34 Fisioterapie, J u n ie 1982, dee! 38, n r 2 th at a pp li c a t io n of icepacks may not be the ideal tec hn iq u e to use as icepacks, a l t h o u g h lowering skin te m p e r a t u r e to levels at which skin vessels will dilate, will not lo we r muscle t e m p e ra t u r e s to levels at which deep vessel c o n st r ic tio n is inhibited. O u r results f u r t h e r suggest t h a t to achieve dila tat io n of vessels it is not necessary to a pp ly icepacks for long er th an 8 -10 minutes. References A b r a m s o n D D , K a h n A, Rejal H, et al. (1958). Re lat ionship between a r a ng e o f tissue te m p e ra t u re s a n d local oxy­ gen up t ak e in the h u m a n fo re a rm . J ournal o f Clinical Investigation. 37, 1031-1038. A ll w o o d M J , Bu rr y HS (1954). T h e effect of local t e m p e ra t u re on b lo od flow in the h u m a n foot. Journal o f Physiology. 124, 345-357. Bar cro ft H. E d h o lm O G (1943). T h e effect of t e m p e r a t u r e on b l oo d flow a n d deep t e m p e r a t u r e in the h u m a n fore ­ a rm . Journal o f P hysiology. 102, 5-20. Bi er m a n W (1955). T h e r a p e u t i c use o f cold. ./. A m . Med. A sso., 157, 1189-1192. K ni ght K L , L o nd er e e BR (1980). C o m p a r i s o n of b l o o d flow in the ank le o f un i n ju r e d sub jects d u r i n g t he r a p eu ti c a pp lic at io ns of heat, cold a n d exercise. M edicine and Science in S p o rts a n d Exercise. 12, 76-80. L ai n g D R , Dailey D R , K i rk J A (1973). Ice th er a p y in soft tissue injuries. N Z Med. J., 78, 155-158. S c a n do la M, Pezzin G (1978). T h e low tem p e ra t u r e mec han ic al rela xati on o f elastin. II. T h e solva ted p r o ­ tein. B iopolym ers. 17, 213-223. V a n h o u t te PM , V er beu re n T J , W e b b RC (1981). Local m o d u la t io n of a dr ene rg ic n eu ro eff ect or in te ra c tio n in the b l o o d vessel wall. P hysiological Review. 61, 151-247. THE MEASUREMENT OF PAIN - A BRIEF REVIEW C. A. L I G G I N S , M . C .S .P .. H.T.. D IP . T.P.* S um m ary P hysiotherapists are now m easuring pain when they assess their patients. Pain has been considered to be unm easurable by some, but a num ber o f subjective and objective m e thods have been devised. S u bjective m ethods appear to be more sa tisfa cto ry than objective m ethods. S e ve ra l m ethods o f subjective m easurem ent are reviewed. S tu d ie s suggest that the N um erical R a tin g Scale (N .R .S .) m a y be an appropriate subjective scale f o r general use. S everal m ethods o f measuring pain r e lie f are also reviewed. P atients te n d to express them selves m ore in term s o f pain r e lie f than in term s o f pain m easurem ent. The principles o f the S ig n a l D etection Theory f o r quantification o f pain are outlined. IN T R O D U C T IO N O n e of the mo st i m p o r t a n t d e v e l o p m e n t s in the p h y s i o t h e r a p y p ro fes sio n d u r i n g the last few years has been th e in creasing em ph a si s on g o o d assess men t pr io r to ph y si o t h er a p eu t i c inter ven ti on. M e a s u re m e n t is the essence o f scientific m e t h o d a nd d u r i n g their assess men t o f pa tien ts, p hy sio th era pi sts ro utine ly m ea su re such things as muscle s t r e n g th a n d jo in t m o tio n , b u t until recent times it has no t been usual for them t o mea sur e the m a j o r a c c o m p a n i m e n t o f so m any of the c on d it i o n s they tr eat , name ly pain. A c c o r d i n g to H u s k is so n (1974) “ pa in c a n n o