9 E k lu n d , G .: “ Som e physical p ro p e rtie s o f m uscle v ib ra to rs u sed to elicit to n ic p ro p rio ce p tiv e reflexes in m a n .” A cta. Soc. M ed. U p p sa la . 76: 271-280. 1971. m Brinicw orth, K . E. a n d Schuster, D . G .: “ S tudies of Physical P ro p e rtie s o f V ib ra to rs .” U n p u b lish e d . 1974. 11 B ishop, B . : “ V ib ra to ry S tim u la tio n — P a rt I I I — Possible A p p lica tio n s o f V ib ra tio n in th e tre a tm e n t of M o to r D y sfu n c tio n s.” Physical T h e ra p y 55: 2 139-143. Feb. 1975. 12 B rin k w o rth , K . E .: “ F u rth e r Studies o n th e C linical A pp lica tio n o f th e T o n ic V ib ra to ry R eflex.” U n p u b ­ lished. 1975. 13 M atthew s, P. B. C . : “ T h e reflex e x citatio n o f th e soleus m uscle o f th e d e ce reb ra te c a t c au sed by v ib ra tio n ap p lie d to its te n d o n .” J. Physiol. 192: 773-800, 1967. 184: 450-472. 1966. <4 B row n, M . C ., E ngberg, I. a n d M a tth e w s, P. B. C . : “ T he relative sensitivity to v ib ra tio n o f m uscle re ce p to rs o f th e c a t.” J. Physiol. 192: 773-800. 1967. 15. H a g b a rth , K .-E . a n d E k lu n d , G .: “ T h e m uscle v ib ra to r __a useful to o l in neu ro lo g ica l th e ra p e u tic w o rk .” S cand. J. R e h a b . M ed. I : 26-34. 1969. 16. H a g b a rth , K .-E . a n d E k lu n d , G .: “ T o n ic V ib ra to ry Reflexes in Spasticity B ra in R esearch 2: 209-203. 1966. SEPTEMBER 1975 13 O P S O M M I N G D ie ontw ik k elin g v a n die tonies-vibrerende-refleks as ’n diagnostiese e n ’n terapeutiese h u lp m id d e l w o rd bespreek. D ie tonies-vibrerende-refleks w ord gedifinieer as die toniese re fleks-sam etrekking v a n skeletspier w a n n ee r d it o n d e rw o rp e is a a n hoS frikw ensie m eganiese v ibrasie m et refleksinhibisie v a n die a n ta g o n is. H ie rd ie refleks is in die la b o ra to riu m - situ asie v ir die laaste tie n ja a r o n d e rso e k e n die kliniese to e p a ssin g w o rd n o u voorgestel. D ie tyd v a n to ep a ssin g , v ibreringsw ydte en frikw ensie w a t as d ie geskikste vir kliniese g e b ru ik b e skou w ord, w ord bespreek. A n d e r a an v e rw a n te neurofisiologiese a sp e k te v a n die tonies- vibrerende-refleks w ord besk ry f te n o psigte v a n hulle v e rb a n d m et die kliniese situasie. D ie to nies-vibrerende- refleks w ord as ’n n u ttig e h u lpm iddel in fisieketerapeutiese w erk b e sk o u , m et b e so n d e re to e p a ssin g in die neurologiese veld. F isio te ra p e u te m o et die b asiese beginsels v a n hierdie teg n ie k v e rstaa n o m dit m et m ak sim a le voordeel in kliniese p ra k ty k toe te pas. F I S I O T E R A P I E PHYSIOTHERAPY IN T H E COMMUNITY M. J . R U N N A L L S * ♦Senior lec tu re r; H e a d , D e p a rtm e n t o f P h y sio th e rap y , U niversity o f S tellenbosch a n d T y g e rb e rg H o sp ita l, Tiervlei. T he p o p u la tio n e x p losion, to g e th e r w ith im p ro v e d m edical care, h a s led to a n in sid io u s increase in th e n u m b e rs o f geriatric, ch ro n ic ally ill a n d d isabled p a tie n ts. T h e n u m b e r of h o spital beds is ever in sh o rt supply. T h e p o p u la tio n explosion how ever, does n o t seem to have ra dically influenced the n u m b e r o f p ra c tisin g p h y sio th era p ists. A t th e tim e o f w riting