TH E USE OF ENTONOX IN CONJUNCTION WITH T H E P H Y S IO T H E R A P Y T R E A T M E N T OF BURNS M . J. R unnalls, Dipl, in P h ysio th e ra p y , C .T .P . ( Cape Town) S e n io r L ecturer a n d H e a d , D epartm ent o f P h ysio th e ra p y , U niversity o f Stellenbosch, P h ysiotherapist, K a rl B rem er H o spital, B ellville a n d M . W. S tephan, B .Sc. in P hysio­ therapy (S te ll.) Ju n io r L ecturer, U niversity o f Stellenbosch, P hysiotherapist, K a rl B rem er H o sp ita l, B ellville. Page 12 P H Y S I O Introduction Every physi ot her ap ist is well a w a r e of the pr obl em s that occur whe n tr e a ti n g patie nts with bur ns. O n the on e ha n d pati en ts experience t r e m e n d o u s psychological tr a u m a d u r i n g the painful pr oc edu re s necessary to m ai n ta in the ra ng e of m o ve m e n t o f all the affected j oi nt s a n d to prevent the f or m at io n o f c o nt r a ct ur e s, bu t on the o t h e r ha nd it is no easy task for any p h ysi ot her ap ist to pe r fo r m active- assisted m o v em e nt s when she kn ow s full well th a t the patient will certainly hav e to experience a fair a m o u n t o f pain. In an a t t e m p t to ov e rc om e the pain ele ment involved d u r in g ph y si o th er a py tr ea tm e n t, E n t o n o x , a relatively haza rd- fr ee medical gas was admi ni ste re d. Bot h the ra nge o f m o v e m e n t , 1 a n d the d u r a ti o n o f the time in sec onds taken to p e rfo rm the required m ov em e nt impr ove d. As no special bu r n s unit exists, all pati en ts with bu rn s were tr eat ed with the closed tec h n iq ue in a general surgical ward. M ethod A r a n d o m selection of 24 pati en ts was s u b m itt e d to testing. T h e testing was d o n e every a f t e r n o o n over a period of three days, the pa tients ha vin g alr ead y received the classical, prescribed ph ys io th er a p y tr e a tm e n ts in the mornings. T h e ra nge of m o ve m e n t a nd the time in sec onds take n by th e patient to move t h ro u g h the v a rio us affected ranges were not ed. On the first day of the testing series no gas was admin istere d. O n the second da y medical 0 2 was a d m i n i s ­ tered t h r o u g h a m o ut h pi e ce a n d the s a m e valve as the E n t o n o x a p p a r a tu s . Finally on the third d a y E n t o n o x was a dm in ist ere d t h r o u g h a m ou thp ie ce. Mo u th pi ec es were used in preference to face m asks to eli minat e fu r th er infection a nd also disc om for t where the face itself was bu rnt . T h e patie nts were in fo rm e d th a t the pu r p o se o f the a dm i n i st r a t i o n of the va rio us medical gases was merely to ascertain which gas w ou ld en ab le t h em to p e rf or m the required m o ve m e nt to the best of their ability. At no time was a ny m ent io n m a d e o f the pa in relieving element. T h e patie nts held the m ou thp ie ces themselves d u r i n g the a dm in i st r at i o n o f the E n to n o x . In this way it was ens ur ed th at a d m i n i st r a t i o n of the gas ceased sh o u l d the patient lose c ons ciousness as the m o ut h pi e ce w oul d then be released au tom ati cal ly. E ach patient was in structe d to inhale fully for 12-20 breaths. T h e r e u p o n the patie nts were requ ired to d o the m o v em e nt s to the best o f their ability w i t h o u t assistance. T he total range of m o v em e n t a n d the time take n to perform this m ov em en t were noted. H E R A P Y JUNE, 197' ANALYSIS OF CASES DATA t-test Results t P N o gas vs Medical 0 2 M o ve m en t 0,02 > 0 , 0 5 Tim e 0,6631 > 0 , 0 5 N o gas vs M ov em en t 3,2 0,01 > p > 0 ,0 0 1 * E n to n o x Time 2,8 0,01 > p > 0 , 0 0 l t E n t o n o x vs Medical 0 2 M o ve m en t 4,09 0,001 p t T im e 2,44 0, 011 MEANS M o ve m en t Time N o gas 54,425 22,40 Medical 0 2 54,700 28,85 E n to n o x 67,125 16,90 * = Significant, t = Very significant, t Highly significant. P a tie n t using the E n to n o x a p p ara tu 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. ) JUNE, 1973 P H Y S I O T H E R A P Y Page 13 R E S U L T S P a tie n t Age Sex R a c e J o in t M o v e m en t R a n g e o f M o v e m en t in ° T im e in seco n d s B efore M e d . 