Survey to Determine the State of Services Available to Amputees and Orthopedically Disabled Persons: Report II-Orthotic Services USA-1962
Leroy Wm. Nattress, Jr.
Bertram D. Litt
Prepared for the Office of Vocational Rehabilitation Department of Health, Education and Welfare, under Grant RD-430 to the American Orthotics and Prosthetics Association.
Archaeological evidence demonstrates that musculo-skeletal injuries were treated during the stone age. The earliest treatment was for sprains, strains and fractures which were an aftermath of the pursuit of the necessities of life. Somewhere in this pre-recorded history an imaginative mind conceived the idea of splinting the injured extremity and. thus, the science of orthotics had its beginning. Some historians date this as early as 13,500 B.C.
Despite these early beginnings the evolution of orthotics has been slow and spasmodic depending upon the inventive genius of isolated individuals. This pattern of development was equally true of all arts and sciences until relatively recently. Since the advent of the twentieth century the rate of technological advance has accelerated greatly. Perhaps of even greater import has been the coordinated interdisciplinary efforts which have been focused upon specific areas of knowledge, production methods and science. The survey of prosthetic services demonstrated the impact of research and education on practice in that field. However, as recently as the inauguration of this survey, the status of research, development and education in orthotics could be characterized as:
- Representing the ideas of the individual physician and/or the orthotist working closely with him.
- Lacking organizations for the exchange of knowledge, except on the local level, prior to 1946.
- Lacking formal courses of instruction in orthotics.
- Lacking a coordinated research program.
Research in orthotics had its beginning about 1927 with the efforts of Mr. Henry Pope which subsequently led to the establishment of the Pope Foundation. Closely allied with this was the formation of the Warm Springs Foundation and the National Foundation for Infantile Paralysis. During World War II. the U.S. Army became interested in orthotics. Later the Mellon Institute established a research program on materials and their application to orthotics. In this connection, three symposia were presented in conjunction with the University of Pittsburgh. The first, in 1948, marked the beginning of formal education in orthotics.
The first positive step toward providing a means for exchanging information in orthotics was taken in 1946 when the Orthopedic Appliance and Limb Manufacturers Association was formed. This association, with headquarters in Washington, D.C., has served to bring the allied professions of prosthetics and orthotics together in order to benefit both through the publication of a journal, the conducting of national and regional meetings, and the encouragement of the exchange of ideas.
In 1948, a board for certifying the competency of individual orthotists and the adequacy of orthotic facilities was established. This board, now known as the American Board for Certification in Orthotics and Prosthetics, Inc., has worked closely with the American Academy of Orthopaedic Surgeons and the American Orthotics and Prosthetics Association in discharging its responsibility of setting and maintaining standards of professional practice.
The National Academy of Sciences—National Research Council, through its Prosthetics Research Board, voted to expand the definition of Prosthetics to include Orthotics at its meeting in March 1957. Since that time, numerous research projects have been undertaken at the University of California at San Francisco, the University of Michigan. Baylor University, Rancho Los Amigos Hospital, the Veterans Administration Prosthetics Center, the University of California at Los Angeles, and New York University. Funds for these projects have come from the Federal Government through the Office of Vocational Rehabilitation and Veteran's Administration, and foundations, such as the National Foundation, Easter Seal Research Foundation and the Orthopaedic Research and Education Foundation.
The experience of the prosthetic research program indicated the need for an integrated educational program to disseminate the new information and procedures. The structure for this was already available through the Prosthetic Education facilities at the University of California at Los Angeles. New York University, and Northwestern University. In 1958, UCLA led the way by introducing a short term residence course for orthotists, physicians and therapists entitled "functional Bracing of the Upper Extremities." The development of additional curricula was slow, but in September 1961, NYU launched a course in "Lower Extremity Orthotics" which was followed in December 1961, by UCLA's course in "Functional Bracing of the Lower Extremities." The field is now awaiting a course in bracing the trunk and spine being prepared by Northwestern University.
This survey project was conceived in 1958 by Glenn E. Jackson, then the Executive Director of the American Orthotics and Prosthetics Association, who with members of the Association's Committee on Advances in Prosthetics (Carlton Fillauer, Chairman, M.P. Cestaro, Fred Eschen, Charles Hennessy, and Howard Thranhardt) presented a. proposal to the Office of Vocational Rehabilitation, Department of Health, Education, and Welfare. The proposal was approved in 1959.
A Survey Advisory Committee, composed of M.P. Cestaro, Chairman, Dr. Robert Mann and D.A. McKeever, reviewed all phases of the survey plan, the sampling procedure, the administration of funds and the completion of the report. Three men were selected by the Association's Committee on Advances in Prosthetics—John Glancy, John DeBender and Clarence Medcalf—to form a Survey Content Committee. Lester A. Smith, Executive Director of the American Orthotics and Prosthetics Association; Past Presidents Paul Leimkuehler, Ralph Storrs, and Fred Quisenberry; and AOPA's Regional Directors, participated in the numerous meetings of the Survey Advisory Committee and also were active in enlisting the cooperation of orthotic facilities in the survey.
In addition to the 198 facilities which participated by answering the questionnaires, there were a number of individuals who were particularly helpful in suggesting material for the questionnaires and sketches of brace designs fur the illustrations. Notable contributions were made by: Carlton Fillauer. Alfons Glaubitz. Erich Hanicke. Frank Harmon, Herman Hittenberger, Matt Laurence, Charles Rosenquist, Charles Ross, Roy Snelson, E.W. Snygg and Ted Smith. A number of suppliers and their representatives furnished information, illustrations, etc.
A special vote of thanks is due to the individuals who participated in this survey as interviewers: William E. Anderson, Steve Andrusky. Robert C. Apilzsch. Thomas N. Bidwell, Ross L. Bremer. James R. Fenton. Alan It. Finnieston, Richard A. Fitzgerald Jerald D. Gillespie. Charles Richard Greene. Loren D. Jouett. Thomas G. Powell. Jr.. Robert B. Reid. and William B. Smith.
The need for professional orthotic service throughout the United States is evident from the statistics of the United States National Health Survey estimates.
"The average prevalence of cases of paralysis in the noninstitutional population of the United States during the 2-year period, July 1959-June 1961 is 946,000—a rate of 5.4 per 1,000 population."
"Of the total cases of paralysis, 600,000 or 63.4 percent, occurred among persons over the age of 45. For persons of all ages 526,000 cases, or 55.6 percent, were among males."
With such a large demand for orthopedic appliances it became obvious that the following types of information were needed to report on orthotic services:
- Distribution of facilities as related to patient needs.
- Systems of patient management and referrals employed in different areas of the country.
- Types of equipment and devices supplied to patients.
- Techniques and devices used under local conditions, but which have not found widespread use.
- Extent to which output could be increased in case of a national emergency.
The purposes of the Survey were to find this information, to describe the status quo, and to establish a feed-back system between the Research and Education Program- and the field. A pilot study of all facilities in Ohio, con-dueled in 1960 by A. Bennett Wilson, Jr. and LeRoy Wm. Nattress, Jr., revealed Wide variations in orthotic practice even within the boundaries of that single state, and pointed up the empirical nature of the brace prescription. It suggested, however, that orthopedic appliances could be classified by design and/or function. The validity of such a classification system would have to be established by subsequent research programs. However, it was felt that such a system could be used to establish a base-line of current practices for future research, education and service programs.
To satisfy the purposes of this survey it was necessarv to describe the braces and surgical garments being furnished, the conditions for which they are prescribed, the geographic distribution of facilities providing these devices, as well as those aspects of the treatment program concerned with the prescription, application and check-out of appliances.
These goals have been tailored to seek the lowest common denominator in bracing problems. A bracing problem, as here defined, is the manifestation of a symptom, or group of symptoms, which may be caused by any number of syndromes. Placing the emphasis on bracing problems rather than on neuro-muscular and orthopaedic syndromes simplified the survey planning task. This approach led to the assumption that two or more syndromes which produce similar dysfunctions of a particular body member may be. in part, treated by the application of the same type of orthopedic appliance. In this connection it should be recognized that the majority of individuals who are fitted with orthotic devices are in the process of a medical treatment program of which the orthotic device is but one aspect. Accordingly, it was anticipated that almost all initial fillings are ordered by prescription, regardless of the kind of device or where it is being fitted.
The present report is concerned with the survey of orthotic services and practices. It describes the availability of these services; types of procedures being followed and the extent of their application; individual variations; and opinions of orthotists related to the procedures which they employ.
A survey of services is usually a descriptive studs which is undertaken to provide information for the use of a single interested group. In this instance, the survey of orthotic services available to orthopedically disabled persons, the staff and advisory committee felt that the results should be useful to governmental and other agencies which are sponsoring research and education programs: to personnel engaged in these programs; and to orthotisis. practicing physicians and others directly concerned with the treatment and rehabilitation of orthopedically disabled persons. As the survey was aimed at this broad audience it became necessary to investigate the full spectrum of services offered and to identify all pertinent facets of these services.
The first procedure was to define the basic problems on which the study could be built. These were: 1. What services are being offered? 2. To whom are services provided? 3. Why are services provided? 4. How are services provided? 5. Who provides the services?
Although some of this information is available in the literature, almost none of it is presented in a way that is directly applicable to the purposes of this survey. Consequently, it was fell that some systematic organization should be developed so that the material could be investigated in an orderly way. This organization, derived from the empirical findings reported in the literature and the experience of various consultants and committees of experts, defined the basic problems in the following manner:
1) What services are being offered? Generally speaking orthoses may be defined as any device which is used to straighten a distorted part and/or prevent distortion of any part. This definition would include plaster casts, bone nails and a variety of surgically implanted devices: as well as exoskeletal braces, corsets, collars, and splints. For the purposes of this survey the definition of orthoses was limited to the category of exoskeletal devices other than plaster casts. Reference to the Orthopaedic Appliances Atlas, The Journal of Bone and Joint Surgery, Archives of Physical Medicine and other sources reveal that a kaleidoscope of devices are being fitted. Little evidence of systematization or effort to standardize procedures have been published. (Von Werssowetz's recent article on lower extremity bracing
is a notable exception.) Separate types of devices are being applied for cervical, trunk and spinal, lower extremity, and upper extremity problems.
A. Classification of cervical braces can be developed from the basic structural materials used in each brace class or type; leather collars, plastic collars, cotton wrap-around collars, wire and tubular frame collars or braces, and metal braces with varying numbers of posts. A second system could be developed from the type of body contact used in each brace type: a) two rings of total contact (along the jaw and base of the skull and along shoulders, chest and back); b) plates contoured to fit selected areas of the jaw and skull connected to chest plates by supporting beams: c) head supports at the jaw and or forehead cantilevered from a dorsal bar extending from a back brace or wheel chair. A third system could be developed from analysis of the major structural components of each brace type. The third classification system was found to consist of six types of brace designs which are known to be in general use. They include:
- Collars made of a -ingle strip of plastic, leather, metal and cotton or wool, and/or felt. They are fastened or wrapped around the neck. Some arc custom made and others are prefabricated and come in a variety of sizes. These collars are characterized by having no provision for height adjustment (Plate I. J. ).
- Solid two or three piece plastic collars similar to the above, but with provision for height adjustment. These collars are usually purchased front a central manufacturer in a variety of sizes, adjustable to the contours of the individual patient (Plate I. K ).
- Molded Collars. Leather or plastic is molded to a plaster cast of the patient who is to be fitted. The dry and stable collar is cut laterally on either one side or both sides, and is held in position by lacing or straps (Plate I. P).
- Open-cushioned wire frame collars consist of two horseshoe-like omponents, shaped to conform to the contours of the mandibles and base of the neck. These are supported by two, three, or four solid and/or adjustable type posts. The collars are strapped in position posteriorly (Plate I. L). These devices are usually purchased from central manufacturers. The rigid supporting members of these devices are similar to those used in the two and four poster braces. The total contact afforded by the padded wire frames at the base of the neck and along the mandibles is very similar to that offered by the collars.
- Two-poster braces are characterized by two rigid metal supports for the mandibles and occiput. The forces may be applied either anteriorly and posteriorly or laterally. The posts may be anchored to the body in a variety of ways, one of which is illustrated in Plate I. M. Parts for these units may be purchased, as may prefabricated units. In many instances all parts are assembled and or fabricated at the orthotic facility.
- Four-poster braces are essentially identical to the two-poster braces. The two additional posts are frequently used with smaller body plates (Plate I. N).
- Other appliances were lumped into a single category which included:
- Three-poster braces which may have a single anterior and double posterior bar or two posts in front and one at the back.
- Jury Masts are usually characterized by a mandibular support which is either cantilevered or suspended from a rigid posterior post. Some varieties permit motion in one plane.
