Physical therapy in the treatment of the tuberculous patient

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PHYSICAL THERAPY IN THE TREATMENT OF THE TUBERCULOUS PATIENT

A Thesis Presented to the Faculty of the Department of Physical Therapy The University of Southern California

In Partial Fulfillment of the Requirements for the Degree Master of Arts

by Mary Jackson Dodge February 1950

UMI Number: EP63107

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T his thesis, w ritten by

........MARY..JACKSON. DODGE.............. under the guidance of h 3 T .... F a c u lty C o m m ittee, and app ro ved by a l l its members, has been presented to and accepted by the C o u n c il on G ra duate Study and Research in p a r t ia l f u l f i l l ­ ment of the requirements f o r the degree of

MASISR...QF...ARIS.. . . . . . . . . . . . . . . . ..............

Date..... ..................

Faculty Committee

Chairman

TABLE OP CONTENTS CHAPTER I.

PAGE

THE PROBLEM AND DEFINITIONS OP TERMS USED . . . The problem

............................

1

.................

1

Importance of the s t u d y ...................

1

Scope and l i m i t a t i o n s ..........

2

Statement of the problem

Definitions of terms used ................... Tuberculosis

..............................

Physical therapy

.........................

Therapeutic exercise Electrotherapy

.....................

............................

3 3 3 3 3

Posture ....................................

4

Body m e c h a n i c s ............................

4

Scoliosis ..................................

4

Spontaneous pneumothorax

.................

4

..............................

5

Phrenicotomy

Therapeutic pneumothorax

II.

1

.................

5

P n e u m o p e r i t o n e u m .......................

5

Thoracoplasty . . .

3

..........

Method of procedure .........................

5

Organization of the remainder of the thesis .

6

RELATED INVESTIGATIONS

.......................

8

iii CHAPTER

PAGE Related Investigations .....................

III. IV.

8

SURVEY OP INSTITUTIONS FOR THETUBERCULOUS . . .

13

REVIEW OF LITERATURE ON MODALITIES AND PRINCIPLES INVOLVED IN A PHYSICAL THERAPY PROGRAM FOR TUBERCULOSIS .............

30

Bed rest and e x e r c i s e .......................

31

Bed rest and e x e r c i s e .....................

31

R e l a x a t i o n ....................................

38

R e l a x a t i o n ..................................

38

Posture testing and training Posture testing

................

...........................

45

.........................

51

Posture training

Surgical c o n d i t i o n s .............. Surgical c o n d i t i o n s .....................

58 .

Light t h e r a p y ......................... V.

58 6l

AUNIT OF STUDY IN PHYSICAL THERAPY FOR TUBERCULOUS P A T I E N T S .......................

VI.

45

.

66

Objectives of the u n i t .....................

66

Lecture outline

67

SUMMARY AND CONCLUSIONS

............. .............

86

S u m m a r y ....................................

86

C o n c l u s i o n s ................................

89

BIBLIOGRAPHY ..........................................

90

LIST OF TABLES TABLE I.

PAGE Principal Modalities Used in Institutions V i s i t e d ................................... " . . .

II.

28

Most Common Deviation in Postural Alignment Following Thoracoplasty ......................

29

CHAPTER I THE PROBLEM AND DEFINITIONS OF TERMS USED For many years some forms of physical therapy have been "used in the treatment of tuberculosis,

More recently,

the use of therapeutic exercise, especially in the manage­ ment of the case involving thoracic surgery, has enlarged this field of application.

I.

THE PROBLEM

Statement of the problem. this study:

It was the purpose of

(l) To discover what constituted a physical

therapy program for the tuberculous patient as evidenced by current practice in selected institutions in Southern California;

(2) to review the literature on the techniques

and principles involved in such a program;

(3 ) to construct

a unit of study covering this material which could be used in a school of physical therapy. Importance of the study.

A recent report of the

Los Angeles County Health Department lists two thousand, two hundred and seventy active tuberculosis cases with

2 residence in the health department area.-*-

An additional

one thousand, one hundred and thirty seven cases were re­ ported to be in institutions in the area, whose residence was elsewhere.2

Since the role of physical therapy in

the treatment of this disease has recently changed, a survey of current practices, and revision of plans of instruction was important. Scope and limitations.

The survey of current prac­

tices was limited to eight institutions located in four counties of Southern California.

In this study, techniques

designed specifically for use in the care of the tuberculous patient, or adapted to this use, were considered.

It was

realized that other modalities might be used concurrently in a tuberculosis unit.

Certain modalities were found to

be used in the same form as for any other condition. were not described in detail as to techniques.

These

It was

assumed that students would learn the fundamentals of electrotherapy, exercise, body mechanics, and the pathology of tuberculosis elsewhere.

Annual Report of the Los Angeles County Health Department, Los Angeles, 19^7-19^8* P« 3^* 2 Ibid., p. 34.

3 II.

DEFINITIONS OF TERMS USED

Tuberculosis.

"An acute or chronic infection in­

volving chiefly the lungs, gastro-intestinal tract, genito­ urinary tract, bones, joints, and g l a n d s . "3 Physical therapy.

Physical therapy has been defined

as "the management of disease by means of physical agents such as light, heat, cold, water, electricity and mechanical agents. Therapeutic exercise.

"The use of scientifically

supervised movements of the body, with or without apparatus, for the purpose of restoring diseased or injured tissues as near to normal function as it is p o s s i b l e . "3 Electrotherapy.

This term may be applied to the use

of any type of electrical treatment, but the chief use in tuberculosis is the use of light, artificially produced.

3 "Physical Therapy for Thoracic Surgery Patients,". Veterans Administration Pamphlet, 10-22 (Washington, B.C.: United States Government Printing Office, 1947), p. 3» 4

Frank H. Krusen, Physical Medicine W.B. Saunders Company, 1941), p. I.

/ \ Philadelphia:

5 J.S. Coulter, and C.O. Molander, "Therapeutic Exercise," Handbook of Physical Therapy (third edition; Chicago: American Medical Association” 1939 )> P* 127.

4 Posture.

Posture denotes "any relative arrangements

of the different parts of anything, especially of the body."^ Body mechanics.

At least one authority considers

7 body mechanics and posture as practically synonymous. For the purposes of this paper they were considered to have the same meaning. Scoliosis.

Scoliosis is the term used to indicate g a lateral curvature of the spine. Spontaneous pneumothorax.

"Spontaneous pneumothorax

is a condition resulting from a rupture of the ling with sudden accumulation of air in the pleural space,

causing

positive pressure and collapse of the affected lung.

Wellesley College Studies in Hygiene and Physical Education, "Grading Anteroposterior Standing Posture," Supplement to The Research Quarterly of the American A s s o ­ ciation of Health and Physical Education, 9 -m79-89* MarchApril, 1938. 7 Handbook American O 0 Practice

Robert Bayley Osgood, "Body Mechanics and Posture, " of Physical Therapy (third edition; Chicago: Medical Association, 1939)* P* 116. William Bierman, Physical Medicine in General (New York: Paul B. Hoeber, Inc., 1944), P • 353*

9 Florence S. Linduff, "Physical Therapy and Chest Surgery," The Physiotherapy Review, 27:95* March-April, 1947.

5 Phrenicotomy.

"Phrenicotomy is a surgical procedure

which consists of severing or crushing the phrenic nerve through a small incision in the neck.1^ Therapeutic pneumothorax.

Therapeutic pneumothorax

is the introduction of air into the pleural cavity through a small hollow needle, under measured volume and pressure. Pneumoperitoneum.

11

"Pneumoperitoneum is the injec­

tion of air into the abdominal cavity by the same procedure used in giving pneumothorax. Thoracoplasty.

1P

A surgical procedure in which parts

of ribs are removed for the purpose of collapsing all or part of the lung.

The lining of the ribs is left so that

they will grow again and restore the chest wall.

III.

METHOD OP PROCEDURE

Interviews with heads of departments of physical therapy and nursing in eight Southern California insti­ tutions having tuberculosis units were arranged,

10 I b i d ., p. 9 6 . •j -1

k°c • c i t .

12

p. 97-

and a

6 survey made of methods and modalities being used in these departments. A library study was made of modalities and prin­ ciples which were found to be involved in a physical therapy program for the tuberculous patient.

The facilities

of the Doheny Library, the Medical and Physical Therapy Libraries at the University of Southern California, and the Library of the Los Angeles County Medical Association, were used. A short unit of study,

intended for incorporation

in a course in therapeutic exercise for students of Physical Therapy, was constructed on the basis of infor­ mation gathered.

IV.

ORGANIZATION OF THE REMAINDER OF THE THESIS

Chapter II will review the literature on related investigations. Chapter III will describe a survey made of eight Southern California institutions having tuberculosis units, as to the use of physical therapy modalities. Chapter IV will review literature pertaining to modalities found to be in use. Chapter V will describe a unit of study intended for

7

incorporation in a course in therapeutic exercise for physical therapy students. Chapter VI will consist of summary and conclusion.

CHAPTER II RELATED INVESTIGATIONS Related investigations.

In the field of therapeutic

exercise and posture training for the tuberculous patient there has been considerable activity in the last few years. The first evidence of this in the literature apparently was the publication of the work being done during the war at Fitzsimons General Hospital.-1- The program there was started by the Array as part of the rehabilitation of the war injured. This article did not differentiate between the needs of the subjects with chest wounds and those with tuberculosis and other infections.

The purpose of this work was described

as follows: The objectives of the physical therapy pro­ cedures are to prevent shoulder stiffness, to increase vital capacity by assisting in the re­ expansion of the lung, to assist in the resto­ ration of function of the shoulder muscles, to augment respiratory control of the muscles of Inspiration and expiration, to maintain body strength and physical stamina and to insure proper axial alignment and good posture by pre­ venting the development of deformities.2

Ora L. Huddleston, Roberta Winston, and Miriam. Engelland, "Physical Therapy Procedures in Preoperative and Postoperative Care of Chest Surgery Patients," The Physiotherapy Review, 25:203-207, September-October, 19^52 Ibid., p. 203.

Pre- and postoperative care was described.

The pr e­

operative program was started as soon as the patient was received on the surgical ward, and the training was resumed on the first postoperative day.

This early care included

bed positions, breating exercises, heat to relieve pain. were enumerated.

shoulder exercises, and

Special precautions to be observed

This routine was gradually agumented until

about the end of the second week when the patient might be sent to the physical therapy department for supplementary treatment.

The use of ultraviolet light and hot packs was

mentioned.3 As no differentiation of conditions was explained it was not possible to tell which of these procedures were-used for tuberculous conditions.

The work outlined in this ar­

ticle seemed to fit the wounded or accidentally injured rathern than the victim of tuberculosis for whom rest and the avoidance of fatigue are so important.

h

One of the collaborators on the first article con­ tinued the discussion of the Fitzsimons program a year l ater. ^

At this time several types of cases were described

3 I b i d ., p. 205. ^ Prank H. Krusen, Physical Medicine W.B. Saunders Company, l§4l), P- 530.

(Philadelphia:

5 Helen R. Winston, ’’Physical Therapy and Chest Surgery, The Physiotherapy Review, 26:227-230, September-October, 1946.

10 including tuberculous conditions.

A general program was

outlined and divided into preoperative, immediate post­ operative, intermediate postoperative, and late post­ operative phases.

In the first stage the patient was

told of the problems which would arise and the measures which would be employed to mee them.

The first post­

operative day, treatment was started in the form of positioning in bed, breathing and abdominal exercises, and shoulder motion.

Supplementary treatment by means

of radiant heat, ultraviolet, and hot packs was mentioned. The later phases were not described in detail.

A strenuous

exercise program, including heavy resistance exercises, was indicated.

The program was said to last about a month.

As in the former article, no differentiation was made be­ tween the conditions as to type of treatment or speed of progression. Linduff,

6

writing on the same subject in connection

with work in the veterans hospitals, has divided the tuber­ culous and nontuberculous, and outlined treatment for various types of surgical cases under each.

Under tuber­

culous conditions are listed phrenicotomy, pneumothorax, pneumoperitoneum, and thoracoplasty.

a.

„

Similar routines,

Florence S. Linduff, Physical Therapy and Chest Surgery," The Physiotherapy Review, 27=9^-100, March-April,

19^7 .

11 consisting of posture, range of motion,

and abdominal

exercises are given for the first three.

