July 2018 O&P News

Page 1

JULY 2 01 8


Osseointegration: The Australian Experience After 500 Surgeries PG.12

Building A

Wireless Myoelectric Implant Records High-Quality EMG Signals PG.16




Charles Dankmeyer Jr., CPO PG. 22


Understanding the Role of the Technician PG.28



Limb s and ry

Vol. 27 • No. 7 | July 2018

Departments & Columns 25 State by State A monthly column dedicated to


the most important state and local O&P news.

26 Classified Ads 27 Meetings & Courses 27 Ad Index




28 Tech Tips Understanding the role the technician plays during the O&P patient-care process.

Wireless Power Implanted Myoelectric External Implanted Building a Dream Facility (EMG) Intramuscular Transceiver Amplifiers/Telemetry Wireless Data Spaces housing O&P patient-care businesses should be Electrodes designed to be both practical for staff and inviting to patients. Representatives from four O&P facilities share their strategies for intentionally designing patient-centric spaces—featuring comfortable and light-filled patient-care rooms and functional gait labs and fabrication areas—that have resonated with O&P patients as well as clinicians and office staff.

Research & Presentations 12

Osseointegration: The Australian Experience After 500 Surgeries

22 O&P Visionary Charles Dankmeyer Jr., CPO, calls for O&P professionals to unite and participate in opportunities to advance the profession and better serve patients.

By William Lu, PhD; Seamus Thomson; Jiao Jiao Li, PhD; Iana Wong; Calina Betlazar-maseh; and Munjed Al Muderis, MB ChB, FRACS, FAOrthA


Wireless Myoelectric Implant Records High-Quality EMG Signals By Charla L. Howard, PhD; Isaac Myers, PhD; Brian Crofts, MS; Scott Hiatt, MS; and Daniel McDonnall, PhD

On the Cover/Photo Credit: Scott Sabolich Prosthetics and Research

O&P News | July 2018



JoAOin PA?

Editorial Board O&P Practitioners

Randall Alley, CP, BSc, FAAOP


Get a competitive edge with exclusive faceto-face and distance learning opportunities on a variety of topics …plus valuable CEs!

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


NETWORKING It’s not just who you know, it’s who others know. Networking is powerful.

HAVE A VOICE Gain a say in what happens in government through AOPA’s advocacy efforts.

Increase your purchasing power through members-only discounts on insurance, UPS, workplace apparel, and credit card processing.

Improve documentation with coding, billing, and audit resources and research so you get fairly paid for services while providing excellent patient care.

Jonathan Naft, CPO


Learn more at www.AOPAnet.org/join


O&P News | July 2018

Visit www.AOPAnet.org/join

Sue Borondy Endolite

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

Georgia State University


Ability Prosthetics & Orthotics Inc.

Jennifer Fayter

Mark D. Geil, PhD

or email info@aopanet.org.

Debbie Ayres

University of Hartford

Northwestern University Prosthetics-Orthotics Center

Call 571-431-0876

Advanced O&P Solutions

Matthew Parente, MS, PT, CPO

Tufts University School of Medicine


Michael Angelico

Jeffrey M. Brandt, CPO

Hanger Clinic

Steven A. Gard, PhD


O&P Industry

Robert S. Lin, MEd, CPO, FAAOP

Mark Pitkin, PhD, DSc

Membership has its benefits:

Fabtech Systems LLC

Kempfer P&O

O&P Researchers and Educators


Scott Wimberley

American Board for Certification in Orthotics, Prosthetics, and Pedorthics Inc.

American Association of Breast Care Professionals

Let your business stand out and get noticed by peers, patients, and your community. Mobility Saves Lives & Money.

Fabtech Systems LLC

Joel J. Kempfer, CP, FAAOP

Geauga Rehabilitation Engineering


Glenn Hutnick, CPO, CTP, FAAOP

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


Sarah Clark

Scott Viglianti

O&P 1

WBC Industries

Tony Culver

Lisa Watkins

Grace Prosthetic Fabrication Inc.


Steve Hill, CO, BOCO

MBA, CAE, Board of Certification/Accreditation

Delphi Ortho

Claudia Zacharias

Explore New Heights & Expand Your Limits!

Follow ALPS on

Making Lives Better Tel: 727.528.8566 Tel: 800.574.5426




BUILDING a Dream Facility The importance of patient-centric design in the O&P clinic

he orthotic and prosthetic profession has often been described as clinical care at the intersection of science and art. O&P clinicians must balance the needs of individuals living with limb loss, limb difference, and other mobility challenges with respect to both form and function. The level of customized care offered by many O&P providers imposes unique requirements for the physical space a clinic needs to operate. Patient-care rooms share walls with labs where prosthetic sockets are fabricated and components are assembled to create a truly custom device. Gait rooms with parallel bars and ramps create a safe space for patients to explore their new mobility. The ultimate delivery of a device is just one aspect of an expansive set of services provided in O&P facilities. In this article, a diverse group of representatives from O&P practices across the country share their approaches to creating the ideal environment for the provision of O&P care. Each description offers a different take on the idea of a “dream facility,� but all share a common theme: The patient comes first.


O&P News | July 2018


Bulow Orthotic and Prosthetic Solutions By Michelle Prichard, Director of Patient Services

PHOTOS: Bulow Orthotic and Prosthetic Solutions

Bulow Orthotic and Prosthetic Solutions (OPS) recently moved into a new 6,000-square-foot O&P patient-care facility. We were fortunate that we had a clean slate and were able to custom-design the clinic exactly how we wanted it. There are six patient-care rooms, including one with 24-foot parallel bars, another with 20-foot parallel bars, and a third with 12-foot bars. There also is a room designed specifically for pediatric care. An additional private room was installed for patients who are here for a long day, such as a cast-to-test fitting day; this space was designed for comfort and includes a TV. The facility features a 1,500-square-foot lab, where we are able to complete all of our fabrication and day-today adjustments and repairs on site. Bulow OPS—part of BCP Group, which has 30 clinics in eight states—is located in Nashville and surrounding cities. We have 19 employees, including four CPs, two COs, and one CPO. All of our clinics are patient-centric, primarily in the attitude that our employees take toward our patients and our jobs. We have developed a great culture where we focus on treating patients like special guests on a day-to-day basis. But we also designed the facility to be comfortable for patients; for example, there are TVs in a couple of patient rooms and in the waiting room and a coffee bar in the waiting room. The facility also has multiple large windows in almost every room to let the sunshine in—which is my favorite feature of the space. Outside the building, there is a large, flat parking lot, which garners positive feedback from patient after patient. And finally, we have one wall decorated with words that our team voted on to describe our culture. The top goals in the design of our facility included the following: 1. Patient comfort and convenience 2. Function: large patient rooms, complete lab/fabrication space 3. Décor to highlight the high-tech and interesting field of O&P. We have been so pleased with the look and feel of this clinic that we have already designed a new satellite clinic in Murfreesboro, Tennessee, to match. I think we have found our new template.

O&P News | July 2018



Limb Lab By Brandon Sampson, CP, Owner; and Nicole Ver Kuilen, Athlete, Advocate, and Amputee

Brandon Sampson, CP


O&P News | July 2018

away and focusing on the collaboration between our patients and practitioners. One example of this is in how we built both gait rooms to be visible from the main lobby, with frosted glass to preserve privacy. Individuals who are in the lobby often cheer on patients they glimpse walking in the gait room. When we had the opportunity to design our dream facility, we were intentional about the design choices. We wanted it to feel like a design studio—a creative space—not only for the practitioners and technicians, but also for the clients.

