THE AUSTRALIAN JOURNAL OF PHYSIOTHERAPY

THE ROLE OF PHYSIOTHERAPY IN REHABILITATION

By M. NAOMI WING, M.B., B.S.,
Honorary Assistant Rheumatologist, Royal South Sydney Hospital,
Sydney, Australia.

In a previous article in this journal the in medical teaching now is to regard the
duties of the physiotherapist in a particular patient "as a human being, not just a case".
centre were detailed (see page 79); it is His psychological and physical disabilities
the purpose of this article to apply that all tend to produce in the individual a stress
description in a wider field. situation; and this may occur because he
has suffered from an accident to any part
Rehabilitation. of the body or has been the victim of an
The aim of rehabilitation is "to take the illness involving even the smallest part of
patient from the bed to the job". To achieve the anatomy. Until this altered outlook is
this end a large team-organization is neces- adopted at the student level, it will be diffi-
sary; and as a member of this team the cult to ensure a realization of the respon-
physiotherapist plays a very important role. sibility of each trained person towards the
It is true that, consciously or uncon- patients who come under his care.
sciously, rehabilitation has always been the No patient should be discharged as cured
aim of every medical and ancillary service until he has become, if possible, capable of
dealing with the care of patients; but it earning his living, either in his own occupa-
was not recognized as "the third phase of tion or in the one for which he has been
Medicine" until the achievements of the trained in the Rehabilitation Centre; and
organization established during World War no patient should be labelled as relieved
II were slowly applied to civilian needs. At unless he has been made capable of self-
first, individual services confined to their care or has been carried as far in his
own departments were found to be expen- functional activities as the anatomical and
sive and inefficient, but once the tealn-idea pathological state present will permit.
was accepted the results in the Services This goal should always be the aim of
rapidly iluproved, and the techniques we treatment from the moment the patient has
are teaching today have evolved mainly an operation or accident or from the day he
from this beginning. It is not due entirely commences his illness. The physically
to the experience of World War II, how- disabled persons constitute a great economic
ever, that these Rehabilitation Centres have loss, and, as their numbers are increasing
come to be regarded as necessary. It is one at an alarming rate, it is essential that every
of the results of the world-wide impulse effort should be made to return every sick
that leads the cOlnmunity to assume the or injured individual as speedily as possible
responsibility for the individual whether in to gainful employment, or at least to make
regard to his general welfare or his need in them capable of self-care so as to allow the
distress, and is evident in all Educational, other members of the family to become
Health, and Social Services. wage-earners.
In other parts of the world all under-
graduate training in the Courses for The Role of the Physiotherapist in
Medicine as well as in those for the Rehabilitation.
ancillary services have been adjusted to suit How can the physiotherapist assist in
these methods; unfortunately in New South these achievements? The answer is: ((By
Wales the awareness of this necessity is being an intelligent and cooperative member
not apparent in any field. The world-trend of the team."
 THE ROLE OF PHYSIOTHERAPY IN REHABILITATION 177
This team consists of a Director and of rehabilitation do not lead just to jobs,
medical and lay members as follows: but to professions in which the initial aim is
I . Medical Members: Physician, Surgeon, service to one's fellow-man" Details of
Orthopredic Surgeon, Psychiatrist, N eurolo- specific training tend to obscure one's out-
gist and the members of the other specialties look in this regard, and constant emphasis
as required. should be laid on this aspect in every branch
of the training.
2. Lay Members: Records, Physiotherapy,
Occupational Therapy, Vocational Train- The physiotherapist and the occupational
ing, Speech Therapy, Splint and Brace therapist are more intimately associated
Making, Placement Service, as well as with the patients for longer periods of time
specialists in the various forms of industry. than are any other members of the team"
They are responsible for exploring the
3. The Patient and his Relatives.
patient's aptitudes and for knowing his
There are two types of rehabilitation- wishes about the future. Confidences ex-
( I) with the short-term traumatic or post- changed with these members of the team
operative programme and (2) with the reveal the patient's personality more than
long-term programme for the chronically any other means of assessment, and it is
disabled" As a different type of personality through the information from their obser-
in the physiotherapist is required for these vations, when revealed at the Rehabilitation
groups, it is wise to have both branches of Conferences, that suitable individual pro-
work, if possible, in the same Centre where grammes can be worked out.
the staff can be interchanged for the benefit
of the patients and of the staff members Rehabilitation Techniques.
themselves. Having found compatible people with the
Personality Qualifications for the correct approach, one begins the method,
Physiotherapist. the priniciple of which is to survey the
patient as. a human being with family and
To be technically competent is not a financial responsibilities, with work prob-
sufficient qualification for the physio- lems, and with a disability which has tem-
therapist or any other member of the team" porarily disorganized his whole life. Let
The requiretnents are: us emphasize once more that the rehabili-
I. The ability to carry out instructions tation programme should begin on the day
accurately. on which he has the operation or accident,
2. The ability and desire to cooperate or on which his illness begins. This is a
with the other members of the team, saving in time, in money, and in human
especially with the occupational therapist. suffering, because delay has been known to
3. To possess or cultivate those powers lead to unnecessary tnental and physical
of observation which are so necessary for deformities which at a later date are more
helping in the evaluation and in the difficult to repair. These then are the steps
planning for the disabled.. in the whole method:
4. The possession of common sense and I. Evaluation.
human understanding and perseverance in 2. Physical Medicine.
order to give the patient confidence and lift, 3. Psychological Supportive Training.
which is an essential part of his psycho- 4. Vocational Training.
logical retraining. The basis of the technique includes a
s. To have that infectious enthusiasm positive diagnosis, both pathological and
for rehabilitation which takes possession of functional, and the consideration of the
all who work successfully in this field. patient's rehabilitation potentiaL His dis-
These qualifications can be acquired by abilities are recorded as well as the possi-
the undergraduate only if the idea of ser- bilities of treatment. To the patient the
vice is instilled into him. The various forms abilities are stressed rather than the dis-
of training which contribute to the success abilities.
 THE AUSTRALIAN JOURNAL OF PHYSIOTHERAPY