For the theraco-

plasty cases, more detailed instructions are given due to the muscle imbalance caused by the surgery.

Precautions

to be observed and contraindications received consideration. She concluded that better results and the elimination of chest cripples can be accomplished by these programs. 7 Treister,1 has reported a posture program for the tuberculous patients in the Veterans Hospital at Brecksville, Ohio. patients,

Two phases were described, one for all

and one for those having thoracoplasty..

Bed

posture was regulated for all, especially during formal rest periods, when patients were required to lie flat on the bed without pillows under the head.

Posture analysis

was made, and training given by the physical therapist as soon as the patient became ambulatory.

X-rays showed that

deformity began to develop a few days after thoracoplasty, requiring early institution of treatment.

The therapist

therefore began her visits to the patient before surgery and continued to aid and guide him in retaining structural balance until he was able to carry on for himself.

^ Bert A. Treister, "The Prevention of Postural D e ­ formity after Thoracoplasty,” Archives of Physical Medicine, 30:446-449, July, 1949.

12 No recent experimental work, and very little mention of any kind was found in the literature on light therapy in treatment of tuberculosis.

CHAPTER III SURVEY OF INSTITUTIONS FOR THE TUBERCULOUS In order to determine what physical therapy modali­ ties were in use in the treatment of tuberculous patients, it was considered desirable to investigate actual current practice in this respect.

Visits were accordingly made to

eight institutions, work observed, and chief physical thera pists interviewed. The first institution visited was a Veterans Adminis tration hospital for the tuberculous, three hundred pa tients.

caring for about

The department of physical therapy

was composed of t]iree registered therapists under the direc tion of the Chief of Medical Rehabilitation, who was a Physiatrist.

The hospital being entirely devoted to the

care of this type of patient the therapists spent full time in this work.

However, all kinds of physical therapy were

done for incidental and concomitant conditions and only one therapist spent full time on posture and postsurgical care. Patients were divided into seven classes according to the amount of general activity allowed.

The individual

patie nt ’s condition was nevertheless considered the best guide in planning physical therapy.

No work was started

ib

on admission, nor at any time without specific order. Occasional orders were received for relaxation instruction for special cases, usually post surgically. When this was done the Jacobson-1- principles of relaxation were followed. All orders for posture and exercise were for the care of thoracoplasty patients.

This was a routine order.

The therapist saw the patient usually three days before surgery, explained the difficulties which would follow, and the care which must be taken to avoid deformity. posture test was made by subjective judgment.

A

Arm and

shoulder exercises were demonstrated and reasons for them explained.

Every effort was made to reassure the patient

and to assure cooperation. day following surgery.

Treatment was resumed on the

If pain, due to muscle spasm,

occurred, massage and occasionally heat, were ordered. Hot fomentations were preferred to infra-red for the heat, but both were used occasionally.

Passive and active range

of motion of the arm and shoulder were given, starting with two' times and progressing to about five times with1 each motion by about the end of the week, depending on the condition of the patient.

Edmund Jacobson, Progressive Relaxation University of Chicago Pressl 192971 ^29 pp.

(Chicago:

15 Pulse and respiration were taken before,

and five

minutes after, all activity in the early stages.

It was

considered that the pulse should be normal at the end of the five minute period.

The emphasis throughout all

treatment was on underdoing rather than overdoing.

This

point was stressed by all members of the staff who were contacted. Bed positions were checked daily by the physical therapist and the nursing staff was aware of desired positions.

The surgeon wished to have the patient in

a side lying position, primarily on the affected side, with a pillow under the side and none under the head. Rest periods of twenty minutes in every four hours on the back or unaffected side were allowed.

In the back

lying position pillows were to be used under the head and shoulders.

On the unaffected side two pillows were

to be used under the head. Deformities were found to appear chiefly after the third stage of surgery, when the patients were said to become complacent,

and the therapists found

to work hardest to secure cooperation.

that they had

The most frequent

pattern of postural malalignment in the ambulatory patient was one in which the subject tended to stand on one foot with the weight on .the unaffected side,

hip prominent

high on that side.

affected side was

The shoulder on the

and

16 high., the other frequently showed a winging scapula.

The

head and neck deviated toward the unaffected shoulder. To combat these tendencies, the patient while still in bed in the earliest postoperative stage, was taught to "creep" with the fingers on the affected side toward the foot of the bed, depressing the shoulder.

As soon as he

was able to get out of bed, work was started in the sitting position before a mirror.

The effort was made to reeducate

and strengthen the shoulder adductors by mild active and slightly resistive exercises. stretched,

Shortened neck muscles were

and head position corrected.

ment was practiced by the patient.

Conscious realign­

Antero-posterior curves

were readjusted consciously with the aid of the therapist. Static contractions of the abdominal muscles were practiced as a means of restoring tone to these muscles. exercises were ever given.

No breathing

The patients were seen once

daily. Very little light therapy was used for tuberculous conditions.

Occasional orders for ultraviolet for skin,

bone and joint, laryngeal, been received.

and lymph node infections had

Empyema was occasionally treated by ultra­

violet . The second institution visited was also a Veterans Administration hospital.

It was a large general hospital

17 with a tuberculosis unit where about three hundred and fifty cases were treated.

One registered physical therapist

spent full time in this unit doing posture,

relaxation,

and

postsurgical work, under the direction of the chief of the tuberculosis service.

Patients were divided into seven

classes and both treatment and general activity regulated accordingly. Orders for posture training were usually for surgical cases.

These included general work for phrenicotomy, pneu­

mothorax,

and pneumoperitoeum cases as well as special

training for thoracoplasty patients.

Subjective tests of

posture were made, and exercises formed the chief mode of correction.

However, mirrors were used both at the bedside

and in the treatment room to aid the patient in self cor­ rection and habit formation. for shoulder retraction,

The exercises used were chiefly

and neck extension.

Some indepen­

dent exercise was also assigned to each patient.

Pulse

and respiration were not generally taken, though this varied according to the physician on service at different times.

When taken,

it was considered normal if the pulse

returned to the regular rate within eight minutes. and masks were worn by all who went on the wards.

Gowns Relaxation

by the Jacobson technique was taught to all surgical patients, and to others on order.

18 The physical therapist was generally notified at least three days before patients were to go to surgery for thoracoplasty,

and at this time oriented the patient by

explanation and demonstration in the problems to be faced and the methods of management.

Posture was subjectively

evaluated.

Work was resumed on the first postoperative day

as a rule.

No massage was given and heat was used only on

the lower body or legs.

Bed positions were checked twice

daily when other treatment was done.

The surgeon desired

chiefly the back lying position, with the head in overcor­ rected position, without pillows.

Any comfortable position

was allowed for rest.

Sand bags were used only occasionally

and on special order.

Deformities were said to appear to

the greatest extent after the third stage.

The typical

picture was one with head and neck to the unaffected side, high shoulder on the affected, with winging scapula usually on the unaffected side.

The weight was usually carried on

the side opposite the incision,

throwing that hip into

prominence. The bed exercises consisted of passive range of motion for the first week, to the shoulder, No abdominal exercises were done.

arm, and neck.

Very occasionally on

special order some breathing exercises were taught.

Ambu­

latory patients came to the treatment room on the ward. They did mild shoulder and arm exercises, neck stretching,

19 and abdominal contractions. attention.

Sitting posture received most

Deformity was combatted chiefly by these exer­

cises, and the attempts df the patient to straighten the body in front of the mirror. Very little light therapy was used.

Occasionally

ultraviolet was ordered for skin conditions. The third institution was a county sanitorium, with a bed capacity of about twelve hundred.

One registered

physical therapist did most of the posture and exercise treatments.

Two nonprofessional helpers did other work.

The patients were not formally divided into classes.

No

relaxation had been taught but the therapist expressed interest in methods in use.

Pulse and respiration were

not checked. Occasional orders for posture training for nonsurgical patients were received, but not until the patient was able to come to the physical therapy department.

The

method was that of development of kinesthetic awareness of corrected position, with the aid of the therapist. Mirrors were used.

Standing and walking posture were

checked as well as sitting. and very mild.

Exercises were seldom done

Testing was subjective.

The patients were

seen only twice a week because of shortage of personnel. Thoracoplasty cases received care pre- and immediately

20 postoperatively in the wards by the physicians.

The p h y ­

sical therapist did not go on the wards and treated the patients only after they were judged ready to make the trip to the department.

Massage,

frared, were frequently used. at this time were:

and heat, chiefly in­

The deformities encountered

Head and neck deviated toward the u n ­

affected side, shoulder high on the affected, and scapula usually winging on the same side.

The weight was customarily

carried on the unaffected side with the hip prominent. of motion was carried out with the shoulder and arm. dominal.

Range No ab­

or breathing exercises were, done and few exercises

of any kind.

Most work was done before a mirror with e m ­

phasis on conscious realignment and development of kines^. thetic awareness.

Treatment was given only twice a week

but patients carried on as well as possible between visits to the department. Orders had recently been carried out for ultraviolet on the following conditions:

Infected lymph nodes,

laryngeal, peritoneal, bone and joint,

empyema,

and cutaneous in­

fections . The next hospital,

the fourth in this series, was

a county general hospital with a unit for one hundred and fifty tuberculous patients.

The physical therapy depart­

ment, under the direction of the staff physicians consisted

21 of two registered physical therapists, but neither did any work on posture or postsurgical care of patients in the tuberculosis unit. the surgeon.

Preoperative orientation was done by

A definite program for checking bed positions,

securing range of motion of the arm, and preventing defor­ mity, was carried on by the nursing staff.

Exercises for

the shoulder and arm, and neck realignment were included. Mirrors were used as aids.

The only deformity which had

been observed was the high shoulder on the affected side with deviation of the neck to the other. Wo training in relaxation was given and no light therapy was employed. Hospital number five was a county hospital having a unit of about two hundred tuberculous patients.

The one

registered physical therapist had only recently received orders to correct posture and deformities for three of these patients after surgery, program in the future.

and expected to expand the

Wo work had been done in the ward.

When the wound had been healed after thoracoplasty the patients had been sent to the physical therapy department for treatment.

Heat and massage were used,

exercises were

given for range of motion of the shoulder and arm. dominal contractions were practiced.

Ab­

Posture was studied

and conscious realignment procedures were employed.

22 No light therapy or relaxation techniques were employed. ,Hospital number six, another county general hospital, was not doing any work in physical therapy for tuberculous patients, of whom there were about eighty.

However,

a new

building to accommodate one hundred and twenty additional cases was being built, and upon completion it was hoped that this care could be introduced in that unit. Hospital number seven was a military hospital which included a unit for the care of about two hundred tuber­ culous patients.

The department of physical therapy was

under the supervision of a physiatrist.

One physical

therapist spent half of each day in the tuberculosis unit. Gown and mask were worn at all times on the wards. patients were not divided into formal classes.

The

Pulse and

respiration were taken on patients in the early stages of treatment and great care was taken to avoid overexertion at all times.

Bed positions and posture were checked on

nonsurgical patients only on special order.

Relaxation

techniques, following the Jacobson principles were given to special cases.

Posture was corrected when necessary

for patients following phrenicotomy, pneumothorax and pneumoperitoneum.

The greater part of the time was spent

with thoracoplasty patients.

Orders were routinely received

23 about a week before surgery.

The patient was seen and

effort made to explain difficulties which might result in respect to postural alignment. were shown.

Procedures to be followed

It was explained that continued effort would

be necessary on his part but that he would be helped and guided in his efforts and the results could be good. Preoperative posture was subjectively evaluated. Treatment was resumed as soon after surgery as the individual patient was considered well enough by the p h y ­ sician, usually within a few days.

If muscle spasm and

pain occurred massage might be done immediately.

Bed

positions were checked at least daily when other treatment was carried out.

The position desired by the surgeon was

side lying, with a sand bag under the operated side. position was on the back without pillows.

Rest

Early bed

exercises consisted of range of motion for shoulder and arm, at first passively, with conscious effort to secure complete relaxation of the part, followed by active motion. To these were added flattening of the neck against the bed while lying on the back, flexion of the neck toward the affected side, and abdominal contractions,

The hand on

the operated side was moved by the patient toward the feet by crawling with t h e 'fingers.

The deformities were most apt

to appear after the third stage of surgery, and to be most

2k

difficult to control in some cases after the patient became ambulatory.

The usual pattern was one with the shoulder high

on the affected side, neck and head toward the unaffected side.