Ver Kuilen’s Perspective Limb Lab! What a cool place. While in Minnesota, I stopped by Limb Lab for a tour. Several years ago, I remember walking in downtown Rochester, Minnesota, and seeing mannequins with prostheses in the window box of the building. I had never seen a mannequin that looked like me! I thought, “What is this place?” When I turned the corner, I saw straight into the facility’s lab through the windows, where technicians were building legs and arms. It dawned on me that this was a prosthetic clinic. So cool! Most amputees never get the chance to see where the magic happens, and this clinic

PHOTOS: Limb Lab

Nicole Ver Kuilen

Sampson’s Perspective The first Limb Lab location opened in October 2013, and the flagship facility was built in August 2014. The facility is located in a historic building downtown. We hired a local architect and gutted the entire building. All the wood used in the office is from my family farm, Six Mile Grove Woods, so the space has some extremely personal touches. During the project, we discovered really cool architectural features of the building. What we really do, as prosthetists, is connect people to parts, and that function is mirrored in the physical appearance of our space, including the steel beams that are bolted to exposed cement columns throughout the facility. We wanted to be inviting and welcoming, and to focus on transparency—not only in how we build limbs but also in how we communicate with our clients and the people passing by. In fact, we have people living with limb loss walk in all the time. Our goal was to break down emotional barriers by removing physical barriers. We wanted to share what it means to recreate your life after limb loss by taking the stigma of the clinical visit


PHOTOS: Limb Lab

was purposefully making that process open to the public. I thought that was truly visionary and a simple idea to put the patient first. I knew then that I had to someday meet the business owners. Recently, I reached out to founders Brandon Sampson, CP, and Marty Frana to see if I could come in for a tour. They immediately responded and said they’d been following my Forrest Stump journey and they’d love to have me! And not only that, but I actually had met Brandon back in the day when I was a little girl and he was shadowing as a new prosthetist. It wasn’t until we reconnected that I remembered. How cool is that? They invited me in to share their vision for opening Limb Lab in 2004. As we chatted, what stuck out to me most was their approach with every patient. They ask: What are the five most important things you want to be able to do with your prosthesis? Then they get to work to see how they will be able to build the appropriate device. Although this might sound simple, putting the patient’s goals first is critical; obviously, we all have different goals and mobility needs in our life. We should never assume that every person wants to do the same thing with his or her arms or legs. When I was handed my first prosthesis as a kid, it wasn’t waterproof or meant for running—even though water and running activities were the two most important things in my life, and still

are to this day! My first leg had a foam covering to look like a leg. But to me, that wasn’t as important as being able to wade in the water with my friends or run without my foot breaking! Because the leg was made to look like a leg, we had to sacrifice functionality. And at the end of the day, that wasn’t what I wanted. Brandon and Marty put the patient first, and it’s clear in the design of their lab. They were intentional about making it feel like a community you can enjoy being part of. The rooms are still private, but with translucent walls so you can see shadows of people walking, to promote mobility to all patients. In addition, Limb Lab shared with me what they are doing to help create a better future for amputees. One example is how they are collecting data related to socket design. One of the most difficult—and most important—parts of building a prosthesis is the socket. It doesn’t matter what fancy feet or technology you have; if the socket doesn’t fit, you aren’t going to wear it. It can take many appointments to get the right fit, which is why the process for making a prosthesis is so expensive. It’s time consuming. Sockets are made by hand. Each prosthetist wraps your leg in plaster and then hand molds what will eventually become your socket. So, Brandon is doing something pretty cool to start taking the guesswork out of this process. He’s scanning every

step of that “by hand” process to create a duplicate 3-D model via technology invented by Standard Cyborg. Why? To gather data! By creating a scanned model during every step of the process, Brandon is capturing subtle changes between the residual limb, his plaster hand cast, and edits to the socket to gather valuable data that we can then aggregate and interpret to understand how a socket is made. He’s been collecting this information for every patient he works on. Think about the power of all that data! I love what Brandon and Marty are doing, and I look forward to keeping in touch with them and seeing all the innovative work they come up with. They are truly helping to revolutionize the patient experience with prosthetics.

O&P News | July 2018



Scott Sabolich Prosthetics and Research By Scott Sabolich, CP, Owner

Our Oklahoma City facility was built in 2004 and has 35 employees. Our Dallas facility was built in 2012 and has 10 employees. Because we only work with prosthetic clients, our practitioners have really been able to hone their skills as prosthetists. We hope by focusing solely on prosthetics we can provide the most specialized prosthetic care experience. Often this results in us being a destination facility for clients who are difficult to fit. Our family has been in the field of prosthetics in Oklahoma since

O&P News | July 2018

PHOTOS: Scott Sabolich Prosthetics and Research


1947. In Oklahoma City, we built a 21,000-square-foot facility from the ground up, solely for prosthetic development and research. We did this with the patient in mind. This set-up helped enable every aspect of the facility to be built around the needs of the patient and to enable staff to provide care for the patient. We maintain strong relationships with referral sources as well as clients. We have worked very diligently to develop and implement the patents that we hold in socket design. This has enabled us to work with clients that are difficult to fit and face challenges in being fit locally in their own communities. We also work closely with many of the rehab facilities in Oklahoma City and Dallas. We work closely with the University of Oklahoma Medical Center, Oklahoma and Dallas Departments of Veterans Affairs, and many more. The combination of history, construction, and relationships makes our facilities unique. Our master hallway in Oklahoma City is more than 250 feet long. It is perfect for indoor running trials. I also love our nine-acre campus. It includes a lake and walking trails to test different slopes and surfaces for our clients. Some clients comment on the two-story lobby with integrated training stairs, which has an outlook tower over the campus. We also have a 9,000-square-foot lab on site that allows us to turn around and deliver prostheses at an extremely fast but controllable pace for our clients. These are a few favorite aspects of our patient-centric model. In thinking about design, we knew our facility needed to be large enough to meet current needs, have space to grow or rework internally without building additions, and ultimately function as a hub for future satellite facilities. Our Dallas facility, which is 12,000 square feet with a fully functioning lab, opened in 2012. We are in the process of evaluating other potential locations for our next satellite facility.


EARN CREDITS AT YOUR OWN PACE www.AOPAnetonline.org/aopaversity




Learn & Earn TOP QUALITY

orthotic, prosthetic, and pedorthic education and CE credits from the organization that knows O&P.

It’s as easy as 1-2-3 1. Set up your free personal online account 2. Choose your education and study 3. Take the quiz and print your certificate Membership has its benefits:



Learn more at www.AOPAnet.org/join

Start earning your credits today!

Visit www.aopanetonline.org/aopaversity.


Eastside O&P By Ben Clark, CPO, Owner



Make Your First Impressions Count With Customized Polo shirts, Scrub tops, and Lab Coats for your O&P staff

Create an attractive business image, promote your brand, and foster team spirit with AOPA’s new Apparel Program. To order your apparel, go to


AOPA Polo Shirts–Now for Sale Order AOPA polo shirts for your office! The shirts are black with a white AOPA logo. Moisture wick, 100 percent polyester. Rib knit collar, hemmed sleeves, and side vents. The polos are unisex but the sizes are men’s M-2XXL. $25 plus shipping. Order in the bookstore at bit.ly/aopastore.

Enter access code: ICON-AOPA Enter your AOPA member id Create your user profile

AOPA is partnering with Encompass Group, a leading provider of health-care apparel, to offer members special prices on customized polos, scrub tops, and lab coats.

10 O&P News | July 2018





PHOTO: Eastside O&P

Eastside Orthotics and Prosthetics was started in September 1980. It has always been at the same location in East Portland, Oregon. We occupy approximately 2,000 square feet in a small strip mall next to a bar and a tax service company. It has not been updated besides some small improvements, like the bathroom, since 1980. I am the third owner of Eastside and just purchased the company in March 2018. We are a small group of five on staff: two CPOs, two office administrators, and one lab manager/technician. We are growing fast and will need another patient-centric prosthetist soon.