a n d w ith c o m p u lso ry re g is tra tio n o f p h y sio th era p ists with th e S o u th A fric a n M edical a n d D e n tal C o uncil having ■*ieen recently p ro m u lg a te d , th e re a re 1 149 registered p ra c tis­ i n g p h y sio th era p ists in S o u th A frica. T h e re su lts o f w hich indicate th e essential a n d ju d ic io u s use o f p h y sio th era p y services, especially de ce n tra lised /d eh o sp ita lised p hysio­ therapy w ith in th e c o m m u n ity . T h e fo llow ing q u e stio n s m ust th e re fo re be p o s e d : (1) Is p h y sio th e ra p y o f any v a lu e in th e c o m m u n ity ? (2) I f so, in w h a t w ay m ay p h y sio th e ra p y services be efficiently a n d com prehensively utilised to th e benefit o f th e c o m m u n ity ? The p h y sio th e ra p ist to d a y m ay n o lo n g er b e re g ard e d as “ the k in d lady w h o m assages p a in a n d p araly sis a w a y ” . The a verage p h y sio th e ra p y tra in in g in S o u th A frica to d ay consists o f a fo u r y e a r B.Sc. degree in P h y sio th e rap y . “ T he trad itio n a l love o f h e a t m u st be su perseded by a m o re realistic a p p ro ac h to th e p a th o lo g ica l c h anges w h ich h a v e o ccurred in disability a n d w h ich a re irreversible. A n a cc ep ta n ce o f the fact th a t a gas o r e lectric fire c a n give as m u c h relief fro m pain as a ra d ia n t-h e a t lam p o r sh o rtw a v e d ia th e rm y m ac h in e m ust b ecom e a re a lity .” (P a tric k 1973) A rticle received M a rc h 1975. T h e official definition o f p h y sio th era p y in S outh A frica states th a t p h y sio th era p y is th e skilled use o f physiologically b ased m ovem ent tec h n iq u es su p p le m e n ted w h e re necessary by m assage, e le c tro th e ra p y a n d o th e r physical m eans fo r the pre v en tio n a n d tre a tm e n t o f injury a n d disease. It is used to assist th e processes o f re h a b ilita tio n a n d re s to ra tio n o f fu n c tio n in cluding th e achievem ent o f p ersonal independence. C learly th e a im o f p h y sio th era p y in th e co m m u n ity sh o u ld bias strongly to w a rd s a tea ch in g a n d advisory c apacity. T h e p a tie n ts , th e ir fam ilies a n d relatives, a n d th e p u b lic in general m u st b e e d u c a te d to a ccep t th eir re sponsibility in p a rta k in g o f th e re h a b ilita tio n a n d long te rm m an a g em e n t o f th e c h ronically disabled a n d diseased. I f th e p a tie n t is in c a p a b le o f a cc epting th e responsibility fo r th e c o n tin u a tio n o f h is/h e r o w n se lf-tre atm en t p ersonally, th is sh o u ld be a ssu m e d by th e fam ily a n d relatives o r b ecom e a p u blic responsibility. T h e ro le o f th e general p u blic in th is re g a rd is extrem ely im p o rta n t. W h a t then, is the ro le o f th e p h y sio th e ra p ist? T h ere a re m any a v enues o p e n to the p h y sio th era p ist w ith in th e c o m m u n ity . I t c a n only be o f benefit to discuss som e o f these avenues. F irstly , c o n sid er th e p ro b lem s involving g e ria tric p a tie n ts. T h e ten d en cy to d a y , is fo r th e o ld er p e rso n to g ra v itate to w a rd s in stitu tio n s w here n u rsin g facilities are availab le if re q u ire d . M an y o f th e e n cro a ch in g pro b lem s o f o ld