Will Congress act to provide for the ongoing care of America’s wounded warriors?
By Keith Loria and Janice T. Radak
The unfortunate truth: The need for prosthetic and orthotic (P&O) care is growing in this country, thanks, in part, to events on the other side of the globe—namely, unconventional warfare in Iraq and Afghanistan, although uncontrolled cardiovascular disease and diabetes continue to each play their devastating role. Over the past 18 years, more than 1,650 US troops have suffered combat-related limb loss in Iraq and Afghanistan and another 320,000 wounded warriors have suffered a traumatic brain injury, many of whom require orthotic care.1
Furthermore, consider these facts:2,3
- For every US soldier killed in World War I and World War II, 1.7 soldiers were wounded.
- For every US soldier killed in Operation Iraqi Freedom and Operation Enduring Freedom, 7 are wounded.
- Combined, almost 53,000 service members and nearly 40,000 civilian contractors have been physically injured in the recent military conflicts.
- In addition to physical wounds, it is estimated that as many as 400,000 service members live with combat-related stress, major depression, or post-traumatic stress disorder, among other mental issues, all of which can have an impact on quality of life.
- Current P&O education programs graduate approximately 250 professionals a year,1 far fewer than will be needed to treat the growing population of wounded warriors and civilians. To help address this growing need, the Wounded Warrior Workforce Enhancement Act, a bill making its way through each chamber of the US Congress, authorizes a competitive grant program to help colleges and universities develop or expand master’s degree programs focusing on prosthetics and orthotics.
“Far too many veterans who sacrificed limbs for our country experience frustrating delays in their care because of the shortage of qualified orthotics and prosthetics specialists,” said Senator Tammy Duckworth (D-IL) who, along with Senator Dick Durbin (D-IL), introduced S 1315. “This legislation will help make sure our workforce is better prepared to meet the needs of veteran amputees.” A comparable House bill (HR 2487) was introduced by Rep. Matt Cartwright (D-PA).
If the bill becomes law, P&O programs that receive a grant would require students to rotate through facilities run by the Departments of Veterans Affairs (VA) or Defense or that hold a VA contract. The bill also requires the VA to establish a Center of Excellence in Prosthetic and Orthotic Education to provide evidence-based research on the knowledge, skills, and training that clinical professionals need to care for veterans.
“The men and women who serve our country and suffer serious injuries should expect nothing less than the highest standard of care when they come home,” said Durbin. “Senator Duckworth and I have seen the work Illinois researchers and scientists can do in the field of orthotics and prosthetics, and to say it’s remarkable would be an understatement. We should be doing everything we can to advance this groundbreaking work, which supports America’s heroes.”
Senator Tammy Duckworth (D-IL)
A Synergistic Opportunity
Christopher Hovorka, PhD, CPO, LPO, FAAOP, assistant professor in the Department of Rehabilitation Science and Technology at the University of Pittsburgh, calls the bill an important opportunity for schools in P&O across the United States.
“Since the 1980s, funding for schools across the nation (including P&O programs) has been shrinking at an alarming rate,” Hovorka said. “Today, P&O programs are almost completely reliant on tuition and fees to keep afloat. So, the Wounded Warrior Workforce Enhancement legislation is a mechanism in which P&O schools can partner with DoD and VA facilities to extend their reach and receive commensurate funding and support for their efforts. It is a good synergy.”
And a much needed one, as well. According to Durbin’s office,1 the number of veterans with an amputation has more than tripled, from 25,000 in 2000 to almost 90,000 in 2016. This upsurge is not only as a result of service-related injuries stemming from the changing nature of war—such as the increasing use of improvised explosive devices and medical advances that help save more lives—but also a consequence of such illnesses as diabetes and cardiovascular disease. Skilled medical care and rehabilitation and advancements in orthotics and prosthetics have allowed these service members and veterans to thrive. Youth and nonprofit groups that engage wounded warriors in sports have also played a role.
However, the Bureau of Labor Statistics4 reports that employment of orthotists and prosthetists is projected to grow 22% from 2016 to 2026—much faster than the average of all occupations. Meanwhile, demand is expected to grow even faster. According to a 2015 workforce analysis,5 demand for P&O professionals will be about 60% higher than the available supply of certified providers. The authors of that analysis note that demand is based on the growing number of patients (aging Baby Boomers as well as a greater number of veterans) and supply is based on the graduation rate minus the attrition rate. The authors conclude: “With relatively few O&P education programs currently available, the expected attrition rate will likely outpace the growth in the supply of certified O&P professionals.”
So, a key goal of the proposed federal legislation is to educate more P&O professionals to do the needed research to develop appropriate clinical therapies for our wounded warriors.
