Drawn to O&P

COVER STORY

Drawn to O&P

How four professionals from various backgrounds found their way to the O&P profession

&P

Walk into any O&P business, and you will likely find a diverse group of employees from varying backgrounds. While some arrived at an O&P career having grown up in a family business, others pursued the profession after spending time as O&P patients. Still others gravitated toward the profession because they enjoyed classes in high school or college that provide a solid basis for continuing O&P education.

Today, young O&P professionals are coming from an even broader spectrum of backgrounds. Engineering students and researchers, allied health-care professionals, and even computer scientists are finding a place in the ever-growing O&P landscape.

In this series of first-person profiles, a panel of individuals from vastly different backgrounds describe their introductions to the O&P profession and discuss the roles they now fill.

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COVER STORY

The Physical Therapy Route

Chris Doerger, PT, CP

EDITOR’S NOTE: We caught up with OPIE Software Clinical Advisor Chris Doerger, PT, CP, at the Annual Meeting of the American Academy of Orthotists and Prosthetists, where we asked her how she became part of the O&P profession, what roles she has taken on since becoming a certified prosthetist, and her vision of a diverse future in O&P.

Chris Doerger, PT, CP

On Finding O&P My first exposure to orthotics and prosthetics was as a physical therapy student at the University of Miami, but it wasn’t a focal point in

my education. When I was first introduced to the practice of O&P, I was working for a large hospital system as a PT in a neuro outpatient clinic. It was a multidisciplinary clinic; we had orthopedics across the hall and a physiatrist upstairs, and we even had neuro-psych on the second floor.

For one hour on Thursdays we had an “orthotics clinic.” For that one hour, our local CPO would come to the clinic and would see our patients that could potentially benefit from orthotic intervention. So, in our little mini-clinic, we would have the physiatrist, the CPO, and the therapists, and we would look at the patients together, in real time; talk about their cases; and get them what they needed.

I participated in that orthotics clinic for quite a while, and it was shortly after I started that Scott Saunders, CPO, first asked me if I would see any of his amputees. Of course, I said, “No,” because I didn’t work with amputees; I worked with neurological, traumatic brain injury, and

Chris Doerger, PT, CP, with a patient during an OPAF First Clinic.

stroke patients. But he kept coming back to me and asking if he could send his amputee patients to me; I said, “Surely, there is someone in Orlando that can do a better job than I could, which is the only reason I’m telling you no.” He said, “Well, you’d be surprised.”

I said, “OK, fine. Well, if that’s the case, send them over, and let’s see what we can do.” That relationship developed my interest in performing rehab and doing physical therapy with the limb loss population. It got to the point, being the curious person that I am, that I wanted to learn more about prosthetics. Scott was a phenomenal resource. He was there for me when I called him, he would tell me what the different knees did, and he taught me about socket fit.

Ultimately, he encouraged me to go back to school. He suggested a number of great programs, and I ended up at Northwestern.

After graduating from Northwestern, I got started in the profession at Evolution

Industries. Craig MacKenzie, CP, was nice enough to hire me and teach me about what he was doing with his business at the time, which was custom liner design, central fabrication work, socket design, and even management of his central fabrication. I became the clinical and technical director at Evolution.

Eventually Össur acquired Evolution, and I moved into a clinical position that was more of a teaching position. I was teaching clinicians, students, and even PTs about the different Össur products and about how they could more effectively teach their patients to use the devices.

Toward the end of my Össur career, I was probably spending more time talking to PTs on subjects that were less about Össur products and more about documentation, like documenting K levels, and how they could help O&P clinicians by providing corroborating information that the payors were seeking.

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Now, I am in a new position at OPIE Software where I am a clinical advisor, doing something very similar. I am doing a bit of teaching and training on OPIE Software, but also working in the background on updating clinical notes, making them more clinically accurate, and communicating that information to our customers. Obviously, legislation just dropped, so documentation is more important than ever before.

