Orthotics. Canadian Association of Occupational Therapists, May

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1 Orthotics hot Topics provide occupational therapists and occupational therapy students with a list of references in an area identified as emerging and/or topical by CAOT members. CAOT invites you to contribute to the ongoing development of this document. CAOT would like to thank Pat McKee, Associate Professor, Department of Occupational Science and Occupational Therapy, University of Toronto, who developed this hot Topic. The following excerpts are from: McKee, P. and Rivard, A. (2011 in press) Foundations of Orthotic Intervention. In T. Skirven, L. Osterman, J. Fedorczyk, & P. Amadio (Eds.). Rehabilitation of the Hand and Upper Extremity (6th ed.). Philadelphia, PA: Mosby Elsevier Inc. An orthosis (splint) is a custom-made or prefabricated device applied to biological structures impaired by acute injury, cumulative trauma, disease, surgical intervention, congenital anomaly or degenerative changes - to relieve pain, stabilize body joints or tendons, protect against (re) injury, promote healing, prevent or correct deformity - to ultimately promote current or future occupational performance and participation in roles important to the individual. (p. 1569) 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 enabling occupation. 1 The International Organization for Standardization (ISO, an international standardsetting body, founded in 1947 with headquarters in Geneva Switzerland) (1998) recommended that the term orthosis be used to describe all such devices. 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. 2 (p. 1567) 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. (p. 1567) The therapist who provides orthotic intervention requires sound knowledge of anatomy and physiology, bio-mechanics, human occupation, orthotic materials and mechanical principles of orthotic fabrication. Also required are skills in activity analysis, client assessment and education and fabrication techniques. 3 Unlike most other interventions in occupational therapy, orthotic intervention results in an individualized device, that the client wears outside the clinic, that meets specific biological and occupational needs. Optimal benefit from orthotic intervention is achieved through an individualized client-centered, bio-occupational approach that addresses clients biological (anatomical and physiological) needs as well as their occupational performance issues, within their unique social and physical environmental contexts. (p. 1566) A client-centred approach challenges us to modify our language and terminology, as discussed earlier, and advocates for the careful selection of assessment tools and outcome measures. 4 Routine use of function-based, client-centered evaluations promotes optimal Canadian Association of Occupational Therapists, May

2 collaboration with the client and a focus on occupational rather than on biological outcomes. Examples include the Canadian Occupational Performance Measure 4,5,6, the Disabilities of the Arm Shoulder and Hand (DASH) 7, and the Patient-Specific Functional Scale. 8 These measures have the added benefit of providing evidence of orthotic efficacy. 4 (p. 1569) McKee and Rivard 9 have developed the following guiding principles for a bio-occupational approach to orthotic intervention: 1. Use a client-centred approach 2. Consider psychosocial factors 3. Consider environmental factors 4. Optimize body structure and function 5. Enable activity and participation 6. Well engineered 7. Optimize usability 8. Provide choice 9. Optimize comfort 10. Minimize harm 11. Optimize cosmesis 12. Optimize convenience 13. Use a less is more (minimalistic) approach 14. Provide comprehensive client/caregiver education 15. Monitor and modify 16. Evaluate outcomes References From introduction 1. McKee, P. & Rivard, A. (2007) Occupation-based orthotic intervention. In E.A.Townsend & H.J. Polatajko, Enabling Occupation II: Advancing an Occupational Therapy Vision for Health, Well being & Justice through Occupation. Ottawa, Ontario: CAOT Publications ACE. p International Organization for Standardization.(1998) : Prosthetics and orthotics - vocabulary, part 1: General terms for external limb prostheses and external orthoses. Geneva, Switzerland: author. 3. Buning, M.E. (2008) Assistive technology and wheeled mobility. In E.B. Crepeau, E.S. Cohn, B.A.B Schell (Eds.). Willard & Spackman s Occupational Therapy (11th ed.). Philadelphia, PA: Lippincott. 4. McKee, P. & Rivard, A. (2004) Orthoses as enablers of occupation: Client-centred splinting for better outcomes. Canadian Journal of Occupational Therapy. 71(5): Law, M., Baptiste, S., Carswell, A., McColl, M., Polatajko, H., Pollock, N. (1998). Canadian occupational performance measure (2nd Rev. ed.). Ottawa, ON: CAOT Publications ACE. 6. Hannah, S. & Hudak, P. (2001) Splinting and radial nerve palsy: A single-subject experiment. Journal of Hand Therapy, 14(3): Beaton, D.E., Katz, J.N., Fossel, A.H., Wright, J.G., Tarasuk, V. & Bombardier C. (2001) Measuring the whole or the parts? Validity, reliability, and responsiveness of the disabilities of the arm, shoulder and hand outcome measure in different regions of the upper extremity. Journal of Hand Therapy. Apr-Jun;14(2): Stratford, P., Gill, C., Westaway, M., & Binkley, J. (1995). Assessing disability and change on individual patients: A report of a patient specific measure. Physiotherapy Canada. 47: McKee, P. & Rivard, A. Biopsychosocial Approach to Orthotic Intervention. (2011 in press). Journal of Hand Therapy. 2 Canadian Association of Occupational Therapists, May 2011

