Page Ten P H Y S I O T H E R A P Y April, 1957. ELECTRO-THERAPY OF PARALYSES (BASIC PRINCIPLES AND METHODS OF APPLICATION) (Continued from "Physiotherapy", January, 1957.) By Dr. Harold Thom Special reprint from the Z eitschrift Fur Orthopadie und Hire Grenzgebiete Vol. 84, N o . 1, 1953. E d ito r: Prof. D r. M ax Lange, Bad Tolz Published by Ferdinand Enke, S tuttgat W, H asenbergstreige 3. 6. General Directions for Treatment Before comm encing the therapy, a detailed clinical and electrical survey should be m ade and the data recorded on a suitable printed form. This is the only means of obtaining a reliable picture o f the progress made during the treatm ent. Since the therapeutist is now able to in­ vestigate the individual characteristics of each muscle o r each set of muscles by varying the stimulus param eters, it has proved useful—necessary in fact— to keep an accurate record o f th e optim um adjustm ents o f the param eters which suit each individual characteristic, w hether obtained empirically o r ascertained from I / 1 charts. If these are conscientiously recorded, conscluions may be draw n as to the progress o f treatm ent. Use should only be made however, o f those impulse values which, while inconven­ iencing the patient as little as possible, are m ost successful in creating a response. A t th e same time the impulse value should rem ain w ithin the limits o f an adjustm ent which is as close as possible to norm al stimulus conditions. Thus the gradient o f th e individual impulses should be as steep as possible and th e impulse duration as short as possible, b u t as long as may be necessary to effect the stim ulation required. The aim of all electro-therapy must be to obtain the strongest possible contraction of the muscle structure requiring treatm ent. I t is often found th at th e staff carrying o u t a certain treatm ent are content with the contraction o f any one muscle, instead o f being concerned with stim ulating the damaged muscle or muscle group selectively, always assuming th at this is possible in the particular case being treated. F o r successful treatm ent, the im portant thing is not only to discard all preconceived ideas but in each case to try to achieve the best possible result from a functionally useful and powerful muscle contraction by selecting the m ost suitable impulse values. F o r this reason, firm rules fo r treatm ent cannot be given, only general 'directions which m ust be modified from case to case.1) It is inadvisable, especially in the case o f poliomyelitis, to start excitation current therapy, i.e. to use impulse currents, until all inflammatory and spastic phenom ena have disappeared. U p to this point only constant D C therapy should be used, the efficacy of which has already been discussed above. A dequate anatom ical knowledge is an essential pre­ requisite for all effective electrotherapy o f paralyses. The correct application o f electrodes demands accurate know ­ ledge not only o f the position o f muscles and nerves, but also o f their function. In principle, there are two methods o f electrode technique viz. unipolar and bipolar. In the form er, tw o electrodes o f unequal size are used, the smaller being referred to as the active or effective electrode, and the larger as the in­ active, indifferent o r dispersive electrode. In unipolar electrode technique the muscles o r nerves are stim ulated from certain definite m otor points on the surface o f the skin. These are in the m ain empirically determ ined areas, whence the nerve situated below can be stim ulated with an optim um current density. The motor point is generally located where the m ain branch of the nerve enters the muscle it serves. U nder the conditions prevailing in form er times, this m ethod o f muscle stim ulation was the best available, yet it possessed grave disadvantages, especially in the therapy o f badly paralysed muscle structures. With the m ore powerful currents required with this m ethod, stimu­ lation is very painful, as the whole o f the current is con­ centrated a t a single p oint (see.Fig. 4). M oreover, in view o f the extensive dam age to the particular nerve stimulated, there appears, from the outset, to be little p oint in using it for transm itting a stimulus. In m onopolar electrode treat­ m ent, since the m otor point is norm ally located