by Sarah Schmelling

Anissa Pongratz, MPT, works closely with her husband’s O&P facility to offer amputees comprehensive care.

Right now is not the happiest of times in orthotics and prosthetics (O&P) and physical therapy relations. The controversy over just where each profession’s territory ends is a constant topic at industry conferences and certainly behind closed clinic doors.

So what do you do if you happen to be a physical therapist married to an O&P professional? For Anissa Pongratz, MPT, based in Phoenix, the answer was simple. By developing her physical therapy practice within an O&P facility owned by her husband, Joseph Pongratz, CPO, FAAOP, she not only bridged the gap between these fields, she also helped create a cohesive business that benefits patients and her community, as well as her own base of knowledge.

“I’ve learned so much already,” says Anissa, who opened her 2,000-square-foot clinic within the 10,000-square-foot Mesa, Ariz, O&P facility close to 2 years ago. “It is a great concept, and from what I’ve heard from patients, it’s absolutely necessary.”

Coming Together

Her husband’s company, Pongratz Orthotics & Prosthetics Inc, opened in 1997 and has three branches: Phoenix; Mesa, Ariz; and Tucson, Ariz. Anissa says the majority of her patients are amputees who have also been seen by the O&P side of the facility, but she does get other types of orthopedic referrals, as well as patients with brain and spinal cord injuries.

She was working at a hospital, focusing on patients with this kind of injury, when she met Joe; she says her patients used his company’s ankle-foot and knee-ankle-foot orthotics. But it was not until the two talked about getting married that they came up with the idea of teaming up. “We realized what a great concept that was, that the two of us could come together, because our professions really complement each other,” she says.

She began investigating by talking with amputees from the support group. “I’d ask about their physical therapy experiences, and they’d say, ‘Oh, I couldn’t find a therapist,’ or, ‘I never got therapy,’ explaining how difficult it was to find a therapist who was proficient working with amputees,” she explains. “I saw a need as there wasn’t a PT in this area who specialized in prosthetics.”

When Anissa and Joe opened her physical therapy clinic within the O&P facility, she and Joe decided from the beginning that it would be a separate business entity. “We’re partners. I’m not an employee of his, and he’s not an employee of mine,” she notes. “We’re on equal playing grounds.”

However, the sheer proximity of the two types of clinics within the building means that patients can receive both O&P and physical therapy without having to travel long distances. It makes it easier for the referring physician to direct patients to receive both services; it can even make things simpler for insurers. “Everybody [who hears about it] believes in this and sees the value of what we do,” Anissa says. “Why would an insurance company send a prosthetic patient to this PT clinic as opposed to another down the street? Well, really, it’s hands-down; why wouldn’t you? We provide everything under one roof.”

She says that beyond O&P and physical therapy, the clinic also has a counseling component that gives it a family-like atmosphere. Tyler Ritchey, a below-the-knee amputee, founder of Limbs to Life amputee support group and prosthetic patient liaison, provides counseling services and support groups, puts together outdoor and social activities, and just generally facilitates amputees getting to know one another.

“A lot of patients I’ve talk to have said, ‘I don’t know another amputee … Who do I talk to?’ and Tyler makes the connections,” Anissa says, adding that she also loves seeing patients talking together and connecting in her waiting room.

Under One Roof

The general process of the facility works like this. A physician refers a patient who is going to have surgery to the facility. Ritchey is often asked to provide preoperative consultation to let the patient know what to expect, while Joe Pongratz explains all of the stages the patient will go through and how the prosthetic will work.

Anissa usually sees the patient when he/she is in the second prosthetic phase after the operation, “and the patient would be coming to me with the physician referral, not from Joe,” she explains.

“From there I work on postoperative strengthening, pre-gait training, balance training, and standing and sitting. Then, we start with the gait mechanics,” she says, adding that specific treatment depends on the patient.

She spends a lot of time with many patients working on gait abnormalities. “A common concern is lack of endurance. They’ll say, ‘I’m exhausted from going to the grocery store,’ ” she says. “So then I work with them on energy-saving techniques, which are generally associated with improved gait mechanics.”

During and after their physical therapy, patients often continue to see Ritchey for his support groups and social activities, which include everything from skydiving and wakeboarding to golf.

So in short, “it’s not just that you’re here to get therapy for 8 or 12 weeks and you’re out the door,” Anissa explains. “[Patients are] seen from preoperative counseling, to being fit with a prosthesis, to going through the phases of recovery and rehabilitation, through their prosthetic phases, and most importantly, they have their support group where they can socialize with the people they’ve met here.”

Working Together

Both Anissa and Joe know well the current controversy over the boundaries between O&P and physical therapy. She says that, “Just out of our personal relationship we can’t be competitive,” and beyond that, providing the two specialties together can be beneficial for both sides.

For one thing, she says, it is always helpful to have a prosthetist on hand when she needs one. At any time, she can run over to a prosthetist and ask him or her what he or she is seeing in a patient’s gait, “because I’ll see hip weakness, I’ll see gluteal weakness, while they might see a knee angle that’s off and they can change that,” she says. “Where I’d be struggling to strengthen a muscle that could only be strengthened so far, [for them] it’s just a few twists of the screws.”

She also has the luxury to get several prosthetists’ opinions and gains different perspectives based on their training and experiences. “One prosthetist is a transfemoral amputee, I can learn from her about her amputation and how she’s rehabilitated in her lifetime. Another employee is a transtibial amputee and I have the ability to brainstorm with him based on his different set of circumstances,” she says. “I am fortunate to have the opportunity to learn different perspectives from clinicians.” 

