DESEMBER 1973 F I S I O T E R A P I E 5 P HYSIO THERA PY IN THE M A N A G E M E N T O F THE STABBED CHEST A n n Fairlie B.Sc. Ph ysioth erapy (W i t w a t e r s r a n d ) T h e r ol e o f p h y s i o t h e r a p y in t h e m a n a g e m e n t o f t h e surgical p a t i e n t is p l a y i n g a n e v e r i n c r e a s i n g r ol e. A short c o m p a r a t i v e s t u d y w a s c o n d u c t e d a t N o n - E u r o ­ pean H o s p i t a l , J o h a n n e s b u r g in w h i c h t w o g r o u p s o f r a n d o m l y s e l e c t e d p a t i e n t s a d m i t t e d w i t h s t a b b e d c h e s t s and h a e m o p n c u m o t l i o r a c e s w e r e s t u d i e d . T h e first g r o u p w a s m a n a g e d in t h e u s u a l m a n n e r , that is t h e p a t i e n t w a s r e s u s c i t a t e d , a n i n t e r c o s t a l d r a i n was i n s e r t e d a n d s o m e f o r m o f p h y s i o t h e r a p y w a s g i v e n the next d a y , s o m e 12 - 18 h o u r s a f t e r t h e i n t e r c o s t a l drai n h a d b e e n i n s e r t e d . / j T h e s e c o n d g r o u p w a s m a n a g e d s i mi l a r l y e x c e p t a S f n d a r d i s e d r o u t i n e o f p h y s i o t h e r a p y w a s i n s t i t u t e d I M M E D I A T E L Y a f t e r i n s e r t i o n o f t h e i n t e r c o s t a l d r a i n . T h e p a t i e n t s w e r e t h e n s t u d i e d u s i n g t h e f o l l o w i n g pa r a me t e r s . I. V i t a l o g r a p h S t u d i e s : T h e v i t a l o g r a p h is a p o r t a b l e i n s t r u m e n t d e s i g n e d f o r a s i ngl e b r e a t h t est w h i c h is g r a p h i c a l l y r e c o r d e d a n d f r o m w' hi ch p a r a m e t e r s o f v e n t i l a t o r y f u n c t i o n c a n be m e a s u r e d a n d c a l c u l a t e d . F i g u r e 1 s h o w s t he v i t a l o g r a p h in use. T h e f o l l o w i n g l u n g c a p a c i t i e s w e r e c o m p a r e d : — (a) F o r c e d V i t a l C a p a c i t y ( F V C ) . ( b) F o r c e d E x p i r a t o r y V o l u m e ( F E V ) . (c) M a x i m u m V o l u n t a r y V e n t i l a t i o n ( M V V ) . T h e s e o b s e r v a t i o n s w e r e m a d e 12 h o u r s a f t e r r e ­ m o v a l o f t h e i n t e r c o s t a l d r a i n s i n b o t h g r o u p s . 2. D u r a t i o n o f I n t e r c o s t a l D r a i n a g e . 3. D u r a t i o n o f H o s p i t a l i s a t i o n . 4. I n c i d e n c e o f T e m p e r a t u r e s . 5. R a d i o l o g i c a l R e s o l u t i o n . R e s u l t s s h o w' e d a d i s t i n c t i m p r o v e m e n t i n t he g r o u p r e c e i v i n g i m m e d i a t e e a r l y p h y s i o t h e r a p y . R E S U L T S O F S U R V E Y : 1. V i t a l o g r a p h : In o n l y t h e M V V p a r a m e t e r w a s t h e r e a s i gni f i c a nt d i f f e r e n c e b e t w e e n t h e t w o g r o u p s . I n t h e gTOup r e c e i v i n g e a r l y p h y s i o t h e r a p y t h e r e w a s a m e a n M V V o f 4 0 , 4 % o f t h e e x p e c t e d n o r m va l u e . I n t h e u n t r e a t e d g r o u p t hi s v a l u e w a s 3 1 , 8 % o f t h e e x p e c t e d n o r m . 2. D u r a t i o n o f I n t e r c o s t a l D r a i n D r a i n a g e : A v e r a g e d u r a t i o n f o r t h e t r e a t e d g r o u p w a s 1, 50 da y s . I n t h e u n t r e a t e d g r o u p d r a i n a g e d u r a t i o n w a s 2, 77 d a y s . 3. T i m e o f H o s p i t a l i s a t i o n : T r e a t e d g r o u p 2, 5 d a y s . U n t r e a t e d g r o u p 4,1 d a y s . 4. I n c i d e n c e o f T e m p e r a t u r e s : I n t h e t r e a t e d g r o u p , 2 o u t o f t h e 12 p a t i e n t s d e ­ v e l o p e d t e m p e r a t u r e s i n e x c e s s o f 9 9 ° F . I n b o t h t h e s e e a s e s t h e p y r e x i a l a s t e d l ess t h a n 8 h o u r s . I n t h e u n t r e a t e d g r o u p , 8 o u t o f t h e 9 p a t i e n t s d e ­ v e l o p e d t e m p e r a t u r e s i n e x c e s s o f 9 9 ° F . 