age c o u ld be stav ed off by a d e q u a te e d u c a ­ tio n o f th e elderly as to th e im p o rta n c e o f m ovem ent a n d th e up rig h t, active a n d a le rte d p o stu re (T ucker, 1960). P a rtic i­ p a tio n in specially o rie n ta te d exercise classes w hich m ain ta in p o stu re , jo in t m o bility, vital cap a city , physical fitness a n d general m o rale sh o u ld be o rganised by p h y sio th era p ists fo r th e h e alth y b u t elderly in such in stitu tio n s. T h e elderly p a tie n t w h o has b e en hosp italise d fo r som e tim e, e.g. fo r th e tre a tm e n t o f th e fra c tu re o f th e n eck o f the fe m u r o r cere b ro -v ascu lar a ccident sh o u ld have th eir hom e en v iro n m en t e v a lu a te d before th e ir discharge. T h eir re h a b ilita tio n p ro g ra m m e sh o u ld e n su re th a t they will be a ble to c ope w ith th e o rd in a ry activities o f daily life such as ge tting in a n d o u t o f th e b a th , being a b le to get to the w ashline to h a n g o u t th e daily w ash a n d , if n eed, to m anage stairs. I t is a lso necessary to see th a t they c a n neg o tia te tra n s p o rt so as to e n su re c o n tin u e d c o n ta c t w ith th e c o m ­ m u n ity ; I do n o t m ea n th e local b u s o r tr a in service, b u t ra th e r th e use o f a taxi o r p riv a te c ar. U n less th e elderly are re h a b ilita te d to this ex te n t, a n d th e ir fears allayed by d e m o n s tra tin g th e ir m o b ility they will ten d to w ith d raw a lto g e th e r. 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. ) 14 P H Y S I O T H E R A P Y SEPTEMBER, 1975 W h en th e elderly p a tie n t reach es th e sta g e o f b e c o m ng a “ n u rsin g p ro b le m ” , th e fam ily sh o u ld be in s tru c te d by th e p h y sio th e ra p ist as to th e o p tim u m p o sitio n in g in b e d so as to p re v en t th e d e v elo p m en t o f p re ssu re sores a n d c o n tra c ­ tu res. T h e fam ily sh o u ld b e ta u g h t ho w to tu r n th e p a tie n t in bed, ho w to m ove th e p a tie n t u p a n d d o w n in th e bed, how to sit th e p a tie n t fo rw a rd a n d h ow to get th e p a tie n t b o th o n a n d o ff th e b e d p a n . T h e c o rre c t m echanical use o f th e body by th e fam ily a n d relatives will n o t o nly p re v en t b ack in ju rie s, b u t will c o n se rv e a n d give th e m en erg y fo r o th e r activities so necessary w h en o n e is c o n sta n tly in v olved in n u rsin g th e c h ro n ic ally b e d rid d e n . S econdly, th e ro le o f th e p a tie n t, fam ily, relatives a n d frien d s becom es increasingly im p o rta n t w hen o n e surveys th e m in c o n ju n c tio n w ith th e fo llow ing g ro u p s o f c h ro n ic diseases a n d d isa b le m e n ts: (a) d isa b le d c h ild re n — e.g. c ere b ral palsy, talip es e q u in u s varus, p o liom yelitis, a c u te infective p o ly n eu ritis a n d th e b lin d ; (b) d isabled a d u lts — e.g. p a rap leg ia , q u a d ra p le g ia , h ead injuries, hem ip leg ia; (c) th e y o u n g c h ro n ic ally ill — e.g. m u co v iscid o su s, Still’s disease, a sth m a , h a e m o p h ilia ; (d) th e c h ro n ic ally ill a d u lt — e.g. c h ro n ic b ro n c h itis, e m p h y sem a, rh e u m a to id a rth ritis , m y o ca rd ia l in frac tio n , disse m in a ted sclerosis. B asically