Some Useful Equipment in the Rehabilitation of Permanent Spinal Paraplegics. By A L F R E D R O T H B E R G S u p e r i n t e n d e n t P h y s i o t h e r a p i s t , R e h a b i l i t a t i o n C e n t r e , W . N . L A . — H o s p i t a l . J o h a n n e s b u r g . Page Six _ P H Y S I O T H E R A P Y J u lyJ9 5 4 . (I.) A B A L A N C I N G A I D . r p H E p h ysi ca l r e h a b i l i t a t i o n o f p e r m a n e n t sp i n a l p a r a p l e g i c s h a s t o - d a y b e c o m e a n e s t a b l is h e d item in t h e p r o g r a m m e o f A a d e q u a t e l y e q u i p p e d R e h a b i l i t a t i o n ce n tr es . It h a s b e c o m e po ss ib le to t e a c h t h e m c r u t c h w a l k i n g with t h e a i d o f l on g co r se t - t y p e c al ip er s. P r o v i d e d n o u n t o w a r d c o m p l i c a t i o n s o c c u r , th i s p r o g r a m m e us u a lly t a k e s f o u r to six m o n t h s . O c c a s i o n a l l y , ho w e v e r , t h e p h y s i o t h e r a p i s t e n t r u s t e d wi th t he r e - a m b u l a t i o n o f sp i n a l p ar a p l e g i c s e n c o u n t e r s a p a t i e n t w h o is no t p r o g r e s s i n g a c c o r d i n g to sc hed ul e. A p a t i e n t w h o s t a r t e d very p r o m is i n g l y , se e m s to a p p r o a c h a st a n d st i l l in his p ro g re s s. S o m e t i m e s it is a p a t i e n t wit h a c a u d a e q u i n a lesion a n d re su l t an t flaccid pa ra ly sis o f his legs w h o h a s d o n e ver y well d u r i n g ev er y s t a g e o f p r e - a m b u l a t i o n exercises. H e h as d e v e l o p e d a n a d e q u a t e s h o u l d e r g i r dl e a n d s t r o n g a r m a n d h a n d muscles. His ba ck a n d a b d o m i n a l mu sc les h a v e been built up . H e is ev en w a l k i n g well wit h his c a l i p e r s in th e w h ee l- cr u tc h. Y et w h e n he c h a n g e s to o r d i n a r y c r u t c h e s he b e c o m e s d i s a p p o i n t i n g l y slow. H e lacks j u s t t h a t little e x t r a c o n f i d e n c e w hi ch w o u l d give h im th a t e a s y lift f o r t he s w i n g - t h r o u g h m o v e m e n t , t h a t well e x t e n d e d b a c k a n d b r a c e d s h o u l d e r s b ef or e ad va n c i n g , th e c r u t c h e s , a n d t h a t s t e a d y s h i f t i n g o f weight f r o m sid e to side, all o f w h ic h m a k e t h e c r u t c h - w a l k i n g o f s o m e p a r a p l e g i c s ,1 c o n s i d e r i n g t h e i r g r a v e di sa bil it y, a p p e a r a l m o s t gr aceful. A n o t h e r t y p e o f flaccid p a r a p l e g i c m a y be h a n d i c a p p e d by ge n u in el y w eak b a c k a n d a b d o m i n a l musc les . In t h e wheel- c r u t c h we find h im r es t i ng hea vi ly o n t h e axi l l ar y p a d s , a l m o s t h a n g i n g b e t w e e n t h e u p r i g h ts . H e re se nt s e x t e n s i o n o f his b ac k , t e n d s t o d r a g his legs, a n d is n o t eas ily p e r s u a d e d to use hi s s t r o n g a r m s to lift h i m s e l f t o w a r d s th e s t r a i g h t p os i t i o n . If given o r d i n a r y c r u t c h e s h e w o u l d e i t h e r s a g f o r w a r d o r try to m a i n t a i n h i m s e l f s t a n d i