Through the Ages:
Helping Your Patients Meet the Challenge of Orthotic Compliance
By James Benelli, CPO, and Sandy Hargrave, CO
Spinal Technology, Inc., West Yarmouth, Massachusetts.
When it comes to ensuring orthotic compliance, it's not about acting your age.
Rather, your focus must be on understanding the age of your patients. Each
demographic group brings with them a unique set of concerns when being
outfitted with an orthosis. For some, appearance issues will be paramount.
Others will focus on comfort. Most will want to see or experience proof that
their brace is helping them to lead a better life.
Some compliance solutions transcend age. Patients should be given an
opportunity to view the design of a brace before it is ordered. In some cases,
less restrictive or cumbersome options may be available. The option to use
transfer papers or decals can allow a degree of orthotic personalization that
may make bracing a bit more tolerable.
In each case, the key to success hinges on establishing a dialog with your
patients. Only by appreciating their unique concerns can you successfully
address their issues. Understanding your patient's developmental stage will
allow you to tailor your approach, and maximize the value of the information
you are providing.
Taking Baby Steps
Working with pre-adolescent spinal patients involves unique challenges. While
older children may be able to understand (to some degree) their need for an
orthosis, infants and toddlers are more likely to be frightened and upset.
Providing information and attention at the outset can help ensure compliance
and, ultimately, correction.
Beginning With the Parents...
It is often difficult for adults to understand their medical condition and the
possible necessity of wearing an orthosis; for a young child, it may be
virtually incomprehensible. It is therefore imperative that the orthotist work
closely with parents to help the child understand what is happening. Engaging
the parents will also help make them active participants in their child's care.
The value of this team approach cannot be overstated. While you may be called
upon to answer initial questions regarding bracing, the parents will
ultimately live with their child's everyday orthotic challenges. Preparing
parents for this responsibility is at least as important as preparing the
child for what he or she will be facing.
To accomplish this, sit down with the child's parents without the child
present. Be frank about the child's condition, but also mindful of the fact
that many parents are initially as frightened and confused as their child.
Provide them with as much information as possible in easily understood terms.
Try to explain in layman's language any medical terminology that they may
Learning About Your Young Patient...
This is also an excellent opportunity for you to find out about your patient
beyond what his or her X-rays may show. In addition to the medical data that
you must collect, you should strive to assess the child's stage of cognitive
development. To what extent is he or she aware of what is happening? What are
the child's specific fears or concerns, and how do the parents think these
concerns should be addressed? You may also find out something about the
child's life independent of his or her condition. Discovering what your
patient likes or dislikes now may help you to build a better bond with him or
It is critical that you take the time to get to know your young patient as
well. Spend some one-on-one time with him or her. The key here is to spend at
least as much time listening as talking. The child may have concerns or fears
that have not been articulated by the parents. At the same time, you may learn
a piece of medically relevant information that has escaped the parents' notice.
Using a model can help older toddlers and pre-adolescents visualize what is
occurring, but be careful not to get too scientific. Simple analogies such as,
"Your spine is twisting a little bit, so that it looks like an 's'" can help
make their condition more concrete. For older children, you might also use
photographs of other, similarly-aged patients who have undergone bracing.
Remember, your patient's experiences as a child will not only dictate their
bracing compliance; they will mold his or her feelings toward medical
professionals for years to come. This is an especially important consideration
when working with patients suffering from chronic conditions. A child who will
be wearing a brace for months or years may not experience peer difficulties
today, but could face problems in the future. By helping your patient
understand their condition, you are giving him or her the knowledge and tools
to overcome challenges.
When it comes to orthotic compliance, adolescents want to know what is in it
for them. Teens often focus on the here and now rather than what could or
might be. Social situations in these image-conscious years can be challenging
enough without also having to wear an orthosis.
Getting teens to put aside today's awkwardness for tomorrow's better health
may be difficult. Ironically, this is a critical time for corrective orthotic
care. The skeletal growth that young people experience during their early teen
years often offers the last best opportunity for corrective action.
Adolescence is a time filled with emotions and hormones, but the last thing an
adolescent wants to be treated like is a child. Speak to your patient as a
young adult. Take the time up front to explain what the bracing will involve.
Engage your patient in a constructive discussion, but do not be surprised if
he or she becomes angry or defiant at the prospect of wearing a brace.
As an orthotist, you must help your patient find the benefit in bracing.
Patiently show them what level of correction they might expect if they follow
a regular bracing regimen. In turn, explain what will happen to their body,
and their appearance, if they elect not to adhere to their treatment. When
possible, use photographs of actual patients who are about their age.