3 The following articles and textbooks listed within this hot topic represent only a portion of the existing literature on orthotics. The particular journals/textbooks listed have been included for one of the following reasons: 1) they provide an overview of orthotics including theory and therapy techniques, 2) synthesize available evidence on the effectiveness of specific orthotics or 3) illustrate how orthotics can be used to enable occupation. The assessment tools listed are supported by good psychometrics and provide justification for clinicians clinical reasoning for occupational therapy interventions. The associations listed can provide good networking opportunities for clinicians, further education courses, and resources for practice. General Textbooks Edelstein, J.E. & Bruckner, J. (2002). Orthotics: A comprehensive clinical approach. Thorofare, NJ: Slack Inc. Lusardi, M.M. & Nielsen, C.C. (2007). Orthotics and prosthetics in rehabilitation. (2nd ed.). St. Louis, MO: Saunders Elsevier. McKee, P. & Morgan, L. (1998). Orthotics in rehabilitation: Splinting the hand and body. Philadephia, PA: F.A. Davis. Pendleton, H.M. & Krohn, W.S. (Eds.). (2006). Pedretti s occupational therapy: Practice skills for physical dysfunction. (6th ed.). St. Louis, MO: Mosby Elsevier. Radomski, M.V. & Trombly, C.A. (Eds.) (2008). Occupational therapy for physical dysfunction. (6th ed.) Philadelphia, PA: Lippincott, Williams &Wilkins. Upper Extremities Textbooks Burke, S.L. & Clark, G.L. (2006). Hand and upper extremity rehabilitation: A practical guide (3rd ed.). St. Louis, MO: Elsevier Churchill Livingstone. Cooper,C. (Ed.) (2007). Fundamentals of hand therapy: Clinical reasoning and treatment guidelines for common diagnoses of the upper extremity. St. Louis, MO: Mosby Elsevier. Coppard, B.M. & Lohman, H. (2007). Introduction to splinting: A clinical reasoning and problem-solving approach (3rd ed.). St. Louis, MO: Mosby Elsevier. Hogan, L. & Uditsky, T. (1998). Pediatric splinting: Selection, fabrication and clinical application of upper extremity splints. San Antonio: Therapy Skill Builders. Jacobs, M.A. & Austin, N.M. (2002). Splinting the hand and upper extremity: Principles and process. Philadelphia, PA: Lippincott, Williams &Wilkins. Skirven, T., Osterman, L., Fedorczyk, J., and Amadio, P. (2011 in press) Rehabilitation of the Hand and Upper Extremity (6th ed.). Philadelphia, PA : Mosby Elsevier. Lower Extremities Textbooks Nawoczenski, D.A. & Epler, M.E. (1997). Orthotics in functional rehabilitation of the lower limb (5th ed.) Philadelphia, PA: Saunders. Seymour, R. (2002). Prosthetics and orthotics: Lower limb and spinal. Philadelphia, PA: Lippincott, Williams & Wilkins. History of Splinting Fess, E. (2002). The history of splinting: To understand the present, view the past. Journal of Hand Therapy, 15(2), Evidence Supporting the Use of Orthotics Ada, L., Foongchomcheay, A. & Canning, C.G. (2005). Supportive devices for preventing and treating subluxation of the shoulder after stroke. Cochrane Database of Systematic Reviews, Issue 1. Art. No.: CD DOI: / CD pub2. Egan, M., Brosseau, L., Farmer, M., Ouimet. M.A., Rees, S., Tugwell, P., Wells, G.A. (2003) Splints and Orthosis for treating rheumatoid arthritis. Cochrane Database of Systematic Reviews, Issue 1. Art. No.: CD DOI: / CD Firmin, F. & Crouch, R. (2009). Splinting versus casting of torus fractures to the distal radius in pediatric patient presenting at the emergency department (ED): A literature review. International Emergency Nursing, 17(3), Canadian Association of Occupational Therapists, May

