A New Orthotics Terminology: A Guide To Its Use For Prescription and Fee Schedules
E.E. Harris, M.R.C.S. *
Prepared for consideration by the Task Force on Standardization of Prosthetics-Orthotics Terminology, Committee on Prosthetic-Orthotic Education-Committee on Prosthetics Research and Development, National Academy of Sciences. This work was supported jointly by the Veterans Administration and the Social and Rehabilitation Service through Contracts #V101(134)P-75 and #SRS-72-6, respectively.
MacLean and Kamenetz in Orthotics Etcetera, edited by Licht 6, list more than 80 braces used in the treatment of spinal conditions, a list which does not include the large number of cervical supports. These braces are identified by proper names—or eponyms—derived from the place of origin, the developer, or sometimes a name unrelated to either. A similar plethora of names is used for braces applied to other parts of the body.
These eponyms frequently do not give the site of application and often give no indication of the function provided. Two braces ordered by one eponym from two suppliers may result in two braces which are significantly different, not only from each other but also from the description of the original developer. Because the terminology is illogical the use of these named braces can only be learned by rote.
Professional bodies, fee-paying agencies, and wholesale manufacturers have their own difficulties in using the existing orthotic nomenclature. The teaching of aspirant physicians and orthotists cannot be done logically. Communication between physician and orthotist depends upon each placing the same identity on the given name. The agencies have difficulty in developing a fee schedule which reflects the service and skill of the orthotist and the function of the brace he supplies.
For some years many who use orthotics terminology have been making attempts to develop nomenclatures better adapted to their own purposes. The three university prosthetics-orthotics teaching schools had each studied the problem. New York University had produced a spinal terminology which has a great deal of merit but does not readily transfer to other parts of the body. The American Orthotic and Prosthetic Association has consulted with the American Academy of Orthopaedic Surgeons and the Committee on Prosthetics Research and Development of the National Research Council on nomenclature problems of mutual interest. Discussions by members of these three bodies extended over a number of years. From these discussions it became evident that to prescribe a brace in terms of desired function it is first necessary to analyze the patient's sensorimotor deficit.
Dr. Newton C. McCollough, III, Associate Professor of Orthopaedics, University of Miami; Mr. Charles Fryer, Director, Prosthetic-Orthotic School, Northwestern University; and Mr. John Glancy, C.P.O., Indiana University, were therefore charged by the three bodies with the task of developing a method of recording sensorimotor deficit.
The outcome of their work on the lower limb was published in Artificial Limbs in 1970 7. It included a form which recorded sensorimotor and skeletal deficits briefly, and mostly graphically. This document was called the Technical Analysis Form and has been widely used by a number of centers. The form also provided a place for brace prescription. It has proved useful for teaching and research purposes, but has been considered by some to be unnecessarily extensive for routine clinical use. To produce a similar form for the upper limb has proven to be difficult, but one has now been developed and is undergoing field trials. The development of a spinal technical analysis form is still in an embryonic stage.
These technical analysis forms do not in themselves solve the problems of terminology for braces. Fee-paying agencies have become increasingly restive because modern costing and fee scheduling demand computerizing. The orthotics and prosthetics professions have therefore been under pressure from these agencies to produce a logical nomenclature for use in fee schedules.
The American Orthotic and Prosthetic Association therefore approached the Committee on Prosthetic-Orthotic Education (CPOE) of the National Research Council for help.
The two committees, CPRD and CPOE, then consulted the American Academy of Orthopaedic Surgeons and the university prosthetics-orthotics teaching schools. They also consulted the Social and Rehabilitation Service of the Department of Health, Education, and Welfare and the Veterans Administration and, with their support and active participation, set up a Task Force to develop a standardized prosthetics-orthotics terminology.
The Task Force on Standardization of Prosthetics-Orthotics Terminology held its first workshop meeting in Dallas on March 28-30, 1971 2, and has had subsequent workshops in Washington, September 9-11, 1971 3, March 1-2, 1972 4, and July 28, 1972 5. There have also been a number of subcommittees and individuals assigned to study specific items.
The Task Force is composed of physicians, surgeons, prosthetists, orthotists, therapists, engineers and administrators active in the field of rehabilitation drawn from university teaching programs, hospitals, private practice, fee-paying agencies, and manufacturers.
The prime objective was to develop terminologies based on logical systems which could also accept new devices with which a physician can communicate to an orthotist or prosthetist the functions desired from a device. Secondary objectives derived from this would be that such a system would provide a logical system for the teaching of physicians, therapists, orthotists, and prosthetists, for the development of fee-paying schedules, and would provide an authority list for information retrieval systems.
