All patients from childhood to early and late adulthood can utilize orthotics. Some can argue that the general population uses orthotics on a daily basis. Shoes are the foundation to all lower extremity orthoses. The design of the shoe can facilitate or inhibit body mechanics, shock absorption, and provide stability. For example a running sneaker is designed with a rubber heel to absorb shock during activity. They are also designed with shanks to provide support through the arch of the foot when stationary or during dynamic movement. Lastly, the sole is to provide support and cushion to the forefoot. These components are the foundation and the implications of using orthotics, specifically lower extremity orthotics.
Orthotics can be applied to all joints of the body. They are constructed for the lower extremity, trunk, and the upper extremity. Common lower extremity orthotics include ankle-foot orthoses (AFO), knee-ankle-foot orthoses (KAFO) like a Craig-Scott orthotic, hip-knee-ankle-foot orthoses (HKAFO), and trunk-hip-knee-ankle-foot orthoses (THKAFO) such as standing frames. Moving to the upper extremity, common orthotics include an arm-hand orthotic like a dynamic spring-loaded hand orthosis. Upper extremity splints, wrist hand orthotics, shoulder stabilizers, and bracings for fractures are other devices that can be used. The axial skeleton has specific orthotics as well to facilitate stability and improve independence. Examples of axial orthotics include a lumbosacral corset, lumbosacral flexion-extension-lateral control orthotic, a Taylor brace (TLS FE) to control thoracolumbosacral flexion-extension. Orthotics specifically made for the trunk to correct scoliosis include the Milwaukee brace and the Boston thoracolumbosacral orthotic.
Examples of cervical orthotics include collars such as the Philadelphia Collar, a four-post orthosis, and a halo orthosis. As stated earlier orthotics can be applied to all joints of the body. Both, neurologic and orthopedic conditions can increase prognosis when implementing orthotics in their plan of care. Neurologic conditions such as cerebral palsy, diabetic neuropathy (O’Sullivan, 2014), hemiplegia, multiple sclerosis (MS), parkinson’s disease, polio, spinal cord injury (SCI), and stroke diagnoses rely on the use of orthotics and implement them in treatment as well as everyday life. O’Sullivan states that other diagnoses within the orthopedic field that can utilize the advantages of orthotics are fractures to the upper extremities or lower extremities, low back pain, trauma experienced from a motor vehicle accident, plantar fasciitis, and structural abnormalities like scoliosis.
Conditions that encompass both structural and neurologic pathologies that benefit from orthotics are cervical stenosis, spondylolysis, and spondylolisthesis producing balance and ambulance impairments. Orthotic prescriptions are non discriminatory and can be implemented into the plan of care and daily use for patients experiencing a variety of diagnoses. Neurologic, orthopedic, or a combination of both pathologies can optimize patient independence with the application of an orthotic device. Indicating pathologies and symptoms for the appropriate use of orthotic devices vary by case to case. Not every patient who is diagnosed with a particular pathology does not always fit the standard for implementing an orthotic device.
For example, early diagnosis of Multiple Sclerosis (MS) do not experience the chronic effects of balance and coordination deficiency, joint instability, and muscle fatigue and weakness. Therefore use of an orthotic device may not be warranted until the symptoms progress. Factors to consider when assessing the indication of an orthotic device are the degree of balance and coordination, joint instability, muscle fatigue and weakness, age and lifestyle, medical history, previous/current patient condition and prognosis, and secondary risk factors. A careful and precise evaluation must be completed before implementing an orthotic device.
The application of an orthotic device has many positive implications. Orthotics are designed to improve and preserve independence and mobility. Fisk also stated that orthotic application can decrease the risk of comorbidities. Supportive devices play a major role in improving balance and stability through static and dynamic activity. Orthotic use aids improving gait speed, distance, and exercise capacity with the use of reciprocating gait orthotics. Orthotics have the power to increase independence and participation of activities of daily living. These goals are achieved by the advantages of posture and stability, improving gait, increasing exercise capacity, and improving strength and range of motion (ROM).
Along with all the advantages of orthotic use, it is important to consider the drawbacks and potential risk factors that coincide with the application. Side effects will be discussed in depth in the “Side Effects” section of this paper. It is important to stress negative effects of orthotic use including increase in patient reliance on the device and they are a contributor to muscle atrophy. According to Wolff’s Law, the musculoskeletal system responds to the demand placed upon the system. Meaning, bone and muscle grow stronger when demand stresses these structures. An orthotic is an external device that supports an unstable joint, therefore reducing the stress placed resulting in muscle and bone degeneration.
