







































All articles are permanently available online to the public without restrictions or subscription 

fees. All articles are free to be used, cited, and distributed, on condition that appropriate 

acknowledgment is included. Authors are the copyright holders of their original 

contributions and grant the Canadian Online Publication Group (COPG) a license to 

publish the article and identify itself as the original publisher. CPOJ articles are licensed 

under the Creative Commons Attribution 4.0 International License.   

 

CPOJ Website: https://jps.library.utoronto.ca/index.php/cpoj/index 

Editorial Office: cpoj@online-publication.com    

ISSN: 2561-987X 

CPOJ is a member of, and subscribes to the principles of, the Committee on Publication 

Ethics (COPE).   

 

 

VOLUME 5, ISSUE 1 

 2022 

 

EDITORIALS 

 

Raschke S.U. Editorial opinion: value within the prosthetic and orthotic provision process. Canadian Prosthetics & Orthotics Journal. 2022; Volume 5, Issue 1, 

No.9. https://doi.org/10.33137/cpoj.v5i1.38442 

https://online-publication.com/wp/
http://creativecommons.org/licenses/by/4.0/
https://jps.library.utoronto.ca/index.php/cpoj/index
mailto:cpoj@online-publication.com
https://publicationethics.org/about/our-organisation
https://publicationethics.org/about/our-organisation
https://publicationethics.org/members/canadian-prosthetics-orthotics-journal
https://doi.org/10.33137/cpoj.v5i1.38442


 

1 

Raschke S.U. Editorial opinion: value within the prosthetic and orthotic provision process. Canadian Prosthetics & Orthotics Journal. 2022; Volume 5, Issue 1, 
No.9. https://doi.org/10.33137/cpoj.v5i1.38442 

 

 

 
EDITORIALS 

 

EDITORIAL OPINION: VALUE WITHIN THE PROSTHETIC AND ORTHOTIC PROVISION PROCESS 

Raschke S.U. * 
 

British Columbia Institute of Technology (BCIT), 3700 Willingdon Avenue, Burnaby, British Columbia, Canada. 
 

 

 

 

 

  

 

 

 

 

The recent Special Edition of the Canadian Prosthetics and 

Orthotics Journal focused on the theme of Health 

Economics in Prosthetics and Orthotics, highlighting some 

of the complexities associated with providing optimal 

solutions to the end-users of prosthetic and orthotic devices.    

Many people enter the field of prosthetics and orthotics with 

the desire to connect with and help people, but the 

underlying reality is that this desire will always be fiscally 

constrained. For his reason, it is essential to be able to 

critically analyse one’s work from a cost: benefit perspective 

and to be able to define and communicate the value of that 

work to payors whether one works on the clinical or the 

engineering side of the sector. 

An underlying theme in the Special Edition was the 

significant changes in practices that had emerged once 

payors began linking reimbursement to the presentation of 

objective outcome measures a decade ago. At that time 

prosthetists and orthotists were increasingly required to 

present objective criteria to communicate and to justify their 

component and device choices if they wished to be 

reimbursed. This was a significant shift in the practice 

paradigm, as previously measurement activities had been 

limited to device production and fitting related tasks.   

The response to this new requirement was a palette of 

outcome measures developed and validated by prosthetic 

and orthotic researchers for use in a clinical setting. These 

measures allowed the quantification and tracking of typical 

rehabilitation outcomes such as mobility, function, activity 

levels and pain, along with dimensions intended to capture 

client satisfaction levels,1 allowing prosthetists and 

orthotists to meet payor requirements. These measures 

also gave prosthetists and orthotists fluency in the objective 

language of the medical and scientific communities, 

allowing them to begin to articulate the previously 

undocumented interactions with their clients that go beyond 

the “simple” provision of a device and bring “added value” 

to the provision process. The adoption of an objectively 

anchored clinical practice model helped make visible what 

had previously been invisible. 

