Hygiene and Its Implications in O&P Practice

Prior to beginning a career in O&P, I had minimal interaction with individuals with poor hygiene and assumed that cleanliness standards I considered normal were commonplace.

Prior to beginning a career in O&P, I had minimal interaction with individuals with poor hygiene and assumed that cleanliness standards I considered normal were commonplace. It was only after beginning residency that I realized how frequent exceptions to this were. A patient I had during my residency stands out in my memory. She was an elderly woman who wore an AFO and orthopedic shoes. In addition to other obvious signs of poor hygiene, a live insect could be seen either in the device or on her clothing during every encounter. Time was devoted during each appointment to cleaning the device, a task I expected patients to perform on their own. She exhibited several other atypical behaviors, including wearing excessive layers of clothing (regardless of the weather) that did not appear to have been cleaned regularly. She drove a vehicle that was filled from floor to roof with what appeared to be trash, with just enough free space for her and her sister to sit in the front seats. After noticing items missing from the office after her visits, the administrative staff limited access to paper cups, toilet paper, and other loose items to prevent them from being taken during her visit. She was pleasant to work with and engaged constructively in encounters. With time I came to understand, as most clinicians eventually do, that working with patients who have poor hygiene is a relatively common experience.

Personal Hygiene Standards

Several key hygiene practices, including bathing, washing hands, and brushing teeth, are performed at least daily by most individuals in our society. Cleaning of clothing, washing hair, and nail care are typically performed routinely, though less frequently. The market research firm The Harris Poll conducted research on hygiene and found that “while nearly all (99 percent) of US adults shower, there are many meaningful differences in how they do it.”¹ They reported in 2024 that “60 percent of Americans typically shower in the morning (5 a.m.-noon), 36 percent in the afternoon/evening (1-7 p.m.) and 33 percent at night (8 p.m. to 4 a.m.).”¹ They also found generational differences in showering habits. “Gen X is more likely than Gen Z or boomers to take a shower daily (69 percent versus 59 percent, and 53 percent), and Gen Z is least likely to wash their hair every day (22 percent versus 34 percent millennials, 35 percent Gen X, and 30 percent boomers).”¹ Differences based on sex and whether the individual lived with a spouse or partner were also found. “Men who live with a spouse or partner are more likely than those men who do not to say they shower every day (72 percent versus 53 percent). Women who live with a spouse or partner are more likely than women who do not to shower daily (63 percent versus 55 percent).”¹

This research on US residents forms some basis for hygiene standards and expectations regarding personal grooming. Any patient can present with poor hygiene at a particular appointment, but the cases we view as problematic are usually extreme and persistent. Practitioners and staff often have a sense of foreboding about these encounters, and these patients and their hygiene habits may be the source of derogatory comments and dark humor, as they were in the case of the patient mentioned earlier.

The Roots of Hygiene Practices

In a developed and industrialized country with almost universal access to fresh water and cleaning products, hygiene may be thought of primarily in terms of social acceptability. However, the roots of hygiene practices appear to go deeper than that. In an article titled “The Natural History of Hygiene,” scientist Valerie Curtis, PhD, cites examples of hygiene practices among animals (grooming to remove parasites, removing fecal matter from nests, and avoiding grazing in areas where fecal matter is present) as evidence of an evolutionary basis for hygiene: “Animals that were good at behaving in ways that avoided the ravages of micro- and macroparasites were better at passing on their ‘hygiene genes’ than those who didn’t exhibit such behaviors…. Gradually, hygienic behaviors were selected for, often becoming an instinctive part of the behavioral repertoire….”²

There is clear evidence that hygiene has been a priority throughout human history.^3,4 The archeological and written historical record includes ample evidence that the removal of waste and other unacceptable material from the body and clothing has been part of the human social experience based on an aversion to impurity that predates the modern understanding of the health risks associated with it. Based on multiple studies on hygiene motivation around the world, Curtis proposes that humans have an instinct for hygiene. “When interviewed about the ‘why’ of their hygiene habits, we found that people found it hard to explain their reactions to certain stimuli. Faced with feces, bodily fluids, rotten food, and creepy-crawlies, people would say, ‘I can’t explain it—they are just yuck!’ It seemed that there was a powerful sense of disgust involved, which compelled people to avoid nasty, sticky, oozing, teeming stuff.”² Curtis “hypothesized that disgust in humans evolved to serve hygiene; in other words, to do the job of making people avoid disease” and suggested that “such behaviors happen largely independent of conscious decision-making, and that disgusting cues should almost automatically lead to hygiene behaviors.”²

As modern medicine increasingly explicated the relationship between cleanliness and health, hygiene behavior was connected explicitly with the prevention of disease. Curtis suggests that “the gut feeling of disgust provided the motive to avoid the sick, and the search for a rational explanation for why this was a good thing to do came later…. The history of hygiene science could thus be said to be one of zeroing in on explanations for what we already felt in our gut and deep in the ancient animal centers of our brains.”²