The main reason I wanted to be a part of the Eastside team was that the culture was already patient-centric. When I first arrived, this culture was not being represented well by the physical appearance of the office, but the communication and clinical experience was always patient first. This office uniquely works with a high volume of transfemoral amputees and has historically been an advocate for treating patients with the best technology for the individual. My goal is to extend the patient-centric culture further into every area of the patient experience. I have asked many Eastside patients what they like most about our facility. The answer I keep hearing is that

Eastside feels like home; it is unassuming and comfortable; and they feel like their care is not rushed and that we are listening. For me, my favorite space in the facility is the gait room, which is very functional, with parallel bars that extend into a steep ramp and stairs. We are currently remodeling the office to increase the patient-first feeling. I was unhappy when I first noticed the waiting room window that separates the front office from the patient is chest high and very small. We are opening up the wall so it will be wheelchair height and allow for easy communication with our team. We are restructuring our lab and moving the dangerous equipment and tools so there is more room for

c e n t r a l

© 2018 fabtech Systems llc. all rights reserved.

Click Medical™/ Revofit™

patients to move around the office and not feel they are confined to patient rooms. Right now, I am more concerned in fostering the support of the peerto-peer relationships that could be happening within this community of amputees. We are planning to start a women’s amputee group at the office in the next couple of months. The goal is to introduce these amazing and inspiring amputees to one another so they can share how they overcame everyday challenges and learn from each other. These opportunities can be as simple as an office barbecue that is open to the patients, to encourage the community to come together.

f a b r i c a t i o n

extremiti3D 3D printing Specialists

reaktiv brace designs, built with PDe

iDeo Specialists

Advanced 3D Printed Devices. Advanced Orthotic Bracing:

3D Printing Specialists:

Advanced Prosthetics:

Work with the inventors of PDe. We are the experts in reaktiv™ bracing, built with PDe™ ( and other advanced design styles ).

We provide extremiti3D printed prosthetic sockets and protective cover devices.

Click Medical™/ Revofit™ Adjustable Sockets, Smartpuck™ Socket Designs, Hifi™ Sockets, Elevated Vacuum, Upper extremity and many more.


fabtech Systems is a click Medical recommended fabrication facility.

Make more possible. Visit fabtechsystems.com for more information, or call: 800.FABTECH FTS-OPEdge-Halfpage-Ad-Dec2017-7.1x4.675.indd 1

} 1/9/18 6:40 PM

O&P News | July 2018


Research & Presentations

Osseointegration: The Australian Experience After 500 Surgeries By William Lu, PhD; Seamus Thomson; Jiao Jiao Li, PhD; Iana Wong; Calina Betlazar-maseh; and Munjed Al Muderis, MB ChB, FRACS, FAOrthA [add credentials in if we get them]


here is no doubt that an amputated limb can have a dramatic and detrimental effect on patients and their families. Unfortunately, amputations are estimated to occur at a rate of 1.5 per 1,000 people, equivalent to a worldwide amputee population of more than 10 million.1 Amputations can occur due to traumatic accidents, tumors, malformations at birth, or even infection. When an amputation involves a lower limb, the mobility of the patient can be greatly limited, which may result in wheelchair confinement. The common solution for lower-limb amputees to regain function and mobility is to use an artificial leg that can restore some functionality of the lost limb. Thanks to modern advancements in biomechanics and robotic engineering, we have seen vast improvements in artificial limb designs in recent years. A wide range of prosthetic options are currently available on the market, ranging

12 O&P News | July 2018

from hydraulic polycentric knee joints that help reduce energy expenditure, to advanced bionic leg systems that are programmed to assist the patient’s gait through a complex array of algorithms and microprocessing power.2 It is thus not surprising for people to believe that the current prosthetics could completely replace the missing body parts and fully restore mobility. However, the personal experiences of lower-limb amputees and their families tell us that the solutions available today are still far from ideal, and many patients are still challenged to perform even the simplest daily activities.

Problems With Current Prostheses The major problem lies in the way that these robotic limbs are attached to the body. For more than six centuries, the main method to attach a limb prosthesis was through a socket-mounted system.3 A socket is essentially a customshaped bucket that is designed to wrap

Research & Presentations

around and append to the residual limb by means of pressure, grip, or vacuum suction on the soft tissue (skin, muscles, and fat). One can easily imagine the amount of stress exerted on the skin, especially when full body weight is constantly loaded onto the limb. As a result, patients using socket prostheses often suffer from chronic skin problems, such as discomfort, sweating, heat, and chafing due to friction, skin ulcerations, and pain.4 Apart from the many issues related to discomfort, socket prostheses have a number of other crucial drawbacks as well. Because socket prostheses attach mechanical limbs to the body through layers of soft materials (e.g., fabric and silicone liners), the many layers involved in this attachment not only reduce patients’ ability to precisely control the leg position, but they also largely dampen the sensory feedback required for the patient to sense the ground and walk with confidence. Despite the improvements in modern artificial limbs, their functionality and practicality are still greatly restricted by these drawbacks of the traditional socket system.

Development and Advantages of Osseointegration In 1965, Professor Per-Ingvar Brånemark invented the modern dental implant by threading transoral titanium implants into the bones of the upper and lower jaw to act as anchorage for dental prostheses.5 This invention sparked the modern concept of “osseointegration,” which essentially means biomechanically integrating artificial biomaterials with the living bone. Based on this concept, in the early 1990s the first transcutaneous femoral prosthesis was implanted on an aboveknee amputee. 6 Instead of using a socket to adhere to the body through layers of soft tissue, osseointegration inserts a metal implant directly into an amputee’s residual bone, with the distal end passing through the skin,

Figure 1 Osseointegration involves inserting a metal rod directly into an amputee’s residual bone, with the distal end exiting the skin, which then attaches to an artificial limb system.

which connects to an artificial limb system (see Figure 1). This technology provides a rigid and intimate biomechanical connection that directly loads the amputee’s skeletal system, which would reduce bone resorption if not enhance bone formation. It also allows the patient to restore proprioception (feeling of the ground); increase motion of the hip; increase ability to control the prosthetic limb; benefit from greater comfort during sitting and standing; and experience easier donning and doffing, reduced pain levels, and overall better mobility and quality of life—these advantages basically circumvent all of the challenges caused by traditional socket design.

Safety Concerns The idea of a piece of metal protruding through the limb may sound intimidating to some people. Understandably, the medical community in the early days raised concerns regarding infection risks among patients who received this type of surgery.

The Journal of Bone and Joint Surgery (JBJS) recently published an in-depth article that investigated the safety concerns of osseointegrated reconstruction in transfemoral amputees.7 Among 86 transfemoral amputees who had received an osseointegrated implant for more than two years in Australia, the study found that mild infection and irritation of the soft tissue in the skin-penetration area were common. However, the study also reported that these infections were usually minor and could be successfully managed with simple measures such as a single course of oral antibiotics. Moreover, the paper concluded that “severe infections resulting in septic implant loosening are rare.” Overall, osseointegrated implants are becoming well-accepted among clinicians, with the belief that the infection risks are minor and manageable. Among the patients, it was found that the use of basic hygiene practices, such as daily showering and routine cleaning of the skin-penetration area, can keep the infection risks at a lower level.8

O&P News | July 2018


Research & Presentations

Figure 2

Osseointegration enables the direct loading of the residual limb (right), while in the traditional socket-mounted prosthesis the residual limb can easily deviate from the mechanical axis (left). This deviation results in severe limitations in functional control while the nonloading of the residual bone also can lead to severe osteoporosis.

