June, 1961 P H Y S I O T H E R A P Y Page 5 T R E A T M E N T N O T E S SO M E SU G G ESTIO N S IN THE REH ABILITATIO N OF HEMIPLEGICS E. J E N N IN G S , M .C .S .P . A. In E arly Flaccid S ta g e: (1) Teaching the pa tie n t to roll over by them selves onto their unaffected side. T h ree a c tio n s :— (a) L ifting th e affected a rm a cro ss th e chest. (b) W riggling the toes o f the unaffected side u n d e r the T en d o -A c h ille s o f th e o th e r fo o t a n d so o b ta in in g leverage to b rin g th e affected leg over. (c) G ra sp in g the side o f th e bed to w a rd s w hich she w a n ts to tu rn , a n d th e n p u llin g w ith the a rm a nd leg and a t the sam e tim e tu rn in g the head. See D ia g ra m I. (2) Use o f rope atta c h e d to the lower corners o f the bed. T h e length o f th is ro p e m u st be a d ju s te d to be ju s t long e n o u g h fo r the p a tie n t to re ac h w ith h e r o u t ­ stretched unaffected h a n d . A p a d d e d a re a in the m iddle o f the ro p e facilitate s the g ra sp ; this can be k e p t in p o sitio n by a d hesive stra p p in g . T h e p a tie n t sh o u ld be given a c ro o k stick to b ring the ro p e w ith in her reach. M o st p a tie n ts will be a b le to sit u p w ith th e use o f this ro p e w ith in a few days. N .B . A single cen trally placed ro p e w ith a w ooden h andle is d a n g e ro u s, as th ere is n o side to side c ontrol. See D ia g ra m I. (3) F oot Board. T h is is a 4" c u b ic al piece o f w o o d , 6" lo n g e r th a n the span betw een th e legs o f th e bed. T w o sem i­ c irc u la r sc allops a re c u t o u t o f o n e side to fit a g ain st the legs o f th e bed a n d p re v en t it fro m slip p in g side­ ways. P R O F. R A Y M O N D D A R T (continued fr o m p age 4) T hirdly, I have d o n e it to sh o w ho w w o rd s ta k e o n the m eaning th a t we give to th em by th e s o rt o f lives we lead, a nd also how in te r-rela te d all p ro fessio n al p ro g ress h a p p en s to be. T h ere is a g re a t tendency a m o n g s t im m a tu re h u m a n beings to im agine th ey increase th eir ow n im p o rta n c e n o t by self-im provem ent b u t by de rid in g o th e rs ; o r by in sin u atin g th at groups o f w o rk e rs o th e r th a n th e ir o w n p a rtic u la r class are o f lesser value in th e general schem e o f things. Y o u will often h e a r superficial th in k e rs say “ O h ! w h a t c a n sh e k now a b o u t it? She’s o nly a n u rse ” , o r, “ H o w c a n he k n o w ? H e ’s only a lab o u re r, a s h o p a ssista n t, a b rick lay e r, o r w h a t n o t” . Jt was th ro u g h d o c to rs a n d n u rse s c a rin g fo r th e w elfare a nd elevated sta tu s o f all m edical a u x iliaries th a t led to w h a t has been d one so fa r fo r y o u a n d y o u r e d u c a tio n a n d th ro u g h you fo r sick S o u th A fricans. Finally, I h o p e th a t I have in d ic a te d , th ro u g h w h a t has ™n. behind a n d h a p p e n e d to y o u r p ro fessio n in S o u th Africa d u rin g th e p a st 40 y ears, so m e th in g o f the a v alan c h in g developm ents y o u c an a n tic ip a te d u rin g th e 40 y ears th a t n ow e in front o f y o u . T h o se de v elo p m en ts a re in y o u r h ands. Use: T h e b o a rd is placed o n th e floor a t e ith e r end o f the bed (head p re fe ra b ly , fo r height). T h e p a tie n t is b ro u g h t u p to it in a c h a ir a n d h e r feet a re p laced slightly a p a r t a g a in st it o n th e g ro u n d . T h is prev en ts h e r w eak leg fro m slip p in g u n d e r the bed a n d g reatly a ssists the p h y sio th e ra p ist in h e r efforts to get the p a tie n t to sta n d u p a n d sit d o w n a n d to b a la n ce in sta n d in g . T h e p a tie n t o f c o u rse pulls h e rse lf u p , b u t th e p h y sio th e ra