December, 1961 P H Y S I O T H E R A P Y Page 7 O RDER OUT OF CHAOS MISS M. R O P E R , M .C .S .P . L ectu rer in P h ysiotherapy, D ep t, o f P hy sio th erap y , U niversity o f C ape T ow n n pcture delivered a t th e P o s t-G ra d u a te C o u rse o n T h e ra p e u tic M o v e m en t, U niversity o f C a p e T o w n , D e p a rtm e n t ' o f P h y sio th e rap y , O c to b e r 1961.) “A n d the E arth was w ithout fo r m a n d void— a nd the S p irit o f G od m oved.” In o th e r w o rd s o rd e r em erged fro m chaos. [ am not going to tell y ou a n y th in g new, a n y th in g yo u do not already know . I am g o ing to a sk y o u , w ith m e, to th in k over som e o f the basic p rin cip les we all le a rn t as stu d e n ts. I hum bly suggest th a t in th e ru sh a n d b u stle o f o u r clinical work we m ay have fo rg o tte n a n d d isc ard e d som e useful and im p o rta n t c o n c e p ts— o r a t least we h a v e n o t developed and used th em w ith all th e th o u g h t a n d skill in o u r pow er. The definitions o f “ m ove” in C h a m b e r’s D ic tio n a ry are many— here are som e o f th em . “ T o im pel, to excite to a ctio n , to persuade, to in stigate, to a ro u se , to live o n e ’s life” . All germ ane to w hat we th in k a b o u t a n d how we a ct in tea ch in g o u r patients to m ove. P e rh a p s th e m o st p e rtin e n t o f all, the last o ne “ to live o n e ’s life” . As P h y sio th e rap ists isn ’t o u r m ost im p o rta n t a im in all ou r trea tm e n ts to re sto re “ o r d e r ” in m ovem ent th a t has become “ c h a o tic ” — c h a o tic d u e to p ain, lim ited range, loss o f m uscle p ow er a n d n e u ro -m u s c u la r c o -o rd in a tio n ? We have h e ard fro m P ro fe ss o r W ells a n d P ro fe sso r Stam m ers so m e th in g o f th e a n a to m ic a l p h y siological b a ck ­ ground o f th e o rd e re d m o v em e n t, a n d fro m P ro fe ss o r A llen a challenging lectu re o n its im p o rta n c e . B u t is n o t this restoration o f o rd e re d m o v em e n t o u r ow n g re atest c o n tri­ bution to re h ab ilita tio n , p ro v id ed it tak e s in to a cc o u n t the “ w hole p e rs o n ” . In the c rea tio n o f th e U niverse, a n d in it th is W o rld , is not m an th e highest c rea te d being a n d is n o t his gift o f free will the m ost p re cio u s gift w ith w hich he h as been end o w ed ? So in o u r h u m b le effo rts to re sto re o rd e r to a d iso rg a n ised chaotic m o to r system , sh o u ld n o t o u r fo rem o st a im (by arousing, exciting to a ctio n , a n d p e rsu a d in g ) be to enlist the p a tie n t’s free will, a n d help him to d irec t it to w a rd s his (Continued fr o m opposite page) linked to g eth e r by a c om plex system o f in te rc o n n e c tio n s, by m eans o f w hich, it is assu m e d , th e c ere b ral c o rte x e stablishes a p redom inance o v e r the o th e r c o m p o n e n ts o f th e brain. C onsequently the resu lts o f a n a to m ic a l a n d physiological studies o n sim pler ty p e o f a n im a l b ra in c a n n o t necessarily be applied to th e m uch m o re com plexly o rg a n ised h u m a n brain. R e f e r e n c e s General: B arnett, C. H ., D avies, D .V ., a n d M a c C o n aill, M . A . (1961. Synovial Joints. Their Stru c tu re a n d M echanics. L o n d o n : L ongm ans, G re e n a n d C o. xi + 304 pp. Chusid, J. G . a n d M c D o n a ld , J. T . (1960). C orrelative N euroanatom y a n d F unctional N eurology. 