Role of Prosthetists and Orthotists in a Rehabilitation Team

Original Editors - Naomi O'Reilly and ReLAB-HS

Top Contributors - Naomi O'Reilly, Nicolette Chamberlain-Simon, Kim Jackson, Shaimaa Eldib, Oyemi Sillo, Ashmita Patrao and Rishika Babburu      

Introduction

According to the The International Society for Prosthetics and Orthotics (ISPO), a prosthetist/orthotist is defined as:

"a health care professional who uses evidence-based practice to provide clinical assessment, prescription, technical design, and fabrication of prosthetic and/or orthotic devices. Prosthetists/Orthotists work independently or as part of the health professional team. They set goals and establish rehabilitation plans that include prosthetic/ orthotic services and clinical outcome measures. The profession aims to enable service recipients so they have equal opportunities to fully participate in society."

While technically prosthetics and orthotics are separate disciplines, their common goals in rehabilitation unite them into one cooperative entity. In many cases individuals may have dual training, while some may have training only in prosthetics or orthotics. Currently there is a global shortage of prosthetics and orthotics personnel.

The field of prosthetics and orthotics is commonly referred to as P&O. In the United States, the acronym is more commonly written as O&P.

Prosthetist

A prosthetist is a healthcare professional who performs a patient evaluation and designs, measures and fits prostheses. A prosthesis is defined as an "externally applied device used to replace wholly, or in part, an absent or deficient limb segment."

While prosthetists only work with exoskeletal prostheses (in contrast to an implanted device), their scope can include bone anchored prostheses. In addition to providing artificial limbs, some prosthetists provide mastectomy prostheses or restorations of other missing parts of the body.

In some cases, the prosthetist will be involved in pre-operative care for a patient anticipating an amputation. Often a patient is referred to a prosthetist after amputation to begin prosthetic treatment. Providing prosthetic care often includes long-term follow-up and collaboration with surgeons, primary care doctors, physiotherapists, occupational therapists, caretakers, and other members of the healthcare team.

Orthotist

An orthotist is a healthcare professional who performs a patient evaluation and designs, measures and fits orthoses. Orthoses are designed to achieve one or more of the following goals:

• Control biomechanical alignment
• Correct or accommodate deformity
• Protect and support an injury
• Assist rehabilitation
• Reduce pain
• Increase mobility
• Increase independence

Orthotists work with a wide variety of custom-fabricated, custom-fit, and off-the-shelf devices, including lower limb orthoses, upper limb orthoses, spinal orthoses, cranial remolding orthoses, protective helmets, and shoes. Orthotic treatment can involve acute or chronic care and often involves collaboration with surgeons, primary care doctors, physiotherapists, occupational therapists, caretakers, and other members of the healthcare team.

Other P&O Team Members

Associate Prosthetist/Orthotist or Prosthetic/Orthotic Assistant

An associate prosthetist/orthotist or prosthetic/orthotic assistant performs clinical duties under the supervision of a prosthetist/orthotist.

Technician

A prosthetic/orthotic technician is a non-clinical service provider, who works under the supervision of the orthotist or prosthetist to support the technical design of P&O devices and are competent in P&O device fabrication. They generally specialise in device fabrication and have a background in material science, engineering principles, or technical procedures/ processes and their role is generally in the design and fabrication of the devices. They generally do not have clinical contact with patients, though they may provide support to resolve technical issues with the devices.

Pedorthist or Foot Orthotist

A pedorthist or foot orthotist performs duties similar to an orthotist, but limited to conditions of the foot.

Governance

In many countries governance of the development and management of P&O services are limited or non-existent, with limited guiding frameworks in use. In a recent study only 30 out of 197 countries had some degree of regulation of the prosthetist and orthotist workforce. This study also highlighted that there is currently no international professional governing body specifically for prosthetists and orthotists, as is seen with many other health and social care professionals e.g. World Physiotherapy or World Federation for Occupational Therapy.

