Page Four P H Y S I O T H E R A P Y July, 1954. THE MEDICAL A P P R O A C H TO THE RESETTLEMENT OF THE DISABLED ' B y F. S. COO K SEY, o .b . e ., m .d ., m . r . c . p . D irector, D epartm ent o f Physical M e d icin e'K in g ’s College H ospital; C onsultant Adviser in Physical M edicine to the Ministry o f H ealth. (IN T E R N A T IO N A L C O N G R E SS L EC TU R E). IT is an axiom o f medical teaching th at the doctor’s responsibility does not end until a sick o r injured p atient has resumed his norm al place in the com m unity; o r, in the case o f perm anent disability, u n til.h e has been resettled in the m ost suitable conditions. Even so doctors are often criticized for showing too little interest in rehabili­ tation and even less interest in resettlement. There are reasons for this app arent contradiction between principle and practice which m ust be taken into account when con­ sidering the medical approach to resettlement. In medical education emphasis is laid on the p a ra ­ m ount im portance o f accurate diagnosis, o f finding the cause o f illness and the means o f preventing it. Treatment, which seems so im portant in the presence o f sickness, is, nevertheless, a necessity only until a disorder can be p re ­ vented ; whilst resettlement applies only to a minority o f cases in which treatm ent has failed to enable patients to return to their norm al way o f life. Thus the natural trend o f medical interest is tow ards the acute stage o f illness, and resettlement is ap t to be regarded as a specialized procedure to be considered only when the d o cto r has failed in his primary, objective. A nother factor is th at th e doctor has around him the nurses, physical therapists, laboratory facilities, surgical instrum ents and drugs which he needs for the treatm ent o f illness, and he is personally responsible for directing the use o f these agents. W hereas, although the doctor is ex­ pected to advise on the medical aspects o f resettlem ent and his certificate m ay be an essential prelim inary to action, he is no t so directly concerned with the m anagem ent of these services. Indeed, he may have very little say in re­ settlement beyond m aking a,recom m endation, which m ay o r may not be acted upon by people he seldom, ,if ever, meets. The facilities for social and industrial welfare, includ­ ing resettlement after illness, which have been developed in recent years are now so elaborate th a t it m ay well be asked if it is still practicable fo r doctors? who are already overtaxed by the urgency and complexity o f purely medical m atters, to assume much, if any, responsibility for resettle­ ment. The answer is th at medical responsibility cannot be avoided because treatm ent m ust be related to the type o f life 'to which the p atient will be returning, and those con­ cerned w ith the resettlem ent services are dependent upon medical advice as to w hat conditions are suitable for a particular m ental o r physical disavility. By way o f examples, the stresses and strains o f life play a m ajor p a rt in the aetiology o f peptic ulceration and it is recognized th at successful treatm ent depends as much on knowing how such conditions can be avoided as upon medical o r surgical procedures. A gain, lifting strains m ust be restricted or avoided after prolapse o f an intervertebral disk, and only a doctor call assess the extent o f the weakness in the individual and decide if a particular type o f work is likely o r n o t to- be harm ful. Likewise, the physical effort permissible in h eart disease requires re­ assessment from time to time because the cardiac con­ dition is liable to change and usually for the worse. Similarly in other unstable conditions, such as tuberculosis and arth- . ritis, medical advice a b o u t living conditions m ay be m ore effective than drugs. O n the other hand, in stable conditions, such as poliomyelitis, medical guidance during resettle­ m ent is less im p o rtan t; but, as in m ost disorders, treatm ent at a n earlier stage m ust be related to fu tu re activity. F or instance, it fnay be necessary to arthrodese a flail wrist / jo in t and for the m ajority o f people fixation midway between pronation and supination is the m ost useful position; but a typist will not be able to resume her work unless the wrist is fixed in full pronation. C ountless examples, equally convincing, can be found in every branch o f medicine. The conclusion m ust be that resettlement is an essential and integral p art o f medical practice; but the d o cto r’s attention is being constantly diverted to the m ore urgent problems o f acute illness, and his opportunity to apply his interest in resettlem ent is restricted because the necessary facilities are usually remote from his own practice and he has little direct responsibility for their operation. Therefore, the practical problem is how to m ake it easier for the doctor to apply his natural and essential interest in resettlement. Somewhat