n g with his s p in e flexed at a m a r k e d an g le . In ei th er p o s i t i o n h e w o u l d a p p e a r g lu ed to th e g r o u n d a n d c o n v i n c e d t h a t it w as i m po ss i b l e for h i m to p r o p e l h im se lf f o r w a r d . In t h e c a t e g o r y o f sp a sti c p a r a p l e g i c s t h e r e is a fa irly f re q u e n t t y p e o f m i d - t h o r a c i c c o r d lesion, in w h i ch t h e p a t i e n t e v e n t u a l l y m a s t e r s his a b d o m i n a l s p a s m sufficiently to a s s u m e th e erec t p o s i t i o n in th e w a l k i n g m a c h i n e , a n d w i t h t h e a i d o f c a l i p e r s le a r n s t o p r o p e l h im se lf in it. H o w e v e r , w h e n p r o m o t e d to c r u t c h e s , his f o r m e r c o n t r o l o f spa sti cit y se em s lost. A d o p t ­ i n g a p o s t u r e o f a c u t e flexion at th e hips, h e c a n j u s t m a i n t a i n hi m sel f b e t w e e n t h e c r u t c h e s . E v e ry effort at re la x in g his tens e a b d o m i n a l s p r o d u c e s o n l y a reflex a c t i o n r e t u r n i n g h i m t o t h e initial flexed po si ti on . All thes e ty pes, wit h c o n s t a n t t u i t i o n , will e v e n t u a l l y l ear n th e a r t o f c r u t c h w al ki ng . G r a d u a l l y t h e i r c o n f i d e n c e will incr eas e. T h e y will t r u s t a m u sc le even i f it is s o m e w h a t bel ow n o r m a l s t r e n g t h , a n d th ey will lose t h e a p p r e h e n s i o n o f a n i m p e n d i n g fall. But w h e n e v e r th e r e h a b i l i ta t io n t h e r a p i s t m e e t s o n e o f t h es e difficult p a t i e n t s , m u c h a d d i t i o n a l t i m e will h av e to be d e v o t e d t o s u c h a p a t i e n t , g u i d i n g h i m t o w a r d s b e t t e r balan ce. A flaccid p a r a l y s i s c a s e o n c e d e s c r i b e d to m e his difficulty in b a l a n c i n g w i t h c a l i p e r s a n d c r u t c h e s . H e sa id his t r u n k felt like a s h a r p e n e d pencil t r y i n g to s t a n d wit h its p o i n t o n a p o l i sh ed table. A n d , p o i n t i n g 10 his pelvis, he a d d e d t h a t t h e t a b l e w as no t s t e a d y eith er. W i t h this p i c t u r e in m i n d it s e em ed w o r t h t r y in g w h e t h e r sta b ili zin g t h e " t a b l e ” w o u l d fa ci l i ta t e a n d sp ee d u p t h e a c q u i s i t i o n o f b a l a n c e in t he e r ec t po si t i o n . T h e sim pl es t w a y a p p e a r e d to be a f ix at io n o f t h e w a l k i n g ca l i p e r s to t he g r o u n d . T h e p a t i e n t c o u l d t h u s be freed f r o m fe ar o f fa ll ing a n d c o n ­ c e n t r a t e o n t h e b a l a n c e o f his u p p e r bod y. FIG. 1. FIG. 2. FIG. 3. 