- A metal ring or halo supporting the top of the head which is attached posteriorly to a rigid supporting rod. This device may or may not incorporate a variety of additional features,
- Zygoma supporting braces which permit jaw motion while stabilizing the head. They are supported by a single posterior rod terminating in a fairly large occipital pad with metal processes for stabilization at the zygomatic arch and secured by a strap around the forehead. Auxiliary equipment such as traction and wheel chair supports, casts, and Skeletal Fixation Halos and other similar devices have not been included in this study as the application of these devices rarely utilize the services of an orthotist.
B. Spinal devices are found to include a large variety of surgical garments, corsets, and braces. The distinction between these three categories was not defined and considerable overlap in terminology was noted. A number of plastic, Celastic and/or glass body jackets, which are also referred to as corsets by some authors, been described as being used for various conditions of the spine and trunk. As no classification of these units existed it was clear that one would have to be developed if the survey was to study this area in the allotted time.
C. Lower extremity devices fall into three clear-cut categories: night splints, shoe modifications and braces. It was found that these devices overlapped somewhat and that am one or all three methods of treatment were recommended by different author- for identical problems. Generally speaking, lower extremity braces were noted as consisting of an armamentarium of standardized components which are available as prefabricated units. The components are then assembled and fitted with beam support on one side of the limb, both side or dorsally. The braces are usually described by enumerating all of the major components, noting only the type of vertical supporting elements, or by a name which may have either local or widespread acceptance. The lower extremity brace components include: shoe attachments, ankle units, upright components, knee components, pelvic joints and belts, a variety of bands, slings, lacers and auxiliary components.
D. Upper Extremity Devices presented a different class of problem. The complex nature of the upper extremity nemo-muscular systems provides For a broad spectrum of specific disabilities. The literature revealed several different approaches to these problems:
Georgia Warm Springs
Rancho Los Amigos
A variety of traditional splints are also used. More recently, several development centers have been working on externally powered devices.
The alternative was to study the application of these systems to specific upper extremity disability problems, or to identify the facilities providing upper extremity devices and how frequently they are called on to make them.
2. To Whom Are Services Provided? The population of individuals being fitted with orthotic devices includes those persons with a broad variety of orthopedic disabilities resulting from disease entities, trauma and congenital conditions: psychosomatic conditions; and those resulting from internal conditions which require orthotic support.
3. Why Are Services Provided? Orthotic devices are prescribed and provided as a part of the medical treatment process. The criteria for selection of a device seems largely based on the formal education, training and experience of the individual physician prescribing a particular device for a particular patient. Depending upon the attitudes and habits of the individual physician he may (or may not) consult with an orthotist, a therapist or others.
4. How Are Services Provided? Following expectations derived from the results of the prosthetic survey it was anticipated that patients being treated at hospitals or other institutions and those being treated with the support of Bureaus of Vocational Rehabilitation, the Veterans Achninistration or other institutions might always be expected to be provided with an orthotic device ordered by a physician's prescription. Similarly, private patients were expected to be Idled according to a medical prescription for their first orthotic device: but not necessarily for the replacement of a worn-out device.
Referring to the clinic treatment procedures followed in prosthetics, it was anticipated that the physician and auxiliary personnel might perform a checkout immediately following final application of the completed device to determine whether the fit and function are adequate.
In the instance of a variety of devices which are furnished by drug stores, department stores and mail order houses, the question was posed as to what types of devices arc used and to what extent they arc provided without benefit of medical prescription.
5. Who Provides the Services? A. Orthotists are primarily responsible for fabricating and fitting orthotic devices. Devices are also fitted by corsettieres, surgical garment fitters and others.
B. Physicians are responsible for the treatment program of their patients. In this capacity they are expected to prescribe and checkout orthotic devices. In a limited number of cases they are known to fit and/or fabricate devices directly for patients.
C. Nurses and therapists are directly concerned with instructing patients in how to use, don and remove these devices. They may also participate in prescription and occasionally checkout. There are a small number of therapists who fit and fabricate orthotic devices.
D. Social workers, psychologists, rehabilitation personnel, family members and others may also be involved in various aspects of the treatment program dealing either directly or indirectly with the orthotic phases of treatment.
Orthotists have been defined as being responsible for fabricating and fitting orthotic devices, Their services reflect the practice of the physicians whom they serve. As each orthotist usually works with a number of physicians, any sample of responses from orthotists relating to observable facts, though not necessarily to opinions, would also represent the responses of a considerably larger sample of physicians. The problems selected for investigation in this survey were, therefore, limited to those which could reasonably be answered by orthotists. This approach meant that the data to be collected would have to be in terms of the first four questions—who? how? to whom? and what services are offered? However, it was hypothesized that the last question, why?, would be answered by the results of the first four. i.e.. uniformity of prescription practice, or selection of a single brace type throughout the country for an individual problem would indicate the presence of firm criteria, without actually describing them: conversely conflicting practice would indicate the lack of criteria.
In discussing the purposes of the survey of orthotic service it was established that the information to be sought should include data describing:
- types of personnel and facilities providing orthotic services:
- Ways in which services are provided (treatment system );
- Types of conditions fitted;
- Types and frequency of application of orthotic devices:
- Reasons for orthotic device selection;
- Orthotic areas in which additional research and education is indicated.
From the experience with the pilot study and the survey of prosthetic services, it was felt that the orthotic material could be collected in much the same manner.
Collection of information was largely limited to orthotists as they had been identified as the individuals who could most efficiently provide the greatest quantity of descriptive data on orthotic devices and their application. However, as a considerable number of non-orthotists also fit orthotic devices, it was felt that personnel in drug stores and surgical supply houses should be interviewed in all cities and towns where time permitted. A special short form was used for these facilities to determine the extent of services rendered. Mail order houses and department stores were omitted from the study because of the lack of time available in any given city and the extensive time required to obtain permission and cooperation from these facilities.
The collection of this information required that certain procedures be developed to standardize nomenclature. The first step was to distinguish between spinal corsets and braces—surgical garments were here considered as devices other than corsets and braces, i.e., trusses, athletic supports for the knee and ankle, colostomy appliances, etc. In as much as spinal braces may be applied to the trunk with corsets and corsets may have metal supports, the definition was drawn in terms of the rigid supporting members. It was established that for the purposes of this survey, the following definitions would be used when considering spinal appliances:
Braces—All devices which contain a rigid frame of support including both vertical and horizontal metal bars.
Corsets—All devices which may or may not contain rigid vertical or horizontal metal bars or supports, but not both.
A preliminary questionnaire was developed illustrating the metal parts of 18 spinal braces. The purpose was to find out whether medical syndromes could form the basis for a classification system for spinal bracing. A large number of conditions were reported for each brace type and a variety of braces for each syndrome.
The survey committees, numerous consultants and a group of orthopedic surgeons and physiatrists agreed to the assumption that any two or more syndromes which produce similar dysfunction of a body member could be considered as a bracing problem. Using this theory as a point of departure, a number of bracing problems immediately became apparent. These included:
Cervical Disc Rupture, Lesion, or Reduction of the Foramina, Postoperative Fixation, or Dislocation in the low Cervical area.
Torticollis, or Wry Neck
Cervical Spinal Strain or Injury, or Whiplash
Kyphosis (Dorsal Spine)
Lordosis (Lumbar Spine)
Fractures or Postoperative Conditions:
Low Cervical and High Dorsal Spine
Mid-low Dorsal and Upper Lumbar Spine
Low Lumbar or Sacral Region
Low Back Pain or Strain, with or without Disc Complications
Pes Varum and/or Valgum
Genu Valgum and/or Varum
Knee Flexion Contracture
Upper Extremity Disabilities
The validity of this approach and completeness of this list was further discussed with a number of orthopedic surgeons and physiatrists. Their consensus was that the list could also include: Congenital muscular weakness and muscular dystrophy, Non-union of long bones, Spina bifida vera, Break-down of upper extremity conditions. However, they indicated that the frequency of occurrence of these additional categories did not warrant their inclusion in this survey unless specific reasons for doing so arose. (They were accordingly omitted.)
The advisability of collecting data describing the purposes underlying individual brace applications (i.e.. supportive, corrective, etc.) was also considered. This type of material was not included as it was felt to be based on value judgments, frequently second band, rather than statement of fact, and did not seem to be germane to the broad purposes of the study. It was felt that this type of information might better apply to a medical follow-up study of a particular condition in which the relative efficacy of various treatment procedures were being evaluated. Examination of the list of bracing problems revealed four major categories:
- Spinal (Including the Neck and/or the Trunk)
- Lower Extremity
- Upper Extremity
- Major debilitating neuro-museular syndromes which may effect more than one of the preceding categories.
Description of spinal braces for the neck and trunk are usually based on one or more bony landmarks and a formula for fitting the device with one or more variations suggested for persons of different body builds. Frequently, different bony land marks may be used by authors describing very similar devices. Thus, for the survey to describe these devices it was first necessary to develop a system of reference which would be acceptable and meaningful to all of the orthotists to be interviewed. It was felt that this could be accomplished by using illustrations of basic brace design.
Respondents were asked the names of the devices which they were called on to furnish for each of the spinal bracing problems enumerated above. For each condition they were asked to identify the illustration ( see Plate I., Plate 2, Plate 3, Plate 4, Plate 5, Plate 6, Plate 7, Plate 8, Plate 9) which most closely resembled the device which they fitted. They were then asked to identify the ways in which their spinal or cervical device differed from the illustrated device.
The brace patterns, which are illustrated, were selected on the basis of apparent major differences in design and function. The approach to cervical bracing was detailed above (pages 57-58). It was fell that the majority of spinal braces in use today are modifications of a limited number of basic appliances. The array of basic patterns for the trunk were hypothesized as including:
- Low back posture type support similar to that designed by Gold-thwait for the sacro-iliac (Plate 3) ;
- A low back type of brace frequently called a chair back or Knight spinal brace (Plate 2) ;
- A low back design which applies pressure to the back by lever action of the Williams type (12) (Plate 4) ;
- A high back brace with paravertebral bars supporting the lumbar and dorsal spine of the Taylor type (Plate 5 ) ;
- An anterior hyperextension brace which applies pressure anteriorly at the sternum and pubis, and posteriorly at the affected area of the spine of the Lennox Baker or Jewett types (Plate 6) ;
- A Milwaukee type scoliosis brace (Plate 7 ) ;
- A molded body jacket (Plate 8).
The major debilitating syndromes (paraplegia, hemiplegia, poliomyelitis, cerebral palsy, etc.) present serious problems for both upper and lower extremity orthotics. The immediate problem in these areas seems to be the identification of number and types of facilities that are now providing services for these patients.
In lower extremity orthotics respondents were asked whether during the past twelve months they had fitted orthoses for each of the six lower extremity joint dysfunctions listed. The devices most frequently prescribed and fitted for each condition were then described by noting the components. An intensive armamentarium of lower extremity components was listed for this purpose.
In upper extremity orthotics questions were restricted to asking how many devices of all varieties were fitted in the past twelve months: how they were provided locally: how the individual who did the fabricating learned to make them? Although some of these questions call for a value judgment, they were retained as the upper extremity is the one area of orthotics where research and education programs have been available for the past four years.
The survey of orthotic services was designed so that the findings would parallel those of the prosthetic services in so far as the similarities and dissimilarities in the material would permit. The questionnaires consisted of four units.
The first, Questionnaire A, was a mail form, which was sent to approximately 1100 facilities. It was designed to gather information on the different names applied to identical appliances in different parts of the country.
The second part was designed In collect information on the types of services rendered: number: background and responsibilities of employees: area served: ability to increase production in case of national emergency and types of help that might be needed for this purpose. This questionnaire was mailed to the facilities before they were interviewed so that the information could be used to facilitate the interview.
The last two parts, administered during personal interviews, were designed to determine: who participated in the various stages of the orthotic treatment program (prescription, trial lining, checkout and filial application); how this was done (in a formal group or serially); the frequency that prescriptions were required for replacement of appliances in the major areas of disability, i.e.. cervical, spinal, lower extremity and upper extremity: the orthotic devices being used for each of the bracing problems enumerated above: and the frequency with which they were applied to each of the bracing problems.
The questionnaires were field tested and reviewed by the Advisory and Content Committees before final printing. These questionnaires were administered by seven two-man teams of orthotist-interviewers in the field.
The rationale for the selection of interviewers and training procedure followed in the prosthetic services survey had proven sufficiently successful so that it was used in the present study. A group of fourteen orthotists were selected on the basis of interest, background and age. All were well established in a family business: and either were Certified by the American Board for Certification in Orthotics and Prosthetics. Inc.. or were prepared to become certified in the near future. They were brought to Washington in the third week in April to attend a training course in the use of the survey forms.
