2018: A New Year for O&P, New Challenges, New Tax Law, and a New Publication to Enhance AOPA’s Scope of Communications JANUARY 2 01 8
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Vol. 27 • No. 1 | January 2018
Departments & Columns 2 Publisher’s Note
08
22 State by State A monthly column dedicated to
18
the most important state and local O&P news.
24 In the News 26 Meetings & Courses 27 Classified Ads COVER STORY
04
We Did Everything To Save That Leg
27 Ad Index 28 Tech Tips Expert insights for technicians.
Five health-care professionals with expertise in O&P weigh in on the topic of gait salvage and amputation Contributions from Michael Dillon, PhD, BPO (Hons); Stefania Fatone, PhD, BPO (Hons); Grace Wang, MD, FACS; Eric Burns, CO; and Mallory Lemons, CPO
FEATURES
Research & Presentations 08
Comparing the Transfemoral HiFi System to a Traditional Ischial Containment Socket By Tyler D. Klenow, MSOP, CPO, LPO
14
A Flexible AFO: Contradiction to Traditional Thought?
18 O&P Visionaries Jeffrey Brandt, CPO, discusses the ideal O&P environment
By Suzanne Guiffre, PT, EdD; Joseph Whiteside, CO, LO; and Cathy Bieber Parrott, PT
O&P News | January 2018
1
Publisher’s Note
W
elcome to the New Year and the first issue of the vastly revised O&P News, the first since the primary assets of this publication were acquired by AOPA. We are excited to bring you a new format and general scope of all things O&P related. You may ask, what is the method to the madness? Fair question. Being aware that the O&P community is a relatively small niche in the overall medical community, we would like to offer more diverse content to reach a more diverse audience. We would like to share all things O&P with our referral community, including therapists, orthopedic and vascular surgeons, rehabilitation physicians, physical medicine, and any and all avenues that surround and affect the education, science, and business of orthotics and prosthetics. This open dialogue creates grounds for innovation to meet the demands of the present whilst mapping the future. The new magazine also taps into a high ongoing demand for O&P research. With each monthly issue of the magazine, O&P News will endeavor to present the public with a hot, controversial, or other topic of bottom-line value, and a perspective from an experienced O&P practitioner—what would I change if I could in the O&P world? Jeffrey Brandt, CPO, has been good enough to provide this month’s practitioner’s perspective, and we want to have others follow. We’ll also present quality papers or presentations, most if not all of which have not been published elsewhere beyond in abstract form. We also are providing manufacturers a chance to voice their findings, hopes, and insights, in the broad-based form of a sponsored content article. Collectively, we think this can meet some unmet needs, and provide for an expansion of quality research to be shared with all avenues of the O&P and general health professions. Each issue will feature clinical insights from top minds in patient care, research summaries, and insights from leaders with vast experience in the O&P field to share their wisdom, product news, and anything relevant to the related branches of health care. This month’s issue focuses on gait salvage, with a feature article from notable researchers Michael Dillon, PhD, BPO (Hons) and Stefania Fatone, PhD, BPO (Hons). Their views on partial foot amputation and shared decision making are complemented by perspectives from University of Pennsylvania vascular surgeon Grace Wang, MD, FACS, and notable practitioners Mallory Lemons, CPO, and Eric Burns, CO. With each month, O&P News will strive to show relevant themes through multiple lenses and perspectives as the facets of the industry expand. Welcome to the new O&P News. We hope you find it a thoughtprovoking and informative new resource that complements AOPA’s flagship publication, O&P Almanac. Thomas J. Fise, JD Publisher O&P News
Editorial Board O&P Practitioners
Randall Alley, CP, BSc, FAAOP Biodesigns Inc.
Hutnick Rehab Support Services Inc.
Kevin Carroll, MS, CP, FAAOP
Greg Mattson, CTPO
Hanger Clinic
Glenn Garrison, CPO
Hospital for Special Surgery
JoAnne Kanas, PT, CPO, DPT
Pediatric Orthotic and Prosthetic Services, LLC, Shriners International Headquarters
Thomas P. Karolewski, CP, FAAOP Hines VA Hospital
O&P News | January 2018
Fabtech Systems LLC
Scott Wimberley
Fabtech Systems LLC
O&P Industry
Michael Angelico
Advanced O&P Solutions
Debbie Ayres
Joel J. Kempfer, CP, FAAOP Kempfer P&O
American Board for Certification in Orthotics, Prosthetics, and Pedorthics Inc.
Robert S. Lin, MEd, CPO, FAAOP
Jeffrey M. Brandt, CPO
Hanger Clinic
Jonathan Naft, CPO
Geauga Rehabilitation Engineering
Ability Prosthetics & Orthotics Inc.
Sue Borondy Endolite
Matthew Parente, MS, PT, CPO
Jennifer Fayter
University of Hartford
Nabtesco & Proteor in USA
Justina S. Shipley CO, MEd, BOCP, FAAOP
Russell Hornfisher
Shriners Hospital For Children
Eric Shoemaker, MS, CPO
Orthotic Holdings Inc.
Jeffry G. Kingsley
Kingsley Manufacturing
Ability Prosthetics & Orthotics Inc.
Karen Lundquist
Rhonda F. Turner, PhD, JD, (BOCPO, CFm)
Brad Mattear, LO, CPA, CFo
American Association of Breast Care Professionals
O&P Researchers and Educators
Steven A. Gard, PhD
Northwestern University Prosthetics-Orthotics Center
Mark D. Geil, PhD
Georgia State University
Mark Pitkin, PhD, DSc
Tufts University School of Medicine
Amputee Coalition Nabtesco & Proteor in USA
Matt Perkins
Coyote Design and Rehab Systems
Don Pierson, CO, CPed Arizona AFO
Brooke Raasch
Össur Americas Inc.
Jon Shreter, CPO
Prosthetic and Orthotic Management Associates Corporation
Michael Sotak
O&P Technicians
PEL
Sarah Clark
Scott Viglianti
O&P 1
WBC Industries
Tony Culver
Lisa Watkins
Grace Prosthetic Fabrication Inc.
WillowWood
Steve Hill, CO, BOCO
MBA, CAE, Board of Certification/Accreditation
Delphi Ortho
2
Glenn Hutnick, CPO, CTP, FAAOP
Claudia Zacharias
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COVER STORY
We Did
Everything
To Save That Leg Professionals from across the health-care spectrum share their thoughts on gait salvage and amputation decisions
H
ealth-care professionals involved in amputation decisions must take a number of factors into account in determining when and how to proceed. There has been much discussion over the years regarding when it’s appropriate to pursue limb salvage versus when a patient will benefit from amputation, which may lead to gait salvage. Perhaps the most important part of the decision process involves ensuring all individuals on the health-care team and their patients are fully educated about amputation, rehabilitation, and prosthetic advancements. O&P News asked five experts on this topic—Michael Dillon, PhD, BPO (Hons); Stefania Fatone, PhD, BPO (Hons); Grace Wang, MD, FACS; Eric Burns, CO; and Mallory Lemons, CPO—to weigh in with their expertise and insights on this important subject.
4
O&P News | January 2018
COVER STORY
Shared Decision Making
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A decision aid for people facing partial foot amputation due to peripheral arterial disease
M
MOBILITY
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Authors:
Michael Dillon, PhD, BPO (Hons)1 Stefania Fatone, PhD, BPO (Hons)2 Matthew Quigley, MCPO (Hons)1
PL
Graphic design: Jake Eadie, MCPO, BHS, BID (Hons)
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t 1. Discipline of Prosthetics and Orthotics, College of Science, Health and Engineering, La Trobe University, Australia, 3086 2. Northwestern University Prosthetics-Orthotics Center, Feinberg School of Medicine, 680 N Lake Shore Drive, Suite 1100, Chicago, IL 60611
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Decisions about amputation surgery are always difficult. Often these decisions come at the end of a protracted period of ill health, where regular visits to wound care or high-risk foot clinics often occur in parallel with treatments for other health conditions such as diabetes or kidney disease. Unfortunately, at some stage, when the recalcitrant foot ulcer just won’t heal, or the foot is black and gangrenous, amputation is an inevitable next step. In our interviews with people about their experience of partial foot amputation, this is a familiar tale. Some people describe being in this “limbo-land� for months or even years in extreme cases, with their lives put on hold. Given this intense exposure to the health-care system, we have been surprised by how poorly informed many people seem; it is as if people had never considered the prospect of amputation, or the likelihood of wound failure and amputation had never been discussed as a possible event someday down the road. As a result, many people describe being blindsided when the discussion turns to amputation surgery. Of course, there are lessons to be learned from these experiences. Having interviewed people at the end of this journey, often years after living with an amputation, many wished they had had the opportunity to engage in meaningful discussions about the path ahead, even if the likely outcome couldn’t be predicted exactly. In other areas of health care, such as cancer treatment, research shows that just knowing what the path ahead might look like can help people prepare for the inevitable hiccups along the way, irrespective of the outcome. Participants
day
42
SA
Michael Dillon, PhD, BPO (Hons) La Trobe University’s National Centre for Prosthetics and Orthotics, Victoria, Australia; and Stefania Fatone, PhD, BPO (Hons), Northwestern University, Chicago, Illinois
1/3 same mobility as before illness and amputation
2/3 reduced mobility compared to before illness and amputation
// 015
Michael Dillon, PhD, BPO (Hons) and Stefania Fatone, PhD, BPO (Hons), are co-authors of “A Decision Aid for People Facing Partial Amputation Due to Peripheral Arterial Disease,� along with Matthew Quigley, MCPO (Hons).
