Atlas of Orthoses and Assistive Devices

555 Pages·2017·133.006 MB·English

by  Joseph B. Webster, Douglas P. Murphy

ATLAS
of
ORTHOSES
and
ASSISTIVE DEVICES
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Fifth Edition
ATLAS
of
ORTHOSES
and
ASSISTIVE DEVICES
Joseph B. Webster, MD
Associate Professor
Department of Physical Medicine and Rehabilitation
School of Medicine at Virginia Commonwealth University
Staff Physician, Physical Medicine and Rehabilitation
Hunter Holmes McGuire VA Medical Center
Richmond, Virginia
Douglas P. Murphy, MD
Associate Professor
Department of Physical Medicine and Rehabilitation
School of Medicine at Virginia Commonwealth University
Staff Physician, Physical Medicine and Rehabilitation
Hunter Holmes McGuire VA Medical Center
Richmond, Virginia
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Atlas of Orthoses and Assistive Devices, Fifth Edition ISBN: 978-0-323-48323-0
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Notices
Knowledge and best practice in this field are constantly changing. As new research and experience broaden
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Previous editions copyrighted 2008, 1997, 1985, and 1975 by Mosby Inc., an imprint of Elsevier, Inc.
ISBN: 978-0-323-48323-0
Library of Congress Cataloging-in-Publication Data
Names: Webster, Joseph B. (Joseph Bradley), 1965- editor. | Murphy, Douglas
(Douglas P.), editor.
Title: Atlas of orthoses and assistive devices / [edited by] Joseph Webster,
Jr., Douglas Murphy.
Description: Fifth edition. | Philadelphia, PA : Elsevier, [2019] | Preceded
by AAOS atlas of orthoses and assistive devices / [edited by] John D.
Hsu,
John W. Michael, John R. Fisk. 4th ed. c2008. | Includes bibliographical references and index.
Identifiers: LCCN 2017025277 | ISBN 9780323483230 (hardcover : alk. paper)
Subjects: | MESH: Orthotic Devices | Biomechanical Phenomena | Orthopedic
Fixation Devices | Self-Help Devices
Classification: LCC RD755 | NLM WE 26 | DDC 617/.9–dc23 LC record available at
https://lccn.loc.gov/2017025277
Senior Content Strategist: Kristine Jones
Senior Content Development Specialist: Jennifer Ehlers
Publishing Services Manager: Patricia Tannian
Project Manager: Stephanie Turza
Design Direction: Patrick Ferguson
Printed in China
Last digit is the print number: 9 8 7 6 5 4 3 2 1
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C O N T R I B U TO R S
Mark F. Abel, MD Josephine R. Bundoc, MD David Drake, MD
Charles Frankel Professor Professor Director, Interventional and Integrative Pain
Division Head, Pediatric Orthopaedics College of Allied Rehabilitation Medicine
Department of Orthopaedic Surgery Sciences University of the East Department of Physical Medicine and
University of Virginia Ramon Magsaysay Memorial Medical Rehabilitation
Charlottesville, Virginia Center, Inc. Hunter Holmes McGuire VA Medical Center
Quezon City, Philippines Richmond, Virginia
Daniel Acker, OTR/L CHT
Clinical Coordinator William E. Carter III, MD, MPH Christopher C. Duncan, MD
Occupational Therapy Assistant Professor Assistant Professor (Clinical)
Georgia Hand Shoulder and Elbow Department of Physical Medicine and Department of Physical Medicine and
Atlanta, Georgia Rehabilitation Rehabilitation
Virginia Commonwealth University University of Utah School of Medicine
Tamara A. Alexander, PT, DPT Richmond, Virginia Salt Lake City, Utah
SCI Clinical Specialist
Department of Veteran Affairs John Chae, MD John S. Early, MD
Tibor Rubin Medical Center Professor and Chair Clinical Professor
Long Beach, California Department of Physical Medicine and Department of Orthopedic Surgery
Rehabilitation University of Texas Southwestern Medical
Alan P. Alfano, MD Professor Center
Professor Department of Biomedical Engineering Dallas, Texas
Department of Physical Medicine and Case Western Reserve University
Rehabilitation Medical Director Joan Edelstein, MA, PT, FISPO
University of Virginia Neuromusculoskeletal Service Line Special Lecturer