5. R a d i o l o g i c a l R e s o l u t i o n : I n t h e u n t r e a t e d g r o u p , 2 p a t i e n t s d e v e l o p e d r a d i o - l o g i c a l l y c o n f i r m e d p n e u m o n i c c o n s o l i d a t i o n . A s a m e a n s o f c o m p a r i s o n , r a d i o l o g i c a l r e s o l u t i o n d i d n o t p r o v e t o b e a r e l i a b l e p a r a m e t e r a s c e r t a i n c r i t e r i a a r e l ai d d o w n b e f o r e d i s c h a r g e o f t h e p a t i e n t m a y o c c u r . O n e o f t h e s e c r i t e r i a is a d e q u a t e r a d i o l o g i c a l r e s o l u t i o n o f t h e h a e m o - p n e u m o t h o r a x . T h e s e r e s u l t s c l e a r l y s h o w b e n e f i t i n t h o s e p a t i e n t s t r e a t e d b y e a r l y p h y s i o t h e r a p y , a n d s u g g e s t t h a t a s u r g i c a l u n i t m a n a g i n g t hi s t y p e o f i n j u r y s h o u l d h a v e a r e s i d e n t P h y s i o t h e r a p i s t a t al l t i me s . T h e a i m s o f t h e P h y s i o t h e r a p y a n d t h e p r o g r a m m e u s e d is set o u t b e l o w. THE FORMAT OF PHYSIOTHERAPY WAS STANDARDISED AND THE FOLLOWING AIMS AND METHODS WERE USED: 1. P H Y S IO T H E R A P Y T O IN C R E A S E IN T R A ­ P L E U R A L P R E S S U R E : (i) T h e n o r m a l i n t r a - p l e u r a l p r e s s u r e is s l i ght l y n e g a t i v e . A n y f o r m o f v a l s a l v a m a n o e u v r e w o u l d t e n d t o i n c r e a s e t h i s i n t r a - p l e u r a l p r e s - 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 DECEMBER, 1 9 7 3 THE p r e s e n t s - M i n i d y n e m k III TRANSISTORISED FARADIC U N IT i Representing another advance in the evolution of the Minidyne, the M ark III version incorporates printed circuits which reduce the size but also enhance the reliability; continuing features are wide range of surge speed control with output sufficient for all forms of faradic techniques audible as well as visual indication of surge speed enabling the operator to anticipate a muscle reaction without having to watch the control panel fitted with Ever Ready PP9 batteries which will give up to six months' use without replacement and are obtainable worldwide W E IG H T reduced to: 4 lbs. (1,8 kg) SIZE reduced to 8" x 5-J" x 2 \ " (2 0 c m x 13,5 cm x 6 cm ). PRICE: R87,50 complete with accessories. M E D I C A L D I S T R I B U T O R S "S™* 'C APE Y O R K ’ I 252 JEPPE ST. | JO HANNESBURG | D e W aal House, 172 V ic to ria Road | W oodstock, C.P PLEASE ADDR ESS ALL CO RRESPONDENCE TO P .O . BOX R IG ASSEBLIEF ALLE KO RRESPONDENSIE A A N POSBUS 3378 JOHANNESBURG TEL. A D D . 'D IS M E D ' PHONE | FOON 23-8106 TELEX: 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. ) sure an d this increased in tra-p leu ral pressure would obviously facilitate drainage o f an y o f the abn orm al contents in the intra-pleural space resulting fro m a stab w ound. T his facilitated drainage w ould n atu rally occur thro u g h the intercostal drain. An ideal m ethod to increase intra-pleural pres­ sure had to be fo u n d w hich was simple, w ould occupy th e p a tie n t’s atten tio n and co n cen tra­ tion an d thereby distract his atten tio n from any resulting pain. In this study th e patients w ere asked to blow up a n u m b er o f coloured balloons. T h eir attention was focused on the colours and d e ­ grees o f difficulty th a t each b allo o n ’s difference represented. T hey w ere often set th e challenge o f inflating a large num ber of balloons. This simple m anoeuvre fulfilled th e above cri­ teria adm irably an d large quantities o f a ir an d blood w ere noted to d rain during this procedure which basically is a sim ply modified val salva m anoeuvre. A s soon as full drainage fro m the intra-pleural space had occurred full lung expansion becam e possible an d was facilitated by th e following exercises. (ii) G eneral deep