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. ) 38 Fisioterapie, Ju n ie 1982, dee! 38, n r 2 assoc iat ed with these disabilities. How ever, the patients ac c ep te d tlieir disabilities q u ite readily a n d the aids soon beca me part o f their daily routine. F ra c tu re s F r a c tu r e d f em u rs were the c o m m o n e s t e n c o u n t e r e d (see Table). As the m aj o ri ty o f f rac tu red femurs were c o m p o u n d fract ures , ho sp it al tr e a tm e n t was usually conservative, na me ly skeletal t ra c tio n for three m o n th s . Phy sio th e ra py co nsisted of general b o d y s tr e n g th e n in g exercises as well as specific q u a d r ic e p s str e n g th e n i n g exercises, which were c o m m e n ce d imm e di a te ly to m ain tai n jo in t mobility a n d muscle str ength. F o ll ow in g this, gait t r ai ni ng on crutches was initiated a n d pa tie n ts were inst ru cte d no t to b e a r weight on the injured leg f o r a f u r t h e r three m o n th s . Th is regime was followed because it was felt that partial w e ig ht- be ari ng was a con cep t th at w oul d be a b u s e d by the patie nts a n d on ce ou t of ho spital sup ervision, they w ou ld t ak e full weight on the injure d limb with re -fr ac tur e a possible co mp li cat io n. F r a c tu r e s o f the foot (especially the calcaneus), were seen following l and -m in e explosions. As a result o f as soc iated severe soft tissue da m a g e , pa tie nt s de ve lo pe d ad he s io n s a nd fibrosis which led to c o n tr a c t u r e s o f the intrinsic muscles a n d l ong digit flexors, limiting their ra nge o f m o v em e n t. Pr o m p t p h y s io th er a py in the form o f passive stre tc h in g ha d to be in stituted t o m ai n t ai n full range o f m o v e m e n t, thu s allowing n o r m a l func tio n d u r i n g the gait cycle. How eve r, despite vigo rou s ph y si o t h er a p y , c o n tr a c t u r e s still oc cur re d, d ue to the severe n a tu r e o f the injury. Thes e patie nts were fitted with a special shoe, the so-called “ la nd -m in e b o o t ” with a r o c k e r b o t t o m sole, t o c o m p e n s a te for this action. A m putations P h ys io th e r ap y pl aye d a large role in the re ha bi lit at io n of a m p u t e e s d u ri n g all stages o f their tr e a tm e n t p ro g r a m m e . P r e - p r o s t h e t i e t r e a t m e n t c o n s i s t e d in iti all y o f the ap pl ic at io n of elastic c o n in g ba n da g e s to the s t u m p to reduce the swelling a n d to s ha p e the stu m p . C o b a n elastic bandages were fou nd to be the mo st effective in this regar d an d were c o m m e n c e d so on a fte r o p e r a t io n ( + 5 - 10 days). Light pressure was ap pl ie d until the stitches were re m o ve d an d firm pressure was a p pl ie d th erea fter. G e ne ra l body st re n g th e n i n g exercises to the s t u m p (d y n a m i c st u m p exercises) were t a u g h t to the patie nts a n d pe r fo rm e d daily. G a i t train ing on c ru tch es followed a n d the pa tie n ts were disc har ge d with in str u cti o ns to r e tu rn to the hospi tal d ur i n g the follow ing o r t h o p a e d i c clinic week for m e a su r e m e n t a n d cas ting o f the prosthesis. T h e a verage d u r a t i o n o f t r ea tm e nt from initial injury to disc har ge with prosthesis was 3 - 4 m o n th s . This was often p ro lo ng ed d u e to a d d it io n al injuries su sta in ed by the pati en t, e.g. m ultiple fractures o f the ot he r limbs, b ur ns , etc. T h e Pn e u m a t i c P o s t - A m p u t a t i o n Mobility A i d ( P . P . A . M . Aid) was used for c o m m e n c i n g s t a n d in g b ala nc e a n d gait t r ai ni ng in elderly patients. Th is was also used for bilateral l owe r-limb a m p u t e e s in the pe rio d p r io r to receiving their prosthcses. In a small p e r cen tag e o f bclow -k nee a m p u t e es , a plas ter -o f- par is pylon was m ad e to aid the patient d u r i n g the i n te r m ed i at e stage at h o m e a n d to ac c u st o m him to an artificial limb. In o r d e r to m ak e the pylon secure, it h a d to be ex te n d ed to ab o ve the knee a n d this p r ev ent ed knee flexion d u r i n g the gait cycle. A l t h o u g h this increased patient in d ep e n d en c e in the interim per iod while aw aiting o r t h o p a e d ic clinic week, it was f o u n d th at b a d gait p a tte rn s de ve lo pe d which were difficult to co rrect once the pe r m a n e n t prosth es is was received. This idea was then a b a n d o n e d . T uberculosis T u be rc u lo s is with its a t t e n d a n t c o m pl ic a tio ns , is prevalent in O w a m b o l a n d . Pa tients with tuber cu los is of the hip (the m