March 2022 O&P Almanac by AOPA

The Magazine for the Orthotics & Prosthetics Profession

M AR C H 2022

Expansion of Prior Authorization P.16

New! O&P Educator Column Profiles Technical Instructor P.32

State-Level Legislation Addresses Coverage Mandates

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P.48

BEST PRACTICES IN

PEDIATRIC BRACING UNIQUE PROTOCOL AND EXPERT TIPS FOR TREATING HYPERTONIA AND EQUINUS DEFORMITY AS A TEAM P.20

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MARCH 2022 | VOL. 71, NO. 3

contents

COVER STORY

FEATURES

DEPARTMENTS | COLUMNS Views From AOPA Leadership......... 4

Join AOPA for the 2022 Policy Forum

AOPA Contacts............................................6 How to reach staff

Numbers........................................................ 8

At-a-glance statistics and data

Happenings............................................... 10

Research, updates, and industry news

BEST PRACTICES IN PEDIATRIC BRACING

People & Places........................................ 14

Transitions in the profession

What are the keys to success in managing patients with hypertonia and equinus deformity? Two experts in the field discuss their recommendations for orthotists and other team members tasked with providing braces to improve stability and mobility among patients with excess muscle tone. P.11

20 | Bracing for Success as a Team Clinicians at Ann & Robert H. Lurie Children’s Hospital of Chicago have experienced a unique level of success in gaining and maintaining correction of equinus gait in children with hypertonia. Brigid Driscoll, PT, DPT, CO, LO, coordinator of the program, explains the steps involved and shares tips for orthotist-physical therapist collaboration.

Reimbursement Page.......................... 16

Expansion Plans

What to expect when five orthotic codes are added to prior authorization Opportunity to earn up to two CE credits by taking the online quiz.

By Christine Umbrell

26 | Team Considerations for Managing Equinus Deformity in Children

Beverly Cusick, MS, PT, COF/BOC, offers her insights on what orthotists should know about the condition of hypertonous, the sources of equinus deformity, assessing ankle dorsiflextion range of motion, and managing equinus deformity conservatively.

Member Spotlight................................. 36 n n

JL Artificial Limb and Brace Phoenix Molded Shoes, Inserts, and Braces

AOPA News............................................... 40

AOPA advocacy, announcements, member benefits, and more

O&P EDUCATOR Education for Everyone............................................. 32 Meet an O&P professional who believes education is her true calling. Joanna Kenton, MHA, CPO, LPO, FAAOP, teaches prosthetic technology at Century College—and helps plan the education for the annual AOPA National Assembly.

MARCH 2022 | O&P ALMANAC

Marketplace............................................... 41 Careers........................................................ 44

Professional opportunities

Calendar......................................................46

Upcoming meetings and events

Ad Index....................................................... 47 State By State.......................................... 48

Arizona, New York, Virginia, and Washington

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VIEWS FROM AOPA LEADERSHIP

Now Is Our Time. Educate. Advocate. Celebrate.

HE FUTURE OF THE orthotics and prosthetics profession requires a commitment to and investment in advocacy. O&P is a small and unique field, which is what many of us find so compelling. But the fact that we’re not a massive piece of the healthcare puzzle, and the lack of general understanding about the complexity of O&P services, also present a significant challenge when advocating for our profession and our patients’ needs. No one in O&P—not even our largest representatives—can shine a bright enough light by themselves to create change at a legislative and regulatory level. To be successful in our advocacy efforts, everyone must pitch in if we are to be seen. This spring, we all have the perfect chance to do so. We will be back on Capitol Hill in person on May 17 and 18 for AOPA’s 2022 Policy Forum. After two years of having to conduct this event virtually, we will meet with legislators and their staff in Washington, D.C. Whether you are a business owner, a practitioner, a student, a resident, an administrator, or an educator, I encourage you to participate. Now more than ever, it will take all of our unique ideas, backgrounds, and skills to cut through the noise in Congress. I would especially like to encourage you to invite one or more of your patients to join you. Having sat in many meetings with members of Congress and their staff, I can tell you first-hand that the presence of patients speaking about how O&P care has transformed their lives highlights in a personal, memorable way the impact we all have on the patients we serve. Having all voices represented, and in large numbers, will make the biggest impact. Participating in the Policy Forum is one of the best opportunities to learn about the legislative and regulatory issues facing the profession. You will acquire or hone your advocacy skills. Before meeting with our elected officials, we will spend a day getting you up to speed on the issues. You will have the opportunity to practice advocating for your needs. This year we will continue our push to see the Medicare Orthotics and Prosthetics Patient-Centered Care Act (HR 1990 and S 2556) become law. In addition to this pivotal legislation, we will continue to seek funding for O&P education and research. We also will detail ways Congress can mitigate disparities occurring in the O&P field that negatively impact our patients. And we will make the case for veterans to retain their right to select their own O&P providers. The Policy Forum also is a time to come together and celebrate what we do for the profession and the patients we serve. This year is special because we get to celebrate the 30th anniversary of the first Policy Forum. We’re excited to look back at how far we’ve come—while also focusing on the future. For those of you saying, “Gee, I’d like to come but I have so much going on in my office,” I’d ask you to consider the implications of not coming. We all know the challenges facing our profession; we talk (often at great length and loud volume) about all the things that are hurting O&P. By investing a few days now, we can take steps to protect our future and the future of our patients. So, join us. You will leave Washington knowing that you’ve done your part to help elected officials understand the needs of our profession and patients. I look forward to seeing you in D.C. this spring!

Dave McGill is president of AOPA.

MARCH 2022 | O&P ALMANAC

Specialists in delivering superior treatments and outcomes to patients with limb loss and limb impairment.

Board of Directors OFFICERS President Dave McGill Össur Americas, Foothill Ranch, CA President-Elect Teri Kuffel, JD Arise Orthotics & Prosthetics, Spring Lake Park, MN Vice President Mitchell Dobson, CPO Hanger, Austin, TX Immediate Past President Traci Dralle, CFm Fillauer Companies, Chattanooga, TN Treasurer Rick Riley O&P Boost, Bakersfield, CA Executive Director/Secretary Eve Lee, MBA, CAE AOPA, Alexandria, VA DIRECTORS Jeffrey M. Brandt, CPO Ottobock, Exton, PA Elizabeth Ginzel, MHA, CPO Össur, Fort Worth, TX Kimberly Hanson, CPRH Ottobock, Austin, TX John “Mo” Kenney, CPO, FAAOP Kenney Orthopedics, Lexington, KY Jim Kingsley Hanger Clinic, Oakbrook Terrace, IL Linda Wise WillowWood, Mount Sterling, OH Shane Wurdeman, MSPO, PhD, CP, FAAOP(D) Research Chair, Hanger Clinic, Houston Medical Center, Houston, TX James O. Young Jr., CP, LP, FAAOP Amputee Prosthetic Clinic, Tifton, GA

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AOPA CONTACTS

Our Mission Statement A trusted partner, advocating for and serving the orthotic and prosthetic community by: • Fostering relationships with decision makers to ensure equitable access • Providing education that promotes professional excellence • Supporting research that informs innovative care • Advancing equality to strengthen the orthotic and prosthetic profession and improve the lives of patients.

A world where orthotic and prosthetic care transforms lives.

EXECUTIVE OFFICES Eve Lee, MBA, CAE, executive director, 571/431-0807, elee@AOPAnet.org Akilah Williams, MBA, SHRM-CP, senior manager for finance, operations, and HR, 571/431-0819, awilliams@AOPAnet.org HEALTH POLICY & STRATEGIC ALLIANCES Ashlie White, MA, director of health policy and strategic alliances, 571/431-0812, awhite@AOPAnet.org Susannah Engdahl, PhD, manager, health policy and research, 571/431-0843, sengdahl@AOPAnet.org Sam Miller, manager, state and federal advocacy, 571/431-0814, smiller@AOPAnet.org MEETINGS & EDUCATION Tina Carlson, CMP, senior director, education and meetings, 571/431-0808, tcarlson@AOPAnet.org Kelly O’Neill, CEM, senior manager of meetings and exhibition, 571/431-0852, kelly.oneill@AOPAnet.org Kristen Bean, digital meetings specialist, 571/431-0876, kbean@AOPAnet.org

MARCH 2022 | O&P ALMANAC

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AMERICAN ORTHOTIC & PROSTHETIC ASSOCIATION (AOPA) 330 John Carlyle St., Ste. 200 Alexandria, VA 22314 AOPA Main Number: 571/431-0876 AOPA Fax: 571/431-0899 www.AOPAnet.org

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O&P ALMANAC Eve Lee, MBA, CAE, executive director/ publisher, 571/431-0807, elee@AOPAnet.org Josephine Rossi, editor, 703/662-5828, jrossi@contentcommunicators.com Catherine Marinoff, art director, 786/252-1667, catherine@marinoffdesign.com Bob Heiman, director of sales, 856/520-9632 , bob.rhmedia@comcast.net Christine Umbrell, editorial/production associate and contributing writer, 703/6625828, cumbrell@contentcommunicators.com

SUBSCRIBE O&P Almanac (ISSN: 1061-4621) is published monthly, except for combined issues in June/July and November/December, by the American Orthotic & Prosthetic Association, 330 John Carlyle St., Ste. 200, Alexandria, VA 22314. To subscribe, contact 571/431-0876, fax 571/431-0899, or email info@aopanet.org. Yearly subscription rates: $59 domestic, $99 foreign. All foreign subscriptions must be prepaid in U.S. currency, and payment should come from a U.S. affiliate bank. A $35 processing fee must be added for non-affiliate bank checks. O&P Almanac does not issue refunds. Periodical postage paid at Alexandria, VA, and additional mailing offices. ADDRESS CHANGES POSTMASTER: Send address changes to: O&P Almanac, 330 John Carlyle St., Ste. 200, Alexandria, VA 22314. Copyright © 2022 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 AOPA, nor does the association necessarily endorse products shown in the O&P Almanac. The O&P Almanac is not responsible for returning any unsolicited materials. All letters, press releases, announcements, and articles submitted to the O&P Almanac 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 With Us! Reach out to AOPA’s membership and more than 11,400 subscribers. Engage the profession today. Contact Bob Heiman at 856/520-9632 or email bob.rhmedia@comcast.net. Visit bit.ly/AOPAMedia2022 for advertising options!

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NUMBERS

Cerebral Palsy in the United States Many orthotists treat children with cerebral palsy—the most common motor disability in children

U.S. PREVALENCE

764,000

Children and adults who currently have CP

HIGHER INCIDENCE AMONG BOYS

3.6 Per 1,000 2.4 Per 1,000

Incidence among black children

Incidence of boys with CP

Incidence among white children

Incidence of girls with CP

Incidence among Hispanic children

2.7 Per 1,000 1.3 Per 1,000

2.5 Per 1,000

Medical costs are 10 times higher for children with CP

Children under 18 who have CP

HIGHER INCIDENCE AMONG BLACK CHILDREN

3.6 Per 1,000

MEDICAL COSTS

500,000

Medical costs are 26 times higher for children with CP who also have an intellectual disability

Incidence among Asian children

>$1 Million

Total lifetime costs of care for a child with CP

TYPES OF CEREBRAL PALSY IN UNITED STATES TYPE OF CP

Spastic Hypotonic Ataxic/Dyskinetic Mixed/Spastic Other/Unspecified

PERCENT OF CP CASES

82.9% 5.1% 1.6% 4.5% 5.9%

SOURCE: “Prevalence of Cerebral Palsy in 8-Year-Old Children in Three Areas of the United States in 2010 and Preliminary Evidence of Trends in Its Relationship to Low Birthweight,” Pediatric Perinatal Epidemiology, September 2016.”

