| AOPA's Early Years | Expanding Services | OALMA Becomes AOPA | Technology Takes Off | 21st Century and Beyond | Moving Forward |
AOPA’s Early Years
While 1917 marks the year AOPA was established, the association’s past is tied to the history of O&P in the United States, predating the association itself.
The Civil War and its 60,000 amputation surgeries spurred the growth of the O&P industry in the United States. Some of AOPA’s oldest member companies have histories dating back to that time period and its aftermath, as veteran amputees sought improved devices. For example, J.E. Hanger, one of the first amputees of the Civil War, designed the “Hanger Limb” from whittled barrel staves and was granted two patents from the Confederate government. He was later commissioned to develop prosthetic limbs for veteran soldiers.
After the war, Albert Winkley patented the “slip socket” to reduce friction between the socket and the stump by wrapping a piece of leather around the residual limb, and, in 1888, established the Winkley Artificial Limb Co. William Arbogast, a railroad brakeman who became a bilateral amputee in a train accident in 1905, established Ohio Willow Wood, a prosthetic manufacturing company in 1907. In 1911, R.W. Snell bought the prosthetics and orthotics end of a surgical supply business in Memphis. The D.W. Dorrance Co. was founded in 1912, manufacturing a popular arm prosthesis; the company later underwent a merger to become the Hosmer Dorrance Co., now a subsidiary of the Fillauer Cos. Fillauer got its start in 1914, when George Fillauer, a German immigrant, opened a pharmacy that offered orthoses.
Against this backdrop, AOPA emerged in 1917, just as the United States entered World War I—a conflict that would leave 2,300 American soldiers as amputees. The story of the founding of AOPA—originally called the Association of Limb Makers of America (ALMA)—was documented in ALMA’s 1922 “Open Letter to Each Physician and Surgeon of the Land,” which read as follows:
On April 15, 1917, 12 representative artificial limb manufacturers of the United States were called to Washington by the Council of National Defense. A conference was held with the surgical staff of the U.S. Army and Navy. The purpose was to impress on the limbmakers the importance of immediate preparation for efficient and skillful service for the amputated soldiers as soon as they returned from Europe. As a result of the conference and under advisement of the government officials, the Association of Limb Makers of America came into existence.
During ALMA’s earliest years, the association did not have a central office or staff. “The major value of ALMA was that it permitted the free exchange of ideas between limb manufacturers. At its meetings, some attempts were made to present technical papers and, from time to time, the organization published a newsletter or magazine called the ALMAnac,” reports the History of Prosthetic-Orthotic Education.
One of the earliest gatherings of association members occurred when 33 members assembled at the 1918 Annual Convention in Indianapolis. Between the years of 1917 and 1922, ALMA held eight meetings in different states, had regional offices throughout the country, and developed a code of ethics.
November 1918 marked the end of World War I and also denoted the evolution from simple one- and two-person shops to larger facilities. O&P research initiatives became more prevalent, thanks in part a research program instituted by ALMA.
ALMA members also were kept busy during the 1920s due to the rise of industrial accidents. A 1924 article in Surgical Appliance and Instrument Review
stated, “Competent investigators have found that industrial accidents alone in the United States injure over a million and a half. Of this number, about 30,000 are amputation cases.”
ALMA soon began its focus on elevating the profession. In 1924, ALMA President Chester B. Winn gave a rousing speech during the association’s Seventh Annual Meeting, which was documented in an issue of Surgical Appliance and Instrument Review.
Winn spoke of the association’s emphasis on the use of “clean competition” to avoid price fixing and noted that ALMA members should conduct their business “with a firm resolve to make their product better and in keeping with the standard advanced by our association, which has brought forth a gradual increase in the benefits to be derived from correctly manufactured prostheses.”
After the bombing of Pearl Harbor on December 7, 1941, the United States entered World War II, and ALMA took on a larger role, ensuring prosthetic professionals were prepared for the deluge of amputee and limb-impaired patients. Such support was essential as the brutality and length of U.S. involvement led to 18,000 amputees.
This time period also saw many improvements to O&P devices. Some practitioners began to use plastic laminates instead of wood. Researchers at Northrop applied the same cable system used to control aircraft to power split hooks in upper-limb prostheses. In fact, the first patella tendon-bearing below-knee prosthesis was introduced, which became the basis for more modern prostheses.
