ORTHOTICS AND ASSISTIVE DEVICES
Elizabeth L. Koczur, Carrie E. Strine, Denise Peischl, Richard Lytton,
Tariq Rahman, and Michael A. Alexander
Knowledge of orthotic and assistive devices is an important component of rehabilitation practice. Having an understanding of normal upper and lower body movement is fundamental for appropriate recommendation and fabrication of an orthosis. Likewise, clinicians' understanding of typical language and communication behaviors, literacy skills, and socialization needs is a prerequisite to the recommendation of augmentative and alternative communication (AAC) devices, assistive reading and writing aids, and social media tools.
Similarly, the role of orthotic and assistive devices for patients also relates to the overall rehabilitation goal of eliminating, minimizing, or helping them to overcome the limitations imposed by their underlying disorders across areas of physical, cognitive, and psychosocial functions. While some orthotic and assistive devices allow a patient to achieve a degree of independence in a single area of function (such as mobility), pediatric rehabilitation seeks to treat that patient as a whole person across his or her activities of daily living, learning, leisure and recreation, and/or vocational functions. Thus, the role of orthotic and assistive devices needs to be seen not just within the context of independence but also within the context of interdependence with others in a person's surroundings.
Interdependence recognizes that all people have strengths and weaknesses and that all people function most effectively when they do so within social networks that consist of life partners (parents, siblings, children and, often, other relatives); close personal and family friends; teachers and schoolmates; paid workers (such as caregivers, aides, nurses, therapists, physicians, and other health care providers); coworkers; acquaintances; and unfamiliar people. Interdependence occurs when each of us uses our strengths to build relationships that help support our weaknesses. Dr. Al Condeluci in Community & Social Capital asks that we "consider the notion of reciprocity (1). The more you become connected with your community, the more people begin to watch out for each other."
Dr. Condeluci also applies literature from the field of social capital to the rehabilitation vision for people with disabilities: "Social capital refers to the connections and relationships that develop around community and the value these relationships hold for the members... those tangible substances that count for most in the daily lives of people: namely good will, fellowship, sympathy, and social intercourse among the individuals and [others] who make up a social unit." Thus, an adolescent who has a spinal cord injury (SCI) but can use her head control to independently drive a wheelchair at home, in school, and in the community still cannot participate and contribute to planning the eighth grade class yearbook if her family has not yet been able to buy an adapted van to take her to the Starbucks where her classmates meet to work on the project on Thursday evenings, unless she is perhaps able to participate from home through her head-or speech-controlled computer via Skype, FaceTime, or social media.
The key to identifying the most appropriate orthosis, augmentative communication, or assistive technology system is being creative and having a proper understanding of the anatomical, biomechanical, language and communication, and social networking needs of the patient and being sensitive to the patient's (or the parents') preferences and desires.
The pediatric population adds a further challenge. Early development is heavily based on fine and gross motor skills. Infants and children use these skills to explore and manipulate their environments. Studies have indicated that the inability to master the environment independently may lead to decreased socialization, learned helplessness, and a delay in normal development (2,3). Therefore, an orthosis, augmentative communication device, or assistive learning system should allow for and assist in the growth of the child.
Several team members are involved in prescribing, fabricating, and fitting the orthosis, augmentative communication device, or assistive technology system option. The physician, often with input from the therapist, provides patient assessment and a prescription of the recommended device (4). The therapist and/or orthotist are instrumental in its fabrication and fitting. A team including a speech-language pathologist, an occupational therapist, a special educator, and/or a rehabilitation engineer is often beneficial for AAC device recommendations. Finally, the patient and family play an important role in its acceptance and use. If the device is cumbersome and difficult to manage, it will be rejected and find a home on the top shelf in the closet (5).