similar problem s confront physical thera­ pists. N aturally their first concern is th at the treatm ent they adm inister will lead to full recovery and th a t they will be given the opportunity to treat cases so early that they can virtually prevent disability. A t the sam e time they are interested in the problems o f resettlement, but they have even less direct responsibility than the doctors. I f there is any criticism o f physical therapists it is perhaps that there is a tendency to keep patients on treatm ent too long in the attem pt to achieve a complete cure in the ana­ tom ical and physiological sense when it might be more praticable and economical to be content w ith a fair func­ tional result and to get th e 'p a tie n t back to w ork without unnecessary delay. F o r instance, it is satisfying to obtain full movement in a stiff shoulder o r knee after injury; but few people need full abduction o f the shoulder o r m ore than 90 ° o f knee flexion fo r their w ork and everyday activities. A useful functional range o f m ovem ent is often obtained relatively quickly, but the last few degrees^ o f abduction or flexion m ay take m onths. A t the sam e time it is not uncom m on to find th a t patients who were discharged with some lim itation have recovered full movem ents spontan­ eously m onths or perhaps years later. Thus it is ju st as im portant to know w hen'to stop treatm ent and get on with resettlement as it is to recognize when treatm ent is indi­ cated. A nother aspect is seen in the m anagem ent o f hemiplegia. T he first aim o f treatm ent is full recovery in the affected limbs, but experience shows th at, whilst m any patients regain the ability to walk fairly well, w orthwhile recovery in the affected hand is the exception. In the long run it is m ore realistic to recognize th at m ost cases are unlikely to regain useful function in the hand and to teach the 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. ) July- 1954. P H Y S I O T H E R A P Y Page Five tient how to live with the disability and how to m ake - one hand do the w ork o f two hands as; far as possible. It is difficult for physical therapists who are treating a d i s a b l e d patient day after day to form an objective view o f the case. This is no criticism of-physical therapists as s u c h but an inevitable consequence o f the nature o f their ' work which brings them so close to the im mediate problems, whereas the doctor has not only the advantage o f reviewing the case at intervals but also o f evaluating all the various m e t h o d s o f treatm ent for which he is prim arily and ulti'- , - mately responsible. Thus if physical therapists are to play the fullest part in rehabilitation an d resettlement, ways „ must be found to enable-them to obtain a more objective view o f their work. This is best achieved through the te c h n i q u e o f progress and resettlement case conferences, - wherein they can' m ake their observations along .with their colleagues from other departm ents and then hear the medical sum ming-up o f the case as a whole. One o f the m ost im portant things to find, o u t is the size o f the problem o f resettlement. T h e' M inistry of Labour have accurate figures in .th e industrial field.. O n. k h e medical side less is know n, but 'som e indication can rbe obtained from a survey o f a , thousand- consecutive patients discharged from t h e ,. wards o f R in g ’s College ' Hospital in the sum m er o f 1950. 'This showed th at nearly 75 per cent, o f the patients were expected to m ake-full recovery and return to their employment or, .in the case o f scholars, housewives, and those retired from w ork, to resume their norm al, place in the comm unity. A further- 10 per cent, would resume their usual activities in spite o f some perm anent disability; 7 per cent, would suffer- with chronic illness but be able to do their own work during remissions; and-4 per cent, were unfit for any w ork. Under- 1 per cent, would require resettlement in alternative w ork in the immediate future,- but it was assumed th at some o f the 7 per cent, chronic sick who might return to their w ork would require resettlement in m ore suitable w ork in due course. The rem aining 3. per cent, were patients who were expected to die o f cancer, heart disease and so on in the - near future. The figures are too small to draw conclusions, but the alarming feature is th at apparently only 75 per cent, o f patients passing through a h acute hospital m ake full > recovery. A further ]7 per cent, w ith perm anent disability or chronic illness can work but need the help o f the rehabili­ tation and resettlement services to a greater o r lesser extent. Even allowing fo r a wide m argin o f error, in these figures it is clear that at least 10 per cent, o f the patients passing Jthrougb our acute hospital beds heed help in theit, rehabili­ tation and resettlement, and this becomes a very big problem in terms o f the total hospital population .in