0 2 E n to n o x B efore M e d . 0 2 E n to n o x N .M . 24 F N .E . W rist F le x io n to ex te n sio n 39° 30° 45° 2 0 " 2 0 " 2 0 " I.S. 32 F N .E . S h o u ld e r A b d u c tio n 60° 56° 60° 2 2 " 2 2 " 16" E lb o w F le x io n to ex te n sio n 35° 36° 40° 38" 41" 27" J.F . 28 F N .E . H ip F le x io n to ex te n sio n 57° 5 7 = 48° 17" 17" 17" A b d u c tio n 36° ' 30° 46° 8 " 1 0 " 13" M .O . 24 F N .E . E lb o w F le x io n to ex te n sio n 1 1 2 ° 114° 104° 13" 23" 9" S h o u ld e r A b d u c tio n 55° 48° 40° 17" 18" 1 1 " J.T. 32 F N .E . K n e e F le x io n to ex te n sio n 9 3 = 92° 5 9 = 1 2 " 19" 14" ■®!.T. 42 F N .E . S h o u ld e r A b d u c tio n 40° 30° 65° 39" 23" 51" E lb o w F le x io n to ex te n sio n 23° 17° 26° 52" 56" 23" W rist F le x io n to ex te n sio n 2 0 ° 25° 28° 45" 31" 17" M .M . 34 F N .E . E lb o w F le x io n t o ex te n sio n 23° 47° 69° 15" 29" 36" W rist F le x io n to ex te n sio n 37° 31° 65° 17" 27" 2 2 " N .M . 29 F N .E . S h o u ld e r A b d u c tio n 73° 6 6 ° 75° 1 0 " 7" 14" A.N. 13 F N .E . K n e e F le x io n to ex te n sio n 81° 4 7 ° 72° 35" 2 2 " 2 2 " H ip F le x io n to ex te n sio n 4 3 = 16° 48° 27" 2 1 " 26" A b d u c tio n 1 0 ° 1 0 ° 30° 2 1 " 18" 2 1 " K .J. 4 F N .E . E lb o w F le x io n t o ex te n sio n 85° 91° 3 7 = 1 1 " 52" 24" S.J. 3 F N .E . E lb o w F le x io n to ex te n sio n 114° 114° 1 1 1 ° 41" 6 " 6 " C.P. 5 M N .E . E lb o w F le x io n to ex te n sio n 2 0 ° 15° 25° 15" 2 0 " 17" J.C. 18 M N .E . W rist F le x io n to E x te n sio n 50° 72° 116° 17" 8 " 9" H ip F le x io n t o ex te n sio n 7 3 = 63° 80° 13" 2 2 " 1 0 " E lb o w F le x io n to ex te n sio n 113° 123° 135° 18" 1 1 " 6 " N .K . 2 2 M N .E . W rist F le x io n t o ex te n sio n 1 0 ° 1 0 ° 38° 17" 2 2 " 1 2 " E lb o w F le x io n t o ex te n sio n 1 2 ° 26° 55° 37" 2 0 " 25" P.K . 42 M N .E . K n e e E x te n sio n t o flexion OO O o OOoo 94° 57" 48" 31" *P.K . 1 1 M N .E . E lb o w F le x io n to ex te n sio n 42° 75° 90° 1 1 " 1 1 " 1 0 " W rist F le x io n to ex te n sio n 1 7 = 36° 38° 2 1 " 26" 1 2 " M.W . 31 M N .E . E lb o w F le x io n to ex te n sio n 79° Oo0 0 1 0 1 ° 1 2 " 9" 9" W .R. 1 2 M N .E . H ip F le x io n to ex te n sio n 65° 73° 90° 55" 17" 1 1 " A b d u c tio n 1 0 ° 1 1 ° 26° 14" 15" 6 " D.A. 33 M N .E . S h o u ld e r A b d u c tio n 46° 45° 48° 1 2 " 1 2 " 16" E lb o w F le x io n to .e x te n sio n 65° 64° 73° 15" 13" 9" D.B. 42 M N .E . S h o u ld e r A b d u c tio n 54° 46° 51° .17" 27" 18" H .J. 13 M N .E . W rist F le x io n to ex te n sio n 54° O o 95° 15" 13" 2 2 " S.S. 43 M N .E . Shoulder- A b d u c tio n 34° 37° 42° 23" -29" 23" E lb o w F le x io n t o ex te n sio n 60° 55° 6 6 ° 17" 17" 19" H .A . 52 F E. W rist F le x io n t o ex te n sio n • 73° 85° 105° 16" 13" 7" E lb o w F le x io n t o ex te n sio n 69° 1 0 2 ° 119° 2 2 " 1 0 " 8 " J.L. 28 M E. W rist F le x io n t o ex te n sio n 115° 8 6 ° 129° 7" 9" 7" R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) Page 14 P H Y S I O T H E R A P Y JUNE, 1973 \ / It costs you LESS to insure through your Own Association Association COLONIAL A MUTUAL J.?, £he T™ ste e s, S.A. S O C IE T Y O F P H Y S IO T H E R A P IS T S, Group Endowm ent Fund, P.O. Box 1194, Johannesburg. Without obligation, please tell me how I can obtain M A X IM U M protection at M I N I M U M cost— p lus valuable disa b ility benefits— by insuring through my own A ssociation Group Endowment Fund. N A M E ______________________________________ ________________ __________ _________________________ A D D R E S S ___________________________________________________________________ ____ __________ A ge next Birthday ____________________________ Occupation ............... ........ .................. ........ .............................. . Where employed --------------------------------------------------- ----------------------- How much can you afford to pay each month w a y o S M S e Growth w it h Security S a w an d nmvest wsftln the SOUTH A FR IC A N I M P E R M A N E N T B M p tlH D IN G SO C IETY G ra n t 2467/3 A. C. MILLER & CO. ORTHOPAEDIC MECHANICIANS • Technicians registered with S.A. Medical and Dental Council specialising in the following: O R T H O P AED IC A P P L IA N C ES, S U R G IC A L C O R SET S, C E R V IC A L C O LLAR S, C H IL D R E N 'S S H O E S A N D BOOTS, A R T IF IC IA L LIM BS, LA T E ST IN P LA STIC M O D IFICA TIO N . H IRING A N D SELLIN G OF H O SP IT A L EQUIP­ M E N T A N D S IC K R O O M REQ U ISIT ES, e.g. W H EEL C H A IR S, C O M M O D E S , H O SP IT A L BEDS, W A L K IN G A ID S , T R A C T IO N A P P A R A T U S , etc. 9 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. ) JUNE, 1973 P H Y S I O T H E R A P Y Page 15 Discussion From the above analysis it is clearly demonstrated that when Entonox was used (1) the further increase in the range of movement was highly significant and (2) the decrease in the time taken to perform each movement was very significant. I t can be seen that when no gas and medical 0 2 were used there was no difference in the measurable quantites. As regards the means it is evident that there is virtually no difference between the values of the use of no gas and medical Oa whereas there is an appreciable difference o f the values when Entonox is used. F inally in th is stu d y it w as n o tic e d th a t c e rta in p a tie n ts even a lth o u g h th e ir re ad in g s w ere n o t as g o o d , w ere definitely m o re e n th u sia stic in p e rfo rm in g th e ir m ovem ents, a p p a re n tly d u e to less p a in . T o ta l analg esia is n o t alw ays experienced especially in th e case o f p a tie n ts w ith h igh alcohol c o n su m p tio n . T hese p a tie n ts , how ev er, a lth o u g h they still experience p a in seem to re a c t m o re fa v o u ra b ly to p h y sio th era p y tre a tm e n t a id e d b y E n to n o x . A subjective co n clu sio n w as e v id e n t fro m m a n y o f these p atien ts w h o v o lu n te e re d th a t tre a tm e n t w as m u ch m o re c o m fo rtab le w hen E n to n o x w as a d m in istere d . Conclusion F ro m th e re su lts o b ta in e d it seem s c lear th a t E n to n o x h as a role to play in relieving th e p a in ele m en t d u rin g p h y sio ­ th era p y tre a tm e n t to m a in ta in j o in t ra n g e a n d p re v en t c o n tra c tu re s in th e p a tie n t suffering fro m b u rn s a n d e n ab lin g their re h a b ilita tio n to be m o re p lea sa n t. References 1 J o in t M o tio n , M e th o d o f M e a su rin g a n d R e co rd in g , A m erican A c ad e m y o f O rth o p a e d ic S urgeons, 1965. A C K N O W L E D G E M E N T S 1. P rof. P . A . Foster, M .B ., C h.B. ( Cape Town), F .F .A ., R .C .S .I ., D .A . (D ublin), D .A . (London) a n d D r. J . F. C oetzee, B .S c ., M .B ., Ch.B. (U niv. S tell.) D epartm ent o f A naesthesia, U niversity o f Stellenbosch a nd K a rl B rem er- H o spital, Bellville. 2. P rof. J. J. W . van Z y l, M .B ., C h.B ., (Cape Town), M .D . (S tell.), F .R .C .S . (E din.), D ep a rtm e n t o f Surgery, U niversity o f Stellenbosch a n d K a rl B rem er H o sp ita l, Bellville. 3. J. F. C oetzee, B .S c ., M .B ., C h.B . (Univ. S tell.) D epart­ m e n t o f A naesthesia, K a rl B re m er H o sp ita l, Bellville. 