The training course was given by the Project Director, the Associate Project Director and two members of the Survey Content Committee. Because of the nebulous nature of the orthotic data to be collected, special emphasis was placed on a thorough training course. A complete set of forms was administered to each of the trainees so that they were able to appreciate the problems of both the interviewer and the respondent in a typical interview situation. Although this initial experience was partially a role-playing experience, the trial interviews were made as realistic as possible by emphasizing that these questionnaires were to be included with the data collected in the field.
As in the prosthetics survey, interviewers were sent out in two-man teams to expedite the interviews, minimize the personal bias and help maintain adherence to the presentation system taught in the training course. The interviewers were sent to areas in which they were not acquainted. Trips were limited to two weeks because of the difficulty in maintaining the desired level of performance for longer periods.
Questionnaire A was mailed in November and December 1961, alerting the field to the forthcoming survey. Trip itineraries were planned in April and appointments at the orthotic facilities were scheduled by telephone. A follow-up letter was sent to remind the facility of the survey interview and its purpose and enclosing a copy of Questionnaire Part I which was to be completed before the interview. The interviewers called the facility a day in advance to finalize the appointments.
The data for the Orthotics Survey were collected in seven two-week trips conducted during the last few days of April and the month of May, 1962. The trips were scheduled so that the Project Director or Associate Project Director could accompany the team during the initial experience in the field. Thus, problems which arose during the first interviews were clarified and adjustments in procedures provided. During the trips, telephone communication was maintained in order to follow progress and to solve any additional problems as they arose.
Completed forms were mailed to Washington where they were checked for completeness and accuracy. Facilities were contacted for additional information where necessary. The questionnaires were then edited, tabulated and analyzed.
In preceding paragraphs it was established that the total population or universe of facilities which are engaged in the fitting and/or fabrication of orthotic devices includes: orthotic facilities (both private and institutional), surgical supply houses, drug stores, department stores, mail-order houses, physicians and therapists. It was also established that this survey would be conducted primarily witb orthotists, with a fragmentary representation of drug stores and surgical supply houses. The rationale for the selection of this limited population was the observation that although all seven groups were engaged in fitting orthotic devices, only the orthotic facilities are directly responsible for both fabrication and fitting.
The prosthetics survey sampling procedure began with the construction of a comprehensive list of facilities that fit or fabricate artificial limbs and/or braces. This list of approximately 1145 facilities was assembled in the following way:
- During the summer of 1960, a search of telephone directory "Yellow Pages" of all cities of 7,000 population or more was conducted and a card file compiled.
- During the subsequent fall and winter this file was cross checked with all of the files available in the Association Office.
- The file was organized by states and the state lists were sent to Regional Directors of the American Orthotics and Prosthetics Association and to knowledgeable prosthetists and/or orthotists in each state for review and revision.
The report qualified this population figure by stating "the number of . . . semi-retired individuals who conduct small practices, surgical houses and drug stores that also measure and fit appliances [make it] impossible to be certain that an exact tally has been compiled". Examination of this list revealed that approximately 500 of the facilities were concerned with prosthetics. During the prosthetic survey 40% of the sample stated that they were engaged in the fabrication and fitting of prosthetic devices only. If the figure for that sample can be accurately extended to cover the population estimate of 500 prosthetic facilities, then the rough population estimate should include 300 facilities that fit and or fabricate both prosthetic and orthotic device and 650 that fit only orthotic devices, leaving 200 facilities which fit only prosthetic devices.
The sampling procedure was designed so that the findings of the present orthotic survey could be compared to those of the prosthetic survey. Thus, the selection of the sample had to include facilities with the following characteristics:
- Facilities of All Sizes
- Private and Institutional
- Association Membership and Non-membership
- Certified and Non-Certified Facilities
- Comparable geographic and city size representation
The geographic division used in the prosthetic survey was used again in designing the orthotic services survey. This division is illustrated above (See map). It was developed by modifying the geographic distribution used by the United States National Health Survey to conform to characteristics peculiar to prosthetic services and practices. However, whereas the prosthetics survey sample was planned on the basis of selected controls with the aim of representing the entire population, the orthotic survey selected two or three facilities in each area which had been generally acclaimed by their peers as representative of best practices. The balance of the facilities were selected at random within the large, middle and small size cities in each area.
As the prosthetic services survey sample was a quota sample, facilities were chosen in specific cities to represent pre-defined population sizes. Because of the larger number of facilities engaged in orthotics and the plan adopted, the city population sizes in the orthotics survey are less clearly defined:
City Size in the Prosthetic Survey
Metropolitan Area-----750.000 or more
Small City-----70,000 or less
City Size in the Orthotics Surrey
Large City-----400,000 or more
Medium Sized City-----110-350,000
Small City0-----100,000 or less
The plan called for interviews with approximalely 160 orthotic facilities and from 25-50 drug stores and surgical supply houses. The sample from which the findings were drawn came from 159 facilities: 143 were interviewed during the field trips, 14 during the training course and two were collected while field testing the forms. In addition. 36 short form interviews were collected in drug stores and surgical supply houses.
The facilities who furnished interview data for this survey are located in 81 cities throughout the country. Their distribution by geographic area is shown on the following map. It is clear that approximately half of the sample was drawn from the Mid-Atlantic, Southern, and Midwestern areas while the North Central, Rocky Mountain and Pacific Northwestern areas are the most sparsely represented. Comparison with the census figures shows that this sample distribution of orthotic facilities parallels the national census figures for the population of people. With respect to city size, 41% of the sample was drawn from the larger cities, 33% from the medium sized cities and 26% from the small cities. Complete data was contributed by 90% of the facilities.
Twenty-one of the 159 are classed as institutional facilities in that they are located in institutions such as public and private hospitals, children's hospitals, and rehabilitation centers.
Eighty-seven of the facilities are association members. Eighty-six are certified. Eorty-three are neither certified nor association members.
It was stated above that the facilities interviewed were selected at random in each of the geographic areas: certification, association membership, private or institutional operation and size were also mentioned as criteria, but they were actually left to chance distribution. The problem of defining facility size was such that this factor is discussed below with the other findings describing the sample of facilities. These other factors are: area served, ability to increase production in the event of national emergency, education of personnel, and influence of drug stores.
Facility size may be measured by the total of the services offered or by number of employees. In the field of orthotics neither indicator is clear.
Production figures vary from less than sixty units to more than five thousand units per facility per year. However, not only is it difficult to equate collars and corsets with double long leg braces and Milwaukee braces, but also production methods vary from facilities that fabricate all their components from metal stock and bolts of cloth, to those who fit preassembled braces. Production per man hour is obscured partially by this same factor and partially by the variability in the time required to fit any two patients with the same type of orthotic device. Production totals and rates of production may therefore be considered as an unreliable indicator of shop size.
Private orthotic facilities offer a broad spectrum of services. The most frequent items mentioned, in addition to braces, collars and corsets, are trusses, surgical garments, shoes, hospital supplies and prosthetic devices.
As illustrated by the data in Table 1. approximately 46% of the facilities offer prosthetic services. These data suggest that, relatively speaking, more orthotic facilities offer prosthetic service in less in less densely populated areas than in the larger metropolitan areas. This should, however, be weighted by two additional factors:
- Fewer facilities were interviewed in the smaller cities than were interviewed in the larger cities.
- Many of the facilities interviewed in the smaller cities were institutional shops in which the usual practice was to provide orthotic devices for specific types of patients.
The range of facility sizes has been measured by the number of individuals who spend all or the major portion of their work day in fitting, fabricating or repairing orthotic appliances. These findings are illustrated in Table 2. where the number of Orthotic production personnel in each facility are shown in city size and geographic distributions.
The pattern of these distributions indicates that there are small facilities having two to four orthotic employees: a middle group having between six and seven employees: and large facilities with more than ten employees. However, due to the presence of rehabilitation renters with large orthotic facilities in the small cities, the percentage of facilities of each size is approximately equal in each of the city size groups.
The geographic distribution demonstrates a preponderance of smaller facilities in all areas except the North Central Stales and California. Conversely the heaviest representation of middle-sized facilities occur in these two areas. The larger sized facilities seem most heavily represented in the Southern and Midwestern areas.
The distribution of facilities according to city size and geographic areas is summarized in Table 3. It is apparent that more than 73% of these orthotic facilities report that the majority of their patients reside within 50 miles. Approximately 9% of the small facilities report that most of their patients travel more than 200 miles to obtain orthotic services. This distribution is approximately the reverse of findings in the prosthetics services survey.
The data in Table 3 indicates that the extent of area served is directly related to the population density. Thus, the larger the city, the smaller radius usually served. This is further reinforced by the figures showing more facilities serving large areas in the South, Midwest, Rocky Mountains and Texas-Oklahoma.
To estimate the possible increase in production which could be anticipated in the event of national emergency, facilities were asked what kind of help they would require. 133 of them gave the following information: Table A
Fifty-nine of the 137 facilities responding felt that they could increase production about 25% with their present staff. Another 30 thought they could increase production from 34 to 200% without adding staff.
With staff doubled. 51% of the facilities thought they could increase their production by 51 to 150% and another 16% thought they could increase production by more than 150%. These estimates are, however, largely based on present production methods. A few facilities mentioned that if prefabricated components could be supplied (as done by the Army during World War II) the output could be increased by an incalculable amount.
The orthotist who works closely with the physician in the hospital setting is required to have more training and education than the orthotic technician who fabricates devices according to a pattern. The training and background of the individual who is essentially a business manager is still different. All three types of individuals are required in the average facility.
Facility owners and managers were asked to supply data describing the education of all personnel employed in each facility. One hundred and twenty-six facilities supplied statistical information on the education of 197 owners and managers, and one hundred and twenty-one of them furnished these data for 495 fitters, technicians, corsettieres, etc. The data in Table 4 clearly indicates the majority of individuals who fit and/or fabricate orthotic devices have completed high school. In addition, 20% of the owners and managers and 11% of their professional employees have attended college. However, approximately 10% of this latter group have only a grade school education.
The influence of drug stores, surgical supply houses, department stores, etc., is difficult to assess. Of the 35 such facilities interviewed, less than half had supplied braces (as defined by this survey) for any one of the twenty-four conditions for which information was sought.
A minimum of 24 of the 36 drug stores and surgical supply houses reported fitting devices for twelve of these twenty conditions. It is interesting to observe that Dorsolumbar, Low Back and Post-operative conditions were the only three which might be thought of as requiring orthopedic attention, whereas the other nine—abdominal general, ankle, hernia, knee, maternity, obesity, posture, ptosis, and sacro-iliac conditions—are more general medical problems.
Approximately half of these facilities, however, stated that they provide devices for individuals with kyphosis, lordosis, poliomyelitis, scoliosis and low cervical or high dorsal fractures.
Comments by interviewers indicated that most of these facilities furnish collars and braces only by medical prescription, although some surgical garments are provided on request. It was also reported by many of these facilities that they fitted only routine cases and referred more complicated fittings to a local orthotic facility.
For the Purposes of This Survey—
Surgical Garments are defined as all devices which do not contain a rigid frame or support including both vertical and horizontal metal bars.
Braces are defined as any device which contains a rigid frame or support including both vertical and horizontal metal bars.
B. Patient Management Systems
Patients who are furnished with orthotic devices are usually in the process of a multifaceted course of treatment under the supervision of one or more physicians. Many of the procedures entail a clinic team approach.
The survey of Prosthetic Services pointed out that the prosthetic research and education program developed and disseminated a specified clinic team approach. This was based on the theory that various experts engaged in the rehabilitation of the amputee could gel maximal results by working together in the formal clink setting. The report noted that, as the prosthetic clinic team operations became routomozed, there was a tendency to dispense with formal clinic meetings when possible. A loosely defined clinic team operation was anticipated in orthotics as the physician-orthotisl relationship has been one of long standing.
Inasmuch as prosthetics and orthotics are similar with respect to the procedures involved in prescribing, fitting, final application and medical follow-up of patients and devices, it seemed desirable to determine the ways in which these steps are actually conducted in the orthotic field. It was obvious that patients whose treatment was being underwritten by institutional sources undergo more standardized treatment procedures than do privately financed patients.
Accordingly, data was collected separately for both of these groups. This information was collected for each of four major groups of orthotic devices: collars and corsets; spinal braces; lower extremity devices; and upper extremity devices.
One hundred and fifty orthotic facilities described the way in which the prescriptions they received had been written. These data are summarized in Table 6. As the physician is the key member of any prescription team, the number of physicians involved in the prescription process and the number of facilities reporting each category of brace are equal. However, as not every facility furnishes collars, corsets, spinal braces, lower extremity braces and upper extremity braces, the figures are different in each category. It is also true that not all facilities which performed a given service, provide it to both private and institutional patients.
