orthosis evaluation tammy j. lesage mot, otr/l, cht elisabeth mcgee dpt, mot, otr/l, pt, cht, mtc

Orthosis EvaluationOrthosis Evaluation

Tammy J. LeSage MOT, OTR/L, Tammy J. LeSage MOT, OTR/L, CHTCHT

Elisabeth McGee DPT, MOT, Elisabeth McGee DPT, MOT, OTR/L, PT, CHT, MTCOTR/L, PT, CHT, MTC

Orthotic EvaluationOrthotic Evaluation Interview, chart Interview, chart

review and reportsreview and reports Injury/ surgeryInjury/ surgery Hand dominance Hand dominance ObservationObservation Hand posture/ useHand posture/ use PalpationPalpation

Assessments for:Assessments for:PainPain

Skin and allergiesSkin and allergies WoundsWounds BoneBone Joint/ LigamentJoint/ Ligament Muscle/ TendonMuscle/ Tendon Nerve/ SensationNerve/ Sensation VascularVascular ROMROM FunctionFunction ReimbursementReimbursement

Orthotic ClassificationsOrthotic Classifications

Tammy J. LeSage MOT, OTR, Tammy J. LeSage MOT, OTR, CHTCHT

Elisabeth McGee DPT, MOT, Elisabeth McGee DPT, MOT, OTR/L, PT, CHT, MTCOTR/L, PT, CHT, MTC

TerminologyTerminology OrthosisOrthosis: is a noun and should be used in : is a noun and should be used in

place of the word place of the word splintsplint OrthosesOrthoses: is a pleural noun and should be : is a pleural noun and should be

used to replace the term for multiple used to replace the term for multiple splintssplints ““Fabricating an orthosisFabricating an orthosis” should be used ” should be used

in place of the verb in place of the verb splintingsplinting OrthoticOrthotic: is an adjective and is used to : is an adjective and is used to

describe a noun associated with the science describe a noun associated with the science of orthotics, such as orthotic device, orthotic of orthotics, such as orthotic device, orthotic treatment plan, orthotic intervention, treatment plan, orthotic intervention, orthotic fabrication, or orthotic codingorthotic fabrication, or orthotic coding

TerminologyTerminology

Durable Medical Equipment, Prosthetics, Durable Medical Equipment, Prosthetics, Orthotics, and SuppliesOrthotics, and Supplies (DMEPOS Quality Standards) (DMEPOS Quality Standards) DMEPOS suppliers must comply with the DMEPOS DMEPOS suppliers must comply with the DMEPOS

Quality Standards and become accredited to obtain Quality Standards and become accredited to obtain or maintain Medicare billing privileges or maintain Medicare billing privileges

Healthcare Common Procedure Coding System Healthcare Common Procedure Coding System (HCPCS) (HCPCS) Level 2 ManualLevel 2 Manual Orthotic devices are described by the CMS using L-Orthotic devices are described by the CMS using L-

codes that are found in this manualcodes that are found in this manual L-codes found here and are used to bill for orthosesL-codes found here and are used to bill for orthoses

Classifications SystemsClassifications Systems

Modified Orthosis Classification Modified Orthosis Classification System (MOCS)System (MOCS)Jacobs, 2014Jacobs, 2014Uses current terminology that Uses current terminology that

meet Medicare standards for meet Medicare standards for reimbursementreimbursement

ASHT’s Expanded Splint/Orthosis ASHT’s Expanded Splint/Orthosis Classification System (ESCS) Classification System (ESCS)

Modified Orthosis Modified Orthosis Classification System (MOCS)Classification System (MOCS)

Articular Nonarticular

Location (FO, HFO, WHFO, WHO, EWHFO, etc.)

Joint Positions (flex, ext, etc.)

Joint(s) Involved /Torque Application (wrist, MCP, PIP, DIP, etc.)

Immobilization Restriction

Location (humerus, MC, phalanx)

Mobilization

Design Options (dorsal, volar, radial, ulnar, circumferential, etc.

Direction(s) of Torque Application (flex, ext, etc.)

