1. Orthosis Evaluation Tammy J. LeSage MOT, OTR/L, CHT
Elisabeth McGee DPT, MOT, OTR/L, PT, CHT, MTC

2. Orthotic Evaluation Interview, chart review and reports
Injury/ surgery
Hand dominance
Observation
Hand posture/ use
Palpation
Assessments for:
Pain
Skin and allergies
Wounds
Bone
Joint/ Ligament
Muscle/ Tendon
Nerve/ Sensation
Vascular
ROM
Function
Reimbursement

3. Orthotic Classifications
Tammy J. LeSage MOT, OTR, CHT
Elisabeth McGee DPT, MOT, OTR/L, PT, CHT, MTC

4. Terminology
Orthosis: is a noun and should be used in place of the word splint
Orthoses: is a pleural noun and should be used to replace the term for multiple splints
“Fabricating an orthosis” should be used in place of the verb splinting
Orthotic: is an adjective and is used to describe a noun associated with the science of orthotics, such as orthotic device, orthotic treatment plan, orthotic intervention, orthotic fabrication, or orthotic coding

5. Terminology
Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS Quality Standards)
DMEPOS suppliers must comply with the DMEPOS Quality Standards and become accredited to obtain or maintain Medicare billing privileges
Healthcare Common Procedure Coding System (HCPCS) Level 2 Manual
Orthotic devices are described by the CMS using L-codes that are found in this manual
L-codes found here and are used to bill for orthoses

6. Classifications Systems
Modified Orthosis Classification System (MOCS)
Jacobs, 2014
Uses current terminology that meet Medicare standards for reimbursement
ASHT’s Expanded Splint/Orthosis Classification System (ESCS)

7. Modified Orthosis Classification System (MOCS)
Articular
Nonarticular
Location (FO, HFO, WHFO, WHO, EWHFO, etc.)
Location (humerus, MC, phalanx)
Joint(s) Involved /Torque Application
(wrist, MCP, PIP, DIP, etc.)
Joint Positions (flex, ext, etc.)
Direction(s) of Torque Application (flex, ext, etc.)
Immobilization
Restriction
Mobilization
Design Options (dorsal, volar, radial, ulnar, circumferential, etc.
Orthotic Intervention for the Hand and Upper Extremity, 2014

8. ASHT Splint/Orthosis Classification System
Rehabilitation of the Hand and Upper Extremity, 2011

9. ASHT Splint/Orthosis Classification System
Rehabilitation of the Hand and Upper Extremity, 2011

10. ASHT Splint/Orthosis Classification System: 6 Criteria
Articular or Non-articular
Anatomic focus (e.g. 2nd digit PIP)
Kinematic direction (i.e. where joints are moved or positioned into.- e.g. flexion)
Primary purpose (e.g. mobilization)
Type or number of secondary joint levels
Total number of joints included in the orthosis

11. Key Anatomical Headings/Classification By 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

12. Classification by Function
Immobilization
Mobilization
Restriction
Torque Transmission

13. Immobilization

14. Mobilization

15. Restriction

16. Torque Transmission

17. Non-MOCS/SCS Nomenclature
Static Orthosis
Serial Static Orthosis
Dynamic Orthosis
Static Progressive Orthosis

18. Static Orthosis
Has no moving components and immobilizes a joint or part.
Used for:
rest – arthritis
protection – fracture
positioning – CVA
loss of motor function
- nerve injury
Used with permission from Sammons Preston

19. Static Orthosis
Used with permission from Sammons Preston

20. Serial Static Orthosis
A splint the achieves a slow, progressive increase in ROM by repeated molding of the splint. Low load, long duration stretch.
Examples:
C bar
serial cast
Used with permission from Sammons Preston

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

22. Static Progressive Orthosis
Permission from Sammons Preston

23. Stress-Strain Curve & Orthotic Forces Placed Upon Tissues

24. Static Progressive Orthoses Serial Static Orthoses
Utilizes the principle of Stress Relaxation
constant strain causes decreasing stress in tissue
The tissues are stretched and held at a constant length. The stretching forces relax over time.
Theory: Relaxation occurs due to the realignment of fibers and tissue elongation when tissues are held in a fixed position over time.

25. Dynamic Orthoses
A static based orthosis with a mobile, resilient component attached. Components consist of elastics, rubber bands, springs that produce motion
Used with permission from Sammons Preston

26. Dynamic Orthoses
Used with permission from Sammons Preston

27. Dynamic Orthoses Principle of Creep
constant stress causes increasing strain in tissue
A constant load is applied for several hours during the day over a period of weeks or months.
Low load, long duration stretch theory.

28. Which Mobilization Orthoses ??
End Feel of the joint
Stages of wound healing

29. How much force with Mobilization ?
Dr Brand’s theory:
“Keeping the tissues at a physical state that demonstrates the need for change will stimulate the cells to multiply and make changes in response to the need. The more time in the orthosis, the more quickly the tissues will respond.”

