May 2018 O&P News

MAY 2 01 8

THE ORTHOTIC & PROSTHETIC COMMUNITY NEWS SOURCE

What Do Physicians Think of O&P? PG.8 Open-Frame AFO Versus Total-Contact AFO in Patients With Spastic Equinovarus Secondary to Chronic Stroke PG.14 Three Brachial Plexus Injury Subjects’ Function After One(+) Year of Upper-Extremity Myoelectric Orthosis Treatment PG.19

Embracing Innovation

in O&P Business Operations PG. 4

O&P VISIONARY:

Ted Snell, CP PG. 24

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Tech Tips

Attention to Detail

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Vol. 27 • No. 5 | May 2018

Departments & Columns 26 State by State A monthly column dedicated to

8

the most important state and local O&P news.

30 Classified Ads 30 Ad Index 31 Meetings & Courses

COVER STORY

04

32 Tech Tips

19

Attention to detail is a critical component the fabrication process.

Embracing Innovation in O&P Business Operations O&P facilities can leverage the increasing amount of data collected at facilities to conduct in-depth reviews of financial work in progress, analyze trends related to new patient prescriptions, and capture outcome measure data—which is increasingly important as the health-care environment shifts to a fee-for-value model.

By Mark Brady

FEATURES

8

24 O&P Visionary Ted Snell, CP, discusses attention to patient rehabilitation and generating cost savings.

What Do Physicians Think of O&P? Physicians generally believe O&P clinicians are an important part of the care team and commonly refer patients who are poststroke or who have suffered trauma to orthotists, according to the results of a recent survey of physicians and physiatrists.

Research & Presentations 14

Relative Influence of Orthotic Support Features Within an Open-Frame AFO Versus a Total-Contact AFO on Function, Endurance, and Activity Level in Patients With Spastic Equinovarus Secondary to Chronic Stroke

19

Three Brachial Plexus Injury Subjects’ Function After One(+) Year of UpperExtremity Myoelectric Orthosis Treatment

By David R. Coleman, CPO, FAAOP

By Beatrice Janka, MPO, CPO, and Nicholas LeCursi, CO O&P News | May 2018

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COVER STORY

Embracing Innovation in

O&P Business Operations

4

O&P News | May 2018

COVER STORY

Over the past several years, the use of data has become commonplace in many orthotic and prosthetic practices. Discussions about the importance of outcomes measures and the transition to evidence-based practice have been on the top of all conference agendas. There also has been an increased focus on research to support prosthetic and orthotic intervention, both from cost-savings and quality-of-life perspectives.

While no one is questioning the impact that data analytics can have on the provision of O&P care, there is less discussion about the use of data on an operational level in the O&P practice. In the following article, Mark Brady, chief financial officer for Ability Prosthetics and Orthotics, shares three key strategies for embracing innovation in O&P business operations and using data analysis to better prepare for the evolving financial environment in health care.

O

ne way Ability Prosthetics and Orthotics has embraced innovation to better plan for the future is by incorporating data analysis into our management portfolio. We conduct indepth data analysis of our financial work in progress (WIP), which helps us identify trends and potential changes in the business earlier in the cycle. A few years ago, we started having our practitioners review their financial WIP and project which month they anticipate delivery for each claim. We then look at how accurate the projection was and evaluate which cases either moved up or slipped in the timeline and why.

The O&P business can be volatile due to a number of factors, including payor approval delays, resetting health-care deductibles, or simply the weather. Over time, we have built a database of this information, which has improved our accuracy in projecting billings for a given month or quarter.

This information allows us to make more informed decisions about when to hire, when to open a new office, or maybe even when to pull the reins back a little. This process also helps the practitioners to prioritize and manage their caseloads with greater efficiency as well as to improve their own forecasting skills, all of which results in higher revenue per employee and an increase in profitability.

We also conduct trend analysis around new patient prescriptions. For example, current billings may be light— but if new prescriptions over the past few months have been increasing, that is a leading indicator of increased billings in the next quarter. This helps us in projecting future revenues, but it also helps us better understand our referral sources and enables us to identify any referral sources that are growing or have decreased, helping us focus our educational and marketing efforts.

O&P News | May 2018

5

COVER STORY

The Importance of Data Analytics in the Changing Health-Care World

By Paul Prusakowski, CPO, FAAOP OPIE is dedicated to helping practices succeed by providing training in workflow and processes that leverage data for informed decision making. Practices should have a well-thought-out data strategy in order to measure and improve the critical success factors in their organizations.

New dashboards and analytics tools are being developed to give immediate access to powerful decision-making information that will help steer practices toward success.

We recognize that not every practice can afford to have high-level business managers as part of their company. The tools and training and our supportive user community help to bring very powerful tools to small business owners who were trained as clinicians, and who may not necessarily be as well versed in advanced business management processes such as data analytics. These skills are now requirements to remain competitive in the changing health-care world.

Paul Prusakowski is chief executive officer of OPIE Software.

There is a ton of really good information in OPIE that can help you better understand your business if you know how to leverage it. This in no way means we rely solely on the data in making business decisions—remaining patient-centric is at the core of our value system—but conducting targeted data analysis around these key trends is another tool in our kit we use to help us manage the business. In some cases, we could not get exactly what we wanted out of OPIE—for example, cost of goods sold and gross margin at the claim

6

O&P News | May 2018

level—but by combining some information from OPIE in Microsoft Excel with other information from our accounting system, we were able to create a new combined database and generate our own reports to better meet our business needs and give us much greater visibility into the business than we ever had before.

A third, and probably the most impactful, way we have adapted data to help better prepare for the future is capturing outcome measures. This may seem like just a clinical process on the surface, but we believe it actually has significant financial implications for O&P providers on the reimbursement front. (For in-depth information about collecting outcome measures data at O&P facilities, see “Measure for Measure” on page 30 of the March issue of O&P Almanac.)

The larger health-care market is gradually moving from a fee-for-service model to a fee-for-value model, and there is a strong likelihood this will happen in O&P in the not too distant future. Plus, the industry has struggled to get Medicare and commercial payors to approve new technologies, partly due to the subjective nature of the benefits and the lack of quantifiable data.

The ability to present payors with quantifiable, objective outcomes data that demonstrates the impact on the patient’s mobility and functionality will be critical—not only in helping the industry get codes on newer technologies approved by Medicare (and at fair reimbursement rates), but also in obtaining authorization and negotiating fair reimbursement from commercial payors. We continue to have success in leveraging our outcomes data on difficult cases to the successful outcome for the patient, and in changing physicians’ minds for treatment protocols based on outcomes data.

Mark Brady is chief financial officer of Ability Prosthetics and Orthotics.

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What Do Physicians Think of O&P? Survey indicates physicians have generally positive opinions about contributions of O&P professionals

S

o, you really want to know what physicians—your referral base— think of O&P professionals? To answer this question, we conducted a survey of a couple dozen surgeons and physiatrists.

According to respondents, O&P professionals generally receive about a B+ rating. Of course, the survey is not large enough to have real statistical validity, but perhaps you’ll recognize a few results as comparison points—and identify areas where others in our profession, and maybe even yourself, might improve.

In large measure, the physicians in our survey recognize the O&P professional as an important part of the care team—88 percent, or 15 of 17, agreed with this statement. There also is good continuity of care; one physician said, “I often escort patients into their office to describe what I am looking for.” Another noted, “Prosthetists accompany patients to their ortho clinic appointments.”

Participating physicians were asked which diagnoses they were most likely to refer to an orthotist for orthotic intervention. The most common responses

8

O&P News | May 2018

were poststroke patients and patients who have suffered a traumatic spinal injury, followed by patients with osteoarthritis, scoliosis, and plagiocephaly, in that order. Seventy-five percent of respondents said they never refer patients for plagiocephaly, but that may reflect more on the surgeons and physiatrists included in the survey.

When asked about their impression of the value that O&P professionals provide within the care team and the services provided to patients by O&P professionals, results were almost uniformly favorable, with a poignant comment that “they have the content expertise.”

The physicians were asked whether they had been involved in a very disappointing experience with a patient they referred to O&P. Not surprisingly, about half were able to highlight such an episode, with responses such as, “Socket doesn’t fit very well,” and, “Miscommunication/not listening to the patient.”

There was a fair assessment that the “level of skill is not the same in all practitioners.” There also were a couple of “business” intrusions into patient care cited: “Frequent incremental prescription requests for equipment that is more expensive but not always indicated,” and “… Typically, bad experiences happen when the process in not patient-provider based, but rather like a salesman selling or simply delivering a piece of medical equipment.”

The surgeons and physiatrists all had very positive suggestions for what O&P professionals could do to better serve the limb loss and mobility challenged population. Responses included, “… Make sure surgeons know they are available for patients and see them concurrently with the team.”

We all wish all of our grades were perfect in school—straight As! Overall, the comments reported by physicians in the survey do seem fair and directed toward improvement.

It may be helpful to recognize that, for surgeons, amputation is sometimes

not the outcome they had hoped or anticipated for a particular patient.

Finally, sometimes when you have a bit of a tough conversation or encounter with a referring physician, you can

never be sure what happened that day in practice, and what tough news they may have had to deliver to a patient. Remember that physicians have a tough job, too, and deserve the benefit of the doubt.

QUESTION 1

What is your Q1medical What is specialty? your medical specialty?

Answered: 17

Skipped: 0

Orthopedic surgeon

Vascular surgeon

Physiatrist

General surgeon

Other (please specify) 0%

10%

20%

30%

40%

50%

60%

70%

80%

90% 100%

QUESTION 2

Are orthotists and prosthetists part of the care team for your limb loss or mobility challenged patients?

Yes

No

Other (please specify)

0%

10%

20%

30%

40%

50%

60%

70%

80%

90% 100%

O&P News | May 2018

9

QUESTION 3

QUESTION 4

In what type of setting do you interact with orthotists and prosthetists with your patients?