Weight was carried on the unaffected side,

hip was prominent.

and that

During this period the emphasis on treat­

ment was on the development of kinesthetic awareness of cor­ rected position and habit formation.

The patient was aided

in aligning himself on a firm base by dividing the weight equally on both feet, base,

shifting the trunk squarely over the

and the head and neck moved into alignment by contrac­

tion of the muscles of the neck on the operated side.

The

swinging scapula, almost always on the unaffected side, was retracted by tipping so that the inferior angle was held down close to the ribs.

The general principles of muscle

reeducation were employed to aid the patient to acquire the ability to make these shifts, first before a mirror standing still, then in walking.

Patients were urged to align them­

selves before the mirror every time they got out of bed, and to check again before returning to bed. No light therapy was used for tuberculous conditions. The eighth institution visited was a privately owned sanitorium of one hundred beds.

There was no physical therapy

department, but there was a program of exercises and posture work being carried out by the nursing staff.

General activity

25 was regulated according to the status of the patient In a regular progression,, starting with sitting at the side of the bed.

Privileges were added at intervals.

Gowns and

masks were worn by the nurses when on the wards.

Pulse

and respiration were checked in connection with exercises given. Bed posture was observed and corrected from the time of admission.

Back lying,, with rest periods on the diseased

side was preferred.

The nurses were said to be "posture

conscious" and to check positions frequently. Actual posture instruction was given chiefly to thoracoplasty cases, necessary.

although other cases received it when

Preoperative orientation started a week or two

before surgery.

The patient was taught what to expect„ and

what the program to prevent deformity would be. test of any kind was done.

No posture

Postoperative training began the

day after surgery with gentle hand and forearm motion. After six or seven days the patient was taught to lie on the operated side on a firm bolster. about six inches and made more rigid.

At first this was The patient started

with only a minute or two on the bolster and increased gradually until several hours were spent in this way, with rest periods on the back.

Great care was taken to have the

position exactly correct.

Small bags filled with shot were

26 placed on the anterior of the operated shoulder just under the clavicle.

The only part of the body which was said to

get out of alignment was the head, which was carried toward the unaffected side.

These patients were not out of bed

for any reason for six months. shoulder were done in bed.

Exercises for the arm and

The emphasis, particularly at

first, was upon functional activity such as reaching the back of the head.

It was said that concentration on the

aim of accomplishing a practical act, rather than on the arm and shoulder seemed more effective with timid patients. Massage was done to relieve postoperative muscle spasm, but no heat was ever used.

No relaxation techniques

or light therapy were used. In the course of these surveys it was found that interest was centered primarily on prevention of deformity following thoracoplasty.

Where time allowed, posture train­

ing and bed exercises were sometimes given to nonsurgical cases as well.

Posture testing was subjective,

recorded only in progress notes.

and usually

Interest was expressed by

therapists in more exact methods for testing if sufficiently simple and not too time consuming. struction varied.

Methods of posture in­

Some used principally exercises for

strengthening muscles needed for support.

Others, endeavoring

to avoid all unnecessary activity for these patients, tried

27 to teach the subject to sense the difference between good and poor alignment, and to make corrections by means of kinesthetic perception.

Exercises were used by all who

had such a program to promote range of motion and normal use of the arm and shoulder. Very little light therapy was in use for tuberculous conditions.

Massage was used as an auxiliary treatment for

pain as in other conditions.

Heat was occasionally employed

locally for the same purpose. Relaxation techniques, based upon the Jacobson principles were being used to some extent.

Those in charge

frequently expressed interest in other possible methods and in further knowledge as a whole.

28

TABLE I PRINCIPAL MODALITIES USED IN INSTITUTIONS VISITED

Non Surgical Cases Occa­ Rou­ F re ­ tinely quently sionally Bed Posture

2

1

Bed Exercise

Surgical Cases RouFreOccatinely quently sionally 6 7

Posture Test

3

6

Posture Training

3

7

Relaxation

2

1 2

Heat Massage Light Therapy

1

5 3

1

29

TABLE II MOST COMMON DEVIATIONS IN POSTURAL ALIGNMENT FOLLOWING THORACOPLASTY*

Affected Side Number of Hospitals

Unaffected Side Number of Hospitals

Head

6

Neck

6

High Shoulder

5

Winged Scapula

1

3

Prominent Hip

4

Weight Carried

4

* Six hospitals reporting.

CHAPTER IV REVIEW OF LITERATURE 'ON MODALITIES AND PRINCIPLES INVOLVED IN A PHYSICAL THERAPY PROGRAM FOR TUBERCULOSIS In the visits to institutions it was found that the physical therapists were chiefly concerned with the teaching of bed positions,

relaxation, bed exercises, posture,

the prevention of deformities after surgery.

and

Some light

therapy was being used. The fact that a thing is being done is not sufficient as its justification,

and progress in any event requires

effort for improvement.^

Therefore, further study concerning

the modalities and principles Involved in the treatment of conditions due to tuberculosis by physical therapeutic measures was considered advisable, particularly as this use of some of these measures is a comparatively recent develop­ ment.

Literature referring directly to tuberculosis was not

always available.

Consequently, material which seemed

appropriate to debilitated patients, those lacking normal support for maintaining the upright position,

to the con­

servation of energy, or promotion of effective rest, was

^ Carter V. Good, A.S. Barr, and Douglas E. Scates, The Methodology of Educational Research (Appleton Series in Supervision and' Teaching; New York: D. Appleton-Century Company, Inc., 1935). P- 2.

also considered suitable for consideration.

By this means

it was hoped that a more adequate understanding upon which to base the adaptation of modalities new to this field* as well as a review of traditional ones could be provided.

I.

BED REST AND EXERCISE

Bed rest and exercise.

While any decision concerning

the policy regarding the prescription of bed rest* or its modification by activity of any kind* would rest with the physician* an understanding of basic principles involved* and opinions of authorities on the advantages and disadvan­ tages* might well provide a valuable guide in planning a p r o gr am . Until about 1922* when the use of X-ray brought about earlier recognition of tuberculous lesions* bed rest was usually prescribed only when a patient displayed such symp­ toms as fever* tachycardia*

anorexia*

and weakness.2

1930* it had become recognized as important.

By

There still

has been no agreement* however* between the principles of complete and partial bed

r e s t . 3

2 R.S. Anderson* tfChanging Concepts in the Bed Rest Treatment of Tuberculosis*" Diseases of the Ches t* 14:169* March-April* 1948. 3 L o c . cit.

32 S m a r t a d v o c a t e d some modification of rest since he did not consider it to be an ideal status for any individual for an indefinite period of time. five classifications.

He divided patients into

His program ranged from complete

inactivity except for some diversion, gressive,

for the active, p r o ­

acute or subacute cases, through progressive

stages of activity.

Exercises of the larger skeletal

muscles and occupational work for the quiescent and apparent­ ly arrested cases led to a two year rehabilitation program for the negative group.

He warned, nevertheless,

that more

patients died from over exercise than from too much bed rest. He urged proper timing and amount of exercise,

carefully

adapted to the capacity and status of the individual, that:

stating

"Exercise should, under no circumstances cause toxic

symptoms,

shortness of breath,

or fatigue,

from which the

patient does not recover after a few minutes

r e s t .

"5

He

advocated both physical and mental activities, properly graded and selected to promote recovery from the disease, and for social and economic rehabilitation. P i n e ,

^ in discussing the vast program under way for

^ Elliott Smart, "Modifying Rest with Exercise in Pulmonary Tuberculosis," Medical Journal and Record, 1 3 8 : 267-2 7 0 , October, 1933, 5 I b i d ., p. 268. ^ Irving Pine,"Medical Aspects of Rehabilitation," The American Review of Tuberculosis, 152:517* May, 19^8.

33 the rehabilitation of the tuberculous veteran* .has urged consideration of the use of bed exercises and relaxation techniques. The Veterans Administration has divided patients into five classifications for general purposes according to the disease status* and seven for activity and the specific exercise program.^

Exercises are allowed at the discretion

of the physician in charge about two weeks before the patient gets out of bed for the first time. graded.

These are very carefully

It was hoped that by starting exercises before the

patient was to get up* some of the deformities and disabili­ ties which so often resulted from bed rest might be avoided. These were kyphosis* osis* flat feet* weakness.

flattening of the lumbar spine*

shortened achilles tendons*

scoli­

and general

The possibility was considered that energy ex­

pended in training the muscle might be less than that expended by beginning activity in an untrained condition. o

Covalt*

has written on the subject of bed exercises *

for postsurgical patients.

She was discussing nontuberculous

^ "Physical Therapy in Tuberculosis*" Medical Rehabi­ litation Service* Veterans Administration Pamphlet (Washington* D.C.: Unibed States Government Printing Office* September 2 7 * 1946)* 49 pp. ^ Nina Covalt* "Bed Exercises in Early Convales­ cence and Ambulation*" The Physical Therapy R eview* 28:5159* March-April* 1 9 4 8 .

34 subjects but much that she said could be true in these cases as well.

She felt that bed exercises correctly performed

would serve to reeducate and strengthen muscles so that they would perform with less expenditure of energy when the patient was ready to assume the upright position.

Muscles weakened

directly by'surgery would b e ne fi t, and deconditioning due to inactivity of the body would be reduced. Keys ,9 said that there had been a revolt against the indiscriminate use of bed rest.

He felt that it was clear

that this measure frequently exaggerated the debility con­ sequent to the original disease.

Experimental evidence was

reported to show., on normal subjects forced into a regime of complete rest,, that: Contrary to some expectations there is little loss in simple muscular strength,, but endurance as well as postural coordination and adjustment are quickly impaired. Cardiovascular capacity and efficiency are reduced, the circulating blood volume shrinks, the heart gets smaller and rela­ tive tachycardia develops, even in basal rest. The appetite remains fairly good, but constipation is troublesome. The body goes into negative nitro­ gen balance unless the protein intake is much in­ creased. Thiamine and riboflavin appear in the urine in unusual amounts, and a negative potassium balance provides further indication that tissue disintegration is under way. The calcium balance tends to become negative, suggesting that even the bones are not immune to the destruction wrought

9 Ancil Keys, nThe Physiology of Exercise in Relation to Physical Medicine," Archives of Physical Medicine, 26:633* October, 1935-

35 by a few weeks of inactivity.^ Keys,-*--*- appealed to the specialist in physical medicine to aid the physiologists in finding means of avoiding these ■undesirable effects of bed rest.

The scientific use of exer­

cise was believed to be in its infancy, needed.

and much research

More careful prescription of exercise was urged,

both as to kind and manner of execution. In the event that exercise has been decided upon to prevent or counteract the effects of prolonged bed rest for any tuberculous patient,

the information already available

on the physiology of exercise should be considered in planning a program,

even though, as Keys has pointed out, this infor­

mation is incomplete.-*-^ As has been m e n t i o n e d , the possibility of ultimate conservation of energy through muscle training before the patient was to become ambulatory,

received consideration by

those formulating the policies of the Veterans Administration. In this matter, Bainbridge, ^

has said that the efficiency

kQC. cit. 11

I b i d ., p. 637-

12

I b i d ., p. 633-

-*-3 CjT. a n t e ., p. 3 1 . 14

F.A. Bainbridge, The Physiology of Muscular E x er ­ cise (Second edition, revised by G.V. Aurep; London: Long­ mans, Green Company, I9 2 3 )., p. 16.

of muscle if influenced chiefly by training, speed., and fatigue.

The trained muscle was considered to be better

coordinated, resulting in less wasted motion. exercise was found to be less efficient.

Unaccustomed

When the trained

and untrained individual took the same amount of exercise the pulse was found to increase less in the trained man. The difference was considered to be due to the greater out­ put of the heart beat,

and greater utilization of oxygen

carrying capacity of the blood, which lessens the need foroutput.

In addition, better coordination conserved energy.

He stated that:

"The effect of these changes is not only .

to increase a man's power of doing muscular work but also to enable such work, whether heavy or light to be performed with the utmost economy of effort.”^5

Fatigue was not con­

sidered to be the necessary result of exercise. Other investigators have found that while exercise' was a great factor in increasing the pulse,

training de­

creased the time necessary for the pulse to return to normal Furthermore,

the type of exercise was important.

Speed exer

cises caused the largest increase, while strength exercises

15 i b i d ., p. 1 7 9 .