in our research have suggested that conversations with health professionals could be supplemented by written material, given that many of the narcotics used to help manage pain make people fuzzy-headed and concentration difficult. People have suggested that these written materials might include facts about the risks of complication, pain, mobility, or quality of life, as examples. Many people lamented the burden of
being in-and-out of the hospital and the time they lost. In hindsight, many wished they had made the decision to amputate earlier. However, one of the barriers to making this decision earlier was often a lack of knowledge about what life would be like living with an amputation. Typically, it was chance encounters in hospital waiting rooms with others already living with amputation that helped inform their decisions.
O&P News | January 2018
5
COVER STORY
It is these insights from the lived experience that have shaped our belief that shared decision making is one of the best ways we can help inform people about these types of difficult health-care decisions.
sions about amputation surgery are inherently difficult. All we can do as clinicians is ensure that patients have access to accurate and unbiased information about all the treatment options, engage in meaningful conversations, and are well
“Shared decision making is a collaborative process designed to empower patients to take an active role in decisions about their health care.” Michael Dillon, PhD, BPO (Hons) Shared decision making is a collaborative process designed to empower patients to take an active role in decisions about their health care. Clinicians can facilitate the process by encouraging participation in decision making, providing accurate information about the different treatment options, and supporting patients to reflect and deliberate on the difficult decisions they have to make. The process can be supported by resources such as decision aids that present information about the different treatment options and facts about the likely outcomes and risks in a way that helps people understand. While the concept of shared decision making may be new to many, it is well established in other areas of health care, such as cancer treatment. In these areas, shared decision making has been shown to help clinicians and patients engage in meaningful conversations that, in turn, support patients in taking an active part in decisions about their health care. There is good evidence that patients become more knowledgeable about the different treatment options, can accurately perceive the risks and benefits of different treatment options, and, as a result, are more satisfied with the health care they receive and have less regret about the decisions they make. It is important to reiterate that deci-
6
O&P News | January 2018
supported as they grapple with the difficult decision. In this way, we can help ensure that people make a well-informed decision about their health care, irrespective of the path they choose.
Multidisciplinary Intervention Grace Wang, MD, FACS (Vascular Surgeon), University of Pennsylvania, Philadelphia, Pennsylvania
Compounding the issue is the complexity of the disease process itself. Foot wounds are often the result of peripheral arterial disease (PAD), a condition characterized by narrowings in the blood vessels in the leg that lead to decreased circulation of the foot. The causes of PAD are multifactorial, with diabetes, end-stage renal disease, hypercholesterolemia, and smoking acting as significant risk factors for this disease. The presence of a foot wound usually indicates multilevel, severe PAD, and consultation with a vascular surgeon or interventionalist is critical to ensure that the blood flow is optimized to ensure that the wound can heal and infectious processes can be resolved. Debridement may take place afterwards with a podiatrist to effectively drain abscesses or remove infected toes. Following revascularization and further surgical procedures, it is also critical that medical management of comorbidities takes place, as glucose
control plays a role in wound healing, and smoking cessation has been shown to increase the patency rate after surgical bypass or interventions. This highlights the need for a multidisciplinary team (endocrinologist, medicine, smoking cessation specialist) to effectively address all aspects of the care of a patient with a foot wound. In the event that revascularization is not possible, due to a lack of conduit for bypass, a lack of distal targets, or an unsuccessful endovascular intervention, primary amputation may be considered. Here, it is important that the patient understands that there are no revascularization options and amputation is likely. Having discussions with family present, and sometimes with the help of a palliative care or geriatrics consult, can be helpful, to establish goals of care in this situation. The process of dealing with the end stages of PAD is challenging and can involve multiple meetings as the patient’s plan is formulated.
Maintaining Patients’ Mobility Eric Burns, CO Hanger Clinic, Tucson, Arizona
Diabetic and vascular disease patients are some of the largest populations seen in pedorthics, orthotics, and prosthetics. The numbers have risen to epidemic proportions. Concurrently, this group has undesirable outcomes, with mortality rates rivaling many cancers after above-ankle amputations. O&P can make a significant impact to these patients by making safe mobility a priority at every visit. These patients are often in a constant state of decay and declining overall health. Loss of mobility parallels their loss of independence, stability, cardiovascular health, quality of life, balance, social isolation leading to depression, inability to heal, increased pain, and mortality rates. At the same time, safe mobility can positively influence all of these factors. Gait speed is a predictor of future health-care costs and longevity. In
COVER STORY
O&P, our contributing role to improved outcomes of this population is the concept of gait salvage. Diabetes mellitus and vascular patients are life-long O&P patients. We can be the “first responders” to prevention, with pedorthics providing both medical devices (shoes and inserts) and education to change the current outcome trajectory. Educated patients can make behavioral changes to slow and even reverse the advancement of these diseases. As patients progress, orthotists must pick up the baton to provide orthotic devices for wound care and safe ambulation, with safe ambulation defined as stable, reduced peak pressures, reduced shear, protection, and addressing any deformities causing any of the above.
A patient who is able to walk consistently for 20 minutes a day will reduce their risks of a future ulcer, have reduced pain, suffer less depression, and report a higher quality of life, slowing or reversing the symptoms of this disease. When the health-care community provides a safe platform for these patients to move independently through their environment, their decay can dramatically slow. Education on the value of mobility at every stage of care will improve outcomes at each corresponding step. It is much easier to maintain mobility and independence than it is to regain. Driving the importance of maintaining gait is a valuable goal for this population, and O&P can make a valuable contribution.
“Adding gait salvage as a goal during a patient’s decline, from the initial ulcer to major amputation, will benefit the patient’s overall health, stability, quality of life, and independence.” Eric Burns, CO
Prosthetists should limit the number of days between amputation and fitting the initial prosthetic fitting via post– operative protectors, postop follow-up, and providing an environment for safe ambulation. All disciplines should work together maximizing active, safe, weight-bearing days between medical interventions. Gait salvage is simply an added goal. Research is extremely clear that maintaining patients’ mobility will dramatically improve the outcomes of tens of millions of patients. Adding gait salvage as a goal during a patient’s decline, from the initial ulcer to major amputation, will benefit the patient’s overall health, stability, quality of life, and independence.
Functional Outcomes Mallory Lemons, CPO Hanger Clinic, Oros Valley, Arizona
When a patient goes to a doctor or is admitted to the hospital, they want to understand their underlying diagnosis. This includes understanding what they need to do to help lessen their symptoms, and understanding how their diagnosis will affect them and their long-term outcomes. This can be overwhelming even though the patient’s behavior can directly impact their personal results. But often, health-care providers don’t put a strong enough priority on mobility. Focusing on increasing standing and walking time can have a dramatic positive impact on the patient’s overall
health and well-being. Salvaging gait, or maintaining safe mobility during these multiple interventions, will usually have a positive effect. A focus on achieving mobility can have a positive impact on a patient’s physical health and help slow the effects of a sedentary lifestyle. There are multiple considerations of which a patient, their family, and the health-care provider should be aware. These include the time that the patient will be non-weight-bearing following a below-knee amputation versus a partial foot or limb salvage operation, the amount of rehabilitation needed during the patient’s recovery period, and possible re-hospitalization or revision over the first year, postamputation, that might be needed. All of these factors should be taken into consideration because they can affect a patient’s recovery time, which in turn affects their short- and long-term mobility. After an amputation, patients are encouraged to be non-weight-bearing (at times for multiple months), despite the level of their amputation. These long periods of inactivity have been shown to decrease a patient’s functional capability. We need to think of any form of amputation in regards of functional outcomes. We need to keep our patients up and mobile, not sedentary and chairbound. Mobility and function essentially save or prolong lives. Recovery from an amputation should not be more bed rest, but should be a step toward functionality.
