Rancho Los Amigos recognized for leading contributions in orthopedic rehabilitation

About 10% of U.S. orthopedists were trained at Rancho Los Amigos National Rehabilitation Center.

For several decades, Rancho Los Amigos National Rehabilitation Center, in Downey, Calif., has been a proving ground for orthopedic rehabilitation techniques and pioneers as well as a training arena for those aspiring to enter the field.

Rancho has had an impact on medicine world wide, not just in the United States, said Vert Mooney, MD. “It changed the character of chronic care, which brought it up to the forefront of rational care.”

A visit that rehabilitation pioneer Marian Weiss, MD, who established the famous Konstancin Rehabilitation Center near Warsaw, Poland, made to Rancho inspired him to employ systems he saw in use there at his own center. This is but one example of how those around the world learned from observing the Rancho techniques, Mooney said.

Recognized hospital

Today the 395-bed facility continues to be a top-ranked rehabilitation hospital providing orthopedic rehabilitation through centers of care for spinal cord injuries, stroke, pediatrics, limb preservation/amputation, arthritis and rheumatology, post-polio patients and orthotics/prosthetics.

“It is one of the most recognizable names internationally as an orthopedic hospital,” said Douglas E. Garland, MD, an Orthopedics Today Editorial Board member who once worked at Rancho. “One of the grandest concepts and perhaps one of the biggest contributions of the center was to treat categorical diseases, as well as the individual, with a ‘team’ approach utilizing physicians, nurses, therapists, prosthetists, psychologists and research engineers. This allowed critical mass of uncommon disease entities wherein expertise could be developed, protocolled and disseminated worldwide.”

When the specialty was young, “The model of rehabilitation that emerged was shaped heavily by what happened here at Rancho and the great clinicians who have worked here,” Jorge Orozco, PT, NCS, Rancho chief executive officer, said.

Spine stabilization

Rancho Los Amigos went from being a Los Angeles County poor farm in 1888 to a center offering physical and occupational therapies in the 1920s. Respiratory care for patients with poliomyelitis was provided starting in 1951, followed by chemical, pulmonary and physiological studies conducted at the center, which mainly served patients with polio at the time.

In the mid-1950s, Vernon L. Nickel, MD, was the first orthopedic surgeon to affiliate with Rancho, followed soon thereafter by Jacquelin Perry, MD. They performed spine fusion surgeries on patients dependent on ventilators. Those who could withstand the surgery and demonstrated the potential to be weaned off of their ventilators were eventually rehabilitated.

Perry, the second female orthopedic surgeon in the United States, established a pathokinesiology laboratory at Rancho in the 1960s.

Chronic care

“I think the big innovation came from Nickel,” Mooney said, He who served a fellowship under Nickel in 1959.

Following the Salk vaccine and the result decrease in polio rehabilitation, Rancho became a center for chronic orthopedic problems, such as spinal cord injury. Nickel also treated other musculoskeletal problems, like stroke, amputee care and fractures, Mooney said.

To manage those patients, Nickel recruited an array of talented orthopedists whom he met in travels around the country to work with him. Among those was his first recruit, David F. Apple, MD, who went on to found the Shepherd Center in Atlanta. The combination of Nickel’s dynamic personality and the allure of working at Rancho made it difficult for many young orthopedists to refuse the offer.

Orthopedic trainees today are not as aware of Rancho’s contributions as they once were, said Mary Ann E. Keenan, MD, a member of the Orthopedics Today Editorial Board, who worked in Rancho’s stroke and brain injury areas and on the joint service.

“At the time it was the main contributor in the field doing orthopedic procedures,” she said.

Nickel’s influence

Rancho was known for its early technological achievements realized with help from engineers working at nearby Rockwell International, then called North American Aviation. Several assistive devices were developed at the center, such as the halo apparatus for upper spinal traction and immobilization that Nickel and Perry introduced in 1955.

