Growth of the O&P Profession

In the early days of O&P, people broke into the field through apprenticeships. They watched limb and brace makers, and learned the skills necessary to make a leg or fashion a brace. Many businesses were family-owned, and people passed down knowledge to their children.

Today, orthotics and prosthetics has developed into a thriving profession, and has earned a place among other allied health professions, such as physical therapy and occupational therapy. Educational options continue to evolve, offering would-be apprentices the opportunity to develop some of the same skills as physicians and researchers in other health care sectors.

Increasing by numbers

When the American Board for Certification in Orthotics and Prosthetics (ABC) was created in 1948, it certified 22 O&P practitioners, a number which has grown significantly in the past 60 years. According to a study prepared for the National Commission on Orthotic and Prosthetic Education (NCOPE), “Issues Affecting the Future Demand for Orthotists and Prosthetists: Update 2002,” the projected number of certified O&P practitioners – 4,757 by the year 2020 – would not be sufficient to meet the needs of an aging population. According to ABC, the actual number of practicing orthotists and prosthetists has far surpassed expectations, as the number of certified practitioners has already reached 5,568 in 2007.

Although NCOPE’s study does not include the most recent data, its conclusions correctly asserted that the number of practitioners needs to rise in order to meet the number of patients requiring orthotic and prosthetic treatment.

“We have to figure out a way to turn out more graduates,” said Tom Karolewski, CP, FAAOP, assistant director of the Prosthetic-Orthotic Center at Northwestern University in Chicago. “The Baby Boomers just turned 65, and for the next 20 years, there is going to be a tremendous increase in numbers of individuals entering 65 and above. Diabetes and other diseases will cause amputations or will require orthoses [for many of these individuals].”

Advancing the technology

Hands holding small tree
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Fortunately for those individuals, new O&P technologies increase at a rapid pace.

“The changes have been enormous from when I first started in the field to the present,” said Jeff Eichhorn, CP, director of orthotics and prosthetics at Shriners Hospital for Children in Philadelphia. “Everything from silicone suspension liners, locking systems, and different types of carbon energy-storing feet has flooded the field with technology.”

These changes have not only advanced technology for devices that are already available, but also provided an influx of new options for amputees.

“It’s an exciting time to be involved with prosthetics because there are a lot of developments happening, both with powered devices and also with the means of controlling them,” said Jack Uellendahl, CPO, prosthetics clinical specialist at Hanger Prosthetics & Orthotics in Phoenix.

Uellendahl expects changes during the next 5 to 10 years, and notes that the beginnings of many of these developments have come about only in the last 10 years.

“Even 30 years ago there were some powered systems available, but they’re much more widely available and much more widely used in the upper limb today than they were then,” he said. “In the last 10 years, we’ve seen some powered systems come into the lower extremity. Mostly passively powered [systems] like the C-Leg, but some powered products are actually reaching the market as well now.”

Improving patient comfort and options

Another aspect of new development came in gel form. Gel liners and other such fitting techniques have allowed some amputees who were previously unable to wear prostheses the opportunity to be fit for certain devices.

“The use of gel liners has impacted the comfort of a prosthesis, and comfort is where it all starts,” Uellendahl said. “If we can’t make a prosthesis that is going to be comfortable for someone, it doesn’t matter how high tech the componentry is, because [the patient] wouldn’t be able to use it effectively.”

Even children with limb loss or limb differences have started to benefit from the advancements, thanks to a “trickle down effect.”

“The technology of energy-storing feet is giving kids the opportunity to play sports and keep up with their peers in track, football, basketball,” Eichhorn said. “It has given them the opportunity to be accepted more within the sports fields.”

He also points to the opportunity for practitioners to gain experience with other medical technology, such as CAD/CAM systems and the software associated with those systems.

“The increase in technology [is exciting], not only for the patient but also for the practitioner, who is able to work with this higher technology.”

Eichhorn noted that the future wave of technology will be borne from necessity in order to meet the new wave of amputees, especially those coming home from the conflict in Iraq and Afghanistan.

“From my understanding, the quadrilateral socket was invented after World War II,” he told O&P Business News. “Many patients, even those who aren’t in any kind of a conflict, can benefit from all the technology coming up.”

Luring people to O&P

Perhaps one of the most significant changes in O&P is the fact that an increasing number of people are familiar with, and interested in, the profession. The media’s portrayal of amputees – through coverage of athletic events and inspirational stories – has created a new wave of professional interest.

“[O&P is] attracting a different type of practitioner into the field because of a greater awareness of prosthetics through the media,” Uellendahl said. “I think that a big benefit for amputees and for the profession is being able to attract people who had more of an engineering background to become practitioners.”

