Prosthetics and orthotics: a survey of centres in the Kingdom of Saudi Arabia
M. H. S. al-Turaiki *
L. A. al-Falahi *
This paper reports the results of a survey carried out to evaluate existing prosthetic and orthotic facilities and programmes of education, training, and research and development in the Kingdom of Saudi Arabia. One hundred and twenty hospitals and medical rehabilitation centres were each circularised with a questionnaire requesting information that mainly concerned (i) types of prostheses/ orthoses, (ii) area of facility, (iii) personnel number and qualifications, and (iv) problems encountered and suggested solutions. The completed questionnaires revealed that in the final analysis of data there were only ten prosthetic/orthotic facilities.
The survey provided useful data on the personnel, equipment, and facilities available in each hospital or medical rehabilitation centre, together with details of the services to prospective referring clinicians. Two centres were found to provide high quality services by qualified personnel. There were no formal prosthetic/orthotic training programmes and there was only one prosthetic/orthotic research and development centre.
The respondents generally felt that there were three major problems: (i) lack of qualified personnel, (ii) lack of materials and components, and (iii) lack of continuing education and training programmes. It is hoped that presentation of these results will provide facts for both health-care providers and educators which may be used as a basis for development in this important area of healthcare.
In the Kingdom of Saudi Arabia, there is a sufficient number of disabled people, resulting from birth defects, non-communicable diseases and accidents to warrant implementation of rehabilitation programmes. Accordingly, the government has introduced many rehabilitation activities through the Ministries of Health, Social Welfare, Education and Defence.
The population of Saudi Arabia is estimated to be about 10 million, living over an area of approximately 900,000 square miles. One of the greatest benefits resulting from Saudi Arabia's new wealth is the enormously improved system of health-care which it has been possible to develop. Free medical care is provided by the state for Saudi citizens, non-Saudi residents (with very few restrictions), and pilgrims to the Holy Places of Islam. Specialised hospitals have been built and equipped with the world's most up-to-date medical instruments. King Faisal Specialist Hospital in Riyadh provides treatment for selected patients and King Khalid Eye Specialist Hospital in Riyadh is considered as one of the best equipped hospitals for eye care in the world. The Armed Forces Hospitals for the Armed Forces personnel and their dependents, the National Guard Hospitals, and the University Hospitals also provide specialty treatments for heart disorders and kidney failure, along with a host of other diseases. The Saudi Arabian Fourth Development Plan (1985-1990) aimed at raising the number of hospitals to 283, while hospital beds would be annually increased by 14% to reach 55,600 beds by the year 1990. This is considered vital if the government is to provide proper medical care for its people. The plan also aimed at raising the number of primary health-care centres to 15,000.
The country is divided into eleven health regions, each headed by a regional health director who is responsible for preventive and curative health services. The Ministry of Health provides almost 60% of the health services (67% of the hospital beds, 59% of physicians and 54% of the nurses). About 25% of the services are provided by more than 10 different governmental agencies and 15% of the services are provided by the private sector. They constitute a pooling of resources which demands solid planning and co-ordination. A study sponsored by the Ministry of Planning found that there is inadequate collaboration between health providers. Only to a certain extent does the Ministry of Health receive information from other health suppliers. The inefficient information system makes the planning and evaluation of health services a rather difficult task. There are no clear indications as to why, how, or by whom statistics of health services and their activities are to be collected, compiled, and analysed.
Despite the extensiveness of the medical statistics compiled by the Ministry of Health for its annual reports, no regular reports were available on the number and types of disabilities present, nor on the size and geographical distribution of the disabled population. There were no general statistics on the number and type of prostheses/orthoses prescribed in the Kingdom. In view of the lack of adequate information regarding the number, condition and geographical distribution of disabled persons, accurate correlative study between available resources and actual needs is not possible. All of this information is required for planning prosthetic/orthotic services and the evaluation of future needs in terms of personnel, facilities and funds.
