New technological advances from engineering and space research are also opening new horizons in the rehabilitation of amputees and other orthopedically disabled persons. With VRA support, the Woodrow Wilson Rehabilitation Center Foundation in Fisherville, Va., and General Electric are collaborating to review GE's fund of technology from industrial, military and space research, to develop and improve orthotic and prosthetic appliances and equipment for medical rehabilitation. At Case Institute of Technology in Cleveland, the VRA is supporting a project aimed at enabling patients to use their paralyzed arms or legs by actuating muscles with electronic devices.

The VRA program has three assets in building the Nation's resource of research manpower:

(1) The research program attracts more and more research competence from an ever greater variety of professions into rehabilitation investigations.

(2) In the research project review process-through the study groups and the National Advisory Council on Vocational Rehabilitation who review these projects-the contributions of highly qualified and competent professional and lay leaders are secured.

(3) Rehabilitation research fellowships are awarded to enlarge and enrich our research resources by developing competent research workers in the professional fields which contribute to the vocational rehabilitation of disabled persons.

7. Training workers for rehabilitation

VRA's training grant program is a response to a serious shortage of qualified professional rehabilitation counselors, rehabilitation physicians, rehabilitation nurses, therapists, prosthetics experts, and a number of others. These shortages of trained personnel will become even sharper with the new personnel demands growing out of new programs such as Medicare, community health programs, and the planned heart disease, cancer, and stroke programs.

Each year since the start in 1955 has seen an increase and in 1965, with a $19.8 million appropriation, 526 teaching programs received support and grants were made for 3,780 traineeships and research fellowships. In addition, support was provided for short-term continuing education courses which reached over 6,300 individuals.

Training grants have enabled schools to employ faculty, field teachers, and clinic supervisors, and thus expand their admissions. They have enabled curriculum changes for incorporation of more rehabilitation content, more information about the nature and effects of disability, and the techniques and services that are utilized.

From a quantitative standpoint, manpower has been augmented in fields where there were serious shortages. More trained clinicians are working in rehabilitation settings than ever before, and a number of graduates are now on the faculties of participating schools.

Support is currently concentrated in the fields of medicine, with special emphasis upon residency training in physical medicine and rehabilitation; rehabilitation counseling; nursing; speech pathology and audiology; occupational therapy; physical therapy; psychology; recreation; sociology; dentistry; prosthetics, and orthotics; and social work. Encouragement is also given to the development of curriculums designed to provide specialized skills and knowledge required

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by workers for the blind, the deaf, the mentally retarded, and the emotionally disturbed. Training programs that are interdisciplinary in nature and pilot projects with collaborative practice also are being encouraged.

Training efforts in five major fields will serve to illustrate these activities.

(a) Rehabilitation medicine.-Rehabilitation calls for the talents of many medical specialists, but it is the primary function of specialists in physical medicine and rehabilitation. There is an acute shortage of physicians qualified as specialists in this comparatively new field. and the training grant program has given emphasis to increasing this number as well as helping to insure that all physicians will be knowledgeable about rehabilitation concepts and techniques.

Teaching grants to schools of medicine are made to stimulate the inclusion of rehabilitation content in the instruction of all undergraduate students. In 1964, they reached 70 of the 91 approved schools of medicine and osteopathy. In 1956, the first year in which teaching grants were awarded, only six schools received grants.

Grants for undergraduate traineeships include provision for medical students to have intensive work experience of 2 or 3 months' duration in research or clinical service in rehabilitation. In the first year of this program in 1960, 76 students were awarded such traineeships. In 1964, about 272 students had this experience.

Since 1955, when only 4 physicians were receiving VRA traineeships for residency study in physical medicine and rehabilitation, the number has grown to 139 in training on June 30, 1964. In addition to these, 36 physicians enrolled in other residency training programs were pursuing special supplementary training in physical medicine and rehabilitation.

Another great need is for educators equipped to give leadership in instruction in physical medicine and rehabilitation. To meet this need for broadly trained academicians, an academic careers program has been established. Grants for this purpose offer opportunities to promising physicians for advanced study in rehabilitation topics that will enhance their qualifications for academic posts. Four were in training at the end of 1964.

