Bracing offers an arsenal in the war against musculoskeletal disorders

Musculoskeletal disorders cover a very broad information base ranging from such varied conditions as carpal tunnel syndrome to rheumatoid arthritis. The symptoms range from minor irritation to complete disability. With such a broad focus, our purpose here will be to cover the conditions affecting the lower extremities and, more specifically, intervention through prophylactic lower-extremity bracing.

The Venerable Brace

The modern brace traces its origins to the armor of the Middle Ages. Armored warriors found that, even with seriously compromised limbs, they were able to walk because of the support offered by rigid, hinged armor. In today’s world, the armor of the medieval knights has given way to fabric fasteners and polymers, but the function remains essentially the same.

Although individual cases vary radically, we can speak in generalities for the purposes of this article. Generally, physical therapists see the victims of injuries almost immediately. Once the individual is diagnosed and the initial treatment is completed, the patient will almost immediately be referred to a PT.

As an example, in the most common form of injury, the ankle sprain, the patient will be treated as an outpatient unless the injury is severe or painful enough to warrant hospitalization. Depending on the degree of severity, the patient will usually be instructed to take it easy for a few weeks, and in some cases will be given an anti-inflammatory. It is imperative to begin physical therapy immediately. However, in the real world, this does not always happen.

First, if the patient has not been hospitalized and is covered by an HMO, the patient must first visit the primary care physician (PCP) for treatment. If the PCP makes a referral, frequently this will require approval. In some cases, the approval process is painfully slow. Depending upon the nature of the insurance and the geographical region, it can sometimes take weeks to get an appointment with the PT. The poor patient is made to wait during the time frame when physical therapy should be applied. Therefore, it is very probable that the condition may be several weeks old before therapy begins.

In the case of chronic conditions that have progressively worsened over the years, physicians have finally become more astute with regard to physical therapy interventions. We now know that the intervention of a PT can often dramatically improve the lives of patients whose conditions affect their ambulation. In both cases, more often than not the patient will present with a brace, or you will recommend bracing.

To Brace or Not to Brace?

Ankle and foot bracing has always been one of the single best tools for the prevention of further injury or reinjury, an early return to activity, and rapid recovery in patients with conditions where the prognosis is recovery. In ambulatory patients with chronic conditions, bracing is, of course, invaluable.

Coding for ankle braces and related footwear can be extremely complex, and every effort should be made to ensure proper coding. There are a few basic points to remember. First, a brace is broadly defined as a rigid or semi-rigid device used to support a weak, injured, or deformed body member, or to prevent or eliminate motion in a diseased or injured body part. Coverage for custom ankle-foot orthosis (AFO) is allowed when the patient could not be fitted with a prefabricated AFO. Evaluation of the patient, measurement, casting and fitting are included in the allowance for the orthosis. It is also important that the written and signed order be received by the supplier prior to the submission of the claim, as the claim will be denied as not medically necessary without this order.

If you are billing Medicare, you will need a Durable Medical Equipment Regional Carrier (DMERC) number. DMERC numbers can be obtained by calling (866) 238-9652. If you are billing any carrier other than Medicare, you do not need a DMERC number.

Choose your Weapon

In the war against disability, the world of bracing offers an arsenal. If a patient presents with a brace, the PT may disagree with the choice of brace. If the patient presents unbraced and it is determined to use bracing, we have an arsenal of products at our disposal in varying degrees of complexity, but with similar applications.

Choosing a particular brace depends on numerous factors, such as the patient’s condition, age, and weight. (Bariatric patients, of course, must have a brace more capable of bearing weight.) The patient’s prognosis is also a vital factor. A patient with a sprain or work-related RSI is expected to make a full recovery, whereas the condition of a patient with myasthenia gravis has a far less optimistic prognosis. The patient’s health is also an important consideration. A bandage or sleeve may be adequate for a young and vital patient, whereas a geriatric patient may require a more substantial form of bracing. In pediatric patients, growth must also be considered. If the brace is rehabilitative, it is important that its weight and configuration do not interfere with its function.

Once the obvious has been covered, it is crucial that the brace be fitted to the patient, as opposed to the patient being fitted to the brace. Most off-the-shelf braces work very well and fit the majority of individuals. Many of them are adjustable. However, the fit must be perfect if the treatment is to be effective.

Another consideration is the probability of patient compliance. A brace that is difficult to apply is less likely to ensure compliance. A bariatric or geriatric patient will be less flexible, so it will be difficult for these patients to apply a brace that requires bending and reaching. Many physicians are so familiar applying braces that to them the application is second nature, and they forget that it is a new experience to the patient. This is where feedback from the PT is invaluable. As a general rule of thumb, human beings will always follow the path of least resistance. The easier it is to apply a brace, the higher the probability of patient compliance.

One factor that is sometimes overlooked is the brace’s physical appearance. People in general are self-conscious and, at times, statement conscious. The ankle brace as a fashion statement might not make the cover of a glamour magazine, but it can be important to your patient. Children are especially self-conscious; they may be subjected to “gimp” comments and may want a cool-looking brace. A teenager might want something that appears macho or impressive. Some individuals even have color preferences. The best way to deal with this is to simply ask the patient about his or her cosmetic preferences and discuss the options.

