The Prosthetics and Orthotics Podcast
The Prosthetics and Orthotics Podcast is a deep dive into what 3D printing and Additive Manufacturing mean for prosthetics and orthotics. We’re Brent and Joris both passionate about 3D printing and Additive Manufacturing. We’re on a journey together to explore the digitization of prostheses and orthoses together. Join us! Have a question, suggestion or guest for us? Reach out. Or have a listen to the podcast here. The Prosthetic and Orthotic field is experiencing a revolution where manufacturing is being digitized. 3D scanning, CAD software, machine learning, automation software, apps, the internet, new materials and Additive Manufacturing are all impactful in and of themselves. These developments are now, in concert, collectively reshaping orthotics and prosthetics right now. We want to be on the cutting edge of these developments and understand them as they happen. We’ve decided to do a podcast to learn, understand and explore the revolution in prosthetics and orthotics.
The Prosthetics and Orthotics Podcast
The Doctor is In: Telemedicine for O & P with Dr. Nate Crider
Dr. Nate Crider joins us to discuss his approach to prosthetic care through telemedicine, where he bridges the gap between prosthetists, patients, and insurance requirements. As a PM&R specialist, he has expanded to 14 states in just three years, improving outcomes by bringing medical expertise directly to prosthetic clinics.
• Telemedicine solves mobility challenges for amputees while improving communication between medical and prosthetic providers
• Insurance documentation requires specific medical necessity language that many primary care providers don't understand
• Collaborative appointments with patients and prosthetists ensure accurate assessment of functional needs and appropriate technology selection
• Technology advancements including osseointegration, pattern recognition for upper extremities, and K2 microprocessor knees are changing patient options
• Proper socket fit, liner replacement, and supply management significantly impact patient comfort and functional outcomes
• Interdisciplinary approaches with surgeons, PM&R specialists, and prosthetists lead to better amputee care from surgery through rehabilitation
• Small and large prosthetic practices benefit from specialized medical documentation support that reduces denial risks
For more information about Dr. Crider’s telemedicine services, connect with him on LinkedIn or contact Madrina company, which operates in 46 states.
A special thanks to Advanced 3D for sponsoring this episode.
Welcome to Season 11 of the Prosthetics and Orthotics Podcast. This is where we chat with experts in the field, patients who use these devices, physical therapists and the vendors who make it all happen. Our goal is to share stories, tips and insights that ultimately help our patients get the best possible outcomes. Tune in and join the conversation. We are thrilled you're here and hope it is the highlight of your day. Hello everyone and welcome to the Orthotics and Prosthetics podcast.
Speaker 1:Yoris is actually out of town.
Speaker 1:He's actually at Rapid TCT and seeing all the new things there, so if you're there and you see him say hey.
Speaker 1:But today I'm super excited to have Dr Nate Kreider with us and this is really a first for us because it's going to be very interesting to see the medicine side of amputee care, and one of the things if you don't follow him already on LinkedIn, you should. One of the things that I really love about what Dr Kreider is doing is really immersing himself to help patients have better outcomes, and that starts from the very beginning, and I know at our company, east Point Prosthetics and Orthotics, we've used him multiple times for some prostheses and what's great is he actually knows what we're talking about and the positive side to that, too, is this gives a direct correlation to not only the outcomes, but some of the things that we're going to be using for the patients and the why. So I'm really excited to dive in deep with some of that with Dr Kreider. So, dr Kreider, welcome to the show. So we always start off with this question how did you get involved with orthotics and prosthetics?
Speaker 2:Well, I'm a physiatrist, so physical medicine, rehabilitation and I did my residency at Carolinas Rehab in Charlotte, north Carolina, which is now Atrium, which has a big prosthetics program, you know, doug Toman, and I'm doing a big, and that was I really enjoyed. You know all of my rotations. We rotated with prosthetists during our time in the clinic as well as, obviously, in the acute inpatient rehab and in the follow-up clinics. There I was doing more regenerative medicine, doing injections, you know, ultrasound, guided fluoroscopy, guided joint injections, tendons, ligaments, spinal injections with plate-large plasma and stem cells, bone marrow concentrate, which was really cool stuff, you know. It works really well. But that's not covered by insurance, and so I've always, you know, had been doing side jobs at the same time too, and so I've always, you know, had been doing side jobs at the same time too.
Speaker 2:And a friend of mine who is a prosthetist said to me you know, can you help me with this? Like, this is a big need that I can't get notes and orders for, you know, these prostheses in a timely fashion, that have what need to be in them from someone who knows what they're talking about. You know, is this something you could do for me? And obviously that presents tons of logistical challenges. Um, but uh, we decided to uh make that work, and so I started doing that in North Carolina and Colorado about three years ago and there's been a huge need for it. So I just call up prosthetists and say, hey, is this a problem that you have? You know, do you have a hard time teaching primary care doctors what needs to be in these notes and getting them back in time? And the answer is overwhelmingly yes. And so I've just been growing, you know, since that time to where I'm no longer even doing regenerative medicine. I'm all in on, you know, prosthetics and orthotics. So it's growing rapidly. Now I'm doing it in 14 states.
Speaker 1:That's amazing. I mean, 14 states is awesome and it's such a service to not only the patients but prosthetists and the patients to get the right information. But I know it's not been without its speed bump right, because you can't teleport yourself physically in, and so, as I know, some of the stuff that you've posted on LinkedIn has been like this aspect of telemedicine, which is so important and does help patients. That journey and even some of the background of the legislation and the paperwork side of things that's, I guess, more on the political side and how that affects what you're doing and the future.
