Page 8 P H Y S I O T H E R A P Y December. 1968 TABLE VI Results in Comparison between Two Consecutive Periods 1964-1966 and 1966-1967 Year R efused Treatment D ied B efore Treatment O esophago- Gastrec- tom y O esophago- C olic By-pass R a d io ­ therapy Intubation Total 1964 18 37 Total 51 13 30 135 273 to 1966 6 .6 % 13.9% D ied in H ospital 12 23.5% 6 46.6% 5 16.6% 46 34.1% 106 39.1% 1966 10 17 Total 56 *38 t l 8 8 137 27 250 to 1967 4% 6.8 % D ied in H ospital *6 14 f 8 *16% 25% t4 4 % 4 50% 20 14.6% 13 48.1% 68 27.2% ♦W ithout Pre-operative Radiotherapy. fW ith Pre-operative R adiotherapy. Paper delivered at the Post-R egistration Course at S.A .S.P . N ation al Council M eeting in Port Elizabeth, M ay, 1968. DERANGEMENTS OF THE KNEE T H EIR R E C O G N IT IO N A N D T R E A T M E N T M r . J. D . O S M O N D , f .r .c .s ., H ead o f D epartm ent o f O rthopaedics, Livingstone H ospital, Port Elizabeth. The P hysiotherapist has alw ays fulfilled an integral and important role in O rthopaedic Surgery. One can state categorically that m o d e m orthopaedics is ju st n o t feasible w ithout the assistance o f the “ P h ysio” . We “ O rth opods” are very jealou s and proud o f this special relationship. I have chosen to speak abou t the knee-joint as this is a surgical field where our com bined talents are com m only required. A lso , the knee-joint ranks second only to its upstairs neighbour, the hip, in im portance. Derangem ent, in its orthopaedic context, m eans a m echanical m alfunction. The knee-joint is a reasonably uncom plicated hinge-m echanism but is particularly vulner­ able to derangem ent o n accou nt o f a num ber o f fa c to r s: 1. T H E A N A T O M Y is such that there is n o bony stability such as we encounter in the other great weight-bearing jo in ts o f the low er limb, i.e. The ball-socket o f the hip, the ankle-m ortice, the virtually unshiftable sacro-iliac jo in t with its great supporting interosseous ligaments. This means that the knee depends for stability o n its ligam ents and m uscular support, the latter principally provided by the quadriceps. T he quadriceps are all-im portant and m aintenance or restoration o f quadriceps bulk and pow er is w ithout doubt the m ost im portant single ortho­ paedic fun ction o f the “ P h ysio” . “ Quads. E x .” is the cardinal way back to health o f the deranged knee and I cannot over-em phasize its im portance. It is furthermore a paradox o f locom otor fun ction that these great m uscles are invariably inhibited and wasted in any derangem ent, w hile the hamstrings are n o t sim ilarly affected. 2. SU SC E PT IB IL IT Y TO T R A U M A T IC D E R A N G E ­ M E N T . In this era o f high-speed travel and organised vigorous sporting activity, it is n o t surprising that the knee com m on ly bears the brunt o f a traumatic m isfortune. The classic rugby tackle is directed against the outerside o f the knee, and before this winter is over, a few m ore crippled players w ill be receiving your and our attention. A rticular fracture o f the knee is outsid e the scope o f this address and traum atic injuries will be confined to soft-tissue structures. 3. M IN O R C O N G E N IT A L A N O M A L IE S . The knee-1 jo in t is quite com m on ly the seat o f m inor congential ano­ malies such as knock-knee or patellar instability. These m ay give rise to quite severe disability. Furtherm ore, aggravating deform ities or predisposing weakness m ay result from m alnutritional states, such as rickets. D erangem ents o f the knee are usually classified as internal or e xtern al but for the purpose o f brevity, and since this classification d oes not really help on e appreciate the problem any better, I am going to describe derangem ents in their order o f clinical frequency. A . L IG A M E N T O U S IN JU R IE S . These m ay vary from m inor sprains to com plete ligam ent rupture or avulsion. Since the disability caused by, and treatment required for rupture or avulsion is the sam e, I will n o t separate these two entities and refer to