Page Six P H Y S I O T H E R A P Y January, 1951 ABSTRACTS Amputees and Artificial Limbs. Henry H. Kessler, M.D., Ph.D., Newark, N.J. In Journal of the Am erican Medical Association, 142:3:176, January 21, 1950. (This paper was prepared at the request of the Council on Physical Medicine and Rehabilitation and is one of a series appearing in The Journal. Later the entire series will appear in book form as the Council’s Handbook o f Physical Medicine and Rehabilitation). Am putees react to their disability in a variety of w a y s .'A small num ber adjust rapidly because of ex­ cellent medical care and prosthesis and favourable social, econom ic and vocational conditions. Others, overwhelm ed by the severity of their disability (such as a high double above-knee am putation), or by the lack of satisfactory conditions of living, becom e com ­ pletely helpless. The m ajority, however, struggle valiantly and patiently until the weight o f circum ­ stance tips the balance for or against them. Rehabilitation is a concept of treatm ent which can facilitate and perfect a satisfactory adjustm ent. By rehabilitation is meant an integrated plan of treatment in which full restoration of the patient is the com ­ bined responsibility of the surgeon, limb maker, physical therapist and all ancillary personnel con ­ cerned with the preparation of the patient for gainful employm ent. Rehabilitation of the amputee does not begin with his discharge from the hospital nor with the fitting of the prosthesis. Properly, rehabilitation begins when the patient is hurt. Faced with the triple threat o f loss of an organic part of the body, severe em otional shock as a reaction to this experience and the social pre­ judice of the man of the street to the obviously crippled, the amputee is prey to a thousand anxieties and apprehensions. One of the m ost com m on causes o f poor fit o f the prosthesis is an inadequate stump. Immediately after amputation certain changes take place in the stump which make it, actually, a patho­ logic organ. These changes occur in all parts of the stump, skin, subcutaneous tissue, fascia, muscles, blood vessels and nerves. There are three types of changes in the stump which influence the patient’s ability to wear a prosthesis satisfactorily: atrophy, contractures and circulatory trouble. Contractures are responsible for much poor adjust­ m ent to artificial limb's. Improper postoperative posture and muscle imbalance are the m ost com m on causes. The practice o f placing pillows under the thigh or knee is a frequent practice which cannot be to o strongly condem ned. The im proper position of the limb induced by these pillows or sandbags is usually unnoticed by the solicitous nurse or relative w ho placed them there. The cause o f these contractures can be easily dem on­ strated b y having the patient lie on his back, flex the sound hip on the abdomen with both hands and attempt to place the stump of his amputated leg on a table, in a flat position. Invariably, the stump will be elevated and flexed. Thus the flexed stump makes proper fitting o f a prosthesis difficult, if not impossible. It is like fitting a round peg in a square hole. These flexion contractures can be prevented by elim ination of all pillows and sandbags from the patient’s stump. The use o f m oleskin traction skin strips may also prevent the form ation of these con­ tractions. Once they have appeared, they must be vigorously treated by repeated and systematic mani­ pulation and stretching — manually, by forced m ove­ ments, resistive exercises or weights and pulleys. A bduction contractures also frequently follow above­ knee amputations, especially in the presence o f short thigh stumps. Development o f the adductors and the extensors of the hip by system atic exercise is necessary for proper control of the prosthesis as well as elimina­ tion of the contracture. Other exercises also are necessary; the amputee who carries out systematic conditioning activities will find operation of his limb considerably facilitated. The amputee is not expected to becom e a professional athlete — m erely to train like one! Certain other specific exercises are indispensable to good limb wearing. For example, the basis of good walking is balance. For the bilateral above-knee amputee, proper balance is impossible w ithout good abdominal muscles. These men are m ost in need of adequate muscle con­ ditioning, but all above-knee amputees require strong abdominal muscles as a basis for good balance. Few amputees require simplicity m ore than does the man w ho has lost his upper extremity. Loss of a leg can easily be compensated for, and its function dupli­ cated, by mechanical means, because weight bearing is easily reproduced. But when a man loses his hand or arm its functions of grasp and touch cannot be duplicated — they can only be imitated, and poorly at best. Thus so m any arm amputees becom e discouraged with their prosthesis; they expect too much. It is there­ fore necessary that the patient’s psychologic pre­ paration include awareness of the limitations of his prosthesis. He will be saved m any heartaches and pre­ pared for a realistic attitude tow ard his own possi­ bilities. The am putee’s ability to use his prosthesis and walk properly is affected by four im portant factors: a flexed or contracted stump, a poorly fitted or aligned pros­ thesis, fear of falling and im proper balance. The after-care of the stump and the fitting of the prosthesis has already been discussed. Unless the patient is given the necessary training, he will not conquer his fear of falling or overcom e his improper balance. The artificial limb is a special instrument which demands some understanding of its use and application. To expect the amputee to walk well im me­ diately after his limb has been fitted is to presume that he has the com bined knowledge o f the surgeon, engineer, limb maker, physical therapist and physio­ logist. Although the period o f training will vary with the nature of the amputation and the attitude of the patient, a standard period of training would be about one month. During the first week the patient learns to apply his prosthesis correctly. Exercises in balance are carried out in a gymnasium with hand rails or at hom e with tw o strong chairs about tw o and a half feet (76 cm .) apart. Practice should be done before a long m irror, and the eyes of the amnutee should be on his reflection and not on his feet. W ith hands on supports, the patient slowly shifts his weight to the side of the normal leg until the foot is in line with the chin and 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. ) January- 