James Huff Me Curdy, and Leonard A. Larson, The Physiology of Exercise (Third edition; Philadelphia: Lea and Febiger, 1939)* P • 57-

37 caused the least acceleration.

Some experiments have shown

no Increase In pulse after moderately severe exercises with gentle resistance.1^

The respiratory rate was also believed

to be slower in the trained than in the untrained individual, although it was increased by the standing position and by 18 exercise. The type of breathing, whether costal or diaphragmatic was another point to be considered.

When exercise was strenu­

ous enough to call for more than ordinary ventilation of the lungs it has been found that diaphragmatic breathing was supplemented by the participation of the upper ribs in respiration.1^

This amount of effort seems definitely

contraindicated in tuberculous patients, but as Metheny has said: Exercise can increase the tension in a muscle; it can also relax or decrease the tension in a muscle. Exercise can increase the rate of the heart beat and reaise the blood pressure; it can also cause the heart to beat more slowly and the blood pressure to d e c r e a s e . 20

u

I b i d ., p. 64.

18 I b i d ., p. 106. 19 Ru ssell Burton-Orpitz, An Elementary Manual of Physiology (Philadelphia: W.B. Saunders Company, 1938T* P- 202. York:

20 Eleanor Metheny, "Body Dynamics" (In press; New McGraw-Hill Book Company, Inc., to be released 1950).

38 It seemed obvious, in the light of this material that the greatest care must be observed in selecting exercises for tuberculous patients.

The amount and manner of execution

of prescribed activity apparently would be of equal importance. Possibly/ as Nesbitt21 has recently suggested,

the terminology

in regard to rest and exercise should be changed when speaking of these measures in the case of debilitated patients,

to

avoid confusion concerning these seemingly contradictory pre ­ scriptions.

In discussing arthritis she emphasized the need

for carefully graded activity and care to preserve good bodily alignment during the period of enforced bed r e s t .22

At the

same time she made it clear that this activity might be very slight,

and at all times the condition of the individual

patient was the deciding factor.

What is termed "exercise"

in common usage may differ greatly from the meaning implied in reference to activity for such patients.

II. Relaxation.

Again,

RELAXATION the question of terminology has

arisen in respect to the meaning of the words "rest" and

O *1

Mary E. Nesbitt, ’’Physical Therapy in the Treatment of Rheumatoid Arthritis,” The Physical Therapy Review, 29:3^5* August, 19^9L o c . cit.

"relaxation".

K r a u s e , 2 3 while stating that rest should be

the basis of all treatment of tuberculosis,

felt that rest

might have quite different meanings to different people. To him, rest meant relief from strain,' which he described as "any state of physical or mental activity or inactivity that does not reach the point of conscious fatigue: and by fatigue we would include ennui. K r u s e n , 2 ^

said that while rest was prescribed more

frequently than any other measure, no instruction was usually given as to how to rest.

To get the best results

something more than the mere admonition to rest must be supplied in some cases, will.

since not everyone can relax at

The importance of obtaining really effective rest

in tuberculosis was stressed. nf. Pitkin, recommended the development of a p h i l o ­ sophy of life as the best means of insuring relaxation. He offered his techniques as second best. of tension was,

His definition

"A strain in a muscle caused by contraction

23 Allen K. Krause, Rest and Other Things Williams and Wilkins Company, 1 9 2 3 )* P- 5*

(Baltimore

2>i I b i d ., p. 1 9 . 25 Frank H. Krusen, Physical Medicine W.B. Saunders Company, 19^1), p . 539* Walter B. Pitkin, Take It Easy and Schuster, 1936), pp. 1-1B3

(Philadelphia:

(New York:

Simon

40 of its

f i b e r s .

n2^

The small tensions were believed to be

the most troublesome because most difficult to recognize and therefore most likely to persist.

Irritability and fatigue

might be the result of these unrecognized conditions. Activity of the brain was cited as a source of tension, giving rise to impulses to the muscles.

ideas

He recommended the

cultivation of an attitude of restful attention in the place of tense alertness.

For the sick, the habits of the sick

animal who crawls away and dozes were called to mind.

Imi­

tating the manner of a restful type of person was another suggestion.

Stretching,

and changing to another type of

activity were given as ways of breaking down tension in a muscle.

Lying on the floor, trying to make the body feel

heavy was included. pO

Bartley and Chute,

who considered some cases of

tuberculosis to be the result of conflict,

leading to frus­

tration and fatigue, have described the neuro-muscular condition which may follow: Among the changes frequently attributed to the frustrated organism is an increase In t en sion. Tension is used to refer to: (l) The experience of being tense, (2) a nervous system phenomenon,

27 I b i d ., p. 30. o& S. Howard Bartley, and Eloise Chute, Fatigue and Impairment in Man (New York: McGraw-Hill Book Company, Inc., 19^7), P- 371-

hi

not directly equated with muscular tonicity, or (3 ) a neuro-muscular phenomenon. One might also make a fourth category to include the many cases in which the meaning is either a supposed mixture of the varied used mentioned above, or so vague as to be intangible. This last group would actually cover the large majority of the uses of tension in dealing with frustration.^9 Believing that the state of complete relaxation was desirable and too seldom attained, Jacobson,

-30

has made e x ­

tensive studies in the clinic and laboratory of the problem. He reasoned, much as did Krause,3-** that a person confined to bed and left to fidgit and worry after merely being told to rest, was apt to lie with muscles in a state of tension. He therefore sought a scientific means of attaining the complete relaxation desired.

Tuberculosis was one of the

diseases which he specifically mentioned as productive of the symptoms of hypertension.3^ The object of Jacobson’s method was to eliminate the residual tensions in the muscles which were seen to persist after the patient was supposedly lying at

r e s t .

33

These

29 I b i d ., p. 377. 3® Edmund Jacobson,Progressive Relaxation The University of Chicago Press, 1 929 )., p. 2. 3-1- Krause, J

op. c i t ., p. 1 9 .

Jacobson,

33 i b i d .

op. c i t ., p. 18.

p. 2 9 .

(Chicago:

42 signs were enumerated as:

Irregular respiration,

pulse rete, small movements, other deep reflexes, colon and aesophagus,

increased

the presence of knee jerk and

starting at noises,

sometimes spastic ,

and active mental processes.

He found

that by teaching a subject to recognize the feeling of con­ traction of a muscle he could teach him to perform the reverse of contraction,

or progressively complete relaxation.

By training successive groups of muscles in the body this way, including the small muscles of the throat and eyes, the patient learned to achieve a state of relaxation far beyond the ordinary sense of the word.

After the patient

achieved success in the recumbent position, ciple was applied to activities,

the same prin­

the object being to reduce

body tensions to a minimum, while carrying on necessary acts. The contraction of only the necessary muscles with the relaxation of all other groups was sought.

This method

was suggested as a means of obtaining greater rest for the qii

tuberculous.^

Rathbone, ^ made much use of rhythmic exercises for the purpose of obtaining relaxation.

These were of quite

an active type, being done chiefly in the standing,

sitting,

3^ i b i d ., p. 180. 35 Josephine L. Rathbone, Relaxation (New York: Bureau of Publications of Columbia University, 1943), pp. 95-96.

43 and kneeling positions,

and even those done while lying down

requiring large movements.

These exercises were designed to

promote motility of the joints,

especially of the spine.

Relaxation was to be- obtained through the loosening effect of these large rhythmic movements. F i t z h u g h , ^ suggested a method of rapid relaxation for those who did not feel that they could adopt a more elaborate method.

This was an exercise done lying supine on a bed with

a pillow for the head. feet,

The patient strongly dorsi flexed the

at the same time raising the head and stretching the

arms toward the feet.

When the shoulders left the bed a deep

breath was taken, then released through the mouth with the jaw relaxed, as the body dropped back on the bed. In another theory of relaxation,

Metheny,^7 ascribed

the symptoms of neuromuscular hypertension to an overflow of the initial drive to action which has not been completely overcome by the inhibiting influence of social custom and the impulse to conformity on the part of the individual. This overflow of energy is expended in unnecessary and u n ­ productive motion.

This extraneous motion in producing

^ Mabel L. Fitzhugh, "Rapid Relaxation," The Physio­ therapy R eview, 27:295-296, September-October, 19^7York:

37 Eleanor Metheny, "Body Dynamics," (in press; New McGraw-Hill Book Company, Inc., to be released 1950)*

44 fatigue, frustration, and therefore greater susceptibility to worry and further frustration, produces constant muscular tension for.which there is no normal outlet.

While she be ­

lieves that the underlying emotional problems of the tense state must be found and either solved or faced, a physical approach to relaxation may help.

The rest achieved through

temporary success in relaxation may be a great aid in the objective approach to the problem. Sports and other diversional methods which break the pattern of worry and anxiety, releasing tension, are advo­ cated by Metheny when their use is possible but she has tried to devise a system for the use of those who can not indulge in these activities for some reason.

She says:

"Learning to relax consciously requires time, patience, understanding, a real desire to acquire the ability, and a willingness to use the ability after it has been

a c q u i r e d ." 3 8

Her method of conscious relaxation is based on the concept of the living muscle as an ever active organ, which when tense is doing something which produces undesirable results. To learn to relax, the mind must direct the muscle by focusing on some motion.

Any motion can be used for practice.

She

believed that tension was increased by trying to eliminate

^

Ibid., Chapter VI, p. 7-

45 all contraction.

Slow movements which require the full

attention of the mind to control, were recommended in order to break the pattern, of worry in the same way that the more strenuous and time consuming sports function to bring about relaxation.

Any part of the body can be used to practice

the slow controlled movements,

as long as concentration

serves to break up thought patterns.

After the method has

been learned it can be applied to normal activities,

learn­

ing to maintain relaxation under conditions of progressive difficulty.

III.

POSTURE TESTING AND TRAINING

While the correction of posture in the care of the tuberculous patient was frequently recommended, no specific techniques or principles to be applied to this particular type of case were found in the literature.

Some method of

evaluating posture for the purpose of comparison of con­ dition during the course of the illness and as a basis for records also seemed necessary.

Therefore it was considered

advisable to consult the general literature in the field of posture for pertinent material. Posture testing.

It was realized that the average

hospital could not provide elaborate equipment, nor would

46 the staff have time for extensive measurements^

calculations,

or recordings for the purpose of posture testing.

Further­

more the fatigue factor must be kept uppermost in the minds of those working with these patients.

These facts would

eliminate some of the more elaborate systems. The simplest method., and one which was found to be in general use during the survey of institutions was that gener­ ally known as the subjective m e t h o d . ^

This has been defined

as,the “Subjective judgment of experts, holding in mind the criteria of good and poor posture.

The plumb line method.,

in which points are rated according to deviation from a vertical line bisecting the center of the body, has been h*] considered a subjective procedure. x This method was out­ lined as long ago as 1913 "by Bancroft,^-2 who described her procedure as follows: The long axis or diameter of the trunk of the body is a perfectly vertical line: the long axis of the neck and head taken together is also a vertical line. To assist the eye in determining these points, a line may be dropped from the front of the ear to the forward part of the foot; it will be seen to parallel the axes of these large segments of the body, and at the same time will

39 Cf. a n t e ., p. 2 5 . 40 Thomas K. Cureton., Jr. , "Bodily Posture as an Indicator of Fitness," Supplement to The Research Quarterly of the A m erican Association of Health, Physical Education, and Recreation, 12 s35*4, May, 1941. 41 Loc. cit.

serve to show that the weight is perfectly balanced in relation to the feet.^3 She judged the quality of the position by the amount of deviation from this line.

The lateral alignment was

observed from both front and back.

The position of the

head was checked for deviation to either side, and the levels ■ 44 of the hips and shoulders noted. lie Me M i l l a n , m e n t i o n e d using this vertical line test, although she recommended the use of photographs at the b e ­ ginning of treatment and repeated at two month intervals. C u r e t o n , ^ has approved this method in one of his more recent articles, but has long been active in the search for more objective techniques. method as:

He defined the objective

"Objective photography or measurement of posture,

scaling the scores on specific items or combining the scores into a composite or average r a t i n g . I n

1941 Cureton made

a survey of objective methods available at that time, but did not find any method which he considered sufficiently

4S ^

Loc. cit. I b i d ., p. 11.

4r ^ Mary Me Millan, Massage and Therapeutic Exercise (Philadelphia: W.B. ^aunders Company, 1921), p. l8§4 ^ Cureton, o p • c i t ., p. 3 6 3 .