Introduction of The Osseointegration Group of Australia In the last few years, with the introduction of modern techniques of anchoring the skin to the bone and moving away from a two-stage to a single-stage surgery, Professor Munjed Al Muderis, MB ChB, FRACS, FAOrthA, from Sydney, Australia, has successfully converted the osseointegration technology from a niche procedure for a

14 O&P News | July 2018

selected number of patients to a popular intervention that can be applied to a wider population of amputees. This technique has dramatically reduced the time needed for rehabilitation, the risks of infection, and other complications. Osseointegration for amputees has now become a standard method of treatment in this population. Currently, there are only a few clinics in the world offering the pioneering technology of osseointegration to amputees. It

is estimated that around 1,000 procedures have been performed worldwide. One of the largest clinical groups offering the procedure is The Osseointegration Group of Australia, led by Al Muderis. The Australian team has performed over 500 osseointegration cases to date. It adopts a multidisciplinary approach with expert input from surgeons, pain specialists, anesthetic and rehabilitation specialists, physiotherapists, prosthetists, psychologists, nursing staff, engineers, and clinical researchers on each individual case. This multidisciplinary structure allows the team to address challenging cases ranging from the femur, tibia, and humerus, to the radius, including extremely short residuums and complex cases. Moreover, the Australian team also is the first center to perform osseointegration in a single-stage surgery, which can reduce the total rehabilitation period to as short as three to six weeks.9 The improvement is largely due to a newly designed press-fit Osseointegrated Prosthetic Limb (OPL) implant that achieves interlocking bony ingrowth in a relatively short period of time. The new implant contrasts with the original screw-fixation devices, which require a two-stage surgical procedure with a total rehabilitation time of six to eight months before a patient can ambulate without walking aids. In addition, this refined single-stage approach reduces a patient’s exposure to risks of complications, with a noticeable reduction in the number of elective soft-tissue refashioning surgeries and the overall infection rate.

Further Advantages Importantly, the experience from The Osseointegration Group of Australia offers insight into many of the clinical challenges commonly observed in the field. The surgical risks and complication rates for above-knee amputees is now comparable to common joint arthroplasty procedures. In Australia, to date, there have been no femoral osseointegration implants removed due

Research & Presentations

to infection, and the revision rate for a femoral single-stage osseointegration surgery is currently below 1.5 percent. Traditionally, patients with amputations due to peripheral vascular disease (PVD) or diabetes have been excluded from this surgery. However, a recent study published by the Australian team has shown that osseointegration may conversely provide a restorative effect against the progression of the underlying diseases among these patients.10 Moreover, other studies investigating bone mineral density changes have demonstrated significant advantages through the direct loading of the residual bone, which reversed the risks of severe osteoporosis commonly observed in longterm socket users (see Figure 2). In addition, customized 3-D-printed titanium implants enabled the team to reconstruct amputations beyond the femur, with more than 140 transtibial cases and several transhumeral, transradial, and digital cases performed. Furthermore, the multidisciplinary team has successfully combined limb lengthening technology with osseointegration to reconstruct extremely short (<5-cm) bony residuums. Recent breakthroughs in targeted muscle reinnervation (TMR) surgery have demonstrated promising results in pain reduction as well as enabled advanced functional control for upper-limb amputees.11

Recognition and Future Development Having gone through significant improvements in implant design, surgical technique, and rehabilitation protocols, osseointegrated limb reconstruction has come a long way since it was first performed more than 30 years ago. Osseointegration is now considered a safe and effective method of limb reconstruction that can restore the functionality of a lost limb as close as possible to normality. By combining osseointegration and TMR technology, amputees nowadays are able to regain their mobility without

enduring common problems caused by the traditional socket and enjoy a life with reduced pain and greater prosthetic control. So far, only two osseointegration devices have been approved in Europe, Australia, and New Zealand, and are commercially available in these regions. Patient-specific devices and investigational device trials are currently underway in the United States and are showing promising results. It can be expected that approval by the U.S. Food and Drug Administration of these devices will take place within the next few years. Therefore, it appears that scientists and clinicians have found a suitable alternative to replace sockets as a preferred method of prosthetic attachment. Osseointegration not only offers new hope to the millions of amputees for regaining mobility and improving their quality of life, but also represents a huge step toward the future development and application of advanced bionic prostheses. William Lu, PhD; Seamus Thomson; Jiao Jiao Li, PhD; Iana Wong; Calina Betlazar-maseh; and Munjed Al Muderis, MB ChB, FRACS, FAOrthA, are part of the Clinical Research Team at The Osseointegration Group of Australia.

References 1. Dillingham TR, Pezzin LE, MacKenzie EJ. Limb Amputation and Limb Deficiency: Epidemiology and Recent Trends in the United States. Southern Medical Journal. 2002 Aug; 95(8):875-883. 2. Hafner BJ, Willingham LL, Buell NC, Allyn KJ, Smith DG. Evaluation of Function, Performance, and Preference as Transfemoral Amputees Transition From Mechanical to Microprocessor Control of the Prosthetic Knee. Archives of Physical Medicine and Rehabilitation. 2007 Feb 1; 88(2):207-217. 3. Thurston AJ. Paré and Prosthetics: The Early History of Artificial Limbs. ANZ Journal of Surgery. 2007 Dec 1; 77(12):1114-1119.

4. Meulenbelt HE, Dijkstra PU, Jonkman MF, Geertzen JH. Skin Problems in Lower-Limb Amputees: A Systematic Review. Disability and Rehabilitation. 2006 Jan 1; 28(10):603-608. 5. Brånemark PI. Osseointegration and Its Experimental Background. The Journal of Prosthetic Dentistry. 1983 Sep 1; 50(3):399-410. 6. Hagberg K, Brånemark R. One Hundred Patients Treated With Osseointegrated Transfemoral Amputation Prostheses—Rehabilitation Perspective. J Rehabil Res Dev. 2009 May 1; 46(3):331-344. 7. Al Muderis M, Khemka A, Lord SJ, Van de Meent H, Frölke JP. Safety of Osseointegrated Implants for Transfemoral Amputees: A Two-Center Prospective Cohort Study. JBJS. 2016 Jun 1; 98(11):900-909. 8. Hebert JS, Rehani M, Stiegelmar R. Osseointegration for Lower-Limb Amputation: A Systematic Review of Clinical Outcomes. JBJS Reviews. 2017 Oct 1; 5(10):e10. 9. Al Muderis M, Lu W, Tetsworth K, Bosley B, Li JJ. Single-Stage Osseointegrated Reconstruction and Rehabilitation of Lower-Limb Amputees: The Osseointegration Group of Australia Accelerated Protocol-2 (OGAAP-2) for a Prospective Cohort Study. BMJ Open. 2017 Mar 1; 7(3):e013508. 10. Atallah R, Li JJ, Lu W, Leijendekkers R, Frölke JP, Al Muderis M. Osseointegrated Transtibial Implants in Patients With Peripheral Vascular Disease: A Multicenter Case Series of Five Patients with One-Year FollowUp. JBJS. 2017 Sep 20;99(18): 1516-1523. 11. Kuiken TA, Li G, Lock BA, Lipschutz RD, Miller LA, Stubblefield KA, Englehart KB. Targeted Muscle Reinnervation for Real-Time Myoelectric Control of Multifunction Artificial Arms. JAMA. 2009 Feb 11; 301(6):619-628.

