The modern day orthotist is qualified to degree level and has knowledge of mechanical engineering, anatomy, physiology and child development. They are the bio-mechanical backup to the clinical team, linking knowledge of materials science, mechanics and the human body. Previously, the public and professionals alike latched on to the term ‘an orthotic’ to describe insoles. The word ‘orthotic’ is an adjective, so we can say an orthotic device or an orthosis. An orthosis can be used to treat any external body part either to protect it or to correct or prevent deformity. Each orthosis is named by the joints it covers. Therefore a foot orthosis (FO) works on the foot and a knee-ankle-foot orthosis (KAFO) covers the entire leg from above the knee. The following case study shows how the involvement of the orthotist facilitates finding a simple solution for a complicated problem. The subject in this case is a two-year-old spina bifida child with a high thoracic lesion. She will always be non-ambulant. There is a significant kyphotic curve (a curve going forward) in the spine. The apex of the curve has a bony prominence which is susceptible to pressure sores if posture is not supported. At the time of assessment there was a pressure sore in this region caused by sitting in a chair. [login type="readmore"] [caption id="attachment_1458" align="alignright" width="150"] Fig 1 Sketch of two-year-old subject sitting on the floor[/caption] The subject’s postural control is compromised. A lack of postural control results in the compression of internal organs. Sitting unsupported on the floor requires the use of hands for balance. Therefore the child is unable to perform bimanual activities. Added to this are complications such as constipation due to compression of the intestines and susceptibility to colds due to the lungs also being compressed. Social development may also be hindered. All considerations were discussed by the clinical team, with the parents at its core. ENGINEERING PART To heal an existing pressure sore it needs to be offloaded. The pressure in this case is coming from the horizontal force on the apex of the kyphosis when seated. In this case the most effective way to offload the area is firstly to correct the kyphotic posture. This will also reduce internal compression of the organs. We decided to do this by facilitating standing and controlling the position of the spine. The use of a static stander was discounted as the child would get too bored in it and it would not be used for a long enough time every day to relieve the pressure sore adequately. [caption id="attachment_1459" align="alignleft" width="150"] Fig 2 A standing shell similar to that used in the case study[/caption] The solution in this case involved taking a mould of the child made from axillae to feet, and a positive model made. (The cast was removed, filled with plaster of paris cement and a positive cast produced.) This model was modified to the desired shape. A 4.5mm co-polymer, polypropylene, was vacuumed on to the mould, forming a plastic negative of the body – this is known as a standing shell. The plastic which would have been in contact with the pressure sore was removed and replaced with foam. Our subject was strapped into the shell. While in it she could stand at the table or counter, (with the aid of a step stool or box), and could be placed anywhere around the house. She could also be put into a mobile unit which is like a standing wheel chair. This enabled her to move around the house independently and to play outside with friends. [caption id="" align="alignright" width="150"] Fig 3 Sketch of subject in a standing wheeler[/caption] OUTCOMES After a period of using the standing shell (in conjunction with other aspects of treatment) the pressure sore healed. In addition, the parents reported a huge improvement in constipation and fewer incidences of respiratory problems. It was also reported that the subject was happy to use the standing shell and was enjoying her new-found independence. In the future we are hoping to be permitted to design a moulded spinal orthosis to improve sitting posture & prevent recurrence of the pressure sore. Brian Kinsella BSc, MSc, MIEI, MBAPO, MIAPO, HPC registered, has degrees in mechanical engineering, prosthetics and orthotics and a Master’s degree in bio-engineering. He is also a member of the Institute of Engineering Ireland, British Association of Prosthetists and Orthotists, is a co-founder and chair of the Irish Association of Prosthetists and Orthotists, and is registered as a practicing clinician with the Health Professions Council in the UK.