Prosthetics and orthotics are small, yet grand artistry embedded in medical rehabilitation.
“While many physical conditions are curable, some patients must endure the lasting consequences of such disorders, ranging from the loss of limbs to independence. Our role in assisting them lies in providing training to help regain movement to the greatest extent possible, allowing them to lead lives as normally as before, underscoring the crucial importance of Physical Medicine and Rehabilitation (PM&R).”
Physical Medicine and Rehabilitation (PM&R) is gaining increasing recognition and popularity, with its benefits and importance acknowledged more widely than ever. However, one of the subspecialties of PM&R, prosthetics, and orthotics remains relatively obscure to many. This field involves the design and specification of specialized devices to either assist an existing body part (orthotics) or replace a missing one (prosthetics), thereby facilitating patient recovery and promoting improved mobility for a more comfortable life. In this article, Dr. Aom-Netraya Nimpitakpong, a PM&R physician, sheds light on the intricacies of prosthetics and orthotics through her captivating experiences and stories.
Art in the field of medicine
Dr. Aom was exposed to the medical field from childhood, guided by her parents, who were both doctors. Through their conversations at home, she absorbed their approach to patient care. Even as a child, she eagerly embraced opportunities to aid her kin, administering medications under the supervision of her parents. Yet, as the sands of time continued their relentless march, the pivotal moment arrived when Dr. Aom stood at the crossroads, poised to carve her own destiny in life.
“During my younger years, I was keen on art, painting, and handicrafts. My father consistently supported my creative pursuits. Despite being enrolled in the Science-Biology program in high school, I served as the President of the Art Club, creating a somewhat contradictory situation. The decision between pursuing medicine or architecture weighed heavily on my mind for some time when the university entrance exam loomed. Ultimately, I opted for medicine, acknowledging that my artistic skills might not measure up to those with more innate talent in the field.”
In the fourth year of her medical study, it dawned on Dr. Aom that her studies were not unfolding as anticipated, especially when treating ailments with medications whose mechanisms remained abstruse and unobservable to the naked eye.
“It was as if the processes occurring within the body were arcane, beyond the reach of my hands—unlike the tangible nature of crafts. My role seemed limited to adjusting dosages, altering administration routes, or changing medications while monitoring lab results. While these steps can be considered an art in their own way, it was not the familiar hands-on craft I had envisioned. I felt like I had ventured down the wrong career path and confided in my mother that I was contemplating quitting.”
One fateful day in the fifth year of her medical schooling, Dr. Aom had an opportunity to see a patient with her professor. There, she encountered a patient grappling with the aftermath of an intracerebral hemorrhage and hemiplegia. Following surgical intervention, the once feeble body side stirred to life, reclaiming walking ability. However, a haunting caveat lingered.
The recovery carried a bittersweet caveat—the muscles orchestrating ankle dorsiflexion remained obstinately dormant, resulting in a persistent foot drop with the toes dragging along the floor, interfering with walking. Undeterred, my professor prescribed a cloth contrivance wrapped around the lower leg and tethered to a loop of strap cradling and elevating the forefoot. A mere accessory, yet a potent catalyst for a more seamless and dignified gait, it transformed the ordeal of walking into a triumphant stride.
“The instance I laid my eyes on a simple yet profound contraption -- I was awestruck. In the medical arena, it was more than just a tool; it was an exquisite masterpiece, a holy grail I have long sought. A revelation that stirred the artistic bent within me, promising the profound impact of my skills on countless patients. It was akin to discovering light at the end of the tunnel, an epiphany and powerful beacon that obliterated the disenchantment that clouded my medical journey.”
“In mere seconds, my skepticism about the path chosen dissolved, replaced by an unwavering belief that my artistic prowess could weave a transformative narrative for those in need. Eager to unravel the mysteries of this medical artistry, I inquired of my professor about the domain of such impactful decisions. The revelation that specialists in prosthetics and orthotics, nestled within the folds of Physical Medicine and Rehabilitation (PM&R), practice this discipline. At that moment, I knew—I had found my calling.”
PM&R is essential in all treatment contexts
Upon completing her studies, Dr. Aom encountered the profound significance of Physical Medicine and Rehabilitation (PM&R) during her compulsory service in a remote province. Under the challenges of overcrowded public hospitals, patient stays were the shortest necessary to make room for those with more critical conditions. Dr. Aom observed the plight of patients, particularly those recovering from paralysis due to strokes, postoperative trauma patients, and elderly individuals. Despite their ongoing dependence and inability to walk or even sit, in some cases, once their conditions stabilized, the doctors discharged them. Dr. Aom could not help but wish for these patients to have the opportunity for proper recovery under continuous hospital care.
However, the reality was far from ideal. Nevertheless, she recognized the importance of empowering these individuals with self-care instructions for physical and occupational therapy, enabling them to embark on a journey of self-rehabilitation at home. This approach aimed to make the most of their hospitalization experience, preventing unnecessary bedridden states and fostering a return to their daily activities as seamlessly as possible.
Dr. Aom is now a dedicated physiatrist, focusing on treating foot and walking disorders. Her practice incorporates state-of-the-art physical therapy equipment and customizes prosthetics and orthotics, including therapeutic insoles and shoes. She tailors the interventions to address specific issues and lifestyles of each patient, ensuring effectiveness and a personalized approach to rehabilitation.
