Page Four P H Y S I O T H E R A P Y April, 1957. THE TREATMENT OF HEMIPLEGIA IN CHILDREN B y SOPHIE LEVITT, B.Sc. (Physiotherapy) Rand. H E M IP L E G IA is encountered by most physiotherapists, their approach differing according to the aetiology o f the condition and to its clinical stage. This article outlines th e m ethods o f treatm ent o f hemi plegia in children as practised by the physiotherapy staff o f the Johannesburg School and T reatm ent C entre for C erebral Palsied C hildren. I t is hoped th a t certain aspects o f these treatm ent techniques may prove o f value n o t only to those handling child hemiplegia, but also to those hand ling adults suffering from the condition. Principles of Treatm ent Parents are often heard com m anding their young hemi- plegics to “ use your bad arm .” A lthough perhaps objecting to the w ord “ b ad ” many physiotherapists agree w ith this p oint o f view in principle, in th a t they recom m end intensive therapy o f the affected side. T his approach has been discarded a t the Johannesburg School and T reatm ent C entre, where it is believed th a t such em phasis o f the hemiplegic side loses sight o f th e child as a whole, both physically and psychologically. T he body’s right and left sides do no t function as independent units. h i r s c h b e r g in their studies o f gait in adult hemiplegics have recorded abnorm al electrom yographic patterns of the muscle w ork on the unaffected side. A lthough, this may be due to a m echanical disturbance rath er th an to any specific pathology o f th a t side, the existence o f a disturbance is clearly dem onstrated. I t is also interesting to note th at h e l l e b r a n d t , in her w ork on “ cross education,” has shown th a t electrom yographic activity takes place in the limb opposite to th a t carrying o u t a strong volitional movement. A rm am putees, particularly o f the bilateral type, have found th a t the absence o f a reciprocal arm swing interferes with the control o f balance and o f walking. T he author has found it interesting to note th a t some o f her cases of Parkinson’s disease have rem arked on the increased facility o f walking once a reciprocal swing o f the arm s w ith the legs was achieved. T he affected side should, therefore, not be treated in isolation but as p art o f the p atient’s overall function. The hemiplegic child usually does not wish to m ake the effort to use a limb which does not move as easily as the others, and one agrees w ith r o b i n a u l t th a t until the child reaches three years o f age and prior to the need for skilled activities, he feels no loss in w hat he has never used. T hen and later, he will devise ways o f function, no m atter how poorly, w ith no, or only m inim al, use o f the affected limb. D em ands by therapists, teachers and parents th a t he should use the hemiplegic side will often result in a growing resistance to doing so. Some children will hide the affected hand by pulling down a jersey or shirt sleeve to cover it. T he reaction o f adults to hemiplegic limbs has been discussed by c r i t c h l e y , the B ritish neurologist, who has concerned him self m ore w ith the neurological denial o f paralysed limbs than with the environm ental causes o f the reactions. This neurological phenom enon o f “ anosognosia” appears to be related to disturbed body image—a perceptual aberration. T here are cases o f “ hemiplegia” in children which do not move their limbs because o f astereognosis rather than because o f spasticity o r flaccidity, and a neurological report should be obtained to check this possibility. In any event, whatever the reason for lack o f use o f the affected side, constant dem ands m ade directly on th a t side, do not seem to the a u th o r to provide a solution. A ‘holistic’ evaluation o f those cases where increased movem ent o f the affected side has resulted from ‘one-sided’ physiotherapy m ust take into account the aggravation o f other existing problems and /o r the creation of new ones. C erebral Palsy workers also suggest the possibility o f difficulties related to handed ness and th a t enthusiastic physiotherapy