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Physical Rehabilitation Programmeankle-Foot orthosis
Manufacturing guidelines
0868
/002
0
9/20
06
200
MISSION
The International Committee of the Red Cross (ICRC) is an impartial, neutral and independent organization whose exclusively humanitarian mission is to protect the lives and dignity of victims of war and internal violence and to provide them with assistance. It directs and coordinates the international relief activities conducted by the Movement in situations of conflict. It also endeavours to prevent suffering by promoting and strengthening humanitarian law and universal humanitarian principles. Established in 1863, the ICRC is at the origin of the International Red Cross and Red Crescent Movement.
Acknowledgements:
Jean François GallayLeo GasserPierre GauthierFrank JoumierJacques LepetitBernard MatagneJoel NiningerGuy NuryPeter PoestmaHmayak Tarakhchyan
and all prosthetists-orthotists who have worked in ICRC-assisted physical rehabilitation centres.
International Committee of the Red Cross19 Avenue de la Paix1202 Geneva, SwitzerlandT + 41 22 734 60 01 F + 41 22 733 20 57E-mail: [email protected]© ICRC, September 2006All photographs: ICRC/PRP
�Manufac tur ing Guidel ines Ankle -Foot O r thosis
Table of contents
Foreword 2Introduction 4Choosingbetweendifferentdesigns 4Castingandrectification 51.FlexibleAFO 6
1.1MouldingofEVA 61.2Orthosistrimline 61.3Vacuummouldingofthepolypropylene 61.4Preparationofthepolypropyleneshell 71.5Preparationofthestraps 81.6Initialfittingandfinishing 8
2.RigidAFO 82.1MouldingofEVA 82.2Orthosistrimline 92.3Plasticreinforcement 122.4Vacuummouldingofthepolypropylene 132.5Preparationofthepolypropyleneshell 142.6Proximalstrap 142.7Distalstrap 152.8Instepstrap 162.9Initialfittingandfinishing 18
3.AFOwithTamarackFlexureJointTM 183.1MouldingofEVA 183.2Orthosistrimline 183.3Plasticreinforcement 183.4InstallationofTamarackFlexureJointTM 193.5Vacuummouldingofthepolypropylene 193.6Preparationofthepolypropyleneshell 203.7Preparationofthestraps 223.8Initialfittingandfinishing 22
4.AFOanti-talus(anteriorshell) 224.1MouldingofEVA 224.2Orthosistrimline 234.3Plasticreinforcement 244.4Vacuummouldingofthepolypropylene 244.5Preparationofthepolypropyleneshell 254.6Preparationofthestraps 264.7Initialfitting 264.8Finishing 26
Listofmanufacturingmaterials 27
� ICRC Physical Rehabi l i tat ion Programme
Foreword
The ICRC polypropylene technology
Sinceitsinceptionin1979,theICRC’sPhysicalRehabilitationProgrammehaspromotedtheuseoftechnologythatisappropriatetothespecificcontextsinwhichtheorganizationoperates,i.e.,countriesaffectedbywarandlow-incomeordevelopingcountries.
Thetechnologymustalsobetailoredtomeettheneedsofthephysicallydisabledinthecountriesconcerned.
Thetechnologyadoptedmustthereforebe:
• durable,comfortable,easyforpatientstouseandmaintain;• easyfortechnicianstolearn,useandrepair;• standardizedbutcompatiblewiththeclimateindifferentregionsoftheworld;• low-costbutmodernandconsistentwithinternationallyacceptedstandards;• easilyavailable.
Thechoiceoftechnologyisofgreatimportanceforpromotingsustainablephysicalrehabilitationservices.
Forallthesereasons,theICRCpreferredtodevelopitsowntechniqueinsteadofbuyingready-madeorthopaediccomponents,whicharegenerallytooexpensiveandunsuitedtothecontextsinwhichtheorganizationworks.ThecostofthematerialsusedinICRCprostheticandorthoticdevicesislowerthanthatofthematerialsusedinappliancesassembledfromcommercialready-madecomponents.
WhentheICRClauncheditsphysicalrehabilitationprogrammesbackin1979,locallyavailablematerialssuchaswood,leatherandmetalwereused,andorthopaediccomponentsweremanufacturedlocally.Intheearly1990stheICRCstartedtheprocessofstandardizingthetechniquesusedinitsvariousprojectsaroundtheworld,forthesakeofharmonizationbetweentheprojects,butmoreimportantlytoimprovethequalityofservicestopatients.
Polypropylene(PP)wasintroducedintoICRCprojectsin1988forthemanufactureofprostheticsockets.Thefirstpolypropyleneknee-jointwasproducedinCambodiain1991;othercomponentssuchasvariousalignmentsystemswerefirstdevelopedinColombiaandgraduallyimproved.Inparallel,adurablefoot,madeinitiallyofpolypropyleneandEthylVinylAcetate(EVA),andnowofpolypropyleneandpolyurethane,replacedthetraditionalwooden/rubberfoot.
In1998,aftercarefulconsideration,itwasdecidedtoscaledownlocalcomponentproductioninordertofocusonpatientcareandtrainingofpersonnelatcountrylevel.
�Manufac tur ing Guidel ines Ankle -Foot O r thosis
Objective of the manuals
TheICRC’s“ManufacturingGuidelines”aredesignedtoprovidetheinformationnecessaryforproductionofhigh-qualityassistivedevices.
Themainaimsoftheseinformativemanualsareasfollows:
• TopromoteandenhancestandardizationofICRCpolypropylenetechnology;• Toprovidesupportfortrainingintheuseofthistechnology;• Topromotegoodpractice.
Thisisanotherstepforwardintheefforttoensurethatpatientshaveaccesstohigh-qualityservices.
ICRCAssistanceDivision/HealthUnitPhysicalRehabilitationProgramme
� ICRC Physical Rehabi l i tat ion Programme
Choosing between different designs
Withoutgoingintodetails,somefeaturesofdifferenttypesofAFOaresetoutbelowtoassistinthechoiceofdesign.
Flexible AFO• Dorsiflexionassistance• Poormedio-lateralstabilizationofthesubtalarjoint
Rigid AFO• Blocksanklemovements• Mediolateralstabilizationofthesubtalarjoint• Possibilityofcontrollingforefootadduction/abduction
AFO with Tamarack Flexure Joint TM
• Mediolateralstabilizationofthesubtalarjoint• Freeankledorsiflexion• Freeorrestrictedankleplantarflexion
AFO anti-talus• Blocksanklemovements.Particularlyefficientforpreventingankledorsiflexion• Poormediolateralstabilizationofthesubtalarjoint
Introduction
Theaimofthisdocumentistodescribeseveralmethodsformanufacturingankle-foot orthoses (AFO),workingwiththepolypropylenetechnologyusedattheICRC’sphysicalrehabilitationcentres.
�Manufac tur ing Guidel ines Ankle -Foot O r thosis
Casting and rectification
Patientassessment,castingandrectificationofpositivecastimpressionsareperformedinaccordancewithprostheticandorthotic(P&O)standards.
ForflexibleAFO,thecastcanbetakenwith5degreesofdorsiflexionsoastoprovideapreloadandensuresomespringaction.
� ICRC Physical Rehabi l i tat ion Programme
1.1 Moulding of EVA
AflexibleAFOdoesnotusuallyrequireanyEVA.However,incaseswhereitisnecessarytheproceduredescribedinsection2.1(page8)shouldbefollowed.
1.2 Orthosis trim line
Toachievethegoalofallowingdorsiflexionoftheanklewhilepreventingpassiveplantarflexion,thereareanumberofdesignoptions.
FlExIblE AFO1
4Markthetrimlineasfollows:
A Thetopishorizontal,2cmbelowthefibulahead.
B Attheankle,pass2cmbehindthetipofthemalleolitoallowflexionofthepolypropylene.
C Attheforefoot,leavethesidesofthetoesandtheheadofthemetatarsuscompletelyclearandpassthetrimlinebelowthem.This will allow the polypropylene to follow the movement of the metatarso-phalangeal joints.
Pullastockingovertheplastermodel.
1.3 Vacuum moulding of the polypropylene
Dustthestockingwithtalcumpowder.
Measurementofthepolypropylenesheet:
� Calfcircumference+10cm.� Instepcircumference+10cm.� Legandfootlength+10cm.(Seenextpicture.)
Thickness3mm,4mmor5mm,dependingonthepatient’sweight.
�
2
1
3
Manufac tur ing Guidel ines Ankle -Foot O r thosis
Heatthepolypropyleneat180°for20to25minutes,dependingonthethicknessofthepolypropyleneandtheefficiencyoftheoven.
Drapethepolypropyleneovertheplastermodelandstickittogetheralongtheanteriorside.
Tightenthepolypropylenearoundthesuctionconebymeansofaropeorsomethingsimilar.
Openthevacuumvalve.
4CutofftheexcessPPwithapairofscissorswhileitisstillhot.
Keepthevacuumonuntilthepolypropylenecoolsdown.
1.4 Preparation of the polypropylene shell
Drawthetrimlineonthepolypropyleneasdescribedinsection1.2(page6).
Followingtheoutline,cuttheorthosiswithanoscillatingsaw.
Removetheplasticshellfromtheplastermodel.
RemovethestockingfrominsidetheAFO.
Grindtheorthosistrimlineandsmoothit.
� ICRC Physical Rehabi l i tat ion Programme
IfanEVAhasbeenmoulded,transferthetrimlinetotheEVAandcutofftheexcesswithapairofscissors.
1.5 Preparation of the straps
Fortheproximalstrap,followtheproceduredescribedinsection2.6(page14).
