INFLUENCES ON THE ORTHOTICS AND PROSTHETICS PROFESSION
Historically, the study of orthotics began with the ancient art of splint and brace making. 1,2 Bonesetters and brace makers eventually developed into what we now call orthopaedic surgeons and orthotists. Although progress can be documented throughout human history, the most significant contributions to orthotic/prosthetic sciences were made in the 20th century, stimulated by the aftermath of the first and second world wars and the polio epidemics of the late 1940s and early 1950s. 3–5 Injured veterans who returned home from battle with musculoskeletal and neuromuscular impairments or traumatic amputation and polio survivors with diminished neuromuscular function increased the demand for orthotic and prosthetic services. To improve the quality and performance of assistive devices at the end of World War II, particularly for veteran amputees, the U.S. government sponsored a series of research and development projects under the auspices of the National Academy of Sciences. 6 The National Academy of Sciences conducted an extensive research effort, The Artificial Limb Program, in late 1945 when a consensus conference revealed that few modern scientific principles or developments had been introduced in prosthetics. 7 In addition, research and educational committees were formed to advise and work with these research groups. Between 1945 and 1976, universities, the Veterans Administration, private industry, and other military research units were subcontracted to conduct various prosthetic research projects. 8 Although the focus of the Artificial Limb Program was prosthetics, it was anticipated that these efforts would also benefit orthotics.
A formal research directive in orthotics did not begin until 1960. 9 Efforts to investigate the clinical aspects of orthotic practice considered a systematic approach to prescription formulation that lead to development of the technical analysis forms. 10 Nomenclature to describe an orthosis and its function was standardized to identify the body segments it encompassed with the desired biomechanical control mechanisms. 11 The advent and use of thermosetting plastics in prosthetics and the introduction of thermoplastics to the United States, lead by Dr. Gordon Yates, in conjunction with the development of industrial techniques for vacuum forming sheet thermoplastics in orthotics, induced more changes in the orthotics and prosthetics industry. These events lead to the development of numerous innovative designs in prostheses and orthoses in the 1960s and 1970s. 5,12,13 The advent and establishment of the aerospace industry provided advances in ultra light materials engineering that continues to have an impact on the profession of orthotics and prosthetics. 5,14 The development of CAD/CAM (computer aided design/computer aided manufacture) systems for orthotics and prosthetics, which began in the 1970s, and is still in progress today, has transformed the art and workmanship that distinguished the orthotist and prosthetist from other health professionals. These developments will continue to evolve as CAD/CAM technologies improve the design, manufacture, and diagnostic aspects of the orthotics and prosthetics profession in the 21st century.
At the turn of the century in the United States, most health care workers were physicians. Today, physicians make up less than 10percent of health care providers. 15 The increasing advances in technology and methods of patient care have created an enormous expansion of knowledge that has made health care progressively more complex. The increasing knowledge and skills required to provide comprehensive care to patients has resulted in more specialization within the health professions. 16,17 Unfortunately, the proliferation of professional specialties also created problems of fragmented care, mislabeling and misdiagnosis, therapeutic uncertainty, and poor distribution of personnel, resources, and information. 18 Because of these complexities and problems, no single health care discipline is able to provide complete care of the patient. 19,20 To cope with these problems, today’s health care requires the collaboration of health professionals from various specialties working together within an interdisciplinary environment. 15,18,20–24
Changes have also occurred in the structure of third party reimbursement for health care services. The developments of disease prevention strategies and managed care, the move of health care provision away from the hospital setting, and the widening scope of primary care have mandated a collaborative, interdisciplinary approach to health care delivery by professionals within multiple disciplines. 25,26 As the health care industry continues to grapple with the demand to deliver effective health care at lower cost, there is a need to create effective programs to prepare health care providers for these changes. 27 Downsizing in health care, reorganization from traditional functional structures to patient-focused structures, and the use of total quality management approaches that reward group participation over individual efforts contribute to the increased emphasis on interdisciplinary team health care. 28,29 Subsequently, there is a growing need to overcome existing barriers between health care professionals. The next generation of health care professionals will practice in settings that are more intensively managed and integrated. Subsequently, the managed care system in America will continue to channel professionals into new roles that require them to strike an equitable balance between resources and needs. 26