Which of the following diagnoses would you most likely refer to an orthotist for orthotic intervention?

(Example: “I see patients in a clinic setting with a prosthetist to evaluate their prosthetic needs,” or “We have an orthotist on staff at our facility.”)

RESPONSES I call orthotists and prosthetists to discuss patients after I see them in clinic. But I do not work with them directly as they are not part of our hospital or clinics.

Office operating room clinic

Poststroke

Both are true Clinic & inpatient rehab Prosthetists accompany patients to their ortho clinic appts

Scoliosis

Clinic. Inpatient service.

I work in a rehab facility with in house prosthetists and orthotists. I run the prosthetic/orthotic clinic 4 days/week with CPO present all the time.

We have a multidisciplinary amputee clinic and a CPO is present from our facility.

We have several O&P staff at our facility and we have a monthly clinic with a prosthetist present to evaluate prosthetic needs.

0

We have those services available - but I do not have any overlap with them.

1

Orthotist on staff. I often escort patients into their office to describe what I am looking for.

2

Patient and inpatient unit

3

I refer patients to the prosthetist

4

University-based amputee clinic and rehab clinic. The university employed P&O and a few community-based P&O individuals who work with the university attend clinic.

5

International education programs

Traumatic Spinal Injury

Plagiocephaly

Osteoarthritis

0

1

Total Weighted Average

QUESTION 5

What has been your impression of the services provided to your patients by prosthetists and orthotists? #

RESPONSES

1

Excellent care provided, as I primarily work with amputees and refer to prosthetists.

2

Good

3

Excellent

4

Very patient centered, effective, helpful, timely.

5

Excellent. A great, invaluable member of the team.

6

Good

7

Excellent quality and service. Very compassionate. Follow-up on every patient.

8

Excellent

9

Very good

10

Thorough

11

Generally good

12

Varies by who the practitioner is, I have found qualified and experienced practitioners who are willing to listen and work in a team approach. Others are in just for the most expensive device and no follow up.

13

Excellent

14

My experience has been good.

15

An important part of the care team. Always helpful.

10 O&P News | May 2018

2

3

4

QUESTION 6

In what ways do you see value in having prosthetists and orthotists as part of the care team for your patients? #

RESPONSES

1

They bring their expertise to the patient in preparing them for new activities such as walking again. They can be very helpful to discuss prosthetics with patients before they have an amputation (especially to allay their fears, and answer their questions).

2

Input + patient eval

3

They are an essential part of any nonoperative treatment.

4

Educated/informed source to help patients get correct/appropriate care & DME (OT)/orthoses & prostheses.

5

They aid in operative decision making.

6

Coordination and communication

7

I rely on their opinion and guidance, O&P prescription, and adjustments when I see patients.

8

Improving patient care

9

In clinic evaluation to help determine the best orthosis for a specific patient.

10

Continuity of care. Rehabilitation.

11

Open communication. They will often stop by my office with questions regarding a particular patient’s care.

12

When they are knowledgeable and experienced they add to the patient care.

13

They have the content expertise to help patients with mobility.

14

Education for our patients as to what a prosthesis or orthosis can offer them, what the different device options are, and how the process to order, fabricate, fit, and align the device actually works.

15

It is a necessity.

QUESTION 7

What are the most important outcomes expected as a result of your patients working with a prosthetist or orthotist? #

RESPONSES

1

Satisfaction with the use of their prosthetic, and refitting as needed to achieve best outcome of walking again, pain-free.

2

Cooperative working environment

3

Pain relief, improved function

4

Improved function - improved quality of life

5

Comfort in their socket

6

Functional gains

7

Good fit, good quality of device. Follow-up with patient. Communicate back to me with issues.

8

Excellent fitting/functioning prosthesis/orthosis

9

Mobility, ability to walk

10

Successful rehab/prosthetic fit

11

Proper fit. Often difficult to have patients pick something off the shelf.

12

Improved mobility, ADLs

13

Improved quality of life. Excellent fit. Patient satisfaction with service

14

A collaborative process that ultimately improves the mobility, stability, or activity of daily living that was in need of help. Also a patient/provider experience that was professional and kind.

15

They are receiving needed P&O services.

O&P News | May 2018

11

QUESTION 8

Have you or your patient ever had a very disappointing experience when you have referred the patient to a prosthetist or orthotist? What could orthotists and prosthetists learn from any such episode?

#

RESPONSES

1

No

2

Yes

3

Yes, usually due to poor communication with physicians (referring) and patients.

4

No, but limited experience as a resident physician.

5

Not yet

6

Socket doesn't fit well—very hard and not well-placed

7

Rarely happens, but when it does, there is often some miscommunication to the patient.

8

No

9

Not that I can think of.

10

No

11

No

12

Practitioner is not a good listener and dismisses the physician and patient. Frequent incremental prescription requests for equipment that is more expensive but not always indicated.

13

Yes. Did not listen to patient. Needed better fit. Limited options offered.

14

Yes. These bad experiences typically happen when the process is not patient-provider based, but rather like a salesman selling or simply delivering a piece of medical equipment.

15

Yes. The level of skill is not the same in all practitioners. Some adapt but some do not.

QUESTION 9

In your opinion, how can prosthetists and orthotists better serve the limb loss and mobility challenged patient populations? #

RESPONSES

1

Be willing to go to patients’ homes to discuss amputation, prosthetics, perhaps initial evaluations in the home setting since it is challenging for freshly post-op patients to make it to another office.

2

Be more involved in surgery

3

Ours work well on our team

4

I wish prosthetists were considered clinicians instead of technicians.

5

Embrace new technologies, adjustable sockets

6

Community education. Ensure follow-up of patients to prosthetist/orthotist for device issues, and follow-up to physician from medical issues.

7

I think they already do a great job

8

More options for joint clinics

9

Not enough experience for me to comment on this.

10

Schedule routine interval follow up to ensure proper fit and patient satisfaction.

11

Be willing to participate as a member of the care team, do not go for the quick profit but for the long term well-being of the patient

12

Make sure surgeons know they are available for patients and see them concurrently with team

13

By being health-care professionals, being patient and kind, and always trying to educate the patient and their family. Also understanding that the process takes time, and custom devices need many modifications and adjustments to be successful.

14

Remaining a part of the health-care team.

12 O&P News | May 2018

QUESTION 10

Do you believe that prosthetic and orthotic services are important to the rehabilitation and mobility of your patients?

QUESTION 12

In your opinion, how can prosthetists and orthotists better serve the limb loss and mobility challenged patient populations?

RESPONSES Yes Yes

RESPONSES

#

QUESTION 11

1

Better interaction between them and relevant surgeons.

2

Come into the operating room.

What is your process for obtaining prosthetic and/or orthotic devices for your patients? #

RESPONSES

1

Already have direct lines of communication to a prosthetist and hand therapists (not orthotists).

2

I am not sure.

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O&P News | May 2018

13

Research & Presentations

Relative Influence of Orthotic Support Features Within an Open-Frame AFO Versus a Total-Contact AFO on Function, Endurance, and Activity Level in Patients With Spastic Equinovarus Secondary to Chronic Stroke

By Beatrice Janka, MPO, CPO, and Nicholas LeCursi, CO

Introduction Approximately 795,000 people experience a stroke every year in the United States.1 Many people suffering from common neuromuscular disorders, including stroke, have secondary gait impairments. Studies have recommended a variety of ankle-foot orthosis (AFO) stiffnesses, in both plantarflexion and dorsiflexion, to compensate for the biomechanical deficits associated with some neuromuscular conditions.2-9 A previous pilot study demonstrated the effects of incrementally manipulating three key sagittal plane characteristics: the resistance to dorsiflexion, resistance to plantarflexion, and initial ankle alignment.10 Data suggests that these three variables, when isolated from one another, may have predictable and systematic influences over sagittal gait kinematics.

While some research has been conducted to expose the effects of AFO properties related to sagittal plane mechanics, anecdotal evidence strongly suggests that a properly fitting orthosis with effective triplanar control is important in the success of the orthosis treating these biomechanical deficits. This is especially true for patients suffering from neuromuscular conditions who have triplanar involvement and tone, where the sagittal plane influence of

14 O&P News | May 2018

the orthosis may be biomechanically coupled to the support of the foot and ankle in other planes and also may indirectly influence kinematics up the kinetic chain to the knee and trunk.

Open-frame custom AFO designs are used in a variety of applications. These open-frame designs offer many benefits over total-contact designs. Open-frame AFOs are much lighter weight than total-contact AFOs and are less bulky.

Decreased bulk of the footplate allows for more intimately fitting shoes to be worn. The contact area also is minimized, allowing for volume fluctuations and breathability. These orthoses are typically easier to don due to their lower profiles, which may be an advantage for neuromuscular patients who could potentially also have upper-extremity involvement. Despite the wide range of benefits for these open-frame orthoses, their effectiveness at controlling the triplanar postural deficits of spastic equinovarus has not been rigorously evaluated. Specifically, the features of the orthoses that may impact their efficacy have not been explicitly identified. This study focuses on the relative influence of one orthotic support element, the supramalleolar extension,11 with the intent of broadening the base of knowledge of this feature’s effectiveness in controlling spastic equinovarus.

Methods Patients

Two patients were recruited for this pilot study. Each patient was wearing an AFO daily at the time of recruitment.

Patients were independent ambulators without an assistive device as well as with and without their AFO. See Table 1 for specific patient characteristics.

Apparatus

Patients wore three different orthoses during the course of the study. The first orthosis tested was the patient’s own orthosis that they had been wearing prior to enrollment in the study. This will be referred to as the polypropylene AFO (PP AFO). This orthosis was not the focus of this study, but use and outcomes were measured against this orthosis as a basis for comparison. This aided in determining which measures were sensitive enough to detect differences among conditions. The overall design of this orthosis was not controlled but was very similar for both patients. The PP AFOs were total-contact, polypropylene, articulated AFOs with a posterior calf shell, free-motion thermoformable joints, and a fixed plantarflexion stop.