While it is not formally considered a professional governing body due to its multidisciplinary mission, many educations programs and clinics follow the standards of The International Society for Prosthetics and Orthotics (ISPO). ISPO is a global, multidisciplinary membership organisation dedicated to improving the quality of life for people with reduced mobility by promoting access to appropriate and equitable rehabilitation, mobility devices, and other assistive technology. Through international conferences, events, workgroups, and their journal Prosthetics and Orthotics International, ISPO provides a platform for the exchange and communication on all aspects of the science, practice, and education associated with P&O care and related areas. ISPO has approximately 3,300 members of different professional disciplines in over 100 countries, including prosthetists and orthotists, P&O technicians, orthopedic surgeons, rehabilitation doctors, physiotherapists, occupational therapists, orthopedic shoemakers, nurses and biomechanical/rehabilitation engineers.

Where they Work

The practice of P&O occurs in various settings, including independent private orthotic or prosthetic practices, hospitals, inpatient and outpatient rehabilitation facilities, rural outreach clinics, home health settings, short term nursing facilities and long term care settings and Non-Government Organisations (NGO). Individuals may also work within academia, research and education in universities.

Within these settings, prosthetists and orthotists work with adults and children of all ages with a wide range of conditions including:

• children born with congenital limb deficiency or cerebral palsy
• people who have had an amputation following an accident
• patients with muscular weakness after a stroke or spinal injury
• patients at risk of contractures after burn injuries
• patients requiring stabilisation after surgery
• patients with diabetic foot ulcers
• the elderly who have lost a limb as a result of vascular disease
• other conditions affecting the neuromuscular or musculoskeletal system

Knowledge and Skills

Prosthetists and orthotists help improve movement and function through the provision of P&O devices to increase quality of life and optimise function. With rapid advances in technology and health care, the roles of the prosthetist and orthotist have expanded from a technologic focus to a more inclusive focus within the rehabilitation team. P&O occupations are a spectrum of specialised health care disciplines that combines a unique blend of clinical and technical competencies to provide assistive products for people with physical impairments. Patient examination, evaluation, education, and treatment are currently significant responsibilities of practitioners. In addition to treatment planning and the implementation for custom P&O interventions, professionals may also be responsible for modular or prefabricated devices, soft goods, mobility aids, postural supports, wheelchairs and other assistive products related to P&O services. Most technical tasks are completed by technicians who work in the office, in the laboratory, or at an increasing number of central fabrication facilities. The advent and availability of modifiable prefabrication systems have reduced the amount of time that the practitioner spends crafting new prostheses and orthoses.

Assessment

According to the American Board for Certification in Orthotics, Prosthetics & Pedorthics, patient assessment may include, but is not limited to, the evaluation and documentation of:

• Anthropometric data
• Cognition
• Circulation
• Skin integrity
• Protective sensation
• Pain
• Central and peripheral nerve integrity
• Endurance
• Biomechanics
• Gait analysis including temporal and spatial assessment
• Range of motion
• Muscle strength
• Posture, balance and safety
• Proprioception
• Orthotic and/or prosthetic requirements
• Myoelectric activity and potential for use of functional electrical stimulation and/or neuroprosthetics
• Activities of daily living
• Environmental barriers including social, home, and work reintegration
• The need for physical and occupational therapy modalities

Management and Intervention

Formulation of a treatment and intervention plan follows a comprehensive assessment to design an intervention that will alleviate limitations, improve function and enhance quality of life. Prosthetic and orthotic intervention includes, but is not limited to:

• Preparatory care
• Material selection
• Fabrication of orthoses and/or prostheses
• Prototype development including evaluative wear
• Structural evaluation
• Diagnostic fitting
• Assessment of intervention
• Functional exercise
• Gait training
• Functional training (both self care and work related)

Resources

WHO Standards for Prosthetics and Orthotics. Geneva: World Health Organization; 2017. Licence: CC BY-NC-SA 3.0 IGO.

ISPO Education Standards for Prosthetic and Orthotic Occupations. 2018

The Australian Orthotic Prosthetic Association Scope of Practice

The Australian Orthotic Prosthetic Association Competency Standards