"Prosthetics and orthotics involve careful and nuanced consideration of various factors. When ordering a prosthetic leg for a patient, I must select components aligned with their lifestyle and budget. In cases requiring team collaboration, planning encompasses the level of amputation to facilitate prosthesis wearing, wound healing, and walking with the prosthesis. Upon the arrival of the prosthesis, my role extends to educating the patient on its usage. My responsibility spans from pre-surgery evaluation to after the patient can resume walking. Crucially, the patient plays an integral role in determining the most suitable option for their needs."
Success is when patients can use the device as if it were an inherent body part
Dr. Aom told us a poignant story of an elderly patient ensnared by polio since youth. The condition caused one foot to twist outward when walking, causing pain and shackling any hope of walking long distances on foot, forcing the patient to rely on a wheelchair. The patient had received many orthotics from many hospitals. Since the patient’s ankle deformity was quite severe, most hospitals offered orthotic solutions that best stabilized the patient’s ankle for a steady walk.
Therefore, the orthotics gravitated toward rigid plastic, metal ankle splints, or high-profile boots. Their cumbersome frames and weighty burdens transformed the simple act of donning them into an arduous ritual, a time-consuming ordeal that clashed with the rhythm of daily life. As a result,
the clunky boots lay abandoned, relics of a failed attempt to corral a wayward limb. The patient, forsaking the clutches of conventional solutions, chose to fashion a self-made orthotic. Walking became a trial, but the journey persisted.
The efficacy of prostheses and orthoses hangs on a single thread -- the willingness of patients to embrace them. No matter how impeccably designed these devices may be, their potential lies dormant if relegated to the shadows of neglect.
My mission is to engage in heartfelt conversations; I strive to unravel the intricacies of their needs and challenges. Within these dialogues, I outline the landscape of possibilities, delineating the merits and pitfalls of each option. Yet, it is not a unilateral decision, but rather, it evolves into a collaborative journey. In this shared exploration, patients become active participants, wielding influence in the decision-making process alongside me. This process mirrors an intimate heart-to-heart conversation, an exchange where the crystallization of understanding takes center stage. It is not merely about crafting orthotics but co-creating a solution that seamlessly integrates into their lives.
After conversing with the patient, Dr. Aom realized that while the patient could articulate their desires, no proposed solution aligned with their needs. She reflected, “As physicians, we invariably strive to recommend the optimal course of action from our professional perspective. However, we may overlook that our notion of optimal might diverge from the viewpoint and preferences of the patient. Consequently, we must find a balanced approach that harmonizes our medical expertise with the unique circumstances and objectives of the patients.”
“I vividly recall the day the patient arrived in a wheelchair to gather his custom-designed shoes. However, upon trying on the shoes we had meticulously co-designed and adjusted, his exhilaration was palpable as he stood up and walked home unassisted. He even strolled through his neighborhood without any walking aids. Witnessing how my work brings such joy to people fills me with immense happiness. Particularly during follow-up inspections, when patients sheepishly reveal that the shoes I crafted for them became worn out due to heavy use, it brings me profound fulfillment. To me, well-worn shoes are emblems of success, demonstrating that they are genuinely beneficial and utilized to their full potential.”
Prostheses and orthoses, encompassing prosthetic legs, arms, joint splints, and bespoke therapeutic insoles and shoes, are akin to intricately crafted works designed with specific purposes. The true worth of these tools comes to fruition when they successfully address and alleviate the diverse conditions afflicting patients.
“This specialized medical craft often operates in obscurity. Patients navigating their health challenges are frequently surprised when they stumbled upon these finely honed solutions. Witnessing the transformative impact of prostheses or orthoses, as they assuage pain and enhance daily life, prompts expressions of surprise and gratitude. Many reflect on the years of unnecessary suffering, expressing a desire for awareness of such treatments earlier.”
Incessant updating knowledge for the masterpiece
As previously highlighted, she is passionate about drawing, design, and craftsmanship, with a specific fondness for therapeutic insoles and shoes. This niche occupied a special place in her repertoire of skills and favorite creative endeavors. Driven by an insatiable curiosity, she consistently seeks advanced knowledge in the design, materials, and modifications, all aimed at crafting interventions that wield a distinctive impact on each patient experience—much akin to crafting a breathtaking piece of artistry.
The fields of prosthetics and orthotics consistently evolve with the discovery of new methods and materials. Consequently, I actively seek courses and training to stay abreast of these innovations, aiming to enhance my knowledge base. This continuous learning equips me to apply acquired insights creatively, solving problems for patients with flexibility and adaptability. Recognizing the uniqueness of each set of feet, even our left and right, underscores the importance of staying informed and employing tailored solutions in this dynamic landscape.
In Physical Medicine and Rehabilitation (PM&R), the focus extends beyond adhering to treatment guidelines. It represents an application of knowledge not solely dictated by the capabilities of the patients but instead driven by our commitment to improving their well-being. With empathy at the forefront, we holistically listen and understand our patients, providing care with genuine concern and dedication to restoring a high quality of life to the best extent possible.
