necessary pression to generate a torsion for-
ce at the joint level” 7; this realty generate, in orthotic devices
meant to provide, in lower segments, antigravitational sup-
port, the necessity to incorporate metallic or other consis-
tent material/s)
- (when) in order to improve mobility/ range of motion (ROM)
...
 BACKGROUND. Basic principles and mechanisms of action
... but, in the mean time, to ensure - as emphasized - pro-
tection (in order to prevent/ avoid possible severe skin
and subcutaneos structures’ lesions), the angle on which
the orthosis is recomended to pull is perpendicular 12
to the segmental axis, to be (facilitated) to/ (be) move(d)
- the total end range time (TERT) principle/ theory 14 (which
although expressly proven, yet, for proximal interphalan-
geal joint - PIP - flexion contractures of orthopaedic causes)
we reckon, including according to our own clinical expertise,
to be in generally suitable for counteracting joint posture
alterations of central nervous system (CNS)’s lesions ori-
gin (spasticity), too, considering also the path-physiological
links between these two mentioned muscle tone disorders

14 Flowers KR, LaStayo P Effect of total end range time on improving passive range of motion. J Hand Ther.,7(3):150-7, 1994
...
...

...
”Pathophysiology of Impairment After a Central Nervous System Lesion” 15
15 Mayer NH, Simpson DM (Eds.) Spasticity – Etiology, Evaluation, management and the Role of Botulinum Toxin. WE MOVE TM, 2002
... BACKGROUND. Basic principles and mechanisms of action
Lesions - especially severe/ extended - within CNS, usually affect
(also, mainly) descending pathways including the cortico-spinal tract.
This frequently results, immediately in paralysis and some of the
affected muscles will become immobilized in a shortened position
(primary related cause of muscle shortening; subsequently, this path-
physiological condition seems to be the first generator of spasticity 16
(plus: Maier et al. 1972, and respectively, Williams, 1980 - cited by15).

Secondary to the impairment of the muscle tone controlling/ smoo-

thing descending fascicles, it results in imbalance of spinal cord (re)-
activity, with consequent later rearrangements, thus being genera-
ted abnormal muscle tone and contractions - including with abnor-
mal reflex responses -, i.e. generating practically some of the com-
mon signs of pyramidal syndrome, including spasticity; hence, spas-
ticity aggravate contracture and vice-versa, in vicious cycle, with
including therapeutic consequences, related to a requested, logical,
simultaneous/ syncretic, approach of both these principal types
- and of others as well, if necessary - of muscle hypertonia 15 ...
16 Gioux M, Petit J Effects of immobilizing the cat peroneus longus muscle on the activity of its own spindles. J Appl
”
”

(după - reprodus
în: 2010/2011
Dr. Radu Braga
Cat. Fiziologie,
UMF Bucureşti -
http://www.fiziolo
gie.ro/curs08/FA
Fibre Ib NM2011.pdf)

