Physiatry and O&P: A Synergistic Partnership

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By Charles Levy, MD

Physiatrists and prosthetist/orthotists have much in common. Both practitioners are members of small and somewhat misunderstood specialties, are trained to care for people with disabilities, and try to improve patients' function. Practitioners  from both professions devise treatment plans based on biomechanical analyses of their patients/clients. Further, both professions are challenged to justify their treatments and judgments by increasingly skeptical payers. Both professions must face the incursion into their practices of other professions or specialties that may not be as well trained or qualified.

With all these similarities, there should be no surprise that there exists a natural synergy when prosthetist/orthotists and physiatrists work together. Among physicians, physiatrists are uniquely qualified to work with people who have undergone amputations or who need or are considering orthoses. The specialty of physical medicine and rehabilitation (PM&R) grew out of the need to care for disabled veterans and promote their recovery after they had survived their initial injuries and illnesses. Many of these veterans had newly acquired amputations. Although the scope of the field has broadened, PM&R residency still requires exposure to prosthetics and orthotics.

As a specialty that also performs electrodiagnostic evaluations and cares for people with a wide variety of musculoskeletal complaints, physiatrists must gain mastery of the musculoskeletal and peripheral nervous systems. They also take responsibility for the rehabilitation of those with central nervous dysfunction, including stroke, traumatic brain injury, and spinal cord injury. They devise solutions for those with physical, cognitive, and emotional impairments.

In these and many other settings, PM&R residents learn to function as both members and leaders of multidisciplinary teams. These experiences lead physiatrists to perceive people in multiple dimensions of function, recognizing strengths and weaknesses along personal, spiritual, psychological, social, medical, vocational, and physical axes.

The most natural setting for prosthetist/orthotists and physiatrists to meet is in a prosthetics/orthotics or amputee clinic. Typically, the overriding goal of such clinics is accurate, comprehensive assessment and management of patients referred for orthotic or prosthetic considerations.

The physiatrist in such a clinic has multiple important roles:

First, the physiatrist provides the prescription for all prosthetic and orthotic devices. Ideally, the physiatrist provides an independent viewpoint, free of the potential of conflict of interest, since the physician has no financial stake in the prescription. Because of this independence, the physiatrist is often seen as more credible in the eyes of the patient.

Often the physiatrist is placed in the role of "quality control," offering an independent assessment of whether the proper item was fabricated to reasonable standards.  The physiatrist can also help the patient understand what can be realistically expected from certain devices and what devices are appropriate in a given situation.

The physiatrist also has the ability to explore and offer solutions beyond the immediate issues related to prostheses and orthoses. These issues can include wound healing and pain management; evaluation, treatment, or referral for related medical disorders, such as diabetes, peripheral vascular disease, or peripheral neuropathy; and the prescription of physical therapy or occupational therapy as part of the treatment plan. Those who present to a prosthetics/orthotics clinic may have vocational, adjustment, or musculoskeletal issues which the physiatrist can address.

Physiatrists deeply appreciate the host of complementary skills prosthetist/orthotists bring to the table. Most physiatrists rely on the prosthetist/orthotist as the expert in fabrication and fit. Further, the prosthetist/orthotist typically learns of advances in the O&P field before the physiatrist. As partners, the physiatrist and prosthetist/orthotist can untangle complex problems such as pain or poor use of the prosthesis. The physiatrist can help rule out or treat factors intrinsic to the patient, such as weakness, pain, and volume fluctuation. The prosthetist/orthotist often takes the lead in assessing alignment and componentry. Prosthetists/orthotists help by sharing their knowledge and experience not only of what is likely to be successful, but also of what is unlikely to be successful.

Because physiatrists' and prosthetists/orthotists' backgrounds and interests are not identical, it is important that professionals from both disciplines earn each other's respect. Thoughtful, compassionate care, with a willingness to learn, will build trust. Building and maintaining trust takes constant attention, and only a few instances of transgression can severely damage the relationship. Thus, it is imperative that physiatrists follow professional conduct, taking responsibility for excellence in medical and rehabilitative treatment and always keeping the best interests of the patient in mind. Likewise, prosthetists/orthotists who stand behind their work, follow sound biomechanical principles, and bill reasonably and accurately will earn the respect and trust of their medical colleagues.

In the best relationships, both parties learn from each other and enhance each other's abilities to accurately assess patient problems, potentials, and the capacities and limits of available equipment. In this give-and-take, we learn to support and improve each other's practice, and we deliver superior service to our patients/clients.

Charles E. Levy, MD, is assistant professor, Department of Ortho-paedics and Rehabilitation, College of Medicine, University of Florida, and is the author of numerous peer-reviewed and book chapters.