near the centre o f the muscle, only one half o f the muscle will be perm eated by the current. The so-called “ D istal shift of the m otor po in t” constantly observed by the old thera­ peutists (the indifferent electrode being usually applied proximally) is thus readily explained, because movement o f the stim ulation point causes an increasingly large part, and eventually the entire muscle, to be perm eated by the current. In the past, since adaptation to th e different conditions o f sound and de-enervated muscle structure by varying the form o f current was impossible, the only alternative was to attem pt to stim ulate diseased muscle from the topographical viewpoint. Since, however, paralysed muscle requires much greater current strengths th an adjoining sound muscles, in the end it was usually a case o f so-called “ puncture,” i.e., only the sound antagonists were stim u­ lated, the muscles really requiring treatm ent being at best only stretched in an unsuitable m anner. Since to-day, variation o f current form perm its close adaptation to the physiological o r pathological conditions o f the various nerve muscle systems (at any rate for thera­ peutic purposes), a bipolar electrode technique is preferable. This involves placing tw o large, well padded electrodes over the origin and insertion of the muscle concerned (see Fig. 5). This ensures from the outset th a t the whole d is ta l p r o x im a l m u sc le F ig. 4. F lo w o f th e c u r re n t, w ith u n ip o la r s tim u la tio n , s ta r tin g fro m th e m o to r p o in t. O n ly o n e h a lf o f th e m u scle is p e rm e a te d . 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 Eleven d is ta l — n e rv e X H i-M — m u s c le p r o x im a l F ig . 5. F lo w o f th e c u rre n t, w ith b ip o la r s tim u la tio n . T h e w h o le m u scle is evenly p e rm e a te d . muscle is perm eated at a maximum current strength. This means th at higher current strengths can be applied and stronger muscle contractions obtained w ithout causing pain to the patient. Reference has already b e e n m ade to the advantages of preliminary treatm ent with galvanic current. The resultant hyperaemia and the reduced stimulus threshold (rheobase) for t h e subsequent active o r passive electro-gymnastic treatm ent m a y , however, also be achieved by other methods which prom ote circulation, e.g. h o t baths, vapour baths, electro-thermal baths, e t c . l a m p e r t has also observed favourable results a f t e r using hyper-therm ic baths (in small d o s e s ) . The diagnostic curves (I /1 curves) give a reliable indica­ tion regarding the selection o f the form of current to be used for therapy. As the effective time is increased, longer impulse durations will be required, and as the excitation threshold is increased, a greater current strength is needed. Generally speaking, it is a useful principle to try to m anage with a minimum o f current intensity and to extend the period according to the conditions revealed by the I /t curves. In order to reduce the pain factor and to obtain the desired selectivity o f stimulus, a gently rising (not vertical) current impulse should be used alm ost invariably. Since the refractory o r recovery period o f the muscle is always prolonged in relation to the increase in effective time, this point m ust also be taken into account in selecting the rest period. As a general rule, the rest period should be three to five times the impulse duration. F o r treating badly paralysed or badly atrophied muscle structure, gradually rising current impulses o f altogether 150—600 ms duration and intervals o f 3— 5 seconds should be used (see Fig. 6). T he intensity is stepped up gradually until a strong contraction occurs. Fig. 6. Im p u lse s e q u e n c e w ith lo n g tr ia n g u la r im p u lses a n d ex ten d e d in te rv a ls, fo r tr e a tm e n t o f p a ra ly tic d is o rd e rs o f a m e d iu m to s ev ere degree. Intensity, gradient and impulse duration m ust now be varied in relation to each other until an optim um relation­ ship has been established between a maximum contraction (confined mainly to the diseased muscle group), and mini­ mum sensory strain. T his is the only way in which a suit­ able. selective exercise therapy can be achieved which is also adapted functionally to the existing conditions. In the initial