It is clear that several disciplines are being consulted in the prescription of many of the orthotic devices prescribed today. It was also found that in many instances the patient is seen by the various members of the team on a serial basis, i.e., one person at a time, rather than in the formal clinic meeting. More formalized clinic meetings are reported approximately twice as frequently for institutional patients than for private patients (Table 6 ).
The group consultation or clinic meeting referred to in Table 6 does not imply that several persons are present at prescription. It frequently refers to a situation where a physician is in telephone communication with the ortho-list. The verbal prescription arrived at in this manner is later documented by a written note. The comments of the interview subjects pointed out that orthotic prescriptions are rarely written in full detail as a medical prescription, i.e.. a brace name may be used to imply all of the detail which many years of mutual experience between physician and orthotist have made clear.
Although fewer facilities supply upper extremity orthoses than other types of devices, the percentage of facilities reporting group or multiple participation in prescription of these devices (94.5%) shows the highest frequency in Table 6. These data also reveal that multi-disciplinary groups are most frequently consulted in the prescription of lower extremity orthoses.
Analyzing these data for geographic variance revealed that multi-disciplinary participation in prescription of devices for institutionally sponsored patients is most frequent in the Southern States (22-24 of 25 facilities reporting) and in Texas-Oklahoma (12-14 of 16 facilities reporting). When the figures relating only to braces are consulted, the New England, Rocky Mountain and California areas demonstrate participation in 50-67% of their prescriptions. The least amount of interdisciplinary consultation was noted in the North Central, Midwestern and Mid-Atlantic areas. In these areas less than 50% of the facilities reported taking part in prescription of spinal or upper extremity braces, although the majority of Midwestern and Mid-Atlantic States facilities reported that they were called on to participate in the prescription of lower extremity braces.
The fitting of a rough, unfinished device on the patient before final modification is here referred to as a trial fitting. This is a procedure in which the ortholist is always the most active participant, although a physician, therapist or nurse may also participate. Trial fittings are most frequently used for upper extremity devices and least frequently for collars and corsets, Other clinic members most frequently participated in the trial fitting of this latter group.
When the geographic distribution of these findings was examined it was found that this procedure is less frequently employed in the eastern half of the country and more frequently used in the western half, particularly with respect to braces.
Checkout of an orthosis is the evaluation of the appliance and its lit. Final application of an orthosis is. as the term suggests, the last fitting of the appliance before its wear or use by the patient. Checkout and final application are procedural steps which are thought of as reasonably close together in point of time.
The term "checkout" came from the prosthetic research and education programs where it had become an integral part of the team approach to fitting amputees. In this sense, it is an evaluation of the man-machine complex to determine the adequacy of function.
Preliminary investigation regarding checkout and final application in orthotics revealed that there were many instances in which devices were finally applied in the absence of a physician in the orthotic facility, at a hospital or in the patient's home. In these instances, the patient is seen by the physician as much as two weeks later as part of the ongoing treatment process or for routine follow-up.
Almost all of the facilities reported that physicians conduct "checkout" with the aid of few other consultants. Conversely, orthotists are usually the only individuals present at final application of orthotic devices.
The number of facilities which reported the same individuals as participating in both checkout and final application refer to situations where both physicians and orthotists. and occasionally others, participate. However, the small number of facilities reporting group participation at final application clearly indicates that checkout of orthotic devices occurs subsequent to final application.
Further analysis, according to geographic distribution, reveals that group participation is seldom resorted to in the final application and checkout of corsets and collars except for the checkout of institutional cases in the eastern third of the country. With respect to checkout of spinal braces. 6 of the 8 North Central and 10 of 19 of the Mid-Atlantic facilities reported group participation for institutional cases as did approximately one-third of the New England, Southern. Midwestern, Texas-Oklahoma and California facilities. A somewhat similar pattern was noted for lower extremity orthotics, except that fewer North Central and more of the California facilities reported group participation. One-third of the facilities in the eastern half of the country also reported group participation in checkout for private patients as opposed to 15% of the western facilities.
Facilities that furnish upper extremity orthoses reported group participation in checkout with the highest relative frequency—50/115 for institutional cases and 24/121 for private patients. Approximately half of the New England. Mid-Atlantic, Midwestern, Texas-Oklahoma and California facilities reported this procedure, as did a third of the Southern facilities. Group participation was noted on a more scattered basis for private upper-extremity cases. This was observed primarily in large rehabilitation facilities.
Facilities were requested to furnish percentage estimates of the frequencies with which they required prescriptions for the replacement of orthotic devices for each of the eight categories defined above. The variation of the percentages estimated by the facilities was rather large. Typical answers include the following percentage figures: 1, 5, 50, 85, 90, 95 and 100. Although the figures reported by the facilities in a given area or city size group usually clustered about one extreme or the other, there were always a number of estimates of all sizes. To minimize the bias of these skewed variations while still considering a measure of the entire sample of responses, these data were reduced to arithmetic means.* The means of the estimated percents for each of the eight categories are presented in Table 7.
The figures in Table 7 indicate that prescriptions are required for the replacement of almost all orthotic devices paid for by institutional facilities. The major exception occurs in the collar and corset category. Prescription of replacement devices for which payment is made seems markedly less frequent.
Unsolicited comments by the respondents indicated that replacement of devices for young children, geriatric, and other patients who were undergoing growth, or continual change, was always done by prescription. Conversely, replacements for stabilized adults were usually provided without prescription. It was further noted that the first type of replacement was usually occasioned by change in body dimensions or neuro-muscular conditions, while the second type of replacement was necessitated by wear. Finally, the first type of replacement was most frequently institutionally sponsored, while the second type, of replacement was more frequently privately financed.
Analysis of this material, according to city size, revealed no difference between the entire sample and any of the three city size sub-samples. The geographic distribution of these findings showed essentially the same pattern illustrated in Table 7 except that the average figures for the replacement of orthotic devices for institutionally financed patients was 100% in the Midwestern, North Central, Texas-Oklahoma and Pacific Northwestern areas. The pattern in New England and Mid-Atlantic states was correspondingly lower.
C. Cervical Orthotics
The findings of the Survey of Cervical Orthotics are based on a series of questions devised to seek descriptions of the braces which each facility furnished to patients with each of the major cervical bracing conditions. A description of brace variations follows the presentation of the findings enumerating the brace types prescribed and furnished to patients with each of the cervical conditions investigated. The geographic distribution of these variations is then given and a summary of production methods.
Consideration of medical syndromes in terms of resultant bracing requirements, as described above (pages 60-63) led to the identification of five major groups of bracing problems which relate to the cervical spine.
- Cervical Disc Rupture, Lesion or Reduction of the Foramina, Postoperative Fixation or Dislocation in the Low Cervical area.
- Torticollis (Wry Neck).
- Cervical Spinal Strain or Injury or Whiplash.
- Congenital Weakness, Muscular Dystrophy, etc.
- . Fractures of the Low Cervical Region.
The first four groups are discussed in this section and the problems of bracing cervical fractures will be presented in the section on spinal bracing.
Any or all of these medical conditions may be, in part, treated by the application of a cervical brace or collar. Examination of the medical literature and catalogues of manufacturers and wholesalers of surgical and orthotic supplies reveals a considerable armamentarium of devices suitable for bracing cervical conditions. Following the classification procedure detailed in pages 57-58 above, these devices were divided into seven categories based on the structural considerations and anticipated frequency of applications. Typical examples of the six most frequently anticipated brace types are illustrated in Plate I..
The first four categories of devices are collars. For simplicity and convenience in this survey, they are referred to as:
Non Height Adjustable Collars (Plate I., Illustration J)
Height Adjustable Collars (Plate I., Illustration K)
Molded Collars (Plate I., Illustration P)
Open Wire Frame Collars (Plate I., Illustration L)
Illustrations J and K clearly demonstrate that these devices may be prefabricated while Illustration P clearly indicates that the device must be molded to a cast of the patient.
The remaining collar is intermediate in design and lends itself to a variety of fabrication procedures. The structural features of the open wire frame collar are intermediate between collars and braces. The two rings of total contact at the head and trunk (of some varieties) resemble collars while the supporting posts are more characteristic of cervical braces.
The last two categories of devices are braces referred to as:
Two-Poster Braces (Plate I. Illustration M)
Four-Poster Braces (Plate I. Illustration N)
These devices have rigid metal posts that are braced against the head and trunk so that these body members will be stabilized in the desired position. The two-poster variety usually employs larger head and trunk plates to offset the reduced number of vertical elements. Two-poster braces may have laterally positioned uprights rather than anterior and posterior ones, ( as illustrated ). Cervical braces also include three and five post varieties but the anticipated frequenvy of use suggested that these be left to the "Other Deviced" category.
The last category of devices has been referred to as "Other Devices." This is a catch-all category to include all other major variations of cervical orthotic devices.
There are 151 orthotic facilities which furnished information enumerating the devices fitted to patients for each of the four cervical bracing conditions. One hundred and forty-five of them also described these braces in so far as they differed from the Illustrations in Plate I..
- One hundred and thirty-nine of the 151 facilities which reported fitting ten or more patients with cervical orthoses, during the preceding twelve months, provided them to patients with cervical disc rupture, lesion or reduction of the foramina, post-operative fixation or dislocation in the low cervical area. Devices of all of the major types were provided for patients with this type of condition (Table 8).
- Thirty-four of the 151 facilities provided them to patients with torticollis. In most of these instances comparatively few prescriptions were received for this condition although the prescriptions called for all of the major brace types.
- All of the 1-15 facilities which provided detailed information describing cervical devices had furnished collars or braces for patients with cervical strain, injury or whiplash. Although all six brace types illustrated in Plate I are described for this condition, no unusual or other variations are used.
- Only 44 of the 151 facilities reported fitting cervical devices to patients with congenital weakness, muscular dystrophy, or related problems. Despite the comparatively modest number of prescriptions received for this condition, their variation was extensive.
Examination of Table 8. points out that the full spectrum of the preselected brace types are being applied for each and every one of cervical conditions. The "other" category is reported for only three of the four conditions and is clearly the smallest group reported. Four-poster braces are reported by more facilities than any other type for three of the four conditions: disc rupture (87%); torticollis (41%); congenital weakness (31%). Height adjustable collars are reported by the largest number of facilities for the remaining condition, cervical strain (77%). The non-height adjustable collar types were reported by the second largest number of facilities for three conditions: cervical strain (52%); congenital weakness (32%); and torticollis (38%).
Whereas the preceding section discussed the overall frequency of application of brace type by bracing condition, the present section analyzes the geographic variation of brace types prescribed and furnished for each of the four bracing conditions.
1) Patients with cervical disc rupture, lesion or reduction of the foramina, post-operative fixation, or dislocation of the low cervical region were most frequently fitted with four-poster braces. This is also the only device which is used by the majority of facilities in every geographic area of the country. The only sizeable exception to this finding is the observation that five of the Southern facilities fitted non-height adjustable collars (type J) to an average of 91% of their patients with these conditions while twenty-one fitted a mean average of 76.6% with four-poster braces.
Five of the forty-nine facilities located in the Western half of the country provided height adjustable (K) or non-height adjustable (J) collars to patients with these conditions. Nine of the sixteen providing non-height adjustable and eleven of the 28 providing height adjustable collars were located in the Middle Atlantic and Southern States.
None of the facilities in these two areas were called upon to provide cushioned wire frame collars (L) for these conditions. Very few of these (type L) devices are being prescribed for cervical disc rupture or related cervical problems. In the New England area the open wire frame designs are being furnished by a number of facilities where they seem to be replacing the solid plastic collars (J & K).
A small number of prescriptions call for the molded leather collars. One-fourth of the New England and Mid-Atlantic States facilities and approximately two-thirds of the California facilities provided them.
2) Patients with torticollis are most frequently provided with variations of the four-poster brace. These devices are used on a nation-wide basis. The next most broadly utilized device for this condition, non-height adjustable collars, were reported by none of the facilities west of Kansas and Nebraska.
Although 14 of the 27 facilities in the Midwest that fit cervical devices provide them to patients with torticollis, none of the facilities in the Pacific Northwest had been requested to provide them during the twelve month period.
3) Collars are obviously the most broadly prescribed group of devices for cervical spinal strain, injury or whiplash.
The height adjustable collars are used more frequently in the Western half of the country and are the second most frequent choice in the Eastern states. The non-height adjustable collars are the most frequent prescription in the Eastern states and the second most frequent choice in the Western states.
Open wire cushioned collars are reported by more facilities for these conditions than for all of the other three bracing problems combined. Molded collars and two-poster braces were reported by two facilities in different areas of the country.
4) Medical practice in the treatment of conditions such as congenital weakness, muscular dystrophy, etc., in the larger and middle size cities rarely includes application of cervical orthoses (as defined in this survey). In these instances, particularly in large cities, the rigid two and four-poster braces are usually prescribed. As the city size becomes smaller there is a definite shift towards the use of collars of all types.
