March 2023 O&P Almanac

PUTTING YOUR BEST FOOT FORWARD

CUSTOM: FOOT ORTHOTICS • AFO’S • RICHIES

One size does not fit all. At Hersco, our team of professionals works to fabricate orthotics from your scans and casts to match your patients’ specific needs.

Customer service is at the heart of everything we do and we work endlessly to help you be as effective and efficient as possible. When you want the job done quickly and accurately, Hersco is here to help.

16 WOMEN’S STUDIES

CHRISTINE UMBRELL

Meet MacJulian “Mac” Lang, CPO, FAAOP, clinical manager at Arm Dynamics’ Northwest Center of Excellence, and find out how he helped return transhumeral patient Austin Anderson to his dream job as a tree feller at Yosemite.

Views From AOPA Leadership

Takeaways From Working Together at the 2023 AOPA Leadership Conference

Greetings to all! In late January, we hosted the 2023 Leadership Conference in Savannah, Georgia. More than 100 leaders from AOPA’s membership spent two days reflecting on the strategic priorities we launched last year, revisiting what had been accomplished in 2022, and digging into what the focus needs to be for 2023. It is always inspiring when leaders across our orthotic and prosthetic (O&P) profession, from small business practitioner-owners to large manufacturer executives, come together to share examples and expertise with the intention to make our profession better. Some of the topics discussed included the future of patient care, the future of manufacturing, using data to drive outcomes, supporting the workforce, and building on state-based advocacy efforts. Attendees had the opportunity to break out into smaller groups to discuss how to address the challenges we face in the day-to-day provision of O&P care. The results of the breakout sessions provided further refinement of AOPA’s strategic priorities. Specifically, three issues came to surface that attendees felt are limiting the growth and advancement of the profession and the care we provide to our patients. With this feedback and guidance from membership, the AOPA Board of Directors and staff will continue the work in 2023 and into the future.

• First, when compared with other healthcare professions, the delivery of O&P care is not where it should be in terms of standardization, clinical documentation, and outcome measures. We will continue to address these issues in order to positively impact the care we provide to our patients.

• Second, inefficient payment processes are leading to delays in care for patients, unnecessary bureaucratic burdens, and inappropriate reimbursements. We will continue to make the case to payors that we all need to work together to improve the processes of payment for O&P care—to make them more efficient, to reduce burdens, and to improve our ability to serve patients.

• Third, the Healthcare Common Procedure Coding System is overly complex and potentially inadequate, creating inefficiencies for patient-care facilities. We will continue the work to eliminate confusion and increase efficiencies, with the focus to remain on improving patient care.

These takeaways from our leadership conference provide us with the direction we need to continue the work to positively impact AOPA members and the patients we serve. When we work together, collaborating our efforts and sharing our expertise, we all benefit—the profession benefits.

As always, we would love to hear from you as we build out the tactics and plans for the future. We welcome you to share your thoughts by email at info@AOPAnet.org

Very truly yours,

Teri Kuffel, JD

Teri Kuffel, JD, is president of AOPA.

Board of Directors

OFFICERS

President

Teri Kuffel, JD

Arise Orthotics & Prosthetics, Spring Lake Park, MN

President-Elect

Mitchell Dobson, CPO, FAAOP Hanger Clinic, Austin, TX

Vice President

Jeffrey M. Brandt, CPO Brandt Ventures, Exton, PA

Immediate Past President

Dave McGill Össur Americas, Foothill Ranch, CA

Treasurer Rick Riley Bakersfield, CA

Executive Director/Secretary

Eve Lee, MBA, CAE AOPA, Alexandria, VA

DIRECTORS

Arlene Gillis, MEd, CP, LPO International Institute of Orthotics and Prosthetics, Tampa, FL

Elizabeth Ginzel, MHA, CPO Össur, Fort Worth, TX

Kimberly Hanson, CPRH Ottobock, Austin, TX

John “Mo” Kenney, CPO, FAAOP Kenney Orthopedics, Lexington, KY

James Kingsley Hanger Clinic, Oakbrook Terrace, IL

Lesleigh Sisson, CFo, CFm Prosthetic Center of Excellence, Las Vegas, NV

Linda Wise Fillauer Companies, Chattanooga, TN

Shane Wurdeman, MSPO, PhD, CP, FAAOP(D)

Research Chair Hanger Clinic, Houston Medical Center, Houston, TX

A world where orthotic and prosthetic care transforms lives.

Our Mission

AOPA staff and volunteers are committed to our mission of being 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.

Our Vision

A world where orthotic and prosthetic care transforms lives.

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 | AOPAnet.org

EXECUTIVE OFFICES

Eve Lee, MBA, CAE, executive director, 571-431-0807, elee@AOPAnet.org

Akilah Williams, MBA, SHRM-CP, director of finance and strategic operations, 571-431-0819, awilliams@AOPAnet.org

HEALTH POLICY AND ADVOCACY

Joe McTernan, director of health policy and advocacy, 571-431-0811, jmcternan@AOPAnet.org

Devon Bernard, assistant director of coding and reimbursement services, education, and programming, 571-431-0854, dbernard@AOPAnet.org

Sam Miller, manager, state and federal advocacy, 571-431-0814, smiller@AOPAnet.org

Susannah Engdahl, PhD, manager, health policy and research, 571-431-0843, sengdahl@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

MEMBERSHIP & COMMUNICATIONS

Joy Burwell, director of communications and membership, 571-431-0817, jburwell@AOPAnet.org

Betty Leppin, senior manager of member services, 571-431-0810, bleppin@AOPAnet.org

Nicole Ver Kuilen, manager of public engagement, 571-431-0836, nverkuilen@AOPAnet.org

AOPA Bookstore: 571-431-0876

Reimbursement/Coding: 571-431-0833, LCodeSearch.com

O&P ALMANAC

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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.

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Copyright © 2023 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.

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SOME SAY ONE-SIZE FITS ALL WE SAY one-size fits almost no-one!

We have big ambitions for the word FIT.

It’s given that the AFO should fit and follow the shape of the leg and fit and adapt well to the shoe, for a comfortable wear for each individual. But fit should also mean a good dynamic function for the individual, and

that’s where the similarity between a one-size version and an Allard AFO STOPS!

We offer different models for different needs of support and stability. Our 25 years experience and development of composite AFO confirms the necessity of variety to meet and fulfill the need from patients in the best possible way, not only one way!

Responding footplate is a key function

for control, safety and comfort. Within each model we offer 4-5 different sizes (XS-XL) to match different foot sizes and heights of users. All sizes have

individual composite lay-up to optimize dynamic response,

especially of the important footplate. (Both build height and footplate length can also be adjusted, 1-1.5 cm).

MOBILITY MATTERS

RESEARCH ROUNDUP Hip Muscle Exercises May Boost Mobility

a new study from the United Kingdom, 20 additional minutes of daily exercise lowers hospitalization risk for diabetes by 23%.

Low levels of activity among individuals with below-knee amputation while wearing their prostheses may lead to atrophy in the residual limb. Researchers from Imperial College London discovered that knee extensor muscles are at particular risk of atrophy and sought to determine whether strengthening the hip abductors could provide effective compensation for weaknesses in knee extensors.

Led by Ziyun Ding, PhD, the research team studied a group of combat-wounded soldiers in the United Kingdom who had been using prostheses for at least six months. The researchers took high-resolution MRI measurements and captured motion data as participants engaged in defined activities. They also leveraged computational modeling to study internal loading.

Ding’s team found that hip abductor muscles are key to improving functional mobility, and individuals with lower-limb amputation should consider engaging in targeted muscle activities and electrical stimulation, using activities similar to rehabilitation activities of some stroke patients. The study was published March in Journal of Biomechanics.

Researchers To Study Neurally Controlled Bionic Legs With OI

Shirley Ryan AbilityLab and its research partners have been awarded a $1.5 million grant from the Department of Defense Congressionally Directed Medical Research Program to advance the field of bionics by studying osseointegration (OI) combined with targeted muscle reinnervation (TMR) and pattern-recognition control to operate a fully powered bionic prosthesis.

“It’s this combination of technologies that makes the device ultranovel, advanced, and intuitive,” said Levi Hargrove, PhD, the study’s lead researcher and director of the Regenstein Center for Bionic Medicine at Shirley Ryan AbilityLab. “We hope that it will enable the bionic limb to feel light and comfortable and to offer unprecedented control for the user. This study … marks a significant step forward in the field of osseointegrated bionic legs.”

Hargrove’s facility will partner with Integrum and Northwestern Medicine, which will implant the device and perform TMR surgery on eight research subjects. The study builds on existing collaborations with researchers at Chalmers University of Technology in Sweden. “We are very excited to embark on this opportunity with our partners in Chicago, and hope that this is just the beginning of more extensive collaborations,” said Rickard Branemark, CEO and founder of Integrum AB.

