Page 8 P H Y S I O T H E R A P Y Martk 1963 PHYSIOTHERAPY PILOT SC H EM E-A Contribution to Geriatric Services By A L F R E D R O T H B E R G , Vice-Chairman, S.A.S.P. T he care for the aged as an organised effort on a nation­ wide basis is com paratively new in South Africa. The N ational Council for the Welfare o f the Aged was instituted only just over six years ago. Its third biennial congress to o k place at the end o f 1962, in Johannesburg. A t th a t conference it was apparent th a t m uch good work for the care o f o u r aged has already been achieved—yet m uch rem ains to be done. Physiotherapy is only sporadically found in a few institu­ tions, b u t is hardly anywhere employed to its fullest potential. One can explain this unsatisfactory state o f affairs, but only with reasons which are not altogether convincing, and which are certainly not o f perm anent validity. I t m ust be realised th at the care for the aged is a vast field, and has m any facets. M any o f those enthusiastic people who sponsored welfare w ork for our aged citizens, were prom pted by a sincere desire to help, but were not always fam iliar with the m any aspects o f this task, nor its varied requirem ents. F irst things had to come first, and to m ost o f these pioneers the elem entary problem s o f housing and feeding seemed to cover the subject exhaustively. T o provide accom m odation, sustenance and nursing for the aged was already a form idable enterprise. D epending largely on support from the general public, fund-raising was a m ajor concern, and occupied the minds o f the various m anagement comm ittees, often m ore th an anything else. G radually, however, it became evident th a t additional needs had to be satisfied. C om paratively early the social w orkers were recognized as an essential p art o f the team looking after the elderly. One after another, voluntary organizations and enthusiastic individuals interested in brightening the evening in the lives o f o ur aged, joined in. Sunshine C lubs, Candlelight Clubs, Time Clubs, to name only a few, took groups o f elderly ou t to spend a day in the open, to go to shows, o r to enjoy other entertainm ent. Individual helpers provided transport to take patients to dentists and out-patient departm ents o f hospitals. C ertain services were sometimes available at the homes themselves. In annual reports o f several institutions mention is made, e.g. of regular chiropody services, physiotherapy, however, hardly figured in such reports. T o an organisation such as the S.A. Society o f Physio­ therapy, this was rather a disappointm ent. We had become interested in the care o f the aged quite som e time ago. We had focussed the attention o f our members and our students on the great contribution physiotherapy can make to geriatric services. W ith the growing interest o f the general public in the welfare o f the aged, we expected to be in the forefront o f services laid on for the benefit o f the aged. When this expectation was not fulfilled we felt compelled to search for reasons. We found, th a t in many instances M anagem ent C om ­ mittees were no t ready for the introduction o f physio­ therapy. Generally, there existed considerable ignorance o f the nature, aims, and objects o f physiotherapy. Bluntly, it was stated th a t physiotherapy as such was not for the aged. W hen attention was draw n to leading institutions overseas, where physiotherapy had become an integral p a rt o f geriatrics, the usual reply from individual homes was, th at am ong their particular residents or patients there were none suitable for physiotherapy. A nd between the lines one could always read th at the introduction o f physiotherapy was considered an expensive venture, and th at there were no funds for such an experiment, anyhow. D octors and specialists, to o , felt th a t they were up against a form idable wall when they tried to persuade the boards o f m anagem ent to incorporate physiotherapy in their treatm ent plans. T here was only one way o f overcoming such ingrained preoccupations. Substantial p ro o f had to be produced, that physiotherapy was an essential item in the program m e of a well-run home for the aged, and th a t the finance involved was within the limits o f m ost institutions. T his p ro o f was provided by some voluntary workers from our midst, who offered their skill and experience to help in the rehabilitation o f o u r aged. The experiences of these members were closely watched by our C entral Executive C omm ittee, and when their success showed th a t physiotherapy was m aking valuable contri­ butions to the care o f the aged, the C .E.C. offered the assistance o f the S.A.S.P. to the Johannesburg Council for the Aged. The S.A.S.P. was invited to jo in the Council, and from this has resulted the development