Charlottesville, Virginia MetroHealth System Program in Physical Therapy
Cleveland, Ohio Columbia University
Omkar Baxi, MD New York, New York
Orthopaedic Surgery Resident Lynette Codamon, PT
New Jersey Medical School Section Chief Steven R. Edgley, MD
Newark, New Jersey Inpatient Physical Therapy Associate Professor (Clinical)
Hunter Holmes McGuire VA Medical Center Department of Physical Medicine and
Tanya Berenz, MS, OTR/L Richmond, Virginia Rehabilitation
Occupational Therapy Division University of Utah School of Medicine
Department of Physical Medicine and Bill Contoyannis, MEngSc Salt Lake City, Utah
Rehabilitation Rehabilitation Engineer
Michigan Medicine REHAB TECH Jason Edinger, MD
University of Michigan Melbourne, Australia Assistant Professor
Ann Arbor, Michigan Department of Physical Medicine and
Benjamin J. Darter, PT, PhD Rehabilitation
Roy Bowers, HDip Prosthetics and Assistant Professor University of Pittsburgh School of Medicine
Orthotics Department of Physical Therapy Pittsburgh, Pennsylvania
Principal Teaching Fellow School of Allied Health Professions at
Department of Biomedical Engineering Virginia Commonwealth University Alberto Esquenazi, MD
National Centre for Prosthetics and Physical Therapist Director, Gait & Motion Analysis
Orthotics Department of Physical Medicine and Laboratory
University of Strathclyde Rehabilitation MossRehab
Glasgow, United Kingdom Hunter Holmes McGuire VA Medical Center Elkins Park, Pennsylvania
Richmond, Virginia
Jonathan N. Brantley, DPM Deanna Fish, MS, CPO
Chief of Podiatric Medicine and Surgery Katherine L. Dec, MD Clinical Outreach Manager
Department of Surgery Professor Orthomerica Products Inc.
Hunter Holmes McGuire VA Medical Center Department of Physical Medicine and Orlando, Florida
Richmond, Virginia Rehabilitation
Virginia Commonwealth University School Mark Fisher, MD
of Medicine University of Pittsburgh Medical Center
Richmond, Virginia Pittsburgh, Pennsylvania
v
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vi Contributors
Benjamin D. Fortson, MS, CO Christopher Hovorka, PhD, CPO, LPO, Jayme S. Knutson, MD
Certified Orthotist, Resident Prosthetist FAAOP Assistant Professor
Prosthetics and Sensory Aids Service Prosthetics and Orthotics Program Department of Physical Medicine and
Hunter Holmes McGuire VA Medical Center School of Applied Physiology Rehabilitation
Richmond, Virginia Georgia Institute of Technology Case Western Reserve University
Atlanta, Georgia Senior Staff Scientist
John R. Fox, CPO Department of Physical Medicine and
Chief, Orthotic and Prosthetic Laboratory Jared Howell, MS, CPO/L, FAAOP Rehabilitation
Prosthetic Treatment Center Director, Orthotics and Prosthetics Program MetroHealth Rehabilitation Institute
U.S. Department of Veterans Affairs School of Allied Health Sciences Biomedical Engineer
Richmond, Virginia Baylor College of Medicine Louis Stokes Cleveland Veterans Affairs
Houston, Texas Medical Center
David R. Gater Jr., MS, MD, PhD Cleveland, Ohio
Professor, Chair and Residency Program Timothy Hudson, MD
Director Faculty Physician Gary J. Kroll, CO, CTO
Department of Physical Medicine and Physical Medicine and Rehabilitation Assistive Technology Department
Rehabilitation Hunter Holmes McGuire VA Medical Center Gillette Children’s Specialty Healthcare
Penn State College of Medicine Richmond, Virginia St. Paul, Minnesota
Hershey, Pennsylvania
Marjorie Johnson Hilliard, PT, MS, EdD Michael Kwasniewski, MD
Lance L. Goetz, MD Associate Professor Department of Physical Medicine and
Staff Physician, SCI&D Service Associate Chair of Professional Education Rehabilitation
Hunter Holmes McGuire VA Medical Center Department of Physical Therapy and Virginia Commonwealth University
Associate Professor Human Movement Sciences Richmond, Virginia
Department of Physical Medicine and Northwestern Feinberg School of Medicine
Rehabilitation Chicago, Illinois Loren L. Latta, PE, PhD
Virginia Commonwealth University Professor Emeritus
