American Academy of Orthotists & Prosthetists

February 2008 • Vol. 4, No. 1

Advancing Orthotic and Prosthetic
Care Through Knowledge

Orthotists: Our Role is Vital for Successful AIS Treatment

   A unique healthcare environment providing advanced prosthetic and orthotic appliances
   to our nation's veterans.

Richard H. Nelson, CPO
John Milani, CPO

Introduction

It has been the mission of the Prosthetic and Sensory Aids Service (PSAS) to provide specialized quality patient care by furnishing properly prescribed prosthetic equipment, sensory aids, and devices in the most economical and timely manner in accordance with authorizing laws, regulations, and policies. PSAS serves as the pharmacy for assistive aids and as case manager for prosthetic equipment needs of the disabled veteran. PSAS has a national network of prosthetic and orthotic laboratories that provide a unique system of healthcare for those veterans who have had an amputation of the upper or lower extremity, or who have suffered from paralysis or weakness of a limb (figure 1). To provide these services and meet the challenges of our current Department of Veterans Affairs (VA) patients and future combat patients, the Veterans Health Administration (VHA) has prosthetists and orthotists who are dedicated to serving our VA patients and providing the most current technology and products. Efforts to ensure that our prosthetic and orthotic laboratories are functioning at their highest level include accreditation of labs and certification of staff by nationally recognized credentialing agencies, as well as residency programs and continuing education.

Accreditation and Education

The VA actively seeks independent accreditation of its network of orthotic/prosthetic laboratories. At this time, 58 (100 percent) of its O&P labs are accredited by the American Board for Certification in Orthotics, Prosthetics & Pedorthics (ABC) or the Board for Orthotist/Prosthetist Certification (BOC). These labs are authorized to custom fabricate prosthetic and orthotic appliances for any veterans requiring these devices, and who choose to have their devices fabricated and fitted by the VA. The VA also has more than 600 contract providers nationally, from which patients can elect to have their custom devices fabricated and fitted.

Additionally, VA orthotic and prosthetic laboratories are currently staffed by 185 employees. Of these, 132 (72 percent) are certified as orthotists and/or prosthetists by ABC or BOC. The VA actively recruits certified practitioners for its facilities.

Seeking to maintain competency, the VA supports and encourages its certified orthotists/prosthetists staff through funding of continuing education programs at the national and regional levels. Most of the certified orthotists/prosthetists have attended at least one national or regional continuing education symposium in the past two years. Sizable VA contingents have been very noticeable at recent American Academy of Orthotists and Prosthetists (the Academy) annual meetings.

Full-day VA business and clinical education sessions have preceded each of these Academy programs.

Supplementing these efforts, the VA is in the process of developing its own education programs to meet the unique needs of its O&P clinical and technical staff.

Desiring to mentor the development of new O&P clinicians, the VA is working with the National Commission on Orthotic and Prosthetic Education (NCOPE) to host O&P residency programs in its facilities. Currently, NCOPE accredits residency programs at 17 VA O&P Labs. The number of VA NCOPE-accredited facilities will continue to increase in the coming months.

In partnership with the VA Office of Academic Affiliations, each VA O&P lab accredited by NCOPE has the opportunity to recruit and employ as many as two O&P residents per year.

As in the Capabilities summer 2006 publication, the VHA has developed a polytrauma system of care to meet the rehabilitation needs of a new generation of veterans with injuries from current combat operations in Iraq and Afghanistan. Blasts are the most common cause of recent combat injuries. The term polytrauma is now being used to describe the injuries to multiple body parts and organs that occur as a result of exposure to blasts. Traumatic brain injury frequently occurs in polytrauma in combination with other disabling conditions such as amputation, auditory and visual impairments, spinal cord injury, post-traumatic stress disorder, and other medical problems. Due to the severity and complexity of their injuries, service members and veterans with polytrauma require an extraordinary level of coordination and integration of clinical and other support services. As part of this system of care, our PSAS and prosthetic and orthotic laboratories are active participants at these Polytrauma Centers and throughout the VHA system of care to provide quality services and products to these injured combat patients and to current patients.

Emerging Technologies

Veterans at VA Medical Centers can expect to benefit from the latest scientific advances in healthcare and emerging technology available (figure 2). VA healthcare specialists have access to the latest technologies, and many labs have CAD/CAM capabilities, which enhance access. These include orthotic stance control knee systems, prosthetic microprocessor components such as the RHEO KNEE®, Adaptive Knee, the C-Leg,® and PROPRIO FOOT™. These computer-controlled hydraulic, pneumatic, and rheomagnetic systems are regulated by internal feedback. Sensors in the pylon and the knee itself send information such as toe load, knee angle, and other information to an onboard microprocessor (figure 3). It is the goal to increase mobility and improve quality of life for a greater range of amputees than ever before.

No less important than new prosthetic technology is the overall care an amputee receives during rehabilitation. The model for that care has changed over the years to improve services to VA patients. The goal is not only to teach amputees to walk or use an artificial arm and hand, but also to integrate body, mind, and machine. Continuing care and long-term support from VA multidisciplinary teams have shown that patients often can improve their functioning months or years after injuries or amputation.

In the past, most VA prosthetic patients were injured or lost limbs in combat. Today the typical patient is a middle-aged male who has suffered an amputation or loss of function due to disease or cerebral vascular accident. Times change, however, and the VA is providing orthoses and prostheses to increasing numbers of women veterans and veterans of the current conflicts in Iraq and Afghanistan.

The Future of the VA

Looking to meet future needs, the VA established a full-time position of national clinical manager to oversee the practice of orthotics and prosthetics at its facilities. John Milani, CPO, serves as national clinical manager. The national clinical manager is tasked with comprehensive management of the O&P labs, development of NCOPE O&P residency programs, O&P facility accreditation, staff certification, continuing professional education and development, and professional and work environment standards. Milani formed and chairs the O&P Lab Workgroup. This workgroup is made up of certified orthotists and prosthetists from VA O&P labs around the country serving in an advisory capacity for the development of quality improvement and strategic plans for the VA O&P laboratories.

Current strategic planning envisions VA O&P labs as setting the standard for the practice of orthotics and prosthetics. The VA expects to be one of the largest affiliations for O&P residencies in the United States. Through increased funding of continuing education, state of the art facilities, and opportunities for research, the VA hopes to encourage progressive O&P clinicians to select careers in its facilities.