At the time that this study was initiated, little information existed that defined the current status of the prosthetic/orthotic facilities and the needs of the disabled. Observations made during field visits by an ad hoc committee to various medical rehabilitation institutions have brought to light a variety of deficiencies in prosthetic/orthotic care that warrant further inquiry. In order both to correct these deficiencies and to sharpen the focus on the prosthetic/orthotic education and training, research and development and manpower development programmes, it was decided that it would be useful to determine, by means of a survey, exactly what programmes were actually available. The real need of improving these services or introducing new ones as perceived by the practitioners working in the field, could then be assessed.
This investigation describes the prosthetic/ orthotic units in the hospitals and medical rehabilitation centres surveyed with respect to number of patients treated annually, types of orthoses and prostheses, area of facility, number of staff and their qualifications, materials and components, as well as the problems encountered and suggested solutions. It proceeds by enumerating and describing those facilities and the problems in prosthetic/ orthotic care noted by principal workers themselves. The recommendations and conclusion of this report apply generally to the Ministry and non-Ministry of Health existing facilities.
Origins and objectives
This work was initiated out of field visits to various medical rehabilitation institutions by a committee consisting of an orthopaedic surgeon, a physiatrist, a physical therapist, a bioengineer and prosthetic/orthotic consultants. Their observations have brought to light a variety of deficiencies in rehabilitation services that warrant further inquiry. A comprehensive survey was, therefore, recommended to evaluate the existing facilities and patient needs and define the main problems of these services.
The principal aims of the survey were to review:
- the existing prosthetic and orthotic facilities;
- the programmes of education and training in prosthetics and orthotics;
- the prosthetic and orthotic research and development facilities; and
- the manpower development programmes in the field of prosthetics and orthotics.
Finally, the survey aimed to ascertain the personal opinions of the principal workers in the field as to the current status of the prosthetic/orthotic services, and in particular, their comments and remarks towards how the services, in their area, should develop in the future.
In order to achieve these aims, an evaluation was carried out by means of questionnaires. The questionnaire consisted of eight major sections. The first section asks if there is already prosthetic/orthotic services available in the hospital or not. The second section, which is the clinical services section, aims at obtaining information on: the total number of patients annually seen at the department/unit; the types of patients seen; and the number of fittings carried out annually of upper and lower limb prostheses, upper and lower limb orthoses, spinal orthoses, orthopaedic shoes, wheelchairs and finally car adaptation. The third section, dealing with the total area of the facility and areas of each section separately, was included to obtain background information on the ratio of staff and/or patients to the area. The fourth section is concerned with personnel numbers and qualifications to obtain accurate information on the qualified and non-qualified personnel and their nationalities. The next three sections are concerned with the need for establishing prosthetic/orthotic services and asks more specific questions concerning the opinions of the hospital staff as to whether a workshop producing plastic splints only is considered enough for their requirement.
The final section of the questionnaire deals with comments and remarks regarding future plans for improving the existing facilities or providing new services in order to ascertain the respondents' personal views on the prosthetic/ orthotic requirements in accordance with their local needs based on their experience.
Results received from eighty out of the one hundred and twenty questionnaires circulated to hospitals and medical rehabilitation centres were divided into two groups based on the availability of medical rehabilitation services. The results of the respondents with one or more of the four major fields of medical rehabilitation (Prosthetics/Orthotics, Physical Therapy, Occupational Therapy, and Speech and Hearing Therapy) were analysed by dividing them into two groups based on the existing prosthetic/orthotic facilities. The following are hospitals and centres providing prosthetic/orthotic services.
Ministry of Health existing facilities:
- Riyadh Medical Rehabilitation Centre (RMRC) was established in 1974 and serves as the principal supplier of prostheses/orthoses to patients from the Kingdom as well as neighbouring countries. The medical service is provided by a full-time expatriate lady physiatrist and two orthopaedic surgeons who attend weekly out-patient clinics. There is no inpatient facility. Only 6 out of the 12 qualified technicians and 20 assistant technicians are Saudi citizens (Table 1).