MARCH 2022 | O&P ALMANAC

1,200 to 1,500 Preschool-aged children diagnosed annually with CP

MOBILITY ISSUES AMONG CHILDREN WITH CP

59%

Percentage who can walk independently, some with orthoses

33%

Percentage who have limited or no walking ability

Percentage who require the aid of handheld mobility devices, including walkers and crutches

“Orthotic devices help to compensate for muscle imbalance and increase independent mobility. Braces and splints use external force to correct muscle abnormalities and improve function, such as sitting or walking. Other orthotics help stretch muscles or the positioning of a joint.” —“Cerebral Palsy: Hope Through Research,” National Institute of Neurological Disorders and Stroke

SOURCE: Sources: Data provided by American Board for Certification in Orthotics, Prosthetics, and Pedorthics; and National Commission on Orthotic and Prosthetic Education.

Approximately one in 323 children in the United States have some form of cerebral palsy (CP)—a group of disorders that affect a person’s ability to move and maintain balance and posture. Many of these children benefit from orthotic intervention to aid in their mobility. (See also “Bracing for Success as a Team” on page20).

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Happenings RESEARCH ROUNDUP

Walk Test Results May Vary By Setting

Renee Van Veld, DPT, PT, of SRT Prosthetics & Orthotics (right), observes a patient performing the two-minute walk test in the clinic.

Case Study Demonstrates Successful Bracing in Infantile Idiopathic Scoliosis Among infants with idiopathic scoliosis, serial casting often is the recommended treatment, but Australian researchers have successfully treated an infant with a large thoracic curve using a thoracolumosacral orthosis (TLSO). Jeb McAviney and Benjamin Brown, MChiroprac, PhD, of Macquarie University treated an 11-week-old infant with a 44-degree thoracic scoliosis by having him wear a TLSO on a part-time basis for eight months. At the end of treatment, the patient’s curve had been reduced to 7 10

MARCH 2022 | O&P ALMANAC

degrees, with a rib-vertebral angle difference of 0 degrees. During a final follow-up visit when the patient turned 2, the researchers found no evidence of scoliosis. “The use of an orthosis as a standalone treatment in this patient resulted in significant reduction in a large thoracic scoliosis,” the researchers concluded. “Based on the results witnessed in this patient, further investigation into bracing as an alternative to casting is warranted.” Details were published in Journal of Medical Case Reports in January.

PHOTO: SRT Prosthetics & Orthotics

Prosthetists should recognize that patients’ walking distance in clinical settings during two-minute walk tests (2MWTs) may differ from published results, according to a study published in January in Prosthetics and Orthotics International. A research team led by Christopher Shank from Western Michigan University and Robert “Bob” Gailey, PhD, PT, from University of Miami studied the 2MWT data for 290 patients with lower-limb amputation and data from 12 prosthetists’ 2MWT administrative questionnaires. They compared 2MWT distances with published distances and found that clinical 2MWT distances were significantly lower than distances obtained in a research setting. They attributed lower walking distances to inconsistent path dimensions and potential obstacles in proximity to the test areas, as well as possible variations in test administration techniques. “Demonstrating the value of what prosthetists do as caregivers is important. Today, outcomes are the best way to objectively show the importance of prosthetic interventions,” explained Gailey. “However, knowing that the selected outcomes are accurate is critical. Comparing data to the literature, or even other clinics, may not be accurate.” Gailey recommends that each clinic review the outcome results collected from its patients and include the averages as baseline data in every report. “It is also important to understand that not every patient will improve,” he added. “For example, just maintaining or slowing the decline of function with age in older patients is an extremely positive result. This is a story that needs to be told with every patient.”

HAPPENINGS

Apply for Pilot Grant Funding by April 30 AOPA and the Center for Orthotic and Prosthetic Learning and Outcomes/ Evidenced-Based Practice (COPL) are accepting requests for pilot grant proposals in O&P research. Applicants will be eligible for one-time awards ranging between $5,000 and $30,000.

Studies must be completed within one year from the start date, which will be set once approval from the Institutional Review Board is received and initial payment is made by AOPA. AOPA and COPL will give preference to grants that address evidence-based clinical application in O&P. Applications involving patient-engaged, participatory research are encouraged. Plan to apply before the April 30 deadline. View proposal topics and guidelines at https://www.aopanet. org/wp-content/uploads/2022/02/ COPL2022RFP_Final-Final.pdf. Contact Ashlie White, AOPA’s director of strategic alliances, with questions at awhite@aopanet.org. Apply at https:// aopa.wufoo.com/forms/pxmpts616jwxln/.

FUTURE OF MEDICINE

Report Predicts Shift to ‘Care at Home’ Nearly $265 billion in care services for Medicare fee-for-service and Medicare Advantage beneficiaries could shift from traditional healthcare facilities to patients’ home settings by 2025, according to a new report from McKinsey, “From Facility to Home.” Based on a survey of physicians who serve this patient population, the shift could come “without a reduction in quality or access,” according to McKinsey. The “care at home” concept, also discussed in the February O&P Almanac article, “Setting the Stage for ValueBased Healthcare,” encompasses such concepts as primary care visits via telehealth, self-administered dialysis at home, and skilled nursing facility services at home with remote patient monitoring and support for activities of daily living. “Care at home could improve the quality

of care and the patient experience by providing patients with care in the comfort of their homes and by potentially reducing adverse health events,” noted the McKinsey researchers. Payors could potentially benefit from lower medical costs resulting from fewer preventable adverse health events and lower-cost sites of care, although the value could be partially offset by the reimbursement costs for care-athome services, according to McKinsey. Healthcare facilities and physician groups could benefit from savings within value-based payment arrangements or reimbursement for providing at-home services, but there could be increased costs for partnering with other providers to deliver care, noted the researchers. “Ultimately, the value from care at home will likely depend on which specific opportunities are pursued and adopted.”

VETERAN VIEWPOINTS

Comorbidities Among Veterans With Limb Loss After leaving military service, more than 80 percent of veterans with limb loss also have diagnoses in one or more of the following categories: mental disorders, diseases of the nervous system and sense organs, and diseases of the musculoskeletal system and connective tissue. —“Healthcare Inspection: Prosthetic Limb Care in VA Facilities,” Department of Veterans Affairs.

FAST FACT

Amputation Causes in Canada

Vascular disease, specifically diabetes, is the leading cause of lower-extremity amputation, responsible for more than 65% of lower-extremity amputation in Canada from 2006 to 2011. Trauma accounts for 80–90% of all upperextremity amputation. —“Trends of Limb Amputation Considering Type, Level, Sex, and Age in Saskatchewan, Canada, 2006-2019,” Archives of Public Health, January 2022.

O&P ALMANAC | MARCH 2022

HAPPENINGS

EDUCATION UPDATE

Salus University To Launch MSOP Program

STORAGE

FAST FACT

Decline in Global Diabetes Deaths In a new study of global deaths among people with diabetes between 1995 and 2016, mortality in diabetes decreased in 17 of 19 areas (six data sources in Asia, eight in Europe, one in Australia, and four from North America). In eight of the 19 data sources, mortality decreased more rapidly in people with diabetes than in those without diabetes. —“Trends in All-Cause Mortality Among People With Diagnosed Diabetes,” The Lancet Diabetes and Endocrinology, Feb. 1, 2022.

MARCH 2022 | O&P ALMANAC

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T OVEN

Salus University will debut a new O&P program for students pursuing master’s degrees in O&P this fall, when it expects to host its first cohort of students. The program will be housed in a new facility at the university’s Elkins Park, Pennsylvania, campus. In adding the program, the university seeks to help fill future demand for O&P J. Chad Duncan, PhD, CRC, CPO services, and is seeking accreditation by the National Commission on Orthotic and Prosthetic Education. “Salus’s program is unique in that its whole curriculum is based on cultural humility,” said J. Chad Duncan, PhD, CRC, CPO, chair and program director of O&P at Salus. “The goal of this approach is to push the next generation of clinicians in being more holistically focused on patient care. I hope this approach draws diverse interest to Salus’s O&P program.” Duncan, who previously was director of the O&P program at Northwestern University, is excited to build the new program from the ground up. The Salus O&P program will complement several existing healthcare-related programs the university already offers. Duncan will establish curricula amid an interdisciplinary model. Salus expects an initial class of 24 students, overseen by four faculty.

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Rural, Minority Patients Experience Diabetes Care Disparities 11X17

Date: SEPTEMBER 29, 2021 ELKINS PARK CAMPUS - WEST WING

PRESENTATION

Adults with diabetes who live in rural areas, as well as those who live in areas of socioeconomic disadvantage, were much less likely to achieve optimal diabetes care than people who live in urban areas and in less socioeconomically deprived areas, according to a new study by Mayo Clinic researchers. Outcomes were worse among racial and ethnic minority groups, according to the researchers, whose findings appeared in December 29 in JAMA Network Open. Shaheen Shiraz Kurani, PhD, and her research team examined more than 31,000 medical records of 18- to 75-year-old patients with diabetes who were cared for in 75 primary care practices across Minnesota, Iowa, and Wisconsin. They found that patients living in more deprived and rural areas were significantly less likely to attain high-quality diabetes care compared with those living in less deprived and urban areas. “These geographic disparities that affect rural populations present major challenges for patients with diabetes and point to the need for geographically tailored interventions that take into consideration the specific resources available in rural sites,” said the researchers.

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HAPPENINGS

AWARDS & HONORS

Five O&P Companies Honored With Hanger Partner Awards Hanger has awarded its ninth annual Partner Awards to five companies for their roles in providing products and services used to deliver O&P care and empower patients’ lives. The Rising Star, Collaboration, Innovation, and Operational Performance Partner Award winners were selected by members of Hanger’s clinical and operational teams, while the Clinicians’ Choice Award winner was chosen by Hanger clinicians. • Clinect was awarded the Rising Star Award, which recognizes an emerging leader driving industry change. Clinect was recognized for providing excellent service through its automated electronic communications, which not only share critical information with patients, but have helped Hanger capture Net Promoter Score responses and outcomes data. • Spinal Technology received the Collaboration Award, which is granted to a partner that made outstanding contributions resulting in shared success. Spinal Technology was recognized for its collaboration with Hanger Clinic clinicians on challenging cases and postfitting evaluations, as well as its customer service, consistency, and ease of doing business • Point Designs was honored with the Innovation Award,

which recognizes a partner that has exhibited expansive thinking in product innovation and technology, resulting in positive clinical outcomes. Point Designs was selected for its work leveraging advanced 3D-printing technology to manufacture high-strength prosthetic fingers for people with partial hand amputations. • ALPS received the Operational Performance Award, which is granted to a partner that outperformed industry benchmarks in quality, efficiency, and cost containment. ALPS received the award due to its outstanding fulfillment rates and on-time deliveries, being a valued partner in cost savings initiatives, and supporting Hanger’s clinicians through education to ensure quality outcomes. • Blatchford was honored with the Clinicians’ Choice Award, which recognizes an exceptional partner who consistently went above and beyond to support Hanger clinicians and their patients. Blatchford was recognized for its superlative customer service; being supportive in education, order support, and postdelivery support; and going above and beyond to help clinicians provide the best possible care to patients.