o f pilot schemes, by which, on a voluntary basis, physiotherapy was provided in establishments fo r the elderly, for groups o f residents and i patients, selected and referred by their medical officers. These efforts did not rem ain unnoticed. The appreciation expressed by the C hairm an o f C omm ittees o f Bramley H ouse, in the A nnual R eport for 1962 o f the R and Aid A ssociation showed th at physiotherapy had m ade its impression. T he Johannesburg Council for the Care o f the Aged brought the scheme to the notice o f the N ational Council. W ithin less than a year the S.A.S.P. obtained representation on both the N ational Council and the Executive Com m ittee o f the Johannesburg C ouncil for the C are o f the Aged. A t the G eneral M eeting o f the N ational C ouncil for the W elfare o f the Aged in Novem ber, 1962, when for the first time the S.A.S.P. was represented as an affiliated organisa­ tion, w ith its delegate as a m em ber o f Council, a unanim ous resolution was passed expressing the C ouncil’s thanks to the S.A.S.P. Judging from their success, Pilot Schemes o f the type developed and tried in Johannesburg, although not a patent solution, seem to supply within limits one answer to the demand for physiotherapy in geriatrics. Such Pilot Schemes do no t call for a voluntary effort o f more than an evening o f two hours per week. They have m et with the m ost grateful response from the elderly themselves, and have inspired members o f allied professions, such as the nursing and social services, as well as interested helpers from the general public, to link hands w ith us to form team s which w ork ini splendid co-operation. O f course, there must be n o m isunderstanding o f our attitude to such voluntary services. While the S.A.S.P. is m ost appreciative o f the fact th a t we have in our ranks enthusiastic members who are rendering this service to our aged, it is not suggested th a t their generous offers should be exploited. We are fully aw are th at we are dealing with a pilot scheme, operated by voluntary workers, in their spare time, after a busy day in their hospital departm ents, and suitable only for patients who are still receptive and co-operative in the evening. O f necessity this can only provide a service of limited scope. I t must restrict itself to those carefully selected cases, where even with little time a t our disposal we can be o f sub­ stantial use. N o t much more can be done th an marginal physiotherapy, where we can enlist the assistance o f the nursing staff, other voluntary helpers, o r members o f the patients’ families. In limited fields, e.g. re-education in walking, im provem ent o f general mobility, and certain routine exercises, such schemes may already produce striking results. They are sufficient to prove th a t w ithout physio­ therapy a m odern institution for the aged is n o t complete in its services. But for any sizeable establishment, such a voluntary service is not adequate. 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 9 Notes on the Application of Wet Ice By Dena Gardner, M .C .S .P. The application o f cold has proved an effective means of physical therapy. T he physiological effect o f cold applied for a short duration is rem arkably similar to th at o f heat; it appears m oreover th a t th e effect o f the form er lasts longer and is a m ore suitable preparation for activity because the patient feels refreshed, as for example, after a cold b ath or shower, in contrast to the feeling o f ennervation which results from the application o f heat. N orm al functional activity is the ultim ate aim o f most physiotherapeutic procedures and cold applications help to accelerate the p atien t’s physical rehabilitation. Equipment The requirem ents are simple and inexpensive, i.e. some medium-sized turkish towels and an ordinary household bucket three-quarters full of ice. Flaked o r shaved ice is preferable because it is no t lumpy and adheres m ore readily to the surface o f the towels, however finely crushed ice is quite satisfactory and easier to obtain. Tw o wet and folded towels are placed between layers o f ice in the bucket and water is added to a depth o f ab o u t tw o or three inches in the bottom o f the bucket. It is essential th at the tem perature of the ice and water mixture is as low as possible so th a t the flakes or fragments o f ice adhere to the surface o f the towels; ice cubes are unsuitable as they fail to reduce the tem perature sufficiently and also make the application uneven and uncom fortable for the patient. Plinths upholstered in plastic (Continued fr o m page 8) The obvious developm ent is th at once such a pilot scheme operates successfully, it creates a dem and for an aug­ mented service which cannot reasonably be expected from voluntary workers. I t