them under the com m on heading ‘R u pture’. M inor Sprains are benign and w ill recover whatever treatm ent is, or is n o t, instituted. T hey m ay be associated w ith considerable early pain and thus be over-diagnosed and, consequently, overtreated. Certain sim ple criteria should help on e to ascertain whether a sprain is a minor one: 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. ) D e c e m b e r, 1968 P H Y S I O T H E R A P Y Page 9 (a) The patient can take weight w ithout excessive limp or pain. There is n o instability. (b) The jo in t is not effused, (c) There is n o t m uch bruising or sw elling, (id) The X-ray is norm al. O bviously a thorough exam ina­ tion should preclude radiography anyway. A firm 6 in. crepe bandage, a handful o f aspirins and som e instruction regarding quads exercises should suffice. T w o or three weeks off vigorou s sport is advisable. Severe Ligamentous Injury. A t the other end o f the scale, we encounter severe ligam entous injury, nam ely, a com plete r u p t u r e ; or a stretching, w ithout actual disruption, resulting in a general slackness. The history reveals a heavy blow or twist to the knee and these patients are severely disabled. On exam ination, w e will fin d : (a) the patient cannot take w eight w ithou t severe pain and the knee tends to collapse; (b) there is generally m uch sw elling and bruising; (c) the jo in t is distended with a bloodstained effusion; Id) there is ligam ent instability. T his m ay be gross and easily dem onstrable; (e) the X -ray (an essential investigation) m ay well show a w idening o f on e aspect o f the joint-sp ace, and there m ay be avulsion fragments o f bone pulled o ff by the dam aged ligam ent or ligaments. The ph y sic a l exam ination o f any sprain ed knee should include: 1. D eterm ination whether the join t is effused. If an effusion is present, it should be aspirated. A spiration is essential both as a diagnostic and therapeutic m anoeuvre. It is inexcusable n o t to aspirate a large effusion w ithout delay. 2. The state o f the m ain ligam ents, i.e. the collateral ligam ents and the cruciates. Y ou will all kn ow the sim ple clinical tests for these structures. 3. E xam ination for “ cartilage-block” . T w o factors may obstruct full exten sion o f the knee: H am strings spasm or a true intra-articular m echanical block to the jo in t surfaces, classically seen in the case o f the torn, displaced m eniscus. It requires considerable experience to distinguish between these. 4. The integrity o f the quads m echanism . M any m iddle- aged or elderly p eop le have a degree o f degenerative change in either the patellar-tendon or supra-patellar expansion o f the quads. Either o f these structures m ay rupture, som e­ times during a sim ple stum ble. Clearly, this individual is quite incapable o f extending the knee and the exam ining finger should localise the rupture w ithout difficulty. 5. The site o f tenderness should be noted. G o o d stability plus tenderness localised to a ligam entous attachm ent to bone indicates the need for conservative treatment. In add ition , im m ediate relief can be obtained by injection into the tender area o f som e suitable local anaesthetic, possibly mixed w ith hydrocortisone. One sm all w ord o f caution; patients w h o have com plete rupture o f a m ain ligam ent may present with little pain and only slight tenderness. Other criteria, how ever, will confirm the diagnosis. The treatm ent o f the ruptured collateral ligam ent should be operative. Ruptured cruciates alone (which incidentally is m ost un com m on ) and the “stretched” collateral ligam ent, m ay all be treated conservatively. H ere on e depends on plaster o f paris cylinders, quads drill and m asterly inactivity to allow nature to repair the damage. Ruptured ligam ents are em inently reparable and one should n o t delay surgical intervention. I personally sew the ends together w ith m onofilam ent nylon which is strong and remarkably non-irritant. B y the sam e token, the ruptured supra- and