2 P H Y S I O T H E R A P Y MARCH, 1974 P H YSIO TH ER APY IN RELATION TO .ORTHOPAEDIC SU R G ER Y IN THE T R E A T M E N T O F C E R E B R A L PA L SY b y T H E P H Y S IO T H E R A P Y D E PA R TM EN T (A. MATHIAS, B.Sc. (Physio) Wits SENIOR PHYSIOTHERAPIST) FOREST TOWN SCHOOL FOR CEREBRAL PALSIED CHILDREN, JOHANNESBURG. SUMMARY 1. Introduction. (a) The Integration o f the Orthopaedic Approach with other techniques used. (b) Preparation for hospitalisation. 2. Physiotherapy in Relation to Specific Surgical Pro­ cedures. 3. N ote on the Forest Town B o o t 4. References. SUMMARY Physiotherapy in relation to O rthopaedic Surgery in the treatment of Cerebral Palsy. Orthopaedic Surgery is an integral p a rt o f the tre a t­ ment of cerebral palsy; the success o f such surgery being largely dependent on the pre- and post-operative therapy which the patient receives. A form at of physiotherapy which decreases post-operative disturbance and enhances the results of surgery has been developed a t th e F o rest Town School for Cerebral Palsied C hildren an d is described as it pertains to surgery o f th e low er extremities. The Integration o f the Orthopaedic Approach with other techniques used in the Treatment o f Cerebral Palsy. Physiotherapy has been used in th e treatm en t o f C ere­ b ral Palsy since the time that treatm ent was directed towards it as a specific condition. T h e ro le o f physio- tnerapy has varied with the passage o f time. A t first, it was considered to be th e only treatm ent indicated, albeit used in conjunction with braces, by W in th ro p Phelps, who also advocated the “Team A pproach” (K eats, “C ere­ bral Palsy”—Thomas 1965). Different techniques or approaches to th e physio­ therapeutic treatm ent of Cerebral Palsy becam e estab­ lished and are fully described in the literature. (A m erican Journal of Physical Medicine, Vol. 46, N o. 1, F eb ru ary 1967). Orthopaedic surgery, when it first entered th e field, was used as a substitute treatment, disregarding physio­ therapy, with disastrous results fro m th e orthopaedic angle. It is now appreciated that the success of surgery is largely dependent on the quality of therapy w hich the patient receives, and orthopaedic surgery and bracing is now an integral p a rt of the treatm ent o f th e cerebral palsied. The physiotherapist shares the responsibility fo r the state of the patient. However, there still exists a great d eal o f confusion and doubt as to the role of orthopaedic surgery, am ong therapists working in the field. This is m ainly due to the fact that some exponents of accepted treatm en t tech- O P S O M M IN G Fisioterapie m et betrekking to t O rtopediese Chirurgie in d ie behandeling van Serebrale V erlam m ing. O rtopediese C hirurgie is ’n in teg rate deel van die be­ handeling van serebrale-verlam m ing; en die sukses van sulke chirurgie is grootendeels afhanklik van d ie mee- gaande terap ie w at die pasient ontvang. ’n V o rm aat van fisioterapie w at die navolgende steum is van chirurgie ver- m inder en die voordele daarvan verbreed is ontwikkel op F orest T ow nskool vir Serebraal V erlam de Kinders en word beskry m et betrekking to t chirurgie van die onderste ledem ate. niques have, in th e past, condem ned th e use o f ortho­ paedic m easures in this regard. In addition, there are certain difficulties in treating post-operative cases which m ay prove hazardous to the inexperienced therapist. T here is as yet, very little in th e literatu re to guide the therapist in this aspect o f treatm ent. (] D uring th e p ast fifteen years we have developed^- fo rm at o f physiotherapy which is used in the treatm ent o f cerebral palsied children and adults undergoing sur­ gery, which largely elim inates perm anent post-operative com plications and ensures m axim al success. A t F o rest Tow n Sdhool an eclectic appirolaeih to therapy is em ployed, ra th e r than strict adherence to any one technique. T h e type o f treatm ent used is dependent on th e p articu lar requirem ent o f the child at any neuro- developm ental stage and on the type o f disability (i.e. the patho-physiology). Some children respond best to a specific technique while others require a com bination of techniques to achieve the best results. T hus a b ab y w ithout head co n tro l an d uninhibited ab­ n orm al reflexes w ould respond best to the B obath tech­ nique using reflex inhibiting patterns and facilitation of n orm al responses, w hile in th e same child arm weight­ bearing m ight be achieved by using techniques o f sensory stim ulation to the extensors o f the arm as advocated by R ood. In an older child, how ever, w here co-operation may be enlisted, Proprioceptive N eurom uscular Facilitation could play an im p o rta n t p a rt in the breaking dow n of 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. ) , nrmal synergies provided th a t due regard is given to h n e u r o lo g ic a l aspect o f the child’s condition— and [[jus careful positioning is im p o rta n t when using this ^T rT the^am e way as physiotherapy has been a d ap te d to pet th e needs o f th e cerebral palsied child, so has the thopaedic approach been tem pered to suit th eir par- ? pillar problem s. T hus orth o p aed ic assessm ent m ust ntnrally take into account the general neurological con­ dition of th e child and the effect th a t surgery o r splintage anil have upon this. . , . , , The integration o f th e orthopaedic ap proach w ith other seeds o f therapy presents m inim al problem s when all members of th e team a re aw are o f all aspects o f the child’s condition. This includes n o t only the orthopaedic and neurological facets, b u t also educational and emo­ tional problem s w hich present themselves in th e cerebral palsied child. One o f the basic principles in th e treatm en t o f cerebral „aisy is the understanding and accurate assessm ent o f the abnorm al synergic patterns and th erap y is directed towards m odifying or changing these p atterns in o rder \ achieve as no rm al o r as functional a p attern as ossible. H ow ever, due to in tractab le spasm, o r w here an abnorm al synergy can n o t be inhibited in a functional position (e.g. as in a persistent exaggerated positive sup­ porting reflex producing equinus o f the foot), norm al development is even fu rth e r im paired. H ere the o rth o ­ paedic approach, w hether it be conservative (i.e. bracing, “New C oncepts in Bracing in C erebral P alsy” by Alice L. G arrett, M .D . et al. Physical T herapy, July 1966, Vol. 46 N o. 7) o r operative, is o ften the m ost dynamic method o f facilitating no rm al developm ent. By way of exam ple, a child w ho is unable to develop standing balance due to a persistent exaggerated Positive Supporting R eaction producing equinus could b e consider­ ably helped by w earing th e F o rest Town B oot, which will enable him to stand on a plantigrade foot. e.g. Case I. ‘Carel, spastic quadriplegic, is m ore affected on the Right than on th e Left. H e was pulling u p to standing at 15 m onths, b u t h e was unable to learn to stand alone because o f bilateral equinus feet. A fte r w earing F o rest Town Boots, h e w alked a t 20 m onths, fo r th e following six months, he could stand and w alk w hile w earing the Forest Town Boots, b u t n o t w ith o u t them .’ In addition th e effect o f the Positive Supporting Reflex could be overcom e by p u ttin g th e triceps surae muscles at a m echanical disadvantage as is achieved by a gastrocnemius recession and T.A .Z -lengthening opera- % n. 7 The correction o f deform ities and contractures m ay enable a sedentary child to becom e u p rig h t and m obile and th e psychological im portance o f this achievem ent cannot be over-estim ated. M oreover, the educational aspect o f the ch ild ’s developm ent is also enhanced as the experience o f the u p rig h t position plays an im portant part in the aw am ess o f spatial orientation an d hence in perceptual developm ent. T he im provem ent in body image and th e subsequent perceptual concepts b rought about by th e attainm ent o f the u p right position has been repeatedly observed. A particular exam ple is o f a child who, in the “ D raw- a-man” test w ould produce a picture o f a m an either lying down o r w ith no p articu lar relationship to the upright w hile the lim bs showed n o constant orientation. Post-operatively and follow ing m obilization, she drew a man standing u p rig h t and o n his feet. In addition, increased m obility a ttain ed by surgery enables the child to explore his environm ent and thus learn new sp atial concepts w hich h e was un ab le to grasp beforehand. Successful integration o f th e orth o p aed ic approach with o ther techniques used depends m ainly on a close IVIAART 1974 3 co-operation between surgeon a n d therapists. Surgery is never perform ed in isolation—all m em bers of the team including th e teachers are aware o f the aims, purposes an d possible problem s o f surgery. Post-operatively, a change of positioning in th e classroom m ay be indicated as well as an adaption to classroom furniture. Tlie em phasis in therapy m ay be changed by surgery. Changes in p a tte rn produced by surgery, if n o t antici­ p ated, could cause alarm . H ow ever, w ith th e therapist well aw are o f this, the opposite pattern w hich m ay be produced can be im m ediately counteracted before it has a chance to take over o r cause an y kind o f stress. In the use o f th e R o o d technique therapists have realised 'the need fo r carefully th o u g h t o u t m ethods o f splintage. I t is im p o rtan t to be aw are o f certain neuro- physiological principles in o rd er to know w hich muscles are being facilitated an d which are being inhibited by the splint used; and thus m ethods o f sensory stim ulation as advocated by R ood m ay be achieved by th e splintage itself o r superim posed o n th e particular m ethod o f splintage used. T he o rth o p aed ic technician participates as a valuable m em ber o f the team and his aw areness of th e special problem s o f the C erebral Palsied child along w ith his close co-operation w ith the surgeon and th erap ist enables him to ad ap t an d m odify orthopaedic appliances in such a way th a t th e optim al support, correction and m obility can be achieved. I t has been show n th a t the orthopaedic ap proach to th e treatm en t o f the cerebral palsied child is, in our experience a t F o re s t T ow n, a n essential m odality to supplem ent and com plem ent th e overall treatm ent and m anagem ent o f th e child. Preparation for Hospitalisation O utline o f the procedure w hich has evolved a t Forest T o w n A t F o rest T ow n all staff m em bers co-operate an d p a r­ ticipate in the p rep aratio n o f a child fo r surgery. I t is appreciated th a t there can be a great d eal o f em otional traum a to b o th parents an d child unless th is aspect is carefully and fran k ly handled. Basic to the success o f any m ethods which m ay be em ployed is th e general attitude tow ards surgery (on the p a rt o f the staff) which is inevitably com m unicated to the parents and children. A t F o rest Tow n, in m any cases, surgery is regarded as an indispensable m odality which contributes to th e child’s general progress, rath er th an a m ethod w hich is con­ sidered a last resort in th e case o f failure o f therapy. T hus parents understand, rig h t fro m th e beginning, th a t should surgery be recom m ended it w ould benefit the child, w hether th e aim w as lim ited to cosmesis or to increased function. Staff and Parents P rep aratio n o f the child fo r hospitalisation starts w ith the m em bers o f staff handling the child and then w ith th e parents, then staff an d p aren ts together, p rep are the child. 1. I t is im perative th a t all m em bers o f the team are fully acquainted w ith the type o f procedure to be un d er­ taken and the reasons fo r its being selected as p a rt o f th e treatm ent program m e. 2. T he teaching staff w ho, will fo rfeit a certain am ount of valuable tim e in th e classroom , are aware th a t surgery aim s to benefit the child as a w hole and thus consider the time lost in the classroom is justified by the overall benefit gained. (Parents, too, understand th at a t this p articu lar stage surgery takes precedence over schooling.) 