breathing exercises are done in order to achieve m axim um inspiration an d ex­ piration. T h e p atien t is instructed to blow a t a tissue or coloured stream ers as h ard an d as long as possible. A fte r every blow the tissue can be m oved fu rth e r aw ay fro m th e patient so that his breath m ay reach th e tissue. This increases th e intra-pleural pressure thereby facilitating drainage and expansion o f the lung. U nilateral an d p o sterio r basal breathing exer­ cises to th e affected side and b ilateral lateral costal breathing exercises are taught to the patient w ith a good explanation as to w hy he must use th a t side. By concentrating on the affected side, th e p atien t will then be ab le to assist in re-expanding this collapsed area. (iii) Coughing is interspersed regularly betw een the exercises. T h e p atien t is ta u g h t to cough, i.e. right from th e b ottom o f his chest an d n o t just to m ake noises in his th ro a t and to expectorate any secretions if present. T his increases th e intra-pleural pressure and aids drainage as well as getting rid o f an y secretions th a t m ay be present in th e lungs and bronchial tree. 2. PH Y SIO T H E R A PY T O F A C IL IT A T E D R A IN A G E: Trunk exercises have a n u m b er o f beneficial effects:— (a) By tru n k m otivation the p atien t twists from side to side and in doing so the p atien t ex­ pands and contracts each hem ithorax a lte r­ nately. T his m anoeuvre assists re-expansion and thus th e expanding lung forces out in tra ­ pleural fluid, i.e. drainage is facilitated. (b) T runk exercises are also associated w ith gross alterations in p o stu re and these are achieved by a few sim ple exercises which follow. Changes in posture tend to m ove th e in tra ­ pleural contents tow ards th e site o f th e drain. Exercises Used: Sitting; A rm s bend, opposite elbow to touch . opposite knee w ith tru n k rotation. Sitting; A rm s a t sides, tru n k flexion to both sides so th a t han d touches floor on th a t side. pES EM B ER 1973 Sitting; A rm s reach, loose arm and tru n k swing­ ing fro m side to side. S tanding A rm s to stretch position then bend dow n a n d /o r to touch floor w ith hands, keeping the Sitting; knees straight and back up again to ex­ tension position w ith arm s to stretch position. Standing; A rm s y ard ; bend a n d touch left foot w ith rig h t h an d then up to starting position. R epeat — touch rig h t fo o t w ith left hand. T h ere are m any m ore variations o f tru n k exer­ cises but it is best to keep to a few sim ple exercises w hich can be m astered w ithout m uch difficulty by th e N on-E uropean. T here are m any o th e r reasons fo r keeping to the som e ro u tin e exercises. T hese patients are n o t in hospital fo r a long p erio d so they do not have time to get bored w ith the sam e exercises th an variations which they find difficult to m aster. I t is also essential th at they do these exercises correctly in order to fulfill th e above aim and th e re ­ fo re a large am o u n t o f valuable time especially in th e im m ediate treatm ents w ould be w asted in c o r­ recting a large variety o f exercises. 3. P H Y S IO T H E R A P Y T O P R E V E N T A C C U M U L A ­ T IO N O F S E C R E T IO N S I N L U N G S : C oughing an d breathing exercises a re done in o rder th a t'th is aim m ay be fulfilled an d these exer­ cises have already been described in M eth o d l(ii) an d (iii). I f a large am o u n t o f secretions have accum ulated in th e lungs and bronchial tree p o stu ral drainage should be done. 4. P H Y S IO T H E R A P Y T O IN C R E A S E L U N G P E R F U S IO N : Strongly m otivated general body exercises such as running on the spot, jum ping to stride position an d back again fro m the standing position, and squats (i.e. knees bend to full flexion an d then extension), increase the resp irato ry rate, the pulse ra te an