PEOPLE & PLACES PROFESSIONALS

BUSINESSES

ANNOUNCEMENTS AND TRANSITIONS

Otto Fernandez has been named chief commercial officer for WillowWood. Fernandez brings more than 25 years of experience to the role, including 12 years at Össur, as well as 12 years at DuPont in Latin America Otto Fernandez and the United States. At WillowWood, Fernandez will focus on be ramping up sales in U.S. and international markets and leading the marketing and education teams to support customers and sales efforts. “It’s a privilege to be joining WillowWood at this pivotal time in its 115-year history,” said Fernandez. “It has been exciting to witness the rapid growth of WillowWood’s ever-expanding liner portfolio while also entering into new areas such as high-activity feet. I am looking forward to leading and working with the talented team at WillowWood to accelerate growth, integrate acquisitions, and help the company realize its full potential.” “Given WillowWood’s commitment to advancing innovation, the timing is right for us to step up our commercial efforts,” said Daniel Rubin, WillowWood’s COO. “Otto brings the experience and know-how to successfully position our product portfolio with its focus on improved outcomes.”

Hanger Inc. was named one of “America’s Best Midsized Employers” by Forbes in February. The company, which employs nearly 5,000 individuals, was selected for the recognition through an independent nationwide survey of more than 60,000 American employees working for midsized to large companies. Respondents ranked their willingness to recommend current employers to friends and family, and had the option to nominate other notable organizations within their industry. “We are honored to be recognized for a second year in a row, thanks to positive feedback from our incredible team members, who inspire us every day with their dedication to fulfilling our purpose of empowering human potential together,” said Vinit Asar, Hanger president and CEO. “Being acknowledged as one of America’s best employers reaffirms our ongoing commitment to being an employer of choice.”

MARCH 2022 | O&P ALMANAC

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REIMBURSEMENT PAGE

By JOE MCTERNAN

Expansion Plans Medicare expansion of prior authorization creates challenges and opportunities

L0648

L065

L 1 8 51

L1832 L1833 Editor’s Note—Readers of Reimbursement Page are eligible to earn two CE credits. After reading this column, simply scan the QR code or use the link on page 18 to take the Reimbursement Page quiz. Receive a score of at least 80%, and AOPA will transmit the information to the certifying boards.

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EDICARE PRIOR AUTHORIZATION HAS been in effect for

certain lower-limb prosthetic Healthcare Common Procedure Coding System (HCPCS) codes for more than a year. By almost all accounts, prior authorization has been a positive experience for providers, Medicare beneficiaries, and contractors. Initial concerns regarding the impact of prior authorization on beneficiary access have been alleviated as the program continues to operate

MARCH 2022 | O&P ALMANAC

efficiently. Prior authorization decisions are consistently made well within the 10-day decision timeframe, with an effective process in place to expedite requests that are more time sensitive. Just when O&P providers were getting comfortable with the program as a regular Medicare process, CMS announced the first expansion of Medicare prior authorization, to include five additional HCPCS codes that describe certain spinal and knee orthoses. CMS will roll out the program in three phases, with Phase 1 beginning next month in four states. This month’s Reimbursement Page reviews the lessons learned over the past year and looks ahead at how expansion of the program may impact your O&P business.

Initial Impact

Medicare prior authorization became a reality for prostheses with the February 2020 CMS announcement that six lower-limb prosthetic HCPCS codes—L5856, L5857, L5858, L5973, L5980, and L5987—would require prior authorization as a condition of payment. While initial implementation was delayed because of the COVID-19 public health emergency, nationwide implementation for the six initial prosthetic codes became effective

nationwide for claims with dates of service on or after Dec. 1, 2020. Just over one year later, the program is in full swing and is running efficiently. According to data provided by the Durable Medical Equipment Medicare Administrative Contractors (DME MACs), approximately 80% of prior authorization requests for lower-limb prosthetic codes are approved on their initial submission, and almost all requests are approved after the first resubmission. This has led to better outcomes for patients, who are receiving medically necessary care in a timely manner; providers, who are seeing fewer claim denials; and the DME MACs, who are improving communication and education processes for providers. The six codes initially selected for inclusion in the Medicare prior authorization program all represent relatively high-cost prosthetic components. Four of the codes describe components that include microprocessor control. Medicare prior authorization has allowed providers to obtain a coverage decision on high-technology, high-cost components prior to expending the financial resources to purchase the components, resulting in more opportunities for patients who may benefit from expanded access to the technology offered by these advanced components.

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While expansion of Medicare prior authorization has been expected—due to the relative success of the program so far—the expectation was that expansion of the program would most likely include additional lower-limb prosthetic codes. The expansion of the program to include orthotic HCPCS codes creates new challenges and concerns about the impact prior authorization may have on beneficiary access to timely and clinically appropriate care.

Adding Five More Codes

On Jan. 22, CMS announced the expansion of Medicare prior authorization to include the following five orthotic HCPCS codes: • L0648: Lumbosacral Orthosis, Sagittal Control, With Rigid Anterior and Posterior Panels, Posterior Extends From Sacrococcygeal Junction to T-9 Vertebra, Produces Intracavitary Pressure To Reduce Load on the Intervertebral Discs, Includes Straps, Closures, May Include Padding, Shoulder Straps, Pendulous Abdomen Design, Prefabricated, Off-the-Shelf • L0650: Lumbosacral Orthosis, Sagittal-Coronal Control, With Rigid Anterior and Posterior Frame/ Panel(s), Posterior Extends From Sacrococcygeal Junction to T-9 Vertebra, Lateral Strength Provided By Rigid Lateral Frame/Panel(s), Produces Intracavitary Pressure To Reduce Load on Intervertebral Discs, Includes Straps, Closures, May Include Padding, Shoulder Straps, Pendulous Abdomen Design, Prefabricated, Off-the-Shelf • L1832: Knee Orthosis, Adjustable Knee Joints (Unicentric or Polycentric), Positional Orthosis, Rigid Support, Prefabricated Item That Has Been Trimmed, Bent, Molded, Assembled, or Otherwise Customized To Fit a Specific Patient By an Individual With Expertise • L1833: Knee Orthosis, Adjustable Knee Joints (Unicentric or Polycentric), Positional Orthosis, Rigid Support, Prefabricated, Off-the-Shelf • L1851: Knee Orthosis, Single Upright, Thigh and Calf, With Adjustable Flexion and Extension Joint 18

MARCH 2022 | O&P ALMANAC

(Unicentric or Polycentric), MedialLateral and Rotation Control, With or Without Varus/Valgus Adjustment, Prefabricated, Off-the-Shelf. Medicare prior authorization for these five codes will be implemented in three phases. Phase 1 includes New York, Illinois, Florida, and California and begins April 13, 2022. Phase 2 adds Maryland, Pennsylvania, New Jersey, Michigan, Ohio, Kentucky, Texas, North Carolina, Georgia, Missouri, Arizona, and Washington and begins July 12, 2022. Phase 3 includes all remaining states and territories and begins Oct. 10, 2022. Four of the five orthotic HCPCS codes that will be subject to Medicare prior authorization describe off-theshelf (OTS) orthoses that also are part of the Medicare DMEPOS competitive bidding program. The only custom-fitted orthosis HCPCS code included in Medicare prior authorization is L1832.

Expansion Concerns

Medicare prior authorization for lower-limb prostheses has been relatively successful, with almost all prior authorization requests receiving affirmative decisions after the initial submission (80%) or the first resubmission (>95%). Expansion of the program to include orthotic HCPCS codes creates a new set of challenges and concerns—especially regarding beneficiary access to clinically appropriate care. While a 10-day response time for prior authorization decisions for prosthetic codes will typically not impact access to care due to the process involved in fabricating and fitting a complete prosthesis, it may have a much more significant impact on the timely provision of orthoses to Medicare beneficiaries. Orthoses are often needed immediately to treat emergent injury or instability of the part of the body they are necessary to support. Requiring up

to a 10-day wait for a prior authorization decision may not be realistic for patients who require immediate stabilization to prevent further injury. AOPA has discussed this concern with CMS and the DME MACs, who have indicated they are aware of the need to address emergent situations and will provide additional guidance in the future. Another concern, specific to the four OTS orthotic HCPCS codes, is how the additional administrative cost associated with prior authorization submission will impact providers who submitted and were awarded competitive bid contracts. Many providers that submitted bids that did not assume any of this additional cost will now be required to absorb this cost, even if it significantly reduces or even eliminates assumed profit margins that were calculated as part of their competitive bidding submission.

What Happens Next?

Medicare prior authorization for lower-limb prostheses has proven to be a successful program, but orthoses and prostheses are different product categories with distinct and unique delivery models. While prior authorization may benefit patients, providers, and the Medicare program itself, several concerns must be addressed to ensure there are appropriate pathways for positive clinical outcomes. AOPA will continue to facilitate constructive dialogue with CMS and the DME MACs to develop an efficient and successful prior authorization program going forward. Joe McTernan is director of reimbursement services at AOPA. Reach him at jmcternan@AOPAnet.org. Take advantage of the opportunity to earn two CE credits today! Take the quiz by scanning the QR code or visit bit.ly/OPalmanacQuiz. Earn CE credits accepted by certifying boards: www.bocusa.org

COVER STORY

BEST PRACTICES IN

PEDIATRIC BRACING

O&P ALMANAC | MARCH 2022

COVER STORY

Bracing for Success as a

Team

Unique protocol for children with hypertonia relies on collaboration and commitment By CHRISTINE UMBRELL

RTHOTISTS ACROSS THE

NEED TO KNOW

A set of solid ankle-foot orthoses

• In the treatment process, teamwork is essential to ensure optimal intervention and goes beyond the therapist-orthotist relationship. Compliance relies on parent participation and support, particularly because the program requires an hour of daily strengthening exercises during the first couple of years. • Solid AFOs are recommended to avoid breakdown of the midfoot and tightness of the heel cord. Design should be based on the patient’s level of activity, extent of hypertonia, and failures and successes with previous AFOs.

MARCH 2022 | O&P ALMANAC

PHOTOS: Courtesy of Lurie Children’s Serial Casting Program, Getty Images

• The team at Lurie Children’s Hospital designed a protocol for gaining and maintaining correction of equinus gait in children with hypertonia. Once full ROM is gained through serial casting, patients comply with four components that include the use of daytime AFOs, nighttime AFOs, strengthening exercises, and center of mass training.

country regularly treat pediatric patients who struggle with hypertonia, including patients with cerebral palsy (CP). These clinicians adopt a variety of methodologies to fit patients with different types of orthoses, often partnering with physical therapists—all with the goal of improving stability and mobility among patients with excess muscle tone. Clinicians at Ann & Robert H. Lurie Children’s Hospital of Chicago have experienced a significant level of success in gaining and maintaining correction of equinus gait in children with hypertonia. They adhere to a strict protocol that relies on serial casting, daytime and nighttime orthoses, and ongoing physical therapy,

PHOTO: Courtesy of Lurie Children’s Serial Casting Program

COVER STORY

according to Brigid Driscoll, PT, DPT, CO, LO, senior physical therapist and orthotist at Lurie, and coordinator of the serial casting program. Follow-up studies of children who have taken part in the Lurie program have demonstrated a success rate of more than 90% when they were able to comply with all aspects of the program, according to Driscoll. For children who were not able to complete all of the components, the success rate dropped to less than 40%. The Lurie team has two active institutional review boards, through which they plan to conduct further investigations and publish details about their program. As a dual physical therapist/ orthotist and an integral part of the Lurie team that has helped hundreds of children improve their mobility, Driscoll has a comprehensive understanding of the rehabilitation process for children with excess muscle tone. Here, she shares the components of the program adhered to at Lurie Children’s Hospital, and offers additional suggestions on clinical collaborations and orthotic componentry when working with this patient population.