O&P News | January 2018
7
Research & Presentations
Comparing the Transfemoral HiFi System to a Traditional Ischial Containment Socket By Tyler D. Klenow, MSOP, CPO, LPO
This article is a follow-up to research originally presented at AOPA’s Second World Congress and Centennial Celebration in Las Vegas in September 2017.
8
O&P News | January 2018
Research & Presentations
Figure 1 HiFi Imager
Background The High-Fidelity™ (HiFi) Interface (biodesigns Inc., Westlake Village, California) implements a series of alternating zones of tissue compression and release to focus the attachment of the prosthetic interface to the residual long bone(s). This is accomplished through use of a novel casting jig called the HiFi Imager™ (Figure 1). This stands in contrast to traditional socket designs, which are based on tissue containment and uniform tissue loading, in the case of hydrostatic socket designs, or selective loading of pressure-tolerant areas, in the case of ischial-ramus containment (IRC), quadrilateral, and patellar tendon-bearing designs. The HiFi system was originally developed as an upper-extremity application but has been used regularly for patients with lower-extremity amputation as well. The HiFi Interface system offers several benefits due to its indirect skeletal fixation. One such reported benefit is increased proprioception of the prosthesis by the amputee, called osseoperception.
This phenomenon is caused by vibrations that are transferred to soft tissue in traditional interface designs being transferred to the bones, thereby increasing proprioceptor and mechanoreceptor activity. The HiFi has been found to improve alignment of the bone within the prosthesis, affect ground-reaction force (GRF) patterns, and alter foot behavior. This article will review these findings.
Methods Summary This study evaluates the first subject fit with the HiFi interface in Southeast Michigan. The subject in this case study is a 65-year-old male with transfemoral (TF) limb loss to his right lowerextremity sustained in a blast injury during his service in the U.S. Army during the Vietnam War. He is 6’0” tall, weighs 230 lbs, and is K3 ambulator. His prosthetic use reportedly exceeds 12 hours each day. The prosthesis consisted of an IRC socket, flexible interface rigid frame design, cushion liner, X2 microprocessor knee, and 1C63 foot utilizing
the Harmony elevated vacuum system. The study was performed at the Motion Analysis Laboratory at Eastern Michigan University (Ypsilanti, Michigan), which includes an eightcamera Vicon Motion Capture system, a 30-foot elevated platform, and two embedded AMTI force plates. The subject performed 20 walking trials in both the HiFi and IRC conditions. The subject was tested first with the IRC and then fit with the HiFi Interface, which he wore for 30 days before being tested again. Before each testing session, the subject was administered the Oswestry Low Back Pain Disability Questionnaire v2.0 and Western Ontario and McMaster University Osteoarthritis (WOMAC) index to measure the effect of the sockets on perceived disability. All components besides the sockets, including suspension technique and footwear, were kept consistent between testing sessions. All socket fittings and adjustments were performed by an ABC-certified and HiFi-certified prosthetist. This study analyzed several
O&P News | January 2018
9
Research & Presentations
Table 1 Temporal-Spatial Results SSGV (m/s)
Cadence (steps/ min)
Stride Length (m)
Lt Step Length (m)
Rt Step Length (m)
Lt Step Width (m)
Rt Step Width (m)
Lt CoM Lat Dev (cm)
Rt CoM Lat Dev (cm)
IRC
0.93
100.00
1.12
0.52
0.60
0.11
0.11
33.21
40.57
HiFi
0.97
101.23
1.14
0.55
0.59
0.12
0.12
29.97
33.13
+/-
0.04
1.23
0.02
0.03
-0.01
0.01
0.01
-3.24
-7.44
sig.
0.001
0.176
0.092
0.003
0.356
0.254
0.089
0.397
0.054
Stride Time
Lt Swing Time %
Rt Swing Time %
Lt Stance Time %
Rt Stance Time %
Lt Single Stance %
Rt Single Stance %
IRC
1.21
39.70
43.06
60.78
56.94
43.05
40.09
HiFi
1.18
36.90
42.49
63.10
57.51
42.67
36.72
+/-
-0.03
-2.80
-0.57
2.32
0.57
-0.38
-3.37
sig.
0.000
0.400
0.202
0.542
0.201
0.314
0.202
to adducted position, reducing 14.1 degrees between peaks from the IRC to HiFi condition. This also shows increased stability with the HiFi as excessive hip abduction subsequent to circumduction indicates reduced balance and balance confidence as they are strategies to reduce lateral falling and increase minimum toe clearance.
aspects of prosthetic gait, including temporal-spatial parameters, kinematics, kinetics, and foot behavior using a metric designed to measure occurrence of the dead spot phenomenon (DSP). Perceived disability also was measured using the two questionnaires.
Discussion This study analyzed the effect of the HiFi interface system on temporal-spatial gait parameters, kinematics, kinetics, and foot behavior using a previously described method to calculate characteristics of dead spot phenomenon occurrence. Perceived disability also was measured through the use of two surveys. With use of the HiFi, the subject of the case was able to walk faster and in a more symmetrical manner while decreasing the deviation of his center of mass. All of these results indicate a more stable gait pattern. These results are shown in Table 1. Significant kinematic findings include reductions in abduction of the prosthesis from an average abducted
Degrees (°)
Figure 2 20 17.5 15 12.5 10 7.5 5 2.5 0 -‐2.5 -‐5 -‐7.5 -‐10
An increase in hip extension of 12.8 degrees compared to the IRC was also shown with the HiFi, which is important in transfemoral users as hip extension controls the stability of the knee joint in stance and gait. These results show an increase in prosthetic control and proprioception with the HiFi and are illustrated in Figure 2.
Maximum Prosthetic-‐side Hip Angles 15.6 8.3 2.83
-‐5.8
Hip Adduction
Hip Extension IRC
HiFi
Difficulty: 1 = none 2 = moderate 3 = very 4 = extremely
10 O&P News | January 2018
Research & Presentations
Figure 3
These results may be explained by a phenomenon that occurs with the vertical GRF patterns of the two conditions and is shown in Figure 3. The second hump of the classic “double hump” of the vertical GRF graph is somewhat flattened in the IRC condition whereas it is a much more smooth form in the representative sample of the HiFi condition. The second hump of the graph is typically referred to as the “propulsive hump,” and a more rounded shape would indicate a smoother loading pattern of the foot in the HiFi condition compared to the IRC condition. It may be that the intimate fit of the HiFi Interface leads to less motion of the socket on the residual limb (RL). This would result in less force being absorbed by the RL tissue and instead transferred to the foot for increased loading and subsequent energy return. In terms of foot behavior, stance time decreased as a result of HiFi use, most likely due to the increase in walking speed of the subject. This reduction caused a statistically significant increase in mean DSP average and threshold values. The three calculations that comprise the DSP metric described in an article published on this topic in Clinical Biomechanics are DSP qualifying time, total DSP area, and DSP magnitude, of which DSP average and threshold factor into. When walking with the HiFi prosthesis, normal qualifying time was found to increase nearly 5 percent. This means the dead spot in the foot occurred for a
longer relative period in the HiFi than with the IRC socket. While this is normally negative in the clinical setting, it is more an indictment on the foot than the socket. Reduction in movement of the socket on the limb results in more force being exerted into the foot. The change in measured DSP in this study can only mean that the change in socket design affected the behavior of the foot in walking. The claimed benefits of the HiFi Interface system and supporting biomechanical changes previously discussed may have led to reduction in perceived disability, noted by results of the
Oswestry and WOMAC questionnaires. The Oswestry is a valid and rigorous measure of condition-specific disability and, as a result of the 30-day wear period with the HiFi, one-point reductions in eight of the 10 disability questions were shown. A six-point change was previously found to be clinically significant in a rehabilitation setting. This change signifies a reduction in the subject’s disability category from severe to moderate. These results are shown in Table 2. Similar incremental, but sweeping, reduction in disability was found in the WOMAC results with this subject. All pain and stiffness scores reduced with HiFi use and a majority of the questions regarding difficulty of physical activity also were reduced. In total, this subject’s WOMAC disability score was reduced 19 points with use of the HiFi, eclipsing the score of nine-point reduction that was previously found to be clinically important in a population with hip osteoarthritis and eight-point reduction found in a similar population with knee osteoarthritis. These results are shown in Figure 4.