infra-patellar tendons should be similarly m anaged. A t operation, o n e has the chance o f a g ood lo o k around the jo in t and can deal with any other derangem ent such as a concom m itan tly torn m eniscus or loose flake o f bone lying free in the joint. I m ight m ention the syndrom e know n as the “Terrible T riad” o f knee injury, i.e. 1. Ruptured m edial ligam ent 'I which is not all that 2. Ruptured anterior cruciate J- uncom m on 3. T orn m edial meniscus. J now adays. A single operation would deal with all three aspects. Y ou , o f course, are all aware that the m ost com m on ly dam aged knee ligam ent is the M edial. T he results o f operative repair follow ed by six weeks in a plaster o f paris cylinder plus plenty o f quads ex. can be quite brilliant. B . T H E T O R N M E N IS C U S : Y ou are all aware o f the problem o f the torn m eniscus and the w ay it may cause pain, effusion, clicking, locking, giving-way, and quadriceps w asting. The giving-away is due to m om entary quadriceps inhibition due to noxiou s reflex activity being set-up in certain sensory end-organs o f the deranged join t. The m eniscus itself is very richly innervated by both pain and proprioceptive nerve endings. There is n o question that the torn m eniscus should com e out, and the sooner the better. M inor contusion s or peri­ pheral detachm ents can and do resolve spontan eou sly and com pletely. Clearly these m inor injuries should be given every chance to get better w ith ou t surgery. C linically they present as a “sprained-knee” and should be treated as such. H ow ever, the badly torn m eniscus presents a real danger to the join t and recurrent grinding and jam m ing o f the torn part between the articular surfaces can o n ly result in severe degenerative change, proceeding to a full-blow n O .A . A patient presenting with a locked knee sh ould be adm itted forthwith and operated o n w ithin a day or two. Otherwise the Surgeon is perfectly justified to operate at his and the patient’s convenience. I f there is to be som e delay, it is m ost im portant that the patient performs daily quadriceps drill. Rem em ber that menisci can a lso cause trouble by being discoid or by becom ing cystic. M eniscectom y is a g ood operation and a go o d orthopod is by definition, a go o d m eniscectom ist. T he bad results are due to: 1. M isdiagnosis resulting in the rem oval o f a lily-white norm al m eniscus. 2 . In com p lete removal. 3. T o o late surgical intervention so that irreparable joint dam age has already been sustained. 4. Clum sy surgery. 5. Inadequate post-operative physiotherapy, i.e. super­ vised graduated quads drill. I allow m y patients up on the third p ost-op . day as long as their temperature is normal and good quads, control is present. They m ay go hom e, in their original R.J. bandage, as so o n as they are am bulant and return to the Orthopaedic D epartm ent on the tenth day to have the join t inspected and sutures rem oved. A ny m oderate or large effusion is aspirated at this stage. I w ou ld like to m ention a num ber o f different derange­ m ents which may well be m issed if one is unaware o f their p resen tation : C. C H R O N IC S U B L U X A T IO N O F T H E P A T E L L A : This interesting condition m ust rank as the m ost m isdiag­ nosed derangem ent o f the K nee Joint. The pull o f the quads, is such that the patella has an inherent tendency to subluxate, or even dislocate, towards the lateral side o f the knee. T his tendency increases with kn ock -kn ee and thus is more com m on in the fem ale who has a “ ph ysiological” genu valgum , so to speak. The tendency is counteracted by the horizontal pull o f the low est fibres o f the vastus m edialis which are inserted into the m edial edge o f the knee-cap, and also by the forward projection o f the large lateral fem oral condyle acting as a buttress against lateral shift o f the patella. R elatively m inor departures from the anatom ical norm m ay allow o f patellar instability. The sufferers w h o are usually adolescent girls or