o f a dom inant hand may be associated with speech delay and defects, tem per tantrum s and even convulsions. Development of Function How, then, should th e physiotherapist attem pt to develop function in the affected side? Physiotherapy m ust be planned to involve the use o f the whole body, including the affected side, in enjoyable and interesting m o to r activities, h e r n , o f Q ueen’s Square N ational H ospital for N ervous Diseases, L ondon, has pointed out the additional necessity o f “ purposive move m ents” in her adult hemiplegics. Purposive, enjoyable and interesting movem ent in a child is best stim ulated through play, his means o f learning and self-expression. Aims o f Treatm ent 1. Prevention o f deformities or contracture. 2. R eciprocation. 3. Bilateral activity. 4. Balance training. 5. Postural training. 6. E ducation in walking. A lthough these aspects o f treatm ent will be discussed under the above headings, it will be obvious th at these aims overlap and th a t they are all incorporated in the basic aim o f developing function in the affected side. 1. Prevention of deformities D eform ities vary according to the individual case, the m ore com m on ones being shoulder abduction or semi abduction, elbow flexion or pronation, w rist palmarflexion, clenched w rist and thum b, hip and knee flexion and feet in either equinis, equino-varus o r valgus. To prevent these deform ities or postures becom ing contractures, movements to counteract them are employed. (a) Shoulder: Children respond well to reaching overhead for large toys, hanging up toys o r doll’s clothes on a line, hitting balloons o r pom -pom s or bells suspended above the child’s head. Exercises with a pole, soaping a m irror, the swinging o f two light gym clubs and turning a skipping rope are useful for older children. Ball exercises are of particular value in all movements. A daptions o f the medicine ball exercises o f M ajor M ajor have been made at the Johannes-) burg School and T reatm ent C entre with rew arding results. Stride standing, double handed throw and catch of a netball from overhead, from the chest, from each side, from between legs, backw ards, under each leg, bouncing from hand to hand and against a wall are all used. Different sized balls are recom m ended, the large beach ball being of special value w ith the very young child. Shoulder exercises such as the “ windmill,” sliding hands up a wall to touch marks or pictures a t different levels, the powdered board, pushing away weighted toys on a slippery board and others known to physiotherapists, can supplem ent treatm ents. (b) Elbow: Elbow m ovem ents usually emphasise extension and supination. M ost o f the exercises for shoulder elevation incorporate elbow extension, y a m s h o n et al have pointed out th a t when the shoulder is flexed o r abducted to 90 degrees, elbow extension is easiest for the hemiplegic, v e r a f o r d uses this optim al position and suggests giving the elbow m otion resistance by grasping the patient’s hand. M any clinicians, including y a m s h o n , f o r d , r o o d , p h e l p s and f a y , have used th e tonic neck reflexes described by neuro-physiologists. T onic neck reflexes are associated with elbow extension, which m ay occur when the head is 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. ) April, 1957. P H Y S I O T H E R A P Y Page Five turned towards the hemiplegic arm and also when the head is extended. The latter is particularly noticed in four foot kneeling and, according to Ford, as the patient looks up when reaching overhead. The author’s general impression is that tonic reflexes are not as prevalent in hemiplegics as in other cerebral palsy children. S upination can be motivated by the child turning his hands to receive a toy, hold a ball or discover what his physiotherapist has "artistically” drawn on his palm. The children at the Johannesburg School and Treatment Centre have patronised the artistic efforts of their physiotherapists by carrying out various desired motions in order to see the drawings. The children's speech is also stimulated by this technique, and the skin-pencil or