Patient 1’s PP AFO had a padded lateral supramalleolar trim line and a sulcus length footplate, and the posterior stop

Research & Presentations

was set for an ankle angle of 5 degrees of plantarflexion. Patient 2’s PP AFO had a full-length footplate, and the ankle angle at the plantarflexion stop was set to 10 degrees of plantarflexion. (Unless otherwise noted, the ankle angle refers to the angle measured from the lateral border of the foot to the bisection of the lower leg.)

The second orthosis will be referred to as the total-contact triple-action AFO (TC TA AFO); see Figure 1a.

This AFO was a custom hybrid doubleupright AFO. It was fabricated using wet lamination, carbon fiber, and acrylic resin to provide a rigid structure, which isolated the control of sagittal stiffness and ankle alignment to the ankle joints.

Triple-action ankle joints were used to facilitate optimization of sagittal plane mechanics including plantarflexion resistance, dorsiflexion resistance, ankle range of motion, and ankle alignment. The TC TA AFOs had a total-contact pretibial shell and lateral supramalleolar extension.

The footplate incorporated all clinically relevant contours to manage the patients’ foot posture. Patient 1 required the use of two triple-action ankle joints to provide adequate active influence over sagittal plane kinematics, while Patient 2 required only one triple-action ankle joint and a single-axis companion joint medially.

The third orthosis will be referred to as the frame triple-action AFO (F TA AFO); see Figure 1b. This orthosis was fabricated exactly the same as the TC TA AFO, with the exception of a flat footplate attached using a caliper plate to the ankle joints and minimal contact trim lines. The only coronal support element present in the F TA AFO was the lateral supramalleolar extension and associated three-point force system.

Each patient was provided with New Balance model 813 shoes. These shoes were chosen based on several factors, including high bending stiffness of the sole, outsole rocker profile, limited outsole compressibility, and a wide/ deep toebox.

Figure 1

Figure 1a.

Total-contact triple-action AFO for Patient 1

Figure 1b.

Frame tripleaction AFO for Patient 1

Table 1

Patient Characteristics Gender Age

Patient 1

Patient 2

Male

Female

78

51

Years Post CVA

17

20

Involved Side

Left

Left

Height/Weight

5’7”/200 lbs

5’1”/200 lbs

Ankle

2

1+

Knee

2

0

DF (Knee Flexed)

10 degrees

5 degrees

DF (Knee Extended)

0 degrees

2 degrees

Knee Extension

-5 degrees

0 degrees

DF

4+

0

PF

3-

0

Knee Flexion

4-

2

Spasticity (MAS) ROM

MMT

Knee Extension

4

4

Hip Flexion

4-

4-

15 degrees

25 degrees

0 degrees

0 degrees

5 degrees

0 degrees

Hindfoot inversion (swing/ non-weight bearing) Posture

Hindfoot inversion (weight bearing)

Knee varus (weight bearing)

O&P News | May 2018

15

Research & Presentations

StepWatch activity monitors were employed to measure relative activity while wearing the AFOs during the testing period. StepWatches have been previously used to investigate activity level after stroke and have been proven to be reliable with this population.12,13

Two different survey instruments were used. The first was a modified version of the Prosthetic Evaluation Questionnaire (PEQ), 14 which we refer to as the “OEQ.” Questions from Groups 1, 4, 6, and 7 of the PEQ were used, and the term “prosthesis” was

replaced with “orthosis.” It also was changed from a time frame of four weeks to two weeks. The second survey was the Quebec User Evaluation of Satisfaction with Assistive Technology (QUEST)15 with the “Services” section omitted.

Procedures

Table 2

Outcome Measures and StepWatch Variables for Patient 1 Superscripts indicate a significant difference (P < 0.05) from the No Brace (NB), PP AFO (PP), TC TA AFO (TC), and F TA AFO (F) conditions. The 6-min WT was only performed once per condition.

Outcome Measures StepWatch Variables (Daily Averages)

No Brace

PP AFO

TC TA AFO

10-m WT (m/s)

0.68

0.74

0.83

6-min WT (m)

160

180

175

215

Stride Length (cm)

88 (PP, F)

77 (NB, TC, F)

90 (PP, F)

99 (NB, PP, TC)

Sound Side Steps

N/A

2,484

2,384 (F)

2,976 (TC)

Distance (m)

N/A

1,911 (F)

2,150 (F)

2,948 (PP, TC)

Time Active (min)

N/A

276 (F)

261 (F)

348 (PP, TC)

(TC, F)

(TC, F)

(NB, PP, F)

F TA AFO 0.96 (NB, PP,

TC)

Table 3

Outcome Measures and StepWatch Variables for Patient 2 Superscripts indicate a significant difference (P < 0.05) from the No Brace (NB), PP AFO (PP), TC TA AFO (TC), and F TA AFO (F) conditions. The 6-min WT was only performed once per condition.

Outcome Measures

StepWatch Variables (Daily Averages)

No Brace

10-m WT (m/s)

0.45

6-min WT (m)

150

PP AFO

0.74

TC TA AFO F TA AFO

0.71 (NB)

0.80 (NB)

210

205

230

Stride Length (cm) 59 (PP, TC, F)

74 (NB, TC, F)

85 (NB, PP)

91 (NB, PP)

Sound Side Steps

N/A

2,391

3,012

Not Tested*

Distance (m)

N/A

1,761 (TC)

2,525 (PP)

Not Tested*

Time Active (min)

N/A

216 (TC)

297 (PP)

Not Tested*

(PP, TC, F)

(NB)

*The F TA AFO condition was not tested outside the office due to donning issues.

16 O&P News | May 2018

Each patient was evaluated and their affected lower extremities were cast. The two custom AFOs previously described were fabricated. The frame and total-contact AFOs were checked to ensure nearly identical dimensions and ankle joint placement. Emphasis was placed on proper modification and implementation of the lateral supramalleolar extension on both orthoses such that both orthoses derive similar support from those features. The orthoses were fit by an experienced and certified orthotist. The optimal ankle joint settings were determined based on the manufacturer’s standardized optimization procedure.

For each orthotic condition, the patients wore StepWatches for at least 12 days. They wore one StepWatch on the shoe of their uninvolved limb and one on their AFO. Patients completed outcome measures for each of the three orthosis conditions as well as a no orthosis condition. These included the 10-meter walk

Research & Presentations

test (10-m WT), six-minute walk test (6-min WT), and stride length. Walking tests were administered over several visits to reduce fatigue. The OEQ was administered in written form for each condition directly after the StepWatch data collection period. The QUEST was administered verbally with all three tested AFOs visible at the end of the study as a means of direct comparison for all conditions.

Results The results of the study are detailed in Tables 1 through 5.

Discussion For Patient 1, there was a clear preference toward the F TA AFO. Patient 1 had the fastest 10-m WT velocity, farthest 6-min WT distance, and longest stride length with the F TA AFO. The only StepWatch outputs that were statistically different among the tested conditions, steps per day and minutes of activity per day, were highest for the F TA AFO condition. The calculated distance walked per day was farthest for the F TA AFO condition. The QUEST reflected that Patient 1 perceived an increase in function with the F TA AFO. Patient 2 had slightly less agreeance in results. At the time of data collection, Patient 2 was unable to independently don the F TA AFO. This was due to her upper-extremity deficits as well as the necessary change to her donning habit. With the F TA AFO, she was required to insert the AFO in the shoe before donning. This change in donning procedure discouraged her from using the F TA AFO during the study. For this reason, StepWatch data was not collected for this condition. Patient 2 had the farthest 6-min WT distance and the longest stride length with the F TA AFO. Her 6-min WT distance was very similar between the PP AFO and TC TA AFO conditions, but her stride length was longer with the TC TA AFO compared to the PP AFO. Her 10-m

Table 4

QUEST Summary for Patient 1 Top Three Considerations Highest Ranked Orthosis for Each Consideration 1) Effectiveness

F TA AFO

3) Safety

All orthoses ranked equally safe

2) Comfort

PP AFO

Table 5 QUEST Summary for Patient 2 Top Three Considerations 1) Effectiveness 2) Safety

3) Durability

Highest Ranked Orthosis for Each Consideration* TC TA AFO

All orthoses ranked equally safe TC TA AFO

*The F TA AFO condition was not included in this comparison as this patient did not wear it outside the office.

WT velocities were no different between the three AFO conditions. Minutes of activity per day was the only StepWatch output that was statistically different for Patient 2, and this was higher for the TC TA AFO condition compared to the PP AFO condition. However, the calculated distance walked per day was also higher for the TC TA AFO condition.

One question related to the use of the StepWatches was choosing appropriate output variables for comparison.

For both patients, it was discovered that stride length as measured in the clinic changed depending on orthotic condition. Many of the StepWatch output variables do not take stride length into account. This could have important implications. If patients can walk the same distance in fewer steps, it may appear as though their activity level has either remained unchanged or decreased if only the number and frequency of

steps are considered. For these two patients, minutes of activity per day and the distance calculated from stride length and steps per day seemed to best reflect the functional differences that were measured by the other outcomes and the survey.

In addition to the functional measures, it was important to acquire subjective feedback regarding the AFOs, with the goal of determining whether the results of the functional measures aligned with how the patients viewed the orthoses. Initially the OEQ was used to collect information regarding specific aspects of the orthoses. However, this questionnaire is rather lengthy, and did not seem to be an effective means for these patients to compare the orthotic conditions. The second survey instrument, the QUEST, while simpler, seemed to be more sensitive to variables of interest.