The profession’s increased visibility has brought greater responsibility. This exposure has paved the way for better practices, documentation and research.

“When a prosthesis and an orthosis were so low in cost that it had almost no impact on the health care system, there was no interest in any research to speak of, and it probably wasn’t necessary,” said John Michael, MEd, CPO/L, president of CPO Services Inc. in Portage, Ind. “As O&P has matured as a profession, as our technology has matured, suddenly we have become a factor in the health care system.

“I think that drives interest then in having better proof [to back our recommendations], and the fact that we have this cornucopia of choices makes it a perfect time for us to develop better proof,” he said. “The move to better documentation serves patients better.”

Another aspect of change in the field has been one of personal preference. Over the years, more amputees have chosen prostheses without cosmetic coverings.

“Because of the visibility of amputee athletes and people with limb differences and other disabilities in the population, there is a much bigger acceptance of amputees and of people wearing prostheses that look like prostheses, instead of looking like legs,” Uellendahl said. “That was pretty much unheard of 30 years ago.”

Eichhorn sees the same effect in the children he treats.

“We fit a lot of kids without cosmetic covers, as patient preference,” he said. “At least within the last 5 years, more kids aren’t going with the straight cosmetic [covering]. They are [asking for] colorful patterns and different graphic designs to be laminated on their prosthetic sockets.

“The cosmetic is there. It is just the mentality has changed of what is cosmetic.”

Building better O&P businesses

PlantDuring the past 30 years, the business of O&P has become more sophisticated, with practitioners now running fairly complex business operations.

Michael remembers the “how-to” of running a successful O&P facility when he joined the field in the 1970s.

“If you did ‘good’ – that is, if you focused on direct patient care and did the best you could for your patients – by the end of the year, you would also be doing ‘well,’ meaning the business part would take care of itself.”

That formula has become more complex now, and it takes a good deal of planning and commitment to sustain a practice. Practitioners who combine business and marketing skills with attention to patient care will prosper over others who concentrate on only one side.

“In the old days, you gradually became a viable business over 3 years to 5 years, but you really focused on the patient,” he said. “In today’s world, you have to have at least half your focus on the business when you start. The impact of patient care takes 3 to 5 years to come to the surface, but the impact of doing poor business planning immediately becomes a problem.”

Many practitioners have applied today’s standard business practices to their own businesses, which has helped them thrive.

“I think the one thing that jumps to my mind that almost everyone either has done or is seriously considering is moving to a full electronic platform for patient records and billing,” Michael said. “It ultimately saves time, and that is the one thing that we cannot get more of.”

Complete electronic platforms can include electronic billing, electronic compliance and electronic tracking and referral systems.

“That is the kind of practice that I see as the ‘norm’ in 2050,” Michael said. “[Practitioners] have important demands for business savvy and legal compliance, and if they are set up electronically, they can do a lot of that efficiently.”

Leveraging collective success

Electronic systems are just one example of another way the O&P community continues to thrive, according to Michael.

“I think we also do a better job of building on our collective success,” he said.

He cited that the American Orthotic and Prosthetic Association (AOPA) will soon release an updated CD with electronic forms for running an O&P practice: measurement forms, tracking sheets and sign-in sheets, to name a few. In addition, both AOPA and The Orthotic & Prosthetic Group of America (OPGA) offer procedure manuals that meet many of the major compliance requirements.

“[Another] huge advantage to all of us, including our patients [is that] if people run their practice rationally, it avoids some of the terrible confusion we had in years past,” Michael said. He cites an example where a facility continued billing insurers only one-third of the current wholesale cost for myoelectric prosthesis batteries not realizing the price had gone up over the 15 years since they established that fee.

“A lot of that kind of basic naivety is diminishing,” he said. “At this stage in the evolution, I would say we have voluntarily raised the bar for ourselves.”

He sees the O&P profession in an important stage of transition, with a clear path to forward development.

“I think it is becoming increasingly clear that the old models are not completely effective in the new world,” Michael said. “We begin to see what we need to be more effective in the new world, and I think we’re starting to build the infrastructure to let us compete effectively.”

He expects these improvements to continue into the future.

“I think our best is good, and I think it is far better than it was in 1950,” he said. “And I suspect that it will be better yet in 2050.”

Advancing the Profession

The growth that the O&P profession has experienced in the past continues to expand more each year. O&P Business News asked some of today’s leading authorities about the most influential voices in the field thus far.

John Michael, MEd, CPO/L

“I don’t see any major drivers [of change within the profession]. What I see is hundreds of little drivers that collectively push us in the right direction. It is the 30-year accumulation of little changes that suddenly made it clear that we are going to move into an era – we will live in an era, we will function in an era – where technical compliance, where paperwork tracking is a crucial skill.