Speaker 2:So I mean that's a nice thing about telemedicine is I don't have to transport myself and it's actually more efficient of a clinic than I ever had trying to do a prosthetic clinic in person. You know where you're trying to get all of the information out of the patient, who might not fully know what the plan is or what's going on, and trying to get people into the building, and these are patients with disabilities and mobility trouble. So actually getting them into your office on time and the workflow of just space can be an issue and the workflow of just space can be an issue. Trying to have the prosthetist there during the call is absolutely the best way to do it and that's a challenge to really do every time in person, especially if you guys are driving out to the doctor's office and waiting an hour to be seen, you know, because they're running late, because they're trying to see a million people. So telemedicine has really solved all of those problems for us by typically having the patient call in while they're in the prosthetist's office anyhow. So we're always doing it alongside the prosthetist so there's no miscommunication, so we can really nail down the plan and answer any questions and we don't have all those mobility issues. You know, I even work with, like mobile prosthetists who are in a van outside the patient's home and they bring me to the patient and so there again, I mean you can't get a patient into the doctor, great, bring the doctor to the patient. So it's been. And just the efficiencies of the workflows I mean I'm able to do these visits so efficiently because of the level of communication that I have with the prosthetists before the visit and during the visit that I would have never had trying to do that in person.
Speaker 2:So, yeah, telemedicine, you know, became a thing during COVID. So before that, you know, zoom wasn't so much of a thing. There weren't really video calls or, you know, just internet bandwidth or whatever reason. And then during zoom, they said, hey, we're going to cover in in person telemedicine video call the same rates that we do as an in-person face-to-face call and we're going to count it as a face-to-face visit. And the fact that it counts as a face-to-face visit is what makes it compliant for prosthetics that we can prescribe DME over telemedicine. So that's what's been potentially at risk.
Speaker 2:When they made that rule in 2020, they put a four-year sunset on it. It was set to expire December 31st of 2024, this last New Year's Eve they just kind of waited on ever extending it or making it permanent. It's hard to get stuff done in Congress, for whatever reason. It's just kind of gotten lumped in with those continuing resolutions to fund the government. It's just kind of gotten lumped in with those continuing resolutions to fund the government. So it was extended for three months alongside the federal funding extension. You know, at that deadline where the government was going to shut down on New Year's Eve, they funded the government for three more months, made telemedicine be a thing for three more months. And now in March, the same thing happened again Another deadline, another government shutdown looming, another six-month extension this time. So now we've been told it'll continue to be compliant.
Speaker 2:I mean, that's the main thing is it has to be compliant, right? That's what the process or ultimately using the service for is to know that they can deliver a device and have its hold up to insurance, and so that really depends on it remaining a compliance service. As a face-to-face visit, yeah, it's been super helpful, like you said, I mean having someone who knows what the prosthetist is talking about, and even having the prosthetist in the room, even if you go to the doctor's office and you're talking to their you know primary care PA and NP and saying you know, look, I need you to say these things so that it's clear that this patient is a candidate for the you know, microprocessor knee. But I can't just say hand you something to write. You have to write it yourself, please. You know that's a big ask to try to teach every, every provider how to do that and it's a lot for them to try to keep up with. It's a changing field. You know I'm kind of being asked to do two things Explain to the insurance company, why highlight things in this patient's history of why they are a candidate, according to the insurance company's criteria, for those components.
Speaker 2:So you really have to understand each of the L codes in the DWL, what those components are and who they're indicated for according to the insurance criteria, which is most primary care doctors don't know either of that. They don't know the prosthetic plan or the rationale for it or what needs are being met by those devices and how that aligns with what their insurance actually covers. And then you're also having to explain to insurance at the same time of why a lesser device wouldn't meet their basic mobility needs right. So you're having to understand what the lesser device is and what their actual needs are. You know that makes it so that those devices wouldn't work and what an advanced prosthesis would offer to meet those needs that couldn't be done with the lesser. So with each one of them you have to know the prosthetic plan that you guys are recommending and why we're not recommending something cheaper. And you're just telling the story for the insurance company.
Speaker 2:So, and that that's one side of it. Obviously that's the documentation, medical necessity side. And there's the whole other side of you know, just talking through with the patient of like what you know is is this, is this what you need, you know, is this what you want? What are your goals, what are your barriers, you know, and just trying to make sure that we're all on the same page. Because you know we've all seen people with microprocessor ankles sitting in their closet because it's too heavy or something. I mean you know there's downgraded to K2 six months later because they didn't progress in PT like you thought they would. I mean there's a reason that insurance has these criteria.
Speaker 2:They're not necessarily the bad guys. In some ways it's right to start someone with a preparatory prosthesis and advance them as their needs change. You know, they're not necessarily doing variable cadence right off the bat and now that we can do a K2 microprocessor like, maybe that's not even a big deal. But yeah, I think it's a benefit to everybody to get them the right prosthesis at the right time and then have the accessibility to get back in and get the right one when it is time. You know, I think sometimes that's a barrier too.
Speaker 2:You get on their first socket and then they're lost to follow up and they come back in with a 20 ply fit and oh, I haven't been wearing it for months because it hurts too much. You know, I haven't been able to get in with my doctor. Now it's easy, you know you're just like hey, it's six months or you're. You know you're due for new supplies. Maybe you should come in and we'll check and make sure that your socket still fits. And oh, yeah, oh, you've been walking more. You're out and about, but the uneven ground is trouble like what can we do about that? You know, let's talk about your makes it easy when we can do it at the same time. Instead of making it a separate trip to somebody that doesn't even know what's going on, you can say go see your doctor and the doctor is like, okay, you have a prosthesis, right, it's not broken or anything you know. They don't necessarily know what they could be doing if they had a prosthesis that was appropriate for them.