Parallel to changes in technology and health care, the orthotist’s and prosthetist’s role has expanded from a focus on the technical aspects of device design to a more inclusive role as members of a comprehensive rehabilitation team. 30 In addition, orthotists and prosthetists have been pressed to maintain a contemporary understanding of issues relating to the increasing complexity of technological developments, patient evaluation, education and treatment. As orthotics and prosthetics has progressed from a traditional cottage industry to an allied health profession, education programs will be challenged to meet these varied demands. 31
The Need for Orthotists and Prosthetists
Currently, it is estimated that there are more than 1.75 million amputees in the United States. 31,32 Both diabetes-related and peripheral vascular disease-related amputations are expected to increase in the coming years. 34,35 In 1990, over 3.5 million people used orthoses. 31,35 In addition, it is estimated that approximately 35 million Americans possess an orthopedic ailment that interferes with their activities and may require orthotic care. 33 A study by the National Commission on Orthotic and Prosthetic Education (NCOPE) estimates that by the year 2020, the number of people with paralysis, deformity, or orthopedic impairments will increase by 25 percent, and the use of orthoses to accommodate these conditions will increase by 31 percent. 31 Some suggest advances in technology will reduce the weight of orthoses, enhance the functional features, and improve the cosmetic appearance of orthoses. 31 These advances could also enhance patient use and increase the need for orthotic care. 36,37 It is also projected that a greater number of persons will be unable to receive care by an orthotist compared to amputees receiving care by a prosthetist. 31,38
The aging American population will also increase the demand for orthotic services over the next two decades. In the year 2000, the median age of the American population was above 36 years of age as compared to 29 years of age in 1975. 36 Similarly, the percentage of elderly in the population has almost doubled in the last 40 years, and this is a trend that is expected to continue. By the year 2020, more than 35 million people over age 65 will represent about 17 percent of the population, 39 compared to eight percent in 1950. 31 The population of the very old (over 85 years) will increase by about 30 percent 31 and will consist of about 12 million individuals. 39 By 2010, the proportion of the population at greatest risk for back injuries and paralysis will increase considerably as Baby Boomers reach the ages of 46–64. This increase means that a greater number of certified orthotists will be needed to meet the needs of these individuals. 31 Population projections based on the National Health Survey suggest that of the individuals who use orthoses and who possess complete or partial paralysis of extremities, 40 percent are 65 years of age or older. 33 This percentage of the population is expected to increase considerably after 2010, which will further widen the gap between services needed and trained providers. 33 Additional research indicates the continually growing segment of the geriatric population with the high incidence and prevalence of comorbidity and disability suggests that enhanced preventative and rehabilitative programs that provide comprehensive assessment and rehabilitative services will be mandatory. 40
As of January 2002, there were 3371 practitioners certified by the American Board for Certification in Orthotics and Prosthetics, Inc.(Sloane, L. ABC, personal communication: January 18, 2002.) Of these individuals, 1137 were certified Orthotists, 1088 were certified Prosthetists, and 1146 were certified Prosthetist-Orthotists. Current estimates report that 25–35 percent of the physically challenged do not have access to a qualified practitioner. 41 By the year 2020, 1.5 million people nationwide, will not have access to a certified Orthotist, and over 227,000 patients will be unable to receive care from a certified Prosthetist. 31
Last year, only 188 students graduated from U.S. accredited orthotics and/or prosthetics programs (Seabrook, R. NCOPE, personal communication: January 9, 2002.). This is offset by the fact that almost a quarter of all certified orthotic and prosthetic practitioners are 60 years of age or older. 31 In essence, schools are not producing graduates fast enough to meet the growing patient need. 31,41 Even with a 10 percent increase in the number of graduates between the years 1995 and 2020, the actual number of patients who will have the opportunity to be treated by a certified practitioner decreases significantly. Double-digit growth in the number of education programs will be necessary to meet this future demand. Additional education programs need to be created now to provide a sufficient number of certified practitioners in the future. 31
In order to develop additional educational programs, those allied health programs that may have the resources and ability to create an orthotics and prosthetics practitioner level program within their current allied health department must be identified. 42 Universities with experience developing successful allied health or interdisciplinary degree programs should be targeted, as they will have the resources to complement a program in orthotics and prosthetics. In this type of setting, an entry-level master’s degree program in orthotic science and a subsequent, parallel program in prosthetic science should be developed to help meet the national need for qualified practitioners.