p ist (sta n d in g o n the affected side) h o ld s th e h a n d in p o sitio n a n d e n co u ra g es th e p a tie n t to p u sh u p w a rd s w ith b o th legs. T h e w o o d e n b a r a lso prev en ts the bed fro m m oving. B . W alking S ta g e : A s s o o n as the p a tie n t can b a la n c e h e rself in sittin g a nd sta n d in g , w a lk in g is c om m enced. T h e re a re m an y m e th o d s; here a re a few w hich I have fo u n d u s e fu l:— (1) A ssisting on the affe c te d side. The p a tie n t supports h e rse lf in the parallel bars o r on a hand-rail round the room. N .B . B a ck w ard w a lk in g is a lm o st a s easy as fo r ­ w a rd s w alking. A c h a ir is placed a t e ith e r end o f the bars. T h e b a rs m u st be low e n o u g h fo r th e p a tie n t to lea n o v e r slightly to th e unaffected side. See D ia g ra m II 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 June, 1961 B andage C ontrol N o te w ide a n d ste ad y sta n c e o f p h y sio th e ra p ist w h o is p u sh in g th e p a tie n ts w eight o n to h e r u n affected side. D ia g ra m I I I f th e re is c o m p le te flaccidity o r a d d u c tio n s p a s ­ tic ity a bandage m ay b e tied w ith a c love-hitch a ro u n d th e f o o t a n d a n k le , th e lo n g end b e ing held in the p h y sio th e ra p ist’s fre e h a n d . B y th is m e a n s excellent c o n tro l o f th e leg, w hich ten d s to get b e h in d th e o th e r fo o t a n d so p re v e n t p ro g ress, can be o b ta in e d w ith o u t th e p h y s io th e ra p is t’s h a v in g to c h a n g e h e r p o sitio n . (2) A ssisting on the a ffe c te d side, w alking round a table. T h e p a tie n t’s th u m b ov er the edge m ak e s the c o n tro l. See D ia g ra m I I I N o te th e c o u n te r-a c tio n o f b o d y w eight b y th e p h y sio ­ th e ra p is t w h o s u p p o rts o n th e unaffected side. B a n d a g e C o n tro l. D ia g ra m I I I (3) A ssisting on the unaffected side with no o ther support. T h e p h y sio th e ra p ist tak e s the w eight o f th e p a tie n t b y su p p o rtin g th e fo re a rm o n h e r h ip a n d leaning a w ay w hilst she p u ts o n e a rm u n d e r th e sh oulder jo in t a n d s u p p o rts th e p a tie n ts h a n d in h e r o th e r h and. T h is is a case o f b a la n c in g b o d y w eight, a n d a good, w ide, ste a d y sta n ce is necessary. (4) N o t assisted. P a tie n t w a lking by h e rse lf w ith a 4-legged stick. B o d y b a la n ce a n d a rm sw ing sh o u ld n o w be c o r­ rected . T h e p a tie n t sh o u ld be ta u g h t to flex th e knee a n d h ip a nd to sw ing th e leg fo rw a rd in a stra ig h t line, p u ttin g th e heel o n th e g ro u n d first, in stead o f the u su a l, typical pelvic tilt a n d sem i-c irc u lar sw inging a ctio n . A pparatus to regain strength a n d m o bility: T h e “ E xercycle” is a sm all b u t very useful piece o f a p p a ra - ra tu s , co n sistin g o f o n ly th e c ra n k s h a ft a n d p e d a ls o f a bicycle, a n a d ju s ta b le re sistan c e a n d a d istan c e guage. It c a n be u sed to m obilise a n d stre n g th e n b o th th e a rm s a n d the/ legs (b y p u ttin g it o n a tab le o r o n th e floor). \ F o r th e legs it is p laced a g a in st a wall a n d th e p a tie n t is "able to tre a d le it w hilst sittin g a little fo rw a rd in her own chair. F o o t p late s m a y be m a d e o r p u rc h a se d , to fit o ver the p e d als, a n d these h ave a heel s to p a n d stra p s to keep the fo o t in p o sitio n . V ery goo d a u to -a ss is te d m o v em e n ts m ay th u s be acc o m p lish e d w ith o u t distress to the p a tie n t. (T h is a p p a ra tu s m a y b e p u rc h a se d fro m P ro te a H o ld in g s L td . P rice £6 15s. Od.) C . L a te r S ta g e : A su ita b le hig h c h a ir fo r