10th ed. L os A ltos, C a l.: L an g e M edical P u b lic a tio n s, 360 pp. CIrOS C la rk , W . E . (1952). The Tissues o f the B ody. 3rd ed. O x fo rd : C la re n d o n Press, xi + 407 pp. P a rtic u la r: B asm ajian, J. V. (1959). “ S p u rt” a n d “ s h u n t” m uscles: a n e le c ro m y o g ra p h ic c o n firm a tio n . J . A nat. L ond., Vol. 93, pp. 551-3. J- C . B. (1958). A M e th o d o f A n a to m y. 6th ed. B a ltim o re : W illiam s a n d W ilkins, xxv + 879 pp. M acC onaill, M . A . (1949). T h e m o v em en ts o f b ones a nd jo in ts. 2. F u n c tio n o f th e m u sc u la tu re . J . Bone J t. Surg. Vol. 3IB , pp. 100-104. M a rtin , C. P. (1933-34). A c o m p a ris o n o f th e jo in ts o f th e a rm a n d leg a n d th e significance o f th e s tru c tu ra l diff­ erences betw een th em . J . A n a t. L o n d ., Vol. 68, pp. 511-520. re tu rn to n o rm al o rd e re d bodily fu n c tio n — to live his ow n life? T h is brings m e to m y first p o in t: B ring in the pa tie n t— n o t ju st lite rally b u t in every sense o f th e w ord. P sychologically a n d physiologically he will benefit m o st if he c o -o p era te s as fully as possible in his re h a b ilita tio n p ro g ram m e. P sychologically how d a n g e ro u s d ep en d e n ce o n a n o th e r ’s efforts c a n be. H o w re stric tin g to th e w hole c o n ce p t o f re ­ h a b ilita tio n is ju s t th e alle v ia tio n o f p ain o r even, to ta k e an e x tre m e e xam ple, m a in te n a n c e o f m uscle a n d jo in t by e lectrical m ean s a n d passive m o v em en ts o n ly : passive m o v em e n ts p e rfo rm e d by th e p h y sio th e ra p ist w ith o u t m ak in g th e p a tie n t “ t h in k ” th e m o v em e n t as it is d o n e fo r him . T h is th in k in g th e m ovem ent a t o nce b rin g s him in to th e p ictu re, a n d as we all k n o w is p h y siological c o m m o n - sense in th a t it helps to m a in ta in th e m em o ry p a tte rn . T h e idea o f th a t m ov em e n t is k e p t alive by m ak in g th e p a tie n t realise th e afferen ts fro m m uscle te n d o n a n d jo in t as th e p a tte rn is p e rfo rm e d . P sy chologically it is co m m o n sense as he is a u to m a tic a lly p a rtic ip a tin g in th is in itial a ctivity a n d is th e re fo re realising th a t he has to do so m e th in g him self to effect his ow n cure. M e d ia f o r M o v em e n t— W a te r o r d ry land. W ater will be d e alt w ith by M r. N icol. M a n u a l or M echanical— D ry la n d tre a tm e n ts by m o v e ­ m en t will in clude th e use o f m a n u a l a n d m echanical a ssis­ tan c e o r resistance. B oth have a d v a n ta g e s a n d d isa d v an tag e s as y ou very well k now . W e a re all a w a re o f th e d a n g e r o f u sing m ech an ic al aids to m ov em e n t, m ea n in g specifically m ech an ic al a ssista n ce w ith sp rin g s o r w eights. W e k n o w th e d a n g e r o f o v e r-stre tch in g tissues if th e a id c a n n o t be fully c o n tro lle d , o r th e d a n g e r o f rep etitiv e irrita tin g m o v e ­ m en ts usin g su sp en sio n o r b ila tera l pulleys— yet in selected cases th ey can be m o st valu a b le as th ey m ay p ro v id e a m ean s o f e n a b lin g th e p a tie n t to w o rk on his own, i.e. w ith o u t th e o b v io u s assista n ce o f th e p h y sio th e ra p ist, w hen w ith o u t th e sling o r pulley o r sp rin g he c o u ld do little or n o th in g a t all. M a n u a l assistance o r resistance is so m e tim es b e tte r th a n m ech an ic al m eans. It is sensitive a n d a d a p ta b le to the c h a n g in g sta te s o f tension, spasm o r in c o -o rd in a tio n in the n e u ro -m u s c u la r m ec h an ism , a n d c a n th e re fo re m o re read ily be a d a p te d to m eet these c hanges. O n th e o th e r h a n d to o m uch m a n u a l h a n d lin g c an be psychologically u n d e sirab le, leading to dep en d e n ce o f th e p a tie n t o n th e p h y sio th e ra p ist. M e chanical m eans can be a rra n g e d a n d w o rk e d by th e p a tie n t himself,- even a t hom e. T h ey a re tim e-saving fo r th e p h y sio th e ra p ist, w hereas m an u a l tec h n iq u es a re tim e- c o n su m in g . P e rh a p s th e gre atest d a n g e r o f a