Historically, the best outcomes for O&P patients have resulted from all members of their care team providing cooperative efforts. Collected case histories offer evidence of the gratifying successes achieved when members of a fully informed patient-centered team pool their skills and knowledge, especially when those skills are highly specialized in areas such as upper-limb prosthetic rehabilitation or osseointegration (OI). As specialized skills advance, so must the teams that support and foster their results in the form of progressively empowered patients.
Team Structure: Greater Than the Sum of Its Parts
The word team carries with it a sense of disciplined preparedness, strength, and power. Knowledge that a unified care team is committed to their success often imbues patients with confidence and comfort.
“The patients like it that we communicate, know each other, talk to each other, and work very well together, and it makes them feel so much more comfortable,” says Alta Fried, MS, OTR/L, CHT, director of hand therapy at the Atlantic Hand Therapy Center, New Jersey, and cofounder of the Amputation Rehabilitation Medicine and Surgery (ARMS) Clinic. She also stresses that structured monthly meetings are essential to a truly multidisciplinary team, while each member also takes care of patients individually throughout the month.
“We set up two mandatory team meeting days: Four days after our ARMS clinic, we meet on Zoom to discuss each discipline’s follow-up items to accomplish; on a Friday afternoon two weeks later, in preparation for the next clinic, we meet on Zoom again to confirm that all tasks are completed. If not, we identify and address the outstanding items. Staying on schedule is important for everyone, especially for the patient.
“We also request our patients’ permission to share their images with or without their face, as they choose, so that we can communicate quickly and efficiently between team members. There are also instances where we refer the patient out to different therapy clinics closer to the patient’s home, not within our network; and pictures and videos speak volumes as to the patient’s situation and needs.”
John Miguelez, CP, FAAOP(D), president, senior clinical director, Arm Dynamics, California, agrees that putting the patient at ease is key. “Many of our patients have been through terrible accidents, and their worlds have flipped upside down. So spending time with our team and developing that relationship helps build trust and lowers some of the barriers that are there, creating a rapport and openness that optimizes prosthetic rehabilitation.
“The center of the team is the patient, and keeping the patient motivated and engaged is critical to their long-term success.” 
Miguelez worked in conjunction with the upper limb-loss team at the Walter Reed Army Medical Center in the early 2000s to develop a prosthetics program for wounded soldiers returning from Afghanistan and Iraq. He hoped to shift their care model to support a collaborative multidisciplinary team approach similar to the care model he established at Arm Dynamics centers.
“At Walter Reed, there was a broader team that included the patient, surgeons, prosthetists, occupational therapists [OTs], psychologists, and other specialists, so no one was vying for control of the patient. We understood from our own centers the importance of this enhanced communication between team members, and it reinforced our commitment to have a full-time occupational therapist at every center we opened. The therapist is integrated into every stage of that care model, from initial evaluations to final fittings, and I think patient outcomes are much better because of it.”
Rob Dodson, CPO, FAAOP, clinical manager, Arm Dynamics, Texas, agrees that the dedicated presence of such a skilled multidisciplinary team has a powerful effect on patients. “Our patient population is mostly trauma-related limb loss, and even with a congenital patient, you’re still dealing with the trauma the parents went through, and addressing their concerns and what the next steps will be for their child. Any major trauma is going to have some effect on the patient’s mental health. And in upper-limb loss it’s very crucial, although often overlooked. Someone once told me that 99 percent of what we’re fitting is between the ears.
“Now we’re starting to see, through the advent of TMR [targeted muscle reinnervation], RPNI [regenerative peripheral nerve interface], and osseointegration surgeries, ways that are really decreasing people’s pain and enhancing their ability to control a prosthesis. So more and more, collaborative care teams are appearing, especially in the upper-limb community, as more upper-limb prosthetists are seeing the value of connecting directly with occupational therapists.”
John Rheinstein, CP, FAAOP(D), Hanger Clinic, New York, observes that the team approach seems to be evolving positively: “I’ve been working for four years within a surgeon-physiatrist-prosthetist-therapist-social worker-psychologist team here in New York focused on amputation care. We’ve developed closeness and trust. We engage in constructive dialogue and learn from everyone’s point of view. The doctors have a collaborative approach rather than an authoritarian approach. They encourage everyone’s input and productive criticism in the interest of continual improvement.
