Impressions Gained on a Recent Trip Abroad B y N O R M A N K L A S S , B.A., M .B., D . Phys. M ed. H e a d o f the P hysical M edicine a t S outh R and, N igel, G erm iston a nd Far E ast R and H ospitals a n d A ssista n t at the General Hospital, Johannesburg. R E S U M E O F A TALK GIVEN T O T H E S O U T H E R N TR A N SV A A L B R A N C H O F TH E P H Y SIO T H E R A P Y SO C IETY . Page 4 P H Y S I O T H E R A P Y March, 1960 Israel. T h e first place I visited w as Israel. Physical M edicine is v ib ra n tly alive in th is new c o u n try . T h e U n iversity has a P ro fe sso r o f Physical M e d icin e; th ere are several A ssistant P ro fe sso rs o f Physical M e d icine; a n d th e M edical S tu d e n ts receive a very so u n d g ro u n d in g in o u r subject. A lth o u g h the pro fesso rial sta ff are supposed to be p a rt- tim e, th ey spend p ractically the full w o rk in g d a y a t th eir posts, a n d c om m ence seeing p riv ate p a tie n ts a t the tim e w hen we cease w o rk fo r the day. T h e re are a lso several full-tim e R e g istra rs, so th a t a great d eal o f re sea rc h w ork is being done. T h e re is a school o f P h y sio th e rap y o f w hich th e head, S a n d ra S aber, is a fo rm e r stu d e n t of, a nd tea ch e r a t W its. U niversity. P h y sio th e rap y stu d e n ts have a very p ractical and well o rganised 4 year c o u rse and th eir qualifica tio n is recognised by the C h a rte re d Society o f P h ysiotherapy. T h e O c c u p a tio n a l T h e ra p y d e p a rtm e n t a t the Sarafend H o s p ita l w as one o f the best I have seen anyw here, h e a t e r s m ain ly fo r polios. T w o extrem ely useful “ a rtic le s” I saw th ere w ere a little tro lle y driven by b a tte rie s, fo r collecting p a tie n ts from the different w ards, a n d a “ gallow s” c h a ir, in w h ich the seat a n d b ack and gallow s p a rt c an all be ad ju ste d fo r polio p a tie n ts to sit in o r fo r th e ir re-e d u c atio n in w alking. It is a very c o n sid era b le im p ro v e m en t on the one used at S toke, M andeville. T h e O c c u p a tio n a l T h e ra p y D e p a rtm e n t m ak es pra ctic a lly every splint, c aliper and a p p lia n c e needed in th e w hole ho sp ital. A g re at convenience- in all the h o sp itals d e alin g w ith p o lio p a tie n ts is th a t the to ilets have sw ing d o o rs, a nd at the W .C . seat th ere are h o riz o n ta l a n d tran sv erse bars at different heights so th a t h a n d ic ap p e d p a tie n ts can assist them selves. H y d ro T h e ra p y plays a very large a n d extrem ely im p o rta n t p a rt in p h y sio th e ra p y tre a tm e n ts in this, a nd every o th er c o u n try I visited, except in E n gland a n d , u n fo rtu n a te ly , as in S o u th A frica. T h e b a th a t the S arafen d H o s p ita l c ost £75,000— a gift fro m a C a n a d ia n W o m e n ’s O rg a n iz a tio n — a n d has parallel b a rs and n u m e ro u s ap p lia n ce s in it. Jn a d d itio n , it has electrically o p e rated g a n tries to m ove the p a tie n t fro m the stre tc h e r to the b a th , w ith the m inim um o f effort a nd h a ndling. T h e re a re w eekly c o n jo in t m eetings o f Physicians, S urgeons, O rth o p a e d ic Surgeons. Specialists in Physical M edicine, P h y sio th e rap ists a n d O c c u p a tio n a l T h e ra p is ts , to discuss inte restin g p a tie n ts o f the week. T h e Society de alin g w ith o u r subject consists o f Physical M edicine, rh e u m a to lo g y a n d re h ab ilita tio n , so th a t the field is very