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The current state of health care in the United States is being streamlined in an effort to control cost, efficiency, and efficacy. Although these three parameters are independent by definition, they are highly interdependent in relation to overall patient treatment. This relationship not only determines how well the patient is served in the health care setting but also determines how successful the health care provider is during the process of managing the patient. “The prosthetics industry, like other health care services, is increasingly asked to quantify its quality and value.”1 As noted in the Journal of Burn Care Rehabilitation, “Goals identified by managed care organizations are to contain costs and to provide services that produce functional outcomes.”2 In the case of treating a patient with an amputation in the prosthetic clinic, the clinician must manage all three parameters while keeping the patient’s best interest and potential for success as the ultimate goal. In an effort to maximize the potential positive outcomes for the patient, the prosthetist will need to prescribe and construct the most appropriate prosthesis, in the most efficient manner, and within the most reasonable cost parameters while giving the patient an opportunity for an improved functional ability. Given theses guidelines, the one variable that seems most integral to achieving overall success is whether each patient will be able to use the new prosthesis effectively. A physical therapist (PT) with knowledge and skills in treating patients with amputations in all aspects of their particular care can be a strategic element in managing this variable.
Therefore, the prosthetist, in conjunction with the PT, can control cost, efficiency, and efficacy of successfully treating patients with amputation while meeting the ultimate goal of patient improvement in quality of life through correct use of the new prosthesis. A prosthetic clinical design including both professionals in the same clinic, “in-house,” could be considered the ultimate in a streamlined multidisciplinary team care approach for patients with amputation. “Total patient care, in the form of a cooperative multidisciplinary team approach to treating each patient’s specific needs, is an idea that is universally and enthusiastically embraced.”3 It has also been written that “the complimentary business model also is cost efficient for payers and insurers in time savings, transportation, and other costs including fewer appointments.”4 This team concept in patient treatment is not new or revolutionary. In fact, “the clinic team, which is where the total patient care concept originated, was really introduced after World War II in order to treat people who had amputations.”3 Since that time, it has generally been accepted as well as understood that the patient will benefit most with a cooperative effort by all professionals involved in that particular patient’s overall care. It is also easy to recognize that the patient will benefit with the variety of health care professionals and their particular areas of expertise as being a comprehensive care approach. This approach can be effective with both the simple patient case as well as the most complex. For comparison, in the case of the multidisciplinary team working with the complex challenges of the patient who has had a stroke, “The physical therapist, occupational therapist, and the clinical social worker are important members of the team, each of whom contributes specialized knowledge and interventions on behalf of the patient.”5 The approach can be seen as similar in prosthetics with relation to physical therapy; the combination of two allied health professional fields working as a team on behalf of the patient. The patient can be seen by both professionals who have their own specialized knowledge and aspect of care for the patient with an amputation, theoretically allowing the patient to be conveniently and efficiently seen within the same setting. “Patients don’t like having to see the doctor, then wait to see the prosthetist, then wait again to see the physical therapist.”6 However, there are both professional and ethical considerations to any combined business, especially health care-related practices. These areas of consideration include professional role boundaries and financial boundaries as those between prosthetists and PTs. It is generally understood that the prosthetist is the practitioner who is specifically educated and skilled in patient evaluation, measurement, prescription suggestion, and construction of prosthetic devices to help improve the patient’s quality of life. In comparison, the PT is the practitioner who is likewise specifically educated and skilled in certain areas, such as the adaptive aspects of the patient, which includes the patient evaluation and treatment of the functional limitations and the implementation of a specific treatment plan to decrease these limitations and improve the patient’s quality of life. Although these are two distinctly different areas of care for patients who have amputation, there are areas of overlap, some of which can be viewed as a positive benefit to the patient but can create some disconnects in the comprehensive team treatment model. One such area is gait training and use of the prosthetic device. In the case of patients with a lower extremity amputation, “the degree of success with ambulation may directly influence how much amputees will use their prostheses and may be predictive of their overall level of activity.”7 During a related study of the impact of a comprehensive allied health team approach with nurses and PTs and the role boundaries of these service providers; “the practitioners were not threatened by overlapping roles, and recognized that confidence in their own roles and an understanding of the roles of the other workers was necessary to avoid feeling threatened.”8 This study also described role overlap as helping the clinician with confidence in their particular area of expertise while improving the feeling of optimizing patient overall care. In consideration of financial practice arrangements, the American Academy of Orthotists and Prosthetists states specifically in its ABC Canons of Ethical Conduct that “the orthotist and prosthetist shall refer all patients to the most cost beneficial service provider, taking into consideration the nature and extent of the problem, treatment resources and availability of health care benefit coverage, and the likelihood of receiving appropriate and beneficial care.”9 An observation can be made that the patient’s best interest may be achieved by receiving a beneficial and cost-effective treatment, including both prosthetic and physical therapy care, in one comprehensive setting. An important detail to this scenario is that neither prosthetic care nor physical therapy treatment can be given with the intention of financial reimbursement through recognized payers without a physician’s written prescription, which helps to distinguish this particular comprehensive practice model from a self-referral practice situation. Acknowledging the current atmosphere of prosthetics and physical therapy interaction and the potential for perception of the encroachment by the latter profession, it is not widely known whether this combination of health care professionals can successfully thrive despite the potential advantage gained by combining these specialties for the patient with amputation. Retired Col. Charles Scoville, PT of the US Army Amputee Patient Care Program at Walter Reed Army Medical Center, recently gave light to similar circumstances requiring research by saying “you can write a lot of articles on how great a process is, but without the hard scientific data that this is definitely an advantage, it’s just opinion.”10 Given these considerations, the following research question warrants investigation. Do prosthetists see a benefit in having in-house physical therapy services for patients with amputation?
