Studies of the Upper-Extremity Amputee IV. Educative Implications
Sidney Fishman, Ph.D.
From the foregoing discussions, it will be apparent that one of the major
purposes of the Upper-Extremity Field Studies was to introduce certain
influences into the professional activities of the several groups (physicians,
therapists, prosthetists) concerned with the care of the amputee and his
reintegration into society. It was anticipated that changes in methods of
patient care arising from these influences would in turn affect the welfare of
the amputee group. In this sense, therefore, a major aspect of the Field Studies
was the educative process involved in the attempt to change the operational
patterns of those responsible for amputee care by strengthening the
philosophies, attitudes, and skills which had been taught during the short-term
courses of instruction. Continued encouragement, assistance, and guidance were
required to habituate these groups to the procedures proposed during the
instructional courses.
The second phase of the Field Studies, the results of which will be discussed
in the next issue of Artificial Limbs (Autumn 1958, Vol. 5, No. 2), is most
properly considered a research activity. The purpose in this phase of the
program was to attempt to evaluate the effects of these efforts on the over-all
status of the amputee through the use of objective and subjective measurements.
To accomplish this second phase, detailed studies were made of the status of the group of amputees prior to their treatment by the prosthetic
clinic and again at a time after the completion of treatment.
In approaching the task of estimating the effectiveness, or lack of
effectiveness, of a two-pronged (research and education) program of this type, a
number of problems arise. In this particular case, fortunately, we have the
opportunity of deferring evaluation of the second phase, the research
activities, until after those results are presented in a second installment.
The results of the educative effort are perhaps best considered in terms of
Jesus' parable of the sower, as set forth in The Gospel According to St. Matthew
(Chapter 13):
3 ... Behold, a sower went forth to sow;
4 And when he sowed, some seeds fell by the way side, and the
fowls came and devoured them up:
5 Some fell upon stony places, where they had not much earth:
and forthwith they sprung up, because they had no deepness of earth:
6 And when the sun was up, they were scorched; and because they
had no root, they withered away.
7 And some fell among thorns; and the thorns sprung up, and
choked them:
8 But other fell into good ground, and brought forth fruit, some
an hundredfold, some sixtyfold, some thirty fold.
9 Who hath ears to hear, let him hear.
In some few places and among some persons, no effects are to be noted. Among
others minor temporary changes evolved, and in still other instances important
permanent improvements were brought about. We may consider these effects under
three broad categories-impact on the medical management of the amputee, impact
on public and private rehabilitation agencies, and impact on social
attitudes.
Impact on the Medical Management of the Amputee
It has been emphasized consistently throughout the foregoing sections that a
"prosthetic-clinic approach" to the problem of the amputee was a basic tenet of
the field-studies program. In this approach, the fundamental decisions relating
to the rehabilitation of the patient were made in concert by a group consisting
minimally of a physician or surgeon, a physical and/or occupational therapist,
and a prosthe-tist. Whenever possible, vocational counselors and other personnel
trained in the psychosocial aspects of rehabilitation also were included.
The second aspect of the prosthetic-clinic approach involved an attempt at
considerable standardization of the process of patient care and usually included
eight more or less formal treatment steps-preprescription examination,
prescription, preprosthetic therapy, prosthetic fabrication, initial checkout,
prosthetic training, final checkout, and follow-up. As a consequence of these
efforts, three major changes occurred in the medical care of amputees-
introduction of prosthetic-clinic procedures, staff and patient education, and
upgrading of existing services.
Introduction Of Prosthetic-clinic Procedures
Although similar clinical procedures have been developed and practiced in the
treatment of other disabilities, and even occasionally in prosthetics, the
attempt at systematic introduction of such procedures on a broad basis was a
novel one. In addition, experimental exploration and validation of the essential
adequacy of such procedures is hardly ever available. As a major outcome of the
Field Studies, however, the basic validity of the clinical procedures in the
field of upper-extremity prosthetics has been established. In addition to these
accomplishments, certain other changes occurred with respect to the patient-care
activities of each of the specific professions-the physician and surgeon, the
physical and occupational therapist, and the prosthetist-concerned with the
handling of the upper-extremity amputee.
