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Despite the time and expense that goes into making them, many custom lower-limb orthotic devices end up gathering dust in the back of people’s closets. Perhaps the ankle and foot braces didn’t fit well and rubbed against tender skin. Maybe the devices didn’t help as much as the user had hoped or they were embarrassed to be seen in them. Without the orthotics, patients often try to correct gait problems on their own, stressing their joints and causing bigger orthopedic problems down the road. Orthotists, who craft the custom devices, and physical therapists, who work with patients who use them, have told researchers that they would like better assessment tools so they can measure the end result of the care they provide. But there’s a lack of standardized measurement instruments focused on custom orthotics and some practitioners say they don’t have enough time during patient visits to administer them anyway.
To get a better handle on the situation, researchers at the Center for Rehabilitation Outcomes Research (CROR) at the Shirley Ryan AbilityLab surveyed orthotists and physical therapists around the country on their perspectives on quality-of-care indicators for people who use custom ankle-foot orthoses (AFOs). To come up with questions, they convened an advisory committee made up of consumers, clinicians and orthotics manufacturers. The resulting survey consisted of 91 questions across eight sections and used branching logic to skip items that weren’t relevant based on a participant’s previous responses. Respondents were asked to rate the importance of 10 quality themes; only those who rated an area as “extremely important” or “somewhat important” were asked for further input. They also were asked about the best methods of collecting information for each topic. The options included patient self-report; clinician-report; patient performance measures; and records collected by a facility.
Orthotists have different responsibilities in patient care than do physical therapists.
Allen Heinemann, PhD
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A total of 461 orthotists and 153 physical therapists completed part or all of the survey, which was sent out in late 2017. The average age of those responding was mid-40s. About 72% of orthotists were male and roughly 82% of physical therapists were female, reflecting the gender distribution of their disciplines. There was broad agreement between the two groups on many issues, including the importance of there being minimal pain and skin damage from using the devices. They also agreed that a user’s balance was extremely important and that gait pattern was more important than walking speed or endurance.
But there were also significant points of divergence. For example, almost 86% of physical therapists rated clinician follow-up with patients as extremely important compared with only 65% of orthotists. Similarly, almost 80% of therapists ranked continuity of care as extremely important versus about 60% of orthotists. That doesn’t surprise CROR Director Allen Heinemann, PhD. “Orthotists have different responsibilities in patient care than do physical therapists. Their job is to make and deliver an orthosis that meets patients’ needs and give them instructions on how to use it. But if a patient has ongoing needs related to using the device more effectively, that’s the job of the PT.”
When the topic turned to measurement, at least 50% of orthotists and physical therapists indicated they were familiar with seven of the 16 standard assessment instruments they were asked about. Among the performance tests they rated were the Timed Up and Go (TUG) test, which predicts fall risk; the 10-meter walk test, which measures walking speed; and the 6-minute walk test, which measures endurance. Among that group, at least 60 percent said that they believed 12 assessments were “excellent” or “good” ways to measure quality and were feasible for them to administer. But several respondents commented that adding standardized measures to a patient’s visit wasn’t really practical in today’s fast-paced health-care environment. “All of the tests listed are great evaluative tools if we had the time to do some, let alone all of them,” one wrote. “It’s difficult to justify spending that much time with any patient in an environment where insurance companies don’t want to pay for custom devices.” The commenter continued: “The most valuable evaluative tool that I use is watching the patient ambulate from the waiting room to the exam room.”
People will waste less time communicating about the progress of patients if they use the same instruments
Allen Heinemann, PhD
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Despite the time pressures, more than 50% of the respondents reported they could devote 30 minutes or longer to administering a battery of standardized instruments each time they saw a patient. That finding surprised the research team, causing them to wonder if the people taking the survey had misinterpreted what they were being asked. Heinemann speculates that the respondents were including the assessments they were already doing during a patient appointment in the 30 minutes. What the researchers wanted to know was if they could take an additional half hour to administer a standardized set of measures. “We probably should have worded it more specifically,” Heinemann says.
Still, the survey results supported the idea that the field of custom orthotics could benefit from a standardized set of tests that would allow quality to be measured across institutions and over time. “People will waste less time communicating about the progress of patients if they use the same instruments,” Heinemann says. “If you have common measures that make sense to people, it improves communication and outcomes.”