Figure 4
Western ntario and MUniversity cMaster University Western Ontario O and McMaster Osteoarthritis Osteoarthitis Index (WOMAC) Index (WOMAC) IRC vs. HiFi WOMAC Results 70 60 50 40 30 20 10 0
Disability Score
% Disability HiFi
IRC
Difficulty: 1 = 1none Difficulty: = none 2 =2 =moderate moderate 3 3= =very very 44 == eextremely xtremely
O&P News | January 2018
11
Research & Presentations
Conclusions The results of this study indicate the compression and release socket design and HiFi Interface system specifically can affect several metrics of gait, including temporal-spatial, kinetic, kinematic, and measured foot behavior in prosthetic users at the transfemoral level. This is the first known report to conclude a change in foot behavior as result of a socket. The perceived disability of the subject also reduced with the use of the HiFi Interface. Further research is needed to determine if these trends would hold true in a larger sample size. Tyler D. Klenow, MSOP, CPO, LPO, is the lead practitioner for the Port Charlotte location of Orthotic & Prosthetic Centers Inc. (OPC). OPC is a clinical O&P company in the Southeast United States with 23 offices in Florida, North Carolina, and South Carolina. OPC is a licensee for the HiFi system. Reach Klenow at tklenow@ opcenters.com. References
Table 2 Oswestry Low Back Pain Disability Questionnaire v2.0
Section 1 - Pain Intensity
IRC Socket
HiFi
+/-
3
2
-1
2 - Personal Care
2
1
-1
3 - Lifting
2
2
0
4 - Walking
3
2
-1
5 - Sitting
2
1
-1
6 - Standing
2
1
-1
7 - Sleeping
2
1
-1
8 - Sex life
1
1
0
9 - Social life
3
2
-1
10 - Traveling
3
2
-1
Total
23
15
-8
Severe
Moderate
Disability Category
Subject’s answers to ten (10) disability-related questions scored on a scale of 0-5. - 0 indicates least amount of disability, 5 indicates most severe disability
Western Ontario and McMaster University Osteoarthritis Index (WOMAC) Category Pain
Activity
IRC Socket
HiFi
Difference
Walking
2
1
-1
smith MJ. Comparative Efficacy of Transfemoral
Stair climbing
4
2
-2
Prosthetic Interfaces: Analysis of Gait and Perceived
Nocturnal
3
2
-1
1. Klenow TD, Kahle JT, Fedel FJ, Ropp J, High-
Disability. J Prosthet Orthot. 2017;29(3):1-7.
Rest
2
1
-1
2. Klenow TD, Kahle JT, Highsmith MJ. The Dead
Weight bearing
2
1
-1
Morning stiffness
3
2
-1
Stiffness occurring later in the day
2
1
-1
Descending stairs
3
2
-1
Ascending stairs
4
3
-1
Spot Phenomenon in Prosthetic Gait: Quantified With Analysis of Center of Pressure Progression and Its Velocity in the Sagittal Plane. Clin Biomech. 2016;38:56-62.
Stiffness Physical
Rising from sitting
2
1
-1
Standing
2
1
-1
Bending to floor
3
2
-1
Walking on flat surface
2
1
-1
Getting in/out of car
2
2
0
Going shopping
2
2
0
Putting on socks
2
2
0 -1
Lying in bed
2
1
Taking off socks
2
2
0
Rising from bed
2
2
0
Getting in/out of bath
3
2
-1
Sitting
2
1
-1 -1
Getting on/off toilet
3
2
Heavy domestic duties
3
3
0
Light domestic duties
2
1
-1
Total Score
59
40
-19
61.5%
41.7%
-19.8%*
% of total (96)
*16% improvement found to be clinically significant in osteoarthritic population
12 O&P News | January 2018
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Research & Presentations
A Flexible AFO: Contradiction to Traditional Thought? By Suzanne Guiffre, PT, EdD; Joseph Whiteside, CO, LO; and Cathy Bieber Parrott, PT
This article is a follow-up to research originally presented at AOPA’s Second World Congress and Centennial Celebration in Las Vegas in September 2017.
Introduction Research shows ankle-foot orthoses (AFOs) improve walking ability, reduce energy expenditure, and improve selfconfidence in persons with neurologic conditions.1 However, noted disadvantages of AFOs are orthotic size and weight, discomfort, safety issues, poor effectiveness, and the finding that dissatisfaction with AFOs has been found to be up to 75 percent, with lack of compliance ranging from 6 percent to 80 percent.2 Some report AFOs are too restrictive to movement and skin problems are an issue.3 Prior to this study, we tracked users of thermoplastic AFOs (n = 104). Fortyeight percent (50 clients) were unsatisfied
14 O&P News | January 2018
with their AFO. It was discovered that this lack of tolerance included 12 with a solid AFO, 30 with an articulating, 13 with a carbon fiber, and one with a double upright. Non-use did not seem related to the origin of the AFO (our clinic versus another), type of AFO, or diagnosis. The most common problem with non-use was postural instability resulting in limited walking ability. Other problems included weight, lack of comfort, decrease in dynamic balance, and inadequate ankle varus control. It was unacceptable that so many patients were dissatisfied or not using their AFO; thus, alternatives were pursued. There is previous research on silicone AFOs that showed increased comfort; however,
Research & Presentations
these lack the required stiffness for gait.4 The AFO desired needed to provide structural integrity with adequate stability, provide sensory input, improve function during walking, and be a positive experience for the client. Also needed was optimum shank-to-vertical inclination angle espoused by Owen5 as essential for normalizing gait. The result was a custom, total contact flexible AFO (patent pending) using EVA thermoplastic (Figure 1) in varying thicknesses to match patientspecific needs for functional assistance, sensory input, and structural stability. Initial response from clients included appreciation of the light weight and comfort of the soft flexible material. More active people who previously used an AFO describe increased ability to accommodate to uneven surfaces without losing balance but retaining the stability for controlled walking. We have now embarked on a study to evaluate the flexible AFO’s (FAFO’s) effectiveness for improving gait, balance, endurance, and client satisfaction.
Methods Inclusion criteria included a physician-prescribed AFO for clients with stable neurologic conditions. Exclusion criteria include cognitive impairment, nonambulatory, or recent acute complication (wound or inflammation in the foot, etc.). Baseline measurements taken prior to receiving the FAFO included balance measured by the Berg Balance Scale (BBS), spatial and temporal gait parameters obtained from the GaitRite Walkway System, the SixMinute Walk Test (6MWT) for aerobic endurance, and videotaped gait with Coach’s Eye. These same measurements were repeated after the client used the FAFO for two weeks and again after three months. In addition, wear-related questions from the Orthotic and Prosthetic Satisfaction Survey (OPUS) were administered at the two-week and three-month sessions.