t be said to hav e been relieved unless pa in o r p ain relief has been directly m e a s u r e d ” . T h u s the q u e st io n o f the feasibility of pain m ea su r e m e nt mu st be raised. Pain is an a b s t r a c t i o n a nd ther ef ore has been c on sid ere d by m an y to be u n m ea su ra b le . S e n i o r L e c t u r e r , S u b - D e p a r t m e n t o f P h y s i o t h e r a p y , Univ ers ity o f D u rb a n - W e st v i ll e Received 30 Ap ril 1982. O psom m ing F iosioterapeute m eet nou p yn wanneer hulle hut pasiente evalueer. Pyn is deur som m ige as onm eetbaar beskou, m a a r ’n a antal su bjektiew e en o b jektiew e m etodes is ontwerp. S u b je k tie w e m etodes b ly k m eer bevredigend te wees as objek tie w e m etodes. Verskeie m etodes van su bjektiew e m eting w ord hersien. S tu d ie s stel voor d at die N um eriese W aardebepalingskaal (N um erical R a tin g Scale, N .R .S .) 'n g e s k ik te su b jektiew e sk a a l vir a lgem em e g ebruik m ag wees. Verskeie m e todes om p yn ve rlig tin g !e m e et w o r d o o k hersien. P asiente is geneig om liu lse lf eerder in term e van pynverligting as p y n m a a t uit te druk. Die beginsels van die Sein V asstellingsteorie (S ig n a l D etection Theory) van pyn kw a n tifiserin g w ord geskets. H o w ev e r , psychologists have been c o n f r o n t e d by s im ila r '' p r o b l em s relating to the m e a su r e m e n t o f pe rsona lity, d e pr es s io n a n d sleep, a n d they hav e c o p ed with this since the early pa rt o f the century. W hen m e a su r e m e n t o f pa in is being c o nsi der ed , a dist inctio n must be m a d e between ex per im en tal a n d clinical pain. M e a s u r e m e n t o f pa in in the l a b o r a t o r y is relatively easy. Specific a n d g r a d e d stimuli can be used a n d the r esp ons es analysed. It is thu s possible to o bt ai n a large d e g r e e o f s a m e n e s s in e x p e r i m e n t s a n d re la ti v e ly r e p ro du c ib le results can be o b t a i n e d (Ro se n, 1977). Ho w ev e r, with clinical pain the n a tu r e o f the stim ul us may no t be ob vi ou s a n d in some cases pain levels give no ind ica tion o f the severity of the disease. In a d d it i o n pain may be m od ifi ed by m a n y be ha v i o u r a l fa ctors ( Hu sk is so n , 1974). The p r o b l e m o f pa in m e a s u r e m e n t has been a p p r o a c h e d basically in tw o ways. T he most used is the “ subje cti ve ” m e t h o d in which the pa tie n t is a sk e d to re p or t his pain experience directly. A lt ern ati ve ly a n “ obj ect ive ” o r indirect m ea su re (visible o r non -v e rb a l) can be used if there is a re la tio n sh ip betw een the m ea su re a n d relief o f p a in (Rosen, 1977). 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. ) p hysiotherap y, June 1982, vol 38, no 2 35 Th er e are several ways by which subjective m ea su re m e n ts of pain can be o b t ai ne d. T h e simplest for m is a qua litative scale by which th e pati en t r e po rt s the presence o r ab se nce of pain. Al ternative ly, the pa tie nt can be as ke d to express his pain in o r de re d categories, th at is, using w o r d s to explain various levels of pain. Nu m e ric al ra ti n g scales can also be used in which a n u m b e r is a ll oc at ed to a. given pa in level. S IM P L E D E S C R IP T IV E S C A L E (S .D .S .) This m e t h o d co nsists o f f ou r o r five po in ts b ased o n a simple verbal de sc ri p t i o n o f pain, for ex ample, NIL , M I L D , M O D E R A T E , S E V E R E