O&P News | July 2018


Research & Presentations

Wireless Myoelectric Implant Records High-Quality EMG Signals Charla L. Howard, PhD; Isaac Myers, PhD; Brian Crofts, MS; Scott Hiatt, MS; and Daniel McDonnall, PhD


ver the last decade, prosthesis manufacturers have released substantially more dexterous myoelectric prosthetic arms. In spite of the improvements of these advanced myoelectric systems, complete functional adoption of these devices is unacceptably low. Myoelectric devices are rejected by between 23 and 39 percent of users, which is comparable to the rejection of body-powered prostheses (between 26 and 50 percent).1 Amputees cite awkward use and lack of utility of their myoelectric prostheses, as well as dissatisfaction with the ability to perform activities of daily living, as the primary reasons for rejection.2,3 Thus, despite the potential for improved function with a myoelectric device, poor control of the system limits the adoption of advanced arm prostheses. These issues highlight that the technology for prosthesis control is not at a suitable level to take advantage of advanced prosthetic upper limbs. A large challenge with the implementation of current myoelectric devices is the common use of only two surface electromyography (EMG) electrodes for collection of control signals. Not only limited by the small number of control signals, surface EMG signals have multiple issues that limit their utility for myoelectric control. Intuitive control of precise motion is limited with surface

16 O&P News | July 2018

EMG as it is difficult to record isolated signal from a single muscle due to the cross-talk (multiple muscles captured in one signal) that occurs as signals travel through the tissue and skin.4 Further, the quality of the surface recording can be impacted by muscle and skin motion, along with a changing socket environment. Limitations in the control signals extracted from surface EMG signals limit successful implementation of advanced control algorithms and intuitive movement. Thus, these advanced prostheses still require serial selection and control of individual joints and grips, resulting in slow, unnatural motions. To address these issues, we have developed a myoelectric implant that records 32 channels of intramuscular EMG from multiple residual muscles and transmits these data to an external transceiver placed in the prosthetic socket (see Figure 1). Our objective is to provide simultaneous multidegree-offreedom prosthesis control, ultimately providing intuitive and dexterous control. This approach supports a high number of independent control signals and provides access to EMG from deep muscles that cannot be accessed with surface electrodes. The system comprises a hermetic implanted module with eight EMG leads and one reference lead. Each lead contains four single reference electrode

Research & Presentations

Figure 1

Illustration of the implanted myoelectric device for control of an upper-limb prosthesis. The eight leads from the implanted device can be independently placed in the muscles of the forearm and various depths. The implant will transmit the recorded EMG signal to a small external transceiver that also powers the device, located in the prosthetic socket. The transceiver also will relay the EMG signal to the prosthetic hand.

Prosthetic Limb Electronics and Battery

External Transceiver

sites for 32 total recording channels. The system design allows for independent placement of each lead, enabling access to multiple muscle sites at locations and depths inaccessible by other systems. The implant receives power inductively from an external transceiver and sends digitized EMG data to the transceiver via infrared light. The safety and function of the implanted system was tested in a sixmonth animal study to confirm the device can successfully transmit highquality, low-noise EMG signals that can be used to control a prosthetic device in real time.

Methods Surgical Procedure

Five canines were implanted with the myoelectric implant in their upper left forelimb for six months to evaluate the safety and function of the implanted system. The study was conducted at a U.S. Department of Agriculture accredited contract research organization under approval by the Institutional Animal Care and Use Committee. The eight electrode leads extending

Wireless Power Wireless Data

Implanted Amplifiers/Telemetry

from the electronics package, each containing four electrodes, were inserted into the long head of the triceps (two), the lateral head of the triceps (three), and one each in the posterior, middle, and anterior portions of the deltoid. A reference electrode lead was placed between the triceps and deltoideous muscles. The leads were placed using a custom insertion tool and secured using a polyethylene anchor built into the end of each lead. The leads also were secured to the fascia to prevent movement. Data Collection

At the end of the six-month period, the chronic viability of the device functionality was tested by collecting EMG data from each animal while at rest and walking. The EMG signals were sampled at 2,000 Hz. Tests were video recorded to support the analysis. The external transceiver was held over the implanted device with an adhesive wrap, and the animals also wore a custom vest that was used to carry the processor for data collection. When used with a prosthesis, the transceiver will be mounted in the socket and will transmit the EMG information to the prosthesis,

Implanted Myoelectric (EMG) Intramuscular Electrodes

as illustrated in Figure 1, creating an integrated system with no belt-worn components for the user to don. EMG Data Processing

The transmitted EMG signals were processed to evaluate the signal-to-noise ratio (SNR) for each device during walking. SNR quantifies the difference between the actual signal of interest and the background noise of the channel. A high SNR represents a dynamic range of muscle activation used for myoelectric control improving the accuracy and intuitive feel of the prosthetic control. Low relative noise (high SNR) also allows for rapid detection of the onset of the contraction enabling real-time prosthesis control, increasing the embodiment of the device. The raw signal was bandpass filtered with cut-off frequencies of 5 and 750 Hz, and the DC offset was removed. The EMG signal recorded at rest was used to characterize the noise of each channel. The root mean square (RMS) of the signal was calculated for each 25-ms (50-sample) window along the length of the signal. For each channel, the individual RMS calculations were

O&P News | July 2018


Research & Presentations

binned at 6-μV increments. During the period of quiescent muscle activity, the lowest three occupied bins contained approximately 80 percent of the signal across animals and channels. This portion of the signal was labeled as noise. The signals from the walking trials were windowed and binned in the same manner, and the mean RMS value of the signal contained in the lowest three occupied bins was used as the noise value in the SNR calculation. Muscle activation events during the walking trials were identified using a double threshold (time and amplitude) detection method.5 The start of a muscle activation event was identified when the signal was greater than 2.0 times the noise of that channel for 100 ms. The time threshold was selected as it falls within the time delay range that would be considered to provide real-time control of a prosthesis.6-8 The amplitude threshold was selected to have a low chance of false positives while still identifying the onset of muscle activation. The threshold selections were confirmed by comparing the number of identified events to the number of steps counted in the video recordings of the walking trials. For each muscle activation event identified, the average RMS over the activation period was calculated. The event SNR (event RMS/channel noise RMS) was calculated and averaged for each channel. The average value includes the early low amplitude (near threshold) period of muscle activation lowering the overall SNR. Thus, to illustrate the full dynamic range of the signal, the SNR also was calculated using the peak RMS of each event. Lower SNR values also could be the result of a channel being located in a less active muscle, resulting in smaller amplitude events. To confirm lower SNR values were the result of less activity and not high noise levels, the average channel SNR was correlated with the channel noise for each device. A large negative correlation would signify that low SNR values were the result of higher

18 O&P News | July 2018

Figure 2

A 32-channel EMG recording from the implanted device during 12 seconds of walking. Channels 1-8 were located in the long head of the triceps; channels 9-20 were located in the lateral head of the triceps; and channels 21-32 were in the deltoid.

noise on the channel. Low or positive correlations would confirm lower SNRs were due to less muscle activation.

Results Figure 2 shows the 32-channel EMG signal for one animal during walking. Figure 3 shows an example of a quiescent period followed by a muscle activation event measured in the long head of the triceps. These periods were confirmed to correspond to shoulder extension (quiet) and flexion (active) in the video recording. We found that each device had a high, dynamic SNR across all channels. When calculated with low-amplitude, early onset period, the average device SNR was between 5 and 9. Figure 4A illustrates the range of average SNR values across the 32 channels in each device measured with the real-time onset window. However, when the SNR was calculated from the peak of each event, the SNR was

much larger (Figure 4B), illustrating the dynamic range of the signal. The correlation between the SNR and noise for each device was very low and mostly positive (-0.007 – 0.22), confirming that channels with lower SNR values were not due to higher noise levels.

