ROLE OF PHYSIOTHERAPY IN ORTHOPJEDIC SURGERY 77

THE ROLE OF PHYSIOTHERAPY IN ORTHOPlEDIC SURGERYBy C. H. HEMBRO\V

INTRODUCTION.

Orthopredics is the largest speciahty insurgery. If we include Injuries, mysurv~ys ~ave ~hown that over 60% of thesurgIcal tn-patIents are orthopc;edic patientsand 35% or more of the out-patient~ ingeneral clinics. As orthopredic patIentsatt~nd more frequently and for longerperiods than, for example, patients treatedfor appendicitis or for hernia, It will bes~en .that the. major part of a surgeon'stIme is spent In orthopcedic work.

In the vast majority of orthopcedic caseswe require the valued help of the physIo­therapists, and this help is, I am afraid,often taken for granted and 15 yieldedfaint praise. An efficient physiotherapydepartment is of equal importance to aho~p~t~l as an operating theatre. TheactIvItIes of the latter are often dramatizedbut the operation is only an incident in th~treatment-a preparation for the real bene­fit to be gained from physiotherapy. Sinceorthopredic wo~k deals with the movingparts, we require the help of the physio­therapist to supervise the return of func­tion, namely, movement.

What do we mean by physIotherapy?There we must be careful, for the meaningo~ the word, like "democracy", varies indifferent countries. By derivation it impliescure by natural means. I quote from arecent authoritative article! the views ofmany orthopcedic surgeons on the subjectof physiotherapy:

"PhysIotherapy IS of great value forselected cases It IS a form of paSSIve treat­ment and as such 15 given sparIngly, becauseSOine patients are only too happy to be atthe If ease on a couch and receIve treatmentwhich, fOf remedIal purposes, IS a POOl 3ub­stItute for theIr own actIvItIes Pahentsperform their remedIal exerCIses under thesuperVISIon of a masseuse, and tI11s arrange­ment 15 found to be more satIsfactory thanto use a specially traIned physical traIning

1 'RehabilItation of the War InJured", by WilhamBrown Doherty, M D, and Dagobert D ReevesPh D, PhilosophIcal Library, New York, page 445'

In~tl uctOl fOl exerCbe" and restrict themasseuse to phYSIotherapy, because otherWIsecertain patients wIll tend 10 e\ ade the phySIcaltraIning Instructor for more pleasurablett catment at the hands of the masseuse"

In Victoria we include in physiotherapythe r:atural means of active and passiveexerCIse and manIpulation. The surgeonI quoted does. not, but thinks of his helpers~s being phySIotherapIsts, physical exerciseInstructors, and occupational therapists.

The term orthopredlCS IS derived from theGreek and means literally "straight child""It wa~ used by Andrey, a French surgeon,w~o, In 1747, .wrote a book on how to keepchl1dren straIght and called it "ortho­I:redic~". Orthopredic surgery In presenttImes 15 that field of medIcal practIce whichd~als with malformations, injuries, anddiseases of the bones, muscles, joints andnerves. Robert Jones's definItion was "thetreatrn~nt by manipulation, operation, re­educa~lon, and rehabilitation, of the injuriesand dIseases of the locomotive system".

From the point of view of the physio­therapIst, orthopredics forms the largestsource of cases for treatment. In a month'scross-section of cases in the PhysiotherapyDepartment at the Alfred Hospital, Mel­bourne, the following was the proportionof types'

General orthopredic .. 59%Osteoarthritis .. 17%Chest e • • • • • • • •• 13%NeurosurgIcal . . . .. 6%Others 5%

(A wide interpretation would give ortho­predic cases 82%.)

Orthopcedic cases were:Fractures 42 %Injuries (other than frac-

tures) 20%

Others " ~ " . ~ 38%. Of course these figures would vary in

dIfferent hospitals and in private practice.

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FOUNDATIONS OF ORTHOP..EDICS.In my opinion the foundatIons of ortho­

predics rest in a knowledge of-I. Normal growth and development of

children.28 The action of muscles-kinesiology.3. Normal body mechanIcs and posture.4. The pathology of InjUry.5. The Interpretation of symptoms,

especIally pain.6. OsteoarthritIs. The effects of wear

and tear and age on JOInts and othertissues.

The prInCiples of orthopcedlcs should beapplied over the whole of medicine andSUI gery, for they are general In scope. Theuse of rest and splinting to promote repairin injured tissues, to control infection, andto prevent deformity and contractions; andthe use of active purposive movements torestore function are of general applicabtlity.