Producing a greater number of appropriately trained, certified practitioners may also help address professional encroachment in O&P. Currently, inter-allied health competition for orthotic and prosthetic patient care has been forcing certified practitioners to operate in areas where, more often than not, other allied health professionals are better educated and just as skill oriented. 43 Practitioners in other allied health professions have increasingly provided services traditionally covered by orthotists (Raschke S, 2001 unpublished data). Today, upper extremity orthotic patient care tends to be associated with the profession of occupational therapy. Prefabricated orthoses, particularly for the foot and knee, are currently being prescribed and fit by a variety of allied health and medical disciplines including pedorthics. In addition, an industry of manufacturers that create pre-fabricated orthoses are directly marketing their devices to the patient. 44 The orthotic and prosthetic education and knowledge of many of these allied health providers usually consists of a single short course in orthotics and prosthetics. This creates a significant problem because most of these health care providers have neither received sufficient education, nor do they possess an appropriate understanding of the complexities of providing comprehensive orthotic care. In light of this, there has been a proliferation of alternative short course orthotic and prosthetic education programs. The shortcoming of these brief entry-level education programs is that there is insufficient time to teach essential orthotic and prosthetic theory and practical clinical skills. Educational programs in physical therapy and occupational therapy, in addition to chiropractic, podiatric, and medical doctor programs, have similarly added short review courses to some of their curricula. Other programs have developed that aim to teach a combination of clinical/technical skills (P.W. Minor University, Pedorthic Footwear Association courses, etc.). In these programs, the curricula for comprehensive clinical orthotic and prosthetic care is delivered in review courses spanning from a few days to a few weeks. By sacrificing depth of curricular content through consolidated alternative orthotic and prosthetic practitioner education programs in order to rapidly produce a greater number of clinical practitioners, orthotic and prosthetic clinicians will remain unprepared for the demands of rapid advancement in technology and health care. 45 These developments could weaken the orthotic and prosthetic profession’s ability to become a peer with other allied health professions. 30 Quality orthotic and prosthetic patient care involves a complex nature of matching orthosis/prosthesis design with knowledge of material science, patient evaluation, and problem solving skills. Short course programs will not create an individual with advanced knowledge and skills in today’s complicated health care environment. In addition, programs lacking comprehensive skills development would reduce the quality of orthotic and prosthetic services provided, limit the body of research knowledge, and slow advancement of the profession.
ORTHOTICS AND PROSTHETICS EDUCATION
Development of Formal Education
While the number and type of orthotic devices are constantly changing due to new developments in technology and materials, the level of curriculum that provides the education and training for orthotists and prosthetists has not kept pace. 13 Some suggest these basic problems in (orthotic and prosthetic) education exist: the lack of a uniform vision of the future of orthotics and prosthetics, 30 the lack of contemporary curricular design, and the lack of texts designed to provide a comprehensive overview to teach students about the evolving, fragmented, and complex discipline of orthotics and prosthetics. 46
These issues stem from the slow development of orthotic and prosthetic education. Early prosthetists and orthotists learned the trade by example through apprentice training. Learning occurred through mimicking demonstrated techniques by more experienced individuals. The first coordinated education effort in orthotics and prosthetics began in 1952 as a comprehensive 6 week program offered at the University of California at Los Angeles. 7 This new program was designed to provide practicing prosthetists with the results of a nationwide research effort supported by the Veterans Administration and Armed Forces and coordinated by the National Academy of Sciences. 6–8
To meet the national need for prosthetic care, additional programs were formulated at New York University and Northwestern University. As knowledge developed from the research programs, the curricula expanded to include lower limb prosthetics. Preparatory courses were subsequently developed in prosthetics to teach less experienced practitioners. 7 Courses in orthotics were added later. Each program shaped the mode of training into intensive curricular modules consisting of a series of courses in each discipline (orthotics or prosthetics). Students who successfully completed these courses were awarded a certificate of completion.
