October, 1955 P H Y S I O T H E R A P Y Page Seven CONSERVATIVE TREATMENT OF POLIOMYELITIS By M RS. W. B R O W N E, B.Sc.(Physiotherapy) R a n d . & M RS. M . G O O D M A N , B .Sc. (P hysiotherapy) R a n d . (A paper presented together w ith a practical dem onstration at the Polio Postgraduate Course held in M ay, 1955, in Johannesburg). ■ cr/H IL E treating polio patients a t the Johannesburg W G eneral H ospital, we have tried to gain as much k n o w le d g e as possible o f the disease and its treatm ent from various sources. But it is from practical experience with the patients themselves, studying the individual peculi­ arities in their m anner o f walking, rate o f progress, an d so on th at one gains a real understanding o f this fascinating a n d rewarding branch o f physiotherapy. We all learn the basic principles o f th e treatm ent o f polio patients during the course o f our studies, but these cannot often be applied w ithout modification. In practice, hundreds o f questions arise for which one can only find an answer by study o f available books and articles, discussion with other people interested in the subject, and careful observation and judgm ent. The following will be a description o f the treatm ent which m ost patients are receiving a t the H ospital, an d a discussion of som e o f the difficulties which m ay crop up. We do however realise th a t our knowledge o f the subject is incomplete, an d th at some o f the points mentioned may be controversial. As soon as a patient is put under o u r care, we start a case history file for him in addition to the hospital cards which are too small to hold enough detailed inform ation for these long term patients. T he early history o f the patient is taken dow n, together with the sym ptom s at onset, previous treatm ent and so on. A fter careful observation of the patient during tw o o r three treatm ents, it is possible to add accurate notes on th e present condition o f the joints and muscles. This procedure gives the physiotherapist a clear picture o f th e p atient’s condition; and further has the advantage o f providing a written record o f the p atient’s progress, to which both patient and physiotherapist can refer for encouragem ent when a static period in the tre a t­ ment seems to have been reached. It is essential th a t the physiotherapist should determine the cause o f the various abnorm al conditions. The inability to dorsiflex the foot, for instance, may be due to total paralysis. The sam e sym ptom however, may be found | when spasm o f the antagonists is present, o r in the case of mental alienation. Each o f these causes will require different corrective treatm ent. In the sam e way it is im­ portant to note any existing deformities or faults in walking, and ascertain w hether they are due to spasm, paralysis, or in long standing cases, ju st due to4 habit. One must not be satisfied with an exam ination only at the commencement o f treatm ent, but should be contin­ ually on the look out fo r changes in the p atien t’s condition. One thus notes the progress o f the patient and m ore im­ portant, can discover if any adverse changes have developed. It is im portant to gain the co-operation o f a patient. New patients should be m ade to understand th a t although the prognosis is always uncertain, a lot depends on their will to improve, co-operation with the staff, and their determination to practise, even when not under supervision; that a muscle will only increase in size if worked to a maximum, and th a t we can often strive for, an d obtain a well-functioning limb, even if a certain muscle never regains full stength. But in spite o f all this encouragem ent to the patient, the physiotherapist herself m ust take a lot o f responsibility during the treatm ent. She should avoid interruptions and general discussions with the patient and both she and the patient should concentrate hard o n the attem pted move­ ment, m ore especially if there is very little movement present. T he physiotherapist is also responsible for v a ilin g th e routine, giving bed and standing exercises, weights and free movements. She should also encourage progression wherever possible. Ball and pole exercises, pulleys,' springs, and occasional class treatm ents, add interest to th e work, but should not be given as a substitute for basic corrective exercises. O ccupational therapy combined with physiotherapy has proved valuable as well as interesting to m ost o f the patients. W hen patients are warded, we plan as full a program m e o f activity as possible. We treat them when possible in the out-patients’ departm ent and encourage them to get dressed rather th a n to shuffle around in a gown an d slippers. We now come to the actual treatm ent o f these patients. In the fever hospital they receive hot packs, passive move­ ments, an d later active movements. Sub-acute stage: A fter exam ination, the full program m e o f treatm ent for the patient is worked out. A s the