I propose to discuss the subject underthe first four headIngs gIven above and toexplain briefly tho"e aspects which are ofinterest to and needing the cooperatIon ofphysiotherapists

GROv\ TIl AND Dr\ ELOP!1ENT OFCHILDREN

ThIS iq fundamental knowledge requiredin the understandIng of physical, congenital,and acquired abnorlnalities and deformities.A full di';Cl1ssion of this important subjectis too long for this lecture It i" a basicsubject for the physical educatIon cour~eand ~hould be 111uch more stressed than Itis in the medical and physiotherapy courses.I shall mention only a few aspects of growthand development of normal children andselect tho"e whIch are I111portant to you.

Periodicity.The ~rowth chart of a normal child does

not sh~~ an even rate of ascent, but dis­plays well-defined periods of acceleratedgrowth, followed by longer periods otslower growth. There are three of theseperIods of accelerated growth The firstIS to be observed in the first year of infancyand is completed with the first dentitionThe second commences at five years ofage, reaches a peak in the seventh year, and

corresponds to the second dentition. Thethird commences at puberty and continuesthrough adolescence. Each of these periodsof rapid growth is associated with charac­teristic body changes. Skeletal growth pre­cedes muscular and visceral growth in eachcase. The first springing-up period in thefirst year does not alter the body propor­tions greatly and is followed by a slowerfilling-out stage till the second peak. Thenthe child becomes thinner and the limbs,particularly the legs, becoine longer In com­parison with the trunk. Between the agesof seven and eleven or twelve years, accord­lng to sex, the second period of slow growthoccurs and is followed by the thIrd peakcommencing at puberty. The profoundchanges assocIated with this stage ofdevelopment are followed by the third andlast filling-out period in later adolescence.These three main springing-up periods~ofbabyhood, of second dentition, and ofadolescence - are characteristic of theaverage child and they are of great import­ance as they are periods of instabIhty andvulnerabihty during which disturbances ofgrowth and body function are liable toarise.

In conSIdering any individual child, how­ever, it must be remembered that there isa marked individual variation and that wecannot compare anyone child strictly withthe average standards. The age alone of achild is therefore not an exact or reliableguide to his physical or to his mental level.The growth of each child may be modifiedby telnporary abnormalities, such as diet,dIsease or environment, but the mostinfluential factor is heredity.

In the middle of the second period, atthe age of six years, a child enters schooland in the change to the new way of life,t1l1 adjusted, he becomes very susceptIbleto postural defects. These are best cor­rected while the child is growing rapidly,for any defects that have not been correctedwill tend to become fixed in the slowergrowing period.

InequalityThe variOUS body systems do not all grow

at the same rate and time. A baby maydribble because its salivary glands havedeveloped beyond its power of swallowing..The weight of a child may outstrip the

ROLE OF PHYSIOTHERAPY IN ORTHOPJEDIC SURGERY 79

skeletal development and the abIlity tocarry the weight. In these times the pro­gress of many children is judged solely onthe gain in weight, but heavy chIldren areoften over-fed. Deformities may then arlseas a result of the actIon of gravity on thebody leading to bending of bones, such asthose of the lower limbs with the productionof knock-knees or bow-legs. Should theconditions causative of rickets be present,the onset of these deformities is facilitatedby softening of the bones. Too rapidgrowth of bone may lead to lessening ofmuscle tone and to fatigue, and posturalerrors are likely to appear. Developmentof the heart may lag behind the generalphysical progress. Unevenness of growth()f the various body systems is especiallypronounced in adolescence. There are alsodifferences in grovvth in the case of sexwhich shall be taken Into considerationo

Basic Activities.It is very important that towards the age

of ten years those basic activIties whichlater vvili form the foundatIons of all skilledacquirements should be learned andmastered. These are activities such asstanding, walking, sitting, running, skip­ping, hopping, jumping, throwing, catching,swimming, dancing and playing games.Research is needed as to the age at whicheach basic activity should be acquired. Iishould be recognized that the saine level ofskill is not reached by all in the basicactivities. YJVe must seek always to adaptour procedure to the age and naturalactivities of children. If we watch childrenat play on a Saturday, when left to theirown devices, we find they turn the day intoshort alternate periods of activity and rest.Thus they obtain a great deal of exercisebut in changing their activities get varietyand avoid fatigue

EpiphysesThe epiphyses form the weakest part of

the bone; this must be remembered whencontemplating any forcible passive move­ment, as damage can be done to the growingbone ends. The abnormalities of the variousepiphyses caused by avascular necrosesshould be understood by aU physio­therapists.