ballpoint drawings can be easily removed. Placing small variously shaped objects in the child’s palm and encouraging him to first feel them and then to supinatc in order to see them is not only indirect movement exercise, but also uses visual images to counteract the astereognosis of hemiplegics, as discussed by t i z z a r d , p a i n e and c r o t h e r s . This supplements the training of occupational therapists and educationalists. If assisted active supination is given, the grasp of the physiotherapis must be on the forearm and not twisting the hand. (c) W rist anil H and: W rist and hand are not dissociated for exercises. Holding the wall bars, parallel bars, the pole, various size balls, beanbags, the handles of a pram and examples of how the hand may be opened and grasp improved. M any activities in occupational therapy, the nursery school and kinder garten, such as water play with plastic toys, dishes, rags and rubber balls, dough modelling, fingerpainting, plasticene crafts, washing dolls' clothes, specific educational toys all develop the use o f the hand. The activities must be skill fully chosen according to the individual case, as some children can carry out certain tasks satisfactorily with the unaffected hand alone. I f this situation arises it is not, however, discouraged, as the child needs to establish his handedness and despite the many discussions on the subject— the unaffected hand eventually becomes the leading hand Such activities are, Ihcrefore, permitted, whilst others are chosen to develop the hemiplegic hand as an assisting hand, passively, actively and also in bilateral or reciprocal action (discussed below) The emphasis on a particular kind of activity may vary at different stages of the child’s develop ment. E xercises: A standard elbow exercise based on the natural activity of the young child is pronelying, hands placed flat at sides of shoulders— head raise progressed to pushing up on open hands, extending elbows. The head extension may stimulate the extensor reflex. Crawling with open hands is applicable to some cases and most hemiplegics enjoy the “ wheel barrow,” where they walk on their hands as the therapist holds the legs. Action songs, used in association with the nursery and other teachers are strongly recommended. Examples are "Pat-a-cake,” " W e all clap hands together,” “ Fishes swim through water clear, birds fly through the air,” “ Rolly-poly,” and many others. M any of the finger plays are valuable in their original or adapted versions, e.g. “ Ten little gentlemen,” “ Six little Ducks,” “ The Baby's Cradle,” “ Eensy Weensy Spider.” Leg movements are also based on counteracting the deformities and are predominantly included under the aims of Reciprocation and Bilateral activity. The limbs can also be exercised through the use of syn- kinetic movements, associated movements or mass move ment patterns against resistance, as well as the use of other neurological reflexes, including “ unlocking" reflexes. Foot dorsiflexion, for example, can be elicited by resisting hip and knee flexion ( p h e l p ’s Conditioned M otion); wrist ex tension by resisting elbow flexion and supination; wrist and PA TTERN M O V E M E N T S —contra-lateral stage. finger extension by stabilising shoulder abduction to 90 degrees, elbow flexion to 90 degrees and forearm in supina tion. Resistance is given to elbow extension with resulting overflow to wrist. Added resistance to wrist results in ex tension. The more extensive patterns discussed by k a b a t can be employed in certain cases. The "pattern movements” of t e m p l e f a y are discussed under Reciprocation. C ontractures: Contractures are prevented by the corrective movements which are supplemented by proficiently applied passive manipulations, but not by forced movements. In cases where contractures are developing, a night- splint is used. The London Hospital type or the Denny- Browne adjustable sling for talipes has been found effective for the foot. Below the knee irons are occasionally used. Although raises on heels and/or soles are more common. There are those who recommend "full-length” leg braces in adults ( w e s s e r o w i t z ) , but this is not recommended for children, and interferes with the teaching of a good walking pattern. F o r tight deformities manipulation into below knee plasters for about six weeks has shown marked improvement. The plasters must be below knee and walking plasters, so that the physiotherapist can train gait in this corrected position. 