February O&P News

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THE ORTHOTIC & PROSTHETIC COMMUNITY NEWS SOURCE

Going Lean and Driving Value PG. 4

O&P VISIONARY:

Charles Kuffel, MSM, CPO, FAAOP PG. 20

PLUS

Tech Tips 3-D Printers

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Just for Fun, What Would Happen If You Had a Therapist and a Physician in Your Practice? PG. 10

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Improving Patient/Practitioner Communications PG. 12

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EVERYTHING O&P

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Vol. 27 • No. 2 | February 2018

Departments & Columns 22 State by State A monthly column dedicated to

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the most important state and local O&P news.

24 In the News 24 Classified Ads 25 Meetings & Courses

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COVER STORY

04

Going Lean and Driving Value

26 Tech Tips Benefits and limitations of

3-D printers.

28 Ad Index

Experienced O&P professionals share their experiences and insights on developing more efficient business practices, including best practices for outsourcing and investing in new technologies, as a myriad of market drivers force the shift to a leaner O&P business model.

Contributions from Kathleen DeLawrence and Brittany Stresing, CPO, FAAOP

FEATURES

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Just for Fun, What Would Happen If You Had a Therapist and a Physician in Your Practice?

20 O&P Visionary

Your facility can benefit in several ways by having a local physician or physical therapist spend time on-site at your facility each week.

By Thomas F. Fise, JD

Charles Kuffel, MSM, CPO, FAAOP, calls for more emphasis on volunteerism, advocacy, and professional recognition.

Research & Presentations 12

Improving Patient/Practitioner Communications

By Andrea Sherwood, MPO, CPO

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Finding the Right Balance

By David Moser, PhD, BEng, BSc, and Mike McGrath, PhD O&P News | February 2018

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A strong voice today… and for the next 100 years Editorial Board Glenn Hutnick, CPO, CTP, FAAOP

O&P Practitioners

Together we are AOPA.

Randall Alley, CP, BSc, FAAOP Biodesigns Inc.

Hutnick Rehab Support Services Inc.

Kevin Carroll, MS, CP, FAAOP

Greg Mattson, CTPO

Hanger Clinic

Fabtech Systems LLC

Glenn Garrison, CPO

Scott Wimberley

Hospital for Special Surgery

Fabtech Systems LLC

circa 2000

circa 1900

JoAnne Kanas, PT, CPO, DPT

O&P Industry 100 years ago Pediatric Orthotic and our Pros- O&P predecessors thetic Services, LLC, Shriners thought we needed a unified Michael voice Angelicoto secure International Headquarters Advanced O&Pwere Solutions the future of our profession.

They right.

Thomas P. Karolewski, CP, FAAOP Hines VA Hospital

Robert S. Lin, MEd, CPO, FAAOP Hanger Clinic

Join AOPA.

Jonathan Naft, CPO

Geauga Rehabilitation Engineering

Sue Borondy

Matthew Parente, MS, PT, CPO

Jennifer Fayter

University of Hartford

Nabtesco & Proteor in USA

Justina S. Shipley CO, MEd, BOCP, FAAOP

Russell Hornfisher

Eric Shoemaker, MS, CPO

Orthotic Holdings Inc.

Jeffry G. Kingsley

Kingsley Manufacturing

Ability Prosthetics & Orthotics Inc.

Karen Lundquist

Rhonda F. Turner, PhD, JD, (BOCPO, CFm)

Brad Mattear, LO, CPA, CFo

American Association of Breast Care Professionals

O&P Researchers and Educators

Steven A. Gard, PhD

Northwestern University Prosthetics-Orthotics Center

Amputee Coalition Nabtesco & Proteor in USA

Matt Perkins

Coyote Design and Rehab Systems

Don Pierson, CO, CPed Arizona AFO

Brooke Raasch

Össur Americas Inc.

100 years ago our O&P predecessors thought we needed a unified voice to secure the future of our profession. They were right.

Mark D. Geil, PhD

Our profession needs a strong voice today and for the next 100 years.

Your membership matters!

O&P Technicians

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Sarah Clark

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WBC Industries

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Ability Prosthetics & Orthotics Inc.

Endolite www.aopanet.org/join

Shriners Hospital For Children

Together we are AOPA.

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for CertificaOur profession needs aAmerican strongBoard voice tion in Orthotics, Prosthetics, Joel J. Kempfer, CP, FAAOP today and for the next 100 years. and Pedorthics Inc. Kempfer P&O Your membership matters!

Jeffrey M. Brandt, CPO

O&P News | February 2018

Georgia State University

Mark Pitkin, PhD, DSc

Tufts University School of Medicine

Jon Shreter, CPO

Prosthetic and Orthotic Management Associates Corporation

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Grace Prosthetic Fabrication Inc.

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COVER STORY

Going Lean and

DRIVING VALUE Insights from one O&P business manager and one owner/practitioner

O

ver the past several years, there has been ongoing discussion regarding how to incorporate the most efficient business model and maintain high standards. Perhaps you’ve taken a hard look at your business in the new year and found yourself anxiously clinging onto ignorance.

Whoever coined the term that ignorance is bliss was not familiar with business, let alone the challenges of the health-care industry. As O&P professionals, we cannot afford to rest on comfort in a volatile and ever-changing environment. Hopefully you’ve come to a realization that your business needs an overhaul—welcome to your new reality.

Though change can be daunting, advice and insights from experienced professionals can help ease the process. O&P News has reached out to two O&P professionals to offer their perspectives on implementing a lean O&P business model. Here, Kathleen DeLawrence, chief operating officer of Ability Prosthetics & Orthotics Inc., and Brittany Stresing, CPO, FAAOP, owner of LimBionics, offer their business savvy and practitioner insights on how to approach a lean business model and discuss the role of central fabrication.

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O&P News | February 2018

COVER STORY

Know Your Business Kathleen DeLawrence Chief Operating Officer, Ability Prosthetics and Orthotics Inc.

The O&P profession is starting to see a shift away from the traditional business model of front, mid, and back office, with practitioners seeing patients and technicians running the lab. A myriad of market drivers—not the least of which is the changing reimbursement cycle—is forcing our profession to shift to a leaner business model. To know your business is to be highly cognizant of its surroundings, both external market forces and internal industry drivers. The health-care arena in the United States is at a tipping point, and the O&P industry is being affected as well. With extended approval timelines from commercial providers, coupled with aging accounts receivables due to a higher number of appeals, as well as threatening changes in the Local Coverages of Determination (LCDs) and reimbursement from the U.S. Department of Veterans Affairs (VA), we are left to examine and criticize our own balance sheets while simultaneously reducing business expenses.

Historically, companies turn to outsourcing as an immediate consideration for reducing business costs. In our industry, the opportunities for consideration in this arena relate to central fabrication and centralized services for claims administration (e.g., insurance verification, authorization, and billing) the cost of which should offset the expense of the headcount and overhead of these internal resources. Efficiency of business processes is always going to drop the most value to a company’s bottom line.

It is not an easy path for an owner to step up and lead this type of change; however, I have found the best approach is to garner the true allegiance of one’s employees. It has been my experience that employees know that there are inefficiencies in a business, can recommend

most of the changes quite effectively, and truly wish things would change, yet they are not willing to take the risk to suggest the changes to an owner. This reluctance to speak up on the part of staff members can be overcome if leadership engages employees to participate in defining the change. While the O&P industry is predominantly composed of privately held businesses, they are potentially in the best position to embrace true change as they are held mostly accountable to themselves. If leaders in the O&P industry want to survive the current health-care environment, then they must look within and determine immediately what they are willing to change in order to survive, drive value into their business, and protect what they have built.