The Task Force has not yet completed its work, but it has developed a method of prescribing orthoses which is currently being used and which now forms the basis for some fee-paying schedules. These schedules are also being used as part of an effort to develop a comprehensive standardized orthotic nomenclature and an authority list for use in information retrieval systems. It is therefore desirable that a description of its rationale and correct use should be available. It is presented here in two sections.
Firstly, there is an account of the rationale. Secondly, the method of use for prescription is described.
Development Of An Orthotics Terminology
This section is not; a chronological account of the many variations suggested and tried before the development reached its present form. The practicality of the current version has been proven in field trials. It will doubtless evolve further with use.
The term "orthosis" has itself been the subject of discussion. It has been agreed that other terms in use such as brace, splint, appliance are unacceptable. The need for a comprehensive term and its international use led to the adoption of "orthosis" as the proper term for that heterogenous group of devices called variously braces, splints, calipers, supports, etc. The Concise Oxford Dictionary does not include the word "orthosis" at all, and Webster's Dictionary gives it a psychological meaning. It was suggested by some that an "orthosis" might be described as "a piece of equipment applied on the exterior of the body to influence motion by assisting, resisting, blocking or unloading part of the body weight." Dorland's Pocket Medical Dictionary, 21st Edition, 1968, gives "a brace or other orthopaedic device which is applied to a segment of the body for the purpose of protecting the segment or assisting in restoration or improvement of its function" as the definition. Stedman's Medical Dictionary, 21st Edition, 1966, defines orthosis as "any medical device applied to or around a bodily segment in the case of physical impairment or disability." This seems to be the most concise and is the one most generally accepted although it has not been adopted formally.
Next, it was decided to consider the body as comprising three major anatomical areas, namely, upper and lower limbs and the spine. It was pointed out that, embryologically, the head and the tip of the coccyx are the extremities and it was agreed that in the future "limb" should replace "extremity" in the terms "upper and lower extremities."
All orthopedic appliances, braces, splints, calipers, etc., are, therefore, henceforth designated as "orthoses" and they are applied to the spine, and the upper and lower "limbs."
It was also agreed that in the future all proper names should be eliminated from the terminology. To replace them a terminology based on function was sought. This proved impractical because it is possible to apply an orthosis to one part of the body to influence a distant part of the body. Examples of this would be to add a "raise" to the footwear to correct a pelvic tilt or by limiting dorsiflexion of the foot to promote extension at the knee.
It was then suggested that orthoses could be described by the joints they encompassed, and this is the system which was adopted and which has proven practical.
For example, in the lower limb, orthoses would be described by the combination of joints:
Thus an orthosis embracing the hip, knee, ankle and foot is  a "hip-knee-ankle-foot orthosis;" one encompassing the knee, ankle and foot-formerly a "long-leg brace"-becomes  a "knee-ankle-foot orthosis." The various "short-leg braces" are now  ankle-foot orthoses. Other variants such as  a "hip-knee orthosis" or  a "hip-knee-ankle orthosis" can be derived from this system. Orthoses such as the Swedish Knee Brace for recurvatum or the U.C.B. shoe insert embrace only one joint and become respectively "knee orthosis" and "foot orthosis."
In practical use such a terminology becomes too long to use when many joints are involved and the initial letters are used for "acronyms" as:
The terminology accepts certain joint complexes such as the hand, wrist, and foot as units for descriptive purposes. For prescription it is sometimes necessary to subdivide these units into the component joints.
Thus, hand orthoses (HO) are subdivided for prescription into:
and the foot orthoses (FO) into:
The spine is considered as four joint complexes which are not subdivided:
The long bones of the limbs which are between the major joints separating and acting as levers on them are not included in the basic schema. In fracture bracing, pseudarthrosis, and following osteotomy, etc., they become important, and must be included for prescription. Because they are only used in the special circumstances they are listed, with one exception, in italics, e.g.:
Image 5 Image 6
Note that the Forearm is the exception to the use of italic type for long bones. Although anatomically pronation and supination take place at the elbow joint, in practice it is the forearm which must be controlled.
The joints of the body can now be listed, together with the "distance pieces" between them where necessary, in vertical columns, subdivided for convenience into the three major groups. Sometimes an orthosis extends over more than one group. For example, a shoulder-abduction orthosis may be a "shoulder-elbow-wrist-hand thoraco-lumbar sacral orthosis" or for short SEWHTLSO and a hip-abduction orthosis might be a "thoraco-lumbar sacral hip orthosis" or TLSHO.
The joints, etc., are now listed vertically and we can identify the orthosis to be used around these joints. The prescription now needs to specify what action the orthosis should have on those joints.
