As we discussed in the beginning of Part One: “Do I need corrective lower limb bracing?”, corrective lower limb bracing is devoted to helping people whose lower limbs have deformities, injuries and/or are affected by various diseases that make it hard and/or painful for them to walk. We then explained how many people who seek to improve their walking with corrective lower limb bracing (CLLB) are often disappointed with the results due to one or more of the following factors:
- improper diagnosis
- improper brace selection
- improper brace fit
We then listed the three primary reasons that individuals need corrective lower limb bracing – deformity, trauma, and disease, and explained how disease-related need for CLLB is the most likely to be misdiagnosed, then detailed the ways to increase your chances of getting a proper diagnosis of your lower limb difficulties. If you have yet not read Part One, we strongly encourage you to do so, because proper diagnosis is generally the most important – and hardest – element to get right – and if you’re not properly diagnosed, you cannot move to the second most important step: proper brace selection.
Ortho Rehab Designs receives many calls and emails from individuals in need of CLLB who ask a variation of the same two questions:
- How do I figure out what I need?
- What should I get?
The reason is simple: There are many brace manufacturers out there offering multiple products ranging from relatively inexpensive off-the-shelf braces to extremely expensive custom models using aero-space type materials – and it’s hard for you – and even your doctor – to sift through and decipher all of the offerings, information and claims to decide what’s best for your needs, both physically and in terms of your insurance and budget.
So what follows is a brace selection process that will help you more efficiently sort through the choices out there and more accurately choose the brace that will work best for you.
Step 1: Proper diagnosis. If you are not 100 percent confident that you are completely and properly diagnosed, stop reading and go back to Part One. As we emphasize there and above, you should not proceed to brace selection until you have first been properly diagnosed.
Step Two: Initial filtering. Filter out the types of braces you do definitely not need by making a checklist of answers to the following questions about your diagnosis:
- What is the level of deformity?
- Is there loss of function?
- Is there loss of balance?
- Do you use a cane or a walker?
- What muscle groups are not functioning?
- Is the affected musculature below the knee only, or above knee too?
- Are there rigid deformities, such as Achilles tendon contractures, et al?
- Are you trying to address ankle pain, knee pain, hip pain, and/or back pain?
- Do you need a brace that helps stabilize the joints through structure and reduce the symptoms in conjunction with producing a therapeutic normalized gait?
After you have made a checklist of the answers to these questions, you can go to the next step; learning about the brace market so that you can more quickly and accurately shop for braces that match your checklist requirements.
Step Three: Learn the market. Whether you’re buying a brace, a car or a pony, it’s important to “know your market” before you start shopping or you’ll waste time at best and make the wrong choice at worst. What follows is a brief discussion of the main braces categories, types and sub-types.
The two brace categories are off-the-shelf and custom. Off-the-shelf braces are becoming more commonly used because either your insurance doesn’t cover the generally-more expensive custom braces and/or you don’t have the cash to pay for it yourself.
The primary types of braces range from something as simple as arch supports and ankle gauntlets to multi-jointed, high-tech orthoses that deal simultaneously with hip, knee, ankle and foot issues. Nevertheless, it’s important to understand the total market because that way you can more easier navigate it to find the brace you need.
Technically, the most common type of CLLB is a foot orthotic, known as an FO. Doctor Scholl’s and related arch supports fall within this type, though many people do not think of arch supports as “real” orthotics. The most common type of “real” CLLB is the ankle-foot orthotic, known as AFO. Within the AFO family are jointed, non-jointed and “floor reaction” AFOs, the latter of which is the most common, and is also known as a FRAFO. All AFOs support the lower limb, starting from below the knee. A major selection factor for AFOs and FRAFOs is knowing from your checklist which muscles are not working.
The next level of CLLB starts above the knee and those braces are, as you might expect, called KAFOs. They are all jointed, but some have locking joints, while others have free joints, and still others have adjustable joints. As with AFOs and FRAFOs, a major selection factor is knowing from your checklist which muscles are not working.
The final level of CLLB is the above-mentioned hip, knee, ankle and foot brace, known as, you guessed it, HKAFOs.
As a general rule, there are many off-the-shelf FO, AFO and FRAFO choices and mostly only custom KAFO and HKAFO choices for two simple reasons:
- There are more people with below-the-knee issues requiring CLLB; and
- The higher up the leg the affliction goes, the more complex the diagnosis becomes, and the more intricate the solution.
To say it another way, the more muscles and joints that are involved, the more functional loss there is, the more angles there are to deal with, and thus the more decision and solution branches there are, so it’s hard to make a one-size-fits-all KAFO or HKAFO.
Step Four: Off-the-shelf or custom? In an ideal world, everyone would have a custom brace, but many insurance plans want to pay only for off-the-shelf (OTS) braces if they are available – and for some patients, access to custom braces is limited or difficult. Thus both OTS and custom braces have their advantages and disadvantages, and, for patients who simply need a brace that addresses drop-foot, your needs can be adequately or even best met by an OTS brace.