Adistalstrapmightbeneeded,dependingonthecapacityofthepatient’sshoetoholdthefootinsidetheorthosis.Ifthisisneeded,followtheproceduredescribedinsection2.7(page15).
1.6 Initial fitting and finishing
IfEVAisused,glueitpartiallyinsidetheorthosis.
TheinitialfittingisperformedaccordingtoP&Ostandards.
Carryouttherequiredmodificationonthepolypropyleneandsmooththetrimline.
GluetheEVAcompletelyinsidethepolypropylene,cutoffthesurplusandsmooththetrimline.
RIgId AFO2
2.1 Moulding of EVA
EVA(6mm)maybemouldedpriortothedrapingofthepolypropylene,forthefollowingreasons:• toimprovecomfort;• topreventskinbreakageinpatientswithsensationloss;• fororthosesusedatnight.
Followtheproceduredescribedbelowor,ifthecasedoesnotrequireEVA,goontothenextsection.
�Manufac tur ing Guidel ines Ankle -Foot O r thosis
4Positiontheplastermodelwiththeforefootpointingdownwards.
MeasurementoftheEVAsheet:• width,instepcircumference;• length,thatoftheplastermodel
(leg+foot);• thickness,6mm.
HeattheEVAat120°for3to5minutes,dependingontheefficiencyoftheoven.
DrapetheEVAmanuallyovertheplastermodelandholditinplaceuntilithascooledcompletely.
4Cutofftheexcesswithacutterorapairofscissors.
StapletheEVAontothefrontoftheplastermodel.
2.2 Orthosis trim line
2.2.1 “Standard” trim line
4Markthetrimlineasfollows:
A Thetopmustbehorizontal,2cmbelowthefibulahead.
B Attheankle,passtheline1cmanteriortothetipofthemalleoli.
C Attheforefoot,leavethesidesofthetoesandtheheadofthemetatarsuscompletelyclearandpassthetrimlinebelowthem.This will allow the polypropylene to follow the movement of the metatarso-phalangeal joints.
�0 ICRC Physical Rehabi l i tat ion Programme
2.2.2 Trim line to correct forefoot adduction
Forefootadductioniscommonincasesofclubfoot.
4Markthetrimlineasfollows:
A Thetopmustbehorizontal,2cmbelowthefibulahead.
B Increasecoverageofthelateralmid-foot,passinginfrontofthecuboid,to enlarge the area of pressure.
C Attheforefoot,thelinemustbeproximaltothe5thmetatarsalhead.
D Decreasecoverageofthemedialmid-footatthenavicular/malleoli,to facilitate donning.
E Attheforefoot,coverthemedialsideofthemetatarsalheadandtoe,to correct forefoot adduction.
��Manufac tur ing Guidel ines Ankle -Foot O r thosis
2.2.3 Trim line to correct forefoot abduction
Forefootabductionisoftenseenincasesofcerebralpalsy.
4Markthetrimlineasfollows:
A Thetopmustbehorizontal,2cmbelowthefibulahead.
B Decreasecoverageatthelevelofthelateralmalleoli,to ease donning.
C Attheforefoot,thelinemustbedistaltothe5thmetatarsalhead,to avoid metatarsus abductus.
D Increasecoverageofthemedialmid-footatthelevelofthenavicular,to increase mid-foot support.
E Attheforefoot,thelinemustbeproximaltothe1stmetatarsalhead.
�� ICRC Physical Rehabi l i tat ion Programme
2.3 Plastic reinforcement
TheAFOmayneedreinforcement,especiallyatanklelevel.Ifnecessary,useoneofthefollowingmethods;otherwisegoontothenextsection.
2.3.1 double layer of polypropylene
4Asecondlayerofpolypropylenecoveringtheankleandthefootismouldedatthesametimeasthemainlayer.
Cutapieceofpolypropylene:• thickness,3mm;• width,instepcircumference;• length,footlength+10cm
Grindthelast3cmattheproximalendtograduallyreducethethicknessofthepolypropylene.
4Thetwolayersareheatedatthesametime.
Thereinforcementisplacedontheplastermodel,thenthesecondlayerisvacuum-mouldedimmediatelytoobtainaperfectsealbetweenthetwo.
A double layer of polypropylene has the disadvantage of reducing flexibility of the forefoot in relation to the metatarso-phalangeal joint.
��Manufac tur ing Guidel ines Ankle -Foot O r thosis
2.3.2 Channels in the polypropylene
Thepresenceofchannelsintheplasticsignificantlyimprovesitsstrength.Thereareseveralwaysofmakingthesechannels.
4CuttwostripsofEVA:• thickness,6mm;• width,7mm;• length,15cm.
GrindbothdistalandproximalendstograduallyreducethethicknessoftheEVA.
Pullastockingovertheplastermodel.
Gluethestriplightlyontothestocking.
The more anterior the position of the channel, the more the AFO will resist dorsiflexion of the ankle.
Reinforcements prolonged along the side of the mid-foot increase the volume of the orthosis so that it may no longer fit into the patient’s shoe.
2.4 Vacuum moulding of the polypropylene
Ifthishasnotyetbeendone,pullastockingovertheplastermodel.For maximum efficiency, the EVA used to make channels in the polypropylene must not be covered with a stocking.
Followtheproceduredescribedinsection1.3(page6),takingintoaccountthepresenceorabsenceofadoublelayerofpolypropylene(section2.3.1,page12).
�� ICRC Physical Rehabi l i tat ion Programme
2.6 Proximal strap
Useaready-madeVelcrostrap40mmwide,ormakeastrapwithPerlonwebbingorsomeotherstrongmaterial.
4Withalargetubularrivet,fixthebeltholdingthelooponthemedialside,1.5cmbelowtheproximaltrimline.
Theloopshouldbeplacedonthepolypropyleneandnotbeincontactwiththepatient’sleg.
2.5 Preparation of the polypropylene shell
Drawthetrimlineonthepolypropyleneasdescribedinsection2.2(page9).
Cuttheorthosiswithanoscillatingsaw,followingtheoutline.
Removetheplasticshellfromtheplastermodel.
RemovethestockingfrominsidetheAFO.
Grindtheorthosistrimlineandsmoothit.
IfEVAhasbeenmouldedbeforehand,transferthetrimlinetotheEVAandcutofftheexcesswithapairofscissors.
��Manufac tur ing Guidel ines Ankle -Foot O r thosis
4Insertthebeltthroughthelooptomeasuretherequiredlength.
Fixthestrapwithalargetubularrivetonthelateralside.Makesurethestrapisperfectlyhorizontalbeforefixingit.
Coverthesurfaceofthestrapincontactwiththepatient’slegwith3mmEVA.
4Fixthestrapwithalargetubularrivetonthelateralside.Makesurethestrapisperfectlyhorizontalbeforefixingit.
Coverthesurfaceofthestrapincontactwiththepatient’slegwith3mmEVA.
2.7 distal strap
Youmustchoosebetweenadistalstrapandaninstepstrap.Thelatterhastheadvantageofholdingthecalcaneumfirmlyinsidetheorthosis(equinuscorrection).
UseaVelcrostrap25mmwide.
4Withalargetubularrivet,fixthebeltholdingthelooponthemedialside,4cmabovethemalleoli.
Theloopshouldbeplacedoverthepolypropyleneandnotbeincontactwiththepatient’sleg.
�� ICRC Physical Rehabi l i tat ion Programme
2.8 Instep strap
UseaVelcrostrap25mmwide.
Twotechniquesarepresented,dependingonwhetherthebackofthefootisinaneutralpositionorneedsavalgus/varuscorrection.
2.8.1 Neutral position
4Withalargetubularrivet,fixthebeltholdingthelooponthemedialside,atanangleof45°passingthroughtheposteriordistaltipofthecalcaneum.
Theloopshouldbeplacedoverthepolypropyleneandnotbeincontactwiththepatient’sleg.
4Insertthebeltthroughthelooptomeasuretherequiredlength.
Fixthestrapwithalargetubularrivetonthelateralside,atthesameangleof45°.
Coverthesurfaceofthestrapincontact
withthepatient’slegwith3mmEVA.
2.8.2 Varus/valgus correction
Thestrapwillpassthroughaslotcutinthepolypropylene.
4Theslotiscutonthelateralsideforvaruscorrectionandonthemedialsideforvalguscorrection.
Markthepositionoftheslot40mmfromthebackofthefootandperpendiculartoalinedrawnatanangleof45°passingthroughtheposteriordistaltipofthecalcaneum.
Theslotshouldbe30mmlong.
��Manufac tur ing Guidel ines Ankle -Foot O r thosis
4Makeholesalongtheslotaxiswithadrillfittedwitha4mmbit.
4Withacutter,connecttheholeswitheachother.
Finally,smooththetrimlinewithafile.
4Theloopisplacedonthemedialsideforvaruscorrectionandonthelateralsideforvalguscorrection.
Fixthebeltholdingtheloopwithalargetubularrivet,atanangleof45°passingthroughtheposteriordistaltipofthecalcaneum.
Theloopshouldbeplacedoverthepolypropyleneandnotbeincontactwiththepatient’sleg.
4Insertthebeltthroughtheslotononesideandthroughtheloopontheothersidetomeasuretherequiredlength.
Fixthestrapwithalargetubularrivetjustoutsidetheslot.
Coverthesurfaceofthestrapincontactwiththepatient’slegwith3mmEVA.
�� ICRC Physical Rehabi l i tat ion Programme
AFO wITh TAMARACk FlExuRE JOINT TM3
2.9 Initial fitting and finishing
IfEVAfoamisused,glueittemporarilyinsidetheorthosis.