Congenital A bnor1nalitl,es.More should be known of the various

congenital abnormalIties. MInor abnor­Inalities Iil the back and In the foot areoften seen, and sometImes they are assumedto be the source of sylTIptoms, but this isnot so. They increase the vulnerabIlity ofthe part, being a lack of full development;therefore the part is more easily Injuredand recovers less speeddy.

KINESIOLOGY

The second foundation for orthopredicsIS a knowledge of kinesiology. This subjectincludes all that is known of l11uscles,IncludIng theIr anatomy, ph) slology, actIon,and function. From kineSIology we haveour art of muscle re-education. We learn,for example, what IS the best type ofquadriceps exercise and why the best resultscannot be expected from treatIng cases of\veak quadriceps in a class by word of COln­ll1and Class work gives the best resultsonly when we gather together a small groupof persons of approximately the same ageand condition who are suffering fromidentical troubles. This we can get in theservices, but in civil life the individualvariations of each case rarely receive thebest consideration in a class~ Healthyrivalry may be an advantage; but unwel­come cOlnparison is a detrilnent.

The principles of muscle re-educatlonlearned for use in cases of paralysis shouldforIn the basis of all muscle work in otherconditions, such as injuries or arthritis.The use of reciprocal inhibition in theexatnination of a patient must be remem­bered. If we wish to examine a shoulderwe can get a relaxed deltoid by getting thepatient to press down with the elbow, withthe arm in an abducted position.

I want to draw your attention to SOllIeaspects of the use of tTIuscle re-educationthat I think could be improved. We shouldbe more alert to increase the task of therecovering patient and to rehabilitate theresidual one to normal life by the develop­luent of compensation and adaptatIon.

Muscle re-education illustrates anotherprinciple which applies generally in phYSIO­therapy. People like to lie back whilepassive treatment is carried out. We must

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teach each patient that he is the only onewho can bring recovery-we only show theway!

BODY MECHANICS AND NORMAL POSTURE

The study of the lnechanical factorsgoverning the body functions is a huge sub­j ect, and consideration of the normalposture is only a small part of it, but forus it is a very important part. In manyconditions we treat, it forms the basis ofthe remedial exercises, as in sciatica and inosteoarthritis.

In those whose long-standing posturaldefects have become structural, no greatcorrection can be achieved, but we mustattempt to apply the principle of posture asthe little correction we can get often makesan immense difference in the relief ofsymptoms.

PATHOLOGY OF INJURY

I make no apology for discussing at somelength this most lmportant leg of the ortho­pcedic structure, for injuries form themajority of orthopredic cases and, if youconsult only the statistics of the ever­increasing toll of the road, you will agreethat the treatment of injuries will becomethe paramount problem of physiotherapy.Above all I would like to combat the stillprevalent feeling that the presence of painalways indicates rest, and that the amountof pain is relative to the severity of thetrouble and to its indications for treatment.Largely these dicta owe their origin toHilton's great book on "Rest and Pain""It seems so normal to regard pain as pro­tective. It is usually so in the case of theskin, and from that we drift to the viewthat all "pain is nature's signal that theintegrity of the tissues is threatened; andthat rest is required to stop further damageand allow repair". The widespread appli­cation of this theory to cases of injury hasresulted, and still results, in the productionof countless numbers of stiff and painfuljoints, and in prolongation of disabilitiesIn many serious diseases, such as gastriccarcinoma or puhnonary tuberculosis, theremay be no pain. Pain is an accolupanyingand purposeless reaction in many diseases

We must always try to think of the causeand the meaning of the pain in each case.Don't be content with empirical treatment.

In acute injury, pain is due to involve­ment of nerves by the injury and byexposure or to stimulation of the nerve endsby the effusion, by pressure or toxic action,and by general tension. The symptoms dueto effusion appear some time after theinjury; and the pain is often badly localizedor referred to spots away from the injury.

Muscle SpasmIn acute injuries pain may lead to muscle

spasm and the contraction of the musclegives more pain as the effusion is lyingbetween the muscle fibres, and a viciouscircle is thus set up. We must relieve thepain to stop the muscle spasm and dispersethe effusion, and we may use variousmethods, such as massage, heat, or gentlemovements, but often the pain is so greatthat morphia IS required The pain isusually caused more by the effusion thanby the damage done by the injury. Localancesthesla is sometimes used, as in ankleand back sprains, and in the milder caseswhere there is not lTIuch damage to theligaments or other tissues but there is agreat amount of effusion; and it may havevery good effects. The effusion has thetendency to coagulate into small sand-likethickenings which are very painful. Crepitusmay be felt.