fully covered. Turkey. I next visited the U niversity o f Is ta n b u l. T u rk e y is a very p o o r c o u n try and a lth o u g h a very old o ne it is only no w beginning to tak e an active p a ri in Physical M edicine, b u t it is d o in g so extrem ely well a n d is a lre a d y fa r ah ead o f a n y th in g d o n e in S o u th A frica, a n d o f pra ctic a lly every­ th in g d o n e in E ngland. H e re a gain, th ere are P rofessors o f Physical M edicine, A ssistan t P rofessors, a n d n u m e ro u s full tim e R egistrars. H e re again, also, a g re at d eal o f R esearch W o rk is being d o n e , a n d 1 w as show n a m achine w hich, it is claim ed, stim u la te s only the sy m p a th e tic nerves, b u t n o t the v o lu n ta ry nerves. T h ere is n o P h y sio th e ra p y school yet, a nd the w ork is d one by girls w h o are picked by the P ro fe sso ria l Staff, a n d they a re ta u g h t u n d e r th eir supervision. H y d ro T h e ra p y plays a very im p o rta n t p a rt in tre a tm e n t, a n d an excellent idea here is to have all the hem iplegias, p a rap leg ia s, a n d sim ilar c o n d itio n s c o n c e n tra te d in one w ard. M edical stu d e n ts receive a so u n d g ro u n d in g in Physical M edicine. I w as show n several p a tie n ts w h o h ad had flexion c o n ­ tra c tu re s o f th eir knees, w h o had been m a n ip u la te d a n c r splinted, a n d fo r w hom g ood results a re claim ed. A n inte restin g in n o v a tio n here w as a form o f con v ey o r b elt let in to the flo o r o f the gym nasium , on w hich p a tie n ts p ractice w alking. It can be set to m ove a t different speeds. A n im p ro v e m en t on th is w as seen in several h o sp itals in S c a n d in a v ia. T h is can be tilted up to give resistance to w alking. Like in Israel, a nd all o th e r c o u n trie s visited, except E ngland, th ere a re w eekly c o n jo in t conferences o f Specialists in Physical M edicine, S urgeons, Physicians, O rth o p a e d ic S urgeons, P h y sio th e rap ists a n d O c c u p a tio n a l T h era p ists, w ho e xam ine a nd discuss and tre a t patients. T h e sp eciality here is called P hysical M e dicine and R e h a b ilita tio n . In c id e n ta lly , m edical stu d e n ts a re charged no fees in T u rk ey , so th a t all o f the 3 U niversities th ere are at least 500 stu d e n ts each year. I w as asked to lecture a t the U niversity on m eth o d s o f tre a tm e n t used in S o u th A frica w ith p a rtic u la r reference to polio, o f w hich they h ad h ad a recent severe epidem ic. 1 was scheduled to speak fo r one h o u r, b u t a t the end o f this tim e th ere were still so m an y q u e stio n s a n d so m u ch discussion th a t I w as kept fo r 2y h o u rs. T w as even a sked h ow m uch m y pra ctic e b rings in a nnually. A W o rk m e n ’s C o m p e n s a tio n A ct has ju s t com e into b eing a n d g re at efforts are m ade to re h a b ilita te all h a n d i­ c ap p e d individuals. Italy. R o m e w as the next place I visited. A s far as I c o uld le a r n ' ' the sta n d a rd o f Physical M edicine is p o o r a n d receives b u t scant a tte n tio n . T h e re is a h o sp ital a b o u t 15 m iles so u th o f R o m e w hich tre a ts a cu te polios, a n d w here the m eth o d s are sim ila r to ours. It w as in te restin g to n o te th a t in every c o u n try I visited, in clu d in g E n g la n d , m ore a n d m ore electrical stim u la tio n is b e ing used in the tre a tm e n t o f polio. A P ro fe sso r o f R h e u m a to lo g y in R om e d e m o n stra ted som