17 Walker H – Spasticity After Stroke – http://www.slideworld.org/viewslides.aspx/Spasticity-ppt-2253430

 ... BACKGROUND. Methodological considerations
Thereby, the role of ortoses applications to counteract
spasticity - by slow stretching - has a very strong intimate
base of action.
Regarding stretching - a major physiatric therapeutic
method to approach spasticity - there are described
five basic methodological parameters to be addressed
including within related orthotic devices prescribing18:
- Intensity (amount of tension stretching applied on spastic segments
- Duration (length of time spastic/ shortened structures are
submitted to stretching at one session/ repetiton)
- Dose (the total end range time - TERT - of stretch application)
- Frequency (periodicity of the stretching sessions, per: day,
week, month, - even - year/s)
- Repetitons (number of times of stretching/ sessions) ...
18 Brashear A, Elovic E Spasticity. Diagnosis and Management. DemosMEDICALPublishing, LLC, New York, 2011
 ... BACKGROUND. Methodological considerations
As already emphasized, in the related clinical practice, the-
re is quite largely accepted (although without solid proofs,
according to Evidence Based Medicine’s - EBD - principles
and methods: in a detailed literature review there could
only be found ”some positive evidence supporting the
immediate effects of 1 stretching session” 19) the stretching
methodological paradigm of ”longer the better”.
Thus, it can be considered 18 that a stretching session, in
order to be effective, must last at least 30 seconds, but
protocols for appling such procedures recommend - consi-
dering also the afore presented five methodological para-
meters - these ones to range form single session to several
months (durations: 20sec-45min/stretch session)
19 Bovend'Eerdt TJ, Newman M, Barker K, Dawes H, Minelli C, Wade DT. The effects of stretching in spasticity: a systematic review.
Arch Phy Med Rehabil. 89(7):1395-406,2008
 Masa înclinată (basculantă/de verticalizare progresivă –
tilt table - v. imagini prezentate anterior) a fost folosită pe
scară largă pentru acombate efectele spasticității asupra
razei de mișcare (ROM) a articulațiilor membrelor inferioa-
re - predominant dar nu exclusiv, distal – în cadrul mana-
gementului redorilor/ posibilelor deposturări articulare con-
secutive. Atunci când este folosită corect, numeroase arti-
culații, inclusiv cea a genunchiului, șoldului și - în anumite
condiții - chiar articulații ale membrelor superioare, pot fi
tratate simultan.
Intensitatea întinderii poate fi controlată prin modificarea
unghiului la care este înclinată masa.
…
… Crescând unghiul de înclinare și aducând pacientul
într-o poziție aproape verticală crește greutatea/ forța
gravitațională care acționează asupra structurilor
mio-teno-articulare portante.
Acțiunile benefice ale acestei metode includ, în plus – și
se va detalia/completa mai departe – ameliorări ale pos-
turii, o mai bună toaletare pulmonară și ameliorarea pro-
gravitațională, a: drenajului urinar, tranzitului intestinal,
respectiv a densității osoase.
Efectele ortostatismului/ încărcării gravitaționale asupra
densității osoase și respectiv, invers: ale restricției orto-
statice, deși destul de larg menționate în literatură, nu
sunt totuși, confirmate în totalitate și par a depinde de in-
tensitatea și durata tratamentului precum și de
momentul în care acesta a fost început.20, 21 ...
20 http://www.sci-info-pages.com/other_issues.html#Osteoporosis and Fractures
21 Uebelhart D1, Bernard J, Hartmann DJ, Moro L, Roth M, Uebelhart B, Rehailia M, Mauco G, Schmitt DA, Alexandre C, Vico L – Modifications
of bone and connective tissue after orthostatic bedrest. Osteoporos Int.;11(1):59-67, 2000
...
Astfel, în perioada următoare unei leziuni
neurologice centrale, masa înclinată poate fi utili-
lizată pentru fiecare dintre problemele enumerate
mai sus sau/și (în spiritul promovării eficienței, în
cadrul balanței: efort - inclusiv al kinetoterapeutului
-/beneficii terapeutico-recuperatorii), pentru
abordarea simultană a mai multora dintre acestea.
 Marked posturee alterations/
articular deformations and
preliminary related ”soft”
approaches
(casuistry of the P(n-m)RM
Cliniic Division of TEHBA)

Vegetative state in a patient, after severe

TBI (traffic accident)
(casuistry of the P(n-m)RM Clinic Division of
TEHBA)

Patient in vegetative state (after severe TBI (traffic accident),

on the tilt table (casuistry of the P(n-m)RM Clinic Division of
TEHBA)
 Tilt table
(TEHBA - P(n-m)RM Clinic Division casuistry)
 O altă metodă, care însă, se adresează, în linii mari, acelorași sco-
puri dar permite o pozitie mai funcțională, este cadrul de sprijin orto-
static/de verticalizare (standing frame - v. imagini prezentate ant).
Ambele dispozitive (tilt table, standing frame) pot fi utilizazate
pentru a remedia problemele descrise, necesitând mai puțin efort
din partea kineto-terapeutului.

