A History of ACPOC: The Hector Kay Lecture
Curtis D. Edholm, M.D., 4-16-1998
As a start I want to welcome you to Grand Rapids, my home for almost 50 years, I want to say how much I appreciate the honor of giving this year's Hector Kay Lecture. When Dr. VandenBrink asked me to talk about the history of ACPOC, my eyes immediately glazed over, and I thought, "that's what my audience will do too". However, believing that if we don't know whence we come, it's difficult to know who we are, and as a history minor in college, I thought I should be interesting -to me at least. I wondered if Dr. VandenBrink had been concerned about George Santayana's belief that "those who cannot remember the past are condemned to repeat it".
My report of the events leading up to ACPOC's first few years will, of course, be biased. I am like one of the mythical blind men feeling a leg or tail or side of the elephant - but I know it -and I can hope that some of you perhaps have only felt the ear or the trunk. I am not giving a history of my own clinic and I'm not stating the whole history of management of amputees.
Although, we are interested primarily in children in this organization, our history goes deeper that that.
Near the end of World War II our military personnel who were amputees were not satisfied with the prostheses given them. Even when specialized centers - such as Percy Jones Army Hospital in nearby Battle Creek were used, fitting and functional results were disappointing. And so the Army's Surgeon General, Norm Kirk, asked Secretary of War Stimson, for help from the National Academy of Sciences.
The National Academy of Sciences, the NAS, had been established by Act of Congress in March 1863, with its charter signed by Lincoln, as a private, nonprofit, nongovernmental organization. Its function was to provide expert scientific advice at the request of the government. In 1916 the NAS established the National Research Council - NRC. NRC became the operating agency for the NAS. And over the decades several hundred committees have been formed, have functioned and some dissolved. The funding for activities of NAS-NRC have come mostly from the U.S. government. Members of the committees were not compensated and were reimbursed for only certain expenses.
In early 1945 a conference of surgeons, prosthetists and other scientists led to a crash research program by the army, navy, and late the VA In 1945 NAS-NRC formed the Committee on Artificial Limbs which worked with universities, subcontractors and independent labs. The committee was renamed the Advisory Committee on Artificial Limbs in 1947 and functioned until 1955. It was changed to the Prosthetics Research Board for years 1955-59 when another re-organization occurred. Prosthetics Research Board was abolished and the Committee on Prosthetics Research and Development was formed - the CPRD.
The army formed the Army Prosthetics Research Laboratory near Washington (APRL) and the navy, the Navy Prosthetics Research Laboratory (NPRL) near Oakland and California under the direction of Colonel Maurice Fletcher and Captain Thomas Canty respectively. The VA developed its own research and development division under Dr. Eugene Murphy. Resulting from all their co-operative work were lighter weight, prostheses using aircraft metals, plastic and laminate socket, and more durable cables among many things. These research groups had multidisciplinary teams. The VA was also of help in beginning the prosthetic school at UCLA in 1953. Prosthetic schools to teach techniques of prescription, fabrication and fitting were also started at the Rehabilitation Institute of Chicago operated with Northwestern University and at NYU for prosthetists, therapists, and physicians. NYU worked closely with the VA Prosthetic Center. The NAS Prosthetics Research Board was advisory to the VA on all aspects of research, development, and education in prosthetics. And the Board would accept or reject all experimental limbs and terminal devices or components once evaluated. The Committee on Artificial Limbs had recommended evaluation studies be carried out and this activity was begun in 1948 at NYU under the direction of Dr. Sidney Fishman. Part of the study was on how to evaluate a prosthesis in actual use. But testing occurred at various stages of development and production before an item was recommended for general production and use. It seems impossible to overemphasize the importance and accomplishments of the NYU program.
I suspect you are asking yourself "what does this have to do with ACPOC?" Well, I finally can turn to children and will ask your indulgence while I may seem to be parochial.
In Michigan the Michigan Children Commission (MCCC) was headed by Dr. Carleton Dean, a physician with a Master's degree in Public Health. For several years during the war he was aware that child amputees were being examined and fitted with prostheses and were rejecting them as being inadequate or uncomfortable. He was determined to remedy this situation. Dean met with Drs. Charles H. Frantz and George T. Aitken in 1946 to organize a Juvenile Amputee Program for Michigan to not only fit the best device available, but to instruct and train that child in its use - an idea commonplace now, but not then. After initial examination of the child at one of the Grand Rapids Hospital orthopedic clinics, the child was admitted to Mary Free Bed which was then a convalescent home for children. As Dr. Aitken has written "We were in the middle ages prosthetically. Limb manufacture was very crude .. .scaled down components were scarce. Improvisation was the order." (1) During the next several years they found prosthetic needs of children differed age to age and reported that the child was not a miniature adult to whom adult principles and modes of fitting could be applied.