2. Reciprocation A ll simple movements of the limbs are given reciprocally (from side to side) and to a tune or rhythmic counting, in order to develop rhythm between both sides of the body. Toy pedal cars, tricycles, reciprocal pulley circuits and the arm reciprocator are used. The latter consists of the pedals of a small toy car. As the child turns the pedal with his hands, the car rolls up to him from the other end o f the room. 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 Six P H Y S I O T H E R A P Y April, 1957. The Skis for quadriplegias are also used for th e hemiDlegia, as they involve opposite leg and arm m otion, whilst feet are held fast and grasp is needed to hold the upright poles. Climbing th e jungle gym, o r w all bars, invloves many desired movements as well as reciprocation. A t the Johannesburg School and T reatm ent Centre, t e m p l e f a y ’s pattern movements, based on primitive reflex patterns, constitute an im portant p art o f th e treatm ent, as they emphasise m otion o f the whole body, develop reciprocation and counteract ‘butterfly,’ o r straying, atten tion. R hythm is stressed and it has been noted th a t if the arm is brought behind the back instead o f to the side an ‘unlocking’ o r relaxing, reflex o f the thum b may occur. Swimming is an activity where a stim ulation o f reciprocal m otion in arm s and legs has been observed. 3. Bilateral Activity T he majority o f the movements already described under aims 1. and 2. above are also carried out bilaterally. T he am o unt o f bilateral hand activity may vary with each child and consideration m ust be given, in conjunction with the occupational therapist, to the possibility o f subm erging the dom inant hand. F u rth e r examples o f bilateral exercises include: (i) H and clapping exercises—overhead, front and back, etc. (ii) Jum ping exercises, such as : feet astride and together, bob-jum p, jum ping over toys placed on floor, bunny-jump. (iii) H itting a ball with a cricket bat held in both hands. (iv) Skipping. (v) Heels raise, double knee bend and stretch. (vi) D ouble arm hanging—2 leg open and close. 2 knee bend and stretch. (vii) “ Star exercises” or D ouble arm and leg abduction and adduction simultaneously—in lying, hanging o r holding th e wall bars w ith one side. (viii) Prone or lying on form o r inclined board—grasp sides o f board, pulling up to opposite end of board. 4. Balance I t has been observed th at standing balance on the affected leg is deficient and thus balance training has been introduced into the treatm ent program m es o f the. hemiplegic. Balance positions o f h alf kneeling, h a lf kneel with leg stretched side ways, forwards o r backwards, kneeling, half standing, step standing, foot support standing, etc. are used, and other balance exercises given. 5. Posture Training A t the Johannesburg School and T reatm ent C entre observations are a t present being made o f the variation o f hip and shoulder levels, scolioses, the appearance o f kyp hoses and lordoses and limb postures. Postural exercises and training are based on the individual postural examina tion o f each case. In those cases where the scoliosis is compensatory for a m arked shortening in an underdeveloped leg, exercises are not designed to counteract the scoliosis, but only to mobilise the spine and to strengthen the trunk. 