Private companies also contributed to O&P development. Ohio Willow Wood introduced the first semi-finished, above-knee prosthesis, which used interchangeable parts. In 1948, Jim Snell developed a revolutionary process for making lightweight leg braces, using aluminum that was heat-treated after shaping, with steel bushings at the knee and ankle joints. Patient-care company Wright & Filippis debuted in 1944, and Leimkuehler Limb Co. opened its doors in 1948.
In 1946, ALMA leaders invited orthopedic brace fabricators to join the association, resulting in a name change to the Orthopedic Appliance and Limb Manufacturers Association (OALMA). OALMA established a national office in Washington, DC, and hired an executive director.
In 1948, OALMA members recommended the formation of an organization with the responsibility to establish minimum requirements for the operation of a limb or brace facility to ensure that patients would receive adequate service. The American Board for Certification of the Prosthetic and Orthopedic Appliance Industry Inc. was formed, which later became the American Board for Certification in Orthotics and Prosthetics Inc. (ABC). At the recommendation of an ABC advisory committee, OALMA’s Education Committee developed on-the-job training schedules and course materials for related training to meet the adopted standards for apprenticeship training.
Meanwhile, OALMA continued to hold meetings and grow its membership. The organization began publishing a journal, initially called The Journal of OALMA
from 1946 to 1951, which became the Orthopedic & Prosthetic Appliance Journal
from 1952 to 1967 and Orthotics and Prosthetics
from 1967 to 1988. AOPA co-published the Journal of Prosthetics and Orthotics
from 1988 until the dissolution of the O&P National Office. AOPA also published an early version of the O&P Almanac, initially called the ALMAnac
, and later the OALMA Almanac.
In the middle of the 20th century, when the United States became involved in the Korean War, OALMA members helped tend to wounded warriors once again, with more than 1,500 amputations to U.S. soldiers recorded during this conflict.
The 1950s also marked the establishment of O&P schools at some universities. The University of California–Los Angeles (UCLA) began to offer its Prosthetic Education Program in 1952. New York University and Northwestern University soon followed suit, offering short courses in various aspects of O&P. In 1958, an 18-month program in upper-extremity orthotics was begun at Rancho Los Amigos Hospital in Downey, California, which expanded to a 24-month program to include lower-extremity orthotics.
In January 1958, members of the Executive Committee of OALMA and eight OALMA past presidents met for
four days in Augusta, Georgia, at a “Planning Our Future” event. The event’s minutes noted that OALMA had made remarkable progress during the past decade, and that the profession was undergoing a remarkable transition: “Are we a business or a profession? Hopefully we have to be both. And, are we mechanics, with engineering skills, or are we in the medical field where the structure of anatomy is all important? Again, we have to be both. Therein lies our complicated future.”
OALMA Becomes AOPA
The 1960s were a decade of change for the nation, and for AOPA. In particular, 1960 was a notable year because of the election of John F. Kennedy to the presidency, the development of the first pacemaker, and the first U.S. troops being sent to Vietnam. More than 5,300 U.S. service members became amputees.
O&P technology continued its rapid advance, with innovations such as Ohio Willow Wood’s first solid-ankle-cushion-heel (SACH) foot and Durr-Fillauer’s introduction of nonporous, thermomoldable foam called PeLite. Over at Becker—a manufacturing company originally founded in 1933 by Otto K. Becker—a new double-action joint and modified drop-lock knee joint were being developed. The first reciprocating gait orthosis also was introduced.
A game changer in the U.S. health-care system arrived during this decade, with the enactment of Medicare in July 1965. With 19 million individuals signing up during the program’s first year, Medicare opened access to O&P care to many Americans who had previously gone without due to cost—leading to more growth for the O&P profession.
This was also a period of transition for OALMA, beginning with a name change to the American Orthotic and Prosthetic Association in 1966.
In the early 1970s, AOPA helped develop a guideline for the O&P education coursework essentials, universal orthotic-prosthetic terminology, and new occupational titles and job descriptions. Shortly thereafter, AOPA established the Business Procedures and Liaison Committee. Government and international relations activities also expanded during these years.