a n d V E R Y S E V E R E (figure 1). This m e t h o d has the a d v a n t a g e th a t it is relatively easy for the patient to u n d e r s t a n d a n d use. How eve r, it has the distinct d i s a d v a n t a g e that it lacks the re q ui re d sensitivity for detecting small changes. F o r e x am p le a pati en t may have pain which he cons id ers to be m o r e t h a n m o d e r a te b u t not sufficient to be r e p or te d as severe, s o in pr actice he ten ds to g r o u p his resp onses to on e o r the other. A n o t h e r disa dv an ta g e o f this scale is th at it may give rise to the a ss u m p t io n that the intensity o f p ain increases or decreases in a linear m a n n e r between the v a rio u s grades. VERY SEVERE PAIN SEVERE PAIN MODERATE PAIN MILD PAIN NO PAIN Fig. 1 Sim ple D escriptive S cale (S .D .S .) N U M E R IC A L R A T IN G S C A L E (N .R .S .) This m e t h o d consists o f an 11 p oi nt (0-10) or a 21 point (0-20) scale, n u m b er s b ein g a llo cat ed in as c en di ng o r d e r ac c or d in g to r e por te d p ain intensity (figure 2). Th e N.R.S. is more sensitive t h a n the S. D.S. bu t this type of scale has d is a d v a n t a g e s similar to those o f the S.D.S. VISUAL A N A L O G U E S C A L E (V.A.S.) This m e t h o d uses a s tr a ig ht line, co nv en ti on al ly 10 centimetres long, the extre me limits o f which are m a r k e d by per p en d ic ul a r lines. T h e ends o f the m ain line, which ma y be vertical o r ho ri zo nt al , c arr y a ve rbal des cri pt io n which d e n ot e the extremes o f the pain to be e v alu ate d, th at is “ no p a i n ” a n d “ pa in as severe as c oul d b e” (figure 3). T he patie nt is as ked to m a r k the line at the p os it io n be tween the two extremes, which re presents the level of pain. T hi s scale is the most sensitive o f those av ailable, as the n u m b e r of possibilities is infinite. It has a d i sa d v a n t a g e in that it may present some pa tie n ts with a c o nc e p t o f pa in m ea su re me n t which they find difficult to u n d e r s t a n d . 10 9 8 7 6 5 4 3 2 1 0 Fig. 2 N um erical R ating S cale (N .R .S .) Pain as severe as could be — — No Pain Fig. 3 V ertical Visual A nalogue S cale (V.A.S.) R E L IA B IL IT Y AND V A LID ITY O F S U B JE C T IV E PA IN S C A L E S T h e usefulness o f subje cti ve pain scales d e p e n d s on the two i m p o r t a n t fa ctors o f reliability a n d validity ( M a cr a e , 1977). Reliability d e p e n d s on ab se nce o f r a n d o m o r systematic error. This is often difficult to achi eve in a n y m ea su r e m e n t process, pa rti cu la rly if it is a psychological m ea sur em en t. How eve r, the i m p o r t a n t r e q ui r e m e nt is that the e r ro r be as small as possible in relation to the use m ade o f the m eas ur em en ts . Validity of subjective pa in scales is very difficult to establish as the very n a tu r e a n d m ea ni n g o f the m ea su r e m e n t is alway s in ques tio n. W h e n a physical m e a su r e m e n t is being m ade th ere is usually no p r ob le m r e g ar d in g validity as there is little d o u b t a b o u t w h a t is being mea sur ed . Ho w ev e r, with a p er so n al, individual experience like pain, there is always so m e d o u b t a b o u t w h e t h er wha t is su p p o s ed to be mea sur ed , is, in fact, b ein g m ea su r e d ( M acr ae , 1977). 