Ability Prosthetics & Orthotics is not a small company, but it was intentionally built with lean practices into its business model. We outsource our manufacturing to the best providers based on the clinical case requirements. Our clinical administration processes are all centralized to support our 10 patient-care facilities. This design is leaner than the traditional model in the areas of insurance verification, authorization, billing, audits, and appeals because the company is staffed with a focused, dedicated team

If leaders in the O&P industry want to survive the current health-care environment, then they must look within and determine immediately what they are willing to change in order to survive, drive value into their business, and protect what they have built. that is cross-trained in processes to deliver efficient support to the practices.

We also have invested in a new role in this industry: a clinical research and outcomes director. This staff member supports the clinical staff in outcomes education, data management, and reporting, as well as provides technical input into complex claims management at the onset of the case. This business model is supported by a robust information technology platform, which includes desktop and mobile devices for all staff to interact anywhere with OPIE digital scanning and outcomes measurement and reporting.

O&P News | February 2018

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COVER STORY

This organizational design and platform allows the executive leadership team to be fully engaged in all aspects of managing the business. Additionally, my extensive business management and leadership experience has been leveraged across the organization to raise the bar for all our staff and promote growth. In this we have developed several leaders within the team and continue to train and prepare others. It’s a beautiful thing to be able to promote from within your organization because as the staff evolve and grow, so does the business.

At the core of our model is outsourced fabrication. We use central fabricators for all of our manufacturing, and have since our inception. Jeffrey Brandt, CPO, Ability’s founder and chief executive officer, built the model this way to bring the best-in-class solutions to our patients. We are positioned to source the best clinical solutions for our patients and manage the costs through negotiations with providers for their services. By not fabricating, we do not have the expense of staffing, maintaining, and renting the facility and equipment required to provide in-house manufactured devices. Most importantly, our clinical centers are in Class A medical facilities because we do not have the issues associated with fabrication. Our platform allows our local patient-care offices to remain focused on delivering high-quality care management, collecting outcome measures, and providing patient education for increased success with their devices in daily living. While we are leaner than most O&P companies with this model, it is not the only contributor.

Advances in technology are contributing to the need for business model efficiencies so practitioners can have more clinical time with their patients to make smart design choices based on outcome measures and changing requirements from payors. We continue to lean forward in this arena and train, deliver, and advocate for patients to receive these devices. In

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O&P News | February 2018

order to survive, the O&P business of today must prepare for these efficiencies immediately and introduce changes to remain competitive for the future. Physicians, payors, and patients are going to demand advancements in technology, and we must be ready to meet their needs and substantiate the case clinically.

To promote viable change, business leadership must conduct an honest, thorough evaluation of their businesses. There are various questions to be considered, such as, “Is my business prepared for the future of O&P in a world of integrated electronic medical records, outcomes reporting, and demonstrated, measurable fee for value?” If the answer is, “No,” then it’s time to go out and learn quickly what changes are needed to be better positioned to meet these requirements.

Change takes time, engagement, and buy-in from the entire organization. A coherent plan must be put into place to make the changes necessary to drive toward a desired business model that will be sustainable, and valuable, in the immediate future. Most importantly, do not fear change. It can be quite invigorating and stimulating to your existing business.

All Roads Lead to Patient Care Brittany Stresing, CPO, FAAOP Owner, LimBionics

When I first started thinking about starting LimBionics, I followed an extremely lean business model. In the initial phase, while awaiting accreditation and insurance contracts, I had no additional staff and was unable to treat patients in the office during office hours; I would have to be present in the office during business hours and only see patients before office hours in the morning, during lunch, and after hours to ensure, for inspections, that I was present in the office. I ran on a lean budget with no salary for a few months and minimal inventory. It was imperative to stock only necessary items and place orders on a per patient basis.

The decision to outsource fabrication seemed prudent so that time could be better spent on treating patients and ensuring desired outcomes. Inventory was built as needed, including additional administrative staff and upgraded equipment after the first year.

I learned early on that money should be spent on what affects patients and their comfort in care. Optimal patient care comes first and foremost, and that mindset also paves the way to be creative with how things can be done. I paid attention to certain software I might be utilizing and the features in that software that could save me from doing a few extra steps, such as signatures or mobile use of medical charts. If you are paying for software or services, you should maximize what you can do with it. In this sense, it’s absolutely true that knowledge is key.

When you build a business that is based on your reputation, it becomes an obsession to focus on quality as you hire staff. There is a veritable challenge to find a proper fit for staff. When I decided to add team members to the staff, I could easily have just filled the void quickly,

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but I took the time to find the right fit as far as knowledge, passion, drive, and patient interaction skills that fit my style and optimized patient referrals. This is incredibly rewarding because staff serve as the face of the company. Having invested in employees that care helps with efficiency since their contribution helps the practice evolve.

There are other various implementations that ensure an efficient and productive daily schedule. I keep several binders on hand, including policy and procedures for employees so that all expectations are transparent and communicated effectively. Other binders contain accreditation standards with answers to every point Medicare, Medicaid, and the American Board for Certification in Orthotics, Prosthetics, and Pedorthics (ABC) require to stay updated so there is no sudden panic and chaos if inspectors arrive. There also are set regular meetings when the entire staff gathers to go over the status of patients and paperwork, as well as ways we can improve efficiency from day to day.

It is important to also point out the successes of the office to ensure that hard work is not being overlooked and that dedication is appreciated. As a manager, I make sure to keep my door open to all recommendations from staff. This enables the channels of communication to flow cohesively and offers various perspectives that perhaps would not be evident to me or others.

Another “trick of the trade” involves forms for physicians. When a patient calls for certain devices, we have a preassembled packet of basic information that we will need to be included in the physician’s notes. Patients can take that packet to their physicians before we even see them. This works well for diabetic shoes, ankle-foot orthoses, knee braces, and some prostheses. It eliminates excessive back-and-forth and additional

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O&P News | February 2018

appointments for patients. We try to educate patients so they can speak to the physician’s office with as much knowledge as possible and complete the proper documentation. While creating the forms, we tested multiple versions to determine which forms were easiest for physicians or therapists while also capturing the most valuable information. We used the LCDs as the basis for the forms for different devices to ensure immediate compliance with the LCD criteria for documentation.

Central fabrication was a tough decision; overall, it allows practitioners to spend their time doing what they do best, which is treating patients, and also saves additional staff expenses and liability of technicians getting injured on the premises. Granted, we all still use routers and saws, which have the potential to cause injury during adjustments, but it is still beneficial to minimize the liability as well as additional expenses.

Without a large fabrication facility on site, there is less noise and fewer odors, which results in a more positive patient experience. In the past, I have had a few patients tell me how noise and smells can be an impediment to their recovery process because they trigger memories of their past procedures.

Any business should utilize its strengths. Patient-care facilities should allow for a focus on patient care.

Central fabrication facilities should excel at fabrication. If you find a central fabrication facility that does quality work and has a great turnaround time, that is hard to beat. By separating patient care from fabrication duties, each specialty has the opportunity to focus and grow within its specific interests. The patient is provided with the best fabricated device because it was made by a specialist with the unique skill set for the best outcome. Practitioners do not need to rush to finish a lamination, restricting the quality of the product and the patient visit itself. Again, the outcome of any product or visit should provide an optimal service to the patient.

The O&P profession is not for the faint of heart. When interacting with insurance companies, we are constantly obligated to prove that what we do improves people’s quality of life and mobility as well as prove that we are credible medical professionals. We are regularly reminded of our status on the totem pole, with proper documentation being excluded from medical records, certain treatments being removed from coverage, not being able to bill for our time, being considered durable medical equipment, and videos of high school kids making “prostheses.” These types of developments can wear people down in the profession. That being said, if you believe in optimal patient care and strive to improve the quality of life of your patients, then you’re motivated from day to day.

The O&P industry has to look ahead to the future and determine where it will be in five, 10, and 20 years. The younger generation of practitioners has a lot of experience to gain and should strive to work hard toward their goals to ensure our profession is seen for the incredible asset that it is within the health-care sphere.