aj o r i ty o f pa tients) were pu t on a regime o f drugs a n d strict bed rest with skin t rac tio n ap pl ie d to the limb for three m o n th s . Q u a d r i ce p s exercises were given to m ain tai n str e n g th , a n d t o w a r d s the en d o f three m o n th s gentle hip flexion exercises were given to regain mobility. T h e pati en ts were a m b u l a t e d pa rtial we ig h t-b e ar in g on crutches for six weeks. Patients with tuberc ulo si s o f the spine were tr eat ed a lo n g sim ila r lines, being fitted with a corset where necessary. N E U R O L O G IC A L C O N D IT IO N S Hem ipl eg ia, p a r ap le g ia a n d cer ebral palsy were the c o n di ti o ns mo st c o m m o n l y seen (Table). H em iplegia Hem iple gic patie nts co ns tit ut ed ± 50 percent o f the pati en ts seen with neu ro logic al pro blem s. H y pe rt en si o n with r e su lta nt c e r e b r o v a s c u l a r acc iden t, was the c o m m o n e s t T A B L E . — T O T A L NO. O F P A T I E N T S S E E N — 536 O rthopaedic N eu ro lo g y C hest P h ysio th e ra p y B urns Lo we r limb fractures 93 Hemiplegia 28 Med ica l chest T ot al 47 co nd iti on s 101 Soft tissue injury (u p p e r limb) 35 Cer ebr al Palsy 14 Post sur gery 68 A m p u t a t i o n 32 Par ap legia 12 T o ta l 169 U pp e r limb fractures 3 1 O th e r 10 Tuber cu losis 18 T o ta l 64 Soft tissue injury (lower limb) 22 Polio 10 O t h e r 15 To tal 256 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, Ju n e 1982, vol 38, no 2 39 cause of hemiplegia. In most cases, the u p p e r limb was fo un d to be m o r e severely affected th a n the lowe r limb, resulting in a p o o r e r progn osi s. Ph y s io t h e r a p y in the initial flaccid stage consisted o f co rrect p o s it io ni ng of the pati en t in bed a nd passive m o v e m e n ts to prev ent c o nt r a ct ur e s. This was followed by exercising the pa tie nt t h ro u g h the stages of the no r m al d e v e lo pm en ta l sequence. S t a n d i n g a n d w al k in g w er e first pe rfo rm e d in the parallel bars. Use was som etimes m ade of a pl as ter-of-paris ba ck slab t o s u p p o r t the affected lower limb. Onc e the p a ti e n t was mobile (u sually with the ai d o f a stick) in-pat ien t m a n a g e m e n t ceased a n d the patient was discharged. (T he d e m a n d for beds necessitated an early discharge). Because o f the difficulty o f ou t - p a t i e n t follow- up, the patient usually received' little or no fur th er m an a g e m e n t a n d th er e fo re the best possible result was often not achieved. Paraplegia In most cases t r a u m a was the cause o f par apl egi a. Because |of the lack of facilities a nd the inability o f families to care for patients at hom e, they faced the gr im reality o f being confined to the hospi tal on a p e r m a n e n t basis. These patients were a c c o m m o d a t e d in a special w a r d o f th ei r ow n with specially train ed sisters. F ol lo w in g diagn os is, the pa tients were put on a p r o g r a m m e o f strict b e d rest with tu rn in g e v e ry two h our s to prev ent bed sores, a n d passive m o ve m e n ts to prevent c o nt r a ct ur e s. Onc e the c o n d it i o n stabilised, they were mobilised in a whe elc hai r a n d t a u g h t to m an ag e all activities o f daily living. A special r e h ab ili ta ti o n p r o g r a m m e consisting of s t a n d in g a n d w a lk in g (with aid o f calipers a n d crutches), passive m ov em e nt s a n d s po r t was designed an d carried ou t. T he services o f an oc cu p a ti o n a l ther ap ist woul d have been useful in re ha b ili ta ti n g these patients. A l th ou gh they a p p e a r e d to a d a p t physically to their co ndi ti on, pr ob lem s did manifest on a social level with patients experiencing the f ru str at io ns of being c on fin ed to the hospital for the rest o f th eir lives, a n d they often caused di stu rb an c es in the hospital. C erebral Palsy Ce reb ra l Palsy in child ren was usually first di ag no s ed at 2 - 3 years o f age when the child was b r o u g h t into hospit al by his parents, un a b le to walk. A d e q u a t e facilities for intensive cerebral palsy re h ab ili ta ti on were no t a vailable, a n d a m ak e s h i f t p r o g r a m m e h a d to be devised. This consisted o f an e xp la n at io n o f the c o n d it i o n to the m o t h e r ( t h r o u g h an inter pr ete r) with the hope th at once she u n d e r s t o o d the si tuation, she w o u ld be able to assist with basic p hy si o th er a py at home. T h e following were d e m o n s tr a t e d to the mo ther : • T h e ap pl ic at io n o f pl as ter-of-paris night splints, m a d e for the affected l i m b / s to m ai n ta