3. Staff m em bers an d parents m u st be aw are o f the possible post-operative disturbances, th e reasons fo r them and how to co u n ieract them . T hese may include changes in: F I S I O T E R A P I E 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. ) 4 (a) response level, (b) em otional level, (c) attention span, (d) th e am ount of pain, fatigue o r fear. T h e change usually consists o f a depression o f the first th ree and an increase in ‘d ’. (e) there will be a change in the physical condition and the child’s abilities— this m ay initially ap p ear to be negative, o r retrogressive. It is im p o rtan t to note, how ever, th a t the d u ratio n and intensity o f these disturbances vary trem endously and in our experience th e disturbances are inversely p ro p o r­ tional to th e thoroughness o f the p rep aratio n fo r hos­ p italisation and not dependent on other factors, e.g. the severity o f th e o p eration. (Reynell 1965) It has been repeatedly observed th a t children who have to be adm itted fo r a second o r even th ird p rocedure react w ith less disturbance th a n they did the first time. 4. The surgeon interviews th e parents personally and explains as fully and simply as possible to them an d the child, w hat will be achieved by the operation, w hat period of hospitalisation to expect and w hat p ost-opera­ tive care will be necessary at home. T he im portance o f intensive post-operative therapy is also stressed and the fact th a t th ey m ust be prepared fo r the child to wear an orthopaedic appliance fo r som e tim e afte r the opera­ tion. I t is also pointed out th a t w ith the rem oval o f the m ore obvious deform ity o r disability, o th e r already present but less obvious problem s m ay become m ore a p p a re n t and need fu rth e r correction. T here is no prom ise of a cure. A pproach to the C hild P rep aratio n fo r hospitalisation varies w ith the age of the child and the em otional disposition. T h e pre-verbal child (up to 21 years) needs th e s u p ­ p o rt o f its m other during hospitalisation and, ideally, the m o th er should accom pany th e child. H ow ever, few children are subjected to surgery a t this age. W ith the guidance o f th e psychologist, it is determ ined w hether the child can cope em otionally w ith hospitalisation. Should there be do u b t in this respect, th e o p eratio n is postponed, until conditions are m ore favourable. Preparation through play In th e N u rsery School, prep aratio n takes the form of “H o sp ital Play” . T h ere is a “h ospital corner” in w hich th e dolls are dressed as nurses, patients and doctors and plastic h o sp ital utensils are a t hand. T h e teacher tells a story aro u n d this them e and th e children participate in lively discussion and play. T h ro u g h o u t the school this is reinforced and th e children often indulge in spon­ taneous “hospital play” in the playground. T h e S chool-T reatm ent C entre E nvironm ent C hildren see and know o th e r children w h o have u n d er­ gone surgery and benefited from it. T hey learn to accept therapists, doctors and th e clinical atm osphere as much as p a rt o f life as teachers an d classroom s. O thers w earing and w alking in plaster o f paris are a fam iliar sight! A prospective patient is also show n th e plaster saw and cutters and thus th e rem oval o f his ow n plaster (usually done at school) is n o t a completely new and frightening experience. C linics a re held a t school and th e surgeons are fam iliar and friendly figures w ho inspire confidence. O lder children are given opportunities to talk to the surgeon and to discuss an y aspect w hich m ay be causing con­ cern. F am iliarity with the surgeon and therapists obvi­ ates (the necessity fo r p lay th erap y w ith th e psychologist; how ever, should there be an y indications o f alarm , the psychologist is asked to help the parents and child and advises th e surgeon and therapists in his respect. T he therapist shows the child som e o f the exercises he will have to do a t hospital or at hom e and explains th the aim o f th e operation— “ to m ake it easier fo r you w alk”— will not necessarily be im m ediately achiev b u t will surely follow on prelim inary mobilization, t v sam e physiotherapist is responsible fo r the child do operatively an d th u s the child is secure in th e k n o w le/1' th a t he will be back w ith som eone he know s and tĥ continuity o f treatm en t is m aintained. 5 Liaison with H ospital Staff Because o f a good liaison w ith the hospital staff th nurses are aw are o f th e special problem s o f the cereh ^ palsied child. 151 I t is particularly im p o rtan t fo r the nurses to know W m uch the child can understand and comm unicate t have an indication o f his I.Q. and to be aw are of’ th° fact th a t a non-verbal child m ight w ell comprehend more th an one realises. T he senior physiotherapist attends the w ard round the day after the child is adm itted, im m ediately prior to surgery. It has been found th a t the presence o f a known doctor an d fam iliar therapist m akes a trem endous dij, ference to the security o f the child in th e strange h o sp iP surroundings. Should the child be u n d u ly nervous the therapists will be present when he is taken to the theatre and stays until he is anaesthetised. T h e parents are pre- sent when he comes round. The period of hospitalisation is n aturally reduced to a m inim um and the parents, w ho are well instructed as to how to care fo r him a t hom e, know th a t he may go hom e as soon as his condition perm its. C onclusion. T he success o f surgery is la r g e ly ' dependent on the thorough preparation o f the child beforehand. T0 achieve this, all m em bers o f th e team and the parents must be thoroughly acquainted w ith the purpose and n atu re of th e hospital treatm ent to be undertaken. The child’s em otional disposition is tak en in to account and handled w ith the utm ost care. I t is im p o rtan t to recog­ nise the child’s feelings ab o u t the situation—th a t he may be frightened or angry. T he child m ust know that his feelings are understood and accepted and th a t his prob­ lems are very real. R ath er than belittling his problems, he m ust be given su p p o rt to cope w ith them . MARCH. i 9?4 Physiotherapy in Relation to Orthopaedic Surgery of the Lower Extremities in Cerebral Palsy General pre-operative measures, to be fo llo w ed in • terior m ovem ent of the head which results by i j t i c h t ham strings pulling a sitting child into exten- • L e n g th e n in g of ham strings w ith release of adduc- sl0n' results in a wider sitting base w ith resultant im- tors d balance and the ability to inhibit the M oro P!flex e g- C ase 2. . rnh'an severely in v o lv e d sp a stic q u a d rip le g ic a t six rs old w as u n a b le to sit in a n y p o s itio n due to yLn tinual M o ro re a c tio n . H e 'had th r e a te n e d d isloca- C° n of th e h ip s as a re s u lt o f c o n tra c tu re s o f a d d u c to r "nH psoas m uscles a n d h a d su rg ic a l c o rre c tio n o f these Hpformities. P o s t-o p e ra tiv e ly h e c o u ld sit, le a r n t to • Libit the M o ro -re fle x a c tio n a n d le a r n t to h o ld on with his h a n d s, e ven p u s h in g a w alker. 2 E s t a b l i s h m e n t o f m axim al joint m o b i l i t y and s ta b i lity p e r m i t t e d by d e f o r m i n g forces. 3 . A d j u s t m e n t b y p a t i e n t t o re g im e w h i c h w i l l f o l l o w p o s t - o p e r a t i v e l y . 