4 Hume, P., Hopkins, W., Rome, K., Maulder, P., Coyle, G. & Nigg, B. (2008). Effectiveness of foot orthoses for treatment and prevention of lower limb injuries. Sports Medicine, 38(9), Lee, S.Y., McKeon, P., & Hertel, J. (2009). Does the use of orthoses improve self-reported pain and function measures in patients with plantar fasciitis? A meta-analysis. Physical Therapy in Sport, 10(1), Lin, C.W.C., Moseley, A.M. & Refshauge, K.M. (2008). Rehabilitation for ankle fractures in adults. Cochrane Database of Systematic Reviews, Issue 3. Art. No.: CD DOI: / CD pub2. Rose, K.J., Burns, J., Wheeler, D.M. & North, K.N. (2010). Interventions for increasing ankle range of motion in patients with neuromuscular disease. Cochrane Database of Systematic Reviews, Issue 2. Art. No.: CD DOI: / CD pub2. Sahar, T., Cohen, M.J., Ne eman, V., Kandel, L., Odebiyi, D.O., Lev, I., Brezis, M., & Lahad, A. (2007). Insoles for prevention and treatment of back pain. Cochrane Database of Systematic Reviews, Issue 4. Art. No.: CD DOI: / CD pub2. Spencer, S.A. (2000). Pressure relieving interventions for preventing and treating diabetic foot ulcers. Cochrane Database of Systematic Reviews, Issue 3. Art. No.: CD DOI: / CD Teplicky, R., Law, M. & Russell, D. (2002). The effectiveness of casts, orthoses, and splints for children with neurological disorders. Infants & Young Children, 15(1), Enabling Occupation with Orthoses Amini, D. (2005) The occupational basis for splinting. OT Advance, 21(8):11. Bracks, C. (2007). Low profile extension splint for active extensor lag of the proximal interphalengeal joint. Journal of Hand Therapy, 20(3), Boyette, J. (2005). Splinting for adaptation of musical instruments. Work, 25(2), Davies, T. (2008). The little finger splint that could. Occupational Therapy Now, 10(4), 16. Denys, A. (2003). Pressure relief splinting for an infant: A systematic approach. Canadian Journal of Occupational Therapy, 70(3), Fess, E. (2005) Splinting for work, sports and the performing arts. In E.E. Fess, K.S. Gettle, C.A. Philips, J.R. Jansen (Eds.). Hand and Upper Extremity Splinting: Principles and Methods (3rd ed.). St. Louis, MO: Elsevier Mosby. Ford, M., McKee, P. & Szilagyi, M. (2004). A Hybrid Thermoplastic and Neoprene Thumb Metacarpophalangeal Joint Orthosis. Journal of Hand Therapy, 17: Gillen, G. (2000). Improving activities of daily living performance in an adult with ataxia. American Journal of Occupational Therapy, 54(1), Johnson, C. (2003). The musician. In M. Jacobs & N.M. Austin (Eds.). Splinting the Hand and Upper Extremity: Principles and Process. Baltimore: Lippincott,Williams & Wilkins. Levy, C. (2007). Custom made chest guard for pediatric cancer patients: A case report. Rehabilitation Oncology, 25(2), McKee, P. & Rivard, A.( 2004). Orthoses as enablers of occupation: Client-centered splinting for better outcomes. Canadian Journal of Occupational Therapy, 71(5), McKee, P. & Nguyen, C. ( 2007). Customized dynamic splinting: Orthoses that promote optimal function and recovery after radial nerve injury: A case report. Journal of Hand Therapy, 20(1), McKee, P. & Nguyen, C. ( 2007). Low-profile dorsal dynamic wrist-finger-thumb assistive-extension orthosis for high radial nerve injury-fabrication instructions. Journal of Hand Therapy, 20(1), McKee, P. and Rivard, A. (2007) Occupation-based orthotic intervention. (pp ) In H. Polatajko, N. Cantin, B. Amoroso, P. McKee, A. Rivard, B. Kirsh, D. Laliberte Rudman, P. Rigby, & N. Lin (2007). Occupation-based enablement: A practice mosaic. In E.A. Townsend & H.J. Polatajko, Enabling Occupation II: Advancing an Occupational Therapy Vision for Health, Well-being & Justice through Occupation (pp ). Ottawa, On: CAOT Publications ACE. McKee, P. (2007). Catherine s story: Enabling individual change. In E.A. Townsend & H.J. Polatajko, Enabling Occupation II: Advancing an Occupational Therapy Vision for Health, Well-being & Justice through Occupation (p. 120). Ottawa, On: CAOT Publications ACE. McKee, P. and Rivard, A. (2011). Foundations of Orthotic Intervention. In T. Skirven, L. Osterman, J. Fedorczyk, & P. Amadio, Rehabilitation of the Hand and Upper Extremity (6th ed.). St. Louis, MO: Elsevier Mosby. 4 Canadian Association of Occupational Therapists, May 2011