Different Hats Outside of my work at OPIE, I volunteer with a Wounded Warrior Group called Taskforce Dagger, and I work with the Orthotic and Prosthetic Activities Foundation (OPAF) in its First Clinics. We are attaching PT credits to the First Clinics so that we can continue to bring PTs over into the O&P world. I’m also an adjunct faculty member at the University of Central Florida in the DPT program.

As a caveat, the one hat you will not hear me describe is that of a clinical practitioner. I didn’t work in O&P clinical practice much—not like I did in PT. The week after I finished my residency, my nephew was diagnosed with cancer. I had a decision to make; I was done with residency and it was time to take my Board exam, but my family needed my help. I was fortunate to have a PT job that knew me and would allow me to take the time off I needed to help support my family.

The irony of the story is, where most people would go through a clinical track, and work in patient care for a while, and then go work for a manufacturer, I went about it completely backwards. By the time I could focus, pass my Boards, and apply for a clinical practice position, there weren’t any positions open in the Orlando area, but there was the position at Evolution.

Because I had gone back to a PT position after school, there was a chance that I wouldn’t make it back to working in O&P. It had been a year and a half,

or more, when I started thinking about O&P again, and I probably spent a good six more months working in PT, but it just kept gnawing at me. I knew I completed school and completed the residency, and I just felt like I needed to get back there. I had to come back to O&P.

It’s almost like I found the profession twice: once when I met Scott and started my CP education, and then again when my inner self told me not to let it go.

Vision of the Future Given what we know about healthcare statistics and what we know about the potential growth of the profession, there are going to be more opportunities in the profession in the future than there are today. There is more visibility outside of our profession into what we do now because of the military complex and the way technology is booming, I don’t think the growth is going to be limited to clinicians.

When I see the free papers at the Academy meeting on socket comfort, followed by one on 3-D printing, that’s your indication that there are going to be opportunities in materials, technology, and CAD/CAM, and all the diversity of backgrounds that those areas bring with them. Whether it’s health care, electronics, engineering, or material science, I think all aspects of the profession are going to grow.

With the increased visibility to the profession, people from engineering fields will come in. And we will just get deeper and richer in the knowledge that we have about the materials that we use with our patients and how they can impact their function.

The one thing that I maintain, right now, is that where the folks in 3-D printing and other technologies think that they will be disruptors, that might not actually come to fruition. Ultimately, the technique used to create the device doesn’t matter; determining when to use a certain material and what

device is most appropriate to put on a patient will always be the role of the clinician. How to apply that clinical knowledge, education, and skill set will always be unique to O&P.

The most important tool clinicians have is their critical thinking. There might be a number of industry disruptors that transform O&P, but what is not going to change is role of the clinician in taking these disruptive technologies and knowing when to use them judiciously, in order to create the best outcome for the patient.

The Unique Role of the Nurse Specialist

Nancy Payne, RN, MSN, CWCN

EDITOR’S NOTE: Nancy Payne, RN, MSN, CWCN, is the limb loss nurse specialist at Duke University Hospital and is the only nurse specialist in the country with that designation. Nancy shared the story of her introduction to O&P, and her view of the importance of the multidisciplinary team in caring for limb loss and mobility challenged patients.

Nancy Payne, RN, MSN, CWCN

The role of limb loss nurse specialist was not a position at Duke or anywhere else before I took on the job. I was an orthopedic nurse and followed my surgeon into the room of a patient one day. I listenedto him speak so gently and kindly to this patient who needed a hip disarticulation surgery due to cancer. I thought, “What a way with words he has,” and hoped to be like him one day.

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COVER STORY

He had an amputee clinic where diabetic foot infections were treated. I realized that there was this pattern in patients—I was seeing it over and over again, with infections, disease, and cancer. I wanted to be part of the solution. When the surgeon retired, I realized that someone would need to fill the void.

I thought, “Why can’t a nurse coordinate the care of this patient population and work with all the teams that care for these patients?” Watching children and parents, adults, and cancer patients smile after their amputations, knowing they were past the hardest part, filled my heart with pleasure. I thought, “I can make a difference.”

The limb loss population has medical and surgical needs, both of which I felt empowered to push Duke to do a better job providing care for. The surgical management of a patient does not typically include an assessment of the specific needs at home or take into account the difference between acute rehab and skilled nursing facilities.

