Some Impressions of Rehabilitation Services in the U .S.A. and Canada By M . F. H U M P H R E Y , B.Sc. (P h y sio th e rap y ) Address given to the N a tional Council f o r the Care o f Cripples in S o u th A fridca at its 21st A nnual Genera! M e etin g March, 1962 P H Y S I O T H E R A P Y Page 7 I have been asked to a d d re ss y ou on the h ig hlights o f m y study visit to C a n a d a a nd A m e ric a. I t has been difficult to be s e l e c t i v e , because I e n joyed it all so m uch. In the fo u r m o n th s I sp e n t there, I visited 35 ho sp itals, rehabilitation c en tres a n d fa cto rie s m ak in g o rth o p a e d ic appliances. In A u g u s t I a tte n d e d the 3rd In te rn a tio n a l Prosthetics C o u rse in N ew Y o rk , a n d in S e p tem b e r the 8th In ternational C o n g re ss fo r th e W elfare o f C ripples. I had p lan n e d to see as m an y re h a b ilita tio n c entres as possible, to stu d y v o c a tio n a l train in g a n d see if th is c o uld be incorporated in to a re h a b ilita tio n c en tre, o r even if it was feasible to d o so, a n d to learn as m uch as I c o u ld a b o u t o rthotics a n d p ro sth e tic s as possible, a n d g e nerally to g a th e r as m uch in fo rm a tio n as I co u ld on re h ab ilita tio n . O f all the h o sp ita ls a n d in stitu tio n s I visited, in m y o p inion the W o rk m e n ’s C o m p e n s a tio n B oard H o sp ita l in T o ro n to is one o f the m o st u p -to -d a te a n d m o d e rn re h a b ilita tio n centres on the C o n tin e n t. T h e b u ilding has been b e au tifully d e s i g n e d a nd a g re at deal o f th o u g h t has been e x pended on detail, w hich a d d s to the efficiency in m a n a g e m e n t and pleasant w o rk in g c o n d itio n s fo r b o th p a tie n ts a n d staff. T he large p a rk -lik e g ro u n d s a re a jo y , fo r th ere is n o th in g that peps u p the m o ra le o f a lo n g -te rm bed p a tie n t m o re th an being able to get o u tsid e a w ay fro m the confining a tm o sp h e re o f the w ard. T h e large g ro u n d s a lso p ro v id e a n o p p o rtu n ity for p ro ducing very realistic o u td o o r o n -th e -jo b situ a tio n s, which are so n ecessary in ev alu atin g th e p a tie n t’s w ork tolerance before he is d ischarged fro m ho sp ital. My stay a t the R a n c h o Los A m igos H o s p ita l in L os Angeles proved to be o ne o f the highlights o f all the h o sp itals and re h ab ilitatio n c en tres I visited. I t w as th e o n ly o n e th at offered a co m p re h en siv e service fo r the disa b le d , th a t is from a ccident to final plac em e n t. T h e R a n c h o c aters fo r patients w ho re q u ire p ro lo n g e d h o sp ital tre a tm e n t. T hese patients are g ro u p e d in to tw o classifications. T h e first— long-term illness a n d convalescence, fo r w hich there are 1,700 beds. P a tie n ts in this class a re generally restricted to beds a nd w heelchairs, a n d c o n se q u en tly re q u ire c o n s ta n t nursing a tte n tio n in a d d itio n to m edical c are a n d trea tm e n t. T he second g ro u p a re th o se fo r intensive tre a tm e n t. T hese have 300 beds. P a tie n ts tre a te d in this a rea a re P o st-p o lio , Paraplegic, A rth ritic a nd v a rio u s N e u ro -m u s c u la r diseases and problem s. H e re they p a rtic ip a te in an intensive p r o ­ gram m e o f tre a tm e n t to regain lo st fu n c tio n a n d ability. One h u n d re d beds a re d e voted to th o se p a