youn g w om en, com plain o f 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 10 P H Y S I O T H E R A P Y December, 1968 s u d d e n a t t a c k s o f p a i n f u l g i v i n g w a y o f t h e k n e e a s s o c i a t e d w i t h f r e q u e n t ef f u s i o n s . T h e c o n d i t i o n u s u a l l y b e c o m e s d i a g n o s e d as a n a b n o r m a l i t y o f t h e m e d i a l m e n i s c u s w h i c h i n n o c e n t o r g a n is p r o m p t l y r e m o v e d w i t h o u t a n y relief. T h e d e m o r a l i z e d p a t i e n t all t o o o f t e n b e c o m e s r e g a r d e d as a n e u o r o t i c o r h y p o c h o n d r i a c . T h e d i a g n o s i s d e p e n d s o n d e m o n s t r a t i n g a n a b n o r m a l d e g r e e o f s i d e - t o - s i d e i n s t a b i l i t y o f t h e p a t e l l a . A c o n ­ f i r m a t o r y f in d in g , w h i c h is q u i t e c o n s t a n t , is t e n d e r n e s s a l o n g t h e m e d i a l b o r d e r o f t h e p a t e l l a a n d p a i n in t hi s a r e a o n f o rc i b l y p u s h i n g t h e p a t e l l a in a l a t e r a l d i r e c t i o n . T h e l a t t e r is d u e t o r e c u r r e n t t r a u m a t o t h e h o r i z o n t a l fi bre s o f v a s t u s m e d i a l i s a n d s t r e t c h i n g o f t h e u n d e r l y i n g c a p s u l e . M i n o r d e g r e e s o f th i s s y n d r o m e m a y r e s p o n d t o q u a d s , ex., p a r t i c u l a r l y a i m e d a t b u i l d i n g u p t h e v a s t u s m e d i a l i s . M o r e s e v e r e c a s e s r e q u i r e s u r g e r y — n o t m e n i s c e c t o m y , b u t t r a n s p l a n a t i o n o f t h e p a t e l l a r t e n d o n i n t o t h e m e d i a l s u r f a c e o f t h e ti b i a . O n e s o m e t i m e s f in ds t h a t t h e a r t i c u l a r s u r f a c e o f t h e p a t e l l a is se v e re ly d a m a g e d a n d p i t t e d d u e t o r e c u r r e n t t r a u m a a n d , if t h i s is t h e c a s e , p a t e l l e c t o m y is s i m u l t a n e o u s l y p e r f o r m e d . T h i s o p e r a t i o n is v er y effe ctiv e a n d m o s t p a t i e n t s a r e c o m p l e t e l y r e li ev ed o f s y m p t o m s . D . C H O N D R O M A L A C I A P A T E L L A E : W h i l e o n t h e s u b j e c t o t t h e k n e e - c a p we c o u l d w i t h a d v a n t a g e r e f r e s h o u r m i n d s a b o u t thi s c o m m o n a n d d i s t r e s s i n g c o m p l a i n t . O n c e a g a i n a d o l e s c e n t g ir ls a r e m o s t f r e q u e n t l y i n v o l v e d . E i t h e r s p o n t a n e o u s l y o r a s a r e s u l t o f d i r e c t t r a u m a t o t h e p a t e l l a , t h e a r t i c u l a r c a r t i l a g e o f t h e p a t e l l a u n d e r g o e s a d e g e n e r a t i v e p r o c e s s r e s u l t i n g in u l c e r a t i o n o r f i b r i l l a t i o n . P a t e l l a - f e m o r a l f r i c t i o n e n s u e s w h i c h m a y be v er y p a i n f u l . T h e c o n d i t i o n is f r e q u e n t l y b i l a t e r a l . T r e a t m e n t s h o u l d a l w a y s be c o n s e r v a t i v e in t h e first p l a c e a n d 1 a d v i s e q u a d s , ex. a n d in j e c t t h e k n e e j o i n t w i t h h y d r o ­ c o r t i s o n e . T h e c o n d i t i o n a p p e a r s t o b e se l f - l i m i t i n g a n d u s u a l ly se t tl es a f t e r se v e r a l m o n t h s o r e v e n a y e a r o r t w o . T h e o d d c a s e m a y , h o w e v e r , c o m e t o p a t e l l e c t o m y , a n o p e r a t i o n w h i c h n o o n e s h o u l d u n d e r a t k e l ig h tl y o n a y o u n g w o m a n b e c a u s e o f t h e b a d c o s m e t i c resu lt . E. O S T E O C H O N D R I T I S D I S S E C A N S u s u a l l y af fe cts t h e m e d i a l f e m o r a l c o n d y l e o f a d o l e s c e n t b o y s a n d m a y r e s u l t in t h e f o r m a t i o n o f a l o o s e b o d y . T h e s y m p t o m s m a y r e s e m b l e a t o r n m e n i s c u s o r t h e p a t i e n t m a y p r e s e n t w i t h a n a c u t e l y l o c k e d k n e e d u e t o t h e l o o s e b o d y . T h