hem iplegics a n d o th e rs with stiff hip jo in ts o r lu m b a r spine de fo rm itie s, w h o need to stre n g th e n th e q u a d ric e p s m uscle o r lo o se n th e knee jo in ts, m a y be m a d e b y a helpful c a rp e n te r. ■ (It is n o tic e a b le th a t m o s t p a tie n ts m a k e a bee-line fo r th is c h a ir in th e d e p a rtm e n t, w here it tak e s u p n o e x tra ro o m .) See D ia g ra m IV a H I G H C H A I R fo r general u se a n d Q u a d rice p s resistance exercise. D ia g ra m IV 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. ) June, 1961 P H Y S I O T H E R A P Y Page 7 S pecification s f o r th e c o n stru ctio n o f high ch a ir f o r qu a d rice p s e x ercise : It sh o u ld be m a d e o f s tro n g solid w ood, so th a t it is to o heavy to tip over easily. The legs: s h o u ld b e m a d e 4" lo n g e r t h a n n o r m a l , o f a a r e s h a p e a n d j o i n e d by c r o s s - b a r s 3" a b o v e flo o r level. D o m e s m ay be in s e rte d in t o t h e bases if d e s ire d . The seat: T h is sh o u ld be w ide e n o u g h to a c c o m m o d a te the largest p a tie n t a n d it m a y be b u ilt u p in f r o n t in to a h a lf-d o m e d shape, to p re v en t th e p a tie n t fro m slid in g f o rw a rd s an d a lso to give leverage fo r m uscle w o rk . T he whole surface o f th e se a t m ay b e c overed w ith sp o n g e ru b b e r The b ack: T h e re a re tw o u p rig h t s tru ts fixed to th e re a r corners o f th e seat, ex te n d in g to ju s t a b o v e h e ad h e ig h t o f average p a tie n t; th ey a re jo in e d to g e th e r a t th e to p b y a thick c ro ssb a r, slightly cu rv ed fo r h e ad s u p p o rt. Sling: A b ro a d piece o f c an v a s is p laced ro u n d these uprights a n d stitched to itself. T h is m ak es a n a d ju sta b le back su p p o rt a n d allo w s th e p a tie n t w ith hip o r lu m b a r deform ities to sit in c o m fo rt. ' The arm s: T h ese a re m ad e o f u n p a d d e d w o o d , n a rro w enough to be g ripped easily. T h e y c o m e fo rw a rd fro m the uprig h ts a t elbow level, a lm o st to the level o f th e fro n t o f the seat. T h ere is a s tro n g su p p o rtin g s tru t to th e side o f th e seat. See D iagram IVb Apparatus f o r quadriceps w o rk : F itted to this c h a ir: (1) A t th e m iddle o f th e b a ck o f th e h e ad c ro ssb a r, a stro n g , deeply g rooved p u lley w heel is firm ly screwed in. (2) A t th e m iddle o f th e b a c k o f th e c ro s s b a r betw een the tw o re a r legs o f th e c h air, a swivel p u lle y is fixed so th a t it m oves freely a b o v e th e bar. (3) A ro p e o r m eta l c ab le is inserted betw een th e pulleys w ith a h o o k o n e ach e nd fo r a tta c h m e n t to (a) b a g o r ro d h o ld in g w eights, a n d (b) th e D -lo o p o n th e p a tie n t’s fo o t sling. (4) A “ c u p -h o o k ” is screw ed in to th e b a c k o f th e fro n t c ro ssb a r a n d th is saves th e w eight c ra sh in g to th e floor a n d su b seq u e n t grovelling to p ick u p th e rope. (5) A three-ringed fo o t sling is p u t ro u n d th e p a tie n ts fo o t and a n k le w ith th e D -rin g a t the heel. (6) A sm all b u t s tro n g w o o d e n sto o l, 4 -6 " h igh, 12" long and 8" w ide is p u t u n d e r th e fo o t n o t b e in g exercised. T h is also assists g e tting o n a n d o ff th e c h a ir. T hese stools have m an y o th e r uses in a d e p a rtm e n t. A d ju stm en ts: T h e ra n g e o f m o v em e n t re q u ire d m u st decide th e precise p o in t o f a tta c h m e n t o f the w eights. I f th e ro p e is to o long, th e w eight to uches the g ro u n d ; if it is to o sh o rt it is stopped b y the u p p e r p u lle y wheel b e fo re the p a tie n t h as fully extended h e r knee. A s to p p e r m ay be p u t o n th e ro