tie n ts suffering from re sp irato ry fa ilu re, u su a lly caused by b u lb a r p aralysis and have to be n u rse d in re sp irato rs. I fo u n d the tre a tm e n t o f these p a tie n ts intensely in teresting. A ll p a tie n ts a re ta u g h t glosso-pharyngeal b re a th in g , so th a t th ey will be a ble to spend increasingly longer p e rio d s o u t o f the re sp ira to r. So successful have they been th a t the p a tie n t, th o u g h still suffering fro m pa raly se d re sp ira to ry m uscles, b u t w ho has gained the p o w e r in his lim bs, is a ble to be u p a n d m obile, either w alking o r in a w heelchair. E ven th o se w h o have gained very little m o to r p ow er lead a se m i-in d e p en d e n t life in a w heelchair w ith th e aid o f stra te g ica lly placed artificial muscles. T h e re is a n o rth o tic re sea rc h la b o ra to ry in the hospital a n d it w as here I first saw th e a rtificial m uscle a nd how, by strategic p lacing it co u ld be o f im m ense value to the severely p a ralysed p a tie n t in h is struggle to w a rd s in d e p e n ­ dence. N o t o n ly is it used on splints, b u t it c a n be a tta ch e d to a w heelchair to fa c ilita te th e a p p lic a tio n o f brakes. While I w as th ere I saw the O rth o tis t fitting flexor hinge splints to a w o m a n w hose o n ly fu n c tio n a l m uscle in her lim bs w as the flexor h a llucis longus. W ith this m uscle she was a ble to o p e ra te th e valve a n d so gain som e m ea su re o f independence in feeding. I visited the research la b o ra to rie s in B erkley, L os A ngeles, and W as h in g to n , a nd in each case m y visit w as m u ch too sh o rt. I collected a n u m b e r o f ideas on knee-locks a n d b a c k ­ sto p s fo r c alipers, w hich we a re g ra d u a lly try in g o u t. C a lip e rs have been m y b u g b e ar fo r the p a st five y ears. T h e tim e lost in h av in g them re p aired a n d a d ju s te d is p h e n o m e n al. U ntil recently, a fairly general a ttitu d e o f th e O rth o tis t a n d P ro s th e tis t seem s to have been to p ro d u c e a good piece o f e n g ineering w ith o u t b o th e rin g to o m uch a b o u t w hether the a p p lia n c e is c o m fo rta b le o r easy to m an a g e a n d a pply. I am very glad to re p o rt th a t the U n iversity o f C a lifo rn ia a n d th e A rm y P ro sth e tic s R esearch L a b o ra to ry in W ash in g ­ ton a re rem edying this sta te o f a ffairs. T h is h a s been largely due to th e in tro d u c tio n o f the science o f B io-m echanics, sta rte d w hen it w as fo u n d necessary to e v a lu a te the stresses a n d s tra in s to w hich the hu m an b o d y c o u ld be subjected w hen lau n ch ed in to space. F o rtu n a te ly som e o f these new bio-m echanical engineers a re now d e v o tin g th e ir know ledge to m o re e a rth ly m atters. T h e gre atest strid es h ave been m ade in P ro sth e tic s. I w as fo rtu n a te indeed to be selected to a tte n d the T h ird In te rn a tio n a l P ro sth e tic s C o u rse in N ew Y o rk . T h e n u m b ers w ere lim ited to 20 d o c to rs , m ost o f w hom were O rth o p a e d ic Surgeons, eig h t p h y sio th e ra p ists, tw o o c c u p a ­ tio n a l th e ra p is ts a n d e ight o rth o tists. I have never w o rk e d so h a rd in all m y life, n o r have 1 a tte n d e d a c o u rse w here each and every lec tu re w as o f such a high s ta n d a rd . I th in k the o n ly p e o p le w ho w o rk e d h a rd e r th a n we