To make it more complicated, medical teams do not typically operate on these ischemic or infected patients with traumatic wounds. Wounds fascinated me, and I desired to help this population stay out of the hospital, be relieved of pain, and become mobile again. I thought, “Yes, I can do this!”

The job of prosthetists and orthotists is to work with what others have left them. Excess tissue is not always easy to work with; adherent tissue due to failure of primary healing process means that closer attention must be paid to the patient, which results in more visits to the prosthetist. Orthotists rely on custom-fit or off-the-shelf orthoses to support a body part to promote a better and safer functionality. These were all areas of the patient-care process that I understood.

I also understood that the type of education provided to the patient must parallel the education level of the patient. This was not always happening in the hospital. I now work with nursing residents

Nancy Payne, RN, MSN, CWCN; Congressman Brian Mast; Stella Sieber; and Erica NeSmith pose for a photo after meeting in the U.S. Capitol Building tunnel during the 2017 AOPA Policy Forum.

of the vascular, orthopedic, and plastic surgical teams to provide the patient and, subsequently, the prosthetist/orthotist, with the best outcomes possible.

I truly believe that it is not just one person treating a patient, but that it should be an entire team. I wish there were more nurses in the same role I fill at Duke. I help educate patients and their families, help direct peer visitors, and help organize the physicians, prosthetists, orthotists, and wound care staff—all on behalf of the limb loss patients at the hospital.

I feel connected to the team I work with: physiatrists, physical therapists, occupational therapists, prosthetists, and nurses. Without one of these team members, the patient does not receive the multidisciplinary team approach to help them recover and reintegrate into their world. Seeing individuals walk

again, or young children run and play again, has been my greatest pleasure in my career.

Yes, I also know that the 90-year-old should be given a chance. The older patients are often pretty excited to show everyone that they can beat the odds. Some may give little-to-no hope to the geriatric population to ever walk again after amputation. No matter the patient’s age, I get to work with the prosthetist to meet their goals and those of their family. When they aren’t sure what to ask for, education is key; as a nurse, I always love to educate.

I hope to one day convince the Wound, Ostomy, and Continence Nursing Society to view amputation teaching and care similar to that provided to the ostomate. Both patient populations have had a chronic problem, experienced surgery to remove some-

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COVER STORY

thing, and now have an external device to provide the functionality they previously had, yet one benefits from a fully supported plan of care, while the other does not.

I personally see individuals who need higher-functioning prostheses, and I know that better technology will help them get out of their wheelchair or bed sooner, preventing further medical issues. Likewise, I believe that lighterweight prostheses should be available for neuropathic patients.

The orthoses and prostheses these patients need should be considered a medical necessity, like blood pressure medications or an anterior cruciate ligament repair for an athlete to be able to play another season. The insurance companies have too much control over what the patient has access to, with no real understanding of what the patient needs in order to progress to his or her full potential.

The Call to O&P Research

Stephanie Huang, PhD

EDITOR’S NOTE: Stephanie Huang, PhD, is a research assistant professor at North Carolina State University. She works in the Closed-Loop Engineering for Advanced Rehabilitation (CLEAR) Lab, housed in the Joint Department of Biomedical Engineering at North Carolina State University and the University of North Carolina–Chapel Hill.

Stephanie Huang, PhD

My research career began very early, during the first year of my undergraduate studies at the University of Michigan, where I eventually earned my bachelor’s

degree in mechanical engineering and master’s and PhD degrees in biomedical engineering. I was drawn to research because I’ve always been allured by the challenge of problem solving—trying to figure out something new even when I didn’t quite have all the knowledge I needed to answer a question.

Research also gave me something that I could be good at and excel at outside of the classroom, where I could depend on my tenacity and perseverance to achieve success. I was drawn to the broad field of human biomechanics and rehabilitation because living in a human body, it was something that was tangible and that I could easily relate to. What’s allowed me to develop a multifaceted and comprehensive approach to my research is that I had a wide variety of research experiences within studying human movement.