ll in using m ech an ic al a p p a ra tu s is th a t it c a n becom e to o a u to m a tic a n d lack th e essence o f tru ly “ live m o v e m e n t” . But a g ain , if scientifically a rra n g e d w ith d u e re g a rd to m echanical a n d physio lo g ic a l p rinciples, th e g re a t a d v a n ta g e o f using w eights, fo r exam ple, is th a t p ro g ress c a n be g ra d e d a c c u r­ a tely a n d th e p a tie n t c a n o ften tre a t h im self a t hom e. Group o f Individual— W hich will suit th is p a tie n t b e st? Q u ite likely he will benefit by so m e o f e ac h . W e a re a p t to th in k we c a n n o t give g ro u p tre a tm e n ts if we have no •gym nasium . I so m e tim es th in k a g y m n asiu m is a b a d th in g in a d e p a rtm e n t. It ten d s to be set a p a r t as a se p a ra te en tity ra th e r th a n being th e c e n tra l c o re o f th e w hole set-up. A c tu ally a ro u n d d e p a rtm e n t w ith cubicles a t th e p eriphery a n d c e n tra l space w ith so m e exercise e q u ip m e n t co u ld be a very g o o d p lan ! H o w ev e r, if we a re really g ro u p m inded, g ro u p tre a tm e n ts can be given, even if th e d e p a rtm e n t or clinic will o n ly h old tw o p a tie n ts a n d th e p h y sio th era p ist. O rg a n isa tio n o f like ty p e o f cases a t th e sa m e tim e fo r o th e r 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 December, 1961 tre a tm e n ts will ta k e th o u g h t a n d tim e, b u t in th e lo n g ru n will save tim e, a s e ac h p a tie n t w ill have m o re tre a tm e n t fo r less e x p en d itu re o f th e p h y s io th e ra p is t’s tim e. T h e o b v io u s d a n g e r is, o f c o u rse, to go to th e o th e r ex tre m e a n d “ p u t all th e knees to g e th e r” to save tim e — w hen a ll th e knees m ay n o t re q u ire th e sam e type o f tre a tm e n t, a n d th e re fo re no o n e gets w h a t he really needs m o st. B ut th e p sy c hological effect o f g ro u p tre a tm e n t c a n be very beneficial in help in g th e p a tie n t to a d a p t h im self to live in a c o m m u n ity w ith a p a rtia l d isability. T re a tm e n t T im e P h y s io th e ra p ist p a tie n t tim e is so p recious. I o ften th in k we neglect th is m o st im p o rta n t p a rt o f o u r tre a tm e n t— p a rtic u la rly im p o rta n t in a c o u n try like th is w here d istances a re so great. D o w e p ay e n o u g h a tte n tio n to this h o m e in stru c tio n w hich is so essential in th e “ tra in in g ” , a b e tte r w ord th a n tre a tm e n t, o f o u r p a tie n ts . H e re I th in k y o u will a g ree we m u st be p a rtic u la rly careful to be specific. F o r e xam ple, d o we ta k e a w hole “ so-called tre a tm e n t tim e ” to really teach th e p a tie n t w h a t he h a s to do, a n d instil in to h im th e im p o rta n c e o f his c o -o p e ra tio n . I feel su re if we did in m any instances o u r d e p a rtm e n ts w ould n o t be so full, a n d p a tie n ts w o uld get well m o re quickly. H e re I h ave a p a rtic u la r “ bee in m y b o n n e t” a b o u t th e c o m m o n in stru ctio n o n e re a d s a b o u t exercise fo r five m inutes once every h o u r! Isn ’t it b e tte r to a llo w th e p a tie n t to o c cupy him self as n o rm ally as p o ssib le a n d to d o his “ tra in in g ” say b efore m eals, w hen he has in any case a b re a k fro m w hatever a ctivity he m ay be fo llo w in g ? T R A IN IN G , IN S T R U C T IO N , T E A C H IN G W e a re all tea ch e rs, n o t ju s t th o se o f u s w h o have tak e n a tra in in g w ith th e a im o f try in g to m ak e u s a b le to teach o th e rs to be p h y sio th e ra p ists. T o teach w e m u st k n o w w h a t to teach a n d h o w to teach it. T h ere fo re, b e fo re we s ta r t we m u st have a c le ar p ictu re o f th e p a tie n t’s needs a n d w h a t he sh o u ld