e d i a g n o s i s is m a d e o n t h e t y p i c a l X - r a y a p p e a r a n c e . T r e a t m e n t v a r i e s f r o m m a s t e r l y i n a c t i v i t y w i t h o b s e r v a ­ t i o n , t o p e r i o d s in p l a s t e r o f p a r i s c y l i n d e r s w i t h n o n ­ w e i g h t - b e a r i n g , t o o p e n o p e r a t i o n e i t h e r t o r e m o v e t h e o s t e o c a r t i l a g i n o u s f l ak e o r t o r e p l a c e it in t h e p it f r o m w h e n c e it c a m e . S m i l li e d e s i g n e d his s p e c i a l P i n f o r thi s o p e r a t i o n . F. L O O S E B O D I E S ( T H E S O - C A L L E D J O I N T M O U S E ) — m a y r e s u l t f r o m o s t e o p h y t e s b r e a k i n g of f in t h e O . A . k n e e , o r c a n d e v e l o p in th i s c u r i o u s c o n d i t i o n o f s y n o v i a l o s t e o c h o n d r o m a t o s i s . I f t h e y c a u s e t r o u b l e , th ey s h o u l d be l o ca li se d by X - r a y a n d t h e n su r g i c a l l y r e m o v e d . G . O S T E O C H R O N D R I T 1 S O R E P I P H Y S I T I S — c a n m a n i f e s t in t h e k n e e a s a n O s g o o d - S c h l a t t e r ’s D i s e a s e o r it m a y affe ct t h e l o w e r p o l e o f t h e p a t e l l a a s a S v e n - L a r s e n s y n d r o m e . T h e su f f e re rs h e r e a r e y o u n g a n d f r e q u e n t l y a c t i v e a n d s p o r t s m i n d e d . A d o l e s c e n t b o y s a r e m o r e c o m m o n l y in v o l v e d t h a n gir ls a n d m a y b e d i s t r e s s e d by t h e p a i n f u l l u m p s a t t h e u p p e r e n d s o f t h e ti bi a. H o w e v e r , t h e s e f o r m s o f o s t e o c h o n d r i t i s a r e i n v a r i a b l y se l f- l i m i t i n g a n d s u r g i c a l i n t e r v e n t i o n is n e v e r ju st i f i ed . R e a s s u r a n c e o f M o t h e r , a n x i o u s t h a t h e r l a d h a s b o n e - c a n c e r , a n d d i m i n i s h e d a c t i v i t y o f t h e b o y f o r six m o n t h s o r s o , is all t h a t is r e q u i r e d p l u s q u a d s , ex. si n c e reflex w a s t i n g o c c u r s r a p i d l y . H . P O S T - O P E R A T I V E K N E E - S T I F F N E S S . T h i s u se d to b e a c o m m o n p r o b l e m p a r t i c u l a r l y f o l l o w i n g f e m o r a l s h a f t f r a c t u r e s . I t is d u e b o t h t o i n t r a - a r t i c u l a r a d h e s i o n s a n d t o t e t h e r i n g o f t h e q u a d r i c e p s bellies. N o w a d a y s we c o m m o n l y t r e a t th e s e f r a c t u r e s by I n t r a - m e d u l l a r y N a i l i n g . I t is m o s t i m p o r t a n t t o i n s t i t u t e ea r l y k n e e - m o v e m e n t s a n d we like o u r “ P h y s i o ’s ” t o be g in ac ti ve a n d pa s si v e ex er ci se s o n t h e first p o s t - o p e r a l i v e d a y . T h e r e s h o u l d be a r e t u r n o f 90° o f flex ion in t h e first we ek . I h a v e n e v e r s e en m y o s i t i s o ss i fi c an s a s a re su l t o f t h is r e g i m e , but h a v e s e e n g h a s t l y stiff nes s o f t h e k n e e in p a t i e n t s w h o h a v e b e e n left u n a t t e n d e d f o r t w o o r t h r e e w e e k s a f t e r t h e K . N a i l w a s i n se rt e d . R E H A B I L I T A T I O N S T A I R S M I S S J . M . W A L K E R L e c t u r e r S u b D e p t , o f P h y s i o t h e r a p y U n i v e r s i t y o f W i t w a t e r s r a n d F o r u se in h o s p i t a l g a y m n a s i u m s a n d P h y s i o t h e r a p y S c h o o l s . R e h a b i l i t a t i o n s t a i r s s h o u l d e m b o d y t h e f o l l o w i n g f e a t u re s f o r s a f e t y a n d m a x i m u m u s e f u l n e s s t o t h e r a p i s t s in t he v a r i e t y o f c o n d i t i o n s w i t h w h i c h p a t i e n t s p r e s e n t . (a) S a f e t y : s t r o n g l y a n d s o l i d l y c o n s t r u c t e d , w i t h n o n ­ sl i p s t e p c o v e r i n g a n d w i t h o u t " r a i l p l a y ” . ( b ) W i d t h : o f s u c h w i d t h t h a t a l l o w s t h e t h e r a p i s t t o s t a n d cl o s e t o t h e p a t i e n t . ( c) P