exercises can best be dem onstrated on the lower limb, we shall deal mainly with this p a rt of the body in our talk. Passive movements: Every effort is m ade to overcom e the spasm by stretch­ ing the affected part. This stretching can be taken to the point o f discom fort, but should not be allowed to cause acute pain, as this will only increase the spasm , and actual tearing o f the muscle fibres m ay occur. I t is advisable to apply heat where spasm is severe. Tightness o f plantar- flexors is comm only seen in polio patients. The advisability o f stretching these muscles by the usual m ethod has been questioned, as the stretching effect would be concentrated on the intrinsic muscles o f the fool. A better method, and one which needs less effort, is to grasp the heel with the hand and push th e foot up with the fore-arm . The other hand fixes the leg above the ankle jo in t. The patients can also help themselves to stretch these muscles. A good m ethod is for them to stand bare-footed on the floor when they get up in the morning, while their muscles are still warm. W hen they can get the affected heel on the ground they should bend their knees, thus causing a greater stretch on the calf muscles. In some patients certain muscle groups respond better to a slow stretch which is gradually increased to a m axim um ; whereas o ther muscles may loosen up better with a rhythm ical stretch. Heat: We seldom apply heat to the patients who come for treatm ent, but in severe cases o f spasm, it can be o f value for relieving tension. D uring cold weather, patients whose extremities are affected will work m uch better when these parts have been warmed. D ry heat can be applied, but it is better to immerse the limb in water, as the patient can work the muscles to best advantage in this medium. It appears th a t some patients will retain spasm in several of their muscle groups for m onths after onset o f the disease, in spite o f intensive treatm ent from the beginning. In such cases, heat as well as stretching m anipulations should be used. Patients are encouraged to take hot baths at home, and to do the stretching exercises in the b ath when the muscles are warm and relaxed. 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 Eight P H Y S I O Exercises: We now come to the fundam ental and most im portant part o f the treatm en —the actual exercises to strengthen th e muscles. We must always bear in mind th a t the harder we work a muscle the better are its chances o f improving, and it is im portant to stress this fact to the patient. We must realise, however, th a t we have to treat muscles of varying strengths, and deal with the situation accordingly. W hen confronted with a muscle in which not even a flicker of movement is observed, we must move the jo in t passively, m ake the patient concentrate cn the movement, an d tell him to try and do it himself. It is ju st possible th at he cannot contract the muscle because o f mental alienation, th a t is, because the organisation o f impulses from th e brain to the muscle has been interrupted. In this case there is only apparent paralysis, and it is our duty to try and re-establish the pathw ay o f impulses between th e brain an d the muscle. If th e movement is lost because o f nerve cell injury, we should try to prevent this m ental alienation from taking place, in case recovery o f some o f the nerve cells occurs. We can attem pt this in any of three ways, according to the patient’s response. We can perform a movement and ask the patient to try and work with us; we can ask the patient to try and resist the movem ent we are perform ing; or lastly, th e patient can try to hold th e limb in a position where gravity exercises an opposite pull. Once a flicker is present one can go ahead with active re-education. N ow the patient, can try to move actively and hold the muscle in th e contracted position. Assistance can be given to complete the movement, but the patient does as much as possible on his own. As the muscle strength improves, resistance is given, and m ore exercises are in­ cluded until the muscle is norm al. As soon as the patient is able to do it, he can lift weights, ride the bicycle, and use other ap p aratu s o n his own. In the early stages.and when treating very weak muscles, the physiotherapist must be with the patient during the whole treatm ent, but, as' the muscle groups increase in strength, the patient should be encouraged to w ork on his own before o r after th e tre a t­ m ent time. H e can, for instance, do balance exercises, o r lift weights with his quadriceps. On the whole m anual resistance is preferable to th a t of springs and weights, especially in th e early stages, when the muscle may work better in o n e range than another. M anual resistance can be varied, whereas if a spring were given, it w ould have to be weak enough to be pulled in the w eakest range o f the muscle. F o r most o f the basic exercises the lying or prone lying positions are