Orthotics may play a crucial role in the recovery process. Early stated, there are many diagnoses that indicate the appropriateness of using these devices to improve patients’ independence. Prognosis is impacted in a positive way when orthotics are used in rehab and at home. Two studies researched the effectiveness of orthotic use by evaluating balance, gait, and exercise capacity. A study done to establish the effectiveness of orthotic use was done by Burcu Talu. He studied the effect of ankle and knee supports on balance in early ambulation of patients who experienced a cerebrovascular accident (CVA) causing hemiplegia. This study used a AFO, KAFO, and rigid taping. Specifically they used a foot lifter orthosis (FLO) and an knee immobilizer brace (KIB) for their AFO and KAFO. Three groups were used with group 1 consisted of the KIB, group 2 combined the KIB and FLO, and lastly group 3 applied the KIB and rigid taping.
Results were calculated by using the Rivermead Mobility index (RMI) and the Balance Systems SD. The study concluded that the use of the FLO and KIB provided the most stability and improved balance of those experiencing paralysis. Talu recorded and proved that orthotic devices can aid in the rehab process by improving balance during early ambulation. Specifically, the FLO and KIB used together compared to using the KIB or rigid taping alone. Secondary to the hemiplegic paralysis, CVA patients experience major instability that the orthotics can provide to improve the patients postural stability and functional mobility.
Samadian performed a study to determine the effectiveness of isocentric reciprocating gait orthosis (IRGO) in gait training to improve walking speed, distance walked, and decrease energy consumption in SCI patients with paraplegia. The study spanned 12 weeks with 5 physical therapy visits per week lasting a duration of 2 hours. Therapy included standing and ambulation with orthoses, passive stretching to upper and lower limbs, strengthening to upper limbs, and balance. The orthoses used were 2 KAFO connected by a pelvic band with a reciprocal link to flex and extend opposite hips. The conclusion of the study showed the walking speed increased by 3 meters per minute, distance walked increased 7 meters, and energy consumption decreased by evaluating the heart rate. The study focused on the use of orthotic devices to aid with aerobic capacity/endurance, gait training, functional mobility with increasing distance.
The study concluded that the use of the KAFO improves aerobic capacity, ambulation distances, and ambulation speed. An interesting concept discovered when researching this topic was the long term finances required of a patient. Ideas that were researched reported potential financial fraud within the Medicare system, the effectiveness and price of off the shelf orthotics compared to custom fit devices, and the cost of long term medical intervention. John Fisk reported the potential financial fraud that Centers for Medicare and Medicaid Services (CMS). Medicare and Medicaid is supposed to ensure patient safety and maximize clinical outcomes. In accordance with maximizing outcomes, CSM was designated to provide patients with high quality and cost efficient intervention.
Medicare provides a billing code for minimal self-adjustment off the shelf orthotics that do not require the assistance of a certified professional. These codes are good ways to reduce the cost of an orthotic device but does not mean the patient will have the knowledge of the proper use. Results of improper use delay timely patient care and a not achieving progress in their rehabilitation. “19% of patients who used CSM reimbursement of off the shelf orthotics required a custom-fabricated orthotic, reimbursed by CMS”. Ultimately, Fisk states that there is a misuse of Medicare funds that not only decreases the safety of the patient and patient outcome, but effect the long term cost of health care.
A study computed by Dobson et al produced numerical costs of treatment comparing the use of an orthotic device to treatment alone. It is believed that long term care is not as expensive when appropriate orthotic use is implemented. During the period of 2011 to 2014 the study used 78,707 claims to assess financial cost of treatment with the use of lower extremity and spinal orthosis seperated into groups who received orthotics and ones who did not. The study concluded that a treatment duration of 18 months with an orthotic device decreased cost by almost $2,000. The savings resulted in the increase in outpatient visits for patient to receive care to reduce risk of reinjury. According to this study cost of treatment is more affordable and cost effective when using applying appropriate orthotics. The savings allowed the patient to focus on services such as occupation therapy, physical therapy, or other specific disciplines to achieve patient rehab goals and prevention of comorbidities.
Implementing orthotics into the plan of care requires careful examination to identify the side effects and precautions of the device. This exam includes considering the patient’s previous and current level of function, current impairments, signs, and symptoms, and lastly the goals and lifestyle of the patient. The exam identifies the appropriateness of implementing an orthotic device. Side effects and secondary complications are important to identify and consider when deciding the application of orthotics. In general, increasing the length of time immobilized will increase the risk of comorbidities (Elia, 2018). Some side effects that can be experienced to prolonged use are faulty body mechanics, increased dependence, and pressure ulcers. Decreasing the risk of these effects can improve prognosis and increasing the appropriateness of applying the orthotic.
Pressure ulcers are results of constant shearing forces. Fluctuating volume and girth measurements of the area may increase the risk of experiencing an ulcer. If you are applying an AFO and the patients edema fluctuate then the device may not be appropriate because the device will not fit properly (O’Sullivan, 2014). Orthotics are constructed with a mold of the extremity. If edema decreases or increases the limb will not match the mold causing an improper fit. This may lead to an increase in shearing forces causing ulcers. An improper fit can alter the stability of the joint requiring the device. For example an offset knee joint KAFO that is not properly fitted may cause the offset joint to be located closer to the midline or anterior portion of the knee. This will alter the mechanics of the knee and decrease the stability.