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 Seven F i g u r e s I a n d 2 s h o w t h e ty p e o f d o u b l e leg b r a c e w hi ch o u r w o r k s d e p a r t m e n t a s s e m b l e d a s a p o r t a b l e u ni t o n a s t u r d y steel plat e. It is so c o n s t r u c t e d t h a t it c o m f o r t a b l y a n c h o r s th e p a t i e n t in his w a l k i n g ca l i p e r s to t h e b a s e -p l a t e a n d s t r a p s h im securely t o t h e semi- cyl in dr ic al leg s u p p o r t s . T h e suc ces s o f this a p p a r a t u s w as g ra t i fy i n g . T h e very p a t i e n t f o r w h o m 1 h a d de si gn ed it t u r n e d f r o m a di si n t e r e s te d n e a r - o b j e c t o r t o a n a r d e n t c o l l a b o r a t o r w h o sim pl y c o u l d no t get e n o u g h o f his daily w o r k - o u t in t h e " B a l a n c e r . " A t first still h a n g i n g o n w i t h o n e h a n d to a n o v e r h e a d s t r a p , he s o o n b a l a n c e d w i t h o u t h o l d i n g o n , le a r n e d t o sw in g b a c k to g o o d h y p e r e x t e n s i o n a n d f o r w a r d b e y o n d th e vertical. A f t e r o n l y a c o u p l e o f d a y s h e h i m se l f a s ' e d fo r his c i u t c h e s w h i c h unt il t h e n he h a d l o a t h e d . T o lift th e c r u t c h e s a l t e r n a t e l y f o r a t h r e e - p o i n t s u p p o r t c e a s e d to be a t e r ri f y i n g e x p er i en ce fo r hi m . S h i ft i n g o f th e b o d y weig ht f r o m sid e to side b e c a m e eas y, a n d wi t h i n a n o t h e r few d a y s h e wa s i n d e p e n d e n t wit h his c r u tc h es . It w as o b v i o u s t h a t in his c a s e week s o f a r d u o u s w o r k h ad been sa ve d . Sin ce t h e n m a n y o f o u r p a t i e n t s h a v e q u ic k ly g a i n e d c o n f i d e n c e t h r o u g h t h is si m pl e a p p l i a n c e . Fig. 3 show's a p a t i e n t with a f r a c tu r e o f t h e l u m b a r s p i n e a n d r e s u l t a n t flaccid p a r a p l e g i a se cu re ly b r ac ed in th e a p p a r a t u s . H e is c o n c e n t r a t i n g o n m a i n t a i n i n g t h e erect p o s i t i o n j u s t a f t e r h e h a s release d his gri p o n th e o v e r h e a d s t r a p n e x t to hi m . W e did no t limit t h e a p p l i c a t i o n o f th e FIG. 4. a p p a r a t u s to p l ai n b a l a n c i n g exercises. In o r d e r to e n c o u r a g e a w i d e r r a n g e o f m o v e ­ m e n t , de v e l o p i n c r e a s i n g c o n f id en ce , a n d p r o v i d e a n in ce n t i v e to lo n g er p ra c t i c e p er io ds , we b r a n c h e d o u t in to t h e field o f p l a y a n d g a m e s in t he u p r i g h t p o si t i o n . W e i n t r o d u c e d c a t c h i n g a n d t h r o w i n g o f t e n n i s balls, le a d i n g to a i m i n g a t t ar get s a n d t h r o w i n g t h e ball t h r o u g h h o o p s . T h e fa irly s u b s t a n t i a ! 8-i n c h r u b b e r ball p r o v i d e d t h e next step in the p r o g re s s i o n (Fig. 4). T h r o w i n g it o v e r h i gh b a r s a n d in to n et- b all b a s k e t s a d d e d r a n g e a n d a c c u r a c y to t he b o d y swing. A t t a c h e d t o a r o p e it w a s us ed as a slow p u n c h i n g ball ( Fi g. 5). A few' p a t i e n t s d e v e l o p e d sufficient c o n t r o l a n d c o - o r d i n a t i o n to let t h em try th eir h a n d a t d a r t t h r o w i n g . T o e n c o u r a g e swift a n d s w e e p i n g a r m m o v e m e n t s we g a v e o u r p a t i e n t s ta b l e - t e n n i s bat s a n d s h o w e d t h e m h o w t o hit th e pin g- p o n g ball (Fig. 6). T h is p r o v e d su c h a n a t t r a c t i o n t h a t we rigged u p a n i m p ro v i s e d p i n g - p o n g FIG. 6. FIG. 