O&P News | May 2018

17

Research & Presentations

From a simplicity standpoint, to determine the patient’s activity while wearing a specific AFO, a StepWatch would be attached directly to the AFO. However, it has been determined based on previous research that StepWatches are 98 percent accurate on the leastaffected limb and only 92 percent accurate on the most-affected limb after stroke.12 Therefore, to determine activity, one StepWatch was attached to the AFO, and an additional StepWatch was attached to the patient’s least-affected side. The data from the AFO StepWatch were used only to determine when the AFO was worn, and the data from the second (least-affected side) StepWatch were used for analysis of activity.

Due to upper-limb involvement, securely donning the StepWatch independently on the least-affected ankle was not possible. To manage this, the StepWatch for the least-affected side was mounted on the lateral side of the patients’ shoes. This was determined to be a suitable alternative as long as this was taken into account during programming.

Conclusions The results of this pilot study suggest that for these two poststroke patients presenting with swing phase equinovarus, open-frame AFOs may be equally effective to total-contact footplate AFOs in increasing subject activity level, endurance, and step length. The StepWatch activity monitor, 6-min WT, and 10-m WT may be useful outcome measures, sensitive to the orthotic condition for this patient population.

EDITOR’S NOTE: This research was funded in part by an AOPA Research Award administered by the Center for Orthotics and Prosthetics Learning and Outcomes/ Evidence-Based Practice.

Beatrice Janka, MPO, CPO, is a clinical prosthetist-orthotist within Becker Orthopedic’s

18 O&P News | May 2018

patient-care division as well as an engineer on Becker’s research and product development team. Nicholas LeCursi, CO, is chief technology officer at Becker Orthopedic.

References 1. Mozaffarian D, Benjamin EJ, Go AS, et al. Heart Disease and Stroke Statistics—2015 Update: A Report From the American Heart Association.

2015; e29-322.

2. Blaya JA, Herr H. Adaptive Control of a Variable-Impedance Ankle-Foot Orthosis to Assist Drop-Foot Gait.

IEEE Transactions on Neural Systems and Rehabilitation Engineering. 2004; 12(1):24-31.

3. Bregman DJJ, Harlaar J, Meskers CGM, de Groot V. Spring-Like Ankle-Foot Orthoses Reduce the Energy Cost of Walking By Taking Over Ankle Work. Gait and Posture.

2012; 35(1):148-153.

4. Bregman D, De Groot V, Van Diggele P, Meulman H, Houdijk H, Harlaar J. Polypropylene Ankle-Foot Orthoses To Overcome Drop-Foot Gait in Central Neurological Patients: A Mechanical and Functional Evaluation. Prosthetics and Orthotics International. 2010; 34(3):293-304.

5. DeToro WW. Plantarflexion Resistance of Selected Ankle-Foot Orthoses: A Pilot Study of Commonly Prescribed Prefabricated and CustomMolded Alternatives. Journal of Prosthetics and Orthotics. 2001; 13(2).

6. Kobayashi T, Singer ML, Orendurff MS, Gao F, Daly WK, Foreman KB. The Effect of Changing Plantarflexion Resistive Moment of an Articulated Ankle-Foot Orthosis on Ankle and Knee Joint Angles and Moments While Walking in Patients Poststroke. Journal of Clinical Biomechanics. 2015; 30:775-780.

7. Singerman R, Hoy DJ, Mansour JM. Design Changes in Ankle-Foot Orthosis Intended To Alter Stiffness Also Alter Orthosis Kinematics. Journal of Prosthetics and Orthotics. 1999; 11(3):48-56.

8. Sumiya T, Suzuki Y, Kasahara T. Stiffness Control in Posterior-Type Plastic Ankle-Foot Orthoses: Effect of Ankle Trimline. Part 2: Orthosis Characteristics and Orthosis/Patient Matching. Prosthetics and Orthotics International. 1996; 20:132-137.

9. Yamamoto S, Ebina M, Miyazaki S, Kawai H, Kubota T. Development of a New Ankle-Foot Orthosis With Dorsiflexion Assist, Part 1: Desirable Characteristics of Ankle-Foot Orthoses for Hemiplegic Patients. 1997; 9(4):174-179.

10. Janka B. The Effects of AFO Stiffness and Alignment on LowerExtremity Kinematics in Stroke and Multiple Sclerosis. Thranhardt lecture presented at: AOPA National Assembly 2016.

11. Sabolich J. Modification of the Posterior Leaf Spring Orthosis. Orthotics and Prosthetics. 1976; 30(3):35-36.

12. Mudge S, Stott NS, Walt SE. Criterion Validity of the StepWatch Activity Monitor as a Measure of Walking Activity in Patients After Stroke. Arch Phys Med Rehabil. 2007; 88(12):1710-1715.

13. Fulk GD, Combs SA, Danks KA, et al. Accuracy of Two Activity Monitors in Detecting Steps in People With Stroke and Traumatic Brain Injury. Phys Ther. 2014; 94(2):222-9.

14. Legro MW, Reiber GD, Smith DG, del Aguila M, Larsen J, Boone D. Prosthesis Evaluation Questionnaire for Persons With Lower-Limb Amputations: Assessing ProsthesisRelated Quality of Life. Arch Phys Med Rehabil. 1998; 79(8):931-938.

15. Demers L, Weiss-Lambrou R, Ska B. Item Analysis of the Quebec User Evaluation of Satisfaction With Assistive Technology (QUEST).

Assist Technol. 2000; 12(2):96-105. doi:10.1080/10400435.2000.10132 015.

Research & Presentations

Three Brachial Plexus Injury Subjects’ Function After One(+) Year of Upper-Extremity Myoelectric Orthosis Treatment

By David R. Coleman, CPO, FAAOP

Introduction Traumatic brachial plexus injury (TBPI) is a rare dysfunction causing myriad impairments to the ipsilateral upper extremity (UE) of an individual. 1 Impairments result from a distractive force at the shoulder complex deranging the nerves and disrupting their ability to communicate afferent and efferent signals. Young males are at the highest risk for TBPI because of their incidence of motor-vehicle accident (MVA) or other high-impact traumas, though anyone is vulnerable.2 Disruptions can present as preganglionic avulsion, rupture, neuroma, or neurapraxia1-5 (Figure 1). Treatments vary depending on intact innervations, but the most severe dysfunction and most invasive interventions occur with avulsions.4-6 Elbow flexion is impaired in 95 percent of cases of TBPI due to C5-C6 avulsion or rupture.4 Our ultimate goal as a health-care team is to have our clients achieve normal (M5) or like-normal (M4) elbow flexion on the manual muscle testing (MMT) scale. Many surgical interventions are available, including muscle graft, muscle transfer, nerve graft, and nerve transfer. Which intervention is used is determined from available muscles and nerves, and a degree of compromise regarding impairment in

Figure 1 Traumatic brachial plexus injury

the donor site.1,3-6 Because of the extent of damage from MVAs, the chance of restoring function may mean pursuing interventions with low success rates.

Motor and sensory deficits in the donor sites must be weighed against the prospective increase in value for the client.

There are many validated nerve and muscle transfers, but a couple are typically utilized as a last resort. One treatment is the intercostal nerve (ICN) transfer to the musculocutaneous nerve (MCN) because of the presence of both motor and sensory neurons, and because the number of axons is similar to how many innervated the brachialis. 3-6

Donor-site deficits are inconsequential since they only contribute accessory function to inspiration.4 Far more substantial is the client’s need to perform the inherent action of the nerve to produce muscle activity at the transfer site— meaning muscle recruitment involves a deep breath or Valsalva maneuver.

Muscle transfers often utilize the gracilis muscle for a donor muscle due to lack of noticeable deficit once harvested.

Unfortunately, the ICN transfer is only 46 percent successful at achieving M4 or M5 function with intact elbow flexion muscles.4 With gracilis muscle transfer, the success rate is diminished further.

O&P News | May 2018

19

Research & Presentations

Neurologic therapy protocols for functional improvement of a joint require the therapy be task-specific and high-repetition.7 Most clients can’t be certain they are activating the muscle consistently because of trace (M1) muscle activity, limited range of motion against gravity (M2), unnatural muscle activation (because of the ICN transfer), and paraesthesia. Old protocols of performing elbow flexion with gravity eliminated invite compensations and frustration due to a lack of feedback.

Many clients report being unable to determine whether or not their muscle is even firing, while others become discouraged at the modest gains in arm motion. Utilizing a technology that provides both visual and functional feedback allows the patient to perform reliable muscle activation and pursue functional activity.8 We utilized a custom-made myoelectric elbow orthosis, the MyoPro (Myomo, Cambridge, Massachusetts) to translate the elbow flexion signals into M4 muscle activity (Figure 2). Sensors housed within the humeral section of the device transcutaneously utilize neurons signalling the intention to move.

The client’s muscles amplify the electric activity from the nerves and facilitate transcutaneous detection. With appropriate programming, the muscle activity that is inadequate to produce physiologic elbow motion causes the MyoPro to emulate normal elbow motion.

We understand frequent muscle activation will strengthen the muscle in accord with normal muscle physiology.9-11 Some measure of neuronal reinforcement or neuroplasticity is also possible.8 My goal is to explore if a device like the MyoPro may be effective at transforming BPI surgical failures into successes.

Methods Each subject was evaluated for candidacy as prescribed by their physician after persistent functional shortcoming following ICN to MCN brachial plexus

20 O&P News | May 2018

Figure 2 MyoPro Motion-W

treatments. MyoPro candidacy criteria were affirmed as a normal element of the MyoPro evaluation packet (Myomo.com).

There were no controls or protocols in place for time of fit following surgery, time since initial injury, wearing schedules, or other notable physiologic or metabolic considerations of each client.

Subjects demonstrated their ability to operate the MyoPro consistently and reliably utilizing their available elbow flexor and extensor muscle groups. Each device was initially programmed by emphasizing ease of engaging the elbow motors while managing the electrode sensitivity to minimize exceptionable motor activity.

Each subject’s MMT and Disability of the Arm, Shoulder, and Hand (DASH) scores were procured at the fit appointment. Of our cohort, each subject had spent at least a year in the device.