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. ) 36 Fisioterapie, Ju n ie 1982, deeI 38, n r 2 V A L U E O F S U B JE C T IV E PAIN S C A L E S Do w n ie et al (1978) stu di ed subjective pa in r ati ng scales using pa tie nt s with a variety o f r h e u m a ti c diseases. Thei r main finding was th at there was g o o d c o r re l a t i o n between the pa in scores o b t a i n e d from the S.D. S., N.R.S. a n d V.A.S. T h e i r evidence ind ic a te d th at the scales were m ea su ri ng the same u n de rly in g pa in as there was goo d cal ib rat ion . Thei r evidence a lso ind ic a te d that the II p o in t (0-10) N.R.S. pe r fo rm s b e tte r t h a n eit her the S.D.S. o r V.A.S. Th ey also prefer the N.R.S. o n the g r o u n d s of m e a s u r e m e n t e r r o r a nd suggest th at it p rov id es a go o d c o m p r o m i s e between the S.D. S. , which offers only a few choices a n d the V.A.S., which so m e pa tie n ts find difficult to use, mainl y due to the c o n f u si o n c au s ed by the great f ree do m of choice it offers. In a stud y c o n d u c t e d by the a u t h o r , a n e v al u at io n o f the use o f three subjective pa in r ati ng scales (N.R.S., S.D.S. an d V.A.S.) was mad e, using 50 Afri can patie nts w h o had been referred to the p h y s i o t h e r a p y d e p a r t m e n t for tr ea tm e nt . Analysis of d a ta s h o w e d th at the N. R.S . c o r re la te d well with the V.A.S., b u t n e ith e r the N. R.S . n o r the V.A.S. co rre lat ed well with the S.D. S. O f the 31 patie nts w h o were as ked to give their pr eference o f scales, 14 pr eferred the N .R .S .. 6 the S.D.S. a n d 4 the V.A.S. Seven h a d no preference. The findings suggest that the N.R .S . is p r o b a b ly the most a p p r o p r i a t e subjective m e t h o d o f r a ti ng pa in in the ab ov e patients, followed closely by the V.A.S. T h e S.D. S. a p p ea r s to be a relatively p o o r scale. Al th o u g h several m e t h o d s o f objective pa in m ea su re me nt have been desc rib ed , a reliable a n d valid m e t h o d remains elusive. H u s k is so n (1974) describes several objective m et h o d s i ncl ud in g m ea su r e m e n t s o f re sp i r at o r y function, h o r m o n e levels a n d grip st re n gt h as they relate to a p p r o p r i a t e pa inful con dit io ns. M a j o r de leterious chang es oc cu r in r e sp i r a t o r y function after u p p e r a b d o m i n a l a n d t h o ra c ic surgery. F o r example, the av er a g e fall in a rterial oxygen tens ion a n d functional residual c ap aci ty a f t e r u p pe r a b d o m i n a l o p e r a t io n s is 25 per cent. C h a ng es in vital c ap aci ty are even greater. It is possible for these chan ge s to be i m pr ov e d by pr o vi di n g a d e q u a te pain relief. How eve r, even the most perfect pa in relief does not return re sp i r at o r y fu n c ti o n to p re -op er ati ve levels; therefore the use o f lung f u nc tio n m ea su r e m e n ts as a n objective assessment o f pain level is limited. Ex cre tio n o f c a t ec ho la m in es in urine has been m eas ur ed in p ati en ts with r h e u m a t o i d a r th r it is tr ea te d with simple analgesics. Thes e m ea su r e m e n ts are r e ga rd e d as being o f only limited sensitivity. Also, in pati en ts with r h e u m a to i d a rthrit is, grip st r e n g th m ay be used as an objective measure of pain. Usually, as p ain subsides, e ith e r a fte r inte rv en ti on or d u r i n g a na tu r a l remission, the grip st re n g th increases. F a i r b a n k , O ’Brien a n d Dav is (1979) re p o rt an objective m e t h o d for m e a su r i n g b a ck pain. This relates to the rise in i n tr a - a b d o m i