Speaker 1:Right and I think, even like what you were saying, the supply side of things I think that's one of the things that is definitely overlooked in patient care is some of these patients ride their liners and their dirty socks stretched out socks for so long that they don't even know what a good prosthesis or you know the right prosthesis, feels like, and those simple things as just replenishment of the supplies make such a difference in their quality of life. And you haven't changed anything.
Speaker 2:You haven't changed the socket, you just changed the new liners and such Even just someone else looking at their skin and being like so how have you been cleaning this? Are you putting lotion on underneath it? Why does your leg look like this, just having a doctor that's familiar with the medical issues that come up alongside it? You know how the you know gait deviations can affect their you know back pain or sound side, or get them into physical therapy to work on. You know, maybe even something else that you noticed while they were walking. Hey, it looks like you know you've got Trendelenburg gait. Let's get you into work on your hip muscles, or hey, you know. I'm trying to look at the broader picture of what are the barriers to you doing everything you want to be doing. Some of it's going to be their prosthesis, socket, supplies, componentry. Some of it's going to be other musculoskeletal issues that you know I've been doing this whole time. So, even though I'm not doing injections anymore, I'm still very much doing musculoskeletal medicine and physical medicine. That's my specialty.
Speaker 1:Yeah, I'd like for us to take, or you to take, our listeners through the actual process, right. So how do, first off, how do you engage with the prosthetist, and then let's go to the next step of like what is the overall structure of the appointment, like what is the first thing that you do when you assess the patient, and then how do you link the prosthetist in on that appointment? I think just having a broad sense of like what actually happens during that engagement would be very, very beneficial for our listeners.
Speaker 2:Yeah. So ultimately our referrals come from the prosthetist. The prosthetist are the ones that really facilitate the visit because, like normally they would say, go see your surgeon, go see your primary care and make sure they write everything that we need. And now they say we're going to have you go see Dr Kreider and we'll help you get that set up. And then usually I have them give me some information ahead of time on the things that they already know as far as the prosthetic history Because, again, when I was doing a prosthetic clinic in residency, those were like one hour visits to get the patient into the room elicit kind of their whole history.
Speaker 2:So you know how'd you lose your leg? You know that's. That can be like 10, 20 minutes right there. You know what do you have now. You know as far as componentry, when was it dispensed, what's wrong with it. You know what do you need instead, like all of this kind of stuff you guys already know. That's why you sent them over. So I get a lot of that ahead of time, which means that we don't have to use that precious face-to-face time on that. Instead, I really just try to focus on their experience, you know, because, like I said, a big part of what I'm trying to do is paint that picture to insurance. If someone comes in and says everything's fine, then I'm like oh, then it sounds like you just need supplies, you know, sounds like everything's good. If you say you have no pain, you're doing everything you want to, you're not held back at all, then don't change anything. You know, unless you know. So it's really you know.
Speaker 2:First question I usually ask is like what does it feel like when you walk? You know, like, what is your subjective experience when you try to do something and what problems are you having with your mobility? And then from there you can talk about okay, so the socket, you know it doesn't fit in. What you know, yeah, it doesn't fit anymore. They'll say oh well, what does that mean? Like, what does that feel like? Like, are you having pain or you have instability fallen? Are you sinking down into it? Are you medial, lateral instability?
Speaker 2:You know, um, are you wearing so many socks you're being lifted up out of it? Um, you know, you know, are you wearing so many socks you're being lifted up out of it? You know, it could mean all kinds of things and that is what really shows. Oh, yeah, even though the socket's only three months old, it doesn't fit anymore and so there's no like strict rule of thumb. You know you have to wait six months to get a new socket If the thing doesn't fit at all and they're just not wearing it or developing wounds like they need a new one.
Speaker 2:So, um, you know that's uh, that's a big part of it, and then and then just kind of working head to toe on on each of it. You know what are you, what are you noticing with with the foot, what's hard to do, what are what are your work duties, things like that. So that's a basic physiatry note and that's why I said it can. It can take an hour to in an unfocused interview to get that done, and we get it done just so much more efficiently over telemedicine because of the relationship that I have with the prosthetists.
Speaker 1:Yeah, yeah, yeah, got it Sorry. So that face to face visit you have, you deal, you go right to the heart of the problem because you have the information, some of the original information, so that gets you the efficiency there.
Speaker 2:I know your foot is five years old. You know, I know, that it's delaminating and cracked. That's a pretty easy story of why you now need a new foot. The question is like what kind of foot is right for you at this point? Is it another dynamic response foot?
Speaker 1:or would you benefit from?
Speaker 2:hydraulic, or like. You know, what are your, what are your needs and your goals and your experience with the old one? Oh, the old one was a little too heavy. And you know, the old one, you couldn't sit in a chair comfortably because you couldn't get your ankle under the chair. Oh, you know, before I couldn't get out of a chair very well and I have all these stairs I have to do. You know, these are the kinds of questions that you want to answer for, because each of them might make them more of a candidate for a different kind of device.
Speaker 1:So then, what is the benefit of having the prosthetist there as well? Like I know, you know the benefit, but just for our listeners and even we have patients and physical therapists this kind of interdisciplinary approach really does help the patients and their outcomes.