Discussion The results demonstrate that Ripple’s implanted myoelectric device can transmit high-quality EMG signal after six months of implantation. We found high SNR across all channels, with many devices recording events with a peak SNR greater than 20. There was low noise on all channels, and the lack of correlation between noise and SNR suggests that instances of lower SNR were likely due to lower amplitude muscle activations rather than reduced signal quality. The dynamic SNR was achieved with a very short time threshold for event detection (100 ms), suggesting this system

Research & Presentations

will be able to provide the perception of real-time control for the user. Along with the signal quality, the high-channel count and independence of lead placement offers many benefits over existing myoelectric control systems. These findings support the use of

Figure 3

this device for real-time, simultaneous multiple-degree-of-freedom control of a prosthetic arm. The overall low noise and high relative amplitude of the signal (high SNR) measured with the implanted device will allow signal decode algorithms to rapidly detect the start of

One gait cycle measured from the long head of the triceps showing a period of low noise during shoulder extension and an active contraction during shoulder flexion.

muscle activation events and convey this information to the prosthetic limb. Our detection threshold of 100 ms was well below the suggested detection threshold of less than 250 ms.6-8 Additional analysis of shorter time thresholds with higher amplitude thresholds produced similar results in this study. Thus, advanced decode algorithms will likely be able to reduce the muscle activation detection time even further. The high-quality EMG signal was due to the implantation of the sensors, which eliminated many of the physiological factors that reduce the quality and utility of surface EMG recording. A substantial factor in surface EMG signal amplitude and cross-talk is the thickness of the subcutaneous fat layer the signal must travel through to reach the recording device.4 A model of EMG signal quality found that a 6-mm difference (change from 9 mm to 3 mm) in subcutaneous fat resulted in a 241 percent increase in signal amplitude and a 68 percent decrease in cross-talk.4 These findings suggest that the ability to successfully use a myoelectric device with surface EMG may be limited by the morphology of the amputated limb and that reports of successful prosthesis control using surface EMG may not be applicable to the entire population.

Figure 4

The range of SNR values across the 32 channels for each device. (A) The average SNR for the entire muscle activation event, including the low amplitude onset and relaxation periods. (B) SNR calculated at the peak of the muscle contraction.

O&P News | July 2018



How Does Your Business Measure Up? Use AOPA’s Benchmarking Survey Results to Find


BENCHMARKING: the process of comparing one’s business processes and performance metrics to industry bests.

Performance Area:




Needs Work

Gross Margin Sales Generated Per Employee

Cost of Goods Sold Compensation & Benefits










For Orthotic, Prosthetic, & Pedorthic Professionals



(Reporting on 2016 Results)

2017 Annual Operating Performance Report


• Do you need to know how your compensation and benefits compare with similar sized O&P companies or those in your geographic region? • As a forward thinking manager, do you want to know how your company’s financial performance compares with O&P industry leaders? • There is no better industry resource for this type of information.


2017 Operating Performance Report member/nonmember $185/$325

2017 Biannual Compensation and Benefits Report

2017 Compensation and Benefits Report member/nonmember $185/$325




What are AOPA members saying about the 2017 Annual Operating Performance Report (OPR) and the 2017 Biannual Compensation Report?

“The OPR is one of the most valuable deliverables that AOPA provides….” “Having industrywide benchmarks … gives me data that helps us run our business.”

To order, visit www.aopanetonline.org/store. For more information contact bleppin@aopanet.org or call 571-431-0810.

Research & Presentations

However, with device implantation and independent lead placement, the impacts of physiological limb features on signal quality are removed and offer a promise of quality EMG signal for most limb types.

Conclusion These efforts demonstrate the ability to amplify and transmit quality muscle signals from a high-channel count implanted device measured in real time. This approach has the potential to provide simultaneous multidegree-offreedom prosthesis control, especially if used with advanced algorithms, and may provide benefits to users previously deemed to have low-quality surface EMG signals. This work was supported by grants from the National Institutes of Health, the Defense Advanced Research Projects Agency, and the U.S. Department of Defense.

opnews-july.indd 2

Charla L. Howard, PhD; Isaac Myers, PhD; Brian Crofts, MS; Scott Hiatt, MS; and Daniel McDonnall, PhD, work at Ripple LLC in Salt Lake City, Utah.

References 1. Biddiss EA, Chau TT. Upper-Limb Prosthesis Use and Abandonment: A Survey of the Last 25 Years. Prosthet Orthot Int. 2007; 31:236-257. 2. Biddiss E, Chau T. Upper-Limb Prosthetics: Critical Factors in Device Abandonment. Am J Phys Med Rehabil. 2007; 86:977-987. 3. Dudkiewicz I, Gabrielov R, Seiv-Ner I, Zelig G, Heim M. Evaluation of Prosthetic Usage in Upper-Limb Amputees. Disabil Rehabil. 2004; 26:60-63. 4. Kuiken TA, Lowery MM, Stoykov NS. The Effect of Subcutaneous Fat on Myoelectric Signal Amplitude and Cross-Talk. Prosthet Orthot Int. 2003; 27:48-54.

5. Reaz MBI, Hussain M, Mohd-Yasin F. Techniques of EMG Signal Analysis: Detection, Processing, Classification, and Applications. Biol Proced Online. 2006; 8:11. 6. Farrell TR, Weir RF. The Optimal Controller Delay for Myoelectric Prostheses. IEEE Trans Neural Syst Rehabil Eng. 2007; 15:111-118. 7. Smith LH, Hargrove LJ, Lock BA, Kuiken TA. Determining the Optimal Window Length for Pattern Recognition-Based Myoelectric Control: Balancing the Competing Effects of Classification Error and Controller Delay. IEEE Trans Neural Syst Rehabil Eng. 2011; 19:186-192. 8. Childress DS, Weir RF. Control of Limb Prosthesis. In: Smith DG, Michael JW, Bowker JH, editors. Atlas of Amputations and Limb Deficiencies: Surgical, Prosthetic, and Rehabilitation Principles. 3rd ed. Rosemont, IL: American Academy of Orthopaedic Surgeons; 2004. 173-195.

6/5/2018 10:05:09 AM

O&P News | July 2018


O&P Visionary

Charles Dankmeyer Jr., CPO It’s time for O&P practitioners to unite to improve and advance the profession and the O&P community


hen most people are asked what changes they would make to a profession, they naturally reflect on what is not working. Before I go into that arena, I will take a few lines to remind us that we are part of an incredibly rewarding profession. I often commented to my physician and therapist colleagues that I may have been working for 40 years, but I can count on my fingers how many days were really work—and still have a few left over. We all experience the satisfaction of providing ability to our patients. And to boot, they express amazing gratitude! That does not happen to

22 O&P News | July 2018

doctors and therapists on such a routine basis. Yes, we get the invitations to the graduations, birthdays, and, sadly, the funerals. It is pretty much universally experienced by prosthetists and orthotists that our relationships with patients and their families are very personal and appreciated, so much so that we are considered part of their extended family. And we actually get paid to do this! So with all that going for us, what could we possibly want to change? While we were cruising along in our own personal utopias, our attention was on our day-to-day work. Slowly at first, but with an increasing tempo, our little Shangri-La was invaded by the business of bureaucrats. All of the major payors—Medicare, Medicaid, the U.S. Department of Veterans Affairs, and private insurers—gradually increased their paperwork demand on us in an unwarranted, poorly focused effort at reducing fraud. Once we “mostly” pulled out of that stigma, the focus of the Feds changed to cost control. Other demands came one after another—compliance with the Health Insurance Portability and Accountability Act, K-level documentation, need for custom orthosis documentation, regional contracting, and on, and on, and on. Eventually,