How Do Users Feel About Silicone Partial-Hand Prostheses?

Cosmetic silicone prostheses are commonly prescribed to individuals with partial-hand loss, but data is scarce on satisfaction among users. Researchers from Saudi Arabia and Jordan sought to learn more on this topic by studying 54 individuals with partial-hand amputations who had been fit with these types of prostheses.

After participants completed the validated Arabic version of the Client Satisfaction With Device Survey, the research team analyzed results. Nearly half of the subjects used their devices daily. Most patients

reported satisfaction with durability and donning but dissatisfaction with comfort.

“The satisfaction of individuals with partial-hand amputations can be enhanced by fitting them with cosmetic silicone prostheses. However, these prostheses should meet certain criteria, including fitting, weight, comfort, donning, appearance, durability, skin abrasion and irritation, and pain,” concluded the researchers. “Individuals’ expectations and concerns should be considered as well.”

Details of the study were published January in Prosthetics and Orthotics International

Improving the mobility of patients can contribute to their overall health. According to

OI

Patients Report Improved Quality of Life, Mechanical Complications

Swedish researchers conducted a 10-year cohort study of patient-reported outcomes and complications among individuals with above-knee amputations who had undergone osseointegration (OI). They studied responses from 51 individuals who had completed the Questionnaire for Persons With a Transfemoral Amputation and the Short Form 36 Health Survey, both pretreatment and at subjects’ 10-year follow-up visits.

The researchers identified significant mean improvements between baseline and the 10-year

follow-ups. At the 10-year follow-up, patients reported improved health-related quality of life, more hours of prosthesis use, improved mobility, fewer problems, and an improved situation overall compared to pre-implant. However, reports of increased numbers of mechanical complications of percutaneous modular parts as well as some deep infections “suggest that the implant system and treatment still require improvements, further research, and follow-up periods beyond 10 years,” according to the researchers. The study was published January in Journal of Orthopaedic Translation

IS YOUR FACILITY READY FOR LLLDAM?

Next month is Limb Loss and Limb Difference Awareness

Month. Prepare now to celebrate your patients in April.

O&P BEST PRACTICES

Experts Seek Input To Develop Socket Guidance

AOPA established the Socket Guidance Workgroup, composed of multidisciplinary experts from various countries and backgrounds, in 2020 to provide the prosthetic community with evidence-based clinical best practices and methods in the field of prosthetic socket structural analysis. The goal is to develop guidelines to test the mechanical strength of prosthetic sockets.

To address the knowledge gaps related to socket design, the workgroup conducted a critical analysis of the requirements for mechanical testing of lower-limb prosthetic sockets and developed recommended potential solutions for each gap. They identified gaps in four domains:

• The shape and composition of a mock residual limb, to support and generate realistic stresses within the socket

• Alignment of the socket

• Selection and requirements of accessory components

• Test conditions and acceptance criteria.

The intent is for established researchers, doctorate students, and master’s students to help address these knowledge gaps and report back to the Socket Guidance Workgroup. With AOPA’s support, the workgroup is building and maintaining a database to house the findings.

Francesca Gariboldi, MEng; Andrea Cutti, MD, PhD; Jeff Erenstone, CPO; Stefania Fatone, PhD; Eric Nickel, MS; Saeed Zahedi, PhD; Joshua Steer, PhD; and Alex Dickinson, MEng, PhD, are leading this project. Read a full-length white paper and introductory editorial detailing the gaps and recommendations in the February Prosthetics and Orthotics International.

O&P MIT Launches Collaboration To Advance O&P in West Africa

The Lisa Yang Center for Bionics at Massachusetts Institute of Technology has launched a four-year partnership with the government of Sierra Leone to strengthen the capabilities and services of Sierra Leone’s O&P sector.

An agreement between the Center for Bionics and Sierra Leone’s Minister of Health and Sanitation is designed to strengthen that country’s O&P sector through data collection and operations, education, supply chain, infrastructure, new technologies, and mobile delivery of services. Hugh Herr, PhD, codirector of the Center for Bionics, will lead the MIT team implementing the collaboration.

“From educational services, to supply chain, to new technology, this important [memorandum of understanding] with the government of Sierra Leone will enable the Center to develop a broad, integrative approach to the orthotic and prosthetic sector within Sierra Leone, strengthening services and restoring much needed care to its citizens,” said Herr. Details of the collaboration are available on MIT’s website.

O&P By the Numbers

INVENTORY TURNOVER

O&P Professionals Convene in Mexico

Prosthetists, orthotists, manufacturers, and other O&P stakeholders will travel to Guadalajara, Mexico, next month for the 19th World Congress of the International Society for Prosthetics and Orthotics (ISPO). Slated for April 24-27, the conference will feature educational sessions, keynote lectures, free paper and poster presentations, and exhibits.

Themed “The Art and the Science,” the conference is jointly sponsored by ISPO Mexico, ISPO Canada, and US-ISPO. Stefania Fatone, PhD, program director of the University of Washington’s O&P program, will deliver one of the keynote presentations.

O&P Facility Management

MAJOR CONCERNS/ISSUES AMONG O&P FACILITIES

Stefania Fatone, PhD

Happenings

FAST FACT HEALTHCARE CYBERSECURITY

In January 2023, 40 healthcare data breaches of 500 or more records were reported to the HHS Office for Civil Rights: 23 hacking/ IT incidents, 15 unauthorized access/disclosure, and 2 thefts were reported.

People & Places

PROFESSIONALS

EDUCATION UPDATES

O&P

Master’s

Program Integrates Virtual Reality Features

The Midwestern University College of Health Sciences will welcome its first cohort of 20 students in August to pursue a master’s degree in orthotics and prosthetics. The 30-month curriculum will require students to complete 156 credit hours within two connected phases of learning.

Students will complete a 12-month on-campus didactic phase, engaging in clinically oriented coursework involving client-centered assessment and treatment, movement sciences, anatomical and physiological sciences, O&P engineering design, fabrication, fitting and clinical outcome assessment, scholarly inquiry, and interprofessional collaboration. Then they will complete an 18-month off-campus

The Amputee Coalition recently announced its 2023 board of directors. John Register, a two-time Paralympian and Paralympic Games silver medalist and CEO of Inspired Communications International, was named executive chair of the board of directors. Other members of the Executive Committee are Vice Chair-Elect William Perno, MBA, FACHE, vice president for ambulatory care at Centra Health; Treasurer R. Carter Wood III, CPA, chief financial officer for Buchanan & Edwards; Secretary David S. Sanders, partner at Foley & Lardner LLP; and Immediate Past Chair Lorraine Riche, president of Bloom Health Centers.

Additional members of the Amputee Coalition Board of Directors include Seth McLaughlin, founder and president of Springfield Advisors; Justin Moore, PT, DPT, CEO of the American Physical Therapy Association; Carrie Davis, vice president of patient experience for Hanger Clinic; Chad Jerdee, JD, retired global lead of responsible business, corporate sustainability, and citizenship at Accenture; and Matthew Swiggum, MBA, president and CEO of Proteor USA.

Orthotic Prosthetic Group of America (OPGA) and Össur have announced the recipients of two O&P grants. Kaleigh Neely has been selected as the 2023 recipient of the Russell Walker CP, LP, Emerging Leader Grant, and Abbey Senczyszyn, CPO, has been selected as the 2023 recipient of the Todd Eagen Advocacy in Action Memorial Grant. Neely is an O&P resident with Geauga Rehabilitation Engineering Inc. in Ohio, and Senczyszyn is with

residency/evidence-based practice phase, where they will be matched to a series of planned residency site rotations.

The new program is the only one in the United States to incorporate a Computer Assisted Rehabilitation Environment (CAREN) into its curriculum. The program will be housed in new state-of-the-art facilities located on the university’s Glendale Campus.

Bremer Prosthetic Design Inc. in Michigan.

Now in its second year, the Russell Walker CP, LP, Emerging Leader Grant pays tribute to Russell (Rusty) Walker, a practitioner who was passionate about mentoring the next generation of O&P leaders.

OPGA and Össur Americas are co-sponsoring and co-supporting the inaugural Todd Eagen Advocacy in Action Memorial Grant. Eagen, former president of OPGA, unexpectedly passed June 4, 2022.

“On behalf of Össur and OPGA, we are privileged to announce Kaleigh and Abbey as the recipients of these two grants that will provide professional development opportunities for the future leaders of O&P while memorializing the impact both these individuals left on the O&P profession,” said Adam Miller, president, OPGA. “Both Kaleigh and Abbey are rising leaders in the O&P profession and will be exceptional representatives at the AOPA Policy Forum and the Challenged Athletes Foundation Triathlon Challenge, two nonclinical events that are highly important to the O&P profession and the patients it serves.”