Georgia Tech Deactivates
Meanwhile, in May 2018, Georgia Institute of Technology (Georgia Tech) deactivated its Masters of Science in Prosthetics and Orthotics (MSPO) program, which was one of the highest-ranking programs for P&O and had noted experts (including Robert Kistenberg, Geza Kogler, Young-Hui Chang, Boris Prilutsky, and Robert J. Gregor) all associated with its success. Deactivation means the school has 2 years to determine how it will proceed: close the P&O program altogether, reimagine it, or send it to a new home. At press time, Georgia Tech was still seeking a new home for the program in Georgia’s university system.
From its inception, the Georgia Tech MSPO program sought to advance the P&O profession and care for those who use prosthetic and orthotic devices by conducting rigorous academic level research. In only 16 years, Georgia Tech’s program established itself as a leader and a leadership producer in the profession of P&O and became the first entry-level Master of Science degree program accredited by Commission on Accreditation of Allied Health Education Programs. Deactivation also forced the loss of the entry-level PhD program in applied physiology with a focus in P&O. Leaders in the field, including Hovorka, believe the loss of both programs will reduce the number of clinicians and researchers entering the profession.
“In a profession where the body of knowledge is in its infancy and slowly maturing due to the small pool of scientists that are examining existing knowledge and developing new knowledge, I see the closure as slowing that progression,” Hovorka said. “Another thing to consider is that the entry level Master’s program at Georgia Tech was pioneering. When it began in 2002 and was accredited in 2004, it became the first program of its kind.”
But times change, and so do university administrations. And with those new administrators come new visions. Georgia Tech’s decision to move more toward basic science has meant that applied programs, such as P&O, are no longer a good fit, leading, ultimately, to deactivation.
The director of the program, Géza F. Kogler, PhD, CO, and Kinsey Herrin, another certified orthotist at Georgia Tech, have been working with other universities in the Atlanta metro area and the State of Georgia to find a new home for the program. Kogler told LER that, although there is interest from other schools, the process of program transfer is complex and will take considerable time and effort.
“The program officially is paused and within 2 years, the president of the institution needs to decide if they will reactivate it or terminate it, and that’s the point where we are at right now,” Kogler said. “The fact that there are no signs my contract will be extended past the end of December tells me that, even though it’s not official, the program will be terminated as there’s only myself and one faculty member remaining.”
Christopher Fink, MSPO, CPO/L, residency director for Fillauer Orthotics and Prosthetics, Chattanooga, Tenn., finished the program in 2009 and went on to teach at Georgia Tech. He noted that the program built relationships with other faculty and professors throughout the university who are now performing research related to P&O.
“Many of these projects require the unique clinical expertise of a prosthetist or orthotist to create appropriately fitting devices,” Fink said. “Without our expertise, these projects may end, or they may go in directions that are not beneficial to the P&O field. They might slow to a pace in which we delay important breakthroughs that could change patients’ lives. All we do know is they will lack a point of view and skill set only we can provide.”
Fink was part of the effort to change the minds of Georgia Tech’s leadership, and worked on revamping the entire program, integrating into other schools, adding more students, adding new classes, offering classes to other degree programs and students, and showing the program’s success in producing graduates who are leaders in the field overall.
“It appears that, in the eyes of the administration, we are no longer a good fit at Georgia Tech and there is nothing we can do about that at this point,” Fink said. “We have made the community and alumni aware of the state of the program and asked for their support in the matter.”
It Was a Game Changer
If you look across the nation—in professional P&O organizations, universities, research centers, and the management of practices large and small—you see that many of those positions are led by alumni of the Master’s and PhD programs at Georgia Tech.
Benjamin Lucas, program coordinator for prosthetics and orthotics at the University of the Sunshine Coast in Australia, was a member of the inaugural class of the Georgia Tech program in 2002. He noted that the uniqueness of the program was its strong focus on research for the students, which tended, at least initially, to attract students who were most likely to pursue leadership positions.
“The program was a symbol as the first and one of the main drivers to improve P&O education in the United States, or at least provide a model to improving,” he said.
- Lee Childers,* PhD, CP, senior scientist at the Military Performance Lab, Center for the Intrepid, Brooke Army Medical Center in Fort Sam Houston, was a product of this emphasis and is now able to serve those who have served our country by leading the research mission.
*Disclaimer: The view(s) expressed herein are those of the author(s) and do not reflect the official policy or position of the Brooke Army Medical Center, the US Army Medical Department, the US Army Office of the Surgeon General, the Department of the Army, the Department of the Air Force and Department of Defense or the US Government.
Today, Childers, with a dedicated staff, is charged with conducting scientific research to enable readiness and return service members to high function after extremity trauma.
“When we are able to show that a new prosthetic technology is superior to another, we are able to inform practice within the Center for the Intrepid long before the data is published,” Childers said. “All I need to do is just walk upstairs and tell the chief of prosthetics what we discover in the research lab. This is exactly what I wanted to do with my career and the Georgia Tech program and its faculty was instrumental in putting me on this path that ultimately benefits our service members that have sustained limb trauma.”