6. Education in Walking T he walking pattern in children is not often the same as th a t seen in ad u lt hemiplegics. C ircum duction is a rare problem com pared to hip rotation and foot deformities. The exercises discussed above are related to th e walking pattern. The stress in the education in w alking as in all movement in cerebral palsied children—is based on the capabilities o f th e child, t e m p l e f a y ’s pattern o f walking i.e. the exaggerated norm al walk, is particularly useful for the hemiplegic. I t involves the rhythm ic co-ordinated action o f the affected and unaffected sides. W alking in a placement ladder, in the eversion board, stepping over toys on the floor, stepping on the balance bar and going up steps all counteract the ‘drag’ o f the hemi plegic foot and im prove foot placement. W alking up an inclined plane prom otes dorsiflexion and also diminishes the ‘scraping’ o f the foot. ‘W alkers’ are not used with these children, as they are considered to be too artificial. Instead, the children are encouraged to acquire am bulation at their own natural rate. Concept o f Treatment There is, in some quarters, an unfortunate tendency to consider the treatm ent o f the hemiplegic child only in term s o f his physical handicap. If this handicap is mild, one sometimes hears the suggestion th a t the child should go to a norm al school and attend an O utpatient’s D ep art m ent at a hospital or at a cerebral palsy school. Provided th a t such a child is observed, over a period o f time, by a properly qualified cerebral palsy team , i.e. one including specialised medical, educational and psychological person nel, such an arrangem ent may prove satisfactory. I t is, o f course, clear th a t such an overall assessment can only be effected at an institution which integrates education with treatm ent. Physiotherapists m ust obviously take cognizance o f factors o ther th an the m otor handicap, thus gaining an integrated picture o f their patients. They m ust be aware o f the possible defects in speech, behaviour, learning and perception (the interpretation o f sensory stimulii such as vision, hearing and touch) in otherwise intelligent hemi plegias, and understand what p a rt the physiotherapist should play in handling these difficulties, and possibly consider w hat influence these defects may have on m otion. F o r example, b r u e l l et al posit a “ disturbance o f perception o f verticality in Hemiplegias which could influence walking in dimly lit surroundings, s h o n t z has discussed disabilities in body concept, t e u b e r and his staff have m ade worthwhile contributions to the understanding o f various perception problems o f the brain-injured adult, whilst s t r a u s s and l e h t i n e n have studied the perception, behaviour and learn ing difficulties o f th e brain injured child. T he possible existence o f the various defects mentioned above underlines the necessity o f integrating physiotherapy w ith education, and psychology, as well as with the other therapies with which it so often overlaps. SU M M A R Y The treatm ent o f hemiplegia in children, as developed at the Johannesburg School and T reatm ent C entre for C erebral Palsied C hildren, has been outlined, and some com parisons m ade w ith the treatm ent o f hemiplegia in adults. T h e im portance of treating the affected side as p art of the p atien t’s overall m otor functioning, as well as the im portance of attem pting to co-ordinate physiotherapy w ith education, psychology and other therapies, has been stressed. r e f e r e n c e s ] . B r u e l l e t al. D is tu r b a n c e o f P e rc e p tio n o f V e rtic a lity in P a tie n ts w ith H em ip le g ia . A r c h . P h y s. M e d . V ol. 37: N o . 7. (N o v . 1956). 2. C r it c h l e y M a c d o n a l d : P e rs o n ific a tio n o f P a ra ly se d L im b s in H e m ip le g ia . B r it. M . J . J u ly 30, 1955. 3. F a y T e m p l e : P e rs o n a l C o m m u n ic a tio n 1954. (1954) S p a s tic s’ Q u a rterly. V ol. 3, N o . 3. 4. F o r d V e r a : U s e o f T o n ic N eck reflexes a n d P o s itio n in g in U p p e r E x tre m ity E x e rcises fo r E a rly C e r e b ra l V a s c u la r H em ip leg ia. P h y s. Th. R ev. V ol. 3 2 : N o . 9, S ep t. 1942. 5. H e l l e b r a n d t . C ro s s-e d u c a tio n . J . o f A p p lie d P hysiology. 4 .: A u g . 1951. H e l l e b r a n d t . C ro s s -e d u c a tio n . A r c h , o f P hys. M e d . V ol. XXV111. F e b . 1947. 6. H e r n , K . M .: R e - e d u c a tio n f o r N e u ro lo g ic a l C a ses. P h y sio th era p -. V ol. 36: N o . 