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The Bio in Technology
By Jeff Fredrick, MS, CPO  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. 
Table Of Contents - September 2006
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