APPLIANCES FOR PARALYSIS IN DEVELOPING COUNTRIES

INTRODUCTION

An attempt should always be made in all developing countries to start a simple orthopaedic workshop even if, initially, this is with a single worker. In too many developing countries, it is erroneously felt that appliances can only be made by a highly trained sophisticated orthopaedic technician. This type of person, in the early stages of starting an orthopaedic workshop, is often a drain on the economy of the country, and with notable exceptions may be the worst type of person to employ.

In Uganda up to 1960, the only calipers being made were copies of European and North American types of support with welded tops, adjustable side arms and specially fitted heel sockets in open toed boots. These were exorbitantly expensive, production was appallingly low, and hundreds of patients, as is the case in most developing countries, were crawling because of lack of supports. The totally impractical and expensive open-toed boots made by a local shoemaker only lasted a short time before they broke where the sole joined the open toe. These boots also allowed toes to get dirty and wet without affording the usual protection of a boot. They did not even support the foot properly, as the weak forefoot in polio was incompletely splinted.

Metal crutches made in a loop, while ingenious in concept, were made of steel which required heating before bending. Rubber tubing on the bottom of the metal wore through to the metal within a few weeks, and the wooden handles broke where they had been bored to slip over the steel. Simple appliances were designed in Uganda which could be simply manufactured, and 50 - 100 of them could be made in the time taken to weld, mill and drill a single complicated and completely unnecessarily complex caliper. In most developing countries, however, millions of patients still crawl through lack of simple supports.

In 1960, the first workshop to make simple calipers was started in Uganda. A derelict shed, a vice, hammer, hacksaw, tape measure, an old workbench, a pair of scissors and some simple leather hand-sewing materials were the only tools initially used. The materials were 4.8 mm galvanised wire, bought by the hundred-weight roll, and 6 mm and 8 mm iron used for reinforcing concrete.

Locally produced lining and brown leather, buckles, and thread were used for the calipers. Old blanket, subsequently replaced by cotton waste or cheap cotton wool, was used for padding the top of the calipers. The only two workers in this first workshop were a paraplegic patient with transversemyelitis, who was shown how to use the leather sewing materials, and a completely uneducated and otherwise unemployable labourer to do all the metal work. The metal of the first caliper took less than five minutes to cut and bend, and the first 300 calipers were made without outside assistance in two months by these two almost untrained workers supervised by the author.

Subsequently, a secondhand leather sewing machine was bought to mass-produce the knee pieces. A simple metal bending machine, in conjunction with an adjustable jig and metal cutter, followed and allowed the metal of a complete caliper to be cut and bent in under one minute. A mass-production line for wooden clogs and crutches, with band saws, planers and drills at present enables many thousand of each of these to be made each year. Initially, however, these were cut, carved and drilled by hand, and there is no reason why, in a small workshop in developing countries, this should not continue until increased financial assistance permits expansion and mass-production. It cannot be stressed often enough that, unless a start is made with a simple workshop, and unless some supports are produced, however simply and however crudely, with voluntary money if necessary, governments are unlikely to take more than a passing interest in such projects.

Others help those who help themselves, is a well-worn but true saying, and Ministries of Health in economically poor countries like to support projects which they can actually see are viable. There is no reason why calipers, crutches and clogs should not be made in any developing country, with only the basic equipment mentioned above.

EQUIPMENT AND WORKERS FOR SIMPLE WORKSHOPS

The equipment needed for a wooden crutch is a wood saw, drill, screwdriver, wooden dowels or broom handles, screws, nails, rubber or motor car tyre for the bottoms of crutches, and some 1 or 1.25 diameter square lengths of hard wood. In countries where bamboo is readily available, this can be used instead of the wood and dowels.

The basic equipment required for a clog, in addition to the above, is hard wood, floor linoleum, a chisel and mallet, some glue and some broad-headed carpet tacks. Wood preservative or linseed oil will prolong the life of clogs in tropical countries.

An electric drill on a stand for drilling clogs and crutches, and a smaller leather sewing machine for the knee-pieces of calipers are useful, but not essential. It can be seen that more than enough equipment to start a workshop to make calipers, clogs and crutches can be bought for a few dollars or pounds, and any small shed will do as the first workshop.