Richmond, Virginia Brian M. Kelly, DO Director of Biomechanics Research
Professor, Physical Medicine and Department of Orthopaedics
Gregory Jason Golladay, MD Rehabilitation Miller School of Medicine
Associate Professor University of Michigan Medical School University of Miami,
Orthopaedic Surgery Medical Director, Division of Orthotics and Miami, Florida;
VCU Health Prosthetics Director of the Max Biedermann Institute
Richmond, Virginia Department of Physical Medicine and for Biomechanics
Rehabilitation Mount Sinai Medical Center
Ashraf S. Gorgey, PhD Michigan Medicine Miami Beach, Florida
Director of Spinal Cord Injury Research University of Michigan
Department of Veterans Affairs Ann Arbor, Michigan Timothy D. Lavis, MD
Spinal Cord Injuries and Disorders Chief
Hunter Holmes McGuire VA Medical Center Shannon M. Kelly, MD Spinal Cord Injuries and Disorders
Richmond, Virginia Assistant Professor Hunter Holmes McGuire VA Medical Center
Department of Orthopaedic Surgery and Assistant Professor
Erik Hansen, MD Sports Medicine Department of Physical Medicine and
Department of Orthopaedics Children’s National Medical Center Rehabilitation
Virginia Commonwealth University Health Washington, DC Virginia Commonwealth University
System Richmond, Virginia
Richmond, Virginia Kevin L. Kilgore, PhD
Professor Rondy Michael Lazaro, MD
Anne Hegberg, MS, OTR/L, CDRS Department of Orthopaedics Resident Physician
Senior Clinician MetroHealth Medical Center Department of Physical Medicine and
Driver Rehabilitation Case Western Reserve University Rehabilitation
Marianjoy Rehabilitation Hospital Biomedical Engineer Virginia Commonwealth University
Wheaton, Illinois Louis Stokes Cleveland Veterans Affairs Richmond, Virginia
Medical Center
Joan Hou, MD Cleveland, Ohio Dulcey Lima, CO, OTR/L
TBI/Polytrauma Fellow President
Department of Physical Medicine and Kevin M. King, CPO Orthotic Interventions
Rehabiliation Department of Prosthetics and Orthotics Lombard, Illinois
Hunter Holmes McGuire VA Medical Center University of Virginia
Virginia Commonwealth University Charlottesville, Virginia
Richmond, Virginia
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Contributors vii
Anthony Lin, BA Miguel N. Mojica, CO Ajit B. Pai, MD
Research Fellow Assistant Professor Medical Director
New Jersey Medical School Certified Prosthetist Orthotist Polytrauma Rehabilitation Center
Newark, New Jersey University of Texas Southwestern Medical Hunter Holmes McGuire VA Medical Center
Center Physical Medicine and Rehabilitation
Sheldon Lin, MD Dallas, Texas Service
Orthopaedic Surgeon Assistant Professor
New Jersey Medical School Jeffrey Bulaong Montes, MD Department of Physical Medicine and
Newark, New Jersey Part Time Assistant Professor Rehabilitation
La Consolacion University Philippines Virginia Commonwealth University
William Lovegreen, MS, CPO College of Allied Medical Sciences Richmond, Virginia
Prosthetist-Orthotist Regional Clinical Director
Director JBM Physical Medicine and Rehabilitation Preeti Panchang, MD
Department of Physical Medicine and Centre Fellow in Musculoskeletal and Amputee
Rehabilitation Bulacan Medicine
Veterans Administration Malolos City, Philippines Hunter Holmes McGuire VA Medical Center
Richmond, Virginia Physical Medicine and Rehabilitation
Maximilian Munoz, MD Virginia Commonwealth University
Christopher D. Lunsford, MD Research Fellow Richmond, Virginia
Pediatric Rehabilitation New Jersey Medical School
Department of Physical Medicine and Newark, New Jersey Dawne Pound, OTR/L, ATP
Rehabilitation Occupational Therapist
University of Virginia Douglas P. Murphy, MD Assistive Technology Professional
Charlottesville, Virginia Associate Professor Spinal Cord Injury and Disorders
Department of Physical Medicine and Hunter Holmes McGuire VA Medical Center
Thomas R. Lunsford, MSE, CO Rehabilitation Richmond, Virginia
Certified Orthotist School of Medicine at Virginia
Lone Star Orthotics Commonwealth University Sara N. Raiser, MD
