Superior occupational outcomes are achieved when the central aim of orthotic intervention is to enable current or future occupational performance, rather than merely providing an orthosis.
Orthoses should be comfortable, fabricated from lightweight materials, aesthetically pleasing and convenient to use. These goals are facilitated by applying the guiding principle of less is more.
Orthoses must be thoughtfully designed with client input, carefully constructed and monitored and modified as needed.
Well-designed orthoses can make a difference in a person’s life by relieving pain, providing joint stabilization, protecting vulnerable tissues, and enabling valued occupations and participation in activities important to the client.
Catherine’s Story *
* All stories in this chapter are true, and, where possible, details have been confirmed. All quotes are from the actual clients.Catherine’s 20-year career as a professional concert pianist and recording artist was in serious jeopardy when the sudden onset of pain and immobility in her right hand put an immediate halt to her piano playing due to osteoarthritis of her thumb carpometacarpal (CMC) joint. Recognizing the importance of hand function to her career, and the uncertain potential outcome from surgery, a hand surgeon immediately referred her to occupational therapy.
The occupational therapist made a custom-molded circumferential hand-based thumb CMC-stabilizing orthosis constructed from in. (1.6 mm) thick low-temperature thermoplastic. Although it somewhat controlled her symptoms, Catherine found that it limited joint mobility too much to allow her to play the piano. To address this problem, the thermoplastic through the thumb webspace was removed and replaced with a strip of neoprene that was riveted in place ( Fig. 122-1A ). Although this was more comfortable, piano playing was still restricted.
The next attempt used a prefabricated Rolyan Neoprene Wrap-on Thumb Support that was trimmed down to free up the thumb metacarpophalangeal (MCP) joint and reinforced with thermoplastic that was bonded to the outside of the orthosis, adjacent to the CMC joint ( Fig. 122-1B ). The neoprene was sufficiently flexible to enable the freedom of movement needed to play the piano and supportive enough to prevent pain. Although the blue color was acceptable for piano practice, Catherine found it unsuitable for concert situations.
Further collaboration between client and therapist led to a custom-made black neoprene orthosis with thermoplastic reinforcement ( Fig. 122-1C ). This satisfied Catherine’s functional, cosmetic, and comfort requirements for concert hall performances ( Fig. 122-1D ).
Catherine’s career continued to flourish. Five years later she was still using the orthoses: the black neoprene orthosis (see Fig. 122-1C ) for performances, the blue neoprene orthosis (see Fig. 122-1B ) for practicing, and a more stabilizing black thermoplastic orthosis (see Fig. 122-1A ) for other activities. She returned periodically to the clinic for repair of the orthoses.
A collaborative client-centered approach ensured that the orthoses met both her biological needs (pain relief, joint stabilization, and preservation) and occupational needs (especially her functional, cosmetic, and comfort requirements for concert hall performances), thus enabling her to continue the pursuit of her livelihood and passion. Catherine was overjoyed: “My hands are my life. I am so grateful to my therapist for listening to what I wanted and needed. Without these orthoses, my career would have been over. I call them ‘my friends.’ They enable me to continue performing at the highest technical level.” †
Goals of Orthotic Intervention
This story is reprinted with permission from McKee P. Catherine’s story: enabling individual change. In: Townsend E, Polatajko H, eds. Enabling Occupation II: Advancing an Occupational Therapy Vision for Health, Well-being and Justice through Occupation . Ottawa: Canadian Association of Occupational Therapists; 2007. p. 136.An orthosis (splint) is a custom-made or prefabricated device applied to any part of the body to relieve pain, stabilize body joints or tendons, protect against (re)injury, promote healing, prevent or correct deformity, and assist or increase occupational performance. Orthotic intervention (splinting), a mainstay of hand rehabilitation for several decades, is the process of client evaluation, establishment of objectives, and development of an orthotic plan to ultimately enhance participation in life occupations.
The therapist who provides orthotic intervention requires sound knowledge of anatomy and physiology, biomechanics, human occupation, orthotic materials, and mechanical principles of orthotic fabrication. Also required are skills in activity analysis, client assessment and education, and fabrication techniques. Unlike other interventions in hand rehabilitation, orthotic intervention results in an individualized device that meets specific biological and occupational needs that the client wears outside the clinic.