the country. On the whole,' quite good progress has been m ad e in this country in the development o f facilities for medical rehabilitation, that is to say, the means to restore'physical, and mental function, but the provision for industrial re-, settlement is much better as you will hear from M r. St. John Wilson. However, there is a gap which has not yet been satisfactorily bridged - between the m e d ic a l, and 'in­ dustrial processes. The outstanding problem s at the moment are, first, to m ake it possible fo r the' doctor to develop and apply his interest in rehabilitation and. resettle­ ment. Secondly, to m ake it easier for, physical, therapists to see their w ork in wider perspective and, thirdly, to m ake certain that those concerned w ith industrial resettlement an co,l?su^e<̂ ® good time and given all the medical guid- r * ,|f ey need to enable them to m ake their maximum tnbution to th e welfare o f disabled people. .- t Since the D isabled Persons Employment Act came o operation in 1944 th e Ministry o f L abour have wisely arranged th a t the D isablement Resettlement Officers at th e- employment exchanges should attend the hospitals to discuss the industrial resettlement o f all disabled persons with the alm oners a n d 'th e members ;of the medical staff concerned. U nfortunately the medical profession havel not shown much willingness to m ake use o f this opportunity a n d too often the alm oner and D .R .O . have been at a dis­ advantage because o f the lack o f all im portant medica guidance. Furtherm ore, there is no provision for physio­ therapists, occupational therapists an d others who have got to know the patient’s p e r s o n a lit y ^ well as his physical and m ental capacity during treatm ent to contribute their view ab o u t the most suitable resettlement for the patient. -In recent years efforts to strengthen the link Between the medical and industrial services have led- to the develop­ m ent o f the resettlement clinic or case conference in hospitals. T he purpose is to provide expert medical .social and voca- ' tional guidance during the latter stages o f illness for patients who may require further rehabilitation and resettlement in suitable w ork after discharge from hospital. -' The clinic is conducted by one o f the medical staff interested in rehabilitation, and is attended by the alm oner, physiotherapists, and occu p atio n al' therapist, together w ith the D .R .O . from the local employment exchange and the patient. T he p atien t’s family doctor is invited to attend, b u t'u n fo rtu n ately time and distance often m ake this impracticable.. Invitations are also extended to indus­ trial medical officers, and other experts within and without the hospital when they are,concerned with particular cases. By this means all the interested people are brought together. The usual procedure is for everyone to say w hat he knows and thinks about the case, and the best line o f approach is agreed before the patient is brought/in. The chairm an th en 'ex p lain s the position to the patient in simple terms and invites him to express his own views about the suggested - course o f action until finally a plan o f action is agreed by all concerned. O f course, it is n o t possible to bring so many busy people together to discuss all resettlement problems, and these clinics only deal w ith the m ore interest­ ing and difficult cases. T he routine w ork continues .to be ' done by direct contact between, the alm oner and D .R .O ., but the clinic has the great advantage o f stim ulating interest in these\ problems in the medical, social and industrial field. All concerned learn m dre ab o u t each o th e r’s w ork and -how to overcome the difficulties o f adm inistration and comm unication, which are not easy to avoid in such a complex procedure as rehabilitation and resettlement. O ur own experience at K ing’s College H ospital h a s ' been that the resettlement clinic stimulates interest through­ ou t the hospital. Members o f the medical staff refer cases freely and some attend the clinic themselves whenever possible, thereby dem onstrating th a t if the necessary faci­ lities are' established, and readily available, doctors will apply themselves to the problems o f resettlement. ' The physical therapists welcome the opportunity to express their opinion about a difficult case', and I believe it helps them to get m ore ou t o f their own work. The D .R .O . has not only the advantage o f thorough briefing about the medical aspects before he starts on a case but he can . also bring his own problem cases from the employment exchange back for review o f the medical aspects when he feels this may- be necessary.' There "is little doubt th at the establishment o f resettle­ m ent clinics in all the m ajor hospitals would help m ore than anything else tow ards bridging the vital gap between medical rehabilitation and industrial resettlement'. 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. )