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Just for Fun, What Would Happen If You Had a Therapist and a Physician in Your Practice?

Consider how your facility might benefit from partnerships with other health-care professionals

By Thomas F. Fise, JD

O

&P practitioners talk all the time about things like: “Why can’t we get paid for our time in patient training, gait analysis, and instruction, like the therapists do? It’s unfair—don’t we do the same thing they do?” Or, “The prosthetist/orthotist understands the patient’s mobility needs much better than the physicians do, yet our getting paid is dependent on the exact words in the physician’s order, and Medicare won’t even let us help the doc clarify what should be in his or her notes.”

First, be careful what you ask for. Is everybody ready for CMS to restructure the L-code system so that they begin paying for everything on the basis of the amount of time you spend, rather than paying a set price—a global fee, if you will—for the finished device? Medicare did just this type of restructuring of physician fees in the early 1990s. They hired a Harvard public health expert to go to physician practices, and also to review physician calendars/logs to pinpoint exactly how much time—in minutes and seconds—the doctors actually spent, on average, with the patient. They also factored in actual practice expense costs for gauze, bandages, paper used on the examining table, etc., and added in factors for malpractice costs, and the

10 O&P News | February 2018

intensity of the time the doctor spent and training required—minutes spent performing heart surgery were more intense minutes than those spent taking a history and physical. The result was what became known as the ResourceBased Relative Value Scale (RBRVS), and around 1993, physicians started to be paid based on a set number of dollars for each relative value unit (RVU)—that is, they got paid primarily based on the actual average minutes for each service, and they didn’t much like this result.

As we ponder the payment to the O&P professional versus that paid to the therapist or the physician, recognize that the latter get paid under the Current Procedural Terminology (CPT) coding system (based on RVUs), while O&P gets paid from a subset of the durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) fee schedule. That said, like so many things in life, there is more than one way to skin a cat.

For example, you probably have observed that hospitals have purchased a bunch of physician practices, but did you know that the fee paid to the physician practice can be significantly higher if the visit occurs on the premises of the hospital (viewed as more intense time, almost like time in the emergency

room)? To qualify for this higher reimbursement, the office actually needs to be no more than a set number of feet from the hospital itself—if it is that close, it is considered on premises. You also may know that surgeries/procedures of modest complexity can be performed either in the hospital or in a separate ambulatory surgery center (ASC). The truth is that the amount Medicare pays for practice expenses is generally significantly higher if the patient is treated in the hospital’s outpatient department, rather than if the very same procedure is provided in a free-standing ASC. So, when a physician practice is purchased by a hospital, you can expect that more of its procedures will be done in the hospital outpatient department (even though, in order to keep the “wheels of medicine turning,” a decent volume will continue to occur in the ASC, which the hospital likely bought from the physicians when they purchased the practice).

The point of the above is not to make you an expert on physician payment under Medicare, but rather to demonstrate that practices, even hospitals, are often set up on a structure that takes all the rules into account in order to generate the most generous total reimbursement from Medicare and other payors.

So, back to the “just for fun” question: Suppose for a moment that you had negotiated an arrangement with a local physician to spend one afternoon every week or every two weeks in your practice, and similarly that you had an agreement with a physical therapist to spend one or one-and-a-half days a week in your practice. Consulting with your experienced health-care attorney, you negotiate a contract that assures each of these professionals a minimum billing/ income flow—under their own CPT fee schedule—during the time they are at your practice to see (and bill) your patients. Your agreement would specify terms for rent, staff, etc., ideally in a way that some portion of amounts over

sufficient documentation on their visit. At the same time, your patients could see the physician for primary care-type needs like routine prescriptions, allergy injections, flu shots, or other assessments, or referrals for minor services requiring a specialist—such as minor surgeries, etc.

The fees would be generated by, and belong to, the physician, but you’d also have valuable new cash flow, at the same time making your practice more valuable to your patients.

• Your patients who needed gait assessment, education, and adjustments beyond the basic routine could be scheduled for a visit with the physical therapist—you, as an O&P

your guarantee would come back to your practice. This is the tricky part, and you would absolutely need to engage experienced help from experts in crafting the terms—there are rules from the Office of Inspector General (for example, “Questionable Rental Arrangements for Space in Physician Offices”), contractual agreements with private-sector payors, etc., which must to taken into account, but such agreements can be crafted. The outcome might look something like this: • You could easily schedule your prosthetic and some more complex orthotic patients to see the physician about their mobility needs, assessment of K levels, and generation of

professional, can’t deliver and be paid for those services, but the therapist is permitted to bill them under the CPT schedule (assuming they are not duplicative of the precise services you are obliged to deliver in the global fee under the L-code/DMEPOS fee schedule). As with the physician, having the physical therapist available will have them generating bills under the CPT codes for their own services, but you’d have both valuable new cash flow (rent, referrals to you for new O&P services, and better physician and therapist records), at the same time making your practice more valuable to your patients.

• Your practice would start to look and act more like a multipurpose healthcare facility—patients may routinely have blood pressure, temperature, or even an EKG or an X-ray performed on site by health professionals as ancillary services to the physician practice.

• You may not be able to bill for the above services yourself, but if you bring the professionals who can bill for them to your practice location, you and others may benefit. (Some of these might be billable by a licensed practical nurse in carrying out physicians’ orders, even at times when neither the physician nor the therapist is in the office.)

It’s something to think about. A lot of this will depend on the numbers and availability of the right health professionals. But thinking about your practice this way is how medicine is provided in our complicated health-care system today.

Does your local CVS or Walgreens have a “minute clinic” or “urgent care clinic,” and are they providing inoculations to patients? It’s interesting that CVS is in the process of purchasing one of America’s largest health insurance companies. Is that a captive audience?

When those patients have a prescription provided by a physician in that miniclinic, where do they get the prescription filled? The pharmacy clinic can become something of the primary care “go to” for those patients. Think about it.

Look at your practice through a different lens—patients come to your facility for health care. Does it make sense to be able to offer them more things than can be billed for under the O&P fee schedule, and to bring into your office other part-time health professionals who can deliver and provide other needed services, rather than send them away to another location to have their needs met?

Thomas F. Fise, JD, is executive director of AOPA and publisher of O&P News.

O&P News | February 2018

11

Research & Presentations

Improving Patient/Practitioner Communications Clinician studying the benefits of positive communications is seeking to partner with industry professionals to develop best practices for O&P

By Andrea Sherwood, MPO, CPO

P

assion for patient outcomes and quality care is what drew me to the research topic of good patient/practitioner communications.

My previous career in community relations/public relations for a Fortune 500 company taught me the significant value of good communication. So, my initial intent as an orthotics and prosthetics student was to learn about best practices for clinical communication in orthotics and prosthetics.

However, much to my surprise, I was able to find only one article in the literature regarding communication in O&P. The lack of publications on this topic suggested that we as practitioners have room for improvement when it comes to communicating with our patients. It also highlighted the need for a broader literature review wherein I might learn more about the benefits to practitioners of using good clinical communication that might be applied to orthotic and prosthetic patient encounters.

Hence, I began a review focusing on two specific aims. First, given the lack of literature specific to orthotics and prosthetics, I set out to identify the benefits

12 O&P News | February 2018

experienced by medical providers more broadly from using good patient/practitioner communication. Second, I sought to consider which of these benefits might apply in the context of an orthotic/prosthetic patient encounter.

The review, published in the January issue of the Journal of Prosthetics and Orthotics (JPO), and co-authored by myself, John Brinkmann, MA, CPO, LPO, FAAOP, and Stefania Fatone, PhD, BPO(Hons), identified 17 benefits to medical providers who use good patient/practitioner communication.