I’ve worked in various research labs with different perspectives and approaches under different academic departments,

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Stephanie Huang, PhD, and amputee volunteer James Frazier

where I acquired and gradually accumulated unique skill sets that I could use to solve new research questions. In particular, understanding how to design for humans and how to accommodate humans in the design process is something that I feel is a strong asset for me in pursuing the research I do now in the field of lower-limb prosthesis control. The importance of understanding the needs of your target population or end user (for designing prostheses, that’s the amputee) is something that is often underestimated or overlooked.

I was first introduced to prosthetics research as a doctoral student at the University of Michigan, where my advisor gave me the opportunity to work on part of a grant from the Department of Defense involving myoelectric control of lower-limb prostheses using residual muscles of below-knee amputees. There are many ways that residual muscles can be used for myoelectric control of powered lower-limb prostheses, but my PhD advisor pushed me to pursue direct continuous proportional myoelectric control, free of automation—pure voluntary control.

If I’m being completely honest, I didn’t

become fully invested in this research direction and realize its importance until I saw the emotional effect that direct voluntary control had on amputees. When the amputees I worked with realized they could use their residual muscles of their amputated leg to directly control the behavior of a powered prosthesis, they were amazed and it was empowering. One amputee would later tell me that the experience of this direct voluntary control felt to her like a sense of rebirth; another amputee said he felt like Avatar with a new body; yet another amputee said he felt younger and freer.

This sense of freedom that comes from being reconnected to their complete body (by way of controlling a powered ankle prosthesis directly using their residual muscles) was what made it very clear to me that there was a still a lot to gain in prosthesis technology to get amputees to the height of living that they once had with two intact legs, prior to limb loss. After realizing the potential impact of this line of research, along with noticing that very few researchers were exploring this space, I became fully invested.

Before I started with lower-limb research, I hadn’t known much at all

about amputees or prosthetics. The amputees and clinicians that I worked with became my greatest teachers. During the height of my dissertation research, I spent long hours over the course of many days with a handful of amputees during my experimental testing sessions that allowed me to build close relationships.

Through these relationships, I really started to understand, the best I could as someone with fully intact limbs, what being a lower-limb amputee was like in their daily life, in their thought and decision-making processes, in their general outlook and perspective on various aspects of living with limb loss. What I’ve come to realize in my research approach is that I truly consider the amputees I work with as an integral part of the team. It’s an important mindset and a mindset from which I never waver. Together, we are a team, and we are in it together, and there is trust.

On this foundation of trust, I have learned so much from the amputees through their willingness to share experiences, opinions, and thoughts—both directly related to and indirectly related to my research—which continuously shapes my research trajectory. The amputees that I have worked with throughout my research career also have proven to be some of my strongest and truest advocates; they continue to be the support system I need to continue pushing through my research challenges and struggles, and it is also a sort of validation that the research we are working toward together is achievable and worthwhile.

Just as important as the amputees are the clinicians, including prosthetists and physical therapists, who are able to see things during my testing sessions that I lack the experience and clinical background to see. The clinicians have been invaluable to fostering both creative and critical thinking in working with the amputees to achieve my research goals. Having the opportunity to work with a certain prosthetist at the Orthotics and

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The experimental powered ankle prosthesis is a test bed for direct continuous myoelectric control via residual muscles. The actuators are called pneumatic artificial muscles (PAMs) because their dynamics are similar to skeletal muscle. PAMs can generate high torque output and their compliance provides ample back drivability, which makes them ideal for the powered prosthesis test bed. The inflation pressure of the dorsiflexor/plantar flexor PAMs is directly proportional to the control signal from the residual dorsiflexors/plantar flexors. This allows the amputee to freely control the behavior of the experimental powered ankle.

Frazier is learning to use direct continuous myoelectric control to alter the mechanics of the experimental powered ankle prosthesis according to various environmental conditions. Above, he is freely exploring how he can use his residual ankle muscles to interact with a highly compliant surface (the blue mat). The computer screen shows real-time feedback of his residual muscle control signals.

