September, 1962 P H Y S I O T H E R A P Y Page 5 MEDICINE A N D PHYSIOTHERAPY IN TETANUS by Valerie Rudolph B.Sc. (Physiotherapy) R and. T etanus is an acute infectious disease characterized by tonic spasm o f voluntary muscles. Its colloquial name o f “ Lockjaw” stems from the characteristic spasm o f the masseter muscles which makes opening the m outh difficult, if not impossible. In man, it is caused by the entry into the body o f the bacillis tetani. I t enters via a penetrating wound which may be as small as a pinprick. There are two theories about the mode o f absorption and action: 1. The toxin produced by the bacillis is absorbed by the m otor nerve endings at the site o f the wound and carried along the axis cylinder to the anterior horn cells where it diffuses through the spinal cord and affects o ther cells and so, other nerves. The anterior horn cells are stim ulated by the toxins and a muscular contraction results. 2. The toxin is absorbed into the lym phatic vessels and reaches the spinal cord via the circulation. A lthough the action o f the tetanus-producing toxins is primarily on the anterior horn cells, there is no actual destruction, and the cells return to norm al once the poisonous substances are removed. Continued fro m page 4 Ventilation is the process o f the exchange o f air within the alveoli; diffusion is the gas exchange between the alveolus and the pulm onary capillary vessel; perfusion is the am ount of blood passing through the lungs. All o f these three factors are influenced by endurance training. The maximum cap a­ city of ventilation, expressed as the m aximal respiratory capacity, may gain nearly double its initial value. Thus, the respiratory reserve increases. Probably, the diffusion cap a­ city which, beyond the age o f 20, begins to decrease, and which is one o f th e main capacity-lim iting factors, is like­ wise increased by this form o f training. The perfusion value rises according to the increased capacity o f the heart and according to the im proved capillarization o f the lungs. In star athletes, values up to 35 litres per m inute may be reached, rendering possible the assim ilation o f more than I litres o f oxygen per minute. How now can we attain these advantages for o u r health by means o f endurance training? In o rder to answer this question, we made several experiments. The results were as follows: For a non-athlete it was found th a t an exercise period o f 30 minutes three times per week was sufficient. B ut this endurance training m ust be done in accordance w ith the principles o f “ interval training” , i.e., th e load intensity, the duration o f loading, th e duration o f the rest period and the num ber o f repetitions o f th e exercise m ust be com ­ piled according to a definite plan, for each individual case Should a person, owing to his work, have insufficient time at his disposal, o r should he feel disinclined to visit an athletic track, then it will still be possible for him to attain similar results by means o f an o th er training p ro ­ gramme. One could, namely do w hat is often termed “running on the sp o t” , This should, however, be done daily for a period o f five minutes, preferably on a rubber mat. This should also be carried o u t according to the principles of “ interval training” . D uring the course o f o u r investi­ gations we were often astonished to establish how few stimulants nature dem anded for the attainm ent o f an average degree o f fitness. IN C U B A T IO N P E R IO D The sym ptom s usually manifest themselves ab o u t six days after the initial w ound, but the incubation period may be anything from 18 hours to two weeks. S Y M PT O M S 1. Early Symptoms The patient has an anxious expression on his face, and is restless, with violent headaches and bouts o f temper. A lthough there is excessive yawning, he suffers from in­ som nia and often delirium. There is profuse sweating, pain in the neck and back, and a trem or o f the tongue when it is protruded. Spasm is often present a t an early stage in the injured limb, with a marked hardness o f the muscles in the im mediate vicinity o f the injury. 2. L ate Symptoms There is nystagmus (side to side m ovem ent o f the eyes),, strabism us (squinting), an increase in the reflexes, and a positive Babinski sign. The patient often com plains o f a pain like a stitch in his side, and spasm occurs in m ost o f the muscles o f the limbs and trunk, usually excluding the forearm s and hands. T he m ost im portant sym ptom is the classical “ trism us” or Lockjaw due to spasm o f the masseter muscles. T he spasms are paroxysmal rather than continuous, with a tendency to a backw ard movem ent o f the head and a forward arching o f the trunk. They are often strong enough to raise the entire body so th at only the head and heels rem ain on the bed; and may be so severe as to rupture muscles and fracture bones. The spasm may be initiated by any stimulus such as touch, noise, or even a bright light. A reflex response which is typical o f tetanus is an extensor th ru st o f the foot and leg when the sole is stim ulated, as opposed to the norm al flexor w ithdrawal response. TREA TM EN T Medical Treatment (a) Immediate The first step is, naturally, to attem pt to counteract the effects o f the toxin by the adm inistration o f anti-tetanus serum. As this may cause anaphalactic shock, it is given in conjunction with A .C .T .H . o r cortisone. A course o f penicillin is started as it destroys the spores. A patient with tetanus is fully conscious, and is usually extremely worried, and in the case o f a child, even terrified by the uncontrollable spasm. H