Each subject’s therapist received the same training protocol of prioritizing proficiency and stamina while operating the MyoPro first, then moving onto functional tasks once proficiency milestones were demonstrated. Therapists were instructed in the fit and adjustment of the MyoPro to accommodate changes in subjects’ muscular condition at the elbow that we anticipated.

Results Subject 1

The client is a 60-year-old male who presents with bilateral UE weakness from a MVA in June of 2013. He suffered nerve damage at C2 and C5-7, sternal fractures, cervical myelopathy, and spinal cord injury. Bilateral ICN transfers were performed in December of 2013. DASH and MMT Scores taken when he was fit September of 2014 are compared against scores taken 30 months later in May 2017 (Table 1). Every compartment was restored to a functional strength of at least 4. He reports not using his devices for the past several months as they are no longer necessary. His DASH score dropped to 21 percent of what it used to be, with four tasks remaining of 15 formerly listed as “unable.”

Subject 2

The client is a 19-year-old male who suffered a nondominant left-side BPI with C5 rupture, C6 avulsion, and C7-T1 lesion following a motor-vehicle collision with a tree in October of 2014. He underwent left ICN transfer to his natural biceps in December of 2014. We fit him 10 months later in September of 2015.

Figure 3 Subject 1 in therapy

Research & Presentations

Figure 4 Subject 2 M4 elbow demonstration

Table 1 Client 1 Change in MMT and DASH Scores 9/2014 – 5/2017 MMT

We followed up with the client at our office in October of 2016. He demonstrated M4 muscle strength at the elbow, being able to lift two pounds with full range of motion against gravity (Figure 4). He had already discontinued using the device at this point.

DASH and MMT scores were obtained during his fit appointment and 21 months later in June 2017 (Table 2).

The client reported he hasn’t needed the device for months, using it periodically. He regained good control of his elbow and developed poor control at his shoulder. Mild paraesthesia persists in the arm, though the patient reports the numbness is far reduced from where he started. His DASH score is less than half his initial score, and he reports no longer being unable to perform any task.

Elbow

Right

Left

Wrist

Right

Left

Right

Flexion

3→4

3→4

1→4

1→4

5

5

Extension

3→4

3→4

2→4

2→4

5

5

Abduction

3→4

3→4

Adduction

3→4

3→4

DASH

Initial

Final

Score

70

15

# of “5”s

15

4

Table 2 Client 2 Change in MMT and DASH Scores 9/2015 – 6/2017 MMT

Shoulder Left

Elbow

Wrist

Right

Left

Right

Left

Right

Flexion

1→3

5

2→4

5

5

5

Extension

2→3

5

4

5

5

5

Abduction

1→2

5

Adduction

4

5

DASH

Initial

Final

Score

38

18

# of “5”s

3

0

Table 3 Client 3 Change in MMT and DASH Scores 5/2016 – 6/2017

Subject 3

The client is 23-year-old male, evaluated in February of 2015, who suffered a left nondominant side BPI with C5 rupture, C6-T1 preganglion avulsion, ulnar/ radial fracture with internal fixation, and compartment syndrome secondary to a motorcycle accident in January of 2013.

He underwent left ICN transfer to his musculocutaneous nerve in the days immediately following his trauma. He reports being insensate below his elbow.

Shoulder Left

MMT Flexion

Shoulder

Elbow

Wrist

Left

Right

Left

Right

Left

Right

1→2

5

1→2

5

0

5

1→2

5

0

5

Extension

1→2

5

Abduction

1→2

5

Adduction

1→2

5

DASH

Initial

Final

Score

51

20

# of “5”s

3

0

O&P News | May 2018

21

Research & Presentations

scores. Cases 1, 2, and 3 reduced their DASH scores by 21 percent, 47 percent, and 39 percent respectively. What we can determine from a gross metric like the DASH is some degree of confidence our intervention assisted in reducing each client’s perceived and actual disability by some significant degree. The number of tasks the client was “unable” (an item score of 5) to perform was included to further emphasize the reduction in disability.

His paralysis appears flaccid with fixed rigidity in his fused wrist and paralyzed hand. We fit the client in May of 2016 with his MyoPro. He presents similarly to our initial evaluation, despite taking 15 months to be fit.

During a routine follow-up, we noted the EMG signals were acting a bit inconsistently. Ultimately, we decided to send new electrodes out to the client. We may have lost a matter of time because of the issue.

DASH and MMT scores were obtained at the fit appointment and compared to scores taken 13 months later in June of 2017. Of particular note are the client’s deficiencies in any activity requiring more than 80 degrees of shoulder flexion or abduction, which are limitations of the ICN transfer. Mild paraesthesia persists in the arm, though the patient reports the numbness is far reduced from where he started.

Discussion In BPI rehabilitation, a large amount of weight is given to restoring elbow function.4 Understandably, it is the joint segment that allows the individual the greatest degree of freedom and agency over their immediate environment.

Many activities of self-maintenance, interacting with the world and others, and hygiene occur with some coordination of the normal 150 degrees of elbow ROM and shoulder motion. In the cases presented, restoring elbow

22 O&P News | May 2018

function created large reductions in perceived and actual disability.

Across the spectrum of subjects we treated, functional return was seen.

Subject 1 recovered from having M1 at the biceps bilaterally for 18 months to M4 at some point within the following 25 months. Subject 2 spent nine months stuck at M2 postbrachial plexus reconstruction. Thirteen months after provision of the device, the client demonstrated M4 muscle activity at the elbow, which he maintained during the next eight months until his testing.

Subject 3 had endured M1 activity for 25 months before being fit for his device.

He spent the next 13 months developing his elbow to an M3 level. In each case, clients saw dramatic recovery in elbow flexion after provision of the MyoPro. We would like to extrapolate the trend to assume further time in the device for Subject 3 would mean further increases.

It’s also worth recognizing that Subject 3 was the only one without functional use of his hand, which could reduce opportunities to use the arm functionally. We are more confident of the impact of the intervention in these clients because they saw no increase in functional elbow motion between surgical intervention and provision of the device.

The DASH is used as a scale to produce a score between absolutely no disability (0) and complete disability (100). Each subject decreased their level of disability compared to their initial

Conclusion In some cases, as the nerves reinnervate, spontaneous recovery of function can occur at motor sites. Postsurgical reinnervation primarily occurs within six to 18 months. Many patients evaluated for the myoelectric elbow were no longer candidates after the months between evaluation and delivery of their device due to their recovery to M4 elbow activity without orthotic intervention. Half of all surgical candidates with ICN transfer will never need orthotic management.

However, in the cases presented, spontaneous recovery was unlikely to explain each increase in function and reduction of disability due to the massive extent of time between surgical intervention and any functional return.

It is my opinion that the successes presented are due to the distinct nature of activating the device for motion.

Unlike other modalities, the action of the orthosis begins with the intent to move, causing muscle recruitment. There is no stimulation. Instead, we are reinforcing neural pathways in line with the principles of neuroplasticity and recruiting muscles in accordance with normal muscle physiology. It is very promising that in the future TBPI clients will have another tool that may salvage functional recovery of their limb once surgical and therapeutic options are exhausted.

David R. Coleman, CPO, FAAOP, works at Limb Lab Prosthetics & Orthotics Co. in Rochester, Minnesota.

Research & Presentations

References 1. Shin AY, Spinner RJ, Steinman SP, Bishop AT. Adult Traumatic Brachial Plexus Injuries. J Am Acad Orthop Surg. 2005; 13(6):382-396.

2. Midha R. Epidemiology of Brachial Plexus Injuries in a Multitrauma Population. Neurosurgery. June 1997; 40(6):1182-1189.

3. Tung TH, Novak CB, Mackinnon, SE. Nerve Transfers to the Biceps and Brachialis Branches To Improve Elbow Flexion Strength After Brachial Plexus Injuries. J. Neurosurg.

2003; 98:313-318.

4. Gutowski KA, Orenstein HH. Restoration of Elbow Flexion After Brachial Plexus Injury: The Role of Nerve and Muscle Transfers. Plastic and Reconstructive Surgery. 2000; 106(6):1348-1358.

5. Tu Y-K, Tsai Y-J, Chang C-H, Su F-C, Hsiao C-K, Tan JS. Surgical Treatment for Total Root Avulsion Type Brachial Plexus Injury by Neurotisation: A Prospective Comparison Study Between Total and Hemicontralateral C7 Nerve Root Transfer.

Microsurgery. 2013; 91-101.

6. Ochiai N, Nagano A, Sugioka H, Hara T. Nerve Grafting in Brachial Plexus Injuries. J Bone Joint Surg.

1996; 78-B:754-758.

7. Taub E, Crago JE, Burgio LD, Groomes TE, Cook EW, DeLuca SC, Miller NE. An Operant Approach to Rehabilitation Medicine: Overcoming Learned Nonuse by Shaping.

Journal of Experimental Analysis of Behavior. 1994; 61:281-293.

8. Page SJ, Hill V, White S. Portable Upper-Extremity Robotics Is As Efficacious as Upper-Extremity

Rehabilitation Therapy: A Randomized Control Pillow Trial. Clin Rehabil. June 2013; 27(6):494-503.

9. Kim GJ, Rivera L, Stein J. Combined Clinic-Home Approach for UpperLimb Robotic Therapy After Stroke: A Pilot Study. Archives of Physical Medicine and Rehabilitation. 2015; 2243-2248.

10. Peters HT, Page SJ, Persch A. Giving Them a Hand: Wearing a Myoelectric Elbow-Wrist-Hand Orthosis Reduces Upper-Extremity Impairment in Chronic Stroke. Archives of Physical Medicine and Rehabilitation.

2017; 1-7.

11. Stein J, Narendran K, McBean J, Krebs K, Hughes R. Electromyography-Controlled Exoskeletal Upper-Limb-Powered Orthosis for Exercise Training After Stroke. Am J of Phys Med & Rehab. 2007; 255-261.