1951 P H Y S I O T H E R A P Y Page Seven . ht is evenly distributed over the foot. This the weig . j for ahout three seconds. Next, the ^ h t is slowly shifted to the artificial limb. Much of S. weieht will have to be taken by the hand supports, ur+h time and practice the patient should be able to intain correct balance with the hands resting lightly the supports, until finally balance can be obtained ° ” thout using the supports at all. Additional balancing "xercises are carried out until the patient can stand, th correct posture, and place his foot in front, in and to the side without losing balance. These first exercises are indispensable. The second week is devoted to practicing level walk­ ing on various types of terrain, such as plaster, soft earth, glass and stone. Gait exercises are undertaken in zig-zBf? end side-to-side fashion and on fixed figures on the floor. In the third week exercises include arm m ovements in a standing position, co-ordination of arm m ovem ents and walking, walking over obstacles such as mats and hurdles, walking dow n steps and endurance exercises ffor five minutes. During the last week, com plete freedom is allowed in walking and includes routine sports activities, such as bicycling, riding, dancing and hiking. The double amputee receives special exercise con- ■ sideration. During the first week he must becom e accustomed to his legs. The second week h e learns balance. During the third week he begins to walk, preferably with the assistance of tw o canes or hand rails, and by the fourth week he is generally able to walk without any support or, at the most, w ith one cane. In the meanwhile, he perform s general gymnastics with and without the prosthesis. Patients engage in a variety of sports, including swimming. These exercises and training technics not only are applicable to new amputees but are of value in correcting faults of experienced wearers. Recapitulation The rehabilitation o f the amputee is not a dis­ organised, fragmentary type of treatm ent but an integrated concept of medical care that sees the patient through from injury to employm ent. It begins in the .hospital, where the patient is not allowed to waste |time but begins at once with the developm ent of his mind and body to the demands of daily living. By judicious care of his stump, the patient is prepared for the wearing of a prosthetic appliance. The fit of the appliance is given the greatest consideration. Finally, the patient receives the training which helps him realise fully the potentialities of his new limb. The j artificial limb, good as m any of them are, is only a Substitute for the limb that has been lost, and it behooves the amputee to get all he can out of the prosthetic limb b y training himself to becom e expert in its use. Under existing laws, physically disabled persons of working age may receive physical restoration services, including artificial limbs, vocational training and placement services, to make them employable. The state and federal governm ents have learned that it is a good investment to train handicapped workers to nil useful jobs and lead productive lives. T o be eligible the state-federal services, the disabled person m u s t . j*® of working age, have a substantial jo b handicap Because of physical or em otional disability and have a reasonably good chance o f becom ing employable through rehabilitation services. .Thus the surgeon, limb maker, physical therapist, social worker, rehabilitation counselor and the repre­ sentatives of public and private agencies contribute their joint efforts to provide a full service to the civilian and military amputee. B y availing himself of their services, he can becom e and rem ain a socially satisfied and econom ically independent citizen. Intermittent Treatment of Poliomyelitis with Progres­ sive Resistance Exercise Sedgwick Mead, M.D., St. Louis. In Journal of the Am erican Medical Association, 144:6:458, October 7, 1950. The first report on the use of progressive resistance exercise in poliom yelitis is that o f De Lorme, Schwab, and W atkins in 1948. Every report since that time has been an enthusiastic confirmation of the value of this form of treatment, without a single dissent. As a result of m y experience with the m ethod since the early part of 1947, I believe that it is by far the most im portannt contribution yet made to the treat­ ment of this disease. There h a s ' been sometimes justifiable criticism of the use of physical therapy in poliom yelitis and cerebral palsy. This criticism must be m et by increasing use of quantitative measures of progress such as are provided by the technique of progressive resistance exercise. The manual muscle grades (L ovett) are in­ exact but must also be used until better measures are devised. Goniometric measurements are simple and obvious. It is the duty of the occupational therapist to test the patient against a- checklist o f daily living activities. She can also help the patient to recover co-ordination and skill. Quantitative determinations not only reveal pro­ gress but show when it is lacking. W hen three or four determinations of the resistance maximum all give the same result, even the patient gets the point and is willing to discontinue treatment. The patient with an absolute limitation is thus given realistic insight into his disability and encouraged to learn how to live within it. W ithout such quantitative data it is possible for the unscrupulous or self-deluded physician to con­ tinue treatment of the patient for preposterous lengths of time, holding out vague promises of future cure. It has been asserted that physical therapy in polio­ myelitis is a useless luxury because the patient, bv the physiologic demands of his home activities, will recover to the fullest possible extent without additional exercise. The final case report is pertinent to this objection. The rehabilitation of the patient as a w hole is pre­ sumed. Stabilisations, transplants, epiphyseal arrests, vocational testing, and training are as important as they ever were. Summary 1. The use of progressive resistance exercise in con ­ valescent poliomyelitis is described. 2. A few weeks of intensive daily exercise is alter­ nated with three or four m onths of hom e activities until no further improvement occurs. 3. Advantages of this regim en over continuous treatment include econom y of effort and means, more efficient use of equipment and personnel and better psychological adjustment. Most im portant is the quantitative measure of progress provided. 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. )