Tony Wickman, CTPO

I’ve been thinking for the past decade that the technician’s role has been evolving from an entry-level point of ascension into a viable career. In the past, technicians tried to become practitioners and only remained technicians if something got in the way. However, as technology progresses and consumers become more demanding, our role will ultimately call for more knowledge and competence. In fact, it’s now becoming too difficult for one person to serve as both practitioner and technician. The two roles have become distinct and similarly difficult. Each has its own challenges. In short, they’re separate but equal.

Currently, the highest credential the industry affords a technician is ABC registration, which was developed as an entry-level credential for individuals who had attended a technical-education program. It has blossomed into an all-inclusive credential that is available to any technician with a high school diploma, who has graduated from an accredited technical program or has two years experience in each discipline, and has passed the day-long technician exam. This model served well for many years. Registration was valued because most registered technicians earned more than their non-credentialed counterparts, and it indicated that a technician was serious about his or her work. Registered technicians were seen as more of an asset to their employer and were generally rewarded as such.

In 1997, ABC began to require continuing education for registered technicians in a model that basically mirrored the requirements for other credentialed individuals. This move was lauded by most of us involved in the process because we all wanted the same thing: an increase in the stature of the technician’s role. The end of the first MCE cycle revealed something startling: about one-third of previously credentialed individuals failed to meet the new requirements and therefore lost their registration status. Since that time, the number of individuals seeking credentialing has declined; this attrition continues to this day.

Why are technicians no longer seeking this credential? I have asked this of technicians nationwide over the past year. Most technicians don’t understand the importance of credentialing as a career move or as a protective measure for the industry. The remaining technicians simply don’t care because it doesn’t directly impact their job. In my opinion, both of these points have some merit, but both are ultimately wrong.

Credentialing is a gateway to opportunity. If you aren’t credentialed, you have no voice in the field. No one knows you exist, and subsequently you don’t matter. You can’t join most of the industry’s most prestigious organizations, you don’t get on the mailing lists for continuing education, and you don’t get to help steer the ship. Why be a part of an industry that controls you without the opportunity to help shape the direction it goes?

Though some people do their work just to get by, most of us are in this industry because we care about our customers. We want to help people live as actively as technology will afford, and we want the devices we manufacture to afford patients the maximum possible increase in their quality of life. How can we achieve these goals without credentialing and continuing education?

We can’t just blame technicians. The whole landscape of this industry has changed. Providers are paying less, materials are more expensive, paperwork eats more of our time, and regulatory changes make it more difficult to get the available technology to the people who need it. For a lot of people, the expense of credentialing is just too great in time and money, and the return on investment isn’t there. More and more, the act of credentialing and continuing education is becoming altruistic. Most do it simply because they feel a strong desire to climb whatever mountain is put in front of them. That has to change.

We need to make technical credentialing and continuing education less expensive, and we need to make it mandatory. Several ideas have been put forward to meet these needs. The move to an Internet-based exam has been proposed, and I think it’s a good idea. Initially, I wondered how we’d test hand skills over the Internet. In industries as varied as personal exercise training and massage therapy, though, this has been the norm for years. Current technician testing doesn’t include hand-skills testing anyway; at least, it doesn’t include standards for quality or attractiveness—they’re too subjective. We instead test for all the other information and skills required to ensure minimum competency.

I know, I know—mandating credentialing as a component of accreditation is a real can of worms. But think about it—if credentialing was mandatory for accreditation, it would get done. How many times have you not done good things just because you lacked momentum to do them? If you had to do it, you would, and you would benefit from it. Just think about it—that’s all I’m asking.

I realize these ideas will not appeal to everyone, but I hope they will be provocative and spur some of you to develop better solutions, because there is more to do. If you like these ideas or hate them, tell me so we can consider your point of view. If you don’t speak up now, you may not have another chance. This is a fork in the road, not a dead end—we have to go one way or the other.