- Makkah Medical Rehabilitation Centre was established in 1978 to serve as a main supplier to the Western Region. This centre is fully equipped and staffed by 18 expatriate technicians.
- Abha Medical Rehabilitation Centre has a small prosthetic unit with 2 technicians, no Saudis. The unit is located within Abha General Hospital compound.
- King Fahad Hospital - Madinah: the prosthetic/orthotic unit was established in 1986 in a remodelled building close to the hospital. It is suitably equipped and staffed by 4 technicians who are expatriates. Currently it is operating at a reduced level dut to shortages in materials and com-ponents.
- King Fahad Hospital - Gizan: a prosthetic/orthotic unit was set up in 1984. It is well equipped and staffed with one well-trained technician, head of unit, and 4 qualified technicians, all expatriate. Some of the equipment must be modernised, and also there is need for plastic material and upper limb components.
B. Non-Ministry of Health facilities:
These provide quality services to certain groups of people and are as follows:
- King Faisal Specialist Hospital - Riyadh: it has a relatively active prosthetic/orthotic unit staffed with 2 certified prosthetists/ orthotists and one technician, who are all expatriates.
- Armed Forces Hospital - Riyadh: it has a fully equipped large prosthetic/orthotic unit staffed by 2 qualified prosthetists/ orthotists and 6 technicians who are all expatriates.
- Armed Forces Hospital - Al-Hada (Taif): it has well equipped workshops and highly qualified personnel. This large prosthetic/ orthotic unit which is staffed by 5 qualified expatriate technicians produces all types of prosthetic/orthotic devices with the exception of upper limb prostheses.
- King Khalid University Hospital -Riyadh: the orthotic unit is composed of a small workshop that delivers simple orthoses. It is staffed by 2 technicians, who are expatriates.
- National Guard, King Fahad Hospital -Riyadh has a fully equipped prosthetic/ orthotic workshop, but it is not operational as yet.
There is only one 3-year on the job technical training programme for 6 assistant technicians at Riyadh Medical Rehabilitation Centre. This programme is not recognised by the civil service bureau. This lack of recognition has resulted in difficulty in attracting candidates with reasonable levels of education which would allow them to continue their education and training in this field. Since the current trainees have only elementary school certificates as their basic entry requirement, intensive teaching and supervision have been provided to bring their standard to the appropriate level.
The Joint Centre for Research in Prosthetics/ Orthotics (King Saud University and Ministry of Health) is the only research and development facility in the Kingdom. It was established in 1987. It operates fully equipped orthopaedic assessment, biomechanics, and gait laboratories.
During 1987 - 1988 period, the total number of patients receiving prostheses/orthoses from the nine operational Ministry and non-Ministry of Health centres/units was 8,534 (Table 2). Of these patients, 30% were female and 70% male. Of the total number of orthoses supplied, the commonest variety was shoe adaptation (26%); followed by knee-ankle-foot orthoses and spinal orthoses at 22% each, wrist-hand orthoses (10%), ankle-foot orthoses (8%), hip-knee-ankle-foot orthoses (5%), and surgical (orthopaedic) shoes (3%). Of the 635 prostheses delivered, 86.1% were lower limb and 13.9% were upper limb. The commonest variety was below-knee (44%); followed by above-knee (22%), partial foot (10%), partial hand (4.5%) and below-elbow (4%).
A separate questionnaire on the incidence of different cases and the causes of amputation was sent to Riyadh Medical Rehabilitation Centre which is the largest facility of is kind in the Kingdom, supplying 27.76% of the total number of prosthetic/orthotic devices. Results from the questionnaire indicated that poliomyelitis (37%) was the leading condition; followed by congenital deformities (23%) and amputation (16%) (Fig. 1). Since the polio cases reported represent the percentage referred to the centre, this does not necessarily show the true incidence of poliomyelitis in the Kingdom. With regards to causes of amputation, trauma was found to be the leading cause (40.72%), followed by diabetes/gangrene (24.95%), tumour (5.99%) and congenital (4.99%) (Fig. 2). Specific causes of trauma were road traffic accidents (29.94%), occupational (industrial) injuries and burns (9.98%), and snake bite (0.8%). It is striking to note that amputations due to road traffic accidents are the first cause, considering the high standard of road networks throughout the Kingdom.