th e p h y sio th e ra p ist sh o u ld te a c h , a n d tra in th e a b o v e -m e n tio n e d p a tie n ts to tre a t them selves as fa r as p ossible a n d w h en n ecessary the h elp o f fam ily a n d relatives sh o u ld be e nlisted. P a tie n ts sh o u ld becom e a c q u a in te d w ith a n d a cc ep t th e resp o n sib ility of do in g a n d m o d ify in g th eir ow n exercise p ro g ram m es in a c c o rd a n c e w ith th e d icta te s o f th e ir p re sen t c o n d itio n . A p p lic a tio n o f splints, p o stu ra l d ra in a g e, b re a th in g exercises, specific p o sitio n in g in re la tio n to spasticity, passive m ove­ m en ts a n d a h o st o f o th e r tre a tm e n t a ctiv ities a re a m o n g s t th o se w hich p a tie n ts c a n p e rfo rm fo r them selves. T hey sh o u ld , how ever, a n d th is m u st n o t be fo rg o tte n , see th e p h y sio th e ra p ist a t re g u la r in te rv als fo r e v a lu a tio n , re-assess­ m e n t a n d advice. T h e p h y sio th e ra p ist m u st a t all tim es be av a ila b le to th ese p a tie n ts in an a d v iso ry cap a city . It is a lso esse n tia l th a t w here possible these p a tie n ts sh o u ld be re h a b ilita te d to th e e x te n t th a t th ey c a n m a k e active c o n trib u tio n s to the society a n d the c o m m u n ity . T h ey m ust be c o n sta n tly a w a re o f th e a im s b o rn e in m ind fo r th em . T h e p h y sio th e ra p ist h as a role to play in th e te a m w hich re h ab ilitate s o r if need be, resettles these c h ro n ic ally d isabled o r diseased p eople in a n a lte rn a tiv e o c c u p a tio n . T h ird ly , let us lo o k a t the role o f p h y sio th e ra p y fro m th e p re v e n ta tiv e p o in t o f view. H e re a g a in th ere a re m an y possibilities. B a c k a c h e is a very c o m m o n o c c u p a tio n a l h a z a rd . T h e p h y sio th e ra p ist sh o u ld b e em p lo y e d by in d u stria l c o n ce rn s w ith a view to safety. E m ployees e n g ag e d in heavy lifting activities sh o u ld be in stru c te d a n d tra in e d in the c o rre c t lifting p ro c ed u re s. F u rth e rm o re , w o rk task s involving the a ssu m p tio n o f p o stu re s fo r indefinite tim e p e rio d s sh o u ld b e e v a lu a te d a n d th e e m ployee p o stu re d to th e best m ec h an i­ cal a d v a n ta g e fo r th a t specific task . O ne needs only to th in k h e re o f th e “ fib ro sitic ” n eck p ro b lem s a ttrib u te d to th e p o s tu ra l a ttitu d e s o f typists a n d a ll th e o th e r m u sc u lo ­ skeletal p ro b lem s th a t a rise in c o n ju n c tio n w ith faulty p o stu re . Sim ilarly, th e p h y sio th e ra p ist c o u ld be o f use in th e sc h o o l s itu a tio n w here a d o le sc e n t p o stu ra l p ro b lem s arise. R e m e m b e r a lso , th e specific in tro v e rte d p o stu ra l p roblem s o f b lind c h ild ren . T h e p h y sio th e ra p ist’s kno w le d g e o f func­ tio n a l a n a to m y , physiology, kinesiology, p a th o lo g y a n d exercise th e ra p y w o uld e n a b le h e r to a dvise th e school g ym nastic te a c h e r as to su itab le exercises to in clu d e in th e general exercise p ro g ram m es fo r these ch ild ren . B a c k a c h e is a lso a c o m m o n c o m p la in t a m o n g s t p re g n an t m o th e rs. H e re a g a in p h y sio th e ra p y