We were then able to categorize these benefits into five beneficial themes that we believe would accrue to orthotists and prosthetists who engage in good patient/ practitioner communication. The beneficial themes included the following: 1. Reducing the risk of litigation 2. Efficient and effective patient appointments 3. Improved patient outcomes 4. Improved patient satisfaction and increased referrals 5. Improved job satisfaction for practitioners.

disciplines to find methods of analyzing practitioner communication, learn techniques to teach good communication skills, and develop best practices for the orthotics and prosthetics profession.

Clinical communication is very different from communication between family and friends; therefore, it is important to actively develop these skills, much like we hone our technical skills. As orthotists and prosthetists, our technical skills blend science and art to achieve successful outcomes for our patients. Clinical communication skills also weave together the science and art of communication.

Similar to the development of our technical skills, developing good communication skills requires practice, finesse, and motivation. Are you motivated to better understand the benefits of good patient/practitioner communication? To learn more, please read the full literature review, “Review of Benefits to Practitioners of Using Good Patient/Practitioner Communication,� published in the January issue of JPO, and contact me at andrea567@gmail.com if you have ideas to share on this topic.

These benefits could be yours if you improve your clinical communication with patients. So, how do you improve your communication?

Determining how to improve clinical communication is the next necessary step. I am looking to partner with industry professionals across multiple

Andrea Sherwood, MPO, CPO, is currently in the development stages of creating a business to enhance communication with pediatric patients in orthotics and prosthetics. Her research is published in the Journal of Prosthetics and Orthotics. She has presented at the National AAOP Scientific Symposium, AAOP Midwest Chapter Meeting, Northwestern University Prosthetic Orthotic Program, and other venues.

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Research & Presentations

Finding the Right Balance Both prosthetic knee and ankle-foot technologies influence standing balance outcomes

By David Moser, PhD, BEng, BSc, and Mike McGrath, PhD

Background: Standing The act of standing still and maintaining balance may seem quite simple.

However, despite this apparent simplicity, it is quite literally a complex balancing act and a marvelous feat of biomechanical control. If you reach forward to pass an object or simply point to something, your body’s center of mass (COM) will move, and whether you realize it or not, you’ll make subtle motor adjustments that affect balance to allow for this change. Next time you are standing in a crowd, observe those around you and you will realize that most people don’t stand still for very long. You will notice that they are continuously moving, swaying slightly, and shifting their weight around.

For an individual with limb loss, this is much more challenging and often hazardous, as the body COM is decentralized due to the missing limb mass.

Compromised sensory feedback and a loss of active motor control at the knee and ankle, both of which are used to recover from unbalanced situations, add to the difficulty and risks when standing, particularly on uneven surfaces.

A key problem that arises is a lack of adaptation within the prosthetic limb to adjust for variations in changing ground inclines, which affects limb loading. The consequence is often pain and discomfort at the socket interface, which can result in an unloading compensation strategy to alleviate the discomfort.

A vicious circle is created because the

14 O&P News | February 2018

resulting uneven inter-limb loading then further compromises balance stability, safety, and clinical outcomes.

Why Alignment and Combined Component Selection Matter When considering normal biological control of multiple joints during standing, it is interesting to observe that we rarely stand with the hip, knee, and ankle joint at the full extent of motion.

When standing on level ground, only the knee is close to a fully extended position; both the hip and ankle joints

will be positioned well within the available range of motion. When static, the ground-reaction force is projected from the center of pressure (COP) and passes ahead of the ankle joint (creating an external flexion moment), while at the same time passing slightly ahead of the knee joint, and through or slightly behind the hip joint. Upright stability is created with very little muscular effort in the form of a closed isokinetic chain by the interplay of passive tension created within the limb. Therefore, when considering the combined effect of multiple

Figure 1

Illustration showing the effect changes to ankle joint AP alignment can have on limb stability. The red line represents the ground-reaction vector. Large changes to AP ankle position can cause excessive flexion and extension tendencies, which require physical compensation.

Research & Presentations

prosthetic joints, the most basic considerations relate to joint position and the mechanism that creates resistance to movement. The position or alignment of a prosthetic joint is important since this will determine the combined external moments acting on the leg, and thus the forces at each of the joints involved in the control of stability when standing.

During our research and development of hydraulic ankles, we observed that this was an essential consideration in achieving a good outcome. More specifically, it became clear that there was a direct correlation between ankle alignment and compensatory balance control mechanisms that would occur when standing. Figure 1 illustrates these compensatory mechanisms. Figure 1(a) shows the tendency for unstable flexion, which results when the ankle position is set excessively posteriorly relative to the residual joints. This is caused by an abnormally large external flexion moment acting about the ankle. As the ankle tends to flex, the ground-reaction vector may fall behind the knee, causing an external flexion moment about the knee. With this alignment, patients typically report a feeling of instability and a sensation of falling forward. To remain upright, and to overcome this forwardflexion tendency, the user may add compensatory effort from the hip and knee extensors to sustain limb extension. Clearly, this is undesirable due to the instability and extra muscular effort required. In contrast, as shown in Figure 1(c), when the ankle is set too posteriorly, the external flexion moment about the ankle becomes much smaller. This, combined with an extension moment about the knee, causes a tendency for the limb to over-extend and the COP to move posteriorly, causing a feeling of falling backward. A corrective and undesirable anterior trunk lean compensates and helps move the COM forward to restore balance stability. A stable alignment position, as shown in Figure 1(b), is one that is comfortable, requires little

effort, and allows postural adjustments that mimic natural biological control.

Hence, we refer to this as a biomimetic alignment.

The Effect of Prosthetic Foot Components As stated earlier, aside from alignment, the design of the ankle-foot resistance mechanism also plays a key role in the control of standing stability. An ankle-foot design that is largely elastic in nature will have an unloaded equilibrium point and a natural tendency to release energy whenever the elastic elements of the foot are loaded. The system can be modeled as a pair for springs, as shown in Figure 2(a). When aligned on level ground, fewer problems are encountered since the internal joint moments created are minimal and are largely balanced.

However, when the ground incline changes, the loading applied to the foot can become considerably biased toward hind- or forefoot (depending on incline) during static standing weight bearing.

This, in turn, causes an unbalancing of the internal forces created at the ankle, which can lead to discomfort and instability since these will act through the socket interface.

In contrast, a foot design that includes a hydraulic actuator in series

Figure 3

Illustration of Elan MPF standing support mode. When standing situations are detected, hydraulic resistance is automatically increased to provide higher levels of limb support. A small amount of adjustment is preserved to facilitate natural postural movements.

with a spring, as shown in Figure 2(b), becomes viscoelastic and will actively dissipate force within the range of hydraulic movement. This has the effect of eliminating the internal joint moments that are created whenever loading is applied to the foot. Overall, the system has a tendency to self-align, that is, to rotate to a position where the joint becomes

Figure 2

The equivalent mechanical models of (a) a rigid, energy-storage-and-return ankle-foot, Esprit, and (b) a hydraulic ankle-foot device, Echelon.

O&P News | February 2018

15

Research & Presentations

standing, and to calculate the distribution between the prosthetic and sound sides as a percentage of the total. The results showed that the control group presented with a slight degree of loading bias, with increased loading on their dominant limb (50.5 percent of total load ± 2.2 percent standard deviation). The prosthetic loading outcomes were considered with this finding in mind.

When testing the Esprit foot, the lack of compliance to the Methods inclined ground surface generA recent study in our biomeated compensations at the knee chanics lab sought to examine and hip with increased levels of how various changes to prosthetic joint flexion. This would tend limb components influence to offset the knee joint center, standing performance on slopes. resulting in an external flexion Five adult participants with Changes in standing posture of a transfemoral moment about the knee. The transfemoral (TF) and four adults participant using Orion3 when standing with (a) an MPK knee stance control was with transtibial (TT) limb loss Esprit foot and (b) an Echelon hydraulic ankle-foot. unaffected despite these kinetook part in the study; all were matic changes, and did not alter K3 ambulators. A control group of five adult subjects with no lower-limb tested an Esprit and Echelon foot (Endo- weight bearing support provided by the impairments also participated in the lite). The TT participants tested Esprit, knee. Changes to the resulting standing posture are illustrated in Figure 4, which Echelon, and Elan feet (Endolite). study. contrasts the effect of foot selection.