Traumatic effusion contains fibrin andcells, lymph and serum. The two latter areabsorbed but. the former two are deposited;~or their absorption efficient blood supplyIS necessary and movement without weightbearing is required to tone up the musclesand to prevent adhesions.

The Effects of Injury.We may speak of two aspects of an

injury, namely, the actual damage done,such as rupture of a ligament or muscle;and the cOlnplication--traumatic inflamma­tion. The signs of inflammation are heat,redness, swelling, and loss of function. Ofthese, the most important is the swellingdue to traumatic effusion. Let us study thefactors leading to the production oftraumatic effusion.

(a) Increased formatlon of fluid.Arteries and veins have ruptured, givingextravasation of blood. Lymphatics aredama~ed, causing extravasation of lymph.I f a joint 15 involved, the synovial reaction

ROLE OF PHYSIOTHERAPY IN ORTHOPJEDIC SURGERY 81

to th~ stimulation of the inj ury IS thesecretion of more synovial fluid" The extra­vasated fluid spreads far and wide.

( b) Decreased absorption of fluId. Inaddition, the injury to the veins andlymphatics causes a blockage of drainageof the part and the disposal of the extrafluid in the tissues is reduced and stasisoccurs, and the effusion accumulates. Thusth~ b~lance ~f secretion and absorptIon offluId In the tissues (or In a j oint space) isupset and retentIon occurs.

(c) Reflex causes. The cedema may befurther increased also becallse of accentua­tion ?f a normal physiological state, that is,the dIsturbance of the mechanism regulatingthe normal physlological balance of fluid bynervous control. In some cases this is theInajor factor. In some cases a vIcious CIrcleIS formed, pain produces vasodtlatatlon andtht:ts more effusion. The effusion gives morepain and obstruction to the circulation anda condition called reflex traulllatic dys­trophy IS developed.

It is thought by some that the control offluid interchange depends upon the actlvltyof local perIpheral centres operatingthrough local short reflexes. These are5ufficlent to maintain equilibrium in theabsence of abnormal stimulation via thelong reflexes from the higher sympatheticcentres. Thus injection of a local anres­thetic may stop th~ accumulatIon of flUIdbut, "following on injury, thIS lnechanism ISupset.

In other cases vasOSpaSlTI 15 a feature~lth change of colour and impaired nutrI­tIon of the part. The patient develops aburning paIn out of all proportIon to thetrauma which may be continuous and pro­longed with marked hypercesthesia. Reflextraumatic dystrophy runs a course of manyweeks and treatment is of little avaIl. Osteo­porosis (Sudeck's atrophy) follows, \vithpallor, lose; of 1110vpment. and considerable~tlffnes6.

FracturesThe next point to consider in an injury

is \;vhether a fract:lre is present or not forin each case treatment is different. '

In the case of fractures we must firstreduce the fracture, secondly, maintain the

redllction, and, thirdly, care for the softtissues. Our paramount task is usually toget good union in a satisfactory posItion,and other considerations are usually secon­dary. We may exclude fractures, therefore,from consideration in this lecture. Natureprovides no mechanism for the reductionand the maintenance of reduction in frac­tures, ~nd in the. primitive life of the junglethe anlmal gettIng a fracture is promptlyeaten or starves.

Soft Tissue Injuries.We lTIUst avoid the frequent error of

regarding a soft tissue injury as involvingdall1age only to the structures, thusoverlooking the complication - traumaticeffusion. In most of these injuries thedamage is not great; it is the effusion whichIS the serious problem, especially when theaccident is trivial and the symptoms donot become severe for some hours or daysafterwards"

If we are to look upon the rupture of aligament or a muscle as the most importantaspect of an injury and treat it as we do afracture, by rest till firm heeling occurs,before advising activity, then our resultswill be poor indeed. We find that limbsso treated give rise to stiff and painfulJoints, for traumatic effusion may beregarde~ as a. g.lue which, aided byllnmoblhty of JOInts, is followed byadhesions. After prolonged rest we oftenfind t.hat attempt.s at movell1ent give rise toswellIng and paIn. Rest will relieve thispain, but the stiffness increases; and lateractIve movement will cause swelling andpaIn, ~or fibrosis has taken place aroundthe veIns and lymphatics giving retentionof fluid.. Active. moveluent then produceshypercemla and Increased effusion. Restthus increases the fixity of tissues. Restproduces sti~ness. The only hope ofImp.rovem~nt In such late cases is by per­SIsting vVlth graduated active movement·and the art in obtaining progress is t~Judge correctly the rate and amount ofactive movement to advise.