Also published in the March 2010 edition of the O&P Edge. © 2010 O&P Edge

Tony Wickman, CTPO

When I started out as an orthotic technician over 25 years ago, I believed you should always flatten the plantar surface of an AFO mold. That’s what I was taught because it was the conventional wisdom of the day. Then I had the opportunity to work with a group of physical therapy students. I felt secure in talking with the students about my techniques, because I thought I was applying the best we had to offer to the science of rehabilitation.

The students toured the lab and remarked that we were doing some amazing stuff, until they saw how we were modifying our molds. One of the students posed a question, “Why do you flatten the bottom of the foot when you modify the mold?” I answered that we were building mechanical devices, and that flat surface was our foundation. Wasn’t it?

After that, I started to question my fundamental beliefs on how to build a quality device. I was fortunate to have spent my first few years as a technician with some visionary orthotists, and what they taught me made sense, but at this point, I started to think we might be overlooking a very important part in the process, the part where modifications are made so that a device will become an extension of the patient. I noticed when we make arch supports, we never flatten the plantar surface. On the contrary, arch supports mirror the plantar surface. So what’s the difference between making an arch support and an AFO? Why would we think an arch support should take advantage of the curvatures of the plantar surface, but the bottom of an AFO or other orthoses should be flat?

Not long after that encounter with the physical therapy student, I had the opportunity to work with another visionary, a physical therapist and author, who was teaching a class on Neuro-Developmental Treatment (NDT) at that same physical therapy school. She had a test subject for the NDT class and needed a volunteer to fabricate an AFO. Naturally, our lab was offered and I worked one on one with her, and she helped me understand the intricacies of the foot: its bones, nerves, tendons and vascular structures, and how each of these components have their own set of needs. After working with her, I was convinced that technicians must see the foot as the foundation of an orthoses, not the floor! I knew I had to learn more about pedorthics, tone inhibition and neuro-developmental techniques if I wanted to create bio-mechanical devices, devices that fit properly, as well as focus on the specific pathology without causing any collateral damage.

This level of knowledge is beyond the standard education for technicians, but if I am modifying a mold, it’s my responsibility to know about physiology, neurology, and pressure mapping. Every patient who needs a brace has a pathology. Seldom are those pathologies purely orthopedic, there are typically underlying vascular or neuropathic disorders as well. There is no orthopedic solution for a neurological problem.

Technicians need to be aware of this when building a device, and practitioners need to be aware of this when taking a cast. If the cast is taken weight bearing, on a flat surface, much of the plantar data disappears. When a cast can be taken on a foam block, semi weight bearing, or even hand manipulated, that cast takes on a whole new level of function. The surfaces of the foot become much more natural and the load pressures can be more accurately distributed. Neurological inputs can be reduced and deep-tissue weight-bearing techniques can be utilized, and the brace can better fit the patient. One of the issues with casting a patient on a flat surface or flattening the bottom of a mold is that the device created from that mold can cause collateral damage, by creating excessive pressure on at risk tissue, or exacerbating existing problems and putting the surrounding tissues at risk.

No matter the casting technique, I can make a device, but it may not function properly, and it will certainly be less comfortable for the patient. I see these issues most frequently with neuropathic (CROW) walkers and pediatric devices. I’ve worked with many practitioners to help them change their casting technique for these devices, and by doing so, they are seeing better results with their patients.

I believe a technician’s role is to understand and interpret the orthotist’s vision for the patient and make that vision a reality. I also believe the practitioner and technician should work together as a team to make a device that will assist the patient in the best manner possible. If I don’t have an understanding of the nerve structures on the foot, then it’s probable that I won’t make a properly functioning device. Orthoses are not “widgets” that come off an assembly line, they are custom-made bio-mechanical devices that help improve the quality of life for the people who use them.

In order to increase the overall caliber of the rehab team, I suggest that you learn as much as you can about pedorthics, tone inhibition, and neuro-developmental technique. The manipulation of the surfaces of the foot is the foundation of a good lower limb orthosis and these specialized disciplines will give you a good foundation upon which to build your skills.