Over the past 9 years, Cheryl Maurer, PT, MS, CPed, has moved Functional Mechanics from a traveling minivan to a 2,000-square-foot office by following a unique path as customized as the shoes she is capable of making.

Our feet hurt; sometimes it’s the shoes, sometimes it’s the foot, sometimes it’s the body. In today’s industrialized world, even the ground may share some blame. But we are bipedal creatures, and we continue to walk, often opting for fashion over fit in our footwear. Only 35% of Americans responding to a survey conducted by the American Podiatric Medical Association (APMA of Bethesda, MD) reported that comfort was more important than fashion or style when shoe shopping.¹

Even without poor choices in shoes, more of us—aging Baby Boomers, professional and amateur athletes, residents of paved worlds—will feel foot pain at some point in our lives. The APMA study found that nearly half of all Americans, or 47%, will experience a foot ailment.¹ Harvard Health Publications reports that as many as 75% of Americans experience foot pain at some point.²

With at least 300 types of foot problems,2 that leaves a lot of ground to cover. But health care providers, such as Cheryl Maurer, PT, MS, CPed, and founder of Functional Mechanics, Watertown, Mass, are paving new paths for care—conducting research that better defines what actually happens in the legs and feet when we move; educating the community about foot pain and care; and offering treatment alongside orthotics, devices used to change the mechanics, pressure distribution, and environment around the foot.

Maurer has made decisions that have kept her practice small but successful and advocates her choices for those with similar goals: to build a practice that offers quality care and service, but to limit the financial risk.

Guided by strong philosophies, Maurer has steadily grown her practice from a traveling minivan and temporary space to 2,000 square feet of permanent office space and up to 40 patients per week. This year, Functional Mechanics is poised for even bigger growth, perhaps as much as twice the volume. Maurer will soon complete a doctoral program, which will allow her to devote more time to her practice—she currently works 30 billable hours per week plus administrative and clinic hours. Over the next year, she expects to bring in more staff, more patients, and more revenue, and her disciplined preparations should help her realize these objectives quickly.

The Road to Higher Education
One of her earliest choices was to pursue higher, specialized education. She completed a bachelor’s degree in physical therapy at Boston University in 1990, and after 8 years at Massachusetts General Hospital, she returned to school. Maurer obtained a master’s degree in applied kinesiology at Boston University, became certified as a pedorthic, and enrolled in an orthopedic and sports-medicine doctorate program at the Rocky Mountain University of Health Professions, Provo, Utah.

Her direction has been influenced by personal circumstance—Maurer’s interest in orthotics began early while visiting physicians with a brother who needed custom-made shoes—as well as professional frustration. “Despite the fact that we may address all the traditional impairments—flexibility, retraining of gait—people would come back with the same problems or slightly different problems. Or we would address all of their issues, and they would stand up and the body couldn’t put it together,” Maurer says.

So she started to manipulate the feet and began to see dramatic changes very quickly. Orthotics are a key part of treatment, but certainly not all there is. “Orthotics shouldn’t be the whole treatment,” says Maurer, who studies the relationships between orthotic intervention with biomechanics, patient impairment, and outcomes to correctly identify patients who can benefit from certain treatments.

Have Practice, Will Travel
As she pursued higher academic degrees, Maurer could not obtain enough flex hours to maintain her part-time position at Massachusetts General—a job she relied on for benefits. Diagnosed with multiple sclerosis at 25, she needed to keep health insurance that would cover her medications. A mentor suggested she consider starting her own practice and sublet space to reduce overhead.

The benefits, which included continued use of her clinical skills and networking, outweighed the risk of investing solely her money. “I didn’t have to worry about owing people a lot of money if things fell through,” she says.

Maurer connected with Nancy Roberge, a physical therapist who had begun her practice in a similar fashion. Maurer used Roberge’s space on evenings and weekends. “I only needed to reimburse her for the amount of time I spent in the office, so if I went a couple of weeks with no patients, I had no overhead,” Maurer says.

From 1997 through 2000, Maurer sublet space from various offices. During this time, she bought a minivan and had it modified to accommodate her orthotic equipment, which was designed to fit onto a rolling cart so it could travel with her. “In order to be effective at orthotic intervention, you need equipment that you can use immediately to modify orthotics so the patient can be seen and leave with an end product in one visit,” Maurer says.

Safety Before Speed
Her practice volume grew, and when subleasing became too cumbersome, she rented permanent office space—first 600 square feet in Belmont (also in the Boston area), then 800 square feet down the street, and finally the current 2,000-square-foot space in Watertown. She now sees an average of 30 to 40 patients per week, a volume limited by her choice.

“Unlike the business concept of sell whatever you can and wonder how to produce it afterward, when dealing with health care, that can’t be your philosophy. You need to be able to provide quality service first, so I only take on as many patients as I can handle,” Maurer says. (See the sidebar “Patient Demographics” on page 16.)

Every patient is treated as Maurer would want her family members to be treated. And she complements care where other providers, such as PTs, leave off. If a PT refers the patient, Maurer’s role may be limited solely to orthotics; if a patient self-refers and has an ongoing problem, Maurer may also handle the soft tissue and strengthening work to help the patient improve quickly.

Collaboration with PTs results in patients who are happy with the care from both providers. The rapport she builds, with both PTs and patients, results in a bigger referral network.

Private Pay Pays Off
Maurer also works often with PTs because she is not an insurance provider. “Many insurance companies don’t cover this type of care,” Maurer says, citing diabetes-related care as an exception.