Efforts to focus attention on the orthotic and prosthetic educational system and its impact on physically challenged citizens were formulated in 1970 by the ABC. The conference, known as Ponte Vedra I, proposed to upgrade the minimum educational requirements that needed to be met prior to the practitioner’s completion of a board examination. 30 In 1970, the minimum of a high school diploma was required. By 1972, it was necessary to possess a high school diploma and successfully complete three short-term courses. By 1975, two years of college (an Associate’s degree) was required in addition to three short-term courses. By 1980, a baccalaureate degree in orthotic and prosthetic was required.
In 1976, Ponte Vedra II reexamined the level of education needed and the timetable for practitioners to achieve board certification. 30,47 Because federal education funding was never realized, the decision to accept these changes was established along with the need to reassess the time frames at a later date. As late as 1997, trained practitioners possessing an Associate’s degree were allowed to sit for the ABC board examination. By 1992, the Bachelor’s degree was established as the minimum level of education required for ABC certification. 48,49
Sponsored by the Veterans Administration, the 6 week long University of California at Los Angeles upper limb prosthetic course began in 1952 and became the model for completion of some of the requirements for ABC certification. At that time, no formal degree was required for ABC certification. 7 Eventually, these short courses gave way to longer courses specific to orthotics or prosthetics and culminated with the award of a certificate in the discipline (orthotics or prosthetics). By 1965, New York University required the completion of a Bachelor’s degree prior to the successful completion of the long course certificate. This model still exists today at Northwestern University.
Additional certificate programs developed at other institutions and universities such as Century College, which was formerly known as 916 Technical Training Program and Northeast Metro Technical College, Shelby State Community College, Florida International University, 50 and, later, California State University in Dominguez Hills, Rancho Los Amigos National Rehabilitation Center, and the Newington Certificate Program which is managed by the Hanger Orthopedic Group and is affiliated with the University of Connecticut. Today, only five certificate programs exist: NU, Century College, California State University in Dominguez Hills, Rancho Los Amigos National Rehabilitation Center, and Newington Certificate Program.
Historically, an alternative to the certificate program dates back to 1965 when New York University developed the first Bachelor of Science curriculum to provide entry-level instruction in a consolidated 4 year program. This program involved a 2 year preparatory prerequisite phase consisting of foundation coursework in the natural sciences, social sciences, and math. The junior and senior year curriculum emphasized the specialized prosthetic and orthotic instruction. Subsequently, additional baccalaureate degree programs were developed at the University of Washington, the University of Texas Southwestern Allied Health Sciences School, California State University, Dominguez Hills, and Florida International University. 51 Today, only three Bachelor’s degree programs exist: University of Washington, University of Texas Southwestern Allied Health Sciences School, and California State University, Dominguez Hills.