d id w ere the p ro sth e tists w h o h ad to tu rn o u t three c om plete p ro sth e se s in ten days, u sing m ate ria ls w ith which the m ajo rity w ere u n fa m ilia r, the m ost im p o rta n t o f these being a c o m p o u n d o f fibre glass a n d polyesteresins, used in the p ro d u c tio n o f u p p e r ex tre m ity pro sth e sis, a nd fo r the closely m o u ld e d so ck ets needed f o r th e low er e xtrem ity. T hese plastics p rovide a n ideal m edium as it is in credibly to u g h a n d as its c o nsistency can be v aried fro m a su b sta n c e th at is very h a rd a nd rigid to o n e th a t is soft a n d pliable. Its use has a g re at m an y a d v an tag e s. T h e m a te ria ls a re relatively c heap. N o m ac h in ery , in a d d itio n to th a t fo u n d in a very m o d est w o rk sh o p , is required. T h e p ro d u c tio n is sim ple and re q u ire s on ly intelligent a p p lic a tio n , p a tience a n d p ractice. T h e subjects covered included Surgery, B io-m echanics, F a b ric a tio n o f P ro sth e se s (in cluding a c ertain a m o u n t o f pra ctic a l w ork), H a rn essin g , F ittin g and T ra in in g , together w ith g a in in g a w o rk in g know ledge o f everything. W e have a n u m b e r o f sheltered w o rk sh o p s, b u t 1 d o n ’t k now o f a ny in stitu tio n in o u r a re a th a t tra in s a disabled m an to d o a jo b w hich will fit him o r h e r fo r e m p lo y m en t in o u tsid e industry. B y V oc atio n al T ra in in g I d o n o t necessarily m ean train in g a m an to be a fully qualified tra d e sm a n , as we all k n o w m ost tra d e s re q u ire a m an to be a p p re n tic e d a n d to a tte n d a technical school, b u t y ou can teach a m an w ho, fo r in stance, has been em ployed in the b u ilding in d u stry all his life a nd w h o h as now lo st the use o f a h a n d o r leg, a useful tra d e by w hich he can e arn a living. F o r exam ple, fu rn itu re re p a ir or to o p e ra te a m achine. A b ilities In c o rp o ra te d is a w o rk sh o p on L o n g Island sta rte d by H e n ry V iscardi, him self a co n g en ital bi-lateral a m p u te e, fro m a very sm all beginning w ith a c o u p le o f d isa b le d m en. A bilities In c o rp o ra te d has g ro w n to a very large a n d ex p an d in g business. T h is is no c h a rita b le o rg a n i­ s a tio n , a n d e ach m a n a n d w om an m u st get h im self to and fro m w o rk u n d e r his ow n steam . F o r p ra ctic a l reaso n s m ost w o rk e rs live n e a r the fa cto ry . A p p lica n ts living to o fa r aw ay a re n o t c o n sid ere d . M o s t o f th e w o rk u n d e rta k e n is c o n ­ trac t w o rk fo r in d u strie s in a n d a ro u n d N ew Y o rk . A n y d isabled p e rso n , p ro v id ed he p roves th a t he is w illing to do 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 8 P H Y S I O T H E R A P Y March, 1962 a full d a y ’s w o rk , is c o n sid ere d fo r a vacancy. I saw one m an w heeling h im self ro u n d on a stre tc h er, a n d yet 1 w as a ssu re d th a t he w as a very g o o d w orker. W h en I visited A b ilities I w alked ro u n d th e c a r p a rk a n d e x am ined so m e o f th e co n v ersio n s. I th in k som e o f the a d a p ta tio n s w o uld h ave horrified o u r traffic d e p a rtm e n t, b u t th ey w ere very in genious. O f the 273 p e ople em ployed a t A b ilitie s 52 p e r c en t d ro v e th e ir ow n cars, 41 p e r cent o b ta in e d lifts w ith o th e r m em b e rs o f staff, 