ELECTRICAL NERVE STIMULATION IN TRAUMA IM P R E S S IO N S O N (a) D IA G N O S T IC T E S T S (b) T H E R A P Y A S E X P E R IE N C E D IN S O U T H A F R IC A B y M iss J. B L A IR , M .C .S .P ., T .C .S .P . . S enior L e c tu re r o f P h y s io th e ra p y o f th e U n iversity o f th e W itw a tersra n d . Paper delivered at the T hird International Congress o f the W orld C onfederation o f P hysical Therapy in P aris, S ept. 1959. E conom ically, as has been p roved elsew here, p a rticu la rly in such re h a b ilita tio n centres as exist in A m erica a n d the U n ite d K in g d o m , p h y sio th era p y has a v a luable c o n tri­ b u tio n to m ake to S o u th A frican industry. In Jo h a n n e sb u rg a n d on th e W itw a te rsra n d alone, th e d e v elopm ent o f in d u stry is a tre m e n d o u s a n d ever-increasing program m e. I t is inte restin g to n o te recent statistics m ad e a v ailable by th e M edical C o n su lta n t to the A n g lo A m e ric an C o rp o ra tio n o f S outh A frica L im ited— a m ining g ro u p c o n tro llin g tw enty-one A frica n a n d five E u ro p e a n ho sp itals. In the O range F re e S ta te w here A frican h o sp itals a re m o d ern and P h y sio th e ra p y freely available, o f 44,000 A fricans em ployed a t risk 50 a re h o spitalised a n d spend an a verage o f 9^ days in h o sp ita l; o n disc h arg e 9 8 % — 9 9 % a re fit fo r u n d e rg ro u n d d u ty . O n the W itw a tersra n d w here p h y sio th e ra p y is n o t so w idely used, o f 15,000 A fricans em ployed at risk 50 are h o spitalised a n d spend a n average o f days in h o sp ital; on d ischarge 10 % a re fit fo r u n d e rg ro u n d d u ty , the re m aining 8 0 % sp ending fro m 2— 3 weeks on su rface w o rk a n d light d uties. T h e a u th o ritie s c o n sid er these figures as significant in p ro v in g th e value o f p h y sio th era p y . O f these surgical cases a large p ro p o rtio n o f them are in the tra u m a tic neu ro lo g ica l g ro u p . T h e experiences n o ted in th is p a p e r d o n o t deal w ith the M in e h o sp itals b u t a re fo u n d e d on cases trea te d in the J o h a n n e sb u rg G e n e ra l H o s p ita l G ro u p a n d B a rag w a n a th H o sp ita l. T h e s e tw o u n its a re th e tea ch in g h o sp itals fo r the U n iversity o f th e W itw a te rsra n d M edical School, and a re divided as follow s: . . . T h e J o h a n n e s b u rg G e n era l H o s p ita l is the m ain h o sp ital fo r the a d u lt E u ro p e a n p o p u la tio n o f Jo h a n n e s­ b u rg and d istric t— b o th m edical a n d surgical. I t has 600 b eds a n d c o n tro ls o ver 150 beds in fo u r o f the Jo h a n n e s b u rg n u rsin g ho m es w here a re housed special units, e.g. S urgical, T h o ra c ic , P lastic, N e u ro su rg ica l and G e ria tric s. Its su b sid ia ry h o sp itals in clu d e th e T r a n s ­ vaal M em o ria l C h ild re n ’s H o s p ita l, w ith 200 beds, and th e Q ueen V ic to ria M a te rn ity H o s p ita l, w ith 100 beds. O th e r h o sp itals in J o h a n n e s b u rg include T a r a H o s p ita l w ith 150 b eds— a P sy ch ia tric U n it fo r n on-certifiable p sychiatric pa tie n ts, th e N o n -E u ro p e a n H o s p ita l w ith 100 b eds— a n em ergency c learing c en tre fo r A fricans, A siatics a n d C o lo u red s, a n d B a rag w a n a th H o sp ita l with 1,800 b eds— m ainly fo r A fricans . . . P h y sio th e rap y D e p a rtm e n ts in these u n its, a nd a lso in m ost o f the o th e r larger c entres in S o u th A frica, are u n ­ d o u b te d ly eq u ip p e d to a