One hard-working technician without any formal education, but with the most elementary knowledge of wood and leatherwork is the only person needed initially for making these simple appliances. It is recommended that, where there is already a workshop making expensive and complicated appliances, with a technician who is more interested in his own narrow standards than in the fate of thousands of disabled patients, both workshop and technician should be completely by-passed, unless he be an exceptional and dedicated person prepared to make simple cheap supports. He can continue to make his sophisticated and expensive appliances for the few who can pay for them, but should not in any way be involved in the simple mass-production workshop, unless he can completely adapt to the needs of a poor country.

A voluntary organisation can usually be persuaded to start a practical workshop, and once this is working and supplying simple supports free to disabled patients, the government will soon support this. This has happened in several developing countries, when a selfish orthopaedic technician, tied to union rules, has refused to consider crippled patients, unable to pay anything for supports.

LARGER WORKSHOPS

Once mass-production starts, and many thousands of supports are made each year, separate workshops for each type of material can be built. (Fig. 31b)

Wood workshop:

Basic woodworking equipment will help speed production. Many thousands of crutches, the wooden parts of clogs, the wooden seats of wheelchairs, fracture boards, foot-pieces for plasters, wooden spreaders for tractions, and the wooden part of pulleys can then be mass-produced.

Metal workshop:

This should be provided with the equipment for bending the metal of calipers, and for making wheelchairs, Balkan beams, weights, and the metal of simple pulleys. Knee-bending pieces for calipers may also be manufactured here.

Leather and assembly workshop (Fig. 31c):

This requires the equipment for putting the leather tops on calipers and for making knee-pieces and straps for calipers. Clogs will be assembled here, as well as boots and special leather supports for the knees and hands of very severely paralysed patients.

Special appliances workshop:

This workshop should be responsible for all plastics, such as expanded polyethelene and vitrathene corsets, as well as knee, foot and arm supports manufactured from these materials and from polyester resin. It should be combined with the artificial limb workshop, as much of the equipment required is similar to that required for prostheses.

Training of workshop techicians:

In a fairly small workshop technicians are best trained by apprenticeship, and should go from one workshop to another actually learning to make all the parts necessary for the various supports.

In Uganda such a course was run with 31 technicians from 14 different countries, and although this particular course was compressed into six months, this period would normally be found to be too short. A second course for 14 technicians of one year's duration followed the first course. Large courses will need large workshops, but in most countries the training of three or four technicians by apprenticeship will not necessitate special accommodation, as they will rotate through the workshops as working and contributing members of the staff.

Caliper Banks:

In countries where several clinics have been started, caliper banks are indispensable, and clinics spread throughout the country are invaluable, especially if there are technicians available to assemble and repair calipers as well

as to make clogs and crutches. Ideally, this simple training should take not more than three to six months, provided the technician has a basic knowledge of woodwork and leatherwork. More specialised prosthetic manufacture will take longer to learn. It has been found that it is better in large countries to provide one large well organised mass-production central workshop, turning out thousands of prefabricated parts, which can be assembled throughout the small centres, than several smaller workshops all trying to do the same thing.

UPCOUNTRY WORKSHOPS

A ring of small workshops in upcountry hospitals is necessary because minor repairs, raises on clogs and adjustments to calipers are sometimes necessary to the mass-produced article. The technician who is required to carry out these modifications on clinic days can also be employed making or assembling appliances from prefabricated parts, and stock-taking at other times. The second grade of technician who requires training is a much more skilled person. He may have come for training from another country and may have to be solely responsible for organising a major workshop. Such a technician must know not only how to make all the equipment himself, but must also have received training in the manufacture of artificial- limbs and corsets. The minimum training necessary for such a senior technician is one year, and he must, in addition, have a good knowledge of metal, wood and leatherwork before he starts the course.

An upcountry workshop is similar to the first small workshop in any country, i.e., a single workroom with one technician provided with simple wood, metal and leatherworking tools. There must be a lockable store for raw materials, with a smaller store of finished articles ready for fitting. Ideally, this workshop should be attached to the room used as a polio clinic and as a physiotherapy room.