Figure 1 Flexible AFO with strapping
Results Thirty-one adult clients have completed the study, and six more lack only three-month data. Recruitment is ongoing. While we continue to recruit to obtain a required sample size, we have run preliminary statistics. These findings and other early observational findings are promising. Twenty-eight subjects have completed the two-week data session (15 with FAFOs), and 22 subjects have completed the three-month data session. Attrition has been four subjects, from death (one), hospitalization (one), moving out of state (one), and discontinued use of the AFO (one). Twelve clients were previous AFO wearers, and 19 were new AFO wearers. Diagnoses of clients in the study is shown in Table 1. Satisfaction with the FAFO measured by the OPUS shows the most satisfaction for fit, weight, and durability of the device. Patient satisfaction related to cosmetics and wear ability show less satisfaction. See Table 2 for all OPUS results. OPUS results of clients who had previously worn a typical thermoplastic AFO are analyzed separately, with noted higher satisfaction in several areas. For eight patients who previously used an AFO, satisfaction with the FAFO was 85 percent at two weeks and was maintained at three months. The average
wear time reported was 7.9 hours a day for six days a week. Those previous AFO wearers reported a longer wear time of 9 hours a day. Statistical analysis on data collected so far was completed using the Wilcoxon Signed Rank test because assumptions for parametric t-test were not met. The alpha was set to 0.05 for testing differences among data collections (baseline, two-week, and three-month). Statistically significant results are presented in Table 3. Analysis will be repeated when required sample size is attained. Table 3 shows statistical results. Velocity increased after two weeks with the new FAFO compared to without an AFO. Studies have shown that gait velocity increases with an AFO6 so this finding is in line with other AFOs. However, there was no significant difference in velocity between the two-week and three-month points (p = 0.119). Forty-three percent were limited community ambulators7 (or lower) at pre-AFO data session, but only 26 percent were at two weeks and 33 percent at the three-month data collection sessions. The BBS showed a significant difference between pre-AFO and the twoweek point, with improved balance by an average of three points, which meets the Minimal Clinical Important Difference (MCID).8 Between the twoweek and three-month points, scores improved slightly (one point) but were not statistically significant. Between pre-AFO and the three-month point, findings indicated gains were maintained (p = 0.009). A BBS of less than 45 indicates impaired balance and risk for fall.9-11 The percent identified at risk for each group were as follows: pre-AFO, 39 percent; two-week point, 36 percent; and three-month point, 23 percent at risk for falls. Overall, 82 percent improved their balance scores with the FAFO. The distance measured during the 6MWT showed improvement at each
O&P News | January 2018
15
Research & Presentations
Table 1
Table 2
Diagnoses of clients
OPUS results
Diagnosis Requiring AFO
Number of Subjects in Study
Stroke
5
Spine disorder
4
Drop foot
3
Multiple sclerosis
3
Cerebral palsy
2
Neuropathy
2
Charcot-Marie-Tooth disease
2
Myotonic dystrophy
2
Guillian-Barre syndrome
1
Amyotrophic lateral sclerosis (ALS)
1
Myasthenia gravis
1
Hereditary spastic paraplegia
1
Brain cyst
1
data point, but findings were not statistically significant. The average distance for each data time period were as follows: pre-AFO, 832 feet; two-week point, 866 feet; three-month point, 878 feet. Thirty-two percent of subjects improved on the 6MWT by at least 1 MCID (150 feet).12,13 Again, the FAFO has results comparable to other studies that show an increase in the 6MWT with an AFO.14,15
Item on OPUS Fits Well
82%*
Weight manageable
77%*
Comfortable
64%*
Easy to don
50%*
Looks good
45%
Durable
82%*
Clothes free of wear/tear
82%*
No skin irritation
64%
Pain-free to wear
64%
* Items rated higher for previous AFO wearers.
Conclusion Early data suggests the FAFO is able to provide benefits of increased walking velocity, improved balance, improved walking distance in six minutes, and good client satisfaction. Significance If with more subjects the statistical analysis confirms a positive effect on balance and walking ability, this FAFO
Table 3 Statistical findings Statistical Analysis Wilcoxon Signed Rank Rest Results (alpha = 0.05) Dependent Variable
Percentage That Agree or Strongly Agree at Three Months
will add to an orthotist’s options when prescribing an AFO. The FAFO is no more expensive to manufacture and so far has less orthotic service requirements than current AFOs. We expect the flexible nature of the material to result in reduced need for fit adjustments due to leg swelling or weight changes and with less skin irritation. These reductions should result in further decreased health-care costs and higher compliance. Future studies should be conducted to determine if the FAFO is superior to current devices typically used and whether it provides greater reduced costs and improved patient quality of life. Additional gait parameters also need to be explored.
Statistical Result
Velocity
Clients walked faster with new FAFO at two-week point [WSR test significant (p = 0.000)].
Berg Balance Test
Significant difference noted (p = 0.039) between preAFO and two-week point.
Six-Minute Walk Test
Distance improved at each data point, but not statistically significant.
16 O&P News | January 2018
Suzanne Guiffre, PT, EdD, is program director at Cleveland State University’s Doctor of Physical Therapy Program. Joseph Whiteside, CO, LO, is owner of Whiteside Orthotic and Prosthetic Group Inc., which is the clinic providing the FAFO for this study. Cathy Bieber Parrott, PT, is on the faculty at Youngstown State University’s Doctor of Physical Therapy Program.
Research & Presentations
References
6. Ferreira L, Neto H, Oliverira C, et al. Effect
on Balance and Mobility in Hemiparetic Stroke
1. Slijper A, et al. Ambulatory Function and
of Ankle-Foot Orthosis on Gait Velocity and
Patients. Disability & Rehabilitation. 2011; 33(15-
Perception of Confidence in Persons With Stroke
Cadence of Stroke Patients: A Systematic Review.
16): 1433-1439.
With a Custom-Made Hinged Vs. a Standard Ankle
Journal of Physical Therapy Science [serial online].
12. Perera S, Mody S, Woodman R, Studenski
Foot Orthosis. Rehabil Res Pract. 2012, Article ID
n.d.:25(11):1503-1508. Accessed Aug. 23, 2017.
S. Meaningful Change and Responsiveness in
206495, 6 pages.
7. Perry J, Garrett M, Gronley JK, Mulroy SJ.
Common Physical Performance Measures in Older
2. Bettoni E, et al. Neurological Patients and Their
Classification of Walking Handicap in the Stroke
Adults. Journal of the American Geriatrics Society.
Lower-Limb Orthotics: Acceptance and Satisfac-
Population. Stroke, 1995;(6):982.
2006; 54(5):743-749.
tion. Prosthetics and Orthotics International. 2016;
8. Gervasoni E, Jonsdottir J, Montesano A, Cat-
13. Tang A, Eng J, Rand D. Relationship Between
40(2), 158-69.
taneo D. Minimal Clinically Important Difference
perceived and measured changes in walking after
3. Phillips M, Radford K, Wills A. Ankle-Foot
of the Berg Balance Scale in People With Multiple
stroke. J Neurol phys ther, 2012; 36(3):115-21.
Orthoses for People With Charcot-Marie-Tooth
Sclerosis. Archives of Physical Medicine and Rehabili-
14. Nolan K, Savalia K, Lequerica A, Elovic E. Objec-
Disease—Views of Users and Orthotists on Impor-
tation [serial online]. Feb. 1, 2017; 98(2):337-340.
tive Assessment of Functional Ambulation in Adults
tant Aspects of Use. Disability and Rehabilitation:
Accessed Aug. 23, 2017.
With Hemiplegia Using Ankle-Foot Orthotics After
Assistive Technology. 2011; 6(6), 491-499.
9. Berg KO, Wood-Dauphinee SL, et al. Measuring
Stroke. Physical Medicine and Rehabilitation [serial on-
4. Del Bianco J, et al. Comparison of Silicone
balance in the elderly: validation of an instrument.
line]. Jan. 1, 2009;1:524-529. Accessed Aug. 25, 2017.
Ankle-Foot Orthosis and Posterior Leaf-Spring
Can J Public Health. 1992; 83 suppl. 2: S7-11.
15. Sankaranarayan J, Gupta A, Khanna M, Taly
Ankle-Foot Orthosis Using Gait Analysis in a Sub-
10. Kornetti D, Fritz S, Chiu Y, Light K, Velozo
A, Thennarasu K. Role of Ankle-Foot Orthosis in
ject With Charcot-Marie-Tooth Disorder. Journal of
C. Rating Scale Analysis of the Berg Balance Scale.
Improving Locomotion and Functional Recovery in
Prosthetic & Orthotics. 2008; 20(4), 155-162.
Archives of Physical Medicine and Rehabilitation.
Patients With Stroke: A Prospective Rehabilitation
5. Owen E. The Importance of Being Earnest
2004;85:1128-1135.
Study. Journal of Neurosciences in Rural Practice [se-
About Shank and Thigh Kinematics. Prosthetics and
11. Dogg an A, Mengüllüogg lu M, et al. Evalu-
rial online]. October 2016; 7(4):544-549. Accessed
Orthotics International. 2010; 234(3), 254–269.
ation of the Effect of Ankle-Foot Orthosis Use
Aug. 25, 2017.
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O&P News | January 2018
17
O&P Visionary
Jeffrey Brandt, CPO
CEO of Ability Prosthetics & Orthotics shares his thoughts on the ideal O&P environment
I
t’s hard to believe, but it’s been 25 years since I first volunteered in an O&P patient-care facility, launching my career. I could never have dreamt that I’d have the opportunity to “rule O&P for a day” a quarter century later. A quick note on my background for context because I strongly feel you are a product of your experiences: I began my career as a technician, became a CPO, and founded a patient-care company. I have transitioned from clinician to executive. I am currently working diligently to continue that evolution. My current position has afforded me the opportunity to view and lead my company through a different lens, interact with other health-care executives, and become increasingly politically active. In no particular order, there are a handful of topics that I believe rightly dominate our conversations and that if I ruled O&P for a day, I would change. So it’s 12:01 a.m.—let’s get started.