Cadrul de sprijin ortostatic/de verticalizare se adresează deci, a-

proximativ acelorași condiții patologice ca masa înclinată, cu unele
beneficii față de aceasta (viv-a-vis de combaterea spasticicității):
permite o participare mai activă a pacientului putând fi utilizat și ca
suport fizic în cadrul unor etape ulterioare în tratament; spre exemplu,
acesta este folosit frecvent, la sfârșitul unei sesiuni de kinetoterapie
recuperatorie, pentru a postura pacientul (paralizat și spastic) în
vederea desfășurării de activități ocupaționale sau recreative.
 Standing frame
(TEHBA - P(n-m)RM Clinic Division casuistry)
Referitor la nuanțele/respectiv exemplificări nosologice -
aproape toate având asociată spasticitatea - privind indi-
carea/utilizarea (mai ales în stadiul subacut) a unuia sau
altuia dintre aceste două valoroase tipuri de dispozitive
kinetoterapice, cităm parțial/ fragmentar, în continuare,
din literatură, o importantă sistematizare 22 :
”Pentru a realiza o postură ortostatică “bipedă” (specific u-
mană) – chiar pasivă iniţial (înainte de a începe – eventual
– exersarea mersului) – se utilizează: masa de înclinare/
verticalizare progresivă, ulterior cadrul de verticalizare
sau fotoliul rulant cu posibilităţi de verticalizare.
22 Onose G, Anghelescu A (Editori) și col. – Ghid de diagnostic, tratament și reabilitare în suferințe după traumatisme vertebro-

medulare – în: Platforma de ghiduri de practică profesională pentru specialitatea Recuperare, Medicină Fizică şi Balneologie (Editor
Coordonator: Onose G). Ed. Univ. ”Carol Davila”, București, 2011