Kaleigh Neely and Abbey Senczyszyn, CPO

PHOTO CREDIT: MIDWESTERN UNIVERSITY COLLEGE OF HEALTH SCIENCES

BY JOE MCTERNAN

Orthotic Operating Procedures

Additional codes will be subject to WOPD and face-to-face encounter rules next month

Controlling fraud and abuse in the Medicare program has been a major goal of CMS since its creation. With billions of dollars in Medicare claims being processed on an annual basis, Medicare administrative contractors simply do not have the resources or the time to review every claim that they process to ensure that all medical necessity requirements have been met.

The most realistic and successful way to protect the Medicare program from waste, fraud, and abuse has been through the creation of auditing programs and policy guidelines that identify at-risk services and implement specific efforts to ensure that Medicare funds are being spent appropriately. These programs are valuable and an important part of protecting taxpayer dollars, but there is a delicate balance between fraud and abuse reduction efforts and the creation of unnecessary delays in access to clinically appropriate care for Medicare beneficiaries. We have all experienced frustration with unreasonable claim denials and lengthy appeal processes.

Simply mentioning the acronym “RAC” in a room full of O&P professionals will result in significant grumbling and eye rolling.

Medicare fraud and abuse reduction efforts can be frustrating, but they are a fact of life; O&P providers, for the most part, understand how they work and have developed operating procedures to minimize the disruption that they can create. Just when you feel prepared to handle the challenges of audits and policy requirements, a new challenge often arises that creates the need for adjustments.

While not a new process for the Medicare program, the requirement for both a written order prior to delivery (WOPD) and documentation of a face-to-face encounter between the patient and the prescribing physician has recently been added and subsequently expanded for several orthoses that have been identified by CMS as at significant risk for waste, fraud, and abuse. This month’s Reimbursement Page reviews what is required and discusses how to ensure compliance with the new rules.

Adding 10 Codes

CMS first established requirements for WOPDs and face-to-face encounters in 2006 when it published a final rule for power mobility devices (PMDs). The regulatory authority to require WOPDs and face-to-face encounters was subsequently expanded beyond PMDs in 2012 to include product categories of durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS).

Another final rule published in 2019 created a “master list” of DMEPOS Healthcare Common Procedure Coding System (HCPCS) codes that met specific criteria for high-risk exposure to waste, fraud, and abuse. HCPCS codes on the master list could be selected at any point in the future for inclusion in WOPD and face-toface encounter requirements. The current master list, available on the CMS website, includes several hundred O&P HCPCS codes. Note that inclusion in the master list does not mean that a WOPD and faceto-face encounter are required; it only means that they can be selected for these additional requirements.

Six orthotic HCPCS codes were initially selected from the master list for inclusion in the WOPD and face-to-face encounter requirements with an effective date of April 13, 2022: codes L0648, L0650, L1832, L1833, 1851, and L3960. In January 2023, CMS published a “Federal Register” notice that will add 10 additional orthotic codes requiring a WOPD and face-to-face encounter, effective for claims with a date of service on or after April 17, 2023. The 10 additional orthotic HCPCS codes are L0631, L0637, L1843, L1932, L1940, L1951, L1960, L1970, L2005, and L2036.

The requirement for a WOPD is relatively self-explanatory. There is no difference in what is required for the written order to be considered compliant, but it must be in the possession of the O&P provider at the time of delivery of the completed orthosis.

All written orders must include the following elements to be considered compliant for Medicare documentation purposes:

• Patient name or Medicare Beneficiary Identifier

• Order date

• General description of the item (narrative description or HCPCS code list)

• Quantity to be dispensed

• Treating practitioner name or National Provider Identifier

• Treating practitioner’s signature.

The requirements for a face-to-face encounter with the prescribing practitioner include all of the following, as published by CMS:

• The face-to-face encounter must occur within the six months prior to the date of the WOPD.

• The face-to-face encounter must be used to gather both subjective and objective information associated with diagnosing, treating, or managing the clinical condition for which the orthosis was ordered.

• The face-to-face encounter must be documented in the pertinent portion of the medical record (for example, history, physical examination, diagnostic tests, summary of findings, progress notes, treatment plans, or other sources of information that may be appropriate). The supporting documentation must include subjective and objective, beneficiary-specific information used for

diagnosing, treating, or managing a clinical condition for which the orthosis is ordered.

• If the encounter is performed via telehealth, the requirements for telehealth services must be met. Telehealth requirements are evolving rapidly as a result of multiple waivers that were put in place during the COVID-19 public health emergency (PHE) and extended beyond the end of the PHE as a result of the Consolidated Appropriations Act of 2023.

Creating Compliance

Changing the operating procedures of your practice is never an easy task—but in the case of WOPD and face-to-face encounter requirements, it is an absolute necessity. Failure to meet the regulatory requirements for the 16 orthotic HCPCS codes that require a WOPD and face-to-face encounter as of April 17, 2023, will result in what is known as a “technical denial.” Technical denials are those that are not directly tied to medical necessity and are notoriously difficult to overturn through the appeal process.

In addition to adjusting your internal operating procedures to ensure compliance with the WOPD and face-to-face encounters rule for the 16 designated orthotic HCPCS codes, you also should work with your referral sources to make sure they are properly educated and adjust their documentation accordingly. While you cannot always control how your referral sources practice medicine, often a simple discussion regarding the WOPD and face-to-face requirements will go a long way in ensuring that what you need to support your claim is present in patients’ medical records.

WOPD and face-to-face encounter requirements represent a new documentation challenge, but they represent a fairly simple change—and ultimately will help protect the Medicare program from unnecessary waste, fraud, and abuse.

Joe McTernan is director of health policy and advocacy at AOPA. Reach him at jmcternan@AOPAnet.org

BY CHRISTINE UMBRELL

WOMEN’S STUDIES

With

dearth of

Some women with limb loss experience four feelings that set them apart from their male counterparts: a sense of “feeling invisible” and lacking a connection with other women with amputation; a desire for prosthetic devices that meet their biologic and social needs; a need for assessments and a prosthetic limb prescription process that is tailored to women; and a desire for prosthetists who listen to and understand women’s needs. These findings were discovered in a study published in September by researchers at the U.S. Department of Veterans Affairs (VA).

Fortunately, patient-care facilities, O&P educators and researchers, and

NEED TO KNOW:

manufacturers are stepping up and offering care and devices that lessen some of those feelings in female patients, says Alyson Littman, MPH, PhD, one of the principal investigators of the study. But more needs to be done because “women are not just small men,” says Littman, a research professor of epidemiology at the University of Washington, a researcher at the Seattle-Denver Center for Innovation for Veteran-Centered and Value-Driven Care at VA, and an investigator at the Seattle Epidemiologic Research and Information Center. Clinicians should consider each woman’s prosthetic and orthotic needs individually, rather than relying on preconceived assumptions, she says.

f Researchers are increasingly focusing on the needs of women with limb loss during prosthetic intervention.

f One recent study demonstrated that women desire prosthetic devices that better meet their biological and social needs, and that they seek closer connections with prosthetists and other women with limb loss.

f Several new O&P studies focused on prosthetic footwear options, including one study noting that better prosthetic foot design may help to better social participation and other important outcomes for women prosthesis users.

f At many facilities, clinicians are prioritizing more personalized care to ensure women’s individualized needs—in terms of both function and cosmesis— are met when choosing componentry.

f Clinicians should ensure patients are comfortable during appointments by communicating how they will assess their patients’ anatomy, giving patients their focused attention, and asking how their prosthesis will help them feel confident.

a

data focused on women with limb loss, clinicians and researchers look to fill the gaps in understanding and implement technologies that accommodate the specific needs of women

Identifying Gaps

Littman is part of a team conducting three grant-funded investigations into the needs of female veterans. The first study, “Voices of Women Veterans With Lower-Limb Loss: A Qualitative Study,” explored the needs and care of 30 women veterans with lowerlimb amputation who previously been prescribed a prosthesis at the VA.

They launched their studies because “women in general are under-represented in amputee research—it’s not just within the VA,” says Littman, who has been involved in VA research for more than 16 years. “In many of my studies, no women, or very few women, were included,” she explains. “If you’re not intentional about reaching out to women amputees, you won’t get enough feedback. So there’s still a risk that devices are being developed mainly for men.”

The paucity of research into women’s needs has been a detriment to the advancement of O&P, agrees Nicole R. Walker, MS, CPO, a researcher at the Minneapolis VA Health Care System and doctoral candidate at the University of Minnesota Twin Cities. “Due to various federal regulations, women and minorities were long excluded from medical research. And while these regulations have changed, women continue to make up only a very small proportion of participants in O&P research,” she says. “To address this issue, it is important that we prioritize the inclusion of

women-identifying participants in our research studies. This can be accomplished by requiring that potential participants who identify as women be included in a study, or via targeted recruitment of women-identifying participants.”

