The Evolution of Upper-limb Orthotic Practice

While having dinner during one of my residency interviews many years ago I casually worked in a humblebrag intended to draw attention to the quality of my work on a metal upper-limb orthosis. One of the interviewers, a highly regarded clinician with extensive experience, gave an unexpectedly strong response. He observed that in the previous 30 years, upper-limb orthoses had been provided primarily by occupational therapists (OTs) and voiced disagreement with the requirement that O&P students learn to fabricate these devices. My clinical experience in subsequent years confirmed his perspective, and it is likely that the percentage of upper-limb orthoses provided by orthotists has declined even more in the 30 years since that conversation. Orthotists played a significant role in the development and provision of many upper-limb orthotic designs during the mid-20th century (arguably its golden age), but the evolution in orthotic and occupational therapy practice since that time has contributed to changes in how these services are provided. The wrist-driven prehension orthosis (WDO) is an interesting example of an orthosis whose design provides an effective option for individuals with C6-C7 quadriplegia, but the use of which appears to have declined in the 70 years since it was developed. If “there are approximately 17,730 new spinal cord injury cases in the United States each year,” 25 percent of those cases result in C5 or C6 levels of function, and close to 50 percent of those cases involve incomplete tetraplegia, more than 2,000 new patients each year are potential candidates for a prehension orthosis. 1-3 According to Centers for Medicare & Medicaid Services data, 181 claims for L-3900 (custom WDO) were submitted in 2021. Since the average age at injury is 40-45 years, it is likely that many more WDOs were initially provided to patients who are not covered by Medicare. Given the difficulty of determining exact numbers, assumptions about the frequency of WDO provision should be made cautiously, but the experience of most O&P clinicians supports the claim that even if WDOs are still commonly provided, orthotists are providing fewer of them than OTs are. This trend is reflected in the accreditation requirements for O&P schools. The 2010 requirements included the fabrication and fitting of both a metal wrist-hand orthosis (WHO) and a prehension orthosis. The 2017 requirements include only the fabrication of a plastic custom WHO or wrist-hand-finger orthosis, and students are required to fit (but not fabricate) a WDO. There is some evidence of an overall decline in the use of upper-limb orthoses in contemporary occupational therapy practice. In 2020, Frye and Geigle published the results of a survey of OTs “working in US inpatient spinal cord rehabilitation facilities” to determine “splinting practices for individuals with cervical spinal cord injury.” 4 The focus of the survey was on preparing the hand for function using resting hand, wrist, long opponens, short opponens, and metacarpal-phalangeal (MCP) blocking splints. Frye and Geigle found that, except for the MCP blocking splints, OTs “are using splints less frequently for all levels of SCI.” 4 However, “therapists described commonly using…tenodesis splints or orthotics.” 4 A brief overview of the WDO can provide valuable insights into the role of orthotists in providing upper-limb orthotic care. WDO History The WDO was developed in the early 1950s for use by patients with polio. 5-6 The earliest published description appeared in a 1954 article written by John Bisgrove, MD, the chief of Physical Medicine Rehabilitation Services at the Veterans Administration Hospital, West Roxbury, Massachusetts. Bisgrove thanked Bruno T. Tassinari, the “orthopedic technician of the Orthopedic Shop…for his technical advice and construction of the device.” 7 The extent to which Tassinari’s ingenuity and expertise influenced the development of this innovative device may never be known, but his contributions were likely significant, and it is rewarding to see them acknowledged. In 1955, Nickel, Perry, and Garrett described the concept of a “flexor-hinge hand” and described orthotic and surgical options for achieving palmar (three-jaw chuck) prehension. 8 Noting the decline in polio cases during the 1950s, they described how care at Rancho Los Amigos Hospital began to focus on upper-limb paralysis from other causes, since “it is the degree of functional loss rather than the diagnosis that is significant.” 