h igher s ta n d a rd th a n is general in E u ro p e, a n d c o n se q u en tly p h y sio th era p ists have every o p p o rtu n ity a n d e n co u ra g em e n t to im p ro v e accepted tech­ niques a n d evolve a n d develop new ones. A t the Jo h a n n e s b u rg G e n era l H o s p ita l m ost o f the pe rip h e ral a n d c en tral nerve injuries a re d ue to traffic accidents. In th is c o u n try , as in m any o th ers, the traffic h a z a rd is g re at. In a d d itio n , a ssaults (u sually g u n sh o ts a n d sta b w o u n d s) a c c o u n t fo r a high p ro p o rtio n o f the cases tre a te d . A m o n g the A fricans the m ajo rity o f pe rip h e ral n erve injuries a re p re d o m in a n tly sta b a n d k n o b k e rry w o u n d s, th e re a so n being th a t in m ost instances the u rb a n A frica n has becom e de-trib alise d a n d thus lives u n d e r u n n a tu ra l c o n d itio n s, o ften in o v ercrow ded c o m m unities Page 8 w ith few recre atio n al facilities, due to the d e m a n d s o f in d u stry . T he a u th o ritie s are d o in g m uch to im p ro v e the living c o n d itio n s, b u t th ey c a n n o t a lte r the A frican tem ­ p e ram en t, p a rtic u la rly th a t o f the m o re p rim itive A frican. T h e re is also th a t c o lo u rfu lly so rd id p e rso n ality know n a s th e ‘Shebeen Q u e en ’. A shebeen is a d rin k in g den and th e Q u een is the w om an w h o brew s the d rin k , a violently alc o h o lic co n co c tio n often said to include c arb id e, m etal polish, m ethylated spirits a n d d e ad rats, being k n ow n as ‘S k o k ia a n ’ o r ‘B a rb e rto n ’. It is sim ple to visualise th e loss o f in h ib itio n s th e im bibers have— knive, k n obkerries, s tile tto s a n d even tee th , becom e leth a l expressions o f feelings'. W e are fo rtu n a te in th a t, d ue to th e c o -o p e ra tio n and re a lis a tio n o f th e v alue o f p h y sio th era p y by th e m edical staffs o f o u r h ospitals, these p a tie n ts a re seen by th e p h y sio ­ th e ra p y tea m so o n a fte r a d m ission o r a t a very early stage o f th e ir tre a tm e n t; acc o rd in g ly we are given th e o p p o rtu n ity o f m inim ising c o m p lica tio n s a n d p ro lo n g ed afte r-ca re. T h e A fricans a re divided in to e d u ca te d , u rb a n ised and p rim itive categories, a n d a m o n g the m a jo rity o f the m ore p rim itive A frica n s we e n c o u n te r a special p ro b lem . . . it has been observed th a t a lth o u g h he posseses g reat m uscle stre n g th in his tru n k and lim bs his skilled h a n d a nd fingerj p o w e r is c o n sid era b ly less th a n th a t o f the E u ro p e a n . A s a result it is possible to c o m pletely o v e rlo o k w eakness and paraly sis p a rtic u la rly o f the h a n d s, fingers a n d low er leg. T o him it is n o t a d isability a nd his c o m p e n sa to ry a rm and leg stre n g th overrides his local w eakness; m o reo v e r, to th is type o f A frican his lim bs a re m ere ap p en d a g es a n d the loss o f use o f o n e lim b can be m ad e up by th e re m a in in g three. H e is n o t a p prehensive o f injury by violence, or th a t w hich has visible signs, a n d in sim ple tra u m a will m ake a ra p id a n d u n c o m p lica te d recovery. O bservations on D iagnostic Stim ulation. The Galvanic Faradic Test: T h is q u a n tita tiv e m eth o d o f testin g has show n to be m ost in ac cu ra te, as w as proved by the N erve Injuries C o m m itte e o f the B ritish M edical R esearch C o uncil d u rin g the 1939-45 W ar. A t o u r N o n -E u ro p e a n H o