Walker points to three studies (by Hirsh et al., Singh et al., and Katon and Reiber) that have some key differences in the experiences of women with amputations when compared to men. “Women experience greater amputation-related pain, greater time to successful prosthesis fitting, and higher rates of prosthesis rejection relative to men with amputations,” notes Walker. “The small sample of women with amputations historically included in O&P studies likely means we don’t fully understand the unique needs of women with amputations.” Like Littman, Walker is part of a research team seeking to fill this void. Her team is studying gaps in understanding and implementing technologies that accommodate the specific needs of women with amputations.

When Looks Matter

As research identifies areas of focus when treating women with limb loss, clinicians will be better able to meet their patients’ needs, especially for device aesthetics.

For April Mitskewicz, CP, one patient in particular comes to mind when considering the female perspective. Mitskewicz, clinic manager at Hanger Clinic in Marietta, Georgia, has been working with a patient who was born with proximal femoral focal deficiency for almost 20 years. “Her limb presents as a very long transfemoral, longer than the knee center on her sound side,” explains Mitskewicz. As a teenage girl, when being fit with external joints and check straps, the patient “wanted to look ‘cute’ in her prosthesis, and she was not feeling like that at all.” Mitskewicz changed the patient’s socket design to an expandable wall to avoid lengthening the upper section any further than it needed to be, and switched her to a four-bar polycentric knee. In later years, she added an adjustable heel. Now, her prosthesis gives her more confidence: “She lights up a room when she walks in,” says Mitskewicz. “It was a game changer for her. She is one of the most confident women that I have the pleasure of knowing.”

Research supports the importance of Mitskewicz’s decision to consider the cosmesis of prostheses when treating women. A key takeaway from Littman’s VA study is that clinicians and device developers should consider how a prosthesis looks, as well as what it needs to do.

Alyson Littman, MPH, PhD

Nicole R. Walker, MS, CPO

April Mitskewicz, CP, believes it’s important to provide personalized care, and to consider the cosmesis of prostheses.

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prosthetic needs, and, at times, the expec tations of their device do not align with the capabilities of currently available prosthetic solutions, often leading to general dissatisfaction with their care,” explains Matty Major, CPO, PhD, another researcher studying women’s prosthetic needs. Major is an associate professor of physical medicine and rehabilitation and biomedical engineering at Northwestern University, and research health scientist at the Jesse Brown VA Medical Center. He has published on the importance of considering the needs of women prosthesis users, among other topics.

Mitskewicz notes that it’s not just women patients whose expectations must be considered. “I want to know what makes my patients— regardless of gender—confident if they will be exposing their

Inclusive Patient-Care Tips

Treating all patients—regardless of their gender or how they identify—fairly and compassionately is important, says April Mitskewicz, CP, clinic manager at Hanger Clinic in Marietta, Georgia. “I want all of the patients I see to be as comfortable as possible with the care they are receiving,” she says.

She offers several tips for ensuring positive interactions with patients during facility visits:

• “To ensure a prosthesis fits properly, we as clinicians need to be able to feel and assess our patient’s anatomy,” Mitskewicz says. “I always ask if it’s OK before I touch a patient, and I explain what I am going to do before I start.”

• Make sure patients are comfortable by giving them your focused attention, Mitskewicz suggests: “Sit with them and talk. Put your computer to the side—I don’t even bring mine into the room.”

• If you are treating an opposite-gender patient who will need highly involved casting, ask if they would be more comfortable having someone else in the room at the same time.

• Try to determine what will boost your patient’s self-image: “Ask them, ‘How will this prosthesis make you feel confident?’ The answer might be a cover or a special finish on a lamination,” Mitskewicz says.

device,” she says. For example, “if they are going to an event and want to wear a dress or a suit, how they want to look when wearing shorts, or if they plan to wear leggings and want that shape to look symmetrical. There are times that people want the attention on them, and not on their prosthesis.

“Through the years, I have had several patients who say they feel exposed when their limb is not covered,” Mitskewicz adds. “That could make them feel a bit vulnerable, so I always take extra care in checking in with them verbally during the appointment and making sure they are comfortable.”

More Footwear Options

Much of the latest O&P research impacting women has focused on footwear considerations—a hot topic for women with lower limb loss. “Our biggest topic for female-identifying patients who use lower-limb devices is adjustability in shoe wear—being able to go from flats to sneakers, to boots, to high heels,” explains Mitskewicz.

April Mitskewicz, CP

Matty Major, CPO, PhD

Mitskewicz works with a patient at Hanger Clinic in Marietta, Georgia.

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Perspective From a Female-Run Facility

For some women, seeing female clinicians can be comforting. A recent survey from PartnerMD found that, among women, 46% prefer a female doctor.

At the Farmington Hills location of Wright & Filippis, patients always see female clinicians—as the office is fully staffed by women, including four clinicians and three office staff. Amy Webb, CPO, clinical manager of the facility, says that some other locations of Wright & Filippis send female patients to her location when their patients request women clinicians.

Webb believes it’s important to engage with patients and listen to their needs, regardless of gender. However, for certain types of patients, female clinicians may be more understanding—for example, patients with above-knee limb loss for whom gynecological issues may affect socket fit.

“The second biggest topic is having the sandal toe on their feet, to open even more footwear choices.” She notes that clinicians must learn what’s important to their patients, “and check off as many boxes as you can with the foot you choose.”

More footwear options do exist today than a decade ago, but researchers at the VA recognize the need for further expanding prosthetic options to accommodate a variety of shoes.

There is “a series of heel-height adjustable prosthetic feet that are commercially available, and their function during gait is similar to common dynamic response feet,” says Major, who was part of a study published in January on this topic. “Making these solutions more affordable and accessible will help address the challenge women with limb loss experience. Current research is focusing on alternative prosthesis designs that can achieve this goal of footwear accommodation—but through less expensive technology to expand accessibility.”

The January study, which was led by Elizabeth Russell Esposito, PhD, found that the option to wear desired footwear “may be an important part of community reintegration after lower-limb amputation.” After interviewing 100 women veterans on perceived challenges, types of footwear used, and preferences, Esposito, Major, and their team concluded that “women who have greater issues with how their prosthesis affects the shoes and clothing they can wear also have poorer body image, reduced functional capabilities, and lower reported participation in activities.” They noted that “improved prosthetic foot design may help to improve social participation and other important outcomes for women prosthesis users.”

Walker and her team also have spent time investigating prosthetic feet—which she labels “the greatest shortcoming in lower-extremity prosthetics.” Says Walker: “Most commercially available prosthetic feet are designed to function with only a single

She also notes that patients who are the primary caregivers to children may require tailored components, depending on their daily routines with their children—for example, devices that aid in getting down on the floor to play with children, or that facilitate lifting heavy toddlers.

For some pregnant patients in particular, female clinicians—particularly those who have had children themselves—may help patients feel “seen.” “You’ll need to think about weight gain and allow for volume change in the residual limb,” says Webb. “And make sure the foot is weightrated appropriately,” as pregnant patients gain weight. These patients will likely require extra appointments as their bodies undergo rapid changes.

shoe heel height. If a lower-limb prosthesis user deviates from this heel height, the prosthesis becomes misaligned and may cause problems, including pain and instability for the user.” Current feet preclude prosthesis users from changing shoes to those of taller or shorter heel heights, such as high heels, snow boots, sandals, or cowboy boots, according to Walker. While some heel-height adjustable feet are currently available within the O&P market, “these feet only accommodate about a 2- to 2.5-inch heel and do not accommodate the shape of the sole of the shoe,” she says.

Walker’s team at the Minneapolis Adaptive Design and Engineering Program has developed a modular ankle-feet system incorporating an ankle unit and 3D-printed foot shapes that will improve footwear options. The next step will be to implement this device with women veterans to understand how improved footwear options may influence body image and participation. “We hypothesize that increased footwear options will positively impact body image and ability to participate in important life roles and activities,” Walker says.

In another new study, Major’s team found that while the basic function of heel-height adjustable prostheses has not changed much since their conception, the currently available commercial devices can adequately accommodate a large range of footwear. These adjustable prostheses also help encourage healthy biomechanics by minimizing gait compensations that might occur from swapping different footwear on the same prosthesis that cannot accommodate their alignment. “Healthy walking mechanics is critical for women, as they have a higher prevalence of some secondary musculoskeletal conditions than men,” he says. “While perhaps not surprising, our research suggests a health risk to walking with prostheses that are not aligned properly to footwear, and therefore swapping shoes is undesirable. Importantly, we also observed

Amy Webb, CPO

the importance of taking into consideration the individual walking mechanics of women with leg amputation when prescribing, fitting, and aligning their prosthesis, emphasizing the need for personalized rehabilitation interventions.”

Preferences and Choices

In addition to footwear considerations, some patients—and clinicians—would like to see additional improvements in other componentry for women. For starters, many patients would prefer lighter devices. “Many prostheses are very heavy,” Littman says. She recommends that manufacturers “think about designing for smaller people, with less muscle mass.”

