Although orthotics are most widely known to help with foot pain, they are also used for pain reduction and preservation of joints by providing proper joint mechanics and alignment to stabilize joints and decrease joint motion and loading. They can be used for many conditions, such as osteoporosis, stroke, rheumatoid arthritis, carpel tunnel syndrome and back pain, among others. Specifically among geriatric patients, orthoses not only help relieve pain, but can also help prevent falling and alleviate balance issues.
“It might be cliché, but truly head to toes can benefit from the appropriate orthosis. That being said, the elderly must be evaluated and the need documented by their physician in order to be seen by a certified orthotist,” Pat Peick, CPO, of NEBCO Prosthetics and Orthotics, told O&P Business News. “It is important for the patient and caregivers to recognize that the fit of the device must meet many criteria in order for the elderly patient to obtain the full therapeutic benefit. If it is clumsy, difficult to don, uncomfortable or injurious to the skin the orthosis will sit in the closet.”
“Since elderly patients also have other medical conditions that probably come along with orthoses use vs. a younger adult, you have to worry about whether their skin is fragile, if they have visual or hearing impairments, if their hand dexterity is limited, etc.,” Gail Fitzmaurice, CO, of Maine Orthotic & Prosthetic Rehab Services, said. “There are cases where there is a patient you would usually put in a rigid orthosis, but you may have to lean toward a softer type device that will still provide some stability that is not as aggressive because of some underlying condition.”
Fitzmaurice believes that when fitted with the right orthosis, geriatric patients not only benefit from increasing medical health, but from increasing mental health as well.
“Orthoses benefit geriatric patients with balance issues, high risk falls and stabilization,” she told O&P Business News. “Orthoses would also help them as far as feeling good about themselves too and to be able to be a little more independent vs. being confined to a wheelchair or a bed.”
As individuals grow older, health problems, such as stroke, can take a toll on the body, causing pain or weakness in upper and lower extremities.
“What we try to do as orthotists is employ either a supportive or a corrective orthotic intervention that supplements what the patient’s functional needs and wants are for their daily activities,” Eric Weber, CPO, LPO, area clinic manager at Hanger Clinic, told O&P Business News. “In general, I would say in the geriatric population we are less concerned with correcting to absolute neutral as we are to accommodating the patient’s very particular needs and wants for their daily activity, accommodating maybe an insensate foot or structurally supporting an ankle or leg to enhance their daily rituals.”
To determine what orthosis would work best in a post-stroke patient, it is important for orthotists to perform several tests on patients prior to fitting. For example, according to an article published in Topics in Stroke Rehabilitation, for an orthotist to collect and interpret appropriate clinical information on patients with hemiplegic gait pattern to achieve favorable orthotic outcomes, the orthotist must first consider seven domains of management, including range of motion/manual muscle testing, quantitative and qualitative gait analysis data, sensation proprioception status, magnitude of spasticity, previous management, medical team feedback and patient expectations.
Orthotic intervention goals based on stance phase stability, foot clearance, prepositioning of foot, adequate step length and energy conservation should coincide with medical team feedback and patient expectations. Both the medical team and the patient should agree with the goals, which contribute toward an effective orthosis.
“Successful orthotic management is possible when appropriate data collection and interpretation of that data occurs. This informative process, along with medical team interaction, provides an avenue for a clear description of orthotic goals,” the researchers concluded. “Based on these goals, a sound orthotic recommendation can be implemented to improve standing balance and facilitate a more functional gait pattern for the patient.”
Orthoses use for osteoporosis
Osteoporosis is another health problem that may be managed by orthosis use. Although pain reduction and an increase in mobility are important goals, rigidly constructed orthotic devices are unsuitable for long-term therapy.
“Orthotic devices have repeatedly been recommended as a possible adjuvant in conservative therapy of manifest osteoporosis,” Matthias Fink, MD, of Hannover Medical School in Germany, and colleagues wrote in a study published in the Journal of Rehabilitation Medicine. “Although recommended, currently available rigid devices have been reported to have substantial disadvantages. In particular, rigid braces are uncomfortable to wear, restrict movement and their unattractive appearance results in low compliance. Moreover, stable orthotic devices should be used only for a limited period of time.”
To investigate the efficacy of a highly flexible osteoporosis orthotic device, in 2007 and 2008 Fink and colleagues performed an observational study on women with osteoporosis. In the first study, the orthotic device was an elastic back support with paravertebral air chamber pads that was worn continuously during the day. The second study compared orthoses with paravertebral/lumbosacral air chamber pads, the same orthosis without air chamber pads and a placebo body stocking.
Overall, the flexible devices with air chamber pads reduced pain, made daily activities easier to perform, and corrected posture compared with the orthosis without air chamber pads and the placebo body stocking. According to the researchers, the change in posture was believed to be a result of muscle activation due to sensomotor stimulation by the air chamber pads, because the device contained no rigid stabilizing elements.
