June, 1965 P H Y S I O T H E R A P Y Page 3 PHYSIOTHERAPY IN THE REHABILITATION OF PARAPLEGIC AND QUADRAPLEGIC PATIENTS By P. M. D A V IE S . M . C . S . P . , D I P . P H Y S . E D. (S enior P h y s io th e ra p ist. P a ra p le g ic U n it, C o n ra d ie H o s p ita l) T h e re h a b ilita tio n o f th e p a rap leg ic m ust begin from th e m o m e n t he is a d m itte d to h o sp ital. C o m p lic a tio n s arise frighteningly e arly a n d every o n e o f th em delays th e p a tie n t’s e v en tu al disc h arg e as a n in d e p e n d e n t, useful h u m a n being. P h y s io th e ra p y plays a n im p o rta n t p a rt in the tre a tm e n t o f these p a tie n ts b u t tea m -w o rk is e ssential fo r successful re h a b ilita tio n . H o w hopeless is th e task o f the p h y sio th era p ist w h o struggles on w ith a p a tie n t w ho is c o n sta n tly ill w ith b la d d e r in fec tio n , w a tch in g his pressure- sores e n la rg e d aily despite her futile a tte m p ts w ith ultra -v io le t th e ra p y , a n d fighting an endless b a ttle to have the p a tie n t dry a n d not e m b a rrasse d by faecal in co n tin en c e. A t the C o n ra d ie H o s p ita l we have m an ag ed to achieve te a m -w o rk in o u r P a ra p le g ic U nit a n d I d escribe, th ere fo re, p h y sio ­ th e ra p y tre a tm e n t m a d e easy by the c o -o p e ra tio n a n d efforts o f the o th e r m em b e rs o f the team . E le v atin g the fo o t o f the bed a n d re g u la r tu rn in g (o u r p a tie n ts a re tu rn e d every tw o h o u rs) help to d ra in these se c re tio n s. T h is form o f p h y sio th e ra p y is c a rrie d o u t every h o u r o r so d u rin g the d a y a n d if n ecessary d u rin g the n ight, before a n d a fte r tu rn s. C o u n te r p re ssu re a pplied by a n a ssista n t helps to give a s tro n g e r c o u g h a n d a lso av o id s m oving the u n sta b le d islo c a tio n in th e cervical region. P e rc u ssio n a n d v ib ra tin g also h elp to free the secretio n s a nd m ak e co u g h in g easier. W e find fre q u e n tly th a t c ervicals suffer a c u te b ro n c h o - spasm w hen th ey have de v elo p ed a “ wet c h e s t” and this prevents p ro d u c tiv e co u g h in g . A m in o p h y llin in tra m u sc u ­ larly o r in s u p p o s ito ry fo rm is m o st effective fo r relieving this. Passive M ovements W ith in 24 h o u rs the p h y sio th e ra p ist begins daily passive m o v em e n ts to all jo in ts . T h ese a re best d o n e while the p a tie n t is lying on his b ack. T o affect c irc u la tio n a n d p revent pa inful stiffness, e ac h m o v em e n t sh o u ld be d o n e a t least 20 times. W ith a cervical c o rd lesion th e m o st im p o rta n t m o v em en ts a re full e le v atio n o f the sh o u ld e r, w hich in c o rp o ra te s the r o ta tio n s if d o n e in a d iag o n a l p a tte rn , a n d a full stretch o f the flexor g ro u p s o f th e a rm . T o d o this th e sh o u ld e r and e lb o w m ust be ex te n d ed a n d fo re a rm fully p ro n a te d to place biceps o n th e stre tc h , a n d th en the w rist dorsi-flexed a n d fingers e x te n d ed sim u lta n eo u sly . T h e th u m b sh ould be m oved in to full a b d u c tio n a n d ex te n sio n to o , to allow fo r a trick g rip later. S uch a g rip is o b ta in e d by first p la n ta r- flexing the w rist, w hen th e fingers a n d th u m b e xtend, a n d th en w hen an object such as a glass is betw een first finger and th u m b , d orsi-flexion o f the w rist by e x te n so r carpi ra d ia lis h o