In feedback from Littman’s research, “what we heard from women is that [their prostheses] did not always function as they needed them to function; women and men have different functional needs,” she says. “There were also assumptions that women were only interested in cosmetic factors,” rather than functional factors— for example, options that would allow users to hunt and fish. “A key takeaway is that providers need to talk to the patient, whether they are male or female, and listen to what they want and need to do.”

Mitskewicz would like to see devices with a lower profile. “For lower-limb prosthetic devices, some of the concerns I frequently address include the bulkiness of devices under jeans, the trimlines showing through, the lift of an above-knee socket, and the lack of coverage for adjustable heels and protective skins.” She suggests that practitioners spend time ensuring trimlines are more comfortable while sitting, standing, and walking. “Try to make those trimlines as smooth and close to the limb as possible to be both discreet under clothing, as well as reducing wear on their clothes.”

For upper-limb patients, cosmesis should be a priority, Mitskewicz adds. “A common concern is the lack of skins for multiarticulating terminal devices, which patients may want to be discreet at times while still being functional,” she says. “It would be beneficial if payors understood that avocations are as important as vocations, and that cosmesis means social acceptance, not just a way to protect components.”

Walker suggests that companies and providers prioritize prosthesis components that allow for individual expression—for example, by adding a cover or providing prosthetic feet that allow users to more readily change footwear. “I believe we will continue to see prosthesis innovations targeted at encouraging self-expression, in turn increasing user confidence and participation in important roles and activities.”

Of course, self-expression should be available to all patients: “While our research seeks to address the needs of women with amputations, as this population has historically been underrepresented in O&P research, we strongly believe technologies that improve body image and expression should be available to people of all gender identities,” says Walker. “Participation in meaningful life roles and activities is an important indicator of community integration following amputation, and it is essential that providers hear the needs of prosthesis users and support their participation.”

The bottom line, says Major, is that women’s long-term health and well-being will be positively impacted by considering women’s prosthetic needs in relation to accommodating their desired lifestyle and how their limb loss affects perceptions about themselves, functional abilities, and participation in daily activity.

Christine Umbrell is a contributing writer to O&P Almanac

Reach her at cumbrell@contentcommunicators.com

Editor’s Note: Recommended Reading

The following research is referenced in this article and was published with the goal of identifying and meeting women’s prosthetic needs:

Erbes, CR, et al. “Amputation-Specific and Generic Correlates of Participation Among Veterans With Lower-Limb Amputation,” PLoS One. 2022; July 7.

Hirsh, AT, et al. “Sex Differences in Pain and Psychological Functioning in Persons With Limb Loss,” Journal of Pain. 2010; Jan, 11(1):79-86. doi: 10.1016/j.jpain.2009.06.004.

Katon, JG, et al. “Major Traumatic Limb Loss Among Women

Veterans and Servicemembers,” J Rehabil Res Dev. 2013; 50(2)173-182. doi: 10.1682/jrrd.2012.01.0007.

Kent, JA, et al. “Effects of Footwear on the Gait Kinematics of Women With Unilateral Transtibial Amputation: An Observational Case Series,” Disabil Rehabil. 2023; Jan 45(2):322-329. doi: 10.1080/09638288.2021.2022782.

Lehavot, K, et al. “Voices of Women Veterans With Lower-Limb Prostheses: A Qualitative Study,” J Gen Intern Med. 2022; Sept. 37(Suppl 3):799-805.

Major, MJ, et al. “Effects of Women’s Footwear on the Mechanical Function of Heel-height Accommodating Prosthetic Feet,” PLoS One. 2022; Jan 24;17(1): e0262910. doi: 10.1371/journal. pone.0262910.

Major, MJ, et al. “Focusing Research Efforts on the Unique Needs of Women Prosthesis Users,” J Prosthet Orthot. 2021; Jan 8; Online first:10.1097.

Russell Esposito, E, et al. “Footwear Limitations in Women Prosthesis Users Relate to More Than Preference,” Prosthet Orthot Int. 2023; Jan 5.

Singh, R, et al. “Gender Differences in Amputation Outcome,” Disability Rehabilitation. 2008; 30(2):122-125. doi: 10.1080/09638280701254095.

Park Project

Oregon prosthetist helped return a tree feller—and transhumeral amputee—to his job at Yosemite

In each issue of O&P Almanac, the Transformations column features the success story of an O&P clinician who has worked with an inspiring or challenging patient. This month, we speak with MacJulian “Mac” Lang, CPO, FAAOP, who helped Austin Anderson return to his job as a tree feller.

MacJulian “Mac” Lang, CPO, FAAOP, never imagined he’d need to transport a tree trunk to the parking lot of his patient-care center in Portland, Oregon. But that’s exactly what happened after he began working with Austin Anderson, a tree feller at Yosemite National Park, who needed a safe and effective above-the-elbow prosthesis.

Anderson used the tree trunk to test the device Lang created to enable him to use a chain saw and return to work.

Anderson had come to Lang for assistance after being turned away by two other prosthetists who practiced closer to his home in eastern central California. A few months after landing his “dream job” at Yosemite, Anderson was injured while

MacJulian “Mac” Lang, CPO, FAAOP

helping a friend cut down a tree; he ended up with a partially severed left arm, which eventually had to be amputated above the elbow.

Anderson loves the great outdoors and enjoyed his highly physical job as a tree feller, so his highest priority when researching prosthetic facilities was to find a clinician who could help him get back to operating a chain saw safely. After the prosthetists he saw in California indicated they couldn’t help him meet that goal, Anderson sought out Lang, clinical manager at Arm Dynamics’ Northwest Center of Excellence in Oregon.

Prepared for the Challenge

In many ways, Lang was the perfect prosthetist to assist Anderson in his quest for an appropriate transhumeral prosthesis. Lang graduated from Cornell University with a bachelor’s degree in mechanical and aerospace engineering, and worked as an O&P technician before attending the O&P program at California State University, Dominguez Hills. During his first few years treating prosthetic patients, he started to develop an upper-limb specialty—but he saw relatively few upper-limb patients because that population is much smaller than the lower-limb population.

Then Lang began working at Arm Dynamics, which specializes exclusively in upperlimb prosthetic rehabilitation. He was one of the prosthetists who treated service members and veterans under a contract with Walter Reed National Military Medical Center. In doing so, he gained an immense amount of experience working with combat-wounded service members—individuals who were generally young, physically active, and highly motivated. “That changed how I viewed prosthetics and what was possible in returning to function,” Lang says. Many of those patients “pushed boundaries” and sought durable, creative, highly functional solutions.

By the time Anderson entered his facility, Lang and his team had become known for “pushing the envelope” to create individualized solutions that allow patients to return to activities they love. “We practice team care,” says Lang. “A prosthetist, technician, and clinical therapy specialist work together to address the patient’s needs.” He and

technician Cullen Hays have collaborated on the design, fabrication, and customization of every prosthesis since the center opened in 2008.

Upon meeting Anderson, Lang and his team noted several challenges in designing an appropriate device. First, Anderson had a very long transhumeral presentation. “This is challenging for fitting, because of lack of condyles needed for a supracondylar suction suspension that you can get really creative with,” he explains.

Second, Anderson needed a prosthesis that would allow him to work a heavy chain saw safely, engage in other heavy lifting and physical movements while on the job, carry all of his equipment, and even ride a donkey.

Fortunately, Anderson was “eager and motivated” to get back to work, says Lang. During the initial evaluation, Anderson described how he would need to be able to use the prosthesis on his left side to grab and stabilize the saw while using his right arm to run the trigger; he also needed to be able to drop and release the chain saw very quickly in case a tree fell unexpectedly. Lang also considered that Anderson would

be wearing the prosthesis between 12 and 16 hours per day, and would be hiking up to 10 miles a day in the woods while wearing the prosthesis.

Lang, who grew up in Alaska, says, “I knew how to run a chain saw—but I had never felled a big tree.” So, he did some research and discovered that several adapters had already been developed to use with chain saws. However, the available versions were either physical attachments to the chain saw or designed in such a way that it takes too long to detach the chain saw from the prosthesis. “Cutting down dead wood on trees that can be rotten” can be a potentially deadly situation if a chain saw gets pinched or trapped by the weight of a tree, explains Lang. “Safety is paramount,” so he needed to get creative with a quick-release feature that would allow Anderson to disengage and run away from a falling tree without hesitation.

After many hours above-and-beyond what might be expected in typical prosthetic patient care, and “a lot of iterations, prototyping, and improvements,” Lang and Hays designed an above-the-elbow body-powered prosthesis, with a Vari-Pinch

Austin Anderson sought a transhumeral prosthesis that would not only enable him to run a chain saw, but also to traverse Yosemite National Park on foot or by donkey.

Prehensor hook (V2P) from ToughWare and a custom chain saw adapter. A JAWS terminal device from TRS was added later. Those components were paired with a roll-on silicone liner to help with suspension. Finding the right components, which were strong and quick-release, “allowed us to be confident and aggressive in our treatment,” says Lang.