TheinitialfittingisperformedinaccordancewithP&Ostandards.
Carryouttherequiredmodificationsonthepolypropyleneandsmooththetrimline.
GluetheEVAcompletelyinsidethepolypropylene,cutoffthesurplusandsmooththetrimline.
3.1 Moulding of EVA
Followtheproceduredescribedinsection2.1(page8),orgoontothenextsectionifEVAisnotrequired.
3.2 Orthosis trim line
Followtheproceduredescribedinsection2.2.1(page9).
3.3 Plastic reinforcement
Posteriorreinforcementforgreaterplantarflexioncontrolisrequiredwhentheorthosisisintendedtopreventplantarflexion(notfullydescribedbelow).
Followtheproceduredescribedbelow,orgoontothenextsectionifplantarflexionisleftfree.
AsecondlayerofpolypropyleneforpositioningattheleveloftheAchillestendonismouldedatthesametimeasthemainlayer.
4Cutapieceofpolypropylene:• thickness,5mm;• width,2cm;• length,7cm.
��Manufac tur ing Guidel ines Ankle -Foot O r thosis
4Firstthereinforcement(heatedatthesametimeasthepolypropylene)isplacedontheplastermodel,thenthesecondlayerisvacuum-mouldedimmediatelytoobtainaperfectsealbetweenthetwolayers.
4UsethemouldingdummiestoformasnuglyfittingcavityfortheTamarackFlexureJointTM.
Nailthemverticallyontotheplastermodelsothatthemidpointislocatedontheankleaxis.
3.4 Installation of Tamarack Flexure JointTM
Ontheplastermodel,markthepositionofthejointaxis:• laterally,attheapexofthemalleoli;• medially,slightlyposteriortothedistaltipofthemalleoli.
Makesurethatthejointsareatthesamelevelonbothsides.
3.5 Vacuum moulding of the polypropylene
Followtheproceduredescribedinsection1.3(page6),takingintoaccountthepresenceorabsenceofaposteriorreinforcement(section3.3,page18).
Pullastocking(cottonstockinetistoothick)overtheplastermodel.
�0 ICRC Physical Rehabi l i tat ion Programme
3.6 Preparation of the polypropylene shell
Drawthetrimlineonthepolypropyleneasexplainedinsection3.2(page18).
Cutonlythecontouroftheorthosiswithanoscillatingsaw.Donotcutalongtheseparationbetweenfootsectionandcalfsection.
Removetheplasticshellfromtheplastermodel.
ExtractthemouldingdummiesandthestockingfrominsidetheAFO.
4Drawtheseparationlinebetweenthefootsectionandthecalfsection:• Markthemiddleofthecavitiescreated
bythedummies.• Drawa“V”anteriortothemidlineof
eachcavity.Ensurethatthe“V”doesnotextendbackwardspastthecentreofthecavity.
4ForAFOwith plantar flexion control,drawahorizontallineposteriortothemarksjoiningthetwosides.
4ForAFOwith free plantar flexion,drawa“V”posteriortothemidlineofeachcavity.Ensurethatthe“V”doesnotextendforwardpastthecentreofthecavity.
Correct Incorrect
��Manufac tur ing Guidel ines Ankle -Foot O r thosis
4Drillholesatthedimplesleftbytheholesinthemouldingdummies:• 5mmforlargesize;• 4.5mmforsmallsize.
4Useathin-bladedsaw(1/16’’bladekerforless)toseparatethefootsectionfromthecalfsection.
Do not use an oscillating saw because too much material is lost along a ragged, wide cut line.
Smooththetrimlineedgewithahanddeburringtoolorapieceofglass.Do not grind the trim line because this will reduce flexure coverage and reduce the ability of the cavity to anchor and control the flexure effectively.
4InserttheTamarackFlexureJointTMandsecurewithmetalfastenersandanchoringscrews.
Dependingonthethicknessofthepolypropylene,itmaybenecessarytoadjustthelengthofthescrewsiftheendsprotrudeinsidetheAFO.
�� ICRC Physical Rehabi l i tat ion Programme
3.7 Preparation of the straps
Fortheproximalstrap,followtheproceduredescribedinsection2.6(page14).
Insomecasesthepatientmightneedadistalstrap.Ifso,followtheproceduredescribedinsection2.7(page15).
3.8 Initial fitting and finishing
IfEVAfoamisused,glueittemporarilyinsidetheorthosis.
TheinitialfittingisperformedinaccordancewithP&Ostandards.
Carryouttherequiredmodificationsonthepolypropyleneandsmooththetrimline.
GluetheEVAcompletelyinsidethepolypropylene,cutofftheexcessandsmooththetrimline.
Gluetheflexureanchoringscrewswitharemovablethread-lockingcompound(Loctite).
AFO ANTI-TAluS (ANTERIOR ShEll)4
4.1 Moulding of EVA
EVA(6mm)maybemouldedpriortodrapingofthepolypropylene:• toimprovecomfort;• topreventskinbreakageforpatientswithsensationloss.
Do not cover the foot, to avoid an increase of volume which may prevent the patient from wearing normal shoes.
Followtheproceduredescribedbelow,orgoontothenextsectionifthecasedoesnotrequireEVA.
Positiontheplastermodelwiththeforefootpointingupwards.
4CutapieceofEVA:• width,calfcircumference;• length,leglength;• thickness,6mm.
HeattheEVAat120°for3to5minutes,dependingontheefficiencyoftheoven.
DrapetheEVAovertheplastermodelmanuallyandholditinplaceuntilithascooledcompletely.
��Manufac tur ing Guidel ines Ankle -Foot O r thosis
4Cutofftheexcesswithacutterorapairofscissors.
Grindthedistaltrimlinetograduallyreduceitsthickness.
StapletheEVAontothebackoftheplastermodel.
4Marktheorthosistrimlineasfollows:
A Thetopmustbehorizontal,2cmbelowthetibialtubercle.
B Ontheleg,1cmposteriortothemid-line.
C Ontheankle,atthetopofthemalleolitofacilitatedonning.
D Ontheforefoot,clearthesidesandtopofthetoesandtheheadofthemetatarsuscompletely,passingbelowthem.This will allow the polypropylene to follow the movement of the metatarso-phalangeal joints.
4.2 Orthosis trim line
��
2
1
3
ICRC Physical Rehabi l i tat ion Programme
4.3 Plastic reinforcement
Thepresenceofchannelsintheplasticsignificantlyimprovesitsstrength.Thereareseveralwaysofmakingthesechannels.
4CuttwostripsofEVA:• thickness,6mm;• width,10mm;• length,20cm.
Grindbothdistalandproximalendstograduallyreducetheirthickness.
Gluethestripsontotheplastermodel,1cmanteriortothelateralandmediallongitudinalaxes.
Reinforcements prolonged along the side of the mid-foot increase the volume of the orthosis so that it may no longer fit into the patient’s shoe.
4.4 Vacuum moulding of the polypropylene
The procedure described below ensures uniform thickness of the polypropylene all over the orthosis. Do not try to make a single seam on the anterior side, because the creases gathering at the ankle will make it necessary to stretch the polypropylene too thinly.
Ifthishasnotyetbeendone,pullastockingovertheplastermodel.For maximum efficiency the EVA used to channel the polypropylene must not be covered with a stocking.
Dustthestockingwithtalcumpowder.
Measurementofthepolypropylenesheet:
� Calfcircumference+10cm.� Instepcircumference+10cm.� Legandfootlength+10cm.
PPthickness:4mmor5mm,dependingonthepatient’sweight.
��Manufac tur ing Guidel ines Ankle -Foot O r thosis
Heatthepolypropyleneat180°for20to25minutes,dependingonthethicknessofthepolypropyleneandtheefficiencyoftheoven.
Drapethepolypropyleneovertheplastermodelandstickittogetheralongtheposteriorsideandunderthefoot.
Tightenthepolypropylenearoundthesuctionconewitharopeorsomethingsimilar.
Openthevacuumvalve.
4Cutofftheexcesswithapairofscissorswhilethepolypropyleneisstillhot.
Keepthevacuumonuntilthepolypropylenecoolsdown.
4.5 Preparation of the polypropylene shell
Drawthetrimlineonthepolypropyleneasexplainedinsection4.2(page23).
Cuttheorthosiswithanoscillatingsaw,followingtheoutline.
Removetheplasticshellfromtheplastermodel.
RemovethestockingfrominsidetheAFO.
Grindtheorthosistrimlineandsmoothit.
IfEVAhasbeenmouldedbeforehand,transferthetrimlinetotheEVAandcutofftheexcesswithapairofscissors.
�� ICRC Physical Rehabi l i tat ion Programme
4.7 Initial fitting
IfEVAfoamisused,glueittemporarilyinsidetheorthosis.
TheinitialfittingisperformedinaccordancewithP&Ostandards.
4Itisoftennecessarytoflarethepolypropyleneattheposteriorpartoftheheelinordertofacilitatedonningandtoavoidpainfulcontactwiththeedgeoftheplastic.
4.6 Preparation of the straps
Fortheproximalstrap,followtheproceduredescribedinsection2.6(page14).
Insomecasesthepatientmightneedadistalstrap.Ifso,followtheproceduredescribedinsection2.7(page15).
4.8 Finishing
Carryouttherequiredmodificationsonthepolypropyleneandsmooththetrimline.
GluetheEVAinsidethepolypropylene,cutoffthesurplusandsmooththetrimline.