Speaker 2:Yeah, I mean, part of it is because, you know, I don't always get the perfect information on that guide of, like, you know how old the device is exactly, what's wrong with it If it's. If we're replacing things, you know and patients don't know that. If we're replacing things, you know and patients don't know that. And then part of it is clarifying the plan. Oh, I see you've got. You know, you've got like a 15-ply swing in socks from the beginning of the day to the end of the day. Do you want to think about, you know, a volume-adjustable socket? You know, might this be a good candidate for Revo panels? Or, oh, you know, he's on dialysis, like you know he's, he's on dialysis. Like you know same sort of thing like do you want to try like an overlay? Or do you want to try this adjustable socket? Or do you want to try, do you? This guy's got a lot of back pain? Do you want to try? Like a vertical shock pylon? Or you know something like that? Um, the things that, um trying to think of some other examples that have come up where, uh, there's just we're identifying in that during this conversation, we're identifying unmet needs and issues in their daily activities that could potentially be addressed through the prosthetic plan, and so, rather than having to go back and do addendums that's kind of my goal is to get the note right the first time, to where I'm not having to go back to do addendums because I screwed something up or I didn't understand the plan, or it doesn't meet what needs to be in there for insurance. I don't want to have to do peer-to-peers and so we avoid all of those things by nailing down the plan the first time, which requires, you know, that kind of collaboration because plans change too.
Speaker 2:I mean, you know, it's not uncommon that someone comes in for a socket and by the end of it we're talking about a foot, um, not even just because I introduced it, but just because we started talking to the patient of. You know, oh, you're, you're 30 pounds up and this foot's feeling kind of soft. You know, when you walk over it and you're falling forwards, um, you know, that sounds like you need a new foot. Um, so things like that. So sometimes you just identify issues and, rather than having to go back and forth, you just get them what they need that time Identify, foot, drop on sound side. You know, um, hey, I see you're missing some fingers there, have you? Have you guys talked about partial hand prosthetics? Um, you know stuff like that.
Speaker 1:You've touched on some of the the, and I'd love for you just to dive in a little bit deeper to like from your perspective as a physical, medicine and rehabilitation doc. What are some of the common physical or psychological challenges that amputees face during just their initial rehabilitation, but then over over the life of them needing a prosthesis?
Speaker 2:Um, yeah, I mean, obviously, you know, amputees are not a monolith. There's all kinds of different experiences within that group. You know some people, um, you're just trying to make sure that again, again, we're not over equipping them. I guess sometimes that's something that I add where it's useful to have the prosthetist there is. You watch them walk and they're like this person is like K1, maybe K2. Like let's start them there instead of this plan of like, let's just get them, like the best thing, right out of the bag. It's like it's not the best thing right out of the bag. It's like it's not the best thing, uh, if, if they don't use it. So what I'm seeing today is that this person maybe should be starting on something light and stable, um, and something that will give them confidence, you know, in their ability to use it, rather than abandoning it or reducing their prosthetic use because they feel like they can't safely use it. So I've definitely watched people and you know I'm kind of like making eye contact with the process, like, so you're seeing what I'm seeing, right, this is, you know, maybe we'll be seeing him back in six or 12 months and have him do some therapy with a prosthesis before we jump to the plan that you had in mind therapy with with a prosthesis before we jump to the plan that you had in mind, um, and that, like I said, that saves the patient too, because they will not do well with the prosthesis that is inappropriately heavy or complex either. So, um, I think that's some of it as far as they're trying to identify what their experience is going to be, or nobody has a crystal ball.
Speaker 2:You know the, the dysvascular BK, ak is kind of like the like the classic example of, like someone who's you know what are, what are your like realistic goals? You know, with this, what is your level of support at home? What? What is your premorbid condition? What is your, you know, ejection fraction? Um, so, um, yeah, I think that's been an example where it's important to kind of understand, um, what patients might might be getting back to and then the really high level people to do, you know, trying to get them activity, specific prostheses and all these states where there's so everybody can move flaws.
Speaker 2:You know, kind of talking through like there's a lot of different things that you could try to do with that. You know, are you looking for water, shower, swim? Are you looking for a ski? You know snowboard bike. Are you looking for running? You know what kind of running prosthesis would you want? You know, sometimes people are really used to one thing they've always done, and sometimes that's the best thing because they're used to it. You know, and don't mess with something that works. Sometimes they're like, oh, you mean I could use something other than a total need to run on, and they're like, yeah, it gets a lot better than that. Um, you know, um, so, um, yeah, those are. Those are fun conversations to kind of talk through, um, what people's goals are and and nail down the prosthetic plan. I mean I don't know how to make them, but I I have, uh, I know what's out there and what they can. Prosthetic plan I mean I don't know how to make them, but I, I have, I know what's out there and what they can do for people.
Speaker 1:I'd love for you to share cause. I mean, you've been doing this the prosthetic side for like three years, so I'm sure that you've had some repeat patients, so you've you've seen potentially some change in activity levels. Or I'd love for you just to share like a personal story of how maybe you started somebody at a K one and they really put in the work and that sort of thing and K, you know, k three or I mean I guess the more depressing side of this is if they started at a K three and for whatever reason, maybe they had a stroke or something, but you're still involved with them so they can be successful, if they've gone down to a K2 or something like that. But I'd love for you to share a story.