Furthermore, when a structure is torn~here develop~ a scar 0 f fibrous tissue. ItIS characteristic of fibrous tissue to contractand cause lilnitation of lTIOVement with theproduction of pain, and the structure loses

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some of its suppleness. Traumatic effusionmay lead to diffuse fibrosis and perIarticularthickening.

The objectives of treatlnent are, there­fore: (a) sound repaIr of damaged struc­tures, and (b) early absorption of thetraumatic effusion so that it does not causethickenings and adhesions. For this latterpurpose there are many methods used, andsome of these we will consider later. Ofthe two, the second obj ective IS usually themost important.

Traumatic EffusionsFactors in Spread. The spread of

effusion should be observed by physio­therapists during treatment. We shouldseIze every opportunIty to record its spreadwhere rendered visible by bruislng.

Quantity In any particular case theamount of the effusion is not related to theneed for repair but depends on such factorsas the size of the ruptured vessels, the bloodcoagulation time of the indIvidual, thelaxity of the tissues around the injury, e.g.the scalp, and whether there has been restor excessive use after the injury causinghcemorl hage. The effusion is liable tospread far from the injured area. Thatcan be demonstrated when the effusIon isblood-stained and bruises appear far fromthe injured part, as wIth discolorationappearing in the palm of the hand after afracture of the shoulder or in the toes aftera kick on the shin; the bruising shows howslowly the blood is absorbed and, indeed,the staining may never be absorbed, as inpigm~nted scars. Free hremoglobin is alsoa tissue irritant, rendering adhesions lTIOrelikely to form"

Movement. Further spread of theeffusion is brought about by muscular move­ment which also, by increasing the bloodsupply to the limb even by eight tilnes,produces more effusion and, by stimulationof the synovial membrane, produces moresynovial effusion.

Gravity" Gravity also aids the spread ofeffusion, as was seen in the example givenof the injured shoulder, and also, in casesof <:edema, swelling occurs first in the feet.In most shoulder injuries pain is complainedof at the deltoid insertion; this is probably

due to the accumulatIon of effUSion spread­ing down by gravity and collecting at themuscle insertion.

In cases of fractured patellce the dIs­coloration of the skin wlll appear in thebuttock if the patient is in bed, and downthe leg if ambulant. In back lnjuries theeffusion spreads downward.

Seepage The effusion spreads also byseepage. The blood from a deep-seatedhrematoma, as one around a fracture, willeventually appear on the surface. To doso it must pass between the muscle fibres,through the muscle sheath, being absorbedas It goes and beIng altered by the variousstructures in its direction of progress tothe surface. Sometilnes it collects aroundinsertIons and organs or tendon expansions,for exanlple, in the region of the knee, thequadrIceps expansIon, through whIch It mayhave to break to come to the surface as finepartIcles, gIvIng the sensation of crepituswhen pressed, like the crepitus felt in teno­synovitis on movelnent of the tendons.

The Part of the Body Involved In someparts of the body the anatomy of the partfavours the escape and absorption of theeffusion, for example, the thigh or scalp.Adhesions and, therefore, persistent painare not often seen here. In other places thefluid is hindered from escape and absorp­tIon, for example, around the insertions andorIgins near the elbow, in bone, and in partssuch as the heel or finger tips, where'ver­tical fibres bind the skin to the bone. "Pain­ful heel" is very persistent.

In the case of bruised bone, the seepageis de]ayed~ the blood and effusion being"itllated bet\veen the bone cells, in theHaversian canals, and beneath the peri­osteum, and it cannot escape quickly. Thesebruises of bone surfaces stay painful for along time, as In "hockey shin" and traumaticosteitis.

7"he Proportion of Soft Tissue Con­cerned The proportion of soft tissue inthe section of the tissue must be considered,for example, the finger and knee, where thecontent is largely one of bone, fibrotic tissue,and skin, all of ,vhich are not capable oflTIuch swelling, as opposed to the thigh,where there is a small amount of bone anda large amount of muscular tissue. Theresult is that in the thigh an extravasation

ROLE OF PI-IYSIOTHERAPY IN ORTHOP EDIC ~URGERY

of two pInts of fluid will not cause muchswelling and it will have adequate 111eansof escape and absorption; but In the caseof the finger and the knee a small injurymay cause interference with the entirecross-section of the part, thus exaggeratIngthe incidence of the trauluatIc effusion anddelaying its absorption.