18 O&P News | January 2018
Reconsidering K Levels If I were in charge of all of O&P, K levels ultimately would be sunset or, at minimum, would be drastically altered. Our profession, along with payors, rehab physicians, and therapists, would adopt universally accepted activity measures that include psychosocial measures, including quality of life by which to “rate” or “categorize” an amputee or brace wearer’s activity level on a continuum. K levels have become part of the problem, not the solution. O&P has concentrated too much on talking about high-performance amputees, with athletic talents on their legs. We have overlooked the much more typical patients—ones who may be a low K3 (or very high K2), who are somewhat frail in their surroundings and at risk of falls and the serious injuries that accompany them. These patients would benefit from a microprocessor knee (MPK) or other K3 technology, keeping them safer and greatly reducing
O&P Visionary
associated risks. Wouldn’t it be nice if we could provide patients with the devices and components that work best for them as determined by a personalized outcome plan—devices that would keep them safest? Technology advancements and growing bodies of research have overtaken the K-level categorization approach. Our profession, like all of health care, has become more patientcentric, providing us a pathway and demand in which to deliver more personalized care. Technology has afforded us the opportunity to become more granular in defining our patients’ activity level needs—resulting in perhaps a more widespread application and subsequent impact of technological advances to those lower-functioning patients. K levels and the science behind O&P have intersected in the past decade, and the resulting growing divergence further illustrates the one-dimensional nature of the K levels.
Modernizing Medical Policies Next, payors would advance their O&P medical policies to actually foster the provisioning of a brace or limb with quantitative measures in place (those universally accepted above) to effectively match component selection to activity levels and reimburse on a level consistent with the entire episode of care related to that amputation or disability, rather than take a position of least expensive device after investing significant dollars into the patient’s care prior to the amputation or disability. Furthermore, payors would reset their perception of O&P as they move to a fee-for-value proposition where they understand and value the patient care that goes alongside the device. In other words, they would recognize and quantify the fact that there are costs associated with providing care over and above that of the componentry. With the correct assessment measures and categorization model, I would be open to a diagnosis-related group
(DRG)-type approach, where Medicare fairly determines a percentage of who gets different activity-level limbs and normalizes that average into a standard fee for every prosthesis. As long as the reimbursements were adequate, this would give the provider more latitude than waiting for the payor to passively direct our patient care via denials and nonclinical methodologies.
Pursuing Payor Accountability Going hand-in-hand with modernizing medical policies would be increasing payor accountability and providing easier access to gaining authorization for both patients and providers. Payors need to be held more accountable by laws for a patient population that has virtually no difficulty demonstrating medical necessity. Too many of the plans currently offered by insurance companies to employers are not presided over by state insurance institutes, leaving few options for a patient to take a grievance to. Of course, the fight is really not about medical necessity. The patient is an amputee and needs a replacement limb. Which level limb does the payor have to pay for if the patient has a chronic condition with a bracing need, and depends on that brace to maintain his or her mobility and independence? Payors look at costs and their new models. Maybe they want our manufacturers’ invoices and want to see a $15,000 prosthesis. They want to be able to pay us $1,200 to switch out knees and renew them (after two years). They need to be taught to understand the adjustments—and understand a patient may come back 30 times over the next six months. So, payors think that an add-on of $6,000 on top of manufacturer cost is grievous. They think a profit on $1,500 is still low margin. Obviously, we have a long way to go in educating payors. By and large, my experience has been that there is a very broad range of
capabilities of the payor reps with whom we interact. We are always open to educate, and to help them understand. Obviously, there are some who consider themselves “too smart for school,” but there’s nothing lost in trying. A lot of these patients have crystallized over the past year. We are here to try to diminish, if not eliminate, the noise, and zero in on the patient, his or her needs, and his or her hopes and fears.
Ensuring Patients’ Needs Are Met If I could run O&P for a day, I would change things like gaps in care and payments that we have allowed to exist long enough. The concerns are pretty pervasive, including manufacturers, as well as medical policy. Is it all so complex as to justify multiple denials? The range of medical conditions associated with being an amputee is reasonably well understood—trying to interpret Medicare laws shouldn’t be rocket science. For example, this patient is an amputee, he or she clearly has a medical necessity for a replacement limb—but we get caught up on the type of limb that best meets the patient’s needs. We find ourselves working with more quantitative care. Here are the three or four—or five or six—validated rationales for this amputee, and it boils down to receiving this leg. We ought not “afford” to have it take four to six weeks, or even months, to get that leg authorized. But we live amidst change, with excellent benchmarks in the pipeline, and with cultural change in health care and, therefore, insurance. I would change things that interfere with what patients need; we have allowed problems to exist long enough. I have concerns as I think of manufacturers, as well as the current medical policy. I know they are trying to ensure care is offered and used that advances their products. But they don’t seem to finish the job—be that getting a reliability about the codes, doing really
O&P News | January 2018
19
good clinical research, and conducting product follow-up. It would be so much better if they could really help foster ruling on people today. Should it take us more than 10 days to determine whether a patient is eligible for a leg? With acute cases, many payors don’t understand urgency, and don’t understand the care that goes along with providing a device as we move more toward science and thinking to better solve patients’ problems. We need to spend more time figuring out ways to examine “value” of private care. Some of that could overlap to an episode of care and would encourage providers to act with care collectively with continuity of care. Insurance companies should take care to place the right people who understand the care levels to deal with our cases. All O&P professionals really want payors to do is to tell us what they’re looking for and, instead of fighting, to bring us solutions. Write
the manual for us. I am always worried about what patients are thinking. The health-care market has affected patients. Patients want to talk about money/policy insurers. We often are too quick to say, “My patient won’t appreciate that,” but you can’t be afraid to talk to them about cost and what’s involved, and what they can expect from you.
Adopting an Evidence-Based Approach Next, providers would become evidence-based and would utilize some type of electronic medical records system. Outcome measures administered specific to the device should be the basis for every single O&P appointment. Having outcomes information is paramount in justifying patient care and reimbursement, and as such, it is where we are heading and will be extremely important in the long term. Practitioners have to realize that gathering
this information is not a headache or aggravation, but is fundamental to protecting clinicians, patients, and facilities. I understand there may be some more experienced O&P professionals who say, “I’m winding down, and I don’t need this,” but if you were to be audited, or even worse, sued, the fact that you collect, retain, and manage outcomes data may be the best protection for you, your business, your retirement nest egg, and your family. Finally, just before my 24 hours as king of O&P ends, I would turn the focus on manufacturers to sponsor more clinical research, to result in more clinical evidence to result in payors eliminating the use of the words “investigational” and “experimental,” and to drive all of the wishful changes above. I am OK with assisting manufacturers with regard to bench-testing products with patients. This feedback should be prior to the final design phase and not solicited as the product is being released for widespread sale. Manufacturers need to invest more in clinical research and then, upon release of the product, there would be ample evidence to reduce the challenges of education, reimbursement, and ultimately adoption. We have seen examples where additional features built into existing devices or advancements in products have proven not to be worth it to the patients—costs can outstrip value. Manufacturers will need to watch closely and budget their innovation as payors might be showing signs of capping what they are willing to reimburse for a patient’s mobility. Wow! Rethinking K levels, the medical policies, payor accountability, patients’ needs, and outcomes-based care is a lot of work to complete in 24 hours! Time to get back to work. Best wishes for a productive 2018. Jeffrey Brandt, CPO, is chief executive officer of Ability Prosthetics & Orthotics and a member of the AOPA Board of Directors.
20 O&P News | January 2018
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STATE NEWS
State by State A new monthly column dedicated to delivering the most important state-specific O&P-related news
Each month, we talk to O&P professionals about the most important state and local issues affecting their businesses and the patients they serve. This column will include information about medical policy updates, fee schedule adjustments, state association announcements, and more.