p e u n d e r the c h a ir to p re v e n t to o m u ch knee flexion. T h ese p ra c tic a l pieces o f a p p a ra tu s have b een evolved as a re su lt o f seven y ears sin g le-h a n d ed w ork, m o stly w ith hem iplegics, b u ild in g u p fro m n o th in g to g e ria tric u n its in E n g la n d . T h o u g h heavy, th e re su lts o f this w o rk w ere very satisfying. N o w these d e p a rtm e n ts a re p ro p e rly e stablished a n d ru n by a c h a rte re d p h y sio th e ra p ist, a re m e d ia l g y m n ast (m ale), tw o a ssista n t n u rse s and a p o r te r in e ac h h o sp ital. DO ES Y O U R W HEEL C H A IR FIT? M ISS M . H U M P H R E Y , B .S c .(P hys.) W ITS. H o w o ften h ave y ou given o r received this re q u est “ Please o rd e r a w heel-chair fo r th is p a tie n t” . N o m o re — n o less. D o y o u K N O W w hy so m e c h a irs h a v e th e larg e w heels in fro n t a n d so m e a t th e b a c k ? D o y o u K N O W th a t a w h eel-chair w ith o u t b ra k e s is a d a n g e ro u s vehicle? D o y o u K N O W th a t w heels o f 5 in. o r less c a n b e p o s i­ tively leth a l ? D o y o u K N O W th a t th e re a re m a n y m akes o n the m a rk e t a n d th a t th e m a n u fa c tu re rs o f a g o o d a n d re liab le m ak e are o n ly to o re a d y to m a k e a n y a d ju s tm e n t y ou m ay re q u ire ? A w h eel-chair is like a n y o rth o p a e d ic a p p lia n c e w o rn by a p a tie n t a n d sh o u ld be o rd e re d w ith ju s t as m uch care. T h e p a tie n t’s d isability, w eight, age a n d sex a re a ll im p o rta n t fa c to rs to be ta k e n in to c o n sid e ra tio n w hen it is pre scrib e d . F o r it sta n d s to re aso n t h a t if it is n ecessary to o rd e r a w h eel­ c h a ir fo r a p e tie n t it is going to b e a p re tty p e rm a n e n t e ssential fo r th e re st o f his life. A s he is likely to sp e n d a g re a t d eal o f tim e in th e c h a ir it m u s t m ea su re u p to his specific re q u ire m e n ts. I t m u st be c o m fo rta b le . I t m u st be easily m an o e u v rea b le, it m u st be b u ilt in such a w ay as to fa c ilita te tra n s fe r w ith th e m in im u m o f p h ysical effort a n d a b o v e all it m u st be as safe a n d sta b le as a w h eel-chair c a n p o ssib ly be. W H E E L S A ll m odels sh o u ld h a v e tw o large a n d tw o 's m a ll w heels. W h e th e r th e larg e w heels a re a t th e fro n t o r b a c k d e p en d s largely o n th e p a tie n t’s disability. L arg e w heels sh o u ld h a v e a d ia m e te r o f 23 in .; sm all w heels 8 in .— n ot less, as sm a lle r w heels a re m o re likely to b e co m e e n ta n g led in ru g s, c rac k s a n d sm all objects. H A N D R IM P R O J E C T I O N S H o riz o n ta l, vertical o r diag o n a l p ro je c tio n s m ay be a tta c h e d to th e h a n d rim s. T h e n u m b e r, length, a n d th e desired sp a c in g sh o u ld be specified. T h e p ro je c tio n s a re in d ic a te d fo r p a tie n ts w ho have s h o u ld e r m uscle p o w e r, b u t n o p o w e r in the h a n d s. T Y R E S T h e ty res on th e sta n d a rd m odels a re o f solid ru b b e r b u t p n e u m a tic ty res m a y b e p re scrib e d to m a k e rid in g easier. B R A K ES E very c h a ir sh o u ld h ave b ra k e s to p re v en t ro llin g o n a n incline o r w hen th e p a tie n t desires to get o u t o f th e c h a ir w ith o u t its b e ing held by a n o th e r p e rso n . T h e b ra k e s m u st b e w ith in easy re ac h , a n d if a rm rests a re re m o v a b le , m u st b e low e n o u g h so th e y d o n o t in te rfe re w ith m o ving side­ w a rd s o u t o f th e c h air. R e m o v a b le ex te n sio n a tta c h m e n ts sh o u ld be pre scrib e d w ith th e re m o v a b le a rm rests. 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. )