used, as the body is well supported and steady, and few muscles have to be used to m aintain the position. In these positions, the origins o f many o f the muscles are fixed, allowing the inserting ends o f the muscles to work w ithout hindrance. I t is, however, impossible to be dogm atic ab o u t this, as it is rem arkable how the optim um position for the perform ance o f a certain movement varies from patient to patient. F o r example, one person may find th at he can dorsi- and plantar- flex his foot best in th e lying position, while another m ay get the feeling better in the prone lying position with the knee bent a t a right angle; a third person may find it very awkward to move the foot in either o f these positions an d prefer to do it by crossing one leg over the other in the sitting position and working with gravity eliminated A s the treatm ent progresses all the positions should become equally easy but in the early stages we have found it advisable to use the optim um position, as this provides the maximum am ount o f exercise fo r th e muscle. We try to exercise each muscle group in three o r four different ways during the treatm ent. This can be done by giving eccentric, concentric or static movements, by altering th e starting position, o r varying the type of resistance given. This variation adds interest to th e treatm ent, and one can also be more sure th a t all the p arts of the muscle do w ork, because if some fibres do not respond to a ce • type o f movement, they may respond to another tv * also enables one to work a muscle to fatigue in one posit give it a rest by exercising other groups and then to reti°n' to the muscle with a different exercise. T he fo llo w in g some o f the exercises which could be given to weak string muscles. m' 1. Prone lying. A ttem pt to balance leg which is to 90° a t the knee. e*ed 2. As a progression, the physiotherapist can push the le ju s t off balance while the patient tries to recover th original position. e 3. Prone lying. Knee flexion concentrically. Assisted fa e or resisted m ovem ent can be given as required. 4. Prone lying. K nee flexion eccentrically with gravity resisting o r m anual resistance as required. 5. Lying. Thigh supported in sling with hip flexed. Spring attached to foot from a point above the knee. Knee flexion against the spring concentrically o r eccentrically 6. Lying. D raw ing the knees onto the chest against the therapist’s resistance, concentrically or eccentrically. We would here like to emphasise th a t a t the end of a patient’s treatm ent, the muscles should be so fatigued th at it w ould be alm ost impossible for him to do any more w ithout a rest. This fatigue is n o t at all harm ful as subse­ quent increase in muscle strength will show. Guthrie-Smith Apparatus: T here has recently been a fair am ount o f discussion at th e H ospital on the value o f the sling suspension ap­ paratus in the treatm ent of polio patients. When abused, this m ethod o f treatm ent can be a total watste o f time and effort, but when properly used it can be o f great value, for n o o th er m ethod provides so simple a means of giving assistance to a movement, while a t the same time, with resistance given by th e physiotherapist, hard work is pro­ vided for a weakened muscle. We never suspend a patient’s limb and tell him to get on with an exercise, leaving him to swing it aimlessly, but instead supervise the movements, giving resistance wherever possible. As an example o f the uses o f the apparatus we will take the abductor group o f the leg and see how in various stages, slings can be used in its treatm ent. 1. Should a patient have stiff ab d u cto r o r adductor muscles a rhythm ical swing o f an axially suspended limb will help to ease this. 2. In a severely paralysed patient who has not regained th e “ feel” o f the movement, the limb can be suspended an d moved gently in and out, while the patient is| told to think about the movem ent and to try to perform it. 3. As the patient progresses, he can swing the limb freely in th e sling. T he physiotherapist can at intervals and w ithout w arning the patient, suddenly instruct him to stop the movement and to hold th e limb in the abducted position. 4. Finally, the physiotherapist can take up a position to resist the limb, and this resistance can be given concentrically or eccentrically. W hen paralysed muscles are put on the stretch, this acts as a stimulus, and a better contraction will result. This fact should be m ade use o f in sling-suspension exercises and muscles should on the whole be w orked from their fully stretched position. Hubbard Tank: We have m ade considerable use of th e H ubbard Tank for carefully selected cases during this polio epidemic. It is useful when severe paralysis is present o r where there is much muscle spasm, and passive movements are given in this medium. The warmth and buoyancy o f the water relieve the tension o f the muscles an d increase the mobility T H E R A P Y ________________________ Ociober, |9ss 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. ) October, 1955 P H Y S I O T H E R A P Y Page Nine u in v e rv severely paralysed patients it is w orth of the limb, in j eyen jf Qnly for th e psychological while to use 1" bed-ridden patients. A selection o f effect which it ^ tankj a n d t he patient is m ade to exercises is give jb, Qne should only prescribe this w o rk as hard as after careful consideration, as it is tre a tm e n t t o .P ^ operati0n, and the tim e may be better sp en fw ith hard active exercises. SwrnMmng- a ^ a g e o f using a pparatus e.g. bicycle u r n mDlex m o v e m e n ts are in v o lv e d , is th a t the p a t i e n t W!i?ru se t h e u n a ffe c te d m u sc le s to do the work and not the t muscles T o a certain extent the sam e may be said S w im m in g ,'a lth o u g h the advantages o f this exercise are nv For the past few seasons, we have been taking the Hosoital polio patients to the University swimming bath twice a week. H ere they all get together and a very happy oHiinsnhere prevails. As far as the swimming is concerned, we^try to get them to swim as far as possible on their own. in addition, to move the affected p art individually fn the water. F o r example, a patient whose legs a /e affected, will start by walking across the shallow end of the bath, and the number o f times he walks will be progressed from time to time F o r a very weak patient, this is a good exercise as although the water buoys the body, and the supporting muscles of the legs do practically no work, it offers resistance to the forward movement o f the legs and can be quite fatiguing. A fter a short rest the patient will exercise his legs in the swimming position. H e can perform a kicking motion with the legs when in a prone position and holding on to a board. This is excellent for the gluteal muscles, while the same movement perform ed o n the back will exercise the hip flexors. The breast stroke is an excellent exercise for the adductor o f the hip while a new form of the butterfly stroke, where the legs are flexed and then vigorously extended, works the quadriceps very strongly. Where the hip extensors are very weak, and the limb is heavy, it may be necessary to tie an inflated bicycle tube around the hips, to prevent the legs from sinking. To exercise an arm which can be moved o u t of the water, the crawl and back stroke movements can be used. For a patient who had a weak anterior deltoid and pectoralis major, we used to stand in the water, and support him lightly under the back. H e would then lift the arm up and out of the water over and over again. This markedly strengthened the muscles, but could, o f course, have been done equally well on a plinth. In fact, in th e latter position the shoulder girdle would be fixed and a tru er movement would be obtained. Y et the extra interest which the swim­ ming gave the patient m ade him persevere. All the patients need very careful observation during the swimming exercises, o r else they will ju s t rely on the lift of the water and their unaffected muscles to produce movement. One of our patients who had a generally affected left arm, and who was quite unable to lift it out o f th e water, was made to do breast stroke. To keep his limb elevated and away from his body, we tied a slightly inflated bicycle tube over his shoulder, and twisted it once around his wrist. This slight support enabled him to exercise his arm most effectively, and though he went only a t a snails pace, he used to swim three o r four hundred yards at a time. It is in cases like this, where all muscles in the limb are affected to more o r less the same degree, th a t swimming is of value, whereas in a limb with some strong muscles and some weak ones, swimming will probably benefit only the strong ones. In spite of this, swimming can be o f definite value and is an excellent means o f improving the general y musculature o f these patients. Walking: From the earliest stages o f treatment w e start re- ucating the patient’s walking where leg or trunk muscles are affected. This is a most im portant aspect o f the treat­ ment and, if neglected, can result in a m ost ungainly and fatiguing walk. A t first the patient may ju s t be ignorant of th e way he is walking, o r uncertain o f th e ways he can improve this; but it soon becomes habitual, and even when muscle strength improves, the gait may rem ain aw kward. N aturally, we cannot expect a patient to walk correctly when certain o f his muscles are paralysed, bu t we can ensure th at he walks to the best o f his ability. F irst of all, it is im portant to see th a t the p atien t’s feet are properly supported. H e should w ear well fitting shoes and socks. H igh heeled shoes, very open sandals and thick crepe soles should not be perm itted. T he stiff leather shoes which one sometimes sees, allow very little movement and exercise o f the toe and intrinsic foot muscles, while a shoe which is too heavy