Physiatrists and
prosthetist/orthotists have much in common. Both practitioners are
members of small and somewhat misunderstood specialties, are
trained to care for people with disabilities, and try to improve
patients’ function. Practitioners from both professions devise
treatment plans based on biomechanical analyses of their
patients/clients. Further, both professions are challenged to
justify their treatments and judgments by increasingly skeptical
payers. Both professions must face the incursion into their
practices of other professions or specialties that may not be as
well trained or qualified.
With all these similarities, there should be no surprise that
there exists a natural synergy when prosthetist/orthotists and
physiatrists work together. Among physicians, physiatrists are
uniquely qualified to work with people who have undergone
amputations or who need or are considering orthoses. The specialty
of physical medicine and rehabilitation (PM&R) grew out of the
need to care for disabled veterans and promote their recovery after
they had survived their initial injuries and illnesses. Many of
these veterans had newly acquired amputations. Although the scope
of the field has broadened, PM&R residency still requires
exposure to prosthetics and orthotics.
As a specialty that also performs electrodiagnostic evaluations
and cares for people with a wide variety of musculoskeletal
complaints, physiatrists must gain mastery of the musculoskeletal
and peripheral nervous systems. They also take responsibility for
the rehabilitation of those with central nervous dysfunction,
including stroke, traumatic brain injury, and spinal cord injury.
They devise solutions for those with physical, cognitive, and
emotional impairments.
In these and many other settings, PM&R residents learn to
function as both members and leaders of multidisciplinary teams.
These experiences lead physiatrists to perceive people in multiple
dimensions of function, recognizing strengths and weaknesses along
personal, spiritual, psychological, social, medical, vocational,
and physical axes.
The most natural setting for prosthetist/orthotists and
physiatrists to meet is in a prosthetics/orthotics or amputee
clinic. Typically, the overriding goal of such clinics is accurate,
comprehensive assessment and management of patients referred for
orthotic or prosthetic considerations.
The physiatrist in such a clinic has multiple important
roles:
First, the physiatrist provides the prescription for all
prosthetic and orthotic devices. Ideally, the physiatrist provides
an independent viewpoint, free of the potential of conflict of
interest, since the physician has no financial stake in the
prescription. Because of this independence, the physiatrist is
often seen as more credible in the eyes of the patient.
Often the physiatrist is placed in the role of “quality
control,” offering an independent assessment of whether the proper
item was fabricated to reasonable standards. The physiatrist can
also help the patient understand what can be realistically expected
from certain devices and what devices are appropriate in a given
situation.
The physiatrist also has the ability to explore and offer
solutions beyond the immediate issues related to prostheses and
orthoses. These issues can include wound healing and pain
management; evaluation, treatment, or referral for related medical
disorders, such as diabetes, peripheral vascular disease, or
peripheral neuropathy; and the prescription of physical therapy or
occupational therapy as part of the treatment plan. Those who
present to a prosthetics/orthotics clinic may have vocational,
adjustment, or musculoskeletal issues which the physiatrist can
address.
Physiatrists deeply appreciate the host of complementary skills
prosthetist/orthotists bring to the table. Most physiatrists rely
on the prosthetist/orthotist as the expert in fabrication and fit.
Further, the prosthetist/orthotist typically learns of advances in
the O&P field before the physiatrist. As partners, the
physiatrist and prosthetist/orthotist can untangle complex problems
such as pain or poor use of the prosthesis. The physiatrist can
help rule out or treat factors intrinsic to the patient, such as
weakness, pain, and volume fluctuation. The prosthetist/orthotist
often takes the lead in assessing alignment and componentry.
Prosthetists/orthotists help by sharing their knowledge and
experience not only of what is likely to be successful, but also of
what is unlikely to be successful.
Because physiatrists’ and prosthetists/orthotists’ backgrounds
and interests are not identical, it is important that professionals
from both disciplines earn each other’s respect. Thoughtful,
compassionate care, with a willingness to learn, will build trust.
Building and maintaining trust takes constant attention, and only a
few instances of transgression can severely damage the
relationship. Thus, it is imperative that physiatrists follow
professional conduct, taking responsibility for excellence in
medical and rehabilitative treatment and always keeping the best
interests of the patient in mind. Likewise, prosthetists/orthotists
who stand behind their work, follow sound biomechanical principles,
and bill reasonably and accurately will earn the respect and trust
of their medical colleagues.
In the best relationships, both parties learn from each other
and enhance each other’s abilities to accurately assess patient
problems, potentials, and the capacities and limits of available
equipment. In this give-and-take, we learn to support and improve
each other’s practice, and we deliver superior service to our
patients/clients.
Charles E. Levy, MD, is assistant professor, Department of Ortho-paedics and Rehabilitation, College of Medicine, University of Florida, and is the author of numerous peer-reviewed and book chapters.