e must, therefore, be sedated as this relieves the m ental tension and helps to reduce the spasm. Paraldehyde o r phenobarbitone is given, and in a mild case, this may be sufficient to tide the p atient over until the tetanus subsides. General Treatment (b) Later In a severe case, spasm o f the respiratory muscles may cause difficulty in breathing and swallowing, and when this is extreme, a tracheotom y is perform ed and a stom ach tube passed for feeding. Often this is sufficient while the patient is completely quiet b u t the least stim ulation (which is u n ­ avoidable as he m ust be nursed and fed) causes such spasm th a t respiration is impossible. I f very severe spasm is caused only by strong stim ulation such as passing a stom ach tube or catheter, a small dose o f scoline may be given on these occasions. This causes paralysis lasting one or two m inutes R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) Page 6 P H Y S I O T H E R A P Y September, 1962 so giving the d octor time to act w ithout causing serious spasm. Sometimes, however, the spasm is initiated so easily that nursing becomes impossible and the patient may then be p u t on to curare. This is a drug which causes tem porary paralysis o f voluntary muscles. I t is a drastic m easure and is postponed until all m ore conservative m ethods have been tried and discarded as insufficient. I t creates m any problem s, nam ely: 1. T he patient cannot breath, so some apparatus m ust be installed to perform this function fo r him. 2. A ll reflexes are abolished so he cannot clear secretions from his lungs by coughing. 3. A lthough he is incapable o f any m ovem ent w hatso­ ever, he can still feel. There is always the fear of causing pain o r a t least extreme discom fort when suctioning o r perform ing passive movements. K now ­ ing th at the patient cann ot, in any way, com m unicate his feelings it is difficult not to u n dertreat in order to avoid hurting him. However, it is an interesting fact that some patients in B ritain were questioned on recovery ab o u t their feelings while on curare, and none could rem em ber anything significant. The Respirator A Radcliffe positive pressure respirator is used in prefer­ ence to an iron lung because: (a) N ursing is much simpler. (b) T he patient can easily be turned to prevent pressure sores. (c) H e can be positioned fo r p ostural drainage. (d ) H is limbs are m ore easily accessible fo r passive move­ ments. Drug Therapy The adm inistration o f drugs in tetanus is m ost interesting and so, although n o t the concern o f the physiotherapist, will be described briefly. T he drugs and o ther substances given to the patient aim at: (a) D estroying the tetanus-producing spores. (b) M aintaining the nutrition o f the body, and the electrolyte balance. (c) K eeping the patient heavily sedated with the minim um num ber o f side effects. (d ) M aintaining complete paralysis until the spasm subsides. T his may take several weeks. As m entioned earlier, anti-tetanus serum and penicillin are given at the outset. M ost o f the o ther drugs are given intravenously. The Drip A drip containing 5 o r 10 per cent dextrose (depending on the size o f the patient) is set up. T o this is added sodium and potassium chlorides to m aintain the level o f the electro­ lytes. T he o ther additions to the drip are the three sedatives and muscle relaxants m aking up the so-called Lytic cocktail. These are pethidine, largactil and phenergan. Any one o f these would, alone, be adequate fo r sedation, but each in the necessary dose would have detrim ental effects, such as the depression o f respiration by pethidine. I f all three are given together, the dose o f each may be reduced w ithout a corres­ ponding reduction in the level o f sedation. C urare is given continuously fo r som e time, to obtain total paralysis. Some doctors prefer to keep the patient anaesthetized fo r the duration o f the disease by the addition o f p entothal to the drip. Additional Sedation Seconal is given either through the stom ach tube o r as a suppository. Before any m ajo r process such as changing the tracheotom y tube, pheno-barbitone is given to ensure very deep sedation. A process such as this can cause a fatal spasm even when the p atient is on curare. Diet A very high protein diet is fed through the stom ach tube because the large quantities o f drugs tends to produce a negative nitrogen balance. The feed com m only used is C om plan and milk. B lood is sent to the lab o rato ry fre­ quently fo r these factors to be checked, and the drip is adjusted according to the findings. Testing for Recovery A fter ab o u t a week, the curare is stopped and the patient watched fo r any signs o f spasm such as twitching. If these signs appear, curare is given again fo r a fu rth er three o r four days. This procedure m ay have to be repeated several times before the curare can finally be discontinued. As the effects o f the curare take several hours to wear off, an antidote is given so th a t the doctor can see within a short period w hether further therapy is necessary. This antidote is prostigm ine which, in addition to counteracting the curare, produces large am ounts o f secretions in all p arts o f the body. As this m ay be dangerous, atropine is given to inhibit excessive secretion. N U R SIN G The nursing care is one o f the m any vital factors in the treatm ent o f this condition. The patient should be in a quiet, darkened room to reduce stim ulation. Everything should be done with the minim um am ount o f disturbance. H e m ust be turned frequently to help drain the lungs and prevent bed-sores. M