by Robert Aranbayev, DPT, and Salvatore Martella, CPO While physical therapy and prosthetics/orthotics are separate specialties, both inevitably cross paths in regards to prosthetic cases, such as amputee cases. CPOs in their role understand the mechanics of prosthetics and how to create a prosthetic seamless to a patient’s body. The physical therapist has the responsibility to restore healthy movement to injured areas and strengthen a patient’s overall movement to decrease pain and the potential of new injuries. This coexistence between PTs and CPOs leverages two fields of expertise that are essential for creating a long-term solution that positively contributes to the prosthetic user’s quality of life, and this is the model used between New York Dynamic Neuromuscular Rehabilitation & Physical Therapy, New York, NY, and Progressive Orthotics and Prosthetics, Albertson, NY.
Symbiosis Begins with Patients
When a patient receives a prosthetic device, the goal of the PT/CPO team is for the patient to return to their normal life by using the limb in the most functional way. Mobility, freedom and independence are the team’s ultimate goals. Naturally, the prosthetists will be the experts at prosthetics versus the physical therapist. The prosthetists understand the operating sequence of the prostheses, while the physical therapists, at minimal, understand how the prosthetic functions at the most basic level. The optimal relationship has everyone working in their specified role and communicating with one another during pre-prosthetic training and prosthetic training. It is important that everyone is in agreement about appropriately challenging the patients so they can improve without stagnating. For a transfemoral patient, it is extremely important to understand things like stance resistance and swing phase function, especially for the physical therapists, as they’ll be seeing the patients on a regular basis.
A Learning Opportunity
The importance and closeness of the interdisciplinary relationship only may increase organically because of possible knowledge gaps that may exist in a therapist’s overall understanding about prosthetics. Physical therapy curriculums can vary with regard to the depth of study devoted to prosthetics, and some therapists may enter practice with only minimal experience working with patients who need a prosthetic device. Such circumstances can create an opportunity for the CPO to mentor a physical therapist and sharpen his or her understanding about meeting the needs of a prosthetic user. Although prosthetic training programs are available in a variety of formal learning settings, physical therapists oftentimes accumulate most of their prosthetics knowledge through patient cases. One of the best sources for PTs to maximize in-office time with their CPO partner is by asking comprehensive questions and shadowing them in their office. Other great sources for information are prosthetic manufacturer websites and continuing education classes. With better prosthetic education in PT schools, the quality and efficiency of prosthetic patient care will improve. In any case, the interdisciplinary skills of the PT and CPO will continue to interact. The CPO, for example, is able to make proper Rx recommendations by knowing what questions to ask the PT about the patient’s muscle strength, balance, motivation, medical necessity, and K–level. The CPOs must justify every aspect of the prosthesis in order to tailor it for the individual patient; this includes the selection of socket, interface, suspension, and knee ankle complex. The differences in approach for upper extremity and lower extremity cases are also important to note, as there are no weight-bearing requirements when it comes to upper extremity prosthesis.
Fine Points of Fit
The process of fitting a patient with a prosthetic depends on the injury or disease at hand. For some disabilities (such as foot drop), the prosthetic is simply fitted by size. However, when it comes to an amputated limb, the process is much more complicated. It can begin with a temporary initial postsurgical prosthesis, which is kept during the initial phase of healing. Then, it is replaced with another temporary preparatory prosthesis, which is used only during the initial stage of rehabilitation until a functional benchmark is achieved. This type of prosthesis allows the therapist to acquire functional weight-bearing gains toward the maturation of a patient’s gait. This type of preparatory prosthesis may be used during the initial 3-6 months. The next stage is called a definitive prosthetic fitting and generally depends on multiple factors. The definitive prosthesis is not prescribed until the patient’s residual limb has stabilized to ensure that the fit of the new prosthesis will last as long as possible. The definitive prescription is based primarily upon the experience the patient had when using the preparatory prosthesis. To eliminate fear of a lower extremity prosthetic patient returning to a wheelchair, both the PTs and CPOs must constantly encourage and support patients. Scheduling regular follow-up visits instead of waiting for problems or discomfort to appear can also help minimize a patient’s frustration with the prosthetic. And managing the fit of the device on an ongoing basis will help with patient compliance. If the PT sees an early warning sign of a potential problem, such as redness that can be an indication of several fit issues, he or she can send the patient to the CPO and stave off a potentially larger problem.
Communication is Critical
In the early stages of PT and CPO communication, the following must be addressed as soon as the patient enters the PT’s care, or as soon as possible: • Type of prosthesis • Time and fit of temporary prosthesis • Final prosthesis design • Timing of the transfer of temporary to the permanent prosthesis • Type of material used • Antimicrobial prophylaxis • Functional goals Prior to meeting the patient, the PT and CPO must discuss how the patient’s muscle strength, balance, motivation, coordination, and dexterity will be taken into consideration when selecting a prosthesis. The patient’s history and health status, and the type of surgery, must also be discussed. And if a physical therapist ever needs to refer to a CPO, the PT should always check whether the OP practice is certified by the American Orthotic and Prosthetic Association. The PT must also confirm that the OP team has years of experience and is constantly participating in continuing education.
In delivering the prosthetic, a close collaboration between the PT and CPO will reduce turnaround time in delivering the prosthetic to the patient. Time lines for fittings tend to be accelerated if the PT is in regular communication with the CPO. Close collaboration helps the patient procure the documentation required to obtain authorization needed for insurance coverage, which results in the patient getting their prosthesis faster. The sooner the patient can receive their prosthesis, the better. It is common for patients waiting for their prosthesis to become depressed and frustrated, and a longer waiting period just allows an increased likelihood of those feelings to set in. It’s important for the CPO and PT to keep the patient as positive as possible for the best possible results. When patients require follow-up adjustments to their prosthetic, the adjustments are usually done by the prosthetist on an originally established plan. The most helpful way a PT can assist in the follow-up adjustment process is when the PT shares the symptom of a problem a patient is having with the CPO. For example, if the patient is having trouble stabilizing, it’s best for the PT to describe the issue to the CPO versus giving the patient direction on how to adjust the prosthesis. It is important for the PT to let the CPO determine how to fix the fit, function or alignment issue of a prosthetic. If for some reason the physical therapist is not satisfied with the patient’s progress, a device adjustment or alteration should be considered. The future of the PT and CPO relationship will only enhance with better education. And with new technologies on the way, such as the instrumented dual belt treadmill and 3D printers, PTs and CPOs will have an abundance of useful tools to plan a successful solution for their patients who use prosthetics. RM Robert Aranbayev, DPT, is a treating physical therapist at New York Dynamic Neuromuscular Rehabilitation & Physical Therapy. He received an undergraduate degree from Hunger College, New York, and earned a Doctor of Physical Therapy from Touro College. His specialties include the evaluation and treatment of orthopedic disorders and postsurgical rehabilitation. He has a particular interest in the application of manual therapy in sports medicine, and works with a large population of individuals affected by orthopedic and neurological conditions. Salvatore Martella, CPO, is President and co-founder of Progressive O&P Inc. He is also its senior practitioner. Martella has been an American Board Certified Prosthetist since 1995 and an American Board Certified Orthotist since 1996. He earned his Bachelor of Science degree in Prosthetics & Orthotics from Florida International University in 1993. He is a member of the Amputee Coalition of America and of the American Academy of Orthotists and Prosthetists. For more information, contact RehabEditor@medqor.com.