Utilizing Orthotic & Prosthetic Intervention in Wound Care

  Taking a multidisciplinary approach has become the “gold standard” within the medical community, as it has proven to be optimal for patient care. Wound care is no exception, and as the incidence of wounds and diabetes has increased over the years, so too has the need for educational programs and, more recently, an orthotic and prosthetic wound care specialty in order to complement wound care delivery. The evaluation, offloading, and prevention methods established by orthotics and prosthetics have been proven enhancements to all wound care protocols. A multidisciplinary approach to wound care that includes orthotics has also improved outcome measures and decreased healing times for neuropathic patients while improving quality of life for this high-risk population. Orthotic/prosthetic intervention can play an important role in wound care treatment or preventative care. It is important to understand the services that orthotic/prosthetic facilities offer and how to obtain these devices. Many factors including patient need, facility inventory, and insurance coverage affect the waiting time for a particular device. By understanding the orthotic options and keeping open communication, the patient benefits through quality care and improved quality of life. This article looks at the development of orthotics, the special role it plays in the wound care industry, how wound care providers can best integrate orthotics into daily practice, and pathways to consider to become specialty credentialed (see Table 1).

Roots of Orthotics & Prosthetics

  Archaeologists have uncovered evidence of orthotic and prosthetic devices being used on Egyptian mummies and in tombs dating back to 300 B.C.¹ The study of orthotics is said to have begun with blacksmiths and armor makers fabricating ambulation devices for injured people through the making of splints and braces. After the Civil War and subsequent wars, injured soldiers served as the stimulus for improved ambulation options, leading to advancements in the study of prosthetics, which have closely been associated with amputation surgery performed as a lifesaving measure for military soldiers. Before the Civil War, few artificial limb companies existed. But by the time the aftermath of World War II and polio epidemics of the late 1940s and early 1950s set in, survivors of musculoskeletal and neuromuscular impairments or traumatic war-related amputations further increased the demand for orthotic and prosthetic services. Although orthotics and prosthetics may seem to be worlds apart in that the former involves treating body parts while the latter replaces damaged limbs, a correlation exists between the patient evaluation process, the fabrication process, and the understanding of gait. In 1948, the American Board for Certification in Orthotics, Prosthetics & Pedorthics (ABC) was formed to set minimum standards for practitioner education and experience levels as well as to test clinical knowledge. Today, the field of orthotics and prosthetics is a well-recognized specialty in the medical community. As of 2010, more than 5,600 practitioners had been certified by ABC.