Each participant stood, facing down Result (a) shows the Esprit and (b) a slope on an instrumented ramp, for Results and Discussion a period of at least 15 seconds. At least One of the chosen outcome measures shows the Echelon. Both TF and TT three trials were recorded for each inter- of the study was to measure the ground- subjects presented similar compensations vention. During this time, joint angles reaction force under each limb while to standing posture. were measured using a 3-D motion capture system. The chosen gradient of the slope was 5 degrees. This complies Figure 5 with guidelines set out in the Americans With Disabilities Act of 1990 (ADA)5.

60% Espirit, MPK standing support off (TF) Ground-reaction forces (GRF) and COP 58% movement were recorded using Kistler 56% Echelon, MPK standing support off (TF) 54% force plates embedded within the ramp Echelon, MPK standing support on (TF) 52% as indicators of inter-limb loading distriControl mean + S.D. 50% bution and balance control.

48% Espirit (TT) All the TF participants were fitted 46% Echelon (TT) with an Endolite Orion3 micropro44% cessor knee (MPK). This MPK has an Elan, MPF standing support on (TT) 42% enhanced standing support function, 40% which can be switched “on” or “off ” Transfemoral Transtibial by the programming clinician and was tested in both conditions. With each of Bar chart showing the mean degree of asymmetry between the prosthetic and sound the knee conditions the TF participants limb ground-reaction forces for each of the three prosthetic conditions.

Figure 4

Sound/ dominant side

16 O&P News | February 2018

Prosthetic/ non-dominant side

Ground-Reaction Force Distribution Between Limbs

fully compliant with the ground interface, providing a high degree of stability. When standing situations are detected using microprocessor foot (MPF) control, it is possible to further enhance stability by applying a higher level of hydraulic resistance while maintaining an ability to adjust upright standing body posture.

This enhanced standing function is illustrated in Figure 3 and acts as a brake on the ankle joint.

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Research & Presentations

Figure 6

Example, inter-limb ground-reaction force loading, TF (top row), TT (bottom row), for each of the tested prosthetic conditions. Sound limb loading shown blue and prosthetic limb loading shown red. Control data (bottom right) is included for comparison.

18 O&P News | February 2018

results from the study. The top row shows TF subject results; the magnitude of the force under the sound limb (blue) is clearly greater than that under the prosthetic limb (red) for the Esprit condition. The spread of the vector lines at the ground represents the COP movement, which is visibly smaller for the Echelon condition with MPK standing

Figure 7 Percentage Change in COP Movement from Control Mean

In terms of loading distribution between limbs, the Esprit condition proved to be the most asymmetrical for both TF and TT subjects, with the sound limb bearing 54 percent of the load, on average. This fell outside of the “dominant limb� range of variation.

Echelon improved limb load distribution for both levels of limb loss, exhibiting loading levels comparable with able-bodied participants. The addition of MPK standing support for the TF subjects and MPF standing support for TT subjects produced results nearly indistinguishable from the able-bodied participants, with average intact limb loading of between 49.9 and 51.0 percent. Under these conditions, prosthetic side loading was occasionally greater than the sound side. A breakdown of the results is presented in Figure 5.

The inter-limb loading can be visualized using 3-D Pedotti diagrams, which show direction, magnitude, and temporal variation of the ground-reaction forces. Figure 6 illustrates some sample

support on, indicating improved balance.

Similarly, for the TT subject shown, the Esprit condition displays a loading asymmetry with increased weight bearing on the sound limb. The Echelon conditions present more even load magnitude distributions, occasionally with more weight bearing evident on the prosthetic side in some cases. The addition of Elan MPF standing support mode reduces the spread of the vector lines at the ground, indicating less COP movements and more stability of posture.

The other outcome measure in this study related to balance ability was COP fluctuation. The COP movement gives a good indication of how well balanced a person is and provides some indication of whole body COM motion and control activity. For each prosthetic condition, this value was calculated relative to the baseline for the able-bodied control participants. The results are shown in Figure 7. For TF subjects, Esprit was once again the poorest performing condition, with an 80 percent increase in movement compared to able-bodied measurements.

The prosthetic condition that was closest to the control data was the combination of a hydraulic ankle and MPK standing support. For the TT subjects, subjects using Esprit presented a mean increase in COP movement of 27 percent, compared to able-bodied participants. For the two hydraulic ankle conditions, however, this

100

Less Stable

80

Espirit, MPK standing support off (TF)

60

Echelon, MPK standing support off (TF)

40

Echelon, MPK standing support on (TF)

20 0 Espirit (TT)

-20 -40 -60

More Stable Transfemoral

Echelon (TT) Elan, MPF standing support on (TT)

Transtibial

Mean percentage change in center-of-pressure movement, compared to the mean value for able-bodied control participants, for each of the three prosthetic conditions.

Research & Presentations

measure was significantly reduced, indicating greater stability than the controls.

The least COP fluctuation, indicating a high degree of stability, was achieved with Elan, the combination of a hydraulic ankle and MPF standing support.

Conclusions It is well known that individuals with lower-limb loss are particularly susceptible to falls. This vulnerability and safety issue is partly attributable to the level of stability provided by the prosthesis, the activity being performed, and the ground surface. Changes to anklefoot component selection can have a significant effect on inter-limb loading and its variation1,2. It is therefore critical that multiple prosthetic joint types are considered in combination with each other since component features can act cumulatively to either hinder or assist standing balance stability. This is most evident with hydraulic ankles, such as Echelon, and MPF, such as Elan,

which have standing support features to improve standing balance and promote greater weight bearing on the prosthesis.

Devices like these should be considered in view of reducing socket discomfort, the risk of falls, and severity of secondary complications, such as lower back pain and osteoarthritis, that are related to poor posture and long-term asymmetrical limb loading3,4,6.

David Moser, PhD, BEng, BSc, is head of research at Endolite, part of the Blatchford Group. Mike McGrath, PhD, is clinical research scientist at Endolite, part of the Blatchford Group.

References 1. De Asha AR, Munjal R, Kulkarni J, Buckley JG. Walking Speed Related Joint Kinetic Alterations in Transtibial Amputees: Impact of Hydraulic ‘Ankle’ Damping. J Neuroengineering Rehabil. 2013;10(1):1.

2. Moore R. Effect on Stance Phase Timing Asymmetry in Individuals

c e n t r a l

© 2018 fabtech Systems llc. all rights reserved.

Click Medical™/ Revofit™

With Amputation Using Hydraulic Ankle Units. JPO J Prosthet Orthot.

2016;28(1):44–48.

3. Portnoy S, Kristal A, Gefen A, SievNer I. Outdoor Dynamic SubjectSpecific Evaluation of Internal Stresses in the Residual Limb: Hydraulic Energy-Stored Prosthetic Foot Compared to Conventional Energy-Stored Prosthetic Feet. Gait Posture. 2012;35(1):121–125.

4. Johnson L, De Asha AR, Munjal R, Kulkarni J, Buckley JG. Toe Clearance When Walking in People With Unilateral Transtibial Amputation: Effects of Passive Hydraulic Ankle. J Rehabil Res Dev. 2014;51(3):429.

5. ADA.gov homepage [Internet]. [cited 2017 Dec 8]. Available from: https:// www.ada.gov/ 6. Gailey R. Review of Secondary Physical Conditions Associated With Lower-Limb Amputation and LongTerm Prosthesis Use. J Rehabil Res Dev. 2008;45(1):15.