Normal and pathological joints may:
and the joints and long bones may also have an:
In the spinal orthosis right and left lateral flexion substitute for abduction and adduction, and right and left rotation for internal and external rotation of the limbs.
In the limbs pronation and supination, inversion and eversion, and opposition substitute for internal and external rotation where appropriate.
Originally there had been a desire to express axial loading as axial compression and tension but in practice it seemed better to relate the loading on the bones and joints to gravity.
The possible motions, whether normal or pathological to any particular joint, are then arranged horizontally so that a matrix is made in which the designated action of the orthosis on the movement and load of each joint can be prescribed. These matrices can be used separately for the three major regions of upper limb, lower limb, and spine or combined in one master orthotic prescription chart. To simplify the charts motions of joints which only occur with pathological conditions have been "greyed in" to indicate that these areas will only need prescription when there is pathological movement.
Prescription is based on the control by the orthosis on anatomical joint motions and is based on five types of basic controls which are represented by symbols and which may be modified by four supplementary symbols. This system is based on one suggested by Staros et alia of the Veterans Administration some years ago.
The orthotics nomenclature system is based on the analysis of an orthosis in terms of its control on anatomical joint motions.
Image 8 Image 9
The five types of basic controls used in the system to indicate the effect of an orthosis on anatomical joint motions are:
- F = FREE Free motion permitted in any given direction.
- A = ASSIST Application of an external force for the purpose of increasing the range, velocity, or force of a desired motion (spring, motor, alignment to use gravity, etc.).
- R = RESIST Application of an external force for the purpose of decreasing the velocity or force of a desired motion.
- S = STOP Inclusion of a static unit to deter an undesired motion in one direction. Used alone, "S" means restraint of gross motion in the neutral position.
- H = HOLD Elimination of all motion in prescribed plane (verify position).
and the four supplementary symbols for variations of basic controls:
- v = variable Other than with "STOP," "variable" is seldom used; an exception would be its use with "RESIST" when frictional force is changed.
- L = LOCK Device includes an optional lock.
- ° = Specification of degrees Denotes a desired limitation of range; final position in a given direction is expressed in degrees. (The AAOS system of joint range-of-motion measurements is used.)
- % is used in axial loading to indicate the amount in percentage of the normal load.
In the axial plane the application of an orthosis may totally or partially eliminate the effect of gravity.
If the intent is completely to obstruct or stop the effect of gravity, e.g., in the Milwaukee Brace, the control symbol "S" is used. (The fact that it is not completely effective does not alter the indication; the intent is the determining factor.)
If the intent is to allow partial weight to be borne on a part, the amount is specified as a percentage of the normal load.
Lastly, a place is given for remarks so that the physician may supplement the prescription when necessary.
In daily clinical practice the physician and orthotist are part of the team responsible for rehabilitation of the patient. They usually know each other well and should have a mutual understanding. The physician should know enough about materials suitable for and fabrication of orthoses to understand the limitation they may impose on the orthotist. The orthotist must know enough of medicine and physiology to understand the clinical reason for the physician's prescription. Both have to meet the needs of the patient, which include the intellect, psychology, vocation, and environment, as well as the physical deficit. Orthoses of many differing designs and materials may have identical control characteristics but vary considerably in durability, weight, and cosmesis. Molded plastic splints may be ideal in a temperate climate but be unacceptable in a humid tropical heat. A lady on Fifth Avenue may need a very different orthosis to the farmer with a similar physical deficit. While it is the duty of the physician to analyze the patient's physical deficit and the controls required from the orthosis to overcome or minimize the disability, it is not his responsibility to particularize materials or fabrication unless there is a specific clinical need. Sensitivity to specific materials is a clinical reason for countermanding their use. Other physical factors may make it clinically necessary to prescribe a specific lock to enable a patient to operate it. For this type of information exchange the remarks column is used.
The physician and orthotist as a team will have their own preferences based on their own particular skills and experience. An orthosis provided to a prescription at one center may differ from that provided to a prescription at another center, and both may be correct. The eventual orthosis provided may reflect the relationship between the physician and orthotist and also the social and vocational needs of the patient.
At the present time it is tempting to visualize orthoses in current use by their eponyms such as "Milwaukee Brace" or "TIRR Drop Foot Brace," and then translate them into the matrix. The proper use of the chart is to prescribe the controls desired from which the orthosis will be visualized which might then vary from the one in common use. There are new materials and fabrication methods developing such as vacuum forming of polypropylene, polycarbonate, and other plastics in sheet form leading to new kinds of orthoses. The proper use of the chart will aid in identifying the bio-mechanical requirements for which the new materials can be used to make the next generation of orthoses.