In this evaluation all members of the or of unknown retiology, as in rheumatoid

team participate and, when they have arthritis.
collected all their special infortnation, the Evaluation of the mechanism having to
facts are recorded and the information do with stability is extremely important.
is pooled. An evaluation conference is held, While actual fractures of weight-bearing
with the patient present, and each member bones make them unstable, instability can
of the team makes his contribution to the arise from causes, such as loss of ligamen-
programme and the goal to be achieved. A tous support and impairment of reciprocal
time-limit is set, and the patient is and coordinated muscular function about a
encouraged to commence his task. The joint. Malalignment in bones and joints
obj ective is the best physical, physiological, produces both instability and torsion,
emotional, vocational, social, and econotnic causing alteration in length and disturbance
status of the individual, commensurate with in the mineral content of the bone.. The
his disability and remaining abilities.. When physiotherapist must have the knowledge
basic physical functions are impaired, man to enable him to observe these facts in his
can utilize reserves which are surprisingly evaluation.
efficient. Remember that Rehabilitation is Pain must be eliminated before a patient
not only for the severely disabled, but con- can participate in any Rehabilitation pro-
stitutes part of adequate medical and sur- gramme. The medical evaluation will bring
gical care. this out, but the physiotherapist should note
The physiotherapist plays a very impor- all movements that promote pain.
tant part in teaching the detailed exercises
essential to this method. As it is a team The Evaluation Programme.
organization, every member has an impor- When all the facts are gathered together
tant duty to perform; but repeated exercise from the various members of the team, the
is essential to all programmes, and it is the physical evaluation is complete, and a patho-
physiotherapist's task to evaluate this aspect logical and functional diagnosis can be
of the patient and to assist in the organiza- established. Special therapeutic and restora-
tion of the programme. tive measures must be planned in detail to
The physiotherapist assists in the meet the needs of the patient The diagnosis
Rehabilitation planning by identifying the of muscular deficiencies and alterations in
nature, extent, and distribution of the the bones and joints which cause elimina-
existent abnormal muscular activity, for tion of activity as well as the therapeutic
example the motor manifestations lnay use of physical agents and procedures for
appear as incoordination or ataxia in the restoration of physical function belongs
cerebellar lesions, and as spasticity in to the field of physical medicine.. The
cerebral palsy and in other neurological physiotherapist is trained to perform tech-
diseases involving the pyramidal tracts. nical functions in this field, but must be
Included in muscular dysfunctions are the guided by the detailed medical diagnosis.
reflex phenomena of muscle spasm, such as The functions of the physiotherapist tnay
is seen in the neck and shoulder girdle, in be stated as follows:
painful shoulder conditions, and in the
I. He evaluates the status of muscular
lower back with an underlying strain.. Inter-
power and the range of motion in the
ference with the function of joints sin1ilarly
various joints.
requires specific diagnosis and classification,
and an evaluation of the possibility of 2. Following specific direction given to
spontaneous improvement Joint-action may him by his Medical Supervisor, he plans
be impaired because of trauma or because programmes in exercise and activity for
of disuse due to paralysed muscles each patient in particular..
or immobilization, or the joints may be The whole scheme of exercises is based
involved by an active disease-process on the Acts of Daily Living, the "A.D.L.",
whether due to infection, or degeneration, a term that one hears so frequently in these
 THE ROLE OF PHYSIOTHERAPY IN REHABILITATION 179

