December 2005

Building Bridges

By James E. Glinn, Sr, PT, and Greg Huckert, MA, PTA, CPO

The development of new relationships between orthotists and physical therapists in the care of UOA can benefit both clinicians and patients

Population changes have given orthotists and physical therapists the opportunity to tap into an expanding market of Baby Boomers with unicompartmental osteoarthritis (UOA) of one or both knees. There is the potential for both orthotists and physical therapists to target their products and services not only to physicians and health care organizations, but directly to the individuals in need. Physical therapists providing orthotic devices have always been a subject of heated debate in the orthotic community. The lack of qualified orthotists, reimbursement pressures, an expanding scope of education and care, as well as the desire to help their patients have, increasingly, put physical therapists in a position where providing orthotic devices may be both necessary and desirable. If physical therapists have the skills and education to provide some types of orthotic devices and services is not the primary concern, rather it is how the physical therapists and orthotists can work together to attain mutual benefit.

The patient population of individuals with UOA is so large and continually growing that there is a definite need for physical therapists and orthotists to work together, and avoid "turf wars" that may have existed in the past between the two professions.

Examining the recent changes in the area of orthotics, the following is evident:

1. Improved function of products through applying new-gained knowledge and biomechanics;
2. Improved structure of products through the use of new materials and fabrication techniques; and
3. Creation of three-tiered product lines of braces: custom fabricated, custom fit, and off the shelf models.

Recent changes in physical therapy education opportunities and in several state practice acts have produced doctorate-entry level education; specialty training such as orthopedics and sports physical therapy; direct access practice without medical referral; and inclusion of fitness and wellness services by physical therapy organizations. Large numbers of physical therapist-owned practices and physician-owned physical therapy practices (where permitted by state law) have opened up across the United States over the past 5 years.

The American population has changed as well, and with these changes comes the need to know when, how, and who may benefit from orthotic devices designed to alleviate UOA. Some of the following societal changes have caused the development of new pathways for orthotic products and physical therapy services, including an active aging Baby Boomer population, sky rocketing health care costs, 38.7 million people without health care insurance,¹ and joint replacement surgery—not always the best option.

The previous changes have produced, among other things, a Boomer population of 61,823 individuals who are not insured; this is higher than any other group except those under 18 years of age.¹ Baby Boomers make up 27% of the total US population and have a spending power of $1 trillion and an average household income of $57,000.² In general, the Baby Boomer population has a significant amount of discretionary income and is willing to spend it to help maintain their youth and fitness. This population, however, is often not enthusiastic about paying for health care services out of pocket, yet is increasingly doing so in the form of health insurance co-pays, deductibles, and share of cost.

THE NORMATIVE MEDICAL MODEL
Historically, orthotic products (particularly custom products) have been ordered by specialized physicians such as orthopedists and physiatrists. Physical therapy has evolved under this medical referral model as well. Ideally, the physician's office may still be the best "point of entry" for an individual ultimately requiring an orthotic device and/or physical therapy intervention.

Consumers, however, are increasingly looking to alternative solutions to health care, and certainly some of the 38.7 million citizens without health care insurance have made a choice not to purchase coverage. Off the shelf orthotic devices (even functional UOA braces) in commercial store sites and access to physical therapy and related wellness and fitness clinics then are two possible points of entry for customers/clients.

THE BIOMECHANICAL MODEL
While neither physical therapists nor orthotists diagnose disease processes from a medical diagnostic standpoint, both professionals are highly trained in pathobiomechanics. Physical therapists are thus trained to make biomechanical diagnoses.³ It is not unusual for a patient with osteoarthritis in one or both knees to explore and access nonsurgical alternatives to this long-term degenerative condition. Patients with ligamentous deficiencies such as anterior cruciate ligament (ACL) tears may also choose programs that offer nonsurgical solutions. In individuals with UOA and/or ACL deficiency, nonsurgical management needs to be of much longer term than most insurance-based physical therapy can offer.