��Manufac tur ing Guidel ines Ankle -Foot O r thosis
ICRC Code Description Unit of measure Quantity
For negative and positive cast :ODROSTOCOT60 Tubular stockinet, 60 cm cm 70According to size:• MDREBANDP10• MDREBANDP12• MDREBANDP15
Plaster of Paris bandages10, 12 or 15 cm x 3 m
Piece 3
OTOOPLASPW40 Plaster of Paris powder Each As requiredFor EVA and plastic moulding :If required, according to colour:• OPLAEVAFERA06• OPLAEVAFLIV06• OPLAEVAFKIN06
EVA 6 mmTerra, olive or beige colour
Each As required
None Nylon stockinet Piece 1According to colour and thickness:• OPLAPOLYCHOC03• OPLAPOLYCHOC04• OPLAPOLYCHOC05• OPLAPOLYLIV03• OPLAPOLYLIV04• OPLAPOLYLIV05• OPLAPOLYSKIN03• OPLAPOLYSKIN04• OPLAPOLYSKIN05
HomopolymerTerra, olive or beige colour3, 4 or 5 mm thickness
Each As required
For the TAMARACK Flexure JointTM:According to size:• OCPOSOOTTAL• OCPOSOOTTAS
Large size (740L)Small size (740S)
Piece 1
EHDWGLUEL243 Glue, Loctite 243, blue, threadlock, 50-ml bottle As required 4For the proximal strap:OSBOSTRVP440 Strap, Velcro, PVC, with loop, brown, 400 x 40 mm Piece 1OHDWRIVET131 Rivet, tubular, 13 mm x 12 mm Piece 2
orOSBOVSBO30 Strap, polyester, black, 40 mm cm 25None Strap, Velcro, 40 mm cm 20None Loop, 40 mm x 100 pieces Piece 1OHDWRIVET131 Rivet, tubular, 13 mm x 12 mm Piece 2For distal/instep strap:OSBOSTRVP325 Strap, Velcro, PVC, with loop, brown, 300 mm x 25 mm Piece 1OHDWRIVET131 Rivet, tubular, 13 mm x 12 mm Piece 2
orOSBOVSBO24 Strap, Perlon webbing, 25 mm cm 20None Strap, Velcro, 25 mm cm 15OSBOVSBO35 Loop, 25 mm x 100 pieces Piece 1OHDWRIVET131 Rivet, tubular, 13 mm x 12 mm Piece 2
list of manufacturing materials
MISSION
The International Committee of the Red Cross (ICRC) is an impartial, neutral and independent organization whose exclusively humanitarian mission is to protect the lives and dignity of victims of war and internal violence and to provide them with assistance. It directs and coordinates the international relief activities conducted by the Movement in situations of conflict. It also endeavours to prevent suffering by promoting and strengthening humanitarian law and universal humanitarian principles. Established in 1863, the ICRC is at the origin of the International Red Cross and Red Crescent Movement.
Acknowledgements:
Jean François GallayLeo GasserPierre GauthierFrank JoumierJacques LepetitBernard MatagneJoel NiningerGuy NuryPeter PoetsmaHmayak Tarakhchyan
and all prosthetists-orthotists who have worked in ICRC-assisted physical rehabilitation centres.
International Committee of the Red Cross19 Avenue de la Paix1202 Geneva, SwitzerlandT + 41 22 734 60 01 F + 41 22 733 20 57E-mail: [email protected]© ICRC, September 2006All photographs: ICRC/PRP
Physical Rehabilitation Programmeankle-Foot orthosis
Manufacturing guidelines
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Physical Rehabilitation Programme
Patellar tendon-bearing orthosis
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Manufacturing guidelines
MISSION
The International Committee of the Red Cross (ICRC) is an impartial, neutral and independent organization whose exclusively humanitarian mission is to protect the lives and dignity of victims of war and internal violence and to provide them with assistance. It directs and coordinates the international relief activities conducted by the Movement in situations of conflict. It also endeavours to prevent suffering by promoting and strengthening humanitarian law and universal humanitarian principles. Established in 1863, the ICRC is at the origin of the International Red Cross and Red Crescent Movement.
Acknowledgements:
Jean François GallayLeo GasserPierre GauthierFrank JoumierJacques LepetitBernard MatagneJoel NiningerGuy NuryPeter PoestmaHmayak Tarakhchyan
and all prosthetists-orthotists who have worked in ICRC-assisted physical rehabilitation centres.
International Committee of the Red Cross19 Avenue de la Paix1202 Geneva, SwitzerlandT + 41 22 734 60 01 F + 41 22 733 20 57E-mail: [email protected]© ICRC, September 2006All photographs: ICRC/PRP
�Manufac tur ing Guidel ines Patel lar Tendon-B ear ing O r thosis
Table of contents
Foreword 2Introduction 4Choosingbetweentwomethods 41.Castingandrectification 52.PTBOwithanterior-closingshell 6
2.1EVApreparationforincreasedweightrelief 62.2MouldingofEVA 72.3Orthosistrimline 82.4Plasticreinforcement 92.5Posteriorshell 102.6.Anteriorshell 122.7Preparationforinitialfitting 142.8Initialfittingandfinishing 17
3.PTBOwithposterior-closingshell 193.1EVApreparationforincreasedweightrelief 193.2MouldingofEVA 203.3Orthosistrimline 213.4Plasticreinforcement 223.5Anteriorshell 223.6Posteriorshell 253.7Preparationforinitialfitting 263.8Initialfittingandfinishing 27
Listofmanufacturingmaterials 28
� ICRC Physical Rehabi l i tat ion Programme
Foreword
The ICRC polypropylene technology
Sinceitsinceptionin1979,theICRC’sPhysicalRehabilitationProgrammehaspromotedtheuseoftechnologythatisappropriatetothespecificcontextsinwhichtheorganizationoperates,i.e.,countriesaffectedbywarandlow-incomeordevelopingcountries.
Thetechnologymustalsobetailoredtomeettheneedsofthephysicallydisabledinthecountriesconcerned.
Thetechnologyadoptedmustthereforebe:
• durable,comfortable,easyforpatientstouseandmaintain;• easyfortechnicianstolearn,useandrepair;• standardizedbutcompatiblewiththeclimateindifferentregionsoftheworld;• low-costbutmodernandconsistentwithinternationallyacceptedstandards;• easilyavailable.
Thechoiceoftechnologyisofgreatimportanceforpromotingsustainablephysicalrehabilitationservices.
Forallthesereasons,theICRCpreferredtodevelopitsowntechniqueinsteadofbuyingready-madeorthopaediccomponents,whicharegenerallytooexpensiveandunsuitedtothecontextsinwhichtheorganizationworks.ThecostofthematerialsusedinICRCprostheticandorthoticdevicesislowerthanthatofthematerialsusedinappliancesassembledfromcommercialready-madecomponents.
WhentheICRClauncheditsphysicalrehabilitationprogrammesbackin1979,locallyavailablematerialssuchaswood,leatherandmetalwereused,andorthopaediccomponentsweremanufacturedlocally.Intheearly1990stheICRCstartedtheprocessofstandardizingthetechniquesusedinitsvariousprojectsaroundtheworld,forthesakeofharmonizationbetweentheprojects,butmoreimportantlytoimprovethequalityofservicestopatients.
Polypropylene(PP)wasintroducedintoICRCprojectsin1988forthemanufactureofprostheticsockets.Thefirstpolypropyleneknee-jointwasproducedinCambodiain1991;othercomponentssuchasvariousalignmentsystemswerefirstdevelopedinColombiaandgraduallyimproved.Inparallel,adurablefoot,madeinitiallyofpolypropyleneandEthylVinylAcetate(EVA),andnowofpolypropyleneandpolyurethane,replacedthetraditionalwooden/rubberfoot.
In1998,aftercarefulconsideration,itwasdecidedtoscaledownlocalcomponentproductioninordertofocusonpatientcareandtrainingofpersonnelatcountrylevel.
�Manufac tur ing Guidel ines Patel lar Tendon-B ear ing O r thosis
Objective of the manuals
TheICRC’s“ManufacturingGuidelines”aredesignedtoprovidetheinformationnecessaryforproductionofhigh-qualityassistivedevices.
Themainaimsoftheseinformativemanualsareasfollows:
• TopromoteandenhancestandardizationofICRCpolypropylenetechnology;• Toprovidesupportfortrainingintheuseofthistechnology;• Topromotegoodpractice.
Thisisanotherstepforwardintheefforttoensurethatpatientshaveaccesstohigh-qualityservices.
ICRCAssistanceDivision/HealthUnitPhysicalRehabilitationProgramme
� ICRC Physical Rehabi l i tat ion Programme
Choosing between two methods
Thefollowingindicationsmighthelpinmakingachoicebetweenthetwopossiblemethods.
Weight relief: partial or complete?
Accordingtotheprescriptionand/orthepathology,theorthosismustpartiallyorcompletelyrelievetheweightappliedontheleg.
Tothisend,alayerofEVAisaddedunderthefootpriortothedrapingofthepolypropylene.
Thefollowingfiguresgivearoughestimateofthedegreeofweightrelief:• NoEVA:70%oftheweightonthelegand30%ontheorthosis.• 3mmEVA:50%onthelegand50%ontheorthosis.• 6mmEVA:30%onthelegand70%ontheorthosis.• 12mmEVA:0%onthelegand100%ontheorthosis.
Introduction
Theaimofthisdocumentistodescribetwomethodsforproducingpatellar tendon-bearing (PTB) orthoses,workingwiththeICRCpolypropylenetechnologyandorthopaediccomponentsusedattheICRC’sphysicalrehabilitationcentres.