treatm ent o f a seriously degenerated muscle at constant current strength, there is often evidence o f rapid fatigue which manifests itself in a noticeable decrease in the degree of contraction. In such cases it is advisable either to prolong the rest period still further, o r to suspend the treatm ent on this occasion. T he current intensity should n o t be increased since improved therapeutic results cannot be forced. In fact, if treatm ent is greatly overdone, th e muscle m ay even suffer damage. As time goes on (in many cases after only a few treatm ents), the increased im provem ent is shown by the fact th a t contractive capacity of the muscle either remains constant, o r is less easily exhausted. Circum stances perm itting, in the first instance it is advisable to carry out the treatm ent at least once or twice, a day. Provided no prem ature fatigue phenom ena appear, the treatm ent can soon be extended to last fo r a period o f 10 minutes. Longer periods are unnecessary, since the aim m ust always be to apply the treatm ent for short but frequent periods. F o r muscle structure which is only partly paralysed and where atrophy is low, short impulses o f 50— 150 ms. are sufficient, with usually 1— 2 seconds for the rest period. Should this faster rhythm overtax the p atien t’s strength, especially when at the same time he has to struggle to achieve additional active innervation, the rest period should be extended. F o r norm ally innervated muscle, as encountered in cases o f atrophy from disuse after fractures, enforced rest for longish periods, etc., the use o f so-called tetanizing surge current impulses is the m ost prom ising method. This involves impulses o f approxim ately 0.5— 5 ms and an interval o f approxim ately 10—20 ms. The resulting tetanal muscle contraction is best interrupted by regular intervals; in this process, the impulse sequences gradually rising to the selected maximum level and ebbing somewhat m ore rapidly, cause contractions which in their external course very closely approach the physiological movements (see Fig. 7). The surge rate and the form and intensity o f the impulse sequences used m ust be adapted to the conditions prevailing a t the time. Since muscle structure atrophied solely from disuse differs but slightly from norm al muscle in its reaction to electric impulses, its selective stim ulation is very difficult to achieve. W ith individually selected impulse durations, rest periods, current strength and gradient, as well as electrodes carefully selected as to size, and positioning, there is scope for considerable success in this field, i f necessary, the stimulus may be applied from th e m otor point, using an active electrode. E l . Jin_ 10-20 ms F ig. 7. S u rg in g im p u ls e s e q u e n c e w ith s h o rt re c ta n g u la r im p u lse s a n d b rie f in te rv a ls, fo r tre a tm e n t o f n o rm a lly in n e r v a te d m u scle s tru c tu re s in th e c a se o f a tro p h ie s o f disu se a n d th e like. 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 Twelve P H Y S I O T H E R A P Y April, 1957. In all cases o f atrophy due to disuse, as caused, for example, by a mechanical (plaster of paris, etc.) o r func­ tional im m obilization (habitual paralyses, psychogenic paralyses, etc.) considerable improvements may frequently be achieved in a rem arkably short space of time by electro­ therapy. G eneral directions for treatm ent m entioned so far refer to flaccid paralyses as com m only encountered after nerve injuries, plexus lesions and poliomyelitis. As such muscles are inadequately supplied with nerve impulses, the problem is to preserve them from degeneration by applying artificial stimuli, related as closely as possible to natu ral processes, and by constant exercise, to ensure that the regenerating nerve finds a relatively sound muscle rath er than one which has degenerated into connective tissue.. Q uite different conditions are encountered in the case o f spastic paralysis. H ere it is n o t so much the m otor paths which are disturbed as the inhibitory, accelerator and co-ordinating paths. Owing to its own increased reflexes, the spastically paralysed muscle is already in a state o f constant convulsion (spasmophilia), and the pre­ ponderance o f these muscles frequently leads to character­ istic distortions o f the limbs. Since