Orthotic Intervention for the Hand and Upper Extremity, 2014

ASHT Splint/Orthosis ASHT Splint/Orthosis Classification SystemClassification System

Rehabilitation of the Hand and Upper Extremity, 2011

ASHT Splint/Orthosis ASHT Splint/Orthosis Classification System: 6 Classification System: 6

CriteriaCriteria1.1. Articular or Non-articularArticular or Non-articular

2.2. Anatomic focus (e.g. 2Anatomic focus (e.g. 2ndnd digit PIP) digit PIP)

3.3. Kinematic direction (i.e. where joints are Kinematic direction (i.e. where joints are moved or positioned into.- e.g. flexion)moved or positioned into.- e.g. flexion)

4.4. Primary purpose (e.g. mobilization)Primary purpose (e.g. mobilization)

5.5. Type or number of secondary joint levelsType or number of secondary joint levels

6.6. Total number of joints included in the Total number of joints included in the orthosisorthosis

Key Anatomical Key Anatomical Headings/Classification By Headings/Classification By

Location Location Joints Involved Orthosis Classification

Shoulder, elbow, wrist, hand, finger orthosis

SEWHFO

Shoulder, elbow, wrist, hand orthosis SEWHO

Shoulder, elbow orthosis SEO

Elbow, wrist, hand, finger orthosis EWHFO

Elbow, wrist, hand orthosis EWHO

Wrist, hand, finger orthosis WHFO

Wrist, hand orthosis WHO

Hand, finger orthosis HFO

Shoulder orthosis SO

Elbow orthosis EO

Hand orthosis HO

Finger orthosis FO

Classification by FunctionClassification by Function

Immobilization Immobilization Mobilization Mobilization RestrictionRestrictionTorque Transmission Torque Transmission

ImmobilizationImmobilization

MobilizationMobilization

RestrictionRestriction

Torque TransmissionTorque Transmission

Non-MOCS/SCS NomenclatureNon-MOCS/SCS Nomenclature

Static OrthosisStatic OrthosisSerial Static OrthosisSerial Static OrthosisDynamic OrthosisDynamic OrthosisStatic Progressive OrthosisStatic Progressive Orthosis

Static OrthosisStatic Orthosis

Has no moving Has no moving components and components and immobilizes a joint or immobilizes a joint or part.part.

Used for:Used for: rest – arthritisrest – arthritis protection – fractureprotection – fracture positioning – CVApositioning – CVA loss of motor functionloss of motor function - nerve injury- nerve injury

Used with permission from Sammons Preston

Serial Static OrthosisSerial Static Orthosis

A splint the achieves A splint the achieves a slow, progressive a slow, progressive increase in ROM by increase in ROM by repeated molding of repeated molding of the splint. Low load, the splint. Low load, long duration long duration stretch.stretch.

Examples:Examples:

C barC bar

serial cast serial cast


Static Progressive OrthosisStatic Progressive Orthosis

An orthotic device An orthotic device that mobilizes joints that mobilizes joints or stretches soft or stretches soft tissue. The device tissue. The device includes a non-includes a non-elastic mechanism elastic mechanism that adjusts the that adjusts the amount of traction amount of traction force and angle force and angle acting on the part.acting on the part.

Static Progressive Orthosis Static Progressive Orthosis

Permission from Sammons Preston

Stress-Strain Curve &Stress-Strain Curve &Orthotic Forces Placed Upon Orthotic Forces Placed Upon

TissuesTissues

Static Progressive OrthosesStatic Progressive Orthoses Serial Static Orthoses Serial Static Orthoses

Utilizes the principle of Utilizes the principle of Stress RelaxationStress Relaxationconstant strain causes decreasing stress in constant strain causes decreasing stress in

tissuetissueThe tissues are stretched and held at a The tissues are stretched and held at a

constant length. The stretching forces relax constant length. The stretching forces relax over time. over time.

Theory: Relaxation occurs due to the Theory: Relaxation occurs due to the realignment of fibers and tissue elongation realignment of fibers and tissue elongation when tissues are held in a fixed position when tissues are held in a fixed position over time. over time.

Dynamic OrthosesDynamic Orthoses

A static based A static based orthosis with a orthosis with a mobile, resilient mobile, resilient component attached. component attached. Components consist Components consist of elastics, rubber of elastics, rubber bands, springs that bands, springs that produce motionproduce motion



Principle of CreepPrinciple of Creepconstant stress causes increasing constant stress causes increasing

strain in tissuestrain in tissueA constant load is applied for A constant load is applied for

several hours during the day over several hours during the day over a period of weeks or months.a period of weeks or months.

Low load, long duration stretch Low load, long duration stretch theory.theory.

Which Mobilization Which Mobilization Orthoses ??Orthoses ??

End Feel of the End Feel of the jointjoint

Stages of wound Stages of wound healinghealing

How much force with How much force with Mobilization ?Mobilization ?