Speaker 2:And I think that's one of the things that can get lost sometimes when people go to their primary care for these things is the primary care thinks everybody. Every amputee is, you know, running on a blade and that there's no need for a prosthesis if you're just mostly sitting in a chair and using it for transfers and positioning in your chair and staying for ADLs and stuff like that. So there's a huge need for people's independence. For K1 ambulation, that is someone who is a good prosthetic candidate if they're using it for those things with the right prosthesis. So that is. I think sometimes people get dissuaded from using a prosthesis by doctors who don't understand how that can help with lower level of mobilities. As far as just having independence and safety, you know I've definitely identified. One person that comes to mind was coming in for their first prosthesis on one side and you know it was a dysphascular kind of case and I was like, well, let's take off your other shoe and just look at your other foot. You know your other foot's good, right? Yeah, well, let's just lay eyes on it. And he's got just, you know, black mummy toes just dried up, um dry gangrene, um dead toes. And I was like, let's, let's wait on um. You know um dead toes and I was like, let's, let's wait on um, you know fitting this right now and I want you to go see your surgeon immediately, you know, and uh, sure enough, you know, and it's on back a couple months later. Uh, for bilateral bolognese Um. But then that's a different prosthetic plan you know for for an initial DK bilateral um versus what they had been thinking he would be um, you know, when he really was about needing surgery, um, so that's a good, good reminder to me always is like, yeah, check the other foot, you know, and just make sure that you know the whole picture of what's going on. Ask them about their sound side, um, um. As far as people that are um improving, yeah, I mean absolutely. Um. As far as people that are um improving, yeah, I mean absolutely.
Speaker 2:You see people that have tried. You know all these different things and um sometimes that maybe get labeled as having tough customers, kind of like. You know someone that's just never going to be happy um, but then you know we say let's, there's more, don't give up on this. You know there's more adjustments, there's better fitting socket, change the alignment, there's different things you haven't tried and then you see them back and they're happy. So, you know, I think sometimes people do get really frustrated when things aren't going well. They're having sores, they're having pain, but this is a lifelong thing.
Speaker 2:And yeah, I've been asked, you know you need to see them in follow-ups, like after I deliver the vice and I don't. I see you have a prosthesis, you know. Um, very good, you know I don't need that follow-up. I'm not, I'm not adding any value to that, but I'm gonna be seeing them. But these, these are lifelong patients. This is my career. I'm gonna be seeing them in follow-up either in six months for supplies, or in a year when they, you know, have advanced, you know in K levels or they, you know, for whatever reason, lost weight because they're more active, you know things like that. So I'm seeing people in follow-up, usually organically, just because they continue to need things and this is the best way to get that care, and primary care is happy about it too. That's.
Speaker 2:The other thing is, like some of the prosthetists, when I do those cold calls of like, do you need help with this? Sometimes they'll say you know, I'm worried about losing referrals from surgeons or primary cares because they want to see what happened to my patients. Why am I not getting these follow-up visits? And my understanding of how this has gone across the board is that they're happy to not have to be dealing with this, even if they did know what needed to be in the notes. These are difficult visits for them, you know. They take a long time. There's a lot of paperwork on the back end. Even if they get the note right, there still is time. There's a lot of paperwork on the back end. Even if they get the note right, there still is multiple faxes for DWO and prescription and maybe addendums and maybe peer-to-peers. These offices are not hurting for follow-up visits. They are happy to have somebody take that off their plate. So yeah, I think that's the role for long-term management of prosthetic needs should be with a subspecialist, and I think most generalists agree.
Speaker 1:I love that. I love that. The other thing that I love and I'd love for you to share like you live, eat and breathe this now, and you know I've seen you around some of the shows and I'd love for you to take me through the first orthotic prosthetic show that you went to. And then I'd love for you to dive into some of the technology things of. Even over the last three years. Things have changed, and even the reimbursement. I mean you've already mentioned a couple of things the adjustable sockets, k2 microprocessor knees and that sort of thing. But so the first thing is I'd love for you to take you know what was your initial reaction when you first went to one of these O&P shows, and then I'd love to just talk and maybe nerd out over some of the technology.
Speaker 2:So, yeah, you know, even in residency, I hadn't, you know, gone to a trade show, so this was my first time kind of seeing it all in one in one big hall, and seeing all the people that I've worked with was kind of the funniest thing. I'm just like kind of wandering around with my badge and just recognizing, like person after person that I've been seeing online I mean 14 states and working with, like most prosthetists in most of those states, prosthetists in most of those states. This is something that benefits everyone. You know, whether you're working with you know a big company like Hanger, or you're a small mom and pop shop like everybody, every one of their patients benefits from having a doctor that knows what's going on, and so and it doesn't matter to me whether you're sending one patient a month or you know three a day, um, so, so I know all of these prosthetics coming from all over the country and all the different kinds of clinics, um, and they're all they all kind of like I get this like double take and they're like looking at me through their, through their, uh, making a frame out of their fingers, like hey, I've only ever seen you when you're, you know, three by three inches, um, uh.
Speaker 2:So that was kind of uh fun to see them and and and and see and see the clinicians you know connect with each other, like oh, you used Dr Kreider, this has been great, like you know, just kind of like um going through all the ways in which it's affected their workflow, um, and and seeing the excitement um from them. So I think, um, I think it's been a game changer in a lot of ways. You know, not even just for like efficiencies and timelines, but, like I said, just for like um, you know quality and and um, and even connecting you know prosthetists to one another. You know, as I learned, you know tricks, from what one person is doing to another, um, we had someone with a, a really short residual limb and quad weakness, um, that he was wanting to build, like you know, a thylacer with uprights and he's like, can I get extension assistant in the prosthesis? You know how do I do that um, and so we were kind of like talking.