“In the past, we would see surgeons hand off patients after wound healing. Now, more progressive physicians stay involved and are more attuned to and invested in the outcomes. Hopefully that approach is spreading across the country. Watching patients progress through rehab and being open to feedback allows the surgeons to continually improve future care.”
“Another important part of our team approach is regular presurgical meetings to discuss how to optimize each patient’s residual limb for their prosthesis,” Rheinstein says. “This is especially important for those with rotationplasty, unusual trauma, and complex upper-limb cases. When a surgeon spends the extra time on a well-planned amputation, it has the potential to save a patient a lifetime of pain and limit reduced function. A good amputation makes all the difference.
“I’ve always tried to encourage surgeons to view amputation as an opportunity for reconstruction and restoration. Once a surgeon makes that philosophical shift, it allows everything else to fall into place. They start bringing in all the knowledge and resources the team has to offer to provide successful outcomes.”
Michael Jenks, CPO, Integrum, points out that the multidisciplinary team approach to care is not original to O&P, but has been effectively used by cancer centers. He experienced it more personally, however, when his wife, who has a transfemoral amputation, needed a surgical revision and researched the OI prosthetic option.
“Dr. Rickard Brånemark, who founded Integrum, really exemplified the multidisciplinary approach, and it is a key consideration when he identifies top centers to provide the Integrum implant. Integrum OI centers of excellence like UCSF and Atrium that my wife and I visited had teams led by the surgeon, with input from prosthetist, therapist, psychologist, nutritionist, psychiatrists. The team members each interviewed my wife and I—about why she wanted it done, [and explained] why they were motivated to do it. We also interviewed them in terms of the questions we had. We were impressed and felt that the team genuinely had our best interests in mind.”
Their experience, and the results, were extremely positive; today, as regional business development manager for Integrum, Jenks brings his personal experience to support the development of the OI centers.
Like Brånemark, other surgeons are recognizing the value of highly specialized collaborative teams and taking action to develop teams of their own. “We saw that the care for individuals with limb loss is so fragmented, and it ends up dominating most of their life,” says Omri Ayalon, MD, assistant professor of orthopedic surgery, NYU Grossman School of Medicine, associate program director, NYU-Langone Orthopedic Hospital Hand Surgery Fellowship, and codirector, NYU’s Center for Amputation Reconstruction (CAR). “We realized that having a team that’s not only in the same physical space, but also specialized to a high degree across disciplines, will benefit not only the individual who’s being treated but also the team that’s taking care of that person.
“Having a true multidisciplinary clinic in the same space as you evaluate these individuals helps make treatment decisions and helps influence the course of care—it not only streamlines it for the individual, resulting in less need for appointments, but also increases the flow of ideas among the treating physicians, prosthetists, therapists, patient advocates—and interestingly, also results in an environment in which individuals with limb loss can meet in person and share their experiences with what has worked and what hasn’t worked for them.”
Taylor Reif, MD, orthopedic surgeon and oncologist, Limb Lengthening and Complex Reconstruction Service, Limb Salvage and Amputation Reconstruction Center, Hospital for Special Surgery (HSS), New York, considers the specialized skills OI patients need from their collaborative team members: “Part of every osseointegration patient’s care is the physical therapist, who most of the time has taken some interest in working with these patients because they’re not the same as an amputee who has a socket prosthetic, because they can usually push the osseointegration patient further, functionally, and get them to complete complex tasks. These patients have more endurance, so they can do physical exercises for longer periods, go further, and do more mobility tasks—so a therapist who is eager and willing to work with a patient’s gait mechanics should also take them further than they would other patients.”
He notes that in addition to the key members typically found on smaller teams—orthopedic surgeon, prosthetist, therapists, and mental health expert—their team also needs to include a physical medicine and rehabilitation (PM&R) physician.
“We’re looking for more interested PM&R/physiatry doctors to join us and see how they can benefit the patient from the outpatient setting, as well, because currently that’s an underutilized space where we’re looking to expand and be more collaborative.”
Haris Kafedzic, CPO, Eschen Prosthetic & Orthotic Labs, New York, has fitted more than 130 OI patients with prostheses, many of them at the Osseointegration Limb Replacement Center he has worked with since 2016 at HSS.