For standard orthoses the use of the form may not be essential unless it is required for filing or for the paying agency's purposes. The terminology is independent of the matrix. To write "AFO with plantar R" might be sufficient. However, to use the chart does ensure that all necessary controls are included. With familiarity the system becomes much less formidable.
When the orthotist receives the prescription he will usually recognize it as an orthosis with which he and the prescribing physician are familiar. If, in the light of newly acquired knowledge or personal thought, he wishes to provide a different orthosis producing the same control more efficaciously, common courtesy would cause him to consult with the physician first.
Some examples are given below of the method of use for specifying the controls required from which more than one orthosis might be derived.
Ex. 1 shows a knee-ankle orthosis with knee lock which might be made with conventional double sidebars, drop lock at knee and Klenzak joints or with plastic thigh and leg shells and a knee lock, dorsiflexion of the foot being obtained by the trim line of the lower plastic shell.
Ex. 2 prescribes an orthosis for drop foot of which there are a number currently available such as AMBRL, TIRR, etc. 1, as well as the conventional double uprights.
Ex. 2 Fig. 2
More than one division of the chart may be needed to describe the controls.
Ex. 3 is a spine and hip orthosis with adjustable head restraint to assist sit- and stand-balance in a child with cerebral palsy. There would be a number of variants in actual design depending on the materials used.
Fig. 3 Ex. 4
The above example describes the controls for a scoliosis with right thoracic and left lumbar curves. The "R" under axial load might well be "S." At the present time it is probable that a "Milwaukee" orthosis would be supplied to this prescription.
Ex. 5 shows that complex hand orthoses can be presented.
It has been shown that externally powered devices can be prescribed accurately as can pulsed electrical neuromuscular stimulation.
This terminology has had ready acceptance by those who have been exposed to it. A number of physicians, orthotists, therapists, etc., have used it in a limited way in some clinical evaluation programs.
It is being used in university orthotics and prosthetics schools to teach the principles of orthotic treatment and of prescription and is therefore influencing an increasing number of those engaged in rehabilitation.
It is also being used to develop an authority list for an orthotics and prosthetics information retrieval system. It is hoped to identify all orthoses in international use by their current names and relate them to this terminology. Such a system is only of general interest to most practitioners, but becomes essential in any research project.
It has had field trials by the Veterans Administration, and since September 1972 has been used for fee schedules by the Department of Welfare and the Bureau of Crippled Children's Service for the state of Ohio where it has been well received by the administration as well as the professions. Other states are adopting the terminology for use in computerized schedules.
The New Orthotics Terminology And Fee Schedules
It was not the purpose of the Task Force, nor was it within its powers, to develop fee schedules. However, a logical terminology which could be used for computerized schedules was an urgent requirement of fee-paying agencies. It had been suggested that otherwise they would need to devise their own. Therefore one reason for developing the terminology was for use in fee schedules and it must be shown to be suitable for such usage.
The Veterans Administration is currently using the terminology and is also developing a fee schedule from it. The state of Ohio's Department of Public Welfare, Division of Medical Assistance, and the Bureau of Crippled Children's Services have been the first to adopt it for a computerized fee schedule which has been in operation since September 1972. A number of other states are also proposing to use the terminology to develop similar schedules.
The schedules of the Veterans Administration and the state of Ohio differ considerably but this new terminology is equally at home in either.
The Veterans Administration already has a pilot program to test a prosthetics schedule which reflects the professional expertise of the prosthetist rather than the complexity of mechanism or cost of materials used. A fee is paid which is related to all prostheses provided for any one given level of amputation irrespective of its complexity. Over a number of prostheses the margin of profit averages out. It is recognized that there are some mechanisms of considerable cost such as some knee-control mechanisms for which there is a separate schedule. The prosthetist provides these items on a cost and handling basis so that he may give the patient what is needed without having to consider a financial interest in its supply.
It is proposed that a similar schedule for orthoses be developed on the same principles used by the Veterans Administration. The new terminology with its grouping of encompassed joints lends itself to such an arrangement. If the development of powered orthoses demands complex costly mechanisms a schedule for such items can be developed. That the fee schedule is not detailed does not mean that the prescription itself will not be specific on the controls which are required from the orthosis.
The state of Ohio's schedule is more detailed and specific. The Department of Public Welfare and the Bureau of Crippled Children's Services have authorized a description of it.