Occupation is defined as all manner of human activity, pertaining to self-care, productivity, and leisure. Occupational performance involves the integration of the biopsychosocial dimensions of the person and is defined as “the result of a dynamic, interwoven relationship between persons, environment and occupation over a person’s lifespan; [specifically, it is] the ability to choose, organize, and satisfactorily perform meaningful occupations, that are culturally defined and age appropriate, for looking after oneself, enjoying life, and contributing to the social and economic fabric of a community”.
Several occupational therapy clinicians and scholars have suggested that enabling occupational performance can be translated to mean enabling activity and participation , as described in the most recent version of the World Health Organization’s (WHO) International Classification of Functioning, Disability, and Health, commonly known as ICF. In this classification system, activity is defined as the execution of a task or action by an individual, whereas participation is defined as one’s involvement in a life situation. Another construct put forth by the ICF is body functions and structures , which refers to the anatomic parts of the body and physiologic functions of body systems. Although the ICF is useful for guiding therapeutic approaches, it does not explicitly consider the concepts of individuals’ values, what is meaningful to them, and the social roles that affect their participation and occupational performance. We contend that these concepts are essential to the orthotic intervention process to ensure usability ‡ of the orthosis and optimal outcomes from the intervention.
Orthotic usability refers to the effectiveness, efficiency, and satisfaction with which users can participate in activities in their various environments while wearing their orthosis.Orthotic intervention, as it is commonly described in hand therapy literature, tends to be predominated by discussions of orthoses being used to address biological (anatomic or physiologic, or both) disorders of the upper extremity. This reflects the medical model approach that focuses on the client’s diagnosis or disability.
With the publication of the revised ICF and the move to a more social model of rehabilitation, practitioners are being urged to focus on enabling occupation and function from a more holistic (occupational) perspective. Indeed, several publications discuss the use of orthoses to enable occupation and function. For example, Stier suggests that “significant attention to the client’s meaningful occupations, whatever they may be, is required to design a splint [orthosis] that will enable individuals to do what they want to, need to and are expected to do”.
In keeping with these developments, we contend that optimal benefit from orthotic intervention is achieved through a client-centered, bio-occupational approach that addresses clients’ biological (anatomic and physiologic) needs as well as their occupational performance issues § within their unique social and physical environmental contexts. This is supported by Mattingly and Fleming’s “two-body practice” concept in which they describe the reasoning of occupational therapists as including both the body as a machine , and the person as a life filled with personal meanings .
Splint Versus Orthosis—What’s in a Name?
Occupational performance issues are actual and potential barriers to the satisfactory performance of meaningful occupations.“Words are the power of a profession” (Thomas C. Timmreck, 1998, p. 48).
Although it is common practice for therapists to use the term splint in verbal and written communication, the term is likely to conjure up an image of two pieces of wood lashed to an injured leg by an untrained person on a ski slope. Furthermore, it in no way suggests the process of enabling occupation. The International Organization for Standardization (ISO), an international standard-setting body founded in 1947 with headquarters in Geneva, Switzerland, recommended that the term orthosis be used to describe all such devices. In 1998, the ISO defined orthoses as “externally applied devices used to modify the structural and functional characteristics of the neuro-muscular and skeletal systems by applying forces to the body.”
In 2000, the United States Centers for Medicare and Medicaid Services (CMS) introduced L-codes, which therapists must now use for reimbursement for custom-made orthotic devices. What is noteworthy is that each device is called an orthosis . The word orthosis is therefore used throughout this book.
Twenty-two-year-old Rasheed was involved in a single-vehicle car accident, which resulted in a severe brain injury, a right calcaneal fracture, and a right humeral fracture. At 3 months after the injury, while an inpatient of a neurorehabilitation facility, his occupational needs were reevaluated. He wore an Aircast walking brace on his right foot, which was satisfactory. Due to impaired balance, he required a two-wheeled walker or a manual wheelchair (for outdoors or longer distances), but right upper limb dysfunction prevented independent ambulation and restricted other functional activities. Though his humeral fracture was healed, elbow heterotopic ossification caused pain at end range and he lacked 70 degrees of active elbow extension. Furthermore he had weak active wrist extension due to moderately severe right radial nerve palsy, although reinnervation was progressing well. The circumferential, prefabricated wrist support provided to him in acute care was fitting poorly and “got in the way” and thus was not usable. Rasheed was very motivated to get better despite impaired recent memory and deficits in high-level attention.