The Institute for Rehabilitation and Staff Physician Resident Physician
Research Department of Physical Medicine and Department of Physical Medicine and
Houston, Texas Rehabilitation Rehabilitation
Hunter Holmes McGuire VA Medical Center University of Virginia
Nathaniel Makowski, PhD Richmond, Virginia Charlottesville, Virginia
Instructor
Department of Physical Medicine and Leif M. Nelson, DPT, ATP, CSCS Aaron Rasmussen, CO, MBA
Rehabilitation Assistant Chief, Clinical Care Certified Orthotist
Case Western Reserve University Extremity Trauma and Amputation Center Assistive Technology
MetroHealth Medical Center of Excellence Gillette Children’s Specialty Healthcare
Cleveland, Ohio U.S. Department of Veterans Affairs St. Paul, Minnesota
New York, New York
Earnest P.S. Mawusi, DPM, ABFAS Doug Reber, CO, LO
Co-Founder Tom F. Novacheck, MD Director
Ambulatory Foot & Ankle Center Director Education and National Residency Program
P.C. Limb Salvage Center Gillette Children’s Specialty Healthcare, Hanger Clinic
Attending Physician St Paul, Minnesota; Austin, Texas
Department of Podiatric Surgery Center for Gait and Motion Analysis
Hunter Holmes McGuire VA Medical Center Adjunct Associate Professor Reynaldo R. Rey-Matias, PT, MD,
Richmond, Virginia Department of Orthopedics MSHMS
University of Minnesota Chair
Barry Meadows, PhD, CEng, MIMechE, Minneapolis, Minnesota Department of Physical Medicine and
Csci, MIPEM, FISPO Rehabilitation
Visiting Professor Melissa Oliver, MS, OTR/L St. Luke’s Medical Center
National Centre for Prosthetics and Assistive Technology Program Coordinator Associate Professor
Orthotics Physical Medicine and Rehabilitation St Luke’s College of Medicine
University of Strathclyde Service Quezon City, Philippines
Former Head of Neurobiomechanics Hunter Holmes McGuire VA Medical Center
Westmarc Richmond, Virginia
Southern General Hospital
Glasgow, United Kingdom
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viii Contributors
Christopher A. Robinson, MS, MBA, Amy Strouse, DO Jeffrey T. Tubbs, MD
CPO, ATC, FAAOP(D) Resident Physician Inpatient Section Chief
Assistant Professor Physical Medicine and Rehabilitation Spinal Cord Injury and Disorders
Department of Physical Medicine and Penn State Hershey Medical Center Hunter Holmes McGuire VA Medical Center
Rehabilitation Hershey, Pennsylvania Assistant Professor
Northwestern Feinberg School of Medicine Department of Physical Medicine and
Chicago, Illinois Seth K. Stubblefield, MD Rehabilitation
Clinical Research Assistant Virginia Commonwealth University
Olivier Y. Rolin, MD, PhD Department of Orthopaedic Surgery and Richmond, Virginia
Resident Physician Sports Medicine
Physical Medicine and Rehabilitation Children’s National Health System Joseph B. Webster, MD
Virginia Commonwealth University Health Washington, DC Associate Professor
Systems Department of Physical Medicine and
Richmond, Virginia Ryan Sumrell, BS Rehabilitation
Research Health Science Specialist School of Medicine at Virginia
Natasha Romanoski, DO SCI Research Commonwealth University
Assistant Professor Hunter Holmes McGuire VA Medical Center Staff Physician, Physical Medicine and
Department of Physical Medicine and Richmond, Virginia Rehabilitation
Rehabilitation Hunter Holmes McGuire VA Medical Center
Penn State College of Medicine Terry J. Supan, CPO, LPO, FAAOP, Richmond, Virginia
Hershey, Pennsylvania FISPO
President and CEO Justin L. Weppner, DO
Augusto Sarmiento, MD Supan Prosthetic Orthotic Consultations Department of Physical Medicine and
Professor Emeritus Rochester, Illinois Rehabilitation
Department of Orthopaedics University of Virginia
Miller School of Medicine Mukul Talaty, PhD Charlottesville, Virginia
University of Miami Research Engineer
Miami, Florida Gait & Motion Analysis Laboratory Tiffany Williams, MS, OTR/L
MossRehab Occupational Therapy Division
Shannon Schultz, MD Elkins Park, Pennsylvania; Department of Physical Medicine and
Resident Physician Division of Science and Engineering Rehabilitation