Most of the current literature covering the care by prosthetists and PTs of patients with amputation does not specifically describe the interaction of the two professions as a multidisciplinary team concept within one location of clinical practice, an in-house setting. It is assumed that these two professions work together toward a particular patient service but in different physical locations. However, there is literature that does give attention and focus to the results of the professional interaction as it relates to patient care, history of the team concept, and overall benefits of this interaction.3,6,11–13 There is a continuous call for research in all aspects of health care, especially in the field of prosthetics. It has particularly been requested in prosthetics to increase research efforts “that address functional benefits of evidence based rehabilitation” given that “structured therapy training programs on ultimate outcome could change the role of therapy in treatment of the lower extremity amputee.”14 No specific literature has been cited that discusses perceived opinions of either prosthetists or PTs about working collaboratively in the same setting. It is even proposed that the concept of a multidisciplinary team approach is “a widely held misconception that this sort of team is available only in large medical centers.”15 The only relative study of a team approach of prosthetics and physical therapy was a 1987 study of lower limb amputees seen in an inpatient rehabilitation setting.16 The current body of literature also notes that the overall functional outcome for patients with amputation may ultimately depend on the patient’s ability to function with or without a prosthesis through physical therapy intervention.17 This leads further to the need for a close working relationship between the prosthetist and the PT as well as the increased demand for research as to how the two professionals can accomplish this successfully.
An exploratory descriptive study to better understand the opinions of prosthetists about having in-house physical therapy services for their patients with amputation was structured as a 10-part survey. At total of 40 prosthetic clinicians with credentialing as a certified prosthetist (CP) or certified prosthetist/orthotist (CPO) as recognized by the American Board for Certification in Prosthetics and Orthotics (ABC) were randomly chosen from a list of practitioners across the country within regions of the Durable Medical Equipment Regional Carriers (DMERC) as established by Medicare. The practitioners were chosen randomly within the four regions, numbering 10 per each region for a total of 40 practitioners, ultimately representing all areas of the country. The ABC list of certified practitioners was used as a simplification tool in locating currently practicing prosthetists across these areas. With respect to the number of clinicians being surveyed, it was expected that 50% of the questionnaires would be returned given the practicality of the simple and concise questionnaire format and the inclusion of a self-addressed stamped envelope for ease of return. The questionnaire consisted of two questions pertaining to the clinician’s work history and eight statements about various aspects of interaction between the prosthetist, the PT, and the patient, relevant to a multidisciplinary clinical approach to patient care. The eight statements directed the clinician to respond with answers ranging from “strongly agree,” “agree,” “somewhat agree,” “somewhat disagree,” “disagree,” to “strongly disagree.” These eight statements were grouped in four pairs of contrasting statements regarding a particular topic. A section for additional comments was also supplied for the clinician. Statistical analysis of the clinician’s responses was applied to derive meaning and interpretation to the research question. The analysis consisted of first noting the number of years each respondent had worked as a CP as well as whether they had ever worked in a clinical setting with or without an in-house PT. The following four pairs of statements were then scored on a six-point basis. Statements 3, 5, 7, and 9 of the questionnaire, which are positively directed toward in-house physical therapy, were scored as follows: strongly agree = 6 points, agree = 5 points, somewhat agree = 4 points, somewhat disagree = 3 points, disagree = 2 points, strongly disagree = 1 point. Statements 4, 6, 8, and 10 of the questionnaire, which are contrastingly negative toward in-house physical therapy necessity were scored as follows: strongly agree = 1 point, agree = 2 points, somewhat agree = 3 points, somewhat disagree = 4 points, disagree = 5 points, strongly disagree = 6 points. Point totals were then calculated separately on each of the eight statements. Comparisons of point totals for a variety of statements and their corresponding factors of interest were then calculated for a detailed interpretation. These included comparisons of respondents who had less than the average (18.5 years experience as a CP) with those who had more than the average on three topics; preference of working with a PT in-house versus outside source, history of working with a PT in-house versus not having worked with one in-house, and perceived benefit to both professions versus the perceived overlap of services. The other category of comparisons included those between respondents who had a history of working with a PT in-house and their responses to the three topics of preference of working with a PT in-house versus an outside source, perceived benefit to both professions versus the perceived overlap of services, and the perceived efficiency of seeing patients with combined services versus the perceived increased time involvement of combined services in one clinic.