will impede the walking o f very weak patients. Calipers should only be used when absolutely essential to the patient, such as in the case o f complete loss of the dorsiflexors o f the foot, an d they should be discarded as soon as possible. I f they are used when the muscles themselves could work, they relieve the muscles o f their natural function and these will then deteriorate. T he sam e applies to th e use o f the crutches and sticks. In th e early stages it is preferable to allow the use o f crutches rath er th an to allow th e patient to walk in an ungainly way. There is a trem endous difference between the support offered by crutches an d th a t given by sticks, as the latter are really com paratively unsteady; but as soon as possible progression should be m ade to sticks and later to having no support at all. W e never start re-education o f walking in the wheel- crutch, as this does n o t offer th e necessary support to a weak patient. Instead o f being able to concentrate o n his walking, he is always conscious o f the fact th at he must prevent th e wheel-crutch from running waay from him. T he parallel bars provide an ideal piece o f apparatus for the re-education of walking. They offer a steady support for a sufficient distance to enable several steps to be taken. In addition, they provide a suitable means o f support fos standing exercises. As soon as possible the patient is taught to walk with crutches. A t each treatm ent, his walking should be watched by th e physiotherapist so th at his faults can be corrected. H e should also walk in fro n t o f a m irror to learn to recognise and to correct his own faults, e.g. limping, uneven timing, o r uneven spacing of steps. T he following are a few exercises which are given to the patient in the parallel bars. 1. Stride, standing. Balancing w ithout holding on. 2. Stride, standing. Transference o f weight from one leg to the other. 3. Stride, standing. Two arm bend an d stretch in all directions. 4. Stride standing. C atching an d throw ing a ball. 5. K icking a ball w ithout holding on. 6. W alk standing. Transference o f weight from one leg to the other. 7. Standing. Free leg swinging forw ard and backward. This exercise encourages th e patient to use his ankle . dorsiflexors to keep his foot from hitting the floor. 8. Standing. Bending the knee slightly, then attem pting to straighten up against gravity. 9. Standing. A ttem pted raising on to the toes. T hi: is progressed to Heel Raise, K nee Bend. 10. Standing. M arking time, progressed to stepping over sand bags. 11. H alf standing, with knee unlocked, to exercise the quadriceps. 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 Ten P H Y S I O T H E R A P Y October, 1955 Most o f the polio patients have a fear o f falling when they start to walk, and in fact often do fall. The following exercise gives them more confidence, as they learn to regain their balance when this is upset, thereby lessening their chances o f falling. In addition, they learn not to be frightened at the thought o f a fall, as this fear often makes them over cautious and prevents them from walking to the best o f their ability. They should also learn to get up after a fall. Exercise: The patient stands in the stride position on a large mattress. The physiotherapist then tries to push him off balance, first sideways and then forw ards and back­ wards, while the patient resists this. When the patient falls he is taught to get up again. As soon as possible, patients are taught to walk up and down steps, and up and down sloping surfaces. We are lucky at the G eneral Hospital to have a very convenient ram p just outside the Gym, so that patients soon learn to overcome this rather difficult obstacle. I would now like to deal with four topics—mental alienation, inco-ordination, trick movements, and the relative value o f certain im portant muscle groups to the patient. Mental Alienation: One o f the biggest problems we have to cope with in the treatm ent o f poliomyelitis is th at o f m ental alienation: a patient who has tem porarily lost some or all o f the power in a muscle, tends too lose the ability o f voluntary activation o f th at muscle, even though the nerve cells controlling the muscle may have recovered, th at is, he has forgotten how to contract the muscle. The treatm ent o f this condi­ tion has already been dealt with. Inco-ordination: One also comm only finds inco-ordination in polio patients. C o-ordination is the working together o f various groups o f muscles to perform a desired movement with the minimum expenditure o f time and energy. I f one muscle o f a group which usually act together is lost, inco-ordination will result, e.g. if the quadriceps are paralysed, the natural movement o f walking is upset, and the patient has to re-organise his movements to accom m odate for this loss. H e may do this by swinging his leg forward w ithout bending the knee, and locking the knee mechanically w ithout using the