e o f his tre a tm e n t to me in a rth ritic a n d o th e r c o n d itio n s in his p riv a te C o n su ltin g R o o m s. T h is consisted o f giving w h a t a p p ea red to be a c o u n te r-irrita tio n w ith an in stru m e n t th a t lo o k ed like a sm all fa k ir’s bed, a n d th en ru b b in g a p o w d e r in to th e p u n c tu re w ounds. W hen I tried to d is­ cover w h a t this p o w d e r w as, the P ro fe sso r su d d e n ly becam e very deaf. H e also gave d eep X -R a y T h e ra p y tre a tm e n t, even to a spine w hich h a d recently been fra c tu re d . Y et the am a zin g th in g is th a t the pa tie n ts, one and all, said they w ere feeling c o n sid era b ly b e tter. T h e O rth o p a e d ic section o f the R om e U n iv e rsity is a m o st m agnificent in stitu te. H ere I w as show n a m achine fo r a p p ly in g g ra d u al a nd g ra d u a te d stre tc h in g to flexion c o n tra c tu re o f knees, and w hich w as a lso claim ed to give excellent results. 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, 1960 P H Y S I O T H E R A P Y Page 5 Sw itzerland. T h e next p o rt o f c all w as Z u ric h . S w itzerland h a s excellent P h y s io th e ra p y Schools a t all th ree U niversities. T h ey have P ro fe sso rs o f P hysical M edicine, A sso c ia te P rofessors, a nd full-tim e R e g istra rs a n d M edical S tu d e n ts a re well ta u g h t in P hysical M edicine. T h e g ro u p consists o f Specialists in P hysical M edicine a n d R h e u m a to lo g y , a nd h e re also, re g u la r w eekly conferences a re held by Specialists in P hysical M edicine, S urgeons, O rth o p a e d ic Surgeons and all a n cilliary staff. A g re at d eal o f research w o rk is also being done. I t tak e s longer to specialise in Physical M edicine th a n a n y o th e r subject, n am ely 5 years fo r P hysical M edicine, a nd a n e x tra 2 years f o r R h e u m a to lo g y . H y d ro T h era p y , as in a ll o th e r progressive c o u n tries, plays a m o st im p o rta n t p a rt in tre a tm e n t. T h e P h y sio th e ra p y D e p a rtm e n t a t the C a n to n H o s p ita l in Z u ric h is a t least 3 tim es th e size o f the one a t th e G e n e ra l H o s p ita l, a lth o u g h it h a s m a n y less beds. T h e re a re 60 p h y sio th era p ists on the staff, w hich m eans a b o u t o n e fo r every 15 in-p atien ts. 'C o m f o r t o f p a tie n ts is c o nsidered to such a n e x te n t th a t „they even have electric h a ir d rie rs a n d n u m e ro u s b a th ro o m s ''f o r p a tie n ts to use a fte r tre a tm e n t. A ll in fra-re d lam p s here a re fitted w ith filters a n d I saw a m o st ingenious a p p a ra tu s f o r tre a tm e n t w ith m o ist heat. I f a p h y sio th era p ist w ants to d o research w ork she is given every facility to d o so. P h y sio th e rap ists in Sw itzerland w o rk in cycles o f 11 days, d u rin g w hich tim e th ey m u st d o 88 h o u rs w o rk . Y et th eir salaries, like salaries in every c o u n try I visited, a re low er th a n th o se paid in S o u th A frica, w hilst In c o m e T ax is c o n sid era b ly higher. A ustria. N e x t I visited V ie n n a w here I w ork ed w ith th e w orld fa m o u s P ro fe sso r B o h ler. P h y s io th e ra p y does n o t a p p e a r to be used m u ch except fo r re h a b ilita tio n a n d exercise classes. P ro fe sso r B o h le r p ro u d ly p o in ts to 4 larg e notices on all fo u r w alls o f th e g ym nasium w hich read th a t “ / / any m ovem ent gives p a in that m ovem ent m ust not be given.” Scandanavia. N e