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The
Future of O & P (or at least our best guess!)
Gerald Stark, BSME, CP, FAAOP Director
of Product Development & Education
What does
the Future Hold?
What does the future hold for Orthotics and Prosthetics? It is
a rather broad and difficult question to answer. One can only look to
the past and examine the processes that contributed to the significant
quantum leaps in the modern development of O & P. The evolution of O &
P tells of both periods of technologic plateaus and dynamic touchpoints.
These profound touchpoints have included such concepts as lamination,
thermoforming, myoelectric control, thermoformed plastics, dynamic response
feet, CAD/CAM, cushioned liners, and computer controlled knees.
The way we communicate with each other has already shifted
dramatically. The future will see changes in how we share information
with each other, our customers and how we educate students.
Technologic change is not the only area that as altered
O & P radically. The way we do business has shifted as O & P fully assumes
its roll as an allied health profession rather than a trade. The clinician
will be challenged to become even more savvy to the healthcare changes
and practices to provide quick, cost effective service. As a result the
way we evaluate, perform, and deliver our products will be transformed.
Product Development
Although the basic purpose of the orthotic and prosthetic product has
not changed over the years, there have been great changes with respect
to materials and electromechanical controls. The future may bring even
more dramatic changes as endoskeletal attachment and limb transplantation
are explored. Unfortunately there will probably be a greater polarization
between the high technology products and simplified systems that fit into
cost containment methods. Future “developments” may involve making inexpensive,
off-the-shelf products that simplify or eliminate many features.
Materials
The future will probably see more materials from other fields such as
thermal cooling foams, custom cushioning gels with better resiliency and
comfort. Adaptive seating with load memory formed with computer digitizing
methods has opened new possibilities. New plastic and composite technology
is on the horizon that increases strength for paper thin orthoses and
allows more dynamic responsiveness. Frank Snell, CPO, FAAOP, President
of Snell Prosthetic & Orthotic Laboratory in Little Rock, Arkansas echos
this perception. “The one thing I see is, just like in the recent past,
more improvements in materials that improve patient comfort and fitting.
Many designs that may not have been possible in the past may be revisited
in the future. Products like the Alpha liner and composite technologies
have greatly impacted the options we can offer patients.” Other materials
such as magnetic fluids, flexible batteries, conducting materials, and
force sensing films will change existing products and make possible concepts
previously thought to be impossible.
Electromechanical Applications While advances in upper
extremity controls continue to become more sophisticated, new products
that use electromechanical control applications have emerged. New programmable
“intelligent” knee designs that can adjust themselves to gait conditions
have just been introduced. The sensors and controls can also be applied
to other devices such as feet, shock absorbers, lower limb orthoses, and
alignment units. Although “low cost” portable force plates have already
been introduced that use lasers to establish correct alignments, the future
may bring self-adjusting units that do it automatically. The prosthetist
may monitor the alignment devices and make adjustments at a computer that
records the adjustments and suggests optimal load patterns.
Integrated and Implanted Attachment
If the obvious infection problems could be rectified, direct endoskeletal
attachment would be a revolution in prosthetics. Tom Karolewski, CP, Prosthetics
Instructor at Northwestern University’s Prosthetic Orthotic Center in
Chicago seems to think so. “I think that one advancement that would greatly
change prosthetics is the research in direct endoskeletal attachment by
Dr. Branemark in Gothenberg, Sweden. This would eliminate the need for
the socket and all of the related fitting issues. The prosthesis would
become an extension of the skeletal structures and components could include
more functions being freed from the weight restrictions of the interface.”
Tunnel tendonplasties or “tendon loops” have also been explored which
can voluntarily operate servos increasing control and proprioception of
the prosthesis. Limb transplant procedures have recently made headlines,
but rejection inhibiting drugs have a number of long term health risks
before this becomes a viable option.
Electronic Analysis & Delivery
CAD/CAM
Although CAD/CAM has not permeated as deeply as everyone thought it would,
clinicians are learning to adapt this technology to their practices. This
slow growth may be due to the initial apprehension of using a computers
and the difficulty of visualizing three-dimensional objects on a two dimensional
monitor. Some of this has been improved with practitioners who are more
familiar with computers and recent developments in computer digitizing
and visualization.