Brigid Driscoll, PT, DPT, CO, LO, (center) works on casting a young patient with two other members of the team at Ann & Robert H. Lurie Children’s Hospital of Chicago.

Correcting Equinus Gait

The team at Lurie Children’s Hospital designed their protocol toward maintaining correction of equinus gait in children with CP, and additionally children with habitual toe walking and talipes equinovarus. They follow a comprehensive serial casting program developed for long-term retention of range of motion (ROM) and correction of the gait pattern. Once full ROM is gained through serial casting, patients

are asked to comply with four components that include the use of daytime ankle-foot orthoses (AFOs), nighttime AFOs, strengthening exercises, and center of mass (COM) training. The program involves several key steps: 1. Weekly serial casting. “We set our casts at the R1 dorsiflexion ankle ROM measurement with the knee in extension,” says Driscoll. “When O&P ALMANAC | MARCH 2022

COVER STORY

MARCH 2022 | O&P ALMANAC

A patient performs side-kick exercises in casts for gluteus medius strengthening.

them out of the daytime AFOs,” she says. All program participants also wear nighttime AFOs, set in 5 to 10 degrees of dorsiflexion, and continue wearing them even after they stop using daytime AFOs. “We use the nighttime AFOs through the growth years to make sure that we maintain the corrected range of motion, so that they don’t have to go through casting again.” 3. Physical therapy intervention/ strengthening. The Lurie program starts physical therapy and strengthening exercises the first week of casting because patients have significant weakness in their trunk and hip muscles. “We really focus in on strengthening, getting the co-contraction of the abdominals and the back extensors, teaching the children to bring their ribs down in line with the thorax, keeping the thorax over the pelvis, and maximizing strength in that position,” Driscoll explains.

Children are asked to perform one hour of physical therapy exercises per day. The protocol comprises a threestage strengthening program, according to Driscoll: Stage 1 exercises emphasize the posterior shift of the COM onto the heels; the trunk is aligned over the pelvis with a posterior shift of the body for weightbearing through the heel of the foot, while maintaining a vertical tibia (not forward). Exercises focus on strengthening and postural control in this position. Stage 2 exercises focus on isometric and eccentric hip abduction to ensure patients have stability for single-limb stance. Stage 3 places emphasis on terminal knee extension in order to achieve heel strike for a heel-toe gait pattern. Calf strengthening exercises of the antagonist muscle groups also are also performed daily once casts are removed.

PHOTO: Courtesy of Lurie Children’s Serial Casting Program

we place the kids in their casts, we put them at their R1 measurement, which is the actual length of the muscle, so we can allow the muscles to naturally grow—without forcing unavailable range.” The team changes out casts weekly or biweekly at the new R1 measurement in optimal alignment of all planes, which eventually helps achieve a plantigrade weightbearing foot position. “Once we reach full ROM, which is R1 15 degrees and R2 20 degrees, we stop the weekly serial casts.” 2. Orthotic intervention postcasting. The Lurie team believes orthotic intervention is critical to maintain the corrected length of the muscle that has been achieved through casting. AFOs are necessary for proper ankle and foot alignment with the newly lengthened calf muscles; patients do not initially have adequate calf strength to maintain weight through their heels with proper foot and ankle alignment without the use of AFOs. Additionally, 10 to 12 weeks of serial casting is not long enough to adequately strengthen the trunk and proximal hip muscles for correction of their gait pattern. “The AFOs are a necessary tool for continued strengthening and repetition of a new walking pattern with an emphasis on center of mass,” says Driscoll. AFOs help ensure adequate lower leg support for strengthening of proximal muscles for alignment and postural control, and are necessary to help create new motor patterns, she explains. Once the serial casting phase is over, the Lurie team molds patients for both daytime and nighttime AFOs. The daytime braces are solid AFOs set at a 90-degree angle. “As we are able to see that they can align their trunk properly, and keep their tibia vertical and their center of mass through their heels,” which typically happens over a one- to two-year period, “then we start to gradually wean

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PHOTOS: Courtesy of Lurie Children’s Serial Casting Program, Getty Images

optimal intervention, protocols—attain these changes 4. COM training. In according to Driscoll. “An through adhering to a regimented addition to strengthorthotist has the expertise program that requires compliance with ening exercises, of materials, AFO designs, all aspects, including effective orthotic program particiand history of success/fail- wear. “Sometimes serial casting is used pants undergo COM ures of previous orthoses,” to delay surgery—but our goal is longtraining. “Their COM she explains, “while the term correction of ROM and the gait is so far forward that physical therapist has pattern without the need for surgical it contributes to the Rear view of a the advantage of closely intervention,” explains Driscoll. development of heel child in AFOs observing a patient’s funccord contractures,” tional progress on a more Effective AFOs says Driscoll. “Once frequent basis.” When Driscoll recommends solid, rather they’re in the casts a new orthotic device is indicated, than articulated, AFOs for this patient and are aligned with the tibia collaborating and sharing this informapopulation to ensure they can control vertical, the goal is to teach the tion results in the development of an all of the degrees of freedom. “What is children to bring their COM posteoptimal AFO design for each individual so important is eccentric control of the rior, over their foot (primarily their child, according to Driscoll. tibia,” she says. “Unless your patient heel), and maintain that corrected When treating has adequate eccentric position first in standing and evenpatients with hypertonia, control of the soleus, you tually during walking.” After many the orthotic compoare going to allow exceshours of exercises and practice in nent of the intervention sive forward translation the standing position, children are should be geared toward of the tibia over the foot, able to progress to the dynamic improving stability in and the heel is going to phases of walking. “Our goal is to young patients, according pull up in an articulated have them walking with their COM to Driscoll. “My primary AFO—causing breakdown posterior, in a stable stance leg goal is that the orthosis of the midfoot, along with position, kicking their foot out in A patient wearing is providing the most tightness of the heel cord.” front of them with the contralatAFOs in shoes with stable base of support Using a solid AFO with eral leg, and achieving a heel-toe vertical tibia at the foot and ankle,” a vertical tibia ensures a gait pattern.” she explains. “Inhibiting plantigrade foot position unwanted ankle movement allows the in weight bearing, and will assist in Shared Goals child to more easily work on proper advancing gait as the child achieves In the treatment process adhered to at trunk alignment, along with proximal adequate postural control and proxLurie Children’s Hospital, and in other hip and trunk strengthening. Standing in imal strength, according to Driscoll. collaborations between physical therathis corrected alignment also provides There’s not one solid AFO design pists and orthotists treating children the ability to effectively correct a that will work for everyone because with hypertonia, teamwork child’s center of mass more posterior.” hypertonia can vary greatly from child is essential to ensure Achieving this goal requires both physto child. Driscoll recommends evalical therapy and orthotic treatment. uating the patient’s level of activity, Driscoll has experienced signifextent of hypertonia, and failures icant success in improving and successes with previous AFOs. ankle ROM, trunk and At Lurie, she primarily fits patients lower-extremity strength, with hybrid AFOs—solid AFOs with and correction of gait an intrinsic insert that has posting to patterns in patients align the hindfoot. The AFO has a long with hypertonia— footplate to assist in a posterior weight avoiding the need shift, ensuring weight bearing through for surgical interthe heel. vention. Children For patients with significant hyperat Lurie Children’s tonia, Driscoll prefers an R-wrap style Hospital—and at AFO, or AFO with a supramalleolar a few additional orthosis combination, to better capture children’s hospitals and maintain the foot/ankle in the that have adopted proper alignment, while minimizing the Lurie casting skin breakdown.

COVER STORY

PHOTO: Courtesy of Lurie Children’s Serial Casting Program

Partnering With Parents

Collaboration in orthotic intervention goes beyond the therapist-orthotist relationship to include patients, parents, or other family members, according to Driscoll. “Our patients and their parents are the core members of the treatment team. It’s very important to educate them from the beginning, and give them the empowerment of understanding their diagnosis, the role of orthotists and physical therapists, and the role that orthotic intervention is going to play in their life toward achieving independence and function,” she says. In the Lurie program, parental involvement is mandatory. “This program is very demanding,” says Driscoll. “Serial casting is very successful in gaining ROM, but the PT and orthotic intervention

An AFO typically used at Lurie Children’s Hospital play critical roles for long-term correction.” Compliance relies on parent participation and support,

particularly because the program requires an hour of daily strengthening exercises during the first couple of years. “It’s very rigorous, but we have a high success rate, with a large number of children who never require surgery.” For orthotists who see a large pediatric patient population, Driscoll recommends clear communication with physical therapists to align goals and collaborate on the most appropriate orthosis, to be used in combination with effective strengthening exercises. The team approach, with the patient’s best interests in mind, will likely facilitate more optimal outcomes, and increased stability and mobility. Christine Umbrell is a contributing writer to O&P Almanac. Reach her at cumbrell@contentcommunicators.com.

O&P ALMANAC | MARCH 2022

COVER STORY

s n o i t a r e d i s n o Team C

for Managing Equinus Deformity in Children Expert encourages ongoing learning and shares clinical insights for further study

ORKING WITH CHILDREN with hypertonus in the

MARCH 2022 | O&P ALMANAC

PHOTOS: Beverly Cusick, MS, PT, COF/BOC; Getty Images

deformity (EQD). “The current drive to rely exclusively lower-limb muscles can be a challenge for orthotists upon published evidence to prescribe orthoses for children seeking to support their orthopedic and sensorimotor devel- with complex conditions is gaining momentum, while the opment, according to Beverly Cusick, MS, PT, COF/BOC, current body of evidence of orthotic efficacy for the same who has spent more than four decades studying typical and children is generally weak and excludes successful stratepathologic orthopedic and neuromotor development and is gies that are not yet researched or published.” a frequent lecturer, author, and instructor on the subject. “Ambulatory children with cerebral palsy Progressive Learning and Success (CP) and habitual toe walking typically develop Cusick began using specialized cast boots for chilhypertonus in the triceps surae muscles that dren with CP in 1977 and since then has studied limits ankle dorsiflexion mobility. The common orthotic design and effectiveness. She currently term for this condition is equinus deformity. maintains a private physical therapy practice and These children can benefit significantly from is an on-call associate professor for the Rocky the biomechanical benefits of specialized casts Mountain University of Health Professions. and ankle-foot orthoses,” Cusick says. “One “I began my lifelong quest for understanding of the most valuable resources for a pediatric the mechanisms underlying treatment strateBeverly Cusick, rehabilitation team is a capable, innovative gies in 1974, when I saw highly skilled therapists MS, PT, COF/BOC orthotist who understands and works to transform children with CP, stiff muscles, and support the management goals.” poor motor control into notably more relaxed and capable Cusick encourages clinicians to utilize not only clinical children in one treatment session,” she recalls. “That expedata but also their own expertise and knowledge from the rience led me to undertake a search for understanding how basic sciences when working with children with equinus that change occurred and how to sustain it in daily life.”

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In 1977, Cusick saw “sensational gains in upright stability and ankle range of motion” in children with CP and EQD who wore specialized cast boots. “The influence of full foot loading on a stable base provoked me to add foot and ankle development, function, and EQD development and management to my search for knowledge and skills,” says Cusick. She discovered and followed the work of Lois Bly, who documented the kinesiology and biomechanics of early sensorimotor development, and of Mary Weck and Moira Tobin-Wickes, who studied the biomechanics and kinesiology of gait development and founded the belowknee serial casting program at Ann and Robert H. Lurie Children’s Hospital in Chicago. “My 45 years of study have illuminated both the complexity of the processes of developing movement skill and the simplicity of striving to build effective control of the whole-body center of gravity throughout life—the primary key to managing equinus deformity without injury from toxin injections or surgery.”