any further stim ulation w ould only increase the spasm o f the muscle structure, any form o f exercise under electro-stim ulation is co n tra­ indicated. (U nfortunately such cases are still being irrespon­ sibly treated with th e so-called “ faradic ro ll”). I t should be the aim o f any treatm ent to loosen the spasm as far as possible, and the simplest and most practical way of doing this is with stable galvanization. In many cases the results may be fu rth er improved by using a definite impulse current (impulse duration 20 ms, interval 20 ms, triangular rise). Very low currents, usually 0.5—2 mA are used. In the case o f slight spasms it would be a great advantage if means could be found to stim ulate selectively such muscles as are unable to hold the balance against the gradually increasing contraction. In many such cases it is impossible even for an experienced and careful th era­ peutist to achieve appreciable selectivity even with the im proved means o f modern excitation current therapy. Practical exercises under electro-stim ulation also require th a t the position o r the placing o f the limbs to be treated be taken into consideration. To apply electrotherapy to an extensor, the jo in t in question m ust be in (gentle) flexion. Similarly, a flexor cannot be exercised if the extremity is already in extreme flexion. Frequently, in spite o f partial o r even to tal .anatom ical restitution which may have been applied in the meanwhile, the patient has lost th e capacity to innervate the remaining muscles or even intact muscle groups still left to him after disease o r injury. In such cases electro-therapy can con­ trib u te decisively tow ards restoring the lost innervation paths, and fo r this the patient’s Co-operation is essential. F o r controlling th e p atient’s real and active co-movement as well as fo r his own assistance, sim ultaneous movement o f th e relative contra-lateral muscle structure is a valuable help. O f m ore im portance, however, are the “ intention exercises” referred to by f o r s t e r , which, is often the olny alternative when mobility o f th e other side has also been lost. In f o r s t e r ’s opinion, in fact, systematic voluntary attem pts a t innervation have a stim ulating effect on the regenerative process itself. I t is the purpose o f the intention exercises to replace by an electric impulse, the vain attem pt o f the patient to carry out a particular movem ent; or alternatively, to assist an already existing but inadequate willed impulse by sim ultaneously releasing an electric impulse. The sim ultaneous co-operation o f these two impulses is best guaranteed by letting the patient release the electrical stim ulus himself. N orm ally for this purpose, a supple­ m entary device is used by means o f which the patient can either release an individual impulse with a key, o r can himself determ ine the intensity, duration, and rhythm o f the surge current by using a rotary control. The form and maximum strength o f the impulse sequence must be set in advance according to the degree o f paralysis. F o r this the general directions stated above apply. The value, and in fact the necessity fo r regular and properly timed stim ulus intervals is frequently overlooked. It can often be observed th at the rate o f progress, after an extended period o f electro-therapy, has increased enor­ mously, especially after a fairly long break in the treatm ent. The frequency and duration of such intervals must be adapted to the individual circumstances o f the patient. The m ost suitable distribution o f stimulus and interval, or exercise and rest, will depend largely on the experience o f the particular therapeutist. N orm ally, 2—3 weeks of continuous treatm ent should be alternated with 1 week’s rest; and after treatm ent lasting several m onths a similar period o f rest is to be recommended. O ther reasons, how­ ever, may frequently compel the plan o f treatm ent to be varied according to circumstances. H ospital treatm ent (possibly limited) will require a different arrangement from treatm ent carried out on out-patients. It is surprising how exhausting an intensively conducted course o f electro-therapy can be for the patient, since the form er’s physical and m ental endurance may easily be strained to its limit by the misapplied zeal o f his