Describing the final version of the prosthesis, Lang notes it includes a “big trigger on the back that can immediately disengage. We refined the terminal device a lot to make sure it really meets his needs.”

Lang and his team spent many hours working with Anderson both inside the center—carrying heavy weights with the prosthesis to prepare him for work at the park—and outside in the parking lot, using the prosthesis to practice holding a chain saw and cutting through a tree trunk. “We made sure he was prepared” for the many challenges associated with the work responsibilities of a tree feller at a national park.

Using his new prosthesis, Anderson was able to return to his job, “living the dream” in Yosemite as one of only two tree fellers. “Now I’m capable of safely running a chain saw to continue to do what I love,” says Anderson. “This is only because I had a team who supported me and created the right prosthesis for my arm.”

But Anderson’s story doesn’t stop there. He recently left his job at Yosemite to become a certified arborist, where he continues to use his prosthesis and chain saw. He has a primary prosthesis as well as a backup, older version to use in case the primary is in need of repair. “If he absolutely needs his prosthesis for work, it’s unrealistic to think he won’t need a backup on occasion,” explains Lang. The prosthetic care team trained Anderson to do minor repairs on the device. “If he’s on a 10-mile hike from his car and a cable breaks,” he can fix it himself.

Quality Care, High Confidence

Lang is glad he was able to help Anderson return to function and return to the work he loves so that he can earn a living. He believes Anderson made the right choice to seek out a provider who specializes in upper-limb care, especially as he had such

a specific—and potentially risky—need.

“It’s a scary thing to provide someone with a prosthesis that allows them to do something dangerous,” says Lang. “If you’re not confident” as a prosthetist in treating such a unique patient, “then you shouldn’t do it.” Because Lang’s facility is laser-focused on upper-limb prosthetic solutions, he and his team were able to find the right solution. “Our patients have high expectations. Patients challenge us because they expect more. Sometimes we have unique design challenges— but we can design, prototype, and work with manufacturers to come up with solutions,” he adds. “That’s the fun part of prosthetics.”

Lang and his team also invest time and resources to help ensure patients continue to wear their devices. Within the upper-limb prosthetic patient population, prosthetic abandonment can be a problem, with many patients deciding not to use their devices. “We can’t ensure someone wears their prosthesis,” Lang acknowledges, but he believes that designing patient-specific solutions facilitates patients wanting to use their customized devices.

When it comes to getting prosthetic care approved by payors, the team at Lang’s center works closely with Arm Dynamics’ national justification and authorization team. They encourage patients to become self-advocates by speaking directly to their insurance providers about why they need a specific sort of prosthesis. The reality is

that O&P patient care requires that both healthcare professionals and their patients advocate for their needs, according to Lang. This is an important endeavor, he says, because many patients need their prostheses to return to work. For example, “if we couldn’t provide [Anderson] with a prosthesis that returned him back to work,” then he wouldn’t be able to provide for himself, says Lang. “So, we need to teach patients to advocate for themselves with insurers and to get referring physicians to help advocate for the device that’s recommended.

“The resilience of patients is a huge factor in how successful they will be,” adds Lang. “Patients that are dogged and that advocate for themselves, patients who want second opinions, that have a drive to make things work—that’s all a huge part of their success.”

Lang says his experience working with Anderson was truly transformational. “He really wanted to go back to work because he loved it,” says Lang. “There was immediate gratification to provide him with a prosthetic solution—and a clear indication of the impact of our care.”

DO YOU HAVE A TRANSFORMATIVE PATIENT-CARE EXPERIENCE YOU’D LIKE TO SHARE WITH O&P ALMANAC READERS? Contact Editor Josephine Rossi, jrossi@contentcommunicators.com, with your story to be considered for an upcoming profile.

MacJulian “Mac” Lang, CPO, FAAOP, and technician Cullen Hays designed an above-elbow body-powered prosthesis with a quick-release feature to allow Anderson to disengage quickly.

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Destination Prosthetics

Patients travel from across the country for a week-long fitting protocol in Virginia

For patients of the Prosthetic Care Facility of Virginia, distance is no barrier to treatment. Individuals fly in from around the country— and even overseas—to consult with John Hattingh, CP, LPO, CPO(SA), who specializes in prosthetic problem solving. “Many of my patients have seen multiple prosthetists and still can’t walk successfully,” says Hattingh. “I manage to find the actual problem, and I have had a 100% success rate.”

Hattingh grew up in South Africa and trained with Ottobock in Germany. He was a biomechanical engineer and a prosthetist, mastering skills that serve him well as he treats patients. Hattingh immigrated to the United States in 1990 and worked as a clinical prosthetist in Seattle, where he also attained adjunct staff status at the University of Washington. He opened his own facility and remained in Seattle for 25 years, until he and his wife, Michele, decided to move to a warmer, drier climate.

Hattingh sold his practice to a large, national firm and moved back to Capetown, where he and Michele did philanthropic work for three years. They returned to the U.S. about 10 years ago, opting for the East Coast. Hattingh opened Prosthetic Care Facility of Virginia in Leesburg, Virginia, in 2013. “Except for the climate, it doesn’t matter where I’m located, as long as I’m near an airport, since so many of my patients travel to see me,” Hattingh explains. His facility is truly a family affair: Hattingh is the sole practitioner; Michele administers the practice; their son fabricates devices; and their daughter-in-law handles front-office duties.

The facility specializes in high-level patients, and Hattingh has implemented a “destination prosthetics program” that includes local accommodations for patients who travel. Patients begin the program on a Monday, which includes a full evaluation and the start of treatment, which can last until 7 or 8 p.m. They return every afternoon for fittings and modifications until treatment is finalized at the end of the week.

“We make sure patients are comfortable and functional, and they fly home on Saturday,” says Hattingh.

The high-tech facility is equipped to handle a diversity of cases, including above-knee amputations, hip disarticulations, and hemipelvectomies, as well as transtibial amputations. Hattingh stocks high-end components, including a wide range of electronic knees, to allow patients to trial different devices.

The facility occupies 4,800 square feet, with a large room in the middle for gait training and other activities. A GAITRite gait mat provides data on how the patient is walking, including weight distribution, step and stride length, and speed. Hattingh and his team test patients’ gait throughout the week to establish variable cadence, ascension, descension, and other movements. The goal is to design a prosthesis that is “as human as possible” by creating symmetry and optimal alignment. “Some have no symmetry when they come in, and our focus is to get them completely symmetrical. That’s how we measure the outcome.” He also assesses patients’ functional goals to ensure they can return to activities they enjoy.

While in town, patients have use of a gym, which allows them to build strength and practice particular movements on various machines. Hattingh sometimes refers patients to a local physical therapist to assist with muscle tone and core strength development.

Some of Hattingh’s success stories include a patient from Poland who couldn’t walk but is now able to hike and ride a trail bike, and a hemipelvectomy patient who was unable to walk, but after treatment became a runway model. Another patient from Britain who wanted to participate in fun runs was running stepover-step on her second day in the facility.

Above all, Hattingh delights in getting patients back to being fully functional members of society. “That’s huge for them,” he says, “and for me.”

Deborah Conn is a contributing writer to O&P Almanac. Reach her at deborahconn@verizon.net

Prosthetic Care Facility of Virginia specializes in prosthetic problem solving and strives to ensure patients can walk successfully.

FACILITY: Prosthetic Care Facility of Virginia

OWNER: John Hattingh, CP, LPO, CPO(SA)

LOCATION: Leesburg, Virginia

HISTORY: 10 years

John Hattingh, CP, LPO, CPO(SA), and Michele Hattingh, office administrator

HISTORY: Eight years

Software Solutions

Ohio company offers a cloud-based system to streamline O&P practice management

Information technology specialist Josh Lau, chief executive officer and founder of Nymbl Systems, happened upon the O&P profession when a client asked him to find new management software for his O&P practice. Lau conducted intensive market research among orthotists and prosthetists to gain an understanding of their needs. When he couldn’t find software that addressed all of these needs, he opted to develop a solution. Lau found investors to get his fledgling company off the ground, launching Nymbl Systems in 2015. He hired Chad Feinberg, co-founder and chief operating officer, soon after, and brought on additional team members to refine the software with new technologies and coding languages, which enabled nearly instant updates and faster scaling from the original version.

Nymbl began serving customers in 2017; six years later, the company has nearly 30 employees, located in Columbus, Ohio, and throughout the country. Its customer base has more than doubled since then.

Nymbl Systems is 100% cloud-based, allowing users to access its features from any screen with an internet connection: computer, tablet, or smartphone. Its billing system is integrated with Waystar, a cloud-based technology platform that allows its customers to access real-time eligibilities; it also enables companies to automatically pull in patient payments.