Centres; it is arranged in accordance with In the second group one finds:

the patient's physical status and with the (a) Paraplegics, either as a continuation
recommendation of such accessory mechani- of their initial care, or for those unfor-
cal devices as are required. tunate individuals who have been allowed
For detailed instruction of the therapist, to develop complications.
Edith Buchwald has worked out excellent (b) Hemiplegics, who always need
charts in her book, "Physical Rehabilita- retraining for a long period.
tion for Daily Living" (McGraw~HiI1 Book (c) Quadriplegics.
Company Limited, New Yark). She takes,
(d) Amputees.
for instance, the specific function of eating
a meal while sitting in bed, and teaches a ( e ) Patients with miscellaneous disabil i-
method of working out the simplest move- ties resulting from conditions such as arth-
ments of these functions, also the exercises ritis, poliomyelitis, cerebral palsy, multiple
necessary to retain these movements, and, sclerosis, or Parkinson's disease.
if necessary, the preparatory exercises for (f) All patients with traumatic con-
individual muscles before these movements ditions.
can be achieved. These exercises can be
applied to all functional activities. The Duties of the Physiotherapist in the
Tea11l Work.
Types of Disabilities. Patients may be classified as (I) bed
The types of disabilities encountered fall patients, (2) wheel-chair patients, (3)
into two groups: ambulatory patients.
I. Those with acute short-term con- A.D.L. (Acts of Daily Living) Inay
ditions. involve different problems for different
2. Those with chronic long-term dis-
levels.
abilities. In everyone of these programmes the
physiotherapist is necessary and her duties
In the first group one finds: may be tabulated in the following order:
(a) Postoperative patients reqUirIng
I. Making muscle charts for preliminary
techniques such as breathing exercises and
and all further evaluation of the patient.
prophylactic conditioning of muscles neces~
sary to prevent the evils of uncontrolled 2. Teaching the preparatory exercises
rest. for the individual muscles and, when these
(b) Traumatic and orthopredic patients are complete, the movements concerned in
with fractures, amputees, paraplegics in the the functional activity.
initial stage of their disability, and others 3. The use of splints, braces, and all
with muscle and nerve injuries which appliances; also checking them for the
seriously impair function. necessary adjustments and renewals.
( c) Patients with vertigo following 4. Teaching the patients and their rela-
fenestration operations. At King's College tives how to use these devices.
Hospital a very special routine has been
worked out for these patients with excellent 5. Wheel-chair techniques and all the
results. exercises that lead up to these, such as mat
( d) Thoracic patients both medical and exercises and balancing, or getting from
surgicaL bed to wheel-chair and from wheel-chair to
(e) The early planning of prophylactic bed.
care for all patients with medical conditions 6. Crutches and crutch-walking with all
necessitating more than a week of bed rest, the preliminary exercises.
especially those patients suffering from dis- 7. The making of plaster casts for
turbances of the central nervous system and prophylactic care and curative treatment,
the cardiovascular system, for example and as an ad j unct to splint and brace
with hemiplegia. making.
180 THE AUSTRALIAN JOURNAL OF PHYSIOTHERAPY

Crutch-walking includes a knowledge of The future is indeed bright for the

the various forms of gait, balancing physiotherapist who is willing to devote his
exercises, the correct type of crutch or or her time to the task. The attitude that
prosthesis, and the use of them, and also it is too much bother to travel to a Centr~
the individual requirements of each patient. which is not on the same suburban line will
There are no standard appliances for the not help in the progress of Rehabilitation
various disabilities; these need careful and nor give satisfaction to the individual
detailed measurements and instructions to engaged in this profession.
the patient and brace-maker. If the research outlook is stimulated in
young people and the great service they
During all these proceedings it is neces-
are able to perform to the disabled is
sary for the occupational therapist and the emphasized more and more during their
physiotherapist to work together so that the training, they should develop a better atti-
functional gains may be translated into real tude towards the patients in their care. It
life situations and eventually into vocational is a miserable and humiliating experience to
training which is the aim of all rehabilita- become physically handicapped and depen-
tion programmes. dent on other people; the kindly con-
Besides all these duties, the physio- siderate word and cheerful personality of
therapist must keep accurate records of the the therapist may be the only bright spot in
patient's progress and pass them on to the a dreary day for the patient.
Record Department, with notes on his It is well to remember, when handling
evaluation of the patient's personality and the sick, never to discuss one's own miseries
cooperation in the programmes of treat- and disappointments nor impose upon the
ment~ patients unsuitable conversations of a per-
The more Rehabilitation Centres we sonal nature, not appropriate to the situa-
have, the more physiotherapists we shall tion. Unfortunately, many patients com-
need, and the wider must be the training to plain that the therapists and the nurses
cover the altered outlook and the team alike seem to be more interested in dis-
organization. cussing the events of the previous evening
than in concentrating on their duties. We
Conclusion. all have a duty to perform when we become
At present in New South Wales the members of these honourable professions,
medical students go into practice poorly and especially as members of a Rehabilita-
equipped to evaluate the disabled, and with tion team. Let us approach them with
little knowledge of the functions of the humility and with an observant and
various ancillary services; the training of enquiring mind, remembering that technical
students and postgraduate medical training efficiency tempered with the milk of human
need to be revised to fit in with the altered kindness and common sense can accomplish
regime. marvels.