n a l pres sur e d u r i n g lifting; pressure being directly p r o p o r t i o n a l to the theo retic al lo ading o f the l u m b a r spine. I n t r a - a b d o m i n a l pressu re was m e a su r e d with an intrag ast ric p re ssu re t ra ns du ce r. Rises in pressure were pl ott ed agai nst a pa in ra tin g a nd so m e co r re l at i o n was d e m o n s t r a t e d betw een pressure rise a n d perceived pain. The evidence ind ica ted th at pres sur e rises may be re lated to low b a c k pain a nd , therefore, m ay be used as a m e t h o d of objectively m e a su r i n g such pain. A l t h o u g h it is highly desi rab le th at g o o d objective m e t h o d s o f pa in m ea su r e m e n t be so u g h t , most o f those ev al ua te d so far hav e been fo u n d to be unreliable. M E A S U R E M E N T O F PA IN R E L IE F I n assessing the effects o f t r e a tm e n t, pain relief can be m ea su re d instea d o f pain severity. A c co r d i n g to Hu sk is so n (1974) this has three advan tage s: • the m a g n i t u d e o f the response does not d e p e n d o n the initial pa in severity, all pati en ts st a r ti n g f r om the same baseline; • it is not necessary to a ss u m e th a t differences in va rious p a r ts o f the scale are equal; • it is m or e usual for a pati en t to express hi mself in terms o f pa in relief by say ing “ my pain is a little b e tte r ” r a th e r th an “ my pain is n o w m o d e r a t e ” . Pain relief can be m eas u re d by cal cu la tin g the difference betw een the pain score a fte r tr ea tm e n t a n d the initial score. Hu sk iss on gives the following a c c o u n t o f the m e t h o d s which can be used for m ea su r in g pain relief: • a simple descriptive pain-relief scale, in which the patient s c o r e s p a i n r e l i e f as E X C E L L E N T , G O O D , M O D E R A T E . P O O R . D O U B T F U L o r A B S EN T; a l t e r n a t i v e l y N O N E . S L I G H T , M O D E R A T E o r C O M P L E T E . • num eric al pain relief scales; pa tie nt s can be a ske d to assess th eir present pain as a pe r cen tag e o f the initial level. A n o t h e r m e t h o d is to express p ain relief in fractions, for exam ple, pain is m or e th an h a lf relieved o r less t han half relieved: such a scale has a m p l e scope to i m p r o v e its sensitivity. S IG N A L D E T E C T IO N T H E O R Y F O R Q U A N T IF I­ C A T IO N O F PAIN T h e m e t h o d s alr ead y d es cri b ed for m ea su r in g pain are ra th e r in co m pl ete in dica tors; a t best they can prov ide guides to p a ti e n t's pain levels. T h e r e is a ten de ncy for them to reinforce the idea th at pa in can be m eas ur ed in a scries o f steps st a r ti n g with an initial t h r es ho ld a n d c o n ti nu in g t h r o u g h a rising scale fro m nil to the worst possible pains. A c o n c e p t o f pain asse ss me nt has been in tr o d u c ed with its origins in c o m m u n i c a ti o n s engineering. This is called the “ signal dete cti on t h e o r y ” , o r m or e descriptively the “ sensory decision t h e o r y . " T h e idea was develo ped , in relation to pain by C l a r k (1969). T h e principle o f the th eo ry is that pain th re sh ol d has tw o c o m p o n e n t s : • a mea sur e o f senso ry discr im in abi lit v which re mains u n a lt e re d w h a te ve r the chang es in the pa tie nt 's e x p ec ta t io n , m o o d a n d motiv ati on: • an asse ssmen t o f the s u bj e ct ’s response bias o r atti tud e. In s h o r t the th eo ry can be app lie d to distin gui sh