Hand Skills and Technician Education

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By Miki Fairley

With the increasing use of 3D printing, CAD/CAM software, and a push to use technology to increase efficiency, are traditional hand skills still as necessary for O&P technicians as in the past? Do O&P technicians also need skill sets in these more advanced technologies? The short answer to both questions is yes according to O&P clinicians, business owners, and educators. The O&P technician education programs provide students with the foundation in these skills and the tools to take hold of opportunities, adapt to new technology changes, and develop their own approaches to succeed as the profession evolves. The O&P EDGE  spoke to educators to gain insight about how these programs are not only keeping pace with but are ahead of the curve on the fast-paced changes in O&P.

Mike Brncick, CPO,director, Orthotics and Prosthetics Program, Joliet Junior College (JJC) and Chad Smith, CO/L, CPed/L,orthotic technology instructor, Orthotic and Prosthetic Department, Century College, describe CAD/CAM and 3D printing as more tools for the toolbox, "not a replacement for the toolbox," as Smith says.

"You're still going to have to work with the patient and make adjustments to be sure biomechanical objectives are being accomplished and that the fitting goes well," Brncick adds.

"Although traditional hand skills may not be used as often or in the same way, I believe that you need to have a firm grasp of traditional hand skills to understand and use this advanced technology to its fullest potential," Smith says. "As an orthotist, I like my thermoplastics more than thermosets and non-adjustable composites."

Smith adds that he doesn't see the O&P field ever fully transitioning to a material that can't easily and quickly be heat-adjusted. "Our O&P practitioners and technicians rely heavily upon an ability to quickly adjust custom devices with the use of our traditional hand skills in a single appointment setting. Most 3D printing still presents problems with end-use device strength, durability, and printing times. The added expense of reprinting a 3D-printed device further tips the scale to a continued need for traditional hand skills."

Katie Voss, CO/L, faculty/program director, Orthotics Department, Century College, adds, "We will need our most experienced technicians and clinicians to transform their expert O&P hands skills into digital O&P fabrication techniques to keep the O&P field ahead of those that may want to encroach upon our field through today's easy accessibility of CAD and 3D printing."

"Hand skills are directly related to spatial abilities and creativity," says Joe Young, CPO, director/instructor, Orthotic and Prosthetic Technician Program, Francis Tuttle Technology Center, "Without the ability to visualize and create, no amount of technology is going to make a great O&P professional. The greatest leveraging of modern technology is when a person with the skill and knowledge of O&P fabrication is empowered by new technology to create a better, more efficient way to produce devices that better fit the needs of the patient."

"Technicians' hand skills are as important as they've always been because clinicians are being pushed to do less hand-skills fabrication and more patient management," says Tim Fair, CPO, MSIDT, CPO/L, academic chair, Orthotics & Prosthetics Department, St. Petersburg College. "Also, the O&P field of clinicians and technicians continues to age, so there will be that gap to fill as patient needs continue to rise." He adds, "Although 3D printing likely will improve to become a primary choice in the future, it currently is too slow. Devices can be fabricated much faster using traditional hand skills."

Mike Madden, CPO, FAAOP, instructor, Orthotic & Prosthetic Technologies program, Oklahoma State University Institute of Technology (OSUIT), and Bernard Hewey, CPO, director, O&P Technology Program, Spokane Falls Community College (SFCC), also believe hand skills are still as important as ever, pointing out that many of the O&P facilities that are using additive manufacturing processes are using them mainly for check sockets and some components. Industrial-level 3D printers are still cost prohibitive for many facilities, Hewey notes. Scanning and CAD/CAM technologies take fabrication as far as producing a model from which the finished device is made. "Hand casting, model rectification by hand, and many of the traditional fabricating methods are still the standard approach for a majority of O&P facilities," Madden says.

Good hand skills are high on potential employers' list for job candidates. Ruthie Dearing, MHSA, JD,program coordinator, O&P Technology Program, SFCC, says, "Most of the inquiries we get from practices for hiring request someone with excellent hand skills."

The Future of Hand Skills
Will hand skills still be as necessary in the future? "Absolutely," Hewey answers. "That's the one constant."

