C. Ralph Hooper Jr., CPO: Scoliosis Bracing Pioneer

Hooper marks the trim lines for fitting the Charleston Bending Brace. Photographs courtesy of Ralph Hooper.

As a young practitioner, C. Ralph Hooper Jr., CPO, was fascinated by the fabrication of orthoses for patients with scoliosis and chiefly for patients with adolescent idiopathic scoliosis (AIS), the most frequent scoliosis diagnosis requiring orthotic intervention. "I can remember the intricacies of making a Milwaukee Brace and checking the results with the doctor on x-ray examination," Hooper says.

The cumbersome Milwaukee Brace, or cervico-thoracolumbo-sacral orthosis (CTLSO) developed in 1946 by Walter Blount, MD, and Albert Schmidt, MD, had been the gold standard for scoliosis orthotic management until 1972 when the lower-profile "underarm" Boston Brace was developed by the late Bill Miller, CPO, and John Hall, MD, and found to be far more comfortable, easier to wear, and more cosmetic. In 1977, Hooper spent three months with Miller in Boston, Massachusetts, mastering the new thoraco-lumbo-sacral orthosis (TLSO) design. At that time, Frederick E. Reed, MD, the physician with whom Hooper had been working in Charleston, was participating in a one-year fellowship at Boston Children's Hospital. "When he returned to Charleston, we started a scoliosis brace clinic, Orthopedic Associates of Charleston, which became very busy and popular within the region," Hooper says.

Daughter Sparks Groundbreaking Invention Hooper's interest in scoliosis orthotic management took a more focused and personal turn in 1980 when his daughter Jessica, then ten years old, was diagnosed with AIS. "During a routine health exam, it was discovered that she had a right thoracic scoliosis," Hooper recounts. "Her scoliosis was the type that was not considered a candidate for the Boston Brace, and she would be required to wear a Milwaukee Brace with a metal superstructure up to and around her neck. Needless to say, she was going to have none of that. And I had fit far too many of these braces and had seen the emotional, physiological, and family issues involved to welcome the idea of Jessica wearing this type of brace...."

The answer to the dilemma came while Hooper and Reed were looking at a lateral-bending x-ray of Jessica's spine. They noticed that the curve had completely corrected and was very flexible. "We both realized that Jessica was not going to wear a brace during the day, and maybe putting her spine in the position demonstrated on the x-ray during the night would be better than nothing." Being aware of the history of the side-bending concept in orthotics, they saw the possibilities for a brace for Jessica. "So, I made the first Charleston Bending Brace for my daughter Jessica out of necessity," Hooper says. "The results were remarkable, and we tried the brace on other patients with positive results."

Hooper measures the distance from the patient's axilla to the trochanter on the convex side of the curve as she is sidebending.

Jessica's completely corrected curve has lasted into adulthood. "Jessica did not have any other treatment modalities for her scoliosis," Hooper says. "She had a 30 degree thoracic curve to start with and wore her brace for 24 months, ending with a complete correction to zero degrees. While this is not the norm, it was a welcome exception for me."

Later Hooper and Reed collaborated with Charles T. Price, MD, who treated a much larger population of scoliosis patients. "Dr. Price became our champion research professor, directing the first research publication in 1990" (Price, C.T., D. S. Scott, F. E. Reed Jr., and M. F. Riddick. 1990. "Nighttime Bracing for Adolescent Idiopathic Scoliosis with the Charleston Bending Brace. Preliminary Report." Spine 15 (12):1294-9). Subsequent research has supported the efficacy of the Charleston Bending Brace, and scoliosis bracing in general, to slow or stop curve progression, although some curves continue progressing and more aggressive intervention, including surgery, may be needed.

The Charleston Bending Brace is molded to conform to the patient's body while bending toward the convexity of the curve, thus "over-correcting" the curve while the patient sleeps, the National Scoliosis Foundation explains. The brace is generally prescribed for single curves in the 20 to 40 degree range.

Following the design's success in treating Jessica, the Charleston Bending Brace was introduced commercially, bringing its benefits to patients throughout the United States and beyond. Although not indicated for all patients, the Charleston Bending Brace and the other nighttime designs that followed it have the advantage of less wear time than the typically prescribed 18 to 23 hours. They also allow the young patients to pursue their daily school and sports activities and wear the clothing they like without the restriction of braces and without risk of negative reactions from peers.

Professional Highlights "The invention of the Charleston Bending Brace is by far the number one highlight of my career," Hooper says. "I have had the opportunity to travel the world and lecture in venues that I never envisioned possible." He adds, "Another unforgettable experience was attending the American Academy of Orthopaedic Surgeons (AAOS) Annual Meeting when the first scientific research paper with results of the Charleston Bending Brace was presented in 1990."

Hooper prepares to fit the patient with her new Charleston Bending Brace.