Advantages of OTS braces. A primary advantage of OTS braces is cost: Whether your insurance pays for it or not, they are priced between $20 and $1,000, depending on brace type and, especially, materials. Braces at the low-cost end are usually made of fabric; those on the high end are usually made of carbon fiber. Another advantage is easy access. Off-the-shelf braces are widely available on the web, and that is where most people begin their searches and research. You can also find OTS braces in many general-product stores as well as specialty medical equipment stores. Finally, there is initial convenience. Most OTS braces can be fitted in one visit, usually in a half hour or less – and for the most part, Ortho Rehab Designs tells patients that, when it comes to OTS AFOs, they are all pretty much the same at each respective pricing level, so find a new one that fits right and you are set.
Advantages of custom braces. While many people who need CLLB need mostly to address drop-foot issues, others need also to walk with better stability, better function, and a normal gait, and their search for the right brace is often complicated by deformity and/or neurological deficits that make even standing properly a big challenge.
This is the great advantage of custom designs over OTS braces; they can be manufactured, fitted and adjusted to specifically address each person’s body shape, symptoms, neurological deficit and/or joint deformity.
Naturally, this great advantage comes with its own costs. Custom brace prices generally start near the top of the OTS price range and go up from there; you can expect to spend between $700 and $7,000 for a custom brace. At the lower end are basic braces with no joints or movement, usually made from thin thermoplastic. At the high end are 100 percent custom braces, made with two dozen or more layers of carbon fiber that are rigid in some places, flexible in other places, have energy-storing or energy-return characteristics as well as one or more joints and/or upright springs. They can also be tailored for height, weight, and level of patient activity.
Access and initial convenience “costs” are also higher with custom braces. If you don’t live in or near a big city, finding a custom brace provider can be almost impossible. At Ortho Rehab Designs, for example, we have patients who drive or fly hundreds or even thousands of miles to get a custom brace. And even if you do have easy access to a custom brace provider, measurement, fitting, and adjustment can take several hours over more than one visit. In the end, however, if you have more than simple drop-foot issues and you can afford it, custom braces are the best way to go.
Step Five: Create a Possibles List. Okay, you’ve completed the first four steps and you’re ready to actually start selecting your brace. As I mentioned in Step Four, most people start their brace search and research on the web, so now create a “Possibles List” of sites from which you might want to get your brace – the quick definition of which is: Sites that comprehensively answer your Step Two question list.
If a site doesn’t easily and clearly answer essentially all of those key questions, they don’t go on your Possibles List, period. That’s because, if they don’t address those key areas, then they either don’t care enough about their patients or aren’t competent enough to consider. It’s really that simple – and it’s really that important, because I can’t emphasize enough how much pain and frustration you can avoid by picking a brace provider that knows what it’s doing and cares enough about its customers to get it right.
Step Six: Create a Probables List. After you make your Possibles List of braces and brace providers that might work for you, narrow it further: Create a Probables List, which is basically a list of those brace providers who meet an additional set of criteria, some of which you may need to determine by email, online chat or telephone exchanges:
- What steps do they take to make sure all of my issues are addressed?
- Does the company pre-evaluate?
- Does it prototype its braces before production?
- How well does the company explain to me how the brace works and, more specifically, how it will mechanically correct my deformity or loss of balance?
- Will they treat me without a doctor’s prescription?
As you can see from the Probables List criteria, not all of the answers are as clear-cut as they are for the Possibles List. There are yes-no answers, the most critical of which is the last one: If a provider says “we don’t need a prescription,” ask them why they do not work by prescription. Yes, you can buy a brace without a prescription because it is considered to be a “durable medical device” similar to a cane or wheelchair, but whether it’s an internet or “brick & mortar” brace provider, prudent providers consider a prescription to be a “must have” for insurance and liability reasons – and because some people are not good brace candidates. Some will never walk right no matter how expensive a brace they buy; others cannot wear a brace because their skin is too fragile to tolerate the pressure and continuous contact common to all braces. Others take medication or have other motor control and neurological deficits that simply cannot be corrected by CLLB and are better addressed by wheelchairs and/or walkers.
The other Probables List answers are “fuzzy:” they provide additional technical information on which you can base your selection decision, and also help you get a feel for the provider and its staff – because a key element of selecting the right brace and getting it properly fitted is making sure that the company and its staff are a good fit too.
Be sure to carefully document the information and your impressions of the Probables List companies. You will need that for the next step.
Step Seven: Consult with your doctor and get your prescription. Discuss your Probables List with your doctor. The more complete and detailed your list, the better this step will go. Your doctor will not only provide addition decision input and perhaps a specific recommendation, but also let you know if you can physically tolerate a given brace. This is most likely the point at which you will select the brace you want and your doctor will write you a prescription for it.
Step Eight: Buy your brace! If you have followed this procedure, there is a high probability that you have just selected a brace that is exactly what you need to help you walk better and with less pain. In so doing, you have taken a big step toward a better life, and avoided the pain and frustration that comes with improper diagnosis and/or improper brace selection. Congratulations!
Next: Proper brace fitting