"Bodily Posture as an Indicator of Fitness,

4 7 ibid., p. 3 5 4 .

-

accurate for research purposes.

48

nine ways of making measurements. three main types, devices,

48

In this study he evaluated These were divided into

the conformateur devices,

and photographic schemes.

spine tracing

He felt that there were

possibilities of errors in all of them.

A new procedure was 4q then developed which combined some of the other devices. 27

A conformateur with metal rods which could be clamped into ' place was used. straight line.

A plumb line showed the relations to a This was used in combination with a silhou­

ette picture, giving a double check.

At the time of this

study he considered this to be the most accurate method. Mac

E

w

a

n

,

devised a variation on this method by

using aluminum pointers fastened to the subject by adhesive tape.

These pointers were placed at the end of the sternum,

and the spinous processes of alternate vertebrae from the seventh cervical to the first sacral. was known,

Since their length

it was possible to determine the location of

points on the body which were obscured in the silhouette by simple computation.

Thomas Kirk Cureton, Jr. , "The Validity of AnteroPosture as an Indicator of Fitness," Supplement to The Research Quarterly of the American Physical Education Association, 9 : 101-113* October, 193149 I b i d ., p. 111. 9 Charlotte G. Mao Ewan, and Eugene Howe, "An Objeotive Method of Grading Posture," The Research Quarterly of the American Physical Education Association, 3 :1^4, October, 1932.

Massey,

•R1

and Cureton,

R2

have both made reviews of

the subject more recently, but have added no basically new material. Kraus and Eisenmenger-Weber,53 regarded an accurate test of posture as a- necessity for the proper prescription of exercises and for checking progress.

They felt that

X-rays were necessary in cases of structural scoliosis, and provided much data, but did not show muscle condition. The cost of X-rays presented a difficulty in ordinary ci r­ cumstances also.

The photographic method, while desirable

for the general indications of the p a t ie nt ’s mental and physical condition was considered similarly expensive and lacking in data on muscles.

In addition they found it hard

to show habitual posture as the patient assumed the best possible position for the picture. To meet their requirements they divided the measure­ ments into structural and functional.

For the structural,

5 1 Wayne W. Massey, nA Critical S-^udy of Objective Methods for Measuring Anterior Posterior Posture with a Simpli fied Technique,11 The Research Quarterly of the American A ss o­ ciation for Health, Physical”Education, and Recreation, "PH 3-22, March, 19435^ Cureton, "Bodily Posture as an Indicator of Fitness, Q P - c i t ., pp. 348-367. 53 Hans Kraus, and S. Eisenmenger-Weber, "Evaluation of Posture Based on Structural and Functional Measurements," The Physiotherapy R eview, 2 5 :267-2 7 1 .

50 the patient was given a few minutes in the standing position to assume habitual posture before taking measurements. expansion was then taken over the xiphoid bone.

Chest

The scapula-

spine distance was measured in inches from the spinous p r o ­ cesses of the vertebrae to the inferior angles of the scapulae, using a protractor and ruler. with a water level, spines of the ilium.

The scapula level was taken

as was that of the anterior superior Leg length was determined by measuring

with a steel tape from the anterior superior spine of the ilium to the internal malleolus.

Angle of pelvic tilt was

measured by placing a protractor on the hip joint so that the straight line paralleled the axis of the femur, other arm was parallel to the sacrum. was then read.

the

The obtuse angle

The plumb line method was used for the

antero-posterior curves of the thoracic and lumbar regions, measurements being taken from the line to the spinous proces­ ses of the vertebrae at the apex of the kyphosis, fifth lumbar, using a calibrated water level.

The func­

tional measurements included pectoral elasticity, by arm raising, hamstring length, the supine position,

judged

judged by leg raising in

and erector spinae combined with, h a m ­

strings in forward bending. done where needed.

and the

Muscle strength, tests were also

51 Posture training.

In teaching posture the problem

would be simplified if a standard applicable to all indi­ viduals were possible.

However,, the more this subject has

been investigated the more evident it seems to have become that individual differences in the construction of the body are such that a single standard is impossible. Goldthwait*y vertebrae*

made X-ray studies of the pelvic bones*

and ribs* showing the variations in form and

attachment.

He felt that no particular posture could be

considered normal for all. Me

C

l

o

y

*

55 aiso used X-ray to determine the place of

hereditary differences in the structure of the spine and pelvis in the posture of the individual.

He found that

there was a great range of variation* which could not be ascribed to bad postural habits because of manifestation before the weight bearing age.

He said that:

’’Those

attempting to prescribe individual treatment should be careful to know the facts about the individual before

5 Joel E. Goldthwait* Lloyd T. Brown* Loring T. Swaim* and John G. Kuhns* Body Mechanics in Health and Disease (third edition; Philadelphia: J.B. Lippincott Company* 19^1)* p. 3 3 . 55 c.H. Me Cloy* "X-ray Studies of Innate Differences in Straight and Curved Spines*" The Research Quarterly of the American Association for Health and Physical Education* 9:5057, May* 1938“:

52 attempting rigid prescription.”^ Steindler,57 said that in normal posture the compen­ sation takes place in the spine itself, 'while in the abnormal it is reflected in the position of the hip, knee joint, feet, the feet-finally maintaining the balance.

and

The forces-

of gravity as they affect the body were given the greatest 58 importance in determining desirable alignment. The center of gravity was defined as the point through which the gravi­ tational forces of all the mass points of the body must pass. As long as these forces passed through this center,

and this

point was located directly over the base of support, the t

body was considered to be in balance.

Equilibrium in the

standing position was deemed to be an active process re­ quiring muscle action to counteract gravitational forces. In locomotion this equilibrium was said to be lost and regained. B r u n n s t r o m / ^ has analyzed posture in terms of gravi­ tational stresses and the expenditure of energy.

She felt

56 I b i d ., p. 5 7 . 57 Arthur Steindler., Mechanics of Normal and Pathological Locomotion in Man (Springfield, Illinois: Charles C. Thomas, 1935), P . 19^. i bid., p . 1 5 . 59 Signe Brunnstrom, "The Changing Conception of Posture,” The Physiotherapy Review, 20:79-84, March-April, 1940.

53 that any method of posture training should emphasize the relationship and balance of body segments.

The minimum

expenditure of energy in balancing these segments in standing and in motion were her objective.

The pelvis,

supported by

the femora, was described as a lever of the first order, hip joints providing a double fulcrum.

the

If the weight is

balanced there is no need for muscle action because the lever is inactive.

If the weight is moved away from the

center the imbalance will be increased by the extent of this distance and the tendency will be for the pelvis to tip in the direction of the weight.

For perfect balance

the line of gravity must pass through the center of the pelvic mass.

The bilateral oblique force of the upthrust

from the ground should neutralize the force of gravity at this point.

Theoretically no muscular effort is required

to maintain pelvic balance. approximated,

The closer this balance is

the less energy is required.

The balance of the shoulder girdle was analyzed in the same m a n n e r . ^

The scapula and humerus, hanging at the

distal end of the clavicle, were said to participate in the movements of the clavicle at the sterno-clavicular joint. This joint acts as a pivot point, but does not bear weight.

60 I b i d ., p . 8 2 .

The weight of the upper extremity is supported by the muscles and fascia connecting it with the neck and head, ribs.

and by the

The position of the shoulder girdle was said to depend

on the position of the head and cervical spine in relation to the thoracic spine and ribs.

She considered a realign­

ment of the head possible in all postural cases without structural deformities of the spinal column.

She contended

that any attempt to balance the shoulder girdle by muscle action of the retractors not only causes expenditure of energy, but puts the pectorals on stretch, which causes them to contract, due to the stretch reflex.

At the same

time the shoulder retractors should become adapted to their new position. Metheny,

(51

has developed a practical method of

training for both static and dynamic posture, with the forces of gravity in mind.

Posture improvement by her method re­

quired a knowledge of how to use the body in a way which would conserve energy. other purposes.

This energy would be available for

The necessity for the habitual use of good

body mechanics was stressed.

Intensive and extensive muscle

reeducation were employed to develop kinesthetic perception. According to her theory, unless the individual can'sense the

Metheny,

op. c i t ., Chapter IV.

55 right and "wrong positions there is no basis for the correc­ tion of alignment by conscious placement of body parts. Muscles are shortened and strengthened by exercise,, but this will not automatically correct posture. must become habitual.

The changed position

Kinesthetic perception must be de­

veloped to the point where the desired position is the most comfortable one. In order to accomplish the correction,

Metheny aligns

the body by balancing the segments on upon the other., each being placed directly over its own supporting surface so that the force of gravity will tend to hold the structures together.

f)'?

In this manner less muscle action is required

to maintain balance. Much of Metheny's interest is in dynamic posture., the static posture being regarded as a preparation for motion.^3 back,

what she described she called walking with the

and walking with the legs.

In order to progress for­

ward the balance of the body is deliberately lost and re­ gained.

For walking with the legs as is desirable,

a new

base of support must be prepared before the old one is lost. One leg should swing forward,

62 I M I - > p-

2 l i

■

^3 ibid., Chapter V.

thigh leading,

to prepare the

56 new base, then the back leg should push off. be diagonal, with the whole body in line.

This push should

The force expended

should be in the direction of the desired progress, the center of gravity of the body.

and through

This eliminates the unneces­

sary expenditure of energy in extraneous-motion. Mensendieck

64

had similar ideas concerning the develop­

ment of balanced posture.

She said:'

We must become temporarily muscle conscious in order to differentiate between the use of right and of wrong muscles. The repeated conscious choice of right muscles will lead eventually to habits of movement that are automatically correcti.e. correct automatisms.65 In her method the mirror was used to observe the struc­ ture and alignment of the body and the effect of motion.

The

feet were placed parallel, weight on the balls of the feet and buttocks contracted.

The shoulder blades were to be

drawn together with the lower angles leading.

The arms were

stretched downward, palms facing backward, without allowing the scapula to move. neither up nor down.

The head was to be held with the chin

66

^ Bess M. Mensendieck, The Mensendieck System of Functional Exercises, Vol. I (Portland Maine: The SouthworthAnthoesen Press, 1937), 154 pp. 65

Ibid., p. 5 7 .

^

Ibid., p . 6 5 .

57 Darrow,

67 1 started correction from the hip region with

pelvic rotations.

To correct hollow back,

push back on a towel held around the body.

she had the subject For forward head

and neck she advised the supporting of weights on the head, arching the neck backward, and dropping the head forward, then pressing back against resistance.

In regard to the

shoulder and chest she said that the emphasis has been on developing shoulder strength without intbascapular fixation, whereas if control were gained strength would follow. H

a

n

s

s

o

n

,

6

8

said that for posture correction,

exercises

were not always the answer and when used should be selected with care. habits.

Change was more frequently made through motor

They must first be changed in the motor pathways

in the nervous system.

A different muscualr response will

follow, both for balance and for movement.

This is best

accomplished by slow, repeated movements and visualization of the body relationships during movement.

If this correc­

tion is held for a short time he maintained that it would help to increase tone in muscles.

67 May Goodall Darrow, "The Posture Problem up to Date," The Physiotherapy R eview, 14:20-25, March-April, 193^* 68 k.G. Hansson, "Body Mechanics and Posture," Journal of the American Medical Association, 128:947-953* July 2 8 ,

1945.

58 It seemed that while in posture testing no really quick and accurate method had been devised,

ample material

was available for development of a method of posture train­ ing suitable to the tuberculous patient.

Many of the authori­

ties agreed that the best type of training was that which emphasized the development of kinesthetic perception,

and

body alignment by conscious adjustment, based upon und er ­ standing and habit formation, building by exercise.

rather than upon strength

It was generally implied that suf­

ficient strength would follow the habitual correction of alignment.

IV.

SURGICAL CONDITIONS

Surgical conditions.

The literature on the actual

care of the tuberculous patient who has had thoracic surgery is very meagre. In regard to cases involving phrenicotomy, pneumo­ thorax,

and pneumoperitoneum,

L i n d u f f , ^

^ as recommended

preoperative correction of bed posture, posture analysis, and posture training if necessary.

Postoperatively,

this

work is continued with the addition of encouragement of range

^9 Florence F. Linduff, "Physical Therapy and C h e s t ' Surgery," The Physiotherapy Review, 2J:96-97> March-April,

1947.

59 of motion,

and abdominal exercise.

