Chapter 2 The orthotic prescription
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.
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.
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.
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.