4. E sta b lish m e n t o f r a p p o rt w ith p a tie n t a n d p a re n ts. 5 P re p a ra tio n o f p a tie n t a n d p a re n ts f o r h o sp ita lisa - ■^n and th e effects th e re o f. *2 6. A ssessm ent o f p a tie n t as re g a rd s: (a) em otional reaction to surgery and hospitalisa­ tion, (b) a n tic ip a te d c h an g e in p a tte rn s o f m o v e m e n t a n d /o r spasticity, following surgery, e.g. (i) Pre-operative ad d u cto r spasm may mask lesser degree o f spasticity in abductors of hip, with consequent over-action of abductors following adductor transfer, (ii) Pre-operative p a tte rn o f h ip and knee extension, adduction and equinus o f feet caused by positive supporting reflex, m ay change to com plete flexion after lengthening o f triceps surae, due to weak spastic extensors of knee and ‘breaking u p ’ of total extensor pattern. T h ere fo re p re -o p e ra tiv e ly , s tre n g th e n voluntary e x te n ­ sion, even th o u g h e x te n s o r sp a stic ity is p re se n t. 7. Preparation o f appliances which are to be used post-operatively. 8. The therapist should have a good understanding of the indications, aim s and procedures o f surgical tre a t­ ment of the cerebral palsied. *3 9. An appreciation, on the p art o f the therapist, of any changes occurring in the p atien t’s condition which may necessitate early consultation w ith the surgeon, e.g. (i) a complaint of pain in the hips, w hich m ay indicate threatening subluxation, or (ii) the developm ent o f a ‘Rocker-bottom” foot, (iii) developm ent o f pelvic obli- ity with possible developm ent o f scoliosis. General Post-operative Measures /. Immediate post-operative period (a) D uring this tim e the p atien t is sedated; to relieve pain and spasm. A fter the first few days spasm only may need to be prevented; and valium is usually prescribed for this purpose. (b) N ursing postures should be corrected to prevent abnorm al reflex spasticity, e.g. the head should be in the m id-line and slightly flexed forw ard to prevent extensor spasm in m any cases, or flexor spasm of the legs in patients w ith a residual symmetrical tonic neck reflex. (c) P re v e n tio n o f p re ssu re sores. (d) T h e ra p y given w hile p a tie n t is in p la s te r in clu d e s: (0 M a in te n a n c e o f u p p e r e x tre m ity m o b ility a n d stre n g th . (ii) A bdom inal and h ip extension exercises, also abduction when not in a spica. (iii) M a in te n a n c e o f f o o t m o v e m e n t w h e n po s- sible. (e) R o u tin e p o st-o p e ra tiv e c h e s t care. M A A R T 1 9 7 4 M S . O R A P I E 2. R e m o v a l o f Plaster o f Paris (a) M inim ise apprehensions and fear by giving a suitable sedative, and by the presence of a fam i­ liar therapist d u rin g actual rem oval o f plaster. (b) Prevent any untow ard m ovem ent o f the lim b by preventing and controlling spasm. (c) G ive adequate skin care. (d) C heck appliances. N.B. R etain plaster o f paris backslabs fo r use when appliances are n o t used, o r fo r use as night-splints. (e) T here m ay be increased spasm and pain, o r fear o f movem ent, and it is advisable to use valium (prescribed by d octor) at th e beginning; decreas­ ing and discontinuing its use as soon as possible during the day. M any children have spasm at night, and as rest is necessary fo r child and parent, it is often necessary to take m easures to ensure this. Re-assurance, support, if necessary to tal bodily su p ­ p o rt, are very often needed until a child becomes used to being w ithout the su p p o rt of the plaster. Physiotherapy in Relation to the Hips, e.g. Adductor Transfer, Psoas Release, with or without Release o f R ectus Femoris. Pre-operative therapy C onservative therapy aim s at establishm ent of postural control in all basic m o to r developm ental sequences. M obility and stability o f th e hips is very often im paired due to muscle instability caused by spasticity o r contrac­ ture o f the h ip flexors, adductors and internal rotators. Long-standing muscle im balance m ay lead to subluxa- tion and anteversion o f the fem oral necks w ith eventual dislocation. Surgery aim s to correct muscle im balance, and prevent bony deform ity, or to correct deform ity w hen such has developed. *4 E arly physiotherapeutic m easures to prevent deform ity include: 1. M obilisation o f the hips F ro m infancy this is done w ith the baby in supine in flexion, bringing the toes to the m outh. T his activity ensures spinal m obilisation as well as full external ro ta ­ tion and flexion/abduction o f the hips. I t also helps to prevent the contracted, stiff hips som etimes seen in older children, where hip flexion contracture m ay be decreased by surgery, but th e inability to fully flex the hips persists, w ith resultant flexion o f the spine instead. T he use o f a F rejka pillow prevents adduction and effectively breaks up a to tal extensor pattern. 2. W eight-bearing with corrected alignm ent In n orm al developm ent, a baby starts taking weight from ab o u t five m onths o f age onw ards. W eight-bearing w ith the head o f the fem ur located in the acetabulum is necessary fo r th e developm ent of a norm al acetabulum and this process is com pleted by the age o f fo u r years. In the presence o f spastic adductors and psoas muscles, there is a tendency for th e developm ent of anteversion o f the fem oral neck, coxa valga and subluxation o f the hip, w ith failure o f acetabular developm ent. I t is there­ fore im p o rtan t th a t w eight-bearing is encouraged even th o u g h the child is no t neurologically m atured. M easures used to correct alignm ent and prevent abnorm al patterns when standing include: 1. U se o f F o rest Tow n Boot (o r below -knee iron, w ith backstop) to provide plantigrade feet. In spite of heels riding u p in boots w ith irons, the boot provides a plantigrade surface. 2. R oller between legs to ensure abduction and a wide standing base. 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. ) 6 P H Y S I O T H E R A P Y m a r c h . T H E p r e s e n t s — M i n i d y n e m k III TR AN SISTO RISED FAR AD IC UNIT continuing features are wide range of surge speed control with output sufficient for all forms of ludible ? f w e l l l w visual indication of surge speed enabling the "jperalw to anticipate a muscle reaction without having to watch the control panel fitted with Ever Ready PP9 batteries which will g.ve up to six months use without replacement and are obtainable worldwide W EIGHT reduced to: 4 lbs. (1,8 kg) SIZE reduced to 8” x 5 }" x 2 }" (20cm x 13,5cm x 6cm). PRICE: R96.50 complete with accessories. M E D I C A L D I S T R I B U T O R S E D M S BPK X A P E Y O R K ' I 252 JE P P E ST . | J O H A N N E S B U R G | D e W a a l H o u s e , 172 V ic to r ia Road_ P L E A S E A D D R E S S A L L C O R R E S P O N D E N C E TO P .O . B O X | 33?8 J O H A N N E S B U R G R IG A S S E B L I E F A L L E K O R R E S P O N D E N S IE A A N P Q S B U S • Woodstock, C£_ TEL. A D D . 