extensors, when he takes his weight on this leg. Unless this situation is watched for and corrected, th e patient may habitually walk in this inco-ordinated way, even when muscle power has returned, i.e. he has learnt to do w ithout a certain muscle, and must be taught to use it again. Trick Movements: A third very im portant point which I wish to discuss is the question o f trick movements. A trick movement occurs when a patient produces a similar movem ent to the one desired w ithout using the affected muscle at all, or without using it to its best ability. It usually occurs when a patient is asked to perform a movement which is difficult o r impossible for him to do. H e subconsciously substitutes another movement in his desire to perform th e action. The physiotherapist must always be on the look out for these movements. Some are obvious, while other more obscure ones are most difficult to spot. They all result in the patient not working the required muscle, and must be rigidly prevented. T he simple mechanism o f these trick movements should be explained to the patient, and he himself should learn to spot when he is making a mistake. In fact, long standing, well trained patients can usually spot these movements as soon as they occur. A few o f the common trick movements are: 1. Half-lying. A nkle-dorsi and plantar-flexion. The patient uses his trunk side flexors to produce a hip updrawing movement. W ith the heel as a fixed point on the bed, the trick movement is produced. 2. In- and eversion o f foot. This is produced by internal and external rotation o f the hip. 3. Lying, leg axially suspended in a sling. H ip abduction Trick movement is produced by the trunk side flex o rs 4. Lying, leg axially suspended. H ip abduction. Patient externally rotates the hip and then performs the abduction movement. This movement is thus per­ form ed o r aided by the hip flexors. 5. Prone lying. Knee flexion, done by flexing the hip M echanism : T he ham string muscles pass over two joints, and can extend the hip and flex th e knee. If the hip flexors should contract and flex the hip, the hamstrings are put on the stretch, and by mechanical action, the knee will be slightly flexed w ithout muscular contraction. 6. T he same action can be seen in extension o f the knee. If the hip is extended a stretch is put on th e quadricepsj an d extension is facilitated. 7. P rone lying. Knee flexion. W hen the hamstrings are weak, the action o f gravity can be decreased by in­ ternally rotating the hip, and letting th e leg fall slightly sideways. Value o f Muscle Groups: Before closing, I w ould like to m ention the relative value o f three muscle groups o f th e leg in different every­ day activities. Standard anatom ical text books mention the m ain actions o f muscles w ithout elaborating on the various conditions under which they function. This I feel leaves an unfortunate gap in o u r knowledge. T he hamstrings, for example, while smaller and less powerful extensors o f the hip th an gluteus maximus, are m uch m ore useful for ordinary purposes o f life, as they act norm ally in walking and standing, while the gluteus maximus does not. Any norm al person can prove this to himself by feeling the gluteus during walking, as it remains relaxed. T he result is th a t one who has lost th e use o f his gluteus maximus may stand and walk norm ally, while one who has lost the ham strings can stand and walk only by throwing the weight o f the trunk so far back th a t it tends to over­ extend the hip. This is done to prevent his falling forwards as the ham strings only, and no t the glutei, are able to counteract gravity in this position. A patient whose gluteus maximus is absent is still able to do straight leg raising in the prone lying position. The hamstrings can be felt to contract on any norm al person doing th e above exercise. The ham string muscles are also o f utm ost im portance in the stability o f the knee. I t is thought by some that when the knee is locked in the standing position, it forms a rigid support w ithout muscular activity, and th at hyper­ extension is prevented by the various ligaments. But I clinical observation dem onstrates th a t the hamstrings act as im portant ligaments o f the knee an d w ithout them the leg will hyper-extend progressively. This hyper-extension will eventually overcome the resistance o f the cruciate, co-lateral, an d posterior ligaments, which then stretch rapidly and progressively. T he quadriceps are often affected in polio, and this can result in a severe disability to the patient. T he patient can stand erect without difficulty because o f the tendency o f the weight o f the body to hyper-extend the knee. Such persons can walk, provided that they avoid flexing the hip far enough to cause flexion o f the knee by the weight o f the leg and foot. They do this by taking very short steps which they can lengthen somewhat w ithout danger by swinging the hip forw ard as far as possible with each step, giving