At the Academy Annual Meeting and Scientific Symposium, a technical presentation generated a discussion of fabrication methodologies and how they determine or define a prosthesis. The conversation called into question the notion of what Western society defines as a prosthesis. Is it simply a socket, shank, foot, and suspension—or can it be something alternative? Can it include nontraditional or repurposed items? Do the alternatives meet the accepted or modern definition of a prosthesis?
The World Health Organization (WHO) defines a prosthesis as an “externally applied device used to replace wholly or partly an absent or deficient limb segment.”1 The specific details of how that limb segment is replaced is determined by the prosthetist and patient and is not prescriptive as to the exact materials or components. Quality standards remain essential and the WHO outlines that “reuse of prosthetic and orthotic components must be monitored properly to prevent use of low-quality, overused, or defective items, which could result in accidents and injuries.”1
While patient safety remains paramount, prosthetists and orthotists are equally committed to improving access, mobility, and quality of life. This raises an important question: How can clinicians deliver effective care when resources are limited, and creative solutions or alternative materials are required? In many settings, particularly in developing regions, clinicians often devise innovative approaches when traditional options are unavailable. This adaptability reflects the inherent problem-solving nature of the profession, especially in environments where regulatory constraints may be reduced. The WHO does specify that “in order to fabricate high-quality prostheses and orthoses most efficiently, prosthetics and orthotics service units require high-quality components, materials, consumables, tools, machines, and other equipment, some of which are often imported.”1 This highlights an ongoing challenge between innovation driven by necessity and the infrastructure required to consistently deliver high-quality care.
Evolving Clinical Roles and Workforce Skillsets
In more developed healthcare systems, where access may be of less concern and advanced fabrication options are readily available, the emphasis has shifted toward the care provided with the device rather than the device itself. As a profession, we have moved away from counting the number of prostheses and orthoses provided and, appropriately, focused on more clearly defining our role within the interdisciplinary healthcare team. Over the past 15 years, educational requirements and standards, both in the entry-level educational content and in the residency programs, have reduced focus on fabrication. The National Commission on Orthotic and Prosthetic Education has transitioned from tracking patient devices to requiring minimal activity volumes (MAVs). MAVs encompass patient encounters in which a resident observes, assists with, or independently provides patient care. Similarly, the American Board for Certification (ABC) organizes competencies into domains rather than quantifying items produced or fit. Clinical reasoning skills such as evaluation, creation of a treatment plan, and troubleshooting are the primary focus of assessment more than the hands-on fabrication of the prosthesis or orthosis.
Anecdotally, it seems students are entering the profession with less prior experience in tooling and fabrication. The increasing educational requirements and broader evolution away from a traditional trade work model are likely contributing factors, yet students are drawn to the profession by a desire to design and assemble solutions that utilize psychomotor skills. O&P requires a unique combination of attributes that has long distinguished it from others in the interdisciplinary medical field. Clinicians have the opportunity to spend their days in a dynamic work environment—one that is less stationary and sedentary in nature than many others in the modern workplace. Due to increased documentation requirements, evolving clinical care models, and the growing use of centralized fabrication, the frequency of technical work performed by certified prosthetist/orthotists is declining.
Traditional fabrication skills remain incredibly valuable, particularly as educational standards include more clinical-based competencies. For example, clinicians must evaluate an orthosis or prosthesis fabricated off-site prior to fitting a patient. Their expertise is needed to confirm technical specifications are met in addition to making any necessary adjustments during the patient appointments. Situations may also arise that require a clinician to step into a fabrication role, such as when a technician is unexpectedly absent or out of the office for an extended period. These realities underscore that technical proficiency remains essential and must not be diminished in clinical practice. The 2022 ABC Practice Analysis of Certified Practitioners in the Disciplines of Orthotics and Prosthetics noted that in “personnel at their primary work setting,” the biggest change from 2015 was in the domain of fabrication. In orthotic care the percentage reduced from 55 percent to 41 percent, while in prosthetics it reduced from 60 percent to 45 percent.2 This trend raises important questions about how patient outcomes are impacted when clinicians are required to troubleshoot devices but face limitations in technical abilities or access to on-site equipment. Often a delicate balance must be found that allows clinicians the ability to per-form both clinical and technical tasks effectively or work in team-based models that include specialized technical roles.
Fabrication, Education, and Materials Innovation
Many O&P technicians discover the field and are trained on the job, often without formal education in engineering or manufacturing. As a result, understanding the conceptual or underlying theory as to why processes are a certain way is challenging. Why is lamination performed with five layers or six? Is there a formula for that? Students in clinical education often struggle with these concepts as well. How does one choose the thickness of a plastic sheet or the appropriate durometer of foam to use as a foot orthosis top cover? An increasing number of students are entering the field from engineering or biomedical engineering backgrounds and are seeking these quantitative answers or equations. This underscores the continued need to transform experiential knowledge into useful evidence-based information.