The Physician and Surgeon
As a result of the principles and procedures instituted under the program,
the period during which the amputee is considered a patient under medical
management was extended significantly. Formerly an amputee was a patient during
surgery and through a limited period of postoperative care. Today, the period of
medical supervision continues through the entire process of limb prescription,
fabrication, training, and evaluation.
As an additional outgrowth, a subspecialty within the fields of orthopedic
surgery and physical medicine has been developed. A limited number of physicians
have become expert in the field of limb prosthetics. Since the amputee
represents a relatively small portion of the total population requiring medical
service, it is not feasible for large numbers of physicians to specialize in
this field. But in order to provide competent service for amputees it was
essential that a few physicians in each major population center be thoroughly
equipped to provide the care required. Physician specialization in the very
restricted field of prosthetic restoration has come about as a direct result of
the program.
Through the program the physician has learned much concerning the technical
specifics of prosthetic restoration. As a result of this education, his respect
for the contributions made by the skill and experience of the therapist and
prosthetist in the process of amputee rehabilitation has increased. The
interdisciplinary approach to the problem of amputation and prosthesis has
become accepted and appreciated as a significant forward step in the medical
management of the amputee. As a general consequence, the physician has been able
to acquaint himself with, adapt, and then apply modern-and gradually
higher-standards of prosthetic care for his patients. Knowing, perhaps for the
first time, what constitutes and what is involved in providing a good
prosthesis, the physician is now able to require a standard of service not
previously possible.
The Physical and Occupational Therapist
For the therapist, the short-term courses in upper-extremity prosthetics
filled a gap left by the usual curricula in schools of occupational and physical therapy.
Perhaps for the first time, a systematic approach to the amputee problem was
taught and practiced. As a result, the therapist has been able to carry out the
major responsibility of amputee training with a background of general technical
knowledge directly relating to artificial limbs. In addition, closer
professional liaison developed between the therapist, the physician, and the
prosthetist with regard to the amputee. As a result, in most instances
upper-extremity amputees are now routinely referred to the therapist for
instruction in the use of the artificial limb, whereas in the preprogram days
the number of therapists qualified to give this service and the number of
amputees availing themselves of it were both insignificant.
The Prosthetist
The program sought and helped to provide a proper professional role for the
prosthetist. As a group, prosthetists were for the first time exposed to formal
university instruction and to closer relations with medical, paramedical, and
psychosocial disciplines. Thus the prosthetist has been helped toward a
redefinition of his status on a higher professional level.
This progress in the direction of a more professional role was aided in no
small measure by the acquisition of a new technology involving the use of
biomechanical principles, plastics fabrication, and principles of harnessing and
controlling artificial limbs. This improved knowledge has resulted in improved
service, increased status, and greater interprofessional satisfactions.
One cannot say at this early stage in the evolution of this field just what
the ultimate or proper interrelations may be between the professions concerned.
Certainly the appropriate relationships will tend to vary from location to
location, depending upon personnel and situational considerations. There can,
however, be no gainsaying the facts that a period of growth has been stimulated,
that the adequacy of the present treatment situation far surpasses that of the
old, and that there has been developed a climate which gives every indication of
providing additional professional status for the prosthetist.
Staff And Patient Education
A second value provided by the studies relates to the matter of staff and
patient education. It is as true in limb prosthetics as in the other healing
arts that there are no standard procedures which will apply with equal
effectiveness to every patient. Moreover, limb prosthetics is still a field in
which the contributions of each of the specialists are but partially understood
by the others. Consequently, there is an important need for a
cross-fertilization of ideas and a distillation of the best thinking for a given
patient by the process of group activity. In this sense, an important
achievement of the prosthetic clinic may be considered the intraclinic education
of the team members.