[Also], private development by private O&P component manufacturers has given us better high-tech solutions and better low-tech solutions. They have broadened the choices for our patients. I think that is in everyone’s best interest, including my own as a taxpayer.

The challenge now becomes [that] … at the moment, we have a lot of marketing information, much of which is hyperbole, and we have a little clinical experience. … That is, I think, where the evidence-based practice comes in. I do not want to retard the innovations through research and development, especially through product development that private manufacturers are doing. I think it challenges us all then to make good decisions. But I would like to see the academic infrastructure strengthen and move forward so the new generation of CPOs is better equipped than I am, at this point, to make specific decisions.”

Mark Edwards, MHPE, CP

“I think the forefathers of formal education would probably be the people from the original three schools: University of California at Los Angeles, New York University and Northwestern University. So people like Sid Fishman, Norm Berger, Miles Anderson, Clinton Compere, Blair Hanger, Colin McLaurin and Fred Hampton, just to name a few.

The development of NCOPE certainly pushed the profession to be looked at more critically in the educational arena so that we are on par or meeting minimal standards to be able to communicate and compete with other allied health professions.”

Tom Karolewski, CP, FAAOP

“Some of the influential individuals – such as Sid Fishman, Charlie Fryer, Blair Hanger, Don Colwell and Miles Anderson – were instrumental in the development of O&P education. The list of people who pioneered the early development of O&P education in the United States is extensive.”

Jeff Eichhorn, CP

“For myself, one of the biggest influences in my career, was Jack Uellendahl. At the time, he was the director of orthotics and prosthetics at RIC and I was an employee there. He was influential in my career.”

Jack Uellendahl, CPO

“It is a normal progression. I wouldn’t say it was one thing that revolutionized prosthetics. It is a combination of many different developments: better manufacturing, better electronics, smaller lightweight things, some materials have played a big role.

I wouldn’t say that it was manufacture-driven necessarily, although the manufacturers are certainly out there to try and find the best components and the best devices for fitting people. But there were also practitioners who were innovative and came up with new ways and new products themselves.

[Progression] requires all people involved working together. Engineers are great at designing and inventing new ways to do things, but they need input from practitioners and users to figure out what is [necessary]. Then you need to have a manufacturer that is going to pick that up and make it into a product and make it available. It requires all of those parties working together and finding new solutions.”


Accelerating through education

After the days when entering the O&P profession involved apprenticeships, practitioners were required to have completed high school. Over the years, the educational requirements were raised to associate’s degrees, and beginning in the early 1960s, New York University was the first to offer the bachelor’s degree program, according to Mark Edwards, MHPE, CP, director of prosthetics education at Northwestern.

In the late 1980s, ABC ruled that all O&P practitioners must hold bachelor’s degrees in order to qualify for the certification test.

Recently, NCOPE has declared that by 2010, colleges and universities must have a plan to convert all O&P programs to entry-level, clinical master’s degrees, if they do not have a full master’s program already in place. Georgia Institute of Technology and Eastern Michigan University were the first to establish master’s level programs. Northwestern University is another institution transitioning to a master’s degree in both orthotics and prosthetics.

Currently, these master’s degree programs meet the same minimum requirements as bachelor’s programs and certificate programs, Edwards said. The difference is that students taking those courses graduate with a master’s degree.

These requirements will change in the near future, Karolewski said.

“There definitely will be a separation between what used to be the certificate program and a master’s level program,” he said. “There will be an introduction of a variety of different courses, from clinical – how to deal with bedside manner and patient care – to research, so that the average clinician can have more research-based knowledge.

“Stepping up to a master’s level helps give us a little bit more credibility,” he said. “Practitioners will be able to understand the components better as the future progresses. Not only that, but it helps to elevate us to keep us equal with the other allied health.”

Thus far, O&P’s course has been charted by many other industries, especially those in the health care sector.

“I think it probably has taken a pretty similar path to most of the allied health professions, specifically physical and occupational therapy,” Edwards said.

Karolewski would like to see this path continue.

“Physical therapists are at a doctorate level and occupational therapists are at the master’s level,” he said. “It just stands to reason that we also need to step up and be at the same level as the other allied health professionals.”

Eventually both educators foresee that the O&P students of tomorrow will possess a greater set of skills than the students of yesterday, and of today, thus advancing the profession even further.

“I would suspect that students graduating from programs with this entry-level master’s degree will be better consumers of research and have higher levels of education in some of the core science courses,” Edwards said. “I think that with a clinical master’s degree, and as better consumers of research, that practitioners then can speak with and collaborate with other allied health professionals to develop evidence and data for better quality care.”