Hand skills may not be as important in the initial device fabrication but are still essential for modifying devices to optimize function during the fitting process and to accommodate changing clinical needs during rehabilitation, Voss believes.

Although additive manufacturing works well with the one-off production of custom O&P devices and components, hand skills are still needed for post-production, Madden says. "Fabricating devices involves fitting essentially static systems—or rather, dynamic systems with a limited functional range, to dynamic bodies. Unless we start producing disposable systems, normal patient physiological changes will always require good hand skills at all levels of O&P to make these adjustments."

O&P Tech Skills Evolution
Madden recounts the changes he has seen since the 1980s. "We were still learning how to fabricate exoskeletal prostheses with a horizontal alignment fixture; today we are teaching 3D image capture and using CAD software to rectify models. I learned to laminate using nylon; now we are teaching advanced composite applications. I learned how to design a quad socket; now we teach ischial containment, subischial, and various other socket designs, and gel interface technologies. Friction and polycentric knees, single-axis and multiaxial feet have morphed into microprocessor-controlled components. Suction suspensions with a pull sock have transitioned into elevated vacuum and neural/osseointegration technologies."

"We have a much better understanding of material properties now," Brncick says. "There's much more science behind what we are doing." However, there are still gaps in understanding and applying these materials in O&P device fabrication, he adds. "Facilities generally develop their own ‘recipes.' We're still searching for guidelines as to how to best utilize materials." Federal agencies may start putting some pressure on the O&P field to find those answers, so he foresees an increase in materials research.

Hewey notes advances in materials. Resins used for lamination are now more reliable, easier to use, less hazardous, lower in volatile organic compounds emission, and more efficient. He also points out advances in thermoplastics such as the use of carbon composite fibers and pre-preg—high-performance carbon-fiber materials that have been pre-impregnated with an optimal balance of partially cured epoxy resin.

Fair likewise says that more eco-friendly and less hazardous materials are becoming available, including resins. He mentions alternatives to carbon fiber composites and the Rush Foot, which utilizes a glass composite.

Smith also sees the decreasing cost of more advanced technologies, including digital modification and design software, multi-axis foam carvers, 3D scanners, and 3D printers affecting technicians. "Early O&P adopters of 3D-printing technology are coming out of the shadows. What they once used to hide behind closed doors, they are now putting on display to set themselves apart from their competitors and advance the field of O&P for all of us."

Viewing the Future
"We as a profession are on the cusp of some very exciting technological developments in O&P, and the technician will play an integral part of the technological revolution and must be prepared to fulfill that niche," Madden says. "I tell my students that though how you do what you do may change, you will always have a job if you embrace the change that technology brings and transition your skills, adapting them to emerging technologies." For instance, Madden mentions a recently developed PLA polymer with a nano-copper additive for fused deposition modeling (FDM) 3D printing. "The additive eliminates a wide range of microorganisms that can develop post-production within the porous 3D print; the implications for applications within O&P socket technology are tremendous."

Brncick foresees robotics and electronics as a big part of the future. "The more that technicians learn about 3D printing, robotics, and electronics, and materials science, the more they will be in demand."

Smith's view of the near future is increased use of CAD modification software and multi-axis carvers. "O&P companies in our local area are starting to invest heavily into 3D scanners, modification software, and even robotic seven-axis carvers. Most of our students are exposed to these technologies during their internship hours."

Voss and Smith see a rosy future for 3D-printing technologies in O&P. "Early adopters will continue to experiment with 3D printing, and large O&P central fabrication companies and O&P device manufacturers will race to utilize 3D printing in the most efficient and effective ways," Smith says.

More advanced printers will become affordable to own, Voss believes. "O&P colleges and universities, as well as small practices, will want to own this technology, and 3D printers and printer materials will be widely tested, verified, and made specifically for O&P application in regard to strength, durability, time, and cost."

Smith foresees O&P-specific 3D printers and proprietary O&P materials, similar to the dental industry, helping to drive development of 3D-print O&P billing codes and 3D-print O&P device regulations. "The hope would be to stop all others that want to encroach on our field without having any O&P formal training or O&P partnership for guidance. I hope that regulations will turn the ‘wild west' of custom O&P-device 3D printing back into the hands of O&P medical professionals."