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 Eight P H Y S I O T H E R A P Y July, 1954. t ab l e. Be fo re lo n g w e o r g a n i s e d th e first " m a t c h " b etw een t w o c o m p l e t e pa ra p l e g i c s s u p p o r t e d in t h e leg -stabili zer. F i g u r e 7 s h o w s a set b etw een a n e x p e r t a n d a beg in ner , t h e l a t t e r still h o l d i n g o n t o a n o v e r h e a d st r ap . All th ese ac t i v i t i e s c o m p e n s a t e d us t o s o m e e x t e n t f o r ou i in abi li ty to i n t r o d u c e on a n a d e q u a t e sc ale t he m u c h a d m i r e d w h e e l - c h a i r s p o r t s a n d g a m e s d e v e l o p e d by Dr. G u t t m a n n o f S t o k e - M a n d e v i l l e , f o r wh ic h, u n f o r t u n a t e l y , o u t cen t r e- o f- ci t y h o s p i t a l h as n e i t h e r a m p l e g r o u n d s n o r facilities. O t h e r uses o f the a p p a r a t u s c a n be f o u n d in t h e r e h a b i l i ta t io n o f b ad ly af fe ct ed pol io- p a t i e n t s. A s u i t a b l y a d a p t e d s m a ll e r m a c h i n e h elp ed a ba d ly p a r a l y s e d po li o -c h il d o f f o u r y ea r s o n t o ca l i p e r s a n d c r u t c h e s , a n d a little boy suff ering f i o m c e r e b r a l palsy built up c o n f i d e n c e t o o v e r c o m e ev en t u al l y his t e n d e n c y to fall to t he g r o u n d . B o th ch i l d r en en j o y e d ex er ci se a n d play wit h t h e i r legs firmly se cu re d . In thes e c a s e s a g a i n m u c h t im e w as sa ve d . In the O c c u p a t i o n a l T h e r a p y D e p a r t m e n t t h e a p p a r a t u s m ay be help ful t o let p a t i e n t s c a r r y o u t s u c h wide- r a n g e m o v e m e n t s as - a - ■ M B w o o d p l a n i n g a n d ------ — f saw ing. T h e p o r t a - ' f l M ' jfj . _ * I ‘ bility o f t h e a p p a ­ r a t u s s h o u l d i n ­ c r ea s e its usefuln es s. ( (I . ) P O R T A B L E O V E R H E A D F R A M E . (Fig . 8). T h i s f r a m e w as __ d e s i g n e d a t a n e ar ly * a W j f t * i > st a g e o f o u r w o r k If A . L FIG. 8 . w i t h s p i n a l p a r a p l e - S ' ■ ■ gy. , i ' M i; ' ' • C m I f I ' f g gics. A t t h a t t i m e, m*.----- ^ _________________ n o w se veral ye ar s a g o , w e s o m e t i m e s received at o u r , s 2 ^ ' l C e n t r e p a t i e n t s wi th f r a c t u r e d spin es , w h o h a d a l r e a d y » . 1 & W j R j l s p e n t a l on g p e r i o d in th ei r local h o s pi ta ls , a n d h a d ^ ^ ^ ^ ______ . 4 d e v e l o p e d l ar g e p r e s s u r e s o r e s o n b a c k a n d hip s. A < j j f l L * J M F f l P H *1 ^ I t r e a t m e n t p r o g r a m m e f o r th e s e s o r e s w as w o r k e d o u t ■ ■ m ' i H l l j l ^ 0 r in g r e a t de ta il in c o n j u n c t i o n wit h th e n u r s i n g s t a ff ® ! i H U i n thi s c a r e f u l r o u t i n e it w a s a n i m p o r t a n t p o i n t t o | | J I \ a v o i d fric ti on a n d i r r i t a t i o n o f th e af fected a r e a s wh en m o v i n g t h e p a t i e n t f r o m t h e w a r d to th e r e h a b i l i t a t i o n •- 