Contributing to O&P professional organizations in various capacities has also been satisfying for Hooper. "Serving as ABC [American Board for Certification in Orthotics, Prosthetics & Pedorthics] orthotic exam chairman for two years was especially meaningful and rewarding," he says. Hooper has served in various elected positions and on committees with ABC and the American Orthotic & Prosthetic Association (AOPA), as well as various state organizations, including as past president of the South Carolina Society of Orthotists and Prosthetists (SCSOP). He is also a past president of the Florida Association of Orthotists and Prosthetists (FAOP) and of the Florida Chapter of the American Academy of Orthotists and Prosthetists (FAAOP), positions he held while living in Florida during the mid-80s to mid-90s. During that time, Hooper worked for Danforth Orthotic Prosthetic Laboratories, Winter Park, and J.E. Hanger Southeast, Orlando.

The Changing O&P Scene "I have been involved in orthotics and prosthetics for more than 30 years, so I have seen significant changes," Hooper notes. The two most important changes he has observed are ongoing in areas directed toward the common goal of advancing the field: practitioners and products. "One major change is that practitioners today are by far more educated than practitioners [were] when I began my career," he points out. "Practitioners today also have much more responsibility to meet and exceed the expectations of the patient and referral source." He continues, "The second area of change is the product itself. Manufacturers of O&P products have introduced the newest technology into our products, and their innovations through research and investment have benefited O&P tremendously."

O&P Confronts Challenges Hooper sees increasingly complex and heavy-handed government regulation as the biggest challenge facing the O&P profession at the moment. He is especially concerned about the Centers for Medicare & Medicaid Services (CMS) decision to accept only physician documentation to justify medical necessity and payments to O&P providers, although generally physicians are not experts in O&P, Hooper points out. Historically, most physicians have relied on O&P clinicians for their recommendations as to what prosthetic or orthotic devices are best suited for individual patients, he adds. Although CMS modified its decision somewhat to allow the orthotist's or prosthetist's notes to be included in the physician's records, these notes cannot be used to document medical necessity.

Hooper believes that orthotists and prosthetists must be considered healthcare professionals rather than simply device suppliers. "I believe our biggest long-term challenge is the battle for definition and survival as professionals in the healthcare industry. Even today, in the vast majority of cases with very few exceptions, a CPO with a master's degree is entering a hospital or healthcare facility as a 'vendor' rather than a healthcare provider. We have not yet separated ourselves from the product. We are still not viewed as healthcare providers delivering a service with the product."

Looking Ahead As to the profession's future, Hooper says, "Going forward, I would like to see O&P develop and maintain an...independent identity in the healthcare delivery system. I would like to see our present L-Code description system overhauled or done away with completely and replaced with a modern reflection of what we really contribute to the rehabilitation process of the patient."

Hooper recently partnered with his longtime friend, A.J. Filippis, CPO, president of Wright & Filippis, Rochester Hills, Michigan. In January 2013, Wright & Filippis acquired a majority interest in Hooper's company, Carolina Orthotics & Prosthetics, headquartered in North Charleston, South Carolina. "I still remain as president and a minority shareholder and partner," Hooper explains. "My immediate plans are to grow Carolina Orthotics & Prosthetics through acquisition and [by] opening patient care facilities in desirable locations throughout the Southeast."

Past, Present, Future Hooper, a fourth-generation Charlestonian, attended Gardner- Webb College, Boiling Springs, North Carolina, from 1967 to 1969. From 1971 to 1973, he attended the College of Charleston and took classes at The Citadel, the Military College of South Carolina's civilian Graduate College and Evening Undergraduate Studies Program. In 1976, he earned his graduate certificate in orthotics from New York University Medical School, New York, and his orthotics certification from ABC. He earned his graduate certificate in prosthetics from Northwestern University, Chicago, Illinois, and received his ABC prosthetics certification in 1978.

Enjoying Family Time and Outdoor Recreation Hooper and his wife, Jackie, enjoy the slopes in Vail, Colorado.

Hooper and his wife, Jackie, love the outdoors and spend a week each year riding horses at a working cattle ranch in northern Montana. They also have a horse in Charleston, as well as four cats and two dogs. "We snow ski each year and love to sail. I enjoy fishing and hunting as well," Hooper adds. Hooper has two daughters, Jessica and Michelle, who both work with him in the administrative side of the business, and two grandsons.

His Advice: Find What You Love Hooper's advice to those thinking about a career in the O&P profession is advice he has followed himself: "There are many challenging jobs related to the delivery of orthotic and prosthetic services; find what you love and best suits you." Following this course has provided a richly rewarding career for Hooper, with more yet to come. He says, "I am not sure I will ever completely retire, and at this point, retirement is not on my radar. I can't imagine not being involved with orthotics and prosthetics in some capacity."

Miki Fairley is a freelance writer based in southwest Colorado. She can be contacted via e-mail at linkEmail('miki.fairley','gmail.com');

C. Ralph Hooper Jr., CPO: Scoliosis Bracing Pioneer

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