be ta u g h t: th e re ­ fo re, we m u st h ave as c o m p le te a n u n d e rsta n d in g o f the c o n d itio n as possible. T h e re is som e d iso rd e r, d y sfu n c tio n , call it w h a t you w ill, d u e to p a in , stiffness, w eakness, in c o -o rd in a tio n — in o th e r w ords c h a o tic m ov em e n t. W e have to devise a p a tte rn , a sequence, a c u rric u lu m th a t will e nlist th e p a tie n t’s free will a n d c o -o p e ra tio n , in o rd e r th a t we m ay h elp h im to re sto re his m o v em e n t to o rd e r. W e m u st th e re fo re k n o w as precisely as p o ssib le w h a t is the reaso n fo r th is d iso rd e r befo re we c a n begin to p lan o u r p ro g ra m m e o f train in g . G ra n te d we m u st h ave a n a d e q u a te d iag n o sis fro m o u r M edical D ire c to rs — b u t h a v in g th is it is o u r jo b to find o u t th e d etails o f th e pdin, lim ited m ovem ent, spasm , c o n tra c ­ tu re , w eakness, a n d so on. A ssessm ent o f the Condition A ssessm ent o f th e c o n d itio n is obviously essential before th is p la n c a n be m ade. I su b m it th a t c a re fu l assessm ent b e fo re tre a tm e n t is sta rte d , even if it tak e s th e w hole o f the first tre a tm e n t p e rio d , will save tim e in th e long ru n . T h is assessm ent sh o u ld be as a c c u ra te as p o ssible a n d sh o u ld be re p ea te d a t in te rv als, even if a g a in a tre a tm e n t p e rio d is ta k e n to d o so. A c heck c a n th e n be m a d e a s to w h e th er p ro g ress is really b e ing m ade. A ccurate R ecords T h is c o m p a ris o n c an o nly be m ad e if a c c u ra te reco rd s a re k e p t. T hese a re p ro b a b ly th e m o st th o rn y p ro b le m s o f all. H o w to strik e th e b a la n ce betw een to o m uch w ritin g a n d n o t e n o u g h in fo rm a tio n . H e re I th in k specific c h a rts (sim ilar in prin cip le to th e m uscle c h a rts we a ll use) a re helpful. P ro b a b ly e ach u n it sh o u ld devise th e ir ow n so th a t all a re fa m ilia r w ith th e la y o u t, in clu d in g th e m edical officers in c h a rg e o f th e p a tie n ts . C h a rts fo r jo in t ra n g e a n d fu n c tio n a re p a rtic u la rly h elpful here as a tick o r figure is all t h a t is needed. T im e is c ertain ly saved here if colleagues h ave to ta k e o v e r a tre a tm e n t, specially in m y case as I k n o w h ow illegible m y w ritin g c a n be! H e re th e re a re o n e o r tw o p o in ts I th in k we sh o u ld strive to n o te w ith som e degree o f a c c u r­ a cy : a c tu a l ran g es o f m o v em e n t m ea su re d by a g o n io m e te r o r assessed as tw o -th ird s o r on e -h alf, ra th e r th a n th e vague p h ra se “ m o v em e n ts lim ite d ” , th e n a b it la te r “ m o v em en ts im p ro v in g ” . F o r th e severely disa b le d fu n c tio n a l charts a re a g re a t help as all th a t is re q u ire d is a sy m b o l against a n a ctiv ity — c an dress him self, w a lk , etc., w ith assistance u n a id e d , etc. All th is will be o f little avail unless we have th e full c o -o p e ra tio n o u r w o rk re q u ire s fro m th e doctors in c h a rg e o f o u r c a s e s : w ith o u t th a t we a re in a b a d w ay. Aim s o f M ovem ent H a v in g no w a re a so n a b ly c le ar p ictu re o f th e disability — is th e lim ita tio n d u e to sp a sm ? Is th e jo in t irrita b le ? Is it d ue to m uscle w eakness o r in c o -o rd in a tio n ? — a n d so o n — we m u st d e cide w h a t a re th e m a in a im s o f m ovem ent a n d h o w c a n they best be achieved. F o r exam p le if m obility be re q u ire d th en m o v em en ts sh o u ld be c h o se n th a t require m in im al effort b u t c a n be p e rfo rm e d qu ick ly , recruiting m o m e n tu m to h elp. I f p ow er be lac k in g th e n m axim um effort fo r a s h o rt tim e m u st