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O&P News | May 2018

23

O&P Visionary

Ted Snell, CP

Lifelong practitioner discusses the need to generate cost savings while focusing on patient rehabilitation

I

feel very privileged to be part of a company that has a history stretching back more than a century—and we continue to serve. We have a past, present, and future, and I am a staunch believer that your past is very intertwined with your present and your future. Who could ask for a better job? I take a few hours to produce something that literally changes people’s lives!

We are not people who manufacture and deliver a device. Rather we manage an ill population. It seems everything started to change around 1965, when Medicare was enacted—health care became a given right. Health is at least as much a responsibility as a right.

Somehow, O&P then missed out on the chance to be an insider on the solution with Medicare and CMS. We continue to pay that price. We should be aiming to develop a more cooperative relationship with CMS. We have made progress. We are an essential benefit, and with the publication of the RAND Corp. simulation study on advanced transfemoral prostheses, we have a solid study to justify the value— that is, cost—of what we do.

But a truly cooperative relationship with CMS would be one where our singular, unique patient-care role is

24 O&P News | May 2018

if we worked with CMS to define legitimate expectations? Bundling, in some form, is here to stay, but we need to help CMS in its need to tackle patient responsibility issues—patients are responsible for their body and costs. If they can’t handle that, really, what can we hope to do for them?

Ted Snell, CP, at the 2011 AOPA National Assembly Snell Anniversary Celebration

recognized by CMS, and that necessarily involves O&P working to create some cost savings. Sure, the insurance middleman sucks down a bunch of money that we wish we could use for patient care. But if we focus on how to generate cost savings, maybe we can get beyond chasing a series of boxes that we need to check to get care paid.

Medicare and Medicaid really operate without any buy-in responsibility for the care received. In this sense, these two government programs are different from private pay, which imposes more controls on care. We are stuck in an awful business model where we don’t control when or if we get paid! What

Patient Responsibilities Look, if your practice, particularly your independent practice, hasn’t started to evolve in the direction of helping manage patient responsibilities, to reduce costs and increase opportunities, you may soon teeter on being lost. A few years back, I decided that in order to continue to operate our business and succeed, I needed first “to get over myself.” It ain’t the way it used to be, Ted! We live and function in a broken health system.

For example, we need to know about the drugs our patients are supposed to be taking. They see us much more often than they see most of their primary care physicians, so if they aren’t taking their meds, we need to step up and get them back on the right track. Our system needs to link easy local community access to care with reductions in drug

O&P Visionary

cost. If you are taking your drugs, and following your diet, then patients ought to earn a substantial discount off their drugs—all linked to their reporting to that community-based care center.

When the evil, outrageous draft Local Coverage of Determination (LCD) on lower-limb prosthetics came out, I looked at it as a future business primer. If you read that and didn’t find some ways you could improve efficiencies with your patients and reduce costs, you weren’t paying attention. With transplants, patients must meet certain conditions to qualify for an organ. If you are still a smoker, there’s no access to a replacement lung; and if you need a new liver but are still drinking, no dice!

I used that draft LCD as a template—it is legitimate for payors to require that patients commit to rehabilitation and to certain compliance skills to earn their right to a replacement limb. Proper wound care, and following physician orders as to postsurgical weight bearing, are fundamental patient qualifications.

What would you rather be required to do: help monitor that patients are taking their diabetes and heart meds, or be required to go through preauthorization? Both are ways payors try to control their costs. Telemedicine has opened a bunch of options to help manage amputees through telemedicine clinics in rural areas, the same as in urban areas. Take advantage of your frequent encounters with patients to get involved in case management—are they making their doctor’s appointments? Have their sutures been removed? Are you maybe willing to have a physician “in” your practice, with increased cash flow, but increased liability?

The Orthotics Side of the Business A moment about orthotics. Tech has been taking away a lot in orthotics. In both orthotics and prosthetics, we used to be a craftsman employment—but no more, since tech took over.

mind that there may not be a code for it. Many of the bigger players just don’t seem to “get” that government and payors are setting prices—the sky is definitely no longer the limit! My view is that a solid K-3 ambulator can walk on anything, whereas a committed K-2 patient who is pushing hard to maintain their activities of daily living—they can get into trouble, get hurt on a K-2. Maybe we have some things upside down.

Other amputee lessons learned—don’t compare one amputee to another as each one is different; there are so many variables that defy comparisons. Establish that patient as K-3—there is a real liability for the insurer if they deny the patient over your findings with a patient who actually meets the K-3 threshold.

Ralph R. Snell, CPO, and Ted Snell, CP (right)

Still, in orthotics, as a provider you can provide a patient service—usually a custom orthotic device. Fees are lower, but there is still room for a profit. If you are a true mobility practice, you need to have capacity for orthotics. It is underutilized, and there are plenty of misconceptions about whether patients are getting the care they actually need.

But the same may be true at your local physical therapist.

Osseointegration Let’s talk about osseointegration. This is not as big a deal in the South yet—our patient base is less healthy and poorer than in most other parts of the country.

New tech naturally goes first to where the money is. At this point, I am not too worried that an engineer sitting in the operating room with the surgeon and a patient is going to replace what I provide as a prosthetist.

Rethinking K Levels K levels are flawed, as we all know. Manufacturers fear losing the edge if they don’t keep producing better things—never

Parting Thoughts We have a very small profession, with a ton of different organizations. If businesses consolidate, couldn’t associations also? My practice working with patients from the U.S. Department of Veterans Affairs (VA) has declined; there were many hassles, so I am not that sad. Ultimately, I see the VA being merged into Medicare—it will dawn on the feds to consolidate their health-care business and responsibilities.

And succession planning/retirement … my retirement is either the coffin or being confined to a wheelchair—otherwise, I’m in for the duration. In this volatile environment, you really need a good historical perspective. You can’t buy a book and learn how to manage your O&P practice. For me, this is really more about personal satisfaction than financial gratification. If you are thinking retirement, accumulate the needed resources while working, as the value of your practice if you try to sell it is a lot less than it once was.

Thanks for the chance to spout off— time for the next patient.

Ted Snell, CP, is president of CFI Prosthetics Orthotics.

O&P News | May 2018

25

STATE NEWS

State By State

The latest news from several states, and a message about the Affordable Care Act

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.

California To comply with CMS regulation 42 CFR 42 C.F.R. 438.602(b), the state of California is requiring all suppliers and vendors to enroll in state Medicaid managed care programs as of July 1, 2018.

It was brought to the attention of the O&P Alliance that California Medi-Cal will not enroll a mastectomy fitter, citing on its website for provider enrollment, “Currently, Medi-Cal does not enroll registered assistants, technicians, and/or certified fitters as providers.”

AOPA and O&P Alliance partners have reached out to Medi-Cal and will continue to update our members on this issue as additional information becomes available. Visit the AOPA Co-OP with related questions.

Connecticut A fiscal review of Connecticut S.B. 376, Insurance Fairness for Prosthetics, was released by the Legislative Regulation Review

26 O&P News | May 2018

Left to right: Michael Oros, CPO, FAAOP, president and chief executive officer, Scheck & Siress; Scott Studebaker, vice president of advancement and development, Provident Life Services; Cori Zacher, vice president of operations, postacute, at Care Northwestern Hospital; Traci Dralle, CFM, vice president, Fillauer Companies Inc.; Rep. Peter Roskam (R-Illinois); Ashlie White, manager of projects, AOPA; James Kaiser, CP, LP, president, Illinois Society of Orthotists and Prosthetists; and Jim Kingsley, chief operating officer, Scheck & Siress

Committee and the Office of Fiscal Analysis, which showed that passage of the bill would cost the state roughly $600,000 per year due to the Affordable Care Act’s insurance mandate provisions.

Following the release of the analysis, the Connecticut Amputee Network issued the following call to action: “It’s not too late to contact your state legislators! The vote in Hartford for our bill— Insurance Fairness for Prosthetics—S.B. 376, has been postponed, and the vote has not yet been scheduled. So, if you have not had a chance to call or write your state senator and/or state representative, it is not too late! Now is the time to reach out to your legislators.”

Georgia The National Commission on Orthotic and Prosthetic Education (NCOPE) and the

Commission on Accreditation of Allied Health Education Programs (CAAHEP) were notified officially, by institution administrators, on March 29, 2018, that the O&P master’s program at Georgia Institute of Technology (Georgia Tech) has placed the program on an “inactive status” effective May 2018.

No new students will matriculate into the program after this date for up to two years. NCOPE understands from the program director that the program is currently undergoing a shift to a new department within the university as well as an evaluation regarding the sustainability of the program within the university.

Matthew Nelson, CPO, senior clinical prosthetist and coding and reimbursement manager for Freedom Innovations LLC, said, “As the current president of the Georgia Society of

STATE NEWS

state. We are actively working on a Orthotists and Prosthetists, I wrote licensure bill that will protect our a letter directly to [G.P. “Bud” patients and our businesses,” said Peterson, PhD] supporting the NCAAOP President Brittany StresMSPO program at Georgia Tech. ing, CPO, FAAOP. He is the current president of the Georgia Institute of Technology.

In this letter, I highlighted the Texas successes of the program to include O&P providers in Texas accomplishments of some its graduare planning to file two ates. I also emphasized the need for bills to expand Medicaid coverage the 13 active O&P programs in the for individuals 21 years of age and country to flourish and the need older in the 2019 legislative session. for these programs to continue Separate bills will be introduced for to produce the next generation of prosthetics and orthotics, individuclinicians to keep up with the needs ally. For more information about of our aging population. this ongoing effort, please contact “President Peterson responded Catherine Mize, LPO, at cmize@ to my letter and indicated that Health-Connect.net. the final decision on the program would be made in the coming year Affordable Care Act and would be based on a number Update of factors. I would like to encourage Several states have moved to circumall O&P professionals in the state of vent the Affordable Care Act (ACA) Georgia to reach out to their legislaas insurance providers unveil plans tors and ask for their support and to Rep. Jackie Walorski (R-Indiana) and Bernie Veldman, CO, that do not comply with the ACA’s ask them to reach out to President chief executive officer of Midwest Orthotic Services regulations. CMS Administrator Peterson in support of the MSPO Seema Verma issued a statement program at Georgia Tech.” reinforcing that the ACA remains (R-Indiana) at its office in South Bend, the law of the land and that CMS can Indiana. The group reported that Walor- enforce the provisions on a state’s behalf, Illinois In response to an invitation ski met with Midwest staff and members if the state fails to substantially enforce made during the 2018 AOPA of the executive team, as well as a veteran the law.