Nymbl’s software includes a standardized workflow module with customizable alerts for multiple users. The system manages each patient from the moment they check in through assessment, device production, fitting, and follow-up. It automates many purchasing and inventory tasks, includes direct scan functionality, and offers business intelligence analytics. Other features include automated appointment reminders through email and text, integrated Outlook and Gmail calendars, customizable forms, and the ability to create fabrication templates and track device development. O&P facilities can email or text medical history forms to patients so they can be completed prior to their appointments, in a secure manner.

Feinberg says the solution is extremely accessible: “We can get the system up and running in less than seven hours of training and fewer than 30 business days to full implementation,” he says. The company offers a customer support team as well as a customer success team that reaches out to customers to head off problems.

The company prioritizes word of mouth to market its product. In addition, Sami Shilling recently joined the company as demand generation manager to focus on lead generation efforts. She oversees marketing efforts such as email campaigns, social media presence, webinars for current and prospective customers, and conference and tradeshow exhibits.

Nymbl emphasizes social responsibility, requiring employees and the management team to engage in charity work every quarter. “We have a list of every community where our employees are located and opportunities for service in each one,” says Feinberg. “One of our longer-term goals is to partner with some of our local customers in the Columbus area to better serve our community.”

The company continues to solicit feedback from the O&P profession and modifies the system in response to customers, according to Feinberg. Nymbl releases new software features on a monthly basis, all based on feedback and suggestions from customers.

“O&P practice management software is behind similar systems you see in healthcare, and these healthcare systems are behind the rest of technology,” notes Feinberg. “Our goal is to bring O&P practice management in line with existing tech capabilities. We add features like patient portals, omnichannel messaging with patients, Gmail and Outlook calendar integrations, and other capabilities that are not yet present in the O&P arena.

“Our customers are really good at running O&P businesses; we are really good with software and technology,” Feinberg adds. “Our mission is to mesh the two and make Nymbl the go-to for billing and business management in the O&P space.”

Founder and Chief Executive Officer Josh Lau

COMPANY: Nymbl Systems

OWNERS: Josh Lau and Chad Feinberg

LOCATION: Columbus, Ohio

Nymbl Systems, which has grown to nearly 30 employees, offers a cloud-based billling and business management solution.

Co-Founder and Chief Operating Officer Chad Feinberg

Deborah Conn is a contributing writer to O&P Almanac. Reach her at deborahconn@verizon.net

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Stay up to speed on all of the rules and regulations for 2023— join AOPA’s regulatory staff and guest speakers for the 2023 monthly webinar series.

Webinars provide relevant content and the opportunity to earn 1.5 continuing education credits each month. They are a great way to promote team building, providing an opportunity for your staff to come together and refresh their skills. One registration provides access for five staff members at your office location. (Contact Kristen Bean at kbean@AOPAnet.org to register more than one person from your facility— maximum of five per facility.)

New this year, and in response to feedback on preferred ways to access the webinars, all 2023 webinars will be available on demand (asynchronous) instead of live. Topics will be announced at the beginning of the month, and the webinars will be automatically delivered to AOPAversity accounts by the end of the month—then remain available. The popular Clinician’s Corner session will be featured in several webinars.

The January webinar, Standard Documentation Policy Article Review, and the February webinar, Urban Myths, are available now. The March webinar will be available soon.

The full-year series is $790 for AOPA members—a great value at 12 for the price of 10! Nonmembers may purchase the series for $1,999. Individual webinars may be purchased at $79 for AOPA members and $199 for nonmembers.

Call for Papers

Submit Your Proposal by March 31

Register for the series at My AOPA Connection. You also may register for single topics. Note that AOPA experts and guest speakers will be available to answer questions should they arise after you view the webinar. Contact AOPA’s experts with suggested webinar topics or questions: Email jmcternan@aopanet.org or dbernard@aopanet.org

Don’t Miss the AOPA Policy Forum

May 10-11 | Washington Marriott Capitol Hill | Washington, DC

Join forces with other O&P professionals to advocate on behalf of the profession—and your patients! The Policy Forum is your opportunity to learn about the latest legislative and regulatory issues and how they will affect you, your business, and your patients. Don’t miss this chance to educate members of Congress about the importance of O&P care for patients living with limb loss/difference and limb impairment. Visit the AOPA website for details.

Share your knowledge and expertise with attendees at the 2023 National Assembly in Indianapolis in September! Submit your proposal to the appropriate Workgroup: Clinical Education, Business Education, Postmastectomy Education, Technical, Technical Tips and Tricks, or Digital O&P Care. Visit the AOPA website for details, and plan to submit your proposal before the March 31 deadline.

SAVE THE DATE

SEPTEMBER 6-9

Mark your 2023 calendar now and start making plans to travel to Indianapolis September 6-9 for the 106th AOPA National Assembly! Visit AOPAassembly.org

Welcome New AOPA Members

The officers and directors of the American Orthotic & Prosthetic Association (AOPA) are pleased to present these applicants for membership. Each company will become an official member of AOPA if, within 30 days of publication, no objections are made regarding the company’s ability to meet the qualifications and requirements of membership.

Ypsilon® FLOW ½ & ToeOFF® FLOW 2 ½

FLOW AFOs are Allard’s newest generation of AFOs fabricated with a new proprietary formula. This proprietary formula offers increased ROM in the sagittal plane and smoother transition (flow) throughout the gait cycle. The footplate is shaped to allow more clearance for the forefoot in the shoe toe box. Plus, both Ypsilon® FLOW ½ and ToeOFF® FLOW 2 ½ are designed to accommodate lower shoe heel heights, fitting more shoe styles. For more information call 888-678-6548 or email info@allardusa.com. Request your FREE Magnetic Level!

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%! 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.

Mecuris Solution Platform

Mecuris provides CPOs with a flexible software that enables them to design individual orthoses and prostheses online. The software is provided on the web-based Mecuris Solution Platform. It will help streamline a clinic’s business for the best patient care possible. The lean structured tools and functionalities can be used free of charge. In the Free Plan, five downloads/month are included as well.

See how to best combine traditional with digital workflows in a free webinar while earning CEUs in the process. For more information, go to www.mecuris.com/en

Naked Prosthetics

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 wearesp.com

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 are available in a dozen color coatings to match our wearers’ preferences and styles. To learn more, visit npdevices.com

Skeo Unique Custom Liner: The Right Solution Is Unique

Unique Liners from Ottobock are highly customized, so you can achieve innovative fitting results. The silicone Skeo Unique custom liner is recommended when high stability and durability are required. This liner:

• Is appropriate for very conical or scarred residual limbs

• Stabilizes residual limbs, even those with significant soft tissue

• Skin-friendly silicone enables a superior connection with the residual limb

• Easy handling, easy cleaning.

Utilize the new Ottobock EasyScanner or the free Custom4U iPad app with a Structure scanner to digitally capture the limb. STL files from any scanner can be uploaded into our iFab Customer Center (iCC) for easy digital ordering without shipping casts.

Learn more at shop.ottobock.us

Uneo Unique Liner: There’s No One-Size-Fits-All When It Comes to Liners

Unique Liners from Ottobock are highly customized, so you can achieve innovative fitting results. The urethane Uneo Unique custom liner achieves an exact and comfortable fit, thanks to the extraordinary flow characteristics. Other qualities include:

• Polyurethane gel to cushion highly sensitive or scarred residual limbs

• Good pressure distribution within the socket

• Comfortable impact absorption

• Skinguard antibacterial or fresh scent options available.

Utilize the new Ottobock EasyScanner or the free Custom4U iPad app with a Structure scanner to digitally capture the limb. STL files from any scanner can be uploaded into our iFab Customer Center (iCC) for easy digital ordering without shipping casts.

Learn more at shop.ottobock.us

RUSH ROGUE 2

The RUSH ROGUE 2 provides an optimal vertical shock experience, axial rotation for improved comfort, predictable performance, ultimate fiberglass strength, and flexibility for daily life and high impact activities. And now, patients will no longer have to choose performance over SANDAL TOE availability. With the RUSH ROGUE2 & EVAQ8 models, patients can choose optimal performance with the freedom to express themselves in their preferred daily footwear.

Walk YOUR Way with RUSH Sandal Toe by PROTEOR. For more information, visit proteorusa.com

The Xtern Line: A Step Up for Foot Drop By Turbomed Orthotics

Turbomed has extended its line of AFOs to include three models: Xtern Classic, Summit, and Frontier. The Xterns will allow running, walking, and even hiking as long and far as you want without discomfort. Their unique design acts as an exoskeleton to the impaired limb, keeps the foot at 90 degrees, and provides the user with unparalleled levels of function.

The Xtern Summit is lighter than the Classic, has more dorsiflexion power, and features a see-through design. The Xtern Frontier was designed for patients with reduced hand dexterity and requiring front leg support. Visit turbomedusa.com, and think outside the shoe!

“I designed this composite to allow you to transition from plastic to composite thermoforming.”