2 p e r c ent w ere ta k e n to w ork by a m em b e r o f th eir fam ily, J p e r cent travelled to w ork by tra in a n d the o th e r 2 p e r c ent e ith e r cam e by train o r bus. N o tr a n s p o r t w as p ro v id ed by th e fa cto ry . A t th e M ay. T . M o rriso n C e n tre in San F ra n c is c o ro u tin e P h y s io th e ra p y a n d O c c u p a tio n a l T h e ra p y tre a tm e n ts are c a rrie d on. A n in te re stin g fe a tu re a b o u t this C e n tre is th a t th ere is a V o c a tio n a l E v alu a tio n Service, w hich carries o u t w o rk sa m p lin g o r jo b sim u la tio n testing u n d e r the p ro fe s­ sio n a l sup e rv isio n o f a P h y sio th e ra p ist, O c c u p a tio n a l T h e ra ­ p ist a n d a n In d u s tria l E ngineer. T h e w ork sa m p lin g p ro c e d ­ u re tak e s p lace o v e r a p e rio d o f several days. T ests have been devised w hich will fit in to the D ire c to ry o f O c c u p a tio n a l T itles p re p a re d by th e U n ited S tates E m p lo y m en t Services. T h is service h a s b een m o st useful to th e L o ca l D e p a rtm e n t o f L a b o u r a n d is used extensively by in su ra n ce c a rrie rs fo r assessing th e c lie n t’s d isability. In these cases the p a tie n t can be placed in a w o rk s itu a tio n in th e C e n tre ’s w o rk sh o p a n d w a tched a n d a ssessed fo r a fu rth e r p e rio d , a n d w ith luck e v entually p laced in in d u stry . T h e In s titu te fo r C rip p le d a n d D isa b le d in N ew Y o rk is ru n o n sim ila r lines to the M a y T . M o rriso n , a lth o u g h th is is a m u ch bigger o rg a n isatio n . A n inte restin g fe a tu re o f b o th is g ro u p discussion o f in d iv i­ d u a l p a tie n ts in a n e n d e a v o u r to assess their a b ility, p ro g ress a n d e v en tu al p lac em e n t. I s a t in a t a n u m b e r o f these m eet­ ings w here th e p e rso n n el varied in n u m b e r fro m 10 to 25, a n d it o c cu rre d to m e th a t p e rh a p s in som e cases the p a tie n t w as suffering fro m a n o v e rd o se o f a tte n tio n . I fo u n d th a t th e a p p ro a c h to th e v o c a tio n a l tra in in g and e m p lo y m en t o f the h a n d ic a p p e d a t these C e n tre s w as m ost stim u la tin g , b u t it w as a t th e G o o d w ill In d u strie s in O k la ­ h o m a C ity th a t I fo u n d a so lu tio n to th e tra in in g a n d e m p lo y ­ m e n t th a t ap p ea le d to m e very stro n g ly , p a rtic u la rly in th a t it c o u ld be so easily a d a p te d to o u r ow n needs. I t is a b u si­ ness, n ot a sh eltered w o rk s h o p , w hich is ru n w holly on scrap m a te ria l— o ld c lo th e s, fu rn itu re , h o u se h o ld a p pliances, b u ild in g m a te ria l, sc rap iro n , b o o k s a n d m agazines a n d m an y o th e r c o m m o d itie s. T h ese a re collected, re p aired a n d th en resold in th e ir ow n sh o p s a n d in su b-econom ic areas. T h e w o rk s h o p p a y s its ow n w ay a n d is n o t subsidized by G o v e rn m e n t o r p riv a te en te rp rise. In itia lly a lo an w as o b ta in e d fro m th e N a tio n a l O rg a n iz a tio n in W ash in g to n . W ages p aid a re very sm all, b u t c o n fo rm to th e m in im u m w age laid d ow n by the F e d e ral a n d S tate W ag e a n d H o u r R e g u la tio n s. T h is is a b o u t 80 c ents p e r h o u r (a b o u t 5s.) b u t th a t 5s. w o uld o nly have the sam e b u ying p o w e r as 2s. in o u r c o u n try , w hich m ean