(b) Rehabilitation counseling.-Rehabilitation counseling is primarily concerned with helping a disabled individual to achieve his most productive role. Specific emphasis is placed on the client's occupational adjustment. Rehabilitation counselors are employed in State vocational rehabilitation agencies, rehabilitation centers, hospital rehabilitation programs, the public employment service, sheltered workshops, and in a variety of rehabilitation programs in public welfare or public health agencies. They work in a close team relationship with physicians, social workers, and other professional personnel serving disabled persons. In many agencies, the counselor carries responsibility for employer education and community publicity programs designed to attain a greater acceptance of handicapped persons as qualified job applicants. The counselor's responsibilities in State vocational rehabilitation agencies have already been described.

The number of graduates of rehabilitation counselor training programs (a master's degree course) needed annually for replacement or to fill new positions in expanding programs is now estimated at 1,200. University training programs in rehabilitation counseling currently

graduate many less than these requirements. Because of the urgent need, especially in the State vocational rehabilitation agencies, a large proportion of the training grant funds, second only to medicine, is used for the support of counselor training. In fiscal year 1964, such teaching grants were made to 38 educational institutions, and 775 traineeships were awarded. Of this number, about 360 were graduated and ready for employment, since the curriculum is generally 2 years.

(c) Physical therapy. The shortage of physical therapists is a matter of grave concern in the total development of rehabilitation programs, for physical therapy is an essential element in the treatment of nearly all kinds of disability. Training grants in physical therapy are directed toward improving and expanding the training programs in approved schools; accelerating the growth of newly established schools in geographical areas needing them; providing opportunities for advanced study by graduate physical therapists, and fostering experiments in new methods of training.

Since 1958 traineeships have been awarded to 85 experienced physical therapists for graduate study in physical therapy or related sciences, such as anatomy and physiology. Those who have completed their graduate training are now working in teaching, research, or administrative positions in the field.

VRA assistance now represents the largest scholarship program for this field. During 1964 traineeship grants were made to 41 of the 42 approved schools of physical therapy, and slightly over 400 undergraduate or certificate students received VRA assistance.

(d) Prosthetics and orthotics. Since 1953, over 9,000 rehabilitation personnel including prosthetists, orthotists, physicians, physical and occupational therapists, and rehabilitation counselors have received specialized training in the fields of prosthetics and orthotics (artificial limbs and braces) in VRA-sponsored courses at three universities. The VRA-sponsored traineeships have brought teams of medical personnel to these classes where the clinic team approach to rehabilitation, practiced today in all of the major hospitals and specialized rehabilitation centers, had its initial impetus and development through student participation in amputee clinic practice sessions.

Trained personnel in prosthetics and orthotics are urgently needed to staff clinic teams and rehabilitation centers throughout the country. There is also a great need to provide training to residents in orthopedic surgery and physical medicine during their residency training.

(e) Training workers for the blind. The recently established university courses for mobility instructors of blind persons are continuing, as are the special training programs to teach rehabilitation. counselors the basic principles and specialized techniques of placing blind persons in competitive employment. The courses for mobility instructors enrolled 28 trainees during 1964. The newly established training of home teacher for the blind enrolled its first class.

Short-term courses for services to the blind conducted among State agency personnel in 1964, included a series on placement of the blind in competitive occupations; on vending stand supervision and operation; on home teaching of the blind; for home teachers and their volunteer assistants; employment of blind persons as telephone switchboard operators; courses in industrial arts for the blind; placement of the blind in Federal employment; and inservice training of home teachers of the blind.

8. Facilities for rehabilitation

Rehabilitation facilities, an indispensable ingredient of the expanding public program, provide an unequaled means for evaluating, treating, training and serving the severely disabled.

There are many types: large centers for training or treating persons with practically all forms of severe disability; speech and hearing centers; optical aid clinics; centers for the blind; halfway houses for patients discharged from mental hospitals who are adjusting to community life; and workshops for various purposes. In addition to the variations in size and in purposes, some are medically oriented while others are primarily vocationally oriented.

State rehabilitation agencies have authority to establish facilities, with funds granted for basic rehabilitation services. Since 1954, 46 States have spent about $17 million to establish more than 300 facilities, most of them operated by private nonprofit organizations, and a few by the States.