Orthotic intervention focused on enabling Rasheed’s independent ambulation and handwriting so that he could work toward his goal of returning to college. His cognitive limitations were also considered.
Rasheed was fitted with a custom-made dorsal wrist orthosis ( Fig. 122-2A ), constructed from miniperforated thermoplastic inch (2 mm) thick, which was sufficiently thin to enable him to actively flex his wrist and to rebound to pull his wrist back to an extended position. Much of the palmar surface of his hand and forearm was left exposed to facilitate gripping the wheelchair rim and handle of the walker. The palmar support was contoured to support the transverse arch of his hand and was covered with leather to enhance comfort and grip ( Fig. 122-2B, C ). Rasheed was now able to ambulate with his walker, propel his manual chair, and hold a pen to write. Furthermore, whenever he stepped forward into the walker, the orthosis was sufficiently flexible to allow passive wrist extension required for weight bearing through his right upper limb.
Professional Reasoning in Orthotic Intervention: Explicit and Implicit
As previously suggested, discussions of the process of orthotic intervention often neglect to include the more subjective (emotional and psychological) aspects of occupational performance, apparent in Catherine’s and Rasheed’s stories. This is in keeping with research on professional reasoning in occupational therapy, which has demonstrated that therapists implicitly include these subjective aspects in their day-to-day practice. Professional reasoning refers to how therapists think when they are engaged in practice and is based on a personal understanding of the client’s situation. This “thinking process” is complex and multifaceted and involves both explicit and implicit types of reasoning. What follows is the presentation of an approach that makes explicit the professional reasoning that occurs when orthotic intervention endeavors to achieve optimal outcomes. Twelve guiding principles that support this approach are discussed.
Client-Centered Bio-occupational Approach
Client-centeredness “embraces a philosophy of respect for, and partnership with people receiving services”. When we describe our intervention as assessing for a splint or splinting a patient or client , then the provision of an orthosis becomes the focus, and the process can be very technical, without sufficient consideration of client-specific context and circumstances. Concerns for biological structures may dominate the process, and important occupational performance issues can be overlooked ( Fig. 122-3 ). In addition, this language suggests a paternalistic approach in which we are doing something to the client and in which his or her knowledge and expertise may not be fully respected nor solicited.
In contrast, we propose that optimal benefit from orthotic intervention is achieved through a client-centered bio-occupational approach that explicitly addresses both the client’s biological needs and occupational performance issues with consideration of his or her unique circumstance.
This approach to orthotic intervention involves (1) identifying and addressing the biological factors that underlie the occupational barriers to optimal participation and (2) designing orthoses using an occupational perspective. This perspective considers the client holistically, including the client’s physical, cognitive, and affective attributes, occupational goals, and environmental contexts. A client-centered bio-occupational approach ensures that the central therapeutic aim of orthotic intervention remains that of enabling current or future occupational performance, rather than simply providing a splint .
A client-centered approach challenges us to modify our language and terminology, as discussed earlier, and advocates for the careful selection of assessment tools and outcome measures. Routine use of function-based, client-centered outcome measures promotes optimal collaboration with the client and a focus on occupational rather than biological outcomes. Examples of client-centered outcome measures include the Canadian Occupational Performance Measure, the Patient-Specific Functional Scale, and the Patient-Rated Wrist and Hand Evaluation. These measures have the added benefit of providing evidence of orthotic efficacy.
Incorporating a client-centered, bio-occupational approach into the previously cited definition of the term orthosis results in the following revision: a prefabricated or custom-made device applied to biological structures —impaired by acute injury, cumulative trauma, disease, surgical intervention, congenital anomaly or degenerative changes—to favorably influence their nutrition, length, strength, mobility, or stability, to ultimately promote current or future occupational performance and participation in roles important to the individual.