2. F e b . 1950. 7. H ir s c h b e r g a n d N a t h a n s o n : E .M .G . r e c o rd in g o f M u s c u la r A c tiv ity in N o r m a l a n d S p astic G a its . A r c h . P h y s. M e d . V ol. X X L L L . N o . 4, A p ril 1952. 8. K a b a t : P rin c ip le s o f N e u ro m u s c u la r R e -e d u c a tio n . P h y s. Th. Rev. M a y — J u n e 1948. K a b a t : S p ecialise d N e u r o m u s c u la r R e -e d u c a tio n . P h y s. Th. Rev. F e b . 1952. 9. P h e l p s , W . M .: P e rs o n a l C o m m u n ic a tio n a n d S tu d y C o u r s e fo r D ip lo m a in C e re b ra l P alsy , B a ltim o re , U .S .A . 1953. 10. R o o d : M .O .T . in th e T re a tm e n t o f th e C e re b ra l P alsie d . P hys. Th. R e v . F e b . 1952. C ontinued on page 15. 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. ) April, 1957. P H Y S I O T H E R A P Y Page Fifteen CHANGE OF ADDRESS Mr. K. Branson, 88, Denys Reitz R oad, Roosevelt Park, Johannesburg. Miss A. M ayor-Davies, G uy s H ospital, L ondon. Mrs. K. R oodt (nee Z. v.d. Spuy), 113, M uldersdrift Road, Roosevelt P ark, Johannesburg. Miss H. M. Smith, c /r . M ain and W orcester R oads, Sea Point, Cape Town. Mrs. J. Nicol (nee J. Feyder), D octors Residence, Esselen Street, Johannesburg. Mrs. C. M atejka (nee C. v.d. Spuy), 44, Servern C ourt, c/r. Claim and H ancock Street, Johannesburg. Mrs. H alpern, 91 N o rth Avenue, O bservatory Curve, J o h a n n e s b u r g . Mrs. M. G oodm an, 16 V ictoria Avenue, Sandringham , J o h a n n e s b u r g . NEW MEMBERS Miss B. van G raan, 148 Dey Street, B rooklyn Pretoria, N. Tvl. Branch. Miss M. Lemmer, 55, B rook St., B rooklyn .Pretoria. N. Tvl. Branch. Miss J. de W. Stassen, Pretoria H otel, Schoeman Street, Pretoria, N. Tvl. Branch. Miss L. van Wyk, 157 Venter Street, C apital Park, P retoria N. Tvl. Branch. BRANCH NEWS SO U TH ER N TRANSVAAL BRA N CH NEW S. We would like to congratulate the student members who obtained their B.Sc. Physiotherapy Degree at the end of 1956. A pplication for full mem bership o f the South African Society o f Physiotherapy from these members has been disappointing. Form s are obtainable from :— MRS. R. B L IE D E N , 706 Tafelberg, Esselen Street, Johannesburg. Eleven student members have joined the Branch. We would like to welcome them and hope to see them at our meetings and lectures. W ESTERN P R O V IN C E BRA N CH -a T he General M eeting was held on January 30th at the Cerebral Palsy School, R ondebosch. Eighteen branch members were present and welcomed M r. M oth from Princess Alice H om e and Miss U rsula Scott from Stoke- Mandeville and now at the C onradie Hospital. Shortage of Physiotherapists Because o f the emergency caused by the current polio outbreak it was decided to form a “ pool” of Physiotherapists from which H ospitals can draw when necessary. Several m em bers have volunteered for part-tim e services. New Office Bearers Chairman: M r. Schermbruker. Vice-Chairman' Mr. Tom H art. Secretary: M r. K . Nicol. Treasurer: M r. B. W oodgate. Committee Members: Miss U. Scott, M rs. Alais, Mr. Oliver, Mrs. E. Myer. Co-opted M em bers: Miss S. Sutherland. Forthcoming Meeting Discussion on Polio:— Guest Speakers: M r. M cM urray and M r. Swartz a t the R ed Cross H ospital Lecture T heatre, R ondebosch. • R eferences— Continued fro m page 6. 11. S h o n t z , F . C . : B o d y C o n c e p t D is tr u b a n c e . J . o f Clin. P syc h . 12: 3 J u ly , 1956. 12. R o b i n a u l t : O c c u p a tio n a l T h e ra p y T e ch n ics fo r P re -s c h o o l H e m ip le g ic : A m . J . o f O .T . V ol. V II. N o . 5. S e p t.— O c t. 1953. 13. S t r a u s s a n d L e h t in e r (1947): P s y c h o p a th o lo g y o f th e B ra in - I n ju re d C h ild . G ro n e & S tr a t to n I n c ., N e w Y o rk . E d it. 1950. 13. T e u b e r H a n s L u k a s : P e r s o n a l C o m m u n i c a t i o n 1954, 1955. T e u b e r a n d M i s h k i n : J u d g m e n t o f V isual a n d P o s tu r a l V ertical a f t e r a n d B r a i n I n j u r y . J . o f P syc h o lo g y, 1954, 3 8 : 161— 175. T e u b e r , P r ic e a n d K r u e g e r : T a c t i l e E x t i n c t i o n i n P a r i e t a l l o b e N e o p l a s m . J. o f P syc h o lo g y, 1954. 