There seemed to be some difference of opinion con­ cerning the danger of deformity following thoracoplasty. One group of writers reported that in their experience scoliosis was too rarely a result to be of much consequence.

70

Of the six hundred and thirteen patients whom

they had observed, deformity. musculature.

thirteen had shown moderate or marked

These occurred chiefly in young girls of poor They agreed that scoliosis could be produced

by destruction of the erector spinae muscles of resection of the transverse processes,

thus removing the only muscle

attachments after the ribs had been taken out, but said that:

"No planned program for the prevention and treatment

of scoliosis was used in this series as it was deemed u n ­ necessary because of the low incidence and slight degree of 71 this complication."' 72 Coulter, 1 on the other hand, while pointing out the

70 T.J. Kinsella, E.S. Marietta, P.M. Matill, E.P.K. Penger, V.K. Punt, L;.M. Larson, S.S. Cohen, and F.C. Nemec, "Thoracoplasty in the Treatment of Pulmonary Tuberculosis," The American Review of Tuberculosis, 59:113-127, February, 19^971 I b i d ., p. 123. 7 ^ W.W. Coulter, and Sam E. Thompson, "A Plea for Increased Caution in the Use of Surgical Collapse Therapy for Pulmonary Tuberculosis," Diseases of the Ches t, 8:237247* February, 19^9*

60 advantages and uses of thoracoplasty as a method of collapse,, warns that:

"We must remember that it is a dangerous and

mutilating operation,

so much so that patients not infre­

quently refuse it because of the deformity produced.^3 The latter view has been maintained by the Veterans Administration.

The deformities which they felt must be

anticipated and prevented as far as possible were: a. Lateral deviation of the neck to the unaffected side. (Note: The scalenic muscles are detached from their origin and left free which disturbs the balance of the n e c k . ) b. The shoulder may be elevated or high on the affected side, with a resulting winged scapula. The hip on the unaffected side is carried h i g h . c. There may be a marked pelvic tilt, high on the unaffected side, with a relaxing of the abdomi­ nal muscles on affected s i d e. d. Scoliosis may occur, beginning in the cervical spine, with a compensatory curve in the lumbar dorsal spine. e. Skeletal changes of the chest wall and sternum on the affected s i d e . f. Poor posture.7^ In their suggested program,

the therapist was to see

73 i M d , , p. 243. 74 "physical Therapy for Thoracic Surgery Patients, Tuberculous and Nontuberculous,M Veterans Administration Pamphlet (Washington, D.C.: United States Government Printing Office, December 31 * 19^7)^ p. 24.

61 the patient preoperatively to get acquainted* postoperative problems and procedures.

Bed posture and re­

laxation techniques were to be explained. diaphragmatic breathing* to be taught.

and to explain

Shoulder exercises*

and abdominal exercise routines were

Temperature* pulse*

and respiration* were to

be checked before exercise and precautions taken to prevent too strenuous activity.

75

Postoperatively* cerning bed positions* shoulder girdle*

in the immediate phase*

care con­

range of motion of the arms and

diaphragmatic breathing*

tractions were to be given.

Later*

and abdominal con­

as the patient was able

to sit up* realignment of the body was to be started.

The

individual character of the problem to be faced at this time was mentioned with a warning against the use of a routine group of exercises.

V.

LIGHT THERAPY

Exposure to the s u n ’s rays was used in the treatment of tuberculous arthnitis as early as the middle of the nine­ teenth century.7^

Finsen*

somewhat later* used the carbon

arc lamp in the treatment of tuberculosis* being notably

75 i b i d .* p. 2 5 . 76 Frank H. Krusen* Physical Medicine W.B. Saunders Company* 19^1) * p . 19*.

(Philadelphia:

62 77 successful in the care of lupus vul ga ri s. 1'

Bernhard and

Rollier, used heliotherapy extensively in their work in Switzerland.*^

Krusen,79 felt that irradiation was still

valuable in the treatment of lupus vulgaris and other skin conditions such as scrofuladerma.

Combined local and

general irradiation was said to be of greatest value in lupus vulgaris and in tuberculous laryngitis. light or ultraviolet might be used.

Either sun­

He highly recommended

the use of ultraviolet in treatment of tuberculous p e ri ­ tonitis and enteritis.

Relief of symptoms was found to

occur in one to three months, usually within a month.

If

sunlight was used for this purpose the early morning sun was preferred because heat interfered with benefits. mercury lamp was considered preferable.

The

General irradiation,

followed by additional exposure of the affected area was the technique advised.

He also recommended the use of ult ra ­

violet in genitourinary and gynecological diseases, culosis of the middle ear, certain eye conditions,

tuber­ bones, O

and joints.

In regard to pulmonary tuberculosis, Kreusen

77 I b i d ., p . •20. 7

Loc. cit.

79 I b i d ., p . 2 5 1 . Ibid., p. 261.

a

63 concluded that ultraviolet could be of benefit in the tuber­ culosis of childhood and in the fibroid type during the in­ active stage. progressive,

He said that it was contraindicated for the exudative forms of pulmonary tuberculosis,

that which involved the suprarenal glands,

for

abdominal lymph

nodes, and certain types of tracheobronchial tuberculids. He recommended that light therapy should be considered in all extra-pulmonary tuberculosis in conjunction with other treatment. Bierman,^1 felt that patients with tuberculosis might, in some cases, be found to be more sensitive than usual to ultraviolet,

and that extra care should be observed in its

application.

Its use in tuberculosis of bones and joints,

lymph nodes, larynx,

and skin conditions was approved.

mentioned scrofuloderma, populonecrotic tuberculids, erythema induratum of Bazin.

He

and

He considered either helio­

therapy or ultraviolet important in the treatment of peri­ tonitis, but disapproved of irradiation of patients with uncomplicated exudative pulmonary tuberculosis,

and of those

with the fibrotic type as well, if accompanied by fever. On the list of cases in which ultraviolet was contraindi­ cated were also those with the rapidly advancing type of

Practice

William Bierman, Physical Medicine in General (New York: Paul B. Hoeber, Inc., 1 9 ^ 4), p . 299»

64 the disease, multiple or large sized cavities, of heart failure, great general devility,

any degree

rapid sedimenta­

tion rate, or unfavorable hematological findings. Op

Kovacs,

approved of both sunlight and artificial

radiation in some forms of tuberculosis.

He preferred h e li o­

therapy in treatment of bones and joints,

lymph nodes and

the genitourinary tract, but said that artificial means should be used when sunlight was not available.

Ultra­

violet was the method of choice for superficial peritoneal and intestinal tuberculosis.

When other pulmonary infections

were complicated by exudative, febrile pulmonary disease, sunlight of low intensity or cold quartz were said to offer the benefit of treatment without the complication of heat. He did not feel that irradiation was of much value in ocular and aural cases.

In lupus vulgaris ultraviolet was said to

be useful. Both Kreusen,

Qo

^ and Bierman,

fill

mentioned the Rollier

technique of solar radiation in peritonitis.

This technique

was described for use with radiation from any source by

82

Richard Kovacs, Electrotherapy and Light Therapy (fifth edition; Philadelphia: Lea and Pebiger, 1945)7 P- 333Kreusen, o£. c i t ., p. 254. ^

Bierman,

op. cit., p. 5 1 6 .

65 Osborne and Holmquest.&5

The method involves division of

the body into parts as follows: legs,

(3) thighs,

dosage,

(4) abdomen,

(l) Feet and ankles, (5 ) thorax.

(2)

The initial

determined by the susceptibility of the individual,

is given ventrally and dorsaily.

The first, section receives

one unit of dosage in the initial treatment.

In the second,

numbers one and two are exposed, with the first receiving double dosage.

In the third, number one receives three, n um ­

ber two double the initial dosage, and number three the b e ­ ginning time.

Increases are made in this manner until all

parts of the body are receiving five units. is thfen done at the same time.

The whole body

This technique is modified

when necessary to suit the individual case.

5 Stafford L. Osborne, and Harold J. Holmquest, Technic of Electrotherapy (fifth, revised edition; Spring­ field, Illinois: Charles C. Thomas, Publisher, 1944), pp. 299-

300.

CHAPTER V A UNIT OF STUDY IN PHYSICAL THERAPY FOR TUBERCULOUS PATIENTS This unit of study was intended to toe' suitable for incorporation in a course in therapeutic exercise for students of physical therapy.

Many different phases of

treatment are included in such a course and it was found that the time given to the subject of tuberculosis usually did not exceed two periods.

Medical lectures covered the

pathology and general treatment of the disease. training., testing;

Posture

and principles of exercise and relaxa­

tion; were usually separate units of the course;

conse­

quently only suggestions for adaptation to the particular purpose were given here.

Some material was provided for

mimeographing and distribution to the students if desired; or for use in periods devoted to the practice of techniques. Light therapy would be a part of the general course in electrotherapy.

The use of this modality in the treat­

ment of tuberculous conditions has been described in the ■standard textbooks on electrotherapy. Objectives of the u n i t . 1.

To provide a background of understanding of the

problems to be met in the treatment of the tuberculous

67 pa ti en t. 2. To outline for the student of physical therapy a program sufficiently flexible to be fitted to any situation. 3 . To point out opportunities for improvement of this service to tuberculous patients. 4. To encourage critical thought concerning the use of modalities concerned. Lecture o ut li ne . I. Definitions. A. Tuberculosis is an acute or chronic infection. It most frequently Involves the lungs, gastro­ intestinal tract, bones,

joints,

and glands.

B. Phrenicotomy is a surgical procedure In which the phrenic nerve is cut or crushed. C. Therapeutic pneumothorax is a surgical procedure in which air is injected into the pleural cavity. D. Pneumoperitoneum is a surgical procedure in which air is injected into the abdominal cavity. E. Thoracoplasty is the removal of parts of several ribs to collapse all or part of the lung perma­ nently.

The ribs grow back later, but in a

smaller circle.

It is usually done in three or

four stages at intervals of ten days or two weeks. There is extensive division of the trapezius,

68 latissimus dorsi., rhomboids,

and pectoral muscles.

The scalenae are detached from their origins. II. History of physical therapy In treatment of tubercu­ losis . A. Light therapy. 1. Sunlight was used in the middle of the n i ne ­ teenth century in treatment of tuberculous arthritis. 2. Finsen employed the carbon arc in treatment of cutaneous tuberculosis. 3. Bernard and Rollier made extensive use of heliotherapy in their work in Switzerland. 4. Both sunlight and artificial light were widely used until recent developments occurred in drug therapy. B. Army program for chest surgery cases. 1. Experience with wounded showed that early exercise after surgery aided recovery,

shortened

hospitalization,, and produced better results. 2. A similar program was started for tuberculous c a se s. C. Veterans Administration Program. 1. Differentiation was made between the program for tuberculous and nontuberculous patients.

69 2. Definite procedures were developed for surgical and nonsurgical cases. D. Present Status. 1. Programs for the tuberculous are being expanded. 2. There is much need for evaluation and improve­ ment . III. General problems and principles of treatment. A. Objectives: 1. Maximum rest should be promoted. 2. Deformity should be minimized or prevented. 3* Return to activity should be aided. B. Recovery from tuberculosis must always be con­ sidered first. C. Approach to patient should be cheerful and f r i e n d l y b u t quiet and casual. D. Each patient is an individual problem. schedule can be followed.

No routine

Each case must be

studied using all available information. 1. Ward charts should be consulted daily for such contraindications to treatment as hemoptysis and fever. 2. Physicians instructions should be carefully considered. 3- Pulse and respiration should be taken before

70 and after exercise.

It is usually considered

that these should return to normal In about five minutes. E. General attitude of patient. 1. Aid in securing cooperation toward general program. 2. Secure cooperation for physical therapy program.

This type of work must be done by

the patient with the help of the therapist. P. In early treatment rest must be as absolute as possible.

Mental as well as physical rest Is

desired. G. Progression to activity must be much slower than usual. H. Activity must be kept below the fatigue level at all t i m e s . I. Danger of deformity and poor posture exists due to: 1. Poor bed posture. 2. General weakness. 3. Muscle imbalance. 4. Habitual protective positions due to. pain. J. Give breathing exercises only on specific order. IV. Modalities used for treatment. A. Bed positions.