Stores for raw materials and finished articles:

Stores for raw materials and finished articles are essential and in large workshops a storekeeper must be employed, who uses recognised book-keeping methods for issuing raw materials and accounting for wastage. All finished articles, which may number several thousands, must be properly issued, both to the major centres and to upcountry hospitals. Offices Ideally, at least two offices are needed. One should be a small one for the technician in charge of the workshop. The other is a larger one for the keeping of records, the issue of equipment and for general administration.

CONCLUSIONS

An orthopaedic workshop can vary in size from a large complex, as in Uganda, employing 70 workers, and training another 20, and mass-producing tens of thousands of supports each year, to a small one-man workshop consisting of a few dollars or pounds worth of equipment with which a few calipers, clogs and crutches can be made. It is important that all developing countries should start initially with the manufacture of simple supports. Crippled unskilled labour should be used where possible, and some attempt should be made to get at least a few of the thousands of crawling cripples upright and walking, who cannot pay anything at all for supports. If necessary, sophisticated expensive workshops employing expatriate technicians should be by-passed unless they are really prepared to make simple cheap appliances out of local materials.

INDIVIDUAL APPLIANCES FOR POLIO PATIENTS

Any appliance, provided that it is comfortable and supports the joint or joints it is intended to support, is better than no appliances at all, and a patient without a support is often a crawling patient. A patient with a support is usually upright and walking. Orthopaedic technicians in over 90% of the developing countries however, feel that nothing but the best for their patients is good enough. They feel that it is better to get one patient up in a well-fitting, expensive caliper made out of duralumin, sometimes after many weeks of personal attention and fitting, rather than 50 or 100 patients walking in sturdy, unsophisticated supports. They forget that this short-sighted policy may mean that thousands of cripples, many of them children, will remain crawling, while a few lucky patients, often those with money, are upright. They forget that it may take months, and often years, before the patient or his relatives summon up enough courage to come for treatment for the first time. These patients usually cannot afford to wait weeks for a support, and often cannot afford to pay anything at all for an appliance.

The fate of sending such patients home without a support is often to condemn them to an early death. Parents will often regard upright children as worth educating. They seldom feel the same about crawling children, especially in countries where poverty is common and families are large. Even when the child does not die, continued crawling will usually make his contractures worse and the subsequent management more difficult. It will be many years before the developing countries of the world will be able to afford anything but a limited number of cheap supports for their crawling millions. Every extra screw and every extra sophisticated part of a support will prolong the time for which all crippled patients will have to wait for the supports they urgently need.

COMPONENTS OF A SIMPLE CALIPER

METAL FRAME OF CALIPER

a. Calipers of less than 1 foot(30 cm) long — 0.175( 4.8 mm) galvanised wire.

b. Calipers 12-20(30-50 cm) — Mild steel 0.25(6.4 to 8 mm).

c. Calipers over 20(50.8cm) — Mild steel 0.31(8 mm).

d. Calipers with a simple knee-piece — Mild steel 0.31(8 mm).

e. Calipers for very heavy patients — Mild steel 0.375(0.96 mm).

SIZE OF RING OF CALIPER

a. Calipers of less than 12(30 cm) — 3(7.6 cm).

b. Calipers of 12-20(30-50 cm — 4(10.2 cm).

c. Calipers over 20( 50 cm) — 4.5(11 cm).

d. Very large calipers — 4.8(12 cm)

LEATHER ON CALIPER

Lining Leather

(a) Centre of knee-pieces

(b) Inside caliper ring

Brown Leather

(a) Outside of knee-pieces

(b) Outside caliper ring

(c) Straps

Cheap Cotton Wool or Cotton Waste

Padding for top of caliper under leather

Buckles

(a) 1(2,5 cm) for small sizes of caliper

(b) 1.253.2cm) for large sizes of caliper

A simple orthopaedic workshop must, therefore, be set up in every developing country to mass produce the cheapest and most durable calipers, clogs and crutches that can be made. (Figs. 31) These are needed by the thousands in almost every tropical country, and they must be paid for by the state with help if possible from voluntary organisations., and made where possible by disabled labour.