Equally important is the role that the clinic must play in the education of
the patient. Most amputees, when arriving for prosthetic care, are subject to
wide and varied misunderstandings and misinterpretations as to the procurement
and ultimate use and value of a prosthetic device. Clinic personnel have become
more effective in educating the patient concerning realistic goals and
anticipations, in addition to providing him with the best type of prosthesis for
his particular needs.
Upgraing Of Existing Services
In the process of applying and studying clinic procedures experimentally, the
last important result evolved-that of an upgrading of existing services, as well
as the establishment of services where none had existed previously. In this
respect, the major contribution apparently has grown out of the introduction of
a coordinated pattern of treatment.
Previously, it had not been uncommon for a prosthetist, physician, and
vocational counselor, for example, to proceed with the care of an amputee
independently of one another. This procedure was often adopted in spite of the
fact that in any situation where an individual is receiving treatment from more
than one specialist, and where the anxieties are such as to provoke some degree
of patient discontent, there is a noticeable tendency for some patients to
distort the intentions and contributions of each profession in relation to the
others. Such problems are further aggravated in those instances where the
patient himself is called upon to act as the means of communication between the professions involved,
since we may be sure that there will always be a certain degree of distortion of
the patient's perceptions of the treatment processes. The clinic procedures were
especially effective in reducing this troublesome method of communication
between the specialists.
We may also anticipate that the behavior and demeanor of the patient toward
the pros-thetist will differ from that he exhibits toward the physician,
therapist, or counselor. These differences in overt behavior patterns may easily
and logically suggest different patterns of treatment to each of the individual
professions. Yet it should be clear that these varying behaviors on the part of
the patient are transitory and that the real solution lies in a uniform
treatment plan rather than in a number of discrete ones. It therefore becomes
clear that, in order to provide amputees with the best available medical and
prosthetic service, the contribution of each of the professional specialties is
best coordinated and amalgamated with that of each of the others. The
prosthetic-clinic procedures, introduced through the studies, permitted a more
uniform evaluation of the patient and assisted in circumventing the problems
inherent in uncoordinated care.
Impact on Public and Private Rehabilitation Agencies
Many groups who have as their adopted or assigned mission the reintegration
of the handicapped individual as a productive member of society have long been
aware of the significance of the process of prosthetic restoration as a link in
the over-all process of rehabilitation. As a direct consequence of this
awareness, and as a necessary outgrowth of their over-all responsibilities in
the rehabilitation field, federal agencies such as the Veterans Administration,
the Armed Forces, and the Department of Health, Education, and Welfare, the
state divisions of vocational rehabilitation, workmen's compensation, and health
and public welfare, and such nongovernmental agencies as the state societies for
crippled children and adults, rehabilitation centers, insurance companies, and a
number of other private agencies have become the largest purchasers of prosthetic services in
the United States.
Through the NYU Field Studies these groups have been made increasingly aware
of the potentialities of prosthetic restoration and have responded by raising
their standards in the field of upper-extremity prosthetics. Having been
provided with professionally competent avenues for the processing of their
beneficiaries through prosthetic prescription, fabrication, training, and
evaluation, these agencies have begun to insist that their clients be treated by
special amputation teams headed by physicians who are experts in the field.
Since these agencies may be considered "consumers" in the sense that they most
frequently pay for the prosthetic services provided, they have been instrumental
in raising the standards by rejecting prostheses and services that do not meet
the minimum standards first set up through the program.
A by-product is that the groups mentioned tend more and more to order
prostheses from those prosthetists who have fully qualified themselves by virtue
of training and experience. In a good many instances, these agencies have shown
themselves willing to spend the additional monies required to obtain services of
the highest quality. In some instances the program has been instrumental in
stimulating the inauguration of local services to avoid the necessity for these
rehabilitation agencies to contract for prosthetic services from distant
sources. The widespread introduction of the clinic-team concept to the field of
limb prosthetics provided the means for greater liaison between rehabilitation
agencies and those persons medically responsible for the process of prosthetic
restoration. Since the clinic-team meetings ordinarily involve a conference of
all of the participants in a given case, the agency itself is frequently
represented at such conferences by a professional staff member. This, of course,
makes for considerable improvement in the continuity of the rehabilitation
process.