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O&P News | February 2018

19

O&P Visionary

Charles Kuffel, MSM, CPO, FAAOP President and clinical director for Arise Orthotics & Prosthetics Inc. offers his idea of a more perfect O&P health-care climate

W

hile sitting at the AOPA Leadership Conference last month, I was approached

by Tom Fise, JD, executive director of AOPA, who asked me to envision a time where I ruled the O&P profession for one day. My initial thought was, “Why me, and what influence do I have in the O&P profession?”

I took a minute to look thoughtfully at my career in O&P. My certification number is in the 1900s—closer to the beginning of the certification numbers than the end—which made me realize that I have been working in this field for quite a while. I thought a bit about the fact that the O&P profession has been very good to me, my family, and my friends. In the past 20 years, I have been fortunate to serve on several influential boards, both locally and nationally, and I have lectured in countries across the world. I have been blessed to assist thousands of individuals in regaining their mobility and discovering their new normal. Being asked to rule “our” O&P profession for one day is quite an interesting and honorable endeavor.

Volunteerism and Advocacy In the perfect O&P world that I envision, each professional would vol-

20 O&P News | February 2018

unteer some of his or her time, talents, and treasures outside of clinical practice responsibilities to positively impact the greater community of individuals we serve. My true passions, other than my four always-compliant children and my wonderful wife, center around volunteerism and patient advocacy.

The O&P profession is filled with opportunities to give of ourselves—to educate others and to advocate for others. It is a true honor to assist our patients in telling their stories. The local O&P chapters and the national organizations rely on volunteers to staff committee and board positions to do work that positively impacts the O&P profession. The established O&P educational system assists practitioners, technicians, and other O&P professionals in acquiring a unique set of skills to assist a relatively small community of people who require our talents. In my O&P world, every student, resident, assistant, and practitioner in our profession would spend some of their time speaking openly to politicians, insurance carriers, and the media about the benefits the O&P profession brings to their constituents, beneficiaries, and viewers. And, a certain level of yearly volunteerism and/or advocacy would be

O&P Visionary

a mandatory part of certification for all O&P professionals and applicable to our professional CEU credits.

International Exposure In my perfect O&P world, all practitioners would spend time each year assisting those outside our borders who need our care. Across five continents, I have had the unique privilege to educate others and help provide O&P clinical support to those in the most challenged of circumstances. I have been overwhelmed by the raw sense of duty and civility that these humanitarian efforts provide.

These experiences have helped me, as a health-care professional, fill a void that is often created by the frustrations that come from dealing with the reimbursement systems and procedures required by our payors in the United States. Our clinical practices can be wrought with undue administrative minutiae, which seem to burden the psyche and complicate the ability for us to assist those requiring our expertise. In this perfect world, all O&P practitioners would carve out some time each year to assist others outside our borders, and their efforts would be recognized by the professional credentialing organizations and account for CEUs. Licensure of O&P Practitioners and Clinical Recognition If I ruled the day in my perfect O&P world, all practitioners would be recognized as licensed, qualified health-care providers and their notes would count as medical record. In the great state of Minnesota, we recently passed licensure for O&P professionals. Although licensure remains somewhat controversial across the states and in our profession, it has elevated our status as health-care providers with our Minnesota colleagues in the medical profession.

In my perfect world, licensing would assist O&P practitioners to be recognized as the sole providers of custom, if not all, O&P interventions. There

In this perfect world, all O&P practitioners would carve out some time each year to assist others outside our borders, and their efforts would be recognized by the professional credentialing organizations and account for CEUs.

would be no question or concern that we provide the highest level of O&P patient care and that the devices we choose for our patients ensure both safety and cost effectiveness. In this world, the licensing of all O&P practitioners (along with the increased educational requirements to a master’s degree), would reflect our commitment to the profession to elevate our status with the federal government, other health-care professionals, and health-care administrators across the country.

Professional Unification My final proclamation for my day to rule O&P would be to unify all the professional organizations under one recognizable umbrella organization.

During my nine-year tenure with the National Commission on Orthotic and Prosthetic Education (NCOPE), I have been fortunate to attend every national AOPA and Academy meeting, several meetings of the International Society for

Prosthetics and Orthotics, and almost every AOPA Policy Forum. Through these experiences, I have been able to meet and discuss the matters of O&P with many colleagues, political representatives, insurance administrators, and other health-care professionals.

Over the years I have come to realize that we have difficulty defining and defending who we are, and those outside our profession do not fully understand what we do and the important role we play in the rehabilitative process. In my perfect, albeit imaginary, world, the unification of the O&P profession would help to narrow our message and definition, and help to support the need, the value, and the cost effectiveness that we bring to the rehabilitative process.

A Job Well Done As my day of rule over the O&P profession comes to an end, I realize that it has been an exhilarating and spiritually fulfilling 24 hours. The educational level and professional licensure of our country’s O&P profession have helped positively influence national and international health-care systems.

O&P practitioners regularly volunteer their time, talents, and treasures to local, national, and international organizations to help educate and advocate. The O&P community has pushed the licensure ball further down the road, and we are recognized by our colleagues in the health-care arena as the qualified and sole providers of O&P care.

Finally, as the blue sky fades into the quiet of the night, I find comfort in the fact that the O&P profession is unified under one, recognizable professional umbrella. Our one voice is heard. It is a voice that is crystal clear as it espouses the altruistic care and concern we have for the individuals we serve across our globe.

Charles Kuffel, MSM, CPO, FAAOP, is president and clinical director for Arise Orthotics & Prosthetics Inc. and immediate past chair of NCOPE.

O&P News | February 2018

21

STATE NEWS

State by State The latest news from Tennessee, Texas, Ohio, and Pennsylvania

Each month, we talk to O&P professionals about the most important state and local issues affecting their businesses and the patients they serve. This column features information about medical policy updates, fee schedule adjustments, state association announcements, and more.

Tennessee Recently passed legislation authorizes a licensed orthotist or prosthetist to utilize one or more nonlicensed individuals to assist in the performance of minor repairs on devices that have been previously dispensed to patients and the performance of other tasks approved by the board.

An O&P representative maintains one seat on the Board of Podiatric Medical Examiners.

“It is advantageous for O&P professionals to establish relationships with other allied health-care boards so that if deregulation occurs, we can maintain representation,” said Michael Fillauer, CPO, LPO, chief executive officer of Fillauer Companies. “It is imperative that we have seats on licensure boards in our states where decisions about our professional standards and practices are being addressed.”

22 O&P News | February 2018

Texas The Texas O&P Board was dissolved under S.B. 202.

Licenses for orthotists and prosthetists are now administered by the Texas Department of Licensing and Regulation (TDLR). TDLR now is responsible for all of the licensing applications, enforcement of rules, web page updates, communications, and reports as required

by Texas legislators.

“The newly appointed advisory board handles all matters pertaining

to the O&P standard of care issues, scope of practice, and details pertaining to the rules of application in the state of Texas. This move has been an improvement in the functionality of the licensing process,” said Catherine Mize, CPO, LPO. As part of the transition, Texas O&P providers have seen fee reductions, with most of the fees required by TDLR set at lower amounts than under the Department of State Health Services (DSHS), as noted in the table.

Texas Orthotist and Prosthetist Licensing Fees

DSHS Fee

TDLR Fee

Reduction in Dollars

Percentage in Reduction

Jurisprudence Exam

$35

$34

$1

3%

Written License/Certification Verification Fee

$25

$0

$25

100%

Changing the name of an accredited orthotics or prosthetics facility

$400

$50

$350

88%

Changing the name of an accredited orthotics and prosthetics facility

$500

$50

$450

90%

Changing the name of the on-site practitioner in charge of an accredited facility

$100

$50

$50

50%

Changing the name of the safety manager of an accredited facility

$100

$50

$50

100%

Criminal History Evaluation Letter

$50

$25

$25

50%

Reinstatement Fee

$100

$0

$100

100%

STATE NEWS

Ohio In accordance with the language of H.B. 49 of the 132nd Ohio General Assembly, the licensing Board for Orthotic, Prosthetic, and Pedorthic Practitioners has being dissolved, effective Jan. 21, 2018.

