The orthotic prescription

Chapter 2 The orthotic prescription



Heikki Uustal



Key Points



• Writing a prescription for an orthosis is one element of the larger process of rehabilitation to improve patient function. It includes evaluation, assessment, and formulation of the specific treatment plan described in the prescription.

• Optimal communication and transdisciplinary education occur when the patient, physician, orthotist, and therapist all are present for both patient evaluation and long-term follow-up. Maintaining this level of collaboration outside of the formal clinic team setting is difficult.

• The certified orthotist functions as a consultant to the clinic team with regard to orthotic management and provides fitting and follow-up of the indicated device.

• A clear understanding of the patient’s disease process, based on a comprehensive history and physical examination, is the foundation for generating the appropriate prescription.

• An effective prescription for orthotic care summarizes the medical issues related to the patient, details the biomechanical functions desired, and specifies key technical attributes of the desired orthosis.

Writing a prescription for an orthosis is a small part of the much larger process of rehabilitation to improve patient function. To understand this larger process, one must understand the roles of the different individuals involved and the goals set for each of those individuals. In the ideal setting, the patient is evaluated and managed by a team of professionals called the orthotic team. The team approach has been used for decades, both in the field of rehabilitation and in the practice of orthotics and prosthetics. The orthotic team at minimum should include the following members: the patient, the physician, the certified orthotist, the physical therapist or occupational therapist, and, when appropriate, the certified pedorthist. The best communication and the best transdisciplinary education among the team members occur if all the team members can be present for both the evaluation and the long-term follow-up of the patient. This ongoing face-to-face interaction fosters a thorough understanding of the disease process and, ultimately, the overall treatment plan. Goals of each component of the treatment plan then can be understood by each member of the team. Contemporary health care cost-containment pressures encourage isolated treatment in the outpatient offices of individual team members, but achieving and maintaining the same level of interdisciplinary understanding as in the formal clinic team setting is difficult.


The overall process of formulating the prescription consists of three distinct phases. Phase 1 involves evaluation of the patient to identify the underlying problems, disease, and disability and to establish a prognosis for future expectations. Phase 2 includes the actual treatment plan of writing prescriptions for the orthosis, therapy, and medication that may be appropriate for the underlying disease process. This phase also includes consideration of alternative measures, such as surgery or injections, to improve the patient’s underlying condition prior to fabrication and fitting of the orthosis. Education of the patient, and of each team member, also occurs in this phase. Phase 3 includes follow-up to assess for functional outcome. Functional outcome can be measured as the patient’s improved mobility, self-care, and reintegration into the community or as improved quality of life for the patient and caregivers. The orthotic team works best if a good balance of medical knowledge from the physician is combined with a good understanding of biomechanics and materials from the orthotist. The cooperative effort of these two key individuals from the orthotic team, and the sharing of knowledge among the other team members, ultimately will provide the most appropriate prescription for the orthosis and the treatment plan. The orthotic prescription then becomes a part of the road map to achieve the final endpoint of improved patient function.



Orthotic team member roles


The role of each individual team member can be precisely defined, but overlap occurs in several areas. These areas of overlap should enhance discussion and communication among team members to generate the most appropriate treatment plan.



Role of the physician



• Perform the medical evaluation, including chart review, history, and physical examination

• Explain the diagnosis and prognosis to other team members

• Alert the team to special considerations, including skin issues, weight-bearing limitations, vascular disease, and spasticity

• Establish restrictions of the treatment program to prevent complications or danger to the patient

• Assess and manage the patient’s pain control regimen

• Assess and manage the patient’s psychological status

• Justify the treatment program to the insurance carrier

• Write prescriptions for the orthotic device, therapy program, and medications

• Regular monitoring and long-term follow-up of all components of the treatment program

• Share knowledge with other team members


Role of the certified orthotist



• Participate in patient evaluation and generation of the orthotic prescription

• Act in a consulting role to provide information on device design and materials options

• Educate the patient regarding the device

• Fabricate the device to prescription specifications

• Deliver and check device fit and function

• Modify and repair the orthosis if, and when, appropriate

• Follow up with the patient and team members

• Share knowledge with other team members


Role of the physical therapist and/or occupational therapist



• Participate in patient evaluation, particularly as related to functional ability, such as transfers, ambulation, stair climbing, and assistive devices, in addition to assessment of other durable medical equipment, such as wheelchairs and bathroom equipment

• Participate in generation of the therapy prescription

• Provide the therapy program, which may include strengthening, range of motion, ambulation, wheelchair mobility, self-care activities, proper use of orthotic device, therapeutic modalities, and home program

• Share knowledge with other team members


Role of the certified pedorthist



• Participate in patient evaluation, with particular attention to the patient’s feet and footwear

• Participate in generating the prescription for appropriate footwear

• Work cooperatively with the orthotist to provide the footwear and appropriate modifications to the footwear

• Educate the patient, especially the diabetic patient, on footwear and foot care

• Share knowledge with other team members


Role of the patient



• Convey appropriate information to the team members

• Listen, learn, and follow the team recommendations

• Comply with the treatment program and proper use of the orthotic device

• Follow up with the team, particularly if complications or problems related to the orthosis or function occur

Through open discussion and mutual respect, members of the orthotic team can function effectively and efficiently to provide the appropriate services and improve the patient’s functional outcome. Communication is the cornerstone of this process.



Definition of orthosis


The simplest definition of an orthosis is any externally applied device to an existing body part that improves function. Common goals for orthotic devices include the following:


1. Stabilize weak or paralyzed segments or joints

2. Support damaged or diseased segments or joints

3. Limit or augment motion across joints

4. Control abnormal or spastic movements

5. Unload distal segments

As we attempt to achieve these fundamental goals, special attention must be given to issues such as the biomechanics of the device, durability of the materials used, and, most importantly, tissue tolerance to pressures exerted by the device. Finally, let us use the term orthosis correctly in our discussions. Orthosis or orthotic device refers to the actual item delivered to the patient. The term orthotics refers to the field of assessment and fabrication of orthoses.

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Jul 12, 2016 | Posted by in ORTHOPEDIC | Comments Off on The orthotic prescription

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