At the same time that payors were compelling clinically 

facing providers to justify their provision decisions, a related 

pressure was building upstream, at the technical develop-

ment level, where payors began to query the costs of new 

technology solutions. Here the critical question was: What 

significant, measurable value does more complex, and 

typically more expensive, technology bring? 

The classic approach to answering this question, much as 

a new pharmacological intervention would be evaluated, is 

an Evidence Based Medicine (EBM) approach which 

became the gold standard in the 1990’s. EBM relies on 

Random Clinical Trials (RCTs) to generate large data sets 

from which criteria such as Minimum Clinically Important 

Differences (MCID) and Dosing can be generated to guide 

policy and funding decisions. Unfortunately, it is not 

 
OPEN  ACCESS Volume 5, Issue 1, Article No.9. 2022 

 

 

Journal Homepage: https://jps.library.utoronto.ca/index.php/cpoj/index 

 

ABSTRACT 

This Editorial presents an overview of the uptake of clinical outcome measures 

in the prosthetics and orthotics sector and considers how the use of objective 

measures contribute to demonstrating value provided. A decade ago, payors 

began to demand objective data to document costs vs. benefits from prosthetic 

and orthotic providers. The speed with which the sector responded to help 

develop measures and to begin to integrate them into practice is remarkable.  

This suggests an encouraging resilience and ability to adapt on the part of the 

sector as other trends such as Values-Based Health Care emerge to challenge 

the sector.    

CITATION 

Raschke S.U. Editorial opinion: value within the prosthetic 

and orthotic provision process. Canadian Prosthetics & 

Orthotics Journal. 2022; Volume 5, Issue 1, No.9. 

https://doi.org/10.33137/cpoj.v5i1.38442 

KEYWORDS 

Orthosis, Prosthesis, Health Economics, Prosthetics, 

Orthotics, Funding, Outcome Measures 

* CORRESPONDING AUTHOR 

 

Silvia Ursula Raschke, PhD, Editor-in-Chief 

British Columbia Institute of Technology (BCIT), 3700 Willingdon 
Avenue, Burnaby, British Columbia, Canada. 

E-mail: Silvia_Raschke@bcit.ca 

ORCID ID: https://orcid.org/0000-0001-7964-4295 

https://doi.org/10.33137/cpoj.v5i1.38442
https://jps.library.utoronto.ca/index.php/cpoj/index
https://doi.org/10.33137/cpoj.v5i1.38442
mailto:Silvia_Raschke@bcit.ca
https://orcid.org/0000-0001-7964-4295


 

2 

Raschke S.U. Editorial opinion: value within the prosthetic and orthotic provision process. Canadian Prosthetics & Orthotics Journal. 2022; Volume 5, Issue 1, 
No.9. https://doi.org/10.33137/cpoj.v5i1.38442 

ISSN: 2561-987X 
VALUE WITHIN THE PROSTHETIC AND ORTHOTIC PROVISION PROCESS   

Raschke S.U, 2022 CPOJ 

 
possible to carry out classic RCTs in the prosthetics and 

orthotics sector due to small patient populations, the high 

costs of such studies and the technical challenges of setting 

up double blinded study designs, which are the gold 

standard for EBM models. 

Instead, prosthetics and orthotics focused engineers and 

researchers turned to Small-N research designs2 (e.g. 

Multiple Baseline, Cross-Over, Repeated Measures, Single-

Blinded, etc.) to compare classes of componentry, (i.e. 

microprocessor vs hydraulic controlled knees or energy 

storing vs no energy storing prosthetic feet) and results 

indicated that class of component chosen can lead to 

measurable differences along a range of dimensions.3,4  

Through this concentrated, two-pronged research effort 

spanning clinical aspects and engineering technology, the 

prosthetics and orthotics sector has been able to transition 

from an unscientific, artisan-based practice to adopting 

objective, data-based ways of thinking in a period of ten 

short years. This is quite an accomplishment. Both clinically 

focused and technology evaluation research studies 

continue to be done and there is a growing knowledge base 

indicating that prosthetic and orthotic technology and 

interventions create measurable changes and experiences 

for the users of the devices.  