Delaware On Nov. 20, 2017, the Delaware Worker’s Compensation Oversight Panel voted to rectify a previous reduction to the Delaware Worker’s Compensation fee schedule. This unanimous vote restored Delaware Worker’s Compensation reimbursement to the Medicare fee schedule rates. “We are grateful that our advocacy and persistence was understood, and that those living with limb loss as a result of work injury will have the financial resources to assist with restoring function [and] regaining confidence and quality of life through prosthetic intervention,” said John Horne, CPO, CPed, president of Independence Prosthetics-Orthotics Inc. Illinois The Illinois Society of Orthotics and Prosthetics (ISOP) has successfully used the Illinois O&P Licensure Law and Parity Law to thwart an effort by an Illinois payor to 22 O&P News | January 2018
issue a contract amendment that would drastically reduce rates currently at 100 percent of Illinois (ICP) Medicaid plans and 100 percent of (MMAI) Medicare plans. The amendment would also split L codes into “Basic O/P” (without a definition) and “Custom O/P.” These initial reductions would have been between 20 percent and 40 percent below current Medicaid/Medicare rates. After a legal review, the payor determined that the amendment reductions were not compliant with Illinois law. “This decision sets a clear precedent for the future. It supports the value of the Orthotic and Prosthetic License and Parity Acts as each act, separate and together, supports our patients. The acts help ensure that our patients receive O&P care from qualified licensed O&P practitioners, and that patients have access to fair insurance coverage,” said ISOP President James Kaiser, CP, LP.
Minnesota Minnesota’s new licensure law takes effect Jan. 1, 2018. All prosthetists, orthotists, pedorthists, and assistants will need to be licensed to practice in the state of Minnesota. Per the new O&P Licensure Act, the Board of Podiatric Medicine has named a seven-member O&P Advisory Council. “It took us about five years to get the Minnesota O&P licensure bill to the governor to be signed into law. It was challenging, but we worked with our
grassroots advocates, many amputees, who spoke to the basic need for consumer protection. The fine lettering of the end result was not exactly the version we started with, but through it all we practiced patience, persistence, and perseverance to get the job done,” said Teri Kuffel, JD, vice president of Arise Orthotics and Prosthetics Inc.
Pennsylvania Highmark Pennsylvania’s Medical Policy on LowerLimb Prostheses now covers vacuum, microprocessor-controlled ankle-foot prostheses, and powered and programmable flexion/extension assist-control prosthetic knees, when medically necessary. The new policy, effective Oct. 31, 2017, signals a shift away from the “investigational or experimental” language previously used to categorize these offerings as “not medically necessary.” This is a huge win for patients and O&P providers in Pennsylvania.
EDITOR'S NOTE: To submit an update for publication, please email awhite@aopanet.org. For up-to-date information about what’s happening in O&P in your state, visit the AOPA Co-OP and join the conversation in the AOPA Google+ Community.
O&P IN THE NEWS
3D Printing Prosthetics Improve VA Wait Times and the Care of Texas Veterans
F
or years, Prosthetic Design Inc. (PDI) has been developing 3D printing technology specific to fabricating lower-extremity prosthetic sockets. This technology is used by PDI’s sister company, Dayton Artificial Limb Clinic, which started fitting patients with 3D printed prosthetics in 2013. Four years later, PDI has optimized this technology and introduced several generations of its Squirt ShapeTM 3D Printer to several facilities and universities around the country. The newest
edition, the third-generation PDI Squirt ShapeTM 3D Printer, is currently in use by the South Texas Veterans Health-Care System (STVHCS) in San Antonio, Texas. The STVHCS is comprised of the Audie L. Murphy Memorial Hospital, the Kerrville VA Hospital, and the Satellite Clinic Division. One of the biggest concerns with fitting a patient with a prosthesis is the wait time involved. Typically, patients wait anywhere from one to three months before being fit with a prosthesis. The process of fabricating the
prosthetic socket takes at least two days when utilizing traditional techniques, but after developing its specialized 3D printer, PDI has achieved a fabrication time of approximately one-and-a-half hours for a transtibial socket—32 times quicker than traditional methods. With the new PDI Squirt ShapeTM 3D Printer, the VA in San Antonio will be able to fit veteran patients exponentially faster, thus having the potential to drastically reduce the Department of Veteran Affairs’ notoriously long wait times.
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100 years ago our O&P predecessors thought we needed a unified voice to secure the future of our profession. They were right. Our profession needs a strong voice today and for the next 100 years. Your membership matters!
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NEW! Co-OP
Co-OP
An AOPA Member Benefit As an online reimbursement, coding, and policy resource, this site includes a collection of detailed information with links to supporting documentation for the topics most important to AOPA Members. Like a Wikipedia of all things O&P, the Co-OP incorporates a crowdsourcing component, which is vetted by AOPA staff, to garner the vast knowledge and experience of our membership body.
Resources include: •
State-specific insurance policy updates,
•
L code search capability,
•
Data and evidence resources,
and so much more!
For more information or to see a live demo, visit the AOPA Booth #100. Learn more and sign up at www.AOPAnet.org/co-op.
www.AOPAnet.org
CALENDAR
Meetings & Courses
2018 JANUARY 8-13 ABC: Written and Written Simulation Certification Exams. ABC certification exams will be administered for orthotists, prosthetists, pedorthists, orthotic fitters, mastectomy fitters, therapeutic shoe fitters, orthotic and prosthetic assistants and technicians in 300 locations nationwide. Contact 703/836-7114,
their residency. Contact 703/8367114, email certification@abcop.org, or visit www.abcop.org/certification.
FEBRUARY 1 ABC: Application Deadline for Spring CPM Exams. Applications individuals seeking to take the May Practitioner CPM exams. Contact 703/836-7114, email certification@ abcop.org, or visit www.abcop.org/ certification.
JANUARY 10 AOPA Webinar: Lower-Limb Prosthesis Policy: A Comprehensive Review. Register online at bit.
FEBRUARY 14 AOPA Webinar: Inpatient Billing. Register online at bit.ly/ 2018webinars. For more information, email Ryan Gleeson at rgleeson@AOPAnet.org.
ly/2018webinars. For more information, email Ryan Gleeson at rgleeson@AOPAnet.org.
JANUARY 19-20 ABC: Orthotic Clinical Patient Management (CPM) Exam. ABC Testing Center, Tampa. Contact 703/836-7114, email certification@ abcop.org, or visit www.abcop.org/
PrimeFare Central Regional Scientific Symposium 2018. Renaissance Hotel, Tulsa, OK. Contact Cathie Pruitt, 901/359-3936, email primecarepruitt@gmail.com;
ABC Testing Center, Tampa. Contact 703/836-7114, email certification@ abcop.org, or visit www.abcop.org/ certification.
FEBRUARY 1 ABC: Practitioner Residency Completion Deadline for March Exams. All practitioner candidates have an additional 30 days after the application deadline to complete
26 O&P News | January 2018
For more information, email Ryan
information, email Ryan Gleeson at
Gleeson at rgleeson@AOPAnet.org.
SEPTEMBER 12 APRIL 11 AOPA Webinar: Enhancing Cash Flow & Increasing Your Accounts Receivable. Register
information, email Ryan Gleeson at rgleeson@AOPAnet.org.
Gleeson at rgleeson@AOPAnet.org.
APRIL 26-28 New York State Chapter Annual Meeting (NYSAAOP). Rivers Casino & Resort, Schenectady, NY. NYSAAOP.org.
MAY 9 AOPA Webinar: Coding: Understanding the Basics. Register online at bit.ly/2018webinars. For Gleeson at rgleeson@AOPAnet.org.
AOPA Webinar: Audits: Know the Types, Know the Players, and Know the Rules. Register online at bit.ly/2018webinars. For more
by Hilton, Atlanta. Register online
information, email Ryan Gleeson at
at bit.ly/2018billing. For more
rgleeson@AOPAnet.org.
information, email Ryan Gleeson
JULY 11
to submit your clinical, business,
AOPA Webinar: Administrative Documentation: The Must Haves and the Sometimes Needed. Register
technical papers, or symposia at
online at bit.ly/2018webinars. For
bit.ly/present2018 to present at the
more information, email Ryan
2018 National Assembly.
Gleeson at rgleeson@AOPAnet.org.
Call for Papers deadline. Deadline
SEPTEMBER 26-29 AOPA National Assembly. Vancouver Convention Center. For general inquiries, contact Ryan Gleeson at 571/431-0876 or rgleeson@AOPAnet.org, or visit www.AOPAnet.org.