71 1. Nonsurgical. a. Objective is to prevent deformities which may result from habitually poor positions. (Kyphosis, flattening of the lumbar spine, shortened'achilles tendons, flat feet.) b. Correction should start on admission. c. Principles used are the same as for other patients confined to bed for long p e r i o d s . The following details may be reserved for class practice if not already covered in course,

and may

be distributed.for future reference in mimeographed form. Bed:

The bed should be firm and level.

Footboard

or other device should be provided to prevent pressure on the feet. Positions on back: Rest position.

This should be used as much as

p os si bl e. Heels are placed against footboard. Knees are slightly flexed.

(A small support

may be u s e d . ) Body should be straight. No pillow is used under head.

Active position.

(For reading etc.)

Bed is rolled up or support used. Pillows are placed so that shoulders and head are in line as much as possible. Position on side.

(Affected side lying is

sometimes ordered.) No pillow is used under head. Pillow may be placed between knees. Prone position. No pillow is used under head. Support should be placed under ankles. Surgical positions. a. Phrenicotomy--position is same as for n o n ­ surgical.

Shoulder position is watched.

b. Pneumothorax--affected side lying is some­ times ordered after initial injection of air. c. Pneumoperitoneum--position is same as for nonsurgucal. d. Thoracoplasty. (1) Presurgically, position may be same as nonsurgical. (2) Postsurgically,

surgeons orders differ.

(a) Position may be same as nonsurgical. (b) Affected side lying on sand bag or

bolster ordered by some surgeons. Use of the bolster Is usually started for short periods and Increased gradually.

Sometimes this position

is maintained for three hours and forty minutes out of every four. No pillow is used under head. B. Relaxation. 1. Objective is to insure maximum benefit from bed rest by reducing tensions. 2. Instruction should be started on admission if possible. 3. Tensions are fine continued contractions of muscle. 4. Signs of tension are: slight movements, temperature,

Irregular breathing,

sighs,

changes in pulse,

and blood pressure.

5 . Causes of tension are often fear, pain, worry, conflict. 6. General methods of reducing tension are: sedatives, massage, baths,

Drugs,

sports, philosophies,

and techniques of conscious relaxation. 7 . The following methods of conscious relaxation are suggested for tuberculous patients.

(These

7k may have been given in detail as a unit of the course.

If not, class practice supplemented

by reading is suggested.) a'. Jacobson method. (1) Patients learn to recognize tension by contracting and relaxing muscle groups. (2) After tension is recognized contractions are omitted.

Patient starts from in­

active condition and tries to relax more and more. (3 ) The whole body is eventually treated, including small muscles of the face. (k) This method does not provide means of breaking thought tre nd s. b . Metheny method (1) Muscles are stretched to break the pattern of movement and improve circu:-lation. (2) Patient tenses and relaxes muscle to perceive difference in sensation. (3 ) Patient concentrates on slow controlled movement to break thought pattern. (4) Any movement may be used for practice. Movement continues in this method, but

75 small muscle groups may be used.

When

patient is ready for increased activity larger groups may be used as first step in muscle reeducation. c. There are a number of simple methods such as trying to nfeel hea vy ”, imitating a relaxed animal or relaxed type of person. C. Bed exercise and postural reconditioning. 1. The objectives are: a. To provide a transition period from bed rest to ambulation. b. To prevent deformity and limitation of range of motion. c. To assure best possible posture. 2. Nonsurgical or general program. a. Exercise must be extremely slight and gentle at first. b. General privileges given to patient provide useful guide to progression.

These will be

such privileges as sitting up in bed, getting out of bed to chair, walking, leaving room. c. Relaxation techniques may be taught or scope extended,

as by inclusion of larger movements

in Metheny method, d. Exercises preparatory to sitting and standing positions should be started.

Ideal opportu­

nity exists here for explanations. (1) First period.

Patient is lying down.

(a) Begin foot exercises. (b) Static abdominal contractions may be used. (c) Kinesthetic perception and muscle reeducation work can be started. (2) Second period.

Patient is allowed to sit.

(a) All of first exercises can be continued with slight progressions. (b) Foot exercises which require sitting can be added. (c) Sitting posture can be taught. (3) Third period.

Patient is allowed to

stand and walk. (a) Static posture training is continued. (b) Dynamic posture training is started. Suggested type of bed exercise and postural recon­ ditioning program.

This is not intended as a

routine, merely as an illustration. used in class practice.

It may be

77 First period.

Patient is lying down.

1. Patient stretches "body 11long" from back of head to heels. 2. Begin foot exercises which can.be done lying down.

Examples are:

a. Circling of the feet. b. Inversion and dorsi flexion. c. Grasping with the toes. 3. Slow controlled rotations of the arms and legs can be practiced.

These should be done to

count so that movements are smooth and com­ pleted at end of count.

Head rotations may be

used in the same way. 4. Abdominal contractions, very gradually increas­ ing in difficulty are suitable. Examples are: a. Static contractions. b. Raising head from bed. c. Pelvic rotations. -d. Raising head and shoulders,

straight and

with rotation. 5. Begin conscious alignment of posture. a. Have patient place feet against footboard. b. Explain knee position which will be desired.

78 c. Explain pelvic alignment.

Have patient

experiment with different positions. d. Patient may be taught to straighten cervical spine against bed. Second period.

Patient is allowed to sit up.

1. Early exercises can be carried on by patient with occasional supervision. 2. Add foot exercises such as picking up objects with toes. 3. Add body twisting and bending. 4. Greater part of static posture can be taught at this time.

Mirror should be used.

Sitting

posture may be practiced as follows: a. Start with feet straight,

flat on floor.

b. Align pelvis, with abdominals firm. c. Stretch tall from back of head, trunk directly over pelvis. d. Rotate shoulders, noting freedom. them to come to rest. wing,

Allow

(If scapulae still

instruct in drawing lower angle close

to ribs.

This should be meticulous muscle

reeducation.)

Note that gleno-humeral joint

is still free. e. Slump forward.

Realign.

Do same without

79 mirror. Third period.

Check position achieved in mirror. Patient is allowed to stand and walk.

1. Teach patient to rise from sitting position without losing alignment, by moving one foot back and tilting body forward before rising. 2. Have patient adjust posture before mirror as previously,

segment by segment, over base of

support. 3. Teach correct walking. a. Walk tall.

Have patient learn to:

(May use mental image of hook

in back of head, bucket over head, etc.) b. Lead with thigh in stepping forward. c. Prepare new base of support. d. Push off from rear foot in line of direction or progression. k. Surgical programs present special a.

Phrenicotomy cases

problems.

are usually treated much

the same as nonsurgical except for need to encourage use of arm on affected side. b.

Pneumothorax cases

are usually kept abso­

lutely quiet for a

few days after initial

injection of air. c. Pneumoperitoneum patients are uncomfortable after injections of air.

Air in abdominal

80 cavity makes body exercise difficult, d. Thoracoplasty necessitates special program. (1) It must be remembere.d that no increase in chest expansion is desired.

A pe r­

manent collapse is intended. (2) Disturbance of muscular arid bony supports creates danger d>f scoliosis.

Tendency

varies as might be expected with age and body type.

All should be carefully

watched. (3 ) Pattern of malalignment varies somewhat but is quite consistent for type of sur­ gery., bed positions., amount of bed rest, customary in one institution. (4) Most common tendencies to malalignment are as follows: (a) Patients tend to stand in slouched position on one foot with weight carried on unaffected side and that hip prominent. (b) Scapula often wings on unaffected side, but may do so on operated side.

Scapula on operated side

may be inside of remaining rib cage.

81 (c) Shoulder is usually high on operated side. (d) Head and neck deviate to the unaffected side. (e) There may be a tendency for trunk to rotate forward in direction of oper­ ated side.

This is especially true

if scapula is inside of rib cage, and therefore slightly forward. (5) Treatment usually starts a week or two before surgery with preoperative orien­ tation.

At this time therapist should:

(a) Get acquainted.with patient. (b) Explain probable difficulties,

and

help which he will receive. (c) Show arm and shoulder exercises to be used. (d) Evaluate posture by best method available.

(it will be most h e l p ­

ful to know whether preoperatively the pelvis and shoulders were level, scapulaspine distances equal,

and

head habitually carried straight. (6) Treatment is continued between stages

82 and immediately after last stage as f ol lows: (a) Bed positions are taught as prescribed. (b) Arm is moved passively onee or twice through small range at first. is instructed to relax*

Patient

and assured

that range of pain will not be entered. Range is increased as fast as possible but always very carefully. (c) As soon as patient can relax arm active assistive and active motion are started.

Patient is shown how

to depress shoulder by "creeping" with fingers toward the foot of the hed. (d) Motions to be carried out with arm are chiefly flexion*

abduction*

inward and outward rotation.

and

Ab­

duction and outward rotation are apt to be most affected. (e) Repetitions of movements are in­ creased gradually.

Patient is en­

couraged to use arm functionally. (f) Bandages may hamper motion at first.

Later., if tight binder is used around body to promote collapse,

scapular

motion will be limited. (g) Massage is often used as an auxiliary treatment to ease pain and muscle spasm.

Occasionally heat is p e r ­

mitted for the same purpose. (7 ) The postural program outlined for other patients can be followed with these added considerations: (a) The use of a mirror is especially helpful. (b) Study head, neck, sitions.

and shoulder p o ­

Note scapulae.

Compare

with preoperative findings. (c) Patient can be taught to shift head to center by education of lateral neck muscles.

This does not mean

bending the neck sideward, but a shift to the side from the base of the neck over the trunk, in the same way that the trunk can be shifted over the pelvis. (d) When the head is corrected,

tension

84 on the upper trapezius is released, making it easier to lower shoulder to normal position. (e) Study action of rhomboids and tra­ pezius.

Reeducate if necessary.

(f) If there is body twist,

strong ro­

tations with pelvis fixed are h elp­ ful . (g) When patient stands he must be im­ pressed with necessity of standing equally on both feet. (h) Greatest tendency to deformity may come some time after last stage of surgery when activity is increased and patient becomes careless.

Con­

tinue to check posture even after alighment seems good.

85 SUPPLEMENTARY READING Florence S. Linduff, "Physical Therapy and Chest Surgery,n The Physiotherapy R eview, 27:95-100, March-April, 19^7t

Bert A. Treister, "The Prevention of Postural Deformity after Thoracoplasty," Archives of Physical Medicine., 30:446-449, July, 1949R.S. Anderson, "Changing Concepts in the Bed Rest Treatment of Tuberculosis," Diseases of the C h e s t , 14:167-179, March-April, 1948. Walter B. Pitkin, Take it E a s y . Schuster, 1936. Cahpter I.

New York:

Edmund Jacobson, You Must R e l a x . New York: Book Company, Inc., 1934. 201 pp.

Simon and McGraw-Hill

Thomas Kirk Cureton, Jr., "Body Posture as an Indication of Fitness," Supplement to the Research Quarterly of the American Association for Health, Physical Education, and Recreation, 12:348-367, May, 1941. Hans Kraus, and S. Eisenmenger-Weber, "Evaluation of Posture Based on Structural and Functional Measurements," The Physiotherapy R eview, 25:267-271, November-December, 1945* Signe Brunnstrom, "The Changing Conception of Posture," The Physiotherapy Review, 20:79-64, March-April, 1940. Eleanor Metheny, "Body Dynamics." In press; new York: McGraw-Hill Book Company, Inc., to be released 1950.

CHAPTER VI SUMMARY AND CONCLUSIONS Su mm ar y.

A survey was made of eight institutions

having units for the treatment of tuberculous p a t i e n t s . It was found that seven of these institutions had programs of treatment employing modalities usually included in p hy ­ sical therapy, although in two cases the nursing staff was entirely responsible.

The one hospital where such a program

had not yet been established was In the process of building a new unit for the tuberculous patients and hoped to expand the physical therapy service to this unit later. An inquiry as to modalities In use revealed that two Institutions routinely checked bed posture of nonsurgical patients,

one occasionally did so.

this for surgical patients.

Six routinely regulated

All seven programs provided for

some type of bed exercise after surgery.

Posture of n o n ­

surgical patients was tested occasionally by three, surgical, routinely by six.

and of

Three occasionally taught posture

to nonsurgical oases, while all seven did so to surgical cases.

Relaxation was taught occasionally to nonsurgical

patients by two institutions, and occasionally by one.

routinely to surgical by one

Heat for the relief of pain and

muscle spasm was used as an auxiliary treatment frequently

87 in one institution,

and occasionally in one.

used routinely in five for the same purpose.

