O&P and Therapy: A Perfect Fit

Close relationships between O&P practitioners and physical and occupational therapists can have a lasting effect on a patient’s success. Many O&P practices have found ways to increase the level of communication with therapists, with some practices embedded in hospitals or even incorporating therapy into their own private practice.

“Having O&P [practitioners] and therapists working together adds to the quality of the care that patients receive because there is a consistency in the approaches, in the prescription process and then in the follow-up care,” Donald Shurr, CPO, PT, manager of orthotics and prosthetics at American Orthotics and Prosthetics Inc. (AOP) in Iowa City, said.

When patients receive information from different groups of people throughout the stages of care —preamputation, periamputation and follow-up in rehabilitation — and those three different groups do not communicate with each other, “it is often very confusing for the patient who has just lost a limb and is scared to death of what is coming in terms of how they are going to be able to get around and who is going to take care of their needs,” Shurr said. “When the groups are all under the same roof, it makes it easier for the patient.”

“A combined approach allows for a seamless care model in which patients can progress at the pace that is best for them in a very efficient environment,” John M. Miguelez, CP, FAAOP, president and senior clinical director at Advanced Arm Dynamics, said. “There is no bouncing between the prosthetist’s office and the therapist’s office. When it is all under one roof, it is working as a collaborative team and the patient really excels with their rehabilitation.”

“You can achieve greater patient satisfaction when the patient has a team supporting them,” Kelly Lee, CP, of the Rehabilitation Institute of Chicago, said. “Prosthetists and therapists have different ways of looking at some of the challenges that amputees face. The prosthetist might approach it from a technical side — building the optimal prosthesis — but the therapist is considering how the prosthesis fits into the patient’s activities of daily living and how it fits into their home environment. When we are working as a team and the therapist and prosthetist are there to give each other feedback, we end up with an optimized outcome.”

Benefits of combining O&P and therapy

In addition to optimizing patient outcomes, incorporating therapy with O&P offers opportunities for using evidence-based practices. “Physical therapists and occupational therapists regularly use outcomes measures and evidence-based practices, probably more than prosthetists do,” Lee said. “When we work synergistically using these tools to assess the patients and use them as a method of tracking progress, we can really see whether some of the prosthetic components that we are using are effective.”

Therapists can also provide valuable and educated feedback to the prosthetist that can help to optimize the patient’s outcomes. “Perhaps a component could be improved or an alignment change is needed, or in the case of an upper-extremity patient, perhaps they need some type of adjustment in either their programming,” Lee said. “Therapists’ feedback can be very helpful because we can make those changes so we can once again optimize the patient’s outcomes.”

Having a therapist in the same building as the prosthetist, like at the Rehabilitation Institute of Chicago and Advanced Arm Dynamics, gives prosthetists the opportunity to see the patient use the prosthesis in a safe environment and confirm that they assessed the patient at the correct functional level. “We can go and watch the patients in therapy and see how they are doing and see [whether] the components are appropriate,” Lee said. “We can evaluate these different components in a safe environment where the patient is under the care of a therapist using appropriate assistive devices.”

Miguelez echoed this point: “Often in an outpatient rehabilitation facility, the method used to determine functional outcome is whether the prosthetist did a good job with the prosthesis. If that is the case, then to have a professional there to help the patient maximize to their potential is almost like an insurance policy. It does not matter how well the prosthesis is designed; the patient cannot use it if they miss the mark.”

Working closely with therapists also offers opportunities for adapting or trying new technologies. For example, a patient may be using a last-generation myoelectric arm and be interested in trying a new multifunction hand or using a prosthesis with pattern recognition. “Working closely with an experienced occupational therapist can help the patient to figure out if they are able to adapt to and benefit from some of the newer technologies that they would not be able to integrate at home or independently,” Lee said.

At Advanced Arm Dynamics, Miguelez said the staff is committed to research and development. “When you do research and development with a shared team that has different perspectives, you can really accomplish some pretty cool things,” he said. “One of the things we are working on right now is trying to create a predictive outlet for how well patients can do and how it might relate to reimbursement.”

Miguelez also mentioned that having a therapist on staff helps when working with insurance companies for coverage. “The therapist is, a lot of the time, a medical necessity and works for outcome and therefore plays a critical role in the approval of services,” he said.

Combined approach in action

Shurr has worked for APO since 1985, and although the company does not employ therapists on staff, it is situated within a major university teaching hospital so prosthetists are able to work closely with orthopedic surgeons, therapists and all members of the medical team.

“It is a little unusual because most or many large universities have their own services that they control as employees,” Shurr said. “I have had and continue to have very close relationships with most of the people who provide us with patients and who consult us for ideas about what they should be thinking about before they do an amputation, for example, and what kinds of opportunities we could provide their patients after amputation in terms of prosthetics.”

Shurr played a role in establishing the current model of care between APO and the University of Iowa Hospital. He served as a physical therapist for the hospital for 16 years before obtaining his certification in O&P. As a therapist, “my understanding was that I needed to get together with the prosthetists and orthotists who worked with me at the time and learn as much as I could from them about how they operate and in turn teach them as much as I could about how I operate,” Shurr said.