As long as there was a coordinated research program with an orderly system for introducing new techniques and technological developments into the education programs, each school delivered relatively consistent orthotic and prosthetic curriculum. Nonetheless, the close relationship between the national research program and education programs ended in 1975 with the dissolution of the National Research Council. Subsequently, orthotic and prosthetic education programs began to drift apart in their curriculum, their lowest denominator being the minimum subjects and hours previously established by the Education Accreditation Commission (EAC). 30
In 1984, the EAC recognized the need for advanced education in the orthotic and prosthetic profession. 52 To address this need, the first Master’s degree program with an emphasis on orthotics and prosthetics was formulated at the University of Connecticut in collaboration with Newington Children’s Hospital. 53,54 The program focused on the expanding role of the orthotics and prosthetics professional in the health care system and was designed to prepare board eligible or ABC certified prosthetists and/or orthotists for positions of leadership in health care. Subsequently, a Master’s degree program in prosthetics was offered at Rutgers University. In 1999, St. Ambrose University formulated an entry-level Master of Orthotic Science degree program. Other programs (Georgia Institute of Technology and Eastern Michigan University) have begun the process of formulating entry-level graduate programs offering a Master of Science degree in prosthetics and orthotics. 55
The expensive nature of orthotics and prosthetics educational programs compared to other academic programs limited their growth within large institutions. The high costs of operating orthotic and prosthetic practitioner education programs involves significant laboratory and didactic classroom space, in addition to a large and varied inventory of equipment and supplies required to develop students’ psychomotor skills. Concomitantly, orthotic and prosthetic university program development has been hindered through limited funding in the form of small grants arranged via the Department of Education. Since the 1980s, the movement away from funding allied health programs has further stifled growth in orthotic and prosthetic education. The funding limitations in orthotics and prosthetics make the acquisition of additional roles by orthotic and prosthetic educational programs a challenge for the future. 56
A reduction in federal funding resulted in the closure of some Bachelor’s (Florida International University, New York University) and postBachelor’s certificate (Univeristy of California at Los Angeles, Shelby State Community College) orthotic and prosthetic education programs. In 1999, the Rehabilitation Services Administration Long-Term Training program (within the Department of Education) diverted funding from orthotic and prosthetic education to rehabilitation counseling degree programs (Shurr, DG. American Prosthetics and Orthotics Inc., University of Iowa Hospitals and Clinics, personal communication: July 4, 2001.). These funding cutbacks have placed even greater demands on existing orthotic and prosthetic education programs nationwide. Funding shortfalls closed the St. Ambrose University Master of Orthotic Science program in December of 2001 before it admitted its first class. 57 The graduate program at Rutgers University is on a moratorium and at this time is no longer accepting students (Craelius, W. Rutgers University, personal communication: January 29, 2002.). 55
Accreditation of Orthotic and Prosthetic Education Programs
The NCOPE was formed as a committee of the ABC and the EAC for the purpose of accrediting the orthotic and prosthetic educational programs and institutions. The early education standards, referred to as “essentials,” represented the optimum skills and knowledge domains. Eventually, the essentials were revised to meet the profession’s growing needs. Curricula were then developed from the essential standards giving some direction to the education programs. In 1991, the EAC recommended the formation of a stand-alone group whose responsibility was to accredit orthotic and prosthetic educational programs. Subsequently, NCOPE was formulated as the accreditation body for the orthotic and prosthetic profession to ensure educational programs met the minimum quality standards. 58,59 Recognition of orthotics and prosthetics was bolstered in 1992, when NCOPE applied to the American Medical Association’s Committee on Allied Health Education and Accreditation and eventually became officially recognized as an Allied Health Profession. The Committee on Allied Health Education and Accreditation later became an independent accrediting agency that was renamed the Commission on Accreditation of Allied Health Education Programs (CAAHEP), and now serves as the accrediting agency (Seabrook, R. NCOPE, personal communication: January 25, 2002). The NCOPE now serves as a subsection of CAAHEP and is considered the content expert in orthotics and prosthetics, which serves as a Committee on Accreditation within the CAAHEP system. 60 These developments allowed higher standards of accreditation and recognition for orthotic and prosthetic education. Today, the orthotic and prosthetic practitioner education programs are accredited by the CAAHEP system, while the orthotic and prosthetic associate and technician education programs are accredited by NCOPE (Seabrook, R. NCOPE, personal communication: January 25, 2002). National recognition and formal accreditation has ensured that the orthotic and prosthetic education programs will maintain high standards of education. To maintain these high standards, all orthotic and prosthetic programs must develop educational outcomes by 2007 and create assessments of psychomotor skill and knowledge domains of program curricula (Malas, B. National Association of Prosthetic and Orthotic Educators, personal communication: January 18, 2002.). 60,61 Although accreditation standards exist for Bachelor’s degree and postBachelor’s certificate programs, no advanced level of accreditation exists for orthotic and prosthetic Master’s degree programs. Inevitably, as orthotic and prosthetic graduate degree programs evolve and create advanced curriculum, they will need to create new standards in conjunction with NCOPE.