s th a t th e m in im u m w eekly wage w o uld be e q u a l to a b o u t £4.0.0 a n d a t sheltered e m ploym ent £4 7s. 6d. p e r w eek. H ow ever, th ere is ro o m fo r a d v a n c e ­ m en t fo r th o se w h o a re c a p a b le a n d selected cases a re often h e lped to find jo b s in o u tsid e industries. E very em ployee is a w o rk e r w ith som e d isa b ility — fro m the m an a g er d ow n to the office boy. Its success is largely d u e to a sm all b u t discerning B oard o f D ire c to rs, w ho have succeeded in p lacing the rig h t m an o r w o m a n in th e rig h t jo b . Its success is also very largely d u e to a very well o rg a n iz ed a d v ertisin g c am paign, w h ereb y th e w hole city has been m ad e a w are o f th e ir existence a n d in d u ce d to help on th e basis th a t it is good business. A ll article s collected a re so rte d a n d re p aired . T h o se n o t in th is c ateg o ry such as p a p e r a n d iro n , a re sold as scrap. F o r c lo th in g a b a le r is used to p a ck c lo th in g into co n v en ien t b u n d les fo r sto ra g e u n til such tim e as it can be so rte d , dry-cleaned o r la u n d e re d , p rio r to b e ing priced a nd tic k e te d a n d p a ck e d in to c a rto n s fo r d e sp a tc h to th e c o m ­ p a n y ’s re ta il sh o p s. In itia lly a d ry c lean er w as em ployed to tea ch selected p e rso n n el the trad e . T h ese in tu rn ta u g h t o th ers, a n d m an y have been em ployed by d ry c leaning e sta b lish m e n ts in th e city. T ic k etin g is d o n e by m eans o f a sim ple p u n c h , w hich in this in stan c e w as o p e ra te d by an a d u lt a th e to id . B oots a n d Shoes. H e re again a c o b b le r w as em ployed initially a n d train ees h ave in th eir tu rn ta u g h t o th ers, and m an y a re no w e m ployed in the C ity. F u rn itu re o f all d e sc rip tio n s is collected a n d repaired e ith e r in th e W o o d w o rk o r U p h o lste ry section. T h e sam e prin cip le being ap p lie d as in th e dry -cle an in g a n d shoe d e p a rtm e n ts. T h e re is an electrical a n d ra d io re p a ir shop. T ra in e e s in th is section, if they sh o w sufficient a p titu d e may be d ra fte d in to a n o th e r section d o in g c o n tra c t w o rk and “ n u isa n ce ” jo b s fo r local in d u stry . C irc u it b o a rd s a re wired o n a c o n tra c t basis fo r local m a n u fa c tu re rs. E m ployees w o rk in g in this se ction a re p aid a t a m uch hig h er ra te , in fact, a t th e sta n d a rd piece ra te , a s the j o b s re q u ire certain technical skill. Screws, n u ts a n d b o lts a re so rte d fo r a n o th e r fa cto ry — th is being o ne o f the n u isa n ce jo b s d o n e for local in d u stry . T h e intelligence level re q u ire d fo r th is jo b is very low indeed. T h ese a re b u t a few o f the activities being c arried o u t in the re -tra in in g a n d e m p lo y m en t o f th e disabled. Severely d isabled m en a n d w om en, u su a lly o f a higher social a n d m en ta l sta tu s, were c a rry in g o u t th e a d m in i­ stra tio n a n d d u ties o f fa cto ry forem en. T h ese cases a re not n o rm a lly a d m itte d to a sheltered e m p lo y m en t w o rk sh o p . A t the O k la h o m a In d u strie s the d ire c to r o f the factory w as a w o m a n so severely disabled by P o lio th a t she could barely d ra g herself ro u n d o n cru tc h es, b u t she w as a U n i­ versity G ra d u a te a n d h ad pre v io u sly been