4. The D e partm ent o f M e id c a l Com puting, H o sp ita l Services, Cape P rovincial A dm inistration. 5. M rs . U. Soetem ann, P hysiotherapist, Tygerberg H ospital, Tiervlei. O psom m ing D ie g e b ru ik v a n E n to n o x , ’n re la tie w e veilige m ediese gas, w a t die verm o e h e t o m py n te verlig, tesam e m et die fisio terap eu tiese b e h a n d e lin g van b ra n d w o n d e , is b espreek. F isio te ra p e u tie se b e h an d e lin g s o n d e r enige m ediese gas, m et m ediese O s en m et E n to n o x is gegee. D ie o m v an g van bew eging is gem eet sow el as die ty d in sekondes w a arty d e n s bew eging uitg e v o e r is, is geneem . D ie lesings is statistics vergelyk en d u i a a n ’n v e rd ere v e rb eterin g in die o m v an g v a n bew eging sow el as ’n a fn am e in tyd geneem o m die bew eging u it te voer. U it die re s u lta te verk ry , blyk d it du id elik d a t E n to n o x ’n ro l h e t in die verligting v a n die pyn e le m en t g e d u ren d e die fisioterapeutiese b e h a n d e lin g om gew rigsom vang te b e h o u en o m k o n tra k tu re te v o o rk o m v a n die p a sien t w at b r a n d ­ w o n d e h e t en om h u lle re h ab ilitasie te vergem aklik. P h s io th e ra p y services a t th e S.A. G am es T o com p le te th e M edical Services p ro v id ed a t th e G am es, th e N o rth e rn T ra n s v a a l B ra n c h w as a p p ro a c h e d by th e S e c retaria t to p ro v id e P h y s io th e ra p y Services, o n a c o n ­ tin u o u s basis, fo r th e d u ra tio n o f th e G am es. A C o m m itte e o f fo u r P h y sio th e ra p ists, P riv a te P ra c titio n ­ ers a n d H o s p ita l Staff, w as fo rm ed , to g e th e r w ith th e L iason Officer o f th e S e c retaria t M r. L o u w de B eer, w ho w as ab so lu te ly m agnificent in o b ta in in g all a n d every­ th in g re q u ire d . I n c o -o p e ra tio n w ith th e F irs t A id U n its o n d u ty , fo u r m ain sta tio n s w ere m a n n e d viz., th re e a t th e G a m e s V enues a n d a c o m p le te D e p a rtm e n t in th e H o te l. Ice w as m a d e a v ailable a t a ll th e V enues, a n d to g e th e r w ith stra p p in g o f such in ju ries w h ich m a d e c o n tin u a tio n o f th e ev en t possible to th e A th lete , n o th in g fu rth e r w as co n sid ere d necessary. M o re serious in ju rie s w ere e ith e r re fe rre d fo r H o s p ita l check o r sent to th e H o te l. T h e P h y s io th e ra p y D e p a rtm e n t a t th e H o te l w as staffed th ro u g h o u t th e p e rio d o f th e G a m e s by tw o P h y sio th e rap ists a t a tim e , in th re e shifts. S ta rtin g a t 8.30 a .m ., 2 d a y shifts cam e o n a n d fro m 5.30 p .m . th e n ig h t shift w ere officially o n d u ty till 10 p .m . V ery o ften how ev er, th e la tte r h a d to w o rk till 1 1 p .m . a n d once o r tw ice till a fte r 1 2 m id n ig h t. A ll A p p a ra tu s w as a v ailab le a n d a n Ice M a k in g M a c h in e w as specially in stalled in a sm all k itc h e n n ext to th e D e p a r t­ m ent. T h e w h o le o p e ra tio n w as co n sid ere d hig h ly satisfac to ry a n d th e c o -o p e ra tio n w ith th e F irs t A id U n its w as a n especially p leasing feature. Special T re a tm e n t C a rd s h a d b e en p rin te d t o p ro v id e a n im m e d ia te re c o rd o f p ro c e d u re s re q u ire d , especially necessary a s a n in ju ry w as seen by a different P h y sio th e rap ist e ach tim e th e p a tie n t re p o rte d fo r a tte n tio n . I t is h o p e d t h a t som e a nalysis o f ty p es o f injuries, tre a t­ m e n t p ro c e d u re s etc. will p o ssibly still be fo rth c o m in g fro m th e in fo rm a tio n c o n ta in e d o n th ese C a rd 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. )