“Regular use of the orthosis provides essential elements in the effective management of osteoporosis. On the basis of the active spontaneous erection with reduction of the load on the particularly vulnerable ventral portions of the thoracic vertebrae and the subjectively perceived erection-related pain reduction the device may also contribute to a reduction in fear and incidence of falling as proven in other appliance surveys, the researchers concluded.”
Orthoses for balance
While orthoses can be used because of stroke, diabetes or osteoporosis, they can also help geriatric patients who experience or are afraid of experiencing debilitating falls. Michael Gross, PT, PhD, FAPTA, professor of the Division of Physical Therapy at the University of North Carolina at Chapel Hill, has been making custom foot orthoses for 26 years to help alleviate pain in patients. During that time, geriatric patients would tell him that not only were the orthoses successful in relieving pain, but they felt their balance had been improved, Gross told O&P Business News.
To determine if the use of orthoses could improve balance in elderly patients, Gross and colleagues enrolled 13 individuals older than 65 years who reported at least one unexplained fall during the past year and demonstrated poor balance in a study and found that foot-orthotic intervention significantly improved patients’ balance performance for three of four performance measures.
However, Gross said what surprised him was not the positive influence that orthoses had on balance in geriatric patients, but the magnitude of improvement that they witnessed in several patients.
“Prior to foot-orthoses intervention, we had one participant who was only able to take one step for heel-to-toe walking,” Gross said. “However, after we put the foot orthotics in, she had maybe 10 or 11 steps, and on one occasion she did the heel-to-toe walking the entire length of the clinic, which was many more than the upper limit for the study.
“We hope down the road that this might be an intervention that could be used with older adults who are at risk for falling and that we might decrease the actual number of falls that older adults might incur with this type of intervention,” he said.
It is important for geriatric patients to speak to a physician after they experience a fall even if there are no signs or symptoms that anything is wrong.
“I would suggest anyone suffering from falls, fear of falling, pain, swelling, change of color in the skin or decrease in functional capacity visit their doctor for an evaluation of the problem,” Peick said. “Pain is not always the indication of a problem. Neuropathic changes can dull a person’s sense of pain or joint position in space. This can lead to repetitive tissue damage, a wound or worse. Start with your doctor and follow their advice to a successful resolution.”
Considerations for geriatric patients
When prescribing an orthosis to a geriatric patient, it is important to take into account their entire medical history. Patients with nerve damage may unknowingly develop sores that could lead to further skin damage. According to Weber, a way to avoid the development of sores or other complications is to consider the feeling, shape and functional level of the orthosis being prescribed.
“Depending on the disease state, if a nerve has been compromised, we are very careful not to employ something that could endanger the skin or tissue or cause a sore in some way,” Weber said. “In my practice, I personally steer away from very intimately fitting, rigid, thermoplastic devices when there has been an insensate type of disease. I move toward a non-invasive intervention as I can, such as accommodative inserts, or more traditional conventional metal short-leg bracing.”
Another consideration for geriatric patients is their mental status and whether they need help with daily routines from family members or a care giver.
“If you are prescribing or using an orthotic intervention that is very complicated or requires a battery or maybe many moving parts or complicated joints, they might not be a practical solution for some geriatric populations that may not have mental faculty to really make good use of that,” Weber said. “It’s not that we’re thinking for them, but we’re looking out for them.”
Taking previous health conditions and mental status into account helps with the overall goal of making it easier for geriatric patients to keep their independence, which is a concern for many patients and orthotists.
“I am big on patients having as much independence as possible, even if it is just one strap or the choice to remove the device,” Peick said. “The elderly lose more and more autonomy as they age, so any amount of control I can return to them, the better. I may not choose a completely different device, but more so what we do different to allow as much independence as possible without compromising the outcome.”
Informing the geriatric population
Even when geriatric patients have a strong mental status, they are sometimes uneducated about what their conditions are and why they are going to an orthotist. This can become a problem when they do realize what their condition means, which usually happens during their appointment with the orthotist. According to Weber, this issue can make the job of the orthotist tougher.
“Sometimes the geriatric population is unsure of why they came to your office. They’re unsure of why their doctor prescribed a certain device. It’s not until you’re in the exam room with the patient and maybe a family member that the light turns on in their head and they might reluctantly accept the fact that they will have to wear a supportive device,” Weber said. “If things were more broadly explained from the beginning of their medical treatment, I think the orthotist’s job would be far easier and much more effective.”
Not only is educating the patient before fitting important, it is also important to keep follow-up appointments with them to ensure that the device is being used properly. Unfortunately, not every elderly patient returns for a follow-up after being prescribed an orthosis. Peick believes it is important to learn how orthotic devices have met the mental and physical needs of elderly patients who do not return for follow-ups or repairs. — by Casey Murphy
Disclosure: Weber is employed by Hanger. Fink, Fitzmaurice, Gross and Peick have no relevant financial disclosures.