between the p ain experience itself a n d the p a ti e n t's criteria for r e p o rt in g pain. A pp l i ca t io n o f the th eo ry requires repeated tests o f pa in th r es ho ld s a n d responses, the results a r e then a nal yse d by m at h e m a ti c a l processes usually ap p li e d in c o m m u n i c a t i o n s en g in e er in g to s e p a ra t e mean ing ful signals, re lating to pain, fro m so-called b a c k g r o u n d “ noi se.” In reality the t h eo r y is a n e la b o r at e statistical process which has been mainly a pp lie d in a l a b o r a t o r y si tuation. How eve r, there is n o w in creasing use o f the Signal De tec tio n T h e o r y in the clinical si t u a t i o n (Lan cct , 1980). C O N C L U S IO N This b ri ef review has p r e se n te d so m e o f the m e t h o d s which may be used for m ea su r in g pain. It is inevitable th a t there are m an y differing o pi n io n s on the subject. T h e following 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. ) physiotherapy, Ju n e 1982, vol 38, no 2 37 s ta tem en t by H o u d e (1977) p r o b a b ly puts the whole subject into perspective: “ at pre sen t we have no be tte r measure of pain th an the p a t i e n t ’s o wn re p o rt ol its presence a n d severity in his ow n w o r d s . ” References Cl ark . W. C. (1969). Sen sory decision th eo ry analysis o f the pla c eb o effect on the crit eri on for pain a n d therm al sensitivity../. Abnorm . P sycho/., 74, 363-371. Downie, W. W., L e a th a m , P. A., Rh in d. V. M. el al (1978). Studies with pain ra tin g scales. Ann. Rheum . Dis., 37, 378-381. F a i r b a n k , J. C. T., O 'B ri e n . J. a n d Davis P. R. (1979). Intra- a b d o m i n a l pressu re a n d back pain. Lancet, 2, 1353. Hou de , R. W. (1977). Assessment o f pati en ts with pain. Eds. H ar cus , A. W.. Smi th. R. a n d Whittle, B. in: Pain — New Perspectives in M e a su r em e n t a n d M a n a g e m e n t . Churchill Livingstone. E d in b u r g h, pp. 27-33. Hu sk iss o n. E. C. (1974). M e a su r e m e n t o f pain. Lancet, 2, 1 127-1131. L a n c e t (1980). P a i n f u l c o m m u n i c a t i o n s . L a n c e t, 2, (E ditorial) 805. M ac rae , K. D. (1977). T h e i n te r p r et a tio n of pain m ea su re m e nt s. Eds. H ar cu s. A. W., Smi th, R. a n d Whittle, B. in: Pain — Ne w Perspectives in M e a su r em e n t a n d M a n a g em en t . Churchill Livingstone. E d in b u r g h , pp 21-26.. Rosen. M. (1977). T h e m e a s u r e m e n t o f pain. Eds. H a r cu s , A. W. Smi th, R. a n d Whittle, B. in: Pain — N e w Perspectives in M e a su r e m e n t a n d M a n a g e m e n t . Ch ur ch ill Livingstone. E di n b ur g h , pp 13-20. SYNOPSIS OF PHYSIOTHERAPY IN 0WAMB0LAND, NAMIBIA (SOUTH WEST AFRICA) G A R Y S O BE L , B.Sc. (Physi S U M M A R Y A resum e o f the a u th o r’s experience as the sole physiotherapist at the O sh a ka ti S ta te H o sp ita l s itu a te d d o s e to the Angolan border in Owam boland, Nam ibia, is given. The conditions seen over a one-year period and appropriate treatm ent, are described, em phasising the shortcom ings an d problem s fa c in g a physiotherapist in a rural hospital situ a te d in a bush-war area. P articular em phasis is p la ce d on those p a tie n ts with orthopaedic, neurological a n d burn injuries, as well as those requiring chest physiotherapy. oth era py ) ( W itw ate rsr an d) O P S O M M I N G ’n Oorsig van die s k ry w e r se ondervinding as die enigste fis io te ra p e u t b y die O sh a ka ti Staa tslio sp ita a l naby die A