ld s it by p lac in g ten sio n o n the flexors. T ra p e z iu s is usually fully e n e rv a te d in cervicals, w hile the d e p re sso rs o f th e sh o u ld e r g irdle m ay be pa raly se d . C a re m ust be tak e n th a t the a ctive tra p e z iu s does n ot sh o rte n by the p a tie n t’s lying w ith his sh o u ld e rs elevated d u rin g his period o f b edrest, a n d it sh o u ld be stre tc h ed daily. F u ll ra n g e m o v em e n ts to the low er lim bs help to p revent th ro m b o s is w hile av o id in g c o n tra c tu re s. P o sitio n in g o f the p a tie n t by th e n u rsin g sta ff is im p o rta n t if c o n tra c tu re s are to be a v o id e d , p a rtic u la rly w hen spasm is p re sen t. T h e feet sh o u ld be held in th e dorsi-flexed p o sitio n by a fo o tb o a rd a n d pillows', th e knees held in ex te n sio n , tied w ith a draw - sheet if necessary. W h en a q u a d ra p le g ic h as spastic biceps o r p ersists, d u rin g the early days, in flexing his elbow s, the a rm s sh o u ld be tied dow n by m ean s o f a d ra w sh e et o ver the w rists, u n til he has learnt to stra ig h te n his a rm s by him self, using a tric k m ovem ent. FIG. I Three days after injury a patient with severe dislocation of C l on T I is shown on special foam rubber packs, being helped to cough by a physiotherapist. PA R T 1 Early Treatment: (a) Cervical C ord Lesions The Chest W hen a q u a d ra p le g ic is a d m itte d to the U nit the p h y sio ­ th era p ist is notified im m e d ia tely so th a t she m ay h elp w ith any re sp ira to ry d istress a n d prev en t later re sp ira to ry c o m p li­ cations. T h e p a tie n t is b re a th in g solely w ith his d ia p h ra g m and is u n able to c o u g h o r expel se c re tio n s by n o se-blow ing or clearing his th ro a t, ow ing to the p aralysis o f his a b d o m in a l muscles. W ithin a few h o u rs a nasal c o n g estio n o c cu rs d ue to excess secretio n o f th e nasal m ucosa fo llow ing his injury, ha m pering his b re a th in g a n d if the secretio n s in his lungs are n o t expelled, a h y p o -sta tic p n e u m o n ia o r ate lec ta sis can soon develop. T he p h y sio th era p ist here a cts as a b d o m in a l m uscles for the pa tie n t a n d by a p p ly in g firm, q u ick p re ssu re to his low er ribs and a b d o m e n can e n a b le the p a tie n t to c ough o r blow his nose. (Fig. 1.) 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 4 P H Y S I O T H E R A P Y June, 1965 Active Movements A c tive a nd resisted active m o v em en ts a re given to stre n g th e n th e re m a in in g en erv a te d m uscles. C a re m ust be tak e n th a t th e p a tie n t does n ot m ove his neck o r affect the dislo ca tio n by to o m uch resistance being given. Electrical Stimulation F a ra d ic or g a lvanic stim u la tio n to tem p o ra rily paralysed m uscles helps to p re v en t w asting, relieve oe d em a a n d hasten re -e d u c atio n o f recovering m uscles by p ro p rio c e p tio n . >■ W here the c o rd lesions m ay be in com plete, we give this fo rm o f tre a tm e n t to im p o rta n t g ro u p s such as triceps, ex te n so r c arp i ra d ia lis a nd q u a d ric e p s and the a n te rio r tibial g ro u p in the leg. (b ) Thoracic a nd Cauda Equina Lesions Passive m o v em en ts a re a g ain s ta rte d w ithin the first 24 h o u rs a n d th e ru le o f 20 tim es fo r each m ovem ent follow ed. F u ll passive flexion o f th e h ip is avoided because o f the d a n g e r o f flexing th e spine at the sam e tim e. W e usually lim