Of the 40 practitioners selected across the country, 48% (19 of 40) returned the questionnaire. Of these 19, seven were from DMERC region A, and four each from DMERC regions B, C, and D. These practitioners varied in years of experience as a clinical prosthetist, with an average of 18.5 years within a range of 1 to 37 years. Forty-two percent (8 of 19) had experience presently or in the past working with a PT in an in-house setting, primarily in an institutional- or hospital-based setting. None of the respondents reported working within the same private practice with a PT. Results are listed in table format and include phrases of the multiple questionnaire statements that the practitioners were asked to respond in varying levels of agreement to disagreement. The first set of data is that of the total respondents’ opinion to the statements regarding the effectiveness of physical therapy for prosthetic use (Table 1).
The second set of data is that of the comparisons of respondents with more than 18.5 years of experience as a CP or CPO with that of respondents with less than 18.5 years of experience and their history of working with a PT in-house (Table 2).
The next two sets of data are respective comparisons of respondents with greater than 18.5 years of experience as a CP or CPO versus those with less than 18.5 years experience and their opinions toward individual preferences and perceived benefits of working with a PT (Tables 3 and 4).
The final two sets of data are respective comparisons of respondents who had a history of working with a PT in the same setting versus those who had not, and their opinions toward benefits and efficiency of working with the PT in the same setting (Tables 5 and 6).
Prosthetists with varying years of experience from across the country responded to this research question with a clear majority in agreement for the need of physical therapy as a benefit to patients with prosthetic needs. Of all prosthetists responding, however, only 42% had experience working with a PT in an in-house setting, primarily in either institutional-based or acute care settings. It should be noted that none of the respondents in this small purposive sample reported that they were currently working with a PT in the same in-house setting in a private outpatient practice.
Many derivations can be made from the results of this exploratory descriptive research study because it polled prosthetists from across the country equally within the four Medicare DMERC regions. Although the expected response rate was 50%, a relatively equal response rate of 48% was obtained. Limitations of this response rate can be related to the lack of a comprehensive follow-up contact to nonrespondents because of time and economic constraints. It is understood that “non-response to postal questionnaires reduces the effective sample size and can introduce bias.”18 Although the sample size limits the ability to generalize some conclusions, many trends offer compelling ideas for professional dialog and future research. One trend is that it is likely that most prosthetists across the country, regardless of years of experience, can see the benefits of physical therapy intervention with their patients as it shows with the 91% agreement among all respondents with the statement of “successful outcomes for a patient’s prosthetic use is positively influenced by physical therapy.” Interesting findings included in the comparisons of prosthetists in the study with less than 18.5 years experience versus those with more than 18.5 years experience were that those with less experience have an extremely high percentage agreement (83%; Table 4) with preference for in-house PTs and a 92% agreement that both professions would benefit with in-house PTs (Table 4) despite only 40% having ever worked with an in-house PT (Table 1). This leads to a potential summarization that prosthetists with fewer years experience would prefer to work with an in-house PT for both patient and professional benefits.
Another interesting find was within the comparisons of prosthetists who had worked with an in-house PT versus those who had not. Within these comparisons, there was the extremely high percentage of agreement (95%) among those who had worked with an in-house PT to the statement of “working with a physical therapist in the same setting is beneficial to both the prosthetics and physical therapy professions” (Table 5).
There was also a surprisingly high percentage of agreement (80%) to the same statement by prosthetists who did not have a history of working with an in-house PT (Table 6). Finally, there were almost identical percentages of agreement to the statements of efficiency and time involvement between prosthetists who have worked with an in-house PT versus those who have not (Tables 5 and 6, column 3). This suggests that prosthetists who have not worked with an in-house PT have both a perceived idea of efficiency and the contrasting idea of increased time involvement with the combined service.
There is one outstanding find in regards to the questionnaire statement of “combining physical therapy services in a prosthetic clinic will create an overlap of services to the patient.” Regardless of the comparisons—prosthetists with more than 18.5 years of experience versus those with less years of experience, or prosthetists who had worked with PTs in-house versus those who had not—there was a 55% combined agreement to this statement. It provokes the question of whether prosthetists, in general, believe they are already providing some physical therapy services to their patients. This interpretation alone can lead to further investigation by both the prosthetics and physical therapy’s professional view of scope of practice. It at least should invite dialog between both professions to be opened in addressing the idea in further detail.
The questionnaire to the clinicians did have a comments response page and showed equally as interesting information, which included the potential decreased rehabilitation time with combined services, the interest in working with PTs who view prosthetists as equals in respect to biomechanical experience, the concerns about having PTs who are experienced or trained in prosthetic gait, the issues of having an in-house PT, which might limit outside referral sources for nonprosthetic work because it might be seen as competition, and the benefit of understanding each profession’s role, limitation, and scope of practice in regards to the ultimate in-patient care. Despite the overall positive responses in combining prosthetics with physical therapy services for patients in need of prosthetic care, there are future questions to be answered as a result of this research topic.
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