Without equal distribution of body weight with the KAFO will not stabilize the knee in extension increasing the risk of fall therefore increasing the risk of injury. Lastly, increased dependence on the orthotic can be detrimental. Detrimental effects of increased dependence on an orthotic are bone demineralization and muscular atrophy. Wolff’s Law states that increased demand on the musculoskeletal system increases bone and muscle strength. Implementing an orthotic increases dependence on the device resulting in decreasing demand on the musculoskeletal system. Overall, resulting in decreased muscle strength because muscles are not being challenged as well as bone density. This alone can lead to increased osteoporosis.
A study performed by Christopher Elia recognized the importance of proper education of spinal orthotics. Increased knowledge of the orthotics and the proper fit will minimize comorbidities. Application of spinal orthotics increases risk of dysphagia, pressure ulcers, and respiratory difficulties. Improper fit and use of cervical-thoracic orthotics (CTO) report stage 3 pressure ulcers are experienced with in 6 days of application. CTO’s stabilizing the cervical spine in hyperextension will lead to aspiration, dysphagia, and respiratory arrest secondary to abnormal alignment of the trachea (Elia, 2018). This study concluded that with increased education on appropriate application, patient education, and proper fitting will minimize secondary complications.
Common deviations of gait patterns occurring with orthotics include vaulting, hip hiking, and lateral trunk bending. Vaulting is seen when the patient lower extremity increases in plantar flexion while the contralateral lower extremity swings forward. Orthotic defects include knee lock, decreased dorsiflexion, and a plantarflexing stop. Some anatomical deficiencies that can cause the same pattern are weak hip flexors, pes equinus, leg length discrepancy of opposite lower extremity, and weak dorsiflexors. Hip hiking defects is seen on the same extremity with hip hike when swinging through. Orthotic cause include knee lock, poor dorsiflexion assistance, and poor plantarflexion stopping. Lateral trunk bending is experienced when the patient leans toward the stance leg when transferring weight.
Orthotic deficiencies that cause this are high medial upright, increased abduction of hip joint when using HKAFO, and a poor shoe lift. These abnormal gait patterns are caused by orthotic defects such as abnormal fit, decreased maintenance of the device, and abnormal functioning of the device. Absolute contraindications of orthotics use are uncontrolled edema. Hip and or a knee flexion contracture would contraindicate the use of a KAFo. The degree of spasticity can contraindicate the use of orthotics. A spring action assist in an AFO can increase spasticity. When an open wound is present, orthotics are contraindicated. Increasing pressure and shear forces on a broken down area of skin will contribute to making the wound worse.
An improper size/fit of the device can increase the risk of secondary conditions and are contraindicated. A faulty orthotic can be detrimental to body mechanics, increased pressure, and weaken musculature. An improper produced orthotic can be too long on a supporting shaft causing compensated/unwanted behavior leading to comorbidities. Therapists should carry tools to fix/adjust orthotic if it breaks or parts become loose. If the orthotic is not fixed then the patient can perform ADL’s/exercises without proper form increasing risk of secondary condition.
During this time patients are advised to remove the orthotic until the wound is healed. Treatment and lifestyle modifications are implemented until healing has occurred. During this time, patient plan of care needs to be altered. Patient education and modified exercises are intervened. For example a patient using an AFO and strengthening lower extremities will have to perform exercises in appropriate position. Using therabands for ankle motions and ankle weights for knee and hip exercises. The therapist may also try to fix the orthotic to decrease pressure and increase stability.
Physical Therapy is involved in many aspects of orthotic use in the clinic. Many pathologies and surgical interventions utilize physical therapy for rehab to return to or maximize independence. Orthotic use during and after surgery are very common and physical therapist are experts when following protocols and recognizing the signs and symptoms when to discharge orthotic devices or when to refer a device to achieve patient goals. It is also within the scope of practice to understand how to prepare, facilitate, and progress the plan of care when treating patients with orthotic devices. Educating the physical therapists (PT) and physical therapist assistant (PTA) are imperative for patient education to reduce the risk of secondary conditions.
As part of the interdisciplinary team it important for the profession to be trained and competent in the application and fit of the device, clinically deciding when to refer/discontinue the use of an orthotic device, and educating the patient. Having a knowledge and education base of proper fitting of orthotics will reduce the risk of pressure ulcers. Part of a therapy session includes observation of the injured area which include removing, identifying signs and symptoms, and reapplying the orthotic. Without an understanding of devices a PTA would not be able to provide the best care and prevent secondary risks. A confident PTA who can communicate efficiently motivates and earns patient trust. With proper education from PTA empowers the patient to direct their treatment and ensure participation.