The most basic form of bracing, of course, is the trusty elastic bandage or ankle sleeve. This should be used only for the most basic type of sprain or mild musculoskeletal conditions. The reason is that, while it is convenient and effective, it offers primarily compression and marginal support. It also does little to prevent lateral motion. There are a vast number of excellent neoprene braces available on today’s market. The advantage of neoprene is that it is less restrictive and permits a greater range of motion. Also, it is very easy to apply.

The next option would be the soft ankle brace, which can be fastened with fabric fasteners or laces. Certain lace braces can lace with the shoe so the shoe and brace work in tandem. The splint brace is generally just what the name implies: splints held around the ankle by elastic or a fabric fastener. The splint brace is comfortable, easy to apply and remove, and prevents lateral motion. The ankle walker is more rigid and designed to stabilize the entire ankle. Some ankle walkers may be adjusted and locked to predetermined degrees.

Hinged ankle braces are, as the name implies, hinged. They permit but control the range of motion. The foot may move only with the hinge, and lateral motion is prevented. The ankle stirrup brace is another excellent choice. As the name implies, the ankle brace utilizes a stirrup around the foot. While the ankle stirrup permits extension and flexion, it prohibits inversion and eversion. Additionally, its lining provides compression.

The walking boot is one of the most popular appliances for musculoskeletal injuries or disorders affecting the foot and/or ankle. In many cases, it has replaced the cast, or it will be prescribed by the physician when—once upon a time—casting would have been a necessity. The boot is easy to apply, yet it offers a great deal of support. Some boots also offer hinges. Recently, orthotics, which are attached to ankle braces, have appeared on the market.

In certain cases, it might be necessary to prescribe multiple braces for the same leg or foot. For example, when the patient engages in a great deal of walking during the day and is able to engage in an occasional sporting event, two different bracing systems may be indicated. A soft ankle lace-up brace might be perfect for daily applications, while a hinge brace might be necessary for sporting applications.

Instructing the Patient

Proper patient instruction cannot be emphasized enough. In fact, a strong case can be made for overkill. Compliance is one of the most important ingredients in recovery from an ankle sprain. What is important is that the patient understands everything and receives thorough instruction.

The first issue is the care and maintenance of the brace. Some products require washing; some require lubricants. Although most are waterproof, there are products that should not be immersed in water. Many products are susceptible to heat damage and come with instructions that the product not be left in a parked car on a hot day.

Putting on and removing the brace requires varying degrees of attention depending on the patient’s comprehension. If a patient is frustrating, it is important to not look rushed or show frustration because this will discourage the patient. Rather than checking the fit and saying, “See ya next time,” it is imperative that you or a qualified member of your staff spend time with the patient until the patient becomes comfortable with the brace. Otherwise, the brace will most likely end up in the closet.

In patients with less-severe conditions, if the patient has the slightest difficulty putting the brace on or taking the brace off, it is very likely that he or she will not wear it, particularly in the morning when he or she is in a hurry to leave for work or school. Rapid instructions in an office setting may also seem easy to follow for the patient but may be confusing later when the patient returns home. Although most modern braces are extremely user-friendly, it never hurts to err on the side of caution.

Because of the user-friendliness of today’s braces, many patients will feel that they can forego instruction or even feel that their intelligence is being insulted. It is a good practice to explain that it is a matter of office policy to start from the assumption that the patient knows nothing about ankle bracing (and most of them don’t, although some will have done some basic Internet research when they learned of the intention to brace). This is not to imply that the process of slipping on an ankle brace is intimidating; it is quite the opposite. It is simply to help ensure compliance and, for reasons we will cover in the next section, protect your practice. Finally, it is important to admonish that the instructional process must be billed as either a therapeutic session or part of the fitting, as it is generally not reimbursable if it is billed simply as instruction.

Liability Issues

The final reason so much emphasis is placed on patient instruction is the sad fact that we live in a litigious world. What will follow is not legal advice. Laws vary from state to state, and only a qualified, practicing attorney can offer valid legal advice. However, there are some general admonitions and precautions we should address for the purposes of this article.

With all of the patients who have been fitted for leg and ankle braces, it is a statistical probability that, despite all our efforts to minimize this, injuries related to the bracing process can occur. There have been incidents, some of them legitimate, where patients have claimed that an injury or reinjury occurred because of lack of proper instruction or improper fitting. The patient who was so confident he understood the brace or wished to forego instruction may later come back with claims to the effect of, “The brace was too loose,” “It didn’t fit properly,” “I was not wearing it because I wasn’t shown how,” and similar statements. Even if the patient elected to forego instruction, the physician can—and probably will—be held responsible.

Generally, when there is a personal-injury lawsuit, every conceivable entity involved in the circumstances is named as a defendant. In the unlikely, but not impossible, circumstance that you would be named as a defendant, you will have to answer interrogatories, be deposed, or appear in court. In each of these cases, you will be facing a professional attorney whose job is to make every effort to make it appear that your negligence, oversight, or professional incompetence was responsible for the patient’s injury.

The basic guideline is that elusive term “standard of care.” Generally, following the standard of care means that you exercised a degree of professional skill and caution equal to what another therapist with similar qualifications would use in identical circumstances. In other words, a level of care that is defined as adequate under the circumstances. In reality, this gives a plaintiff’s attorney a huge gray area to attack. The best way around this is to go above and beyond the standard of care. Additionally, many therapists give their patients printed instruction sheets.

David Finch, DO, is a physician specializing in sports medicine. He practices out of Amarillo, Tex,  can be contacted at talktodocfinch@excite.com.