8 These authors described surgical interventions intended to improve hand function, since “only a few patients will accept the brace as a permanent device. These are the patients who are highly motivated to be independent but cannot function without their splints. Most patients gradually become thwarted by the mild discomfort and inconvenience of any external appliance and by the limited functional assistance provided, particularly if they are dependent upon others to put the brace on or take it off.” 8 These barriers to WDO use are confirmed by numerous authors during that time and remain a common feature of contemporary orthotic practice. During the mid-20th century, clinicians in centers around the country, including Rancho Los Amigos Hospital in California, the Texas Institute for Rehabilitation and Research in Houston, the Institute for Rehabilitation and Medicine in New York, and the Rehabilitation Institute of Chicago, created wrist and ratchet-driven prehension orthoses using different materials and including unique features. Some of the material and designs are no longer used commonly, and the Rancho design is likely the most familiar to orthotists. A 1967 article by Engel et al. gives a detailed description of the design developed at the Rehabilitation Center at the University of Wisconsin-Madison. 9 The version of this orthosis currently in the Northwestern University Prosthetics-Orthotics Center collection is my favorite exemplar of the technical expertise that once characterized the orthotist’s skill set. Engel describes the precise location of each component and joint, and how each design feature impacts efficiency, grasp span, pinch strength, and comfort. WDO Usage and Adherence In 1971, Allen surveyed 42 patients who had received the orthosis over a ten-year period and reported that 43 percent of them continued to use their WDO. 10 A similar survey of patients at the University of Wisconsin Rehabilitation Center reported that 35 of 39 patients (89 percent) used their orthosis. 11 Nine of 20 patients (45 percent) who had received WDOs at a facility in Wales reported continued use after discharge. 12 Nichols’ statement that “the acceptance rate for the wrist-driven splints is about one-half of those fitted…” appears to be a fair summary. 6 Inconsistent findings on use and adherence are common in many areas of O&P since they are described in different ways. A more nuanced understanding is required to determine the value of a particular intervention. For instance, Lee reported that 33 percent of patients used the orthosis daily, 55 percent used it more than once a week, and 11 percent used it less than once per month. 12 As with other O&P devices designed for functional rather than therapeutic purposes, varied use of upper-limb orthoses may be appropriate depending on the goals of the clinician and patient. Full-time or consistent use may have advantages, but patients who use a device only periodically for a specific purpose are realizing benefits and justifying the provision of the device. The functional gains made during rehabilitation are one of the factors affecting the ongoing use of WDOs and other upper-limb orthoses. Many devices are used for therapeutic purposes, and the requirements change as the patient’s condition improves. In these cases, discontinuation of an orthosis may represent a successful therapy outcome and does not indicate a failure by the rehabilitation team or the patient. While patients may benefit from a WDO intended to replace and strengthen function of weak muscles early in rehabilitation, a design that requires less time and expertise to fabricate may serve that purpose more effectively than a conventional orthosis. A Changing Landscape Occupational therapist Elaine Ewing Fess described the mid- to late-1950s as “pinnacle times for orthotists.” 13 Noting the large reduction in polio cases in the 1960s, Fess stated that “polio-oriented orthotists and therapists almost literally had to reinvent themselves to find jobs. Looking back, it seems as though therapists were better able to make the transition than were orthotists.” 13 In identifying possible causes for this, Fess quoted a “highly respected orthotist” who in 1958 described “professional problems of prosthetists and orthotists. He identified poor communication with medical team personnel, the physician in particular, as a commonly encountered problem and urged prosthetists and orthotists to become better acquainted with medical protocol and terminology.” 13 The higher level of education obtained by OTs and their superior communication skills likely contributed to an expanded role on the rehabilitation team compared to orthotists. Fess also noted that a 1963 article by Engel (an orthotist) about technical advances in O&P omitted thermoplastic materials, which had been available for more than five years, and that no mention was made of splinting in post-operative cases. 13 A focus on traditional techniques and a failure to incorporate advancements may have contributed to orthotists becoming less relevant in this area of practice. Fess quoted a 1967 report, the “Study of Orthotic and Prosthetic Activities Appropriate for Physical Therapists and Occupational Therapists,” which stated: “Inasmuch as the total number of certified orthetists [sic] and prosthetists in this country…is relatively low and their distribution inequitable, it is realistic to expect that occupational therapists and physical therapists will frequently be called on to function in an area for which they may not be specifically prepared upon completion of their formal education program.” 13 Fess noted that this document closed “the door to orthotist-controlled splinting practice” and “freed therapists, as long as they were qualified, to provide splinting services to patients.” 