sp ita l, fo r in stance, in the presence o f R .D . a n o rm a l response to fa ra d ism w as elicited fro m 6 to 9 w eeks fo llow ing tra u m a to th e nerve in a p p ro x i­ m ately 3 0 % to 5 0 % o f cases, a n d n o response to faradism w as elicited in cases w here v o lu n ta ry m ovem ent w as present in recovering cases in o ver 50% . The A ccom m odation Test: i.e. the cap a city o f a n orm al m uscle to a d a p t itself a n d react to an electrical stim ulus. T h is in itself is fo u n d to be o f little value, b u t c o rro b o ra te d by o th e r evidence is a guide to p rognosis, p a rticu la rly in n e u ro p ra x ia . . In ten sity D uration Curves . O u r experiences in S o u th A frica are th a t this test, i n | the h a n d s o f skilled o p e ra to rs, is highly a c c u ra te and p ro ­ vides va lu a b le in fo rm a tio n o n d iag n o sis a n d prognosis. W e have fo u n d th a t it is m ost necessary to p lo t b o th the sq u a re w ave a n d ex p o n en tial (or fully tria n g u la r) w ave curves, p a rtic u la rly as a p ro g n o stic sign. As experience has show n th a t th ere m ay be a n o rm al o r a lm o st n o rm al c urve using sq u a re w ave c u rre n t b u t a p a rtia l re action o f d e g eneration is c learly e v ident by th e k inks a n d irreg u laritie s in the e x p o n en tial w ave curve. T h is evidence has been confirm ed by E le ctro m y o g rap h ic al tests, w hen fibrillations w ere noted in such cases w here the ex p o n en tial o r tria n g u la r wave fo rm show ed a b n o rm a lity and the sq u a re wave fo rm sim u­ lated th e n orm al. A n o th e r re aso n fo r o u r p reference fo r th is m e th o d is the case w ith w hich the R h e o b a se a n d C h ro n a x ie c a n be read fro m the c h a rt, th u s a series o f c o rro b o ra te d evidence. W e c h o o se the c o n s ta n t c u rre n t, high im p e d a n ce o u tp u t g e n e ra to r re g iste rin g c o n tra c tio n in c u rre n t w ith c o n tin u ­ ously c o n tro lled pulse a n d p a u se d u ra tio n s w ith n o fixed steps, b e ca u se o f th e c o u n te r-a c tio n o f th e sk in resistance fa c to r, its g re ater a ccuracy, a n d its re d u ctio n o f variables. A lso w ith its c o n tin u o u sly in d e p e n d e n t c o n tro l o f the pulse p a u se ra tio , a m o re c o m prehensive g ra p h c a n be o b tain e d . December, 1959P H Y S I O T H E R A P Y 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. ) December, 1959 P H Y S I O T H E R A P Y Page 9 Observations on Therapy: In tre a tm e n t w herever possible we fa v o u r the selective g roup tec h n iq u e ra th e r th a n o th e r m eth o d s in use, as we find it m ore com prehensive, physiologically m ore n o rm a l and less fa tig u in g to the muscles being stim u la te d . By p re d eterm in in g the pulse d u ra tio n a n d a lp h a o r c u rre n t p eak angle to w hich the p a rese d m uscles re sp o n d best, th a t is w ith o u t c o n tra c tio n overlay o f unaffected m uscles, a nd a d a p tin g th e p a u se d u ra tio n to m inim ise fatigue, a m ore effective tre a tm e n t can be given, b e tte r re co rd s kept a nd less variables need be considered. T h e m o re im p o rta n t variables th a t influence reco rd s o f progress being: (a) the exact p o sitio n in g o f electrodes, (b) th e o rd e r in w hich m uscles a re stim u la te d , (c) local skin te m p e ra tu re, a n d (d) the relative c h ange in skin resistance. It is also im p o rta n t th a t this m eth o d o f tre a tm e n t is far less tim e-consum ing. F o r exam ple if ten m uscles