Prosthetists: A Physiotherapist’s Perspective

"I appreciate prosthetists who are excited about their profession and share their knowledge," says Linda McLaren, BSR (PT), clinical resource  physiotherapist-amputation, GF Strong Rehab Centre, Vancouver, British Columbia, Canada.

Constable Laurie White (left) of the Royal Canadian Mounted Police works with physiotherapist Linda McLaren, BSR (PT), in return-to-work kicking tasks. Photo credit: Alignment 2000, published by the Canadian Association of Prosthetists and Orthotists (CAPO).
Constable Laurie White (left) of the Royal Canadian Mounted Police works with physiotherapist Linda McLaren, BSR (PT), in return-to-work kicking tasks. Photo credit: Alignment 2000, published by the Canadian Association of Prosthetists and Orthotists (CAPO).

When a prosthetist calls her to come and see new products that a manufacturer's rep is showing, she's glad to go. "It helps to see a prosthetist evaluating a new product and saying whether it's good or a piece of junk-and why he thinks that. I appreciate most the prosthetists who enable me to learn about their industry and who are willing to show me when a prosthesis is well-made or shoddy." This information also helps her when clients have questions about products they have seen in consumer-oriented publications, such as InMotion or Active Living.

"Trying to improve my knowledge and skills in amputee rehabilitation has been a frustrating educational adventure," McLaren continues. "Little in this area is offered within the physiotherapy profession."

McLaren has been working with prosthetists and amputees for the last eight years, but notes that few physiotherapists have a knowledge of prosthetics sufficient to enable them to work effectively with prosthetists for optimum patient benefit. "With a regular turnover in physios, prosthetists have to rehash the basics with each new one-often, they never got beyond the basics, and prosthetists tell me that is frustrating."

To improve her knowledge, McLaren has started attending P&O meetings, such as the ones held by the Association of Children's Prosthetic-Orthotic Clinics (ACPOC) and the American Academy of Orthotists and Prosthetists (AAOP).

Teamwork

When the prosthetist and physiotherapist evaluate the patient together in an area large enough to walk alongside the patient, they save time and achieve a more accurate evaluation, McLaren says. In one case, she and a prosthetist evaluated a patient, and the prosthetist made three alignment changes. "In most cases, the prosthetist would have made one alignment change in the office, then not see the client for another two weeks," she says. "By seeing the client as a team, we could ask each other, What do you see? What do you think the problem is? What do you think the solution is?'"

When evaluating patients with the prosthetist, McLaren notes that the language the two disciplines use is often very different-and sometimes confusing, both to each other and to the patient. "On the whole, prosthetists use very technical language which often makes absolutely no sense to the new amputee. Physios tend to demonstrate gait deviations and exercises by using their own bodies. We need to explain our concepts in lay language more than in medical terms they may not understand."

McLaren uses a video camera almost every day. "It's amazing what people pick up about themselves and can describe. I think we need to spend more time letting them see how they look as they perform various activities." McLaren also films amputees at the job site and in return-to-work programs. She has received appreciative feedback from prosthetists when showing them a difficult job task in which prosthetic suspension or stability might be important factors.

McLaren appreciates honesty, forthrightness, and openness from prosthetists. "For instance, if they don't have an opinion yet when evaluating a patient, or if they don't know the answer to a question, they should just say so. If they aren't honest with a colleague, how honest are they going to be with their clients?" Prosthetists and physiotherapists gain more respect from their clients when they are forthright, McLaren believes. "You can say, I don't know, but I'll look it up and get the answer for you,' or, if it's a really a question for the physician, tell them they need to talk to their doctor."

The Good, the Bad, and the Ugly

In her years of working with prosthetists, McLaren has seen the good, the bad, and the ugly. "There is a level of accountability that is missing in the prosthetic industry-and it is very much an industry. There are prosthetists who are incredibly dedicated and go the extra mile in the devices they provide, but there also are people who are less diligent about their hand skills and what they produce. A segment of amputees suffer more than they need to because of what they are getting from some prosthetists, and the prosthetic fitting process is more frustrating and more drawn out than it needs to be." With added experience, she says she now can generally "read between the lines" to distinguish between what a prosthetist says he provides and what he actually does.

Amputee Education: A Crucial Factor

Amputee education is a crucial area that is not adequately addressed, McLaren stresses. She works with over 80 amputees a year; about two-thirds are new amputees "who know absolutely nothing. They don't know what to expect and what they should do-or not do-to prevent pain, skin breakdown, and other problems. Nor do they understand their options if they become disenchanted with their first prosthetist."

Patients often equate the best care with the most expensive care, she notes. "We need to spend time explaining about the different categories of prosthetic feet and knees and tying them in to the client's function, so they feel they are getting what's best for them-including the durability of the product- and not necessarily responding to marketing hype." McLaren has a museum of broken components and bad sockets; she uses these to educate her patients.

"Our ultimate goal is to produce educated consumers who spend their money for the most appropriate devices. The goal is that they get back their life as soon as possible. For instance, if they were working, we want to enable them to return to their jobs. And if meaningful leisure activity was a part of their life before amputation, then we want to enable a return to that too."

To McLaren, one of the most rewarding aspects of her job is when clients come back to visit and show pictures of their holiday or their wedding-when they have indeed gotten their lives back.

Linda's List for Prosthetists

Linda McLaren, BSR (PT), has many thoughts on what can be done to stimulate physiotherapists' interest, learning, and longevity in amputee rehabilitation. Here, she lists some requests based on what prosthetists have done to increase her prosthetic knowledge and ability to work effectively as a rehab team member with a prosthetist:

  • Show me what educational prosthetic journals you subscribe to;
  • Sponsor me to go to a trade show and take me from booth to booth, explaining what's a good product and what's not;
  • Tell me about Robert Gailey's One Step amputee rehab course. If you've taken it, lend me the videos or booklet series that you purchased;
  • Help me pay for registration to go to one of the big five international conferences: Association of Children's Prosthetic-Orthotic Clinics (ACPOC), American Academy of Orthotists and Prosthetists (AAOP), International Conference on Advanced Prosthetics (ICAP), International Society for Prosthetics and Orthotics (ISPO), and the Canadian Association of Prosthetists and Orthotists (CAPO);
  • If a prosthetic intern is working in your facility, get us together-they have lots to learn about the physio role, assessment, and treatment;
  • Show me good sockets and bad ones and explain the differences in detail, including shortcuts in casting, fabrication, lamination, etc;
  • Fabricate a "teaching prosthesis" for me to wear-I completely changed my approach to the treatment of transfemoral amputees, especially in the area of balance skills, after trying some of my own exercises wearing a prosthesis. This "teaching prosthesis" is a fantastic tool for me when I have to educate physiotherapy students and new staff members;
  • Tell me about other amputation physiotherapists whom you respect.