Speaker 2:I was like aren't there kfos that have that like, like, can you just use those? And um, and I mentioned it to another prosthetist and he's like, oh yeah, you know, icarus has this new brace that um actually like straps onto a trans-tibial socket and so maybe you could just use that and he doesn't have to make a whole thigh laser Um. And so I like emailed that back to him and he's like, oh great, you know, so stuff like that, um, weird, weird systems that I've seen with, like um, cool, uh, double wall, uh, a trans femoral socket with a smart puck on the inner, um, that and revo system that latches on to the on the rigid outer that latches around the smart puck uh, zero puck actually, because it was on the outside. Um, so, just like, some some innovative things that you see going on in the space that maybe would have just kind of like stayed local to that one provider, um, that you know, if they're willing to share that knowledge, um, um, I can be a vector for that. You know to, to see, oh yeah, this is what you know, and there are, there are, you know, differences in what people are doing across the country. Um, so to kind of see those patterns and share what I'm seeing Um, and then, yeah, as far as the you know being at the show, um, it was cool doing the, seeing the that I mentioned the pattern recognition being one of those changes.
Speaker 2:You know now having a code, it was cool kind of strapping that thing on my on my forearm and, you know, moving a digital device, um, and seeing like how intuitive those can be. And it's just like why is this not in every you know upper extremity prosthesis, when it's so hard to get a multi-articulating hand to do what you want to and it's so easy with a couple more electrodes and a computer? That seems pretty obvious, but that's another one of those cases that needs a good note of. Like. You know, this is why they need to be able to have this kind of dexterity and ease of use. Maybe they've tried one before and had abandoned its use because they just couldn't get the mode switching and couldn't wasn't functional for them.
Speaker 2:Um, with just a two-site pickup, um, or like a shoulder disartic, that was just like too many things to try to control. You know, um, and suddenly you have pattern recognition. You can do that. Um, you know, actually control an elbow and a hand, um, so, um, yeah, that was cool to try. Obviously, the MyoPro stuff you know saw you there Um, that was really cool.
Speaker 2:And seeing the version two again talking pattern recognition, like seeing that, um, you know, right now it's open, close flex extend and pretty soon that's going to be a multi-articulating hand. On the end of a mile pro G right Is the finger one um, which, um, so that was cool to see. Um, the uh, willow wood meta flow was cool, you know, seeing the energy return out of a 59, 68 foot um, so you have that ability to kind of get over the uneven ground. But then you still have that dynamic response, and that that's another one where I'm kind of um, I, I.
Speaker 2:This job also gives me the opportunity to kind of pull the prosthesis that I'm working with, you know, as I'm seeing people, so you know I hear from them, so it's like you know they're, they're trying patients on these things. It's like what do you think about them? And, um, some, some of them, are saying yeah, for people coming from hydraulics it's not enough range, not enough movement, and for people coming from dynamic response it's not enough. You know, springiness, so it's kind of the best of both worlds, but it's also not quite, not quite enough of either world, so just trying to figure out kind of um, what's appropriate for whom. But then when they had like a pylon that you could like pull back I don't know if you saw that right you pull it back and the hydraulic has all this dampening and just sort of really slowly comes back to upright and the Metaflow you can pull it back. You know the ankle dorsiflexes, but then it comes back. It has energy return.
Speaker 1:I think it's neat that you know. I think it's neat that you you know from, so you get to see it from the benefit of the physical medicine and rehabilitation side and then obviously you get to see it executed with the prosthesis and actually, bone anchored.
Speaker 2:That was another thing that I saw there in residency. So I graduated med school in 2012, residency, 2016. And, like I said, I mean Carolina's rehab atrium is like a major quaternary rehab center Like this. They're doing state of the art stuff. That's where, like the starfish procedure is right, ortho Carolina doing the whole like that we rotated to Ortho Carolina. Carolina doing the whole. Uh, like that, we rotated to ortho carolina.
Speaker 2:Anyway, at the time, we uh were basically taught that. You know, bone anchor osseointegration is, you know, they only do it in europe. There's risk of infection, there's risks of fracture. Uh, it's not really a thing here, probably won't be. You know, that's what we learned in 2016.
Speaker 2:Um, and now, like atrium is one of, like, the main spots for it. Like, I actually ran into Doug Tolman there, so the only other doc, uh, dr so was there and Dr Tolman was there. Those were the two MDs that I recognized, anyhow. And uh, yeah, dr Tolman was like, can you, you know, see some of these people over follow up, because we're seeing people from all over the country coming to us for their, you know, bone anchored, you know revision, or, if it is an initial one, to get the surgery at at at atrium, and then we're seeing them in inpatient rehab and then they go back to wherever they're from and have a lot of needs as far as like reassurance, um, and just kind of following.
Speaker 2:That's a long process of, you know, adding the weights and getting back to actually using it. Um, and I was like I don't really know much about this. I mean, when I was with you we just learned that it wasn't a thing. So, um, you know, I'm trying to learn more about that too and it hasn't been coming up a whole lot yet. You know, I think playing more for upper extremity, um, but, um, yeah, trying trying to learn everything I could about that, because I know that's that's coming up yeah, I'm.
Speaker 1:You know. It's interesting because I had the same uh reaction to osseointegration. And now, after talking to Mike Jenks from the Oprah system, right.
