Physical Therapists: Partners or Competitors?

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By Miki Fairley

When we posed this question, we were deluged with responses from orthotists, prosthetists,
physical therapists, and practitioners who are both certified prosthetists/orthotists and physical therapists. This article includes views from prosthetists and orthotists. Next month we will cover views expressed by physical therapists and O&P practitioners who are also physical therapists.

Overall, the emphasis is definitely on partnership, not competition. Several prosthetists/orthotists commented that the expertise of both professionsand teamwork between themis essential for the optimal functional outcome for the patient.

Areas of concern embrace education, training, and communication"speaking the same language." Interestingly, encroachment did not surface often as an issue. In fact, the comment came up several times that a reason physical therapists may be doing more bracing is not that they are seeking more ways to increase revenue, but that they aren't satisfied with what orthotists are providing. Of course, there are legitimate differences of opinion as to what is the best treatment methodology in a particular case.

One certified orthotist pointed out an inequity in reimbursement, noting that physical therapists can bill according to the L-Code reimbursement, plus the physical therapy charge, while orthotists and prosthetists can bill only the L-Code amount, since their services are included in the code.

Here are some of the responses:

Christopher Huff, CO, and Mike Bolton, BOCO , own Advanced Orthotics and Prosthetics, Troy, New York, and share office space with Troy Physical Therapy.

The two orthotists enjoy a strong working relationship with the physical therapists, says Huff. "We complement each other to benefit the patient." For instance, if a patient needs increased range of motion, the orthotists contact the doctor and recommend physical therapy. The physical therapist can contact the orthotists for an evaluation for bracing.

Being under the same roof brings some advantages, says Huff. They can answer any question a patient might have regarding O&P or physical therapy and make adjustments and changes quickly without the patient having to travel.

The orthotists assist the physical therapists by discussing how orthotic intervention may benefit the patient, along with the pros and cons of each type of orthosis. 

"I know some PT's are doing their own bracing," Huff says, adding, "I believe this is due to their not getting the proper correction or support they want for their patients. So they decide they can just do it themselves."

Huff feels physical therapists are qualified to fit prefabricated braces and has no problem with that. "If they try a prefabricated brace that does not work, we can evaluate the patient to determine if a custom-fabricated orthosis will give them what they are looking for."

Huff notes that the physical therapist often spends more time with the patient than the orthotist does and "may see something we don't."

Huff discusses his evaluation and treatment goal with the therapist, welcoming the therapist's input.

Rob Kistenberg, CP, FAAOP
Rob Kistenberg, CP, FAAOP

Rob Kistenberg, CP, FAAOP , O&P Clinical Technologies, Gainesville, Florida, is another practitioner strongly committed to working with physical therapists. "For prosthetists, it is critical that we have a good relationship with physical therapists," he says. New amputees need physical therapy to regain balance and strength and to learn how to walk again correctly, Kistenberg points out. "We also recommend physical therapy for long-time amputees getting a new prosthesis if they have a specific muscle weakness or gait deviations."

Kistenberg usually will accompany the patient to his first or second physical therapy appointment so that the physical therapist will have a good understanding of the prosthesis. Physical therapists don't receive much prosthetic instruction in their education, he notes. "The prosthetic education that they get is very basic and doesn't keep them up to date with the latest products and technology. If it's a prosthetic problem, I can adjust it on the spot, and if it's a strength or balance problem, I'm there to help diagnose that with the physical therapist."

O&P Clinical Technologies offers inservices to physical therapists, family physicians, and others in any prosthetic/orthotic topic in which they have an interest. "Patient care is certainly enhanced when PTs are comfortable with the components and level of technology being used," says Kistenberg. "We try to make sure they are up to date with what we do. This has both a marketing and education component."

Photo Courtesy of Amputee Coalition of America.  Photoghrapher Jose Pico.
Photo Courtesy of Amputee Coalition of America. Photoghrapher Jose Pico.

Gary Horton, CO, FAAOP , Horton's Orthotic Lab, Little Rock, Arkansas, invites physical therapy students from the University of Central Arkansas, located about 30 miles from Little Rock, each semester to his facility. After giving the students an overview of orthotics and prosthetics, he leads a complete tour, then provides a period for discussion and questions.

"After they finish their training and start to practice, we begin seeing referrals from them because they remember us from these tours," Horton says. Discussing physical therapists, Horton comments, "You get a little bit of the competitor,' and more of the partner.' I know a lot of orthotists are skeptical and see them as encroaching in orthotics, but this is a very small percentage of physical therapists, in my opinion."

