When Are Off-the-Shelf Orthoses Appropriate?
24 Jun 2017
An enduring debate in the rehabilitation specialties centers on the feasibility and applicability of prefabricated, aka “off-the-shelf” or “OTS,” orthopedic braces.
From decades ago when virtually all orthotic components were custom-made, the field has evolved to today’s state in which an estimated 35 percent, perhaps more, of all orthoses are prefab, spurred by advanced materials and fabrication technology, aggressive cost containment measures, and Americans’ desire for convenience. A whole new delivery system has emerged, encompassing pharmacies, shoe stores and other retail entities, affiliated rehabilitation providers such as physical and occupational therapists, and even physicians. The question is, when are these alternative delivery options appropriate for the patient’s needs.
To be sure, some types of “soft goods” – e.g. spinal corsets, soft cervical collars, elastic knee supports and wrist gauntlets – don’t require the training and experience of a certified orthotist. These are generally short-term applications in which precise fit and control are not required. In the right circumstances these
OTS devices provide satisfactory support and control and produce cost savings for patients and/or their insurance companies.
But…in various other situations or in the hands of unqualified providers, prefab orthoses not only fail to achieve their intended results but can also be detrimental to patients. The trick is in recognizing when optimal fit and custom assembly are required to achieve the desired results.
Custom Fit vs. Custom Fab
Custom fit and custom assembly and fabrication are two different things. An off-the-shelf device can be modified and adjusted to achieve the best possible result, given that it was not constructed to a custom mold of the patient’s anatomy. Such alterations and accommodations require a degree of training…minimal for basic fabric corsets, soft collars and other soft goods, considerably greater for AFOs, advanced spinal and cervical orthoses, therapeutic knee braces, and others.
The certified orthotist is uniquely trained for this function, as well as all aspects of custom fabrication. The experienced orthotist can both recognize patients and conditions for which prefab bracing is appropriate and work closely with the referring physician, therapists and others involved in the patient’s care to obtain the desired therapeutic outcome.
Regardless of anatomical location and purpose of bracing, some patients are simply not candidates for a prefabricated orthosis. Manufacturers of custom-fit devices typically offer a range of sizes based on statistical norm, which may fit 60-65 percent of the population. Patients outside the norm cannot wear that brace model effectively.
The custom orthosis, on the other hand, is a one-of-a-kind device molded intimately to a cast or computer-generated model of the patient’s anatomy, or with the adoption of new materials technology directly to the patient.
After initial casting or digitizing, the orthotist then modifies the assembly to incorporate therapeutic strategies, provide needed support, accommodate anatomical irregularities and enhance patient comfort. Such modifications are sometimes possible with prefab orthoses but usually to a significantly lesser degree.
Whether or not off-the-shelf products can fill a meaningful therapeutic bracing role, they frequently can be used to predict the efficacy and patient acceptance of a custom orthosis and thus help justify medical necessity. Again, the trained orthotist plays an essential role in making such an evaluation.
One orthotics classification that does not lend itself to prefabricated products is pediatric bracing. The growth and development issues posed by children require specialized designs and sizes that are not conducive to mass production.
A child’s smaller stature offers reduced surfaces on which corrective and supportive forces can be applied and thus less error tolerance; moreover, designs must allow for bone and muscle growth and the reality that such growth does not necessarily occur synchronously.
“Children are not small adults,” is a common watchword in our business, and it particularly applies to prefabricated products. You cannot simply downsize an orthosis designed for adults and expect it to work on a child.
The Compliance Issue
Obviously, all efforts at orthotic management, whether custom-fabricated or off-the-shelf are essentially worthless if the patient refuses to wear the brace. Compliance involves three primary factors: comfort, self-image, and ease of application and removal. The experienced orthotist pays an important role in all three.
Comfort – It stands to reason that a brace formed from an anatomical model will fit more comfortably than a several-sizes-fit-all approximation. Fine adjustments to correct for minor discomfort, add padding, and/or compensate for perspiration are typically easier to complete on a custom-made device.
Self-image – Some patients refuse to wear their orthosis simply because it is embarrassing to them. Prefab braces are usually more bulky and therefore are frequently more obvious to others than custom orthoses. Spinal braces provide a good case in point: Most off-the-shelf models are too large to wear under clothing, whereas many custom spinal jackets can be designed to worn under reasonably fashionable clothes and thus remain largely hidden.
Donning and doffing – With a custom orthosis, we can assembly a custom brace to match the needs and abilities of the patient, but prefab braces often incorporate an amazing number of straps and buckles to achieve as close a fit as possible with a general-sized product. The more closures and adjustments, the more difficult for the patient and caregiver to apply the device correctly and with maximum effectiveness.
Add the potential for improper initial fitting of the device by an undertrained provider, and you have a recipe for noncompliance.
Properly employed, prefabricated braces definitely have their place in today’s rehabilitation milieu. While we respect and value our relationship with all providers of clinical rehabilitation services, we also believe that a certified orthotist is the practitioner best prepared and experienced to select, assembly, fit and maintain orthotic devices, whether prefab or custom.
Please call us today for a free consultation. We have offices located in Beaumont, Nederland and Jasper, Texas.