Sophisticated supports should only be made for those who can pay for them once the mass-production is under way. One exception to the rule for simple supports is the patient, who, because of the special nature of his disability, such as a severely deformed foot, requires a special boot or support made to measure or an appliance to help him or her to become more mobile or self-sufficient in the home or in employment.

In future, when all crippled patients have been fitted with calipers or other supports, a gradual process of improvement should be instituted in a phased programme. A simple knee bending caliper (Fig. 31(e)), should, however, always be made before a complicated one, improvements to wheelchairs should not affect the quantity produced, and long delays should not supersede immediate fitting, except for specially made appliances.

CALIPERS (Fig. 31(d))

Millions of calipers will be needed each year in the developing countries of the world, and the need will increase in the future. The calipers are used mainly for the flail lower limbs of polio patients, and to give support to otherwise weak and unstable knees and ankles. Other supports are also needed to a lesser extent for weak hips and spines.

Calipers of the type made in Europe and the U.S.A. have little application in countries where the expense, complicated design and length of time necessary for manufacture are totally impractical, except for the wealthy few. A cost of several hundred dollars for a single calipers, is quite an impossible sum when a single country may require many thousands each year.

The screws of the complicated duralumin caliper tend to work loose and get lost. The knee-bending mechanisms may clog up with sand and mud in a country where people wade through muddy stream and cross ploughed fields or sandy deserts. The duralumin of the gleaming calipers bends and breaks, and uncared for leather deteriorates quickly in such conditions. In addition, a delay of several weeks or more, while calipers are made to measure, is impossibly long, in countries where patients travel long distances and sometimes find it difficult to stay for even one night. These polio patients are usually children, and the calipers are outgrown or outworn in three to six months, so from every point of view a simple, cheap, foolproof caliper is required, which is immediately available in all sizes.

Attempts have been made in many countries to make simple calipers, and some of these are considerably cheaper than those manufactured in Europe and the U.S.A. Most, however, suffer from the fault that they are merely cheap copies of European ones still requiring welded parts and screws. This all adds to labour costs, and necessitates the employment of skilled and semi-skilled workers.

A very simple design of caliper will be described, which is easy to make and costs less than one-fiftieth of the price of has an imported duralumin caliper with knee pieces. Several thousand have been made each year in Uganda, and they do not require heating or welding. They are strong, and are often lighter than their more expensive counterparts from Europe and North America. They cost less than a dollar, and use virtually unskilled labour for their manufacture.

TYPES OF CALIPER

Below-knee caliper

The components of the caliper without a knee-bending piece are shown in Fig. 31(d). The main components are 3/16 (4.8 mm) gaivanised wire or 0.25(6.4 mm) or 0.31 (8 mm) soft iron or mild steel. Those made out of the latter metal is more difficult to bend but is stronger. The top of the ring is padded with wool or cotton waste, and covered with leather as shown. Soft lining leather is used next to the skin.

Above-knee caliper

This is identical with a below-knee caliper except for its length, the size of the ring, and the fact that it has a simple knee-piece to support the knee (Fig. 31(d). The knee-piece can be adjusted to compensate for a mild flexion deformity (Fig. 22(c).), or for varus or valgus (Fig. 22(c)).

In the case of genu recurvatum, a tight posterior strap a little wider than normal and prevents the knee from displacing backwards.

Hip flexion pieces

In patients with very unstable hips, especially those with an internal or external rotation deformity, a simple hinge on a pelvic band will improve gait. In those with a very unstable spine this is attached to the corset (Fig. 31(f)), instead of to a simple pelvic band.

It should be stressed that, where there are inadequate facilities, nothing but the simplest caliper should be made initially, and the patient can at least be got upright and walking, however badly. The next stage can be the fitting of pelvic bands or corset, if necessary. It should also be stressed that the immobilisation afforded by the extra attachment to the spine or pelvis may mean that the patient may not walk as fast, or as well, as without a corset. This is especially so when the patient can only just manage to walk with a support.