The Rehabilitation Institute of Chicago specializes in upper extremity and multilimb amputees. “In these situations, you have to have a team approach with the physicians, the occupational therapists, the physical therapists and even the speech therapists,” Lee said.

This team approach proved beneficial for one particular multilimb amputee at the Rehabilitation Institute of Chicago. The patient sustained an above-knee amputation, a below-knee amputation, a below-elbow amputation and a partial hand amputation after a motor vehicle accident. “All of these amputations were very complicated presentations; none of them were straightforward,” Lee said. “In this type of case, it takes a physical therapist calling the prosthetist and saying, ‘Well, I think it is a long shot, but let’s get started; I think we are ready and I am going to work with you.’ Then the prosthetist says, ‘I think this person can walk; can you get them up more often?’ It is just that feedback of pushing each other to the maximum capabilities to see what the patient’s limitations are.”

This particular patient went from being bed-bound in a coma to walking independently without assistive devices, according to Lee. “It was a 3-year road with inpatient and outpatient therapists, but he has gone on to be independent and I think that is incredible given his limitations,” she said.

For 10 years, Advanced Arm Dynamics, has offered O&P services with a dedicated full-time therapist who is involved in patient care. The company’s care model begins with expedited fittings that start with an exam with casting. “While we are modifying the cast, the patient is working on range of motion, strengthening, etc., with the therapist,” Miguelez said. “So there is really no downtime for the patient and they progress quickly.”

The therapist, prosthetist and a psychologist perform the initial patient assessments together and establish an appropriate and efficient rehabilitation plan for a given patient. “These different perspectives all come together and unite to find a single rehabilitation plan,” Miguelez said.

The therapists at Advanced Arm Dynamics also offer long-term therapy to help patients achieve advanced skills in the work and home environments. These therapists not only work with patients in the center, but also go to patients’ houses to ensure they are comfortable with activities of daily living. “One of the things we usually do on the fourth day of the expedited fitting is place patients in a temporary prosthesis and go out into the environment,” Miguelez said. “It could be going to the market and buying food. If the patient is not confident about what the prosthesis can and cannot do, having someone there with them to problem-solve and help with the social readapatation is important to long-term success.”

Therapists also perform a workplace assessment with patients to help them develop the skills necessary to return to work. “Patients receive very focused and intentional training to become comfortable with their prosthesis and the wear and care of it and being able to take it out into the community,” Tiffany Ryan, MOT, OTR/L, national director of therapeutic services at Advanced Arm Dynamics, said. “That integration into life is the biggest hurdle for the patient and the therapy team is focused on making sure that happens for the patient.”

“All of these things are value added to the patients as well as the reimbursement agency,” Miguelez said. “When we spend time to develop a prosthesis that the patient actually integrates into their lifestyle, part of it is good design, part of it is good training and part of it is good support and dedication.”

The success of this model is seen in one young patient, who went to Advanced Arm Dynamics after losing his arm in a boating accident. “He was very uncertain about his future and if he would ever be able to work and provide for himself again and interact with people,” Ryan said. “We’ve been able to work with him through that process with O&Ps and therapists working together to ensure that we have the right prosthesis for him, one that met his lifestyle needs and fits his personality, and then we trained him out in the community.”

With the care the patient has received, he now feels comfortable integrating the prosthesis into his life and works full-time in a sales position. “He is super motivated by what he is able to do now,” Ryan said. “Over time, we would see a spark of his personality to the point where now he just radiates with pride in himself.”

Keys to success

When incorporating O&P and therapy, Miguelez stressed the need to create an environment that is filled with respect and communication. “While at the end of the day the main focus is on what is best for the patient, different professionals and different skill sets have different approaches to achieving that,” Miguelez said. “You can run into challenges if you do not have good communication and respect for each other’s skills. It is not just having an O&P facility and adding a therapist. You have to make an investment in creating a team that works well together and respects each other.”

“Communication probably more than anything else is the beginning of success for a combined treatment approach,” Shurr said. “If you do not have easy communication and access to other members of the clinical team, the process is going to be much more difficult.”

The staff at Advanced Arm Dynamics puts time and effort into team building each year. “We create scenarios in which we bring the whole clinical team together and try to work on ways in which we can improve,” Miguelez said. “You are a team and you have a shared goal. It sounds easy, but it is a challenge. Everybody has to work together.”

The keys to communication between O&P practitioner and therapist are similar to those in any work environment, according to Lee, and they include having professional communication and feeling comfortable expressing one’s opinions for the benefit of the patient. “If you remember that both prosthetists and occupational and physical therapists are advocates for the patient and for their outcome and maybe even sometimes for their family, we can have that open communication,” she said. “When you have the opportunity to exchange ideas, you really get the most out of the relationship.”

Lee, Miguelez, Ryan and Shurr all have the advantage of being able to walk down to a colleague’s office or practice room and speak to them while they are with a patient. “But when that is not an option, it is important to communicate, whether in writing, email or phone, directly with the treating clinician and not via the patient,” Lee said.

Ryan stressed the importance of constant communication among the medical team from the first time the patient visits the practice throughout the rehabilitation process. “We are partners in providing services to our patients,” Ryan said. “We plan the rehab process together; we know we each have our goals to work toward as independent clinicians, but they are meshed in each other’s goals. At the end of the day, the patient is the focus.” – by Tina DiMarcantonio