The Bio in Technology

In the now historic second half of the twentieth century, orthotic and prosthetic rehabilitation often was as limited as it was sponsored by the technology available. Inherent deficiencies in technology only allowed us to rehabilitate so far. For example, the heavy weight and quad design of an AK prosthesis in 1960 did not promote higher functional levels in amputees, especially in obese or geriatric patients. And younger, stronger amputees were drastically demeaned by the limits of O&P technology. Think not? Before technology and materials science improved our armamentarium of protocols, the serious notion of amputee sports did not exist. Still skeptical? Bang out a plug-fit, joints and corset, wood core exoskeletal BK for a half dozen of your active patients and ring me up with the results-if you are still in business. Functional level minus what!? We now possess the technological savvy to effectively rehabilitate people of almost every patient class to higher functional levels than even a decade ago-depending, of course, on relevant etiological factors. The limits of O&P rehabilitation are subtly shifting more to the residual biology of the patient as an augment or constraint, rather than technological variants. Let's consider a mock clinical workup: A deconditioned 65-year-old BK amputee presents for a pre-prosthetic consult and possible shrinker fitting. He has been in a wheelchair since a diabetic ulcer began to consume his left foot 15 months ago. Three things we know. At age 65, even one month in a wheelchair can rapidly decondition. Secondly, any 65-year-old undergoing the stress and trauma of a surgical amputation sustains gross weakening of all other structures in the human bio-system. So, thirdly, no matter how expertly I fit perfect, state-of-the-art components, when the patient first stands up, he isn't going far. The point is: most patients are as much, if not more, restricted by their biology today as they were 50 years ago by primitive componentry. Why then is our profession still focused only on technology for reimbursement? In my practice, I now spend as much time dealing with deconditioning and weight gain issues as I once spent choosing the most appropriate prosthetic knee, foot, or socket design. Agree? Whether you do or not, those who intend to encroach on our scope of practice certainly do. The more we streamline technological solutions to O&P rehabilitation, the higher our reimbursement for these services climbs, the more likely it is that related allied health professions will reach into our bag of options. I presently serve on Florida's Board of Orthotists and Prosthetists. It would behoove every practitioner to read who is excluded from licensure, and who is allowed to fit various forms of rehabilitation technology we once believed were the sole prerogative of O&P practitioners. Where will we be in five more years if CAD/CAM, scanners, and "one-size-fits-all" technologies continue to redefine the market? We may find our infatuation with technology has become an enemy in disguise. I've identified a problem, so how about a solution? Is there anything we can do about it? Actually, there is! We need to change how we view our own profession if we want other medical practitioners and the general public to recognize the full potential of our rehabilitation skill set. The single most significant change, as I see it, is the recognition that the O&P practitioner is responsible for rehabilitation as a process. It is a process that, by definition, includes the patient's biology-a process that involves the O&P practitioner as much in the biology of the patient as it does the technology. A practitioner on my staff complains he routinely must show physical therapists how to correctly evaluate and train his patients toward achieving an acceptable prosthetic gait. PTs constantly ask for advice on what is an acceptable outcome. And yet, they are paid for gait training-and we are not. We are providing a definitive service, but are not recognized by payers for this. I submit, the prosthetist-orthotist is, by virtue of the critical nature of his/her intervention, the most inherently qualified member of the clinical team to provide gait training and active stretch and supervision of the same. Who is more qualified than the clinician who actually designed and fabricated a prosthesis to supervise and train a patient in the use of the technology he or she provided? Unfortunately, we are seen as some kind of materials supplier, not a clinician with potential commensurate with our education. So, what can we do about it? Two new O&P codes would help initiate a remedy. Logic argues that prosthetics should include gait training, and orthotics, contracture management when an orthosis is prescribed. The addition of these two basic and well-deserved codes will enable us to gain reimbursement for services we have long provided without any compensation or recognition. Can you imagine adding three visits a week to the reimbursement for a prosthesis to provide the same services physical therapists submit as necessary to competently rehabilitate a patient? In the end, it's not really about what technology we are perceived as providing best in terms of our vulnerability to encroachment. It's more about what we are not perceived as capable of educationally when in fact we are actually providing these services already. It is time for us to realize our complaints and efforts to resist encroachment have profited us little. Maybe the best defense truly is a good offense. All aspects of O&P rehabilitation should rightfully come under our direct purview. Referring the patient to other allied health practitioners for services we are more qualified to provide only inconveniences the patient, lowers the standard of care, and runs up higher reimbursement costs to providers. The case for fair and accurate codes makes itself! Let's lobby for it and more! Jeff Fredrick, MS, CPO, is director of Hanger's Rehabilitation for Development (Hanger RFD) and branch manager at Hanger Prosthetics & Orthotics, Tallahassee, Florida.

The Bio in Technology

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Income Climbs, Poverty Stabilizes, Uninsured Rate Increases

Famed Amputee Elephant Gets New Prosthesis Pads

Famed Amputee Elephant Gets New Prosthesis Pads

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