Earlier in her practice, she had tried private insurance, but the turnaround time for reimbursement was too slow. By maintaining a cash basis, Maurer knows she has financial resources in hand and avoids paying someone to handle the secondary insurance.

“It’s meant the practice has grown slowly, but it’s a strong practice. Interest is there,” she says, but the time constraints of managing a practice and a full-time doctorate program have limited her patient load.

Maurer will become Dr Maurer within the next year, after which she expects to bring on another PT and a part-time pedorthic at Functional Mechanics. They will join an assistant who works 20 hours per week handling administrative items, as well as a part-time aide.

Talking the Walk
With these changes, Maurer expects patient volume to double, in part because of the current demand, but also because of successful marketing efforts that have become standard business practice. Functional Mechanics participates in a number of clinics throughout the year.

Maurer holds educational clinics for staff and, occasionally, clientele at businesses such as gyms, “almost like an in-service for personal trainers, athletic trainers, PTs, and strength and conditioning specialists,” Maurer says. She participates in health fairs associated with sporting events, including the Avon Walk for Breast Cancer, and other organizations, such as the local Coast Guard. And she regularly hosts clinics at local sporting goods stores. “In addition to answering questions about people’s bodies, we do a foot screen and, if necessary, determine if a patient would benefit from a prefabricated or custom orthotic,” Maurer recounts.

The goal is to help participants maintain their health. (As walks become more popular, so do walk-related ailments like bunions.) But the community service has also turned out to be one of Maurer’s more successful marketing methods. “The education of patients in and of itself becomes your marketing—if you really educate and don’t push them,” says Maurer, who credits 20% to 30% of her referrals to patients.

Walking the Talk
The sports clinics enable Maurer to keep up on her footwear. “Anytime you deal with a patient with foot and ankle issues, it doesn’t matter how many times you treat them or give them orthotics; outcome is dependent on footwear,” she says. For this reason, it helps to develop a rapport with retailers who see how footwear changes over time and can help advise customers.

Solutions are as varied as the disorders and patients. For active individuals suffering from overuse injuries, such as people who run more than 30 miles per week, using an orthotic to manipulate the foot-and-ground interface can offset mal-alignment, permitting the body to function in a more optimal way. “It allows the foot and leg to maintain homeostasis without breakdown and to reduce soft-tissue strain,” Maurer says.

Maurer may choose to alter the foot-and-ground interface for patients with neurological conditions, such as Parkinson’s disease, with the goal of improving stability. “We create better input on pressure sensors to create better balance,” Maurer says.

For patients with altered foot structure resulting from polio, an artificial accommodation of the foot helps them to ambulate more steadily and successfully, according to Maurer. “Some studies have shown that just a foot orthotic can improve response time and balance sensitivity, and reduce the risk of strain,” she says.

With the development of new materials and processes, the orthotics provided to these patients are much more functional. New materials can also help to reduce bacteria, moisture, and/or heat. The development of plastics and copolymers with different grades and flexibilities have allowed products to be prefabricated or custom-fit so that the orthotic maintains its integrity but is neither rigid nor as expensive—a particularly valuable trait for children who outgrow their orthotics very quickly.

The biggest advance in the foot-orthotic world, however, according to Maurer, is the technology used to manufacture orthotics. Computer systems are in development that will image a foot and produce an orthotic automatically. While these programs are still in an infantile stage and may encourage the clinician to give up too much control, the technology holds great promise.

The Road Ahead
Laser scanners are used to capture the foot, creating a 3-D image by connecting dots and smoothing them, or by using pressure sensors to generate a footprint image and match the result to the closest standard; this does not necessarily result in the best fit, according to Maurer. “When you make a model by hand and build it to a foot, even with human error, you are much closer in customizing fit,” she says.

The technology lag exists because we don’t completely understand how the foot and leg function. “We have the technology now, but no studies have yet been completed that pull all of the aspects together to identify which changes produce results,” Maurer says.

Maurer conducts research in her office intended to analyze the biomechanics of the body and the effects of foot-orthotic intervention, and to build better footwear—not to generate an automated orthotic. “The frustrating piece is that what we thought was happening is not. For example, with orthotics, we always thought that if you aligned the foot properly, the patient would walk correctly. But we’ve watched treated patients walk and seen that the expected amount of reduction and motion didn’t occur. So the question remains: Was the orthotic not effective, or is the working diagnosis and pathomechanical model incorrect?” Maurer asks.

Similarly, she adds, when a treatment works, we need to discover why it was effective. “If the motion was controlled to the expected degree, did we alter something else in or around the body that allowed the intervention to be therapeutic?” Maurer asks.

To push for answers, Maurer not only conducts her own research, but she also volunteers with industry associations to encourage collaboration. She is currently the exiting vice president of the Foot and Ankle Special Interest Group of the Orthopedic Section of the American Physical Therapy Association. “We will move forward more quickly if we collaborate rather than isolate,” Maurer says. “And though we will do it one step at a time, the path we choose can get us there more quickly.”

Renee DiIulio is a contributing writer for Physical Therapy Products.

References
1. American Podiatric Medical Association. April’s foot health awareness month alert: New survey finds half of Americans suffer from foot pain. Available at: http: //www.apma.org/s_apma/doc.asp?CID=18&DID=19437 Accessed May 1, 2006.

2. Chiodo CP, Ioli JP. Foot care basics: Preventing and treating common foot conditions. A special health care report from Harvard Medical School. Harvard Health Publications. Available at: http: //www.health.harvard.edu/special_health_reports/Foot_Care_Basics.htm Accessed May 1, 2006.