O&P Visionary

the time we spent in our most useful and satisfying role was wrestled away into a smaller and smaller part of our everyday practice. And on top of it, we lost control of our fee schedule. That paycheck is getting slimmer. Our ability to provide much of today’s technology is hampered by margins that prevent us from applying current, appropriate technology. How could we possibly have let this happen? And we did let it happen— no excuses, please. What happened to our professional recognition? CPOs now must complete a master’s degree and a residency, and then pass a national exam to become certified. The educational institutions that provide our degrees are nationally recognized, well-respected universities. Our facilities go through a rigorous accreditation process in order to be accredited. Yet there remains little recognition of O&P as a profession in the eyes of the bureaucrats, and even less desire to limit payment to those qualified by our accrediting bodies. Why? Here’s a little inside baseball: A few years ago I was part of a group representing O&P to those in CMS responsible for creating regulations implementing Section 427 of the Benefits Improvement and Protection Act limiting O&P L codes and payments to only qualified providers. It takes a very long time and a great deal of effort to arrange these encounters. At the table for O&P were representatives from AOPA; the American Academy of Orthotists and Prosthetists (AAOP); the American Board for Certification in Orthotics, Prosthetics, and Pedorthics (ABC); the Board of Certification (BOC); the National Association for the Advancement of Orthotics and Prosthetics (NAAOP); and the National Commission on Orthotic and Prosthetic Education (NCOPE). When we finished our presentation, the leader of the CMS group said, “That’s the same thing we heard from the therapeutic shoe people two weeks ago!” Exit stage

Charles Dankmeyer Jr., CPO, at the 2016 AOPA Policy Forum

left with the usual comments like, “Thanks for the opportunity to meet with you, look forward to working with you to have qualified provider regulations in place.” Sure, not happening. In their world, ABC and BOC certificants are all the same—orthotists, prosthetists, pedorthists, therapeutic shoe fitters, orthotic fitters, and others—all the same. Remember, each of those certifications is aligned with associations that are lobbying CMS, too. It is to their advantage to grab our coattails. Some progress has been made since then, but the basic O&P dilemmas remain. What are the dilemmas? First, too many organizations. I listed six organizations at that one meeting. Those organizations all have varying views, opinions, member bases, and, of course, finances. In order to keep some semblance of order and a cohesive message, they have formed yet another organization called the O&P Alliance. This group discusses common issues, attempts to come up with direction, develops responses to regulations and proposals for new legislation, and so forth. By now you might imagine that melding all those points of view seldom results in a solid direction that is consistently pursued year over year. Rivalries between the groups continue to develop and hamper real

progress. Most everyone is familiar with ABC versus BOC. How about AAOP versus AOPA versus NAAOP? The more we have continued petty bickering among the various groups, the less coherent our message to the regulators. We need one representative organization and one national meeting. We need every opportunity for all of us to be together! The second dilemma? Credentialing. As orthotists and prosthetists, we no longer have a credentialing organization that is solely focused on our profession. The professions have been sliced and diced into multiple certificants at the expense of our profession. ABC and BOC now credential a host of certificants, most of them from simply unbundling the professional orthotist and prosthetist. Whether it’s the pedorthists, orthotic fitters, durable medical equipment (DME) specialists, mastectomy fitters, or the aforementioned therapeutic shoe fitters, they all have been blessed with some sort of credential by the same accrediting bodies that govern O&P practitioners and facilities. Additionally, each of those certificants have their own organizations pushing their own agendas on the same bureaucrats O&P is trying to impress. Want to get away from DME? We need one accrediting body solely focused on the professional practice of O&P.

O&P News | July 2018


O&P Visionary

What about manufacturers and central fabrication facilities? They also have organizations walking the hallways of Congress and hitting the bureaucrats for their own benefit. Why? Because some of them, whose products are geared to O&P patients, have goals not aligned with the professional orthotist and prosthetist. Those who demonstrate respect for our profession need our support. Those who don’t, kiss off. We don’t need the stain or stink from those who unscrupulously sell products and custom devices to other than professional orthotists and prosthetists. Point them out, expose them at every opportunity. They are scum who harm patients and your professional reputation. As practicing professional members of the community, we have an obligation to be united in our efforts to improve our profession and thereby improve the quality of life to the community we serve. We have the ability to obtain full

As practicing professional members of the community, we have an obligation to be united in our efforts to improve our profession and thereby improve the quality of life to the community we serve. professional recognition, have current appropriate technology available, maintain reasonable reimbursement rates, and reduce the regulations unfairly burdening our practices. As a profession we owe that to our patients. We also owe it to those entering our profession so they have the opportunity to practice to their fullest ability. It really is not a choice any longer. It is survival. If I were O&P king for a day, my decrees would be very basic: • Demand your leaders to unite the organizations.

• Demand your credentialing organizations limit their focus to professional practice of O&P. • Get involved, and participate at every opportunity. Attend meetings. Speak up and write letters to elected representatives and editors. This is your profession; take ownership. United, we will make a better world for O&P and the people who need us. Charles Dankmeyer Jr., CPO, is a consultant at Dankmeyer Prosthetics & Orthotics in Linthicum Heights, Maryland, and a past president of AOPA.

Realize the facts. O&P care improves quality of life and is cost effective! Learn more at MobilitySaves.org. Reasons to visit MobilitySaves.org


Visit MobilitySaves.org MobilitySaves.org. Follow us on social media! “Search Mobility Saves” on Facebook, Twitter, and LinkedIn

24 O&P News | July 2018

Learn about the study proving orthotic and prosthetic care saves money

See how amputees rallied when their prosthetic care was threatened

Find supporting data to get your device paid for


State by State

The latest news from Connecticut, Illinois, Michigan, Minnesota, and Pennsylvania

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 features information about medical policy updates, fee schedule adjustments, state association announcements, and more.

Connecticut After insurance fairness legislation passed both houses of the Connecticut state legislature, Gov. Dannel P. Malloy signed the bill into law with a written warning to the legislature advising against the passage of unfunded mandates, stating, “We must proceed cautiously when taking legislative action that may put vital health insurance out of reach for lowincome and middleincome individuals in Gov. Dannel P. our state.” Malloy Local advocates Herb Kolodny and Brenda Novak continue their outreach efforts, with a new mission to inform and educate the Connecticut limb loss community about the new law through their organization, the Connecticut Amputee Network.

Illinois O&P providers in Illinois have reported that Blue Cross Blue Shield of Illinois is denying preauthorizations based on the absence of terminology distinguishing “permanent” from “preparatory,” requiring the term “permanent” to be present. Standard language across the profession would distinguish a preparatory prosthesis from a definitive prosthesis, rather than using the term “permanent.” A poll has been added to the Illinois page of the AOPA Co-OP to solicit feedback from Illinois providers regarding this issue. Michigan Two insurance fairness bills have been introduced in Michigan. Rep. Peter Lucido (R-District 36) introduced House Bill 6009 on May 16, 2018. Shortly after, Rep. Beau LaFave (R-District 108) introduced House Bill 6085. If passed, either bill will amend Act 218 of the Pennsylvania Insurance Code of 1956 to require coverage of prosthetic and orthotic devices and services. “The Amputee Coalition is working with both offices to bring the bills and sponsors together and [is] thankful to patient and professional advocates who have made significant strides this year in raising awareness about the need for this legislation in Michigan and getting it introduced,” said Dan Iganzsweski, director of government affairs for the Amputee Coalition.

Minnesota After extensive conversations between O&P providers and Minnesota Medicaid regarding the Minnesota Health-Care Programs fee schedule, an agreement was reached to increase reimbursement of S1040— cranial molding orthoses—to an allowable of $2,782.80. The fee schedule increase, retroactively effective Jan. 1, 2018, represents a significant win for Minnesota O&P providers and signals an opening for continued partnership with Minnesota Medicaid to ensure access to O&P services for the O&P patient population.

Pennsylvania Pennsylvania O&P providers and the Pennsylvania Orthotic and Prosthetic Society are working with the Amputee Coalition on language for an insurance fairness bill with hopes for introduction in 2019. 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 News | July 2018




CERTIFIED PROSTHETIST/ ORTHOTIST (CPO) CERTIFIED PROSTHETIST (CP) Pittsburgh, Pennsylvania De La Torre Orthotics and Prosthetics is seeking a certified prosthetist/orthotist and a certified prosthetist to join our growing practice. The qualified candidate will see patients in our local clinical offices, various PT departments, and rehab facilities in the greater Pittsburgh area. Requirements: • ABC-certified is preferred • A minimum of two years of recent, successful patient-based experience • Must work well in a team environment • Excellent oral communication skills with patients and referral sources • Ability to learn and use an EMR system is necessary. De La Torre O&P offers competitive compensation and benefit packages including 401(k), medical, disability policies, and certification reimbursement and is an AAP employer.