The Extent of the Involvement of theCross-Section The effects luay in SOlnecases involve the whole cross-section, as ina crushing injury, and in others only a partof it, as when caused b) a blow. Theforlner prevents the escape of effusion andprovides a dIfficult probleln in treatment.

Blind Ends In the fingers and toes theflow of drainage is only one way. Blindends are also found in the back, where manyof the muscles arise from the SaCrU1TI andiliac crest, into which the effusion is guidedby gravity. In the finger, therefore, restand movement need to be carefullybalanced, as In the first case adhesions willform, but lTIOVement will increase theamount of effusion. In bursre the effusionis trapped and cannot spread

Recurrence Another factor in theilnportance of effusion is whether it isrecurrent or not. Recurrent cede111a is likea tide on the beach which leaves lines ofseaweed each time it occurs. The cedemaleaves areas of coagulated lymph each timeit appears, and that should be prevented,as it Inay spoil an otherwise good result;for example, when a plaster is removedfrom the leg after treatment of a fracture.Here preventive bandaging should becarrit.d out till the circulation re~ad j listsitself Think of all these factors that deter~mine the spread of effusion when treatingpatients.

Chronic Inflammation So far we havebeen discussing acute injuries, but there arealso chronic ones to consider. Chronicinjuries consist of the continuing effects ofacute injury, and the sUlnmation of theeffects of tnany Ininute injuries and thoseresultIng £rol11 loss of flexIbility, frOITIfaulty posture, bad habitual postures inindustry, and strain from over-use. Eachminute injury is followed by effusion andby fibrosis, by loss of flexibility, and thenfurther pain and injury. It may then beappreciated that 1t is 1111portant for us to

take early steps to prevent or lImit theeffusion and to disperse it if it is present.We should not wait till coagulations occurand adhesions form and fibrosIs develops~Absolute rest is therefore wrong in mostcases, except perhaps for a short period toallow sealing of torn vessels. Experienceshows that many injuries if left to them­selves develop complications, some of whichmay produce a greater disability than thatof the original injury. It is profitable tostudy the methods of healtng injuries ofthis nature, as it is in management ofinjuries that physiotherapy has its greatesttriumphs.

It is necessary to assure each patient thathis progress depends on himself and on hisown efforts, and to reassure him ac; to hisprogress, explaining that, though the treat­ment is ltkely to be painful, cure will comeIn the shortest time; and that any pain hemay experience during treatment cannot becompared with the pain he would suffer ifthe injury was left untreated until adhesionsdeveloped. The patient must also evincean eager desire to recover. Tell him thatthe condition is to be worked off underguidance.

!he above notes apply to acute traumaticInjUry.

ChronIc inflammatIon can result fromtoxcemia or bacterIal action as well as fromtrauma. In each case the reaction of thebody is Identical, but in trauma the causeceases, whereas In the others it continues,gern1 c;; 0 r poisons being present. In the caseof bacterial infectIon, movement lnay spreadthe bacteria at a faster rate than the bodydefences can cope with and so it Increasesthe trouble. Therefore rest may be requiredtill the disease is under control. Neverthe­less we have to be always on the alert forthe time when the inflammation ceases to bebacterial and passes into the stage of chronictraumatic inflammation; then active move­ments may form part of the treatment.ChronIc toxremia can also give rise tochronIc inflammation of tissues and theformation of adhesions. Usually the dis­tribution then is multiple.

It is important to recognize the abovetypes as the treatment advised for acutesoft tissue inj ury is not applicable to theothers.

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Sumrnary. By way of a summary wemay state that Hilton did not separatetrauma from bacterial injury and, though itis indeed often difficult to do, it is veryimportant that we should attempt to makethis distinction..

Most injuries should be mobilized bygraduated active movelnents or natural useas soon as is possible, supporting whennecessary the inj ured part and applyingmethods to prevent or disperse thetraumatic effusion.

Application of these Principles inPractice.

Acute Injuries.Diagnosis: If the first factor of injury,

actual damage to tissue, is definite, thediagnosis will be apparent. There ,;yill alsobe a history of trauma and a sudden onsetof sympton1S with immediate cessation ofactivity. These injuries can be classifiedin graded groups, such as spasm of muscle,rupture of a few fibres, or complete rupture.