“The halo still has a role today,” Mooney said, noting another technical innovation that originated at Rancho was the ankle-foot orthotic, the AFO brace, made of vacuum-formed plastic on plaster.

A “Golden” assistive robotic prosthetic arm with 7° of freedom was first used at the center and then adapted for the aeronautics industry, John D. Hsu, MD, Rancho’s chief of orthopedics from 1988 to 2003 and another of Nickel’s recruits, said.

Separate services

Nickel reportedly made innovative organizational changes that improved the delivery of care. For example, he introduced segregated stroke, spinal cord injury and amputee services, which allowed local specialists to work part-time at Rancho and direct those services. As a result, considerable responsibility fell on the allied health personnel, ie, nurses and physical therapists.

“That was a big innovation that Nickel introduced,” Mooney said. The different services fostered specialization and allowed allied health personnel to fully appreciate the patients’ problems, sometimes to a greater extent than some residents rotating through the service.

Spine surgery

In addition to being an outstanding surgeon, Perry is recognized as an innovator and a systematic clinician. These characteristics suited her well for the complicated and novel cases she regularly took on at Rancho, Keenan explained.

Among Rancho’s surgical advances was being among the first U.S. centers in the West to use the Harrington spinal instrumentation system for correcting spinal deformity, which occurred when the system and its surgical technique were both new, Hsu told Orthopedics Today.

Perry helped introduce the system there, he noted.

“That was a very important step because then we were able to apply some of these techniques to spinal injury and other patients. Basically we extended the field as much as we could with as little risk to the patient as possible. We tried to make sure that we had all the safety factors there so the operations could be successful,” Hsu said.

Education

Orthopedic rehabilitation education and research flourished at Rancho in tandem with clinical advances.

“At one time, when they were in their prime and so many residents were rotating through there, Rancho had trained 10% of the orthopedists in the country,” Garland said.

Hsu estimated that in the mid-1990s, when there were about 16,000 board-certified orthopedists in the United States, 1,600 of them were Rancho alumni.

At any given time there were up to 10 fellows and 25 to 30 affiliated residents at Rancho, including Americans, Canadians, Europeans, South Americans and Japanese, Hsu said. “They came from all over the world.”

Research into various aspects of orthopedic rehabilitation thrived at Rancho.

“[It] was unique, one-of-a-kind and well supported” by grants from the National Institutes of Health, industry, local charitable groups and the government, Hsu said. “Much of it was not pure scientific research, but practical research,” he added. “We were there to serve the population. Nobody, from anywhere in the world, was ever turned away.”

Rancho’s mission today is to deliver superior medical and rehabilitation services in a culturally sensitive environment to everyone from members of the local community with spinal cord injuries or cerebral palsy to the young polio patients from around the world that Perry continues to see during her once-weekly rounds at the hospital.

“Unlike most rehabilitation centers, Rancho’s history is orthopedics,” Orozco said. “Because of that we have retained a multidisciplinary, interdisciplinary approach here. We have orthopedists working with neurologists, physiatrists and internal medicine doctors. The richness of that diversity is going to allow us to re-emerge as leaders in the field.”

For more information:

• Douglas E. Garland, MD, can be reached at 2760 Atlantic Ave., Long Beach, CA 90806; 562-424-6666; e-mail: dougarland@msn.com.
• John D. Hsu, MD, can be reached at 9060 Suva St., Downey, CA 90240; 562-401-7166; e-mail: jdhsu@usc.edu.
• Mary Ann E. Keenan, MD, can be reached at University of Pennsylvania, 2 Silverstein, 3400 Spruce St., Philadelphia, PA 19104; 215-662-3340; e-mail: MaryAnn.Keenan@uphs.upenn.edu.
• Jorge Orozco, PT, NCS, can be reached at Rancho Los Amigos, 7901 E. Imperial Highway, Downey, CA 90242; 562-401-7022; e-mail: jorozco@dhs.lacounty.gov.