WANTED! A few good businesses for sale. Lloyds Capital Inc. has sold over 150 practices in the last 26 years. If you want to sell your business or just need to know its worth, please contact me in confidence. Barry Smith Telephone: (O) 323-722-4880 • (C) 213-379-2397 e-mail: loyds@ix.netcom.com

AOPA Celebrates Health-Care Compliance & Ethics Week November 4-10, 2018

• Demonstrate your company’s commitment to ethical business practices • Create awareness of the Code of Conduct, relevant laws, and regulations

De La Torre Orthotics and Prosthetics Email résumé to: drew@delatorreop.com Subject line: prosthetist/orthotist job opening


• Provide your staff with recognition for training completion, compliance, and ethics successes • Reinforcement—of the culture of compliance for which your organization strives.

Owner of a strong 20 year referral source getting ready to retire Looking for a resident just out of school or a CPO that wants to enjoy life in the East Tennessee Mountains This position has ownership possibilities. Contact: Tara Smallin Fax: 865/774-9959

Visit www.AOPAnet.org

26 O&P News | July 2018

AOPA has developed several tools and resources to assist you. Visit our dedicated web page for tools, resources and more:



Meetings & Courses

2018 JULY 23-24 Mastering Medicare: Essential Coding & Billing Techniques. St. Louis. Register online at

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 18-20 International African-American Prosthetic Orthotic Coalition Annual Meeting. Embassy

Mastering Medicare: Essential Coding & Billing Techniques.

Suites Downtown Medical

bit.ly/2018billing. For more

Center, Oklahoma City. For more

information, email Ryan Gleeson

information, contact Tony Thaxton Jr.

at rgleeson@AOPAnet.org.

comcast.net, or visit www.iaapoc.org.

information, email Ryan Gleeson at rgleeson@AOPAnet.org.

NOVEMBER 4-10 Health-Care Compliance & Ethics Week. AOPA is celebrating

AUGUST 8 AOPA Webinar: Outcomes & Patient Satisfaction Surveys.

Health-Care Compliance & Ethics Week and is providing resources to help members celebrate. Learn more at bit.ly/aopaethics.

Register online at bit.ly/2018webinars. For more information, email Ryan Gleeson at rgleeson@AOPAnet.org.


AOPA Webinar: Medicare As a Secondary Payor: Knowing the Rules. Register online at bit.ly/2018webinars. For more information, email Ryan Gleeson at rgleeson@AOPAnet.org.

Las Vegas. Register online at

at 404/875-0066, email thaxton.jr@

bit.ly/2018billing. For more



NOVEMBER 14 AOPA Webinar: Evaluating Your Compliance Plan & Procedures: How To Audit Your Practice. Register online at bit.ly/2018webinars. For more information, email Ryan Gleeson at rgleeson@AOPAnet.org.


AOPA Webinar: Year-End Review: What Should You Do To Wrap Up the Year & Get Ready for the New Year?.Register online

AOPA Webinar: New Codes, Medicare Changes, & Updates. Register online at

at bit.ly/2018webinars. For more

information, email Ryan Gleeson at

information, email Ryan Gleeson at


bit.ly/2018webinars. For more


ADVERTISER INDEX ALPS..................................................................3 www.easyliner.com American Orthotic & Prosthetic Association (AOPA)..............2, 9, 10, 20, 24, Cover 3 www.AOPAnet.org

Publisher Thomas F. Fise, JD Advertising Sales RH Media LLC Editorial Services Content Communicators LLC Design & Production Marinoff Design LLC

Cascade Dafo....................................................21 www.cascadedafo.com Fabtech Systems..............................................11 www.fabtechsystems.com Hersco Ortho Labs .....................................Cover 2 www.hersco.com Ă–ssur.................................................Back Cover www.ossur.com

Printing Sheridan 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. Periodical postage paid at Alexandria, VA, and additional mailing offices. 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 | July 2018



The Technician’s Role in Patient Care During the Fabrication Process PHOTO: Bulow O&P

Herman Green, CTP, CPA, with a patient

Technicians should strive for good working relationships with both clinicians and patients By Herman Green, CTP, CPA


28 O&P News | July 2018

PHOTO: Amanda Heller

he role of the technician in O&P patient care during the fabrication process is vital; the technician plays an important part in ensuring successful patient outcomes. The patient-care relationship starts with the clinician and patient but should extend to the technician. Every technician should have a good working relationship with the clinician. He or she should be familiar with what the clinician is striving to accomplish for the individual patient, which means that communication is a key element of the process. Having a good understanding of the patient’s expectations and goals is necessary during the fabrication process. The technician needs to be familiar with these expectations and goals in order to fabricate an optimal device for the patient. With that being said, the patientcare relationship should extend beyond the technician and clinician during the fabrication process to the technician and patient if the opportunity is presented. Building the technician/patient relationship allows the technician to have a firsthand understanding of the patient’s aforementioned expectations and goals. Forming this relationship allows the patient to meet everyone involved in the care and fabrication process of his or her device, ultimately allowing the patient to become more comfortable and relaxed in what can be a very unfamiliar and intimidating process. This is a great

Figure 1

Herman Green, CTP, CPA, has fabricated prosthetic devices for 19-year-old Amanda Heller since she was a baby.

asset in prosthetics but an opportunity that rarely presents itself in orthotics. Patient care continues while a device is being fabricated. With every prosthesis or orthosis that a technician gets the opportunity to fabricate, he or she must be sure to treat it as his or her own—giving it that personal touch. Because no two patients are the same, a technician must be willing to increase his or her knowledge base and realize the endless opportunities to learn and be innovative for the benefit of the patient, as doing so leads to great patient care. As a technician, I am humbled and inspired every day when given the opportunity to help individuals. Great patient care can lead to changing lives and ought to be the motivation of every technician as it can be accomplished during the fabrication process. A good example of this is Amanda Heller, a patient I have known and worked with since she was five months

old. Amanda and her parents have always appreciated the input, care, and concern I have shown. This young lady is now 19 years old and still appreciates the patient care I have applied in fabricating her prosthetic devices over the years (see Figure 1). This encourages me as a technician and gives me motivation to perform my job daily to the best of my ability. Last, but by no means the least, quality is important so take the time and strive to create the best device every time. Remember your name and the company reputation are attached to every device you fabricate so give it your all every time. Quantity paired with quality is important, but quantity without quality isn’t acceptable. With great quality, quantity will follow. Herman Green, CTP, CPA, is purchasing/lab manager at Bulow Orthotic & Prosthetic Solutions.






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

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



Experience all the AOPA National Assembly has to offer while visiting Vancouver.

© Össur, 06.2018



NEW! Pro-Flex LP Align

Less load, more dynamics™ Here we go again! Introducing Pro-Flex LP Align, which couples up to 2 3/4" of heel height adjustability with the mechanical power of the 3-blade Pro-Flex design. So users can maintain proper alignment across a variety of everyday footwear, from sandals to sneakers to dress shoes.

Visit ossur.com/pro-flex-family or ask your Össur rep about a Pro-Flex demo today.

USA (800) 233-6263 WWW.OSSUR.COM


Pro-Flex XC Torsion

Pro-Flex XC

Pro-Flex LP Torsion

CANADA (800) 663-5982 WWW.OSSUR.CA

Pro-Flex LP