Physical Therapists: Are They Encroaching on O&P?

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Are the two disciplines complementary or competitive? How much do they overlap? Here, two physical therapists with wide experience in working with prosthetic and orthotic patients give their views.

Sara Guzman, MPT
Sara Guzman, MPT

"I definitely see O&P practitioners as partners, not competitors," says Sara Guzman, MPT, program coordinator for physical therapy, Rehabilitation Unit, Southside Hospital, Bay Shore, New York. "I don't feel physical therapists are encroaching on O&P's scope of practice, but I think we're getting frustrated with practitioners who produce poor-quality work or have long turnover times.

"We are under tremendous pressure from insurance companies to get people out of the hospital," she continues, adding that physical therapists no longer have two or three weeks to assess patients as they used to. "We all have a responsibility to educate each other for the good of patient care that is getting harder for all of us to render as time goes on."

Guzman discusses patients' diagnoses, problems, the goals involved with using a prosthesis or orthosis, and the prognosis and expected functional levels with the prosthetist or orthotist before they see the patient together. They both then meet with the patient and discuss what would work best for that patient.

Noting that physical therapists have a large influence on which O&P practices patients are referred to, Guzman says, "What I want from a company is competent practitioners, good response and turnover time, and respect for my knowledge of my patients and my patients' needs."

Prosthetic Care: Not an Issue

Robert Gailey, PhD, PT
Robert Gailey, PhD, PT

With almost two decades of experience working with prosthetists all over the country, both receiving and providing referrals, Robert Gailey, PhD, PT, University of Miami School of Medicine, Department of Orthopaedics, Division of Physical Therapy, says, "I have never heard of a physical therapist attempting to fabricate prostheses at any level. Physical therapists have little or no opportunities for prosthetic education or experience, and therefore prosthetists do not need to worry about encroachment. The only physical therapists I know that have an interest in prosthetic fabrication have successfully completed a certificate program in prosthetics."

Consequently, prosthetists should be looking to create a positive working relationship with physical therapists, he points out. "Amputees are looking for comprehensive care. Having a prosthetist and a physical therapist who share a common interest in their rehabilitation is not only good rehabilitative practice, but is also an excellent way to build a referral base."

Orthotic Care: More PT Involvement

However, orthotic care is different, primarily because of the physical therapists' access to fabrication, Gailey says. He divides orthotics into three general categories.

The first category comprises custom high-temperature plastics and durable materials such as metals and carbon fibers. "Few, if any, physical therapists have the education, equipment, or space to justify the fabrication of these types of custom orthotics," he notes.

The second category covers low-temperature plastics and centrally fabricated orthoses, including low-temperature hand and upper-limb orthoses and custom foot or shoe inserts that require castings or foam impressions. "Most of these orthotics are fabricated by physical therapists that specialize in a particular area of rehabilitation and offer the fabrication of these orthotics as a service rather than as a means of generating additional income," Gailey explains, adding, "The time for fabrication, ordering, and fitting often yields less revenue than would be received with traditional therapeutic treatments. In the majority of instances, therapists have taken additional continuing education and have become skilled in the ability to furnish a limited selection of orthotic appliances."

The third category comprises prefabricated, off-the-shelf orthoses. This type of product is commonly provided for convenience or because of economic considerations. However, physical therapists are not the only practitioners who have adopted this means of providing orthotic devices, Gailey points out. "Today, orthotics manufacturers and sales people are constantly trying to find new distribution sources, including physical therapists." 

Do therapists fabricate some specialized orthotics? "Sure they do," Gailey says, adding, "And many of them are extremely skilled, with the anatomical and biomechanical knowledge necessary to provide excellent care." Access to a certified orthotist is difficult in many parts of the country, he points out. "Thus physical therapists are placed in a situation where they must use prefabricated or centrally fabricated orthotics."

Are therapists interested in encroaching on prosthetics and orthotics? "I don't believe so," Gailey says. "Physical therapists have little interest in custom high-temperature orthoses or in working with metals and difficult materials such as carbon fiber. The orthotic devices that most physical therapists fabricate can be time-consuming and provide lower reimbursement. The majority of custom orthotics and complicated cases are - and probably will continue to be - fabricated by certified orthotists."

An effective strategy would be to educate physical therapists about the services that orthotists provide and how there can be improved patient care and more profit for both disciplines if practitioners focus on their own area of expertise and set up a complementary referral system, Gailey says.

"My personal belief is that prosthetics and orthotics should be fabricated by prosthetists and orthotists and therapy should be performed by physical therapists, unless the therapist has the appropriate skills or is filling a void in services," he stresses. "I have spent my career trying to define the line between the two professions while promoting and demonstrating how we can prosper together. 

"I personally do not adjust prosthetics or fabricate orthotics," he continues. "I believe that if I did, patients would become confused as to what my responsibility on the rehabilitation team is. I have given lectures around the world on how the two disciplines can create a complementary scenario by providing services that offer patients the best possible outcome."

Gailey firmly concludes, "We need to be allies - not adversaries."