CMS has pointed to the expansion Policy Forum, Rep. Peter Roskam patient. During the meeting, Walorski (R-Illinois) visited Scheck & Siress on was asked to sign on and support current of short-term health plans as an alternaApril 6, 2018, for a roundtable event O&P legislation, including H.R. 2599, tive action that states can use to provide relief for residents. AOPA and its Alliwith the company and other health-care H.R. 3696, and H.R. 2322. ance partners are watching these develleaders in the 6th District to discuss areas opments closely as changes could have a where the health-care system could be North Carolina more efficient; how to provide regulatory O&P providers in North potential impact on O&P coverage. relief to reduce the burden on providers Carolina are working to get for provision of care; the opioid crisis— a licensure bill introduced in the state. what providers are observing and what Following a series of discussions during can be done in Medicare and beyond to the 2017 North Carolina O&P ScienEDITOR'S NOTE: To submit treat and prevent opioid addiction; and tific Conference, the North Carolina an update for publication, please innovation in health care.

Chapter of the American Academy of email awhite@aopanet.org. For Orthotists and Prosthetists (NCAAOP) up-to-date information about launched the effort to draft legislation Indiana what’s happening in O&P in your Following an invitation made through its Business Affairs and Policy state, visit the AOPA Co-OP and during the 2018 AOPA Policy Committee. join the conversation in the AOPA “Now is the time for practitioners to Forum, Midwest Orthotic Services Google+ Community. recently hosted Rep. Jackie Walorski pay attention to what is going on in our

O&P News | May 2018

27

CLASSIFIEDS

CLASSIFIEDS

CLASSIFIEDS

CERTIFIED ORTHOTIST (CO)

UNIVERSITY OF VIRGINIA

Prosthetic & Orthotic company in Fredericksburg, Virginia, is seeking an ABC-certified orthotist. The ideal candidate needs to be motivated and dedicated to providing the best patient care possible. This person will be responsible for patient care, assessment/formulation of treatment plans, documentation, education, fabrication, and ordering proper components and supplies.

We are a busy, growing prosthetic & orthotic company looking for the right person so that we may continue to expand our practice. This is a great opportunity for the right person to add to our orthotic department, which is very active with pediatrics to geriatrics. We offer a competitive benefits package and look forward to hearing from you. Interested candidates, please email your résumé to Chris Taylor at chris@mobilitypo.com.

CERTIFIED PROSTHETIST ORTHOTIST (CPO) AND CERTIFIED ORTHOTIST (CO)

Email: chris@mobilitypo.com

CO/CPO Altru Health System located in Grand Forks, North Dakota, is seeking an CO/CPO. Altru is a regional integrated health system focused on delivering World Class Care to the residents of our region. As a member of the Mayo Clinic Care Network, we work together and share a common philosophy, commitment and mission to improve the delivery of health care through high quality, data driven, evidence-based medical care and treatment. We are a hospital based practice that has been in business for over 40 years. Strong interest in Cranial shaping helmets preferred as we are a Star Scanner facility with a large pediatric population. Fully staffed on site fabrication facility to support your practice.

Candidates must be ABC certified with five years of related experience preferred. Grand Forks offers excellent school systems, year-round outdoor recreation, sporting events, fine arts and a vibrant downtown.

altru.org/careers EOE

28 O&P News | May 2018

The Prosthetics and Orthotics Division in the University of Virginia’s School of Medicine seeks a certified prosthetist and orthotist (CPO) and a certified orthotist (CO) to consult, provide, and fabricate orthotic and prosthetic devices for adults and children with musculoskeletal impairments throughout Central Virginia. The successful candidates will be responsible for managing comprehensive orthotic and/or prosthetic patient care. This includes patient assessment, formulation of a treatment plan, implementation of the treatment plan, and follow-up care and practice management.

Candidates for both positions should have either a bachelor’s degree with completion of an NCOPEaffiliated certificate program and completion of NCOPE-affiliated residency program; or an associate degree with at least 10 years of direct P&O experience. Qualified candidates must be certified through the American Board for Certification in Orthotics, Prosthetics, & Pedorthics and have one year of postcertification experience. Some experience with foot/ ankle and pediatrics is required. Also, candidates should be knowledgeable with DME billing codes, insurance compliance, and current trends in the prosthetic and orthotic industry.

Successful candidates for the CPO position should also possess interpersonal skills to help build referral bases. For these candidates, a history of prior practice management is preferred, and supervisory and/or office management skills are a plus.

Applicants should complete a staff application through the Jobs@UVa website, and provide a cover letter, résumé, and a list of three references. To apply for either position, visit https://jobs.virginia.edu, click on University Staff, and search for posting # 0622645 for the CPO position or posting # 0621917 for the CO position.

For more information about the division, please visit https://med.virginia.edu/orthopaedic-surgery/ orthopaedic-divisions/orthotics-and-prosthetics/.

Visit: https://jobs.virginia.edu This position is restricted and contingent upon continued funding.

The University of Virginia is an equal opportunity and affirmative action employer. Women, minorities, veterans, and persons with disabilities are encouraged to apply.

NEW SURVEY

How Does Your Business Measure Up? AOPA’s 2018 Operating Performance Survey

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Participants receive a confidential company report plus the final published report.

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WANTED! A few good businesses for sale.

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

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

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Get your facility up to speed, fast, on all of the O&P HealthCare Common Procedure Coding System (HCPCS) code changes with an array of 2018 AOPA coding products.

Ensure each member of your staff has a 2018 Quick Coder, a durable, easy-to-store desk reference of all of the O&P HCPCS codes and descriptors.

• 2018 Coding Suite (includes CodingPro single user, Illustrated Guide, and Quick Coder): $350 AOPA members, $895 nonmembers 2018 CodingPro CD-ROM (single-user version): $185 AOPA members, $425 nonmembers • 2018 CodingPro CD-ROM (network version): $435 AOPA members, $695 nonmembers • 2018 Illustrated Guide: $185 AOPA members, $425 nonmembers • 2018 Quick Coder: $30 AOPA members, $80 nonmembers.

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ADVERTISER INDEX ALPS..................................................................7 www.easyliner.com American Orthotic & Prosthetic Association (AOPA)..........................23, 29, Cover 3 www.AOPAnet.org Fabtech Systems..............................................13 www.fabtechsystems.com Hersco Ortho Labs .....................................Cover 2 www.hersco.com Össur.................................................Back Cover www.ossur.com Ottobock.......................................................... 3 www.professionals.ottobockus.com

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.

30 O&P News | May 2018

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.

CALENDAR

Meetings & Courses

2018 MAY 9 AOPA Webinar: Coding: Understanding the Basics. 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.

JULY 11 AOPA Webinar: Administrative Documentation: The Must Haves and the Sometimes Needed. Register

AUGUST 8 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.

Vancouver Convention Center.

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

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

JULY 23-24 Mastering Medicare: Essential Coding & Billing Techniques.

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

Center, Oklahoma City. For more information, contact Tony Thaxton Jr. at 404/875-0066, email thaxton.jr@ comcast.net, or visit www.iaapoc.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.

NOVEMBER 12-13 Mastering Medicare: Essential Coding & Billing Techniques.

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

NOVEMBER 14 OCTOBER 10 AOPA Webinar: Year-End Review: What Should You Do To Wrap Up the Year & Get Ready for the New Year? Register online at bit.ly/2018webinars. For more

AOPA Webinar: Evaluating Your Compliance Plan & Procedures: How To Audit Your Practice. Register online

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

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

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

OCTOBER 18-20 International African-American Prosthetic Orthotic Coalition Annual Meeting. Embassy Suites Downtown Medical

DECEMBER 12 AOPA Webinar: New Codes, Medicare Changes, & Updates. Register online at bit.ly/2018webinars. For more information, email Ryan Gleeson at rgleeson@AOPAnet.org.

O&P News | May 2018

31

TECH TIPS

Details, Details, Details

Close attention to each step of the fabrication process is essential for high-quality orthotic and prosthetic devices

By Michael Martinez, CTO, CPOA

O

ne of the things that I find most important as a lead or senior technician is attention to the details. This concept reaches far into our daily work. In the end, close attention to detail pays off when a patient is fit with a quality device that was produced safely, efficiently, and in a timely manner.

Quality Control Each device delivered to the practitioner or facility (if you work in a central fabrication lab) should go through a series of checks to make sure the device has been fabricated as ordered on the work order and meets a standard of quality that ensures a functional and cosmetically appealing orthosis or prosthesis.

Whether delivery is to the practitioner, the patient (after adjustment), or a facility that utilizes central fabrication, there is an expectation of quality that is the responsibility of the fabrication team.

This includes but isn’t limited to appropriate componentry or plastic thickness for weight, correct torque settings, and use of a thread locker. Good communication between technical staff also is critical as jobs get handed off to other members of the fabrication team who are assigned different parts of the fabrication process.

Examples include metal bending, then handing off to the leather work technician; or plaster modifications, then handing off to the thermoforming technician who then completes the fabrications or hands if off again to have straps and other accessories applied.

At the end of this process, there should be a final check of each device to ensure all of the standards of quality

32 O&P News | May 2018

U N I V ER SIT Y OF V I RGI N I A HE A LT H SYST EM

PLACE LABEL HERE.