Speaker 1:We rotated with him when he was at Hanger in Charlotte I was like hey, I know you, I was a resident for him back in the day, so I did my residency in Charlotte for prosthetics but then we reconnected. Actually not too long ago he came on the podcast talking about the osseointegration, Completely changed my view on that and we actually have a patient that's going through that procedure right now and I'm very excited for this patient to get it, because the socket stuff just wasn't working out and the reality is it was a quality of life issue for them and I think this is really going to change how they interact with the world. I think it's going to be amazing. So and you know that technology is increasing so much and then the whole fracture thing and and spiral fractures and all that stuff just the mechanisms that they have now in in that has really put me at ease, Like it's.
Speaker 1:This is a good, a really good thing. And and there's a lot of things, like from the 3d printing side, of things that I'm excited about that they're not even thinking about on the osseointegration side, like how do you contain that tissue? So like just tissue containment, you know, how do you protect the site from any water creeping in or what have you. So there's a lot of things that are interesting that I think are going to come along with that as osseointegration becomes more prevalent.
Speaker 2:So especially for upper extremity. I mean, I think that's going to be one of the best uses of it.
Speaker 2:And you know, I think upper extremity use is gonna, is gonna go up. I think we've. We see a lot of people who are, you know, 40 years old and have never used congenital, never used a prosthesis, so like I didn't want to hook, you know it was not useful for me, I would rather do things one-handed. And now it's like whoa, I see what people are doing and I want one of those. You know they're so fast and so dexterous, so so strong. You know, with with my electrics, um, like, suddenly I think we're gonna have a lot more people that are actually using a prostate, amputees who had gone without. We're now going to use up our family prosthetics yeah, I think it's a yeah, it's a impartial hand and you're talking about new rules.
Speaker 2:I mean the coverage for that. Now you know another code, so that's opening the doors for people who have just been trying to get by without them, and so that's then the challenge for me is insurance says why do you need fingers? Now, you haven't had fingers for 30 years. You know what changed and you know the answer is the overuse. You know more weakness, more arthritis. Although you can't use your other hand, you're getting thumb pains, you know. I mean there's all kinds of reasons why fingers are useful, but when you haven't used one for that long, it's an easy denial for insurance to be like. Well, obviously you didn't need one. So that's kind of partially where we're coming in. It's just trying to be a storyteller.
Speaker 1:Yeah, yeah, where do you see kind of this amputee rehabilitation? We talked about osteointegration, some of the upper extremity stuff, but where do you see it going in the future? So let's just say, you know, take a look at your crystal ball and say, in the next five years, 10 years, what are you seeing? Are you seeing? I mean? So in a little bit of context, there is, I mean, I think you hit the nail on the head and and we haven't gotten new codes for some of these things in a long time, and we're starting to see a cascade of codes that is going to be amazing for our patients. So I'd love, I'd love for you just to hear a little bit about that, looking into your crystal ball as far as into the future.
Speaker 2:I think more of it's going to come also from the surgical side. I mean, there's incremental gains that are coming on. You know the devices, but they're all pretty much iterations of similar things. You know the FlexWalk foot, you know was, you know a game changer making a foot out of carbon fiber, and now there's different versions of the same foot Versus.
Speaker 2:I think surgeons are actually starting to-innervation to prevent, you know, neuromas and phantom pains or to, like we're talking about that starfish procedure to provide, like, a useful site for myoelectric pickups that you could have intuitive control of, like eye digits or things like that.
Speaker 2:Um, you know the ewing's procedure where they, you know, attach the antagonist muscles to each other, is amazing.
Speaker 2:You know, again, to try to make the phantom limb match the imagined limb in the mind uh, match, I guess, make the phantom limb match the prosthetic limb, right, that's kind of the idea of that procedure to to give you back, um, that sense of position in space and space and stretch on your tendons and reflexes to reduce phantom pain, ultimately, anything that will reduce phantom pain.
Speaker 2:You know that saphenous device is really cool. They're going to need some codes for that for that to be, you know, a viable thing. But if you're not familiar with that one, you know know, turning the sensations of like initial contact through foot flat into a vibration sensation that could actually be put on like higher up on the limb where a patient has sensation still. So they have some kind of a biofeedback of foot strike to try. That allows them to kind of use those nerves and have that sense of position in space and supposedly relief. Relief, phantom pain, which is a game changer, I mean gabapentin and mirror therapy and desensitization is not really enough. So I think more of it's going to come probably from the surgical side and maybe from some of these devices, external stimulators and things like that.
Speaker 1:Well, I think having people like you that are now can communicate with some of the surgeons and like how much that foundational aspect of an amputee's care is affected by the quality of the amputation I think is a really important thing to share. And one of the things that I love to see is it appears that a lot of these younger surgeons that are coming in they are super into outcomes as well and data-driven and that sort of thing, and I think it's a really exciting time for this idea of the interdisciplinary stuff, especially with the osteointegration coming down of you've got physical medicine, rehab, you've got a surgeon, you've got the patient and the prosthetist.
Speaker 2:I think surgery used to look at amputation as a failure. Right, this is what you do when you couldn't save the limb, and then it's just kind of like just make it happen. But now, absolutely, there's a lot of being done in the surgical suite to plan ahead for the various issues, and I think that's always changing too. You know Colorado, I see a lot of the Ertl Bone Bridge, which you know you don't see as much elsewhere around the country and I don't know that all of them are seeing benefit from it. It kind of gives you a weird limb shape that can be uncomfortable in a socket. I think the idea was it would reduce more of the sheer kind of stuff. But um and so they're. You know they're innovating, they're trying things and they, I think they are following like, obviously that didn't really take off everywhere else quite to the same level. So um and versus.