d the ventilatory m inute volum es. These exercises should be done until the pulse is ap p ro x i­ m ately 140 beats per m inute, an d this increases lung perfusion an d ventilation. B oth these factors tend to decrease the existing atelectasis an d facilitate resolution. P urely on a prophylactic basis atelectasis is also prevented. T h e m ovem ent o f the body moves th e fluid in ­ side the chest a ro u n d and drainage is also assisted. I f the p atien t is unw illing to do m any o f these above agility exercises it is necessary fo r th e Physio­ therapist to carry the drip, an d the p a tie n t to carry the underw ater drainage bottle. T he p a tie n t should then be m arched up and dow n the w ard a t a fast pace. 5. P H Y SIO T H E R A PY T O P R E V E N T P O S T U R A L D E F O R M IT IE S : T h e p o stu re o f the p atien t is corrected, if neces­ sary, in sitting an d standing. T h e usual deform ity ad o p ted is a high shoulder on the affected side which is corrected by instructing the p atien t to push th a t arm tow ards the ground and splinting o f the arm and chest w all is corrected w ith special arm and shoulder exercises plus the tru n k exercises w ith associated arm m ovem ents as already m entioned. W henever correcting posture the ideal m eth o d is fo r th ere to be a m irro r in fro n t o f th e p a tie n t so th a t he m ay see his deform ity and so be able to c orrect it. 7F 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. ) 8 P H Y S I O T H E R A P Y DECEM BER, 1 9 7 3 MARE YOUR DAY A LITTLE EASIER! 4 t h F l o o r , P r i t c h a r d H o u s e , 83 P r i t c h a r d St reet , J O H A N N E S B U R G . T e l e p h o n e 2 3 - 4 4 0 5 '. 87 M a r i o n A v e n u e , G l e n a s h l e y , D U R B A N . T e l e p h o n e 8 3 - 7 2 2 6 . F u lly illustrated catalogues and price lists o f o ur full range are available free to you. Just drop us a postcard (P.O. B o x 75-2, Joh an nesb urg) or telephone 2 3 -4 4 0 5 ' any time, in clu d in g nights, weekends and holidays. W e ’re also happy to execute p h o n e orders, o f course. Y o u p h y sios are a hard-worked group, we know. In the d a y ’s work, environm en t 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 w hile there’s not much we can do to help fix the backgroun d in w hich y o u work, y o u ’ll find a com fy, practical w o rk in g rig in the new special- purpose u n ifo rm w e ’ve designed with you in mind. It’s a continental style dress, with Berm uda-type shorts to match. A side , vent in the skirt and the generous cut, mean that y o u ’ ll w ork m o re 1 easily, and feel com fo rtab le right through the hard day. Y o u r o p tio n o f short or long sleeves, in drip -dry, hard-wearing fabric . . . white or saxe blue. Sizes 3 2 to 42 . Elegance and efficiency . . . what m o re c ou ld y o u ask? 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. ) p E S E M B E R 1973 F I S I O T E R A P I E 9 A r m a n d s h o u l d e r e xe r c i s e s b e i n g : - - Si t t i ng; A r m s b e n d , e l b o w ci r cl i ng. Si t t i ng; H a n d s c l a s p e d in f r o n t , s t r e a c h u p a b o v e h e a d t h e n p u t h a n d s b e h i n d n e c k k e e p i n g e l b o w s wel l b a c k (so e x t e r n a l r o t a t i o n a t t h e s h o u l d e r j o i n t o c c u r s ) t o u p a b o v e h e a d a g a i n a n d d o w n . M o r e e m p h a s i s is l a i d in t h e l a t e r t r e a t m e n t s o n the c o r r e c t i o n o f a n y p o s t u r a l d e f o r m i t y t h a t m a y h a v e o c c u r r e d , b u t t h e s e s h o u l d n o t r e s u l t if a d e ­ q u a t e l y c o r r e c t e d i n t he e a r l y t r e a t m e n t s . N O T E : (I) M o s t o f t h e p a t i e n t s a r e u n d e r t he i n f l u e n c e of a l c o h o l w h e n a d m i t t e d a n d so t h e P h y s i o ­ t h e r a p i s t h a s t o use e v e r y m e a n s o f g e t t i n