'D I S M E D ' P H O N E I F O O N 23-8106 T ELEX : 43-7129 S .A . 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. ) 1974 j external rotation o f legs when doing 3 A h d u c t i o n a n u ^ . g h t b e a r i n g j c r a w l i n g > s l t t i n g i o r ■.■-jscs for , a CnriKht kneeling- ^ he first step in walking. T his ' " ormaT s e q ^ n c e and a n im p o rta n t therapeutic î a a RT F I S I O T E R A P I E c x e r c is c 5. 7. lions 8. Abduction b ra c ^ ^ abduction (m anual, springs or 6. Use of r . ,the older child. . . . dental ' gth of rectus fem o n s by using posi- - M a i n t a i n leng h extension a n d knee flexion. s ami moyem hould be im proved as fa r as de- Pelvic staBimy^ ^ js dependent on: forming f.orc.esm,‘ cie ’ strength, extensors, abductors and A b d o m i n a l m usuc ,jd u d iirs in eaia • interfere w ith postural control w l’e,c, tlg DeM c control is often better in kneel- in " p r o v id in g there i s no rectus fem o n s contrac- lurc)' <- „ „ CPnce o f psoas contracture o r rectus fem oris In the Presehj D0Sture will increase lu m b ar lordosis, ^ be l e s s e n e d by having th e p atient support • ^ s o l f with his arms straight o ut in fro n t o f him. 9 Sec g e n e r a l pre-operative m easures. l while the child is w earing long S .a n d ? n , w it h ^ , 7 tS’ t h e f o l l ° w i n ® is s t a r t e d :>-• ith full support when necessary. In m ost cases the ability to stand erect, even fully supported, w ithout the spasm o r co ntracture which was present pre-operatively, gives the child and his parents a great deal o f pleasure and encouragem ent. P ostural training begins on the day a fte r rem oval o f plaster, and is given concom m itantly w ith m obilisa­ tion and strengthening exercises. (ii) A ssisted w alking (in calipers when necessary). T his activity acts as an incentive to m ost children. A ll th e m easures described under pre-operative therapy are used. Increased post-operative m obility will facilitate ro tatio n which is given a t first, in rolling, w ith or w ithout resistance at h ip o r shoulder, then in the m ovem ent from fo u r-fo o t kneeling to side-sitting and up to kneel-stand- ing. If arm su p p o rt is used, the hands should be in a flat supportive position, instead o f grasping an d pulling w ith the arm s. H alf-kneeling m ay be a progression from step-stand­ ing, as the adductors, ham strings and hip flexors are stretched. T his position should be achieved as soon as possible after surgery, and the lengthening m aintained. R esistance to th e pelvis anteriorly on the w eight-bearing side, and laterally to the no n w eight-bearing knee, facili­ tates full extension o f the w eight-bearing h ip and external ro tatio n of th e no n w eight-bearing knee. Standing. I t is easier to start standing u p from sitting on a high stool, w ith hand support. T he stool is lowered, to increase m uscle w ork and p ostural control. G ive approxim ation through th e knees to facilitate quadriceps, and prevent the head from leading into to ta l extension. A great deal o f sensory training (proprioceptive, kin- aesthetic) is given with a great variety o f slight postural changes and adjustm ents to acpustom the p atien t to the altered centre o f gravity and skeletal alignm ent. T h is is essentially sensori-m otor learning. *6 Standing at first in parallel bars, using han d s fo r sup­ port, in different positions. W eight transference, laterally as well as antero-posteriorly, and reciprocal arm m ove­ m ent precedes walking. W alking starts in th e parallel bars with hand support. This is progressed to w alking w ith a rollator, crutches and sticks, or independent walking. T ru n k ro tatio n is an im p o rtan t com ponent of the w alking p attern and is facilitated by resisted walking, the therapist resisting at th e hips either anteriorly to increase flexion, o r posteriorly to increase extension and external ro tatio n o f the leg. Give dow nw ard approxim ation of the pelvis to increase extension. *7 I f there is a tendency to w alk w ith flexed knees, the use o f a gaiter or sim ilar splint on th e one leg ensures w eight-bearing and extension o f th e hip on th a t side, while on the other leg one achieves h ip extension in the inner range and knee extension in o rder to enable the gaitered leg to clear the ground. T he above m easures apply to treatm ent in cases where locom otion is aim ed for. In those cases w here h ip sur­ gery is perform ed to facilitate nursing, treatm en t includes m obilisation, but n o t necessarily exercises in weight­ bearing positions. W hen surgery is done to facilitate sitting, as in wheel­ chair cases, the program m e is followed as far as is possible; a certain am ount of pelvic stability is needed fo r sitting balance. Physiotherapy in Relation to Surgery o f the Knee F o r Pre-operative measures, see under general pre- operative requirem ents. Assess p atien ts’ disability. *8 Post-operative Stage, in plaster o f paris 1. W hether non w eight-bearing, or in w eight-bearing 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. ) 8 P H Y S I O T H E R A P Y M ARCH, 1974 casts, e m p h a sis m u st b e o n im p ro v in g pelvic stability by stre n g th e n in g th e a b d o m in a ls , e x te n so rs a n d a b d u c to rs a n d e x te rn a l ro ta to r s o f th e hips. Patients are often able to long-sit fo r the first time while in plaster after a ham string release or lengthening. T his m ay lead to excessive sitting and possible hip flexion contracture w ith w eakening of hip extensors. 2. Prone-lying should be enforced for at least h a lt a day. ,. , 3. P ostural reactions are stim ulated in standing be­ tween bars, also in assisted walking. 4. P osterior arm balance reactions and weight-bearing. 