u n a b le to find e m p lo y m en t. I f th is e n te rp rise can be se lf-su p p o rtin g in a c ity o f som e 300,000 in h a b ita n ts, w here the m a rk e t for se c o n d -h a n d goo d s is so m e w h a t lim ited, su re ly in a city w ith o ver a m illion in h a b ita n ts a n d a n e n o rm o u s po ten tial m a rk e t fo r se c o n d -h a n d articles, a n o rg a n iz a tio n ru n on sim ila r lines sh o u ld flourish. F o r in stance, a w ork-testing u n it co u ld be in stitu te d w hereby an in su ra n c e c om pany, on p a y m e n t o f a sm all fee c o uld get e x p ert a dvice on a client w ho claim s th a t, b ecause o f his d isab ility he can n o longer go b ack to his fo rm e r em p lo y m en t. T h is w o uld be a n o th e r so u rc e o f revenue fo r the business. T h e u n it c o uld also, p e rh a p s, u n d e rta k e th e re -tra in in g o f m en fo r a specific jo b fo r G o v e rn m e n t o r p riv ate o rg a n iz a tio n s w h o w ould be p re p a re d to tak e a m an b a ck a fte r he w as severely disabled, p ro v id ed he c o uld d o a specific jo b . I feel the answ er is n o t to do v o c atio n al tra in in g o r re ­ tra in in g in a h o sp ital, b u t to have a se p a ra te w o rk sh o p w ithin easy re ac h o f th e re h a b ilita tio n centre. T h e a d v an tag e w o uld be th a t th e p a tie n t w ould be rem oved fro m the h o sp ital a tm o sp h e re as q u ick ly as possible. P e rh a p s som e agree m e n t c o uld be reach ed w hereby in d u stry w ould u n d e r­ tak e to re -tra in p a tie n ts w ho h ad c o m pleted th eir physical tra in in g a t a re h a b ilita tio n centre, o r th o se w h o required w ork h a rd e n in g o r light w o rk fo r a sta te d p e rio d a n d could be d ra fte d to the m a in te n a n c e sq u a d o f a fa cto ry . T h e p e r­ so n n e l em ployed in in d u stry c o uld be divided in to four categories, the first— th o se w ho c o uld n o t be train ed to do a n y th in g b u t the sim plest rep etitiv e tasks, a n d co u ld never be p laced in th e o u tsid e in d u stria l la b o u r m a rk e t. T h o se w ho co u ld be re -tra in e d , b u t b ecau se o f the n a tu re o f their d isability, i.e. c o n tin u a l b re ak d o w n s— fo r ex am p le the pa rap leg ia s, it w o uld n o t be p o ssib le to c ast on th e open m ark e t. T h ird ly , th o se w ho c o uld be re -tra in e d a n d e v en tu ­ a lly a b so rb e d in to in d u stry . A n d lastly, a m a in ten a n ce sq u a d — th o se w h o re q u ire light w o rk fo r a sta te d p eriod. In co n clu sio n , I w o uld like to say how very helpful a nd friendly I fo u n d th e people. I w as offered m o re ho sp itality th a n I w as a b le to accept. W h en I re tu rn e d to N ew Y o rk 1 a tte n d e d the 8 th W orld C ongress o f the In te rn a tio n a l Society fo r R e h a b ilita tio n o f the D isa b led a n d fo r m e the hig hlight o f th is w as the a n n o u n c e m e n t th a t th e C o u n c il’s film “ N ew L egs” h a d w on 2nd p rize in the R e h ab ilita tio n F ilm c o m p e titio n . I wish to th a n k th e N a tio n a l C o uncil fo r th e g e n ero u s stu d y g ra n t w hich m ad e p ossible m y visit to A m erica a n d C a n a d a . 