...
… Alegerea între utilizarea mesei şi respectiv cadrului de verticalizare are drept
criterii principale următoarele: diagnosticul clinico-funcţional, statusul fizic şi psihic
ale pacientului şi corolar, obiectivele de etapă precum şi finale ale programului de
recuperare.
• În principiu, masa de verticalizare progresivă este utilizată pentru cazurile mai severe
(din punct de vedere al statusului neurologic de ansamblu sau/și al stării generale
biologice, inclusiv de anduranţă) şi respectiv, la antrenarea precoce, pentru
realizarea încărcării gravitaţionale progresive şi exersarea secvenţelor alternative de
mişcări ale mersului.
• Cadrul pentru asistarea ortostatismului este indicat în cazurile mai puţin grave - în ce
priveşte adaptabilitatea/ toleranța, hemodinamice - sau în stadiile mai avansate de
neuroreabilitare dar şi (oarecum paradoxal) în situațiile de paraplegie fără evoluţie
motorie favorabilă. ...
• Concret, masa de înclinare/ verticalizare progresivă (tilt table) se recomandă pentru
iniţierea verticalizării pasive/ asistate în cazurile de:
• a) paraplegii „înalte“ - cu leziunea mielică situată deasupra nivelului T8 - complete
(AIS/ Frankel-A) sau incomplete senzitiv, de tip AIS/ Frankel-B, mai ales la începutul
programului de recuperare
• b) paraplegii incomplete (AIS/ Frankel-C la care deficitul motor este sever), pentru
încărcare gravitaţională progresivă şi antrenarea precoce a patternului mişcărilor
alternative de mers
• c) (severe): tetrapareze, hemiplegii (inclusiv spinale) și - eventual, în anumite cazuri -
tetraplegii complete (AIS/ Frankel-A) - nepermițând folosirea altor dispozitive pentru
asistarea ortostatismului
• d) tranzitoriu (ca element psihologic de protecţie) la debutul programului de
verticalizare, chiar la pacienți la care acesta s-ar putea iniţia direct, cu ridicarea
pasivă în standing frame - pentru a nu amplifica starea emoţională negativă (teama
de a cădea din poziţie ortostatică). ...
... Cadrul de verticalizare (standing frame) este recomandat la
pacienţi spinali - având focarul lezional osos vertebral stabilizat
(operator sau conservator):
• a) paraplegii „joase“ - cu leziuni medulare situate caudal de
mielomerul T8 - complete (AIS/ Frankel-A) sau incomplete de
tip AIS/ Frankel-B sau C (sever), la pacienţi echilibraţi cardio-
vascular (inclusiv ce au depăși riscul de hipotensiune arterială
ortostatică tranzitorie sau/și de disreflexie autonomă) și fără co-
morbidităţi semnificative sau acutizate și respectiv în:
• b) (eventual) hemipareze de de tip encefalic sau/şi spinal, la
pacienţi echilibraţi cardio-vascular (inclusiv ce au depășit riscul
de hipotensiune arterială ortostatică tranzitorie sau/și de
disreflexie autonomă) și fără co-morbidităţi semnificative sau
acutizate. ...”22
• Mai noi şi eficiente (dar scumpe), datorită facilităţii de
verticalizare (repetabile oricând/ deseori pe zi), sunt fotoliile
rulante prevăzute cu dispozitive mecano-pneumatice/-hidraulice
sau electro-mecanice pentru (auto-) verticalizare - din păcate,
deşi deosebit de benefice şi necesare, încă neuzuale la noi.23
23 http://www.mobilitycare.net.au/mobility_products/lifestand-helium-standing-wheelchair.html - Brochure
Problema recâştigării/asistării recuperatorii a posturii ortosta-
tice şi a mersului – sau cel puţin a posturii verticale a trun-
chiului și trenului inferior – este complexă și dificilă.
În acest sens se mai poate utiliza încărcarea gravitaţională par-
ţială și progresivă, utilizând dispozitive robotice (fixe) de tip Lo-
komat (la pacientul spinal subacut sau cronic, incomplet sen-
zitivo-motor) sau mai complexe (exp.: G-EO) sau dispozitive
ortetice mobile (încă și mai avansate și performante ca poten-
țial asistv-recuperator), de tip exoschelet ortetic mecatronic,
pentru asistarea ortostatismului şi mersului – domeniu în care
clinica noastră ocupă o poziţie de pionierat, alături de
prestigioase colective de cercetare, pe plan
mondial (v. mai departe) 24, 25,26,27
24 Dietz V, Grillner S, Trepp A, Hubli M, Bolliger M – Changes in spinal reflex and locomotor activity after a complete spinal cord injury:
a common mechanism? Brain.132(Pt 8):2196-205, 2009
25 Onose G, Cârdei V, Ciurea AV, Ciurea J, Onose L, Anghelescu A, Crăciunoiu T St, Avramescu V, Visileanu E, Epureanu G, et al. –
Considerations regarding the achievement of the experimental model of an orthotic mechatronic device, to assist/ rehbilitate the ortho-
statism and walk in old persons with severe impairments, due to cardio-respiratory insufficiencies and/or in patients with severe neuro-
locomotor disabilities - ROBOSIS: next steps. Comunicare la The Annual National Conference of the Romanian Society of Neuro-
surgery, with International Participation, Iaşi, România, Sept.- Oct., 2008
26 Cârdei V, Onose G, Crăîciunoiu T St, Avramescu V - Dispozitiv Ortetic Mecatronic - Brevet de Invenție Nr. 123160, OSIM, 2011;
27 Swinnen E, Duerinck S, Baeyens JP, Meeusen R, Kerckhofs E. Effectiveness of robot-assisted gait training in persons with spinal
cord injury: a systematic review. J Rehabil Med. 42(6):520-6, 2010
Physical rehabilitative therapy
Robotic fixed apparatus – LOKOMAT:
(https://www.googl
e.ro/search?q=loko
mat&biw=1366&bih
=648&tbm=isch&im
Robotic rehabilitative system
gil=sjAC4osQYJBa
UM%253A%253Bn
automated/
RfyIJV_LFjXEM%2
53Bhttp%25253A%
robotic
25252F%25252Fw
ww.recuperareusoa locomotion
ra.ro%25252F2013
%25252F03%2525 therapy
2Fcalul-ca-si-
terapeut-
hipoterapia-partea-
a-
iia%25252F&sourc
physiological
e=iu&pf=m&fir=sjA
C4osQYJBaUM%2
stereotype
53A%252CnRfyIJV
_LFjXEM%252C_& of
usg=__sJXSmbfB0
vccaGZ- walk: triple
flexion
ic1OZ21HjyQ%3D
&ved=0CCoQyjdqF
QoTCPr5oNOq4cY
CFYHXFAodBYcGl
Q&ei=MoWoVfqYC
IGvU4WOmqgJ#im moving
carpet/
grc=sjAC4osQYJB
aUM%3A&usg=__s
JXSmbfB0vccaGZ-
ic1OZ21HjyQ%3D) treadmill
”Poziţia verticală și – respectiv, inclusiv – mersul, asista-
te prin utilizarea acestor dispozitive vizează (pe lângă
combaterea spsticității – n.n.), în principal, următoarele
rezultate favorabile:
- stimularea pattern-ului generator central de mișcare
(PGCM) de la nivel medular, concomitent cu cea a
propriocepţiei/feedback-ului senzitivo-senzorio-motor
- îmbunătăţirea echilibrului şi coordonării în plan axial
- ameliorarea troficităţii osoase
- facilitarea drenajului gravitaţional al urinei, respectiv
tranzitul intestinal
- ameliorarea imaginii/stimei de sine şi a calităţii vieţii
(QOL), conferite de poziţia ortostatică, specific umană.” 22
 BACKGROUND. Methodological considerations
Very important is the ”wearing schedule”; it
depends on the respective orthosis(es) indication/
objective(s) and on the patient's related
compliance.
For instance, in post brain injury fidgety patients
(including abundantly sweating), resting orthosis/es)
for peripheral segments positioning, might usually
be worn only 30 min on and 3 h off.
Conversely, post stroke patients with moderate
spasticity could wear resting
orthoses 2 h on and 2 h off by day time and also
keep it/them on during night 1 ...
 BACKGROUND. Methodological considerations
...
Hereunder, as already asserted, static progressive ortho-
ses wear also depends on tissue response to
gentle stretching.
The stretch should not produce disconfort - for instance:
it should not awake the patient during sleep - nor
should it generate local/ regional circulation/ inflammato-
ry (response) disturbances (respectively edema); on the
contrary, as long as stretching is mild/ sparing, a resting
orthosis can provide anti-edema action, too.
The same goes for situations - consequent to spasticity
and contractures - of segmental muscle-enthesis shor-
tening: tennsion/ pression must be lowered, so stret-
ching to be harmless and well tolerated, yet still efficient 1 ...
 BACKGROUND. Methodological considerations
...
Furthermore, if a patient needs both, flexion and
extension peripheral splinting, the flexion
orthosis(es) can be worn 1 h on and 2 h off by
daytime, and the extension one(s)