7* * m m y g ____ ' f R j . d e p a r t m e n t , a n d w h e n h e l p i n g h im f r o m t h e lying to t h e /, r y ^ s t a n d i n g p o s it io n f o r w a l k i n g exercises. V, / ; > T h e o v e r h e a d f r a m e r ed u ce d t h e risk o f su c h fri cti on E t o a m i n i m u m . It is wide e n o u g h to al l o w a wheel- > - v s t r e t c h e r o r even a h o s p i t a l bed o n w hee ls t o (it bet wee n th e u p r i g h t po les FIG 9 T h e t r a n s f e r f r o m t h e lying t o t h e s t a n d i n g p o s i t i o n is d i v i d e d in to five sta ge s: ( I) T h e p a t i e n t , r e a d y w it h c a l i p e r s a n d b o o t s , lies flat o n t h e s t r e t c h e r . T h e h e a d e n d o f th e s t r e t c h e r is wh ee le d u n d e r the c r o s s - b a r o f th e fra m e. ( II) H e is as si st e d at th e s h o u l d e r s so t h a t he ca n g r a s p t h e b a r w i t h a r m s ex t e n d e d . (lii) P u l l i n g h i m s e l f up wit h b e n t e l b o w s he is lifted cl ea r o f f t he s t r e t c h e r (Fig. 9). (iv) T h e s t r e t c h e r is sli pp ed o u t . | (v) T h e p a t i e n t , still h o l d i n g o n t o th e b ar . is ge n t l y lo w er ed t o t h e s t a n d i n g ' po si t i o n . (Fig. 10). A c c o r d i n g to t h e stage o f the p a t i e n t 's p r o g re s s eit her t he ax il la ry p a d s o f the w h e e l - c r u t c h ( w a l k i n g m a c h i n e ) o r his o r d i n a r y cr u t c h e s ar c th en p lac ed right u n d e r his a r m p i t s . H e c h a n g e s his g r ip f r o m t h e h o r i z o n t a l b a r o f the f r a m e to th e c r u t c h h an d l e s , a n d is r e a d y to c o m m e n c e s t a n d i n g a n d w a l k i n g exercises. A t t h e e n d o f th es e exercises, t h e lifting r o u t i n e is r ev er sed : T h e p a t i e n t finishes his w a l k i n g exercises i m m e d i a t e l y u n d e r t h e f r a m e . He releases his g r ip o n t h e c r u t c h h a n d l e s , c h a n g e s to a firm g r ip o n t h e h o r i z o n t a l b a r o f t h e f r a m e , pul ls h i m s e l f u p a n d is lifted t o t h e h o r i z o n t a l p o s i t i o n . T h e s t r e t c h e r o r bed is t h e n wh ee le d u n d er , a n d t he p a t i e n t is gen tl y lo wer ed o n t o it. P r e s s u r e so r es , f o r t u n a t e l y , n o lo n g e r c o n s t i t u t e a p r o b l e m . G r e a t st ri d es h av e b e e n m a d e in t h e i r p r e v e n t i o n , a n d p a t i e n t s w i t h f ra c tu r e d sp in es a r e s e n t a t a n ea r l y s t a g e t o th e R e h a b i l i t a t i o n C e n tr e. B u t t h e r o u t i n e o f g et ti ng t h e p a t i e n t f r o m t h e lying t o t h e s t a n d i n g p o s i t i o n wi th t h e a i d o f th e o v e r h e a d f r a m e we h a v e r et ai n ed , It ha s p r o v e d a safe, ti m e- s av i n g a n d , a b o v e all, s a t is f a c t o r y m e t h o d to t h e p a t i e n t w h o feels t h a t h e h i m se l f t a k e s a very ac ti ve p a r t in it. O n w a r m d a y s th e f r a m e is t a k e n t o t h e c o u r t - y a r d a n d t h e p a t i e n t go es t h r o u g h his r o u t i n e in t h e o p e n air. In t h e w a r d s w