Massage was Orders for

light therapy for the treatment of tuberculous conditions were received occasionally in three institutions.' Interest in these programs was generally concentrated on the prevention of deformity in thoracoplasty cases.

Six

reported deviations of the head and neck to the unaffected side after surgery.

Five found that there was usually a

high shoulder on the affected side.

Three found a tendency

to develop a winging of the scapula on the unaffected side* while one noticed this condition on the affected.

Four had

noticed that patients tended to stand with the weight on the foot opposite to the affected shoulder,

throwing the

hip into prominence. A study of the literature concerning the modalities found to be in use and the principles involved revealed that the specific needs of the tuberculous had not received ex­ tensive consideration.

Therefore it was necessary to search

for material which could be adapted to this use. In order to provide a basis for planning a program for tuberculous patients,

literature concerning the impor­

tance of rest, and opinions of authorities on the advisability of modifying rest by exercise of any kind, were consulted. There seemed to be considerable difference of opinion, but

88 some of this apparently was due to differing conceptions of what was meant by the terms "exercise" and "rest11.

There

seemed to be agreement on the importance of complete rest early in the treatment and great care to conserve energy at all times. The methods of securing the most complete rest p o s ­ sible by conscious relaxation were reviewed.

A number of

methods were found which seemed fairly suitable.

Some

used mental images of restful subjects or philosophies,, while some were based on definite physical routines.

Wider

use of the less strenuous of these techniques seemed de­ sirable . The literature on posture revealed ample material on training which could easily be adapted to the debilitated patient.

A number of authorities advocated the development

of a balanced posture which would conserve energy.

To ac­

complish this the cultivation of kinesthetic perception of changes in position,, by which the subject would be able to recognize,

and become comfortable in., a good posture, was

given as the method of choice.

Since it is possible to do

this without strenuous exercise it is an ideal method for the tuberculous patient. would be simple,

quick,

The need for a posture test which and yet sufficiently accurate even

for research purposes was not so satisfactorily met.

89 Very little mention was found of the use of light therapy in the treatment of tuberculous conditions in recent literature., which paralleled the findings on current prac­ tice.

The standard textbooks on electrotherapy contained

instructions on traditional uses. A unit of study was constructed which was intended to be suitable for incorporation in a course in therapeutic exercise for students of physical therapy,

endeavoring to

provide both a knowledge of present usage of modalities in the treatment of tuberculous patients and aids in planning expandion of this program along lines suggested in the literature. Conclusions.

It was concluded that the treatment

of tuberculous patients by physical therapeutic measures offered the physical therapist a new and rapidly expanding field both for practical service and for study and research. A great deal remained to be done in the adaptation of exist­ ing methods and in devising new ways of accomplishing results in view of the necessity for the conservation of energy. More exact methods of measurement and evaluation are needed before much could be accomplished in the line of research. It was hoped that this summary of the present situation would stimulate interest and point the way to progress in this field.

B I B L I O G R A P H Y

BIBLIOGRAPHY A. BOOKS Bainbridge, F.A., The Physiology of Muscular E x e r c i s e . Second edition, revised by G.V. Aurep; London: Longmans, Green Company, 1923- -226 pp. An extensive study of the effects of exercise on the body. Bancroft, Jessie H., The Posture of School Ch il dr en . New York: The Macmillan Company, 1913327 pp. Treats posture study from many angles. methods of judgment and correction.

Gives

Bartley, Howard, and Eloise Chute, Fatigue and Impairment in Man. New York: McGraw-Hill Book Company, Inc., 19^7229 PPDiscusses the causes and effects of fatigue. Contains a section on psychosomatic diseases. Bierman, William, Physical Medicine in G e n e r a l ,Practice. New York: Paul B. Hoeber Inc., 19447 654 pp. Emphasizes the practical techniques of Physical Medicine for the use of the general practitioner. Burton-Orpitz, Russell, An Elementary Manual of Physiology. Philadelphia: W.B. Saunders Company, 193^4 442 pp. A textbook of physiology for students of nursing, physical education and other practical arts. Coulter, J.S., and C.O. Molander, Handbook of Physical Therapy. American Medical’Association,

"Therapeutic Exercise," Third edition; Chicago: 1939Pp • 127-152.

Exercises for different parts of the body are given. Different types of exercise are discussed. Goldthwait, Joel E., Lloyd T. Brown, Loring T. Swaim, and John G. Kuhns, Body Mechanics in Health and D i s e a s e . Third edition; Philadelphia: J.B. Lippincott Company, 1 9 4 1 . 316 pp.

91 Discusses the effects of posture on the systems of the hody. Good,, Carter V. , A.S. Barr, and Douglas E. Scates, The Methodology of Educational R e s e a r c h . Appleton Series in Supervision and Teaching; New York: D. AppletonCentury Company., Inc., 1935890 pp. A book of instruction on the conduct of research and methods for writing papers. Jacobson, Edmund, Progressive Re laxation. Chicago: University of Chicago Press, 1 9 2 9 . 429 PP»

The

Physiological, and psychological bases of tension and relaxation. Specific techniques of relaxation. ______ , You Must R e l a x . New York: Company, Inc., 1934. 201 pp.

McGraw-Hill Book

A description of techniques of relaxation, written for the layman. Kovacs, Richard, Electrotherapy and Light T h e r a p y . edition; Philadelphia: Lea and Febiger^ 1945♦

Fifth 694 pp.

An extensive discussion of the modalities and techniques of electrotherapy. Krause, Allen J., Rest and Other T h i n g s . Baltimore: Williams and Wilkins Company, 1923* 159 pp. Modes of infection, control, treatment of tuber­ culosis. Emphasis on rest. Krusen, Frank H . , Physical Medicine. Saunders Company, 1941. 84b p p .

Philadelphia:

W.B.

Covers in detail the main branches of physical medicine. Intended as a-reference volume. Me Curdy, James Huff, and Leonard A. Larson, The Physiology of Ex ercise. Third edition; Philadelphia: Lea and Febiger, 1939* 449 pp. A textbook for students of physical education on the effects of exercise upon bodily function.

92 Me Millan, Mary, Massage and Therapeutic E x e r c i s e . Philadelphia: W.B. ^aunders Company, 1921. 274 pp. Contains a chapter on posture training. cises given for the debilitated patient.

Exer­

Mensendieck, Bess M . * The Mensendieck System of Functional Ex er ci se s. Vol. I; Portland Maine: The SouthworthAnthoesen Press, I9 3 7 . 154 pp. Contains an analysis of postural mechanics, and postural exercises, Many illustrations of good and bad habits. Osborne, Stafford L . , and Harold J. Holmquest, Technic of Electrotherapy. Fifth, revised edition; Springfield, Illinois: Charles C. Thomas, Publisher, 1944. 780 pp. A text on electrotherapy which includes a dis­ cussion of electrophysics. Osgood, Robert Bayley, ’’Body Mechanics and Posture,” H a n d ­ book of Physical T h e r a p y . Third edition; Chicago: American Medical Association, 1939Pp. 115-126. A section on the history of posture training and the effects of posture on health. Pitkin, Walter B . , Take It E a s y . Schuster, 1936. 244 pp.

New York:

Simon and

Reasons for and methods of obtaining relaxation. Largely the philosophical approach. Rathbone, Josephine L . , Re laxation. New York: Publications of Columbia University, 1943*

Bureau of 157 pp.

Explains factors involved in tension and physical and psychological means of alleviation. Steindler, Mechanics of Normal and Pathological Locomotion in M a n . Springfield, Illinois: Charles C. Thomas, 19354*24 pp.

93 B.

PERIODICAL ARTICLES

Anderson, R.S., "Changing Concepts in the Bed Rest Treatment of Tuberculosis," Diseases of the Ch est, 14:167-^79* March-April, 1948. Brunnstrom, Signe, "The Changing Conception of Posture," The Physiotherapy Rev ie w, 20:79-84, March-April, 1940. Coulter, W.W., and Sam E. Thompson, "A Plea for Increased Caution in the Use of Surgical Collapse Therapy for Pulmonary Tuberculosis," Diseases of the Chest, 8:237247; February, 1949* Covalt, Nina K . , "Bed Exercises in Early Convalescense and Ambulation," The Physical Therapy R e vi ew , 28:51-59* March-April, 1948. Cureton, Thomas Kirk J r . , "Bodily Posture as an Indicator of Fitness," Supplement to The Research Quarterly of the American Association of Hea lt h, Physical Education, and Recreation^ 12:348-367* May, 1941. _______, "The Validity of Antero-Posterior Spinal Measure­ ment ," The Research Quarterly of the American Physical Education Association, 2:101-113* October, 1931* Darrow, May Goodall, "The Posture Problem up to Date," The Physiotherapy Review, 14:20-25* March-April, 1934. Fitzhugh, Mabel L . , "Rapid Relaxation," The Physiotherapy R eview, 27=295-298, September-October, 1947• Hansson, K.G., "Body Mechanics and Posture," Journal of the American Medical Association, 128:947-953* July 2B7 1945• Huddleston, Ora L . , Roberta Winston, and Miriam Engelland, "Physical Therapy Procedures in Preoperative and Post­ operative Care of Chest Surgery Patients," The Physio­ therapy Re vi ew , 25=203-207* September-October, 1945. Keys, Ancil, "The Physiology of Exercise in Relation to Phy­ sical Medicine," Archives of Physical Medicine, 26:635* October, 1935* Kinsella, T.J., E.S. Marietta, P.M. Matill, E.P.K. Fenger, V.K. Funt, L.M. Larson, S.S. Cohen, $nd F.C. Nemec, "Thoracoplasty in the Treatment of Pulmonary Tubercu­ losis," The American Review of Tuberculosis, 59=113-127* February, 1949.

94 Kraus, Hans, and S. Eisenmenger-Weber ''Evaluation of Posture Based on Structural and Functional Measurements," The Physiotherapy R e v i e w , 2 5 :267-2 7 1 . Linduff, Florence S., "Physical Therapy and Chest Surgery," The Physiotherapy R e v i ew , 27:8>3-l(lo, Mareh-April, 19^7Mac Ewan, Charlotte G., and Eugene Howe, "An Objective Method of Grading Posture, 1 The Research Quarterly of the American Physical Education Association, 3 :l44157, October, 1932. Massey, Wayne W., "A Critical Study of Objective Methods for Measuring Anterior Posterior Posture with a Simpli­ fied Technique," The Research Quarterly of the American Association for Health, Physical Education, and Recreati on , 1473-22, March, igWT. Me Cloy, C.H., "X-ray Studies of Innate Differences in Straight and Curved Spines," The Research Quarterly of the American Association for Health and Physical Education, 9 :5°-57, May, 1938T Nesbitt, Mary E., "Physical Therapy in the treatment of Rheumatoid Arthritis," The Physical Therapy Review, 29:3^5-3^9, August, 1949. Pine, Irving, "Medical Aspects of Rehabilitation," The American Review of Tuberculosis, 152:511-518, May, 1948. Smart, Elliott, "Modifying Rest with Exercise in Pulmonary Tuberculosis," Medical Journal and Record, 1 3 8 :267-27 0, October, 1933* Treister, Bert A., "The Prevention of Postural Deformity after Thoracoplasty," Archives of Physical Medicine, 30:446-449, July, 1949Wellesley College Studies in Hygiene and Physical Education, "Grading Anteroposterior Standing Posture," Supplement to The Research Quarterly of the American Association of Health and Physical Education, 9 :79-89, March, 1938. Winston, Helen R., "Physical Therapy and Chest Surgery," The Physiotherapy Review, 26:227-230, September-October,

197T6 .

95 C.

PAMPHLETS

Annual Report of the Los Angeles County Health Department, Los Angeles, 1947-1948, 69 pp*. "Physical Therapy for Thoracic Surgery Patients, Tubercu­ lous and Nontuberculous*" Veterans Administration Pamphlet. Washington, D.C.: United States Government Printing Office, December 31* 19^733 PP • "Physical Therapy in Tuberculosis," Medical Rehabilitation Service, Veterans Administration Pamphlet. Washington, D.C.: United States Government Printing Office, Sep ­ tember 2 7 * 19^6 . 49 pp.

D.

UNPUBLISHED MANUSCRIPTS

Metheny, Eleanor, "Body Dynamics." In press; New York: McGraw-Hill Book Company, Inc., to be released 1950-