Licensing for orthotic, prosthetic, and pedorthic license types will continue under the administration of the Occupational Therapist, Physical Therapist, and Athletic Trainers Board. While all processes and procedures involved are being finalized, the current board continues to function and meet its day-to-day responsibilities.

“This is an effort by the state of Ohio to reduce the number of licensing boards and will ultimately reduce the fees associated with licensure,” said Bob Leimkuehler, CPO, LPO, owner of Leimkuehler Prosthetics & Orthotics.

Pennsylvania In January, O&P News reported that Highmark Pennsylvania’s Medical Policy on LowerLimb Prostheses now covers vacuum,

microprocessor-controlled ankle-foot prostheses, as well as powered and programmable flexion/extension assistcontrol prosthetic knees, when medically necessary. Additional information and discussion on this topic, including a letter provided by an AOPA member, can be found on the AOPA Co-OP, www.aopanet.org/resources/co-op.

After publication, AOPA members reported the following concerns about the new policy: 1. It appears that in order to meet policy, a new amputee wishing to receive a limb needs to complete a rehabilitation program. We would not proceed making them a limb until we received prior authorization or know that we have met policy criteria.

2. Policy states: Residual limb “has matured.” Most new amputees, once healed, receive a limb. After wearing that limb six to 12 months, the limb shrinks in volume, and then they require a socket change.

Is Highmark Pennsylvania wanting providers to provide temporary

limbs until the stump matures?

3. The policy on suspension systems very clearly states Levels K1-K4 for mechanical, Levels K2-K4 for suction. However, the policy on vacuum systems only states K3.

Why is K4 not listed?

4. The microprocessor ankle-foot L5973 policy states only below-theknee amputee. Why? 5. The microprocessor ankle-foot L5973 policy states that if criteria are met, it is medically necessary.

However, on page 11, the policy states L5969 and L5973 are considered experimental/investigational and therefore noncovered, which is a contradictory policy statement.

EDITOR'S NOTE: To submit an update for publication, please email awhite@aopanet.org. For up-to-date information about what’s happening in O&P in your state, visit the AOPA Co-OP and join the conversation in the AOPA Google+ Community.

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“Search Mobility Saves” on Facebook, Twitter, and LinkedIn

O&P News | February 2018

23

O&P IN THE NEWS

CLASSIFIEDS

OPGA Announces Partnership With Nymbl Systems Orthotic Prosthetic Group of America (OPGA) has announced a new partnership with Nymbl Systems. The arrangement provides OPGA’s members with access to Nymbl’s practice management system at an exclusive discounted rate.

Nymbl’s functionality reportedly allows practitioners to access patient records, submit insurance claims, schedule appointments, and purchase supplies via mobile device.

For more information, visit www.nymblsystems.com or www.opga.com.

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

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Meetings & Courses

2018 FEBRUARY 14 AOPA Webinar: Inpatient Billing. Register online at bit.ly/ 2018webinars. For more information, email Ryan Gleeson at rgleeson@AOPAnet.org.

MARCH 1

APRIL 1

ABC: Practitioner Residency Completion Deadline for Spring CPM Exams. All practitioner

ABC: Practitioner Residency Completion Deadline for May Exams. All practitioner candidates

candidates have an additional 30

have an additional 30 days after the application deadline to complete their residency. Contact 703/8367114, email certification@abcop.org, or visit www.abcop.org/certification.

days after the application deadline to complete their residency. Contact 703/836-7114, email certification@ abcop.org, or visit www.abcop.org/ certification.

APRIL 11 FEBRUARY 23-24 PrimeFare Central Regional Scientific Symposium 2018.

Renaissance Hotel, Tulsa, OK. Contact Cathie Pruitt, 901/359-3936, email primecarepruitt@gmail.com; or Jane Edwards, 888/388-5243, email jledwards88@att.net; or visit www.primecareop.com.

FEBRUARY 26-27 2018 Mastering Medicare: Essential Coding & Billing Techniques Seminar. Doubletree

by Hilton, Atlanta. Register online at bit.ly/2018billing. For more information, email Ryan Gleeson at rgleeson@AOPAnet.org.

MARCH 7-8 AOPA Policy Forum. Washington, DC. Come make a difference!

Educate Congress on issues affecting your patients. For more information, contact Devon Bernard at dbernard@AOPAnet.org or call 571/431-0876.

MARCH 12-17 ABC: Written and Written Simulation Certification Exams. ABC certification exams will be administered for orthotists, prosthetists, pedorthists, orthotic fitters, mastectomy fitters, therapeutic shoe fitters, orthotic and prosthetic assistants, and

MARCH 1 Call for Papers deadline. Deadline to submit your clinical, business, technical papers, or symposia at

MARCH 1 ABC: Application Deadline for Certification Exams. Applications must be received by March 1 for individuals seeking to take the May Written and Written Simulation certification exams. Contact 703/836-7114, email certification@ abcop.org, or visit www.abcop.org/ certification.

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

nationwide. Contact 703/836-7114, email certification@abcop.org, or visit www.abcop.org/certification.

MARCH 14 AOPA Webinar: Medicare Coding Guidelines: MUEs, PTPs, PDAC, and More. Register online at bit.ly/2018webinars. For more information, email Ryan Gleeson at rgleeson@AOPAnet.org.

AOPA Webinar: Outcomes & Patient Satisfaction Surveys.

Register online at bit.ly/2018webinars.

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

SEPTEMBER 12 AOPA Webinar: Medicare As a Secondary Payor: Knowing the Rules. Register online at bit.ly/2018webinars. For more information, email Ryan Gleeson at rgleeson@AOPAnet.org.

SEPTEMBER 26-29 AOPA National Assembly.

APRIL 26-28 New York State Chapter Annual Meeting (NYSAAOP). Rivers Casino & Resort, Schenectady, NY. For more information, visit www.NYSAAOP.org.

Vancouver Convention Center.

For general inquiries, contact Ryan Gleeson at 571/431-0876 or rgleeson@AOPAnet.org, or visit www.AOPAnet.org.

OCTOBER 10 MAY 9 AOPA Webinar: Coding: Understanding the Basics. Register online at bit.ly/2018webinars. For more information, email Ryan Gleeson at rgleeson@AOPAnet.org.

technicians in 300 locations

bit.ly/present2018 to present at the 2018 National Assembly.

AOPA Webinar: Enhancing Cash Flow & Increasing Your Accounts Receivable. Register

AUGUST 8

AOPA Webinar: Year-End Review: What Should You Do to Wrap-Up the Year & Get Ready for the New Year. Register online at bit.ly/2018webinars. For more information, email Ryan Gleeson at rgleeson@AOPAnet.org.

JUNE 13 AOPA Webinar: Audits: Know the Types, Know the Players, and Know the Rules. Register online at bit.ly/2018webinars. For more information, email Ryan Gleeson at rgleeson@AOPAnet.org.

NOVEMBER 4-10 Health-Care Compliance & Ethics Week. AOPA is celebrating Health-Care Compliance & Ethics Week and is providing resources to help members celebrate. Learn more at bit.ly/aopaethics.

JULY 11 AOPA Webinar: Administrative Documentation: The Must Haves and the Sometimes Needed. Register online at bit.ly/2018webinars. For more information, email Ryan Gleeson at rgleeson@AOPAnet.org.

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

O&P News | February 2018

25

TECH TIPS

3-D Printers and O&P These are the tools of tomorrow, but are they worth buying today?