Impact on Social Attitudes
Beyond their influence on the medical and rehabilitation agencies, the
effects of the Upper-Extremity Field Studies also permeated through other facets of our
social structure, although as one departs further and further from the
professional groups directly responsible for the care of the amputee the impact
of the effort becomes more diffused and less specific. Nonetheless, a number of
significant effects remain to be noted. They may be viewed as influencing the
attitudes and thinking of sponsoring agencies, scientists concerned with
physical disability, other groups of disabled, and society at large.
Sponsoring Agencies
Perhaps one of the most important contributions was the demonstration that
within a relatively brief period of time research and development can be
accomplished and the benefits therefrom made available to the average patient
with a disability. It should be recalled that the entire upper-extremity
research program did not get under way until several years after the close of
World War II and that the major prosthetic design improvements depended upon
several years of fundamental biomechanical research. Thus the entire concept and
technology of the care of the upper-extremity amputee has been revolutionized
within a remarkably brief period of six or seven years.
Such demonstrable progress is of inestimable value to those whose
prerogatives require that they decide where substantial private or public monies
should be spent in medical or rehabilitation research. Although it is always
important to verify or evaluate the results of a broad program of research, this
is not always possible. Yet this is precisely what the Upper-Extremity Field
Studies have done.
In the first instance, scientific evidence has been provided concerning the
over-all value and contribution of the six or seven years of research and
development. Secondly, and from a more technical point of view, information was
brought forth concerning those aspects of the care of the upper-extremity
amputee which had progressed most satisfactorily and those phases which require
continuous improvement and attention.
Scientists Cconcerned With Physical Disability
The program of research and education also assisted in the general growth of
scientific thinking on problems of human disability. Some detailed discussion of
these research considerations will be included in the next issue of Artificial
Limbs (Autumn 1958, Vol. 5, No. 2), which will deal with the research aspects of
the studies. The discussion of the educative aspects of the Upper-Extremity
Field Studies would be incomplete without note being taken of the progress that
has occurred in the attitudes and thinking of researchers in the field of
physical disabilities. These advances have been summarized at the recent
conference on the Contributions of the Physical, Biological, and Psychological
Sciences in Human Disability sponsored by the New York Academy of Sciences (page
125).
Other Groups Of Disabled
It is clear that a special service was performed for those individuals who
have incurred disabilities related to, but not identical with, amputation. These
groups are perhaps best typified by those disabilities which require functional
restoration by use of braces or other orthopedic appliances.
Until the time of these studies, there was very little overt expression of
the need for progress in the field of bracing. The prevailing situation was one
that had remained static for decades. With limited exceptions, personal
unvalidated opinion, professional and otherwise, pervaded and still
characterizes the entire field.
Partially as a consequence of the broad educative aspects of the
Upper-Extremity Field Studies, a spontaneous development of interest and desire
for systematic progress arose in this related field, which is often served by
the same doctors, therapists, and pros-thetists-orthotists. People who were
suffering from these types of disabilities and those who cared for them
generated a new feeling of hope and enterprise. The results of these changes in
attitudes are just now being translated into planning for active research and
education.
Society At Large
Further evidence was provided that the systematic treatment of the disabled
is a fundamentally effective and socially desirable process. The "collective
concern" which society experiences concerning the physically handicapped tends
to be reduced with the knowledge that constructive things can be done, and have been done, for this group in
an orderly, scientific manner. Associated with this growth in knowledge is a
reduction in anxiety and prejudice concerning the physically handicapped and a
corresponding increase in their acceptance by society.
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