He agrees that a physiatrist is an important member of the OI team, and suggests having a plastic surgeon on the team as well. “We’re fortunate at HSS that we have a good set of people that really are interested in osseointegration and see the benefit of it—and have been doing it for more than seven years now.
“It’s very important to have a team approach with this, but a lot of that driving force comes from either the prosthetist that has a patient that is unsuccessful with conventional socket prostheses or the orthopedic surgeon. Those are the two members of the team that the patients seek out and are most comfortable with.”
Proving Their Worth: Team-driven Outcomes
Fried describes a patient with upper-limb loss who was initially told by her surgeon that he didn’t think an OT could help her: “Just get a new prosthetic arm, and you’ll kind of figure out how to use it.”
“This patient, a very bright, articulate woman, went online and did her research for a prosthetic hand. She went to a local Hanger clinic where she presented to the prosthetist who told her about the ARMS clinic and set her up for an appointment. When she came into the ARMS clinic, she was amazed to discover that the surgeon, the therapist, the upper-limb prosthetist, and the mental health professional were all in one room, addressing her needs and treatment plan simultaneously. She couldn’t believe that ‘All of you are here together for me?’” 
Because her surgeon was unaware of the prostheses currently available, her residual limb was too long for the prosthetic option she chose to pursue her education and career as a respiratory therapist. She was able to undergo a limb-shortening procedure, however, and her solution included a myoelectric arm that continues to serve her well.
“Her cure was so much different than if she had not discovered the Hanger Clinic and ended up at our clinic,” Fried notes, “because her physician just wasn’t aware of what was possible for her.”
Jacques Hacquebord, MD, chief, Division of Hand Surgery, associate professor, Department of Orthopedic Surgery, NYU Grossman School of Medicine, and codirector, CAR, describes the theoretical case of a man who had a traumatic, very short transhumeral amputation. “He has glenohumeral motion in place, his residual limb is too short to be prosthetically fitted as a transhumeral patient, so he would have to be fitted as a shoulder disarticulation patient.
“This is a very tangible example of where the multidisciplinary team is critical. Because, as a surgeon, you see that the patient may have glenohumeral motion, which is great, but you don’t realize how the glenohumeral motion is difficult to utilize with a prosthetic. So that may drive your surgical decision-making in one direction, whereas if you’re a prosthetist, you’re not concerned about the glenohumeral motion because you can’t take advantage of it.
“The therapist is caught somewhere in the middle—if a patient is going to be fitted as a shoulder disartic, is that patient going to use that glenohumeral motion? And how is that going to affect the strength and the stability and the balance of the injured side to the noninjured side? Can we preserve the glenohumeral motion while also making sure that the scapulothoracic motion stays as good as possible, and that imbalances in the muscles don’t start developing—or that patient starts developing pain because they’ve got scapular dyskinesia?
“If you talk about bionic reconstruction, collaboration becomes even more important, as the possibilities for TMR or RPNI may impact the patient’s prosthetic options,” Hacquebord says.
“If you’re looking at osseointegration or any other future technology, it becomes even more complex. What are you doing now that could impede the possibility of using those technologies in the future? For example, if you have a short transhumeral amputation, and you do targeted muscle reinnervation in the recommended way, you face the potential of losing glenohumeral motion because you’ve now denervated some of those muscles that do the targeted muscle reinnervation.
“If the patient may be a candidate for osseointegration, now the fact that osseointegration has been implanted in the humerus means they can’t fully utilize it, because the glenohumeral motion has been compromised.”
Hacquebord notes that these discussions in a multidisciplinary team are happening in real time. Because one person’s suggestion will be vetted by another, who considers how that affects what they might want to do, “It’s really critical to have these real-time discussions.”
“At the very beginning,” says Ayalon, “after an amputation until they have a solid treatment plan, I do think that these multidisciplinary clinic approaches should be universal—and that creates issues of access. I hope that the paradigm is shifting, that in the future this is just standard of care. But all we can do is work toward that, and make sure that everyone has the same access to this level of care.
Reif notes that OI is a great example of teamwork in medicine “because it often starts with orthopedic surgeons’ initial consult. But we tend to bring in and interface with a prosthetist usually before surgery, because when you’re doing osseointegration surgery, you really need a prosthetist to help you optimize the components that make up the rest of the limb, i.e. everything that’s beyond that implant in the bone.”