5. Back extension to correct kyphosis produced by previously tight hamstrings. F o r R e m o v a l o f Plaster — See G eneral Post-operative page. Post-operative Therapy follows the post-operative p ro ­ gram m e used while plaster casts are w orn, including the follow ing after rem oval o f plaster o f paris: (a) M obilisation, using passive, assisted active, active and resisted movem ents progressing thro u g h the developm ental sequences. In the older child knee flexion m ay be som ew hat pain­ ful. G rad u al flexion, using gravity over a pillow or over the edge of th e bed, with voluntary extension o f the knee, and prevention o f flexor spasm in the unoperated hamstrings is a safe way of ensuring m obilisation. It is im p o rtan t to get flexion, as there m ay be spasm o f the rectus fem oris, which, if not alleviated o r relaxed, rapidly leads to shortening and inability to flex the knees. F o u r-fo o t kneeling, with roller supporting under abdom en and slow rocking, allows patient to mobilise (b) Bilateral calipers are w orn initially until strength and control o f muscles aro u n d the knee is sufficient to enable only one caliper to be worn. T his is done on alternate legs u ntil it can be discarded, or a lesser splint, e.g. gaiter, can be worn. (c) N ightsplints should be used to m aintain correction o f deform ity. (d) Strengthening o f (i) hip m usculature. . . . . (ii)k n ee extensors, using sensory stim ulation, resisted exercises, first in non w eight-bearing, then in w eight-bearing positions. (e) Spasm of the rectus fem oris may be aggravated by the release of the ham strings and the wearing of long calipers. P rone lying w ith knee flexion a n d ( hip extension is useful to counteract this. As soon as the knees perm it, weight-bearing exercises are given in half-kneeling and upright-kneeling. D uring the sam e period that m obilisa­ tion and strengthening exercises are given w ith o u t cali­ pers, the follow ing is carried out while the patient is wearing calipers. (i) Standing, supported o r assisted. T his is started on the first day, (ii) Postural training, i.e. decreasing support to one hand, turning, reaching, bending etc. (iii) W alking with calipers. T he essence of post-ham string surgery treatm ent is the attainm ent of a balance between m obility o f the knee, and controlled stability o f the knee, w ithout tight q u ad ­ riceps muscles. (i) Slow stepping on and off a stool, slow getting up and sitting dow n on a low stool a re two practical hom e exercises. H yperextension o f the knee is to be avoided, or corrected. (ii) R e-education of th e ham strings is done if there is a tendency to rectus fem oris spasm , o r when laxity of knee ligaments predisposes to hyperextension of the knee. Physiotherapy: Programme following Surgery to the Ankle and F oot, with Particular Reference to: Gastro. cnemius Recession and- Tendoachilles Z-Lengthening P re-operative M easures see above fo r G eneral p re. operative aim s. In p articular: 1. Assess: (a) A ction o f th e an terio r tibial m uscle, as well as dorsiflexors o f toes. C heck w hether extensor hal- lucis longue is being used as a dorsiflexor. Assess action o f toe-flexors. (b) Balance o f eversion and inversion o f foot. (c) Strength o f active plantarflexion. (d) P resence o f Positive supporting reflex (exaggerated). (e) Presence o f W ithdraw al reflex. *9 (f) Strength and control o f hip and knee extensors. (g) Spasm o r c o n tractu re o f hip flexors, internal rota­ tors o r ham string muscles; i.e. assess m uscle balance around hip an d knee and im prove it if possible. (h) R ecord any abnorm ality o f sensation, o r size of lim bs (upper an d low er extrem ity in case o f hemi­ plegia). Post-operative period. m T his consists o f three stages: ™ 1. F irst th ree weeks in long or above-knee plaster-of- paris casts which are non-w eightbearing. 2. T h e second three weeks, a fte r rem oval o f sutures, either long o r short, below -knee casts w hich are weight­ bearing. 3. Period a fte r rem oval o f plasters. 1. D u ring this stage, th e therapist should take care th a t the m uscle balance aro u n d th e hip joints does not deteriorate, but im prove it if possible. She should note any evidence o f pain or pressure in th e plaster. 2. D u rin g the second h a lf of the w earing o f a plaster cast, th e cast m ay be above-knee in th e presence of tight ham strings o r weak quadriceps, o r it m ay be below- knee in th e absence o f th e above-nam ed. W e find it useful to start w ith an above-knee cast, w hich we cut dow n below th e knee as soon as c o n tro l of weight­ bearing is achieved, and before we rem ove th e plaster co m p letely .' T his allows time to w ork on th e knee while the foot is still im m obilised. . (a) W eight transference is taught; leg length being equalised by using tem porary raises u n d er other foot. . . . . (b) E stablish control o f knee extension, in weight-bear­ ing. R e-education o f vastus medialis in sitting with knee flexed over edge o f bed, and foot held to dorsiflexion in plaster. In addition all o ther methc#j of muscle stim ulation and strengthening are u su ’ (sensory stim ulation and resistance) as well as the use o f tem p o rary splintage. *10 A fte r R e m o v a l o f Plaster Casts (a) T endon lengthening very often has a widespread effect on the whole limb o r body, in addition to the p redictable expected localised effect. . In this way the extension-adduction p attern which is produced by an exaggerated positive supporting reaction m ay be so altered by a gastrocnem ius recession ana T endo Achilles lengthening that abduction and knee flexion becomes possible, even in weight-bearing, m some cases a child m ay start to craw l post-operatively. w hereas pre-operatively she could only creep, dragging extended legs, e.g. Case 3. ‘Joanne, at two years old, was able to assume sittint position w ith knees flexed, n o t extended due to tight ham strings. H e r arm protective reactions were very slow- She could creep, dragging extended legs, b u t could n°‘ craw l, as she h ad no dissociation of the legs. She trie» to pull u p standing, but could n o t take steps in tn parallel bars, as she h ad co-contraction o f the legs duc 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. ) IV1AART 1974 F I S I O T E R A P I E a grossly exaggerated positive supporting reaction t,irh made h e r stand with rigidly extended, adducted " “ and equinus feet Surgery perform ed: Bilateral G astrocnem ius Recession Xendo A chilles Z-lengthening. S ix m onths later J o a n n e was craw ling, enjoying rolling, sitting much better, pulling up to standing and pushing a w alker on uer own. T here has been a m arked change in her e m o t i o n a l state; from being an introverted, frustrated, unhappy infant, she has changed to an outgoing, happy y o u n g child, eager to explore aro u n d her.’ R e -education o f balance and equilibrium is therefore done, progressing through the different stages o f develop­ ment. Even where the p ostural re a c tio n s are g o o d in s ta n d i n g , the confidence gained by the child while per­ forming the basic gross m o to r activities o f rolling, sitting, kneeling and craw ling will enhance his progress in w alk­ ing- Weight-bearing an d Transference o f W eight Gastrocnemius recession and T endo A chilles Z-leng­ thening, by m echanically reducing plantarflexion and decreasing the effect o f the positive supporting reaction, !%ifts the balance of pow er to the dorsiflexors o f the ankle, thereby predisposing tow ards the to tal flexor p a t­ tern o f the low er extrem ity. To prevent post-operative ‘folding u p ’ o r collapse into flexion with failure to w eight-bear, pre- and post-opera­ tive therapy should establish control o f extension o f the hip and knee. Sensory stim ulation (icing, brushing, vibration) o f the quadriceps, follow ed by active and restricted extension, is given alternatively with w eight-bearing and assisted standing and w alking in calipers. Initially, long calipers or gaiters are used bilaterally to assist extension. As soon as possible one caliper only is used on alternate legs, to give stability on th a t side w ith increased m obility on the other. G aiters or any o ther terrjporary splints may be used. W hen control o f the knees is satisfactory, below-knee irons w ith a back-stop and T -strap where necessary (to correct valgus o r varus) is worn until dorsiflexor strength is adequate. H ere a F orest Town Boot may be used instead; this has the added advantage of stretching the long toe flexors. (a) Refusal to stand m ay be due to: (i) presence o f a w ithdraw al reflex, w hich may p re ­ viously have been m asked by the positive sup­ porting reaction. Flexion should be prevented m echanically until this is overcom e. Begin by standing u p (with hand support) from sitting and stepping up and down from a low stool, therapist m anually assisting ex­ tension. (ii) H yper-sensitivity o f sole o f foot. T he skin should be de-sensitised by brushing, hardening the skin etc. (iii) Painful heel. A child who has never walked with heelstrike m ay have no insulating layer o f thick skin and subcutaneous tissue over the calcaneous to cushion the shock o f weight­ bearing on the heel. A resilient heel-pad will overcom e this problem . (b) E stablish m u sc le -balance a r o u n d th e a n k le , m ain ly (i) increasing strength o f dorsiflexors. Initially it m ay be possible only to get active c o n ­ traction of the tibialis an terio r by facilitation of aorsiflexion in a mass p attern o f flexion (i.e. with knee and hip flexed). T his should be changed to aorsiflexion o f the ankle w ith extended knee (for heelstrike) as soon as possible. F a c ilita tio n o f c o n tra c tio n is g re a tly im p ro v e d by sensory stim u la tio n u sin g ice, b ru sh in g , v ib ra tio n , tn c tio n , fo llo w e d b y a ctiv e a n d re sisted activ e m o v e ­ ment. (ii) Prevent dorsiflexion of ankle by excessive co n ­ traction o f extensor hallucis longus; isolate action o f Tibialis an terio r by repeated contrac­ tions of an terio r tibial in inner range holding the big toe in flexion while activating dorsi­ flexion. (iii) Extension o f the toes w ith the fo o t in dorsi­ flexion to overcom e any tendency of clawing. (iv) M aintenance o f lum brical action, especially when a F orest Tow n B oot is w orn for a long time. (v) W hen dorsiflexor strength is adequate, p la n ta r­ flexion is strengthened to allow push-off in walking. (vi) B alancing the action o f th e evertors and inver­ tors of th e foot. T he above exercises are do n e w ith resistance, in modified p atterns using proprioceptive neurom uscu­ lar facilitation, and ideally also in the w eight-bear- . ing position. (c) E a rly weight-bearing, w hether supported or assisted, is very im portant, as the upright position, w ith the head vertical, and com pression o f the joints, added to the positive supporting reaction, increases exten­ sor tone and postural reflex activity. I f a child is allow ed to be no n w eight-bearing fo r too long, especially if there is a tendency to flexor hypertonus, then there is a danger th a t th e flexors of th e hip, knee and ankle m ay becom e overactive and p re­ clude m uscle-balance. C alcaneous deform ity mav result. W eight-bearing in a corrected standing position is a good way o f preventing this ‘shift’ o f spasticity. (d) G ait-training; w ith em phasis on (i) transference o f weight to equalize w eight-bear- ing. (ii) establishing trunk rotation. (iii) prevention o f hyperextension o f knee. Resisted (from behind and in front) rotational w alking is effective. S tanding and w alking progresses from the use of parallel bars to ro llato r walker, then elbow crutches or tripod sticks, w hich m ay later be discarded. (e) B alance reactions o f the feet in standing and w alk­ ing, e.g. (i) balancing on a roller, (ii) standing on one leg, using other fo o t to roll aro u n d a large ball; w ithout losing contact with the ball. References * * B obath, B., B obath, K . ‘T h e F acilitation o f N o rm al P ostural R eactions and M ovem ents in the T re a t­ m ent o f C erebral Palsy. P hysiotherapy A ugust 1964. * 2 R eynell, J. K . (1965). ‘Post-operative D isturbances observed in children w ith C erebral Palsy’. Dev. M ed. C hild N eurology, 7, 360-376. * 3 Craig, J. J. ‘T h e O rthopaedic A pproach to the T reatm en t o f C erebral Palsy. S. A frican M edical Jo u rn al 47, 1973, p. 1904. * * B leck, E. ‘M anagem ent o f H ip and K nee D efo rm i­ ties’ C erebral Palsy. C u rren t P ractice in O rth o ­ paedic Surgery. Vol. 3, p. 59. E dited by J. P. A dam s. St. Louis. T h e C. V. M osby Co. * 5 B obath, B. ‘T h e V ery E arly T reatm ent o f C ere­ b ral Palsy. Dev. M ed. & Child N eurology. Vol. 9, N o. 4, 1967. * 0 Peiper, A . ‘C erebral F un ctio n in Infancy and C hild­ h o o d .’ P itm an M edical 1963, pp. 230-236. L oco­ m otion, p. 21 1 . * 7 K n o tt, M „ Voss, D . E. (1969). ‘G ait A ctivities.’ Proprioceptive N eurom uscular Facilitation. H a rp e r & R ow Publishers, N ew Y ork City. 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. ) 10 P H Y S I O T H E R A P Y M ARCH, 1974 MAKE YOUR DAY A LITTLE EASIER! You physios are a hard-worked group, we know. In the day’s work, environment and c o m f o r t b e c o m e m o r e a n d m o r e important — and while there’s not much we can do to help fix the background in which you work, you’ll find a comfy, practical working rig in the new special- purpose uniform we’ve designed with you in mind. It’s a continental style ’dress, with Bermuda-type shorts to match. A side vent in the skirt and the generous cut, mean that you’ll work more easily, and feel comfortable right through the hard day. Your option o f short or long sleeves, in drip-dry, hard-wearing fabric. . . white or saxe blue. Sizes 3 2 to 4 2 . Elegance and efficiency . . . what more could you ask? 4 th F loor, P ritc h a rd H ouse, 8 3 P ritch ard Street, JOHANNESBURG. T elep h o n e 2 3 - 4 4 0 5 . 