Andy Steele, CPO, Vice-President of O & P1 in Waterloo,
Iowa adds, “There is no doubt that CAD is here to stay. I think as more
practitioners accustomed to computers emerge, CAD/CAM methods may become
more second nature. This is not to say that experienced practitioner cannot
learn the system. In fact they add to the development of CAD which benefits
from their expertise and knowledge. They are often surprised at CAD’s
ability to make possible things that were impossible before. There have
been great strides in making CAD more adaptable and modular to clinicians.
You can now buy the modules that you want. Computer specialists are constantly
developing the software to adapt to new methods and processes.”
Some clinicians have been successful in adapting different
methods to different levels of amputation or orthoses. Transfemoral shapes
are made using circumferential measurements. Transtibial interfaces are
made using more detailed digitizing methods to capture contours and make
modifications. The future of CAD/CAM will rely on the development of other
computer aided manufacture alternatives to carvers. Squirt-Shape developed
at Northwestern University’s Rehabilitation Engineering Prosthetic Orthotic
Center by Joshua Rolock, Ph.D. forms a socket using heated polypropylene
“squirted” through a small extrusion device positioned by a CNC milling
machine. The shape revolves in a spiral and a socket emerges upside down.
Gait Analysis
In the future, componentry may be demphasized and the services provided
will be enhanced further. Portable computer aided gait analysis systems
for prosthetic and orthotic applications may be in each clinic (provided
there is payment for such a service). Clinicians may be schooled in reading
telemetry systems to record gait and make possible improvements. The computer
may make suggestions for orthotic design and construction.
Education & Communication
The computer has also greatly changed how we communicate. Everyone has
read repeatedly about the effect of the Internet, but it is only now that
its impact specific to O&P is being felt.
Electronic
Education
Electronic libraries, already developed, are evolving so the clinician
can look up articles for specific cases. Past issues of the JPO can now
be cross-referenced on the oandp.com website. Expert information concerning
different types of fittings may be more available through electronic publications
and meetings. Forums will be improved further with video connection for
group consultation and discussion creating a “virtual clinic”.
Mark Edwards, CP, Assistant Director and Prosthetics
Instructor for Northwestern University’s Prosthetic Orthotic Center in
Chicago agrees. “Definitely distance learning will impact education in
O & P especially for those not located near a large medical center. Special
study modules, or Ôkiosks’ are being developed to allow practitioners
to gain greater experience with special or unique cases. This technology
changes how we educate as well by allowing each student and professional
to become self-directed learners. Individuals would be able to structure
their learning specific to their areas of professional growth ultimately
improving their ability to provide comprehensive car. Hopefully it will
also help develop more consistency in education and improve the quality
of services.”
On-Site
Services
With these innovations in electronic communication, the clinician may
be able to provide more on-site and/or mobile services. It may be possible
to record a gait pattern and send it to others for evaluation. Digitized
interfaces could be sent from a mobile site to a central fab and delivered
on a return visit. This would eliminate the need for a full lab and increase
service times.
Business
Management
The way we do business may have the biggest effect on how we provide our
services. “As competition for the healthcare dollar increases, successful
clinicians will be more skilled in the seven principles of business: Human
Resources, Management Information Systems, Marketing & Sales, Management,
Finance & Accounting, Operations, and Strategic Planning, “ says Russ
Hornfisher of Vice-President of OPGA in Waterloo, Iowa. “O & P people
have always emphasized improving technical skills, but developing cost
efficient processes will take center stage in the future.” He also adds,
”We are in a commodity market where products greatly resemble one another.
The consumer revolution is upon us. Patient care providers will focus
on customer service and quantifying outcomes to market the clinic.” On
the subject of consolidation, Mr. Hornfisher adds, “I think we have seen
the biggest consolidation of patient care clinics, the next wave of consolidation
will probably affect the manufacturers of O & P products. It is still
important to remember that about 75% of all allied healthcare markets
are still independent privately owned businesses.”
It is important to remember that some changes in the
past and in our future have not always been perceived as inherently good.
Technologic advances will change the way we do things; perhaps eliminating
some of the familiar and enjoyable craft in making an orthosis or prosthesis.
Change may mean retooling our knowledge of materials and devices so we,
and our profession, do not become obsolete. As always our business skills
must to continue to grow and be refined. We must always remember that
competition is out there. Many groups have looked at O & P with hungry
eyes as a way to augment and insure their own existence. The profession
will have band together to respond to those threats by marketing, improving,
and transforming itself to survive.
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