Keep in mind that fear is not the answer. An open discussion about what your
patient wants to accomplish will allow you to better assess whether his or her
expectations are realistic. Perhaps compromises can be made. For example, if
the child wants to stop wearing their brace for a school dance, that time can
perhaps be "made up" at a later date. By offering some degree of flexibility,
you are also offering your patient a modicum of control over their condition
and its treatment.
Keeping Parents in the Picture...
While mothers and fathers may feel increasing insignificant in their teen's
life, all indications are that young adults still turn to their parents for
structure and guidance. By involving the parents in a dialog, you can help
prepare them for what may be a difficult period. Reiterate the importance of
regular compliance, but mention that it can be balanced with a degree of
You may also warn parents about the possibility that long-term bracing may
exacerbate the regular adolescent pressures associated with academics, dating,
and social maturation. The reality of wearing an orthosis may catch up with the
child long after the initial fitting has taken place. Parents may think that
the child has fully adapted to their condition, only to watch them grow
withdrawn or depressed as time goes on. Encourage parents to look for signs of
trouble, and to contact you with concerns. Working together, you may be able to
determine if the issue can be addressed successfully, or whether additional
help may be necessary.
Engaging the Elderly
Working with elderly patients presents a unique set of compliance challenges.
Health and appearance considerations, as well as the question of comfort, can
weigh heavily on the effectiveness of a bracing system. Design and engineering
can go a long way toward ensuring that elderly patients make full use of their
Make sure that you are not dealing with a patient's condition in a vacuum.
Talk with him or her about any other health concerns. For example, a spinal
orthosis will be wrapped tightly around the patient's upper body to provide
support. For patients with pulmonary issues (such as COPD, emphysema, asthma,
etc.), reduced lung capacity can be a significant problem. These
considerations must be weighed against the effectiveness of the orthosis.
In another case, diabetic patients must be cautious of the possibility of
pressure ulcers if a brace is worn for extended periods of time. Careful
fitting can be the answer in this case, with strategic padding and cut-aways
sometimes helping to alleviate areas of concern. A cut-away can also aid
patients with post-surgical conditions, such as those using a colostomy bag.
Experienced orthotists understand that many elderly patients lose muscle as
they age. This may lead to bony prominences, and substantial discomfort if the
orthosis is designed without taking this into consideration.
Some braces may be cut out when joints or protrusions may be a problem. A foam
brace, such as Spinal Technology's Flex Foamä spinal bracing system, may also
provide a solution. This style of bracing utilizes the rigidity of a
traditional orthosis and combines it with the comfort of a soft body jacket.
The soft inner layer helps cushion the less-padded portions of the patient's
body, while a more rigid external (or internal) frame can provide the
necessary level of support.
...and Looking Good
While numerous studies have shown that adolescent patients are acutely
sensitive to the appearance issues associated with wearing a brace, less
research has been done on similar concerns among the elderly. Both male and
female elderly patients may be concerned about appearing frail or infirm. In
some instances, the issue is a simple case of aesthetics: there are not many
outfits that "go" with an orthosis.
Again, a softer foam brace may be the solution. Some foam orthotics may be
worn under an elderly patient's clothing, allowing them the opportunity to get
the support they need without the look they want to avoid.
Communication is the Key
No matter what your patient's age, listening to questions and concerns is one
of an orthotist's most important duties. Patients must be handled with respect
and compassion. Do not be surprised if the prospect of an orthosis provokes
disappointment, or even anger. For younger children, you must work to counter
the fear of the unknown. With older patients, you must also impress upon them
that seeking help is an indication of inner strength rather than an admission
of physical weakness.
To accomplish this, the patient must feel that they are a part of the
decision-making process. By presenting them with choices rather than
ultimatums, and by answering their questions as clearly and completely as
possible, you can make them feel like a partner in their care. The more
options you present, the more you allow them to assert a degree control over
You must also examine your own abilities as a communicator. How effective are
you at engaging your patients? One avenue for self-examination may lie in your
past. Talk with former patients, who may now be able to provide an honest
appraisal of their feelings and concerns when they first came to you.
Encourage them to assess your strengths and weaknesses, not only as an
orthotist, but also as a communicator. Although it is sometimes difficult to
listen to weaknesses without becoming defensive, this information can be
invaluable as you seek to improve your communication skills.
Your efforts will reward both you and your patient. By establishing an open
dialog, you create a spirit of cooperation that will help ensure a superior