As the O&P profession has transitioned to a master’s degree as the entry-level requirement, the approach to pediatric patient care has been changing. Where do orthotists fit? The previous approach presented to new practitioners was that “children are just small adults” or “that’s the orthosis the child had previously, so duplicate it.” Now, however, the elevated credential has helped to solidify the O&P profession as part of the rehabilitative team working with physical therapists (PTs), occupational therapists (OTs), and physicians.
The pediatric patient in the rehabilitative realm requires a team to achieve success. The team usually consists of the patient, immediate family, PT, OT, physician, and orthotist. The nontraditional team can include, but is not limited to, a speech-language pathologist, teachers, daycare providers, and extended family. Everyone on the team has a role that can contribute to the success of orthotic management of pediatric patients.
When providing orthotic management, one of the questions is what is a child’s job? The answer is to play. By playing, a child learns the ability to cross midline, hand-eye coordination, strength, endurance, motor planning, self-help, calming, alerting, exposure to various sensory stimuli, and much more. Therapists incorporate play into therapy sessions to develop deficiencies such as limited range of motion, strength deficits, poor motor planning, or spatial awareness. Parents and caregivers are expected to provide additional exercise sessions at home to continue to develop the sense of play in children and achieve therapy goals.
The multidisciplinary team approach can have different approaches depending on the situation. One model includes a diagnosis-driven clinic in which a physician, OT, PT, genetics counselor, nutritionist, social worker, orthotist, and durable medical equipment provider are available so the pediatric patient is provided all the necessary care at one visit. A second approach is the orthotist providing care at a therapy center for an entire day. Each provides patient-centered care, while providing in-depth communication between the family, therapist, physician, and orthotist. Effective communication begins by understanding the scope of practice for each allied healthcare practitioner.
The idea of a team approach involving multiple members of the multidisciplinary team begins early in the orthotist’s education. Part of the Eastern Michigan University Master of Science in Orthotics and Prosthetics program are classes focusing on interprofessional development. Rebecca Spragg, MSPO, CPO, program director explains, “There are multiple events throughout the semester and community that put the students in contact with other healthcare professionals.”
One such event includes multiple allied healthcare providers including OTs, PTs, nurse practitioners, physician assistants, and athletic trainers filling out a questionnaire regarding scope of practice for the different allied healthcare providers. Education is provided regarding the different roles of allied healthcare providers, and upon completion a second questionnaire is given to gauge the understanding of the scope of practice between them.
Diagnosis-driven clinics (i.e., for muscular dystrophy, cerebral palsy, or spina bifida) allow the interdisciplinary team to share communication not only about individual patients, but also research for best practice. This allows for optimal orthotic management through discussion of the current needs and future needs in real time. The ability for the physician, therapists, and orthotist to discuss with parents and caregivers how the orthosis will benefit the child in and out of therapy has increased compliance.
The approach for successful orthotic management of the pediatric patient requires collaboration and communication throughout the care team, especially in outpatient clinics when not all team members can be physically present. This is not only advantageous to children’s immediate needs, but also their long-term development. The patient will change in many ways, such as increased range of motion, strength, and skill development, but the orthosis will not change, so constant adjustments and fine tuning will be required. As Janelle Woodruff, PT, states, “I really do believe in the interdisciplinary approach. Teamwork is extremely important to me. Combining the expertise of the orthotists for product, knowledge, and gait mechanics with the physical therapist’s knowledge of the patient’s strengths, deficits, and functional level leads to cooperative problem solving and optimal outcomes. And the opportunity to try again if the first strategy needs a tweak.”
Woodruff emphasizes that the ability of an orthotist to understand the progression of child development when designing an orthosis is crucial. Orthotists can help optimize outcomes by communicating with the therapist about a potential need for changes to the orthosis at developmental milestones.
The feedback and information a therapist can provide the orthotist can avoid potential pitfalls when he or she designs the orthosis for the pediatric patient. This can lead to reduced orthotic follow-up, while allowing the therapist to focus on therapy goals.
When asked about interdisciplinary collaboration, Stephanie Herrle, PT, MscPT, C/NDT, says the key is trust, education, and communication among the interdisciplinary team. This will lead to a strong working relationship for the child to progress in therapy to attain the next goal. The team needs to be able to educate each other on the current orthotic needs of the pediatric patient and the parents if the design of an orthosis is changing.
Having the orthotist in the clinic to evaluate a new patient or adjust a current orthosis has been instrumental in a child being able to achieve goals. The orthotist can discuss therapy goals with the physician and how different AFO designs can assist in achieving them.
While therapists, physicians, and orthotists serve as the more traditional members of the team, nontraditional members can be valuable to the patient too. Teachers and daycare providers can provide the parents with information about wear time, tolerance of the orthosis, and report any skin concerns so appropriate care can be provided. Molly Niemi, MA, CCC-SLP, is a mother and a pediatric speech-language pathologist. In her professional setting, having an orthotist at the clinic all day has been beneficial when families are having concerns regarding fit, as she can inform them of the scheduled days and provide information to the orthotist. The families’ accessibility to the orthotist and therapist has been beneficial, especially when the child is participating only in speech therapy and not PT or OT. Niemi has been able to assist families in navigating follow-ups and evaluations. As a mother, she has been able to assist families in understanding the importance of compliance as not everyone (i.e., extended family or daycare) will see the changes of alignment or function.
Amelia Zimmer, MSOP, orthotic resident, whose previous experience includes working at a PT clinic, values the role of the pediatric orthotist in the team. Her observations during her residency have been that it is easier to get more in-depth collaboration by either attending a diagnosis-driven clinic or the orthotist being present at an outpatient therapy clinic because there is more time to discuss the needs of the child. If the orthotist comes during a therapy session, it can feel rushed.
The interdisciplinary team can not only have positive effects on the individual child, but elsewhere in the O&P profession. They can provide additional perspective and support for legislative movements, including Every BODY Can Move. Education opportunities involving allied health professionals, for example, the Association of Children’s Prosthetic-Orthotic Clinics, encourage the collaboration and communication of therapists, physicians, orthotists, and prosthetists at one conference. No matter the type of setting for multidisciplinary care, a specific diagnosis clinic or outpatient therapy center, the key to success is education, trust, and communication.
Seth Cochrill, CO, is a clinician at Wright & Filippis Pediatric Center, Michigan, and a member of the American Academy of Orthotists and Prosthetists Lower Limb Orthotics Scientific Society.
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