Department of Physical Medicine and Pennsylvania State University Michigan Medicine
Rehabilitation Abington, Pennsylvania University of Michigan
Penn State College of Medicine Ann Arbor, Michigan
Hershey, Pennsylvania Laura L. Tosi, MD
Director, Bone Health Program Ann Yamane, MEd, CO/LO
Weibin Shi, MD, PhD Division of Orthopaedics and Sports Senior Lecturer
Assistant Professor Medicine Department of Rehabilitation Medicine
Department of Physical Medicine and Children’s National Health System University of Washington
Rehabilitation Associate Professor Seattle, Washington
Penn State Hershey Medical Center Department of Orthopaedics
Penn State College of Medicine George Washington University Michael Yeranosian, MD
Hershey, Pennsylvania Washington, DC Orthopaedic Surgery Resident
New Jersey Medical School
Amit Sinha, MD Daniel Tsukanov, DO Newark, New Jersey
Assistant Professor Pain and Sports Medicine
Department of Physical Medicine and Department of Physical Medicine and Kristin D. Zhao, PhD
Rehabilitation Rehabilitation Director
Children’s Hospital of Pittsburgh of UPMC Hunter Holmes McGuire VA Assistive and Restorative Technology
Pittsburgh, Pennsylvania Medical Center Laboratory
Richmond, Virginia Rehabilitation Medicine Research Center
Marcus J. Smith, MD Department of Physical Medicine and
Assistant Professor Rehabilitation
Department of Physical Medicine and Mayo Clinic
Rehabilitation Rochester, Minnesota
Virginia Commonwealth University
Richmond, Virginia
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F O R E WO R D
Advances in technology, materials, and miniaturization, a greater is a must-have for every medical library. The collection of real-world
appreciation of the functional biomechanics of human movement, and clinicians who have contributed to this comprehensive tome have put
a recognition that the specific wants and needs of the individual end together a single-source, authoritative reference that provides both the
user have pushed the field of prosthetics and orthotics to the next level. latest in technological and biomechanical breakthroughs and the core
Keeping current and on the leading edge of these advancements, knowledge of the integrative approach to care that is the foundation
appreciations, and recognitions has become increasingly challenging of PM&R care. It is with great enthusiasm and appreciation that I
for both the super-specialists and the day-to-day clinicians who prescribe, introduce and celebrate the 5th edition of this important atlas.
fit, train in, and monitor the use of these assistive and adaptive devices. David X. Cifu, MD
This new Atlas of Orthoses and Assistive Devices, edited by my esteemed Associate Dean of Innovation and System Integration
colleagues Joseph Webster and Douglas Murphy, represents the cutting- Herman J. Flax, MD Professor and Chairman, Department of Physical
edge solution for all providers who work with these devices and the Medicine and Rehabilitation
individuals who use them. Organized by two of the world’s leading Virginia Commonwealth University School of Medicine
academic physiatrists, who help to champion the prosthetic and orthotic Richmond, Virginia
needs of America’s service members and veterans, this impressive work
ix
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P R E FAC E
This newest edition of the Atlas of Orthoses and Assistive Devices has In 1997, the third edition of the AAOS Atlas of Orthoses and Assistive
been driven by the need for an updated publication that captures the Devices built upon this heritage by assembling a diverse group of experts
significant advances that have occurred in the fields of orthotics, assistive from multiple disciplines and by implementing standards to cite available
technology, rehabilitation medicine, and orthopedics over the past 10 controlled studies and provide scientifically valid justification for the
years. Since its inception, the scope and aim of this publication have opinions expressed.