AOPA partnered with ABC in 1970, calling for the development of an organization focused on continuing education for O&P professionals. As a result, the American Academy of Orthotists and Prosthetists was founded in November 1970. In 1976, AOPA joined forces with ABC and the Academy at a seminal meeting in Ponte Vedra, Florida, to evaluate the O&P profession’s education and occupational status. This meeting led to the requirement of a four-year baccalaureate degree for O&P practitioners going forward.
In the 1970s, the yearly AOPA National Assembly continued to be a popular event. Due to AOPA’s limited staff, most Assembly activities were organized by members, says Don Hardin, who volunteered for the National Assembly Committee in the 1970s and 1980s and served as AOPA president in 1991-1992. Then, as now, members eagerly anticipated the meetings each year, but they were held in hotels rather than convention centers.
AOPA was instrumental in helping to develop the L codes, which were created to provide a consistent, standardized method to describe the way O&P services were being provided. The Health Care Financing Administration (HCFA) adopted the system and established the Healthcare Common Procedure Coding System (HCPCS) in 1978. The L codes are included in HCPCS Level II codes.
In 1979, another seminal AOPA
program made its debut: AOPA’s Loss Control Program, which was designed to save members money by reducing overall rates for malpractice and product liability insurance.
With a slew of new member benefits in place, AOPA membership numbers soared, almost doubling between 1973 and 1980. AOPA was well-prepared to lead the O&P profession into the final two decades of the 20th century.
Technology Takes Off
With the 1980s and the advent of personal computers, the dawn of the digital age arrived. In O&P, there was extraordinary innovation with the development of Van Phillips’ “spring-like” Flex-Foot Inc. in 1984, and the subsequent debut of Ernest Burgess’s energy-storing Seattle Foot. Endoskeletal prostheses also gained ground, featuring modular components. And advances in fiber technology enabled companies such as Knit-Rite to incorporate high-stretch yarns and wicking yarns, as well as silver fiber, into their O&P products.
The 1980s also saw the introduction of computer-aided design and manufacture (CAD/CAM) technologies, which would revolutionize prosthetic practice with increased shape management options, production capabilities, and access to outsourced fabrication as well as greater ease in transmitting digital files.
AOPA extended its interests to such areas as business education and members’ marketing needs. One of AOPA’s most widely regarded publications was released in October 1986: the first edition of the Pictorial Reference Manual of Orthotics and Prosthetics,
now known as the Illustrated Guide.
In 1990, AOPA and the O&P profession claimed a major victory when O&P won the right to be considered a separate field from durable medical equipment for reimbursement purposes. Other efforts on Capitol Hill resulted in the signing of H.R. 3839, which increased funding for O&P schools.
The first AOPA Legislative Conference took place in 1992, as AOPA celebrated its 75th anniversary. At that conference—which was later renamed the AOPA Policy Forum—several O&P professionals convened on Capitol Hill to meet individually with lawmakers and share the O&P message. This marked the beginning of AOPA’s annual trek to DC.
The 1990s saw more technological innovation, marked by the introduction of Endolite’s swing-control microprocessor knee in the early 1990s and the 1997 release of Ottobock’s C-leg, the first fully microprocessor-controlled leg prosthesis system. These technologies changed not only the ability of people to walk but also the reimbursement climate, with greater scrutiny of O&P devices due to the higher costs associated with advanced technology.
Improved componentry brought with it more widespread participation of O&P patients in athletic endeavors. In 1995, AOPA, in conjunction with ABC and the Academy, established and incorporated the Orthotic & Prosthetic Activities Fund. The fund was initially dedicated to providing financial and in-kind support to the 1996 Atlanta Paralympic Games. After the Games, the fund continued to provide support to adaptive sports programs, clinics, and activities.
AOPA demonstrated its influence in 1996 in several ways. In a legislative win, AOPA persuaded the Senate Judiciary Committee to shelve the Prosthetic Limb Access Act of 1996, which would have increased manufacturers’ liability and provided “used” prosthetic devices to the poor. AOPA also worked with the Academy to develop and disseminate educational materials related to the new ABC Facility Accreditation Program and Standards. In addition, AOPA debuted its first website: www.theaopa.org.
21st Century and Beyond
AOPA began the new millennium as a more inclusive association, changing its bylaws in 2001 to include more O&P businesses and thus be more representative of the entire O&P industry. The broader membership led to AOPA having an even stronger, more effective voice on Capitol Hill.