them a waddling gait. Alternatively, they can swing the leg forw ard with force, locking the knee when the heel touches th e ground. I f the patient tries to hurry o r swing the fo o t to o far forw ard he will fall. R unning, jum ping, an d so on are o f course quite impossible. A lthough the hamstrings have been mentioned as being o f prim e im portance in walking, standing, etc., when any force is required in extension o f the hip, the gluteus 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. ) October, 1955 P H Y S I O T H E R A P Y Page Eleven is essential M ovements, such as standing up ""“ “"the sitting position, jum ping, running, etc. are im­ p o ssib le w ithout it. . Whereas the ham strings act when th e hip jo in t is , ♦ straieht the gluteus maximus comes into play !T n t h e a n g l e ’o f the hip is more than 4 5 °. W e have all .v ld how cyclists stoop forward, how old people stoop ?°'rH m b up steps, and th a t sprinters start a race in the „nrhinK position. T h e s e m anoeuvres all aim at getting th hiD at the required angle for gluteus maximus, the s tro n g e s t hip extensor to come into play. In spite o f having strong back extensor muscles, a f i e n t with a paralysed gluteus maximus cannot arch his back in the prone lying position as th e pelvis cannot be fixed. Lastly, I would like to mention the im portance o f all the muscles passing over the ankle joint, for balancing the b o d y when standing, we are continually changing the osition o f our bodies in relation to the centre o f gravity, and it is mainly the muscles o f the foot which are responsible for bringing the body into line again. In concluding, I w ould like to m ention th a t polio patients should, if possible, be treated by one physiothera­ pist for a considerable period o f time. Several weeks are needed before the patient and therapist can work together really effectively tow ards a com m on goal. A fter many months, however, a change o f physiotherapist may do the patient a world o f good, as a fresh approach an d new ideas and exercises alm ost invariably act as a tonic. Finally, we must realise th a t th e treatm ent o f polio patients still leaves much scope for im provement. We should continually be on th e alert to learn new ways and methods o f treatm ent which must inevitably develop with the progress o f medical science. When Ionization is indicated . . . Imadyl Unction Roche' is the substance of choice. Containing 1 % histamine-dihydrochloride it will produce local effects only and will not cause general vasodilation. Imadyl ‘Roche’ is freely available again from UlidiuU fiisMbufotsm Specialists for Physical Medicine Appliances P.O. Box 3 3 7 8 J O H A N N E SB U R G Telephone 2 3 -8 1 0 6 2 3 6 , JEPPE STREET O BITUARY R h o d a Valerie M arks, daughter o f M r. and M rs. H. M arks o f K ensington, Johannesburg, was tragically killed on 27th July, 1955. She was born in Johannesburg and was educated at Jeppe H igh School, an d from there she went on to study Physiotherapy at the W itw atersrand University from which she graduated in 1949. R h o d a w orked for a while at the Johannesburg G eneral H ospital and C oronation H ospital before going to Crow n Mines where she was employed at the time o f her death. H aving spent four m onths’ holiday in E urope, she was returning hom e when the plane in which she was travelling crashed in Bulgaria. She was buried in Israel together with th e o ther victims o f the disaster. N o t only was R h o d a an enthusiastic an d able student and a credit to her University, but she was an extremely loyal and active m e m b e r’o f the South A frican Society of Physiotherapists, and we shall always rem em ber her as a good friend and an outstanding physiotherapist. H er passing is deeply m ourned, not only by her individual friends, but by the Physiotherapy Society as a whole. C O N FE R E N C E Since several m atters o f im portance have arisen recently which must be discussed by representatives o f all Branches o f the Society it has been decided th a t a Conference must be held this year. To minimise costs, this will be held in Johannesburg on O ctober 8th, 9th and 10th. D etails are given below, and members are rem inded th a t they will all be welcome to take p a rt in the business discussions as well as the social functions, though only delegates elected by the Branches are entitled to vote. D RA FT PR O G R A M M E SATURDAY, 8th. 9.00 a.m. 10.00 a.m. 2.00 p.m. 4.00 p.m. 4.30— 5.30 p.m. 7.00 p.m. SUNDAY, 9th. a.m. 1.00 p.m. 2.00 p.m. 4.00 p.m. 4.30— 5.30 p.m. Evening M ONDAY, 11th. 9.00 a.m. 11.00 a.m. 11.30 a.m. 1.00 p.m. 2.00 p.m. Opening Speech an d Welcome by D r. K . Mills, Medical Superin­ tendent, Johannesburg G eneral Hospital. Visits to various hospitals. Business. Tea. Business. Cocktail Party. N ative W ar D ance. Lunch. Business. Tea. Business. Film o r Music. Business. Tea. Business. Lunch. Business. Tea. 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. )