easures causing unavoidable stim ula­ tion, such as injections o r suctioning m ust be carried out with the utm ost care to avoid producing spasm. If anything unforeseen happens, such as the respirator n o t functioning, o r the tracheotom y tube becoming blocked, quick action may save a life; while the reverse is equally true. P H Y SIO T H E R A PY Physiotherapy aim s a t preventing, o r if necessary, treating the complications o f the disease. Common Complications (a) Pneum onia and atelectasis. (b) Jo in t stiffness and dropped feet. (c) Venous throm bosis. (This is not as com m on, but has been noted in a fair percentage o f cases.) The Chest (a) Postural drainage Tw o-hourly postural drainage is carried o u t and is accom ­ panied by “ passive breathing” to obtain the maximurri expansion o f the lungs. The air in the room is kept humid by the constant use o f steam kettles. Oxygen is being pum ped into the lungs by the respirator and the increased air intake caused by the artificial respiration produces over­ oxygenation. T o avoid this, the oxygen supply m ay be cut off during treatm ent so th a t the respirator is still functioning, but is pum ping in ordinary air. The pressure o f the hands on the chest m ust, o f course, be timed to fit in with the rhythm o f the respirator. A lthough vigorous percussion is required, care m ust be taken not to initiate a severe spasm which may prove fatal. I t is best to fit the treatm ent in to correspond with the adm inistration o f the drugs so that there is maximum sedation at the time o f treatm ent. I f the patient shows signs o f irritibility (one o f the first is frowning) it is better to postpone the treatm ent until he is quiet. W hen percussing the chest, stim ulation can be minimized by placing one hand flat on the patient’s ribs and perform ing a hacking move­ m ent on it with the other. (b) Suction Suction should accom pany the postural drainage as there is no cough reflex to clear the secretions when they reach the bronchi. Again, it is essential to realize th e vital R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) S ep tem ber, 1962 P H Y S I O T H E R A P Y Page 7 im p o r ta n c e o f reducing stim ulation to the absolutem inim um as over-stim ulation m ight so easily prove fatal. A soft polythene tube is used in preference to the usual rubber as it accom m odates m ore readily to the curves o f th e throat and bronchi. Suction should be applied through the tracheotom y tube, the m outh and the nose. The respirator has to be disconnected in order to suction through the tube so this m ust be done as quickly as possible. The machine should n o t be turned off, b u t only detached fro m the tube so that there is no delay in restarting the mechanism. The suction tube is held closed while being inserted and is only released fo r suction while being w ithdrawn. While withdrawing it, it is easy to feel when it is passing through some m ucous and it m ay then be moved gently backwards and forwards over this area to clear as m uch secretion as possible. The Limbs (a) The arms Passive m ovem ents o f the arm s are the same as fo r any paralysed patient, and should be done whenever the chest is treated. (,b) The legs As explained earlier, stim ulation o f the soles o f the feet causes an extensor thrust which makes dorsiflexion ex­ tremely difficult. T his difficulty is even m ore pronounced when the curare has ju st been discontinued and there is still a tendency to spasm. T he few days following this appear to be the m ost vital if dropped feet are to be prevented. The spasm may, to a certain extent, be overcom e by applying pressure to the sole very gradually, as it seems to accom m o­ d ate to it. In severe tetanus, the spasm o f the calves if the foot is pushed up suddenly, is so great th a t it is alm ost impossible to overcom e even in a sm all child. Plaster o f Paris splints do n o t appear to be o f m uch value as the spasm bends them o u t o f shape within a few hours. Thrombophlebitis A fter the full range passive movements, it is advisable to carry o u t rapid m ovem ents with a pum ping action obtaining a m axim um stretch and relaxation o f the calves. M assage with the legs in elevation also helps to prevent this com ­ plication. C O N C L U SIO N N o literature has been found on physiotherapy in tetanus and this article has been written in th e hope th a t it may be o f assistance to therapists meeting this fairly rare problem . As can be seen by this description, there is very little specific physiotherapy and th at described here has been evolved by experience (and to some extent, experiment) w ith a limited num ber o f cases treated by physiotherapists at the T ransvaal M em orial H ospital fo r C hildren in Johannesburg, the Red C ross C hildren’s H ospital in Cape Town, and the G eneral H ospital in Pretoria. References War Wounds and Injuries, edited by R . M aingot, F.R .C .S. and E. Fletcher, M .A ., M.B., M .R .C .P. Acknowledgements I would th an k D r. H . U tian fo r his help in explaining the medical aspects o f the treatm ent. THE BIRTCHER MEGASON VI ULTRASONIC UNIT To the more than 20,000 physicians now using ultra­ sonic therapy in the treatm ent of a host of acute and chronic conditions, this precision instrum ent adds new dimensions of accuracy and treatm ent ease. Descriptives and medical journal reprints on request. A N E W C O N C E P T IN T R E A T M E N T “ Cape Y ork,” 252 Jeppe St., Johannesburg . P .O . Box 3378 Telephone 23-8106 and at President House, 20 Barrack Street, Cape Town. P .O . Box 195. Telephone 41-1172 R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. )