should be worn at night (actiually, it’s more

friendliness for patients that, during daytime, to have
predominantly off the orthosis(es) - except for
exercises entailing their incorporate use 1 – see further)
...
... BACKGROUND. Methodological considerations
Regarding orthoses applied to the axial/ spine ske-
leton, the wearing schedule varies mainly by the
same afore mentioned parameters.
For example: soft - ”reminding” collars (Schanz,
Colar) should be worn for about 1-3 weeks (eg.: in
cervical disk hernias without surgical indication) by
day time; when resting in bed – not mandatory.
More consistent/ stabilizing collars – Philadelphia
or Miami J – are recomended to be (almost) continu-
ously worn, generaly for 2 months, including in bed
(at least each time when changing position) ...
 BACKGROUND. Methodological considerations
… Very consistent/firm related orthotic devices, su-
ch as (cervico-thoracic) halo vest or Minerva, has to
be worn continuously until the spine stabilization (os-
seous calus - including aided with osteosynthesis ma-
terials) is confirmed by standard cervical spine X-rays.
Concerning corsets - for instance the ”Boston” ty-
pe (initially indicated for scoliosis correction); accor-
ding to producer’s recommendations, this should be
worn, in the first 2 weeks, progressivley prolonged,
up to arround 6 h/day - mainly in the afternoon
and before going to sleep …
 BACKGROUND. Methodological considerations
…
In the next 2 weeks, the wearing duration of the
Boston corset may progressively increase up to
10 h/day, in sessions of 3-4 h each (spine control
X-rays, with and without the corset recommended).
After 5 weeks it can be attempted - if tolerated - to
increase the wearing of such a corset,
up to 18-23 h/day, including at night.
There has to be done, again, spine control X-rays –
with and without the corset – after 3 months, too
 BACKGROUND. Prescription details
To practically summarize the overall background conside-
ration exposed by now, herein are presented two kinds of
specific modalities of an orthotic device prescription:

...
...

...
...

...
...

...
...

...
...

...
...

Pentru copiii in varsta de pana la 18 ani se poate acorda o alta pereche de incaltaminte
inainte de termenul de inlocuire la recomandarea medicului specialist, ca urmare a modi-
ficarii datelor avute in vedere la acordarea ultimei perechi. Se prescrie o pereche de
ghete sau o pereche de pantofi.Numerele utilizate sunt exprimate in sistemul metric. ...
...
 UPPER LIMB ORTHOSES

”Eight” sling (”eșarfă”)

figure for reducing
shoulder joint subluxation
in hemiplegic patient (by 6) TEHBA - P(n-m)RM
Clinic Division casuistry

Upper limb orthoses - Ortoprotetica catalogue

 Resting hand orthosis - Ortopedica catalogue

Upper limb orthoses -

NDmedical catalogue
(www.ndmedica.ro)

Swan neck
finger
ortoses: oval
”8” three-
point device
(by 6)
 Assistance of wrist and
fingers’ extension through a
dynamic orthosis, in radial
nerve palsy - (by 6)

Dynamic stretching of finger flexors using the Saeboflex

dynamic splint - (by 18)

Splint for ulnar nerve palsy: allows extension, but blocks hyperextension of the IV and V
digits’ metacarpophalangeal joints - (by 6)
 When thumb abduction lacks, grasping may be
impossible or very difficult - resultng in
poor capacity for ADLs and consequent autonomy and
QOL; a thumb splint, holding the thumb in abduction, can
improve grassping - (by Canning and Dean, cited by 28)

28 Carr J, Shepherd R – Neurological Rehabilitation: Optimizing motor performances.

Butterworth-Heinemann, Oxford, Auckland, Johannesburg, Melbourne, new Delhi. TEHBA - P(n-m)RM
A division of Reed Educational and Professional Publishing Ltd., 2002 Printed and
bound in Great Britain by The Bath Press plc, Bath
Clinic Division casuistry
 NESS H200 (2004)
- a complex apparatus,
with five integrated
functions, including “all
in one“ mainly:
- an exoscheleton
(orthotic structure)
very flat and light
and - an exo-
neuroprothesis with
F.E.S. facilities 29

29 http://www.bioness.com/H200_for_Hand_Paralysis.php
- NESS H 200 Brochure -
 SPINAL ORTHOSES

Percentually expressed normal motility of the cervical spine and the effects
upon it of different types of cervical orthoses – synthesized and presented in 11
 SPINAL ORTHOSES

Philadelphia Miami J
(after 6)

Philadelphia -
NDmedical
catalogue
(www.ndmedica.r
o)

Philadelphia - TEHBA - P(n-m)RM

Clinic Division casuistry Cervical orthoses - Ortoprotetica catalogue
Halo (vest) - after 6 Halo (vest) - TEHBA - Sternal-occipital-mandibular
P(n-m)RM immobilizer (SOMI) - after 6
Clinic Division casuistry
Thoracic-lumbar-sacral ortoses (TLSO) - after 6
pre fabricated custom fabricated
(body jacket)

