Pedorthists: Patient Care and Fabrication Are Not Mutually Exclusive

Fabrication: (Fab-ri-cate) to make; create. To construct by combining or assembling. [caption id="" align="alignnone" width="250"] Clinicians' knowledge of fabrication techniques allows for seamless and coherent communication with central fabrication technicians.[/caption] Fabricating a foot orthotic or custom-fabricated or modified footwear that meets the demands of the pedorthic patient's pathology, lifestyle, and activity level can be a daunting task. What looks good on paper or in your mind's eye may well be problematic when put into practice. Many of us who both fabricate and provide patient care have experienced walking into the patient room with our masterpiece of epic quality, a gleaming example of the finest craftsmanship, only to have to make the walk of shame back to the workbench for a "few modifications." There is a well-worn path from the exam room to the fabrication lab in all of our facilities. The remarkable thing is that with a bit of tweaking or a simple addition or subtraction of materials we achieve a remarkable level of success resulting in great patient outcomes. What we think are finished orthotics and custom-fabricated or modified footwear are often the starting points from which we can then fine-tune the devices and achieve the desired functionality, fit, and wearability. Having the knowledge, ability, and skill level required to produce and modify orthotic devices are crucial tools even when using a central fabrication facility. Clinicians' knowledge of fabrication techniques allows for seamless and coherent communication with central fabrication technicians. By knowing the fabrication process and the materials' functionality, limitations, and options, the pedorthist is able to request the most appropriate devices and materials that offer the best opportunity to attain the desired outcomes. In turn, this allows faster delivery. Across the O&P profession, it seems that the new practitioner skill set consists of greater focus on clinical skills rather than fabrication. When I entered pedorthics, most of us came from a technician background with years of fabrication experience apprenticing under a master-level technician and practitioner. We prepped and poured casts, modified plaster, and pulled plastic without the assistance of carvers and CAD/CAM programs. This hands-on work allowed us to learn by feel and to visualize minor variations. For example, it allowed clinicians to be able to recognize what an 1/8-inch cast expansion looked like on the cast and on the finished product. When the same person casts the patient, preps and modifies the casts, pulls plastic, finishes, fits, and dispenses the device, there seems to be a tendency toward greater consistency in the translation of the prescription into the device. Advances in technology, materials, and processes have given today's practitioners many more options in the construction of devices, and the movement toward increased use of central fabrication facilities has given practitioners the ability to move away from the bench and see more patients. At the same time, technology has allowed collaboration between the two groups through the use of digital files of the patient's anatomy, which can be transmitted to the fabricator in a split second. Both technician and clinician are then able to discuss the patient's needs in real time. This allows the clinician to keep his or her hand in the fabrication process virtually, preserving a bit of the "old school" continuity. Communication about new materials involving the practitioner, the technician, and the manufacturer can also be essential in providing positive outcomes. If a lab is contemplating adopting the use of a new and exciting high-tech material, it is important that the process be well thought out and that the patients' best interests are taken into account. Conduct a thorough investigation of the viability of the material as it relates to the desired patient outcome. Involve the material manufacturer in the new product implementation. When the manufacturer works with practitioners and technicians in the early adoption stages of a new material, the manufacturer can communicate appropriate material handling processes and remove the trial and error involved with implementation. Evaluate the material's capabilities, compatibilities, and functionality and whether the fabrication lab has the skill set to adopt this new product into its processes. I experienced the results of what can go awry with new materials when a central fabrication lab I worked with changed vendors for the thermo-moldable graphite composite material it used for foot orthotics. The material, for all intents and purposes, seemed identical to the original. But when put into process, technicians could not pull the material appropriately. They could not attain deep heel cups and could not create arch contours to match the casts. They were frustrated beyond measure. A quick call from a technician to the manufacturer's technical staff and a thorough reading of the material handling instructions proved to be critical in solving the problems. With a simple 20-degree increase in heating temperature and two minutes less in the oven, the material worked like a charm. In the end the lesson is, "Read the instructions and communicate, communicate, communicate." If the technicians, the manufacturer representatives, and the clinicians all share knowledge, the process goes much smoother. As many practitioners detach themselves from device fabrication and spend most of their time in the clinic, it is a must that they stay up to date on fabrication processes. Set aside part of annual continuing education for further hands-on fabrication training workshops, to attend vendor-sponsored workshops, and spend time with fabrication technicians. Talk to technicians about materials and techniques that are being used and what others are asking them to do for particular pathologies. Tips from the technicians regarding how to adjust a particular material and other dos and don'ts prove invaluable in the field. Over time, this shared knowledge can be used to refine the original device order for a better design and improved functionality. The bottom line: be familiar with fabrication processes. Spending time in fabrication keeps clinical skills sharp and fosters innovation in the clinic and teamwork with fabrication staff. Most of all, get your hands dirty, maintain hand skills, and work with colleagues and technicians to learn the shortest path to positive patient outcomes. Howard Hillman, CPed, is the director of training and development at PAL Health Technologies, Pekin, Illinois.

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