Comparing Orthotics & Prosthetics

  The goal of treatment for any neuropathic or dysvascular patient is to preserve the limb and ambulatory function. The role of the orthotist/prosthetist is to redistribute weight-bearing forces on the neuropathic limb. This role is continuous from ulcer management to accommodation and follow up. Orthotists treat the entire body through externally applied devices designed to support or correct deformities. This can vary from upper-limb to spinal deformities to cranial-remolding bands. Prosthetists treat limb deficiencies by replacing the missing limb with a device or prosthesis. The most common orthotic/prosthetic interventions in wound care include:     • Compression therapy: Serves several purposes in the treatment of venous insufficiency by improving circulation and decreasing edema. If a lymphedema specialist is not available, an orthotist can easily measure and fit the patient with compression stockings. Ideally, the patient is treated with wraps until the edema is under control or the venous ulcer has healed enough to prevent reoccurrence. Some facilities may keep stockings on-site; however, there are many different styles and options that patients may choose. Juzo,® Jobst,® and Medi offer some of the more common compression hoses, which should be ordered about two weeks before the patient is ready to begin wearing stockings. The prescription should also detail whether below- or above-the-knee compression is needed and the range of compression desired (low, medium, or high). Open toe/closed toe and designs/colors that will appeal to men and women should also be considered. If the patient is currently wearing professional wraps, a coordination of teams is important to get the optimal fit. For example, when the patient is due for a wrapping change, send him or her to the orthotists, who can remove the wraps and measure the patient before being sent back to the wound care center for new wraps. Once those wraps are worn and ready to be changed, the compression stockings should be ready for the patient to receive.     • Wedge shoes or half shoes: Both strive to offload a pressure area on the bottom of the foot. The wedge shoe has full contact with the foot, but reduces load by lessening the amount of sole in contact with the ground. For example, to offload the forefoot, the heel is elevated and angled to prohibit forefoot contact with the ground. Although effective, a problem with this design is the undesirable effect on balance and gait, which may increase the need for an assistive device. The half shoe is a shoe cut in half across the width and is designed to offload a certain area of pressure such as the heel. It does effectively offload the affected area, however, it puts tremendous stress at the transition point on the foot when weight-bearing.     • Postoperative or cast shoes: Very common in the wound care setting. They contain a rigid sole and removable insole that can be cut out under the ulcerated area for relief. As the simple Velcro design allows for bandage volume, it does not offer an intimate fit, so it cannot control foot motion (which may leave the patient at risk for rubbing). These are particularly helpful when the patient is under a continuous-care program where the foot is monitored closely. They are also very easy to adjust or change as the patient changes. Also, the bottom typically is flat and rigid, so patients may have to adjust their gait.     • Wound care shoe system: A special style of shoes designed specifically with wound care relief in mind, though it’s a more expensive option that is not always covered by insurance. The wound care shoe system is a leather sandal designed to be trimmed away at pressure-prone areas such as bunions or the heel. The leather is fully padded to not induce extra pressure. The sole is a rocker bottom, which allows the patient the full gait cycle — unlike the cast shoe. It has four removable insoles that give plenty of room to offload multiple areas.     • Prefabricated (CAM walker or CAM boot): Primarily designed for treatment of fractures and sprains, as it is basically a removable cast. Eliminates the motion of the ankle with a rocker bottom for easy ambulation and has become popular due to availability and built-in removable layers for pressure relief along the plantar surface of the foot. The soft padding is removable, making sanitation easy. These boots can also be pneumatic, which gives the patient an optimal total contact fit as to decrease adverse pressures.     • Charcot Restraint Orthotic Walker (CROW): Custom-made bivalved ankle foot orthotic, this device is a removable total contact cast that has been proven in treatment of plantar diabetic foot ulcers. This device is plastic and lined with a soft foam padding called plastazote and uses a total contact surface to help distribute pressures evenly up the calf. The insole is a removable custom-molded insert made from different density layers and can be modified to offload an area or areas of concern. The plantar surface has a built-in rocker bottom sole, so the boot replaces the shoe on that extremity. This device is particularly helpful in preventing further breakdown of the Charcot ankle.     • Therapeutic shoes: Designed to prevent or decrease the risk of future complications. In a wound care setting, it is important to first treat the patient for the wound until it’s a manageable size and requires limited bandaging before attempting to place the patient in shoes. To be considered as a therapeutic shoe, the shoe must provide extra depth and must have a closure such as laces or Velcro strap. The main difference between regular shoes and therapeutic shoes is the deeper toe box and overall increased depth to allow room for an accommodative insert. The purpose of the shoes is to achieve a proper fit in order to avoid shearing forces caused from movement of the foot inside the shoe or by an improper width, which can apply undesirable pressure along the sides. Shoe modifications can range from adding an elevation to address height discrepancy to a flared wedge to help control ankle motion. A metatarsal bar on the outside of the shoe is a nice modification to help roll over the metatarsal heads, therefore offloading them. In severe cases such as deformity, custom shoes may be needed in which a custom cast is taken, and fabrication is usually 4-6 weeks.     • Shoe inserts: Go by many different terms such as “foot orthotics,” “accommodative insoles,” and “arch supports.” The insole is molded to the bottom of the foot, causing the entire sole to participate in the force distribution and resulting in lower pressures. There are many different materials that inserts can be fabricated from, but typically will be a compilation of layers made from different materials with different densities for neuropathic patients. For insensate feet, the arch support should be accommodative, not corrective, as one does not want to create adverse pressures that could lead to breakdown. One of the main purposes and goals with inserts is total contact (similar to the CROW boot). Toe fillers and partial feet amputations are addressed based on the level of amputation and need for the patient. A common transmetatarsal amputation for a neuropathic patient would be an insert with a foam block to fill the toe area to fill the shoe. These toe fillers should be carefully fabricated as not to rub on the remaining limb.     • Diabetic socks: Have no seams and are made of materials such as cotton to help wick away perspiration. Decrease the risk of rubbing caused by seams and provide a dry environment. They can also come with silver, which has been shown to be antibacterial and an aid to healing.