Dr Brand’s theory:Dr Brand’s theory:

““Keeping the tissues at a physical Keeping the tissues at a physical state that demonstrates the need for state that demonstrates the need for change will stimulate the cells to change will stimulate the cells to multiply and make changes in multiply and make changes in response to the need. The more response to the need. The more time in the orthosis, the more quickly time in the orthosis, the more quickly the tissues will respond.”the tissues will respond.”

Classification by DesignClassification by Design

Single surface designSingle surface designCircumferential designCircumferential designForearm based, hand based, finger Forearm based, hand based, finger

basedbased

Single Surface DesignSingle Surface Design

Volar/ palmarVolar/ palmar DorsalDorsal Radial half – radial Radial half – radial

guttergutter Ulnar half – ulnar Ulnar half – ulnar

guttergutter

Benefits:Benefits: Support joints of Support joints of

flaccid muscles – flaccid muscles – CVACVA

Effective base for Effective base for outriggersoutriggers

Post operative Post operative orthotics – no orthotics – no pressure to areas, pressure to areas, will damage repair.will damage repair.


Dorsal DesignDorsal Design Advantages:Advantages: Sensory surface Sensory surface

exposedexposed Less distal Less distal

migrationmigration Best for extension Best for extension

outriggeroutrigger Disadvantages:Disadvantages:

Less muscular Less muscular padding, more bony padding, more bony prominencesprominences


Volar DesignVolar Design AdvantagesAdvantages Natural padding Natural padding

(skin/ muscle)(skin/ muscle) Best for flexion Best for flexion

outriggeroutrigger DisadvantagesDisadvantages

Tends to migrate Tends to migrate distally with distally with dynamic tensiondynamic tension

Circumferential DesignCircumferential Design

Covers all surfacesCovers all surfaces Thinner materialThinner material

Contour adds Contour adds ridgity and strengthridgity and strength

Perforated materialPerforated material

Beneficial for:Beneficial for: Immobilization Immobilization

painful jointpainful joint Protect soft tissueProtect soft tissue Orthotic for activity Orthotic for activity

– more comfort and – more comfort and controlcontrol

Good design for Good design for serial static serial static orthoticsorthotics

Helps prevent Helps prevent migration migration

Circumferential DesignCircumferential Design

AdvantagesAdvantages Most stableMost stable Least migrationLeast migration

DisadvantagesDisadvantages More complex More complex

designdesign More difficult for More difficult for

patient to applypatient to apply

Forearm Based DesignForearm Based Design

AdvantagesAdvantages Allows flexibility Allows flexibility

with adjusting with adjusting dynamic or static dynamic or static progressive tensionprogressive tension

DisadvantagesDisadvantages Bulkier and heavier Bulkier and heavier

to carryto carry

Hand Based DesignHand Based Design

AdvantagesAdvantages Light weight, easier Light weight, easier

to carryto carry Less interference Less interference

with UE functionwith UE function

DisadvantagesDisadvantages Difficult to fabricateDifficult to fabricate Inadequate length Inadequate length

for dynamic tension for dynamic tension devicedevice

Common Names Common Names

Radial Bar Wrist Radial Bar Wrist Cock up Cock up

Immobilization Immobilization orthoticorthotic

Static orthoticStatic orthotic


Common NamesCommon Names

Resting Hand or Resting Hand or Functional Position Functional Position OrthosisOrthosis

Immobilization Immobilization OrthosisOrthosis



Common NamesCommon Names

Thumb Spica IP Thumb Spica IP joint includedjoint included

Immobilization Immobilization OrthosisOrthosis



Biomechanical PrinciplesBiomechanical Principles

Tammy LeSage MOT, OTR/L, Tammy LeSage MOT, OTR/L, CHTCHT

Elisabeth DPT, MOT, PT, Elisabeth DPT, MOT, PT, OTR/L, CHT, MTCOTR/L, CHT, MTC

Biomechanical Principles - Biomechanical Principles - Orthoses:Orthoses:

Clinical ApplicationClinical Application Wider longer orthoses are more comfortable Wider longer orthoses are more comfortable

than short narrow orthoses. The length the than short narrow orthoses. The length the forearm trough should be approximately 2/3 forearm trough should be approximately 2/3 the length of the forearm.the length of the forearm.

Smoothed, flared or rolled edges on the Smoothed, flared or rolled edges on the proximal and distal aspect of an orthosis proximal and distal aspect of an orthosis causes less pressure than do straight edgescauses less pressure than do straight edges

You should attempt to maintain ½ the You should attempt to maintain ½ the circumference of the thumb and forearm for circumference of the thumb and forearm for a correct fit.a correct fit.