Orthotic and Prosthetic Program Curriculum
In 1998, the ABC enacted the standard that all new practitioners seeking Board certification must complete a Bachelor’s degree in conjunction with training at an accredited orthotic and prosthetic educational program. 48,49 In addition, a 1 year residency in an NCOPE approved site is required following graduation from an accredited orthotic and prosthetic program. 49 As a result of these certification qualifications, today’s programs designed for education of orthotists and prosthetists are primarily managed in either a Bachelor’s degree program or postBachelor’s certificate program. 50,51 Most Bachelor’s programs require completion of 60 credit hours of general education courses in the first 2 years) followed by a 2 year professional curriculum which prepares the student for the 12 month residency requirement. 51 During the 2 year professional curriculum, the student completes courses which meet the entry-level competencies as established by CAAHEP and its subsection, NCOPE (Table 1). 59
It is assumed that a Bachelor’s degree prepares students for the required year long residency program that, in turn, prepares them for the certification exam. 62 The pedagogical issue today is whether or not a degree (with over 150 credit hours) that is completed in 4 calendar years is sufficient to produce a health care professional who can interact successfully with other professionals as part of a health care team. A potential shortcoming of this approach is that the programs to prepare students for the postgraduate compulsory residency in both orthotics and prosthetics sacrifice depth of curricular content in each discipline (orthotics and prosthetics) for the breadth of knowledge needed to meet the minimum core requirements in both disciplines.
In contrast, the postBachelor’s certificate in orthotics (and prosthetics) begins with the assumption that the core essentials should be taught to students after the completion of a Bachelor’s degree. In addition, students are encouraged to attain clinical and technical experiences in the profession prior to enrollment (note that the essential requirements are the same whether or not the program is delivered as a postBachelor’s certificate or a Bachelor’s degree). Typically, students are admitted into these certificate programs with a science or health-related Bachelor’s degree, though any degree is accepted as long as the essential prerequisites (usually biology, chemistry, physics, psychology, math (Algebra or higher), human anatomy, and human physiology) have been met. 58,59 In this model, it is assumed that a Bachelor’s degree in addition to professional clinical/technical experience prepares the student for the advanced course work of the certificate program. These requirements prepare students for the required 1 year residency and the certification exam. The advantage of this curriculum over the Bachelor’s model is that it does not attempt to simultaneously educate students in both prosthetics and orthotics. However, the drawback is that this model only teaches minimum essential competencies.
Because the Bachelor’s degree and ABC certification have been viewed as the terminal qualification in orthotics and prosthetics, administrative and faculty positions in orthotic and prosthetic education programs have been typically occupied by persons with years of experience or by persons who have been internationally recruited. 53 As a result, most educators neither possess advanced degrees nor do the majority of these individuals possess formal training in instruction or curriculum development. In response to this and other issues, the EAC recognized the need for advanced education in the profession and the master’s program concept was conceived. 52 Unfortunately, no major progress has occurred in the development of additional graduate education programs to significantly influence the orthotic and prosthetic profession.
Education of orthotists and prosthetists has developed primarily in the 20th century, particularly over the past 50 years. What began as a craftsman trade has evolved into an allied health science profession. Two education tracts provide practitioner education today via a Bachelor’s degree program or a postBachelor’s certificate program. To date, only one master’s degree program exists offering a post professional degree. All orthotics and prosthetics education programs are evaluated and monitored by the CAAHEP and its subsection, the NCOPE to ensure individuals are trained to become competent in the profession of orthotics and prosthetics. Minor advancements have occurred in orthotic and prosthetic education over the years, hindered by a lack of faculty and funding. As technology and health care evolve and change, in addition to the increasing encroachment of other health and medical professions, there is an increasing need for orthotic and prosthetic students of the future to keep pace with technology and the competitive health care marketplace. A need for significant advances in orthotic and prosthetic education programs appears imminent in order to lead the orthotic and prosthetic profession into the new millennium.
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