KNEE BENDING CALIPER

This is shown in Fig. 31(f), complete with knee-bending mechanism. This is but one common design of caliper, and has the advantage of being adjustable for a growing child. In practice, however, in the tropics, it is found that the leather of the caliper usually wears, or requires repair by the time the caliper is outgrown, and it is much better to replace the entire caliper. In the simple mass-produced caliper the metal can be used several times, and the caliper recovered as necessary.

They are only indicated for some adults. In developing countries, it is not often worth going to the trouble and expense of making them for children, as children outgrow their supports and require frequent changes. The caliper is identical with an ordinary above-knee caliper, except for a joint opposite the knee joint, which has a rivet on each side and a piece of piping which slides up to unlock the joint, and down to lock it. This is shown in Fig. 31(e).

It can be seen that it is very easily made from an ordinary type of caliper, the only difficult part of this caliper being the exact diameter of piping. It is found in practice, however, that too loose a fit over the piping is not important, as the combination of the leg, knee-piece and two side supports usually give all the stability necessary.

The type I caliper is easier to make but the type II is indicated for all but the simplest of workshops. It must be stressed that a knee-bending caliper in poor countries is not essential, even for adult patients, and patients should initially be fitted with ordinary standard, non-bending supports. As the economy of the country improves the better quality supports with a knee-piece can be gradually made, adults and older children taking initial priority.

The caliper can be made specifically for a particular patient, but the simplest method is to take a caliper 2 (5 cm.) longer then that required, cut it about 1.75 (4 cm.) above the knee, and flatten the congruous surfaces. It should be riveted at the knee joint after the piping has been threaded on the upper limb of the caliper (Fig. 31(e), Type I). It is best to use not less than 0.38(8 mm) mild steel (for larger calipers) as 0.25 (6.4 mm) may break. The diameter of the piping for this is approximately 0.45 (11 mm) with a length of 1.75 (4 cm.). - The leather front knee-piece should be a little longer than normal. The leather strap behind the knee is only placed below the hinge, as shown.

The piping should fit fairly firmly, and the rivet needs to be flush. This may sometimes be difficult to make properly. A disadvantage of this type of knee-piece is that the sharp ends may tear the trousers when the knee is bent. Shorts should therefore be worn, or strengthening material sewn on the inside of the trousers to prevent this. Apart from this disadvantage, the caliper is simple cheap and foolproof, and should be used for some of the of adult patients.

A more sophisticated version of this bending caliper (Fig. 31(e) Type II) consists of a 'hinge' with a rivet merely at the joint itself without the protruding sharp upper end. This hinge is more difficult to make, as the two ends must be flush and interlocking, and the rivet should be congruous with this surface. Half the piping can then slide over the actual hinge rather than only down to it, as in the simple model. A simple stop 3/4 (1.9 cm) below the rivet prevents the piping slipping any further down the caliper.

FOOTWEAR

Boots have many disadvantages in a barefooted community. Apart from expense, they often deteriorate rapidly in wet and muddy conditions. The manufacture of a raise or backstop is a time-consuming and expensive procedure. Patients, whether adults or children, often refuse to wear a boot on one leg and no boot on the other to compensate for moderate shortening, which is one way of dealing with a limited degree of disparity in length. Clogs have the advantage of cheapness and ease of manufacture, and their cost is a mere fraction of that of boots. They give more support to an equinus foot than a boot, and most barefooted patients prefer them to boots. They will also wear a clog on one foot and not on the other to compensate for moderate shortening. Clogs also seem to last considerably better in muddy conditions than boots, especially if waterproofed. They do not, however, support a severely calcaneus, valgus or varus. foot adequately, and a boot must be used for these categories of patients. Boots should also be used for those patients who normally wear shoes, except in the case of young children.

CLOGS

Details regarding the manufacture of a clog are shown in 31(g) and 31(h). It may be seen that this simple design can be mass-produced by the thousand, and has proved satisfactory over a period of several years. It is essential that the back heel support of the clog in the large sizes is made either of thick floor linoleum, vitrathene or a similar strong material, and that it is properly glued and also attached with large tacks. Some patients may need padding in the heel in addition. Where the heel is severely wasted, a specially made clog may be necessary. It is stressed that a varus heel, or one with much equinus, will either need operative correction before a clog is fitted, or a boot.

Continued in part 2