Obtaining Orthotics

  A common misconception is that an orthotic/prosthetic facility is similar to a pharmacy, in that patients arrive with a prescription that is filled while they wait. Many times this is not feasible because patients will need to be seen and evaluated by the practitioner orthotist/prosthetist, who, for the most part, is filling a prescription but has to consider many variables that are different for each patient. For example, if a physician orders “diabetic shoes and inserts,” the patient still needs to be evaluated to determine if the inserts should be customized or off-the-shelf, whether any pressure areas require relief, and what type of material is best suited for the patient. Most facilities prefer appointment scheduling, but sometimes walk-ins are necessary based on logistics or overall need. Once the practitioner has chosen an item for the patient, it is coded through the Healthcare Common Procedure Coding System. The office staff will usually check benefits to determine coverage and patient co-pay. It is important to note that coverage varies depending on the plan or insurance company. Once coverage is determined, fabrication or ordering of the device can begin. Depending on the device, the patient will be contacted when it is ready for delivery or when the wound care professional approves patient fitting.

Patient Communication

  Communication is crucial to providing quality patient care, and wound care providers play an important role in discussing the patient’s needs to the orthotic/prosthetic clinic. From this author’s experience, a basic prescription is a good starting point. For example, a patient with an amputated first ray and ulcer under the first metatarsal head could come to the facility with a basic script that reads, “insert to offload 1st methead.” The trained orthotist or pedorthotist will evaluate the patient and the facility will generate a prescription with the detailed coding and descriptions of the services planned to provide to the patient. This may seem tedious to the ordering physician who then has to sign another script, but it is a double-check system, a chance to make sure the orthotists/prosthetist is providing something within good scope of practice. If the ordering physician disagrees or has questions, he/she has the opportunity to address the issue before patient delivery. Although Medicare is the only provider that requires these detailed prescriptions, a detailed script with coding is effective protocol to use for all patients because it conveys sound patient care and thorough communication.

Therapeutic Shoe Bill

  In 1993, the US Congress introduced the Therapeutic Shoe Bill in an effort to reduce lower-limb amputations and other foot complications related to diabetes. This bill provides coverage for extra-depth shoes and accommodative inserts for patients who live with diabetes. In recent years, this policy has undergone many changes as Medicare tries to eliminate abuse and fraud. This is very important to address since many wound care patients receive Medicare and live with diabetes. Other private insurance companies may or may not provide coverage for therapeutic shoes, but most do not have the stringent requirements of Medicare. Currently, Medicare will allow one pair of approved shoes and three sets of inserts per calendar year. Certain substitutions may occur due to shoe modifications or toe fillers. The shoe provider must be accredited and the individual practitioner must be certified. The wound care physician may order shoes and inserts; however, the diabetes-treating physician must be the one to sign the “statement of certifying physician or certificate of medical necessity.” The supplier providing the shoes must also retain a copy of the physician’s records that document the need for the care provided. This could mean that the patient has to visit his/her primary care physician, in which case it is helpful to provide wound care clinic notes to allow the physician to document accordingly. It’s the responsibility of the supplier to obtain all necessary forms before the patient can receive shoes. Although this can create a delay, it also means that all members of the patient’s care team need to work together to provide the patient with the best possible service. Due to these requirements, many orthotic/prosthetic facilities do not provide therapeutic shoes due to labor intensity and low profits. Amy Rosetta is a certified prosthetist orthotist and licensed prosthetist orthotist on staff at Muilenburg Prosthetics, Houston, TX.

Reference

1. Atlas of limb prosthetics: Surgical, prosthetic, and rehabilitation principles. American Academy of Orthopaedic Surgeons. 2nd Edition; 1981. Edited by John H. Bowker and John W. Michael. Mosby Year Book.