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 encounter.

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 her.

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.

Addressing Adolescents

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.

Finding Flexibility...

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 flexibility.

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 orthosis.

Considering Health...

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.

Feeling Good...

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 their condition.

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 outcome.