She says the value of this “interdisciplinary approach to care” is tremendous, and Joe wholeheartedly agrees. “When [Anissa is] seeing a patient, if there’s a minor adjustment, she can literally just get someone’s attention and we’re there to make adjustments as needed,” he says. “That right there takes us 3 or 4 minutes to do, when it could take an amputee between 1 to 2 weeks to get into a very busy prosthetics company to get the repair done.”

It also works in reverse. “On the O&P side, we spend a lot of time creating and manufacturing these prosthetic devices. They’re state of the art, some of the most advanced materials today,” Joe explains. “But if you don’t have a properly trained therapist who can teach balance control, single-limb support, and awareness of space and multi-terrain environments, your prosthesis is only as good as the therapist who trains the patient to wear it. So the fact that we have Anissa, who’s so skilled and experienced with these amputees, it really allows our job to be a lot easier.”

Anissa makes clear, however, that she will not make adjustments on prosthetics. For her, she says, it is easy to just find a prosthetist in the next room, so they do not have to worry about any O&P professional/physical therapist (PT) confrontations in their facility. She does note, though, that, “For other therapists, especially those who work in rural areas and don’t have a prosthetist nearby, they might have to make adjustments. If they’re trained to do so, and if it’s within their scope of practice, it’s my opinion that they should be allowed to make those changes.” She adds that she stands “behind the [American Physical Therapy Association (APTA)] opinion that physical therapists are qualified if they have received the proper training.”

She can also see the O&P professional’s point of view. “They see PTs as encroaching on their industry, and they want to safeguard their profession and patients,” and she understands that, she says. She disagrees with “an under-trained individual (PT or otherwise) simply making prosthetic adjustments, because the effect on the patient may be tremendous,” she says.

Working with her husband, she says, has helped her see both perspectives. “Because we’re married … I stand behind Joe, but I also stand behind my professional organization, and I see where they’re coming from.”

In truth, she adds, both “sides” are arguing the same point. “The O&P industry doesn’t want an unqualified person manufacturing orthotics and prosthetics for patients without being trained, and the PTs believe the same thing,” she says. “It’s just [a matter of] opening up and recognizing that there are PTs out there who have been trained, and are fully qualified. Thankfully, in our situation, we have clear cut boundaries because of the proximity of our working environments.”

Joe Pongratz also sees both points of view. “I think there are valid conversations for both sides,” he says. “Competency in the industry is the main factor. Anissa certainly won’t say she could fit a prosthetic device or manufacture one, and I certainly wouldn’t say I could establish parameters for gait training for amputees when I don’t have the proper training in it either.”

The couple attends both APTA and American Orthotic & Prosthetic Association (AOPA) conferences together, which can be very enlightening, Anissa says. “It is a great opportunity for me to network,” she says. “I’ve met amputees who do running clinics and who wouldn’t attend the APTA conference; they attend the AOPA conference.”

She says she’s been treated both pleasantly and not-so pleasantly by AOPA attendees. Some view her as an opponent and act rather coldly. “One experience I had at the AOPA conference was when a member approached Joe and me to sign a petition asking for government backing to restrict PTs from manufacturing and fitting orthotics. Joe chuckled and said, ‘Let me introduce you to my wife. She’s a physical therapist.’ ”

On the other hand, she’s met people “who are just thrilled that Joe and I bringing these two disciplines together with respect for each other’s expertise, and we’re doing this for the sake of the patient.”

She has met people who run similar practices in other parts of the country. From them, she seeks professional advice.

Moving Forward

The response from PTs to the Pongratz team approach has been primarily positive, Anissa says, especially from those in her community.

“Because we’re the only facility in this area that does [O&P and physical therapy] and has both under the same roof, everybody sees the value in that,” she says, adding that usually if she hears from another PT in the area it’s a request for an in-service visit.

Anissa’s primary challenge at the moment comes from establishing the new practice; balancing time between marketing, administrating, network contracting, patient care. Finding time between seeing patients—she usually sees from four to six per day—to spread the word about her services is tough. “I’m small, I’m the only practitioner here, but I do wish I had more business coming through the door,” she says.

She has found, however, that when she goes with her husband and Ritchey to market the business to insurance companies or physicians’ offices, and they explain everything they can provide to a patient, they’re almost always successful. “When we present what we offer and all of the support we provide for prosthetic patients, it just seems like nobody can deny us,” she says.

Joe agrees it has been beneficial to show people all of the services they provide within the same facility. “It’s a huge benefit for the patients; it’s a big benefit for the doctors; and quite frankly, it’s also benefited the payors,” he says. “They appreciate it because it improves the quality of patient care, and it also lowers costs.”

The couple is planning to add a physical therapy clinic to the facility in central Phoenix, which Anissa looks forward to because, she says, there is a greater need for those services in that area. “That’s the goal, to expand the practice.”

She says that if there are other PTs interested in starting such a practice, she can personally confirm that it is a great idea. “It’s definitely needed,” she says, explaining that many amputees are not progressed adequately, which may lead to injuries, frustration, and imbalanced walking pattern.

“It’s a shame, because these patients could really benefit from learning the proper gait mechanics from the beginning,” she says. “If they learn it right the first time, then of course they won’t have the habits that you’re trying to retrain.”

Amputees who receive physical therapy from the beginning tend to be happier with their prosthetics, she adds, because they tend to get back to the activities they participated in before surgery faster. 

For all of these reasons, she hopes the idea for creating more O&P/physical therapy practices will spread. “Just based on patient satisfaction alone, I think this has been great; and I wish more people were doing it,” she says. “Phoenix is such a big city, with 5 or 6 million people, and we’re the only facility doing this. Think about all over the country, all the places that would really benefit. It would be nice if more O&P [professionals] and PTs could lay down their swords and work together.”

Sarah Schmelling is a contributing writer for Physical Therapy Products.