In summary, orthotic intervention must be individualized and client-centered, with consideration of the individual’s unique biological and occupational needs, personal attributes, and environmental contexts. The client stories throughout this chapter illustrate how the interaction between the therapist and client influences the outcome as much as the actual orthotic device does. One intervention protocol does not fit all. The best outcomes occur when orthotic interventions are designed with client input and holistic consideration of the individual’s unique circumstances.
Over the period of a few months, Peggy, a 66-year-old physical therapist, developed left (nondominant) unilateral intrinsic muscle paralysis, which resembled combined median and ulnar nerve injuries at the level of the wrist ( Fig. 122-4A ). Hand sensation was unimpaired, and she experienced no pain. An MRI led to the diagnosis of lower brachial plexus compression caused by deposits of fatty tissue. Surgical decompression was ruled out for a variety of reasons.
Fine prehension was very limited since the only functioning muscles in her digits were the extrinsic muscles. She was unable to curve her fingers around a cylindrical object such as a water bottle ( Fig. 122-4B ), because she could not simultaneously flex the MCP joints and extend the interphalangeal (IP)joints.
Two separate orthoses were provided to compensate for the muscles that were paralyzed ( Figs. 122-4C–E ). A hand-based thumb-CMC orthosis with elastic Velcro strap positioned the thumb in partial opposition. A hand-based, figure-of-eight, finger MCP extension-blocking orthosis prevented the extensor digitorum, extensor indicis (EI), and extensor digiti minimi muscles from pulling the MCP joints into hyperextension. The orthosis diverted some of the extension force from the fingers and transferred distally into the extensor mechanism to extend the finger IP joints. With the two orthoses, Peggy’s hand function was improved; she now had reasonable thumb opposition and she could open her hand to wrap her fingers around cylindrical objects ( Fig. 122-4E ).
During the next 3 years, two tendon transfer surgeries were performed with the objective of restoring active thumb opposition. The palmaris longus tendon (Camitz’s tendon transfer) was transferred into the thumb to provide palmar abduction; later the EI tendon was also transferred into the thumb. Neither surgery achieved the intended thumb opposition, although Peggy felt that thumb function was sufficiently improved that she no longer needed a thumb orthosis. Unfortunately, after the EI transfer, full index extension was no longer achieved even when she was wearing the orthosis, possibly due to scar tissue causing adherence of the index extensor digitorum tendon so that it could not glide proximally and pull the IP into extension; this resulted in further loss of hand function ( Fig. 122-4F ).
With her MCP extension-blocking orthosis, Peggy could do all the bilateral hand activities she wanted to do, including tying shoes and changing diapers.
Over the 9 years since the onset of the paralysis, Peggy returned about every 6 months to the hand therapy clinic for replacement of the MCP extension-blocking orthosis, which would “come apart” from the stress of constant daytime use. At one point, an orthotist made her a high-temperature orthosis, but it did not fit well and was never used.
With each orthotic replacement, Peggy and her therapist reconsidered her occupational goals and together they planned how to make improvements in the choice of orthotic materials and design. The most recent design was different from previous orthoses in that the surface area over the dorsum of the hand and fingers was larger, resulting in increased comfort, and bulk through the palm of the hand was much decreased, which facilitated grasping objects ( Fig. 122-4G ). The use of a thermoplastic called FiberForm, which is uniquely formulated with Kevlar and thus is very rigid after molding at a thickness of inch (3.2 mm), made the orthosis stable without doubling of the thermoplastic.
Peggy expressed the following sentiments, “I’m grateful to my therapist for listening to what I needed and adapting the orthosis to meet my needs. It’s important to individualize the approach for each person and not to assume that everyone is the same.”
The following section explicitly identifies and describes 12 guiding principles (summarized in Table 122-1 ) of the client-centered bio-occupational approach to orthotic intervention that is illustrated in these client stories.
|Promote Client-Centeredness||Occupational Considerations||Use a Less-Is-More Approach|
|Optimize Usability||Optimize Cosmesis||Optimize Convenience||Optimize Comfort|
|Biological Considerations||Incorporate Sound Mechanical Principles||Provide Comprehensive Client or Caregiver Education||Monitor and Modify||Evaluate Outcomes|
|Identify and Address Biological Goals||Minimize Biological Harm, Including|