The majority of respondents took the opportunity to express further opinions, particularly with reference to the final section of the questionnaire dealing with comments, and although the quality and depth of the comments varied considerably, only one centre failed to provide any additional remarks. Generally these remarks could be considered under three headings: lack of high qualified personnel, the problems associated with shortages of materials and components, and the requirements for future development.
In order to produce properly fitted and aesthetically acceptable prostheses/orthoses, a clinical prosthetist/orthotist is required, who is capable of interpreting the clinical needs to fulfil the prescription requirements of the clinician. He must be capable of supervising the prosthetic/orthotic technician and overseeing production. At the present time, most of the facilities throughout the Kingdom have only prosthetic/orthotic technicians. There is an urgent need to recruit highly qualified personnel as technical supervisers in order to make sure that the quality of prostheses/ orthoses offered to patients is of an acceptable level, to introduce newly developed techniques, and to utilise newly designed and appropriate components.
More detailed comments were concerned with the desperate need for education not only for the clinicians who are the prescribers of the appliances, but also for the prosthetic/orthotic technicians who are fabricating such appliances. This education is considered vital both for the future development of the service and to upgrade the technical standards.
Although a few seminars have been held during the past years, organised by manufacturers in collaboration with different centres in Riyadh, these have been on lower limb prostheses which only represents 6.4% of the total appliances prescribed. Further they were rather considered as marketing seminars by these companies to introduce their newly produced components than occasions for providing the desperately needed short-term technical courses for upgrading and extending professional competence. Prosthetists/ orthotists would also benefit from courses which reviewed the theoretical and practical aspects of prosthetics/orthotics for the most common conditions. As the majority of the referral prescriptions for prostheses/orthoses were inadequate, improper or redundant, it was also felt that the referring prescribers need more information and knowledge in the art and rationale of prosthetic/orthotic prescription. Therefore, short courses were strongly recommended for physicians, surgeons and therapists practising in this field to acquaint members of the clinic team with basic concepts and modern practices in prosthetics and orthotics.
Due to the large number of patients and the absence of an appointment system at the Ministry of Health Medical Rehabilitation Centres, practitioners have inadequate opportunity to assess or discuss existing conditions to ascertain the needs of the patients. It would, therefore, be justifiable to provide additional medical staff with special interest in rehabilitation and physical therapy, as well as to include occupational therapists in order to give more appropriate pre- and post-prosthetic/orthotic training.
The main bulk of the specialised prosthetic/ orthotic services is concentrated in Riyadh (Table 1). Most of the facilities are well equipped, but the overwhelming majority of rehabilitation workers are still expatriates (92%). Despite the fact that the survey showed that 30% of the total number of patients who required prosthetic/orthotic services were female, there was no female practitioner/ technician employed by any of the surveyed centres/units. To help rectify the current situation, recruitment and education of national professional manpower must be promoted at different levels, taking into account the desperate need for and important potential of female participation, by establishing a high calibre prosthetic/orthotic education programme within the context of a university.
It was also felt that the type of prostheses/ orthoses prescribed for patients depends on the availability of materials and components rather than on the actual need of the patients. This is true for all the services, including those provided by the non-Ministry of Health sector. Linked to this, a number of respondents, in the centres in remote areas, stated that they had shortages of the most essential materials. It is also interesting to note that there was only one centre that offered a few externally powered upper limb prostheses of the myoelectric type. This is probably due to the non-availability of occupational therapy departments which usually provide the amputees with appropriate prosthetic training.