A ten-digit computer code is used for all medical supplies and durable medical equipment. The first four digits identify the code group such as aspirators, bed pans, nebulizers, etc. The last six digits identify specific items within each group. The following extract from the schedule of some spinal orthoses is shown as an example:
||THORACO-LUMBAR CORSET "SPECIAL PATTERN" "YOKE TYPE" WITH POSTERIOR SPRING STEEL UPRIGHTS
||LUMBO-SACRAL ORTHOSES WITH POSTERIOR FRAME AND CHEST STRAPS, "BENNETT TYPE" WITH FULL CORSET COVER
||LUMBO-SACRAL ORTHOSES POSTERIOR FRAME WITH LATERAL UPRIGHTS AND CHEST STRAPS "CHAIR TYPE" WITH FULL CORSET COVER
||LUMBO-SACRAL ORTHOSES POSTERIOR FRAME WITH LATERAL UPRIGHTS AND CHEST STRAPS "CHAIR TYPE" FULL CORSET COVER, REMOVABLE STERNAL ATTACHMENT
||LUMBO-SACRAL ORTHOSES "WILLIAMS FLEXION TYPE" POSTERIOR LATERAL FRAME WITH ELASTIC ABDOMINAL FRONT
||LUMBO-SACRAL ORTHOSES, MOLDED TO CAST BY ORTHOTIST
||LUMBO-SACRAL CORSET WITH POSTERIOR SPRING STEEL UPRIGHTS
||LUMBO-SACRAL CORSET WITH POSTERIOR SPRING STEEL UPRIGHTS "SPECIAL PATTERN"
||SACRO-ILIAC CORSET, TWO DRAW ADJUSTABLE WITH POSTERIOR PAD
The four digits at the top, 6635, identify it as part of the orthotics schedule. The six digits identify specific orthoses. In this transition period familiar eponyms have been included for clarification. These digital numbers are at intervals of ten which allow the insertion of other similar orthoses as required. For daily use each item has been reduced to a single line which appears in the handbook as follows:
||TL CORSET SPL PATTERN YOKE TYPE W/POST-
||LSO W/POST. FRAME & CHEST STRAP BENNETT-
||LSO POST. FRAME W/LAT. UPRIGHTS CHAIR TYPE
||LSO CHAIR TYPE W/REMOVABLE STERNAL ATT.-
||LSO WILLIAMS FLXR TYPE W/ELASTIC ABD.-
||LSO MOLDED TO CAST BY ORTHOTIST
||LS CORSET W/POST. SPRING STEEL UPRIGHTS
||LSC W/POST SPR STEEL W/SPECIAL PATTERN
||SIO TWO DRAW ADJ W/POSTERIOR PAD
For billing a form is used on which 18 such lines are filled in. When the eighteen items supplied have been listed, the form is forwarded for payment without waiting for the end of the month. There is therefore a constant, rather than intermittent, flow of items to the computer, and when certain accounting difficulties are overcome it is hoped that payment will also be more expeditious and evenly spaced.
The state of Ohio's administration has expressed satisfaction with their experience of the terminology thus far. In the first four months of use of a computerized schedule there has been no rejection by the computer, although there have been many thousands of items submitted for payment from more than 40 different orthotic firms. With few exceptions orthotists have welcomed the new terminology despite its complete break with the traditional nomenclature with which they have been familiar for many years.
It is submitted therefore that the new terminology for orthoses which has been developed by the Task Force established by the National Academy of Sciences is now stabilized adequately for general use.
- Committee on Prosthetics Research and Development, Seventh Workshop Panel on Lower-Extremity Orthotics, March 9-12, 1970.
- Committee on Prosthetic-Orthotic Education, Workshop on Standardization of Prosthetic-Orthotic Terminology, March 28-30, 1971.
- Committee on Prosthetic-Orthotic Education, Workshop on Standardization of Prosthetic-Orthotic Terminology, Sept. 9-11,1971.
- Committee on Prosthetics Research and Development and Committee on Prosthetic-Orthotic Education, Research and Development. Workshop on Standardization of Prosthetics-Orthotics Terminology, March 1-2,1972.
- Committee on Prosthetics Research and Development-Committee on Prosthetic-Orthotic Education, Task Force on Standardization of Prosthetic-Orthotic Terminology, July 28,1972.
- MacLean, I.C., and H.L. Kamenetz, "Orthotic Eponyms;" pp. 695-728 in Orthotics Etcetera, Vol. 9 of Physical Medicine Library, Elizabeth Licht, Publisher, New Haven, 1966.
- McCollough, Newton C, III, C.M. Fryer, and John Glancy, "A New Approach to Patient Analysis for Orthotic Prescription - Part 1: The Lower Extremity." Artif. Limbs, 14:2:68-80, Autumn 1970.