Considerations for Managing EQD

Cusick urges all team members to question the validity of their ideas and to become knowledgeable of the following processes, principles, and observations.

On the Condition of Hypertonus:

• The process of physiologic adaptation of musculoskeletal tissues supports their continued routine use by reducing

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the energy cost and promoting tissue longevity. • Resting muscle tone (RMT) is defined as resistance to passive stretch and is produced by physiologic adaptation of the muscles and fascia to routine use. The connective tissue (CT) property of viscoelasticity—velocity-dependent resistance to passive stretch—is evident in normal RMT in the hardest working lower-limb muscles. The quicker the stretch, the greater the resistance encountered. The CT gradually stiffens to support the muscle at the length at which it generates the greatest contractile force at high speed in routine function. • We experience viscoelasticity as a “catch” and measure the joint angle at which it occurs as Resistance-1, or R1 end range of motion. R1 is EMG-silent and is a developmental phenomenon, emerging in typical preschoolers and maturing between the ages of 4 and 10 years. • Hypertonus, defined as increased resistance to passive stretch or stiffness, develops with tissue adaptation to support routine tonic recruitment of the muscle in shortened state. Hypertonus is EMG-silent with no contribution from the nervous system. • In children with hypertonus in the lower-limb muscles, the same R1 catch occurs at significantly reduced muscle lengths. Spasticity involves the nervous system. The perception that R1 end range is evidence of “spasticity” or hyperreflexia in these children is not supported by EMG studies.

On the Sources of EQD:

• The notion that spasticity causes hypertonus has never been validated. “Spasticity” treatments do not reduce hypertonus. • The innate verticality drive is present at birth and dictates that we get up and stay up to stay alive. Most children with CP exhibit the upright drive using compensatory strategies. • Neck and trunk control in all postures is fundamental to effective limb use. The typical acquisition of antigravity neck and trunk muscle strength and control progresses sequentially from head-to-toe, from proximal-to-distal, and in the body planes, from sagittal to frontal to transverse. The first component to emerge in development is antigravity extension in the neck and trunk muscles. This component operates as the foundation for building balance and movement skills in ideal postural alignment. • Optimum, age-appropriate alignment of the spine and limbs supports the delivery of input from load receptors that is needed for body awareness and effective balance and movement skills. Ideal alignment optimizes muscle use and orthopedic development. • The upright drive in ambulatory children with EQD and compromised trunk alignment and control demands that they recruit limb muscles tonically to maintain stability. Upright maintenance wins over limb use for movement and hypertonus develops.

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• Stance-phase control of tibiofibular inclination is essential to normal gait. Typically developing new walkers show a high, wholebody center-of-gravity (COG) that is carried over the forefeet and provokes disruptive acceleration. For a few weeks, the leg alignment shows exaggerated control of inclination. The vertical tibias combine with the oversized feet to operate as a biomechanical braking mechanism that aids in gaining control of COG acceleration. • Young children with neuromotor dysfunction who show premature tibial inclination fail to gain control of forward COG acceleration with COG displaced over the forefeet. The upright drive demands that the posterior lower-limb muscles work excessively to prevent falling. The heels remain elevated, and EQD develops. • Bodyweight is ideally loaded on the heels and lateral foot structures.

feet, depriving them of the sensory input needed for motor learning that would include them.

The notion that spasticity causes hypertonus has never been validated. “Spasticity” treatments do not reduce hypertonus.

Standing foot pronation and supination influence the location of the COG in space and on the feet. Excess foot pronation in standing and walking draws the COG forward and off-loads the heels and lateral

On Assessing Ankle Dorsiflexion Range of Motion

• We must improve both the relevance and the reliability of the findings obtained in assessing and measuring passive ankle dorsiflexion range of motion (DFROM) with the knee extended. All aspects of the procedure demand standardization. At a minimum, the measurement landmarks should be the same as those used in computerized analysis of ankle joint kinematics. • The viscoelastic and resistance properties of the tissues under stretch can illuminate their functional significance. R1 end range indicates the strongest length in routine function. I often detect a second encounter with unforced resistance at R1A end range—the maximum length that is available to the child for use in standing and walking with the foot joints congruent. Most humans use 10 degrees or less of ankle DFROM with knee extended in walking. R2 end range—maximum length—occurs beyond R1A under heavy force and is of no functional use. The capacity to generate contractile force is depleted at R2 end range. Studies of EQD management gather data regarding only R2 DFROM.

On Managing EQD Conservatively • As EQD in ambulatory children with CP and habitual toe walking is evidently a product of routine tonic use of the triceps surae muscles in shortened state for upright maintenance, it is understandable that long-term outcome studies reveal the general ineffectiveness of the strategies that target the shortened muscles directly, such as manual stretching, holding the ankle dorsiflexed with the shortened gastrocnemius under tension in ankle-foot orthoses (AFOs), denervating them with toxin, and surgically lengthening the fascia. 30

MARCH 2022 | O&P ALMANAC

COVER STORY

These strategies never promote healthy muscle use or strength and can lead to scarring, muscle atrophy, and increased weakness. • The conscientious management of pediatric EQD includes efforts to identify and remediate deficits in postural control, and so, to reduce the demand on the triceps surae muscles to activate tonically for upright maintenance. The components of this strategy include improving head and torso alignment and stability, fully loading the heels and lateral foot structures, preventing excess tibiofibular inclination, training the child to control immature COG acceleration, and strengthening the ankle muscles. • Our training tools include providing a progressive series of below-knee casts that are designed to align and fully load the heels without stretching the short muscles, and to provide the mechanical advantages of the new walker’s period

of vertical tibia/big foot time. The ankle joints are plantarflexed to accommodate R1A end range, the heels are supported and loaded, and the forefoot is stabilized to limit anterior weight loading in the casts. The overworked triceps surae and Achilles’ tendon are relieved of routine excessive activation and tension. We expect that the rapid gains in DFROM occur because the newly resting, dehydrated fascia can hydrate, restoring the depleted gliding capacity of the fascia filaments that requires water. The serial casting goal for passive DFROM with the knee extended R1A end range of 10 to 15 degrees past zero with the foot joints congruent. • After achieving the casting goal, the training in bodyweight alignment and control continues with the addition of varus posting to the floors of solid AFOs. The solid AFO ankle reduces functioning degrees

of freedom at the base of support, simplifying the tasks of motor learning and of gaining strength in improved alignment in the proximal muscles. Typical neuromotor development involves immense practice of preparatory and new skills. For example, typical children finish maturing in all kinematic and kinetic aspects of walking after seven to 10 years of daily practice, according to Cusick. “Any expectation of a quick resolution of EQD in children whose neuromotor function is compromised is unrealistic and disregards the sciences of postural control acquisition, massed practice, and physiologic adaptation to routine use,” she says. She advises all pediatric rehabilitation team members to learn more about this issue of hypertonus and to bring strategies that acknowledge and support the process of physiologic adaptation into their work with children.

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O&P ALMANAC | MARCH 2022

O&P EDUCATOR

Education for Everyone Joanna Kenton, MHA, CPO, LPO, FAAOP, imparts her knowledge to O&P students—and helps plan curricula at AOPA’s National Assemblies

This month, O&P Almanac debuts a new column focusing on experienced educators within the O&P profession. Here, you will get to know inspiring individuals who educate the next generation of O&P professionals.

MARCH 2022 | O&P ALMANAC

S AN INSTRUCTOR OF prosthetic

technology, Joanna Kenton, MHA, CPO, LPO, FAAOP, is part of a very small “club” in O&P. Kenton is a professor at Century College in White Bear Lake, Minnesota—one of only six programs in the country offering education for future O&P technicians. She took on the role in August 2017 after nine years in clinical practice, and she is proud to call O&P education her “true calling.” At Century College, Kenton is responsible for teaching several courses, including transtibial, transfemoral, and upper-extremity fabrication. She loves her job—particularly experiencing the “fervor and passion of our students to learn.” She enjoys watching their skills progress and seeing them land their first job in O&P. Teaching prosthetic fabrication has evolved in recent years, says Kenton, given the rise of COVID-19 and the ensuing need to integrate remote learning into parts of the curriculum. “The pandemic has changed the face of education. We had to course-correct to provide instruction at home” during the early days of the pandemic. Most prosthetic technical skill instruction still requires in-person, hands-on

learning for best results, but Kenton would like to see the use of virtual reality and online textbooks to cement learning objectives in the future. Just like her own students, Kenton recognizes the value of ongoing education. She prides herself on continuously seeking knowledge—and was rewarded for her efforts in May 2021 when she earned a master’s in healthcare administration from Minnesota State University Moorhead. As part of her master’s coursework, Kenton completed a capstone research project in which she polled O&P employers to discover their expectations for technicians. “There are so many different products now,” so she set out to learn “what’s really going on in today’s clinical environments” so she could properly prepare her students for entry-level careers as technicians. “The number of respondents was low, but I gained some insights from those who participated,” Kenton says—for example, that the majority of facilities prefer a simple one-lamination removable pin-lock suspension for transtibial designs. She has since implemented some new learning objectives in the classes she teaches.

PHOTO: Courtesy of Joanna Kenton, MHA, CPO, LPO, FAAOP

Joanna Kenton, MHA, CPO, LPO, FAAOP, works with a student, Charles, who is squaring joints on a transtibial prosthesis.

O&P EDUCATOR

Kenton (center) works with students, Josie and Kathy, as they perform their first laminations.

Background in Education

MARCH 2022 | O&P ALMANAC

returned to school to gain her orthotics certification. She held positions as an orthotist/prosthetist in clinical settings for nine more years. When a faculty position opened at Century College almost five years ago, she decided to make the jump to O&P educator—a decision she has never regretted. “My career went full circle,” she explains. Working with O&P patients in clinical settings is “amazing,” she says, but since her bachelor’s degree was in education, she feels she is “meant to be” in her current role, training the next generation of O&P professionals. “This position is an honor,” she says. “I’m teaching fabrication science, and I love it.”

Educating the Profession

Kenton has taken her desire to educate O&P professionals well beyond the Minnesota borders in her volunteer work with AOPA. “As a lover of the fabrication sciences, I have served on the AOPA Assembly Planning Committee—Technical Track for the past three years,” she explains. Last year, she served with Brad Mattear, LO, CPA, CFo, as co-chair for the Technical Track. “My favorite part about volunteering as an Assembly Planning Committee member is seeing our collective work effort unfold at the Assembly,” she says.

Kenton assists as a student, Laurianna, tests her lanyard suspension on a transfemoral prosthesis.