13 Education of therapists on splinting became more common, and “by the late 1960s, therapists were more adept at splinting, and early low-temperature thermoplastic materials were available for clinic use…. By the 1970s, therapists had enthusiastically embraced the field of upper extremity splinting and were off and running.” 13 The functional and therapeutic benefits of many upper-limb orthoses that are prefabricated or fabricated using materials more commonly used by OTs are comparable to those provided by orthotists. WDOs, however, represent an interesting case regarding this changing landscape. Custom fabrication using materials and methods within the scope of practice of orthotists appears to be the best option for obtaining the precision required for optimal function. Despite this, WDOs are provided by OTs using less precise methods. According to Frye, “splint use reduction may be attributed to changes in the healthcare delivery model. Decreasing current inpatient rehabilitation length of stay (LOS) may influence clinicians to prioritize more restorative interventions, such as functional electrical stimulation over splinting, particularly for those individuals with incomplete injuries.” 4 Effective use of a WDO depends on early fitting and extensive training. Fabrication time for a conventional WDO has been estimated at 40 or more hours. 6,9 During a clinical experience placement at the Dallas Rehabilitation Institute in the late 1980s, I shadowed an orthotist who made repeated visits to patients during the fabrication process to ensure the optimal fit and function of each component of a Rancho WDO. This number of visits represents a significant barrier to care when orthotists are not located within the same facility as the patient and therapy team. Designs fabricated by OTs can be provided in less time and as part of the therapy regimen. With limited time allowed for rehabilitation, therapists may be choosing to focus increasingly on interventions and modalities that they can provide more quickly. Looking Forward An appreciation for the contributions of prior generations of O&P clinicians and a careful consideration of the lessons their experience teaches us will help prepare us for the future. To the extent that the primary focus of O&P clinicians is on fabricating and providing devices, we run the risk of becoming irrelevant when newer materials and fabrication techniques are introduced. We will bring the most value to patients and the rehabilitation team by focusing on functional and therapeutic outcomes and becoming skilled at multiple methods for achieving them. These commitments will help us remain relevant and effective as both the methods for helping patients achieve specific goals and the healthcare environment change in ways we may not anticipate. 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 https://www.spinalcord.com/blog/high-level-spinal-cord-injuries-and-their-causes#:~:text=There%20are%20only%20around%20140%2C000,these%20are%20high%20cervical%20injuries https://www.flintrehab.com/spinal-cord-injury-statistics/#:~:text=According%20to%20the%20spinal%20cord,C6%20(10%25) Thomas, C. K., and R. M. Grumbles. 2014. Age at spinal cord injury determines muscle strength. Frontiers in Integrative Neuroscience 8:2. Frye, S. K., and P. R. Geigle. 2020. Current US splinting practices for individuals with cervical spinal cord injury. Spinal Cord Series and Cases 6(1):49. Hoy, D. J., and A. W. Guilford. 1978. The functional ratchet orthotic system. Orthotics and Prosthetics 32(2): 21-4. Nichols, P. J. R., S. L. Peach, R. J. Haworth, and J. Ennis. 1978. The value of flexor hinge hand splints. Prosthetics and Orthotics International 2(2):86-94. Bisgrove, J.G. 1954. A new functional dynamic wrist extension—finger flexion hand splint a preliminary report. In Proceedings (p. 49). Nickel, V. L., J. Perry, and A. L. Garrett. 1963. Development of useful function in the severely paralyzed hand. JBJS 45(5):933-52. Engel, W. H., M. A. Kmiotek, J. P. Hohf, J. French, M. J. Barnerias, and A. A. Siebens. 1967. A functional splint for grasp driven by wrist extension. Archives of Physical Medicine and Rehabilitation 48(1):43-52. Allen, V. R. 1971. Follow-up study of wrist-driven flexor-hinge-splint use. The American journal of occupational therapy: official publication of the American Occupational Therapy Association 25(8):420-2. Knox, C. C., W. H. Engel, and A. A. Siebens. 1971. Results of a survey on the use of a wrist-driven splint for prehension. The American Journal of Occupational Therapy: Official Publication of the American Occupational Therapy Association 25(2):109-111. Lee, A. C. 1988. Survey of rancho flexor hinge splint users. British Journal of Occupational Therapy 51(6):197-8. Fess, E. E. 2002. A history of splinting: to understand the present, view the past. Journal of Hand Therapy 15(2):97-132. https://www.proquest.com/docview/304415882/abstract/6FE7693DCEC24375PQ/1?accountid=147023&sourcetype=Dissertations%20&%20Theses

The Evolution of Upper-limb Orthotic Practice

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