0300010

U N I VWORK IF LABEL NOT AVAILABLE, WRITE IN PT NAME & MR# ER SITORDeR LOWeR eXTReMiTY PROSTheTiC Y OF V IRG IN I A Left AK

Right

BK

Bilateral

Height _________

Date In ________________

Weight _________

Activity Level

Date Needed ________________

0300010

1. Procedure

1

2

3

4

HE A LT H SYS M F T EM

Sex:

Color ________________

PlAce lABel

heat guns, compressors, and carver. All these items are vital to our fabrication duties, and failure could force us to stop production while repairs or replacement are completed. We have a machine maintenance schedule and log that we follow with biweekly, monthly, and semiannual checks to keep our machines safe and in good working order. We keep ours by our Material Safety Data Sheet binder so everyone knows where it is and can complete the checks if our assigned technician is out or busy.

Here.

CusTom oRT

Test Socket 1 _________ 2 _________ 3 _________ Set for hoT Alignment 1 _________ 2 _________ iCs WoR k oRdER Transfer and Finish _________________________________________________________________________________________________________________________ Patient Weig

ht __________ if lABel NOt AvAilABle, Write __ Patient® Heigh iN Pt NAMe t _____ & Mr# 2. Socket Frame / Material Vivak Affe 1/8 cted 1/2 3/16 Thermolyn 10mm 12mm 15mm _______ Orthotist _____ diagnosis _____ Side __________ _____Nylglass) 4C AME/Epoxy Lamination ________________ LEFT (1 sleeve Dacron™© felt 1 Sleeve Carbon braid 2 Sleeves _______________ RighT _______________ _________________________ BiLATERAL Other _____________________________________________________________________________________________________________________________________ ______ ___ delivery OrthOsis type dAte __________ Cast UcBl __ ___________________________________________________________________________________________________________________________________________ plastiC type SMO COrreCt Outer Lamination: with Hosmer attachment block _________ (4 strips 1” Carbon Tape 1 iOn Sleeve Carbon Braid Sleeves Nylglass)padding Polypr2opylen AfO thiC Forefoot e Kness 1/8 leather COlO Other _____________________________________________________________________________________________________________________________________ co-Polymer dUAfO leave as r ®

Work Flow Tracking and Device Delivery Our lab services several satellite offices, and the individual in charge of shipping and receiving at our facility is responsible for ensuring all of our fabricated devices are sent to the correct office. We begin this process with instructions on the original purchase order if we are utilizing a central fabrication facility or the item is an over-the-counter device that we do not stock. This ensures that the device is at the correct location when a patient delivery appointment is scheduled.

Our shipping and receiving staff member also keeps track of devices we send out to other facilities for fabrication so the front office staff can correctly answer the inevitable call from a patient who is checking on the status of his or her device. We use a dry erase board to track these movements; this also allows us to see at-a-glance how much work we have in progress, but not in house, at any given time.

These are just a few examples of attention to detail that can help your fabrication process proceed smoothly and keep all of us technicians safe and efficient when producing O&P devices.

casted 3/16 Black Polyethylene Night Splint ___________________________________________________________________________________________________________________________________________ correct Adduc 1/4 tion White low density Solid correct Abduc tion _________MPe Brown ArticulatedAlpha® Locking _________ 3. Liner Iproform _________ Proflex® _________ Cushion correct Supina padding plaC tion Other durr-flex Semi Solid correct Pronat ement ______ Other _____________________________________________________________________________________________________________________________________ ion full __________________ turbo _ Medial Malleo plastiC lus 4. Suspension Shuttle Lock _________ frAfO Type _________ Suctionankle Valve _________ Type _________ lateral Malleo “t” PlS strap lus leave as casted thiC Knes Suspension Sleeve _________ Tes Belt _________ Velcro Lanyard _________ Navicular Area s Medial Other Type _________ to 90 degree 3/32 s dAfO Style __________________ lateral Other ___________________________________________________________________________________________________________________________________ to ______ Planta 1/8 _______ insert rflex KAfO Torque setting Locktite to ______ dosifle 5/32 extra padding x full metal 5. Components in transFer valgus/varus 3/16 ______ to __________________ Metal/Plastic full Neutral 1/4 Socket Adapters ___________________________________________________________________________________________________________________________ _ Other KO tattoo __________________ Tube Clamps _______________________________________________________________________________________________________________________________ PtBO Knee __________________ padding type __________________ _______ _______ Pylons _____________________________________________________________________________________________________________________________________ full Plastic leave as casted Alipast™ __________________ _______ Metal/Plastic Foot adapters ______________________________________________________________________________________________________________________________ to ______ flexion pOsting Pelite® __________________ _______ HKAfO to ______ extens Stats Adapters _____________________________________________________________________________________________________________________________ Plastic Puff __________________ _______ ion tHKAfO valgus/varus Torque setting Locktite _______ crepe PPt® to tlSO A P Neutral forefo Bi lam Prosthetic Feet _______________________________________________________________________________________ Serial #___________________________ CarbOn ot Post Bi valve Other Medial Prosthetic Knee ______________________________________________________________________________________ Serial #___________________________ reinFOrCeme Scoli __________________ lateral nt Soft frame Ankle ____ Prosthetic Hip ______________________________________________________________________________________________________________________________ Hindfoot Post thigh cuff Medial calf cuff 6. Prosthetic Cover ______________________________________________________________________________________________________ Chest lateral Skin: size & color __________________________________________________________________________________________________________________________ anKle type flexure Joint® upright mat erial 7. Other 3 to 4 tamarack™ Aluminum inches dorsi assist Stainless Steel ___________________________________________________________________________________________________________________________ Oklahoma Width/thickn ess ___________________________________________________________________________________________________________________________ Prox. Thigh free 3/16 x 5/8 double Action ___________________________________________________________________________________________________________________________ 1/4 x 5/8 CHJ Pins ___________________________________________________________________________________________________________________________3/16 x 3/4 Spring 1/4 x 3/4 P# ____________ Prox. Thigh ___________________________________________________________________________________________________________________________ _____________ COntOured Groin ___________________________________________________________________________________________________________________________ JOint head Mid. Thigh stirrup type Medial s ___________________________________________________________________________________________________________________________ Solid lateral long tongue Discal Thigh ___________________________________________________________________________________________________________________________ Split grOwth exte nsiOn P# ____________ Knee Center 8. Adjustments __________________________________________________________________________________________________________ yes _____________ Above Knee ___________________________________________________________________________________________________________________________ Knee Fig. Head types Below Knee ___________________________________________________________________________________________________________________________ free Motion Widest Calf drop lock ___________________________________________________________________________________________________________________________ Knee pad retainer 4 Buckle ___________________________________________________________________________________________________________________________ Mid Calf Offset 5 Buckle Bail ___________________________________________________________________________________________________________________________ Other Smallest Step lock Calf ____________ ____________ Other ____________ TeChniCiAn SiGnATURe: ____________________________________________________________________ DATe:__________________ ____________ Ankle ____________ __________________ ____________ ____________ __________ ____________ P# ______ ____________ FORM # 110179 CAT: 03-H & P/Consult/Health History (ORIG. 02/11) To reorder, log onto http://www.virginia.edu/uvaprint __________________ 1 OF 1 ______ ____________ _ ____________ ____________ ______ hip JOint type ____________ ____________ ____________ free Motion ____________ ____________ i have fabric ____________ drop lock ated orthosis ______ ____________ per work order.

All screws were ____________ ______ retainer ____________ tightened and ____________ Technician signat Loctited.® ____________ range of Motion ____________ ure ____________ ____________ ____________ fOrM # 110181 __________________ P# ____________ ______ _____________ ____________ cAt: 03-H & P/consu _____________ ____________ ______ lt/Health History ____________ (OriG. 01/11) ____________ to reorder,

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log onto http://ww

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have been met. We have a signature line on all of our work orders for the responsible technician to verify that the device was fabricated per the order and is ready for delivery.

Machine Maintenance We use many different machines on a daily basis, and regular maintenance is vital to keep them in good working order. Taking the time to check for wear on belt sanders and band saws can prevent damage to an expensive component/device or injury to a technician if the belt fails while grinding or if a saw blade fails while it is cutting. Over the years, I have seen preventable injuries happen just because no one noticed the fraying belt or careless use of cutting tools.

We give attention to all of our tools, including our vacuum pumps, cast saws,

Michael Martinez, CTO, CPOA, is with UVA Prosthetics and Orthotics in Charlottesville, Virginia.

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

ION TRAT S I G RE

OPEN

PASSPORT

INNOVATION

Vancouver is easy to explore during your time at the downtown Vancouver Convention Centre as there are many nearby top attractions.

• • • • • •

Capilano Suspension Bridge Vancouver Aquarium Forbidden Vancouver Stanley Park Horse-Drawn Tours Harbour Cruises & Events Flyover Canada

• Vancouver Lookout • Dr. Sun Yat-Sen Classical Chinese Garden • Vancouver Art Gallery • Science World • Grouse Mountain

Experience Beyond Vancouver’s unbeatable location makes it the perfect gateway to the rest of British Columbia and beyond, providing you with outstanding opportunities for pre- and post-conference travel.

• Whistler • Okanagan Valley • Jasper • Victoria • Banff • Cruise to Alaska

AOPAnet.org

#AOPA2018

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

RHEO KNEE

®

The perfect combination of stability and dynamics Combining both the safety and stability users need with the dynamic walking experience they want, RHEO KNEE automatically adapts with every step so users can walk their way.

NEW FOR 2018 • UPGRADED Össur Logic app with new user training tools featuring live feedback.

• ENHANCED stability control.

• MORE ROBUST exterior design with easier access to charging port.

Visit ossur.com/rheoknee or ask your Össur representative about RHEO KNEE today.

© Össur, 04.2018

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

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