PHOTOS: Courtesy of Joanna Kenton, MHA, CPO, LPO, FAAOP

Kenton took a circuitous route to becoming a certified clinician-turnededucator. “O&P was not my initial career path; it is actually my third, but favorite, career,” she says. After high school, Kenton attended Crown College and graduated with a bachelor’s degree in human development, with a licensure in adult and early childhood education. “My initial plan was to teach early childhood family education courses,” she says. “Unfortunately, the pay did not cover my college debt and living expenses at the time, so I began a career in financial services.” She found herself placing equity trades with American Express in downtown Minneapolis, “tied down to a phone queue.” When the market crashed in the early 2000s and her job revolved around unhappy clients, she realized it was time for a career change. “One day I ventured into Barnes & Noble and pulled out a book on allied health professions,” Kenton recalls. “And there it was: I saw the Orthotist/Prosthetist Career Page and knew it was the profession for me.” Kenton pursued a postbaccalaureate certificate in O&P and worked as an O&P technician for three years, before completing a residency in prosthetics and becoming certified. She also

“It’s exciting … and it is done as a team.” Technical education is a critical component of the Assembly schedule, due to the accelerating pace of technological change and the need to provide optimal patient care, says Kenton. “Our world is changing at a quantum pace,” she says. “As surgeries and surgical outcomes are improving, technology is evolving, our products are improving, and this is all for the goal of providing the best outcome for our patients. If we don’t evolve, then we fail to provide the best care to our patients.” This year, Kenton and Rick Riley, founder of O&P Boost, are co-chairs of the AOPA 2022 National Assembly Planning Committee, with the conference set to take place Sept. 28 to Oct. 1 in San Antonio. “I am honored to be a part of this process, and to serve alongside some very amazing people who share a similar passion and purpose.” Kenton, Riley, and their team are going all-in on the planning stages for the in-person event, with several new features set to debut—including a Postmastectomy Track and an O&P Digital Education Track. The mastectomy track was added due to overwhelming feedback from the

O&P EDUCATOR

Submit YOUR Fabrication Tip Video

PHOTO: Courtesy of Joanna Kenton, MHA, CPO, LPO, FAAOP

Kenton (far right) discusses an ischial containment transfemoral cast with students, Dan and Sara. community on the need for information, as well as the need to maintain that credential. “It was a gap that needed to be filled,” says Kenton. The addition of the digital fabrication track resulted from the growth of sessions dedicated to this topic: “Digital fabrication has traditionally been a part of the Technology Track,” she explains, but “we felt that the digital world has evolved into its own category. It’s grown its own legs.” Looking toward San Antonio, Kenton is particularly excited for the “Fabrication Tricks & Tips” session planned for the Technical Education Track. This session will be based on submitted short videos on a fabrication tip or trick. Kenton encourages O&P professionals to contact AOPA by April 1 if they intend to submit a tip video for possible inclusion in the session. “These will be reviewed and collated into a session where attendees can vote for their favorite, and winners will receive cash prizes,” Kenton says. “But even more important is the sharing of information that will improve our work as a community and lighten our load—all for the ultimate benefit of our patients.” Kenton also looks forward to the networking component of the Assembly, where she will meet face to face with other O&P stakeholders—including her educational counterparts from

other universities. “One reason why I do this, is to make connections in the O&P world,” she says. “As an educator, it allows me to connect with other content experts to provide our students with relevant O&P content. “O&P is an amazing profession,” adds Kenton. “I get to share my passion and knowledge with the next generation.”

AOPA invites you to make a threeto five-minute video explaining a fabrication “trick or tip” for possible inclusion in a new session at the AOPA National Assembly in San Antonio. Accepted videos will be reviewed and collated into a session where attendees can vote for their favorite, and winners will receive cash prizes. Let AOPA know of your intent to submit a video April 1. For more information, visit https://aopa.wufoo.com/forms/2022call-for-technical-presenters/ or contact Tina Carlson, CMP, AOPA senior director of education and meetings, at 571/431-0808 or tcarlson@aopanet.org.

Spread the Word About the Prosthetic Technician Career O&P clinicians and business owners should promote O&P technician programs to ensure a sufficient pipeline of skilled technicians, says Joanna Kenton, MHA, CPO, LPO, FAAOP, faculty in the prosthetic technician program at Century College in Minnesota. Consider taking the following steps: • Encourage employers to offer attractive and competitive wages for technicians. • Spread the word at the community level by attending middle and high school career days and club meetings. • Use media as a conversation starter—when you see images on social media of individuals using prostheses or orthoses, jump in and explain what you know. • Engage in professional organizations, including AOPA. • Embed outreach in O&P curricula. • Incorporate digital manufacturing in O&P training. • Collaborate with local maker spaces to share information about O&P technician careers.

O&P ALMANAC | MARCH 2022

MEMBER SPOTLIGHT

JL Artificial Limb and Brace

By DEBORAH CONN

Planted in Community New Arizona facility continues a family tradition of neighborhood care

HEN JASON LEAL, CPO,

opened the doors to his own facility on June 16, 2021, he embraced a family tradition begun by his father, Daniel A. Leal Sr., CO, back in 1966 when the senior Leal launched an O&P facility in Tucson, Arizona. “All my family members worked there,” recalls Leal. “My brother and sister are certified prosthetists, as was another late brother. I was much younger than they were, but I grew up helping and started working there when I was about 15.”

Leal (right) works with a lower-limb patient in his Bullhead City facility.

FACILITY: JL Artificial Limb and Brace

PHOTOS: JL Artificial Limb and Brace

Leal (center) and his family members, including his wife, Diahann Leal; mother, Barbara Leal; nephew, Cooper; and son-in-law, Curtis Hargrove, CF

Leal pursued a degree at the University of Arizona and then took the first O&P certificate program offered at California State University, Dominguez Hills. After earning ABC certification, Leal moved to Bullhead City, Arizona, with his wife and two daughters in 1997 to work for NovaCare. There, Leal turned a twice-a-week clinic into a fulltime office. After Hanger acquired the company, Leal continued on and became the area clinical manager for the northwest corner of the state. Eventually, he decided to go back to his roots; he left Hanger and set up his own shop, JL Artificial Limb and Brace. 36

MARCH 2022 | O&P ALMANAC

OWNER: Jason Leal, CPO LOCATION: Bullhead City, Arizona HISTORY: Nine months

Jason Leal, CPO

“If I was going to work that hard, I wanted to do it for myself and my family,” Leal says. “I’ve been much more relaxed because I can work at my own pace and pay more attention to my patients.” His facility provides orthotic and prosthetic services to patients, as well as durable medical equipment requested by physicians. The business is the only locally owned, full-time facility in the tri-state area, according to Leal. “Patients see the same clinician every visit, so we can build relationships and provide better continuity of care.” The facility’s mission statement ends with, “We are planted in this community: We will be here.” Leal works primarily with geriatric patients and those with diabetes. All fabrication is completed in house. He uses 3D scanners and CAD/CAM technology, particularly for orthotic inserts, but he still prefers hand casting lower-extremity

prostheses. The facility leverages electronic recordkeeping and voice-over-internet phone service, all of which involved a learning curve, but Leal enjoys the challenge. “I’m using both sides of my brain now,” he says. The hardest part of starting an O&P practice in a small town, says Leal, is getting insurance approvals. He has contracts with Medicare and a couple of private insurers, and is working with other insurers to gain coverage. He also works through the local hospital and sees long-time patients who followed him to his new practice, while building a new patient base at a healthy rate. Seeing patients succeed is a huge part of the satisfaction Leal has in his work. “One of our patients, a below-knee amputee since she was a teenager, was difficult to fit. But she did great, became a nurse, and when COVID-19 hit, she went to New York to help in hospitals,” Leal says. “She took her success and used it to help other people.” Leal plans to launch a website and incorporate outcome measures into his practice. He will reach out to doctors to explain his services and add to his private insurer contracts. And he will continue the family tradition: His son-in-law, Curtis Hargrove, CF, works at the facility; and his daughter, Olivia Leal, recently came on board as an administrative employee. “I’m doing it like my family did,” says Leal. “And I’m loving it.” Deborah Conn is a contributing writer to O&P Almanac. Reach her at deborahconn@verizon.net.

Data Drives

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MEMBER SPOTLIGHT

Phoenix Molded Shoes, Inserts, and Braces

Foot Comfort and Care Florida company provides U.S.-made shoes and orthoses

EITH BREWER HAS BEEN in

MARCH 2022 | O&P ALMANAC

A Phoenix staff member works on manufacturing custom footwear.

COMPANY: Phoenix Molded Shoes, Inserts, and Braces OWNER: Keith Brewer LOCATION: Sebring, Florida HISTORY: Six years

Keith Brewer on his Harley

accommodate modalities ranging from simple painful ambulation to plantar fasciitis, fallen arches, and metatarsalgia, and may offload callouses and wounds. “We also provide custom lower-extremity bracing, from the double-upright metal ankle-foot orthosis (AFO) to the leather gauntlet with the plastic interface, which has become so popular over the years to address ankle instability.” In addition, the company offers standard AFOs, supramalleolar orthoses, and UCBLs—foot orthoses designed at the University of California-Berkeley Lab. Thanks to his 20 years of experience in the patient-care arena, Brewer takes great pride in the company’s relationship with practitioners and their staff. “I know what they are looking for, and I do everything in my power to deliver,” he says. “I remember when I was in patient care, and asked to speak to the owner of a company we were using. I was told, ‘The owner doesn’t take calls.’ That’s when we started making

our own shoes, and I made a vow that I would always be available to talk to our customers.” Because Phoenix is a U.S. company, it can provide a 12- to 14-day turnaround for custom footwear rather than the more typical two to three months. The company also offers custom inserts in five to seven days, and custom bracing in 21 days or less, Brewer says. “We know with custom devices, adjustments are sometimes needed, and we can turn them around much more quickly than if the product had to be sent back overseas.”

A sample of company products

Phoenix supports local schools in the Sebring area and donates to the Salvation Army. A few years ago, the company was instrumental in raising funds for the local state park to purchase a motorized off-road wheelchair for disabled guests. Brewer doesn’t want to speculate about where technology will take the company, but, he says, “We will be right there with it.” He believes that the country’s dependence on foreign imports and supply chain issues could get worse, placing Phoenix at an advantage as a U.S. company. “I am glad the O&P profession is making it through the pandemic as well as it has, although I was saddened to lose some of our smaller facilities we had worked with for many years,” says Brewer. “I am excited to be part of this wonderful field that is constantly growing and evolving. I am proud to be a member of this profession.” Deborah Conn is a contributing writer to O&P Almanac. Reach her at deborahconn@verizon.net.

PHOTOS: Phoenix Molded Shoes, Inserts, and Braces

the specialized shoe business since he left the U.S. Navy in 1989 and went to work with his sister, Karen Lanier. Shortly after that, he became a certified pedorthist and spent the next 20 years in patient care. “I helped to start Branier Custom Molded Shoes in Sebring, and when they closed their doors in August 2016, I took the employees and opened Phoenix Molded Shoes, Inserts, and Braces,” he says. Phoenix sells its products to orthotists, prosthetists, and pedorthists, as well as podiatrists and orthopedic surgeons. The company, which has 25 employees, makes custom footwear for abnormalities resulting from diabetes, amputations, edema, and other conditions. “Our mission is to provide a quality product made in the United States, with a quick turnaround time and a personal, one-on-one relationship with our customers,” says Brewer. “You can choose a style out of our catalog, or we can match just about any style you throw at us,” he notes. “We offer nine standard colors of leather, as well as laces, Velcro, or a combination of both. We also offer a neoflex material, which is lycra over a polyurethane-type backing that stretches to accommodate any abnormalities.” The company also offers custom-molded functional and accommodative inserts to fit over-the-counter or extra-depth shoes, using such materials as polypropylene, copoly, polyethylene, and subortholene, as well as EVA or cork bases. These

By DEBORAH CONN

EARN

14 CEs

Coding and Billing Got You Confused? Attend the Virtual Coding and Billing Seminar on April 4-5, 2022. But don’t take our word for it. Attendees have said:

I’ve learned more in the past few days than I’ve learned in the past year.

All practitioners should attend this conference so they can learn to document the correct way and ensure compliance.

The speakers are very knowledgeable and helpful. This is my second time at a seminar and I’m still learning so much.