it flexion to 40°. All the o th e r m o v em en ts a re d o n e th ro u g h a full range. T h e m ost im p o rta n t m o v em en ts here a re full hip e x te n ­ sion, w hich m ust be d o n e while the p a tie n t is in the side- lying p o sitio n , a n d late ra l ro ta tio n o f the hip. H ip extension is essential late r to e n ab le the p a tie n t to b a lance w hile sta n d in g , late ra l ro ta tio n will fa cilitate activities such as p u ttin g on his shoes. F o o t a n d toe m o v em en ts m ust n o t be neglected as p re ssu re sores fo rm easily on claw ed toes w hen shoes a re w orn later. FIG. 2 A patient with a recent fracture dislocation of T i l on T12, while being nursed in hyper-extension does manually resisted bilateral arm exercises. Active Movements A c tive resisted m o v em e n ts a re given to the u p p e r lim bs, a n d if d o n e bila tera lly d o n o t shift the u n sta b le d islocation. O u r p a tie n ts pull chest e x p an d e rs reg u larly w hile lying o n th eir backs a n d a lso do m an u a lly resisted b ilateral a rm m ovem ents, in c o rp o ra tin g sta tic w o rk fo r b ack extensors. (F ig. 2.) In in co m p lete lesions we use light su sp en sio n fram es, w hich fit o ver the bed, to give sp rin g resisted exercises to re co v e rin g m uscle g ro u p s in th e low er lim bs. Overcoming Loss of Vaso-M otor Control P a tie n ts w ith fra c tu re d islo ca tio n o f the spine usually re m a in im m obilised in bed fo r th ree m o n th s in o u r U n it to a llow fo r c o m p le te sta b ilisa tio n . A t the e n d o f this period FIG. 3 Frans, a complete lesion at C7 balances in front of a mirror without spinal support. we begin to sit th em up a n d this m ay re q u ire a few days, to ov e rco m e the ten d en cy to faint o r feel dizzy. T h e p a tie n ts a re b ro u g h t slowly in to the sitting p o sitio n on a surgical bed a n d it is o nly w hen they can rem ain in the u p rig h t p o sition fo r an h o u r or so w ith no ill effects th a t they a re re ad y to be lifted in to a chair. B efore they a re raised in th is w ay the p h y sio th era p ist e n c o u ra g e s the p a tie n t to do deep e x p ira to ry b re ath in g , som etim es w ith m an u a l assistance, to aid venous re tu rn . She gives s tro n g resisted exercises to the a rm s to d ra w blood to the w o rk in g m uscle g ro u p s a n d so prevent " p o o lin g ” of blood in the a b d o m e n — th e cause o f fainting. T h e blood ten d s to pool as th e re is no v a so -c o n stric to r to n e in the blood vessels, d ue to the c ord lesion, a n d it takes som e tim e fo r this to a d ju st reflexly. T h is is p a rtic u la rly n o tic e ab le in cervical c ord lesions, a nd som e o f o u r p a tie n ts have had to be given b lood to raise th eir h a em o g lo b in in o rd e r to overcom e p e rsistent fa in tin g spells. Pressure Sores I d o n o t believe th a t pressure so res in cases o f parap leg ia can be tre a te d successfully by p h y sio th era p y , b ut I m en tio n th em here as this form o f tre a tm e n t is freq u e n tly a tte m p te d . In o u r U n it, w here the p a tie n ts a re tu rn e d regularly a nd nursed on fo a m -ru b b e r packs (see Fig. 1) sores d o n ot occur. S h o u ld a lazy o r careless p a tie n t develop a m ild a b ra s io n w hile in his w heel-chair, th ro u g h failing to lift, he is p u t to bed im m e d ia tely a n d th e a re a heals quickly, th ro u g h relief o f pressure. Since deep sinus sores, w ith b one in fection m ay tak e years to h eal, m erely by relieving pressure a n d c o m ­ b a tin g th e in fection, it is necessary fo r the plastic surg eo n to tre a t these surgically. 