38: 191— 202. . T e u b e r , S e m m e s, W e i n s t e i n , G h e n t : P e rfo rm a n c e o f c o m p lex T a c tu a l ta s k a f te r B ra in In ju r y in M a n . A m . J . o f P syc h . J u ly 1954. 14. T i z z a r d , P a in e a n d C r o t h e r s . : D is tu rb a n c e s o f S e n s a tio n in C h ild re n w ith H e m ip le g ia . J. o f A m . M e d . A sso c. 12: J u ly 1954. V ol. 155. 15. v o n W e r s s o w e t z : ̂ S u p p o r te r ’s A p p lia n c e s fo r A m b u la to r y R e h a b ilita tio n o f H em ip leg ics. J o u rn a l P h y s. T herapy R eview . V ol 31. N o . 1. J a n . 1951. 16. Y a m s h o n , W a t c h e k , C o v a l t : T h e T o n ic N e c k Reflex in th e H e m ip le g ic : a n o b je ctiv e s tu d y o f its T h e ra p e u tic I m p lic a tio n s . A r c h , o f P h y s. M e d . 3 0 : 706— 711, N o v . 1949. Y a m s h o n , C o v a l t , N o w i c k i : P h y sio lo g ic a l A c d . to th e F u n c tio n a l T ra in in g o f th e H e m ip le g ic A rm . A m . J . o f O .T . N o v . — D e c . 1949. A C K N O W L E D G E M E N T A c k n o w le d g e m e n t is m a d e to M r. J . H a lp e rn fo r c o n s tru c tiv e critic ism o f th is a rticle. 1. T h e p re s e n t p h y s io th e r a p y s ta ff o f th e J o h a n n e s b u rg S c h o o l a n d T re a tm e n t C e n tre fo r C e re b ra l P alsie d C h ild re n c o n s is ts o f — T h e A u th o r a n d M e s d a m e s: M . B loch B. A . B o w er C . C h a s a n E . M . D o e h rin g . 2. I n a c c o rd a n c e w ith th e new r u lin g o f th e M a n a g e m e n t C o m m itte e o f th e J o h a n n e s b u r g S c h o o l a n d T re a tm e n t C e n tr e f o r C e re b ra l P alsie d C h ild re n , th e C o m m itte e ’s p e rm is sio n to p u b lis h th is a rtic le h as been o b ta in e d . D I A T H E R M Y M A C H I N E S In O ctober, M r. Kelly and I had an interview with Post Office officials. T he points raised were:— (1) W ith what do our diatherm y machines interfere? (2) C an the machines be adapted? (3) Will we be com pensated for machines which have to be scrapped ? The answers we got were:— (1) O ur diatherm y machines are m ost likely to interfere with radio and telecomm unications. (2) T he Post Office representatives thought th at the m achines could be converted to the new frequencies, but suggested th a t we consult M r. Joubert of the Bureau o f Standards. (3) The Post Office w ould definitely n o t pay com pen sation. But (according to the Post Office) the D ep art m ent o f Public H ealth could, if necessary, arrange loans for our members. 1 have contacted the D ep art ment o f Public H ealth and they seem rath er doubtful about this m atter o f loans. We met M r. Jo u b ert in January and discussed the m atter o f conversion o f the old diatherm y machines to the new frequencies. H e had gone into the m atter thoroughly, and was o f the opinion that it would not be wotrh while having our machines converted. It would probably be quite a costly business, and it is doubtful w hether it would be satisfactory. T he frequency would have to be adjusted in such a way that it would be constant under all conditions— namely, tem perature, humidity, load, change o f valve, etc. I f anyone decided to have a diatherm y machine adapted, M r. Joubert suggested th at whoever did the conversion, should be made to guarantee, in writing, th at the work done meets with the requirem ents o f the Post Office. This will prevent exploitation by unscrupulous persons. Meantim e, the old machines may still be used after D ecem ber 31st, 1957, providing th at there are no complaints about interference from them. Should there be any com plaints o f interference, the Post Office would have to satisfay the owner of the machine th at it was h is/h er particular m achine which was causing the interference. I feel th at no more can be done in the m a tte r We must ju st hope th at we have no complaints about interference from our diatherm y machines for as long as they last. M. EM SLIE. 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. )