The Virtual Coding and Billing Seminar is what you’ve come to expect from our Coding and Billing seminars but tweaked and condensed slightly so it can be offered virtually. Content will be presented from 12-4pm ET both days.

For more information, email info@AOPAnet.org.

AOPA NEWS

AOPAversity Webinars

OIN AOPA EXPERTS FOR the most up-to-date informa-

tion on specific topics during these one-hour webinars, held the second Wednesday of each month at 1 p.m. ET. One registration is all it takes to provide the most reliable business information and CE credits for your staff at a single office location. Visit www.AOPAnet.org/education/monthly-webinars for details and registration information.

UPCOMING WEBINARS

April 13 Clinicians’ Corner: Techs and Fitters Join AOPA for the first Clinicians’ Corner of 2022! This webinar will provide tips, tricks, and insights for technicians and fitters—and will be available for scientific credits.

May 11 Supplier Standards & Revalidations

With site inspections and revalidations back in full swing—and new contractors taking the lead—it’s time to revisit the DMEPOS Supplier Standards. Log in to this webinar and learn tips to pass a Supplier Standards Inspection and Revalidation.

Call For Papers

Submit your proposal for the AOPA 2022 National Assembly

HE 105TH AOPA NATIONAL ASSEMBLY will be held

in San Antonio Sept. 28 to Oct. 1, 2022. In addition to the in-person Assembly, virtual elements are being planned. Attendees will participate in general sessions as well as concurrent breakout tracks, an Expo, patient demonstrations, and workshops. Consider submitting an education proposal in one of these key topic areas: • Clinical Education • Business Education • Postmastectomy Education • Technical Education • Digital O&P Care Submissions are due April 1. For submission instructions and details on where to submit your proposal, visit www.AOPAassembly.org.

MARCH 2022 | O&P ALMANAC

Purchase the 2022 AOPA Quick Coder The 2022 AOPA Quick Coder is now available! A speedy reference to HCPCS codes for all orthotic, shoe, and prosthetic codes and modifiers, the Quick Coder also provides references for inpatient billing and off-the-shelf versus custom-fit coding. Changes are being made to the codes on a biannual basis. If a change is made during 2022, AOPA will notify you to ensure your Quick Coder remains up to date throughout the year. To purchase the Quick Coder, access your AOPA Connection account. Email questions to info@AOPAnet.org.

Feature your product or service in Marketplace. Contact Bob Heiman at 856/520-9632 or email bob.rhmedia@comcast.net. Visit bit.ly/AOPAMedia2022 for advertising options.

AliMed® Open Heel and Open Forefoot Orthoses

High-quality performance, designed for your budget! AliMed’s new Open Heel and Forefoot Orthoses help transfer weight off the heel or forefoot, offering effective pressure relief after surgery or trauma, or when wounds are present. Each lightweight orthosis features a soft, seamless inner lining that reduces irritation for greater patient comfort and allows for limited ambulation. XS-XL sizes. • Open Heel Orthosis has a single bridge strap for easy application and a nonslip rubber outsole. • Open Forefoot Orthosis with protective toe guard includes three center straps for optimal fit and a nonslip EVA outsole. Watch our video and learn more at AliMed.com/ wound-care-orthoses.

Multimotion Hip Abduction System • Safe nighttime treatment of correctable pediatric hip contractures • Positions child’s legs in an optimal position and stabilizes the hip joint • Gradual adductor stretch allows for better joint mobilization • Adjustable flexion and extension stops: small 14-degree intervals, regular 12-degree intervals • Mount corrective joint and abduction bars to a custom-fabricated orthosis.

MARKETPLACE

Liner Specialists Since 1993

At ALPS, we understand that the liner’s cushioning performance depends on the mechanical properties of the liner materials. Our expertise in chemistry and position as a leading manufacturer of medical devices has led to the development of a wide range of prosthetic liners, characterized by an innovative and unique component: ALPS gel. ALPS gel ranges from EasyGel enriched with antioxidants for extreme comfort for amputees with sensitive residual limb skin to HD Gel for maximum control and stability for active amputees. With three types of gel to choose from, you can easily find the best solution for your patients and ensure their prosthesis is effective and comfortable. To learn more about ALPS gel liners and how they can benefit your patients, visit www.easyliner.com or call 727/528-8566 or 800/574-5426.

The Original Preflexed Suspension Sleeve ESP created the Flexi family of suspension sleeves as a comfortable, durable, and cost-effective alternative to traditional suspension sleeves. Preflexed at 43 degrees for maximum comfort and natural unrestricted movement. For more information, call ESP LLC at 888/932-7377 or visit www.wearesp.com.

Visit https://www.allardusa.com/contact/district-managers to schedule a virtual meeting with your district manager or email info@allardusa.com to receive your free goniometer!

O&P ALMANAC | MARCH 2022

MARKETPLACE Black Iron Trainer Pivot The TRS Black Iron Trainer is the world’s most popular weight training prosthetic accessory. The Black Iron Trainer Pivot provides 32 degrees of friction-adjustable freedom for added versatility, safety, and control over barbells, dumbbells, and other weight training apparatus. For more information, visit www.fillauer.com.

Naked Prosthetics

Hersco 3D Printing Hersco is delighted to offer HP’s advanced 3D printing technology for custom orthotics. 3D printing has unique design capabilities not possible with other methods— reducing landfill waste by 90 percent! The accuracy of 3D is unparalleled, specs exceed direct-milled polypro, and manual plaster fabrication. Among the benefits: a 90% reduction in landfill waste, many new design possibilities for posting, and the ability to vary thickness and flexibility across the shell. The PA-11 polymer is a biobased renewable material that has been tested and proven in research and industry. Call today, 800/301-8275, for a free sample.

The Runner Junior by Ottobock

It’s all about function. We are the manufacturers of durable prosthetic devices specifically for finger and partial-hand amputations. Our aim is to positively impact our wearers’ lives by providing high-quality finger prostheses. We offer four devices: MCPDriver (shown in rose gold), PIPDriver, ThumbDriver, and our newest device, the GripLock Finger. Our devices help to restore length, pinch, grasp, stability, and protection for sensitive residuum. Robust device engineering and their ability to withstand harsh environments help get people back to performing activities of daily living, and back to work. All available in a dozen color coatings to match our wearers’ preferences and styles. To learn more, visit www.npdevices.com. The Runner Junior by Ottobock is characterized by a durable and lightweight carbon spring that provides both powerful drive and stable turning characteristics to pediatric patients using this blade. With adaptable dynamics and spring stiffness, settings can be tailored to fit individual needs to support optimal outcomes and goals. Contact your Ottobock representative to learn more or visit our website.

MARCH 2022 | O&P ALMANAC

MARKETPLACE Ottobock WalkOn Pediatric AFOs

PDI 3D Central Fabrication

K TOC IN S The 4th Gen Squirt Shape 3D Printer is now available for purchase! Test sockets, definitive sockets, custom liners, and more! Deliver quicker, with a 24-hour socket turnaround. Have a difficult fit or extreme size? Don’t struggle with fabrication, let us print a check or definitive socket for you. For more information, email fab@prostheticdesign.com or call 800/459-0177 for a quote today!

Ottobock’s pediatric WalkOn carbon-fiber AFOs provide support for children with drop foot. Choose from the posterior WalkOn Flex Junior for flexibility and excellent energy storage and return during the gait cycle or the anterior WalkOn Reaction Junior for additional stability. Both feature trimmable footplates for a quick and easy one-visit fitting. Contact your Ottobock rep or visit our website to learn more.

Freedom ShockWave™ by PROTEOR The Freedom ShockWave™ utilizes the industry-leading classic Freedom foot design with its proprietary EnduraCore® hybrid composite technology and incorporates a Spherical Shock Unit (SSU). The SSU provides both vertical shock absorption and axial rotation, giving K3 / K4 patients a shockingly natural and comfortable experience during both everyday and high-impact activities. For more, visit www.proteorusa.com/freedomshockwave.

800/459-0177 | WWW.PROSTHETICDESIGN.COM

The Xtern, a Life-Changing Solution for Foot Drop Patients by Turbomed Orthotics Say goodbye to your painful and stiff in-shoe orthosis! This revolutionary brace, specifically designed for people suffering from foot drop, has one thing in mind: movement. The Xtern sits entirely outside the shoe (and, to add to that, to any shoe!), and is so flexible that it allows maximal range of motion and calf muscle strength. No more rubbing injuries or skin breakdowns: You’ll barely notice it’s there. Walking, running, mountain climbing, skiing? Not a problem! The Xtern will follow you as far and as long as you want. Turbomed’s innovative products are designed in Quebec, Canada, sold in more than 30 countries around the world, and distributed by Cascade in the United States. Visit turbomedusa.com, and think outside the shoe!

O&P ALMANAC | MARCH 2022

AOPA NEWS

CAREERS

Opportunities for O&P Professionals

A few good businesses for sale.

Job Location Key: - Northeast

Lloyds Capital Inc. has sold over 150 practices in the last 26 years.

- Mid-Atlantic - Southeast - North Central

If you want to sell your business or just need to know its worth, please contact me in confidence.

- Inter-Mountain - Pacific

Hire employees and promote services by placing your classified ad in the O&P Almanac. Include your company logo with your listing free of charge. Refer to www.AOPAnet.org for content deadlines. Ads can be posted and updated any time online on the O&P Job Board at jobs.AOPAnet.org. No orders or cancellations are taken by phone. Send classified ad and payment to: O&P Almanac, Calendar, P.O. Box 34711, Alexandria, VA 22334-0711 or email jburwell@AOPAnet.org along with VISA or MasterCard number, cardholder name, and expiration date. Make checks payable in U.S. currency to AOPA. Note: AOPA reserves the right to edit calendar listings for space and style considerations. O&P Almanac Careers Rates Color Ad Special 1/4 Page ad 1/2 Page ad

Member $482 $634

Nonmember $678 $830

Listing Word Count 50 or less 51-75 76-120 121+

Member $140 $190 $260 $2.25 per word

Nonmember $280 $380 $520 $5 per word

ONLINE: O&P Job Board Rates Visit the only online job board in the industry at jobs.AOPAnet.org. Job Board 50 or less

Member $85

Nonmember $280

For more opportunities, visit: http://jobs.AOPAnet.org. SUBSCRIBE

A large number of O&P Almanac readers view the digital issue— If you’re missing out, visit issuu.com/americanoandp to view your trusted source of everything O&P.

WANTED!

MARCH 2022 | O&P ALMANAC

Barry Smith Telephone: (O) 323/722-4880 • (C) 213/379-2397 Email: loyds@ix.netcom.com

Northeast, Mid-Atlantic, Southeast Boston Orthotics & Prosthetics Launches New Hiring Program for Experienced Clinicians

Boston O&P is searching for experienced O&P professionals who want to work in a new clinic in the geographical area of their choice, but may be limited by noncompete agreements with their existing company. We understand that experienced clinicians may have noncompete contracts that limit their ability to practice in a certain area for a specified period of time. Our new program ensures that your contract is honored by relocating you to one of our established clinics outside the restricted area, where you will learn our culture and service programs. We offer flexible schedules to limit the amount of time you are away from your family. Once your noncompete requirements have been honored and your training is complete, you will move to the new clinic near your home, where your role will involve building the internal team to improve the quality of pediatric care in that market and actively building the practice. To be considered, candidates can click on this link https://www.bostonoandp.com/for-providers/experiencedclinicians-new-clinics/. For more information, confidentially contact Boston O&P President and CEO Tom Morrissey.