My name is Jeff Erenstone, CPO, and I own a typical O&P practice. I also am the founder of Create O&P, a company that sells 3-D-printing systems and educates clinicians and staff on how to incorporate these systems into their practices. In addition, I work extensively with adaptive athletes and adaptive sports design. This work first led me to 3-D printing.

Over the past six years, I have spent a lot of time and money testing 3-D printers and software. Most of my experience is with printers that cost less than $15,000, but I also have experience with 3-D-printing services, such as those at central fabrication facilities, that have more expensive machines.

The following are some questions and answers regarding the state of 3-D printing for O&P.

Are 3-D printers worth it?

Yes, unless you plan on retiring in the next few years and don’t like computers.

Any practice with an interest in staying relevant in the future should explore this technology today. Like many other professions that utilize design and engineering technologies, this is where the O&P field is headed. Digital technology allows for faster and more efficient device creation. 3-D printers are the most straightforward tools to take a device from an idea to an object.

As insurance companies continue to increase their requirements on documentation, O&P practices need to find ways to become more efficient if we want to stay in business. To survive the next batch of regulations, we need to learn to focus on increasing efficiency to best prepare for the challenges of tomorrow.

26 O&P News | February 2018

Won’t the 3-D printers of today become obsolete?

Yes, but the knowledge and understanding of digital workflow will not.

Think of the earliest computers you used. My Windows 98 laptop, once a useful tool for work, is now obsolete (and is most useful as a doorstop today).

However, I got my money’s worth from that old laptop, and I am still using the word processor knowledge I gained from using it to write this article now.

Is 3-D-printing technology actually efficient today?

Some of it is, and some of it is not.

Inherently, 3-D printing is the easiest digital way to create a custom object because it requires the least complex toolpath and generally is the simplest tool to program. However, the field is still young. The software, hardware, and materials are just starting to be developed for specialized industries like O&P. On top of that, we already have some amazingly good ways of making custom devices. There is a high bar that needs to be met to displace the methods we already use.

What devices should be 3-D printed?

After a quick search on the Internet, you will see that just about every O&P device you can think of can be 3-D printed.

But is it better than what you are already doing? In most cases, the answer is no. The challenge is sifting through the cool concepts, science experiments, and ineffective devices to find the helpful nuggets that are valuable for your practice.

Create O&P currently owns 23 printers. After printing everything we could think of, I feel comfortable answering the question of what is worth your time today. However, before I do, I would like to add some caveats.

First, my statements only refer to the current state of fused filament fabrication (FFF) printers, also known as fused deposition modeling (FDM), which are the most common. Select laser sintering (SLS), stereolithography (SLA), and direct metal laser sintering (DMLS) machines have different value, but should only be considered by big central fabrication facilities.

Second, new things come out every day. Tomorrow there could be a new device that makes my claims obsolete.

However, I would suggest that new technologies should be reviewed by the market for at least six months before you consider adopting them.

In my view, these are some of the components that may be considered for 3-D printing: • Diagnostic sockets. Across the 3-D-printing industry, prototyping is its greatest value, and diagnostic

The Policy Forum is your

Why should you attend?

to learn the latest legislative and regulatory details and how they will affect you, your business and your patients.

•

Ensure that veterans maintain the ability to receive care from their chosen provider

•

Make sure O&P remains an Essential Health Benefit

Once you are armed with the facts, we as a profession will educate our members of Congress to offer common sense solutions and share how the O&P profession restores lives and puts people back to work.

•

Prevent the expansion of off-the-shelf orthoses and competitive bidding

•

To advance the recognition of criteria which underscore that qualified providers are the ones who can treat patients most effectively, with best outcomes.

BEST OPPORTUNITY

Questions regarding registration, travel or the agenda should be directed to Ryan Gleeson at rgleeson@AOPAnet.org or (571) 431-0876. Questions regarding programming, congressional visits or key issues should be directed to Devon Bernard at dbernard@AOPAnet.org or (571) 431-0854.

HOST HOTEL: Ritz Carlton, 1250 South Hayes Street, Arlington, VA 22202 AOPA has a special rate of $279/night until February 16.

Meet your member of Congress and tell them how, through orthotics and prosthetics:

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REGISTER TODAY bit.ly/policyforum2018

Visit bit.ly/policyforum2018 to learn more.

TECH TIPS

sockets are prototypes. There are huge efficiency gains with 3-D-printed diagnostic sockets. I can consistently scan and modify a below-knee socket in 10 minutes, then print it in less than three hours. I realize that a good technician can match this speed.

However, the machine is always ready, so I can schedule for it and consistently provide same-day care.

This allows my technicians to focus on the fabrication of complex devices that are worthy of their skills, instead of pouring plaster.

• Protective and cosmetic covers. Take a minute to look on the Internet at the amazing covers that have been printed. These covers are really cool and would be extremely hard to make without 3-D printing. A while back, a patient brought in a photo of her dog. We designed a cover with the dog on it, similar to a tattoo. She now shows everyone her leg instead of being shy about it.

• Fabrication molds. It is relatively easy to take the digital limb shape (digital

some amazing devices. I have found the best approach is to make a hybrid of new 3-D-printed designs and wellestablished legacy components. Some upper-extremity parts have been used successfully for 100 years. As they say, “If it ain’t broke, don’t fix it.”

plaster model) and turn it into a mold for a definitive device. Recently we started using 3-D-printed molds to stretch leather calf corsets. We digitally added features to make the leather molding easier—features we couldn’t add to plaster.

• Upper-extremity prostheses and orthoses. This area required more skill and experience to accomplish, but if you master it, you can make

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28 O&P News | February 2018

Publisher Thomas F. Fise, JD Advertising Sales RH Media LLC Editorial Services Content Communicators LLC Design & Production Marinoff Design LLC Printing Sheridan SUBSCRIBE O&P News (ISSN: 1060-3220) is published monthly by the American Orthotic & Prosthetic Association, 330 John Carlyle St., Ste. 200, Alexandria, VA 22314.

To subscribe, contact 571/431-0876, fax 571/4310899, or email landerson@AOPAnet.org. Periodical postage paid at Alexandria, VA, and additional mailing offices.

ADDRESS CHANGES Postmaster: Send address changes to: O&P News, 330 John Carlyle St., Ste. 200, Alexandria, VA 22314.

Get Educated We are all busy, but a little effort now will save you a lot of trouble in the future. There are courses that specialize in 3-D printing, and O&P schools are adding this subject to their curriculum.

If you are not ready to commit the resources needed for a clinical 3-D-printing system and just want to tinker with the tech, you can get a printer for $500 and use free software like Meshmixer and Cura for learning purposes. There are videos on YouTube demonstrating how to use Meshmixer to make sockets and foot orthoses. So, what are you waiting for?

Jeff Erenstone, CPO, is owner and chief executive officer of Create O&P and owner of Mountain Orthotic & Prosthetic Services.

Copyright © 2018 American Orthotic and Prosthetic Association. All rights reserved.

This publication may not be copied in part or in whole without written permission from the publisher. The opinions expressed by authors do not necessarily reflect the official views of the publisher, nor does the publisher necessarily endorse products shown in O&P News. The O&P News is not responsible for returning any unsolicited materials. All letters, press releases, announcements, and articles submitted to the O&P News may be edited for space and content. The magazine is meant to provide accurate, authoritative information about the subject matter covered. It is provided and disseminated with the understanding that the publisher is not engaged in rendering legal or other professional services. If legal advice and/or expert assistance is required, a competent professional should be consulted.

ADVERTISE Reach out to the O&P profession and more than 13,500 subscribers. Engage the profession today. Contact Bob Heiman at 856/673-4000 or email bob.rhmedia@comcast.net.

THE PR EM I E R ME E T IN G F OR ORT H OT IC, PROSTH ETIC, A N D PED ORTH IC PROFESSION A LS.

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