5 McKee, P. & Rivard, A. Biopsychosocial Approach to Orthotic Intervention. (2011 in press). Journal of Hand Therapy Stier J. (2004) Occupation-based splinting. Occupational Therapy Now, 6(4): Component Based Assessments Assessment/Outcome Tools Dynamometer Innes, E. (1999). Handgrip strength testing: A review of the literature. Australian Occupational Therapy Journal, 46(3), Goniometry Goodwin, J., Clark, C. Deakes, J., Burdon, D. & Lawrence, C. (1992). Clinical methods of goniometry: A comparative study. Disability & Rehabilitation, 14(1), Manual Muscle Testing Schmitt, W.H. & Cuthbert, S.C. (2008). Common errors and clinical guidelines for manual muscle testing: The arm test and other inaccurate procedures. Chiropractic & Osteopathy, 16(16), McGill Pain Questionnaire Melzack, R. (1975). The McGill Pain Questionnaire: Major properties and scoring methods. Pain, 1(3), Minnesota Dexterity Test Surrey, L.R., Nelson, K., Delelio, C., Mathie-Majors, D., Omel-Edwards, N., Shumakeeer, J. & Thurber, G. (2002). A comparison of performance outcomes between the Minnesota Rate of Manipulation Test and the Minnesota Manual Dexterity Test. Work, 20(2), Nine Hole Peg Test Kellor, M., Frost, J., Silberberg, N., Iversen, I. & Cummings, R. (1971). Hand strength and dexterity. American Journal of Occupational Therapy, 25(2), Oswestry Disability Questionnaire Ferrari, R. (2007). Responsiveness of the Short-Form 36 and Oswestry Disability Questionnaire in chronic nonspecific low back and lower limb pain treated with customized foot orthotics. Journal of Manipulative and Physiological Therapeutics, 30(6), Semmes-Weinstein Monofilaments Jerosch-Herold, C. (2005). Assessment of sensibility after nerve injury and repair: A systematic review of evidence for validity, reliability and responsiveness of tests. Journal of Hand Surgery-British Volume, 30(3), Functional Assessments Canadian Occupational Performance Measure McKee,P. & Rivard, A.( 2004). Orthoses as enablers of occupation: Client-centered splinting for better outcomes. Canadian Journal of Occupational Therapy, 7(5), DASH Questionnaire Gummesson, C., Atroshi, I. & Ekdahl,C.( 2003). The disabilities of the arm, shoulder and hand (DASH) outcome questionnaire: Longitudinal construct validity and measuring self-rated health change after surgery. BMC Musculoskeletal Disorders, 4(11), 1-6. Jebsen Test of Hand Function Jebsen, R.H, Taylor, N., Trieschmann, R.B., Trotter, M.J., Howard, L.A. (1969). An objective and standardized test of hand function. Archives of Physical Medicine and Rehabilitation, 50(6), Orthotics and Prosthetics User Survey Heinemann, A.W., Gershon, R., Fisher, W., Development and application of the orthotics and prosthetics survey: Applications and opportunities for Health care quality improvement. Journal of Prosthetics and Orthotics, 18(6) Patient-specific Functional Scale Spencer, S.A. (2000). Pressure relieving interventions for preventing and treating diabetic foot ulcers. Cochrane Canadian Association of Occupational Therapists, May

6 Database of Systematic Reviews 2000, Issue 3. Art. No.: CD DOI: / CD Valpar Work Sample Series Jackson, M., Harkes J., Ellis, J. (2004). Reporting patients work abilities: How the use of standardized work assessments improved clinical practice in Fife. British Journal of Occupational Therapy, 67 (3), Associations Additional Information American Society of Hand Therapists American Academy of Orthotists & Prosthetists British Hand Therapy Association Canadian Society of Hand Therapists Canadian Association of Prosthetics and Orthotics Hand Therapy Canada International Federation of Societies of Hand Therapists International Society of Prosthetics and Orthotics, Canada West Coast Hand Therapy Association Several Universities with Occupational therapy programs also have groups: MacHANd Group The Hand and Upper Limb Centre University of Toronto Hand Program Resource Contacts Pat McKee M.Sc., OT Reg. (Ont.), OT (C) 6 Canadian Association of Occupational Therapists, May 2011

7 Questions for Reflection Who could you connect with for mentorship and practice guidance within your area? How could you apply some of the evidence provided in this document into your practice context? How has the information from this document prepared you for working in orthotics? What more do you need to learn to prepare to work in the area of orthotics? What issues or dilemmas have you encountered within your practice related to orthotics? hot topics are time-limited and persons wishing to use them more than two years after publication should confirm their current status by contacting the CAOT Professional Education Coordinator by Canadian Association of Occupational Therapists CTTC Building, Colonel By Drive Ottawa, ON K1S 5R1 Canada Tel (800) Fax (613) Canadian Association of Occupational Therapists, May