Once open, the Juvenile Amputee Training Program was the responsibility of Frantz and Aitken and was open to any Michigan child who qualified for state aid, qualification was based on income, family size and needs. Initially most of the children had acquired amputations, but by the end of the first ten years, half of the child amputee census was congenital. It eventually became apparent that the team approach pioneered in the military hospitals for adult amputees worked well and should also be applied to the care of the child amputee. Because of the success of and information gained from the Juvenile Amputee
Program, Dr. Dean was able to interest Dr. Lesser of the Children's Bureau of the then HEW, who, in turn, interested the NAS and its Advisory Committee on Artificial Limbs. They visited Grand Rapids and the program, and in 1954 a conference here between Children's Bureau, MCCC, NYU, UCLA, the Advisory Committee and Drs. Aitken and Frantz led to a decision that a nationally organized program for the juvenile amputee should be started.
In those years grants from the Children's Bureau were only made to state agencies. Michigan Crippled Children Commission was selected and the Grand Rapids program became the national pilot program. In 1955 funds from the Children's Bureau were made available to MCCC to establish the Area Child Amputee Clinic, operated by MCCC, to be housed at Mary Free Bed, with its own staff. In this new setting, for the first time the outpatient clinic and the rehabilitation care was in the same facility - the general hospitals being used for needed surgery and with the local prosthetists volunteering their attendance and being re-imbursed on a fee for service basis.
The most important additional benefit of the grant was to permit out-of-state patients, who qualified for crippled children care in their home state, to be treated at Grand Rapids under the federal grant. This fact extended the scope and availability of care a great deal. We had always been allowed to treat private patients from any state that wished to come to the clinic.
Also in 1956 NYU was funded to extend evaluation of devices and techniques from all clinics and programs - children and adults.
Tying all this together was NAS-NRC. Its Prosthetic Research Board created the Committee on Child Prosthetic Problems. In 1959 the re-organization of NRC abolished the Prosthetic Research Board and produced the Committee on Prosthetic Research and Development(CPRD) of which Dr. Aitken became a member and in 1962 its chairman, and the Subcommittee was chaired by Dr. Frantz from 1956 to 1967and then by Dr. Aitken from 1967 to 1972 when he was succeeded by Dr. Leon Kruger of Springfield, Massachusetts.
I think that it is fair to say that our organization, ACPOC, is the direct descendent of the Subcommittee on Child Prosthetic Problems. So- what did they accomplish?
That subcommittee was initially composed of Drs. Frantz, Milo Brooks of UCLA, Fishman of NYU, Lesser of HEW, and Colonel Fletcher of APRL. One of the first projects was to survey the country. NYU undertook this survey of all amputee clinics in the U. S. for numbers and types of amputees, frequency and types of staffing of clinics. Dr. Fishman and Mr. Hector Kay carried this out in their Child Prosthetic Study Program on a near annual basis. Hector Kay wrote in 1971 that, "In essence, NYU has acted as an executive arm of the Subcommittee in implementing many of its recommendations." (2) Kay remained with NYU until he went to CPRD as Assistant Executive Director in 1965.
In 1958 SCPP brought together a group of people with known interest in the treatment of the child amputee. Included were the chiefs of eleven existing child amputee clinics from Philadelphia, Durham, Atlanta, Richmond, New York City, Chicago, Birmingham, Buffalo, Newington, Los Angeles, and Grand Rapids. These chiefs agreed at the end of the meeting to co-operate in studies, which would result in improved treatment for the limb-deficient child. Later, other child amputee clinics sought affiliation with the co-operating clinic chiefs. In order to maintain some degree of standards, criteria for inclusion and continuance in the co-operating program were established. I think it worth repeating as some may seem familiar:
- The chief of the clinic was to be a physician and if not an orthopedist one should be represented on the team.
- The child amputee clinic was to be separated clinically from other orthopedically disabled children and from adults.
- Team members were to have completed a basic upper or lower extremity prosthetic course -and preferably a special amputee course.
- Clinics were to meet at least every two weeks.
- Psychological and psychiatric services and other medical specialty consultation services were to be available.
- Clinic load was to be a minimum of 50 active patients under 16 year of age with 25 new cases per year.
- Systematic follow-up at 3-6 month intervals (depending on age) with written reports at each visit.
- Record-keeping capable of providing routine information and special data relating to research problems.
- Available photographic facilities were to be present.