Considering the high percentage of amputations due to road traffic accidents (29.94%) and the high number of amputees between 20 to 40 years of age, who are the ideal wearers of hydraulic knee joints and energy-storing feet, it is unfortunate, that such components have not been made available to the amputees at any of the centres in the Kingdom.
Ischial ramal containment sockets for the above-knee amputee have not even been introduced yet.
Although there are a great number of disabled children and adults in desperate need of specialised seating and mobility aids, it is disappointing to observe that such services are neither provided nor planned for. As far as car adaptation is considered, the only available services are provided by private automobile maintenance workshops (centres) which are not subjected to any kind of clinical/technical quality control.
Although there were no comments regarding the area of facility, the main centre in the Kingdom is located in a rented two-storey building, without an elevator, and has prefabricated buildings for prosthetic/orthotic workshops and prosthetic/orthotic technician training section with a very small area for patient fitting/training. The second biggest centre is located in a block of flats previously built to accommodate the nursing staff of the hospital.
Realising that the needs of the disabled in the Kingdom are not fully met by the existing facilities, the government has planned to establish six medical rehabilitation centres by the year 1993, these are at King Fahad Medical City and Eman Hospital in Riyadh, the Red Sea Hospital in Jeddah, the Gulf Hospital at Dammam, the Onaizah General Hospital in Qassim and the Beeshah General Hospital at Beeshah.
In the opinion of the authors, some deficiencies are regrettably due to the presence of a high percentage of expatriates who are employed despite certain limitations. These may be categorised as: intrinsic and extrinsic.
A. Intrinsic limitations:
- Personal aims for taking employment in the Kingdom.
- Cultural and educational incompatibility,
- Language difficulty.
- Lack of commitment.
- Tendency to utilise their country's products out of loyalty and familiarity which consequently limits the availability of other materials.
- Inadequate level of qualification.
B. Extrinsic limitations:
- Lack of continuity leading to instability and inadequate planning for future development.
- Less job competition giving rise to less incentives for upgrading professional capabilities.
- Lack of authority granted to principal workers.
- Lack of awareness amongst administrators as to the acceptable level of the services provided.
- Fear of contract termination, if conflict arises with superiors.
- Lack of professional interaction and planned management of the disabled.
This survey, indicates that the quality of prosthetic/orthotic services provided by the Ministry and non-Ministry of Health existing facilities falls short of the ideal and that there is a need for very considerable improvement in quality and delivery of service and research. The profession of prosthetics/orthotics is beset by three major problems:
- low number of national staff leading to less continuity;
- too few clinical (properly qualified) prosthetists/orthotists ;
- lack of continuing education and training programmes.
The interaction of these problems has created a lack of confidence and dissatisfaction with the services. The appointment of junior or inexperienced staff, both medical and paramedical, to attend to the disabled, the attitude of key personnel and the poor response or lack of response from senior staff to the need to establish a supervisory body in the Ministry of Health, seriously aggravate the situation and are only a reflection of the lack of concern for this least fortunate group of people and this important field of medicine and rehabilitation.
Upgrading the current services could be achieved through the following:
- recruitment of highly qualified staff;
- provision of materials and equipment;
- introduction of prosthetic/orthotic safety standards;
- establishment of a supervisory body within the Ministry of Health;
- establishment of a professional body of prosthetists/ orthotists in order to assist in organising short-term courses and to set standards in this field;
- introduction of a B.Sc. prosthetic/orthotic training programme in the context of the university. A technician training programme should also be instituted.
Such recommendations would, if implemented, enable the recruitment and education of more national professional manpower, utilising the existing resources effectively and expanding services methodically, as well as ensuring proper coordination between institutions and professionals caring for the disabled.
The data presented in this survey have been provided by those who kindly gave precious time to completing the questionnaires. The authors are grateful to them, and sincerely hope that the data which have resulted from the survey will help promote prosthetics/orthotics in Saudi Arabia. The authors are also indebted to all members of the Ministry of Health Rehabilitation Committee and to their colleague, Mr. Hamayun Zafar, for their valuable assistance.