have been advocating for them for years. Recursive holistic assessment processes for back pain that use intelligently designed frameworks and transdisciplinary team intelli- gence work [3]. Recently Christy Tomkins and I wrote a commentary for JAMA describing a rational process rather than a single test to “diagnose” the disease [4]. These processes are reproducible and researchable. Yet the Na- tional Institutes of Health and other policymakers have paralyzed the advancement of care for real people in the next 2 decades because they can’t reconcile their 20th- century mindset with our country’s 21st-century needs, budgets, and time frames. Jack believes that the future of medicine is exactly what we physiatrists do: build a cul- ture of care. Work with the other physicians as a team. Look at the patient’s goals, not the standard metrics. Share the planning and decision making with the patient. It’s old-time medicine, and it has been tossed out with the statistical games of the past 50 years. It is heartening to see that Drs. Ramirez-Del Toro and Prizinski’s letter reflects distress about our old ways. Fortu- nately, a lot of very influential 21st-century experts are catch- ing up with old Dr. Peirce [5-7]. For now, we can play the reductionist game if it gets us funding. However, we need to insist on teaching and researching the complex recursive process in spinal care or our patients and our society will suffer. Andrew J. Haig, MD Physical Medicine and Rehabilitation The University of Michigan Ann Arbor, MI A.J.H. Disclosure: 1B, consulting; 3A, multiple academic centers; 5B, occasional legal cases; 8B, NIH R-01H00592559: Center for Healthcare Research and Transformation; 9, president, International Rehab forum and Board of International Societies of PM&R http://dx.doi.org/10.1016/j.pmrj.2012.04.010 REFERENCES 1. Haig AJ, Adewole A, Yamakawa KSJ, et al. The ligament flavum at L4-5: Relationship with anthropomorphic factors and clinical find- ings in older persons with and without spinal disorders. PM R 2012;4:23-29. 2. Haig AJ, Tong HC, Yamakawa KS, et al. Predictors of pain and function in persons with spinal stenosis, low back pain, and no back pain. Spine 2006;31:2950-2957. 3. Haig AJ, Theisen M, Geisser ME, Michel B, Yamakawa K. Team decision making for spine team assessment: Standardizing the mul- tidisciplinary assessment for chronic back pain. Arch Phys Med Rehabil 2000;81:1281. 4. Haig AJ, Tomkins C. Diagnosis and treatment of lumbar spinal stenosis. JAMA 2010;303:71-72. 5. Barry MJ. Edgman-Levitan S. Shared decision making—the pinnacle of patient-centered care. N Engl J Med 2012;366:777-779. 6. Cottingham AH, Suchman AL. Litzelman DK. Enhancing the informal curriculum of a medical school: A case study in organizational culture change. J Gen Intern Med 2008;23:715-722. 7. Reuben DB, Tinetti ME. Goal-oriented patient care—an alternative health outcomes paradigm. N Engl J Med 2012;366:777-779. The Complexities Surrounding Decisions Related to Prosthetic Fitting in Elderly Dysvascular Amputees To the Editor, The Point/Counterpoint article in the January 2012 issue of PM&R addressed the challenging decision of whether to fit an elderly dysvascular patient with transfemoral (TF) amputation with a prosthetic limb [1]. We would like to express our appre- ciation to PM&R for publishing this work, to Drs Frieden and Brar for providing a conceptual framework to assist in the formulation of this decision, and to Dr Esquanazi for providing a stimulating counterpoint to this discussion. It is clear that there are no simple decision algorithms to guide clinical decision making, and the available scientific evidence is inadequate. Our goal in submitting this letter is to provide an addi- tional perspective, supplemented by more recent literature, which will, it is hoped, augment the discussion and assist readers as they address this critical issue. METABOLIC COST AND ENDURANCE The metabolic consequences of ambulation with a pros- thetic limb and their implications for fitting a TF prosthetic limb in patients with underlying cardiovascular disease are confusing, and clinicians tend to use various metabolic terms with inadequate precision. The rate of metabolic energy expenditure (mL O 2 /kg/min) is the rate at which oxygen is consumed during a given exercise task and is reflective of the instantaneous cardiac demand (heart rate, stroke volume, and blood pressure). Therefore, it may be related to symp- toms of angina or silent cardiac ischemia when exercise occurs at an intensity in which the oxygen demand of the myocardium exceeds the oxygen supply. In both amputees and nonamputees, the rate of metabolic energy expenditure increases with walking speed and is greater in amputees at any given walking speed. However, amputees choose a self- selected walking speed that is slower than nonamputees. The implications of this are that, if individuals with amputation are allowed to walk at their self-selected speed, then their rate of metabolic energy expenditure is the same as normal and there is no additional cardiac demand. It, therefore, should play little role in the decision to fit or not to fit a prosthetic limb. The metabolic cost of ambulation (mL O 2 /kg/m) in con- trast, is the amount of oxygen consumed per distance walked and is reflective of the efficiency and economy of ambulation. It is increased in amputees compared with nonamputees at all walking speeds. From a clinical perspective, increased meta- bolic cost is reflective of increased muscle work to walk a given distance. Functionally, this may result in more limited endurance and reduced walking distances. 540 LETTERS TO THE EDITOR