Jewett hyperextension
thoracic-lumbar-sacral
orthosis - after 6

TEHBA - P(n-m)RM Thoracic-lumbar corsets - Ortoprotetica

Clinic Division casuistry catalogue
TEHBA - P(n-m)RM Clinic Division casuistry
Thoracic-lumbar, lumbar and lumbar-sacral orthoses - NDmedical catalogue
(www.ndmedica.ro)
Thoracic, lumbar-sacral and sacral-iliac orthoses - Ortoprotetica catalogue
TLSO low-profile scoliosis orthosis
(after 6)

Spinal scoliosis corsets - Ortoprotetica catalogue

 Lumbosacral corset Lumbar-sacral orthosis (Knight
and chair back brace
- (after 6)

TEHBA - P(n-
m)RM Lumbar orthoses - NDmedical catalogue (www.ndmedica.ro)
Clinic Division
casuistry
 LOWER LIMB ORTHOSES

Scott-Craig KAFO
(after 6)

TEHBA - P(n-m)RM Clinic Division casuistry

TEHBA - P(n-m)RM Clinic Division casuistry
”

(http://www.ottobock.ro/orteze/prezentare-generala/genu-neurexa/)
Common plastic rigid AFO - left to
right: non-hinged foot drop AFO
(”posterior leaf spring” AFO) ;
(for) plantar spasticity AFO;
Lumbar spinal cord injury AFO -
(after 6)

TEHBA -
P(n-
m)RM
Clinic
Division
casuistry
AFOs - Ortoprotetica catalogue
NESS L 300: leg cuff; NESS L 300 Plus
gait senzor; wireless
control unit 30
manșetă
30 http://www.bioness.com/H200_for_Hand_Paralysis.php – NESS L300 & L300 Plus – Brochures
 Onose, Popescu et al., 2010

MOD -2008 (see also patent and related

Discussion resource – next slide)
possible further
applications of
advanced systems of
non-inva-sive
BCI/BMI type sys-
tems – thus we have
anticipated with
about 3 years the
actual inte-rnational
project ”Walk again”
(http://www.walkagainproject.org/?pa
ge_idĽ3)
...

...
 Fig. - a (left) and b (right):

Training session with a quadriplegic subject in wheelchair and in front of a

standard table (on the display - right - there can be seen the virtual (reality -
VR) representation of a pair of upper limbs: their movement can be controlled
by the subject with the power of his thoughts/ brain voluntary movements
commands)

(FRAUNHOFER-FIRST, Berlin/ TEHBA, Bucharest, 2008)

 Fig. - Typical set up
(pictured): the robot
is shown in the middle
of a ‘grab’ sequence.
The head tracking
cameras seen in the
schema are mounted
on the facing wall –
off-frame
(FRAUNHOFER-FIRST,
for Berlin/TEHBA,
Bucharest 2008)
(ReWalk™- Israel, 2006 - www.argomedtec.com) (Elegs - USA, 2011 - http://www.eksobionics.com/community)
Indego powered lower limb
orthosis/ exoskeleton –
prospectus

…
…
(http://www.indego.com/indego/en/theindego)

…
…

…
 (https://www.djoglobal.com/pro
ducts/donjoy/x-act-rom-elbow)
(https://www.djoglobal.com/products/aircast/stabil
air-wrist-brace)
Orthoses for (including/ mainly) non-neurologic
conditions

(MTI catalogiue;
https://www.djoglobal.com/prod
ucts/aircast/pneumatic-
armband) …
…

(http://www.donjoy.eu/en_US/54150Rotulax-Elastic-Knee-Open-
Patella.html)

(http://www.djoglobal.eu/en_UK/Aligua-Elastic-72410.html)

…
…

(http://viewer.zmags.com/publication/7b289128#/7b289128/20)

…
…

(http://viewer.zmags.
com/publication/7b2
89128#/7b289128/6)

…
…

…
(http://www.ottobock.
ro/orteze/prezentare- Orthoses for (including/ mainly) non-neurologic
generala/genu- conditions – Ottobock catalogue
arexa/)
 Onose, Popescu et al., 2010

THANK YOU
FOR YOUR
ATTENTION !

Acknowledgments to: A-S Mihăescu, I Colibășeanu, L Onose