In 2001, the 9/11 attacks shocked the world, causing the deaths of nearly 3,000 people and injuring 6,000 more. In response, the United States engaged in war in Afghanistan, known as Operation Enduring Freedom, which continued from 2001 through 2014. Beginning in March 2003, the United States also engaged in Operation Iraqi Freedom.
These U.S. engagements resulted in more than 1,600 major limb amputations as of June 2015, according to U.S. Military Casualty Statistics.
Many O&P facilities and manufacturers rose to the challenge of creating innovative prosthetic solutions for the generally young and active military amputee population.
As the rate of technological innovation accelerated in the 2000s, AOPA member companies kept pace. In 2000, Össur—an O&P manufacturing company founded in Iceland in 1971—acquired Flex-Foot Inc. Össur’s presence in the United States grew throughout the decade, as the company applied for hundreds of U.S. patents and established Össur Americas.
In the 21st century, advanced myoelectric devices have increased in popularity, particularly as more amputees undergo advanced surgeries such as osseointegration and targeted muscle reinnervation. Innovations such as powered orthoses, virtual reality, brain-controlled prostheses, alternative materials, and 3-D printing are leading O&P professionals to explore new solutions.
O&P stakeholders have begun collaborating in unprecedented ways, with AOPA leading the way. In 2005, AOPA joined forces with ABC, the Academy, and the National Association for the Advancement of Orthotics and Prosthetics (NAAOP) to form the O&P Alliance. The Alliance’s accomplishments have included convincing the Centers for Medicare & Medicaid Services (CMS) to make the new Medicare standards more reasonable for O&P, lobbying for removal of O&P from competitive bidding, and pushing CMS to enforce qualified provider regulations.
AOPA also has been the go-to resource for O&P professionals struggling with an increasingly challenging reimbursement climate. As more stringent documentation requirements were enforced, AOPA has provided guidance to help facilities understand the guidelines, navigate the audit and appeal processes, and improve overall documentation procedures. This instruction has come via monthly webinars and periodic coding and billing seminars, as well as via the AOPA website, O&P Almanac, AOPA In Advance, and other member benefits.
AOPA has continued to lead research efforts, securing grants for outcomes-based research, and commissioning a study by Dobson-DaVanzo that ultimately proved the efficacy of custom orthoses versus off-the-shelf devices.
In July 2015, AOPA wielded its influence at a pivotal moment when the DME MACs published a draft Local Coverage Determination (LCD) governing Medicare coverage of lower-limb prostheses. If enacted, this policy would have dramatically and adversely impacted care. AOPA immediately spearheaded an initiative that generated more than 5,000 comments, which were included in the official record for LCD rule-making. AOPA itself submitted 43 pages of comments, and conducted a data analysis demonstrating that the data used by CMS contractors to support their proposed policy was based on outdated information.
On Aug. 26, 2015, AOPA arranged for five speakers at the DME MAC public meeting in Linthicum, Maryland, then organized a patient rally at the headquarters for the U.S. Department of Health and Human Services. At the rally’s conclusion, AOPA representatives met with high-ranking CMS officials, who said they would work with the regional contactors’ medical directors to reach a solution. These efforts were extremely successful; CMS soon announced that it would not finalize the draft LCD, and that the LCD would not be implemented in its original form. CMS has since convened a multidisciplinary Interagency Workgroup to “develop a consensus statement that informs Medicare policy by reviewing the available clinical evidence that defines best practices in the care of beneficiaries who require lower-limb prostheses.” The decision to halt the progress of the proposed LCD was a clear win for AOPA and the profession, effectively defeating a bad payor policy.
AOPA’s member offerings continue to expand. This year, as AOPA celebrates its 100th anniversary, there are several key imperatives that have been set in motion by AOPA that will likely have a favorable impact on the profession, including a national Prosthetic Patient Registry, comparative effective research, new projects with Dobson-DaVanzo, and the Prosthetics 2020 initiative, says Michael Oros, AOPA president. “Our leadership believes the results and impact of each of these will bring long-term value to each of our AOPA members.”
As AOPA members ponder the association’s accomplishments of the past 100 years, it’s clear that AOPA is going strong, continuing to lead efforts to advocate on behalf of the O&P profession today—and into the next 100 years.