O&P Predictions

There has been much discussion regarding where the O&P profession has been, but where is it going? At this moment, technological advancements are brewing and future practitioners are learning breakthrough techniques. If the following predictions are accurate, the O&P profession appears to be headed for a bright future.

“I think in 2050 we will be operating much more like a general practice physician does today,” said John Michael, MEd, CPO/L. “We’ll be seeing patients on our own. We’ll be evaluating and screening them on our own.”

Michael acknowledges that future practitioners will need additional teaching to prepare.

“We will need to know how to detect problems that are outside our sphere of expertise, especially medical problems, and those patients will be referred back into the health care system for a physician evaluation or a specialist evaluation,” he said. “I think the teams will persist in a few medical centers in major cities, especially university-based medical centers.”

Tom Karolewski, CP, FAAOP, offers a colleague’s opinion that O&P might merge with both occupational therapy and physical therapy to produce a generation of “rehab scientists.”

“Rehab scientist is not as far-fetched as one might think,” Karolewski said. “With the increased numbers, [we would] have a bigger organization and a bigger voice in Congress. I could see the benefits involved. The concept has merit.”

High-tech future

“I definitely see the field still increasing in technology,” said Jeff Eichhorn, CP. “In the future, I see the use of CAD/CAM overtaking hand casts and modifying them in a plaster. I believe that the prosthetist will be doing his modifications solely on computers versus on plaster molds. I believe the technology – with myoelectrics, with computerized legs – will only increase from this point of time.”

Jack Uellendahl, CPO expects that a significant portion of patients will be fitted with osseointegration, as well as implantable electrodes. Research is key to these developments, he says, and it will play an even greater part in the next 5 to 10 years.

“There is a lot of interesting research and some clinical application of ways of improving control,” he said. “It is usually the upper limb where we talk about control and powered devices, but with powered devices coming to the lower limb, it’s also exciting to think about what might be possible with control over those powered devices.”

Practitioners and manufacturers will find an increased need for funding for their research and development, according to Mark Edwards, MHPE, CP.

“There is a big need to have funding and support of educational programs,” he said. “[Currently], all programs are struggling to be able to operate on budgets that allow them to use technology, to increase their faculty, to have faculty development programs. Unless there is some grant money or profession support, it is going to be difficult for struggling programs to survive.”

Unstoppable force

As with other health care fields, technology will continue to increase, regardless of the amount of funding available.

“I think there is a potential for – due to the conflict in Iraq and Afghanistan that is producing more amputees – more young, traumatic users who will demand more technology and better educated individuals to be able to service them,” Edwards said. “I think the government will probably have to step in to look at how these individuals are provided quality care, which will then hopefully filter down to the general public.”

Eichhorn wants the same for his patients.

“I believe that this advanced technology will definitely be able to be used on children as well within the next 5 to 10 years,” he said. “I’m always hopeful of new technology that will help our kids and make them better, stronger and faster in the future.”


Looking to the future

For most practitioners, there is no question that the profession is on its way to a positive and high-tech future. Both will involve a great deal of professionalism and research.

Michael envisions more of the same type of forward movement.

“I see less direct involvement by physicians. Many of the evaluation and differential diagnoses and treatment decisions that [have been] made by a physician in a clinic team setting will be made by the local prosthetist or orthotist on the front line,” he said. “That means we need a broader education in patient evaluation and in alternatives to O&P treatments. We need to become patient care managers, or rehab managers.

“I also see increasingly lower reimbursements, and increasingly higher regulations. We need to have more clinically oriented researchers so that we can get that kind of evidence,” he said.

Karolewski agrees that receiving funding for O&P services will continue to be difficult.

“In order to get funding for components, [we need to employ] evidence-based practice,” Karolewski said. “Master’s programs in the future are going to be more research-based so that students will be able complete studies and state why this component is best for this individual.”

As O&P graduates learn more about research and new technologies, they will be equipped to continue with new research, expanding the technologies for the future. The further these technologies advance, the more research practitioners will need in order to best serve their patients.

“The practitioner in the future will be a liaison between the [patient] and the technology,” Edwards said. “Rather than just being somebody who dispenses a device, they will be somebody who coordinates the care, application and design of various technologies to allow these individuals to have a better quality of life.”

According to Michael, the O&P profession is healthy, and well on its way.

“I think we clearly recognize the major challenges, and we’re making a good global effort to face those challenges. I’m pretty optimistic,” he said. “I think we have the raw material we need to succeed.

“There has been no better time [to go into O&P] in the last 30 years than right now,” Michael said. “But it is going to be a challenge. So you have to be committed, you have to have the passion. Then put your heart and soul in it and I think you’ll have a wonderful experience.” – by Stephanie Z. Pavlou

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