Hygiene and Disgust

Beginning in the 1950s, clinical psychologist Paul Ekman, PhD, studied facial expressions and other nonverbal behavior, including facial microexpressions that indicate emotional states. He found evidence that these (often unconscious) expressions are universal. Ekman describes disgust as “a feeling of aversion towards something offensive,” including something perceived “with our physical senses (sight, smell, touch, sound, taste)” and even “by the actions or appearances of people, and even by ideas.”⁵ While there are varying degrees of intensity “from mild dislike to intense loathing…all states of disgust are triggered by the feeling that something is aversive, repulsive, and/or toxic.” Disgust forms an important part of our response to potentially harmful stimuli, and “the universal function of disgust is to get away from, block off, or eliminate something offensive, toxic, or contaminating.”⁵ In that way, disgust provides the benefit of keeping “us safe and healthy (e.g., not eating something putrid, staying away from open sores to avoid catching an infection or disease…).”⁵

A modern understanding of illness and health provides the scientific rationale for our aversion to lack of cleanliness, but we are often disgusted by poor hygiene even if we rationally understand that it does not pose a threat to our health. For example, in clinical practice, open wounds and infections often engender weaker feelings of disgust than more benign sights and smells related to poor hygiene, even though the former may pose a greater risk to our health.

Function and Hygiene

Our patients’ ability to maintain typical hygiene habits may be affected by their diagnosis and comorbidities. “Basic activities of daily living (BADLs)…are those skills required to manage one’s basic physical needs, including personal hygiene or grooming, dressing, toileting, transferring or ambulating, and eating.”⁶ Activities related to personal hygiene include “the ability to bathe and groom oneself and maintain dental hygiene, nail, and hair care.”⁶ The normal aging process often involves a decline in the ability to perform self-care and increased reliance on others to perform BADLs, and many of our patients have musculoskeletal and neurological impairments that create additional barriers to performing these activities independently. Most stroke patients, for example, require assistance with bathing.⁷

In my experience, however, most patients with these impairments we see commonly in practice maintain typical hygiene patterns, and extreme cases of poor hygiene are not explained by these physical limitations.

Mental illness can contribute to poor hygiene. “Low mood, sluggishness, and fatigue can make it difficult for someone with depression to muster the energy to tend to personal hygiene practices such as showering, brushing teeth, doing laundry, or brushing hair.”⁸ Nawaz et al. reported that “poor hygiene patterns and bizarre physical appearances were useful indicators of schizophrenia.”⁹ Armchair diagnoses of mental illness should be avoided, but understanding that poor hygiene may be related to an underlying mental illness can inform our approach with these patients.

Hygiene in O&P

Disgust about patients’ personal hygiene and grooming habits is understandable and should be acknowledged to be minimized, but it should not form the basis for our interactions with them. The cases we find most disturbing rarely present as real threat to our health, and it is our professional responsibility to provide care even if they do. We also have a responsibility to address hygiene practices as they relate to O&P, even if doing so does not resolve the underlying causes. Appropriate care of a device, including cleaning, is necessary to ensure safe and proper function. Additionally, poor hygiene increases the likelihood of skin irritation. This is a sensitive topic that must be handled carefully.

During a discussion with O&P students, I heard Wendy Beattie, CPO, describe a process for addressing this issue in an indirect and sensitive manner with patients. She highlights the need for skin to be clean and soft to reduce the chance of irritation and emphasizes routine hygiene as part of that process. Broaching the topic in this way may provide more opportunities to discuss and help resolve barriers to completing BADLs than a direct, confrontational approach.

According to Ekman, “While there are noted benefits to feeling disgust, it can also be dangerous. Unfortunately, most societies teach the avoidance of certain groups of people deemed physically or morally disgusting and, thus, can be a driving force in dehumanizing and degrading others.”⁵ The way we interact with and talk about these patients may betray an underlying disrespect of them. Our disgust may be understandable, but we must be careful that this is not communicated (intentionally or unintentionally) and does not result in our providing a lower level of care. Developing a genuine care for our patients can help to reduce our instinctual disgust reaction, which “is suspended when it is someone with whom we are close.… While we still may feel some degree of disgust, it is reduced enough that we are able to help those we care about. Now, rather than try to get away, we are called to reduce the suffering of the loved one (e.g., changing a baby’s diaper or taking care of a sick family member).”⁵

It is unrealistic to expect that we care as much for our patients as we do for our loved ones, but reminding ourselves about how we would like our loved ones to be treated by other healthcare providers can help us deal more constructively with habits we find disgusting.

John T. Brinkmann, MA, CPO/L, FAAOP(D), is an associate professor at Northwestern University Prosthetics-Orthotics Center. He has over 30 years of experience in patient care and education.

References

1. https://theharrispoll.com/briefs/shower-habits/
2. Curtis, V. A. 2007. A natural history of hygiene. The Canadian Journal of Infectious Diseases & Medical Microbiology 18(1):11-4.
3. https://www.archdaily.com/994913/from-bathtubs-to-showers-how-people-have-bathed-throughout-history
4. https://professorbuzzkill.com/2022/07/25/people-rarely-bathed-in-the-past/
5. https://www.paulekman.com/universal-emotions/what-is-disgust/
6. https://www.ncbi.nlm.nih.gov/books/NBK470404/
7. Lee, P.-H., T.-T. Yeh, and H.-Y. Yen, et al. 2021. Impacts of stroke and cognitive impairment on activities of daily living in the Taiwan longitudinal study on aging. Scientific Reports 11(1):12199.
8. https://www.health.harvard.edu/mind-and-mood/depression-symptoms-recognizing-common-and-lesser-known-symptoms#:~:text=Neglecting%20personal%20hygiene,doing%20laundry%2C%20or%20brushing%20hair.

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