Contact: Tom Morrissey Email: tmorrissey@bostonoandp.com

CAREERS a suburban setting on two metro-Atlanta campuses in Kennesaw and Marietta. As one of Georgia’s largest universities, Kennesaw State offers undergraduate and graduate degrees, including a growing number of doctoral programs. A member of the University System of Georgia, Kennesaw State is committed to becoming a world-class academic institution positioned to broaden its academic and research missions and expand its scope on a local, regional, and national level. Kennesaw State University, a member of the University System of Georgia, is an Equal Opportunity/Affirmative Action employer, and does not discriminate on the basis of age, color, disability, national origin, race, religion, sex, sexual orientation, and/or veteran status. Georgia is an open records state.

Southeast Open Rank Clinical Faculty Positions in Prosthetics and Orthotics

Department of Exercise Science and Sport Management

Kennesaw State University is now accepting applications for a nine-month, nontenure track Open Rank Clinical Faculty Position in prosthetics and orthotics in the Department of Exercise Science and Sport Management. This position begins August 2022. Rank will be commensurate with experience and determined upon hire.

FOR SALE: Orthotic Equipment Recently retired business owner of a small orthotic fabrication lab is selling orthotic machinery, equipment, and inventory valued at $20,000 retail. Seller is willing to accept 50% of value. This is a great opportunity for a practitioner seeking to work for himself or a company wanting to open a satellite facility to build their business. Take advantage of this valuable offer. For more information:

Responsibilities include: • Area of specialization: prosthetics and orthotics • Teaching face-to-face lecture and laboratory classes courses in prosthetics and orthotics at the graduate level; may include course instruction in related graduate and undergraduate courses • Additional responsibilities may include curriculum development, assessment of student learning outcomes, development of policies and procedures related to the program, contributing to accreditation reports, and supporting research • Some department, college, university, and professional service is expected.

Contact: Bob Genaze, CPO Email: rgenaze@gmail.com Cell: 708/807-3876

Finding your easier with th

Required qualifications include: • An earned master’s degree or a foreign equivalent Finding your next job or hire just got in prosthetics and orthotics, or a terminal degree or For Job Seekers: easier with the AOPA Career Center. a foreign equivalent in a related field is required Finding your next job or hire just got Job searching is easy with the • National board certification from the American Board for easier with the AOPA Career Center. pane-view job search page. Set up Certification in Orthotics, Prosthetics, and Pedorthics For Job Seekers: job alerts, upload your resume or • Must be eligible for licensure as required Job searching is easy with the create an anonymous career profi le by the stateFor of Georgia pane-view job search page. Set up Job Seekers: alerts, upload your resume or that leads employers to you. • Minimum of two years of clinicaljob experience. Job searching is easy with thean anonymous career profile create pane-view job search page. upemployers to you. that Set leads job alerts, upload your resume or Preferred qualifications include: create an anonymous careerfamiliarity profile • Prior teaching experience, including For Employers: that leads employers to you.

with prosthetics and orthotics laboratories Reach 4,500+ O&P professionals Job Flash™ email. • Evidence of teaching and workingthrough with athe culturally For Employers: Ensure high visibility for your open and an ethnically diverse community.

For Employers: Reach 4,500+ O&P professionals through the Job Flash™ email. Ensure high visibility for your open positions through this highly engaging email.

positions through this highly Reach 4,500+ O&P professionals engaging email. through the Job Flash™ email. For a full description of this position, application Ensure high visibility for your open deadlines, and positions application procedures, through this highlyvisit https:// on recruitment options, contact Customer hr.kennesaw.edu/careers.php. formore Jobinformation ID 238343. engaging email.SearchFor Log in at jobs.aopanet.org to get started! Service at clientserv@communitybrands.com or (727) 497-6565. For more information on recruitment options, contact Customer For more than 50 years, Kennesaw State University Service at clientserv@communitybrands.com or (727) 497-6565. has been known for its entrepreneurial spirit and sense of

community. A leader innovative teaching and learning, For morein information on recruitment contact Customer AOPA_PrintAd.indd 1 options, Service at clientserv@communitybrands.com or combines (727) 497-6565. Kennesaw State is located just north of Atlanta, and

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O&P ALMANAC 8/19/21 8:02 PM | MARCH 2022

CALENDAR May 17–18

AOPA Policy Forum. Hilton Crystal City, VA. Register at www.AOPAnet.org.

May 18–20

New York State Chapter of American Academy of Orthotists and Prosthetists (NYSAAOP) Meeting. Rivers Casino & Resort. Schenectady, NY. For more information, visit nysaaop.org/meeting.

June 8 WEBINAR

2022

at www.AOPAnet.org.

June 24–25

Nashville Renaissance Hotel and Conference Center In-Person Meeting. For more information, contact Cathie Pruitt at 901/359-3936, email pruittprimecare@gmail.com, or Jane Edwards at 888/388-5243, email jledwards@attnet. Visit www.primecareop.com.

March 1–31

ABC: Application Deadlines, Exams Dates, O&P Conferences, and More! Check out ABC’s Calendar of Events at ABCop.org/calendar for the latest dates and event details, so you can plan ahead and be in the know. Questions? Contact us at info@abcop.org or visit ABCop.org/contact-us.

July 13

Clinicians’ Corner—Orthotics: How To Get Started Into Digital Workflow. From Scanning, to Carving, to 3D Printing, the Next Step for O&P. 1 PM ET. Register at www.AOPAnet.org. WEBINAR

March 2–5

AAOP. Atlanta. For more information, visit www.oandp.org/events/event_list.asp?DGPCrSrt=&DGPCrPg=2.

March 18–19

August 10

Ohio O&P Meeting. Columbus Hilton at Easton. Visit ohiooandp.com and ohiochapteraaop.com.

May 10–13

AOPA National Assembly. San Antonio, TX. For more information, visit www.AOPAnet.org.

2023 May 19-20

May 11 WEBINAR

September 28–October 1

Clinicians’ Corner: Techs and Fitters. 1 PM ET. Register at www.AOPAnet.org.

OT World. Leipzig, Germany. For more information, visit www.ot-world.com/index-en.html.

Prosthetics Clinicians’ Corner. 1 PM ET. Register at www.AOPAnet.org.

WEBINAR

April 13 WEBINAR

SWOs, PODs, ABNs, AOBs: Your MustHave Documentation. 1 PM ET. Register

Supplier Standards & Revalidations. 1 PM ET. Register at www.AOPAnet.org.

Orthotic & Prosthetic Innovative Technologies Conference. Minneapolis, MN. For updates, check our website at optech.ucsf.edu. Email cme@gillettechilSave Date!Ipsum drens.comLorem to bethe added to conference mailing list. May 19 & 20, 2023

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MARCH 2022 | O&P ALMANAC

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For information on continuing education credits, contact the sponsor. Questions? Email info@AOPAnet.org.

CALENDAR SAVE THE DATE MAY 17-18

SAVE THE DATE MAY 17-18

Use Your Voice. Educate. Advocate. Celebrate. More details on the program to come. www.AOPAnet.org

AD INDEX

Advertisers Index Company

Page

Phone

Website

AliMed Inc.

781-329-2900

www.alimed.com

Allard USA Inc.

866-678-6548

www.allardusa.com

ALPS South LLC

800-574-5426

www.easyliner.com

Amfit

800-356-3668

www.amfit.com

Cailor Fleming Insurance

800-796-8495

www.cailorfleming.com

College Park Industries

800-728-7950

www.college-park.com

Danmar Products

800-783-1998

www.danmarcranial.com & www.danmarproducts.com

ESP LLC

888-WEAR-ESP

www.wearesp.com

Ferrier Coupler Inc.

810-688-4292

www.ferrier.coupler.com

Fillauer

800-251-6398

www.fillauer.com

Hersco

800-301-8275

www.hersco.com

Naked Prosthetics

888-977-6693

www.npdevices.com

Ottobock

800-328-4058

www.professionals.ottobockus.com

PROTEOR USA

855-450-7300

www.proteorusa.com

Spinal Technology Inc.

800-253-7868

www.spinaltech.com

Surestep

877-462-0711

www.surestep.net

TurboMed Orthotics Inc.

888-778-8726

www.turbomedorthotics.com

O&P ALMANAC | MARCH 2022

STATE BY STATE

Become an AOPA State Rep.

Coverage Concerns

If you are interested in participating in the AOPA State Reps network, email awhite@AOPAnet.org.

Activity in several states focuses on legislation mandating O&P coverage

Each month, State By State features news from O&P professionals about the most important state and local issues affecting their businesses and the patients they serve. This section includes information about medical policy updates, fee schedule adjustments, state association announcements, and more. These reports are accurate at press time, but constantly evolve. For up-to-date information about what is happening in your state, visit the Co-OP at www.AOPAnet.org/resources/co-op.

the 2021 legislative session but not passed; in Arizona, bills do not carry over from one session to the next.

New York

New York Senate Bill 03649, which requires mandatory health insurance coverage of prosthetic devices for veterans injured while on active duty, has been referred to the State Senate’s Insurance Committee. Coverage under SB 03649 includes repair and replacement in cases of normal wear and tear, new fitting needs, or changes in a patient’s medical condition.

Virginia

TATE POLICYMAKERS ACROSS THE country have recently shown

their support for mandatory coverage of orthotic and prosthetic devices. AOPA is tracking several developments on the respective state pages of the AOPA Co-OP, with highlights below.

Arizona

Arizona House Bill 2302 has been introduced in the state’s House of Representatives. HB 2302 requires that insurance providers in the state provide coverage for orthotic and prosthetic devices that is at least equivalent to the coverage currently provided under Medicare. This bill has an identical predecessor, HB 2094, which was introduced in 48

MARCH 2022 | O&P ALMANAC

Companion bills HB 925 and SB 405 have seen considerable movement and overwhelming support in the Virginia legislature since their introduction earlier this year. Recommended by the Virginia Health Insurance Reform Commission, HB 925 and SB 405 would revise the existing code of Virginia to require private and employee-sponsored insurance plans to provide coverage for prosthetic care, repealing the existing requirement that coverage for prosthetic devices only be offered and made available. Each bill has

Submit Your State News

passed through both the state Senate and House of Delegates, and will now be reconciled before moving to the governor’s desk for his signature. AOPA testified in favor a previous version of this legislation, HB 503, in January 2020.

Washington

Washington House Bill 1427 has been reintroduced in the state’s House of Representatives after its introduction in early 2021 (in Washington, bills can carry over from sessions in odd-numbered years to sessions in even-numbered years). Similar to Arizona HB 2302, Washington HB 1427 states that health plans issued on or after Jan. 1, 2022, must provide coverage for orthotic and prosthetic devices that are at least equivalent to Medicare. As of this writing, the bill has eight Republican and nine Democratic cosponsors.

Member Resource Alert

AOPA has invested in a resource that allows us to track legislative and regulatory activity related to O&P in every state. We will be updating the state pages on the AOPA Co-OP with alerts as they arise.

To submit an update for publication in the State by State department of O&P Almanac, email awhite@AOPAnet.org.

THE PREMIER MEETING FOR ORTHOTIC, PROSTHETIC, AND PEDORTHIC PROFESSIONALS.

o i n o t n San A SEPTEMBER 28-OCTOBER 1

Join us September 28-October 1, 2022, for

Mark Your Calendars!

an ideal combination of top-notch education and entertainment at the 105th AOPA National Assembly in San Antonio, TX.

www.AOPAassembly.org

Passion for Paralympics Proudly providing technical support for Paralympians since 1988.

March 2022 O&P Almanac

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