in a pos it ion inh ibi tin g the devel opi ng spastic p a tte rn. • Passive m o ve m e n ts to prev ent c o n tr a c t u r e s o f affected l im b / s to be d o n e twice daily at hom e. • A few basic p os tu r e s a n d exercises to assist in the h a nd lin g of the child a n d to prev ent d e t e ri o r a t io n of the con dition . The child was follou'ed u p m o nt h ly where possible, a nd for a few patients w ho lived close by, a p r o g r a m m e of assisted gait using a wa lk er f r am e was c arr ied o u t twice weekly. BURNS Ne arly two- th ird s o f all pa tie nt s with b u rn s were children w ho ha d been b u r n t in acc idental fires in their homes (kraals). Early skin gr a fti n g was p e r fo r m e d a n d the limb splinted to pr event c o n t r a c t u r e f o r m at io n . Earl y remo va l of the d r es sin g was c arr ied o u t ( 3 - 5 days follow ing graft). P h y s io t h e r ap y c o m m e n c e d at this stage. T h is consisted of active exercises as well as gentle passive stre tch in g to m a i n t a i n the fullest range o f m o v e m e n t possible. Because of the ab se nce o f a p hy si o th er a p is t in the p re ced ing fou r m o n th s , so m e patients ha d alr ead y de ve lo p ed severe c o nt r a ct ur e s. In these cases p h y si o th er a p y c on si st ed o f serial splinting, passive st r e tc h i n g and active exercises to decrease the c o n tr a ct u r e s. In th o se patients in w ho m p h y s io th er a py prov ed ineffective, surge ry was c arr ied out. O f the r e m a in in g o n e - th ir d o f the b u r n injuries, the maj ority resulted from motor-v eh icle or la n d -m in e accidents. Most o f these were high perce nta ge surface a r ea b u r n s with the lungs also b eing involved. In these patients, des pite intensive chest p h y si o th er a py , m o rta lit y was high. C H E S T P H Y S IO T H E R A P Y T he spe c tru m o f chest ph y si o t h e r a p y seen was similar to that o f a n y general hospi tal a n d c o n tr i b u t e d to 30% o f the d e p a r t m e n t ’s wo rk lo a d. Medical chest c o n di ti o ns most c o m m o n l y seen were p n e u m o n i a (c h il d h o o d a n d ad ult), p u l m o n a r y t u b e r c u l o s i s a n d l u n g a b s c e s s . C h e s t ph y si o t h e r a p y was also c arr ied o u t p ost-op eratively , usually p o st - a b d o m i n a l surgery. T h e r a p y was c o n ve n ti o n al , consi sti ng o f b re at hi n g exercises, po st ur al d r a in a g e with v ib ra ti o n, percu ss ion and coughing, a nd , where necessary, in ter m itt en t positive pressure ve nti lat io n usin g the Bird Re spirator. A C K N O W L E D G E M E N T S l w o u ld like to th a n k D r D e s m o n d Schatz a n d Mrs Helen Isaacs for their advice, disc ussion a n d e n c o u r a g e m e n t in the wri ting o f this article. I w ou ld also like to t h a n k the S u p e r in te n de n t o f the O s h a k a t i Sta te H os pi ta l, D r van N ie ker k, D i r e c t o r of H e al t h a n d Welfare, O w a m b o l a n d . for pe rm iss ion to publish this articlc. SU B C O M M IT T E E O N R E S E A R C H T h er e has been a very p o o r r e spo nse to the sugge stion th at the feasibility of es tab li shi ng a C o - o r d i n a t i n g C o m m i t te e on Research be investigated. Only a few replies were received a fte r the notice in the D e c e m b e r 1 98 1 issue o f the J o u r n a l . M e m b e r s are r e m i n d e d o f the need t o c o - o rd i n a te research, as trials c arr icd o u t by in dividuals c o u ld well be d u p lic a te d a n d n o t h i n g c o n s t r u c t i v e will emerge. Know ledge a n d ideas s h o u l d be p oo le d in o r d e r to c o - o rd i n a te research. By setting up a register o f what is be ing done , wh o is d o in g it a n d w h e t h er these p er so ns w o u ld be p r e p a r e d to sha re their kn o wl ed g e or ideas, m em b e rs o f the Society who are interested in research a n d / o r clinical trials can be united. W o u ld m em b e rs wh o are inte res ted in d o in g research o r r u n n i n g clinical trials o r w ho are a lre ady d o i n g so please send the following i n f o r m a t io n to: The C h a irm a n , Research, S A SP , P .O . Box 11151, Jo h a n n e sb u rg 2000. Nam e; address; research interest; a lre ad y c ar r y in g o u t r es ear ch /cl ini cal trials; willing to sh a r e ideas; wh e th er interested in receivin ga copy o f the list o f r e se a rc h /c lin ic a l trials being carried out: wh e th er registered for a hi g h er degree. Research is not a luxury. It is essential for survival o f the profession. (B asm ajian). 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. )