Page 4 P H Y S I O T H E R A P Y PARAPLEGIA Its Physical Rehabilitation March, 1963 By A. L. LO M EY , M .D ., Ch.B., D .Phys.M ed.(R and) Specialist in Physical Medicine Head o f D epartm ent o f Physical Medicine, G eneral H ospital, Johannesburg Paraplegia is defined as the paralysis o f the lower half of the body. Its causes are : (1) Injury, (2) Infection, (3) New Growths —all o f which are often seen in any paraplegic unit. But, while injuries o f the spine are com paratively com m on, the o th er two are not nearly so. Nevertheless, in a recent series o f cases two were due to Encephalitis and one followed infection with Bilharzia—the latter m ust be a rare pheno­ m enon. W ith regard to new growths, one o f this series was found to be due to an angiom a o f the spine, i.e. a vascular tum our composed o f a netw ork o f blood vessels. W hatever the cause however, any severe lesion o f the spinal cord produces a disablem ent o f the greatest magni­ tude and results in an im pairm ent o f som e o f the most im portant functions o f the lower half o f the body. Thus there are: (a) M otor disturbances. (b) Sensory disturbances. (c) V aso-m otor disturbances. (d) D isturbances o f the Bladder. (e) D isturbances o f the Bowel. ( / ) Sexual disturbances. T reatm ent has to be directed to alleviate each o f these as well as to the patient as a whole. In form er years such treatm ent was characterised by pas­ sive m ethods which produced helpless cripples whose span o f life was limited to two years. M odern m ethods have veered away from this approach and emphasize activity as the keynote o f all treatm ent. So th a t nowadays a highly active regime^ is pursued in the treatm ent with a resultant complete change in the o u t­ look o f these patients. The general principles underlying all treatm ent is activa­ tion and the m obilisation o f all com pensatory mechanisms in order to shift the psychom otor capabilities from the lower to the upper p arts of the body. Recumbency is avoided, especially prolonged recum bency even in the earliest stages. Plaster o f Paris beds and casts are therefore deprecated and are never used. A nd, as a result o f such measures, m any complications hitherto com m on are avoided. T hus pressure sores, stagnation o f waste products in bowel and bladder, the tendency to urinary infection and the form ation o f stones in the kidney and bladder are minimised or obviated altogether. In addition such activation has an im portant psychological effect on the patient. The elim ination o f toxins by this means avoids organic mental disorders and assists greatly in the dissipation o f the accom ­ panying depressions, hopelessness and resentm ent th at many o f these patients suffer from. The Method of Physical Rehabilitation T he actual m ethod o f physical rehabilitation m ust be im plem ented as follows: (1) Firstly a constructive program m e m ust be built up for each patient. This is reviewed regularly and modified as need be. (2) Two fundam entals underlie this program m e: (i) S tart early. (ii) C ontinue and persist. The aims o f the program m e are: (a) Develop fitness. (b) Prevent atrophy. (c) Prevent contractures and other complications. (d) Institute com pensatory muscle training o f the norm al parts. In im plementing this program m e the following are em phasized: (1) C orrect m aintenance o f position o f paralysed lim bs: This is a function o f everyone associated w ith the case and is necessary to prevent the developm ent o f deformities o f the limbs. These may occur in flexion deformities at the hip and knee, foot d ro p w ith con­ tracted calf muscles, adduction o f hips and clawing toes. The use of splints is discouraged and constant supervision is necessary to avoid these. (2) Passive m ovem ents: A re instituted im mediately after! injury—once or twice daily. These prevent and correct contractures, prom ote better circulation and prevent and delete spasms and m aintain mobility. (3) E lectrotherapy: This is indicated in lower m otor neurone lesions, e.g. cauda equina and cervical nerve ro o t involvement. Daily electrical stim ulation with the faradic or galvanic currents delay atrophy of denervated muscles and im prove the circulation. (4) T he alleviation o f flexor spasm s: Especially o f the lower limbs. These develop below the level o f the lesion after recovery from spinal shock. Various factors favour their developm ent and these include: (а) D istended paralysed Bladder. (б) D istension o f the R ectum and Colon. (c) Infection of (i) U rinary tract. (ii) Pressure sores. (id) Anaemia. (e) C ontracted joints and tendons. T reatm ent consists o f the following: (а) Careful attention to factors (a) to (e) mentioned above. (б) Physical—passive movements carried ou t in a con­ tinuous warm bath, under water, at a constant tem perature. (c) Surgical— neurfyectomy and muscle and tendon section, etc. k (5) C om pensatory muscle training: This consists o r intensively applied graduated resisted exercises to overdevelop the norm al non-paralysed parts. This compensates for the loss sustained as a result o f the paralysis following the lesion, i.e. to ad ap t the norm al parts to take over from the parlysed parts. The long muscles o f the trunk, e.g. abdom inal, erector spinae, latissimus dorsi, quadratus lum borum , are particularly concentrated on as being o f m ost value when thus strengthened and trained. This results in : (a) Com pensation for the loss sustained. (b) Restores am bulation. (c) Helps bladder function. id) Helps bowel function. (e) Restores sexual function. M ethods u se d : (a) Free exercises. lb) U se o f slings. (c) Use of resistance, e.g. springs, weights, etc. (d) T he use o f m ats on the floor. (e) Includes training in: (i) Balance. (ii) A m bulation—using calipers. ( / ) Use o f apparatus—parallel bars, etc. 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. ) March, 1963 P H Y S I O T H E R A P Y Page 5 National Council for the care of Cripples in South Africa EASTER STAMP FUND P A A S S E E L S 1 9 6 3 H E L P K R E U P E L E S EASTER S T A M P S *l_r1