Horton believes that very few physical therapists go into orthotics for financial gain. "I think some of them get into it  because they feel they can't get adequate orthoticsbut this is a small percent. Some of them really and truly believe they can do a better job."

A big help, according to Horton, is "the old-fashioned cliché of good communication. They often see many of us as just being hardware salesmen. We need to let therapists know what we can add as a team member and how we can affect patient outcomes. My method is to meet your therapist and let them know what we doit's not just selling plastics and metalit's assisting with evaluations and developing a patient treatment plan. It's being a colleague, not a competitor."

Jim Rogers, CPO, FAAOP , Orthotic and Prosthetic Associates, Chattanooga, Tennessee, traces the evolution of the present environment of O&P relative to physical therapy.

Commenting that many of his colleagues may see their relationship with physical therapists, especially those in pediatric practice, as one of competition, rather than partnership, Rogers notes that "my perspective is from 28 years of relationship-building with physical therapists, and 18 years of marriage to one."

Rogers has seen the relationship between the professions change considerably, he says, due to many factors: the O&P profession's perceived failure to provide quality pediatric services, geographical concerns, lack of vision on the part of O&P regarding whether the field provides a product or a service, and finally, the pressures of providing care in a managed healthcare environment.

In the early 80s, physical therapists began to specialize, Rogers continues. "Pediatric and neurological specialists evolved and generally possessed a body of knowledge that the average O&P professional did not have. Orthotic design began evolving as an adjunct to therapya functional facilitatorrather than the purely orthopedic solution to unnecessary movement, as most orthotists had been taught."

As a result, Rogers says, tension developed between the physical therapy community and the orthopedic community and, subsequently, between the physical therapy community and the orthotic community. "Orthotists who saw the big picture recognized the opportunity to learn and be an integral part of a change in philosophy and treatment patterns involving children. They listened, learned, and provided solutions. Their practice and their pocketbooks were enhanced. Those who did not respond developed a circle the wagons' mentality and began to build a gulf between the professions.

"The lack of vision, or should I say timing,' with regards to O&P is a much more complex issue," Rogers continues. "We have always chosen to hold on to what we have instead of attempting to define and distinguish our unique contributions to the rehabilitation of individuals with disabilities. This has led to the feeling that PTs, athletic trainers, physicians, and even sales reps have encroached' on our territory." Some items provided by orthotists are now accessible to the public through a variety of avenues that bypass O&P facilities, Rogers notes.

"O&P should have long ago decided that we provide a unique service that simply includes products and put our efforts into defining our profession scientifically and distinguishing ourselves from other allied health professionals. I think our national organizations are now focused and doing a fairly good job of attending to these issues and the greater needs of our profession."

What the average practitioner needs to do is to "forge ahead by building partnerships with other professionals who enhance our care and help provide optimal outcomes," Rogers says, adding that O&P professionals can increase their referral base by educating physical therapists about the difference O&P services can make in the lives of disabled persons. "Inservices, dual educational sponsorships, support groups, health fairs and community service projects aimed at informing the public are only some of the ways we can enhance this relationship to our economic benefit and the benefit of our patients."

Randall Alley, CP
Randall Alley, CP

Occupational therapy is another area in which rapport is needed between O&P professionals and therapists. Randall Alley, CP , director, Business Development and Clinical Research, Hanger P&O, and chairman-elect of the Upper Limb Prosthetics Society of the American Academy of Orthotists and Prosthetists (AAOP), is currently leading a massive project with Diane Atkins, OTR, an occupational therapist noted for her expertise in working with amputees and limb-deficient persons, to generate a national directory of occupational therapists who are either interested in or who specialize in upper extremity prosthetics.

Alley also is working with the American Occupational Therapy Association (AOTA) to initiate a "phys-dis" group within their organization that responds directly to the relationship and interactions between O&P professionals and occupational therapists.

Alley and Atkins also will be writing an article for O.T. Practice about this project. They also plan to give a presentation at next year's Academy meeting in San Diego on working together to provide the initial assessment of persons needing upper extremity prostheses in the hopes of improving outcomes by combining an OT and a prosthetist from the outset.

A second priority is to create a standardized physical assessment form and guidelines, so that everyone is on the same page when they first see a patient, Alley says. "Finally, I am encouraging the Academy to bring about a greater awareness of the need for prosthetists and therapists to come together and initiate a better sharing of knowledge through written materials and practical experience.