Examination of the geographic distribution of facilities furnishing devices for this class of problems reveals that approximately 30% of them are located in the Southern states. None of the facilities interviewed in the Pacific Northwest and only one in New England reported being called on to furnish cervical devices for these conditions.
Other types of devices were described by three facilities. One used only a posterior upright attached by straps to the (best and forehead. A second used only an occipital support similar to that shown in Illustration l-M without the chin piece. A third facility reported they were occasionally called on to provide a chin support, cantilevered from a posterior upright attached to a wheel chair.
Most of the cervical collars prescribed in the past year were furnished as centrally manufactured units. Eighty-nine percent of the facilities that furnished height adjustable collars to patients with cervical strain, etc., and 93% who furnished them for cervical disc lesions reported using prefabricated devices. A somewhat smaller percentage, 62 and 70% respectively, reported using prefabricated collars of the non-height adjustable variety. For the open wire cushioned collars 83% reported using prefabricated collars for cervical disc lesions, etc. All of the molded collars were fabricated at the facilities.
It was previously pointed out that two and four-poster braces differ only in the number of vertical structural elements used to stabilize the position of the head. The other, similar, components used in these braces are:
Mandibular and Occipital Supporting Plates
Straps used to attach these Plates
Breast and Back Plates, or Extensions of Spinal Braces
Over-the-Shoulder and Axilla or Thoracic Straps
A variety of these components are provided by central manufacturers as parts, kits and as prefabricated units. The use of facility fabricated and prefabricated devices are strikingly different for the two- and the four-poster braces which arc prescribed and fitted to patients with cervical disc rupture. lesion or reduction of the foramina, post-operative fixation or dislocation in the low cervical area. Of 55 facilities which described the two-poster braces they had filled for cervical disc lesion during the preceding twelve months, 38 reported fitting only devices fabricated at their facility, 15 lilted only prefabricated units and 2 furnished both. Thirty-eight of the 107 facilities describing their four-poster braces had fabricated them entirely at the facility while 74 had fitted only prefabricated units and 8 others had fitted both.
Differing trends in the use of prefabricated and facility fabricated two-and four-poster braces in different geographic areas are apparent:
- In the Mid-Atlantic and Southern areas of the country the practice of prescribing and fitting two-poster braces is equally divided between prefabricated and facility fabricated units. Facility fabricated four-poster braces are reported by only 16% of the facilities.
- a. In the Midwest 70% of the facilities reporting made their own two-poster braces while only 28% made their own four-poster units.
- In Texas and California two-poster braces were facility fabricated by 90% of those reporting while only 35% reported fabricating their four-poster braces.
- In the New England, North Central, Rocky Mountain, and the Pacific Northwest areas approximately an equal number of facilities reported the use of facility fabricated and prefabricated four-poster braces. A similar pattern was reported for two-poster braces in New England. In the other three areas so few facilities reported using two-poster braces that no pattern may be inferred.
The majority of facilities use "cupped" chin pieces for two-poster braces and open chin patterns for four-poster types. Although either design may be used interchangeably, few exceptions were found.
One modification of interest is the use of laterally placed supports by one facility.
The straps used to attach the mandibular and occipital plates were made of leather, or webbing in 97% of the cases. The four facilities using metal straps included three which used them for two-poster and one for four-poster braces.
Seventy-five percent of the facilities fitting two-poster and 29% of those making four-poster braces reporied that they used yoke shaped chest and back plates similar to those shown in Illustration I, M. Dumbell or butterfly shaped plates (Illustration I, N) were reported by 9% of those furnishing two-poster and 67% of those fitting four-poster braces. Custom fabricated designs reported by facilities scattered throughout the country included full yokes, horizontal, plates, double or paired extensions, spinal brace extensions and absence of extensions.
The straps which attach these braces to the body and maintain the relative position of the chest and back components in a stable manner are usually made of leather and/or webbing. These materials were reported by 82% of the facilities describing their two-poster and 96% of those describing their four-poster braces.
Fitting metal over-the-shoulder straps is always a highly individualized problem. In fitting cervical braces to patients with disc lesion or related problems, facilities may use these metal straps for either 2-poster braces or 4-poster designs, but not for both. Half of these facilities are located in California, three others are located in the Midwest and one in the North Central states. The most striking difference is that 82% of the facilities provide two-poster braces which cannot be modified for height or position without disassembling the brace into its component parts. This practice was reported by only one of the 121 facilities in fitting four-poster braces.
Twelve facilities reported a variety of four additional brace types which they fitted to patients with these cervical problems. These facilities are distributed throughout the New England, Mid-Atlantic, Southern, Midwestern, North Central and California areas, with 7 of the 12 located in middle sized cities.
The other brace patterns reported included: a) Six variations of three-poster braces
- Similar to Illustration I, M but a single anterior post and two posts posteriorly
- Taylor brace with cervical extension, similar to Illustration I,M. Metal over-the-shoulder straps are continuations of the Taylor uprights. The two dorsals bars originate from the Taylor dorsal cross-piece. A single post with a swivel is attached to the chin and breast plate.
- Three molded metal pieces for the chin and angles of the mandible are soldered to a steel band which is supported by two lateral and one anterior post and welded to a horizontal chest plate and metal over the shoulder straps. The brace i- padded and attached to the patient by a thoracic strap and an occipital pad and strap.
- A molded chin piece is welded or brazed to two metal straps which are contoured to lit along the mandible. A similarly contoured horseshoe shaped piece is fitted to the chest extending from just below the sternal notch anteriorly, continuing over the shoulder to just above the scapulae. These two components are stabilized by a fixed length anterior post and two fixed length posts which go from the center shoulder line to the mandibular area. A leather strap holds the metal mandibular plates in position posteriorly.
- Similar to Illustration I, N but only one post is used dorsally.
b) Two Jury Mast variations were reported by four facilities.
1.-3. A cupped chin piece is hinged to the Occipital plate. This structure is cantilevered from a single posterior post which arises from the cross-piece of a Taylor brace. The attachment at the level of the occiput does not permit horizontal rotation in these applications.
4. The posterior post is attached to the body with a thoracic band and to the head with metal extensions continuing to the temple which are anchored anteriorly with a forehead strap. A second strap supports the head from the temples by passing from temple under the chin, with a chin cup, and up to the other temple.
c) One facility reported fitting a "Boldray Brace" for these conditions. This brace stabilizes the head with zygoma bars and a forehead strap attached to a large occipital pad. This structure is supported by a single posterior post arising from the dorsal cross-piece of a Taylor brace.
d) One other facility reported that they participated in fitting skeletal fixation halos for these conditions.
Five of the 34 facilities providing cervical devices to patients with torticollis fitted only "other" types of braces.
- Starting with a four-poster brace, as Illustrated in Plate I., N, a fifth post is added which applies lateral pressure against the mandible, at the edge of the chin Diece.
- A single posterior post, arising from the crosspiece of a Taylor brace, is riveted to an occipital plate. The position of the head is maintained by leather straps passing from the occipital piece to a cupped chin piece.
- A single posterior bar, arising from two crosspieces of a Taylor type brace, has an adjustment for angulation from the vertical at about C7. A leather covered metal collar which is open in front is attached. This collar exerts pressure low under the mandible on the concave side and high on the head on the convex side.
- A single posterior bar, arises from a dorsal band of a spinal brace. Angulation from the verticle is achieved by adjustment of a wing-nut and over a slotted band which is located at about mid-scapular level. The posterior post cantilevers the head with a hinged chin and occipital ring.
- A cloth chest corset with built-in side bars that extend to the head, applies pressure laterally to a chin piece on the concave side and against the side of the head on the convex side.
D. Trunk and Spinal Orthotics
Although orthotic appliances are applied to the trunk for a large variety of medical reasons, the essential purpose of applying an exoskeletal device can only be to position and/or maintain trunk alignment. Malalignment may be due to disease, congenital defect or trauma. In any event, the problems may be reduced to: correction of exaggerated curves in the sagittal plane (scoliosis) or in the frontal plane (thoracic kyphosis or lumbar lordosis) ; fixation of fractures and post-operative conditions; or alleviation of discomfort of the lumbrosacral spine.
Following the procedure described above (pages 60-63) seven bracing problems were defined for this portion of the survey:
- Kyphosis Dorsal Spine
- Lordosis Lumbar Spine
- Scoliotic Curvature (regardless of etiology)
- Low Back Pain, with or without Disc Complications 3. Fracture or Post-operative Condition:
- Low Cervical and High Dorsal Spine
- Mid-low Dorsal and Upper Lumbar Spine
- Lower Lumbar or Sacral Region
Having established that this survey would limit its inquiry to exoskeletal braces and corsets, these two device classes were then defined as:
- BRACES. All devices which contain a rigid frame of support including both vertical and horizontal metal bars.
- CORSETS. All devices which may or may not contain rigid vertical or horizontal metal bars or supports, but not both.
Seven designs were selected as basic examples of the spinal braces now in general use. Illustrations of these patterns were synthesized from drawings submitted by orthotists throughout the country and by previously published illustrations. These basic brace types may be defined as:
Q) A lumbar and lower thoracic brace composed of a metal frame encircling the dorsal half of the body, held in position by a corset or strapped to an apron or abdominal pad. The metal frame includes (flat, canted or curved ) paravertebral and lateral vertical bars attached to (straight, angular or butterfly shaped) pelvic and thoracic bands (Plate 2 ).
R) A lumbar and sacral brace composed of a rectangular frame strapped to an apron or abdominal pad. The frame consists of essentially vertical, but diverging bars and two parallel horizontal bands which form a solid frame with or without projecting members (Plate 3 ).
S) A hollow-back extension type brace which applies pressure to the lumbro-sacral area by lever action adjusted by straps which pass between the two lever arms on either side of the body (Plate 4 ). The brace is stabilized on the body by a corset, pad or apron.
T) A full back brace with a pair of paravertebral bars extending from a (straight, angular or butterfly shaped) pelvic band, at the level of the coccyx or lower sacrum, to the upper third of the scapula or higher. In many variations the upper portion of the vertical bars turn laterally along the superior border of the scapulae. This brace also has a dorsal crosspiece which joins the two uprights at a position between T-10 and the lower third of the scapulae. The brace is attached by a corset, pad or apron and by two shoulder straps which are attached to the superior terminus of the uprights and the dorsal crosspiece (Plate 5).
U) A spinal hyperextension brace consisting of a metal frame which rests against the anterior half of the body, a back pad which holds the brace against the body with varying degrees of pressure: a sternal and a pubic pad which transmit counter pressure anteriorly (Plate 6).
W) A Milwaukee type scoliosis brace (Plate 7).
Z) A molded body corset (Table 8), this may be made of a variety of materials such as plastic laminate, Celastic or glass cloth and resin.
The full array of corsets are lumped under the "Other" category.
An attempt to analyze the frequency with which a spinal appliance was used for a given condition presented a complex problem. Most of the facilities reported one or another of the seven appliance illustrations as being similar to the appliance they fitted, but described their brace as being a variation of the illustration. Some of these variations appear to be very real, while others fall in the realm of semantic differences.
All of these factors have, and continue today, to cloud the picture of spinal and trunk orthotics. To clarify this matter, the data has been analyzed within two parameters: 1) The brace illustration selected by the respondent for a given condition: and 2) The brace type fitted by each facility to 50% or more of its patients with a given condition. To be included in the analysis, a facility must have filled ten or more patients for the condition being studied. (The exception to this was Condition D. scoliosis. )
The tables, therefore, may be interpreted as indicating the basic "appliance of choice" for each condition.
Condition A: Kyphosis or Anterior Curvature of the Dorsal Spine (Table 8 ).
Of 141 facilities reporting that they fitted the same appliance to 50% or more of their patients with this condition, ninety-one (65%) selected illustration T, (Plate 5), as resembling the appliance fitted: thirteen (9%) selected illustration Q, (Plate 2); seventeen (12%) selected illustration U (Plate 6); while fifteen (ll%) reported that they fitted corsets for this condition.
Further analysis of these data bv city size does not show significant variation in the figures reported for the total sample. Variations by area of the country, however, do appear. These variations are in the reported application of devices Q, U and corsets. There are not the variations for appliance T, for in each area 50% to 86% of the facilities reporting, selected it as the appliance of choice.
In the New England area and the Rocky Mountain states, appliance U is seldom fitted for Condition A, while in the South it may be expected to be fitted more often than appliance Q or corsets for Condition A.
In the Midwest, the North Central, the Rocky Mountains and the Pacific Northwest, appliance Q is seldom fitted for Condition A. In those areas in which it is fitted for Condition A, it is routinely modified.