OCTOBER 10 AOPA Webinar: Year End Review: What Should You Do to Wrap-Up the Year & Get Ready for the New Year. Register online at bit.ly/2018webinars. For more information, email Ryan Gleeson at
JUNE 13
MARCH 1
bit.ly/2018webinars. For more
more information, email Ryan
www.primecareop.com.
at rgleeson@AOPAnet.org.
AOPA Webinar: Medicare As a Secondary Payor: Knowing the Rules. Register online at
online at bit.ly/2018webinars. For
more information, email Ryan
2018 Mastering Medicare: Essential Coding & Billing Techniques Seminars. Doubletree
Register online at bit.ly/2018webinars.
rgleeson@AOPAnet.org.
email jledwards88@att.net; or visit
FEBRUARY 26-27
ABC: Prosthetic Clinical Patient Management (CPM) Exam.
bit.ly/2018webinars. For more
or Jane Edwards, 888/388-5243,
certification.
JANUARY 26-27
AOPA Webinar: Outcomes & Patient Satisfaction Surveys.
For more information, visit www.
FEBRUARY 23-24
AUGUST 8
AOPA Webinar: Medicare Coding Guidelines: MUEs, PTPs, PDAC, and More. Register online at
must be received by February 1 for
email certification@abcop.org, or visit www.abcop.org/certification.
MARCH 14
rgleeson@AOPAnet.org.
NOVEMBER 4-10 Health-Care Compliance & Ethics Week. AOPA is celebrating Health-Care Compliance & Ethics Week and is providing resources to help members celebrate. Learn more at bit.ly/aopaethics.
CLASSIFIEDS
ADVERTISER INDEX ALPS................................................ 13 www.easyliner.com Publisher Thomas F. Fise, JD American Orthotic & Prosthetic Association (AOPA).....21, 24, 25, Cover 3 www.AOPAnet.org
Advertising Sales RH Media LLC
International Rehabilitation Canton Forum 2018 (IRCF)................. 23 en.cantonrehacare.com
Printing Sheridan
College Park Industries ...................... 3 www.college-park.com Hersco Ortho Labs ..................... Cover 2 www.hersco.com Ă–SSUR Americas..................Back Cover www.ossur.com
Editorial Services Content Communicators LLC Design & Production Marinoff Design LLC
SUBSCRIBE O&P News (ISSN: 1060-3220) is published monthly by the American Orthotic & Prosthetic Association, 330 John Carlyle St., Ste. 200, Alexandria, VA 22314. To subscribe, contact 571/431-0876, fax 571/4310899, or email landerson@AOPAnet.org. ADDRESS CHANGES Postmaster: Send address changes to: O&P News, 330 John Carlyle St., Ste. 200, Alexandria, VA 22314. Copyright Š 2018 American Orthotic and Prosthetic Association. All rights reserved.
This publication may not be copied in part or in whole without written permission from the publisher. The opinions expressed by authors do not necessarily reflect the official views of the publisher, nor does the publisher necessarily endorse products shown in O&P News. The O&P News is not responsible for returning any unsolicited materials. All letters, press releases, announcements, and articles submitted to the O&P News may be edited for space and content. The magazine is meant to provide accurate, authoritative information about the subject matter covered. It is provided and disseminated with the understanding that the publisher is not engaged in rendering legal or other professional services. If legal advice and/or expert assistance is required, a competent professional should be consulted. ADVERTISE Reach out to the O&P profession and more than 13,500 subscribers. Engage the profession today. Contact Bob Heiman at 856/673-4000 or email bob.rhmedia@comcast.net.
O&P News | January 2018
27
TECH TIPS
10 Tips for O&P Technicians in 2018 Fabrication and design tips from top technicians and practitioners
1
Demand quality tools, like a torque wrench. The best mechanics have the best tools. Jim Young, CP, LP, FAAOP, Amputee Prosthetic Clinic
2
Always put yourself in the patient’s shoes. With every prosthesis you get the opportunity to fabricate, you must be sure to treat it as your own. Craftsmanship, passion, and precision are qualities every technician must possess in order to yield successful outcomes. Herman Green, CTP, CPA, Bulow Orthotics & Prosthetics
3
Whatever you want to learn, find somebody that does it well, and copy them! Do what they do, the way they do it, until you are as good as they are. Only then can you innovate and do it better! Tony Wickman, CTPO, Freedom Fabrications
5
When you vacuum form alipast liners on thoracolumbosacral orthoses (TLSOs), work from the ground up and seam them on the top. That way, you can control/visualize the seam and catch any wrinkles prior to applying vacuum. Then rotate the mold so the seam is down to vacuumform the thermoplastic outer shell.
6
Keep a thread diagram above your sewing machine so if the thread breaks it is replaced correctly to allow proper function of the machine.
28 O&P News | January 2018
Brad Mattear, LO, CPA, CFo, Nabtesco & Proteor in USA
9
Heat-adjusting negative models: If you have a cast that has a flat spot created during casting, rather than pouring it as is and having to correct it during modifying, you can save time and be more accurate by simply using a heat gun to heat-adjust the cast to the desired shape prior to pouring.
Michael Martinez CTO, CPOA, CFo, UVa Prosthetics and Orthotics
7
Having multiples of one tool or machine dedicated to performing a specific and/or repetitive tasks can pay off big dividends in productivity. The time that it takes to change out a sandpaper belt or to adjust the speed on the drill press is wasted time (and money). For example, having several sanders, each with a different grit, will save time and make it easy for busy techs to stay organized and productive.
4
Why is just as important as how. Understanding the goal of an orthosis and the forces applied by certain modifications is just as important as knowing how to fabricate one. This knowledge allows the technician to adapt to challenging orthotic designs and produce the strongest and safest orthosis possible.
instead of paint as the paint easily chips off and can be difficult to stay on some surfaces. This can be bought in most hardware stores or found online at a very reasonable cost. The tape is conformable, so odd shapes and angles are not a problem. Color-coding your tools helps keep “your tools” on your bench and decreases the need to have multiples of the same tool scattered around your lab.
Steve Hill, BOCO, CO, Delphi Ortho
8
Color-code your bench tools. Every wrench/tool on your bench should be appropriately colored (for example, Red Bench = Red Tools). Use Scotch plastic tape
10
Instead of throwing away proflex scraps, upcycle them to make plaster bowls. Do this by filling an existing bowl with plaster to make your mold and set it up on your blisterforming table. Place your proflex in a blister-forming frame (you can even piece together smaller scraps) and pull over the mold. Once cooled, cut out and buff edges with your router.
Andrew C. Adkisson, President, BPM Fabrications
THE PR EM I E R ME E T IN G F OR ORT H OT IC, PROSTH ETIC, A N D PED ORTH IC PROFESSION A LS.
e c n e i r e p Ex
September 26-29, 2018
VANCOUVER CALL FOR PAPERS NOW OPEN! AOPA is accepting clinical, technician,symposia/instructional course, business, and pedorthic abstracts. Submit by March 1 at
Vancouver is easy to explore during your time at the downtown Vancouver Convention Centre as there are many nearby top attractions. • • • • • •
Capilano Suspension Bridge Vancouver Aquarium Forbidden Vancouver Stanley Park Horse-Drawn Tours Harbour Cruises & Events Flyover Canada
• Vancouver Lookout • Dr. Sun Yat-Sen Classical Chinese Garden • Vancouver Art Gallery • Science World • Grouse Mountain
bit.ly/present2018
Experience Beyond Vancouver’s unbeatable location makes it the perfect gateway to the rest of British Columbia and beyond, providing you with outstanding opportunities for pre- and post-conference travel. • Whistler • Okanagan Valley • Jasper • Victoria • Banff • Cruise to Alaska
AOPAnet.org
#AOPA2018
Experience all the AOPA National Assembly has to offer while visiting Vancouver.
© Össur, 01.2016
© ÖSSUR, 01.2018
PHILANTHROPIC PARTNERSHIPS Working together to improve people’s mobility Össur is committed to serving the limb loss and limb difference community. That’s why we’re pleased to renew our sole Platinum sponsorships of both the Amputee Coalition and OPAF and will continue to be the exclusive prosthetic provider to the Challenged Athletes Foundation in 2018. Together with these partners, we’re working to provide invaluable resources, support programs, and grants so every amputee can pursue a life without limitations.
Learn more about Össur and our philanthropic partners at www.ossur.com/partnerships. The joy of receiving bilateral Össur Flex-Run™ feet at an Össur Running and Mobility Clinic presented by CAF.
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