Orthopedic Braces

[Berk Boyraz]

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Orthopedic braces are medical devices designed to address musculoskeletal issues; they are used to properly align, correct the position, support, stabilize, and protect certain parts of the body (particularly the muscles, joints, and bones) as they heal from injury or trauma. These medical devices are often prescribed for the patient to wear during the process of recovery and rehabilitation.

It is important to note, however, that orthopaedic braces should not be worn without the advice or recommendation of a doctor and an orthotist, who is a clinician responsible for prescribing, manufacturing, managing, and monitoring orthopaedic braces and other orthoses.

Orthopaedic braces can be used in various ways. They can be prescribed to stop limbs, specific segments of the body, or joints from moving for a predetermined period. This can be very important in facilitating proper recovery and positioning as the affected body part heals. Braces are often recommended for restricting and assisting general movement, removing weight from healing or injured joints and muscles, and correcting the shape and function to reduce pain and facilitate improved mobility. Patients who have suffered from fractures or broken bones can also be prescribed orthopaedic braces to aid in musculoskeletal rehabilitation.

Patients are generally referred to an orthotist by their primary care physicians or general practitioners. Patients who have suffered from injuries, such as sprains, fractures, pulled muscles, dislocated joints, and broken bones can benefit from wearing orthopaedic braces.

Sports-related injuries are rising with the growing number of sports activities. Athletes are focused on fitness-related activities such as running, cycling, and others. While gaining health benefits through such activities, they are likely to sustain injuries, which can further lead to ligament injury. Indoor athletes are at high risk for ankle ligament tear. Hence, they are expected to generate substantial demand for ankle braces. In addition, ankle braces are recommended by the orthopedicians post an acute ankle sprain.

Athletes also use orthopedic braces to protect themselves from further injury during sports activities. It helps them restrict unwanted movement during matches, thereby, facilitating a convenient play.

Geriatric population is considered as one of the highest contributors to demand for orthopedic braces and supports. This population is highly susceptible to musculoskeletal disorders. Bones and connecting tissues, such as ligaments and cartilages, naturally weaken with growing age. This poses high risk for muscle injury mainly in knees and shoulders of the elderly. This further stiffens the joints, which raises the need for braces and supports to improve mobility. (Grandview Research, 2019)

Orthopaedic braces are generally divided into two categories, depending on the location of its application: upper and lower limb. Braces on the upper limb can be applied to the shoulders, collarbones, the arms, elbows, wrists, hands, and fingers. Lower limb braces, on the other hand, can be fitted over the feet, ankles, knees, and legs. Braces can also be prescribed, designed, and manufactured to correct spinal position in patients with scoliosis.

Supportive lumbar orthosis, lumbar-sacral orthosis, and thoracic-lumbar-sacral orthosis are considered experimental, investigational, or unproven for other indications because their effectiveness for indications other than the ones listed above has not been established. Following a strain/sprain, supportive lumbar orthosis, lumbar-sacral orthosis, and thoracic-lumbar-sacral orthosis (back supports, lumbo-sacral supports, support vests) are used to render support to an injured site of the back. The main effect is to support the injured muscle and reduce discomfort. The following additional criteria apply to custom-fitted and custom-fabricated back braces:

A post-operative back brace is used to immobilize the spine following laminectomy with or without fusion and metal screw fixation is considered medically necessary. This brace promotes healing of the operative site by maintaining proper alignment and immobilization of the spine. Post-operative back braces are considered experimental, investigational, or unproven for other indications because their effectiveness or indications other than the one listed above has not been estalbished.

Knee instability must be documented by examination of the member and objective description of joint laxity (e.g., varus/valgus instability, anterior/posterior Drawer test). For persons with these indications, valgus or varus bracing alleviates pressure on the medial or lateral compartment of the knee.

Exceptionally tall or short stature or obesity does not, by itself, establish the medical necessity for custom-made functional knee braces. Exceptionally tall persons can usually be fitted with a prefabricated brace with extensions, short persons can usually be fitted with a pediatric prefabricated brace, and obese persons can usually be fitted with a prefabricated knee brace with extra large straps. Custom-fabricated orthoses are not considered medically necessary for treatment of knee contractures in cases where the member is nonambulatory. Custom-fabricated orthoses are considered experimental, investigational, or unproven when criteria are not met.

A custom-fabricated unloader brace is considered medically necessary for members who meet criteria for a prefabricated unloader brace and meet medical necessity criteria for a custom-made brace noted in the section on functional and rehabilitation knee braces above. Unloader braces are considered experimental, investigational, or unproven when criteria are not met.

Note: Please see Appendix for guidelines on the reasonable usable lifetime of knee orthoses. These guidelines also provide the medically necessary frequency of replacement interfaces.

Comfort, non-therapeutic cast-braces are considered medically necessary DME after a fracture or surgery. Comfort, non-therapeutic cast-braces are considered experimental, investigational, or unproven for other indications because their effectiveness for indications other than the ones listed above has not been established. These braces are often used after the patient has been in a walking cast. They are usually removable. Molded casts, which allow the user to remove the cast to bathe the affected extremity, can also be used when a fracture is slow to heal or non-healing. The use of these removable casts replaces monthly cast changes. A removable cast of this type offers no therapeutic advantages over a non-removable cast.

Functional cast-braces are considered medically necessary after a fracture or surgery. These have become the standard brace for certain fractures, including tibial-femoral fractures. The functional cast-brace is used following a short period of standard fracture treatment using a non-weight bearing or partial weight-bearing cast, or immediately following surgery. It allows protected weight bearing, and motion of the joints above and below the fracture. The joints are moved earlier, contractures are prevented, and early healing is effected due to the weight bearing. Functional cast-braces are considered experimental, investigational, or unproven for other indications because their effectiveness for indications other than the one listed above has not been established.

Specialized hip braces are considered medically necessary for children with hip disorders to stabilize the hip and/or to correct and maintain hip abduction. These hip braces are considered experimental, investigational, or unproven for other indications because their effectiveness for indications other than the one listed above has not been established.

Example: Pavlik Harness, Frejka Pillow Splint, Friedman Strap

Abduction splint (e.g., the Pavlik harness and the Tubingen splint) is considered medically necessary for the treatment of infants with hip dislocation or persistently dislocatable or subluxatable hips.

Aetna considers orthopedic braces medically necessary in the treatment of congenital defects. Aetna also considers replacement braces medically necessary when the member has outgrown the previous brace or because his/her condition has changed such as to make the previous brace unusable. This includes scoliosis braces.

Increasing use is made of plastic braces. These devices have various names and are often called molded ankle-foot orthoses (AFOs) or molded ankle-foot orthoses (MAFOs). They may also be called orthotics. For information on ankle-foot orthotics, see CPB 0565 - Ankle Orthoses, Ankle-Foot Orthoses (AFOs), and Knee-Ankle-Foot Orthoses (KAFOs). Orthotics of this type should not be confused with simple, removable orthotic arch supports or shoe inserts. For information on foot orthotics, see CPB 0451 - Foot Orthotics.

A Wheaton Brace is considered medically necessary DME to treat metatarsus adductus in infants replacing the need for serial casting. A Wheaton Brace is considered experimental, investigational, or unproven for other indications because its effectiveness for indications other than the one listed above has not been established.

Unna boots are considered medically necessary only for non-fracture care. Unna boots have no proven value when used in conjunction with fracture treatment. They can be used to treat sprains and torn ligaments, provide protection for other soft tissue injuries and may be used after certain surgical procedures as a protective cover to promote healing. Occasionally they are used in the first days after a fracture before a cast is put on. Their use in this regard is controversial.

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