therapeutist. Since, however, the active and energetic co-operation of the patient is o f param ount im portance for successful treatm ent, care should be taken not to forfeit this co-opera­ tion by making excessive demands. In particular, in the case of patients suffering from insomnia, a well balanced therapy is reflected in a pleasant sensation o f tiredness, and an increased desire for sleep. In cases where the patient lacks the necessary will for recovery, the decisive factor inspiring and spurring the patient to co-operate in the restoration o f his physical ability to work is the personality o f the doctor, who should exercise kindness and care, aind be o f untiring endurance. I t has been necessary to devote so much space to the actual technique o f treatm ent, as success o r failure is vitally dependent on its proper execution. Electro-therapy represents a small but im portant factor in the treatm ent o f paralyses, a factor which in, many cases cannot be replaced by any other m ethod o f treatm ent. The problem is to integrate it rationally into th e overall plan o f treatm ent, the ultim ate object o f which, is always the regaining o f active freedom o f movement. S u m m a r y : The physical and physiological background o f modern irritating electrotherapy is discussed in detail, as fa r as it concerns paralytic disorders, especially poliomyelitis. Review o f the importance o f intensity and time o f current, increase, interval with reference to the different types o f paralyses. Indication fo r therapy. •1 a m g re a tly in d e b te d to S e n io r P h y sicia n D r . B e c k e r , o f th e O r th o p a e d ic C lin ic a t A ltd o r f n e a r N iirn b e rg , fo r his v a lu a b le a s s is ta n c e in c o n n e c tio n w ith th is w o rk . L IT E R A T U R E . A r ie f f , A rc h . phys. M e d . (a m e r.) 1948, B d. 49, S. 8 — Bin HE, A . , A llgem . P h y sio lo g ie . S p rin g e r 1952. — B u s c h , A rc h . p h y s. T h e r . 1951, B d. 3, 1, S. 17. — D r o b e c , E in fiih ru n g in die E le k tro m e d iz in . W ie n 1952. — D u e n s i n g , N e rv e n a rz t 1942, Bd. 15, S. 5 0 5 .— D e r s ., A n le itu n g in d. galv. u . fa ra d . B eh a n d lu n g . S p rin g e r 1 9 4 3 .— F i c k , B eitr. z. vergl. P h y sio lo g . d . irrita b le n S u b sta n z . B rau n sch w eig 1863. — G il d e m e i s t e r , Pfliigers A rc h . 1912, B d. 149, S. 389; 1919, B d. 84, S. 176; 1911, S. 1113; 1929, B d. 112, S. 195. — G i l l e r t , G a lv a n is c h e r S tro m , F a ra d is c h e r S tro m , E x p o n e n tia ls tro m . R . P flau m V erlag , M iin c h en 1953. — G r a f , F r e q u e n z 1949, Bd. 3, S. 141. — G r a t z l , D ie N ie d e rfre q u e n z th e ra p ie u . d ia g n o s tik m it M y o to n a p p a ra te n . W ie n 1 9 5 2 .— G r ie s s m a n n , B ru n s ’ B eitr. k lin . C h ir. 1951, B d. 182, S. 7 ; 1952, B d. 182, S. 332. — G r o b e r , K lin . L e h rb . d . p h y s ik a l. T h e ra p ie . J e n a .1950. — H e n s s g e , A rc h . phys. T h e r. 1951, B d. 3, 4, S . 249. — D e r s ., A rz tl. F o rs c h u n g 1947, B d . 2, S. 68. — D e r s ., P sych. N e u ro l, u. m ed. P sy c h o l. 1950, B d . 3, 8, S. 2 4 .— D e r s ., D ts c h . G e s u n d h e itsw , 1951, B d. 6, S. 988. — D e r s ., S elektive niederf’rei)u en te R e iz s tro m th e ra p ie . — G u n t z , in H a n s e n , T h e ra p e u tisc h e T e c h n ik . T h ie m e 1949, S. 157— 180. — H e n s e l u n d W o l f f , N e rv e n a rz t 1949, Bd. 20, S . 463. — H o f f m e i e r , D ie B e h a n d lu n g d e r K in d e rla h m u n g . T h ie m e 1949. — H o l z e r , P h y sik alisc h e M ed iz in in D ia g n o s tik u n d T h e ra p ie . W ien 1940. — D e r s ., Pfliigers A rc h . 1940, B d . 244. — J a n t s c h u . N u c k e i . , W ien . m ed. W sch r. 1951, B d. 101, 19, S . 351. — J a n t s c h u . S c h u h f r i e d , W ien . klin. W sch r. 1952, B d. 64, 17, S . 307. — K l a r e u . F u r s t e n b a c h , Z . N e rv e n h k . u . G re n z g e b . 1948, B d. 1, S . 369. — , K o v a c s , E le k tro th e ra p y a. L ig h t T h e ra p y . L o n d o n 1949. — K o s m a n , O s b o r n e u . I v y , A rc h . phys. M ed . (a m e r.) 1948, B d. 9. — K o w a r s c h i k . W ien . k lin . W sch r. 1947, B d . 