8 7 M a rio n A venue, G lenashley, DURBAN. T elep h o n e 8 3 - 7 2 2 6 . Fully illustrated catalogues and price lists o f our full range are available free to you. Just drop us a postcard (P.O. Box 7 5 2, Johannesburg) or telephone 2 3-4 4 0 5 any time, including nights, weekends and holidays. W ere also happy to execute phone orders, o f course. 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. ) * » B u rke E vans, E . ‘M odifications o f the H am string T ransfer.’ D evelopm ental M edicine & Child N eurology Vol. 8, Oct. 1966, p. 539-551. * » fw itc h e ll, T. B., Ehrenreich, D . L . T h e P la n ta r R e s p o n s e in In fan tile C erebral Palsy.’ D evelop­ m ental M edicine & C hild N eurology’ 1962, V ol. 4, p.602-11. *i« R o o d , M argaret. ‘P ersonal C om m unication’ 1969. Instructional Course. Johannesburg. Craig, J- J- ‘T h e C orrection of E quinus D eform ity in C erebral Palsy’. P ap er read at A nnual Congress o f A m erican A cadem y o f C erebral Palsy, W ashing­ ton, D ecem ber 1974. NOTE o n t h e f o r e s t t o w n b o o t This appliance evolved as a result of the com bined efforts o f the physiotherapy staff at F orest T ow n School, the C o n s u lta n t O rthopaedic Surgeon and the O rthopaedic T e c h n ic ia n s a t th e Jo h annesburg G eneral H ospital. The object of th e b o o t is to prevent tightening a o f the ‘*%endo A chilles and lengthening o f the dorsiflexors r̂h-ile enabling a child w ith an over-active positive sup­ porting reaction to walk. In the boot the ankle is held a t an angle of 90°, the toes are in extrem e dorsiflexion, there is n o pressure on the m etatarsal heads (th e b o o t being recessed here) and the calcaneus is well down. I\/|AART 1974 Discussion 1. The most obvious effect o f the boot is the continuous stretch produced on the triceps surae muscle group (par­ ticularly soleus) and the toe flexors producing w hat m ight be described as a lengthening reaction in these muscles. W hatever the neuro-physiological reaction, this does in fact appear to tak e place to a considerable extent. 2. The rem oval o f pressure from the m etatarsal heads was considered an im p o rtan t attribute o f the boot when it was th o u g h t th a t this area was th e optim al site o f stimulation of the positive supporting reaction. I t was subsequently th o u g h t (Tw itchell 1962) th a t the adequate stimulus fo r the positive supporting reaction was not pressure b u t proprioceptive stretch o f th e ■ p lantar muscles o r triceps surae. T his is also elim inated as the boot allows no m ovem ent at the ankle. H ow ever, we continue to use the boot recessed over the m etatarsal ^eads as we have fo u n d th a t pressure here does never- neless play some p art in increasing the activity o f the positive supporting action. 3. M ost o f the w eight is taken on the calcaneus while the boot is w orn. T here appears to be facilitation of the A nterior T ibial m uscle group. 4. T he dorsiflexors are held in inner range while the boot is w orn instead of being lengthened as happens with the fo o t in constant p la n ta r flexion. T hus activa­ tion of the dorsiflexors is m uch easier. T he b o o t is worn from infancy to prevent any lengthening o f the anterior tibials. Other C linical A dvantages 1. In a p atient w ith the typical ab d u cto r circum duction gait o f hemiplegia, the w alking p a tte rn is facilitated by the breaking u p o f to tal pattern b ro u g h t a b o u t by wearing the boot. 2. The boot serves to control the position o f the foot in the therapy when m ore proxim al p attern s are being executed. 11 3. T he boot is used b o th pre- an d post-operatively as a nig h t splint. 4. T h e b o o t is w orn p ost-operatively' w henever there is a sign o f recurrence of m uscle im balance around the ankle. T h e p atien t walks w ith a F o rest T ow n B oot fo r a few h ours every day, and needs no o ther appliances. R ecurrence rate of deform ity after surgery is therefore reduced. *11 5. T h e boot provides a plantigrade fo o t as a base, instead o f an equinus fo o t, and makes standing balance and learning to w alk m uch easier. C o m m en t T he child is usually first accustom ed to w earing the b o o t as a n ight splint. Some children d o n o t sleep through the night at first and parents have to use their discretion in lengthening the periods o f use. G enerally speaking, th e b o o t is m ost effective when used f o r w alking in. T his is also started very gradually, inspecting fo r signs o f pressure a t lengthening intervals. W hen ordered bilaterally, it m ay be advisable to get th e child used to w alking w ith one at first, w ith an ordinary boot on the other foot. H ow ever, m ost children tolerate the b oots very quickly. T h ere m ay be a tendency, initially, fo r a child to either flex o r hyperextend the knee, as the boot stretches th e spastic triceps surae. Judicious use usually overcom es this problem speedily. C hildren w ith fixed contracture cannot tolerate the b oot; and children w ith gross spasm of the triceps surae m ay n o t be able to tolerate them fo r w eight­ bearing until they have slept in them fo r a length of time. M o re stam ps fo r m ore C rip p les F o u rteen m illion colourful E aster Stam ps have been p rinted by th e N a tio n a l C ouncil fo r th e C are o f C ripples fo r its 30th annual E a ste r Stam p F u n d cam ­ paign, which will be conducted during M arch, 1974 to raise funds in aid of cripples o f all races in the R epublic and South W est A frica. T his m eans fo u r m il­ lion m ore stam ps th a n issued fo r any o f the C ouncil’s previous cam paigns. T h e stam ps will be offered fo r sale in sets o f 20 m the p o p u lar series depicting South A frica’s m aritim e his­ tory in full co lo u r and introduced in the 1973 cam paign. T his new set is available in sheets containing a single set of 2 0 stam ps o r five sets o f 2 0 stam ps and will be sold a t only one cent p e r stam p. T hey are o btainable, together w ith sheets o f interesting info rm atio n ab o u t each o f the 2 0 ships printed on the stam ps, from all C ripple C are A ssociation offices o r from T h e D irector, N atio n al C ouncil fo r the C are o f C ripples in South A frica P.O . Box 10173, Johannesburg 2000 (telephone 31-5151). F I S I O T E R A P I E 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. )