r o v i d e a v a r i e t y o f s t e p s in h e i g h t a n d le n g t h to e n a b l e r e t r a i n i n g s i m i l a r t o c o n d i t i o n s a p a t i e n t m a y m e e t in p u b l i c p l a c e s o r at h o m e . (d ) R a i l s : T w o r a i l s s h o u l d b e p r e s e n t . T h e d i s t a n c e b e t w e e n t h e t w o ra il s s h o u l d b e s u c h t h a t a p a t i e n t c a n c o m m e n c e s t a i r t r a i n i n g u s i n g t w o r a i l s a n d p r o ­ g r e ss t o t h e u se o f o n e ra il , o n e w a l k i n g a i d , etc. ( e) A suff ici ent ly siz ed p l a t f o r m a t t h e “ h e a d o f the s t a i r s ” s h o u l d be p r e s e n t w h i c h will a c c o m m o d a t e b o t h p a t i e n t a n d t h e r a p i s t s i m u l t a n e o u s l y , a l l o w th e p a t i e n t t o t u r n w i t h c o n f i d e n c e a n d e n a b l e t h e pl a c i n g o f a c h a i r i f ne c e s s a ry . I n o b s e r v i n g t h e a b o v e f a c t o r s it is a l s o d e s i r a b l e , c o n ­ si d e r i n g t h e size o f m o s t h o s p i t a l g y m n a s i u m s t h a t t h e st a ir s t a k e u p a m i n i m u m o f sp a c e . W i t h t h e a b o v e p o i n t s in vi ew t h e f irm s u p p l y i n g h o s p i t a l s w i t h R e h a b i l i t a t i o n s t a i r s w a s r e q u e s t e d t o m a k e c e r t a i n a l t e r a t i o n s t o t h e i r e x i s t i n g t y p e w h i c h is c o n s i d e r e d u n s u i t ­ a b l e d u e t o t h e f o l lo w in g f e a t u re s. (a) s t e p s o f p o l i s h e d w o o d , s l i p p e r y , p r o m o t i n g a lac k o f c o n f i d e n c e , p a r t i c u l a r l y in t h e eld er ly . Cb) in su f f ic ie nt d e p t h t o s t e p s t o a l l o w full p l a c i n g o f the a v e r a g e siz ed f o o t . (c) n o v a r i a t i o n in t h e h e i g h t o f t h e ste ps . i d ) in su ff ici en tly siz ed p l a t f o r m a t t h e “ h e a d o f th e s t a i r s ” f o r p l a c e m e n t o f a c h a i r , o r t w o p e r s o n 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. ) December, 1968 P H Y S I O T H E R A P Y Page 11 The modified Rehabilitation Stairs, n o w available, contain the following features: Total length: 105 inches. T otal w idth: 36 inches. ^ Steps and Central Platform are covered with rubber matting in., having a diam ond mesh pattern. Steps: All steps have a length o f 15 inches. There are 3 steps on one side o f 8 in. depth and 4 steps on the op p osite side of 6 inches depth. Central P latform : H as a depth o f 39 inches at a height o f 24 inches from the floor. Rails: Provided on both sides, detachable, held in place by wing nuts. B ein g detachable enables easier transport, thus reduces the total cost and allow s a therapist to rem ove one rail if desired. A n additional feature which m ay be ordered by those centres with a high num ber o f patients, as Paraplegics, w h o com m ence stair training using tw o rails is a second placem ent position for one rail, at the width o f 32 inches as well as the standard w idth o f 36 inches. T he rail at the placem ent o f 32 inches w ould how ever have slight “play” com pared to the p osition at 36 in. Construction: P hillopin o M ahogany is used for the sides, rails and upright pieces o f the steps. T he top shelf, platform and the steps are constructed o f $ inches co n te sh e lf which is stronger than the norm al w o o d and the step support and frame is o f i inch Sou th A frican Pine. A recent m odification, not sh ow n on the photograph, is the raising o f the height o f the rails ab ove the platform to the sam e height ab ove each step and the exten sion o f the slop e o f the rails upwards at the edges o f the platform . It is also planned to investigate the p ossibility a o n e rail being m etal, adjustable in height and capable o f sw inging in­ wards, thus enabling the w idth betw een the tw o rails to be reduced easily. It is therefore advocated for reasons o f increased safety and greater variety in training that these stairs b e c o n ­ sidered in preference to the form er type. A n y suggestions for further im provem ents in design w ill be w elcom ed. T he stairs are available from : Protea E lectro-M edical C om pany at an approxim ate price o f R 170. A ckn ow led gem ent: Protea E lectro-M edical C om p any in revising their design and dealing w ith a fem ale non-crafts­ man-carpenter ! Notes on Uses of the Bird Respirator Treatment by Physiotherapy B y J. M A L C O L M , M .N .Z .S .P . Patients w h o benefit from treatment with the Bird R es­ pirator fall into three main groups. 