O&P is rooted in a rich history of trade-based skills passed down via apprenticeship with the knowledge base of fabrication techniques evolving during times of war and through industrial advancement. The very definition of fabrication has expanded due to advances in materials science, including the development of thermoplastics, composites, and additive manufacturing technologies. Digital workflows and electronic medical records have also transformed how clinicians and technicians optimize solutions.
As diverse fabrication techniques have emerged, a need has arisen to differentiate the newer methods from the traditional. Within the Academy’s Scientific Societies, Fabrication Sciences is the unifying thread among all societies. The focus of the group has become associated with traditional fabrication methodologies, distinguishing it from the Digital Innovation Society (formerly the CAD/CAM Society). The Fabrication Sciences Society honors the legacy of its pioneers by preserving its historical foundations while also modernizing its contributions to the profession. Rather than functioning solely as a how-to resource aimed at the technical audience, the society has made an intentional shift toward emphasizing scientific knowledge that extends beyond technical skills. Incorporating research, outcomes, and scientific testing into the decision-making process via a focus on materials science has been central to this evolution. The US National Science Foundation describes materials science as exploring “the basic structure, properties, and behavior of materials down to the molecular, atomic, and even subatomic levels—to create goods that benefit society.”3
For the O&P profession, it is essential to expand and deepen materials science knowledge that will impact clinical decision-making and ultimately affect patient function and outcomes.
Advancing Evidence and Shaping the Future
Sophisticated scholarly research in O&P is being performed more now than ever before, much of which is aimed at addressing the quantitative shortfalls and their impact on outcomes. In 2020, the American Orthotic & Prosthetic Association (AOPA) established the AOPA Socket Guidance Workgroup to provide the prosthetic community with evidence-based clinical best practices and methodologies for prosthetic socket structural analysis. The group noted that “despite the socket’s central role in comfort and function, no standards or common guidelines exist to test their structural strength, either in ultimate failure load or in fatigue durability.”4 This report highlights the complexity of socket design, in which the material properties of composites, combined with the additional components that comprise the prosthetic assembly, interact to create a complex system. Modifications and additions to sockets such as cutouts, valves, and holes for mounting componentry further alter load distributions and structural integrity and have not been adequately studied.
Similarly, The O&P EDGE article, “Prescribed Precision: Dosing AFO Stiffness for Maximum Outcomes,” underscored the need for a standardized quantitative approach to fabrication of composite AFOs. The article explains that “presented with a plethora of options for materials and more options for fabrication, clinicians are often left to make decisions based on previous experience and intuition.”5 If a standardized system existed where clinicians could order a precise value for stiffness, similar to categorization used for prosthetic feet, patients and clinicians would experience more consistent, reliable, and efficient care. Establishing this baseline would align orthotic practice with technological advancements and the expanding body of scholarly evidence.
Together, these examples illustrate a gap in available technology and standardized, evidence-based application. Advancing quantitative methods and integrating materials science into clinical decision-making will be a critical step in the future of O&P clinical care to ultimately optimize patient outcomes.
As the O&P profession adapts to the modernized and interconnected world, it is paramount that fabrication and materials science knowledge remain integral components of O&P education. Across all domains of practice, clinicians must consider materials sciences in their design choices and understand how these decisions impact patient outcomes, function, and quality of life. At the same time, we must also utilize advancements in technology to elevate the standard of care, and access to care, around the world. Additive manufacturing is already expanding the reach of O&P to a global audience, and, with increased use of renewable power sources and open-source design sharing, communities are connected in unprecedented ways. Even as the profession advances, the foundational element of knowledge transfer—through apprenticeship or training, whether formal or informal—pass knowledge from one generation to the next and is vital to continued growth. As traditional and emerging technologies converge, we are on the brink of reimagining the definition of a prosthesis or orthosis, one that is shaped not only by materials and methodologies, but also by how we collectively utilize resources across the globe.
Lindi Mitsou, MSPO, CPO, FAAOP, is an associate professor at the University of Hartford and cochair of the Fabrication Sciences Society for the American Academy of Orthotists and Prosthetists.
Academy Society Spotlight is a presentation of clinical content by the Scientific Societies of the Academy in partnership with The O&P EDGE.
References
- World Health Organization. 2017. Standards for Prosthetics and Orthotics. Geneva, Switzerland: World Health Organization.
- American Board for Certification in Orthotics, Prosthetics & Pedorthics (ABC). 2022. Practice Analysis of Certified Practitioners in the Disciplines of Orthotics and Prosthetics.
- National Science Foundation. Materials Research. https://www.nsf.gov/focus-areas/materials
- Gariboldi, F., A. G. Cutti, and S. Fatone, et al. 2023. Mechanical testing of transtibial prosthetic sockets: A discussion paper from the American Orthotic and Prosthetic Association Socket Guidance Workgroup. Prosthetics and Orthotics International 47(1):3-12.
- Brice K. 2025. Prescribed precision: Dosing AFO stiffness for maximum outcomes. The O&P EDGE 24(11):22-5.
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