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. ) June, 1965 P H Y S I O T H E R A P Y Page 5 FIG. 4 Richard, supported by plaster back-slabs and toe-raising springs, balances between parallel bars by hanging on the “ Y ” ligaments of his hips. P A R T 2 Later Treatment R e lie f o f Pressure F ro m the m o m e n t the p a tie n t s ta rts sittin g in a w heel­ ch air we m ak e it his resp o n sib ility to prevent p re ssu re sores. Even q u a d rap leg ic s w ith o u t tricep s m u st be ta u g h t to relieve pressure. T h e parap leg ic is e n c o u ra g ed to lift his seat every ten m inutes by pressing on the a rm s o f his c h a ir a nd stra ig h te n in g his a rm s. Q u a d rap le g ic s a re ta u g h t to relieve pressure by lifting o ne leg at a tim e o r leaning over, first to one side a n d then to the o th er. Balance B alance is a n o th e r early lesson w hich m ust be ta u g h t. U sing a m irro r so th a t sight m ay tak e the place o f lost sensation, the p h y sio th era p ist begins by tea ch in g the pa tie n t to balance in his w heelchair, u n til he can d o this w ith his eyes closed. H e th e n learn s to b a lance seated on a plinth (Fig. 3) p rogressing to being a b le to th ro w a n d catch a m edicine ball in this p o sitio n , even possible fo r q u a d r a ­ plegics, It is u n necessary fo r them to w ear a spinal brace to m ain tain the u p rig h t po sitio n . P ra c tice a n d careful in stru c tio n will a llo w even the m ost severely paralysed to sit u n su p p o rte d . In the sam e w ay we d o n o t use special w heel­ c hairs fo r o u r q u a d rap leg ic s. T hey becom e skilful a t h a n d lin g the usual c h a ir a n d it is easier for late r tra n s p o rta tio n and hom e use. Before o rd e rin g c alipers we lea ch the p a tie n ts to sta n d a nd w alk with the aid o f p laste r-o f-p aris back-slabs, re aching tw o inches below the ischial tu b ero sities lo tw o inches a bove the m alleoli and b a ndaged on with six-inch c rep e bandages. T h is a v o id s the unnecessary expense o f o b ta in in g c alipers fo r a p a tie n t w ho m ay never be able to use them successfully, d ue to spasm , lack o f w illpow er, etc. W e have found the m ost su itab le calipers a re those m ade o f light d u ra lu m in iu m , reaching to a b o u t four inches below the ischial tu berosities, a n d having k n o ck-knee stra p s to prevent the m edial aspect o f the knee from pressing a g ainst the m etal u p rig h t, a n d so c rea tin g a sore. Pelvic b ands are unnecessary a nd could easily c au se pressure, as well as h a m p e rin g the p a rap leg ic 's ability to m an o e u v re while on his feet. T h e paraplegics are ta u g h t to w alk between parallel bars, again using m irro rs. T h ey learn to stand a n d balance by ex te n d in g their hips, a nd h a n ging on the " Y " ligam ents o f the hip jo in t. (Fig. 4.) W e teach the fou r-p o in t gait first, to s tre n g th e n the in v aluable latissim us dorsi m uscle. L ater the ''s w in g -to " gait is in tro d u c ed , a n d also the "sw in g -th ro u g h ” gait w hich is faster a nd requires less effort. It is im p o rta n t here to delay teach in g c ru tc h -w a lk in g until the pa tie n t is com pletely a d ep t at w a lking betw een parallel bars and can do this w ithout th in k in g a b o u t it, refiexly. as a norm al person walks. D u rin g this tim e the p h y sio th era p ist hyper- stre n g th e n s his u p p e r tru n k m uscles with m at exercises (craw ling, press-ups etc.), spring-resisted exercises a n d m anually-resisted exercises in diag o n a l p a tte rn s. W e teach FIG. 5 Petrus, with a complete paralysis below C l negotiates a step with the aid of calipers and crutches. 