x t I visited C o p e n h a g e n , S to c k h o lm a n d O slo, w here p ro c e d u re is so m u c h alike, th a t I will d e scribe o n ly C o p e n ­ h ag en as an exam ple o f all th re e co u n tries. A ll three c o u n trie s have P ro fe sso rs, A sso c ia te P rofessors, a n d full tim e R egistrars. T h e G ro u p is called P hysical M edicine and R h e u m a to lo g y . M e dical stu d e n ts receive a goo d g ro u n d in g in o u r subject, a n d P h y sio th e rap y Schools, especially in re h a b ilita tio n exercises are w orld fam ous. \ D e n m a rk had a very severe p o lio epidem ic a b o u t 8 years -'ago, and it is a re v elatio n to see ho w well sufferers fro m th is disease are treated a n d lo oked a fte r fo r th e re st o f th eir lives. P ro p rio c ep tiv e N e u ro m u sc la r F a c ilita tio n technique is used a great deal, and th e tre a tm e n t o f a c u te cases is n o different from the m eth o d s we use in S o u th A frica. T h e w a rd s in th e a cu te fever h o sp itals a re so c o n stru c te d th a t visitors can lo o k in a n d see the p a tie n ts w hilst the p a tie n ts c a n n o t see o u tw a rd s. F o r every b o ttle o f beer sold by the T u b o rg B rew ery a c ertain perce n ta g e com es to the P o lio F o u n d a tio n . I w as offered a 6 m o n th s sc h o la r­ ship to stu d y P olio in S ca n d in a v ia a n d in the U n ited S tates, b u t h a d , m o st re lu c ta n tly to refuse, n o t being a b le to leave m y p ractice fo r so long. 1 saw a y o u n g E skim o b oy w ho h ad p olio. H e a n d 10 o th e r p a tie n ts w ho w ould have been in an iron lu n g c o n ­ tin u o u s ly in this c o u n try w ere sittin g in the g a rd en w ith the a ssistance o f sm all p o rta b le m achines. I also saw a b e au tifu l to y fa rm y a rd o f w hich every single a rticle, including lo n g picket fences, w ere m a d e by a y o u n g girl w h o can o nly use h e r toes, as a result o f polio. I saw a m ost a m a zin g electrically c o n tro lled w heel-chair w hich c a n be m a d e to m ove in a n y direc tio n by m erely e x te n d in g the fingers o f one h a n d — the on ly m ovem ent th is p o lio p a tie n t h a d — a g ain st 4 press b u tto n sw itches. I also saw a m ost in te restin g parap leg ic bed w ith a curved p ro jec tio n a t the fo o t. B y m erely lifting th e h e ad o f the bed th e p a tie n t is en ab led to sta n d w ith o u t leaving his bed. H y d ro T h e ra p y is used very extensively. I saw m o st in te restin g clothes fo r b o th m en a n d w om en w hich c a n be p u t on w ith the m in im u m a rm a n d h a n d m ovem ent, a n d all reinforced in a re a s w here c ru tc h es o r ap p lia n ce s m ay chafe th e cloth. E ngland. F in a lly I visited E n g la n d , a nd fo u n d P hysical M edicine w ith very few exceptions being p ra ctised as it h a s been d o n e fo r years. B u t a g re at d e al o f re sea rc h w ork is being d o n e , a n d p r o o f fo u n d th a t m a n y o f o u r m o dalities are o f very little scientific o r clinical v alu e w hen p u t to c o n tro lled tests. E v ery tea ch in g h o sp ita l has se veral full tim e R e g istra rs yet th ey seem to d o very little research. In th e w hole o f S o u th A frica th ere a re o nly tw o R e g istra rs p o sts. It w as inte restin g to find a t St. T h o m a s ’ H o s p ita l th a t O rth o p a e d ic S urg eo n s w ere referring p a tie n ts to th e Physical M edicine D e p a rtm e n t fo r diagnosis. M o re a n d m o re Specialists in Physical M e dicine a