Anterior-closing shell Posterior-closing shellWeak at ankle level, especially for heavy patients or patients walking with ankle dorsiflexion.
Strong at ankle level, thus suitable for overweight patients or patients walking with ankle dorsiflexion.
Easy to fit into normal shoes.Sometime difficult to fit into normal shoes because of the volume of the orthosis at mid-foot.
�Manufac tur ing Guidel ines Patel lar Tendon-B ear ing O r thosis
Patientassessment,castingandrectificationofpositivecastimpressionsareperformedinaccordancewithprostheticandorthotic(P&O)standards,takingintoaccountthefollowingpoints:• Theproximalpartismanufacturedlikeatrans-tibialprosthesisandensurestheweight-bearing
function.• Thedistalpartismanufacturedlikeanankle-footorthosis.• Theremustbelittleornoweightborneonthelegwhilethecastisbeingtaken.• Inthemethodinvolvingaposterior-closingshell,theEVAusedtoincreaseweightreliefisplaced
onlyundertheheel,soitaffects the position of the cast(seesection3.1,page19).
CasTIng and ReCTIFICaTIOn1
� ICRC Physical Rehabi l i tat ion Programme
2.1 eVa preparation for increased weight relief
Followtheproceduredescribedbelow,orgoontothenextsectionifthepatientdoesnotrequireadditionalweightrelief.
PTBO WITh anTeRIOR-ClOsIng shell2
4PlacetheplastermodelontheEVAsheetanddrawalinearoundit1cmwiderthanthefoot.
4Holdtheplastermodelinavice.
HeattheEVAat120°for3to5minutes,dependingonitsthicknessandontheefficiencyoftheoven.
PuttheEVAunderthefootandholditfirmlyinplacewithanelasticbandageforoneminute.
GrindtheedgeoftheEVAuntilitisperfectlyalignedwiththeshapeoftheplastermodel.
�Manufac tur ing Guidel ines Patel lar Tendon-B ear ing O r thosis
6GluetheEVAundertheplastermodel.
2.2 Moulding of eVa
EVA(6mm)canbemouldedpriortodrapingofthepolypropylene:• toimprovecomfort;• topreventskinbreakageinpatientswithsensationloss.
Followtheproceduredescribedbelow,orgoontothenextsectionifEVAisnotrequired.
4Positiontheplastermodelwiththeforefootpointingdownwards.
CutapieceofEVA:• width,kneecircumference;• length,thelengthoftheplaster
model(leg+foot);• thickness,6mm.
HeattheEVAat120°for3to5minutes,dependingontheefficiencyoftheoven.
DrapetheEVAovertheplastermodelmanuallyandholditinplaceuntilithascompletelycooled.
� ICRC Physical Rehabi l i tat ion Programme
2.3 Orthosis trim line
4Cutofftheexcesswithacutterorapairofscissors.
StapletheEVAontothefrontoftheplastermodel.
4Marktheorthosistrimlineasfollows:
A Thetopmustbehorizontal,6cmabovethepatellatendongroove.
B Thepatellaandthehamstringtendonsareleftfree.
C Theshelloverlapstheantero-posteriormid-lineby1.5cm.
D Attheankle,keeptheline1cmanteriortothetopofthemalleoli.
E Theusualdistallimitoftheanteriorshellishorizontal,at1/3ofthelengthoftheleg,butmaybelongertoprovidegreaterprotection.
F Attheforefoot,clearthesidesofthetoesandtheheadofthemetatarsuscompletely,passingbeneaththem.This will allow the polypropylene to follow the movement of the metatarso-phalangeal joints.
�Manufac tur ing Guidel ines Patel lar Tendon-B ear ing O r thosis
2.4 Plastic reinforcement
Theorthosismayneedreinforcement,especiallyatanklelevel.Ifthisisthecase,followoneoftheproceduresdescribedbelow;otherwisegoontothenextsection.
2.4.1 double layer of polypropylene
4Asecondlayerofpolypropylenecoveringtheankleandthefootismouldedatthesametimeasthemainlayer.
Cutapieceofpolypropylene:• thickness,3mm;• width,instepcircumference;• length,lengthoffoot+10cm.
Grindthelast3cmattheproximalendtograduallyreducethethicknessofthepolypropylene.
4Thetwolayersareheatedatthesametime.
Thereinforcementisplacedontheplastermodel,thenthesecondlayerisvacuum-mouldedimmediatelyafterwardstoobtainaperfectsealbetweenthetwolayers.
The double layer of polypropylene has the disadvantage of reducing flexibility of the forefoot in relation to the metatarso-phalangeal joint.
�0 ICRC Physical Rehabi l i tat ion Programme
2.4.2 lateral reinforcements (channels)
4CuttwobandsofEVA:• thickness,6mm;• width,7mm;• length,15cm.
Pullastockingovertheplastermodel.
Gluethebandlightlyontothestocking.
The more anterior the position of the channel, the more the device will resist dorsiflexion of the ankle.
Reinforcements prolonged along the side of the mid-foot increase the volume of the orthosis so that it may no longer fit into the patient’s shoe.
2.5 Posterior shell
2.5.1 Vacuum moulding of polypropylene
Ifthishasnotalreadybeendone,pullastockingovertheplastermodel.For maximum efficiency, the EVA used to channel the polypropylene must not be covered with a stocking.
Dustthestockingwithtalcumpowder.
Measurementofthepolypropylenesheet:
� Kneecircumference+10cm.� Instepcircumference+10cm.� Legandfootlength+10cm.
Thickness,4mmor5mm,dependingonthepatient’sweight.
2
1
3
��Manufac tur ing Guidel ines Patel lar Tendon-B ear ing O r thosis
Heatthepolypropyleneat180°for20to25minutes,dependingonthethicknessofthepolypropyleneandtheefficiencyoftheoven.
Drapethepolypropyleneovertheplastermodelandstickittogetheralongtheanteriorside.
Tightenthepolypropylenearoundthesuctionconewitharopeorsomethingsimilar.
Openthevacuumvalve.
4Cutofftheexcesswithapairofscissorswhilethepolypropyleneisstillhot.
2.5.2 Preparation of the posterior shell
Drawthetrimlineonthepolypropyleneasexplainedinsection2.3(page8).
Cuttheorthosiswithanoscillatingsaw,followingtheoutline.
Removetheshellgentlytoavoiddamagingtheproximalpartoftheplastermodel,asitwillbeusedtomouldthesecondshell.
Removethestockingfrominsidetheorthosis.
Grindthetrimlineandsmoothit.
IfanEVAhasbeenmoulded,transferthetrimlinetotheEVAandcutofftheexcesswithapairofscissors.
Before moulding the second shell, keep an angle of 90° at the corner of the anterior/proximal trim line because a rounded shape would create a notch in the polypropylene of the posterior shell which might prevent proper functioning of the hinged joint.
Keepthevacuumonuntilthepolypropylenecoolsdown.
�� ICRC Physical Rehabi l i tat ion Programme
2.6 anterior shell
Repairtheproximalpartoftheplastermodelifnecessary.
2.6.1 Moulding eVa
Toimprovecomfort,6mmEVAcanbemouldedpriortodrapingofthepolypropylene,whetherornotthesamehasbeendonefortheothershell.
Followtheproceduredescribedbelow,orgoontothenextsectionifEVAisnotrequired.
4CutapieceofEVA6mmthickandlargeenoughtocovertheproximalhalfoftheplastermodel.
HeattheEVAat120°for3to5minutes,dependingontheefficiencyoftheoven.
PuttheEVAovertheplastermodelandholdittightlyinplacewithanelasticbandageforoneminute.
4RemovetheEVAandcutit,followingthetrimline.
Takethepolypropyleneshell(withitsEVA)andfixthenewlymouldedEVAwithtwostaplesclosetotheproximal/medialtrimline.
��Manufac tur ing Guidel ines Patel lar Tendon-B ear ing O r thosis
2.6.2 Vacuum moulding of polypropylene on the anterior shell
4GlueastripofEVA6mmthickand3cmwidearoundthemiddleoftheplastermodel.The polypropylene draping will stop at this level, where the rope tightened around the EVA will ensure a sufficient vacuum.
GlueanotherstripofEVA6mmthickand3cmwideonthemiddleofthefirstpolypropyleneshellatrightanglestothefirststrip.This will allow the polypropylene to be cut after draping without damaging the shell beneath.
Coverwithastockingtheareareceivingthepolypropylene.Do not cover the strip of EVA where the rope will be tightened because the vacuum may leak through the stocking mesh.
Placetheplastermodelwiththeforefootpointingupwards.
Dustthestockingwithtalcumpowder.
Cutapieceofpolypropylene:• width,kneecircumference+5cm;• length,halftheleglength+10cm;• thickness,4mmor5mm,dependingonthepatient’sweight.
Heatthepolypropyleneat180°for15to20minutes,dependingonthethicknessofthepolypropyleneandtheefficiencyoftheoven.
4DrapethepolypropyleneovertheplastermodelandstickittogetheralongthelongitudinalstripofEVA.
Tightenthepolypropylenearoundthesuctioncone.
Openthevacuumvalve.
Cutofftheexcesswithapairofscissorswhilethepolypropyleneisstillhot.
Keepthevacuumonuntilthepolypropylenecoolsdown.
�� ICRC Physical Rehabi l i tat ion Programme
2.6.3 Preparation of the anterior shell
Drawthetrimlineonthepolypropyleneasexplainedinsection2.3(page8).
CutcarefullyalongtheEVAstripinthemiddleoftheposteriorshellwithanoscillatingsaw.