As health care continues to be rationalized, the next 

emerging stage in  health care policy and decision making 

is trending toward a Values Based Health Care (VBHC) 

model, which seeks to link funding to outcomes.5 This is 

based on emerging belief in the business and policy press 

that the prevalent pathways for funding health care based 

on fee for service, device or process do not necessarily lead 

to the best or most efficient health care outcomes.6,7  

VBHC advocates for decision making processes negotiates 

a compromise between balancing genomic-biomedical-

biomechanical aspects of an individual alongside 

psychosocial and behavioural characteristics, with some 

consideration of what outcomes matter most to the 

individual.  The model embodies lofty ideals and will be 

challenging to implement. Determining what treatment 

goals and objectives are optimal for any given situation will 

require negotiation and sensitivity as “optimal” or “desired” 

as defined by one stakeholder vs another will often be in 

conflict with each other.8 Achieving this balance between 

stakeholders, including individual patients, will take 

considerable time and effort.  

Further complicating this shift is the lack of transparency 

and consistency from payors as to what measures and 

evidence are acceptable and deemed adequate for the 

existing reimbursement models, creating high levels of 

confusion and frustration with the processes. VBHC will 

allow for a much denser data sets to be collected along an  

expanded number of domains. How this data is to be 

organized, evaluated and weighted in a timely and fair 

manner is one of the critical questions that must be 

answered and those answers must be clear. In 

reimbursement processes already burdened by a lack of 

clarity, it will be necessary for payors to work with the sector 

to establish clear and stable goalposts in the various 

domains in which data will be collected, if this approach is 

to be successful.  

Were does this new trend leave the prosthetics and 

orthotics sector? Having navigated the past decade 

amazingly well, my sense is that the sector is in good shape, 

but with one critical caveat.  

A decade ago, payors began to require objective outcome 

measures at a time where few such measure existed and 

were never used in reporting, challenged the prosthetics 

and orthotics sector to objectively communicate the value 

they bring. This externally applied pressure led to 

unprecedented collaboration between clinicians, 

researchers and professional organizations who rose to the 

challenge collectively to create astonishing changes in 

opinions, attitude and practices. The result is the creation of 

a value focused lens that has become baked into the sector.  

The transition has been stressful and disruptive because it 

was driven by outside forces as opposed to being internally 

motivated. Considering at where the sector was a decade 

ago, the transformation is astounding and offers hope. I see 

a maturity and confidence in the sector that was not present 

even 15 short years ago. I believe this comes in large part 

because, for the first time in the history, the sector has had 

to take a hard, critical look at what they do, why they do it 

and what value they create and found, perhaps to the 

surprise of some, that value could be objectively 

demonstrated. This process allowed the sector to 

deconstruct the myth of the “magic in the hands”9 of the 

clinician and replaced it with a genuine and professional 

identity, expressed in the common language of science. 

The caveat is that, the cascade of next generation health 

care technology that is now entering the market will create 

additional, exponential pressures on the sector. Keeping up 

with, integrating and mastering this technology will require 

an ongoing, energetic response. There no time for the 

prosthetics and orthotics sector to sit back, catch its breath 

and enjoy the past decade’s successes. Instead, effort 

needs to be scaled up further with respect to building 

knowledge and expertise in measuring and communicating 

value. 

The future is daunting, but looking back at what has been 

achieved over the past decade, I believe the sector has 

successfully created an objectively anchored foundation 

which will serve it well when navigating what will continue to 

be uncertain waters.  

ACKNOWLEDGEMENTS 

None. 