- Acceptable prescription writing by the physician and checkout procedures by therapist, prosthetists, and physicians.
- Organized post-fitting training program on an outpatient or preferably inpatient basis.
New clinic applications were voted in or out by the SCPP after a site visit usually by Hector Kay. It took some clinics a fair amount of time before they could meet all of the criteria. But the total number of co-operating clinics gradually rose from the original 11 to 30 by 1971, with contact with some 30 others of various status regarding size and organization. I should mention that some had dropped out early for various reasons.
This group of chiefs met under the auspices of the Subcommittee at least once a year to report on progress, exchange opinions and make recommendations. At times symposia on defined topics were held and later published. (3) Usually the Subcommittee would meet twice a year - once at the end of the annual orthopedic Academy meeting and again mid-year in conjunction with the Clinic Chief's meeting. These meetings were also useful in providing feedback to developers and manufacturers of components being field tested. With NYU design testing, this allowed valid results to be more rapidly available. This group information interchange was valuable but not felt to be enough.
In addition to the communication between CPRD-SCPP staff, NYU and the Clinic Chiefs at their meetings, a newsletter was proposed as a medium of exchange of information.
In 1961 at a meeting of the then Clinic Chiefs, Dr. Frantz proposed an idea enthusiastically received. The first ICIB (Interclinic Information Bulletin) was published in October 1961-6 pages long - and had 100 copies printed. This publication was prepared by the Prosthetic-Orthotic Studies of NYU with a grant from the Children's Bureau of HEW. Eventually in 1967 it would gain a Library of Congress catalog number. Its popularity and usefulness increased steadily. In 4 years it had increased to 22 pages and 1700 copies and went to 262 addresses with 800 sent to World Rehab and AOPA. By 1971, 2700 copies were printed monthly. More amazing was that it was a monthly publication. It published variations in techniques of fitting, harnessing, new ideas on nonstandard prostheses, clinical problems and how to solve them, and open questions could be asked. One somewhat unique feature was an assignment schedule for articles from specific clinics at specified future dates. Its format, with these definite publishing dates, must have helped speed information passage, considering the long wait between submission and publication in other periodicals.
In the listing of criteria for participation in the Cooperating Clinics group, it was stated that team members should have taken one of the basic courses in prosthetics and preferably a course in the juvenile amputee at either Northwestern University or UCLA. The Chicago course was started in 1961 and the Los Angeles course in 1964. Hundreds of physicians, therapists and prosthetists attended these courses during the next 20 years. At New York, special lectures in juvenile amputee management were added to their regular prosthetic course. By means of theses course, the general level of care of the child amputee was raised and the next generation of physicians-the residents- were educated. These courses tended to be cooperative affairs. For example, the Chicago course began as a combined effort at Northwestern Prosthetic-Orthotic School with Drs. Claude Lambert and Ray Pellicore and the Area Child Amputee (Frantz and Aitken). It later included Dr. Charles Epps of Washington and Dr. Robert Tooms of Memphis and their data. These courses were offered twice a year for many years. Federal grants covering tuition for some of those attending were available.
In 1970 the Subcommittee began consideration of children's orthotics. Some meetings and workshops had already been held particularly in the lower extremity bracing area. The Clinic Chiefs were showing interest in the area even though they were each primarily representing juvenile amputee programs.
Over the year much had been developed in many centers and had been evaluated in the programs.
The APRL Sierra hand, the Dorrance juvenile hand, quadrilateral sockets for the juvenile AK amputee, PTB prostheses for immature BK amputees, a fabrication manual, field evaluation and instructional course in the Munster type BE prosthesis, lab and field studies on the CAPP electric cart, external power components like the Ontario elbow, the NYU elbow, myoelectric hands, the Michigan hook, the Michigan Feeder Arm and Mark IV Feeder arm, the Michigan electric chair with vertical lift, the ISNY socket, the PPA, the Sway Walker-the list goes on. Certainly a list of which those involved can be proud.
In the mid 1970's it appeared the program would halt. In 1977 the CPRD was dissolved, and with it the SCPP. And with it the Cooperating Clinic Chiefs program support. Much thought was given to what could and should be done. For a few years the Clinic Chiefs held some meetings at various clinic locations. This seemed of value. They have been listed in your annual programs and begin with a reference to year 1972. These were in addition to the SCPP meetings. A meeting had been scheduled for 1977 in St. Louis, but had to be cancelled when the host city chief left that city. The Clinic Chiefs executive committee-essentially the physician members of the last subcommittee - - met twice and conferred several times. In September 1977 they decided to consider establishing a freestanding organization. They believed some of the activities had been valuable and ought to be continued. This included ICIB which had printed recently 2800 issues with 400 going overseas. In a memorandum sent to all clinic chiefs, this idea of a freestanding body, incorporated, with bylaws, hopefully a tax-exempt status, a democratic progression of leadership, executive direction, dues, categories of membership and of multidisciplinary nature was suggested. This idea was to be proposed at a meeting of the "Ad Hoc" clinic chiefs in Grand Rapids called, as a substitute for 1977, in April 1978.