w ere p a ra ­ lysed a n d ind iv id u a l stim u la tio n w ere to be given effectively at a m in im u m p e rio d o f five m in u te s per m uscle, stim u la tio n w o u ld be fifty m in u te s; in g ro u p stim u la tio n all m uscles w ould be tre a te d to g eth e r a n d a to ta l tim e o f five m inutes w ould be necessary, th u s re ducing tre a tm e n t tim e by 45 m inutes. I t is im p o rta n t to m a in ta in as strict a regim e in th era p y a s it is in d ia g n js tic pro c ed u re s a n d the full c o -o p e ra tio n o f the pa ient m ust be th e first c o n sid e ra tio n . A s I m en tioned earlier, a m ere paralysis, p a rtic u la rly if n o t gross, is n o t a disability to m a n y o f the A frica n s, unless it in te rfe re s'w ith their e a rn in g c ap a c ity o r d a n cin g , w hich c o uld well h a ppen th ro u g h early neglect o f the c o n d itio n , but it is often possible to gain their c o -o p e ra tio n by c a p tu rin g th eir im a g in a tio n ; to see th e ir m uscle c o n tra c tio n by m eans o u tsid e th eir own c o n tro l o r volition is ‘w h ite m ag ic ’ to them . W e find th a t freq u e n c y o f the tre a tm e n t is d ep en d e n t on severity, fa tig u e a n d the intelligent c o -o p era tio n o f the p a tie n t. P re -m ed ica tio n is well w o rth th e tro u b le a nd by p re h ea tin g a n d low ering sk in te m p e ra tu re resistance tre a tm e n t is greatly fa cilitate d a n d m o re c o m fo rta b le ; to achieve this, m o ist h e at is th e p re fe ra b le m edium . M e tic u lo u s records o f pulse, pause d u ra tio n , alpha, fa tig u e tim e a n d c u rre n t p e ak re ad in g , to g e th e r w ith tim ely progressing in a p p lic a tio n , is e ssential fo r early re co v e rin g a n d g o o d results. A lso the c o n servative use o f stim u la tio n in c o n ju n c tio n with o th e r form s o f trea tm e n t. Conclusions It h a s becom e increasingly m o re evident th a t the in tro ­ d u c tio n o f e x p o n en tial w ave fo rm c u rre n t a n d the g re ater a cc u rac y a n d w ider ra n g e o f s q u a re w ave fo rm in p h y t o ­ th e ra p y tre a tm e n t u n its have d o n e m uch to pro d u c e m ore a c c u ra te m easures o f diag n o sis a n d m o re effective m ean s o f tre a tm e n t. In S o u th A fric a research a n d investigation in to the tre a tm e n t o f tra u m a , p a rtic u la rly in th a t o f A fricans, is a fascin a tin g a n d g re at challenge a n d o ne th a t th e W orld H e a lth O rg a n isatio n m ig h t c o n sid er in the future. a new approach to vasodilatation by the use of the potent new penetrative agent 1 iN E W F Rubiguent F O R S P R A I N S , F I B R OS I T I S , A R T H R I T I S , S T R A I N S A N D M U S C L E S P A S M R egistered User o f Trade M a r k and D istributors in S o uth A fric a : WYETH LABORATORIES (PTY.) LTD. 54, S T A T IO N STREET, E A S T L O N D O N . M E T H Y L N IC O T IN A T E in co n ju n ctio n w ith the pow erful vasodilator, histam ine o p en s the w ay for the histam ine to penetrate tissu es rapidly. There it p rom otes p rolon ged , pain-relieving hyperem ia, co m fo rtin g analgesia and so o th in g w arm th. Formula H ista m in e D ih y d ro c h lo rid e M e th y l N ic o tin a te G lycol M o n o salicy la te C a p sic u m O leoresin 0 - i % 1 - 0 % 10-0 % o - i % T hese a re in c o rp o ra te d in a b lan d , cosm etically plea sa n t vehicle. H ow Supplied— T u b es o f P ric e — Inexpensive — 5 /6 O ne O unce. p e r tu b e to y o u r p a tie n t. 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. )