50, 2, S. 27. — D e r s . , W ien . Z . N e rv e n h k . \ 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 Thirteen 1948, B d . J , 2 / 3 , S. 1 9 4 . — D e r s . , M U n c h . m e d . W s c h r . 19 5 0 , 2 9 / 3 0 , 1217, 9 2 . — D e r s . , M u n c h , m e d . W s c h r . 19 5 1 , B d . 9 3 , S . 4 2 . — K o w a r - s c h i k u . N e m e c , D t s c h . B a d e w e s e n , B d . 9 , H . 7 . — K r u s e n , T h e 19 5 0 Y e a r B o o k o f P h y s . M e d . a n d R e h a b i l i t a t i o n . C h i c a g o 19 5 1 . — L a - p i c q u e , E x c i t a b i l i t e e n f o n c t i o n d u t e m p s , P r e s s , u n i v e r . d e F r a n c e . P a r is 1926. — L a m p e r t , P h y s . T h e r a p i e . L e i p z i g 19 5 2 . — L a m p e r t u . I s J o n n e n b r u c h , M U n c h . m e d . W s c h r . 19 5 2 , B d . 9 4 , S . 11. — D i e s ., M u n c h , m e d . W s c h r . 1 9 5 3 , B d . 9 5 . — L a q u e u r - M u l l e r , L e i t f a d e n d e r E l e k t r o m e d i z i n . H a l l e 19 5 1 . — N e o u s s i k i n e - A b r a m o w i t s c h , E l e k t r o - d i a g n o s t i k . B e r n 19 3 9 . — N O c k e l , S u b s i d i a m e d i c a 1 9 5 1 , B d . 5 , S . 189. _ _ D e r s . , V o r t r . 5 . D t s c h . B a d e r t a g B a d e n - B a d e n 19 5 1 . — D e r s . , F o r t s c h r . M e d . 1 9 5 2 , B d . 7 0 , 10, S . 2 3 3 . — O s t e r m a n n , P r a k t i k u m d . p h y s .- d i a t e ti s c h e n T h e r a p i e . L i e s t a l 19 5 2 . — P a l m r i c h , J a n t s c h , S c h m i e d e c k e r u . N O c k e l , W ie n . k l in . W s c h r . 19 4 9 , B d . 6 1 , S . 4 0 . — P O L L O C K , A r i e f f u . G o l s e t h , S u r g . G y n . O b s t r . 19 4 4 , B d . 2 9 , S . 1 3 3 ; 1945, B d . 8 1 , S. 1 9 2 ; 1 9 4 5 , B d . 8 1 , S . 6 0 0 . — R a b e , A r c h . p h y s . T h e r . 1951, B d . 3 , 1, S. 10. — R e i n , E in f u h r u n g in d i e P h y sio lo g ie d . M e n s c h e n . B e r lin 19 4 8 . — R e i s s , D i e e l e k t r . E n t a r t u n g s r e a k t i o n , S p r i n g e r , B e r li n 1911. — R i t c h i e , B r i t . J . p h y s . m e d . 19 4 8 , B d . 11. — R o s s l e r , V e r h . D t s c h . O r t h o p . G e s . , 4 0 . K o n g r . 1 9 5 2 , S . 3 3 . — S c h a f e r , E l e k t r o - P h y s i o lo g i e , B d . 1 / I I , W ie n 1941 /4 2 . — S c h i l l e r u . T i g a y , A r c h . N e u r o l , a n d P s y c h . 1947, B d . 5 1 , S . 147. — S c h l i e p h a k e , E r g . p h y s .- d i a t e t . T h e r . B d . I V , S. 2 7 3 . — S c h o l t z , H . G . , A rz tl. P r a x i s 1 9 5 1 , B d . I l l , S. 4 9 . — D e r s . , A r c h . p h y s . T h e r . 1 9 5 2 , B d . 4 , 2 , S. 102. — S c h o l z u . S c h m i d t , A r z t l . F o r s c h . 19 5 0 , B d . IV , 1, S. 4 7 9 . — S c h u h f r i e d , S u b s i d i a m e d ic a 1951, B d . 2 . — S t r a u c h , E r g . p h y s ik .-d ia te t. T h e r . 1 9 5 1 , B d . 3. — T h o m , K r a n k e n g y m n a s t i k 1 9 5 3 , B d . 5 , N r . 3 . — D e r s . , K r a n k e n g y m - n a s ti k 1953, B d . 5 , N r . 5 . — D e r s . , E r g . p h y s .- d i a t e t . T h e r . 19 5 3 , B d . 5. — D e r s ., V e r h . D t s c h . O r t h o p . G e s . , 4 0 . K o n g r . 19 5 2 , S . 4 2 . — D e r s ., K r a n k e n g y m n a s t i k 19 5 3 , B d . 5, N r . o 9 . — T i c h y , S u r g . 19 4 8 , B d . 2 6 ] S. 109. — V o g e l , A r c h . p h y s . T h e r . 19 5 1 , B d . 3 , 1, S . 1. — W a g n e r u . W e t t e r e r , P f liig e r s A r c h . 19 4 9 , B d . 2 5 1 , S. 5 8 5 . — W a h l e n , i n G i l le r t WORLD CONFEDERATION The following resolutions were passed a t "the Third G eneral Meeting o f the W orld Confederation for Physical Therapy held in N ew Y ork in June, 1956. PR E SID E N T O F T H E U.S.A. Resolved: T hat the President o f the W orld Confederation for Physical T herapy send to the President o f the U.S.A. the C onfederation’s deep appreciation o f his message and o f the personal interest expressed therein and its most respectful greetings and prayers for his speedy and complete recovery. W O R L D H E A L T H O R G A N ISA TIO N . Resolved: T hat in conveying to the W orld H ealth O rgani­ sation appreciation o f its decision to adm it the W orld Confederation for Physical T herapy into official relations, the hope be expressed that the services o f the C onfederation will be utilised in the planning and execution o f rehabili­ tation program m es for the sick