REHABILITATION
By DR. HAROLD BALME
ONE of the very few compensations associated with the dark horrors of war is the stimulus to medical research brought about by the presence of new and compelling problems and by the provision of special facilities for their investigation, as a result of which fresh discoveries are made, from which both civilian and military patients ultimately benefit. It is too early to speak of the medical discoveries of this war, but already it has focussed attention upon a most promising development of hospital treatment, namely, that of rehabilitation—not, it is true, a completely new form of treatment, but one which hitherto has been in the main confined to established disabilities and applied as a last resort.
Two facts have given urgency to this problem. The first has been the necessity to get service patients back to their units at the earliest possible moment and in a fit state to resume full duty. The second is the need to reduce permanent disability to a minimum in the case of men who have to be invalided out of the Services, so as to enable them to continue some form of useful employment on their return to civilian life. It has long been recognised that the disability consequent upon serious fractures or operations upon joints has been due to the prolonged immobilisation accompanying the treatment of such injuries, resulting in marked wasting of muscles, circulatory stagnation and oedema, adhesion of soft tissues, and decalcification of bone. It was, however, feared that early movement might interfere with the union of broken bones or set up inflammation in parts recently subjected to operation. These fears have been found to be groundless, and, granted skilful handling, early movement will not only not impede recovery but will actually hasten it by promoting healthy vascularity in the injured tissues. Fractures so treated are found to unite more quickly and more firmly than after prolonged immobilisation, the formation of adhesions is prevented, and muscles no longer become weak or atrophied.
A variety of methods are now employed in achieving these results. As soon as the patient is admitted to a Rehabilitation Department the mune of the disability which may result from his injury or operation is fully explained to him, and the part which he himself can take in preventing such an outcome is made clear. His intelligent co- operation is thus secured from the outset, and he is encouraged all through his treatment to take a note of his various tests and measurements and to keep his own graphs. Muscular drill is then commenced in bed, both before and after operation, or within a few days of an injury or fracture, the amount of muscular exercise prescribed varying from day to day with the severity of the injury and the progress of the case. This drill takes the form of voluntary contractions of muscles at stated intervals, electrical stimulation, or weight-and-pulley exercises. Weights and pulleys have a special usefulness, as they affOrd a concrete test of muscular power, and the patient is able to watch his own progress from day to day as he succeeds in lifting heavier weights with his crippled limb. These exercises are carried out in the ward at regular times through the day, and thus a healthy spirit of rivalry takes place between men with similar disabilities.
Directly the patient is able to get up he is placed in a remedial exercise class. A large number of such classes are held, each group adapted to a particular injury and stage of progress, and each sup- plied with a course of progressive exercises. These are performed under the supervision of a masseuse or trained physical instructor, but in most instances the patients quickly learn the exercises and will carry them out themselves. But no patient, however keen, can keep on repeating the same type Of exercise very long without becoming bored or his muscles getting tired, and at this stage considerable use is made of occupational therapy and organised games, in each case directed towards the particular disability which it is desired to remedy. Great ingenuity is employed in the adapting of occupational devices to the exercise of weakened muscles. Men with stiffened fingers are given cane-work, basket-work and netting, with tools so adjusted (and periodically changed) as to require con- stantly increasing flexion of their fingers ; a man with an injured shoulder will be supplied with a hand-loom and a low stool, so that each movement of his hands when passing the shuttle to and fro will involve raising his arms above shoulder level. Foot-looms are fitted with resistance-springs—just to make it a little harder—and so arranged by means of levers and stops that they can only be worked by the use of the particular group of thigh, calf or foot muscles which it is desired to exercise. In spite of these somewhat unsporting discouragements, men will work all day long at a carpentry bench or at these various forms of occupational therapy, intent upon the particular article that they are making and quite oblivious of the fact that all the time they are exercising their weakest muscles or the joints that are stiff.
The same is true of organised games. Cycling, swimming and various forms of handball have a valuable place in the work of rehabilitation, for not only do they provide good recreation and promote general physical well-being, but they are easily adapted to any particular form of disability, and they help to develop freedom and rapidity of movement whilst at the same time diverting the patient's attention from the part which has been injured and of which he is probably still somewhat nervous. Every patient is provided with a programme card, detailing the various exercise periods, occupational therapy and games prescribed for him day by day, his time being thus fully occupied in activities all directed towards his ultimate recovery. This full occupation, combined with his intelligent co-operation in watching his own progress, has an immense influence on the general morale of the patient, and one of the most striking results of rehabilitation has been seen in the changed attitude of the patients themselves.
Two elements in the scheme are essential to success. The first is the regular supervision of all patients by a Rehabilitation Officer, whose duty it is to prescribe the amount and type of rehabilitation suitable for each new patient and make out his daily programme, to watch his progress from week to week and decide on his fitness to attempt more active movement, to keep a general supervision of the team exercises and organised games, and to examine without delay any patient whose treatment has been possibly too vigorous or who complains of discomfort after exercise.
The other essential is the development of a real team spirit on the part of all taking part in the work of rehabilitation—doctors, masseuses, physical-training instructors, occupational therapists and the like. Weekly meetings are held for the whole team, at which different types of disability are described, clinical cases and X-ray films demonstrated, and a discussion takes place as to the best type of rehabilitation for each group. The results of this new method of dealing with disabilities are most striking, and, apart from the more cheerful outlook of the patients whilst under treatment, statistical studies are already showing that the period before return to duty is tieing substantially reduced, that fractures arc uniting more rapidly and more firmly, that joints are recovering a full and painless range of movement in a far larger percentage of cases, and that the muscular tone and general physique of the patient are both alike raised. From an economic standpoint alone this experiment is abundantly justified, and its effect on the treatment of industrial injuries after the war is likely to be far-reaching.
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