Removetheposteriorshellfromtheplastermodel.
Removethestockingfrominsidetheorthosisandcutofftheexcesswithajigsaw.
Grindthetrimlineandsmoothit.
IfanEVAsheethasbeenmoulded,transferthetrimlinetotheEVAandcutofftheexcesswithapairofscissors.
2.7 Preparation for initial fitting
2.7.1 Preparation of the hinged joint
4SecurethetwoshellsontheplastermouldwithScotchtape.
Markthepositionofthehingedjointonthelateralandmedialsides:• 4.5cmabovethepatellartendon
groove;• inthemiddleoftheantero-
posteriordiameter.
Makesurethatthehingedjointsonbothsidesareatthesamelevel.
��Manufac tur ing Guidel ines Patel lar Tendon-B ear ing O r thosis
4Drillahole3mmindiameterthroughbothshells.
4Assembletheanteriorandposteriorshellswith2slottedscrewsandnuts3mmindiameter(headinside).
Cutandgrindtheboltprotrudingfromthenut.
2.7.2 Proximal strap
Useaready-madeVelcrostrap25mmwide,ormakeastrapwithnylonwebbingorsomeotherstrongmaterial.
4Withatubularrivet,fixthebeltholdingthelooponthemedialsideoftheposteriorshell,atthedistallimitoftheanteriorshell.
Theloopshouldbelocated5mmfromtheanteriorshell.
�� ICRC Physical Rehabi l i tat ion Programme
4Insertthebeltthroughthelooptomeasurethelength.
Fixthestrapwithatubularrivetonthelateralside.
Makesurethestrapisperfectlyhorizontalbeforefixingit.
2.7.3 distal strap
Thisstrapisnotalwaysneeded.Thedecisiontoinstallitorotherwisewilldependonthecapacityofthepatient’sshoetoholdthefootinsidetheorthosis.
Usea25mmVelcrostrap.
4Withalargetubularrivet,fixthebeltholdingthelooponthemedialside,4cmabovethemalleoli.
Theloopshouldbeplacedonthepolypropyleneandnotbeincontactwiththepatient’sleg.
4Fixthestrapwithalargetubularrivetonthelateralside.Makesurethestrapisperfectlyhorizontalbeforefixingit.
Coverthesurfaceofthestrapincontactwiththepatient’slegwith3mmEVA.
2.7.4 Preparation of the eVa
IfEVAisused,glueittemporarilyinsidetheorthosis.
��Manufac tur ing Guidel ines Patel lar Tendon-B ear ing O r thosis
2.8 Initial fitting and finishing
4Thepatientputsontheorthosisbyopeningtheanteriorshellandslidinghis/herfootthroughtheproximalend.
TheinitialfittingisperformedinaccordancewithP&Ostandards,takingthefollowingpointsintoaccount.
• Shouldthepatient’slegslipthroughthebrim,theproximalpartcanbepaddedwithEVAtodecreaseitswidth.
• Whilethepatientisstanding,checkthedegreeofweightrelief.• Aheelliftonthecontrolateralsidemightbeneededtoaccommodatetheincreaseinlengthofthe
legwiththeorthosis.
2.8.1 Finishing of the polypropylene
4Roundoffthecornersofbothanteriorandposteriorshells.
Carryoutanymodificationsrequiredonthepolypropyleneandsmooththetrimline.
GluetheEVAcompletelyinsidethepolypropylene,cutofftheexcessandsmooththetrimline.
�� ICRC Physical Rehabi l i tat ion Programme
2.8.2 Finishing of the hinged joint
Usetwocopperrivets3mmindiameterwithtwobrassorstainlesssteelwashers.
Removethe3mmboltononesideofeachrivet.
Heatthecopperrivetwithaweldinggunand“stamp”itsheadintothepolypropyleneoftheanteriorshellinordertocreatedepressionstocountersinktherivethead.
4Placetherivetheadonananvilandhammergentlyonthepartoftherivetprotrudingfromthewasherinordertocreateasmooth,roundedshapeasshownonthepicture.Usearivetsettorounditoff.
Inserttherivet,headinside,andinstallthewasheroutside.
Cuttherivetwithdouble-actioncuttingpliersorside-cuttingplierssothatonly2mmprotrudesfromthewasher.
Dothesamefortheotherside.
��Manufac tur ing Guidel ines Patel lar Tendon-B ear ing O r thosis
PTBO WITh POsTeRIOR-ClOsIng shell3
3.1 eVa preparation for increased weight relief
The EVA is placed only under the posterior part of the foot, in order to avoid an increase in volume at the mid-foot which may prevent the patient from wearing normal shoes.
Followtheproceduredescribedbelow,orgoontothenextsectionifthepatientdoesnotrequireadditionalweightrelief.
4PlacethemetatarsalheadoftheplastermodelattheedgeoftheEVAsheetanddrawalinearoundit1cmwiderthanthefoot.
4Holdtheplastermodelinavice.
HeattheEVAat120°for3to5minutes,dependingonthethicknessoftheEVAandtheefficiencyoftheoven.
PuttheEVAundertheposteriorpartofthefootandholditfirmlyinplaceforoneminutewithanelasticbandage.
�0 ICRC Physical Rehabi l i tat ion Programme
GrindtheedgeoftheEVAuntilitisperfectlyaligned,aroundandbelow,withtheshapeoftheplastermodel.
6GluetheEVAundertheplastermodel.
3.2 Moulding of eVa
EVA(6mm)canbemouldedpriortodrapingofthepolypropylenetoimprovecomfort.
Do not cover the foot, as this would create an increase of volume which might prevent the patient from wearing normal shoes.
Followtheproceduredescribedbelow,orgoontothenextsectionifEVAisnotrequired.
Placetheplastermodelwiththeforefootpointingupwards.
4CutapieceofEVA:• width,kneecircumference;• length,leglength;• thickness,6mm.
HeattheEVAat120°for3to5minutes,dependingontheefficiencyoftheoven.
DrapetheEVAovertheplastermodelmanuallyandholditinplaceuntilithascooledcompletely.
��Manufac tur ing Guidel ines Patel lar Tendon-B ear ing O r thosis
4Cutofftheexcesswithacutterorapairofscissors.
Grindthedistaltrimlinetograduallyreduceitsthickness.
StapletheEVAontothebackoftheplastermodel.
3.3 Orthosis trim line
4Markthetrimlineasfollows:
A Thetopmustbehorizontal,6cmabovethepatellatendongroove.
B Thepatellaandthehamstringtendonsareleftfree.
C Theshelloverlapstheantero-posteriormid-lineby1.5cm.
D Attheankle,thelinemustremainabovethemalleolitofacilitatedonning.
E Theusualdistallimitoftheposteriorshellishorizontal,at1/3ofthelengthoftheleg,butitmaybelongertoprovidegreaterprotection.
F Attheforefoot,clearthesideandthetopofthetoesandtheheadofthemetatarsuscompletely,passingbeneaththem.This will allow the polypropylene to follow the movement of the metatarso-phalangeal joints.
�� ICRC Physical Rehabi l i tat ion Programme
3.4 Plastic reinforcement
Lateralreinforcements(channels)significantlyimprovethestrengthoftheorthosis.Thereareseveralwaysofmakingthesereinforcements.
4CuttwostripsofEVA:• width10mm;• length20cm;• thickness,6mm.
Grindbothdistalandproximalendstograduallyreducetheirthickness.
Gluethestripsontotheplastermodel,1cmanteriortothelateralandmediallongitudinalaxis.
Reinforcements prolonged along the side of the mid-foot increase the volume of the orthosis so that it may no longer fit into the patient’s shoe.
3. 5 anterior shell
3.5.1 Vacuum moulding of polypropylene
The procedure described below ensures uniform thickness of the polypropylene all over the orthosis. Do not try to make a single seam on the anterior side, because the creases gathering at ankle level will make it necessary to stretch the polypropylene too thinly.
Ifthishasnotyetbeendone,pullastockingovertheplastermodel.For maximum efficiency the EVA used to channel the polypropylene must not be covered with a stocking.
Dustthestockingwithtalcumpowder.
��
2
1
3
Manufac tur ing Guidel ines Patel lar Tendon-B ear ing O r thosis
Measurementofthepolypropylenesheet:
� Kneecircumference+10cm.� Instepcircumference+10cm.� Legandfootlength+10cm.
Thickness,4mmor5mm,dependingonthepatient’sweight.
Heatthepolypropyleneat180°for20to25minutes,dependingonthethicknessofthepolypropyleneandtheefficiencyoftheoven.
Drapethepolypropyleneovertheplastermodelandstickittogetheralongtheposteriorsideandunderthefoot.
Tightenthepolypropylenearoundthesuctioncone.
Openthevacuumvalve.
4Cutofftheexcesswithapairofscissorswhilethepolypropyleneisstillhot.
Keepthevacuumonuntilthepolypropylenecoolsdown.
�� ICRC Physical Rehabi l i tat ion Programme
3.5.2 Preparation of the anterior shell
Drawthetrimlineonthepolypropyleneasexplainedinsection3.3(page21).
Cuttheorthosiswithanoscillatingsaw,followingtheoutline.Toremovetheshell,itmightbenecessarytobreakthedistalpartoftheplastermodelbelowtheankle.However,caremustbetakennottodamagetheproximalpart,whichisneededtomouldthesecondshell.
Removethestockingfrominsidetheorthosis.
Grindtheorthosistrimlineandsmoothit.
IfanEVAhasbeenmoulded,transferthetrimlinetotheEVAandcutofftheexcesswithapairofscissors.