At the same time, he points out, sometimes patients with amputations will present with joint contractures in the knee or the hip, and that becomes a discussion with the prosthetist to determine if they can offset the prosthesis to compensate for the flexion contracture, or whether it would be better to have the contracture released during the OI surgery to try to limit the offset the prosthetist needs to build in.
“There are definitely discussions that can be had beforehand, but most of the discussion is afterwards, when we’re interfacing with the prosthetist to design the best componentry for each individual patient.”
Collaborative team successes are also measured in other ways, points out Laura Katzenberger, CP/L, chief operating officer and director of Clinical Services, Handspring Clinical Services, with CAR. “The CAR clinic has invested in a dedicated research coordinator who collects outcome measures for all our patients. We’re part of a formal research study focused on individuals who have sustained partial hand loss. This important project is geared to document functional and quality of life improvements pre- and post-fitting with various prosthetic technologies.
“CAR is aware that payers routinely deny access to technology that is proven to improve both functional and aesthetic outcomes and that studies like this can change that paradigm.
“This collaborative model is not the standard in the US. We at Handspring are pleased to be part of one of the growing number of innovative surgical/prosthetic/rehab teams like the one that Dr. Hacquebord and Dr. Ayalon have founded at NYU Langone.”
Teaching the Team and Mentoring Others
Kafedzic recommends that those with an interest in participating with an OI team should consult with one of the experienced teams (HSS, University of Colorado, Ohio State University, UCSF, Walter Reed, etc.) to learn why the blended team functions well in cases of this type.
“From the prosthetist’s perspective, it’s seeing it in person that will really change your impression. Every time a prosthetist is sending their patient to one of our HSS OI surgeons, we’ve invited them to come and spend a day with me when their patient is getting a prosthesis. And I’ve trained them in everything I know, answering any questions they may have, because these patients are often traveling from other places, and we want them to have a prosthetist able to take care of them and treat their needs when they go home.”
That invitation remains open to interested prosthetists.
Miguelez educates his own team by sending new members, including technicians, therapists, and prosthetists, into other Arm Dynamics centers so they can see how an effective well-established team interacts with each other.
Their national clinical team created a “Length Matters” guide that is available for surgeons who want to reference the prosthetic options when considering surgical length for an injured patient. “It really opens up the dialogue that we have with surgeons,” Miguelez notes. “We get a lot of calls when they’re in the OR faced with a choice between different surgical lengths in the guide.”
Those choices make a world of difference in the patient’s future abilities. “Our goal is to work with people for the rest of their lives and starting them off with the right surgical length and prosthetic option is an important part of maximizing each person’s fit, comfort, and function.”
Dodson shares the team spirit by collaborating with his patients’ therapists in their local markets. He describes a patient who, like many others, drives 400 or more miles to be fitted at the Arm Dynamics location in Dallas, where they remain for a week, undergoing more than 20 hours of occupational therapy while their prosthesis is being built and fitted.
“When they return home, the hope is that their local OT will consult us as a resource, as needed. When this particular patient began having difficulty opening his hand, his OT called us. By downloading an app on her phone and connecting to his [electric terminal device], she was able to quickly make the corrective adjustment we demonstrated via Zoom. Technology is really improving our ability to solve problems without lengthy travel for in-person evaluations. That previous care model was challenging, but through the use of technology, things are getting better.”
In teaching prosthetics at UT Southwestern, Dodson introduces the concept of team support by giving his card to every student as he offers a future lifeline if they come across a baffling case: “I would much rather you know that you’ve got an available resource and call me,” he tells them, “versus struggling and subjecting a patient to a prosthesis that’s going to push abandonment and rejection of that device. Let’s collaborate.”
Learn more about OI procedures in “Two Approaches to Osseointegration Surgery,” The O&P EDGE, May 2021; “The Present & Future of Osseointegration,” The O&P EDGE, January 2023; and “Constructing an Osseointegrated Prosthetic Leg,” JBJS Essential Surgical Techniques, January-March 2024; or join the American Academy of Orthotists and Prosthetists Bone-Anchored Prosthetics Scientific Society and the Lower Limb Prosthetics Society for opportunities to learn and contribute to discussions that positively impact patient care.
Judith Philipps Otto is a freelance writer who has assisted with marketing and public relations for various clients in the O&P profession. She has been a newspaper writer and editor and has won national and international awards as a broadcast writer-producer.