g t he p a t i e n t s full a t t e n t i o n a n d c o - o p e r a t i o n w h i c h pl a y s so i m p o r t a n t a p a r t in t he e f f e c t i ve ne s s o f t he t r e a t m e n t . T h e P h y s i o t h e r a p i s t m u s t h a v e a r a t h e r a g g r e s s i v e a p p r o a c h in o r d e r to fulfill t h e a i m s o f h e r t r e a t m e n t . T h e s e p a t i e n t s a r e u s u a l l y y o u n g a n d a r e fit e n o u g h e v e n a f t e r t hi s t r a u m a t i c i n j u r y t o b e p u s h e d t o t h e i r m a x i m u m . (2) A l t h o u g h t he p a t i e n t s a r e e n c u m b e r e d w i t h a d r i p ( w h i c h is a l w a y s o n a m o b i l e d r i p s t a n d ) a n d a n u n d e r w a t e r d r a i n a g e b o t t l e , t hi s is n o r e a s o n f o r t h e p a t i e n t n o t t o b e o u t o f b e d a n d b e i n g a b l e t o p e r f o r m t h e r o u t i n e s e t o u t b e l o w q u i t e a d e q u a t e l y . It is o n l y n e c e s s a r y t h a t t he p a t i e n t r e a l i s e s t h a t at al l t i me s d u r i n g t h e t r e a t m e n t h e m u s t be wi t h i n a s a f e d i s t a n c e f r o m t h e d r i p s t a n d a n d b o t t l e i n o r d e r t h a t h e d o e s n o t pul l t h e d r i p or d r a i n o u t a n d a l s o t h a t h e d o e s n o t fall o v e r t h e d r i p s t a n d o r b o t t l e d u r i n g hi s a c t i v e exc r c i s c s . T h e s e p a t i e n t s a d a p t v e r y q u i c k l y t o t h e c i r c u m s t a n c e s a n d n o p r o b l e m s a r e n o r m a l l y e n c o u n t e r e d . F i g u r e 2. S h o w s p a t i e n t w i t h m o b i l e d r i p s t a n d a n d u n d e r w a t e r d r a i n b o t t l e w i t h c a r r y ­ i ng s t r a p . S P E C IF IC R O U T IN E A D O PTED F O R E A C H P A T IE N T IN T R E A T E D G R O U P T h e first t r e a t m e n t l ast s o n e h a l f h o u r ( i h o u r ) w h i c h is f o l l o w e d by a h a l f h o u r rest a n d t h e n f o l l o w e d b y a f u r t h e r h a l f h o u r t r e a t m e n t . T A B L E O F E X E R C I S E S : ( In o r d e r a s gi ven) . 1. Si t t i n g ; U n i l a t e r a l l a t e r a l c o s t a l b r e a t h i n g , p o s ­ t e r i o r b a s a l b r e a t h i n g ( u n i l a t e r a l ) , b i ­ l a t e r a l l a t e r a l c o s t a l b r e a t h i n g . 2. Si t t i ng; C o r r e c t a n y p o s t u r a l d e f o r m i t y p r e s e n t . 3. S i t t i n g ; S t r e t c h a r m s a b o v e h e a d c o m b i n e d w i t h i n s p i r a t i o n a n d t h e n b e n d t r u n k f o r w a r d s a n d t o u c h t h e f l oor w i t h b o t h h a n d s c o m ­ b i n e d wi t h e x p i r a t i o n — x 15. 4. S i t t i n g ; A r m s a t si des, s i d e f l e xi on o f t r u n k t o b o t h s i des so t h a t h a n d t o u c h e s f l o o r o n t h a t s i de — x 8 t o e a c h si de. 5. Si t t i n g ; A r m s b e n d , r i ght e l b o w m o v e s t o t o u c h l eft k n e e a n d t h e n v i c e v e r s a — x 16. 6 . S t a n d i n g ; R u n n i n g o n t h e s p o t w i t h k n e e s u p h i g h a n d a f a s t t e m p o — f o r ± 2 m i n u t e s . 7. S t a n d i n g ; J u m p i n g t o f e e t a s t r i d e p o s i t i o n a n d t h e n t o g e t h e r a g a i n w i t h a r m s c l a p p i n g a b o v e h e a d a n d t h e n d o w n a t s i de s f o r ± 2 mi n u t e s . 8. Si t t i n g ; C o u g h i n g , 9. S t a n d i n g ; A r m s s t r e t c h a b o v e h e a d , i n s p i r a t i o n a n d t h e n t r u n k f l exi on s o t h a t h a n d s t o u c h t h e f l o o r wh i l s t p a t i e n t e x h a l e s — x 1 0 . 10. Si t t i ng; B l o w i n g u p a p p r o x i m a t e l y 6 b a l l o o n s . 11. Si t t i ng: H a n d s c l a s p e d i n f r o n t , s t r e t c h u p a b o v e h e a d t h e n p u t h a n d s b e h i n d n e c k k e e p i n g e l b o w s we l l b a c k t o u p a b o v e h e a d a g a i n a n d d o w n — x 8. 