Prefabricated braces and custom orthotics enhance mobility and quality of life in many patients. The veterinary nurse can play an important role in helping these patients and educating their owners in the use of these devices.
Physical rehabilitation and veterinary medicine have become intertwined over the past 20 years.1 Assistive devices such as braces and orthotics play a large part in making the lives of veterinary patients comfortable, especially those who may not be surgical candidates for orthopedic repair, or whose owners cannot afford surgical repair.
Classification of braces and orthoses
A brace is an orthopedic appliance or apparatus applied to the body, particularly the trunk and lower limbs, to support the weight of the body, to correct or prevent deformities, or to control involuntary movements.2
Generic braces are prefabricated. Braces are placed across a joint, usually to limit its range of motion or promote its stability.4 Premade braces are affordable and best suited to patients with normal anatomy and healthy skin (See Figures 1, 2, 3 and 4).
Companies that make premade braces include:
An assistive device such as OrthoPets™ Toe Ups can be used to good effect in dogs and cats that knuckle over on their back legs because of reduced neural input from degenerative myelopathy, peripheral nerve injury, or proprioceptive deficits.1 Care needs to be taken that the patient can lift the leg sufficiently. The elastic straps are placed under tension and as the animal brings the leg forwards, the elastic aids the foot being moved up into dorsiflexion. This device assists with increasing tarsus (hock) flexion while also keeping the hind paw in a corrected normal standing position (see Figure 5). Also see Table 1 for a list of conditions that respond well to braces.
An orthosis is defined as any medical device attached to the body to support, align, position, immobilize, prevent or correct deformity, assist weak muscles, or improve function.3 Custom orthoses are usually necessary in patients with abnormal anatomy (limb deformity, abnormal skin contours) and in very small or very large patients.4
Orthoses can be used as preoperative, postoperative or “no-operative” solutions. If surgery must be delayed, orthoses allow the patient to move comfortably, give support to the limb, and reduce disuse atrophy.5
Custom orthoses are made from casts of the patient’s limb or are fabricated directly on the patient using a moldable thermoplastic polymer.6 Heat moldable polymers come in numerous varieties depending on the clinical need and can be designed for use with aquatic therapy. Orthoses can be hinged to stabilize or limit the motion of joints.6 Hinged orthoses are custom made because they must fit precisely. Orthotic prescription should consider skin integrity and cleanliness, hair coat, and other concurrent diseases or medications that may potentially affect skin strength and thickness, such as Cushing disease or chronic prednisone treatment6 (See Figure 6, 7 and 8).
Companies that make custom orthoses:
Each company that makes custom orthoses will have a variety of measurement forms to be filled out. This requires the client to bring in the patient so measurements may be taken.
Physical rehabilitation with an orthotic
Most veterinary patients adapt quickly, and behavioral techniques can facilitate this. Device-specific rehabilitation focuses on specific skills. Skills include transitions (sitting, lying down and getting up), navigating stairs, getting into and out of vehicles safely, managing on different surfaces (ground, carpet, hardwood floor, etc.), and managing dog doors. Orthopedic injury leads to compensatory abnormal movement and associated muscle strain and weakness. Gait re-education focuses on resolving these issues.7
Initial training sessions should last a few minutes and be designed and managed so the patient has a positive experience.
Training companion animals to use orthoses is akin to managing limb disuse. It relies on habituating patients to tolerate the device when at rest and also when loading it (using it) when standing, walking slowly (indoors), walking more rapidly (outdoors), trotting, galloping, and during other activities of daily living (e.g. climbing and walking down steps, jumping up or down, and playing).6
Ideally, the orthotic prescription should incorporate a predictive component or a ‘‘vision’’ for the wearer’s future. Reassessment of objectives and timely orthotic modifications should accompany changes in the patient’s neurologic or musculoskeletal status.8 Cost will undoubtedly be a major concern that presents a challenge to providing effective orthotic management.
Team roles when using orthotics on patients
The ideal team for an animal in need of an orthotic device includes the pet owner, the veterinarian, a certified rehabilitation therapist, a veterinary orthotic and prosthetic (V-OP) specialist skilled in the custom design, fabrication and fitting of devices for the intended species – and a veterinary rehabilitation nurse.
The veterinarian is the key person in determining what the patient needs, but the veterinary nurse/technician assists with fitting and helps with client education. The rehabilitation therapist plays an integral part in uniting the body mechanics (muscle and nerve activation, and integration patterns) and the device into the complex biomechanics of locomotion.3 The veterinarian will design a program to incorporate the physical rehabilitation while the patient wears the orthotic device. The device may eventually be removed with enough progress, or it may be a permanent aid for the patient. There are entire continuing educational courses devoted to teaching veterinarians and veterinary nurses about orthoses and prostheses.
The veterinary rehabilitation nurse will work directly with the certified rehabilitation therapist throughout the process.7 Assistance with ordering, fitting, and answering owner questions are all part of the veterinary rehabilitation nurse’s job.
There are advantages to both prefabricated braces and custom orthoses. Many injuries are amenable to these devices. Patients and owners must be trained to use them, but they can have a profound beneficial impact on the mobility and quality of life of companion animals. The veterinary rehabilitation team works as a unit in aiding the patient — and the veterinary nurse is a key member of that team.
1Goldberg ME and Tomlinson JE. Chapter 10: The Disabled Patient Part 1: Assistive Devices and Technology, Physical Rehabilitation for Veterinary Technicians and Nurses, First Edition.
Edited by Mary Ellen Goldberg and Julia E. Tomlinson, John Wiley & Sons, Ames, IA, 2018, 145-162
2The Free Medical Dictionary by Farlex, medical-dictionary.thefreedictionary.com/brace, accessed on July 2, 2018.
3Mich PM and Kaufmann. Chapter 11: Veterinary Orthotics and Prosthetics, Canine Sports Medicine and Rehabilitation, Second Edition. Edited by Chris Zink and Janet B. Van Dyke, John Wiley & Sons, Ames, IA, 2018, 265-293.
4Marcellin-Little DJ and Levine D. Chapter 17: Devices for Ambulation Assistance in Companion Animals. Canine Rehabilitation and Physical Therapy, 2nd Edition, Editors: Darryl Millis and David Levine, Elsevier, Philadelphia, PA, 2014, 305-311.
5Mich PM. The Emerging Role of Veterinary Orthotics and Prosthetics (V-OP) in Small Animal Rehabilitation and Pain Management, Topics in Companion Animal Medicine, 2014, 29: 10-19
6Marcellin‐Little D J, Drum M, Levine D, and McDonald SS. Orthoses and exoprostheses for companion animals. Vet Clin Small Animal, 2015, 45:167–183
7Goldberg ME. The Veterinary Nurse Working with Orthotics or Prosthetics, Proceedings from Atlantic Coast Veterinary Conference, Atlantic City, New Jersey, 2016, 1-4
8Adamson C, Levine D, Millis DL, Marcellin-Little DJ. Assistive Devices, Orthotics, and Prosthetics. Vet Clin Small Animal, 2005, 35, 1441–1451