n d G e n era l P ra c titio n e rs seem to be p ra c tisin g D r. Ja m es C y riax s m a n ip u la tio n s. I found th is in S c a n d in a v ia as well. In th e sa m e w ay m o re a n d m o re d o c to rs a re going in fo r giving e p id u ra l injections. I t w as sad to h e ar th a t a b a th w hich w as b u ilt a t St. T h o m a s ’ only a few years a go is h a rd ly ever used fo r tre a tm e n t, a n d H y d ro T h e ra p y a p p e a rs to be little p ractised. It w as illu m in a tin g , a n d d isconcerting, to find th a t co n tro lled e x perim ents show ed th a t p a tie n ts w h o w ere given s h o rt w ave D i a th e r m y F a rra d is m ; W ax B a th s ; a n d In fra R ed d o n o b e tte r th a n p a tie n ts w ho w ere given o nly analgesic ta b le ts a n d a ctive m ovem ents, a n d th a t fa rra d ic fo o t b a th s a n d flat feet exercises w o uld a p p e a r to be useless, (vide “ P h y s io th e ra p y ” Ju n e , 1959.) O ne Specialist in P hysical M edicine is re p o rte d to h ave told his B o a rd o f G o v e rn e rs th a t th e h o spital d id n o t need a P h y s io th e ra p y D e p a rtm e n t, n o r H y d ro T h e ra p y , a n d he is m o st sc a th in g a b o u t w h a t he calls th e “ d e a r old lad ie s” w h o tea ch a n d exam ine a t th e C h a rte re d Society. N o S pecialist in Physical M edicine can be a p p o in te d H e ad o f a n y D e p a rtm e n t unless he has th e M .R .C .P . as well, so th a t all h ead s o f d e p a rtm e n ts a re highly tra in e d , a n d fully c ap a b le o f d o in g research w o rk , w hich th ey a re d o in g increasingly. O u r speciality sh o u ld th ere fo re so o n be p u t o n a fine scien­ tific basis. T h e tre a tm e n t in a c u te p o lio is sim ila r to o u rs except th a t P h y s io th e ra p y S tu d e n ts a re ta u g h t th e K a b a t M e th o d . D r. C y riax m a in ta in s th a t th e o nly m assage w hich is o f a ny v alue is friction m assage. E le ctro -m y o g rap h y h as reached a very high s ta n d a rd in E n gland, a n d a g re at d eal o f re sea rc h is being d o n e in this. I fou n d th a t th e P ro p rio c e p tiv e N e u ro m u s c u la r F a c ilita tio n m eth o d is being used in hem iplegias as well, a nd even a rth ritic c o n d itio n s. T h e B o b a th m eth o d is a lso being em ployed, fo r hem iplegias and allied c o n d itio n s. A t St. T h o m a s ’ H o s p ita l u ltra -v io le t tre a tm e n t is being given w ith long fluorescent type b u rn e rs, so t h a t all areas can be d o n e a t o n e tim e. I saw these a t th is h o sp ita l 5 years ago, a n d on m y re tu rn re co m m e n d e d th a t they sh ould be p u rc h a se d fo r T ra n s v a a l P ro v in c ia l H o s p ita ls , b u t w ith o u t success th u s fa r. I t is a g re at p ity th a t th ere a re n o P ro fe sso rs in Physical M edicine in E n g la n d a n d th a t c o n jo in t conferences betw een all d o c to rs a n d an cilliary sta ff a re n o t held. Conclusions. I c om e to th e fo llow ing c o nclusions, from w h a t I h ave seen. T h e n a tu re o f p h y sio th era p y is a t long last definitely be g inning to c hange. I t is hig h tim e th a t this sh o u ld h a p p en as o u r d e p a rtm e n t is still very largely being used as a d u m p in g g ro u n d f o r all th o se p a tie n ts o f w hom th e o th e r Specialities w a n t to be rid. W e a re com pletely to be b lam ed fo r this as we have gaily co n tin u e d to use m eth o d s o f tre a tm e n t w hich h ave n o p ro v e n scientific basis. I t is th e re fo re no w o n d e r th a t p e o p le like c h iro p ra c te rs have sto len a m arc h o n th e M e dical P rofession. 