Before moulding the second shell, keep an angle of 90° at the corner of the posterior/proximal trim line because a rounded shape would create a notch in the polypropylene of the posterior shell which might prevent proper functioning of the hinged joint.
��Manufac tur ing Guidel ines Patel lar Tendon-B ear ing O r thosis
3.6 Posterior shell
Repairtheupperhalfoftheplastermodelifnecessary.
3.6.1 Moulding eVa
Followtheproceduredescribedinsection2.6.1(page12).
3.6.2 Vacuum moulding of polypropylene on the posterior shell
Followtheproceduredescribedinsection2.6.2(page13).
3.6.3 Preparation of the posterior shell
Drawthetrimlineonthepolypropyleneasexplainedinsection3.3(page21).
CutcarefullyalongtheEVAstripinthemiddleoftheanteriorshellwithanoscillatingsaw.
Removetheposteriorshellfromtheplastermodel.
Removethestockingfrominsidetheorthosisandcutofftheexcesswithajigsaw.
Grindthetrimlineandsmoothit.
IfEVAhasbeenmoulded,transferthetrimlinetotheEVAandcutofftheexcesswithapairofscissors.
�� ICRC Physical Rehabi l i tat ion Programme
3.7 Preparation for initial fitting
3.7.1 Preparation of the hinged joint
Followtheproceduredescribedinsection2.7.1(page14).
3.7.2 Preparation of the straps
Followtheproceduredescribedinsection2.7.2(page15)fortheproximalstrap,andsection2.7.3(page16)forthedistalstrap.
3.7.3 Preparation of eVa
IfEVAisused,glueittemporarilyinsidetheorthosis.
��Manufac tur ing Guidel ines Patel lar Tendon-B ear ing O r thosis
3.8 Initial fitting and finishing
Seesection2.8(page17).
4Itisoftennecessarytoflarethepolypropyleneattheposteriorpartoftheheelinordertofacilitatedonningandtoavoidpainfulcontactwiththeedgeoftheplastic.
�� ICRC Physical Rehabi l i tat ion Programme
ICRC Code Description Unit of measure Quantity
For negative and positive cast :ODROSTOCOT60 Tubular stockinet, 60 cm Cm 70According to size:• MDREBANDP10• MDREBANDP12• MDREBANDP15
Plaster of Paris bandages10, 12 or 15 cm x 3 m
Piece 3
OTOOPLASPW40 Plaster of Paris powder Each As requiredFor EVA and plastic moulding :If required, according to colour:• OPLAEVAFERA06• OPLAEVAFLIV06• OPLAEVAFKIN06
EVA 6 mmTerra, olive or beige colour
Each As required
None Nylon stockinet Piece 1According to colour and thickness:• OPLAPOLYCHOC04• OPLAPOLYCHOC05• OPLAPOLYLIV04• OPLAPOLYLIV05• OPLAPOLYSKIN04• OPLAPOLYSKIN05
HomopolymerTerra, olive or beige colour,4 or 5 mm thick
Each As required
For the strap:OSBOSTRVP325 Strap, Velcro, PVC, with loop, brown, 300 mm x 25 mm Piece 1OHDWRIVET131 Rivet, tubular, 13 mm x 12 mm Piece 2
orOSBOVSBO24 Strap, Perlon webbing, 25 mm Cm 25None Strap, Velcro, 25 mm Cm 20OSBOVSBO35 Loop, 25 mm x 100 pieces Piece 1OHDWRIVET131 Rivet, tubular, 13 mm x 12 mm Piece 2For the hinged joint:OHDWRIVEC032 Rivet, copper, 3 mm x 20 mm Piece 2OHDWWASHB133 Washer, brass, 13 mm dia. x 3.1 mm thick Piece 2
list of manufacturing materials
MISSION
The International Committee of the Red Cross (ICRC) is an impartial, neutral and independent organization whose exclusively humanitarian mission is to protect the lives and dignity of victims of war and internal violence and to provide them with assistance. It directs and coordinates the international relief activities conducted by the Movement in situations of conflict. It also endeavours to prevent suffering by promoting and strengthening humanitarian law and universal humanitarian principles. Established in 1863, the ICRC is at the origin of the International Red Cross and Red Crescent Movement.
Acknowledgements:
Jean François GallayLeo GasserPierre GauthierFrank JoumierJacques LepetitBernard MatagneJoel NiningerGuy NuryPeter PoetsmaHmayak Tarakhchyan
and all prosthetists-orthotists who have worked in ICRC-assisted physical rehabilitation centres.
International Committee of the Red Cross19 Avenue de la Paix1202 Geneva, SwitzerlandT + 41 22 734 60 01 F + 41 22 733 20 57E-mail: [email protected]© ICRC, September 2006All photographs: ICRC/PRP
Physical Rehabilitation Programmeankle-Foot orthosis
Manufacturing guidelines
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Physical Rehabilitation Programmeknee-ankle-Foot orthosis
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Manufacturing guidelines
International Committee of the Red Cross19 Avenue de la Paix1202 Geneva, SwitzerlandT + 41 22 734 60 01 F + 41 22 733 20 57E-mail: [email protected]© ICRC, September 2006All photographs: ICRC/PRP
MISSION
The International Committee of the Red Cross (ICRC) is an impartial, neutral and independent organization whose exclusively humanitarian mission is to protect the lives and dignity of victims of war and internal violence and to provide them with assistance. It directs and coordinates the international relief activities conducted by the Movement in situations of conflict. It also endeavours to prevent suffering by promoting and strengthening humanitarian law and universal humanitarian principles. Established in 1863, the ICRC is at the origin of the International Red Cross and Red Crescent Movement.
Acknowledgements:
Jean François GallayLeo GasserPierre GauthierFrank JoumierJacques LepetitBernard MatagneJoel NiningerGuy NuryPeter PoestmaHmayak Tarakhchyan
and all prosthetists-orthotists who have worked in ICRC-assisted physical rehabilitation centres.
�Manufac tur ing Guidel ines Knee -Ankle -Foot O r thosis
Table of contents
Foreword 2Introduction 41.Casting,measurementandrectification 42.Preparationofreinforcements 63.Polypropylenedrapingandvacuummoulding 74.Positionofthesidebars 95.Trimlines 116.Assemblyandparallelism 127.Initialfittings 138.Finishing 149.KAFOoptions 15Listofcomponentsandmaterials 16
� ICRC Physical Rehabi l i tat ion Programme
Foreword
The ICRC polypropylene technology
Sinceitsinceptionin1979,theICRC’sPhysicalRehabilitationProgrammehaspromotedtheuseoftechnologythatisappropriatetothespecificcontextsinwhichtheorganizationoperates,i.e.,countriesaffectedbywarandlow-incomeordevelopingcountries.
Thetechnologymustalsobetailoredtomeettheneedsofthephysicallydisabledinthecountriesconcerned.
Thetechnologyadoptedmustthereforebe:
• durable,comfortable,easyforpatientstouseandmaintain;• easyfortechnicianstolearn,useandrepair;• standardizedbutcompatiblewiththeclimateindifferentregionsoftheworld;• low-costbutmodernandconsistentwithinternationallyacceptedstandards;• easilyavailable.
Thechoiceoftechnologyisofgreatimportanceforpromotingsustainablephysicalrehabilitationservices.
Forallthesereasons,theICRCpreferredtodevelopitsowntechniqueinsteadofbuyingready-madeorthopaediccomponents,whicharegenerallytooexpensiveandunsuitedtothecontextsinwhichtheorganizationworks.ThecostofthematerialsusedinICRCprostheticandorthoticdevicesislowerthanthatofthematerialsusedinappliancesassembledfromcommercialready-madecomponents.
WhentheICRClauncheditsphysicalrehabilitationprogrammesbackin1979,locallyavailablematerialssuchaswood,leatherandmetalwereused,andorthopaediccomponentsweremanufacturedlocally.Intheearly1990stheICRCstartedtheprocessofstandardizingthetechniquesusedinitsvariousprojectsaroundtheworld,forthesakeofharmonizationbetweentheprojects,butmoreimportantlytoimprovethequalityofservicestopatients.
Polypropylene(PP)wasintroducedintoICRCprojectsin1988forthemanufactureofprostheticsockets.Thefirstpolypropyleneknee-jointwasproducedinCambodiain1991;othercomponentssuchasvariousalignmentsystemswerefirstdevelopedinColombiaandgraduallyimproved.Inparallel,adurablefoot,madeinitiallyofpolypropyleneandEthylVinylAcetate(EVA),andnowofpolypropyleneandpolyurethane,replacedthetraditionalwooden/rubberfoot.
In1998,aftercarefulconsideration,itwasdecidedtoscaledownlocalcomponentproductioninordertofocusonpatientcareandtrainingofpersonnelatcountrylevel.
�Manufac tur ing Guidel ines Knee -Ankle -Foot O r thosis
Objective of the manuals
TheICRC’s“ManufacturingGuidelines”aredesignedtoprovidetheinformationnecessaryforproductionofhigh-qualityassistivedevices.
Themainaimsoftheseinformativemanualsareasfollows:
• TopromoteandenhancestandardizationofICRCpolypropylenetechnology;• Toprovidesupportfortrainingintheuseofthistechnology;• Topromotegoodpractice.
Thisisanotherstepforwardintheefforttoensurethatpatientshaveaccesstohigh-qualityservices.
