Prescribing orthoses and prostheses: the right need, the right function, the right budget

Every patient is different. A person with a lower-limb loss who is still very mobile, and who needs to get around a lot, work and join social activities has different requirements from an older person with limited health who mostly moves around indoors or needs help with basic daily activities. Likewise, people who need an orthosis to support movement, stabilise a joint or improve gait cannot all be given the same solution.

So the choice must start from a specific assessment of each patient. A correct prescription is not the most expensive device; it is the one that best meets the user’s real needs.

Scales such as the Amputee Mobility Predictor (AMPnoPRO/AMPPRO) or the K0–K4 mobility classification help quantify walking ability in people with lower-limb loss, but must still be combined with the treating team’s judgement. A systematic review showed that age, level of amputation, comorbidity and cognitive health influence walking ability after amputation.

Evidence for individual assessment: the Amputee Mobility Predictor (Gailey et al., Arch Phys Med Rehabil 2002; 191 lower-limb amputees) had an inter-rater reliability of 0.99, distinguished all four Medicare functional levels (P < 0.0001) and correlated strongly with the 6-minute walk test (r = 0.69 and 0.82). The systematic review by Sansam et al. (J Rehabil Med 2009; 57 studies) found that better walking was linked to cognition, fitness, ability to stand on one leg, independence in daily living and pre-operative mobility, and poorer walking to a longer delay between surgery and rehabilitation or stump problems.

In a prosthesis each component, such as the foot, knee, suspension system and connectors, has different characteristics, functions and prices. The choice must rest on each patient’s activity level, motor control, safety and goals of use.

Someone who mostly moves around indoors and does basic daily activities may not need the same configuration as a person who often walks long distances, works outdoors or moves over varied terrain.

The same goes for orthoses: define the treatment and functional-support goal clearly before choosing type, material, construction and level of support. The device must fit the body, match the professional indication and support the activities the patient really needs to do.

No single prosthetic foot is superior to all others. The Cochrane review (Hofstad et al., 2004; 23 trials, 217 participants) could not show any foot type to be overall superior; there was limited evidence that an energy-storing foot (Flex-Foot) outperformed the SACH foot in highly active above-knee amputees on level walking. The authors advise prescribers to weigh the patient’s functional needs, availability and cost. This supports choosing by need rather than choosing the most expensive device.

Rather than defaulting to the most premium parts, determine exactly which functions each patient truly needs, then choose components that are suitable, matched and meet the goal of use.

Optimising does not mean cutting quality at any price, using unsuitable parts or trading safety for lower cost. It is the process of removing unnecessary options, avoiding investment beyond need and focusing resources on the components that bring the most practical value.

When components are chosen correctly, the configuration is sensible, and assembly and alignment are done properly, total cost is better controlled while function, safety and comfort are assured. Cost optimisation is not choosing the cheapest option; it is achieving the use that fits the most reasonable investment.

Not every patient can access high-cost configurations. Up-front cost, maintenance, replacing parts and costs arising during use can all put real financial pressure on the patient and family. A professional solution must take these limits into account from the start.

Instead of offering a single option, the patient is advised on alternatives at different cost levels, with the differences in function, benefit, limits and long-term running cost made clear.

On cost-effectiveness, the review by Highsmith et al. (Prosthet Orthot Int 2010) of 18 studies (7 on safety, 8 on energy expenditure, 3 on cost-effectiveness) leaned in favour of the microprocessor C-Leg knee in above-knee amputees; however the safety and energy studies were of low quality, and the results apply to specific patient groups rather than everyone. The real benefit for each person should therefore be weighed before choosing a premium configuration.

A good prosthesis is not only about brand, technology or specifications. Its real value lies in helping the user stand firmly, move safely, do the necessary activities and improve quality of life in real conditions. The same holds for orthoses: effectiveness is judged by functional support, comfort, fit and practical benefit.

To achieve that, the prescription process must combine professional assessment, technical advice, choice of configuration, trial fitting, alignment and follow-up after use. When needs, health or living conditions change, the solution must be reviewed and adjusted. This is the value of personalisation: not applying one common formula, but finding the most suitable option for each case.

The quality of a solution is not decided only by price or how modern the device is. The core factor is the fit between functional status, daily needs, mobility goals and the patient’s financial means.

Our approach is to provide personalised prostheses and orthoses, from functional assessment and component selection to configuration optimisation and control of the investment. We do not aim to supply the most expensive configuration to every patient, but to find the most suitable for each person: meeting the need, ensuring safety, optimising use and reducing the financial burden within reason.

The orthoses below are specially designed to support, improve or restore body function.