The increase in facilities has had a most profound influence on the character of many State rehabilitation programs. State agency use of facilities has increased 10 times in the past decade. In 1955 the agencies paid for services at rehabilitiation centers for some 2,400 persons. In 1964 the total was 38,000 and over the country about 18 percent of State agency expenditures for services was made to facilities and workshops.

Since 1954 the Hill-Burton Act has permitted Federal help for construction of rehabilitation facilities as well as for building new hospitals. Funds for the rehabilitation facilities are jointly approved by the Vocational Rehabilitation Administration and the Public Health Service.

In all, through December 1964, 314 rehabilitation projects have been approved under the Hill-Burton Act involving primarily medically oriented centers in 48 States, the District of Columbia, and Puerto Rico. In 1964, 10 of the 32 construction projects were for the mentally retarded or mentally ill, and 3 of the 10 were for halfway houses for ex-patients from mental hospitals a rapidly growing phase of rehabilitation for these people.

The rehabilitation workshop is one of the resources for coping with individual disabilities. An estimated 800 workshops are operating now. There is a rising demand for more workshops, and the VRA, the State agencies, and private rehabilitation groups are attacking many problems that have arisen in expanding this phase of the program.

Research is providing some of the solutions to these problems. Projects have been initiated to find answers as to whether a multicommunity workshop is feasible; to find methods of obtaining contract work; methods of applying marketing principles to workshop products; to study the feasibility of establishing statewide systems of workshops; and a number of similar matters that will help the workshop to come into its proper place in the program.

9. Research and training centers

VRA now supports 14 special rehabilitation research and training centers with the necessary resources for continuing, comprehensive programs of clinical research and training to advance the rehabilitation of the disabled. Spread across the Nation are:

(1) Ten medically oriented research and training centers, at New York University in New York City; University of Minnesota in Minneapolis; University of Washington in Seattle; Baylor University in Houston; Western Reserve University in Cleveland; Emory University in Atlanta; Tufts University in Boston; Temple University in Philadelphia; George Washington University in Washington, D.C.; and the University of Colorado in Denver.

(2) Two centers dealing with mental retardation, at the University of Wisconsin in Madison and at the University of Texas in Austin, and

(3) Two vocationally oriented centers at the Hot Springs Rehabilitation Center-jointly sponsored by the University of Arkansas and the Arkansas State Rehabilitation Service, and the Pennsylvania Rehabilitation Center in Johnstown-jointly sponsored by the University of Pittsburgh and the Pennsylvania Bureau of Rehabilitation.

Started only 4 years ago, this program is rapidly taking a key role in advancing the Nation's rehabilitation program-through the unique combination of clinical resources, research and training talents, and State rehabilitation program resources.

In the medically oriented centers, the first to get underway, remarkable increases have been achieved in the depth of training and in research staffs. The quality and intensity of training in rehabilitation are mounting.

In the course of carrying out research and training activities, these centers are providing significant numbers of patients with rehabilitation services-from 750 to 1,000 a year, with increasingly significant cooperative arrangements with State vocational rehabilitation agencies.

In the medically oriented centers, patients are getting better, more comprehensive rehabilitation at an earlier stage of their disability.

These centers have shown-as the vocationally oriented centers and those dealing with mental retardation will be showing-the values of drawing together the top specialists from a variety of disciplines to work coordinately on common problems affecting the disabled. 10. International rehabilitation research programs

This 4-year old program to share and interchange rehabilitation knowledge and efforts has speedily proved its worth. In all, 64 projects in 9 countries-Israel, India, Brazil, Burma, Egypt, Yugoslavia, Pakistan, Syria, and Poland-have been financed with U.S.owned foreign currencies, which result from our sale of agricultural surpluses abroad, and are excess to our Government's regular requirements. These projects deal with a range of disabling conditions— cerebral palsy, leprosy, blindness, cardiovascular disorders, and burns, among others. Also underway is a most fruitful program for interchange of rehabilitation experts between this country and other

nations.

This work can be exceptionally rewarding. For example, Poland's experiment with the immediate postoperative fitting of prosthetic devices upon amputees, generally while the amputee is still under anesthesia, is expected to bring profound changes in orthopedic surgery and prosthetics. An electronic hand, with five sensory