Thoughts from Don: Global to Specific (and back again)

Clinical work starts with a wide variety of global issues. A clinician’s initial interaction could be characterized as a bombardment of general information. This might include family expectations, developmental expectations, therapeutic goal (from a physical therapist, an M.D. or an occupational therapist), family cultural values and the clinician’s own observations.

When you think of the solution, you move right into specifics. Your urge is to become prescriptive. You are on a quest to determine, with certainty, which brace style is correct. The generalities—the global issues—are, of course, guides to the prescriptive choice.

Successful clinicians are receptive to the global issues. It’s a struggle: there’s never enough clinic time, there are a lot of global clues to wade through and often several of these global issues are presenting at once. You learn to filter out the ones you think don’t apply. It’s a challenge to welcome (and really take in) the generalities during that initial assessment.

The orthotic concern is straightforward, twofold and very specific: determining the best position of function and providing stability around that position. (To support this, our Product Selection Guide poster is graded on levels of stability, from left—least stability need—to right—greatest stability need.)

The trick to best bracing success is this: after you devise the prototype recipe for position and support, revisit the global issues. Think of the orthosis recipe as a trial: proposed and theoretical. You then take that specific recipe and replay it against the general realities, with parents, patient and other involved clinicians. Spend some time developing a layman’s comprehension of the plan and find a way to explain it to the team in layman’s terms.

Over the years, I’ve come upon a revelation: the orthotist’s concerns can often be framed as, “What movement will be restricted?” Other stakeholders may often frame their concerns in exactly the opposite way: “How much movement will the child have?” A physical therapist wants the child to be able to do the exercises that are part of the plan. The parent wants the child to be able to move successfully through daily activities.

At this point, be alert for any conflicts between your stability goals and the goals of other stakeholders, and be ready to negotiate a treatment consensus that is in the child’s best interest. The child may remove the brace for some exercises. If those exercises are more important, and if parents are truly committed to reinforcing them, the best solution might be a less-than-ideal walking brace in order to support the exercise. Or the therapist may change the exercise. Ideas for a progression, with checkpoints for changes in brace, exercise or wearing schedule, may surface. Remember that we are still in the theoretical realm here: the effect on the patient is imagined.

Now you’ve committed to your plan and the brace-making process unfolds. When the brace arrives and you run through your own fit checklist (donning the brace, adjusting straps, setting toe rise, looking for redness, evaluating gait), remember to reconsider the global issues as well. A key component of the initial fitting will be to communicate the break-in schedule to the patient and caregivers.

It really takes about three to four weeks before the parent and the child experience the reality of the brace. The global realities may resurface and require a negotiation or change of the overall treatment plan even then. (This is why we offer a 90-day warranty on our custom DAFOs.) The most successful treatment involves striving for a dynamic balance, as a stakeholder group, between experience and imagination.

-- Don Buethorn

Don Buethorn, CPO, is founder-owner of Cascade Dafo, Inc., and Cascade Prosthetics and Orthotics.

Part of the visit is an assessment among clinicians (Kathy Shapiro, PT; Don; and Loretta Sheldon, ROA) of the patient’s gait. Don tests the specific degree of correction possible. At visit’s end, Loretta records clinical notes; the patient listens; Don and Kathy step back to discuss big-picture issues; and the parent is involved as well. Checking foot alignment Taking the big-picture view with parent, PT and patient Putting on the brace, with the patient’s help