Abstract
Dear Editor
In addition to the publication of the article “Prosthetic prescription in the Netherlands: an interview with clinical experts” by Van der Linde et al. in the August 2004 issue of Prosthetics and Orthotics International we felt that some comments about the development of guidelines in the Netherlands could be of general interest.
In the light of the general opinion in daily clinical practice on the basis of scientific evidence the development of guidelines is an established method. In the Netherlands orthoses are prescribed mostly by Medical Doctors in Rehabilitation Medicine or Orthopaedic Surgeons (OS) in collaboration with a Certified Orthotist (CO) and sometimes with the advice of a Physical Therapist (PT) or Occupational Therapist (OT). In our case we were asked by the Dutch College of Health Care Insurance (CVZ) and the Ministry of Health Care to develop a clinical guideline on the prescription of orthoses. Together with the Dutch Society of Physical and Rehabilitation Medicine, the Dutch Society of Orthopaedic Surgery, the Department of Orthopaedic Surgery of the University of Amsterdam and our Department of Rehabilitation we started this project in February 2003. We chose for a selected part of all prescribed orthoses: Knee-orthoses, Ankle-foot-orthoses, Elbow orthoses and the Wrist-hand orthoses.
We realised that developing clinical guidelines for orthoses brings about more problems than developing clinical guidelines for prostheses for the lower limb. In the case of orthoses we have to deal with more diseases and/or disorders in which orthoses are prescribed and more different kinds of clinical professionals are involved. We used the same methods as Van der Linde: literature review (Van der Linde et al., 2004a) followed by interviews with clinical experts in the field (MD in Rehabilitation Medicine, OSs, COs, PTs, Reumatologists and Plastic Surgeons) (Van der Linde et al. 2003, 2004b) and Delphi methods in which statements can be discussed on the internet by a selected group of experts (Van der Linde et al. 2004c). After consensus on the statements is reached, preliminary guidelines will be presented in a workshop in which consensus should be reached. Finally a clinical trial in which the developed guidelines are used in the daily clinical practice will be executed, to examine the usefulness of the guidelines. During this process patients filled out a questionnaire about their expectations and experiences with orthotic prescriptions in general. The dissemination and implementation of the developed guidelines are the most difficult step in the process. The support of the potential users should be sought in a very early stage and during the stages of the development. Guidelines should describe (in this case) only the generic names of the orthosis and not specific (names given by the Orthopaedic Industry) names; in the latter the Insurance Companies could possibly misuse the guidelines for retrenchment.
Up until now we found that there is very little scientific evidence and that we have a great contribution from the clinical expertise from the professionals working in the field of P&O and the incorporation of the patient's opinions.