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 6 P H Y S I O T H E R A P Y June, 1965 all o u r p a tie n ts to w alk w ith e lb o w -cru tch e s, w ith an a r m ­ ba n d w hich is m oveable a n d c a n lock in a h o riz o n ta l p o sitio n . T h ese seem to allow fo r m o re fu n c tio n a l a ctivities, and e lim in a te the d a n g e r o f “ c ru tc h p a lsy ". W e e n c o u ra g e even the q u a d ra p le g ic s to sta n d daily b ecause it is th e ra p e u tic in th a t it p re v en ts o ste o p o ro sis a n d a id s b la d d e r fu n c tio n , even th o u g h it is n o t fu n c tio n a l. I believe th a t the p h y s io th e ra ­ pist sh o u ld be very a m b itio u s , even w ith cervical c o rd lesions, as I h ave been a m a ze d by w h a t th ey c an achieve. W e have at pre sen t a C7 lesion w ho w alks w ith e lbow c ru tc h e s , sw ing- th ro u g h gait, in the w a rd , o n the grass a n d even n e g o tia te s sta irs. (Fig. 5.) T h e p a tie n t s h o u ld be ta u g h t m ax im u m in d ep en d en ce, e.g. c lim bing o n a n d off his bed from a w h e elc h air, to nego- c ia te kerbs, to get in a n d o u t o f a m o to r c a r u n a id e d a n d to dress him self. (F ig . 6.) W e find this is p ossible even w ith cervical c o rd lesions. T h e re is no set ro u tin e o r m eth o d o f tea ch in g these a ctivities. T h e p h sy io th e ra p ist m ust w ork th em o u t w ith e ac h p a rtic u la r p a tie n t a c c o rd in g to his in d iv id u a l needs. Q u a d ra p le g ic s ta k e a b o u t a year to re h a b ilita te fully, while the a v era g e low lesio n m ay tak e n ine m o n th s . T he tim e n a tu ra lly varies, a c c o rd in g to the p a tie n ts ’ ra te o f pro g ress a n d in g en u ity , b u t we d o feel th a t it is a m ista k e to s h o rte n th e p e rio d o f h o sp ita lisa tio n to o m uch. T hey m ight th en n ever re a c h th e degree o f in d ep e n d en c e possible fo r them . In o u r U n it w e w o rk very closely w ith b o th social w o rk e rs a n d o c c u p a tio n a l th e ra p is ts d u rin g th is sta g e o f re h a b ilita ­ tio n , to e n su re th a t th e p a tie n t will be a b le to d o all th a t he will find necessary a fte r his d isc h a rg e fro m h o sp ita l, b o th a t w o rk a n d in his h o m e s u rro u n d in g s. I stress a g a in th e im p o rta n c e o f te a m w o rk in th e success­ ful re h a b ilita tio n o f th e p a ra p le g ic p a tie n t. F IG . 6 Completely paraplegic below T 10, Gideon shows how he climbs into a car, without using his wheelchair. THE ROSSLYN TRACTION COUCH FOR RHYTHMICAL AND SUSTAINED TRACTION T h e a p p lic a tio n o f c o n tro lle d m ax im u m stre tc h or tra c tio n , a lte rn a tin g w ith perio d s o f c o m p le te re la x a tio n h a s p ro v e d beneficial in m an y p a inful d e ra n g e m e n ts o f the lu m b a r-ce rv ica l spine. H L dU alV uZ H htU StS. (PTY.) LTD. “ C A PE Y O R K ,” 252 J E P P E ST R E E T , JO H A N N E S B U R G Telephone 23-8106 an d P .O . Box 3378 P R E S ID E N T H O U S E , 20 BARRACK ST R E E T , C A PE T O W N Telephone 41-1172 P .O . B ox 195 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. )