30. Classification by Design
Single surface design
Circumferential design
Forearm based, hand based, finger based

31. Single Surface Design Volar/ palmar Dorsal Radial half – radial gutter
Ulnar half – ulnar gutter
Benefits:
Support joints of flaccid muscles – CVA
Effective base for outriggers
Post operative orthotics – no pressure to areas, will damage repair.

32. Single Surface Design Dorsal Design Advantages: Disadvantages:
Sensory surface exposed
Less distal migration
Best for extension outrigger
Disadvantages:
Less muscular padding, more bony prominences

33. Single Surface Design Volar Design Advantages Disadvantages
Natural padding (skin/ muscle)
Best for flexion outrigger
Disadvantages
Tends to migrate distally with dynamic tension

34. Circumferential Design
Covers all surfaces
Thinner material
Contour adds ridgity and strength
Perforated material
Beneficial for:
Immobilization painful joint
Protect soft tissue
Orthotic for activity – more comfort and control
Good design for serial static orthotics
Helps prevent migration

35. Circumferential Design
Advantages
Most stable
Least migration
Disadvantages
More complex design
More difficult for patient to apply

36. Forearm Based Design Advantages Disadvantages
Allows flexibility with adjusting dynamic or static progressive tension
Disadvantages
Bulkier and heavier to carry

37. Hand Based Design Advantages Disadvantages
Light weight, easier to carry
Less interference with UE function
Disadvantages
Difficult to fabricate
Inadequate length for dynamic tension device

38. Common Names Radial Bar Wrist Cock up Immobilization orthotic
Static orthotic
Used with permission from Sammons Preston

39. Common Names Resting Hand or Functional Position Orthosis
Immobilization Orthosis
Static Orthosis
Used with permission from Sammons Preston

40. Common Names Thumb Spica IP joint included Immobilization Orthosis
Static Orthosis
Used with permission from Sammons Preston

41. Biomechanical Principles
Tammy LeSage MOT, OTR/L, CHT
Elisabeth DPT, MOT, PT, OTR/L, CHT, MTC

42. Biomechanical Principles - Orthoses: Clinical Application
Wider longer orthoses are more comfortable than short narrow orthoses. The length the forearm trough should be approximately 2/3 the length of the forearm.
Smoothed, flared or rolled edges on the proximal and distal aspect of an orthosis causes less pressure than do straight edges
You should attempt to maintain ½ the circumference of the thumb and forearm for a correct fit.

43. Biomechanical Principles….cont.
Continuous uniform pressure over bony prominences is preferable to unequal pressure on a prominence.
Because some orthotic components must be narrow and the resultant force is great, a contiguous fit is paramount.
Wider straps and finger slings lower pressure applied to the underlying tissues.
Contour mechanically increases material strength

44. First Class Lever System (Three points of fixation)
F = Force
A = Fulcrum
Axis
R = Resistance
FA = Force Arm
RA = Resistance
Arm

45. Mechanical Advantage: Force
Which orthotic design has to best mechanical advantage?
Force ?
Fess, 1987

46. Formula for Force R x RA =F FA R = 9lbs RA = 2.5 inches
FA = Orthotic in
Orthotic in
Fess, 1987

47. Force Orthosis – Forearm 8 inches
9lbs x 2.5 inches
8 inches
= 0.28 lbs force
Fess, 1987

48. Force Orthosis – Forearm 4 inches
9lbs x 2.5 inches
4 inches
= 0.56 lbs force
Fess, 1987

49. Mechanical Advantage Formula for MA MA = FA RA Orthosis #1 4 = 1.6 2.5
4 = 1.6
2.5
Orthosis #2
8 = 3.2

50. Stresses to Skin and Soft Tissue
Tension: opposing forces
Compression: inward forces
Shear: parallel forces
Fess, 1987

51. Pressure Formula for Pressure P = Total Force Area of Application
Orthosis #1
25 gm force
1cm X 1cm
= 0.25 gm P sq mm
Orthosis #2
5cm x 5 cm
= 0.01 gm P sq mm

52. Mobilization Forces Application of force to a moving part.
Must remain constant.
Want rotational element versus translational element.
Optimal rotational force occurs with a 90 degree angle of pull.
Fess, 1987

53. Documentation
Important information to include in documentation when providing an orthotic device. Your thoughts?
Legal implications

54. Documentation Medial condition that warrants an orthotic device
Medical necessity of orthotic device
Type, purpose and anatomical location of orthotic device
Communicated written and oral wear schedule
Precautions discussed
Rehabilitation potential with orthotic device
Goals related to function
Date and time patient to return (if applicable)

55. Documentation Follow up visit Document noted problems with compliance
Changes in the orthotic and wear schedule
Changes with motion if mobilization etc.