ICRCAssistanceDivision/HealthUnitPhysicalRehabilitationProgramme
� ICRC Physical Rehabi l i tat ion Programme
Introduction
Theaimofthisdocumentistodescribeamethodforproducingknee-ankle-foot orthoses (KAFO),workingwithpolypropylenetechnologyandcommercialuprightsidebarswithdroplocksasusedattheICRC’sphysicalrehabilitationcentres.
Thecastingandrectificationmethodsusedcorrespondtointernationalprostheticandorthotic(P&O)standardsofpracticeandarethereforenotdescribedintheseICRCmanufacturingguidelines.
Someimportantpointsshouldneverthelessbetakenintoaccount:
1.1 Anatomy and landmarks
4Malleoli
4The1stand5thmetatarsalheads
4Navicularbone
4Baseof5thmetatarsal,ifprominent
4Greattrochanter
4Medialtibialplateau
4Headoffibula
CAsTIng, meAsuRemenT And ReCTIFICATIOn1
�Manufac tur ing Guidel ines Knee -Ankle -Foot O r thosis
1.2 Cast rectification method
Oncerectificationiscompleted,checkthefollowing:
4Theposteriorlinepassesthrough
1.themiddleofthethigh2.themiddleoftheknee3.themiddleoftheankle
4Heelandforefootareflatontheground
4Thelaterallinepassesfromthegreattrochantertothemiddleofthelateralmalleolus
� ICRC Physical Rehabi l i tat ion Programme
1.3 mechanical knee joint location
4MechanicalaxesaredefinedinaccordancewithP&Opractice,asshownhere.
Thepositiveplasterremainsinaverticalposition:
4Drivetwonailsintothemouldatthemechanicalkneeaxis(theyshouldprotrudeabout5mm)
4Pullanylonorcottonstockingoverthemould
4FixtheEVAreinforcementaccordingtothemeasurementcardandrequirements
4Dustthestockingwithtalcumpowder
PRePARATIOn OF ReInFORCemenTs2
�Manufac tur ing Guidel ines Knee -Ankle -Foot O r thosis
POlyPROPylene dRAPIng And vACuum mOuldIng3
Cuta5mmsheetofpolypropylene(PP)asfollows:
4Heatthepolypropyleneat180°for20to25minutes,dependingonthethicknessofthepolypropyleneandtheperformanceoftheoven.
Drapethepolypropyleneovertheplastermodel.Laythepolypropyleneoverthemouldwithoutstretchingit.
CleanthePPsheet.
4Uppercircumference+10cm
4Totallength+20cm
4Lowercircumference+15cm
3
1
2
3
2
1
Drapeitfirstovertheankletowardsthemiddleanteriorpartoftheorthosismould.Thenpullitaroundtheforefoot.
� ICRC Physical Rehabi l i tat ion Programme
4Stickittogetheralongtheanteriorside.
4Tightenthepolypropylenearoundthesuctionconewitharopeorsomethingsimilar.
Openthevacuumvalve.
4Withscissorsoraknife,cutofftheexcesspolypropylenealongtheweldingseamwhileitisstillhot.
�Manufac tur ing Guidel ines Knee -Ankle -Foot O r thosis
Remarks
Ifthepolypropylenesheetcutaccordingtothemeasurementsoftheplasteristoobigtofitintotheoven,preparetwoPPsheetsinsteadofone.
DrapethePParoundtheplastermould.
Payattentiontotheoverlaparea,pullingthePPgraduallyandcarefully;otherwiseitwillbestretchedtoothinlyandbetooweak.
OpenthevacuumvalveandremovetheexcessPPalongtheseam.
POsITIOn OF The sIde bARs4
4Onthebench,thepositivemouldisinstalledasfollows:
4Thepositionofthekneeaxisshouldbemarkedinrelationtotheverticallineindicatingthelocationofthemechanicalkneejoint.
kneeaxis
�0 ICRC Physical Rehabi l i tat ion Programme
4Theuprightsarecuttotherequiredlength,bentandadjustedfollowingthecurvesofthePPshells.
��Manufac tur ing Guidel ines Knee -Ankle -Foot O r thosis
4Duringadjustmentofthesidebars,thepositionandparallelismofthekneeaxismustberespected.
Axislocationandtrimlines
4TrimlinesdependonthetypeofcorrectionrequiredandthefunctionoftheKAFO.
Inmostcases,trimlinesshouldbedrawnaccordingtointernationalP&Ostandards,asshownhere:
TRIm lInes5
�� ICRC Physical Rehabi l i tat ion Programme
4ThepolypropyleneiscutoffandthetrimlinecontoursaregroundandpolishedbeforetemporaryassemblyoftheKAFOfortrial.
Assembly And PARAllelIsm6
4ThesidebarsaretemporarilyfixedonthepolypropyleneshellswithM3screwsandnuts.
Preciseparallelismofthekneejointisoftheutmostimportanceandmustbeensuredbeforethefirstfittingasfollows:
4method 1:UsingaVerniercalliper
��
InITIAl FITTIngs7
Manufac tur ing Guidel ines Knee -Ankle -Foot O r thosis
4method 2:Usingthecentringpin
4StraptheKAFOonthepatient’slowerlimb.
4Checkthetrimlinesbeforethepatientstandsup.
Oncetheshoesareon,thepatientstandsupandgaittrainingcanbegin.
�� ICRC Physical Rehabi l i tat ion Programme
FInIshIng8
4Thestrapsarefixedwithtubularrivets
4Thetrimlinesarecarefullypolished
4Theuprightscanbecoveredwithfineleather
4Theparallelismofthekneejointischeckedagain
4Theuprightsarefixedwithcopperrivets
��
KAFO OPTIOns9
Manufac tur ing Guidel ines Knee -Ankle -Foot O r thosis
4TheKAFOisreadyfordelivery
4Somepatientsneedanischialseatsupport.Inthiscasethebrimhasananterioropening.Theshapeissimilartothatofquadrilateralsocketprosthesis.
4TheKAFOcanbefittedwithdifferentorthoticjoints(Swisslock,droplock,freeoffset,etc.).
�� ICRC Physical Rehabi l i tat ion Programme
ICRC Code Description Unit of measure Quantity
For negative and positive cast :ODROSTOCOT60 Tubular stockinet, 60 cm Cm 135MDREBANDP10-12-15 Plaster of Paris bandages10, 12 or 15 cm x 3 m Piece 6 to 7OTOOPLASPW40 Plaster of Paris powder Each As requiredFor EVA and plastic moulding :OPLAEVAFKIN06 EVA FOAM 6 mm x 0.95 m x 0.95 m, 0.90 m2, skin colour Sheet 0OPLAPOLYSKIN 04 HOMOPOLYMER 4 mm or 5 mm x 1 m x 2 m 7.5 kg, beige colour Sheet 0.5For components/ sidebars:OCPOKNEEB20DL/16DL ORTHOSIS, ADULT, 20 mm or 16 mm side bar knee joint w.drop lock (pairs) Pair 1OCPOKNEEBO20SL/16SL ORTHOSIS, ADULT, 20 mm or 16 mm side bar knee joint, Swiss lock (pairs) Pair 1OCPOKNEEBO20DL/16DL ORTHOSIS, ADULT, 20 mm or 16 mm side bar knee joint w.drop lock (pairs) Pair 1For straps and rivets:OSBOVSBO26 ELASTIC STRAP 25 mm x 25 m Roll 0.02EHDWZBAKGLUE01 GLUE, SYNTHETIC Litre 0.2OSBOVSBO36 LOOP 35 mm x 100 pcs Box 0.04EBUIZBAKPOPPOWD PLASTER POWDER Kg 12EHDWOHPW45 RIVET (COPPER) 4 mm x 20 mm x 1,000 pcs Box 0.012EHDWOHDW40 RIVET (TUBULAR) 13 mm x 12 mm x 1,000 pcs Box 0.012ORTOZBAKSPAR SANDPAPER 15 x 15 Piece 1OSBOVSBO29 STRAP (PROSTHESIS) 35 mm x 50 m Roll 0.02OSBOVSBO25 STRAP (VELCRO) 30 mm M 1OOMAALIGORTH CENTRING PIN FOR ORTHOSIS 1 30ETOOMEASC15 VERNIER CALLIPER 1 35Special hand tools:OTOOMEASCIR4 _ 7 COUNTOURING INSTRUMENT, ROUND BEAK Each 2OTOOMEASCFL COUNTOURING INSTRUMENT, FLAT Each 2OOMAALIGORTHX CENTRING PIN FOR ORTHOSIS Each 1ETOOMEASC15 VERNIER CALLIPER Each 1
list of components and materials
MISSION
The International Committee of the Red Cross (ICRC) is an impartial, neutral and independent organization whose exclusively humanitarian mission is to protect the lives and dignity of victims of war and internal violence and to provide them with assistance. It directs and coordinates the international relief activities conducted by the Movement in situations of conflict. It also endeavours to prevent suffering by promoting and strengthening humanitarian law and universal humanitarian principles. Established in 1863, the ICRC is at the origin of the International Red Cross and Red Crescent Movement.
Acknowledgements:
Jean François GallayLeo GasserPierre GauthierFrank JoumierJacques LepetitBernard MatagneJoel NiningerGuy NuryPeter PoetsmaHmayak Tarakhchyan
and all prosthetists-orthotists who have worked in ICRC-assisted physical rehabilitation centres.
International Committee of the Red Cross19 Avenue de la Paix1202 Geneva, SwitzerlandT + 41 22 734 60 01 F + 41 22 733 20 57E-mail: [email protected]© ICRC, September 2006All photographs: ICRC/PRP
Physical Rehabilitation Programmeankle-Foot orthosis
Manufacturing guidelines
0868
/002
0
9/20
06
200