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. ) V A C A N C IES N A T A L P R O V IN C IA L H O S P IT A L S S E R V IC E . 1. A p p lica tio n s are invited fro m su itab ly qualified persons f o r a p p o in tm e n t to the u n d e rm e n tio n e d post. 2. A p p lica tio n s sh o u ld be forw arded to th e D ire c to r o f P rovincial H o sp ita ls, P .O . B ox 20, P ie te rm aritz b u rg , and th e reference n u m b e r show n below a g ain st the p o st, should be q u o ted . 3. A p p lica tio n form s (P .H . 9) are o b ta in a b le from a ny Provincial H o sp ita l in N a ta l o r fro m the D ire c to r at the above address. 4. T h e nam es o f tw o referees m ust be sub m itte d . 5. T he closing d a te fo r the receipt o f a p p lic atio n s is F e b ru a ry 29th, 1960. D U R B A N — A ddington H ospital. Physiotherapist Grade II. Reference N o .: 4 0 /4 /2 2 /3 . S alary Scale: £480 x 30 — 720 x 40— 800. Q u a lifica tio n s:— D ip lo m a in P h y s io th e ra p y /R e g is tra tio n or eligibility for re g is tra tio n in P h y sio th e ra p y w ith the S o u th A frica n M edical C ouncil. Previous exp erien c e :— R eco g n itio n is g ra n te d fo r p revious experience on an ap p ro v ed basis. Page 16 ( Continued fr o m Page 5.) C o n c lu sio n s: “ R E C E N T T R IP A B R O A D ” M a n ip u la tio n s are being used m ore extensively, especially in E n gland a nd S c andinavia. In th e sam e way in je c tio n s are being used m o re a n d m ore. All o u r usual m eth o d s o f tre a tm e n t are being so u n d ly investigated. M ore and m ore a tte n tio n is being given to general re h a b ilita tio n , in stead o f c o n c e n tra tin g on sm all isolated areas. It is no w o n d e r th a t w hen I w as in the R .A .F . th e soldiers used to refer to P h y sio th e ra p ists as the “ P at a n d T ickle P eople” a nd “ those w h o ru b y ou up the w ro n g w ay” . W e sh o u ld p ractise H y d ro T h e ra p y very m uch m ore th an we do, a n d research w ork sh ould be d one c o n sta n tly b o th by m edical m en a n d p h y sio th era p ists. P h y sio th erap ists, in m y o p in io n , sh o u ld have a different c arricu lu m , w ith o u t zoology, m uch less a n a to m y and physiology a n d pra ctic a l instead o f theo re tic al psychology. T hey sh o u ld be ta u g h t P ro p rio c ep tiv e N e u ro m u s c u la r tec h n iq u e p a ri passu w ith the tea ch in g o f o th e r clinical w ork. In m y o p in io n they sh ould receive a t least a y e a r’s train in g in K inesiology, such as is ta u g h t in the Physical C u ltu re co u rses in P re to ria a n d S tellenbosch U niversities. March, 1960P H Y S I O T H E R A P Y CAN A D A . Fem ale Physiotherapist (fu lly qualified). 386 bed, m o d ern , fully a ccredited, general ho sp ital. S alary fro m 3,300.00 d o lla rs per a n n u m , 38 h o u r w eek, 3 weeks v a ca tio n , excellent p e rsonnel policy. Passage m oney will be a d v an c ed as loan to be repaid by pa y ro ll de d u ctio n d u rin g first y ear o f e m ploym ent. A p p ly : M r. R . A . Jones, Business M anager, St. T h o m a s-E lg in G e n era l H o sp ita l, St. T h o m a s, O n ta rio , C a n ad a . ADVERTISING SPACE AVAILABLE S O U T H E R N R H O D E S IA — Bulawayo. P h y sio th e rap ist re q u ire d fo r P rivate Practice, A p p ly : M asefield, M edical C e n tre , Bulaw ayo. 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. )