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. ) March, 1962 P H Y S I O T H E R A P Y Page 9 IN T R O D U C T IO N T O A D E M O N S T R A T IO N O F GROUP P A T IE N T S H E L D A T P O S T G R A D U A TE C O U R SE, CA PE T O W N , O C TO BER 1961 by M iss C. Junack, University o f Cape Town, Department o f Physiotherapy, Member S .A .S .P . It is a g r e a t p r iv ile g e f o r m e to g iv e a d e m o n s tr a t i o n o f G r o u p T r e a tm e n ts t o y o u . I hope you will be very c ritical a n d by discussing th e w ork, help us to im p ro v e o u r m eth o d s. M any o f y ou have been tra in e d in E n g la n d , w here Treat­ ment in Groups is ta u g h t a n d very well p ra c tise d . Y o u will have h ad a lo n g spell o f experience in it a n d I d o n o t feel very com p e ten t to give this d e m o n s tra tio n . A fter m y s h o r t p ra c tis e — since th e o p e n in g o f th e School o f P h y s io th e r a p y in C a p e T o w n , I a m fully co n v in c ed th a t (his m ethod o f tre a tin g th e p a tie n t h a s a b ig a n d valu a b le place in P h y sio th e rap y , fo r th e follow ing re a so n s : j Firstly: In my o p in io n th e stro n g e st p o in t lies in the psychological effect. In c o m p a n y w ith o th e rs w ho have suffered in a sim ila r w ay th e p a tie n t is m o re likely to o v e r­ come his sh o c k a n d d ep ressio n a n d to cope w ith his d is a ­ bility. We all k n o w ho w im p o rta n t th e sta te o f m in d is re g a rd in g the healing p ro c ess: th ere fo re, a ctiv ities d o n e w ith o th e rs are found to be o f g re a t assistance. Secondly: I t is a p ra c tic a l way to c o p e w ith a g re a te r n u m b e r o f p a tie n ts — fo u r, six, e ight, o r even m o re c a n be d o n e in th e tim e ta k e n to tre a t o n e o r tw o in d iv id u a lly : b u t it is n o t easily d o n e if effective a n d a d e q u a te tre a tm e n t is to be given to e a c h m em b e r o f th e G ro u p . T h e difficulty lies in k n o w in g every p a tie n t’s p re se n t c o n d itio n p ro p e rly , a n d to tak e his specific needs in to c o n sid era tio n . T h ere fo re, I wish to say th a t G r o u p T re a tm e n ts re q u ire c o n sid e ra b le skill. T h e skill lies in q u ic k a n d g o o d o b s e rv a ­ tion, in th e a b ility o f a rra n g in g a n d o rg a n isin g th e C lass, in a le rt tea ch in g , a n d in e d u c a tin g th e p a tie n t to d o p r o p e r exercises o n his ow n. E xercises will be c a rrie d o u t by all o f th e G r o u p to th e best o f th e ir ab ility , o r, if necessary, th e class m ay sp lit u p fo r in d ividual tra in in g , a n d c o m b in e to w a rd s th e e nd o f the tre a tm e n t in a m ore relax ed a n d en jo y a b le way. F o r th e d e m o n s tra tio n I have c h o se n a g ro u p o f H em i­ plegia, a n d a class o f F ra c tu re d F e m u rs. T h e H e m ip le g ia p a tie n ts have re ac h ed th e ad v an c ed stage. N eedless to say a g re a t deal o f in d iv id u a l a tte n tio n h as been given, a n d is still being c a rrie d o u t, if necessary. T h e p a tie n ts suffering from F ra c tu re d F e m u rs h ave recently been d isc h arg e d fro m H o s p ita l as “ In -P a tie n ts ” , a n d a re in th e n o n -w e ig h t-b e arin g stage. T hey re q u ire a c ertain a m o u n t o f ind iv id u a l a tte n tio n , w hich h as been given in th e class. J 4 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 THedUdViOHlnitm L(PTY.) LTD. “ Cape Y ork,” 252 Jeppe St., Johannesburg . P .O . B ox 3378 . Telephone 23-8106 a n d a t President House, 20 Barrack Street, Cape Town. P .O . B ox 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. )