In all these conditions support of theinjured part is required until it is repaired.But even in those cases as well as whenthere is little or no organic damage, the:l1anagement of the effusion is of paramountImportance.

Indications for Physiotherapy. Theindications for physiotherapy are thereforeto aid repair; to prevent and to disperseany effusion, and to prevent adhesions.

The typical case of injury requires ashort period of rest to allow sealing ofblood vessels and completion of the inflam­matory process of repair. According to theseverity of the injury, this period may befrom three days to three weeks, or more inthe case of ligaments and joints.

Methods: Various methods and combina­tions of methods are advisable. Each, how­ever, has to be used in its proper place andat the right time. If used at the wrongtilDe, or exclusively, harm may result.

Pressure: The application of pressure toan injury by bandage as soon as possibleis one of the best ways of preventingtrouble. When applied early, pressurebandages may limit or reduce the effusionand pain. The bandage lTIUSt be elastic, assome swelling will occur and an unyieldingsupport is apt to be painful.

The forms used are: (a) bandage overwool, (b) crepe bandage, (c) rubber band~age, or (d) HElastoplast".

The support of the pressure bandage withearly active movement is indicated in mostacute injuries.

Aspiration: Aspiration of blood, effusion,or synovlal fluid may be used with strictprecautIon to prevent infection.

Splinting: Support to the injured partmay be needed in combination with activemo;'ement of the limb. Plaster of Paris~plints are often suitable.

Massage; Massage is very helpful in dis­persing the excess of effusion out of thedamaged areas and out of the blind ends,and in aiding its absorption by the veinsand lymphatics. In acute inj uries thebruises require to be worked out byvigorous massage, even if that is painful.

Heat: I need not mention the use ofheat except to warn against its over-use inparts of the body where there is a pre­dOlninance of fibrous tissues} as in theshoulder, lower back, and fingers. Coagula­tion of the effusion may be caused, especi­ally if it be used as the sole method oftreatment.

Movements.Active Movements: No other treatment

except active movement can restore activemotions, and these should be carried outas soon as is possible after the injury.

The skill of the physiotherapist lies ingetting the maximal movement consistentwith the function of repair of the damage,for the earlier the function is resumed, thebetter chance there is of complete recovery.The most skilful is the one who can per­form the most movements without upsettingthe patient.

Activity is given by exercises suitable tothe individual's specific case and the exer­cises are designed to give isolation of thedesired part, such as back exercises isolatedto the back.

The sequence of graduated active move­ment is from gentle movements withoutweight-bearing to active lTIOVements withweight-bearing, to natural movements, toremedial exercises, on to rehabilitation

ROLE OF PHYSIOTHERAPY IN ORTHOPlEDIC SURGERY

exercises. The dtfficulty IS that the patIentsprefer rest and dislike movement, becauseof the occurrence of pain.

Activity gives 1ise to increased hyperremiaand may at first increase the effusion.Graduated effort is required. Movementwithout weight-bearing disperses theeffusion, tones the muscles, and preventsadhesions.

Diagnostic Value of Movements: Physio­therapists can often be of great helpthrough their observations in treatment, innotlcing when and how the pain arises.This 1S done by comparing the effects ofactIve and passive movements. Activemovements may be normal or give painonly when resistance is applied, as In "tenniselbow". They may be limited in one direc­tion, or in some directions only, or in alldirections.

If the results of passive movements areopposite to those of active ones, the troublemust be in a muscle or its attachment. Ifthey are the same, then the site is a liga­ment or other structure. In some casesnothing may be found, as it takes anobscure combination of movement to elicitpain. I f the fault lies In muscle we thenanalyse the movement and Isolate theaffected muscle by tests of function, usingfe-education principles. Teno-synovitis isexceptional. In this condition the pain isvague, widespread, and occurs with allvarieties of movement.

In advocatil1g active painful 1110velnentsthe patient must be reassured, the conditionexplained, and warning given that increaseof pain does not necessarily denote harm.A pal-ient may say that the movement is toopainful. Well, so it is. That is an indicationfor less speed. It IS also an indication tofind some other position in which to carryout the exercise WIth less discomfort, forexample, by eliminatIng gravity, and bymaking the task easier This prInciple maybe applied, for example, in neck, back, andshoulder treatment.