A LONG-TERM MANAGEMENT PROGRAM
Conventionally, there have been six stages of intervention in the management of knee osteoarthritis:

1. Diagnosis made, surgical options discussed
2. Short-term prehabilitation outpatient physical therapy
3. Surgical intervention
4. Inpatient rehabilitation
5. Outpatient rehabilitation
6. Discharge from therapy with a home exercise program

There are three shortcomings to the previous model of care. The long-term nonoperative management solutions are not emphasized. Outpatient rehabilitation may be minimal or nonexistent due to payor limitations. And, the home program is designed with the knee as the focal point rather than the total body

An improved model of management exists in rehabilitation clinics that also offer aftercare, wellness, and fitness programs. The programs may be in physical therapy clinics or in wellness and fitness centers that also offer outpatient physical therapy. Stages of intervention in this model may be described as follows:

1. Referral to physician (primary care or orthopedic surgeon)
2. Prehabilitation outpatient physical therapy, which could take the form of: Type I-Conventional prehabilitation (short term), or Type II-Decision making prehabilitation (long term);
3. Surgical intervention vs adaptive fitness

In the above model, the big difference is that the type II prehabilitation program allows the patient a long-term intervention designed to prevent or delay surgery. Once surgical intervention occurs, the model appears as follows:

1. Surgical intervention
2. Inpatient and outpatient rehabilitation
3. Aftercare to include adaptive fitness

In the above model, then, former patients become clients or members and continue exercise regimens in the center offering aftercare and adaptive fitness programs. The patients are seen for physical therapy management of UOA of the knee(s). In the type II prehabilitation program, the patient is assisted in making a surgical decision through a staged program as follows:

1. Physical therapy evaluation

   A. Conventional evaluation

   B. Unloading assessment

2. Physical therapy

   A. Protected functional exercise

   B. Pain-relieving modalities

   C. Aftercare program design

   D. Adaptive fitness program

   1. Continued protected functional exercise
   2. Protected (adaptive) exercise
   3. Periodic physical therapy reevaluations

BRACING OPTION
Off the shelf models of functional UOA knee braces are often utilized during two different stages in the prehabilitation program. The UOA knee brace is used by the patient during the unloading assessment and during the early stages of the physical therapy program. Once it is determined that such a brace is effective in reducing a patient's pain during activities of daily living, a patient has three orthotic choices:

1. To obtain their own off the shelf UOA knee brace
2. To be fit for a custom fit UOA knee brace
3. To be fit for a custom molded/fabricated UOA knee brace

In the previous models, physical therapists and orthotists can work together in the management of individuals with UOA of the knee(s). The physical therapy clinic can rent or purchase off the shelf UOA knee braces from an orthotist or even purchase them directly from the manufacturer. The orthotists can assist the patients/clients in the physical therapy clinic or in their own office when custom fit or custom knee braces are required. By assisting the physical therapist with their UOA patients, orthotists may more often than not get a prescription for a custom knee brace from a new referral source, indirectly through the physical therapist. Working together can benefit the orthotist and physical therapist and, most important, the patient, client, or customer.

Models of such long-term management have been outlined to include postoperative and nonoperative solutions, including two types of prehabilitation programs, conventional rehabilitation and aftercare/adaptive fitness programs. The importance of the use of UOA knee braces in the long-term management of the UOA knee is currently accepted by most orthopedic surgeons and the medical community at large. A model demonstrating the joint efforts of orthotists and physical therapists can be immediately implemented to benefit many with UOA of the knee(s).

James E. Glinn, Sr, PT, is a physical therapist and practice consultant with 30 years' experience in private practice physical therapy and wellness programming. Greg Huckert, MA, PTA, CPO, is a practicing orthotist/prosthetist and orthotic and prosthetic consultant.

REFERENCES

1. Mills R. Health Insurance Coverage: 2000 United States Census Bureau Current Population Reports. September 2001:1-9.
2. Med Life Mature Market Institute Analysis Population Program. United States Census Bureau; 2000:1-7.
3. Glinn JE Sr. Guide to Developing Cash-Based Programs in Physical Therapy Settings. Bakersfield, Calif: FutureRehab; 2001:12A.

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