The optimal matching of LLPs to patients is a value-laden issue, and therefore a source of disagreement and a sensitive topic for the public. The current K-level classification system requires assignment to discrete functional levels to support medical necessity for LLPs. Concerns persist that K-Level classification may be too coarse and may modulate patient aptitude and clinical trajectory. Even under ideal conditions that reveal and accurately measure important patient-related and LLP specific indicators, controversy would persist over defining an "optimal" outcome. Finally, suboptimal matching of patients to LLPs may unnecessarily increase health care utilization, prevent attainment of maximal patient function, and defer realization of improved quality of life attainable with an appropriate prosthetic. Integral to the identification of good predictive tools that mitigate these issues is the study of OMTs and the relevant patient and LLP characteristics to decision making.
Close collaboration between the prosthetist, physical therapist, and surgeon is very important. The prosthetist is responsible for supplying the patient with the short training and full-length OI prostheses. The short training prosthesis is training equipment made in knee-length to reduce the length of the lever arm. The alignment is altered if needed to compensate for a hip-joint contracture. A simple attachment device connects the short training prosthesis to the abutment (). The attachment device for the full-length OI prosthesis is different and includes a safety function that protects the implant from high torques (). Initially, the torque release level is low. When the bone is stronger and the prosthetic activity increases, the torque release level is gradually increased. Since the patient is not initially allowed full weight bearing, the prosthetic components must be carefully selected. For this reason, a knee component providing effortless flexion and controlled extension is preferred. Another preferred feature of the patient's first full-length OI prosthesis knee is a high degree of flexion to prevent bending loads to the implant system if the patient falls. Either a soft or firmer foot may be used for the foot component. Moreover, an extra dampener is often needed because each step might be distinctly annoying or painful. Later, when the OI is stronger and walking with full weight bearing has been achieved, changing components is possible. For example, a microprocessor-controlled knee can, in many cases, be supplied 6 to 12 months after S2.
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For kindergarten through grade 10, the TPSP offers two or more interdisciplinary units (tasks) per grade level. Aligned with the TEKS, each task includes guided instruction and opportunities for independent research in multiple content areas. At exit level, the TPSP supports an extended independent study under the guidance of a mentor who is an expert in the student’s area of study.
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Specifically, patients who are in need of LLPs are heterogeneous in terms of etiology of limb loss, amputation type (level of amputation, uni- or bilateral), age, comorbidities, frailty, general health status factors, expected life span, mental health status (e.g., depression, post-traumatic stress syndrome), family and social support, and many other factors, including whether they have fragile skin or allergies towards socket liners or other materials. These factors may affect their actual and perceived current and maximum attainable functional ability, and the likelihood that they will receive and use an LLP.8,16
Orthotics and Prosthetics - Noridian
Furthermore, it is unclear to what extent measures of current function and status accurately predict future function. Variability in assigning or predicting the K-Level of prospective LLP recipients may inadvertently lead to inefficient LLP matching. This can occur if a person receives a too-low level LLP when a higher level LLP would enable better function, or if a person receives a too-high level LLP which might be unnecessarily complex for an individual who would have equivalent or better function with a simpler component. It is hypothesized that OMTs with high reliability and predictive validity may optimize the matching of patients to the K-Level they can eventually attain and, more importantly, to the component that would best suit their needs and maximally improve functional and other patient-centered outcomes. Despite the central role of OMTs in the selection of LLPs for Medicare beneficiaries, their utility in the prediction of patient outcomes remains unresolved.
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Medicare reimbursement policies require documentation of current functional capabilities and expected functional potential. Therefore, OMTs must both assess and predict function. However, this runs contrary to the Veterans Affairs/Department of Defense Clinical Practice Guideline for lower limb rehabilitation, which recommends that tools should assess what patients actually do, not what they can do.15 Third-party coverage of LLP requires an additional index is applied to standardize the assessment findings. The Medicare Functional Classification Level (MFCL or K-Level) system (Table 1) broadly defines five classification levels that can be attained with an LLP and range from 0 (no ability to ambulate or transfer; LLP will not enhance mobility) to 4 (ability to excel with [an appropriate] LLP). The classification level assigned is used to determine the medical necessity of certain componentry, and thus to match the ultimate LLP to the beneficiary's clinical needs. However, in practice it is difficult for prosthetists to assess medical necessity for a patient to receive the most appropriate component (whether of higher or lower level or sophistication).