Speaker 2:Ewing's is like the opposite way, where you know started in massachusetts and now it's like people are going there training it, it's, it's going to be a thing. Downside there again is that you have a limb that is changing shape in some way. Atrophy makes for more of a stable limb shape that you can um, at least if it's just gradually atrophying, you can gradually resock it, versus if this is a muscle that is expanding and contracting, um, it's hard to get it to have to always be comfortable. You know, as, as you're active, you know it might, might, might swell when you're when you're more active, and then shrink when you're less. And how do you get a socket that's going to match that? That could be an example, for that overlay could be really helpful. You know, to have that non-global, you know, sock ply fit basically without socks what do you see?
Speaker 1:and this is, you know me coming from the prosthetist side of things I I love it when somebody outside of prosthetics, orthotics like it's been my whole life I started when I was a teenager and, uh, you know, now I'm not a teenager anymore have gray hair starting.
Speaker 1:So so what are? Yeah, a senior, yeah, for sure. So one of the things that I always like to ask is, as a profession, what are some ways to improve what we're doing from your perspective? I mean everybody for the most part in this field, they're in it to care for the patients and all that stuff. But I know there's a lot of times where I have these blinders on and and I try to expand them, but it's not until somebody you know, I have a conversation with somebody like you or somebody that's outside of O&P, even from the business side of things that says, well, what if or why didn't you, or that sort of thing. So, from your perspective of your interactions with multiple prosthetists and that sort of thing, and with your education from the PM&R side, where is there room for improvement for us?
Speaker 2:I mean, obviously, what I'm seeing is that there's a lot of room for improvement on workflow, you know, as far as you know, time to delivery and reducing denials. I mean, I'm a very risk averse person so I could never own a prosthetics clinic person. So I could never own a prosthetics clinic. I would be too afraid of giving out, you know, a $50,000 leg because I thought it was going to be covered and then having them be like, oh, actually that's not covered and you're froze there. Um, is that, you know mom and pop shop? You know can't afford to be wrong on that. They can't be given out, um microprocessor ankle only to have it be deemed experimental and clawed back. That puts them out of business, um, and they don't have a you know uh compliance department to go through every note and make sure that everything is perfect before you submit it. And, um, they don't have the slush fund afterwards to eat the cost if they were wrong. Um, and so I think that's part of why clinics have had to be bought out is to give them that safety and stability and allow them to really do what's best for the patient, you know, without fearing that it's going to put you out of business if it gets clawed back. So that's part of my role is to kind of level the playing field in a lot of ways.
Speaker 2:Right, I'm leveling the playing field for those small mom and pop shops that they now kind of have a compliance department. They have someone that can tell you, like, whether you know, I don't think this is going to be covered. Maybe you want to start them on something else first and see them back. Or you know, if we're going to get this vacuum covered we got to, you know, does this patient have volume fluctuations? Do they have issues with, you know, sweating? Do they, you know, try to make sure we're asking the right questions so that they can feel confident delivering a, you know, high-level technology to their patients without taking on that risk. And it also is obviously leveling the playing field with the, you know, patient and the insurance company, making the insurance company play by their own rules, you know, because sometimes they can be a bully and deny stuff that clearly is indicated according to their own rules. And so you know that's another way that I'm kind of leveling that and that's hard to do otherwise. That and that that's that's hard to do. Otherwise, I mean you're facing an uneven playing field.
Speaker 2:Um, when you submit something that is clearly indicated according to the their rules and you know would be covered by regular medicare, but medicare advantage plan says no, we're not doing that, you know, and it's like, well, don't you have to like, isn't that? You know, the rule? Um, this is clearly indicated. Um, and so I think that is a big hurdle that you guys are facing is that you're essentially powerless, you know, and again, unless you're hanger, you don't have the ability to run that up to the Supreme court, you know, with appeals, um, so you, um, you kind of just have to lose if, if insurance says no. Um, and so I think that's hopefully more of the future is to get a little bit more knowledge and power on your side of the equation, um, as far as what the rules are.
Speaker 1:Um, well, this is this has been great. Uh, I mean, we covered a ton of and I I know our listeners will get a lot from this as well did do you? Do you feel like we? Uh, and I know you didn't have an idea of what we were going to go down, but have we, have we missed anything? Or did we cover quite a bit?
Speaker 2:we, we didn't talk about bracing at all. We do one another talk about bracing.
Speaker 1:I think we should do. Yeah, this would not give the the amount of time for bracing. How can people catch up with you? I know you're on LinkedIn, is what what? What would be the best way to connect with you?
Speaker 2:Yeah, linkedin is fine. You know, like I said, I'm in 14 states. Madrina is the company that I'm with and we're in, I think, 46 states. So you know, if I'm not the first doctor that's licensed, basically the doctor has to be licensed in the state the patient is located in. So I'm not planning on getting 50 licenses, but I could definitely connect you with our company, our director of telemedicine. We can put in the description, maybe, what my 14 states are and the contact information for our director of telemedicine, who would set you up with a doc in the state that you're located in Awesome Well.
Speaker 1:Thanks so much for coming on the show. This was great, absolutely. Again, thanks for having me and thank you for listening to another episode of the Prosthetics and Orthotics Podcast. Have a great day, thank you.