GARY G. BEDARD, CO, FAAOP(D)

ProComp® Carbon-Infused Polypropylene Composite Composite Material Science = Improved Fabrication Processing = Enhanced Clinical Performance. ProComp® is produced in a high-pressure laminating process that infuses discontinuous carbon fiber into homopolymer propylene. The patented prepreg composite sheeting is compatible with standard drape-encapsulation or bubble vacuum thermoforming. Finishing techniques are standard. Four standard gauges are available for both orthotic and prosthetic applications. Eligible for double L2755 application in thermoplastic AFOs and appropriate prosthetic addition codes. For more information, visit fabwithprocomp.com. Contact Gary G. Bedard, CO, FAAOP(D), managing principal, Rhode 401 LLC, at 650-773-3730 or email garyb@fabwithprocomp.com

Contact Bob Heiman at bob.rhmedia@comcast.net

March 31

Deadline to Submit Proposal for AOPA National Assembly. Visit aopanet.org/2023-national-assembly

March 31–April 1

Ohio Chapter AAOP Meeting. Hyatt Regency Columbus, Columbus, OH. Visit ohaaop.attendease.com

April 1–30

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

April 13–15

Georgia Society of Orthotists & Prosthetists Annual Meeting. The Hotel at Avalon, Alpharetta, GA. Visit georgiaop.attendease.com

April 24–27

ISPO World Congress. Guadalajara, Mexico. Visit ispo-congress.com/en

May 5–6

Tennessee Society of Orthotics & Prosthetics Meeting. Nashville. Visit tennsop.org

May 10–11

AOPA Policy Forum. Washington Marriott Capitol Hill, Washington, DC. Visit aopanet.org

May 12

Kentucky Orthotic & Prosthetic Association Meeting. Castle & Key Distillery. Frankfort, KY. Visit kyopa.net

May 17–19

New York Chapter AAOP Annual Meeting. The Rivers Casino & Resort, Schenectady, NY. Visit nysaaop.com

Orthotic & Prosthetic Innovative Technologies Minneapolis. For updates, check our cme@gilletteto be added to conference mailing list.

June 23–24

PrimeFare East. Nashville Renaissance Hotel and Conference Center. In-Person Meeting. Contact Cathie Pruitt at 901-359-3936, pruittprimecare@gmail.com; or Jane Edwards at 901-487-6770, jledwards88@att.net. For more information, visit primecareop.com

July 27–29

Alabama Prosthetic & Orthotic Association Meeting. Birmingham, AL. Visit alabamapoa.org

August 24–26

Texas Society of Orthotic & Prosthetic Professionals Meeting. San Antonio. Visit txsop.org.

November 8–10

New Jersey AAOP Annual Meeting. Harran’s Resort, Atlantic City, NJ. Visit njaaop.org

September 6–9

AOPA National Assembly. Indianapolis. For more information, visit aopanet.org

AOPA Monthly Webinar Series— Now On Demand!

January: Standard Documentation Policy Article Review

February: Urban Myths

Full-year series: AOPA member $790; Nonmember $1,999

Individual webinar: AOPA member $79: Nonmember $199 Register for the series at My AOPA Connection

Share Your Calendar Event

Advertise O&P events for maximum exposure with O&P Almanac Contact Bob Heiman at bob@rhmedia.comcast.net or learn more at bit.ly/23AlmanacMediaKit. Announcement and payment may also be sent to O&P Almanac, Calendar, P.O. Box 34711, Alexandria, VA 223340711 or emailed to 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.

Moving Right Along

Several states are considering So Kids Can Move legislation

So Kids Can Move, the state-level policy initiative spearheaded by AOPA, the National Association for the Advancement of Orthotics & Prosthetics (NAAOP), the American Academy of Orthotists and Prosthetists, and the Amputee Coalition that seeks to introduce legislation mandating coverage of activity-specific O&P devices, has seen great strides during the 2023 legislative session. Here’s a quick update on the action taking place in statehouses across the country.

Arkansas

House Bill (HB) 1252, introduced by Rep. Lee Johnson with the help of Francois Van Der Watt of Van Der Watt Prosthetics and Orthotics, mandates commercial coverage of two additional prostheses: one for physical activity, and another for showering or bathing. Van Der Watt is currently working with Johnson on providing testimony once the bill is heard in committee.

Colorado

After presenting at Rep. David Ortiz’s Disability Rights Conference in December 2022, the newly formed Rocky Mountain Orthotic and Prosthetic Coalition (RMOPC) has worked with Ortiz, Rep. Anthony Hartsook, Sen. Larry Liston, and Sen. Faith Winter to introduce HB 23-1136, which mandates coverage for an additional activity-specific prosthesis for enrollees in commercial plans under 26 years of age. As the first major policy initiative of RMOPC, the So Colorado Kids Can Move Committee will build a network of advocates to show support for the bill once it begins moving through legislative committees.

Indiana

As part of a larger effort to improve O&P access for Medicaid patients in the state, the Indiana Association of Orthotics and Prosthetics (IAOP) has assisted Rep. Harold Slager in introducing HB 1433, which requires that Indiana Medicaid cover an orthotic or prosthetic device that meets both activities of daily living and physical activity needs for patients 18 and younger.

IAOP’s efforts on the Medicaid front also include mandated orthotics coverage, a fee schedule increase to 100% of Medicare, and a Medicaid managed care organization payment floor—the last of which is in a separate bill, HB 1018.

New Hampshire

With the help of NAAOP President Maggie Baumer, State Bill 177, which implements both insurance fairness and mandated coverage of activity-specific orthotic and prosthetic devices for enrollees 18 and younger in state commercial plans, has been introduced in the New Hampshire Senate by Sen. Sue Prentiss. Noelle Lambert, founder of the Born To Run Foundation and past Paralympian and “Survivor” participant, provided additional support in this effort.

New Mexico

With the help of patient advocates Kyle Stepp and Callaway Lewis, along with Lewis’s mother, Laura, HB 131, which implements insurance fairness and mandates

coverage of an additional activity-specific prosthetic or orthotic device for all ages in state commercial plans, has been introduced in the New Mexico House of Representatives by Reps. Liz Thomson, Kathleen Cates, Joshua Hernandez, and John Block. Due to the age-inclusive nature of HB 131, the policy initiative has been styled “So New Mexicans Can Move.” Through grassroots efforts involving advocates from across the state as well as on-the-ground support from AOPA and the Amputee Coalition, the bill has seen overwhelming bipartisan support, passing through both House committees with unanimous approval. The bill will now move to the House floor for a vote by the full chamber.

For more information on these and other state developments, visit the AOPA Co-OP or contact Sam Miller at smiller@AOPAnet.org

O&P advocates visited the New Mexico capitol to advocate for HB 131.

A team of Indiana advocates testified and shared their stories to push for passage of HB 1433.

• Basic business acumen

• Practical knowledge to apply immediately to your work

• Techniques for developing better business practices

• How to think about improving your company’s returns

AREAS OF LEARNING

To complete the certificate program, you must register and complete one core course and one elective course from each of the four areas of learning within a four-year period

LEARNING CORE ELECTIVES

Healthcare Operations Healthcare Operations for

O&P

MANAGEMENT Increase

knowledge and skills to better manage multiple, individual, and team priorities.

HEALTHCARE SALES AND MARKETING Learn the functions of marketing along with a variety of tools and approaches to personal selling along with the many digital marketing tools available. 5

concepts and perspectives

Trust, Move, Live.

Since the introduction of C-Leg and its groundbreaking control technology, Ottobock has never stopped inventing new ways to take your patients as far as they want to go. With a portfolio including the Kenevo, Genium, X3, and now the latest iteration of C-Leg 4, every microprocessor knee supports a journey toward a limitless future.

Kenevo C-Leg 4 Genium X3

22

The Kenevo is designed specifically for users with mobility limitations who need a high level of stability. State-of-the-art technology allows users to feel safer and more independent in their everyday life.

An IP 22 rating protects from dripping water or dust.

67

The C-Leg 4 provides exceptional reliability and dynamically adapts to a wide variety of everyday situations. The legacy lives on with the new C-Leg 4 Update with over 10 new features including supported descent on ramps and stairs. The C-Leg 4 is easier and more intuitive than ever before.

An IP 67 rating provides protection from damage due to casual contact or temporary submersion in fresh water up to 1 meter for 30 minutes.

67

The Genium provides the highest degree of intuitive function to individuals who need to adapt to changing environments, move quickly over short distances, or require more than 2 days of battery life.

An IP 67 rating provides protection from damage due to casual contact or temporary submersion in fresh water up to 1 meter for 30 minutes.

The Genium X3 is the most durable, intuitive and technologically advanced microprocessor knee available. With features that support activities like running, swimming and ascending stairs step-overstep, X3 supports individuals who push the boundaries of mobility.

With an IP 68 rating, Genium also offers the highest level of water protection offered in a microprocessor knee.