And so 20 years ago, in Grand Rapids, Michigan, at Saint Mary's Hospital, the idea was proposed and was accepted by the attendees. This Ad Hoc group then met to design a framework for a proposal. In March 1979 they met and agreed on the form of an organization which was presented to the group in April 1979 in Memphis. One hundred fifty five were registered to attend this meeting. The general format for the Association of Children's Prosthetic-Orthotic Clinics was accepted. Dr. Leon Kruger was elected President as were other officers and a Board of Directors with staggered terms. In September 1979 the Board of Directors met in Washington, D.C. and wrote proposed bylaws. These were presented to 200 registrants at the next meeting in East Orange, New Jersey in April 1980. They too were accepted needing minor changes. We were fortunate in that Dr. Fishman and NYU continued their participation and lent their expertise to again act as the staff and secretariat. Shirley Ferguson was named Executive Secretary and continued a role she had unofficially carried out for SCPP for several years. ICIB had been published only bimonthly since 1976 and was continued, but with very few issues during the next years because of decreased submissions.
In 1983 ACPOC was granted tax-exempt status. A short History of ACPOC was first published in the meeting program for Salt Lake City. Also in 1983 an effort was made to stimulate interest in ICIB by assigning clinic members responsibility for article submission and by publishing quarterly. ICIB was renamed the Journal of ACPOC - -JACPOC - - in 1985 and compiled with peer review requirements. About 4 years ago this publication was replaced by ACPOC NEWS containing not only the announcements and some official messages, but also scientific articles in a format somewhat reminiscent of the old ICIB - - a more informal but no less worthy vehicle.
We should note also in October 1984 in Washington a conference was held on the "Critical Needs of the Child with Long Term Orthopedic Impairment", sponsored by the American Academy of Orthopedic Surgeons, the Division of Maternal and Child Health, Department of HHS and the University of Miami School of Medicine. ACPOC participated together with fifteen other organizations with Dr. Newton McCollough HI as general chairman. It was interesting and thought provoking, but I'm not sure that anything in this world changed as a result.
Dr. Frantz retired in 1970 due to ill health and died in 1978. Dr. Aitken retired in 1977 because of ill health but made his last public function the meeting of 1978. He died in 1984 having never been well enough to attend any of our subsequent meetings. Certainly much has changed since the box lunches of 1978 and '79.I really cannot comment about events of the last twelve years. I've been retired and my slate is blank. But I am aware that 20 years after you met here in Grand Rapids you have formed a viable and valuable organization that can continue the 50 years history of improving care for the limb deficient child.
I would like to close with a personal observation and comment. In preparing this presentation I have reviewed hundreds of pages of records, minutes, and correspondence and I have been impressed again with the importance of the concept of the team. It was key to every step in improvement in child amputee care. And, I suspect, it has played a very important part in the development of the profession and career of each of you in this audience. In this organization you have been given a structure carefully thought out and debated, even if not perfect. This is an association of clinics - - of teams. If there are no teams perhaps there is no reason for the Association to exist. Without the structure of the team, there is a loss of cohesion and purpose leaving only a collection of individuals each with a personal agenda. My hope is that you will remember that each of you is truly the blind man and that, without being a member of and functioning in a team, you will know you own area of interest and the "elephant' of care of the limb deficient child and of this Association will suffer.
1. Aitken, G.T., in Forward to "Upper Extremity Prosthetic Devices for Children" MCCC, Lansing Michigan 1957
2. Kay, Hector W., in "The Children's Prosthetics and Orthotics Program", ARTIFICIAL LIMBS, Vol. 15, #2, pg.6
3. Symposia published under auspices of NAS-NRC
a. Normal and Abnormal Embryological Developments: Charles H. Frantz, Editor, Chicago 1966
b. Proximal Femoral Focal Deficiency: A Congenital Anomaly: George T. Aitken, Editor, Washington, DC 1968
c. Selected Lower Limb Anomalies: Surgical and Prosthetic Management:George T. Aitken, Editor, Washington, DC 1969
4. The Child with an Acquired Amputation: George T. Aitken, Editor, Toronto, Ontario, 1970