All the experts who spoke with LER made it clear that the Georgia Tech program sparked greater discussion and consideration for change in the education and professional standards for clinicians in the profession. By 2005, discussions with members of the leadership in P&O led to raising the entry-level from a baccalaureate to a master’s degree, making it a clear game-changer for the landscape of P&O education in the United States.
Furthermore, in 2005, when the entry-level PhD program in applied physiology, with a focus in P&O, was initiated, it became the first pre- doctoral training program that received support from the National Institutes of Health (NIH) to prepare scientists with specific focus in P&O. Successful implementation of that pioneering program also sparked discussion across the nation.
“The PhD programs at Georgia Tech were strengthened by each other. The PhD program allowed scientists to learn clinically important principles and the master’s degree program allowed clinicians to examine ways of answering research questions,” Hovorka said. “It was a strong synergy that the NIH supported, and the profession of P&O warmed up to after they began to see how capable its graduates were in clinical patient management and problem solving.”
The P&O program at Georgia Tech prepared clinicians with science-based training employing methods that encouraged evidence-based rationale in decision-making. Hovorka noted that, with the closure of the program, there will be a noticeable gap in that type of clinician entering the workforce.
“That is not to say that the existing P&O programs are not doing their job—they are, but each program has a slightly different focus and the program at Georgia Tech had a strong combination of clinical training and science,” Hovorka said. “That will be missed by the profession and, hopefully, it will sound an alarm that will bring the P&O community closer together.”
Georgia Tech’s Response
Lance Wallace, director of issue management and interim assistant vice president of creative strategy and brand management at Georgia Institute of Technology, explained the program was originally set for deactivation in 2017, pausing the program to evaluate it.
“We felt we needed to find a good home for it, rather than just say we were going to shut it down,” he said. “The deactivation was the first step to explore opportunities to find an academic home and we’ve been looking within the university system of Georgia, and that’s the hope that it will find a new home.”
What Georgia Tech does as a whole, he added, is more technological in focus, where this master’s program was more clinical in focus. That’s one of the reasons the university made the decision. For example, the school is working with veterans and others to create and build robotic limbs to enhance the movement of existing prosthetics using such tools as ultrasound technology, and is invested on the technology side.
“The master’s program is very much focused on patient care and fitting prosthetics and orthotics to patients, very important and not something we want to discount in any way, but we want to find a home that matches that clinical environment best,” Wallace said. “We remain committed to the research and are not backing down from that.”
Filling a Need
Childers noted that prosthetic and orthotic technology is advancing rapidly, thanks to a more highly educated workforce that is able to adapt advances in technology to patients. This, in turn, drives the need for a more educated workforce that knows how to utilize those advanced technologies that enable wounded service members to achieve high function.
“The Georgia Tech program was the first MSPO program and drove positive change in our profession. It attracted young, eager, and smart students that were hungry to advance care for people that needed prosthetic and orthotic devices,” Childers said. “They were educated to appreciate and understand the role of research and evidence-based practice to provide the best care for our patients.”
Many graduates of the Georgia Tech program have taken leadership positions throughout the profession, gone on to earn a doctorate and pursue a research career, all while incorporating outcome measures and evidence-based practice in clinics across the country. Then, they contribute back to the profession through facilitating and conducting research, much of which helps service members and veterans.
Passage of the Wounded Warrior Workforce Enhancement Act would allow P&O programs to continue to graduate clinicians whose clinical training and scientific research capabilities are ready to meet the needs of active service members, veterans, and civilians.
Keith Loria, a freelance writer in Washington, DC. He has been writing for LER for 5 years. Janice T. Radak is the Editor of Lower Extremity Review.
- Durbin, Duckworth introduce bill to support wounded warriors. Press release. May 3, 2019. www.durbin.senate.gov/newsroom/press-releases/durbin-duckworth-introduce-bill-to-support-wounded-warriors. Accessed August 14, 2019.
- Singleton D. Caring for our wounded warriors. Huffington Post. December 6, 2017. www.huffpost.com/entry/caring-for-our-wounded-wa_b_10134780. Accessed August 14, 2019.
- Congressional Research Service. US war costs, casualties, and personnel levels since 9/11. April 18, 2019. https://fas.org/sgp/crs/natsec/IF11182.pdf. Accessed August 14, 2019.
- Bureau of Labor Statistics, US Department of Labor. Occupational outlook handbook: orthotists and prosthetists. April 12, 2019. www.bls.gov/ooh/healthcare/orthotists-and-prosthetists.htm. Accessed August 14, 2019.
- DaVanzo JE, El-Gamil A, Heath S, et al. Projecting the adequacy of workforce supply to meet patient demand: analysis of the orthotics and prosthetics (O&P) profession. National Commission on Orthotic and Prosthetic Education (NCOPE). May 27, 2015. http://www.ncope.org/view/?file=Dobson_DaVanzo_Final_Report_-_NCOPE_Workforce_Demand_OP_Professionals_5.27.15. Accessed August 14, 2019.