and disabled. U N ITED N A T IO N S C H IL D R E N ’S FU N D . Resolved: T hat an expression o f appreciation be extended to the U nited N ations C hildren’s F und for its accom plish­ ments in assisting the countries o f the world to solve p ro b ­ lems faced by their handicapped and other needy children; and th at the members of the W orld C onfederation for Physicaj Therapy be requested to co-operate in all possible ways with activities related to U N IC E F in their respective countries. IN TER N A TIO N A L SO C IET Y F O R T H E W ELFARE O F C R IP P L E S . Resolved: T h at sincere thanks be conveyed to the In ter­ national Society for the Welfare o f Cripples for their con­ tinued interest in the W orld Confederation for Physical Therapy and co-operation in its efforts to im prove the physical therapy services available to the disabled. AM ERICAN PH Y SIC A L TH E R A PY A SSO C IA TIO N . Resolved: T hat the grateful thanks o f the W orld C on­ federation for P h y s ic a l! herapy be conveyed to the American Physical T herapy Association and its President, M ary N esbitt, for the devoted efforts o f the B oard o f D irectors o f the Association, its N ational Office Staff, members o f the New Y ork D istrict o f the New Y ork C hapter and o f Catherine W orthingham , C hairm an, and M em bers o f the Congress Planning Committee. CANADIAN P H Y S IO T H E R A P Y A SSO C IA TIO N . Resolved: T hat a warm expression o f appreciation be conveyed to the C anadian Physiotherapy A ssociation for (s. o .), S. 46— 61. — W yss, S ele k tiv e elek tr. R e iz iu n g . Z u r ic h 1934 — D e r s ., Pfliigers A rc h . 1934, B d . 233, S. 754. A u th o r 's address: D r. H a ro ld T h o m , Erlangen, Burgbergstr. 102, G erm any. C H R IST M A S CARDS received by C .E.C ., Christmas 1956. MISS D Y E R — N orthern Rhodesia. M R . R O T H B E R G :—Johannesburg. EAST L O N D O N B RA N CH . W ESTER N PR O V IN C E B R A N C H . N O R T H E R N C A PE B R A N C H . U N IT E D C ER E B R A L PALSY A SSOCIATION. N A T IO N A L C O U N C IL F O R C A R E O F C RIPPLES. C H A R T E R E D SO CIETY O F PH Y SIO T H E R A PY , London. A U S T R A L IA N PH Y SIO T H E R A PY A SSOCIA TION . N O V SK E SY K E G Y M N A ST E R S L A N D SFO R B O N D . B E L G IU M . D E N M A R K . STO C K H O LM —SW EDEN. FIN L A N D . A M E R IC A . W. G E R M A N Y . FOR PHYSICAL THERAPY their generous hospitality which provided a welcome op p o r­ tunity for overseas members to meet their colleagues in a social atm osphere. C O R R E C T IO N . World Confederation for Physical Therapy. The E ditor apologies for the m istake in the caption attached to the photograph appearing in th e January issue. It should read “T he past and present Presidents Miss Elson (U.S.A.) and Miss Griffin (G t. Britain) with Mrs. S. Cole­ ridge o f Sweden at th a t time Second Vice-President o f the Confederation. P O S T IN PAKISTAN. 1st M arch, 1957. Post in Pakistan under World Veterans’ Federation.: This post is an im portant one and it is essential th at applicants should be senior physical therapists with experi­ ence in the training o f students. Jo b description o f Physical Therapist for Pakistan Demon­ stration centre. General Field.— R ehabilitation o f the handicapped. Special field.— Physical Therapy. Duration.—2 years. When required.—As soon as possible. Duties.— U nder supervision o f the Medical D irector. (1) T o organise a physical therapy departm ent at the M ilitary H ospital in Lahore, to serve the needs o f the hospital and the Limb Fitting Centre. (2) T o plan and conduct regular physical therapy courses for suitable local students with the aim o f establishing eventually a form al physical therapy school. (3) T o be available for consultation concerning the developm ent o f the physical therapy in Pakistan as p a rt o f the rehabilitation service.s Qualifications.—Certified physical therapist, with con­ siderable experience o f work with patients suffering from orthopaedic and neurom uscular disabilities. Experience in organisation and supervision o f physical therapy departm ents desirable; teaching experience essential. Language.—English. F u rth er enquiries and applications should be made through the G eneral Secretary: S.A.S.P., P.O. Box 11151, Johannesburg. 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. )