be ex erted . T o tra in en d u ran c e, less e ffo rt o v e r a lo n g er p e rio d w ill be m o re efficient. F o r lack o f c o -o rd in a tio n , precise a n d re petitive m ovem ents m u st be p ra ctised . W h a t is th e p a tie n t’s ow n n a tu ra l rh y th m ? D o we desire a localised o r a g ro u p m o v e m e n t? If th e latter w h a t so rt o f m o v em e n t will th is p a tie n t d o m o st n a tu ra lly ? T h ese a re som e o f th e p o in ts to be b o rn e in m ind. H e re 1 th in k we m ay well c o n sid er the in clu sio n in the tab le of exercise o f a t least o n e a n a to m ic a l m o v em e n t, o n e fu n ctional m o v em e n t, a n d o n e re cre atio n al m o v em e n t. In choosing m o v em e n t let us a lso re m e m b e r th e p rim e m overs, the synergist fix ato rs a n d c o -o p e ra to rs , as o ften m uscle and jo in t c a n be used by th in k in g o u t m o v em e n ts in w hich m uscles a re b ro u g h t in to a c tio n in these v a rio u s ways. T eaching and L earn in g T ea ch in g a n d le a rn in g a re d e p e n d e n t o n e ach o th e r, so in tea ch in g we m u st a ssist th e p a tie n t to le a rn , a n d to do this we need to re cru it all p o ssible afferents. Sound: H o w we use o u t voices, th e to n e , th e speed, the inflection. S o u n d o fte n helps in h e lp in g to e ra d ic a te a lim p if he is e n c o u ra g e d to listen to th e so u n d o f his fo o tstep s. Vision: D e m o n s tra te clearly ou rselv es a n d let h im w atch, m a k e him w a tch his ow n p e rfo rm a n c e in a m irro r, o r o n the so u n d lim b if possible. F eeling: E x te ro ce p tiv e a n d p ro p rio c e p tiv e — to u c h the s p o t w here he sh o u ld feel th e p u ll o f th e m uscle th a t should c o n tra c t m o re fully. M a k e him th in k o f th e m o v em e n t as he d oes it o n his g o o d side. O u tflo w will d e p e n d so m uch o n inflow , p a rtic u la rly in re -e d u c atin g th e fine m ov em e n ts o f th e h a n d , w here w h a t we feel influences so m uch w h a t we do. T h en b a ck a g ain to h o m e in stru c tio n , h o m e w o rk for him to d o a n d m o st im p o rta n t, w hen h e com es a g a in , re m e m ­ b e r w h a t we to ld h im a n d pra ise o r re p rim a n d as th e case m ay be. Conclusion T o co n clu d e, I will q u o te fro m D r. T e g n e r’s fo rew o rd to M . D e n a G a r d in e r ’s b o o k “ T h e P rin c ip le s o f Exercise T h e ra p y ” : “ P h y s io th e ra p y is no sta tic a r t— passive tre a tm e n ts o f inert p a tie n ts m ak in g no effort to help them selves are re g ard e d as p o ssibly p ro lo n g in g ra th e r th a n c u ttin g s h o rt in validism . Y et in spite o f . . . (d isc ard in g m an y passive m e th o d s) m o re p a tie n ts a re re fe rre d fo r p h y sio th e ra p y th a n ev er b efore. T h e gospel o f a ctiv ity h a s been w idely p re ac h ed a n d th e re seem s little d o u b t th a t p a tie n ts a re re ap in g th e b enefit.” L et us th e re fo re c o n tin u e to “ m o v e ” w ith th e tim es— to excit to a ctio n , p e rsu a d e a n d a ro u s e o u r p a tie n ts to live th e ir lives m o re fully a n d actively. T o d o so let u s re m e m b e r w h a t M iss G a rd in e r q u o te s in h e r P re fac e : “I k ee p s ix honest serving m en, (T h e y taught m e all I knew ) Their nam es are W hat a nd W hy a n d When A n d H o w a n d Where a nd W ho.” F in a lly let us p u t o u r w hole selves in to th is m o st highly skilled a n d difficult o f all o u r te c h n iq u es, th e T e a c h in g o f M o v e m e n t, so th a t o rd e r o u t o f c h ao s (h e re in all reverence I p a ra p h ra s e the e n d o f th e b o o k fro m w hich 1 q u o te d a t th e be g in n in g ) m ay “ surely— co m e q u ick ly ” . 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. )