Corsets are seldom used in the South, Midwest, California or the Pacific Northwest, while in Texas and Oklahoma and the Rocky Mountain areas they may be expected to be fitted more often than either appliance Q or U for Kyphotic curvature.
Condition B; Lordosis or Anterior Curvature of the Lumbar Spine (Table 9 ).
Of 137 facilities reporting that they fitted the same appliance to 50% or more of their patients with lordosis, forty-nine (36%) selected illustration S (Plate 4) as resembling the appliance fitted; forty-one (30%) selected illustration Q (Plate 2); nineteen (14%) selected illustration T (Plate 5): while twenty-eight (20%) reported that they fitted corsets or other appliances for this condition.
Analysis by city size indicates that corsets are used more routinely for this condition in small cities than in large or middle size cities. In the small cities they are about as equally used as are appliances resembling illustrations S and Q. In middle size cities there seems to be a decided preference for the use of appliances resembling illustration S and less use of corsets and other appliances. In large cities the overall usage of the appliances mentioned is quite similar, in proportion, to the total observed with the exception of the "Other" category. On the whole the responses indicated that an equal frequency of appliances resembling illustrations S and Q should be anticipated regardless of city size.
Analysis by geographic area shows a decided preference for appliances resembling illustration S in the South and in Texas-Oklahoma while some preference in that direction appears in the Midwest and North Central areas. The reverse is true in the Rocky Mountain area where the preference is for appliances resembling illustration Q. This same preference, to a lesser degree, appears in the New England, Mid-Atlantic and Pacific Northwest areas.
The Mid-Atlantic area seems to show the most diverse practice in dealing with patients of this type. A seeming preference for corsets as an alternative to appliances resembling illustration Q is seen in the Texas-Oklahoma area, but the the opposite trend is seen in California.
Condition C: Low Back Pain or Strain, with or without Disc Complications and Exclusive of Fractures (Table 10).
Of 142 facilities reporting that they fitted the same appliance to 50% or more of their patients with this condition, one hundred and one (71%) stated that they were called upon to fit corsets, while thirty-six (25%) fitted appliances similar to illustration Q and five (5%) fitted other appliances.
Analysis by city size indicates a slight preference for appliances resembling illustration Q in small cities while a slight preference for corsets is evident in the large cities.
Geographic differences are also slight though a preference for using corsets in treating this condition is seen in the South, the North Central area and the Pacific Northwest, while a preference for using appliances similar to that in illustration Q appears in the Mid-Atlantic area, the Midwest and Texas-Oklahoma, where the most diverse practice appears.
Condition D: Scoliotic Spinal Curves (Regardless of Etiology) (Table 11 ).
Of 125 facilities reporting that they fitted the same appliance to 50% or more of their patients With Scoliotic Spinal Curves (with no minimum number of linings during the last twelve months); thirty-nine (31%) selected illustration W (Plate 7) as resembling the appliance fitted: thirty-two (26%) selected illustration Q (Plate 3);twenty-one (17%) selected illustration Z (Plate 8: thirteen (10%) selected illustration T (Plate 5); while eleven (9%) indicated that they used corsets and nine (7%) selected other illustrations or described appliances that were not illustrated.
Further analysis by City Size and Geographic Area indicates that there is no simple approach to the treatment of scoliotic spinal curves with bracing that is generally accepted.
Of the seven conditions studied in this survey, appliances similar to illustration W were reported only for scoliosis, with the single exception of one facility in the North Central area which fits a similar appliance to patients with Kyphotic curvature.
Devices similar to illustration Q were described as generally higher than illustrated with added 'slings', corsets and/or unilateral crutch extensions. All of the facilities reporting the fitting of devices similar to illustrations Q and T for scoliotic spinal curves mentioned some or all of the above modification.
Facilities reporting the application of devices similar to illustration Z utilized numerous materials in fabrication ranging from polyester, resins, to plaster, leather, Celastic and celluloid.
Condition E: Fractures of the Low Cervical and High Dorsal Spine. (Table 12).
Of 108 facilities reporting that they fitted the same appliance to 50% or more of their patients with Fractures of the Low Cervical and High Dorsal Spine or patients who had undergone surgery in these areas, forty-seven (53%) selected illustration T (Plate 5 ) as resembling the appliance fitted: sixteen (15%) selected illustration N (Plate I.), while thirty-five (32%) indicated that other types of appliances were prescribed for this condition.
The smaller number of facilities reporting and the relatively high number which reported appliances that were not illustrated seems to indicate that the treatment of this condition through bracing is not well defined. It is evident, however that the majority of patients with this condition are fitted with modifications of the appliance illustrated in Plate V. There is further evidence that the modifications made must usually result in an appliance which is a combination of illustrations T and M or N. This appliance is used a great deal in the South.
Patients fitted with appliances similar to illustration \ most usually receive a device which varies little from the one shown in Fig. 1. This appliance seems to be most frequently fitted in the Midwest and North Central areas.
The "Other" category is made up of a relatively equal frequency of corsets with cervical extensions, and appliances similar to illustrations Q. U, M. P and Z. The highest relative frequency of "Other'" appliances is reported in the Mid-Atlantic area. Here appliances similar to illustration Q were reported by four facilities. There was no pattern to the remaining reports from that area. In the Midwest four facilities reported fitting devices similar to illustration U, Reports from the remaining areas indicate varying local practice.
Condition F: Fractures of the Mid-, Low Dorsal or Lumbar Spine (Table 13 ).
Of the 134 facilities reporting that they fitted the same appliance to 50% or more of their patients with fractures of the mid-dorsal low dorsal or lumbar spine or patients who had undergone surgery in these areas, fifty-five (41%) selected illustration T (Plate V) as resembling the appliance lined; forty-two (13%) selected illustration Q (Plate 2); twenty-two (17%) selected illustration U ( Plate 4 ) while twelve (9%) indicated that they were called upon to fit corsets and three (2%) indicated that some other appliance was used in the treatment of this condition.
Analysis by city size indicates no preference between appliances similar to illustration T or Q in large cities and a relatively lesser application of braces of the type depicted in illustration U. In middle size cities some preference for appliances of the illustration 1 type was shown, but preference for illustration U and Q type appliances was almost equal. The pattern for preference in small cities was close to that of the total.
Analysis by geographic area shows that for the treatment of this condition appliances of the type shown in illustration Q are most frequently prescribed in the Mid-Atlantic area and the South. Appliances of the type shown in illustration T are most frequently prescribed in the Midwest and Pacific Northwest. This latter design is an important part of the armamentarium for treatment of this condition in other parts of the country. California and New England demonstrated equal preferences for appliances of the type illustrated in Q and T. Braces similar to illustration U are most frequently used in the South and Midwest. Although U type appliances are used in the Western two-thirds of the country, no indication was found that this design is used in New England or the Mid-Atlantic areas.
No distinction was made in the questionnaire between compression type fracture and other fractures of the dorsal and lumbar spine. If such a distinction had been made it is possible that a more definite pattern of bracing might have attained.
Condition G: Fractures of the Lower Lumbar or Sacral Region (Table 14).
Of the 146 facilities; reporting that they filled the same appliance to 50% or more of their patients with fractures of the lower lumbar or sacral region or patients who had undergone surgery in these areas, seventy-nine (54%) selected illustration Q (Plate 2 ) as resembling the appliance fitted: thirty-eight (26%) indicated that they were called Upon to fit corsets: while seventeen (12%) selected illustration T (Plate 5) and twelve (8%) described some other appliance.
In the large cities the practice seems to be to use corsets more than appliances similar to that illustrated in Plate 2. Also, relatively more appliances other than those indicated are used in treating this condition. In middle size cities a higher number of the appliances similar to that, shown in illustration Q arc used and a lesser number of corsets. The pattern for preference in small cities was close to that of the total.
A pronounced preference for appliances similar to that shown in illustration Q is seen in every geographic area except the Rocky Mountains. In that area corsets seem to be the preferred type of treatment.
The procedures followed in fabricating and fitting spinal and trunk appliances fell into three distinct categories:
- Facilities which make all of the parts from which devices are fabricated.
- Facilities which use prefabricated parts in the making of devices,
- Facilities which fit prefabricated devices.
These categories must be further qualified. Facilities which slate that they make all of the parts from which devices are fabricated mean one of two things: they fabricate each appliance for a patient from raw materials or they fabricate each appliance for a patient from stock parts which they have designed and keep available in stock. This latter form of "making all of the parts" overlaps category where the facility may use its stock parts or purchase prefabricated parts from a source of central supply.
As can be seen in Table 15, the majority of all spinal and trunk appliances are fabricated from parts made in the facilities reporting. The use of prefabricated braces is limited except in the fitting of appliances similar to that shown in illustration U (Plate 6).
Analysis by city size dues not show a pattern significanty different from the national total. Analysis by geographic area indicates that in the South and Midwest there seems to be diversity in fabricating procedures which is not seen in the other geographic areas. This diversity is not seen in all appliances and did not prove to be significant.
Of great concern to the Orthotists of this country is the terminology used in referring to the appliances which they are called upon to fit. In order to find out the names applied to a number of spinal appliances. Spinal Orthotics Questionnaire A was circulated in November, 1961. The responses to this questionnaire are summarized in Table 16 and Table 17.
The number of names applied to the braces shown in Questionnaire A may be unrealistically high due to the fact that only one view of each brace was shown; moreover, the illustrations are schematic representation of metal structures rather than complete or finished appliances. Many of the respondents pointed out that their answers were based on what they felt was being represented in this questionnaire rather than on the similar devices that are actually fitted in their facilities.
Table 16 illustrates the number of different names given to each of the eighteen appliances listed in the questionnaire. The range of names given, varies from eight for illustration R to forty-one for illustration 0. The confusion in terminology, however, is more apparent from Table 17 where thirty names of spinal appliances are listed and their use with each of the eighteen illustrations is noted. Of the thirty names half were used in identifying five or more illustrations.
Four of the eighteen illustrations are related to illustrations used in the Interview Questionnaire. These are; Brace Q. (Plate 2) which is essentially the same as illustration A. (Plate IX) Brace S, (Plate IV) which is essentially the same as illustration K (Plate 9): Brace T, (Plate V) which is essentially the same as illustration R (Plate 9); and Brace U (Plate 6) which is essentially the same as illustration E. (Plate 9).
Of the eighteen illustrations in Questionnaire A, (Plate 9), six may be identified by name on the basis of majority identification by the respondents. These are:
- Illustration R—Taylor Spinal Brace. Eight different names were given to this illustration. 98.5% of those responding referred to it as a Taylor Spinal Brace of some variant thereof.
- Illustration B—Taylor Crutch Spinal Brace. Twenty-one different names were given to this illustration. 70.5% of the respondents gave a variety of the name Crutch to this appliance while 88.6% termed it a variety of the Taylor Spinal Brace.
- Illustration J—Taylor Knight Spinal Brace. Twenty-eight different name- were given to the illustration of this appliance. 82.9% of those responding indicated that it was a variety of Taylor Spinal Brace while 55.3% indicated that it was a variety of Knight Spinal Brace.
- Illustration A—Knight Chairback Spinal Brace. Though thirty-four different names were applied to this illustration, 45.8% of the respondents gave the name Chairback or some variant thereof and 34.6% gave the name Knight or some variant thereof.
- Illustration K—Williams Flexion Spinal Brace. Twenty-one different names were applied to this illustration. 97.2% referred to it as a Williams Brace or some variant thereof, while 22.5% included the term Flexion in their name of this appliance.
- Illustration P—Steindler Spinal Brace. Twenty-two different names were given to the illustration of this appliance, however, 59.7% of those responding named it a Steindler Spinal Brace.
E. Lower Extremity Orthotics
Orthoses are now used in the treatment of lower extremity dysfunctions of four types and/or etiologies.
- Neuro-muscular dysfunctions such as spasticity, flaccidity and athetosis
- Congenital or acquired joint dysfunction, deformation or malformation
- Congenital fore-shortened and/or malformed limb segments
The armamentarium of components available for bracing these conditions consist of stylized structural supports and joints which are usually identified as:
Hip Joints and/or Locks
Foot Plates and/or Shoe
Pelvic Bands and Belts
Cuffs, Straps and Bands
Ankle Joints and/or Locks
Uprights and Twisters
Knee Joints and/or Locks
Present practice is to fit these components lo the contours of the individual patient utilizing stops, locks and controls as prescribed, (Plate 10, Page 100. Each brace component is designed and prescribed to provide the support, control and/or freedom of movement necessary to the functional or dysfunctional requirements of the corresponding limb segment or joint. Using this premise as a point of departure it was agreed that major limb deficiencies of congenital etiology required fitting of a prosthetic nature and did not fall within the scope of the orthotics survey. Investigation of orthotic applications to lower extremity fractures was similarly omitted from this survey as stubborn non-union cases constitute the only group of leg fractures where bracing is used as standard treatment.