Curative Effect: Active exerCises do notalways cure. There are many injurieswhich are not likely to recover completelyby active work alone; these require helpby passive movement and manipulation.Injuries of the back, feet, and knees, areexamples. No voluntary control of indivi-

dual joints is present and the part worksas a team. We cannot isolate and wrigglethe joints between the fourth and fifthlumbar vertebrre or between the cuneiformbones. Thus the inj ured joint, limited bypain and muscle spasm, does not take a fullpart in the active range of the rest of theregion. Passive help is required. Whenactive moven1ents are extremely painful.suitable pas~ive help may be given withmuch less discomfort and with subsequentprogress of the active range..

Passive Movements: Passive movementsare the most difficult and dangerousof physiotherapeutic Ineasures. Someauthorities, like Watson-Jones, condemnthem-unnecessarily, I believe. If you tryto visualize the pathological anatomy of thepart being treated, so that you know whatyou are doing and why, passive movementsare of great value. The forms given areassisted active movements with addedjudicious passive stretching at the end ofthe range; and short, slow stretching (con­tinuous stretching in extension is oneform).

Manipulation Movements: These areused with the technique of manipulation.Manipulation is the art of applying forceeffectively but safely. To use manipulationthe physiotherapist must understand themechanics of action of the particular joint;that is a fundamental principle of manipu­lation.

Passive movements should not be usedin the early stages before repair has hadsufficient time. They must not replaceactive movements. It is even more neces­sary than when using activity to watchtheir effects on the range of movement andto cease if it decreases.

All passive movements have the objectof freeing adhesions without reaction, andespecially when active movements cannotdo this for reasons related to pain or theanatomy of the part. Passive movementsalone can be used if active movement is notpossible, as in paralysis or after tendonsuture. Badly used passive movements canproduce disaster. Vigorous repeated pump­ing of the limb, regardless of the con­sequences, may cause detrimental reactionand stiffness; fresh injuries are produced,vvith further effusion. So we avoid passive

THE AUSTRALIAN JOURNAL OF PHYSIOTHERAPY

movelnents In IrrItable Joints. Do not usepassive movements in the presence of con­tinuous pain and muscle spasm, as greaterresistance is evoked" Never use thelTI withunIting or recently united fractures.

General and Special Points: Thomastaught that strict rest must be carried outtill the part was repaired and recovered;and then active use was prescribed-but.then only. Jones allowed movement withinlimits of the pain for safety. Our view isthat, In the case of injury, in the absence offracture or of ruptured Iigalnent any active1110velnent can be allowed. It is perfectlysafe to attempt the painful movements. Infact I ask the patient to find out exactlyvlhat lTIOVelnent hurts most and to practiseIS as best he can" We have two safeguards:(a) people cannot hurt themselves by pain­ful actIve movements, as the muscles at acertain stage refuse duty, and (b) we can~atch the range of lTIOVement and whIle itis Increasing all is well; decrease in therange is a warning.

Due to our efforts the pain shoulddecrease and its threshold recede but, ifassociated with decrease of range, painincreases, we are not on the right track.Excessive reaction will defeat us byincreased formation of effusion andadhesions. Moreover, the pain produced byactive moven1ents should soon clear, saywithin half an hour after activity. Anyphysiotherapeutic 111ethod which produceslasting pain should be modified or stopped.

Movement Can Cause Adhesions: Exces­si\ e reaction can also be caused by using

too little force and by irritating theadhesions with little stretching at passivemovements. Manipulation under an<es­thesia is often required when by one suddenjerk all the adhesions should be ruptured.

Treatment is Difficult : You can see thatthe treatment is hard work for the patientand the physiotherapist, but gives us curesIn the shortest time. A further difficulty ISthat the diagnosis is not always supplied,nor is it correct in all cases. Total diagnosisInay not even have been Inade, and somefactor present though undefined is spoilingthe result of the treatlneni. In those caseswe suspect that the case is not entirelytraumatic and that there is an infection or atoxremia present" \iVith acute trauma theinjury effects cease at once; but in thepresence of toxcenlia or infection freshinjury continues. Such cases often improvewith treatment, but relapse when it is eased..Treatment must be suitably adjusted to thepathological condition.

Chronic InjuryIn chronic injuries the effusion has not

been dispersed and adhesions have formed.Chronic injury may arise without acuteinjury from chronic strain and the sum­mation of many tTIinute injuries daily.

CONCLUSION

Success in treatment lies in trying tounderstand each case. Physiotherapistsshould avoid extremes In any direction, andshould not fit the patient to a routinesystem of treatment.