will, o f course, be realised, th at not every establishm ent will require a daily, full-time, physio­ therapy service. Part-tim e physiotherapists could be em­ ployed, o r several institutions could pool their efforts and organise physiotherapy on alternating days. Two Johannesburg institutions which started physio­ therapy through pilot schemes, have indeed already in tro ­ duced regular day sessions, fully integrated w ith the medical I services, so as to fulfil the increased demand for physio­ therapy. Summary I t is felt th a t at this early stage o f the organisation of comprehensive geriatric services in our country, physio­ therapy cannot afford to sit back and w ait for invitations. In view o f the great contribution th a t physiotherapy can make in the care o f the aged, we should not be reluctant to come forw ard and offer o u r services. O ur branches, and individual members, could be o f great value to local establish­ ments for the welfare o f the aged, and should express their willingness to co-operate, advise, and assist as members of the team . They would thus enhance the efficiency and scope of existing services and ensure for physiotherapy the place it deserves in the care for the aged. W here locally physiotherapy services already exist, and branches and members are participating in the care for the aged, the S.A.S.P. should receive detailed inform ation. The C.E.C. will then be able no t only to express appreciation o f the contributions m ade by our members, b u t also to correlate the experience o f all our workers, provide an exchange o f views and increase the value o f our effort. m aterials make the use o f w aterproof o r plastic sheeting unnecessary, a spare towel is all th a t is required to dry the patient and to m op up after the application. Technique W hen the patient is adequately undressed and ready for treatm ent the therapist takes one folded towel from the ice bucket, rings it quickly and thoroughly, unfolds it to the required size and places it firmly on the p atien t’s skin. As the towel is unfolded flakes o f ice are seen to adhere to the towel, any delay o r shaking o f th e towel m ust be avoided as this would raise the tem perature and consequently reduces the effect o f the application. Once the towel is in contact with the patient’s skin its tem perature rises rapidly, it must therefore be removed after two o r three minutes and re­ placed by another which has been soaking in the bucket. Three o r four towels are usually sufficient. Effects and Uses 1. The Relief o f Pain Cold decreases the speed o f nerve conduction therefore the feeling o f pain is reduced. Ice towels are applied to the painful area as frequently as possible. Pain is a factor which limits movement and inhibits m uscular contraction, it is therefore often possible to obtain an increased range o f movem ent or a m ore satisfactory contraction o f muscles while the ice towel is in situ. 2. The R elief o f Spasm Cold decreases the speed o f nerve conduction and the stretch stimulus is inhibited. F o r the reduction of spasm the ice towel m ust cover the whole length of the affected muscles. Reduction o f spasm in a whole limb is usually m ost satisfactory when cold is applied to the distal parts first. Subsequent treatm ents produce reduction in spasm in a shorter time and the effect is more prolonged. 3. Active Hyperaemia Cold applications o f short duration reduce the superficial blood supply initially but this is followed by an active hyperaem ia which is apparent when the towels are removed. This local increase in the circulation is useful for the reduc­ tion o f swelling and prior to joint mobilisation. Ice towels are applied over the required area, or a hand o r foot may be put directly into the bucket, immersion of hands or feet must be o f short duration initially however, as sensation is acute in these areas. Contra-indications There appears to be very few contra-indications to treat­ m ent w ith ice, most parients like it and find it m ore effective than heat. Patients w ith circulatory disorders such as R eyauds and Buergers disease are however unsuitable for this type o f treatm ent. Advantages The use o f wet ice as described has many advantages: (a) it is effective in a wide variety o f conditions, (6) it is time-saving for b o th p atient and therapist as m any active and passive exercise techniques can be continued while the ice towels are in situ, (c) applications o f cold can safely be carried out at frequent intervals by the patient in his own hom e provided a refrigerator is available. As in the case o f any o th er technique of physical tre a t­ ment, care and accuracy in the application is essential to ­ gether w ith acute observation o f the results obtained. 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. )