ngolese grens in Owam boland, w ord gegee. Die toestande gesien gedurende ’n periode van een ja a r en toepaslike behandeling w ord b e s k r y f m e t k le m op die te k o rtk o m in g e en problem e wat 'n fis io te ra p e u t in 'n plattelandse hospitaal in ’n bosoorlogsarea in die gesig staar. P asiente m e t ortopediese, neurologiese en brandw ond beserings, a so o k diegene wat b orskas fis io te ra p ie benodig, w ord beklem toon. I N T R O D U C T I O N O s h ak a t i Sta te Ho sp ita l is a 600-b ed general hospital situate d in the h e ar t o f O w a m b o l a n d , 52 k m from the An go la n b o r d e r. It is a t r a i n i n g hosp it al f o r O w a m b o nurses, a n d serves over 50 00 00 people, fro m all ar eas of O w a m b o l a n d . T h e p h y s i o t h e r a p y d e p a r t m e n t which ha d been n on - o p e ra t io n a l for f o u r m o nt h s , co nsisted , in May 1980, o f on e p hy si o t h er a p i st a n d f o u r O w a m b o aids, as well as a large gym, e q u ip p e d wi th weights, pulleys, springs, slings, mats, 3 parallel bar s, a n exercise bicycle, 6 plinths, short-wa ve d i a t h e rm y , u l t r a s o u n d a n d f a ra di c machines, 3 Bird res pirat ors, oxygen cylinders, a su c t io n mac hi ne and plaster- of -p aris facilities. T h e aids a ct ed as tr an sla to rs because o f the l an g ua g e b a r ri e r a n d were t a u g h t to apply f u nd a m e nt a l t ec hn iq ues a n d t r e a tm e n t principles following basic instructions. O R T H O P A E D I C C O N D I T I O N S Because o f the w a r sit u at io n, o r t h o p a e d i c c o nd iti on s were by far the c o m m o n e s t seen. Thes e consisted o f injuries Received 26 O c t o b e r 1981. su sta in ed m ostly as a result o f high velocity missiles, m o to r - vchiclc a n d l an d- m in e accidents. F r a c tu r e s were there fo re c o m m o n l y seen, with a m p u t a t i o n of ten the end result o f severe limb injuries. In ad d it i o n , be cau se o f the p o o r im m u n i sa ti o n p r o g r a m m e , poliomyelitis with its resultant defo rmi tie s was a n o t h e r c o n d it i o n not to o infrequ en tly seen. Patients were of ten well in to their teens w he n pr es ent in g for t r e a tm e n t (often for an u n r e la te d medical pr oblem). Every two m o n th s the O r t h o p a e d i c D e p a r t m e n t was greatly e n h a n c e d by the presence o f an o r t h o p a e d i c team from Ty g er be rg H o s p ita l which ra n a special clinic for the d u r a t i o n o f one week. T he tea m cons isted o f a'sp eci ali st o r t h o p a e d ic s u r ge o n a bly assisted by two o r t h o t i s t s / p r o s - thetists w ho pr es cri be d calipers, special bo ot s a n d pro sthe ses for the patients. W it h o u t these aids the pa tie n ts w o ul d be u n a b le to cope o n their o w n o r su p p o r t their families who w ou ld then reject them. I n st r u c ti o n was given in the care an d use o f the aids as well as trai n in g the patie nts to de velop a p r o p e r gait p a tte rn . I nt ere sti ng cases were e n c o u n t e r e d for which solut ions, not readily available in an y t ex t- bo ok , h a d t o be foun d. F o r exam pl e, a bilateral lower limb a m p u t e e w h o lived in a kr aal s u r r o u n d e d by rugged r u ra l ter ra in a n d whos e h o m e h a d a very low e n tr a n c e r e qui re d in str uc ti on in ge tti ng to a n d e n te rin g his ho m e. Psychological pr o b le m s were often 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. )