evolved greatly over the course of the past 65 years. This new edition The fourth edition of this atlas was published in 2008 and provided
reflects the shift in practice that has occurred from the use of traditional an up-to-date overview of the clinical application of contemporary
bracing materials and fabrication techniques to the development of orthoses with an emphasis on the more sophisticated technology and
highly sophisticated and technically advanced orthoses and assistive the application of this technology to achieve measurable results. This
devices. Technological advances have occurred in materials science, in edition also reflected the evolution in the role of the orthotist from
fabrication techniques with computerized modeling, and through the simply performing brace fabrication and fitting to serving as an active
incorporation of more advanced electrical and computerized systems consultant in the development and implementation of the most effective
into the structure and function of orthoses. All of these advances are treatment plan for each individual.
proceeding at a rapid pace. The Atlas of Orthoses and Assistive Devices, 5th edition, builds on
The fifth edition of the Atlas of Orthoses and Assistive Devices is built the tradition of the prior editions with the overall aim of providing a
upon a strong foundation that began in 1952 with the publication of text that has practical application for clinicians by facilitating effective,
the Orthopaedic Appliances Atlas. This original publication, which was informed decisions regarding today’s advanced orthotic devices. This
supported by the Surgeon General, the Veterans Administration, and new edition encompasses both the more traditional fabrication and
the National Research Council, aimed to standardize bracing nomen- fitting principles along with information on advances in the material
clature and classify the use and production of disease-specific devices. sciences, 3D printing technology, functional electrical stimulation,
The first edition of the Atlas of Orthotics was not forthcoming until microprocessor technologies, and robotics. These advances have made
1975 when this text was published by C. V. Mosby under the auspices clinical decision making around the prescription and application of
of the American Academy of Orthopedic Surgeons (AAOS) Committee these devices more complex than ever before. The Atlas of Orthoses and
on Prosthetics and Orthotics. The primary focus of this initial edition Assistive Devices, 5th edition, brings medical and rehabilitation profes-
was to provide a rational basis for the prescription of an orthosis best sionals completely up to date with these advances and creates the
suited for a particular patient’s needs. This edition introduced a new opportunity to achieve optimal results in every patient.
nomenclature using terminology to describe orthoses "by the joints While the 5th edition has maintained the overall organizational
they encompass and … their effect on the control of anatomic joint structure of the prior edition, many new authors and several new chapters
motions," which was subsequently adopted by the International Standards have been added. Despite the greater technological sophistication in
Organization (ISO). orthoses and assistive devices, the new edition has maintained a high
The second edition of the Atlas of Orthoses was published within level of readability and practical application. Comprehension of the
the next decade by the American Academy of Orthopaedic Surgeons content is enhanced by the large number of figures and tables, as well
in order to capture the advances in material science and the application as by the addition of color photographs. The Key Points boxes at the
of orthoses for a variety of conditions. The intent of this publication beginning of each chapter highlight the authors’ primary learning
was to "bridge the gap between a rote therapeutic approach and the objectives. While the field of orthotics and assistive devices could benefit
frontiers of science." This edition established the conceptual organization from a more rigorous scientific foundation, this edition has incorporated
of topics and content that continues to this day in the fifth edition. the most recent research literature and promotes the utilization of an
This text also broke new ground by emphasizing the consideration of evidence-based practice approach.
the orthosis as one of many treatment options, including pharmacologic, Joseph B. Webster, MD
medical, and surgical interventions. Douglas P. Murphy, MD
xi
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1
Orthotic Prescription
Ann Yamane
KEY POINTS
• A prescription for an orthosis communicates the type of device • Optimally, the prescription for an orthosis is determined with
recommended to meet the biomechanical needs of the patient to input from members of the health care team and patient,
improve function and promote participation in life activities. incorporating meaningful shared rehabilitation goals that use
• An appropriate orthotic prescription and treatment plan is patient-centered and interdisciplinary team approaches.
generated based on knowledge of the patient’s disease process • An effective prescription for an orthosis summarizes the medical
along with information from a comprehensive history, physical and functional issues related to the patient, details the
examination, and integration of patient-related and biomechanical functions desired, and specifies key technical
environmental factors. attributes of the desired orthosis.