Biomechanical Biomechanical Principles….cont.Principles….cont.

Continuous uniform pressure over bony Continuous uniform pressure over bony prominences is preferable to unequal prominences is preferable to unequal pressure on a prominence.pressure on a prominence.

Because some orthotic components must Because some orthotic components must be narrow and the resultant force is great, be narrow and the resultant force is great, a contiguous fit is paramount. a contiguous fit is paramount.

Wider straps and finger slings lower Wider straps and finger slings lower pressure applied to the underlying tissues.pressure applied to the underlying tissues.

Contour mechanically increases material Contour mechanically increases material strengthstrength

First Class Lever SystemFirst Class Lever System(Three points of fixation)(Three points of fixation)

F = Force F = Force A = FulcrumA = Fulcrum

AxisAxis R = ResistanceR = Resistance FA = Force ArmFA = Force Arm RA = ResistanceRA = Resistance

ArmArm

Mechanical Advantage: Force Mechanical Advantage: Force

Which orthotic Which orthotic design has to best design has to best mechanical mechanical advantage?advantage?

Force ?Force ?

Fess, 1987

Formula for ForceFormula for Force

R x RAR x RA =F =F

FAFA

R = 9lbsR = 9lbs

RA = 2.5 inchesRA = 2.5 inches

FA = Orthotic 1 - 4 FA = Orthotic 1 - 4 inin

Orthotic 2 - 8 Orthotic 2 - 8 inin

Fess, 1987

Force Orthosis – Forearm 8 Force Orthosis – Forearm 8 inches inches

9lbs x 2.5 inches 9lbs x 2.5 inches

8 inches8 inches

= 0.28 lbs force= 0.28 lbs forceFess, 1987

Force Orthosis – Forearm 4 Force Orthosis – Forearm 4 inchesinches

9lbs x 2.5 inches9lbs x 2.5 inches

4 inches4 inches

= 0.56 lbs force= 0.56 lbs force

Fess, 1987

Mechanical AdvantageMechanical Advantage

Formula for MAFormula for MA

MA = MA = FAFA

RARA

Orthosis #1Orthosis #1

4 4 = 1.6 = 1.6

2.52.5


8 8 = 3.2 = 3.2

2.52.5

Stresses to Skin and Soft Stresses to Skin and Soft TissueTissue

Tension: opposing Tension: opposing forcesforces

Compression: Compression: inward forcesinward forces

Shear: parallel Shear: parallel forces forces

Fess, 1987

PressurePressure

Formula for Formula for PressurePressure

P = P = Total ForceTotal Force

Area of Area of ApplicationApplication


25 gm force25 gm force

1cm X 1cm1cm X 1cm

= 0.25 gm P sq mm= 0.25 gm P sq mm Orthosis #2Orthosis #2

25 gm force25 gm force

5cm x 5 cm5cm x 5 cm

= 0.01 gm P sq mm = 0.01 gm P sq mm

Mobilization ForcesMobilization Forces

Application of force to Application of force to a moving part.a moving part.

Must remain Must remain constant.constant.

Want rotational Want rotational element versus element versus translational element.translational element.

Optimal rotational Optimal rotational force occurs with a 90 force occurs with a 90 degree angle of pull.degree angle of pull.

Fess, 1987

DocumentationDocumentation

Important information to include in Important information to include in documentation when providing an documentation when providing an orthotic device. Your thoughts?orthotic device. Your thoughts?

Legal implicationsLegal implications


Medial condition that warrants an orthotic Medial condition that warrants an orthotic devicedevice

Medical necessity of orthotic deviceMedical necessity of orthotic device Type, purpose and anatomical location of Type, purpose and anatomical location of

orthotic deviceorthotic device Communicated written and oral wear scheduleCommunicated written and oral wear schedule Precautions discussedPrecautions discussed Rehabilitation potential with orthotic deviceRehabilitation potential with orthotic device Goals related to functionGoals related to function Date and time patient to return (if applicable)Date and time patient to return (if applicable)


Follow up visitFollow up visitDocument noted problems with Document noted problems with

compliancecomplianceChanges in the orthotic and wear Changes in the orthotic and wear

schedulescheduleChanges with motion if mobilization etc.Changes with motion if mobilization etc.

orthosis evaluation tammy j. lesage mot, otr/l, cht elisabeth mcgee dpt, mot, otr/l, pt, cht, mtc

Documents

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