1. The C o-operative patient. 2. T he U n co-op erative patient. 3. T he U n con sciou s patient. Group I. This group falls into tw o section s again. (a) Chronic Lung D iseases: B ronchitis, Em physem a, A sthm a. (b) P o st O perative P atien t, and acute respiratory diseases, (a) Chronic Lung D iseases. Aims o f Treatment. (i) Increase the flow o f air through congested bron­ chioles. (ii) F ully expand stiff and rigid chest and increase the m ovem ent o f a fixed or partially fixed diaphragm. (iii) Introduce nebulized broncho-dilators into the bronchioles for relief o f oedem a and spasm . (iv) Clear m ucus and secretions from the chest. M ethods o f Treatment. (i) P osition the patient where possible. U se postural drainage position s to aid the m ovem ent o f m ucus to the m ain bronchus where it can be easily coughed out. (ii) U se the m ou th piece o f the Bird fitted to the neb u ­ lizer (into which the broncho-dilator prescribed, or distilled water, has been added). (iii) Set dials o f m achine as follow s: Flowrate: U se a long flow rate depending on the patient’s capacity (i.e. size o f chest, am ount o f effective lung tissue left, age o f patient). A long flow rate is between 7-15. This introduces positive pressure slow ly so that air pushes gently past secretions to expand collapsed alveoli and enables patient to cou gh ou t m oistened secretions lying in the airway. Even if the patient is to o depressed to cough, gases flowing out o f the lung gradually propel secretions out o f the peripheral airways. Respiratory Pressure: Set again according to patient’s capacity: 15 is considered norm al for an adult, but a man with healthy lungs will take up to 25 com fortably. Air M ix : T his sh ould be pulled full out to give 40° 0 2 and 60° atm ospheric air. Respiration Effort. Set at 40, unless patient very w eak. T his indicates the am oun t o f effort the patient m akes to trigger the respirator, and sh ould be m ade fairly difficult for the voluntary patient. (iv) Instruct patient in use: H o ld the m outh piece in his m outh , gently pinch his nostrils together so air does n o t escape through nose. Teach him to relax on inspiration and let all the air flow into lungs and n o t cheeks. Tell him n o t to block the flow o f air by closin g his throat or blocking the m outh piece with his tongue. (v) E xpiration: Encourage to breathe out as far as possible. H elp by pushing o n low er ribs and pushing diaphragm up. (If patient is tipped the weight o f the viscera will also help diaphragm to m ove upwards). Footnote: W ith asthm atics, low er the inspiratory pressure; use prescribed bronchod ilator and encourage long, relaxed expiration. I f at first y ou w ish to retard the expiratory phase to teach patient to expire slow ly and in a relaxed fashion, use the “ retard guard” which yo u w ill find attached to machine. (b) P o s t O perative P a tie n t and A cu te R espiratory D iseases. In this group is included— 1. P ost operative laparotom y where there is chronic chest disease. 2. T h orocotom y and lobectom y. 3. Pneum othorax. 4. H aem oth orax. 5. Spinal Injuries. 6 . Injuries o f Chest. 7. A telectasis. 8. A cu te infection o f chronic chest conditions. Aim s o f Treatment. (i) M aintain adequate exp an sion o f lungs and good interchange o f air. (ii) Increase flow o f air into collapsed bronchioles. This is effected by the positive pressure on inspiration. (iii) A ssist expectoration. 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. )