The prescription for an orthosis is an essential part of the larger process rather than a custom-fitted orthosis, (2) need for long-term use of the
of rehabilitation to improve patient function and promote participation orthosis, and (3) planes of static and dynamic control necessary at each
in life activities. Each member of the interdisciplinary team offers expertise joint (sagittal, coronal, transverse).3
that allows the team to work collaboratively with the patient to identify In addition, the physician considers additional referrals necessary
goals for orthotic intervention and shared rehabilitation goals. to support the comprehensive orthotic treatment plan. This may include
An effective interdisciplinary approach fosters communication by supporting therapies, medications, surgeries, or injections to improve
involving all team members throughout the treatment process. A col- the underlying condition before provision of an orthosis or to improve
laborative clinical environment allows team members the opportunity the outcomes of the intervention. For example, an individual with a
to clarify their clinical recommendations and educate other team knee flexion contracture and quadriceps weakness may be referred to
members on their areas of expertise. Because of current health care physical therapy in an attempt to reduce the contracture before orthotic
policy and financial demands, this interdisciplinary approach may be intervention. Reducing the knee flexion contracture will improve the
possible in the acute setting but is typically challenging to achieve in effective use of a ground-reaction ankle-foot orthosis (AFO) by increasing
outpatient settings. This lack of face-to-face communication requires the external knee extension moment created by the AFO from midstance
the use of detailed documentation notes by the physician and others to terminal stance.
to convey the assessment findings and clinical reasoning. The interdisciplinary team is most effective when team members
Formulation of the orthotic prescription begins with the physician’s work cooperatively, sharing perspectives and expertise and effecting a
medical evaluation of the patient, identification of the pathology and blend of the physician’s medical knowledge; the orthotist’s understanding
associated functional impairments, and prognosis. The assessment of of biomechanics, design, and material options; and the occupational
the individual consists of a history that includes problems noted by the and physical therapists’ evaluation of functional abilities, education,
patient, prior interventions, and patient expectations and goals. The and therapy to improve function.
identification of patient-related and environmental factors as outlined Follow-up is crucial to assess the functional outcome and success
by the World Health Organization’s conceptual framework, the Inter- of the orthotic treatment plan in meeting the patient’s goals and the
national Classification of Functioning, Disability, and Health (also known patient-centered rehabilitation team goals. Functional outcomes may
as the ICF) provides insight into how an individual functions in daily be patient reported or performance based to assess improved quality
life. This context is key to informing the orthotic treatment plan.6 of life, mobility, self-care, or other constructs of value specific to each
Determining the appropriate orthotic prescription is grounded in individual. The Activities-Specific Balance Confidence (ABC) Scale4 is
the biomechanical needs of the patient as identified through a physical an example of a self-report measure used to assess an individual’s level
evaluation that includes manual muscle testing (MMT), range-of-motion of confidence while involved in specific activities such as walking up
(ROM) testing, and sensory testing. Through the integration of the or down stairs, in crowds, or on icy sidewalks. The Timed Up and Go
biomechanical needs and the personal and environmental factors of (TUG)5 is a commonly used performance measure assessing balance,
the individual, the optimal orthosis design is identified. Although the functional mobility, gait, and potential risk for falls. The routine integra-
actual prescription for an orthosis communicates the type of device tion of outcome measures into the orthotic treatment plan has the
recommended to meet the biomechanical and functional needs of the potential to provide increased knowledge regarding the success of the
patient, the physician’s clinic documentation note contains the necessary orthotic prescription in achieving the desired improvement in patient
information justifying the (1) need for a custom-fabricated orthosis function and increased participation in life activities.
2
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