Frazier is balancing on a 2x4 without holding onto hand rails, and he was able to use the direct continuous myoelectric control to generate small corrective movements using his residual dorsiflexor and residual plantarflexor muscles to generate similar behavior to his intact ankle.

Prosthetics Center at the University of Michigan really set a high bar, a necessary standard, for the clinicians with whom I seek collaborations today.

Currently, I am at North Carolina State University. I am continuing and expanding my research working with below-knee amputees and proportional myoelectric control. I am directing my energy toward a case study with one representative below-knee amputee with hopes that researchers and clinicians in the field who read this case study will be able to gain a comprehensive understanding of what is necessary for amputees to learn to use their residual muscles (plantarflexors and dorsiflexors, independently) for direct neural control of a powered ankle prosthesis and to demonstrate the functional gains that can be

achieved in standing balance and stability with adequate training.

Although in my research I am seeking prosthesis technology that is decades out from reaching the amputee user population, along the way I can see opportunities for delving into more clinically direct questions that will inevitably need to be addressed for future feasibility of implementing direct neural control using residual muscles.

Specifically, I’ve learned the importance of residual muscles—not only for future direct neural control of powered prostheses, but also for improving rehabilitation for amputees following limb loss and for improving the residual limb/ prosthesis socket interface to allow amputees to actively use their residual muscles when using passive devices to enhance the

connection between their body (including their prosthesis) and their environment. I am actively working with a prosthetist now to bring this clinical aspect of the research regarding socket fit and residual muscle health to the attention of clinicians nationwide.

Bridging the gap between clinicians and researchers/engineers/scientists is a longstanding issue and challenge. In fact, it was something that was told to me during my very early years as an undergraduate researcher—that bridging that gap is very difficult. And it is true: Clinicians and researchers coming together, working together, and sharing together on a consistent basis has proven to be a challenge. To address this challenge, it’s going to require a cumulative effort on the small scale of individuals.

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If each of us involved in research does our duty to reach out to make new connections, foster connections to build up the clinician/researcher community, and break down barriers of judgement to gain mutual respect for one another, then gradually we’ll see a shift and a formation of a true conglomerate of clinicians and researchers that is necessary to make a realizable impact in the advancement of prosthesis technology that can improve patient outcomes.

The Computer Science & Engineering Connection

Josef Borrayo

EDITOR’S NOTE: Josef Borrayo is one member of a group of undergraduate electrical engineering students at the University of Washington who found their way to O&P through a capstone project with an outside advisor, David Boone, MPH, PhD, chief executive officer of Orthocare Innovations. Other members of the group include William Aguilar, Sammy Souaiaia, and Naveed Safavi. Here, Borrayo shares his first experience with O&P.

Josef Borrayo is one member of a group of undergraduate electrical engineering students. From left: Borrayo, William Aguilar, Sammy Souaiaia, and Naveed Safavi.

At the beginning of our capstone assignment, we were presented with a number of projects that all seemed enticing. This project, however, was unique in such a way that what we produce would not sit on some shelf; it would be beneficial to society. Our capstone advisor, Joe Decuir, told us to pursue challenges that we would be proud of. Instinctively, the Outcome Assessment Reporting System (OARS) project came to mind.

Prior to the OARS project, we knew very little about orthotics and prosthetics.

Some members of our group were familiar with a project on campus that involved a 3-D-printed hand/wrist prosthesis. Other than this, all four of us [Borrayo, Aguilar, Souaiaia, and Safavi] are undergraduates on the electrical engineering path and entering unfamiliar territory, as this project is mainly computer science.

From our very first meeting with Dr. Boone at his office in Edmonds, Washington, he was generous enough to give us a full tour and a general overview of how prostheses are meticulously

engineered and manufactured, then tested. He also presented his team’s goals and discussed how prostheses can be useful for amputees in improving their mobility and, most importantly, their overall quality of life.

We believe that the utilization of computer science and engineering can be very useful in the future of orthotics and prosthetics to provide pathways that lead to cheaper and smarter prostheses, that are both more efficient and adaptable to provide the best outcome from the user’s experience.

The team of students meets with its advisor, David Boone, MPH, PhD, (left), at his office in Edmonds, Washington.

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