has a place. T h e p ro s­ pective m o th e rs sh o u ld be in stru c te d as to th e c o rre c t m ech an ic al a d a p tio n to th e e n su in g p o stu re o f pregnancy. I n a d d itio n t o b e ing ta u g h t exercises to p re v en t sw elling of her legs a n d fo o ts tra in , she sh o u ld be ta u g h t how to conduct h e r la b o u r so th a t she will be a ble to relax b o th m en ta lly and physically. C o n tin u in g in a p re v en tativ e vein — th e h a z a rd o f the lack o f exercise w ith re g a rd to m y o ca rd ia l in fa rc tio n is c o n sta n tly b e ing b ro u g h t to o u r a tte n tio n . Physiotherapists sh o u ld be em p lo y e d by c o m p a n ie s w ho h ave larg e numbers o f s e d e n ta ry w o rk e rs w h o a re su b m itte d to th e severe p re ssu re o f th e h ig h -p o w e re d bu sin ess life. T h ese business e xecutives c o u ld th en be in stru c te d a n d supervised in a p u rp o se fu l lu nch h o u r exercise p ro g ra m m e expressly d e signed to keep th e m physically fit. W h a t a b o u t th e p re v e n tio n o f sp o rts in ju rie s? The p h y sio th e ra p ist c a n be o f h elp to tra in e rs a n d c o ach es in the d ra w in g up a n d e x e c u tio n o f p u rp o se fu l exercise pro­ g ra m m es a n d schedules sh o u ld be designed to facilitate m ax im u m jo in t range, m uscle length, stre n g th a n d endurance a n d physical fitness. T h u s th e possibility o f m an y specific in ju rie s c o u ld p o ssibly be elim in a ted . In the case o f injuries o c c u rrin g early, p h y sio th e ra p y tre a tm e n t w o uld ensure an e arly a n d m o re speedy re tu rn to th e gam e. F in a lly , lo o k in g a t re h a b ilita tio n in th e c o m m u n ity in its b ro a d e st sense, it is e vident th a t the p h y sio th e ra p ist h a s f definite p ro fessio n al re sp o n sib ility to serve o n varioiS co m m itte es in a n ad v iso ry c a p a c ity : h e alth education-, sp o rts- (b o th fo r the h e alth y a n d the disa b le d ), industrial- a n d a rc h ite c tu ra l lia iso n -c o m m ittee s all seem to in d ic a te this need. F ro m su ggestions a n d ideas set by th e d ic ta te s o f our p re se n t tim es it seem s t h a t p h y sio th e ra p y in th e community, in the fu tu re , is infinitely im p o rta n t. Its successful imple­ m e n ta tio n d e p en d s on enlig h ten e d p h y sio th e ra p y prescription by m ed ic al p ra c titio n e rs a n d th e fo resig h te d d e m a n d of a c o m m u n ity w hich h as a d e v eloped insight. R E F E R E N C E S 1. P a tric k , M a rg a re t K . (1973), “ P h y s io th e ra p y in the C o m m u n ity ,” P hysiotherapy, Journal o f the Chartered S o c ie ty , 59, 6 , 180. 2. T u c k e r, W . E. (1960), A ctive A le rte d P osture. A. C. M IL L E R & CO. O R T H O P A E D I C M E C H A N I C I A N S • Technicians registered with S.A. Medical and I Dental Council specialising in the following: ORTHOPAEDIC APPLIANCES, SURGICAL CORSETS, CERVICAL COLLARS, CHILDREN'S SHOES AND BOOTS, ARTIFICIAL LIMBS, LATEST IN PLASTIC MODIFICATION. HIRING AND SELLING OF HOSPITAL EQUIP­ MENT AND SICK ROOM REQUISITES, e.g. W HEEL CHAIRS, COMMODES, HOSPITAL BEDS, W ALKING AIDS, TRACTION APPARATUS, etc. • Telephone P.O. Box 3412 23-2496 275 Bree Street 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. )