GB/T 42769-2023 in English

《GB/T 42769-2023假肢和矫形器 功能缺失 矫形器治疗的患者、临床治疗目标、矫形器功能要求的描述》由TC148（全国残疾人康复和专用设备标准化技术委员会）归口，主管部门为民政部。

GB/T 42769-2023 Prosthetics and orthotics - Functional deficiencies - Description of the personto be treated with an orthosis, clinical objectives of treatment, and functional requirements of the orthosis

1 Scope

This document establishes a method of describing the person to be treated with an orthosis, the clinical objectives of treatment and the functional requirements of the orthosis.

Note: This document is applicable to recording information for clinical practitioners of orthotics.

2 Normative references

The following documents are referred to in the text in such a way that some or all of their content constitutes requirements of this document. For dated references, only the edition cited applies. For undated references, the latest edition of the referenced document (including any amendments) applies.

ISO 8549-1 Prosthetics and orthotics - Vocabulary - Part 1: General terms for external limb prostheses and external orthoses
ISO 8549-3 Prosthetics and orthotics - Vocabulary - Part 3: Terms relating to external orthoses
ISO 13404 Prosthetics and orthotics - Categorization and description of external orthoses and orthotic components

3 Terms and definitions

For the purposes of this document, the terms and definitions given in ISO 8549-1, ISO 8549-3 and ISO 13404 and the following apply.

3.1
alignment of a skeletal segment
spatial relationship between the ends of the segment

Note: The alignment of a skeletal segment is determined by its integrity and/or shape.

3.2
alignment of a joint
spatial relationship between the skeletal segments which comprise the joint

Note: The alignment of a joint is determined by the integrity and shape of the skeletal segments of which it is comprised, and the action of associated muscular and ligamentous/capsular tissues. These factors also govern the type and range of motion at the joint.

3.3
stability
ability of a segment or joint to maintain its alignment when subjected to muscle forces and or external loading

Note: A skeletal segment or joint whose stability is impaired is said to be unstable (or exhibit instability)

3.4
deformity
abnormal alignment of a skeletal segment (3.1) or joint

3.5
reducible deformity
deformity (3.4) of a skeletal segment or joint for which the application of an external force system will change the alignment

3.6
irreducible deformity
deformity (3.4) of a skeletal segment or joint for which the application of an external force system has no effect on the abnormal alignment

4 Description of the person to be treated with an orthosis

4.1 General

Describe the person to be treated with an orthosis as specified in 4.2 to 4.6.

4.2 Personal factors

State the person's age, gender, height, weight and side dominance.

Describe, where relevant, the person's social and physical environments and their vocational and recreational activities.

4.3 Health conditions to be treated with an orthosis

4.3.1 Disorders or diseases

State the diagnoses and the relevant ICD codes.

4.3.2 Impairments of body structures and functions

Describe any impairments of

——shape, alignment and dimensions of the structures (i.e. the bones, joints, muscles and tendons, ligaments, other soft tissues and segments of the trunk),

——stability and range(s) of motion of the joint(s),

——muscle strength and neuromuscular control, and

——sensation, or the presence of pain.

4.4 Other health conditions

Impairments of the following body systems and functions might influence orthotic treatment:

a) cardiovascular;

b) respiratory;

c) musculoskeletal;

d) skin;

e) neurological;

f) endocrine;

g) the senses;

h) nutrition;

i) cognition;

j) mental health;

k) other systems.

State if there is an impairment of any of these which could influence the orthotic treatment, and note any other related current treatment.

4.5 Motivation and perceived needs

State the clinical impression of the person's motivation and their perceived needs.

Note: The motivation and perceived needs of the person have a major effect upon the rehabilitation objectives. They are interdependent and are influenced by the person's clinical condition, and personality, and environmental factors.

4.6 Activity limitations

4.6.1 General

The health condition and resulting impairments might limit the person's activities and restrict their participation.

Any activity limitations should be identified as detailed in 4.6.2 to 4.6.4.

4.6.2 Changing and maintaining body position

a) Bed mobility:

State if the person is immobile.

b) Transferring:
Describe the person's ability to transfer from

1) bed to chair,

2) sitting to standing, and

3) standing to sitting

as

1) unable to transfer, or

2) able to transfer with assistance from a person, and/or