Thus, this portion of the orthotics survey was reduced to three general areas of inquiry.
1) The extent to which each facility is providing orthotic equipment (i.e., the number of initial and replacement units) for four major debilitating neuro-muscular syndromes: Paraplegia, Hemiplegia, Poliomyelitis and Cerebral Palsy
2) The extent to which each facility employs facility fabricated and prefabricated components and brace units
3) The components used for six key joint dysfunctions:
Knee Flexion Contracture
Formal training courses in lower extremity orthotics became available to orthotists about six months prior to the field work for this report. It is felt that this report represents the state of lower extremity orthotic service prior to the availability of formal training and that a marked change in the practice of lower extremity orthotics may be expected within the next five years.
A total of 152 facilities provided data on lower extremity devices. An additional three reported that they do not fit patients with lower extremity problems.
Each of these 152 facilities reported fitting lower extremity orthoses to patients with Paraplegia during the preceeding twelve month period.
Patients with Hemiplegia were fitted with orthoses by 132 facilities, as shown in Table 18. This condition is being treated by the application of lower extremity devices throughout the country. Application of upper extremity devices is more limited and is used with markedly lower frequency in the Mid-Atlantic states.
One hundred forty-seven facilities estimated that they had fitted 8.265 polio or post-polio patients with lower extremity devices during the preceding twelve month period. This number represents approximately 1,090 patients receiving their first brace and 7,175 patients who were provided with replacement braces. One facility fitted as few as two patients during the year whereas another reported fitting 506. The frequency distribution of the number of lower extremity orthoses provided to patients with motor disabilities resulting from poliomyelitis revealed that approximately half of the facilities produced orthoses for less than 50 patients during the preceding year and that there was a progressive drop in the number of facilities serving larger numbers of patients.
The findings for private and institutional facilities are compared in Table 19. From this table it can be seen that the majority of lower extremity polio braces are fabricated by 11% of the facilities in this sample.
Further analysis of these data by city size or geographic area revealed that the patterns for these subsamples were identical with the patterns for the entire sample.
One hundred and twenty-three of the 152 facilities that provide lower extremity orthoses reported cerebral palsy braces during the preceding 12 month period. One hundred and nineteen of them estimate that they had fitted 7,623 cerebral palsy patients. Two thousand, three hundred and ninety-seven of these were first fittings and 4,695 were replacements of old braces. Table 20 indicates the number of cerebral palsy braces fitted by each facility and clearly demonstrates that the majority of these orthoses are produced by comparatively few facilities. Many of the facilities reported that most of the cerebral palsy bracing in their city or state was done by one particular facility. Although most facilities do provide cerebral palsy braces on request, this is, to a large extent, considered as a specialized orthotic application.
Eight types of orthoses were reported as being prescribed and fitted for cerebral palsy:
- Phelps type braces: double long leg, semi-flexible supports which are designed to give during muscular spasm were reported in all areas. They are used most frequently in Mid-Atlantic, Mid-western, Rocky Mountain, Texas-Oklahoma and California areas (see Table 21). When considered in terms of geographic areas, these devices are the most frequent types reported for this application.
- Newington braces: heavy rigid double long leg braces with pelvic band and spinal extensions (including scissoring attachments). They are designed to position and stabilize the limbs. Although this type of brace is reported in all areas they are seldom furnished in small cities. Moreover, in only four areas (the Midwest, North Central, Texas-Oklahoma and Pacific Northwest) do 25% or more of the facilities report using them.
- Double long leg braces with drop or pin locks. The data provided by facilities described them as regular weight, conventional long leg braces with special knee locks. These braces are intermediate to the two preceding types. They were reported in all areas except Texas-Oklahoma. From the nationwide point of view they are the second most frequently reported cerebral palsy brace type. In New England and the North Central areas they are the most frequent type.
- Double long leg braces with pelvic bands and joints. Facilities also referred to these braces as complete control, conventional heavy duty, rigid full control, aluminum control, complete body control and heavy duty polio type braces. The intent of these braces is essentially similar to that of the Newington Braces. These braces are reported in six areas. They are most frequently used in the Mid-Atlantic and Southern slates (28 and 40% respectively) and occasionally in the Midwest and Texas-Oklahoma region. They are seldom used in the New England and Rocky Mountain areas where this type of brace is usually prescribed as a Newington Brace.
- Single long leg braces were reported by one facility in each of three areas (the South. Midwest and the Pacific Northwest ). These are usually double upright braces with knee locks and spring type ankle locks.
- Double bar braces were reported by one facility in each of four areas. This is actually a miscellaneous category as the braces were not described in detail.
- Single and double bar short leg braces are the most frequently used type of device for cerebral palsy patients in New England. These brace are also reported by two Midwestern facilities and four facilities in four other areas. These types of devices are usually reported in small and middle sized cities.
- One Southern facility reported fitting twisters to cerebral palsy patients.
One hundred of these facilities reported that they are providing night splints to cerebral palsy patients while twenty specifically stated that they do not, (Table 22 ). These devices include foot spreader bars of the Dennis Browne and 'A' frame types and short leg single upright braces with calf bands and ankle joints which are locked in the desired position.
One hundred-twenty of the 121 facilities that reported providing cerebral palsy braces supplied information describing their method of fabrication. Twenty-three staled that they make all their own parts, 77 use prefabricated parts and kits, while ten others follow both procedures. The data is broken down according to city size and geographic areas in Table 23. The typical procedure is to utilize prefabricated kits which means assembling stock parts, bending tbe uprights and positioning the joints to fit the contours of the individual patient.
At least one facility in each area makes a complete custom brace; use of prefabricated parts was more frequently reported by the facilities that produced more than 100 units. The major exceptions to these generalizations are the Mid-Atlantic and Rocky Mountain areas where an equal or larger number of facilities make all or most of their own parts.
Facilities were asked to name and/or describe the components which were used for fitting a prescription for each of the following six joint dysfunctions: Pes Varum, Genu Valgum, Genu Recurvatum, Tibal Torsion, Knee Contrature and Legg-Perthes.
One hundred and thirty-six facilities reported fitting ten or more patients with orthotic devices for Pes Varum during the preceding twelve month period.
A. Night Splints were reported by thirty facilities.
B. Shoe Modifications were reported by eighty-four facilities throughout most of the country. The exceptions occur in New England and the North Central states where only three of the twenty-two facilities reported using shoe modifications for Pes Varum. Four of the California firms reported the use of shoe modifications without additional supports. Two other facilities, one in the South and one in Texas, reported using night splints and shoe modifications as the orthotic treatment procedure being followed.
Eighty reported using heel wedges. Seventy-one of them also reported using sole wedges. Sixteen of this same group (of 71) also used Thomas heels. Nine reported using arch supports and seven reported using shoe reinforcing plates.
- Shoe attachments were described by ninety-four facilities. Twenty-four facilities reported using two types of shoe attachments and four others reported using three types. Stirrups were reported by more facilities in each area than any other type of attachment. (Stirrups, 60; Flat Caliper, 27; Caliper Points, 32.) Seven, facilities located in New England, Mid-Atlantic, Midwestern and California areas reported using Foot Plates with stirrups.
- One hundred and one of the facilities described the types of ankle joints which they used. Sixty-nine reported using free ankle joints while twenty-six reported using spring loaded Klenzack joints.
- 'V' or 'T' straps were reported by one hundred and fifteen facilities.
- Upright components were described by one hundred and twenty-two facilities. Eighty-nine reported using double bar short leg braces while seventy reported using single bar short leg braces.
- Of the four facilities reporting long leg braces, two use knee joints with drop locks, one uses Klenzack joints and one reports using a bale lock.
One hundred and thirty-seven facilities reported that they had fitted ten or more patients with orthotic devices for Tibial Torsion during the preceding year.
A. Night Splints were the only devices provided for Tibial Torsion by eight of the facilities. An additional three utilized heel and sole wedges in addition to the night splints. Seventy-five facilities reported that they were requested to furnish both diurnal and nocturnal devices. The fifty-one other facilities had not been requested to furnish night splints for Tibial Torsion patients during the preceding year.
B. Prescriptions calling for Shoe Modifications were carried out at fifty of the facilities. Forty-eight reported using side wedges, forty-one of these forty eight and the two remaining ones use heel wedges. Eight also used Thomas heels, two in combination with heel wedges, one with a sole wedge and five with both.
- Upright components were reported by 126 facilities which used them for tibial torsion. Cable twisters and/or elastic strap twisters were reported by one hundred and three facilities. Short leg or below the knee units were reported by six facilities. Long leg or single and double vertical supports from the ankle to the knee and from the knee to the hip joints were reported by twenty-seven facilities.
- Information describing other components of these devices was not routinely recorded.
One hundred and thirty-seven facilities reported that they had fitted ten or more lower extremity devices to patients with Genu Valgum, the preceding year.
A. Night Splints are regularly provided by only fifteen facilities in-including: four in California and four in the Midwest, two in the South. Rocky Mountain area and Texas-Oklahoma, and one in New England. In all cases night splints arc reported as being used in connection with braces.
B. Shoe Modifications were reported by twenty-three facilities located in the following regions of the country: New England, the South, the Midwest, Texas-Oklahoma and California.
- Shoe attachments were described by ninety-seven facilities. Stirrups were reported by sixty-six facilities in all areas of the country, caliper points by twenty-four in all areas except the Rocky Mountain states, and split stirrups were reported by eleven (three each in New England and the South, two in the Midwest and one each in the Mid-Atlantic, California and Pacific Northwest areas). Foot plates with stirrups were reported by eight facilities, five in New England and one each in the Mid-Atlantic, South and Midwest areas.
- Upright components were described by one hundred and thirty-six facilities. Double bar long leg braces were reported by seventy-three facilities in all areas except the Rocky Mountain states. Single bar long leg braces were reported by fifty-five facilities located in all areas. Long leg braces with a single lateral A/K bar and double B/K bars were reported by twenty-two facilities located in all areas except the North Central states.
- Ankle joint data was furnished by one hundred and one facilities. Free joints were reported by eighty-two facilities, caliper points by twenty-four. Klenzack and gastroc or pretibial assists were each reported by one facility and eight facilities reported using no ankle joints.
- Knee joint data was furnished by one hundred and sixteen facilities. Seventy-six facilities reported that some or all of their braces for genu valgum do not have knee joints. Thirty-seven facilities located in all areas of the country use drop locks and eighteen others use spring drop locks. Eighteen facilities located in areas other than New England and the Mid-Atlantic states reported using free joints.
One hundred and twenty-six facilities reported fitting at least ten lower extremity orthoses to patients with Genu Recurvatum. Braces were described by one hundred and twenty-four facilities and one other stated that his facility was directed to provide elastic knee caps with lateral uprights to patients with this condition.
A. Night Splints were reported by only four, widely dispersed facilities (one in the Mid-Atlantic, South, Midwest and North Central states).
B. Shoe Modifications were reported by only two facilities.
- Shoe attachment data is available from eighty-four facilities, but little of this information was recorded for the four Westernmost areas. Stirrups were reported by sixty-two facilities. Split stirrups were reported by eighteen facilities, caliper points by sixteen facilities and foot plate with stirrups by five facilities.
- Upright components were described by one hundred and sixteen facilities of which one hundred and thirteen reported long leg bar braces.
- Ankle joints were described by ninety-two facilities. Their distribution does not permit geographic analysis. Free ankle joints were reported by seventy-four, caliper points by sixteen, spring loaded joints by nine and no ankle joints were utilized by three.
- Knee joints were described by one hundred facilities. Free knee joints were reported by sixty-two facilities in all parts of the country. However, only twenty-two of the facilities in both the North Central and Rocky Mountain areas reported using this type of device. Whereas, forty-six to one hundred percent of the facilities in the other seven areas use them. Knee joints with drop locks were reported by forty-eight facilities located in all parts of the country. More facilities in New England, Mid-Atlantic. North Central and Rocky Mountain states reported using drop locks than any other type of knee lock for this brace type. Knee joints with spring drop locks were reported by two of the above fifty facilities and three others. Other knee units reported include:
Bale locks, variable position locks, knee corsets, plunger locks and Klenzack locks.
- Hyperextension blocks were reported as being used in genu recurvatum braces by twenty-seven facilities. Approximately fifty percent or more of the Texas-Oklahoma, Rocky Mountain, Pacific Northwest and North Central facilities use them.
- Bands and straps were reported by eighty-seven facilities. Thorough information describing all of the band and strap components was reported by less than half of the facilities, back knee straps were reported by sixty-one facilities representing all parts of the country. Calf bands were reported by fifty-eight, eight using two bands and fifty using one. Thigh bands were reported by fifty-five, thirty-six using two and nineteen using one thigh band; twelve others also reported using thigh lacer and three thigh sling straps.