Keeping Abreast of Changes
Educators keep up with new technologies, materials, trends, and market needs by consulting their program's advisory committee and other practicing O&P professionals, attending national, regional, and state professional and industry meetings, and reading the latest research, interviewees say. They also keep up with any changes in National Commission on Orthotic and Prosthetic Education (NCOPE)/Commission on Accreditation of Allied Health Education Programs (CAAHEP) educational standards and requirements. Changes may then be made in the curriculum to reflect these changes.

For example, Francis Tuttle has added course sections to introduce students to CAD/CAM and projects with more difficult fabrications, including electronic componentry such as myoelectric prostheses, according to Young.

Century College has added an introduction to CAD software and additive manufacturing techniques, Smith says. Century College has been collaborating with the Massachusetts Institute of Technology (MIT) Center for Bits and Atoms Global Fab Lab Network. Century was the first college in the region to install and implement a digital fabrication laboratory (Fab Lab) and incorporate the MIT initiative across its curriculum in science, technology, engineering, and math (STEM) areas. The O&P program tries to work closely with the Fab Lab and currently partners with the new Additive and Digital Manufacturing Program for seven-axis robotic foam carving.

Because of the recent changes to the NCOPE technician standards, OSUIT has reorganized some course content including adding an eight-week CAD/CAM course and redesigning the lower-limb orthotic course into two modules: a 16-week transtibial section, and an eight-week transfemoral section, Madden says.

Continuing Education
After leaving the technician program and obtaining certification, many graduates extend their certification by completing certification requirements for O&P assistant, orthotic fitter, mastectomy fitter, or pedorthist, note some of the educators. The technician program lays a foundation in skills and didactic learning for these additional certifications. Brncick comments that he enjoys seeing graduates extend their certificates: "They gain so much more knowledge and experience by working under a clinical person doing those other activities."

Given the hands-on nature of technician education, most of the programs do not offer continuing education per se, although some offer the pre-certification courses required by the orthotic fitter, mastectomy fitter, and pedorthist certifications.

However, the OSUIT program faculty is working on developing blended learning opportunities in accord with a university mandate for all its programs. "We are exploring the possibility of developing hybrid courses that would be accessible to working technicians who want to earn their degrees," Madden says.

The largest and most popular continuing education course at SFCC, the Technician CE Course, is held in the fall, with an attendance of about 100. "Last October we had attendees from 19 states, plus we usually have about 10 to 15 from Canada as well," Dearing says.

Although the American Academy of Orthotists & Prosthetists and the American Orthotic & Prosthetic Association provide dedicated technical programs at their national meetings, Madden points out that the challenge for students and working technicians is being able to afford to attend. He adds that the students usually attend state and regional meetings.

Employers often pay for or share costs for practitioners to attend professional meetings and some will pay or share costs for technicians; however, educators point out the value that continuing education brings to employers, since technicians are usually involved in utilizing new products and technologies.

Ongoing Importance of Technician Programs
With only six NCOPE/CAAHEP-accredited technician education programs, Fair says, "People are only vaguely aware of O&P unless they or someone they know needs O&P care, so they don't really think of it as a career option."

With many technician students moving to assistant and fitter career pathways, Smith would like to see more CAD/CAM and 3D printing technologies added to the Century College program to attract a greater variety of students, "thereby increasing the number of students wanting to become and stay career technicians."

Aside from those challenges, the programs also face the lack of value often placed on technical education.

Madden says, "As a former business owner, I understand the challenges of trying to train someone ‘off the street,' teaching someone basic O&P fabrication, componentry, materials, nomenclature, theory, and lab safety. These are only a few of the things O&P technical education provides. I also appreciated the value of good technicians and how they contribute to an O&P practice's success."

As certified practitioners' education now focuses on clinical skills with less emphasis on technical skills, utilizing
new technologies and materials as well as traditional methods to create devices will more than ever require technicians' knowledge and hand skills.

Miki Fairley is a freelance writer based in southwest Colorado. She can be contacted at miki.fairley@gmail.com.