12. S i t t i n g : C o u g h i n g . 13. Si t t i n g ; D e e p b r e a t h i n g — b l o w i n g a t t i s sues/ s t r e a m e r s m o v i n g t h e m f u r t h e r a w a y e a c h t i me s o t h a t i t is n e c e s s a r y t o b l o w h a r d e r e a c h t i m e — x 8. 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. ) 1 0 P H Y S I O T H E R A P Y DECEMBER, 1 9 ? 3 14. Standing; R unning on the sp o t for 2 minutes. 15. Standing; Squats, i.e. knees ben d to full flexion and then extension — x 15. 16. Jum ping; (Same as exercise 7) fo r 2 m inutes. 17. Standing; F eet astride; arm s y ard , bend an d touch right fo o t w ith left arm an d then return to starting position an d vice versa, i.e. le ft arm to touch rig h t fo o t — x 16. 18. Sitting; C oughing. 19. Sitting; A rm s reach — loose arm an d tru n k swing­ ing. 20. Blowing up 6 balloons. . T h e p atien t is then p u t back to bed fo r a h a lf h o u r rest. T his is follow ed by a second treatm en t of exactly th e sam e as the first treatm ent, i.e. th e above tab le o f exercises. T he th ird treatm en t is given th e follow ing m orning (i.e. ± 12 — 18 h o u rs later) an d consists o f th e above routine, except they are done m ore vigorously, and p erform ed m o re times a t a faster tem po. A t this stage, the patients w ith intercostal drains are treated together, in a class. T h e treatm ents are continued twice daily until the dis­ charge of the patient. S U M M A R Y : R eference has been m ade to a sh o rt survey whi h com pared tw o groups o f patients adm itted to hosnit i w ith stabbed chests. T h e results of this survey indicate,! a beneficial result in those patients receiving eari physiotherapy. T h e aim s of the physiotherapy and ̂ suggested fo rm at is presented fo r use in patients win! stabbed chests com plicated b y haem opneum othoraces R E F E R E N C E S 1. J. M . H A Y S E G R E G S O N . “T reatm en t o f p ene. trating W ounds of the C hest.” 2. J. C L A R K . P ersonal com m unication— as a survev on Stabbed C hests lost. 3. H . D . A D A M S . 1961 Surg. Clin. N . A m er. 41 619 4. A . S T E IN . 1965 S.A. M ed. Jour. 24 548. 5. G. R . C R A W S H O W . 1952 S. A. M ed. Jour. 26 499 6. G U Y T O N . T extbook o f Physiology. , 7. L A S T . A natom y - R egional and A pplied. I 8. R A B I N O W I T Z . Review o f 304 cases 1972 Surgical Congress Paper. 9. A S T E IN . 1967 Jo u rn al o f T raum a. 10. G ra n t’s M ethod o f A natom y — 8th E dition. 11. G ra n t’s A tlas o f A natom y. P O ST G RA D U A TE C O U R SE M A N IP U L A T IO N O F T H E S P IN E , 1974 A ustralian Physiotherapy Association T h e n ex t twelve-week full-tim e course will be conducted in A delaide from Septem ber 30 to D ecem ber 21, 1974 if sufficient suitable applications a re received. T his course has been carefully designed to provide an advanced training in m anipulative techniques and their application in treatm ent. L ectures covering anatom y, physiology, pathology, radiology, and exam ination procedures will be given by com petent m edical lecturers. Techniques and clinical application will bf ta u g h t an d supervised by physiotherapists and a physical medicine specialist. T h e course is open to all m em bers of IV South A frican P hysiotherapy A ssociation bu t preference will be given to those w ho have had m ore th a n one year of experience. Participants will be expected to sit fo r exam inations at the com pletion o f the course. C ost fo r each success­ ful applicant will be SA650. Prospectus and application form s are available from : T h e C ourse Secretary, A u stralian P hysiotherapy Association (South A ustralian B ranch) Inc., 175 W ard Street, N o rth A delaide, South A ustralia, 5006. C om pleted application form s w ith enclosures m ust reach the Secretary by M ay 11, 1974. 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. )