One hundred and twenty facilities reported they had fitted patients with Knee Flexion Contracture in excess of fifteen degrees during the preceding year. One hundred and eight provided some descriptive data for these orthoses.
A. No Night Splints were reported though it was understood that some of the other devices described were to be fitted and worn in a recumbent position.
B. Shoe Modifications. Shoe build-ups were reported by ten firms in the Eastern portion of the country.
- Shoe attachments were reported by sixty-four facilities, primarily located in the Eastern two-thirds of the country.
- Upright components were described by one hundred and three facilities. Long leg double bar braces were reported by ninety-eight. Long leg single A/K bar and double B/K bar braces were reported by two others. A long leg single bar brace was reported by one and short leg double bar braces by two.
- Knee joint data was reported by ninety-five facilities, three of which do not use knee joints and seven which employ free knee joints. Seventy facilities reported using variable position lock while the drop lock was reported by thirty-one facilities. Turn-buckles were reported by twenty-four and serrated disc by one facility.
- Ankle joints reported include seventy using free joints, eleven using caliper points, seven using spring loaded Klenzack, two using serrated disc and two reported using gastrocnemius or pretibial assist. Three did not use ankle joints.
- Bands and straps were not reported in a uniform fashion. The indications are that a typical knee flexion contractural brace includes: one calf band and two thigh bands (or a thigh lacer) and a knee cap pad.
One hundred and fifty-three facilities reported they had fitted Legg-Perthes.
Eighteen facilities reported they had been called upon to furnish patients with a Perthes sling and crutch only.
Sixty-two others reported that some of their patients had been furnished a Perthes sling.
One hundred and nine facilities fitted orthotic devices which were nonweight bearing braces without ankle joints including either a lock knee or no knee joint and with an elevation added to the opposite shoe. Twenty-five of these facilities applied traction to the shoe: eight of these facilities also used caliper points in some of their Legg-Perthes braces.
Ninety-two reported using long leg double bar braces with metal ischial ring. Twelve reported using long leg double bar braces with ischial band. Four reported using long leg double bar braces with ischial cuff. Five reported using long leg double bar braces with quadrilateral socket for ischial weight bearing. Five others staled they used long leg double bar braces without any ischial weight bearing.
In regard to knee joints fifty-two reported using no knee joint while fifty-four reported using a knee joint with a drop lock.
One hundred and forty-nine facilities provided information describing their methods of fabricating lower extremity orthoses for Pes Varum. Genu Valgum. Genu lb curvatum. Tibal Torsion. Knee Contracture and Legg-Perthes.
Only eight facilities reported fitting prefabricated braces. Two of these eight use prefabricated braces one to five percent of the time: one about fifteen percent: three about fifty percent and two always use prefabricated units. Four facilities that reported using prefabricated braces fifty percent or more of the time are located in New England. The remaining four are dispersed throughout the country.
Uprights are usually prefabricated. Eighty-seven facilities reported using only prefabricated uprights; ten used them from seventy-five to ninety-six percent of the time; thirteen used them fifty to seventy percent of the time and seven others used them from five to twenty-five percent of the time. The remaining thirty-one facilities reported that they make all of their own uprights. The pattern of these practices are generally identical throughout the country. The Southern states contain the highest percent of facilities that make all their own components; approximately half of the New England facilities make fifty percent or more of their own components and generally speaking most facilities in the North Central states use prefabricated parts some of the time, but two of the eight reporting make their own components for some cases.
Locking knee joints are fabricated by fifty-five of the facilities. Six of them use prefabricated parts from five to ninety-five percent and an additional ninety-three facilities always use prefabricated locking knee components.
Locking ankle joints are made by only fourteen facilities. This refers to five facilities which make all their own; seven which fabricate fifty percent of their locking ankle joints and two which make eighty and ninety percent respectively. One hundred and thirty facilities use only prefabricated locking ankle joints.
Free ankle joints are made by sixty-six facilities, forty-one of which make all their free ankle joints at the facility. In addition to the eighty-three facilities who use only prefabricated free ankle joints; seven use from eighty to ninety-five percent prefabricated joints; fifteen utilize them fifty to seventy percent of the time and three others use them ten to twenty percent of the time.
Caliper points are always made by fifty-four of the facilities while eighty-six reported that they always use prefabricated ones. Of the remaining eight, five made their own fifty percent of the time and three made them from seventy-five to ninety percent of the time.
F. Upper Extremity Orthotics
in the planning stage, it was decided that the complexity of upper extremity orthotics meant that the survey would have to limit its scope in this category. Since the type of training with each orthotist received determined his later practice this was selected as the area to be studied.
At the time the field work for this survey was undertaken (May, 1962) upper extremity orthotics was the only orthotic subject matter area which had been presented (for a reasonable period of time) through one of the OVR sponsored educational programs.
The course, "Functional Bracing of the Upper Extremities," was first offered in 1958 by the University of California, Los Angeles. According to a recent tabulation (July 1, 1962) ninety-one orthotists who have completed the program arc practicing at the present time. Their distribution throughout the United States, as shown in Table 24, indicates that this type of service is available in every geographic area.
Training in upper extremity orthotics has also been made available through the Georgia Warm Springs Foundation and Rancho Los Amigos Hospital as well as through American and European apprenticeship programs. Recently developed procedures such as those of Baylor University, the University of Michigan, etc.. have not yet reached the general public.
One hundred and fifty facilities have information regarding the fitting of upper extremity orthotic appliances. This group estimated that they had fitted 8,160 appliances for upper extremity disabilities during the past twelve months. The distribution of this production in relation to training is shown in Table 25
Over a third of the reporting facilities indicated that they fitted less than twenty-five units in the past twelve months. Further analysis was made of those facilities reporting that they filled less than fifteen units (Table 26). Fifteen facilities did not give useable information: eleven indicated that an other local facility was providing this service while twelve stated that the physicians in their area were not prescribing appliances for upper extremity disabilities. Of this latter group three facilities were located in the New England area: two in the Mid-Atlantic area: four in the South: two in the Midwest: and one in the Rocky Mountain area.
With formal training available in upper extremity orthotics, the one hundred and ten facilities which had not availed themselves of this opportunity were asked to give their reasons for not attending these courses. The majority indicated that the training programs were too costly both in terms of expense and time lost from the facility or that their facility was not large enough to consider providing upper extremity appliances. A third of the answers indicated that fabricating and fitting of upper extremity appliances was not economically worth-while. The remaining group gave a variety of non-responsive answers which could not be tabulated.
- Orthotic services are readily available throughout the United States. There is no need for a patient to be denied the benefits of an orthopedic appliance due to the lack of adequate service for the fabricating or fitting of appliances. However, there is a growing need for trained personnel in the field of orthotics at both the fitter and shop worker level. In the past two to three years, the persons entering the field of orthotics are just replacing those leaving the field through death, retirement or oilier reasons The result is that less well trained individuals are being called upon to accept more responsibility than is warranted for sound patient care. Willi the population increase, this situation is serious today and could become critical within the next decade, In addition, though there has been a drop in the incidence of paralytic poliomyelitis, other conditions requiring bracing are on the increase. These seem to be of a more serious nature, relatively, as they are often complicated by age. mental damage, and impairment of systems other than the musculoskeletal.
- Orthotic services available throughout the United States varies greatly. This does not mean that the quality of service is less in one geographic area than in another. This survey had no yardstick to measure quality; in fact, no known yardstick of orthotic quality exists. The reason for this variety of service seems to be the result of the physician-orthotist relationship in which the physician is his own authority for the appliances fitted to his patients during their treatment process. Thus, even within the same locale, patients with the same disability are fitted with markedly different appliances.
- Physicians of many specialties seem to take more interest in the prescription of orthotic devices than they do of prosthetic appliances. The reason for this is that the patient requiring an orthotic device is generally involved in a continuing treatment program while the amputee is not. In addition, the care of the amputee seems to have gravitated to a few medical specialities. This does not mean that the quality of orthotic prescription is better than that of the prosthetic prescription. In fact, the very opposite seems to be the case. Numerous orthotists reported that not only must a brace name be given in an appliance prescription, but also the prescribing physician's name, so that the anticipated appliance will be fitted. The consequences of such practice are most apparent in today's world with the mobility of patients, physicians and orthotists.
- The initial prescription for orthotic appliances generally comes from a physician who may consult with representatives of other disciplines prior to writing the prescription. This does not imply that orthoses are prescribed by clinic teams, in the formal sense. The orthotist may be consulted prior to issuing a prescription depending on the physician, the condition being treated, and the reputation of the orthotist.
- Prescriptions for replacement appliances are routinely required for patients whose conditions are not static, such as. children, geriatric patients, and patients with progressive disabling conditions. Appliances for patients with stabilized conditions may be provided without prescription, though there is a strum: feeling among orthotists dial prescriptions are desirable in all cases.
- For the four cervical conditions studied during the survey, all six of the devices illustrated in Plate I were reported as being fitted for each condition.
- For the seven spinal and trunk conditions investigated, appliances resembling illustrations Q and T (Plate II and V) were mentioned with sufficient frequency that they appeared in tabulations for six of the seven conditions, and that for five of the seven conditions both appliances were listed.
- From a study of reply data it is obvious that the names of spinal and trunk appliances are most usually based on the name of the person associated with the development of the appliance. In few instances is the name of the appliance based on the anatomical structure with which it is associated or the function it is supposed to perform.
- Corsets, as a class of appliance, were reported for six of the seven spinal and trunk conditions. This finding indicates that they are an important segment of the practice of orthotics. Shoes, also, seem to be an increasingly important segment of the practice of orthotics.
- There is a definite trend toward the use of prefabricated parts in the fabrication of orthotic devices, however, many parts are still made by hand. There is a less definite trend toward the fitting of prefabricated appliances. The majority of facilities which participated in this survey fabricate or are capable of fabricating all of the necessary components for the appliances they fit.
- Definite steps must be taken to offer training for all levels of personnel within the orthotic facility. This training should begin with the basic facts now known regarding anatomy, physiology and kinesiology: mechanics: materials: etc. The beginnings of such courses in orthotics are already available in the existing prosthetic courses. Courses should begin on a vocational, practical level and progress, in time, to the pre-vocational and post-graduate levels.
- The physician must be included with the orthotist in any educational programs because the training the orthotist receives is for naught unless the physicians with whom he works avail themselves of his knowledge and ability. With this, it should be recognized that the relationship between physicians and orthotists must be brought to a higher, more professional level, so that the patient may receive the best service possible in both the medical and mechanical senses.
- Projects should be undertaken that would resolve the differences within the held of orthotics. Immediate attention must be given to the terminology used to refer to appliances so that a system of communication can be developed throughout the United States. In this, the cooperation of both physicians and orthotists is extremely necessary.
- The diversity of approach in the fitting of spinal and trunk disabilities, plus the numerous modifications in existing appliances reported, indicates that detailed research in the areas of bio-mechanics and patho-mechanics of the spine and trunk is necessary so that devices may be prescribed and designed to provide the desired function for the individual patient.
- The diversity of approach to the treatment, i.e. bracing, of lower extremity conditions indicates a need for broad studies of specific problems in relation to bracing rather than further study of lower extremity bracing per se.
- New techniques and methods are being developed by individuals in the field which need to be identified and evaluated. During the survey many devices or methods were found which have been developed, are being prescribed by physicians and used locally with success. Through lack of adequate communication these are not being placed in their proper perspective and evaluated. Means should he made available to utilize this resource to its fullest.
- The diversity of fabrication practice, from the custom-made device, to the fitting of prefabricated devices, must be studied to determine the best method for serving patients. This study should include not only methods of fabrication, but also materials and their application in reducing costs and. at the same time, increasing the service of appliances.
- Further study of methods for increasing production in the event of a national emergency is indicated since more than half of the reporting facilities are located in prime target areas and would be rendered useless in any large scale emergency.
Study of Rehabilitation of Chronically III Planned
The Department of Physical Medicine and Rehabilitation of the New York Medical College has announced a two-week course on "Rehabilitation of the Chronically III Patient," which is scheduled for April 22 through May 3, 1963, at the Bird S. Coler Hospital, New York City.
This course is planned to provide a broad review of the principles, techniques and problems involved in the rehabilitation care of the chronically ill patient. It will consist of lectures, seminars, clinical demonstrations and practice workshops, and will include the contributions of the various disciplines to the rehabilitation process. The teaching stall includes members of New York Medical College, professional staff of the Medical Center and noted guest lecturers. A tuition fee of S150 will be charged for the course. For further information, write to:
Raymond C. Lerner, M.S.S.W.
Coordinator, Post Graduate Education
align="right"Dep't. of Physical Medicine and Rehabilitation
New York Medical College
1 East 105th Street
New York 29, N.Y.
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