DECLARATION OF CONFLICTING 

INTERESTS 

I have no conflicts to interest to declare. 

https://doi.org/10.33137/cpoj.v5i1.38442


 

3 

Raschke S.U. Editorial opinion: value within the prosthetic and orthotic provision process. Canadian Prosthetics & Orthotics Journal. 2022; Volume 5, Issue 1, 
No.9. https://doi.org/10.33137/cpoj.v5i1.38442 

ISSN: 2561-987X 
VALUE WITHIN THE PROSTHETIC AND ORTHOTIC PROVISION PROCESS   

Raschke S.U, 2022 CPOJ 

 
SOURCES OF SUPPORT 

None. 

REFERENCES 

 

1.Ramstrand N, Phillip M. Stevens PM. Clinical outcome measures 

to evaluate the effects of orthotic management post-stroke: A 

systematic review. Disabil Rehabil. 2021; 12:1-20. DOI:10.1080/ 

09638288.2020.1859630 

2.Graham JE, Karmarkar AM, Ottenbacher KJ. Small sample 

research designs for evidence-based rehabilitation: issues and 

methods. Arch Phys Med Rehabil. 2012; 93(8 Suppl), S111–S116. 

DOI: 10.1016/j.apmr.2011.12.017 

3.Chen C, Hanson M, Chaturvedi R, Mattke S, Hillestad R, Liu HH. 

Economic benefits of microprocessor controlled prosthetic knees: a 

modeling study. J Neuroeng Rehabil. 2018; 15(Suppl 1):62. 

DOI:10.1186/s12984-018-0405-8 

4.Koehler-McNicholas SR, Nickel EA, Barrons K, Blaharski KE, 

Dellamano CA, Ray SF, et al. Mechanical and dynamic 

characterization of prosthetic feet for high activity users during 

weighted and unweighted walking. PLoS ONE. 2018; 13(9): 

e0202884. DOI:10.1371/journal.pone.0202884 

5.Catalyst NE. What is value-based healthcare? NEJM Catalyst. 

2017;1;3(1).  

6.Kaplan RS, Porter ME. The big idea: how to solve the cost crisis 

in health care [Internet]. Harvard Business Review. Brighton, MA. 

2011; [cited 11 April 2022]. Available from: 

https://hbr.org/2011/09/how-to-solve-the-cost-crisis-in-health-care 

7.Mattison CA, Wilson MG. Rapid synthesis: Examining the effects 

of value-based physician payment models [Internet]. Hamilton, 

Canada: McMaster Health Forum, 2017; [cited 11 April 2022]. 

Available at: https://www.mcmasterforum.org/docs/default-

source/product-documents/rapid-responses/examining-the-

effects-of-value-based-physician-payment-models.pdf?sfvrsn=2 

8.Marzorati C, Pravettoni G.  Value as the key concept in the health 

care system: how it has influenced medical practice and clinical 

decision-making processes. J Multidiscip Healthc. 2017; 10, 101–

106. DOI:10.2147/JMDH.S122383 

9.Seibt, D. The sociomaterial construction of users: 3d printing and 

the digitalization of the prosthetics industry. [in press 2022] London: 

Routledge. 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

https://doi.org/10.33137/cpoj.v5i1.38442
https://doi.org/10.1080/09638288.2020.1859630
https://doi.org/10.1080/09638288.2020.1859630
https://doi.org/10.1186/s12984-018-0405-8
https://doi.org/10.1371/journal.pone.0202884
https://hbr.org/2011/09/how-to-solve-the-cost-crisis-in-health-care
https://www.mcmasterforum.org/docs/default-source/product-documents/rapid-responses/examining-the-effects-of-value-based-physician-payment-models.pdf?sfvrsn=2
https://www.mcmasterforum.org/docs/default-source/product-documents/rapid-responses/examining-the-effects-of-value-based-physician-payment-models.pdf?sfvrsn=2
https://www.mcmasterforum.org/docs/default-source/product-documents/rapid-responses/examining-the-effects-of-value-based-physician-payment-models.pdf?sfvrsn=2
https://doi.org/10.2147/JMDH.S122383

