Catherine’s Story *

* All stories in this chapter are true, and, where possible, details have been confirmed. All quotes are from the actual clients.

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.

Catherine’s orthoses. A, Circumferential hand-based thumb CMC-stabilizing orthosis made from inch (1.6 mm) thick solid thermoplastic, with neoprene through the webspace, secured with rivets. B, Prefabricated thumb support that has been trimmed down at the wrist and thumb, with inch (1.6 mm) thick thermoplastic bonded to the outside adjacent to the thumb CMC joint. C, Custom-made circumferential thumb CMC stabilizing orthosis made from inch (3.2 mm) thick neoprene with iron-on seam tape through the thumb webspace and inch (1.6 mm) thick perforated thermoplastic (outlined in blue) bonded to the outside adjacent to the thumb CMC joint. D, Catherine playing at Carnegie Hall wearing her black custom-made neoprene orthosis (C) .

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.

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.

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.

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.

Rasheed’s Story

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.

Rasheed’s orthoses. A, Dorsal wrist orthosis made from inch (2 mm) thick thermoplastic, worn during walker ambulation. B, Contoured palmar support covered with leather. C, Palmar view showing the extent of skin left exposed by the orthosis.

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.

Client-centered bio-occupational orthotic intervention.

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.

Peggy’s Story

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.

Peggy. A, Clawhand posture: finger metacarpophalangeal (MCP) joint hyperextension and interphalangeal joint flexion. B, Attempting to grasp a water bottle. C, Hand-based thumb–CMC joint orthosis with elastic Velcro strap positioned the thumb in partial opposition. Hand-based, figure-of-eight, finger MCP extension-blocking orthosis to correct clawhand posture molded from thermoplastic tube. D, Volar view. E, Grasping a water bottle while wearing orthoses. F, Posture of hand after transfer of extensor indicis tendon into the thumb. This extension-blocking orthosis has been molded from doubled inch (3.2 mm) thick thermoplastic. G, Dorsal view of most recent finger MCP joint extension-blocking orthosis.

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.”

Guiding Principles

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.

Table 122-1

Guiding Principles of the Client-Centered, Bio-Occupational Approach to Orthotic Intervention

Promote Client-Centeredness	Occupational Considerations				Use a Less-Is-More Approach
	Optimize Usability	Optimize Cosmesis	Optimize Convenience	Optimize Comfort
Recognize that client has expert knowledge of his or her own situation and its effect on occupational performance Address client’s unique occupational and biological concerns Individualize the intervention Use functional outcome measures Offer options where appropriate Facilitate psychosocial acceptance	Identify and address client’s occupational goals Consider complete client picture, including cognition, affect, physical attributes, occupational demands, environment, and, when appropriate, spiritual beliefs Consider client’s physical, social, cultural, and institutional environments Maximize durability Minimize inconvenience	Lack of construction defects (e.g., pen marks, rough edges, and surface impressions) Lack of soiling of thermoplastic, straps, and stockinette Appearance that is aesthetically acceptable to client, family, or caregiver Minimal visibility (if possible)	Minimize occupational hindrance * Acceptable wearing regimen Durability of all materials including straps Easy to apply and remove Easy to clean and resistant to soiling Easy to adjust, if necessary Easy to understand No unnecessary restriction of function An approach that emphasizes stabilization rather than immobilization Tolerable amount of compensatory motions	No pressure points Tolerable amount of compensatory motions No new discomfort from muscle fatigue No adverse skin reactions Acceptable amount of perspiration and warmth Acceptable weight of orthosis—consider age and strength of the client	Minimize: Size, weight, and rigidity of the orthosis Visibility of the orthosis Amount of skin enclosed Extent of motion restriction Thickness of orthotic materials Complexity of straps and adjustable components Care requirements (e.g., easy to clean)

 

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
Promote healing (e.g., burn, skin graft, fracture, injured tendon, ligament, or nerve) Preserve or restore optimal tissue length and joint flexibility Compensate for weak or paralyzed muscles Protect against (re)injury or degeneration Relieve pain and inflammation Stabilize joints or tendons Prevent or correct deformity Optimize tendon–nerve glide Optimize lymphatic function Apply tissue-specific corrective forces	Pressure points causing injury to skin or compression of nerves Burns caused by molding overheated thermoplastics to the skin Failure to protect injured structures during the healing process Undue stress to tendons or joints, causing inflammation due to poor design, joint positioning, inappropriate dynamic or static progressive force Adverse effects of immobilization, including disuse atrophy and contracture Muscle fatigue Skin maceration Adverse skin reactions Edema Sleep disturbance	As a general rule, extend the trough slightly more than halfway up the sides of the limb. Improve force distribution by increasing surface area. Mold the orthosis to conform to body contours. Increase rigidity of the orthosis with contours molded into thermoplastic. Pad bony prominences prior to molding. Round all corners, including straps and Velcro tabs. Use the longest lever arm possible without restricting motion of other joints. Ensure that the location of straps optimizes the lever arm and joint-controlling forces. Ensure the appropriate width and conformity to contour of straps to distribute the securing force of straps over a large surface area.	Written and verbal instructions concerning: Objectives of orthotic regimen and consequences of nonuse Correct application and removal of orthosis Wearing schedule and circumstances when it can be removed Care of orthosis—how to clean it; precautions against leaving it in a hot environment—and how to make minor adjustments if necessary Indications of poor fit (e.g., pressure points) that need prompt attention	To verify and evaluate effectiveness at meeting occupational and biological goals To verify and evaluate whether orthosis is being used and explore reasons for nonuse or incorrect use To make adjustments and repairs (e.g., to relieve pressure points and ensure adequate mobility of joints that should be unrestricted) To clarify use and care of orthosis	To assess whether occupational and biological goals have been achieved To gather evidence concerning efficacy of orthotic intervention To contribute to the body of professional knowledge

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